A pilot of a veteran suicide prevention learning collaborative among community organizations: Initial results and outcomes

INTRODUCTION

Veteran suicide remains an ongoing public health concern in need of fresh, community-based initiatives. The Department of Veterans Affairs (VA) has built an enterprise-wide integrated behavioral health system that has pioneered numerous suicide prevention methods. However, most Veterans receive healthcare outside the VA, from organizations that may not be equipped to address Veteran suicide risk. One solution is implementing a VA/community suicide prevention learning collaborative to support organizations in implementing suicide prevention best practices for Veterans. Although learning collaboratives have a history of supporting improved patient safety in healthcare systems, to our knowledge, none have focused on Veteran suicide prevention.

METHOD

The current quality improvement project sought to pilot a VA/community suicide prevention learning collaborative in the broader Denver and Colorado Springs areas with 13 organizations that served, interacted with, or employed Veterans.

RESULTS

The collaborative had a large footprint in the region, with organizations interacting with over 24,000 community members and over 5000 Veterans. Organizations implemented 92 Veteran suicide prevention program components within a 16-month period. Overall, the learning collaborative made significant strides in Veteran suicide prevention.

CONCLUSION

Findings suggest that this method facilitates rapid implementation of Veteran suicide prevention practices and may be promising for accelerating uptake within communities.

Pilot investigation of an activity-based approach to building hardiness

BACKGROUND

The purpose was to describe an activity-based psychological hardiness training programme delivered by an occupational therapist and examine its acceptability and effectiveness in improving hardiness.

METHOD

Participants (N=28) completed the 6-hour programme, which included pre/post-programme completion of the Dispositional Resilience Scale-15 (DRS-15) and a Program Evaluation Form. Paired t-tests were used to determine differences between pre-training and post-training scores on the DRS-15.

RESULTS

Results showed a significant increase (p<0.05) in total hardiness, commitment, and control scores on the DRS-15 from pre-training to post-training and good-excellent ratings for all categories on the Program Evaluation Form.

CONCLUSIONS

This programme evaluation described an occupational therapist's role in providing an activity-based psychological hardiness training programme and provided preliminary support for the acceptability of an activity-based approach to training psychological hardiness for service members.

Self-labelled encoder-decoder (SLED) for multi-echo gradient echo-based myelin water imaging

PURPOSE

Reconstruction of high quality myelin water imaging (MWI) maps is challenging, particularly for data acquired using multi-echo gradient echo (mGRE) sequences. A non-linear least squares fitting (NLLS) approach has often been applied for MWI. However, this approach may produce maps with limited detail and, in some cases, sub-optimal signal to noise ratio (SNR), due to the nature of the voxel-wise fitting. In this study, we developed a novel, unsupervised learning method called self-labelled encoder-decoder (SLED) to improve gradient echo-based MWI data fitting.

METHODS

Ultra-high resolution, MWI data was collected from five mouse brains with variable levels of myelination, using a mGRE sequence. Imaging data was acquired using a 7T preclinical MRI system. A self-labelled, encoder-decoder network was implemented in TensorFlow for calculation of myelin water fraction (MWF) based on the mGRE signal decay. A simulated MWI phantom was also created to evaluate the performance of MWF estimation.

RESULTS

Compared to NLLS, SLED demonstrated improved MWF estimation, in terms of both stability and accuracy in phantom tests. In addition, SLED produced less noisy MWF maps from high resolution MR microscopy images of mouse brain tissue. It specifically resulted in lower noise amplification for all mouse genotypes that were imaged and yielded mean MWF values in white matter ROIs that were highly correlated with those derived from standard NLLS fitting. Lastly, SLED also exhibited higher tolerance to low SNR data.

CONCLUSION

Due to its unsupervised and self-labeling nature, SLED offers a unique alternative to analyze gradient echo-based MWI data, providing accurate and stable MWF estimations.

POS1422 USE OF DISEASE MODIFYING ANTI-RHEUMATIC DRUGS AND RISK OF MULTIPLE MYELOMA IN PERSONS WITH RHEUMATOID ARTHRITIS

Background

Biologic therapies used in the management of rheumatoid arthritis (RA) target several cytokines that have been implicated in the pathogenesis of multiple myeloma (MM). Yet little is known about the association between use of biologic or targeted synthetic disease modifying anti-rheumatic drugs (b or tsDMARDs) in RA and the incidence of MM.

Objectives

Our objective was to estimate the association between b/tsDMARD use and the risk of MM among persons with RA using Veterans Health Administration (VHA) data. We hypothesized that b-/tsDMARD use is associated with a lower incidence of MM compared with conventional synthetic DMARDs (csDMARDs).

Methods

In this retrospective cohort study, we identified patients >18 years of age diagnosed with RA in any United States VHA facility from 1/1/2002 and 12/31/2018. All patients met the following inclusion criteria: 1) two or more International Classification of Diseases Version 9 or 10 (ICD9 or ICD10) codes for RA at least 7 days apart but no more than 365 days apart 2) a prescription for a csDMARD within 90 days of the first RA diagnosis 3) one inpatient or outpatient visit 30 days to 2 years preceding first RA diagnosis (indicating a regular user of VHA). Medication data was derived from the outpatient prescription fills, bar coded medication administration (BCMA), and intravenous (IV) data domains. The csDMARDs included in these analyses were: methotrexate, sulfasalazine, leflunomide, and hydroxychloroquine. The bDMARDs included were tumor necrosis factor inhibitors (TNFi) and non-TNFi biologics such as tocilizumab, rituximab, abatacept, and biosimilars; tsDMARD was tofacitinib. Patients with MM before the diagnosis of RA were excluded. Incident MM was determined by 1 or more ICD9/10 code or ICD-oncology codes. Multivariable Cox proportional hazards model were performed to estimate the hazard ratio for developing MM among those during and following the use of a b-/tsDMARD relative to b-/tsDMARD-naïve persons adjusting for age, gender, race, and ethnicity.

Results

27,540 veterans with RA met study eligibility criteria, of whom 8,322 (30%) had taken a b-/tsDMARD. Over the study period there were 77 incident MM over a total of 192,000 person years. There were 55 events in users of csDMARDs, an incidence rate (IR) of 0.40 (95% CI 0.30-0.52) per 1000 person-years and 22 in persons currently or formerly using b-/tsDMARDs (IR 0.41, 0.25-0.61 per 1000 person years). The unadjusted hazard ratio for MM following bDMARD use relative to csDMARD only use was 1.04 (0.63, 1.73), which increased to 1.28 (0.76, 2.16) after adjusting for demographic characteristics (Table 1).

Table 1.

Multivariable Cox proportional hazards model for association between use of disease modifying anti-rheumatic drugs and incident multiple myeloma.

Clinical characteristicHazards ratio (95% CI)csDMARDReferenceb-/tsDMARD use1.28 (0.76-2.16)Age*1.04 (1.02-1.07)Female0.58 (0.20-1.62)RaceReferenceWhite2.11 (1.15-3.86)Black0.70 (0.10-5.08)OtherHispanic Ethnicity0.71 (0.17-2.92)

Abbreviations: b-/tsDMARD- biologic or targeted synthetic disease modifying anti-rheumatic drug; CI: confidence interval

*Hazards ratio reflects risk per every 1-year increase in age

Model adjusted for age, gender, race, and ethnicity

Conclusion

In this nationwide VA study, we did not observe an association between bDMARD use and the incidence of MM. Of note, the median interval from initiation of a bDMARD to the end of follow-up was approximately 5.8 years, which does not allow for an examination of a possible longer term influence.

Disclosure of Interests

None declared

POS1434 USE OF BIOLOGIC OR TARGETED SYNTHETIC DISEASE MODIFYING ANTI-RHEUMATIC DRUGS AND THE RISK OF LYMPHOMA IN RHEUMATOID ARTHRITIS

Background

Epidemiologic studies suggest that disease duration and degree of inflammatory activity of rheumatoid arthritis (RA) contribute to lymphoma development (1). Whether the decrease in inflammatory burden seen with use of biologic or targeted synthetic disease modifying anti-rheumatic drugs (bDMARDs or tsDMARDs) translates into a lower risk of lymphoma in RA needs to be studied.

Objectives

The objective of our study was to examine the effect of administration of b/tsDMARDS on the incidence of lymphoma relative to conventional synthetic DMARDs (csDMARDs) in an inception cohort of Veterans with RA.

Methods

We identified patients >18 years of age diagnosed with RA in any US Veterans Affairs (VA) facility from 1/1/2002 and 12/31/2018 using the VA Corporate Data Warehouse (CDW). To be included, each patient was required to meet the following criteria: 2+ RA diagnostic codes at least 7 days apart but no more than 365 days apart; 2) a prescription for a csDMARD within 90 days of the first RA diagnosis; and 3) an inpatient or outpatient visit 30 days to 2 years preceding first RA diagnosis (indicating they are a regular user of the VA). The csDMARDs included in these analyses were: methotrexate, sulfasalazine, leflunomide, and hydroxychloroquine. The bDMARDs included were tumor necrosis factor inhibitors (TNFi) and non-TNFi biologics such as tocilizumab, rituximab, abatacept, and biosimilars; tsDMARD was tofacitinib. Patients with prevalent lymphoma were excluded. Lymphoma diagnoses were identified using International Classification of Diseases Version 9, 10 and Oncology (ICD9, ICD10, ICDO) codes.

We used marginal structural models as described by Hernan et al (2) and time-varying Cox models to control for confounding by indication while evaluating this association. We adjusted for baseline demographics (age, sex, race, ethnicity, year of cohort entry, rheumatology visits), and time-varying CRP and time-varying Rheumatoid Disease Comorbidity Index (RDCI) (3) to control for confounding.

Results

27,421 Veterans with RA met our eligibility criteria. Most of the Veterans (56%) were in the age range 61-80 years old; 89% male, 76% White, 14% African American. 8,225 (30%) patients were treated with a b-/tsDMARD. The crude incidence rates were 1.71 (95% CI 1.5-1.94) per 1000 person-years for those only on csDMARDs and 1.78 (95% CI 1.44-2.18) for patients during or following use of a b/tsDMARDs. After adjustment with both time-fixed and time-varying covariates using marginal structural models, the incidence of lymphoma was not different between patients who did and did not use a b/tsDMARD (hazard ratio=1.06, 95% CI= 0.82-1.37) (Table 1).

Table 1.

Estimates of Effect of bDMARD or tsDMARD use on Lymphoma relative to use of csDMARDs

Marginal Structural Models; adjusted for:@Demographics1.04(0.80, 1.34)#Demographics + CRP1.06(0.82, 1.37)

* per 1000 person-years

@Demographics = age, gender, race, ethnicity, rheumatology visits, and year of cohort entry

#Adjusts for CRP, baseline rheumatology visits (yes/no) and RDCI.

CRP = C-Reactive Protein, RDCI = Rhematic Disease Comorbidity Index, CI = Confidence Interval, b/tsDMARD = biologic or targeted synthetic DMARD, csDMARD = conventional synthetic DMARD

Conclusion

In this large study using the nationwide VA data, we did not observe an association between the use of b/ts DMARDs and an increased risk of lymphoma.

References

[1]Baecklund E, Iliadou A, Askling J, Ekbom A, Backlin C, Granath F, et al. Association of chronic inflammation, not its treatment, with increased lymphoma risk in rheumatoid arthritis. Arthritis Rheum. 2006;54(3):692-701.

[2]Robins JM, Hernan MA, Brumback B. Marginal structural models and causal inference in epidemiology. Epidemiology. 2000;11(5):550-60.

[3]England BR, Sayles H, Mikuls TR, Johnson DS, Michaud K. Validation of the rheumatic disease comorbidity index. Arthritis care & research. 2015;67(6):865-72.

Disclosure of Interests

None declared

0325 A Comprehensive Evaluation of Sleep Disorders in Male and Female U.S. Military Personnel

Introduction

Sleep disorders are increasingly recognized in military personnel. However, no study has comprehensively evaluated male and female service members with clinically significant sleep disturbances. While, insomnia and obstructive sleep apnea (OSA) are the two most recognized sleep disorders, some studies have suggested that comorbid insomnia and OSA, also known as COMISA, potentially is the most frequent sleep disorder. Further little is known regarding the co-occurrence of nightmares, shift work disorder, depression, anxiety, and posttraumatic stress disorder (PTSD) in this population.

Methods

Participants were 309 active duty service members (females n = 113, male n = 196) in all branches of the military who underwent a clinically indicated sleep evaluation in a military sleep disorders center. All underwent an attended in-lab polysomnogram, were diagnosed with insomnia, OSA, or COMISA and completed self-report measures. Participants completed the Nightmare Disorder Index and Shift Work Disorder Index, and non-sleep questionnaires using the PCL-5 for post-traumatic stress disorder (PTSD), the PHQ-9 for depression, the GAD-7 for anxiety, and History of Head Injuries for traumatic brain injury (TBI).

Results

COMISA was diagnosed in 36.8% of the sample, insomnia in 32.7%, and OSA in 30.4%. Males were significantly more likely to have COMISA or OSA and females were more likely to have insomnia. Polysomnographic variables were consistent with the respective sleep diagnoses. Forty service members (12.9%) met criteria for nightmare disorder; those with OSA were significantly less likely to have nightmares. Shift work disorder was present in 49 (15.9%) and did not differ between sleep diagnoses. PTSD was present in 57 (18%) and those with COMISA were significantly more likely to have PTSD. A history of head injuries was reported by 38.2% and there was no difference in rates between the sleep disorder groups.

Conclusion

The most frequent sleep disorder profile in service members with sleep disturbances was COMISA, which was associated with significantly higher rates of PTSD and anxiety. Conversely, OSA alone was not associated with higher rates of any comorbid disorders. Nightmare disorder and shift work are relatively prevalent in military personnel with sleep disorders.

Support (If Any)

This work was supported by the Defense Health Agency, Defense Medical Research and Development Program, Clinical Research Intramural Initiative for Military Women’s Health (DM170708; Mysliwiec), and the Air Force Research Laboratory, Wright Patterson Air Force Base, Ohio (FA8650-18-2-6953; Peterson). The views expressed herein are solely those of the authors and do not represent an endorsement by or the official policy or position of the U.S. Air Force, the U.S. Army, the Defense Health Agency, the Department of Defense, the Department of Veterans Affairs, or the U.S. Government.

0831 Identifying Sleep-Related Breathing Disorders in Underserved Demographics Using Commercial Portable Monitoring Devices: A Case Report

Introduction

An estimated twenty-five percent of American women are at high risk of having obstructive sleep apnea (OSA). However, male sex is the predominantly reported risk factor. Women are less likely to report “classic” symptoms such as snoring that prompt referral for sleep evaluation. This dichotomy potentially represents a disparity in clinical evaluation and treatment of OSA in women. Consumer digital health devices are frequently used to monitor sleep in people with and without sleep disturbances. They are generally highly sensitive yet have lower specificity when compared with formal actigraphy or polysomnography. They may be used in conjunction with physician evaluation to guide decision-making.

Report of Cases: A 33 year-old female with a pertinent past medical history of obesity (BMI 37.83 kg/m ), depression, chronic pain, and anxiety was referred to our sleep center with a multi-year history of excessive daytime fatigue and non-restorative sleep that persisted despite healthy habits counseling and unremarkable lab evaluation. She ultimately presented her primary care

physician with biometric data collected by her Garmin watch and Oura ring. This data, which

included a reported low SpO of 83%, motivated a referral to Sleep Medicine. Her presentation Epworth Sleepiness Scale (ESS) score and Insomnia Severity Index (ISI) were 14 and 17, respectively. Polysomnography revealed an AHI of 32.6/hr, oxygen nadir of 79%, ODI of 28.7/hr, and a 97.2% sleep efficiency. PLMS index was 23.2/hour but did not contribute

to sleep fragmentation and there was increased proportion of stage N3 sleep (28.2%). Severe

OSA was treated with APAP. The two month follow-up ESS and ISS improved to 9 and 4, respectively. Device data revealed greater than 6 hours of consistent nightly use with a residual AHI of 3.1/hr. She subjectively stated APAP “has been a life changer” personally and professionally, as well as spousal report of resolution of snoring. Her consumer devices similarly reported improved sleep measures.

Conclusion

Minorities and women may be underserved in evaluation, diagnosis, and treatment of OSA. Portable monitoring using readily available consumer biometric devices may be a viable strategy for patients to further identify high risk features and prompt referral by primary care.

Support (If Any)

This work was supported by the Defense Health Agency, Defense Medical Research and Development Program, Clinical Research Intramural Initiative for Military Women’s Health (DM170708; Mysliwiec) and the Air Force Research Laboratory, Wright Patterson Air Force Base, Ohio (FA8650-18-2-6953; Peterson).

An Examination of Chronic Pain Indices and the Updated Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental-Disorders-Fifth Edition

INTRODUCTION

Chronic pain and post-traumatic stress disorder (PTSD) comorbidity is prevalent among veterans and is associated with increased levels of pain severity and pain-related disability. An improved understanding of the relationship between these co-occurring disorders, in addition to effective integrated treatments, will develop by considering the changes to the PTSD diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The current study examined the relationship between the revised PTSD Checklist for DSM-5 (PCL-5) symptom clusters (i.e., intrusion, avoidance, negative alterations in cognition and mood [NACM], and arousal) and chronic pain measurements (i.e., pain severity, interference, and disability).

MATERIALS AND METHODS

Participants included 103 veterans (ages 26-70, mean = 45.33) participating in a randomized clinical trial examining the efficacy of an interdisciplinary pain management program for chronic musculoskeletal pain. The study was approved by a university system Institutional Review Board and affiliated healthcare system.

RESULTS

The participants with a provisional PTSD diagnosis based on PCL-5 responses (N = 76) had significantly greater pain severity, interference, and disability than the participants without a provisional diagnosis (N = 23). Correlations between symptom clusters and pain measurements were mostly significant and positive with varying strengths. The avoidance symptom cluster, however, had relatively weaker correlations with pain measurements and was not significantly associated with the numeric rating scale of pain severity. Path analyses revealed that, after controlling for avoidance symptoms, significant associations remained between NACM and all the pain measurements. After controlling for NACM symptoms, however, there were no significant associations between avoidance symptoms and pain measurements.

CONCLUSION

The current study highlights a need to re-examine the leading theories about the mutual maintenance of these disorders in order to develop effective integrative treatment approaches. PTSD-related avoidance may have a relatively weaker role in co-occurring chronic pain than the other symptom clusters and may have a qualitatively different role than chronic pain-related avoidance. Future research should explore the relationship between the avoidance in PTSD and the avoidance in chronic pain as well as identify which chronic pain measurements are the most useful when examining the relationship between PTSD and chronic pain. The potential impact of trauma-related cognition and mood on chronic pain indicates that this is an important area for intervention and should be considered in the development of integrated treatments for chronic pain and PTSD among veterans.

Early prognosis of respiratory virus shedding in humans

This paper addresses the development of predictive models for distinguishing pre-symptomatic infections from uninfected individuals. Our machine learning experiments are conducted on publicly available challenge studies that collected whole-blood transcriptomics data from individuals infected with HRV, RSV, H1N1, and H3N2. We address the problem of identifying discriminatory biomarkers between controls and eventual shedders in the first 32 h post-infection. Our exploratory analysis shows that the most discriminatory biomarkers exhibit a strong dependence on time over the course of the human response to infection. We visualize the feature sets to provide evidence of the rapid evolution of the gene expression profiles. To quantify this observation, we partition the data in the first 32 h into four equal time windows of 8 h each and identify all discriminatory biomarkers using sparsity-promoting classifiers and Iterated Feature Removal. We then perform a comparative machine learning classification analysis using linear support vector machines, artificial neural networks and Centroid-Encoder. We present a range of experiments on different groupings of the diseases to demonstrate the robustness of the resulting models.

POS0287 USE OF BIOLOGIC DISEASE MODIFYING ANTI-RHEUMATIC DRUGS IN RELATION TO THE RISK OF LYMPHOMA: A COHORT STUDY OF US VETERANS WITH RHEUMATOID ARTHRITIS

Background:

Epidemiologic studies suggest that disease duration and degree of inflammatory activity of rheumatoid arthritis (RA) contribute to lymphoma development. However, the association of the use of biologic disease modifying anti-rheumatic drugs (bDMARDs) in patients with RA on lymphoma risk needs further evaluation.

Objectives:

Examine the effect of administration of bDMARDS on the incidence of lymphoma in an inception cohort of RA.

Methods:

We identified patients diagnosed with RA in any US Veterans Affairs (VA) facility from 1/1/2002 and 12/31/2018 using the Veteran’s Health Administration (VHA) databases. To be included, each patient was required to meet the following criteria: 1) 2+ RA diagnostic codes at least 7 days apart but no more than 365 days apart 2) a prescription for a conventional synthetic DMARD (csDMARD) within 90 days of the first RA diagnosis 3) One inpatient or outpatient visit 30 days to 2 years preceding first RA diagnosis (indicating they are a regular user of the VHA). We excluded patients for any of the following if they preceded the first RA diagnosis: 1) a prior single RA diagnostic code 2) a prescription for any DMARD medication 3) a concomitant diagnosis of another inflammatory arthritis (e.g. psoriatic arthropathy) 4) a diagnosis of lymphoma. Index date for the study is the date of the first qualifying RA diagnosis. Lymphoma diagnoses were identified through VHA records using the International Classification of Diseases-Oncology codes.

Results:

We identified 27,536 veterans with RA in the study period meeting the inclusion and exclusion criteria. Of these, 53% (n=14,705) were in the age range 60 to 80 years. The cohort was 89% male, 75.5% White, 13.7% African American. Over the study period, 1.2% (n=332) of the study population developed a lymphoma.

Conclusion:

Using the nationwide VHA we have identified a large inception cohort of patients with RA of whom 1.2% developed lymphoma over study follow-up. This data will be used in future analyses to produce estimates of the effect of biologic medications on lymphoma risk, adjusting for confounding by indication and other variables.

Table 1.

Baseline characteristics of the cohort based on bDMARD exposure status

CharacteristicbDMARD-naive (n= 19,095)bDMARD-exposed (n=8,441)Overall Lymphomas Age (years)171161 18-4046 40-606378 60-8010074 >8043 Males17,206 (90%)7,270 (86%)Race White14,150 (74%)6,627 (76%) Black2,674 (14%)1,090 (13%) Asian96 (0.5%)46 (0.5%) Native American or Pacific Islander371 (2%)187 (2.2%) Missing1,804 (9%)491 (6%)

Acknowledgements:

The work in this abstract is supported by Investigator Award from the Rheumatology Research Foundation to Dr Singh.

Disclosure of Interests:

None declared

730 Prevalence and impact of sleep problems in active duty military personnel receiving Cognitive Processing Therapy for PTSD

Introduction

Sleep disturbances are common in active duty military personnel and play a key role in the development and maintenance of posttraumatic stress disorder (PTSD). Research indicates that although insomnia and nightmares improve with successful PTSD treatment, they may remain clinically significant. Few previous PTSD studies have assessed sleep disorder constructs using validated instruments. The objectives of this study were to examine the proportion of active duty military personnel seeking treatment for PTSD who reported clinically significant insomnia, nightmares, sleep duration, and excessive daytime sleepiness and to examine the impact PTSD treatment had on these sleep constructs using validated self-report questionnaires.

Methods

Sleep was evaluated in 223 active duty service members participating in a randomized clinical trial comparing group and individual Cognitive Processing Therapy (CPT) for PTSD. Sleep constructs were assessed using the Insomnia Severity Index (ISI), Trauma-Related Nightmare Survey (TRNS), Self-Assessment of Sleep (SAS), and Epworth Sleepiness Scale (ESS) at baseline and 2 weeks posttreatment.

Results

At baseline, 82% of participants reported clinically significant insomnia and 75% reported at least 1 moderately severe nightmare per week. Participants reported averaging 4.76 hours of sleep per night, and 65% reported excessive daytime sleepiness. Over the course of PTSD treatment, there were statistically significant improvements in insomnia, nightmares, and excessive daytime sleepiness, but scores remained in clinically significant ranges. Minimal increases were seen in sleep duration. Of the participants who no longer met criteria for PTSD at posttreatment, 50% continued to report clinically significant insomnia, 52% continued to report clinically significant nightmares, and 44% continued to report excessive daytime sleepiness.

Conclusion

Consistent with previous research, sleep problems persisted for a significant number of service members who completed treatment for PTSD. Insomnia, nightmare, and sleep extension interventions are likely an important part of comprehensive PTSD treatment plans.

Support (if any)

Funding for this work was made possible by the U.S. Department of Defense through the U.S. Army Medical Research and Materiel Command, Congressionally Directed Medical Research Programs, Psychological Health and Traumatic Brain Injury Research Program awards W81XWH-08-02-109 (Alan Peterson), W81XWH-08-02-0116 (Patricia Resick), W81XWH-10-1-0828 (Daniel Taylor), and W81XWH-08-02-0114 (Brett Litz).

WAVE2 suppresses mTOR activation to maintain T cell homeostasis and prevent autoimmunity

Cytoskeletal regulatory protein dysfunction has been etiologically linked to inherited diseases associated with immunodeficiency and autoimmunity, but the mechanisms involved are incompletely understood. Here, we show that conditional Wave2 ablation in T cells causes severe autoimmunity associated with increased mammalian target of rapamycin (mTOR) activation and metabolic reprogramming that engender spontaneous activation and accelerated differentiation of peripheral T cells. These mice also manifest diminished antigen-specific T cell responses associated with increased inhibitory receptor expression, dysregulated mitochondrial function, and reduced cell survival upon activation. Mechanistically, WAVE2 directly bound mTOR and inhibited its activation by impeding mTOR interactions with RAPTOR (regulatory-associated protein of mTOR) and RICTOR (rapamycin-insensitive companion of mTOR). Both the T cell defects and immunodysregulatory disease were ameliorated by pharmacological mTOR inhibitors. Thus, WAVE2 restraint of mTOR activation is an absolute requirement for maintaining the T cell homeostasis supporting adaptive immune responses and preventing autoimmunity.

The Veterans Affairs Patient Safety Center of Inquiry-Suicide Prevention Collaborative: Creating Novel Approaches to Suicide Prevention Among Veterans Receiving Community Services

Background

While the US Department of Veterans Affairs has made significant strides to prevent veteran suicide, efforts have largely targeted veterans actively engaged in and eligible for Veterans Health Administration (VHA) care, which is consistent with the VHA mission. The majority of veterans are not enrolled in VHA care, and many are ineligible for services. Veterans not connected to VHA have experienced an increase in suicides in recent years.

Observations

Since 2018, VHA National Center for Patient Safety has funded the Patient Safety Center of Inquiry-Suicide Prevention Collaborative (PSCI-SPC), which has worked to develop, implement, and evaluate practical solutions aimed at curbing the rising suicide rate among veterans not receiving VHA care. PSCI-SPC has 3 guiding objectives: (1) Develop and test a collaborative, organizational structure to connect VHA and community organizations, such as national, local, public, private, nonprofit, and academic partners who provide high-quality and timely health care; (2) Build and test a learning collaborative to facilitate sharing of VHA suicide prevention best practices with community partners to increase availability, consistency, and quality of mental health services for all veterans; and (3) Implement, test, and refine a novel program to provide affordable suicide prevention interventions to veterans with mental health needs, regardless of their use of, or eligibility for, VHA services. This paper details the current progress for this demonstration project. As these objectives are met, PSCI-SPC will create and disseminate products to support broad implementation of these practices to other VA medical centers and the communities they are embedded in.

Conclusions

PSCI-SPC seeks to fill an important gap in veteran health care by serving as a national clinical innovation and dissemination center for best practices in suicide prevention for veterans who receive care in their communities.

A test of the fear avoidance model to predict chronic pain outcomes in a polytrauma sample

BACKGROUND

Chronic musculoskeletal pain is a complex problem, particularly for individuals with head injury and comorbid psychiatric conditions. The Fear Avoidance Model offers one of the strongest opportunities to conceptualize comorbid traumatic injury and pain, but this model is largely untested.

OBJECTIVE

This study tests the Fear Avoidance Model of chronic pain using a sample from a study of polytrauma patients in a large Department of Veterans Affairs facility who participated in a federally-funded study of interdisciplinary chronic pain management.

METHODS

The present study comprises a secondary analysis of 93 veterans with chronic pain, head injury, posttraumatic stress symptoms and a history of persistent opioid use. Standardized measures of Fear Avoidance Model risk factors (e.g., pain catastrophizing, fear avoidance beliefs, anxiety, depression) were examined as cross-sectional predictors of pain-related disability.

RESULTS

Secondary data analysis revealed that Fear Avoidance Model factors accounted for almost 40% of the variance in pain-related disability, with pain catastrophizing and depression demonstrating the strongest relationships with disability. A summary variable combining all four factors revealed a 6% increase in disability for each factor that was clinically significant for the sample patients.

CONCLUSIONS

This study represents the first attempt to examine a complex, theoretical model of pain in a comorbid pain and TBI sample. Findings revealed a strong relationship between this model and pain-related disability that outperforms pain intensity ratings. This model could be used to guide better treatment for comorbid pain and TBI.

0860 Sleep Disorders In Female Military Personnel

Introduction

Sleep is an essential biological function and the disruption of sleep has deleterious consequences. Military personnel experience unique stressors related to their service, elevating the risk of developing sleep disorders. The etiologies and impact of sleep disorders on military women’s health is poorly understood. This study is the first to prospectively assess whether military women with insomnia, obstructive sleep apnea (OSA), or comorbid insomnia and OSA (COMISA) have different gender roles, military service-associated factors, and biological characteristics than military men with the same disorders.

Methods

This is a prospective observational study of military personnel with sleep disturbances. The study will evaluate women and men matched for sleep disorder. Participants will complete an evaluation to include polysomnography (PSG), sleep questionnaires and validated clinical assessments of associated disorders of interest. The baseline demographics, questionnaire, and PSG results will be analyzed to assess for commonalities or differences between genders.

Results

We have enrolled 45 patients (24% female). Males had a higher BMI (29.1) than females (26). Males were also older (38) than females (35). The leading diagnosis in males was OSA (44%) and insomnia in females (64%). In males, the apnea-hypopnea index (AHI) was 11.3/hr, arousal index (ARI) was 20/hr, and sleep efficiency (SE) was 86.5%. Total sleep time (TST), wake after sleep onset (WASO), and sleep onset latency (SOL) were 364.6, 40.9, and 12.6 minutes, respectively. In females, the average AHI was 6.6/hr, ARI was 15/hr, and SE was 87.2%. Their TST, WASO, and SOL were 359, 44, and 12.6 minutes, respectively.

Conclusion

Military personnel are at increased risk of sleep disorders. Literature comparing male and female characteristics and sleep disorders is scarce. In this study, baseline demographics were similar in both groups but insomnia was the leading diagnosis for women. This emphasizes the importance of adequate recognition and treatment of insomnia in this group.

Support

This study is supported by the Defense Health Agency, Defense Medical Research and Development Program, Clinical Research Intramural Initiative for Military Women’s Health.

1186 Developing And Testing A Web-based Provider Training For Cognitive Behavioral Therapy Of Insomnia

Introduction

Chronic insomnia is a common, debilitating disorder and a risk factor for significant medical morbidity, mental health problems, and workplace difficulties. Cognitive behavioral therapy for insomnia (CBT-I) is the gold standard treatment for insomnia. However, few providers are trained in CBT-I, in part due to a bottleneck in training availability and the time and cost associated with current training platforms. To address this training deficit, our team developed and evaluated CBTIweb.org, a web-based provider training course for CBT-I.

Methods

Feedback from alpha- and beta-testing of CBTIweb.org was collected and used to optimize course content and functionality. Then, a comparison study was conducted in which licensed providers were randomized to complete either the online CBTIweb.org course (n=21) or an in-person CBT-I training (n=23). During all phases of development, providers completed a Computer System Usability Questionnaire (CSUQ), investigator-developed website usability and content questionnaires, and pre/post-training competency assessments.

Results

Independent samples t-tests indicated significant improvements in CSUQ, and website usability and content questionnaires responses from alpha- to beta-testing (all ps &lt; .05). Linear mixed-effects modeling revealed significant within-subject increases in knowledge acquisition (F(34.7) = 65.4, p &lt; 0.001; baseline = 69% correct, post-training = 92% correct) when collapsed across in-person and web-based groups. The interaction group by time interaction was non-significant (F(34.7) = 1.7, p = 0.204), indicating similar gains in knowledge (i.e., equivalence) between the in-person and the CBTIweb.org training formats.

Conclusion

Alpha and beta testers of CBTIweb.org reported high levels of satisfaction while also noting areas for improvement, which were used to update the site. Findings suggest the final CBTIweb.org product successfully trained clinicians compared to an in-person workshop, given knowledge acquisition improvements. CBTIweb.org is an efficient and effective training platform for clinicians to gain knowledge and competence in the most effective treatment for insomnia.

Support

W81XWH-17-1-0165

0483 Predictors of Cognitive Behavioral Therapy for Insomnia (CBT) Outcomes in Active Duty U.S. Army Personnel

Introduction

Cognitive behavioral therapy for insomnia (CBTi) is well established as the first-line treatment for the management of chronic insomnia. Identifying predictors of response to CBTi should enable the field to efficiently utilize resources to treat those who are likely to respond and to personalize treatment approaches to optimize outcomes for those who are less likely to respond to traditional CBTi. Although a range of studies have been conducted, no clear pattern of predictors of response to CBTi has emerged.

Methods

The purpose of this study was to examine the impact and relative importance of a comprehensive group of pretreatment predictors of insomnia outcomes in 99 active duty service members who received in-person CBTi in a randomized clinical trial.

Results

Results indicated that higher levels of baseline insomnia severity and total sleep time predicted greater improvements on the Insomnia Severity Index (ISI) following treatment. Higher depression symptoms and a history of head injury predicted a worse response to treatment (i.e., smaller improvements on the ISI).

Conclusion

Clinically meaningful improvements, as measured by the reliable change index (RCI), were found in 59% of the sample. Over and above baseline insomnia severity, only depressive symptoms predicted this outcome. Future studies should examine if modifications to CBTi based on these predictors of response can improve outcomes.

Support

This study was conducted with support from the U.S. Department of Defense through the U.S. Army Medical Research and Materiel Command, Congressionally Directed Medical Research Programs, Psychological Health and Traumatic Brain Injury Research Program award W81XWH-10-1-0828 (PI: Dr Taylor).

1073 Sleep Disorders Contribute To Anger In Service Members With Posttraumatic Stress Disorder

Introduction

The emotion of anger and behavioral acts of aggression can lead to severe negative consequences, including family violence, legal charges, and death. Anger can be a symptom of posttraumatic stress disorder (PTSD), particularly in service members. Service members report difficulties managing their anger and trouble with the subsequent results. Factors that differentiate service members with PTSD who have anger related problems from those who do not are still unknown. Impaired sleep is associated with negative mood states in the general population and may be a risk factor for anger in those with PTSD. This project examines how sleep disorders commonly diagnosed in service members (i.e., obstructive sleep apnea and insomnia) relate to PTSD and anger.

Methods

Ninety-three service members with comorbid PTSD, insomnia, and nightmares (mean age = 35.86 years, SD = 8.38, 27% female, 45% white) completed polysomnography and other measures as part of a clinical trial. A multiple regression model examined how total Apnea Hypopnea Index (AHI), AHI during REM sleep, insomnia (Insomnia Severity Index), age, and race related to PTSD symptoms (Clinical Administered PTSD Scale-5: CAPS-5). A second multiple regression model examined the same variables’ associations with anger (Dimensions of Anger Reactions-5; DAR-5).

Results

More than a third of the sample (37%) met criteria for OSA (AHI scores&gt;5) and 99% met criteria for insomnia (ISI&gt;10). Total AHI and REM AHI were not associated with CAPS-5 scores or ISI. Across OSA and PSG indices, only greater REM AHI (b=.07, p&lt;.05) and Insomnia (b=.43, p&lt;.05) were positively associated with DAR-5 anger scores. Total AHI was unrelated to anger.

Conclusion

Elevated REM AHI and insomnia were associated with greater anger in service members with PTSD. Current treatments for anger are only moderately effective. Assessing and treating comorbid sleep disorders may reduce anger and enhance successful PTSD treatment.

Support

Consortium to Alleviate PTSD (W81XWH-13-2-0065), DVA (I01CX001136-01), GDHS (W91YTZ-13-C-0015) for DVBIC.

Variables associated with reductions in insomnia severity among acutely suicidal patients receiving brief cognitive behavioral therapy for suicide prevention

INTRODUCTION

This study compared changes in sleep disturbance over time across brief cognitive behavioral therapy for suicide prevention and treatment as usual and examined the mechanisms that link sleep disturbance with several suicide risk factors.

METHOD

Active duty U.S. Army soldiers (N = 152) completed a randomized controlled trial to test the efficacy of brief cognitive behavioral therapy (n = 76) or treatment as usual (n = 76). Six assessments of insomnia symptoms, hopelessness, coping, and suicide beliefs were tracked over 24 months.

RESULTS

Brief cognitive behavioral therapy patients reported a significant decrease in sleep disturbance symptoms over time while treatment as usual patients did not. These improvements were initially observed during treatment and carried over through 12-months. Changes in sleep disturbance predicted changes in suicide risk. Longitudinal growth modeling was used to assess potential mechanisms of this effect. Results suggested that changes in cognitive flexibility, as defined by measures of hopelessness and suicide beliefs, predicted change in sleep disturbance symptoms. These relationships did not differ across treatment groups.

LIMITATIONS

The participants were active duty military personnel. Therefore, the results may not generalize to other patient populations. A greater number of assessment periods in closer proximity as well as additional measures of constructs of interest would have improved the internal validity of this study.

CONCLUSIONS

Brief cognitive behavioral therapy significantly reduces sleep disturbance and suicide risk. Changes in cognitive flexibility, in part, explain change in sleep disturbance across both treatments.

TIE: A Method to Electroporate Long DNA Templates into Preimplantation Embryos for CRISPR-Cas9 Gene Editing

Precise genome editing using CRISPR typically requires delivery of guide RNAs, Cas9 endonuclease, and DNA repair templates. Both microinjection and electroporation effectively deliver these components into mouse zygotes provided the DNA template is an oligonucleotide of only a few hundred base pairs. However, electroporation completely fails with longer double-stranded DNAs leaving microinjection as the only delivery option. Here, we overcome this limitation by first injecting all CRISPR components, including long plasmid-sized DNA templates, into the sub-zona pellucida space. There they are retained, supporting subsequent electroporation. We show that this simple and well-tolerated method achieves intracellular reagent concentrations sufficient to effect precise gene edits.

Paying people to lose weight: the effectiveness of financial incentives provided by health insurers for the prevention and management of overweight and obesity - a systematic review

Curbing the obesity epidemic is likely to require a suite of interventions targeting the obesogenic environment as well as individual behaviour. Evidence suggests that the effectiveness of behaviour modification programmes can be enhanced by financial incentives that immediately reward weight loss behaviour. This systematic review investigated the effectiveness of incentives with a focus on assessing the relative effectiveness of incentives that target different behaviours as well as factors of importance when implementing these programmes in real-world settings (health insurer settings). A narrative review of the academic and grey literature including a variety of study designs was undertaken. Twenty studies met inclusion criteria and were assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Results suggest that incentivizing weight loss is effective in the short term while the incentives are in place. There are various incentive designs, and although the relative effectiveness of each of these on weight loss is not clear, it appears that positive incentives increase the uptake into programmes and may reduce dropouts. As with other weight loss initiatives, there is a need to explore ways to maintain weight loss in the longer term - incentives for weight maintenance could play a role.

Neurocognitive predictors of treatment response to randomized treatment in adults with tic disorders

Tourette's disorder (TS) and chronic tic disorder (CTD) are neurodevelopmental disorders characterized by involuntary vocal and motor tics. Consequently, TS/CTD have been conceptualized as disorders of cognitive and motor inhibitory control. However, most neurocognitive studies have found comparable or superior inhibitory capacity among individuals with TS/CTD relative to healthy controls. These findings have led to the hypothesis that individuals with TS/CTD develop increased inhibitory control due to the constant need to inhibit tics. However, the role of cognitive control in TS/CTD is not yet understood, particularly in adults. To examine the role of inhibitory control in TS/CTD, the present study investigated this association by assessing the relationship between inhibitory control and treatment response in a large sample of adults with TS/CTD. As part of a large randomized trial comparing behavior therapy versus supportive psychotherapy for TS/CTD, a battery of tests, including tests of inhibitory control was administered to 122 adults with TS/CTD at baseline. We assessed the association between neuropsychological test performance and change in symptom severity, as well as compared the performance of treatment responders and non-responders as defined by the Clinical Global Impression Scale. Results indicated that change in symptoms, and treatment response were not associated with neuropsychological performance on tests of inhibitory control, intellectual ability, or motor function, regardless of type of treatment. The finding that significant change in symptom severity of TS/CTD patients is not associated with impairment or change in inhibitory control regardless of treatment type suggests that inhibitory control may not be a clinically relevant facet of these disorders in adults.

The common, autoimmunity-predisposing 620Arg > Trp variant of PTPN22 modulates macrophage function and morphology

The C1858T single nucleotide polymorphism (SNP) in PTPN22 (protein tyrosine phosphatase nonreceptor 22) leads to the 620 Arg to Trp polymorphism in its encoded human protein LYP. This allelic variant is associated with multiple autoimmune diseases, including type 1 diabetes (T1D), Crohn's disease, rheumatoid arthritis and systemic lupus erythematosus. However, the underlying mechanisms are poorly understood. To study how this polymorphism influences the immune system, we generated a mouse strain with a knock-in of the Trp allele, imitating the human disease-associated variant. We did not find significant difference between the polymorphic and the wild type mice on the proportion of total CD4 T cell, CD8 T cell, NK cell, memory T lymphocyte, macrophage, dendritic cells in both peripheral lymph nodes and spleen. However, macrophages from Trp/Trp mice showed altered morphology and enhanced function, including higher expression of MHCII and B7 molecules and increased phagocytic ability, which further leads to a higher T-cell activation by specific antigen. Our model shows no alteration in immune cell profile by the Trp allele, but brings up macrophages as an important player to consider in explaining the PTPN22 Trp allele effect on autoimmune disease risk.

Abstract P2-08-01: Results from a randomized placebo-controlled phase 2 trial evaluating exemestane ± enzalutamide in patients with hormone receptor–positive breast cancer

This abstract was withdrawn by the authors.

Abstract P5-08-28: Incidence of germline BRCA1- and BRCA2-mutated breast cancer in the US

Background: Breast cancer is the most common cancer and second leading cause of cancer death among women in the United States (US).1 Inherited mutations in germline breast cancer susceptibility gene 1 and 2 (gBRCAm) are associated with increased risk of developing cancers, including breast cancer.2 No published reports of gBRCAm incidence within an unselected US breast cancer population are available based on a comprehensive literature review (CLR). The main objective of this analysis is to estimate the incidence of gBRCAm breast cancer in the US.

Methods: For this analysis the Surveillance, Epidemiology, and End Results (SEER) Program 18 registries captured incidence of breast cancer by stage, age and gender.3 The size of the US population was based on United Nation's population projections and standardized to the 2010 population.4 Age-specific gBRCAm distribution and gBRCAm-specific hormonal subtype for estrogen-receptor and progesterone-receptor (ER/PR), and human epidermal growth factor receptor-2 (HER2) estimates were determined from a CLR.5-8 Tumor cells negative for ER/PR and HER2 are referred to as triple-negative breast cancer (TNBC).

Results: In 2016, it is projected that approximately 250,000 individuals will be diagnosed with invasive breast cancer (all genders). Median age range of the population with invasive breast cancer is 65-69 years and 99% are females. Majority (72%) of female invasive breast cancer cases are ER/PR+ whereas 11% of cases are TNBC. Corroborating with current publications, gBRCAm is estimated at 5% for individuals less than 50 years old and 1% among all ages. Median age range of the gBRCAm cohort is 40-44 years. After applying currently available gBRCAm specific literature parameters, the majority (55%) of gBRCAm diagnoses are TNBC.

Conclusion: In the US, patients with gBRCAm represent a small proportion (1%) of all breast cancer tissues evaluated. Majority of gBRCAm patients are diagnosed with TNBC (55%) and are younger (median age range 40-44 years) than overall breast cancer population. Age differences noticed in gBRCAm may have been due to disparity in genetic screening practices among breast cancer population in the US rather than a reflection of gBRCAm expressions. These estimates of gBRCAm incidence are driven by limited reports on an unselected population of breast cancer gBRCAm cohort; therefore sensitivity analysis is required to assess the robustness of these estimates.

1. American Cancer Society. Facts and Figures 2016.

2. Miki Y et al. Science. 1994;266:66-71.

3. Surveillance, Epidemiology, and End Results (SEER) Program (www.seer.cancer.gov) Research Data (1973-2013), National Cancer Institute, DCCPS, Surveillance Research Program, Surveillance Systems Branch, released April 2016, based on the November 2015 submission.

4. United Nations Population Division. World Population Prospects, the 2015 Revision. http://esa.un.org/unpd/wpp/.

5. van den Broek et al. Eur J Hum Genet. 2015;23:588-95.

6.Turkovic L et al. BMC Cancer. 2010;10:466.

7. Atchley DP et al. J Clin Oncol. 2008;26:4282-4321.

8. Spurdle AB et al. Breast Cancer Res. 2014;16:3419.

Citation Format: Kim R, Peterson A, Isherwood A, Uppal H, Barlev A. Incidence of germline BRCA1- and BRCA2-mutated breast cancer in the US [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-08-28.

Abstract OT2-01-13: A phase 3, open-label, randomized, 2-arm international study of the oral dual PARP inhibitor talazoparib in germline BRCA mutation subjects with locally advanced and/or metastatic breast cancer (EMBRACA)

Background: Cancer cells with deleterious mutations in breast cancer susceptibility genes 1 and 2 (BRCA1/2) are deficient in the DNA double-strand break repair mechanism, rendering them highly dependent on the single-strand break repair pathway, regulated by poly(ADP-ribose) polymerase (PARP). Inhibition of PARP results in synthetic lethality in cells with a BRCA1/2 mutation because of accumulation of irreparable DNA damage; PARP inhibitors have the potential to be selectively toxic for BRCA-mutated cells. In addition to catalytic inhibition, it has been shown that some PARP inhibitors induce PARP trapping at sites of DNA damage. The capacity to trap PARP-DNA complexes varies widely across different PARP inhibitors and is not correlated with PARP catalytic inhibition. Preclinical models have shown trapping PARP on DNA is more potent at inducing cancer cell death than enzymatic inhibition of PARP alone. Talazoparib is a dual-mechanism PARP inhibitor that both inhibits the PARP enzyme and effectively traps PARP on DNA, preventing DNA damage repair and resulting in cell death in BRCA1/2-mutated cells. In preclinical studies, talazoparib at nanomolar concentrations showed the highest efficiency at trapping PARP-DNA complexes relative to other PARP inhibitors. In a previous phase 1/2 clinical study, talazoparib as monotherapy (1 mg once daily) resulted in a 50% response rate and an 86% clinical benefit rate at 24 weeks in 14 patients with a germline BRCA1/2 mutation and advanced breast cancer (aBC).

Methods: This open-label, randomized, 2-arm, international phase 3 trial (EMBRACA)

compares the efficacy and safety of talazoparib with protocol-specific physician's choice (capecitabine, eribulin, gemcitabine or vinorelbine) in patients with aBC. The primary objective is progression-free survival by central imaging. Secondary objectives are objective response rate, overall survival, safety and pharmacokinetics of talazoparib. Exploratory objectives include health-related quality of life measurements and biomarker research in blood and tumor samples that may permit characterization of mechanisms involved in tumor sensitivity and resistance to talazoparib. Key patient eligibility criteria include aged ≥18 years with histologically/cytologically confirmed breast cancer; locally advanced and/or metastatic disease appropriate for systemic single-agent cytotoxic chemotherapy; deleterious or pathogenic germline BRCA1/2 mutations by central laboratory; ≤3 prior cytotoxic chemotherapy regimens for advanced disease (prior platinum is allowed provided patients did not relapse within 6 months in the adjuvant setting or did not progress on platinum therapy); prior treatment with a taxane and/or anthracycline unless medically contraindicated; and ECOG performance status ≤2. Patients (N=429) will be randomized 2:1 to receive either talazoparib capsules (1 mg/day, 21-day cycles) or physician's choice treatment. This trial is currently enrolling patients from the USA, Europe, Israel, Ukraine, Russia, Korea, Australia, Taiwan and Brazil (NCT01945775).

This study is funded by Medivation, Inc.

Citation Format: Litton J, Ettl J, Hurvitz SA, Mina LA, Rugo HS, Lee K-H, Yerushalmi R, Woodward N, Goncalves A, Moreno F, Roche H, Im Y-H, Martin M, Bhattacharya S, Peterson A, Hannah A, Eiermann W, Blum J. A phase 3, open-label, randomized, 2-arm international study of the oral dual PARP inhibitor talazoparib in germline BRCA mutation subjects with locally advanced and/or metastatic breast cancer (EMBRACA) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-01-13.

Abstract P5-06-01: Talazoparib antitumor effects in BRCA-deficient breast cancer models

Background: BRCA1 and BRCA2 functions are essential for the DNA double-strand break repair process in living cells with DNA damages. Therefore, germline pathogenic mutations in BRCA1/2 increases the risk of developing cancer.1, 2Poly(ADP-ribose) polymerase (PARP) enzymes are proteins responsible for DNA single-strand break repair. Persistent inhibition of PARP-dependent DNA repair in BRCA-deficient breast cancer cells leads to increased DNA damages resulting in cancer cell death. Talazoparib is a novel and potent, orally bioavailable, small molecule PARP inhibitor. Talazoparib's dual mechanism of action inhibits PARP enzyme activity and effectively traps PARP on DNA, preventing DNA repair, resulting in cell death in BRCA1/2-mutated cells.3 In tissue culture studies, talazoparib is more potent at trapping PARP on DNA to induce cancer cell death compared to other PARP inhibitors.4 Previous studies have demonstrated talazoparib inhibited growth in tumors harboring BRCA1/2 gene mutations. In the MX-1 breast cancer model with BRCA1-deficiency, talazoparib inhibited cell growth in vitro and induced regression in solid mouse xenografts.5 Here, we demonstrate antitumor effects of talazoparib monotherapy in a panel of breast cancer cells and patient-derived breast cancer models with pathologic BRCA1/2 mutations.

Method: A panel of human breast cancer cell lines was treated with talazoparib to determine its cytotoxic effects. BRCA1/2 mutations status was correlated to talazoparib cytotoxic effects. At the molecular level, BRCA1/2-mutant and wild type breast cancer cell lines were treated with dose-escalating talazoparib to also assess the relationship between PARP-DNA trapping complex formation and treatment response. Patient-derived breast cancer xenograft models were used to assess talazoparib monotherapy on tumorigenesis. Immunohistochemistry assays were performed to determine Ki-67, gH2AX and caspase 3 marker expression following talazoparib treatment.

Results: Cytotoxicity was observed in 50% (7/14) cell lines at IC50 values that are achieved in the clinic. BRCA1/2 alterations were detected in 21.4% (3/14) of cell lines sensitive to talazoparib treatment. In 14 patient-derived breast cancer xenograft models selected for this study, 57.1% (8/14) responded to talazoparib monotherapy. Of these, 35.7% had mutations in the BRCA1 (28.6%) and BRCA2 (7.1%) genes. Stable disease was observed in 14.2% (2/14). One stable model had BRCA1 mutations. Tumor regression was observed in 42.8% (6/14) of the models treated with talazoparib monotherapy. Importantly, 66.7% (4/6) of patient-derived breast cancer models that regressed on talazoparib monotherapy had mutations in BRCA1/2 genes.

Conclusions: Cytotoxicity was observed with talazoparib monotherapy in breast cancer cell lines and in patient-derived xenograft tumor models harboring BRCA1 or BRCA2 mutations. Our data demonstrate therapeutic potential of talazoparib monotherapy in breast cancer associated with pathologic BRCA1/2 mutations.

1.Couch FJ et al. J Clin Oncol. 2015;33:304-11.

2. Petrucelli N et al. Genet Med. 2010;12:245-59.

3. Wang B et al. J Med Chem. 2016;59:335-57.

4. Murai J et al. Mol Cancer Ther. 2014;13:433-43.

5. Shen Y et al. Clin Cancer Res. 2013;19:5003-15.

Citation Format: Phan VT, Protter AA, Peterson A, Uppal H. Talazoparib antitumor effects in BRCA-deficient breast cancer models [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-06-01.

Abstract P4-22-08: A single-arm phase 2 study to assess clinical activity, efficacy and safety of enzalutamide with trastuzumab in HER2+ AR+ metastatic or locally advanced breast cancer

Background:Androgen receptor (AR) expression has been observed in up to 77% of human epidermal growth factor receptor 2–positive (HER2+) breast cancer (BC).References:1 Enzalutamide (ENZA) is a potent AR inhibitor approved for patients (pts) with metastatic castration-resistant prostate cancer. In vitro, ENZA enhances antitumor activity of trastuzumab in HER2+ AR+ cell lines and inhibits proliferation in trastuzumab-resistant HER2+ cell lines.2

Methods:Pts with metastatic or locally advanced BC that was HER2+ AR+ by local or central laboratory assessment were enrolled in a single-arm, Simon 2-stage phase 2 study (NCT02091960). Key eligibility criteria included availability of a tissue sample, presence of measurable or evaluable disease per RECIST v1.1, progression on prior trastuzumab and ≥1 prior line of anti-HER2 therapy as the most recent regimen. Brain metastases and history of seizure were exclusionary. Evaluable pts were those with centrally confirmed nuclear AR expression≥10% by immunohistochemistry who received ≥1 dose of ENZA and had ≥1 postbaseline tumor assessment. Pts received ENZA 160 mg daily and trastuzumab 6 mg/kg every 21 days until disease progression. The primary objective was clinical benefit rate at 24 weeks (CBR24), defined as complete or partial response (CR or PR) or stable disease (SD) for ≥24 weeks in evaluable pts. Additional endpoints included safety and progression-free survival (PFS). CBR24 in ≥3 of 21 evaluable pts was required to continue to stage 2 and enrollment of up to 66 evaluable pts total. This design yields a 1-sided type 1 error of 5% and 90% power when the true response is 25%.

Results:Here we present results from stage 1 (data cutoff: Mar 23, 2016), with 22 evaluable pts enrolled (pts 21 and 22 enrolled simultaneously); 18 had received ≥4 prior lines of therapy. Median duration of ENZA exposure was 144 days (range, 22-495), mean number of complete trastuzumab infusions was 6.5. CBR24 was 27.3% (95% confidence interval [CI], 10.7-50.2); 2 confirmed PR and 4 SD ≥24 weeks. Median PFS was 108 days (95% CI, 56-144). All pts experienced ≥1 adverse event (AE) any grade; 5 pts experienced AEs grade ≥3. ENZA-related AEs were reported in 16 pts (72.7%), the most common (in ≥10% of pts) were fatigue (22.7%), nausea (18.2%), diarrhea (13.6%) and arthralgia (13.6%). Serious AEs were reported in 6 pts (27.3%; 2 each of infection and back pain, 1 each of abdominal pain, nausea, vomiting, pyrexia, urinary retention and pulmonary edema). Two pts discontinued due to drug-related AEs: 1 related to both drugs, 1 related to trastuzumab. One on-study death from pulmonary edema was reported, which was not considered related to either drug.

Conclusion:Stage 1 met its primary objective. No new safety signals were identified, and the safety profile in this study was similar to that in men with prostate cancer and women with other BC subtypes treated with ENZA. These results are encouraging for a heavily pretreated population with advanced HER2+ AR+ BC. Enrollment in stage 2 continues with the combination of ENZA and trastuzumab.

1. Micello D et al. Virchows Arch. 2010;457:467-476.

2. Richer J. Presented at AACR Advances in Breast Cancer, San Diego, CA, 2013.

Citation Format: Krop I, Cortes J, Miller K, Huizing MT, Provencher L, Gianni L, Chan S, Trudeau M, Steinberg J, Sugg J, Liosatos M, Paton VE, Peterson A, Wardley A. A single-arm phase 2 study to assess clinical activity, efficacy and safety of enzalutamide with trastuzumab in HER2+ AR+ metastatic or locally advanced breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-22-08.

CRISPR: express delivery to any DNA address

The sudden emergence and worldwide adoption of CRISPR gene-editing technology confronts humanity with unprecedented opportunities and choices. CRISPR's transformative impact on our future understanding of biology, along with its potential to unleash control over the most fundamental of biological processes, is predictable by already achieved applications. Although its origin, composition, and function were revealed only recently, close to 3000 CRISPR-based publications have appeared including insightful and diversely focused reviews referenced here. Adding further to scientific and public awareness, a recent symposium addressed the ethical implications of interfacing CRISPR technology and human biology. However, the magnitude of CRISPR's rapidly emerging power mandates its broadest assessment. Only with the participation of a diverse and informed community can the most effective and humanity-positive CRISPR applications be defined. This brief review is aimed at those with little previous exposure to the CRISPR revolution. The molecules that constitute CRISPR's core components and their functional organization are described along with how the mechanism has been harnessed to edit genome structure and modulate gene function. Additionally, a glimpse into CRISPR's potential to unleash genetic changes with far-reaching consequences is presented.

Centrality and Transverse Momentum Dependence of Elliptic Flow of Multistrange Hadrons and ϕ Meson in Au+Au Collisions at √[sNN]=200 GeV

We present high precision measurements of elliptic flow near midrapidity (|y|<1.0) for multistrange hadrons and ϕ meson as a function of centrality and transverse momentum in Au+Au collisions at center of mass energy √[sNN]=200  GeV. We observe that the transverse momentum dependence of ϕ and Ω v2 is similar to that of π and p, respectively, which may indicate that the heavier strange quark flows as strongly as the lighter up and down quarks. This observation constitutes a clear piece of evidence for the development of partonic collectivity in heavy-ion collisions at the top RHIC energy. Number of constituent quark scaling is found to hold within statistical uncertainty for both 0%-30% and 30%-80% collision centrality. There is an indication of the breakdown of previously observed mass ordering between ϕ and proton v2 at low transverse momentum in the 0%-30% centrality range, possibly indicating late hadronic interactions affecting the proton v2.

Observation of Transverse Spin-Dependent Azimuthal Correlations of Charged Pion Pairs in p^{↑}+p at sqrt[s]=200 GeV

We report the observation of transverse polarization-dependent azimuthal correlations in charged pion pair production with the STAR experiment in p^{↑}+p collisions at RHIC. These correlations directly probe quark transversity distributions. We measure signals in excess of 5 standard deviations at high transverse momenta, at high pseudorapidities η>0.5, and for pair masses around the mass of the ρ meson. This is the first direct transversity measurement in p+p collisions.

Azimuthal Anisotropy in U+U and Au+Au Collisions at RHIC

Collisions between prolate uranium nuclei are used to study how particle production and azimuthal anisotropies depend on initial geometry in heavy-ion collisions. We report the two- and four-particle cumulants, v_{2}{2} and v_{2}{4}, for charged hadrons from U+U collisions at sqrt[s_{NN}]=193  GeV and Au+Au collisions at sqrt[s_{NN}]=200  GeV. Nearly fully overlapping collisions are selected based on the energy deposited by spectators in zero degree calorimeters (ZDCs). Within this sample, the observed dependence of v_{2}{2} on multiplicity demonstrates that ZDC information combined with multiplicity can preferentially select different overlap configurations in U+U collisions. We also show that v_{2} vs multiplicity can be better described by models, such as gluon saturation or quark participant models, that eliminate the dependence of the multiplicity on the number of binary nucleon-nucleon collisions.

Psychometric Properties of a Self-Report Instrument for the Assessment of Tic Severity in Adults With Tic Disorders

The gold-standard measure of tic severity in tic disorders (TD), the Yale Global Tic Severity Scale (YGTSS), is a semistructured clinician-administered interview that can be time consuming and requires highly trained interviewers. Moreover, the YGTSS does not provide information regarding frequency and intensity of specific tics because all motor and all vocal tics are rated as a group. The aim of the present study is to describe and test the Adult Tic Questionnaire (ATQ), a measure for the assessment of tic severity in adults, and to report its preliminary psychometric properties. The ATQ is a brief self-report questionnaire that provides information regarding frequency, intensity, and severity of 27 specific tics. In addition, the ATQ produces total frequency, intensity, and severity scores for vocal and motor tics, as well as a global total tic severity score. Results showed that the ATQ demonstrated very good internal consistency and temporal stability. The total, vocal, and motor tic severity scales of the ATQ showed strong correlation with corresponding subscales of the YGTSS, indicating strong convergent validity. Weak correlations with measures of severity of obsessive-compulsive disorder and attention deficit/hyperactivity disorder, indicated strong discriminant validity. The ATQ, a promising measure for the assessment of tic severity in adults with TD, may be a valuable supplement to the current recommended assessment battery for TD. Furthermore, the ATQ enables clinicians and researchers to track changes in the frequency and intensity of specific tics, which is important given their complex and dynamic nature.

Walleye Sander vitreus (Mitchill) are relatively resistant to experimental infection with VHSV IVb and extant walleye strains vary in susceptibility

Compared to fathead minnow, walleye demonstrate low susceptibility to experimental infection with VHSV IVb, regardless of route of exposure or water temperature at time of infection. In triplicate and duplicate groups, walleye were intraperitoneally (i.p.) injected (10² -10⁸  pfu/fish) or waterborne-exposed (w; 1.4 × 10⁷  pfu mL^-1 ) with VHSV IVb. High cumulative mortality (64-100%) and severe gross lesions associated with VHSV IVb infection were evident only in fish i.p. injected with 10⁸  pfu at 12 °C. These fish had multifocal necrosis of several tissues including the gill and heart. There was no difference in mortality between walleye infected (w or i.p.) at 12 °C (spring stocking) compared with a declining temperature profile from 18 to 12 °C (fall stocking). There were significant differences (P < 0.05) in mortality between four extant walleye strains following i.p. infection, indicating that the choice of walleye strain for stocking might be an important consideration. Viral antigen was found in both i.p. and w-exposed walleye using immunohistochemistry, mostly within the gill and skin of w-exposed fish and most prominently in dermal fibrocytes. VHSV IVb was detected in multiple tissues from 6 to 21 days post-infection using reverse transcriptase quantitative polymerase chain reaction (RT-qPCR).

Relationships between Premonitory Urge and Anxiety in Youth with Chronic Tic Disorders

Tourette's Disorder and other chronic tic disorders are common neurodevelopmental conditions. One characteristic of tic disorders is the premonitory urge, an aversive or unpleasant sensory phenomenon that may precede tics. Initial examination of premonitory urge in pediatric tic disorders suggests that awareness and experience of sensations preceding tics may be related to anxiety and OCD. However, it may be possible that specific anxiety-related symptoms, such as anxious physiologic arousal, are particularly relevant to the experience of premonitory urge. The current study examines relationships between tic-related premonitory urge and anxiety-related symptom clusters in treatment-seeking youths with a primary diagnoses of Tourette's or other chronic tic disorder. The sample consisted of 124 youth, ages 9 to 17, who participated in the multi-site Comprehensive Behavioral Intervention for Tics randomized controlled trial (CBIT; Piacentini et al., 2010). Specific anxiety-related subtypes, including generalized worry, separation, social, and panic/somatic symptoms, as well as severity of obsessions and compulsions, were assessed as potential correlates of premonitory urge. Findings indicated that age, global tic-related impairment, and specific panic/somatic symptoms accounted for a substantial proportion of variance in youth report of premonitory urge. These findings provide information about the characteristics of premonitory urge in pediatric tic disorders, and have implications for the treatment of pediatric tic syndromes.

Nonsuicidal self-injury as a prospective predictor of suicide attempts in a clinical sample of military personnel

BACKGROUND

Nonsuicidal self-injury (NSSI) is a risk factor for suicide attempts, but it has received little attention in military populations, for whom suicide rates have doubled over the past decade. In the current study, the relationship of NSSI with future suicide attempts was prospectively examined in a sample of active duty Soldiers receiving outpatient psychiatric treatment for suicide ideation and/or a recent suicide attempt.

METHODS

Data were collected as part of a two-year prospective study of 152 active duty Soldiers (87% male, 71% Caucasian, mean age=27.53) in outpatient mental health care who reported current suicide ideation and/or a suicide attempt during the month preceding intake. Suicide attempts and NSSI were assessed using the Suicide Attempt Self Injury Interview.

RESULTS

Forty percent of Soldiers with a history of nonsuicidal self-injury and 25% of Soldiers with a history of suicide attempt made a suicide attempt during the 2-year follow-up. Soldiers with a history of nonsuicidal self-injury were more than twice as likely to make a subsequent suicide attempt (hazard ratio [HR]=2.25, P=.045). Soldiers with a history of suicide attempt were no more likely to make a subsequent suicide attempt than Soldiers without a previous suicide attempt (HR=.88, P=.787). Thirty percent of Soldiers with a history of suicide attempt had also engaged in nonsuicidal self-injury. Forty-two percent of Soldiers with histories of both nonsuicidal self-injury and suicide attempt made a subsequent suicide attempt and were more likely to make a suicide attempt during follow-up than Soldiers with a history of suicide attempt only. Number of NSSI episodes, but not number of suicide attempts, was significantly associated with increased risk for future suicide attempt. Results were unchanged when adjusting for baseline symptom severity.

LIMITATIONS

Predominantly male, active duty Army sample.

CONCLUSIONS

Among Soldiers in outpatient mental health care, a history of NSSI is a stronger predictor of future suicide attempts than a history of suicide attempts. Soldiers with a history of both NSSI and suicide attempt are at especially increased risk.

Beam energy dependence of moments of the net-charge multiplicity distributions in Au+Au collisions at RHIC

We report the first measurements of the moments--mean (M), variance (σ(2)), skewness (S), and kurtosis (κ)--of the net-charge multiplicity distributions at midrapidity in Au+Au collisions at seven energies, ranging from sqrt[sNN]=7.7 to 200 GeV, as a part of the Beam Energy Scan program at RHIC. The moments are related to the thermodynamic susceptibilities of net charge, and are sensitive to the location of the QCD critical point. We compare the products of the moments, σ(2)/M, Sσ, and κσ(2), with the expectations from Poisson and negative binomial distributions (NBDs). The Sσ values deviate from the Poisson baseline and are close to the NBD baseline, while the κσ(2) values tend to lie between the two. Within the present uncertainties, our data do not show nonmonotonic behavior as a function of collision energy. These measurements provide a valuable tool to extract the freeze-out parameters in heavy-ion collisions by comparing with theoretical models.

Energy dependence of moments of net-proton multiplicity distributions at RHIC

We report the beam energy (sqrt[sNN]=7.7-200  GeV) and collision centrality dependence of the mean (M), standard deviation (σ), skewness (S), and kurtosis (κ) of the net-proton multiplicity distributions in Au+Au collisions. The measurements are carried out by the STAR experiment at midrapidity (|y|<0.5) and within the transverse momentum range 0.4<pT<0.8  GeV/c in the first phase of the Beam Energy Scan program at the Relativistic Heavy Ion Collider. These measurements are important for understanding the quantum chromodynamic phase diagram. The products of the moments, Sσ and κσ2, are sensitive to the correlation length of the hot and dense medium created in the collisions and are related to the ratios of baryon number susceptibilities of corresponding orders. The products of moments are found to have values significantly below the Skellam expectation and close to expectations based on independent proton and antiproton production. The measurements are compared to a transport model calculation to understand the effect of acceptance and baryon number conservation and also to a hadron resonance gas model.