Intrauterine adhesion in ultrasound-guided manual vacuum aspiration (USG-MVA) versus electric vacuum aspiration (EVA): a randomised controlled trial

BACKGROUND

Intrauterine adhesion (IUA) can arise as a potential complication following uterine surgery, as the surgical procedure may damage the endometrial stratum basalis. The objective of this study was to assess and compare the occurrence of IUA in women who underwent ultrasound-guided manual vacuum aspiration (USG-MVA) versus electric vacuum aspiration (EVA) for managing first-trimester miscarriage.

METHODS

This was a prospective, single-centre, randomised controlled trial conducted at a university-affiliated tertiary hospital. Chinese women aged 18 years and above who had a delayed or incomplete miscarriage of ≤ 12 weeks of gestation were recruited in the Department of Obstetrics and Gynaecology at the Prince of Wales. Recruited participants received either USG-MVA or EVA for the management of their miscarriage and were invited for a hysteroscopic assessment to evaluate the incidence of IUA between 6 and 20 weeks after the surgery. Patients were contacted by phone at 6 months to assess their menstrual and reproductive outcomes.

RESULTS

303 patients underwent USG-MVA or EVA, of whom 152 were randomised to 'USG-MVA' and 151 patients to the 'EVA' group. Out of the USG-MVA group, 126 patients returned and completed the hysteroscopic assessment, while in the EVA group, 125 patients did the same. The incidence of intrauterine adhesion (IUA) was 19.0% (24/126) in the USG-MVA group and 32.0% (40/125) in the EVA group, showing a significant difference (p < 0.02) between the two groups. No significant difference in the menstrual outcomes at 6 months postoperatively between the two groups but more patients had miscarriages in the EVA group with IUA.

CONCLUSIONS

IUAs are a possible complication of USG-MVA. However, USG-MVA is associated with a lower incidence of IUA postoperatively at 6-20 weeks. USG-MVA is a feasible, effective, and safe alternative surgical treatment with less IUA for the management of first-trimester miscarriage.

TRIAL REGISTRATION

The study was registered with the Centre for Clinical Research and Biostatics- Clinical Trials Registry (CCRBCTR), which is a partner registry of the WHO Primary Registry-Chinese Clinical Trials Registry (ChiCTR) (Unique Trial Number: ChiCTR1900023198 with the first trial registration date on 16/05/2019).

Incidence of intrauterine adhesion after ultrasound-guided manual vacuum aspiration (USG-MVA) for first-trimester miscarriages: a prospective cohort study

PURPOSE

Ultrasound-guided manual vacuum aspiration (USG-MVA) is a feasible and effective outpatient treatment to treat early pregnancy loss.

METHODS

This was a prospective observational study at a university-affiliated hospital. All women undergoing either a USG-MVA or electric vacuum aspiration (EVA) were invited to return 3-6 months later for follow-up at which women completed a questionnaire to document their post-evacuation menstrual and reproductive history, and underwent a hysteroscopy if they were not pregnant. The severity of intrauterine adhesion (IUA), if present, was graded (Stage I-III) according to the American fertility society classification.

RESULTS

A total of 292 women had a hysteroscopy after their initial surgical evacuation, USG-MVA 169(57.9%) versus EVA 123(42.1%). Women undergoing EVA as opposed to a USG-MVA had a 12.9% higher incidence of IUA (24.1% vs. 37.0%, p = 0.042) equivalent to 1.84 times higher risk (95% CI 1.01-3.34; p = 0.048). Women having EVA continued to show an increased but not statistically significant trend towards an increased risk of IUA after adjusting for the type of miscarriage (aOR = 1.3; 95% CI 0.66-2.50; p = 0.46).

CONCLUSION

There were no significant differences in their reproductive outcomes and fewer women post-USG-MVA complained of hypomenorrhea. IUA may still occur in women undergoing USG-MVA but it is lower than the rate in women undergoing EVA. Clinical trials registry The trial was registered with the Centre for Clinical Research and Biostatistics - Clinical Trials Registry (CCRBCTR), a partner registry of the WHO Primary Registry-Chinese Clinical Trials Registry (ChiCTR) with a Unique Trial Number: CUHK_CCRB00541 on 22 Dec 2016.

Seeking a Relevant Description of Major Trauma Bleeding: Comparison of Four Major Bleeding Definitions

BACKGROUND

The traditional definition of massive transfusion is 10 red blood cell units transfused within 24 hr. This definition has been faulted for excluding patients who die early from exsanguination. Alternative major bleeding definitions in the trauma literature include time-based (e.g., Resuscitation Intensity) and event based (e.g., Sharpe) transfusion thresholds.

OBJECTIVE

The study objective was to compare four definitions of major bleeding, including a modification to the Sharpe definition, on clinically relevant processes and outcomes.

METHODS

This is a retrospective cohort study of adult trauma patients admitted from the field to a Level I trauma center from 2014 to 2019. Data sources were the trauma registry, blood bank, and electronic medical records. Transfusion thresholds were defined as follows: Resuscitation Intensity-4 units of any combination of crystalloids, colloids, or blood products within the first 30 min of arrival; Sharpe-10 red blood cell units from trauma bay presentation to inpatient admission (a proxy for the interval of hemorrhage control); Modified Sharpe-10 units of any combination of blood products during the same interval. The study analysis consisted of descriptive statistics.

RESULTS

The cohort contained 187 subjects. Of 39 deaths, 28 (72%) occurred within 6 hr following arrival. Modified Sharpe captured 27 (96%) of these 28 subjects, whereas Resuscitation Intensity captured 20 (71%). Sharpe and the traditional definition each captured 22 subjects (79%). Modified Sharpe captured 17%-25% of deaths missed by the other definitions.

CONCLUSION

Modified Sharpe may optimally indicate major bleeding during trauma resuscitation.

Cross-sectional study to assess the psychological morbidity of women facing possible miscarriage

INTRODUCTION

Threatened miscarriage is a common complication of pregnancy. This study aimed to assess psychological morbidity in women with threatened miscarriage, with the goal of identifying early interventions for women at risk of anxiety or depression.

METHODS

Women in their first trimester attending an Early Pregnancy Assessment Clinic were recruited between July 2013 and June 2015. They were asked to complete the 12-item General Health Questionnaire (GHQ-12), the Beck Depression Inventory (BDI), Spielberger's State Anxiety Inventory State form (STAI-S), the Fatigue Scale-14 (FS-14), and the Profile of Mood States (POMS) before consultation. They were also asked to rate anxiety levels before and after consultation using a visual analogue scale (VAS).

RESULTS

In total, 1390 women completed the study. The mean ± standard deviation of GHQ-12 (bi-modal) and GHQ-12 (Likert) scores were 4.04 ± 3.17 and 15.19 ± 5.30, respectively. Among these women, 48.4% had a GHQ-12 (bi-modal) score ≥4 and 76.7% had a GHQ-12 (Likert) score >12, indicating distress. The mean ± standard deviation of BDI, STAI-S, and FS-14 scores were 9.35 ± 7.19, 53.81 ± 10.95, and 2.40 ± 0.51, respectively. The VAS score significantly decreased after consultation (P<0.001). Compared with women without a history of miscarriage, women with a previous miscarriage had higher GHQ-12, BDI, and POMS scores (except for fatigue-inertia and vigour-activity subscales). A higher bleeding score was strongly positively correlated with GHQ-12 (Likert) score. There were weak correlations between pain score and the GHQ-12 (bi-modal) ≥4, BDI >12, and POMS scores (except for confusion-bewilderment subscale which showed a strong positive correlation).

CONCLUSION

Women with threatened miscarriage experience a considerable psychological burden, emphasising the importance of early recognition for timely management.

Homemade Dart Attacks in Hawai'i

Over a 4.5-year period (September 2014 to March 2019), 7 patients presented to the State's only Level I Trauma Center with penetrating injuries inflicted by homemade metallic darts. Previously described in Micronesia, these are the first domestic cases of assaults utilizing this type of weaponry. Retrospective chart review was conducted for all patients who presented to our institution with a dart injury within the study period. Details regarding demographics, imaging, and patient management were collected and described herein. All 7 patients were male with a median age of 24.6 years impaled with darts that penetrated through the deep muscle and tissue layers of the neck, torso, or extremity. Three patients required operative intervention and no mortalities were observed. The depth of penetration and proximity to vital structures highlight the potential for life-threatening injuries from these homemade darts.

A reappraisal of ovarian stimulation strategies used in assisted reproductive technology

Ovarian stimulation is a fundamental step in assisted reproductive technology (ART) with the intention of inducing ovarian follicle development prior to timed intercourse or intra-uterine insemination and facilitating the retrieval of multiple oocytes during a single in vitro fertilization (IVF) cycle. The basis of ovarian stimulation includes the administration of exogenous gonadotropins, with or without pre-treatment with oral hormonal therapy. Gonadotropin-releasing hormone agonist or antagonist is given in addition to the gonadotropins to prevent a premature rise of endogenous luteinizing hormone that would in turn lead to premature ovulation. With the advancement in technology, various stimulation protocols have been devised to cater for different patient needs. However, ovarian hyperstimulation syndrome and its serious complications may occur following ovarian stimulation. It is also evident that suboptimal ovarian stimulation strategies may have a negative impact on oogenesis, embryo quality, endometrial receptivity, and reproductive outcomes over recent years. This review describes the various forms of pre-treatment for ovarian stimulation and stimulation protocols, and aims to provide clinicians with the latest available evidence.

A Single-Institution Experience of Acute Neuropathic Lumbosacral Pain in Patients Treated with Short Course Hypofractionated Radiotherapy in Locally Advanced Rectal Cancer

PURPOSE/OBJECTIVE(S)

There has been increased interest in the use of short course hypofractionated radiotherapy as part of a total neoadjuvant treatment (TNT) approach in the management of rectal cancer since publication of the RAPIDO trial. However, the literature on short course radiation for rectal cancer has not reported significant acute toxicities in the weeks immediately following the completion of treatment. Anecdotally, a subset of patients has experienced acute neuropathic pain characterized in a lumbosacral distribution. This study investigates acute lumbosacral toxicity for patients receiving hypofractionated short course radiation as part of their definitive treatment for rectal cancer.

MATERIALS/METHODS

We retrospectively analyzed 75 patients with locally advanced rectal adenocarcinoma treated with hypofractionated short course radiation (25 Gy in 5 fractions) at our institution between 2016 and 2022. Acute toxicity caused by radiation was defined as that occurring from the start of radiation treatment to either 30 days post radiation completion, the start of chemotherapy, or date of surgery, whichever occurred first.

RESULTS

Among 75 patients treated with hypofractionated short course preoperative radiation with definitive intent, we identified 10 patients (13.3%) who experienced significant lumbosacral neuropathic pain and initiated a report to their medical providers during the acute toxicity time frame. Commonly, this was described as an achy pain in the bilateral buttocks radiating down to the knees or posterior claves. Patients rated this pain between moderate to extreme and management included steroids after failure of improvement with conservative measures, gabapentin, and conservative treatment with NSAIDs and Tylenol. Average time to onset of acute lumbosacral neuropathic pain was 3.7 days (SD 2.05) from start of RT.

CONCLUSION

We have identified a previously underappreciated acute toxicity of neuropathic lumbosacral pain in short course hypofractionated radiation therapy, which may be due to a lumbosacral plexus toxicity. Further analysis will seek to identify predictive factors such as comorbidities and dose to the lumbosacral plexus, and to determine whether there is a correlation between these observed acute toxicities and long-term outcomes.

Transcriptomic classes of BCR-ABL1 lymphoblastic leukemia

In BCR-ABL1 lymphoblastic leukemia, treatment heterogeneity to tyrosine kinase inhibitors (TKIs), especially in the absence of kinase domain mutations in BCR-ABL1, is poorly understood. Through deep molecular profiling, we uncovered three transcriptomic subtypes of BCR-ABL1 lymphoblastic leukemia, each representing a maturation arrest at a stage of B-cell progenitor differentiation. An earlier arrest was associated with lineage promiscuity, treatment refractoriness and poor patient outcomes. A later arrest was associated with lineage fidelity, durable leukemia remissions and improved patient outcomes. Each maturation arrest was marked by specific genomic events that control different transition points in B-cell development. Interestingly, these events were absent in BCR-ABL1⁺ preleukemic stem cells isolated from patients regardless of subtype, which supports that transcriptomic phenotypes are determined downstream of the leukemia-initialing event. Overall, our data indicate that treatment response and TKI efficacy are unexpected outcomes of the differentiation stage at which this leukemia transforms.

Five-year retrospective review of ultrasoundguided manual vacuum aspiration for first-trimester miscarriage

INTRODUCTION

Manual vacuum aspiration is increasingly accepted as an alternative to medical or surgical evacuation of the uterus after first-trimester miscarriage. This study aimed to assess the efficacy of ultrasound-guided manual vacuum aspiration (USG-MVA) in the management of first-trimester miscarriage.

METHODS

This retrospective analysis included adult women with first-trimester miscarriage who underwent USG-MVA in Hong Kong between July 2015 and February 2021. The primary outcome was the efficacy of USG-MVA in terms of complete evacuation of the uterus, without the need for further medical or surgical intervention. Secondary outcomes included tolerance of the entire procedure, the success rate of karyotyping using chorionic villi, and procedural safety (ie, any clinically significant complications).

RESULTS

In total, 331 patients were scheduled to undergo USG-MVA for first-trimester miscarriage or incomplete miscarriage. The procedure was completed in 314 patients and well-tolerated in all of those patients. The complete evacuation rate was 94.6% (297/314), which is similar to the rate (98.1%) achieved by conventional surgical evacuation in a previous randomised controlled trial in our unit. There were no major complications. Samples from 95.2% of patients were suitable for karyotyping, which is considerably higher than the rate of suitable samples (82.9%) obtained via conventional surgical evacuation in our previous randomised controlled trial.

CONCLUSION

Ultrasound-guided manual vacuum aspiration is a safe and effective method to manage first-trimester miscarriage. Although it currently is not extensively used in Hong Kong, its broader clinical application could avoid general anaesthesia and shorten hospital stay.

Automatic slice thickness measurement on three types of Catphan CT phantoms

OBJECTIVE

To develop an algorithm to measure slice thickness to run on three types of Catphan phantoms with the ability to adapt to any misalignment and rotation of the phantoms.&#xD;Method: Images of Catphan 500, 504, and 604 phantoms were examined. In addition, images with various slice thicknesses ranging from 1.5 to 10.0 mm, distance to the iso-center and phantom rotations were also examined. The automatic slice thickness algorithm was carried out by processing only objects within a circle having a diameter half that of the phantom diameter. A segmentation was performed within an inner circle with dynamic thresholds to produce binary images with wire and bead objects. Region properties were used to distinguish wire ramps and bead objects. At each identified wire ramp, the angle was detected using the Hough transform. Profile lines were then placed on each ramp based on the centroid coordinates and detected angles, and the full-width at half maximum (FWHM) determined for the average pixel profile. The slice thickness was obtained by multiplying the FWHM by the tangent of the ramp angle (23o). &#xD;Results: Automatic measurements work well and have only a small difference (<0.5 mm) from manual measurements. For variations of slice thickness, automatic measurement successfully performs segmentation and correctly locates the profile line on all wire ramps. The results show values that are close (< 3mm) to the nominal thickness on thin slices, but less close for thicker slices. There is a strong correlation (R2 = 0.873) between automatic and manual measurements. Testing the algorithm at various distances from the iso-center and phantom rotation angle also produced accurate results. &#xD;Conclusion: An automated algorithm for measuring slice thickness on three types of Catphan CT phantom images has been developed. The algorithm works well on various thicknesses, distances from the iso-center, and phantom rotations.

Abstract 173: Genomic characterization of patient-derived pancreatic cancer organoids

Pancreatic ductal adenocarcinoma (PDAC) is a leading cause of cancer death with few effective therapies. Patient-derived organoids (PDOs) are a 3-D culture model that allow primary tumour cells to propagate, and have gained considerable traction in many cancer types such as PDAC. However, concerns remain regarding whether these models can predict what occurs in patients. We hypothesize that genomic and transcriptomic drift occurring in PDO models impacts the fidelity of drug response. To investigate, matched WGS and bulk RNAseq was performed on paired PDAC organoids and tumour tissue (n=41). Core biopsies were obtained from in patients with Stage III-IV PDAC enrolled in the COMPASS trial (NCT02750657) and divided for sequencing and organoid generation. Tumour cellularity was enriched by laser capture microdissection. Although alterations in the four major driver genes (KRAS, TP53, SMAD4, CDKN2A) remained consistent, other genomic differences were identified. SNV count was higher in organoids (median 6584 vs 5931, p&lt;0.0001), and enriched in SBS5 mutational signature (p&lt;0.0001). This was not significantly correlated with passage number, and private mutations were identified in both tumours and organoids (median 67% overlap). Two organoids showed significant shifts in ploidy, with both diploid to polyploid shifts and vice versa observed. In the transcriptome, expression of Basal-like genes (KRT5, TP63) was decreased. Bias towards the Classical transcriptomic subtype have previously been observed in PDAC organoid cultures. PDO responses to 5-FU, irinotecan, and oxaliplatin correlated with patient response to FFX (n=22, 72% concordance). However, PDO responses to gemcitabine and paclitaxel were poorly predictive of patient responses to GnP (n=10, 38% concordance), and notably, expression of the biomarker hENT1 was not correlated in matched tumors and PDOs (R=0.17, p=0.40). Despite this, tumour expression of the biomarker hENT1 successfully stratified patient responses to gemcitabine, and organoid hENT1 expression was correlated to gemcitabine response in vitro (R=0.47, p=0.005), indicating that transcriptomic drift may be a major contributor to discrepancies in patient-PDO drug response. In summary, organoids recapitulate major histologic features and driver mutations of patient tumours, but genetic drift and subclonal selection are observed even at lower passages. Further study is required to improve the utility of organoids in translational precision medicine.

Citation Format: Irene Y. Xie, Yuanchang Fang, Amy X. Zhang, Karen Ng, Zhen-Mei Liu, Eugenia Flores-Figueroa, Gun Ho Jang, Stephanie Ramotar, Anna Dodd, Julie Wilson, Jennifer J. Knox, Steven Gallinger, Faiyaz Notta. Genomic characterization of patient-derived pancreatic cancer organoids [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 173.

Young-onset diabetes in women with Polycystic Ovary Syndrome: A territory-wide retrospective analysis in Hong Kong

AIM

To ascertain the risk of progression to diabetes among Chinese women with PCOS.

METHODS

Women with PCOS (n = 3978) were identified from the Hong Kong Diabetes Surveillance Database based on the ICD-9 code for PCOS diagnosis and women without PCOS served as controls (n = 39780), matched 1:10 by age.

RESULT(S)

The mean follow-up was 6.28 ± 4.20 and 6.95 ± 4.33 years in women with PCOS and controls, respectively. The crude incidence rate of diabetes was 14.25/1000 person-years in women with PCOS compared with 3.45 in controls. The crude hazard ratio of diabetes in women with PCOS was 4.23 (95 % CI: 3.73-4.80, p < 0.001). Further stratified by age group, the risk of developing diabetes decreased with increasing age but it remained significantly higher in women with PCOS across all age groups. It also suggested that the incidence rate of diabetes in women with PCOS aged 20-29 is highly comparable to that in healthy women aged ≥ 40. More than half of the incident diabetes captured during the follow-up in women with PCOS cohort were young-onset diabetes.

CONCLUSION

Women diagnosed with PCOS at a younger age have the highest relative risk of developing diabetes, suggesting frequent glycemic status screening is required to detect diabetes at an early stage.

Long-term Cardiovascular Risks of Gonadotropin-releasing Hormone Agonists and Antagonists: a Population-based Cohort Study

AIMS

Gonadotropin-releasing hormone (GnRH) agonists and antagonists, critical medications for prostate cancer (PCa) treatment, may differ in cardiovascular safety. This prospective cohort study aimed to compare the long-term cardiovascular risks between GnRH agonists and antagonists.

MATERIALS AND METHODS

Patients with PCa receiving GnRH agonists or antagonists during 2013-2021 in Hong Kong were identified. Patients with <6 months' prescriptions, who were switching between drugs, had missing baseline prostate-specific antigen level or had a prior stroke or myocardial infarction were excluded. Patients were followed up until September 2021. The primary outcome was major adverse cardiovascular events (MACE) as in the PRONOUNCE trial (MACE_PRONOUNCE), i.e. a composite of all-cause mortality, stroke and myocardial infarction. The secondary outcome was MACE_CVM, i.e. a composite of cardiovascular mortality, stroke and myocardial infarction. Inverse probability treatment weighting was used to balance covariates between groups. The Log-rank test was used to compare the cumulative freedom from the primary outcome between groups.

RESULTS

In total, 2479 patients were analysed (162 GnRH antagonist users and 2317 agonist users; median age 75.0 years, interquartile range 68.0-81.6 years). Inverse probability treatment weighting achieved good covariate balance between groups. Over a median follow-up duration of 3.0 years (interquartile range 1.7-5.0 years), 1115 patients (45.0%) had MACE_PRONOUNCE and 344 (13.9%) had MACE_CVM. GnRH agonist users had lower risks of MACE_PRONOUNCE (Log-rank P < 0.001) and MACE_CVM (Log-rank P = 0.027). However, no differences were observed within 1 year of follow-up (MACE_PRONOUNCE: Log-rank P = 0.308; MACE_CVM: Log-rank P = 0.357). Among patients without cardiovascular risk factors at baseline, GnRH agonist users had lower risks of MACE_PRONOUNCE (Log-rank P < 0.001) and MACE_CVM (Log-rank P = 0.001), whereas no differences were observed in those with such risk factor(s) (MACE_PRONOUNCE: Log-rank P = 0.569; MACE_CVM: Log-rank P = 0.615).

CONCLUSIONS

GnRH antagonists may be associated with higher long-term, but not short-term, cardiovascular risks than agonists in Asian patients with PCa, particularly in those without known cardiovascular risk factors.

Mate-pair genome sequencing reveals structural variants for idiopathic male infertility

Currently, routine genetic investigation for male infertility includes karyotyping analysis and PCR for Y chromosomal microdeletions to provide prognostic information such as sperm retrieval success rate. However, over 85% of male infertility remain idiopathic. We assessed 101 male patients with primary infertility in a retrospective cohort analysis who have previously received negative results from standard-of-care tests. Mate-pair genome sequencing (large-insert size library), an alternative long-DNA sequencing method, was performed to detect clinically significant structural variants (SVs) and copy-number neutral absence of heterozygosity (AOH). Candidate SVs were filtered against our in-house cohort of 1077 fertile men. Genes disrupted by potentially clinically significant variants were correlated with single-cell gene expression profiles of human fetal and postnatal testicular developmental lineages and adult germ cells. Follow-up studies were conducted for each patient with clinically relevant finding(s). Molecular diagnoses were made in 11.1% (7/63) of patients with non-obstructive azoospermia and 13.2% (5/38) of patients with severe oligozoospermia. Among them, 12 clinically significant SVs were identified in 12 cases, including five known syndromes, one inversion, and six SVs with direct disruption of genes by intragenic rearrangements or complex insertions. Importantly, a genetic defect related to intracytoplasmic sperm injection (ICSI) failure was identified in a patient with non-obstructive azoospermia, illustrating the additional value of an etiologic diagnosis in addition to determining sperm retrieval rate. Our study reveals a landscape of various genomic variants in 101 males with idiopathic infertility, not only advancing understanding of the underlying mechanisms of male infertility, but also impacting clinical management.

Implementation of ovarian tissue cryopreservation in Hong Kong

INTRODUCTION

Worldwide, >130 babies have been born from ovarian tissue cryopreservation (OTC) and ovarian tissue transplantation (OTT). Ovarian tissue cryopreservation can improve quality of life among young female cancer survivors. Here, we assessed the feasibility of OTC and subsequent OTT in Hong Kong via xenografts in nude mice.

METHODS

This pilot study was conducted in a university-affiliated tertiary hospital. Fifty-two ovarian tissues were collected from 12 patients aged 29 to 41 years during ovarian surgery, then engrafted into 34 nude mice. The efficacies of slow freezing and vitrification were directly compared. In Phase I, non-ovariectomised nude mice underwent ovarian tissue engraftment. In Phase II, ovariectomised nude mice underwent ovarian tissue engraftment, followed by gonadotrophin administration to promote folliculogenesis. Ovarian tissue viability was assessed by gross anatomical, histological, and immunohistochemical examinations before and after OTC. Follicular density and morphological integrity were also assessed.

RESULTS

After OTC and OTT, grafted ovarian tissues remained viable in nude mice. Primordial follicles were observed in thawed and grafted ovarian tissues, indicating that the cryopreservation and transplantation protocols were both effective. The results were unaffected by gonadotrophin stimulation.

CONCLUSION

This study demonstrated the feasibility of OTC in Hong Kong as well as primordial follicle viability after OTC and OTT in nude mice. Ovarian tissue cryopreservation is ideal for patients who cannot undergo the ovarian stimulation necessary for oocyte or embryo freezing as well as prepubertal girls (all ineligible for oocyte freezing). Our findings support the clinical implementation of OTC and subsequent OTT in Hong Kong.

Discerning Clinician Perceptions of an Established Opioid Stewardship (DISCLOSE) Program

Background

The Opioid Stewardship Program (OSP) was created to promote safe and rational prescribing of opioids, where the risks associated with providing opioids for patients must be balanced against the risk of patients experiencing uncontrolled pain. The pharmacist-led OSP was established at 2 Fraser Health Authority (FHA) sites, British Columbia, to provide clinical services through patient referrals and screening. The rate of acceptance of OSP pharmacists' recommendations has been high, but there was a need to assess clinicians' perceptions of the program.

Objectives

To assess the perceptions of health care professionals at FHA hospitals offering the OSP regarding various aspects of the program and to identify areas of the program that could be modified to further optimize service delivery.

Methods

A prospective cross-sectional survey was distributed to about 250 targeted health care professionals, who answered questions regarding their perceptions of the OSP. Data were analyzed using simple descriptive statistics.

Results

A total of 71 respondents initiated the survey, of whom 59 were included in the final analyses. Most participants indicated that the OSP pharmacists' suggestions were valuable for optimizing pain management (52/57, 91%) and preventing adverse events (49/56, 88%). Most participants were satisfied with the quality of communication (51/56, 91%), timeliness to consults (51/52, 98%), and recommendations provided (52/55, 95%). Increasing knowledge transfer, improving communication about intentions for patient follow-up, and expanding services at current sites and to other sites were recommended to improve the OSP.

Conclusions

Clinicians responding to the survey reported a high level of satisfaction with and positive views of the pharmacist-led OSP. Providing more education and clarifying intentions for patient follow-up are modifications that could be made to improve the program.

Abstract A036: Plasma extracellular RNA for the detection of pancreatic cancer

Pancreatic ductal adenocarcinoma (PDA) is expected to become the second leading cause of cancer-related death by 2030. Patients are often diagnosed at the metastatic stage, at which point treatments are limited and have non-uniform efficacy in patients. Advances in transcriptomic subtyping of tumor tissue can segregate patients into two broad subtypes, Classical and Basal-like, which are predictive of survival and response to first-line chemotherapy. However, tumor tissue is often difficult or impossible to obtain, particularly in patients with advanced disease, hindering the clinical implementation of transcriptomic subtyping. Profiling the extracellular RNA (exRNA) content in plasma provides an opportunity for a non-invasive readout of the tumor transcriptome. Here, we aim to establish the feasibility of liquid biopsy—particularly, plasma exRNA-profiling—for the diagnosis and subtyping of PDA. Extracellular vesicle (EV) encapsulated exRNA was isolated from 1mL of frozen plasma collected between 2017-2020 from a pilot cohort of 8 patients with stage III-IV PDA and processed alongside plasma from 6 healthy volunteers. UMI-tagged libraries were constructed from low-input exRNA to generate sequencing data. Gene body coverage analysis indicated that exRNAs consisted of intact full-length transcripts. Of these transcripts, we found that there was a median of 34,975 genes encoded by exRNAs, deriving mostly from protein-coding regions. Most genes captured by exRNA sequencing had low expression. Comparing between groups, we detected a significantly greater number of genes and novel splicing junctions in PDA patients. Of the cancer-specific transcripts, differential expression analysis revealed significant upregulation of membrane organelle and RNA-processing related pathways. PDA exRNA profiles did not completely recapitulate the bulk tumor transcriptome, suggesting specific mechanisms for EV encapsulation of RNAs and exRNA release. To classify tumor subtypes by plasma exRNA sequencing, we identified an exRNA-specific gene panel from bulk tumor transcriptome signatures. Using this gene panel, tumor subtype was correctly inferred from 6/7 PDA patients. A combined gene panel derived from all tumor-associated exRNA signatures distinguished 7/8 PDA patients from healthy controls. In conclusion, plasma exRNA recapitulated elements of the tumor transcriptome and has utility in PDA diagnosis. The establishment of diagnostic markers will be further investigated in the expanded study cohort comprised of 91 unique stage III-IV PDA donors with plasma collected at baseline, 150 stage III-IV PDA donors with plasma banked at timepoints throughout chemotherapy treatment, and 100 age- and sex-matched non-PDA controls donors. Leveraging the study cohort, future work will also investigate plasma exRNA signatures as prognostic markers to predict treatment outcomes and monitor treatment responses in patients with advanced PDA.

Citation Format: Linsey Gong, Ling Xi, Yuanchang Fang, Karen Ng, Gun Ho Jang, Amy X. Zhang, Julie M. Wilson, Stephanie Ramotar, Jennifer J. Knox, Grainne M. O'Kane, Steven Gallinger, Hansen H. He, Faiyaz Notta. Plasma extracellular RNA for the detection of pancreatic cancer [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr A036.

Abstract B031: Loss of GATA6 leads to reduced cell fitness and PDA molecular subtype changes

Background: Pancreatic ductal adenocarcinoma (PDA) is defined by two main transcriptional subtypes, Basal-like & Classical. Classical tumors are more frequent and tend to respond better to chemotherapy with higher expression of genes related to pancreatic lineage development, the epithelial compartment, and adhesion. Conversely, Basal-like tumors are more aggressive, therapy resistant and have higher expression of laminins and keratins. The Classical subtype correlates with GATA6 expression, and ~16% pancreatic tumors show amplification in the transcription factor GATA6 suggesting its importance in the Classical subtype and in tumor survival (Chan-Seng-Yue et al., 2020). The goal of this project is to elucidate the role of GATA6 expression in PDA tumors showing that GATA6 is a key molecular regulator of the Classical subtype influencing tumor growth, maintenance, and phenotype. Methods: Patient derived organoids (PDOs) spanning the spectrum of GATA6 expression were used with CRISPR/Cas9 to establish GATA6 KO lines (n=8). These were then subject to a growth competition assay between cells with and without GATA6 KO and the amount of knockout over time was monitored by Sanger sequencing. Tumor growth curves were generated in a subcutaneous xenograft mouse model over 1.5 months to assess the in vivo growth potential of GATA6 KO cells in a sample with high GATA6 expression. 3’RNA-seq was used to assess gene expression changes in subtype, and GSEA was used to assess pathway enrichment. This was done alongside IHC, capillary Westerns, and flow cytometry to assess changes that GATA6 KO incurs on a functional level. Results: GATA6 KO tended to result in reduced fitness (dropout) in cells when ablated, although the rate and level of dropout varied, suggesting different levels of dependence on GATA6 expression for survival/growth. This was confirmed in vivo when the GATA6 KO failed to grow as robustly as control groups in a sample with high native GATA6 expression. Molecular analysis of all PDO samples showed shifts in expression from Classical to Basal-like. This shift was denoted in changes in subtype score, changes in marker gene expression (i.e., ANXA10 & TP63), and in changes in key pathways associated with each subtype. This shows that GATA6 not only correlates with the Classical subtype but plays a causal role in maintaining it. Even though there was a shift towards Basal-like expression several key characteristics of the subtype were notably absent including enrichment for epithelial to mesenchymal transition, down regulation of MYC and its targets, and the lack of aggressive growth in in vitro and in vivo models (dropout of GATA6 KO cells, low Ki67 expression, and upregulation of apoptosis). This suggests that KO of GATA6 is not sufficient in of itself to cause a true Basal-like phenotype and that instead GATA6 KO might lead to an in-between state that does not quite offer the same growth advantages and may open GATA6 and its pathways to be a potential therapeutic target.

Citation Format: Tristan S.D. Woo, Kena F. Figueroa, Sabrina Ge, Irene Xie, Karen Ng, Pinjiang Cao, Julie M. Wilson, Stephanie Ramotar, Jennifer J. Knox, Grainne M. O'Kane, Steven Gallinger, Faiyaz Notta. Loss of GATA6 leads to reduced cell fitness and PDA molecular subtype changes [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr B031.

Abstract B036: The role of whole genome duplication in progression of pancreatic ductal adenocarcinoma

Introduction: Pancreatic ductal adenocarcinoma (PDA) is a lethal disease that tends to present at an advanced stage, but the evolutionary mechanisms responsible for rapid progression in PDA are poorly understood. Whole genome duplication (WGD) is a hallmark of cancer observed more frequently in late-stage tumors that predicts poorer overall patient survival across cancer types, including PDA. The genome-wide instability that occurs during WGD events can lead to gene dosage imbalances that promote tumor progression and may explain the rapid progression of aneuploidy. Although WGD has been studied extensively in advanced cancer, there is limited data on WGD in primary tumors. We hypothesize that WGD occurs frequently in primary PDA and promotes the rapid progression and high rate of relapse in early stage PDA. We leveraged scWGS to infer copy number profiles and WGD events from tumor cells to determine the rate of subclonal WGD in primary PDA tumors and understand how aneuploidy and genome instability evolve in the earliest stages of tumor progression. Methods: Single cell barcoded libraries from primary treatment naive tumors were prepared with the 10X Genomics Single Cell CNV platform and sequenced to a depth of 20-60x per tumor. Reads were processed using CellRanger DNA pipeline, demultiplexed, and analyzed with Gingko CNV. A total of 10,323 cells from 8 primary PDA tumors (range, 192 – 3146; median = 1286) were recovered, resulting in an average coverage of 0.06x per single cell (range, 0.02x – 0.14x). Results: 5/8 tumors analyzed had evidence of at least one WGD event. The WGD event was identified as a minor subclone in 3 of these 5. Copy number profiles revealed 1-6 distinct subclones in each tumor, demonstrating copy number evolution is ongoing. WGD+ tumors trend towards having higher diversity and higher percentage of genome altered. Conclusion: WGD occurs more frequently in primary PDA than previously understood, and may confer high levels of genetic instability.

Citation Format: Lauren Hummel, Irene Xie, Karen Ng, Amy Zhang, Stephanie Ramotar, Anna Dodd, Grainne O'Kane, Jennifer Knox, Julie Wilson, Steven Gallinger, Faiyaz Notta. The role of whole genome duplication in progression of pancreatic ductal adenocarcinoma [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr B036.

Abstract A003: Developmental parallels in pancreatic cancer subtypes revealed by single cell transcriptomics

Recent research into the transcriptional subtypes in pancreatic ductal adenocarcinoma (PDA) has demonstrated their importance in predicting survival and therapeutic response. The Basal-like subtype is enriched in metastases and generally predicts poorer prognosis, while the Classical subtype is defined by gene expression reflective of pancreatic progenitors. The two-subtype scheme can be further subdivided into five subtypes that help better reflect the vast transcriptional heterogeneity found in PDA tumors. Basal-like A tumors fare worse than Basal-like B tumors. KRAS wildtype tumors are enriched in Classical B, which have the best prognosis, while Classical A is more reflective of the two-subtype Classical program. Hybrid tumors, generally a mix of Basal-like B and Classical A, are intermediate in prognosis between the Classical and Basal-like subtypes. Despite the importance of the subtypes, we have yet to fully understand how subtype programs within single cells of a tumor are intrinsically regulated, and how they contribute to tumor-level transcriptional observations. To investigate, we generated and leveraged a single cell RNA sequencing dataset enriched for malignant tumor cells spanning both primary and metastatic disease. Along with the richly annotated COMPASS dataset featuring bulk RNA sequencing of over 300 laser captured samples, we developed a single sample classifier utilizing gene pairs for assigning Basal-like A, Basal-like B, Hybrid, Classical A or Classical B to bulk tumors as well as individual cells, allowing interrogation of the subtypes across modalities. We find that the bulk subtype of the tumor is generally reflected in the dominant cell subtype. However, there are frequently cells of other subtypes within individual tumors, and substantial differences in cell subtype composition across tumors of the same subtype. In addition, we find that the proportion of Basal-like cells is a significant risk prognosticator. Investigating deeper into the transcriptional drivers of the subtypes reveals differences in expression of programs linked to endodermal development. Transcription factors such as FOXC1 and IRX3 generally related to foregut development are enriched in Basal-like A, forming a gradient of high expression to lower expression from Basal-like A, Basal-like B, Hybrid, Classical A to Classical B. Interestingly, midgut transcription factors such as CDX2 and ELF3 are expressed in the reverse order. Integrating data from single cell endoderm RNA sequencing further supports this finding, suggesting that the subtypes may arise from tumor cells exploiting pathways normally expressed early in development. This work provides a stepping stone to better understanding the mechanisms behind transcriptional subtypes in PDA.

Citation Format: Sabrina Ge, Gun Ho Jang, Michelle Chan-Seng-Yue, Eugenia Flores Figueroa, Karen Ng, Stephanie Ramotar, Anna Dodd, Grainne M. O'Kane, Julie M. Wilson, Jennifer J. Knox, Sandra E. Fischer, Steven Gallinger, Faiyaz Notta. Developmental parallels in pancreatic cancer subtypes revealed by single cell transcriptomics [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr A003.

S2.4a Pythiosis: An emerging disease in Hong Kong

S2.4 Veterinary mycology research, September 21, 2022, 3:00 PM - 4:30 PM

Oomycosis is an emerging disease of humans and animals caused by oomycetes in the Stramenopiles-Alveolata-Rhizaria super group, mainly Pythium insidiosum and occasionally Lagenidium giganteum or Paralagenidum species. In surface freshwater, oomycetes produce motile biflagellate asexual zoospores with marked chemotactic attraction to epithelial surfaces of vertebrate hosts. Infection is the result of encystation and invasion of damaged skin or gastrointestinal mucosa.

 

Of ∼ 4200 cases of pythiosis reported globally between 1980 and 2021 only ∼ 20% involved humans while 80% involved animals, mainly horses, dogs, and cattle. Most human cases occur in India and Thailand, whereas most animal infections were reported in the United States and Brazil. Pythiosis has been reported in mainland China, but the burden of the disease is low and comprises <1% of overall cases in humans.

 

Neither pythiosis nor lagenidiosis has been previously reported in humans or animals in Hong Kong. From January 2018 to January 2022, the Veterinary Diagnostic Laboratory of City University of Hong Kong diagnosed 10 cases of oomycosis (5 canine, 5 feline) after identification of non-parallel walled, irregularly branching, and poorly septate hyphae in the center of necrotic regions of histological sections of formalin-fixed paraffin-embedded tissues (FFPET). Species identity was confirmed by PCR and sequencing of 28S rDNA from DNA extracts of FFPET. There were 8 cases of P. insidiosum and 2 of L. giganteum infection. Serum ELISA was positive for Pythium antibodies in 5/6 cases tested and negative for Pythium/Lagenidium/Paralagenidum antibodies in a German shepherd dog (GSD) with disseminated disease caused by L. giganteum.

 

Affected dogs were young to middle-aged at presentation (9 months to 5 years old). Two dogs had focal cutaneous infections, two had extensive gastrointestinal involvement, and the GSD had disseminated disease with cutaneous, mediastinal, and abdominal involvement.

 

Affected cats were young (8 weeks to 18 months) and presented with subcutaneous/cutaneous disease. Three cats had a distinctive perianal ring of bulging subcutaneous granulation tissue, including one that also had an ulcerated, proliferative and necrotic lesion involving two adjacent hind-limb digits. One cat had facial subcutaneous swelling with mandibular lymph node enlargement and the remaining cat presented with extensive circumferential swelling of one hind limb from the distal paw to the mid-stifle.

 

All cats tested negative for the Feline leukemia virus and Feline immunodeficiency virus. Traumatic or surgical wounds preceding infection were identified in a kitten caught in a rodent glue-trap with skin wounds, in a cat with facial involvement that had an injured globe surgically enucleated, and in a dog with cutaneous pythiosis that had chronic dermatitis.

 

Treatment data were available for one canine case. The GSD with lagenidiosis was treated with combination antimicrobial therapy including voriconazole, terbinafine, minocycline, and azithromycin. The dog responded poorly. Mefenoxam was substituted for voriconazole and hyperbaric oxygen therapy was administered. After initial response, the dog succumbed 4 months from diagnosis. We have had success with the treatment of four feline cases using combination therapy including surgical debridement, immunotherapy with a Pythium vaccine, and combinations of antifungal drugs (posaconazole and terbinafine), and/or antimicrobials (doxycycline/minocycline and azithromycin).

Supporting community overdose response planning in Ontario, Canada: Findings from a situational assessment

Background

Many communities across North America are coming together to develop comprehensive plans to address and respond to the escalating overdose crisis, largely driven by an increasingly toxic unregulated drug supply. As there is a need to build capacity for successful implementation, the objective of our mixed methods study was to identify the current planning and implementation practices, needs, and priority areas of support for community overdose response plans in Ontario, Canada.

Methods

We used a situational assessment methodology to collect data on current planning and implementation practices, needs, and challenges related to community overdose response plans in Ontario, consisting of three components. Between November 2019 to February 2020, we conducted ten semi-structured key informant interviews, three focus groups with 25 participants, and administered an online survey (N = 66). Purposeful sampling was used to identify professionals involved in coordinating, supporting, or partnering on community overdose response plans in jurisdictions with relevant information for Ontario including other Canadian provinces and American states. Key informants included evaluators, representatives involved in centralised supports, as well as coordinators and partners on community overdose response plans. Focus group participants were coordinators or leads of community overdose response plans in Ontario.

Results

Sixty-six professionals participated in the study. The current planning and implementation practices of community overdose response plans varied in Ontario. Our analysis generated four overarching areas for needs and support for the planning and implementation of community overdose response plans: 1) data and information; 2) evidence and practice; 3) implementation/operational factors; and 4) partnership, engagement, and collaboration. Addressing stigma and equity within planning and implementation of community overdose response plans was a cross-cutting theme that included meaningful engagement of people with living and lived expertise and meeting the service needs of different populations and communities.

Conclusions

Through exploring the needs and related supports for community overdose response plans in Ontario, we have identified key priority areas for building local capacity building to address overdose-related harms. Ongoing development and refinement, community partnership, and evaluation of our project will highlight the influence of our supports to advance the capacity, motivation, and opportunities of community overdose response plans.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13762-0.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

The age-dependent association of risk factors with pancreatic cancer

BACKGROUND

Pancreatic cancer presents as advanced disease in >80% of patients; yet, appropriate ages to consider prevention and early detection strategies are poorly defined. We investigated age-specific associations and attributable risks of pancreatic cancer for established modifiable and non-modifiable risk factors.

PATIENTS AND METHODS

We included 167 483 participants from two prospective US cohort studies with 1190 incident cases of pancreatic cancer during >30 years of follow-up; 5107 pancreatic cancer cases and 8845 control participants of European ancestry from a completed multicenter genome-wide association study (GWAS); and 248 893 pancreatic cancer cases documented in the US Surveillance, Epidemiology, and End Results (SEER) Program. Across different age categories, we investigated cigarette smoking, obesity, diabetes, height, and non-O blood group in the prospective cohorts; weighted polygenic risk score of 22 previously identified single nucleotide polymorphisms in the GWAS; and male sex and black race in the SEER Program.

RESULTS

In the prospective cohorts, all five risk factors were more strongly associated with pancreatic cancer risk among younger participants, with associations attenuated among those aged >70 years. The hazard ratios comparing participants with three to five risk factors with those with no risk factors were 9.24 [95% confidence interval (CI) 4.11-20.77] among those aged ≤60 years, 3.00 (95% CI 1.85-4.86) among those aged 61-70 years, and 1.46 (95% CI 1.10-1.94) among those aged >70 years (Pheterogeneity = 3×10-5). These factors together were related to 65.6%, 49.7%, and 17.2% of incident pancreatic cancers in these age groups, respectively. In the GWAS and the SEER Program, the associations with the polygenic risk score, male sex, and black race were all stronger among younger individuals (Pheterogeneity ≤0.01).

CONCLUSIONS

Established risk factors are more strongly associated with earlier-onset pancreatic cancer, emphasizing the importance of age at initiation for cancer prevention and control programs targeting this highly lethal malignancy.

AB0879 Interim analysis of baseline characteristics and 12-week outcomes for a subset of patients with moderate-to-severe plaque psoriasis and psoriatic arthritis from the Psoriasis Study of Health Outcomes

Background

Approximately 30% of patients (pts) with plaque psoriasis (PsO) develop psoriatic arthritis (PsA)1, which is associated with high Psoriasis Area and Severity Index (PASI) and nail involvement. The Psoriasis Study of Health Outcomes (PSoHO) is a 3-year (yr), international, prospective, observational cohort study comparing the effectiveness of anti-IL-17A biologics to all other approved biologics in pts with moderate-to-severe PsO.

Objectives

This interim subset analysis describes the baseline characteristics and Week 12 (W12) effectiveness in pts with moderate-to-severe PsO and PsA in PSoHO.

Methods

Adults with moderate-to-severe PsO for ≥6 months who initiated/switched biologic treatment during routine medical care were enrolled. PsA diagnosis was recorded by the dermatologists based on the medical history and/or information provided by the patient. W12 effectiveness was assessed by the proportion of pts achieving almost clear or clear skin defined by ≥90% improvement in PASI, affected Body Surface Area (BSA), Dermatology Life Quality Index (DLQI), and Patient Global Assessment of Disease Severity (PatGA). Musculoskeletal endpoints were not collected. Data were analysed descriptively, using mean (standard deviation [SD]) or median ([Q1/Q3]) for continuous variables and n, % and 95% confidence limits for categorical variables.

Results

Overall, 1981 pts were enrolled in this study, of whom 461 (23.3%) had a PsA diagnosis and received either anti-IL-17A (n=227; 49.2%) or other biologics (n=234; 50.8%). This subset of pts had a mean age of 48.7 yrs and a median disease duration of 18.9 yrs for PsO and 5.6 yrs for PsA (Table 1).

Table 1.

Baseline characteristics for PsO patients with PsA. Mean (SD) reported for all available data for that measure, unless stated otherwise.

Overall (n=461)Anti-IL-17A (n=227)Other Biologics (n=234)Age, yrs48.7 (12.9)50.9 (12.9)46.6 (12.6)Male, n (%)232 (50.3)112 (49.3)120 (51.3)BMI (kg/m2)29.7 (6.2)29.8 (5.9)29.6 (6.4)Smoking status – Current, n (%)100 (25.4)41 (21.1)59 (29.5)Disease duration (PsA), yrs, median (Q1/Q3)5.6(2.2/13.1)5.6(2.0 / 13.8)5.5(2.3 / 12.8)Disease duration (PsO), yrs, median (Q1/Q3)18.9(9.7 / 28.6)18.9(9.2 / 30.3)18.7(10.1 / 27.3)Any previous biologic therapy, n (%)249 (54.0)123 (54.2)126 (53.8)PASI14.3 (9.3)13.6 (8.1)15.0 (10.3)BSA, %21.7 (19.4)19.8 (17.3)23.5 (21.1)mNAPSI16.6 (22.8)16.5 (25.5)16.7 (20.1)Presence of nail PsO, n (%)217 (47.2)103 (45.4)114 (48.9)PatGA3.5 (1.2)3.5 (1.3)3.6 (1.2)DLQI13.6 (7.9)13.4 (7.8)13.7 (8.0)HADS Depression score >10, n (%)73 (19.3)38 (20.5)35 (18.1)HADS Anxiety score >10, n (%)124 (32.8)62 (33.5)62 (32.1)

BMI = Body Mass Index; BSA = Body Surface Area; DLQI = Dermatology Life Quality Index; HADS = Hospital Anxiety and Depression Scale; HADS >10 indicates significant symptoms of depression/anxiety; mNAPSI = Modified Nail Psoriasis Severity Index; PASI = Psoriasis Area and Severity Index; PatGA = Patient Global Assessment of Disease Severity; Q1/Q3 = Quartile 1/3.

At W12, 62.4% and 42.6% of anti-IL-17A-treated pts achieved PASI90 and PASI100, respectively, compared with 34.2% and 16.8% in the other biologics cohort, respectively (Figure 1). BSA <3% was reached by 70.9% of anti-IL-17A-treated pts and 49.5% in the other biologics cohort, while 71.2% and 44.8%, respectively, reached PatGA 0/1. Among pts with baseline DLQI ≥2, 38.0% and 27.1% of the anti-IL-17A and other biologics cohorts, respectively, reached DLQI 0/1.

Figure 1.

Percentage of patients receiving anti-IL-17A or other biologics who achieved PASI75/90/100, absolute PASI ≤1, BSA <3%, PatGA 0/1 and DLQI 0/1 (baseline DLQI ≥2) at Week 12. Bars represent upper 95% confidence limits.

Conclusion

The effectiveness of blocking IL-17A on skin manifestations and on quality-of-life improvements in pts with PsO and PsA in the real-world study was consistent with observations from clinical trials.

References

[1]Zabotti A, et al. RMD Open 2019;5: e001067

Disclosure of Interests

Lars Erik Kristensen Speakers bureau: Pfizer, AbbVie, Amgen, UCB, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly, and Janssen pharmaceuticals., Consultant of: Pfizer, AbbVie, Amgen, UCB, Gilead, Biogen, BMS, MSD, Novartis, Eli Lilly, and Janssen pharmaceuticals., Grant/research support from: IIT research grants from Pfizer, AbbVie, UCB, Gilead, Biogen, Novartis, Eli Lilly, and Janssen pharmaceuticals., Frank Behrens Speakers bureau: Amgen, AbbVie, Pfizer, Roche, Chugai, UCB, BMS, Celgene, MSD, Novartis, Biotest, Janssen, Genzyme, Eli Lilly, Boehringer and Sandoz, Consultant of: Amgen, AbbVie, Pfizer, Roche, Chugai, UCB, BMS, Celgene, MSD, Novartis, Biotest, Janssen, Genzyme, Eli Lilly, Boehringer and Sandoz, Grant/research support from: AbbVie, Pfizer, Roche, Chugai, GSK and Janssen, Luis Puig Speakers bureau: Celgene, Janssen, Eli Lilly, Novartis, Pfizer, Consultant of: Abbvie, Almirall, Amgen, Baxalta, Biogen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Fresenius-Kabi, Janssen, JS BIOCAD, Leo-Pharma, Eli Lilly, Mylan, Novartis, Pfizer, Regeneron, Roche, Sandoz, Samsung-Bioepis, Sanofi, UCB, Grant/research support from: Abbvie, Almirall, Amgen, Boehringer Ingelheim, Celgene, Janssen, Leo-Pharma, Eli Lilly, Novartis, Pfizer, Regeneron, Roche, Sanofi, UCB, Adam Reich Speakers bureau: Abbvie, Novartis, Janssen, Pfizer, Sandoz, Galderma, Eli Lilly, Consultant of: Abbvie, Novartis, Janssen, Pfizer, Sandoz, Galderma, Eli Lilly, Thorsten Holzkaemper Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Alan Brnabic Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Khai Ng Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Soyi Liu Leage Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Christopher Schuster Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Andreas Pinter Speakers bureau: AbbVie, Almirall-Hermal, Amgen, Biogen Idec, Biontec, Boehringer-Ingelheim, Celgene, GSK, Eli Lilly, Galderma, Hexal, Janssen, LEO-Pharma, MC2, Medac, Merck Serono, Mitsubishi, MSD, Novartis, Pascoe, Pfizer, Tigercat Pharma, Regeneron, Roche, Sandoz Biopharmaceuticals, Sanofi-Genzyme, Schering-Plough and UCB Pharma, Consultant of: AbbVie, Almirall-Hermal, Amgen, Biogen Idec, Biontec, Boehringer-Ingelheim, Celgene, GSK, Eli Lilly, Galderma, Hexal, Janssen, LEO-Pharma, MC2, Medac, Merck Serono, Mitsubishi, MSD, Novartis, Pascoe, Pfizer, Tigercat Pharma, Regeneron, Roche, Sandoz Biopharmaceuticals, Sanofi-Genzyme, Schering-Plough and UCB Pharma

OP0142 COMPARISON OF ATTAINMENT AND PROTECTIVE EFFECTS OF THE LUPUS LOW DISEASE ACTIVITY STATE IN PATIENTS WITH NEWLY DIAGNOSED VERSUS ESTABLISHED SLE - A MULTICENTRE PROSPECTIVE STUDY

Background

Lupus low disease activity state (LLDAS) attainment has been reported to be associated with reduced damage accrual, flare, and mortality, as well as improved quality of life, in cohorts of SLE patients with established disease. Whether these associations are present in recent-onset disease is less well known.

Objectives

To evaluate the associations of LLDAS attainment with outcomes in patients with recent onset SLE.

Methods

Data from a 13-country longitudinal SLE cohort (ACR/SLICC criteria) were collected prospectively between 2013 and 2020 using standard templates. Organ damage and flare were captured using SLICC Damage Index and SELENA-SLEDAI Flare Index, respectively. LLDAS was defined as Golder et al., 2019 [1]. An inception cohort was defined based on duration since SLE diagnosis<1 year at enrolment. Patient characteristics between inception and non-inception cohorts were compared using Wilcoxon rank-sum (continuous variables) or Pearson’s Chi-squared tests (categorical variables). Survival analyses were performed to examine the association between LLDAS attainment and damage accrual and flare.

Results

The study cohort included 4,106 patients of whom 680 (16%) were recruited within 1 year of SLE diagnosis (inception cohort). Compared to the non-inception cohort, inception cohort patients were significantly younger, had higher disease activity (SLEDAI-2K and physician global assessment), used more glucocorticoids and immunosuppressants but had less organ damage at enrolment and only 88 (13.6%) patients accrued damage during a median 2.2 years follow-up (Table 1).

Table 1.Non-inception cohortInception cohortp-valuen=3426n=680Age at enrolment (years), median [IQR]40 [31, 51]33 [25, 44]<0.001Age at diagnosis (years), median [IQR]28 [21, 38]33 [25, 43]<0.001SLE duration at enrolment (years), median [IQR]10 [5, 16]1 [0, 1]<0.001Study duration (years), median [IQR]2.5 [1.0, 5.4]2.2 [0.9, 3.7]<0.001Females, n (%)3155 (92.1%)623 (91.6%)0.68Asian ethnicity, n (%)3037 (89.1%)595 (88.1%)0.49Prednisolone (PNL) use - ever, n (%)2865 (83.6%)620 (91.2%)<0.001Time adjusted mean (TAM)-PNL, median [IQR]5.0 [2.2, 8.6]6.2 [3.2, 10.3]<0.001Cumulative PNL (g), median [IQR]3.4 [0.5, 9.7]3.8 [1.1, 8.5]0.26Anti-Malarial use - ever, n (%)2669 (77.9%)569 (83.7%)<0.001Immunosupressant use -ever, n (%)2367 (69.1%)521 (76.6%)<0.001AMS (TAM-SLEDAI-2K), median [IQR]2.8 [1.2, 4.6]3.1 [1.6, 5.0]0.002TAM-PGA, median [IQR]0.4 [0.2, 0.7]0.4 [0.3, 0.8]<0.001Mild/moderate/severe flare ever, n (%)1789 (52.2%)391 (57.5%)0.012Organ damage accrual, n (%)629 (20.8%)88 (13.6%)<0.001LLDAS at baseline, n (%)1730 (50.5%)195 (28.7%)<0.001LLDAS-ever (at least once), n (%)2637 (78.2%)492 (73.9%)0.014≥50% time in LLDAS (LLDAS-5), n (%)1612 (50.6%)256 (41.1%)<0.001

Significantly fewer inception cohort patients were in LLDAS at enrolment than the non-inception cohort (29% vs. 51%, p<0.001). However, 74% of inception and 78% of non-inception cohort patients achieved LLDAS at least once during follow-up. Limiting analysis only to patients not in LLDAS at enrolment, time to first LLDAS attainment was assessed: inception cohort patients were 60% more likely to attain their first LLDAS (HR = 1.60 (95%CI: 1.40, 1.82), p<0.001) than non-inception cohort patients. LLDAS attainment was significantly protective against flare in the inception (HR, 95% CI) and non-inception (HR, 95% CI) cohorts. Trends towards protection against damage accrual in association with LLDAS in the inception cohort were not significant.

Conclusion

LLDAS attainment is protective from flare in recent onset SLE. Significant protection from damage accrual was not observed, due to low rates of damage accrual in the first years after SLE diagnosis.

References

[1]Golder, V., et al., Lupus low disease activity state as a treatment endpoint for systemic lupus erythematosus: a prospective validation study. The Lancet Rheumatology, 2019. 1(2): p. e95-e102.

Acknowledgements

We thank all patients participating in the Asia Pacific Lupus Collaboration (APLC) cohort, and all data collectors for their ongoing support for APLC research activities.

The APLC has received unrestricted project grants from AstraZeneca, BMS, Eli Lily, Janssen, Merck Serono, and UCB to support data collection contributing to this work.

Disclosure of Interests

Vera Golder: None declared, Rangi Kandane-Rathnayake: None declared, Worawit Louthrenoo: None declared, Yi-Hsing Chen Speakers bureau: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, GSK, Astra& Zeneca, Sanofi, MSD, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Consultant of: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, GSK, Astra and Zeneca, Sanofi, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Gilead, Grant/research support from: Yes. Clinical trials and/or research grants from Pfizer, Norvatis, BMS, Abbevie, Johnson & Johnson, Roche,Sanofi, Guigai, Roche, Boehringer Ingelheim, UCB, MSD, Astra-Zeneca,Astellas, Gilead, Jiacai Cho: None declared, Aisha Lateef: None declared, Laniyati Hamijoyo Speakers bureau: Pfizer, Novartis, Abbot, Shue Fen Luo: None declared, Yeong-Jian Jan Wu Speakers bureau: Pfizer, Lilly, Novartis, Abbvie, Sandra Navarra Speakers bureau: Pfizer, Johnson & Johnson, Novartis, Astellas, Grant/research support from: Astellas, Johnson & Johnson, Leonid Zamora: None declared, Zhanguo Li Speakers bureau: Eli, Lilly, Novartis, GSK, AbbVie, Paid instructor for: Pfizer, Roche, Johnson, Consultant of: Lilly, Pfizer, Grant/research support from: Pfizer, Yuan An: None declared, Sargunan Sockalingam Speakers bureau: Yes. Pfizer, Roche, Novartis, Grant/research support from: Roche and Novartis, Yasuhiro Katsumata Speakers bureau: Chugai Pharmaceutical Co., Ltd., Glaxo-Smithkline K.K., and Sanofi K.K., Masayoshi Harigai Speakers bureau: MH has received speaker’s fee from AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc.,Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Pfizer Japan Inc., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd, Consultant of: MH is a consultant for AbbVie, Boehringer-ingelheim, Bristol Myers Squibb Co., Kissei Pharmaceutical Co.,Ltd. and Teijin Pharma., Grant/research support from: MH has received research grants from AbbVie Japan GK, Asahi Kasei Corp., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Daiichi-Sankyo, Inc.,Eisai Co., Ltd., Kissei Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., Sekiui Medical, Shionogi & Co., Ltd., Taisho Pharmaceutical Co., Ltd., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd., Yanjie Hao: None declared, Zhuoli Zhang Speakers bureau: Norvatis, GSK, Pfizer, BMDB Basnayake: None declared, Madelynn Chan Speakers bureau: AbbVie, Novartis, Consultant of: Advisory Board member for Pfizer, Eli-Lilly, Jun Kikuchi: None declared, Tsutomu Takeuchi Speakers bureau: AbbVie AYUMI Pharmaceutical Corp. Bristol-Myers Squibb Chugai Pharmaceutical Co, Ltd. Daiichi Sankyo Co., Ltd. Eisai Co., Ltd. Eli Lilly Japan, Gilead Sciences, Inc. Mitsubishi-Tanabe Pharma Corp. Pfizer Japan Inc. Sanofi K.K., Consultant of: Astellas Pharma, Inc. Chugai Pharmaceutical Co, Ltd. Eli Lilly Japan, Mitsubishi-Tanabe Pharma Corp., Grant/research support from: AbbVie Asahikasei Pharma Corp. Chugai Pharmaceutical Co, Ltd. Mitsubishi-Tanabe Pharma Corp. Sanofi K.K, Sang-Cheol Bae: None declared, Sean O’Neill Paid instructor for: Advisory board member for GSK, Fiona Goldblatt: None declared, Shereen Oon: None declared, Kathryn Gibson Speakers bureau: UCB, Consultant of: Novartis – co-chair for NSW and steering committee member for ARISE meeting Feb 2021

Janssen Pharmaceuticals – advisory board, Grant/research support from: Novartis, Employee of: Eli Lilly, Kristine Ng Speakers bureau: speaker fees and advisory board (Abbvie, Novartis, Janssen), Annie Law: None declared, Nicola Tugnet: None declared, Sunil Kumar: None declared, Cherica Tee: None declared, Michael Tee: None declared, Yoshiya Tanaka Speakers bureau: Daiichi-Sankyo, Eli Lilly, Novartis, YL Biologics, Bristol-Myers, Eisai, Chugai, Abbvie, Astellas, Pfizer, Sanofi, Asahi-kasei, GSK, Mitsubishi-Tanabe, Gilead, Janssen, Grant/research support from: Daiichi-Sankyo, Eli Lilly, Novartis, YL Biologics, Bristol-Myers, Eisai, Chugai, Abbvie, Astellas, Pfizer, Sanofi, Asahi-kasei, GSK, Mitsubishi-Tanabe, Gilead, Janssen, C.S. Lau Shareholder of: Pfizer, Sanofi and Janssen, Mandana Nikpour Speakers bureau: Actelion, GSK, Janssen, Pfizer, UCB, Paid instructor for: UCB, Consultant of: Actelion, Boehringer Ingelheim, Certa Therapeutics, Eli Lilly, GSK, Janssen, Pfizer, UCB, Grant/research support from: Actelion, Astra Zeneca, BMS, GSK, Janssen, UCB, Alberta Hoi Consultant of: AH is on the advisory board for Abbvie and GSK, Grant/research support from: AH has received research support from AstraZeneca, GSK, BMS, Janssen, and Merck Serono, Eric F. Morand Speakers bureau: AstraZeneca, Paid instructor for: Eli Lilly, Consultant of: AstraZeneca, Amgen, Biogen, BristolMyersSquibb, Eli Lilly, EMD Serono, Genentech, Janssen, Grant/research support from: AstraZeneca, BristolMyersSquibb, Eli Lilly, EMD Serono, Janssen

Ultrasound-guided Manual Vacuum Aspiration is an optimal method for obtaining products of conception from early pregnancy loss for cytogenetic testing

OBJECTIVE

The culture failure rate of conventional karyotyping in products of conception evacuated from early pregnancy loss by traditional electrical vacuum aspiration and/or dilation & curettage remains high. We aim to determine whether obtaining products of conception from early pregnancy loss via another evacuation approach, ultrasound-guided manual vacuum aspiration, could decrease the culture failure rate of karyotyping.

METHODS

For patients with early pregnancy loss, ultrasound-guided manual vacuum aspiration (Case group) and traditional electrical vacuum aspiration and/or dilation & curettage (Control group) were applied as surgical methods for pregnancy loss management respectively. The evacuated products of conception were subjected to cytogenetic karyotyping analysis. The primary outcome was the culture failure rate of karyotyping. Secondary outcomes included the chromosomal abnormality spectrum, maternal cell contamination, and complications from the manual vacuum aspiration procedure.

RESULTS

For the case group, 132 products of conception were genetically analyzed by conventional karyotyping. The culture failure rate was significantly lower than that of the control cohort (2.3% vs 7.4%, p = 0.027). 65.2% of cases were abnormal within the detection scope of karyotyping. The euploid female to male ratio was 0.82 (18:22), suggesting a lower likelihood of maternal cell contamination. The efficacy in achieving complete evacuation was 99.6%. There were no significant complications from the procedure.

CONCLUSION

Ultrasound-guided manual vacuum aspiration approach significantly decreased the culture failure rate of karyotyping and decreased maternal cell contamination tendency, enabling a high and accurate cytogenetic diagnosis. It is especially crucial when the cytogenetic analysis is required in the early pregnancy loss clinics.

AB0428 TREATMENT PATTERNS OF SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS IN TAIWAN – A POPULATION-BASED ANALYSIS

Background

Systemic lupus erythematosus (SLE) is a chronic, autoimmune disease of an unknown etiology with a broad spectrum of organ manifestations, and patients with SLE have limited treatment options to NSAIDS, glucocorticoids, hydroxychloroquine and immunosuppressants. There is a lack of real-world evidence related to treatment patterns of SLE patients in Taiwan.

Objectives

To describe the real-world patient demographics, clinical characteristics, and treatment patterns of patients with SLE in Taiwan.

Methods

A retrospective observational study using Taiwan’s National Health Insurance Research Database (NHIRD) from 1/1/2014 to 12/31/2019 was undertaken. Patients holding catastrophic illness certificates for SLE in 2015-2017 were identified. Enrolled patients aged ≥ 18 years were then divided into three groups (mild, moderate, and severe) based on the highest severity patients experienced in the one year following the enrollment date using a published claims-based algorithm (Garris et al 2013) that incorporates the Systemic Lupus Erythematosus Disease Activity Index, Systemic Lupus Activity Measure, British Isles Lupus Assessment Group Index and expert clinical opinion, and indexed upon the first date of entering the severity group. Baseline patient characteristics and treatment patterns during the follow-up period were measured. The types of treatment considered were NSAIDs, glucocorticoids, hydroxychloroquine and immunosuppressants.

Results

A total of 20,181 patients with catastrophic illness certificates for SLE were included in this study. The mean age of all SLE patients was 46.5 years and patients were mostly female (89.1%). The mean Charlson Comorbidity Index (CCI) score of all SLE patients was 1.5 (SD 1.3). Of these patients, 29.3% (n=5,918) had mild SLE activity, 60.7% (n=12,253) moderate and 10.0% (n=2,010) severe. During the one-year follow-up period, moderate to severe patients had numerically higher utilization rate of all types of treatment compared with mild patients (Table 1). Of all oral glucocorticoid users,27.8% of severe patients used high-dose glucocorticoids (> 15 mg/day) compared to <0.1% for mild and 9.7% for moderate patients. More than 70.0% of moderate to severe patients were prescribed 2 or more types of treatment at the same point of time. Of these patients having concomitant treatment of glucocorticoids with immunosuppressants, glucocorticoid dosage increased with the number of immunosuppressant used, especially in severe patients. 80.4% of moderate to severe patients received glucocorticoid-based therapy as the first-line treatment and the median treatment duration was 3.1 months. The median treatment duration of each first-line immunosuppressant ranged from 0.9 to 4.8 months in moderate to severe patients.

Table 1.

SLE treatment utilization during the 1-year follow-up period

Total (n=20,181)`Mild (n=5,918)Moderate (n=12,253)Severe (n=2,010)n%n%n%n%NSAID7,21235.71,40523.74,98340.782441.0Glucocorticoid14,01969.52,01534.110,29784.01,70784.9Hydroxychloroquine13,27865.82,86748.58,97073.21,44171.7Immunosuppressant7,63037.800.06,31951.61,31165.2Methotrexate8984.500.07866.41125.6Azathioprine5,64228.000.04,84339.579939.8Leflunomide1320.700.01171.0150.8Cyclosporin8544.200.07155.81396.9Mycophenolate9594.800.07746.31859.2Cyclophosphamide7903.900.0170.177338.5

Conclusion

The complexity and intensity of therapeutic approaches in SLE were associated with increased disease severity and patients were often resistant to treatment. These findings reflect the disease burden in SLE patients and suggest there is a substantial unmet need in the SLE treatment paradigm for moderate to severe SLE patients.

References

[1]Garris C, et al. J Med Econ. 2013;16:667–677.

Disclosure of Interests

Yu Sheng Chang: None declared, Wen-Nan Huang: None declared, Chao-Hsiun Tang: None declared, Khai Ng Shareholder of: I am a minor shareholder of Eli Lilly & Company, Employee of: I am an employee of Eli Lilly & Company, Po-Ya Chuang Consultant of: I am a paid consultant for Eli Lilly &Company, Wesley Furnback Consultant of: I am a paid consultant for Eli Lilly & Company, Bruce Wang Consultant of: I am a paid consultant for Eli Lilly & Company, Ching-Yun Wei Shareholder of: I am a minor shareholder of Eli Lilly & Company, Employee of: I am an employee of Eli Lilly & Company, Bradley Wang Shareholder of: I am a minor shareholder of Eli Lilly & Company, Employee of: I am an employee of Eli Lilly & Company

, Tamas Treuer Shareholder of: I am a minor shareholder of Eli Lilly & Company, Employee of: I am an employee of Eli Lilly & Company

Osimertinib and anti-HER3 combination therapy engages immune dependent tumor toxicity via STING activation in trans

Over the past decade, immunotherapy delivered novel treatments for many cancer types. However, lung cancer still leads cancer mortality, and non-small-cell lung carcinoma patients with mutant EGFR cannot benefit from checkpoint inhibitors due to toxicity, relying only on palliative chemotherapy and the third-generation tyrosine kinase inhibitor (TKI) osimertinib. This new drug extends lifespan by 9-months vs. second-generation TKIs, but unfortunately, cancers relapse due to resistance mechanisms and the lack of antitumor immune responses. Here we explored the combination of osimertinib with anti-HER3 monoclonal antibodies and observed that the immune system contributed to eliminate tumor cells in mice and co-culture experiments using bone marrow-derived macrophages and human PBMCs. Osimertinib led to apoptosis of tumors but simultaneously, it triggered inositol-requiring-enzyme (IRE1α)-dependent HER3 upregulation, increased macrophage infiltration, and activated cGAS in cancer cells to produce cGAMP (detected by a lentivirally transduced STING activity biosensor), transactivating STING in macrophages. We sought to target osimertinib-induced HER3 upregulation with monoclonal antibodies, which engaged Fc receptor-dependent tumor elimination by macrophages, and STING agonists enhanced macrophage-mediated tumor elimination further. Thus, by engaging a tumor non-autonomous mechanism involving cGAS-STING and innate immunity, the combination of osimertinib and anti-HER3 antibodies could improve the limited therapeutic and stratification options for advanced stage lung cancer patients with mutant EGFR.

781 IMPROVING THE QUALITY OF DO NOT ATTEMPT CARDIO-PULMONARY RESUSCITATION (DNACPR) FORM COMPLETION

Introduction

The completion of a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) form represents an important part of patient care. However, this can be a sensitive process that has gained national media interest. The aim of this Quality Improvement (QI) Project was to improve the quality of DNACPR form completion in a Care of the Elderly Department.

Methods

The QI project ran from May 2019 to January 2021 and was overseen by a multi-disciplinary team (including patient representation). DNACPR forms on the Care of the Elderly wards were audited monthly against 7 standards which correspond to key sections on the DNACPR form. During the data collection process, interventions were implemented using Plan-Do-Study-Act cycles. Interventions included: appointing ‘DNACPR Champions’ to complete monthly audits and provide personalised clinician feedback, the introduction of a new mandatory e-learning module, the creation of an alert system on nerve centre (the Trust’s electronic handover system) and the development of new DNACPR patient information including webpage development, videos and leaflets.

Results

The project has led to sustained improvements in majority of the 7 standards. The biggest improvements were seen in the inclusion of a review date, correct completion of the mental capacity assessment and the use of patient information leaflets. The documentation of discussions with patient and relatives remained below the audit standards and was largely unchanged during the QI project.

Conclusion

A multi-disciplinary and multi-faceted QI approach has shown to improve the quality of DNACPR form completion. Further work is needed to continue this process and a focus on staff training and ward-level processes will be the priority.

Virtual medical research mentoring and collaboration: breaking the bounds of nationality during the COVID-19 pandemic

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Cardioovascular Analytics Group

Background

Medical research is critical to professional advancement, and mentoring is an important means of early research engagement in medical training. In contrast to international research collaborations, research mentoring programs are often locally limited. With the COVID-19 pandemic causing drifts to virtual classes and conferences, virtual international medical research mentoring may be viable. We hereby describe our experience with a virtual, international mentorship group for cardiovascular research.

Methods

Our virtual international research mentorship group has been running since 2015. The group focuses on risk stratification and outcomes research in cardiovascular medicine and epidemiology. Mentees from any country or region in all stages of medical careers are welcomed. Considering the increasing emphasis of contemporary research on multidisciplinary healthcare and translational research, our team also includes allied healthcare professionals or students, and graduates from natural sciences (Figure 1). With our members’ diverse backgrounds, we firmly adhere to the principle that all members must be given equal opportunities and treatment, regardless of their age, gender, race, nationality, sexual orientation, family background, and institution of study or practice. We make use of virtual platforms and multi-level mentoring (both senior and peer mentoring), and emphasize active participation, early leadership, open culture, accessible research support, and a distributed research workflow (i.e. an accessible-distributed model).

Results

Since establishment, our group has expanded to include 63 active members from 14 countries (Figure 2), leading a total of 109 peer-reviewed original studies and reviews published. We observed no significant difficulty in communication between team members, nor conflicts due to differences in nationality or ethnicity. Most studies involve cross-country and ethnicity collaborations, and inter-disciplinary and inter-regional knowledge exchanges are frequent. Multi-level mentoring ensured mentoring quality without compromising bonding and communication.

Conclusion

An accessible-distributed model of virtual international medical research collaboration and multi-level mentoring is viable, efficient, and caters to the needs of contemporary healthcare. We hope that others will build similar models and improve medical research mentoring globally.

Abstract PO-077: Establishment of a novel living biobank of patient-derived pancreatic cancer organoids with genomic and drug response characterization

Advanced pancreatic cancer has a dismal prognosis and current treatment options (FOLFIRINOX, Gemcitabine/nab-paclitaxel [GnP]) are associated with toxicity. Although some patients achieve partial responses, most progress rapidly and become chemorefractory. While RNA subtypes, genomic alterations, and protein biomarkers have prognostic value, predictive biomarkers to guide therapy are needed. Patient-derived organoids (PDOs) are an increasingly popular model for predicting patient responses to standard-of-care therapy and investigating personalized therapy options. We present a novel biobank of 42 PDOs and drug profiling data with 5 standard of care agents and 3 kinase inhibitors. Tissue was processed from n=103 biopsies from 97 patients with a confirmed pathologic diagnosis of advanced (Stage III-IV) pancreatic ductal adenocarcinoma who presented to a single Canadian tertiary care centre between 2017-2020. Matched WGS was available in all cases. Our PDO generation success was 42/103 (41%). We observed a trend towards decreased establishment in tumors that were KRAS WT, TP53 WT, or had higher HRDetect scores. Conversely, polyploidy, SMAD4 WT, and major imbalances in mutant KRAS were associated with successful PDO establishment. These associations were not statistically significant after multiple comparisons correction, but suggest selection for success with more aggressive tumors. Drug profiling was performed on all 42 PDOs with the individual agents of FOLFIRINOX (5-FU, irinotecan, oxaliplatin), GnP (gemcitabine, paclitaxel), and three targeted agents (afatinib, trametinib, and talazoparib). Combination testing was also performed for gemcitabine + paclitaxel. Drug responses were measured through both viability and growth rate (GRMetrics). We found that GRMetrics minimized effects from different PDO growth rates. Matched clinical data were available for 23 patients who received FOLFIRINOX, 11 patients who received GnP, and one patient who received gemcitabine monotherapy. Similar to previous studies, we found that in vitro PDO responses to 5-FU, irinotecan, and GnP were correlated with patient responses based on RECIST criteria. Interestingly, and similar to previous reports in colorectal cancer PDOs, we found that oxaliplatin responses were not predictive of RECIST response. As expected, PDOs were resistant to afatinib (EGFRi), which reflects negative clinical trials, and may also be masked by use of EGF in growth media. A range of responses to trametinib (MEKi) were seen but were not correlated with KRAS allelic dosage. A similar range of response was seen to talazoparib (PARPi), but did not correlate with oxaliplatin response or HRDetect scores. In summary, we have established a novel biobank of PDOs from advanced pancreatic cancer patients. Notably, PDOs were less likely to establish from tumors that were KRAS WT or HR-deficient, even though these patients are likely to benefit from targeted approaches. Further investigation is required to develop PDO use in clinical drug prediction and drug discovery.

Citation Format: Irene Y. Xie, Laura Tamblyn, Karen Ng, Eugenia Flores-Figueroa, Julie M. Wilson, Gun Ho Jang, Amy X. Zhang, Stephanie Ramotar, Anna Dodd, Nikolina Radulovich, Jennifer J. Knox, Grainne M. O'Kane, Steven Gallinger, Faiyaz Notta. Establishment of a novel living biobank of patient-derived pancreatic cancer organoids with genomic and drug response characterization [abstract]. In: Proceedings of the AACR Virtual Special Conference on Pancreatic Cancer; 2021 Sep 29-30. Philadelphia (PA): AACR; Cancer Res 2021;81(22 Suppl):Abstract nr PO-077.

Cookiecutter Shark-Related Injuries: A New Threat to Swimming Across the Ka'iwi Channel

In a 5-month period in 2019, 3 long-distance swimmers sustained cookiecutter shark-related injuries while attempting to cross the Ka'iwi Channel between the Hawaiian Islands of O'ahu and Moloka'i. This report is the first case series of cookiecutter shark bites on live humans. A retrospective review of the State of Hawai'i Division of Aquatic Resources Shark Incidents List was conducted between March 1, 2019, and July 31, 2019. Trauma registry data and medical records were reviewed in patients treated for cookiecutter shark bites at The Queen's Medical Center in Honolulu, Hawai'i. All 3 patients sustained nonfatal cookiecutter shark bite circular wounds measuring between 8-13 cm in diameter. They were injured swimming over waters with depths of greater than 2000 feet at night. Patients had prolonged transport times to the emergency department (ED), averaging 73 minutes, due to their injuries occurring on the open water. All were hemodynamically stable upon ED arrival and did not require blood products. Tetanus toxoid was updated, and prophylactic antibiotic coverage, including doxycycline for Vibrio spp., was administered. Two of 3 patients were treated with operative management. Open water swimmers crossing the deep waters between the Hawaiian Islands at night are most at risk for cookiecutter shark bites. Wounds may penetrate down to and through the fascial level. Immediate life-saving hemorrhage control administered by personnel accompanying the swimmers on the open water is important for preventing morbidity and mortality. Antibiotic prophylaxis for marine bacteria is recommended.

POS0028 DEFINING THE PREVALENCE OF UNMET NEED IN SLE: DATA FROM A LARGE MULTINATIONAL LONGITUDINAL SLE COHORT

Background:

The recent prospectively validated definition of the lupus low disease activity state (LLDAS) allows characterisation of patients not achieving a treatment goal, providing impetus for an analysis of unmet needs in SLE using formal definitions. Other recently described definitions of high disease burden include disease activity over time, high disease activity status (HDAS) episodes, and the combination of high disease activity, serological activity and glucocorticoid (GC) use (HDAS+SA+GC).

Objectives:

To determine the prevalence of formal categories of unmet need, and the association of these with adverse outcomes, in SLE.

Methods:

Data from a 13-country longitudinal SLE cohort (ACR/SLICC criteria) were collected between 2013 and 19 using standard templates. Unmet need was defined as (i) patients never attaining LLDAS defined as in Golder et al., 2019 [1], (ii) having persistently active disease (time adjusted mean SLEDAI-2K (AMS) > 4), (iii) ever exhibiting high disease activity status (HDAS; SLEDAI-2K ≥10[2]), or (iv) ever exhibiting all of SLEDAI≥10, serological activity, and glucocorticoid use (HDAS+SA+GC)[3]. Health-related quality of life (HRQoL) was assessed using SF36 (v2) surveys and damage accrual using SLE Damage Index (SDI).

Results:

3,384 SLE patients were followed for 30,313 visits over median [IQR] 2.4 [0.4, 4.3] years. 53% of all visits were not in LLDAS; 813 patients (24%) never achieved LLDAS during observation. Median AMS was 3.0 [1.4, 4.9] and 34% of patients had AMS > 4 throughout the study. 25% of patients had at least one episode of HDAS, representing 8% of visits. 702 patients (21%) had at least one episode of HDAS+SA+GC, representing 8% of visits. Each of never-LLDAS, AMS>4, ever-HDAS, and ever-HDAS+SA+GC were associated with significantly greater number of physician visits, higher mean glucocorticoid dose, lower HRQoL and higher mortality. 31%, 58% and 83% of never-LLDAS, AMS>4, and ever-HDAS patients respectively were also HDAS+SA+GC on at least one occasion.

Conclusion:

Data from a multinational longitudinal SLE cohort indicate that unmet need, defined by LLDAS-never, AMS>4, HDAS, or HDAS+SA+GC, is prevalent in SLE, and that these definitions are associated with poor outcomes.

References:

[1]Golder, V., et al., Lupus low disease activity state as a treatment endpoint for systemic lupus erythematosus: a prospective validation study. The Lancet Rheumatology, 2019. 1(2): p. e95-e102.

[2]Koelmeyer, R., et al., High disease activity status suggests more severe disease and damage accrual in systemic lupus erythematosus. Lupus Sci Med, 2020. 7(1).

[3]van Vollenhoven, R.F., et al., Belimumab in the treatment of systemic lupus erythematosus: high disease activity predictors of response. Annals of the Rheumatic Diseases, 2012. 71(8): p. 1343-1349.

Acknowledgements:

The APLC acknowledges all the Data Collectors and Patients for their valuable contributions to research.

Disclosure of Interests:

Rangi Kandane-Rathnayake: None declared, Worawit Louthrenoo: None declared, Alberta Hoi Consultant of: Abbvie and GSK, Grant/research support from: AstraZeneca, GSK, BMS, Janssen, and Merck Serono, Vera Golder: None declared, Yi-Hsing Chen Speakers bureau: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, AstraZeneca, Sanofi, MSD, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Consultant of: Pfizer, Novartis, Abbvie, Johnson & Johnson, BMS, Roche, Lilly, AstraZeneca, Sanofi, MSD, Guigai, Astellas, Inova Diagnostics, UCB, Agnitio Science Technology, United Biopharma, Thermo Fisher, Gilead, Grant/research support from: Pfizer, Norvatis, BMS, Abbevie, Johnson & Johnson, Roche, Sanofi, Guigai, Roche, Boehringer Ingelheim, UCB, MSD, Astra-Zeneca, Astellas, Gilead, Shue Fen Luo: None declared, Yeong-Jian Jan Wu Speakers bureau: Pfizer, Lilly, Novartis, Abbvie, Aisha Lateef: None declared, Jiacai Cho: None declared, Laniyati Hamijoyo Speakers bureau: Pfizer, Novartis, Abbot, Chak Sing Lau Shareholder of: Pfizer, Sanofi, and Janssen, Sandra Navarra Speakers bureau: Pfizer, Johnson & Johnson, Novartis, Astellas, Grant/research support from: Astellas, Johnson & Johnson, Leonid Zamora: None declared, Zhanguo Li Speakers bureau: Eli, Lilly, Novartis, GSK, AbbVie, Paid instructor for: Pfizer, Roche, Johnson., Consultant of: Lilly, Pfizer, Grant/research support from: Pfizer, Yuan An: None declared, Sargunan Sockalingam Speakers bureau: Pfizer, Roche, Novartis, Grant/research support from: Roche and Novartis, Yasuhiro Katsumata Speakers bureau: Chugai Pharmaceutical Co., Ltd., Glaxo-Smithkline K.K., and Sanofi K.K., masayoshi harigai Speakers bureau: AbbVie Japan GK, Ayumi Pharmaceutical Co., Boehringer Ingelheim Japan, Inc.,Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan K.K., GlaxoSmithKline K.K., Kissei Pharmaceutical Co., Ltd., Pfizer Japan Inc., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd., Consultant of: AbbVie, Boehringer-ingelheim, Bristol Myers Squibb Co., Kissei Pharmaceutical Co.,Ltd. and Teijin Pharma., Grant/research support from: AbbVie Japan GK, Asahi Kasei Corp., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Bristol Myers Squibb Co., Ltd., Chugai Pharmaceutical Co., Daiichi-Sankyo, Inc.,Eisai Co., Ltd., Kissei Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Nippon Kayaku Co., Ltd., Sekiui Medical, Shionogi & Co., Ltd., Taisho Pharmaceutical Co., Ltd., Takeda Pharmaceutical Co., Ltd., and Teijin Pharma Ltd., Yanjie Hao: None declared, Zhuoli Zhang Speakers bureau: Norvatis, GSK, Pfizer, Jun Kikuchi: None declared, Tsutomu Takeuchi Speakers bureau: AbbVie AYUMI Pharmaceutical Corp. Bristol-Myers Squibb Chugai Pharmaceutical Co, Ltd. Daiichi Sankyo Co., Ltd. Eisai Co., Ltd. Eli Lilly Japan, Gilead Sciences, Inc. Mitsubishi-Tanabe Pharma Corp. Pfizer Japan Inc. Sanofi K.K., Consultant of: Astellas Pharma, Inc. Chugai Pharmaceutical Co, Ltd. Eli Lilly Japan, Mitsubishi-Tanabe Pharma Corp., Grant/research support from: AbbVie, Asahikasei Pharma Corp. Chugai Pharmaceutical Co, Ltd. Mitsubishi-Tanabe Pharma Corp. Sanofi K.K., BMDB Basnayake: None declared, Fiona Goldblatt: None declared, Madelynn Chan Speakers bureau: AbbVie, Novartis, Consultant of: Pfizer, Eli-Lilly, Kristine Ng Speakers bureau: Abbvie, Novartis, Janssen, Sang-Cheol Bae: None declared, Shereen Oon: None declared, Sean O’Neill Consultant of: GSK, Kathryn Gibson Speakers bureau: UCB, Consultant of: Novartis, Janssen, Grant/research support from: Novartis, Sunil Kumar: None declared, Nicola Tugnet: None declared, Yoshiya Tanaka Speakers bureau: Daiichi-Sankyo, Eli Lilly, Novartis, YL Biologics, Bristol-Myers, Eisai, Chugai, Abbvie, Astellas, Pfizer, Sanofi, Asahi-kasei, GSK, Mitsubishi-Tanabe, Gilead, Janssen, Grant/research support from: Abbvie, Mitsubishi-Tanabe, Chugai, Asahi-Kasei, Eisai, Takeda, Daiichi-Sankyo, Mandana Nikpour Speakers bureau: Actelion, GSK, Janssen, Pfizer, UCB, Paid instructor for: UCB, Consultant of: Actelion, Boehringer Ingelheim, Certa Therapeutics, Eli Lilly, GSK, Janssen, Pfizer, UCB, Grant/research support from: Actelion, Astra Zeneca, BMS, GSK, Janssen, UCB, Eric F. Morand Speakers bureau: AstraZeneca, Paid instructor for: Eli Lilly, Consultant of: AstraZeneca, Amgen, Biogen, BristolMyersSquibb, Eli Lilly, EMD Serono, Genentech, Janssen, Grant/research support from: AstraZeneca, BristolMyersSquibb, Eli Lilly, EMD Serono, Janssen.

A mixed methods evaluation of a 4-week geriatrics curriculum in strengthening knowledge and comfort among orthopaedic surgery residents

BACKGROUND

In 2014, the University of Toronto Faculty of Medicine implemented a 4-week "Orthogeriatrics" rotation for orthopaedic surgery residents. We sought to assess the rotation's impact on trainees' knowledge, attitudes, and behaviours toward caring for older adults, and explore areas for improvement.

METHODS

We used a mixed methods concurrent triangulation design. The Geriatrics Clinical Decision-Making Assessment (GCDMA) and Geriatric Attitudes Scale (GAS) compared knowledge, attitudes, and behaviours between trainees who were or were not exposed to the curriculum. Rotation evaluations and semi-structured interviews with trainees and key informants explored learning experiences and the curriculum's impact on resident physician growth and development in geriatric competencies.

RESULTS

Among trainees who completed the GCDMA (n = 19), those exposed to the rotation scored higher in knowledge compared to the unexposed cohort (14.4 ± 2.1 vs. 11.3 ± 2.0, p < 0.01). The following themes emerged from the qualitative analysis of 29 stakeholders: Increased awareness and comfort regarding geriatric medicine competencies, appreciation of the value of orthogeriatric collaboration, and suggestions for curriculum improvement.

CONCLUSIONS

These results suggest that the Orthogeriatrics curriculum strengthens knowledge, behaviour, and comfort towards caring for older adults. Our study aims to inform further curriculum development and facilitate dissemination of geriatric education in surgical training programs across Canada and the world.

The Role of the Pharmacist in the Care of Patients with Chronic Pain

Pharmacists across the healthcare continuum are well positioned to collaborate with patients to effectively manage their chronic pain. Evidence supports positive outcomes when pharmacists undertake these roles; however, there are barriers preventing uptake across the profession. This paper aims to expand awareness of the breadth of these roles, including pharmaceutical care provision, interprofessional collaboration, pain and medication education, support for patients in self-management and acceptance of responsibility to be culturally responsive and decrease stigma. Pharmacists are accessible healthcare professionals and can improve the care of patients with chronic pain.