Biomarkers of systemic inflammation predict survival with first-line immune checkpoint inhibitors in non-small-cell lung cancer

INTRODUCTION

Pembrolizumab is an established first-line option for patients with advanced non-small-cell lung cancer (NSCLC) expressing programmed death-ligand 1 ≥50%. Durable responses are seen in a subset of patients; however, many derive little clinical benefit. Biomarkers of the systemic inflammatory response predict survival in NSCLC. We evaluated their prognostic significance in patients receiving first-line pembrolizumab for advanced NSCLC.

METHODS

Patients treated with first-line pembrolizumab for advanced NSCLC with programmed death-ligand 1 expression ≥50% at two regional Scottish cancer centres were identified. Pretreatment inflammatory biomarkers (white cell count, neutrophil count, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, albumin, prognostic nutritional index) were recorded. The relationship between these and progression-free survival (PFS) and overall survival (OS) were examined.

RESULTS

Data were available for 219 patients. On multivariate analysis, albumin and neutrophil count were independently associated with PFS (P < 0.001, P = 0.002, respectively) and OS (both P < 0.001). A simple score combining these biomarkers was explored. The Scottish Inflammatory Prognostic Score (SIPS) assigned 1 point each for albumin <35 g/l and neutrophil count >7.5 × 10⁹/l to give a three-tier categorical score. SIPS predicted PFS [hazard ratio 2.06, 95% confidence interval (CI) 1.68-2.52 (P < 0.001)] and OS [hazard ratio 2.33, 95% CI 1.86-2.92 (P < 0.001)]. It stratified PFS from 2.5 (SIPS2), to 8.7 (SIPS1) to 17.9 months (SIPS0) (P < 0.001) and OS from 5.1 (SIPS2), to 12.4 (SIPS1) to 28.7 months (SIPS0) (P < 0.001). The relative risk of death before 6 months was 2.96 (95% CI 1.98-4.42) in patients with SIPS2 compared with those with SIPS0-1 (P < 0.001).

CONCLUSIONS

SIPS, a simple score combining albumin and neutrophil count, predicts survival in patients with NSCLC receiving first-line pembrolizumab. Unlike many proposed prognostic scores, SIPS uses only routinely collected pretreatment test results and provides a categorical score. It stratifies survival across clinically meaningful time periods that may assist clinicians and patients with treatment decisions. We advocate validation of the prognostic utility of SIPS in this and other immune checkpoint inhibitor treatment settings.

Social determinants of health during the COVID-19 pandemic: a systematic review

Introduction

The emergence of COVID-19 has created global transmission. While effective at reducing the spread, public health measures implemented may impact individuals differently leaving them susceptible to the detrimental effects on their health and wellbeing. Therefore this review aims to synthesise the best available evidence on the relationship between the social determinants of health and health outcomes among adults during the COVID-19 pandemic.

Methods

A three-step search strategy was used to find both published and unpublished papers. The databases searched included: MEDLINE, CINAHL, EMBASE, and Google Scholar. Following the search, all identified citations were uploaded into Endnote X9, with duplicates removed. Methodological quality of eligible papers was assessed independently by two reviewers, with meta-synthesis conducted in accordance with JBI methodology.

Results

Fifteen papers were included. Three synthesized conclusions were established a) Vulnerable populations groups, particularly those from a racial minority and those with low incomes, are more susceptible and have been disproportionately affected by COVID-19 including mortality; b) Gender inequalities and family violence have been exacerbated by COVID-19, leading to diminished wellbeing among women; and c) COVID-19 is exacerbating existing social determinants of health through loss of employment/income, disparities in social class leading to lack of access to healthcare, housing instability, homelessness and difficulties in social distancing.

Conclusions

Vulnerable population groups have been disproportionately impacted by COVID-19, including health outcomes such as hospitalisations and mortality. The COVID-19 pandemic has highlighted the need for action on health inequalities and the social determinants of health. Reflection on social and health policies implemented are necessary to ensure that the COVID-19 pandemic does not exacerbate health inequalities into the future.

Key messages

Vulnerable populations including racial minority groups and low income earners have been disproportionately impacted by COVID-19.

Action on social determinants of health is required to ensure COVID-19 does not exacerbate health inequalities into the future.

Life during a pandemic in Australia: wellbeing and social determinants of health

Background

The COVID-19 pandemic has had effects on populations worldwide. The social determinants of health affect an individual's capacity to cope during a crisis which could potentially impact on their wellbeing. The aim of this study was to examine the relationship between wellbeing and the social determinants of health among Australian adults during the COVID-19 pandemic.

Methods

A cross-sectional study of adults residing in Australia was conducted using SurveyMonkey (an online survey) between August - October 2020. Participants were recruited via social media. Wellbeing was measured using the 10-item Multicultural Quality of Life Index and social determinants of health were measured using validated tools and investigator developed questions. Data were analysed using SPSS version 25. Inferential statistics, including independent t-test and one-way ANOVA were undertaken. Multiple regression analysis was used to investigate the predictors of wellbeing.

Results

In total, 1211 responses were received. Females accounted for 80.7% of the responses, men 16.7% and transgender/non-binary 2.6%. The mean age of the respondents was 43 years (SD 14.5). The mean score for total wellbeing was 62.58 (SD 21.22). Housing insecurity (p = 0.000), food insecurity (p = 0.000, social support (p = 0.000) and access to health care (p = 0.000) were all predictors of poor total wellbeing. Being a male (p = .0380) was the only predictor of higher wellbeing.

Conclusions

This study demonstrates that adults in Australia who had poor social support, had difficultly accessing health care, had insecure housing and food insecurity had significantly poorer wellbeing during the COVID-19 pandemic. This study exposes the social determinants of health that are responsible for health and social inequalities. It shows that the COVID-19 pandemic has exacerbated the social vulnerabilities and highlights the need take action on the social determinants of health and inequalities.

Key messages

The COVID-19 pandemic has further exposed the longstanding health and social inequalities that exist in Australia.

Action on social determinants of health is required in a post COVID-19 world to rebuild social protection and safeguard populations from any future public health emergencies.

Determination of the experimental extinction coefficient of therapeutic proteins using the Edelhoch method

The objective of this study was to determine how the theoretical values of the extinction coefficient (EC) compares to the experimentally determined extinction coefficient for a large set of biotherapeutic proteins measured by the Edelhoch method. We have performed extensive analysis based on over 176 observations covering 19 different types of molecules from different structural classes covering mAbs, bispecific antibodies, fusion proteins and BiTE molecules. Precision was measured by assessing the repeatability of the measurements for each molecule and determining the relative standard deviation (%RSD). The maximum RSD observed for any given molecule was 1.7% with an average RSD of 0.9%. Deviation from the theoretical extinction coefficient was determined by calculating the experimental bias first, which is the difference between the mean experimental extinction coefficient and the theoretical extinction coefficient. The percent bias (%bias) was then calculated as (bias ÷ theoretical EC) × 100. The maximum %bias observed for any given molecule was 5.3% with an average %bias of 2.6%. Our results indicate that the Edelhoch method is highly reliable with significant improvement in execution efficiency with reduction in cost, time and improvements in safety when compared to the commonly used methods such as amino acid analysis (AAA) technique.

Is it or is it not? Lessons learned from a case of suspected vaccine strain measles

Background

Measles continues to be a threat to Australia. While post eradication risks are low, imported measles cases from overseas travellers who are non-immune can cause small outbreaks. This case report discusses the challenge of identifying wild-type measles in an individual who was recently vaccinated with measles - containing vaccine (MCV).

Methods

A positive polymerase chain reaction (PCR) result for measles for an adult who had recently received a measles -containing vaccine was notified. Investigation revealed no known epidemiological link, recent overseas travel or contact with recent measles cases during the incubation period.

Results

The results of the initial sequencing to distinguish between wild-type and vaccine-strain measles were inconclusive. A decision was made to re-run the genotyping, collect additional specimens, and quarantine the case until a definitive result was obtained. Sequencing and genotyping revealed that this indeed was a wild-type measles strain.

Conclusions

Changing epidemiology of measles means distinguishing between wild-type and vaccine-strain measles has become a new challenge. The reflection of the public health management of this case has provided is a valuable teaching tool for public health professionals globally, particularly in low incidence measles countries.

Key messages

The lack of an epidemiological link can create confusion for public health staff when investigating possible measles cases. Changes in the epidemiology of measles means distinguishing between wild type and vaccine strain measles is a challenge.

Perceptions of Indigenous Australians towards cardiovascular primary prevention programs

Background

Indigenous Australians have disproportionately poorer health outcomes than their non-Indigenous counterparts. Preventable chronic diseases, such as cardiovascular disease, are primary factors that contribute to their lower life expectancy. Health risk behaviors such as smoking, physical inactivity, poor nutrition and obesity largely contribute to the enduring health divide. Therefore, the aim of this qualitative review was to synthesize the best available evidence on the perceptions of Indigenous Australians towards cardiovascular primary prevention programs.

Methods

A search using MEDLINE, CINAHL, EMBASE, Google Scholar, MedNar, ProQuest and Index to Theses for published and unpublished studies was conducted in January 2020. The methodological quality of the included studies was assessed by two reviewers using the Joanna Briggs Institute (JBI) critical appraisal tool. Meta-aggregation was conducted in accordance with JBI methodology.

Results

Eleven studies involving 249 participants were included. Three synthesized findings were developed 1) External factors can affect participants' experiences of prevention programs. Support from family motivates participation and behavioral change. Support from health professionals that is free from judgment facilitates participation; 2) The complexities of an individual's life influence Indigenous Australian's experiences and participation in prevention programs and health risk behavioral change; 3) A personal desire to change behaviors and participate in prevention programs requires development of knowledge on healthy lifestyles, creation of new social norms and overcoming internal struggles.

Conclusions

Indigenous Australians participation in primary prevention for cardiovascular risk factors and adoption of a healthy lifestyle are influenced by social support, social determinants and personal desire. Future programs need to tackle structural drivers and create a supportive environment to assist in behavior change.

Key messages

Social determinants affect Indigenous Australians experiences and participation in prevention programs for behaviour change. Prevention programs must create a supportive environment with the inclusion of family.

Nano differential scanning fluorimetry for comparability studies of therapeutic proteins

Differential scanning calorimetry (DSC) has been extensively used in the biopharmaceutical industry to characterize protein thermal stability and domain folding integrity. Recently, nano differential scanning fluorimetry (nanoDSF) has emerged as a powerful tool for thermal stability analysis and studies of protein domain unfolding. Due to increased interests in the qualification of characterization methods, we are in this study presenting the qualification results for the comparability studies of thermal stability analysis using nanoDSF. The results show that nanoDSF is able to detect thermal transition signals for mAbs, BiTE® molecules, and cytokines at a wide concentration range with high precision, clearly indicating that nanoDSF is suitable for characterization including comparability studies of therapeutic proteins. Compared to the current recognized industry standard DSC, the nanoDSF method enables thermal stability analysis over a much wider concentration range, consumes considerably less materials, and provides significantly higher throughput.

A Comparison Between Emerging and Current Biophysical Methods for the Assessment of Higher-Order Structure of Biopharmaceuticals

The higher-order structure (HOS) of protein therapeutics is a critical quality attribute directly related to their function. Traditionally, the HOS of protein therapeutics has been characterized by methods with low to medium structural resolution such as Fourier-transform infrared (FTIR), circular dichroism (CD), and intrinsic fluorescence spectroscopy, and differential scanning calorimetry (DSC). Recently, high-resolution nuclear magnetic resonance (NMR) methods have emerged as powerful tools for HOS characterization. NMR is a multi-attribute method with unique capabilities to provide information about all the structural levels of proteins in solution. We have in this study compared 1 D ¹H Profile NMR with the established biophysical methods for HOS assessments using a set of blended samples of the monoclonal antibodies belonging to the subclasses IgG1 and IgG2. The study shows that Profile NMR can distinguish between most sample combinations (93%), DSC can differentiate 61% of the sample combinations, and near-ultraviolet CD spectroscopy can differentiate 52% of the sample combinations, whereas no significant distinction could be made between any samples using FTIR or intrinsic fluorescence. Our data therefore show that NMR has superior ability to address differences in HOS, a feature that could be directly applicable in comparability and similarity assessments.

Chitayat syndrome: hyperphalangism, characteristic facies, hallux valgus and bronchomalacia results from a recurrent c.266A>G p.(Tyr89Cys) variant in the ERF gene

BACKGROUND

In 1993, Chitayat et al., reported a newborn with hyperphalangism, facial anomalies, and bronchomalacia. We identified three additional families with similar findings. Features include bilateral accessory phalanx resulting in shortened index fingers; hallux valgus; distinctive face; respiratory compromise.

OBJECTIVES

To identify the genetic aetiology of Chitayat syndrome and identify a unifying cause for this specific form of hyperphalangism.

METHODS

Through ongoing collaboration, we had collected patients with strikingly-similar phenotype. Trio-based exome sequencing was first performed in Patient 2 through Deciphering Developmental Disorders study. Proband-only exome sequencing had previously been independently performed in Patient 4. Following identification of a candidate gene variant in Patient 2, the same variant was subsequently confirmed from exome data in Patient 4. Sanger sequencing was used to validate this variant in Patients 1, 3; confirm paternal inheritance in Patient 5.

RESULTS

A recurrent, novel variant NM_006494.2:c.266A>G p.(Tyr89Cys) in ERF was identified in five affected individuals: de novo (patient 1, 2 and 3) and inherited from an affected father (patient 4 and 5). p.Tyr89Cys is an aromatic polar neutral to polar neutral amino acid substitution, at a highly conserved position and lies within the functionally important ETS-domain of the protein. The recurrent ERF c.266A>C p.(Tyr89Cys) variant causes Chitayat syndrome.

DISCUSSION

ERF variants have previously been associated with complex craniosynostosis. In contrast, none of the patients with the c.266A>G p.(Tyr89Cys) variant have craniosynostosis.

CONCLUSIONS

We report the molecular aetiology of Chitayat syndrome and discuss potential mechanisms for this distinctive phenotype associated with the p.Tyr89Cys substitution in ERF.

Cytomegalovirus Infection in Kidney Transplant Recipients: Evolution of Approach Through Three Eras

Cytomegalovirus (CMV) prophylaxis is recommended for high-risk patients, while preemptive therapy is considered acceptable for patients at moderate/low risk. After reviewing kidney transplant patients from 1992-1995 and 1996-1999, we decided to replace prophylaxis by preemptive therapy. Herein we have presented our data. From 1996-1999 we treated 129 patients with ganciclovir prophylaxis for 3 months if D+/R- or if they received depleting antibodies. The incidence of CMV was 13.2% versus 3.7% in the 1992-1995 cohort. The increase was associated with mycophenolate mofetil (MMF) use (P = .002). Forty-two percent of the D+/R- developed an infection with 89% of bouts occurring in the first month after cessation of prophylaxis. From 2002-2004, we never gave prophylaxis to 129 patients except when they received thymoglobulin. High-risk D+/R- patients were monitored by polymerase chain reaction (PCR) CMV for 3 months. The incidence of CMV was 17.1% with 54% of the D+/R- developing CMV. CMV infection occurred mostly during the first trimester posttransplantation. Creatinine at 1 year posttransplantation was worse in the presence of CMV infection (154.3 mumol/L-1.75 mg % versus 130.2 mumol/L-1.47 mg %, P = .03). Time to cure CMV infection was longer when MMF was discontinued: 36.7 days versus 69.9 days (P = .026). Our results indicated that CMV incidence is increasing: 3.7% (1992-1995) --> 13.2% (1996-1999) -->17.1% (2002-2004) and that it impairs 1 year graft function. Recovery was faster among patients still receiving MMF compared with those discontinuing MMF. Although MMF inhibits synthesis of anti-CMV IgM, it increases the anti-herpes virus effect of ganciclovir and may protect against chronic allograft nephropathy. Based on our experience, we plan to reintroduce prophylaxis in high-risk patients and to continue MMF when treating CMV infection.

Microextraction of drugs

This review will attempt to provide an overview as well as a theoretical and practical understanding of the use of microextraction technologies for drug analysis. The majority of the published reports to date focus on the use of fibre solid-phase microextraction and so the review is significantly focused on this technology. Other areas of microextraction such as single drop and solvent film microextraction are also described. Where there are insufficient examples in the literature to illustrate important concepts, examples of non-drug analyses are presented. The review is intended for readers new to the field of microextraction or its use in drug extraction, but also provides an overview of the most recent advances in the field which may be of interest to more experienced users. Particular emphasis is placed on the effect various sample matrices have on extraction characteristics.

Automated in-tube solid-phase microextraction coupled with liquid chromatography-electrospray ionization mass spectrometry for the determination of selected benzodiazepines

A simple, rapid, and sensitive method, which allowed us to simultaneously determine seven benzodiazepines (diazepam, nordiazepam, temazepam, oxazepam, 7-aminoflunitrazepam, N-desmethylflunitrazepam, and clonazepam) in buffer solution and in urine and serum samples, was investigated by automated in-tube solid-phase microextraction (SPME) coupled with liquid chromatography-electrospray ionization mass spectrometry (LC-ESI-MS). In-tube SPME, in which the analytes were extracted from the sample directly into an open tubular capillary column by repeated draw/eject cycles of sample solution, is an extraction technique for organic compounds in aqueous samples. The separation of benzodiazepines was carried out under ion-suppressed reversed-phase conditions by using methanol/50mM ammonium acetate in water (60:40) as a mobile phase with a Supelco LC-18 column. The optimal extraction condition was 10 draw/eject cycles of 30 mL of sample in 100mM Tris-HCl (pH 8.5) at a flow rate of 0.3 mL/min using a piece of 60-cm length Supelco-Q plot capillary column as the extraction capillary. The quantitative study was explored by operating in selected-ion monitoring (SIM) mode. The calibration curves were linear in the range from 0.5 ng/mL or 2 ng/mL to 500 ng/mL. The detection limits were from 0.02 ng/mL to 2 ng/mL. At the optimized capillary and fragmentor voltages, the characteristic ions for each compound clearly showed up in the spectra and it is possible to use the LC-MS to identify these compounds. The method was applied to the analysis of biological samples without interfering peaks. However, the recoveries for some of the compounds in serum samples need to be further improved.

Evolution of solid-phase microextraction technology

The main objective of this contribution is to describe the development of the concepts, techniques and devices associated with solid-phase microextraction, as a response to the evolution of understanding of the fundamental principles behind this technique. The discussion begins with an historical perspective on the very early work conduced almost a decade ago. As new fundamental understanding about the functioning of the technology developed, new ways of constructing and using the SPME devices evolved.