Cholesterol accumulation impairs HIF-1α-dependent immunometabolic reprogramming of LPS-stimulated macrophages by upregulating the NRF2 pathway

Lipid accumulation in macrophages (Mφs) is a hallmark of atherosclerosis. Yet, how lipid loading modulates Mφ inflammatory responses remains unclear. We endeavored to gain mechanistic insights into how pre-loading with free cholesterol modulates Mφ metabolism upon LPS-induced TLR4 signaling. We found that activities of prolyl hydroxylases (PHDs) and factor inhibiting HIF (FIH) are higher in cholesterol loaded Mφs post-LPS stimulation, resulting in impaired HIF-1α stability, transactivation capacity and glycolysis. In RAW264.7 cells expressing mutated HIF-1α proteins resistant to PHDs and FIH activities, cholesterol loading failed to suppress HIF-1α function. Cholesterol accumulation induced oxidative stress that enhanced NRF2 protein stability and triggered a NRF2-mediated antioxidative response prior to and in conjunction with LPS stimulation. LPS stimulation increased NRF2 mRNA and protein expression, but it did not enhance NRF2 protein stability further. NRF2 deficiency in Mφs alleviated the inhibitory effects of cholesterol loading on HIF-1α function. Mutated KEAP1 proteins defective in redox sensing expressed in RAW264.7 cells partially reversed the effects of cholesterol loading on NRF2 activation. Collectively, we showed that cholesterol accumulation in Mφs induces oxidative stress and NRF2 stabilization, which when combined with LPS-induced NRF2 expression leads to enhanced NRF2-mediated transcription that ultimately impairs HIF-1α-dependent glycolytic and inflammatory responses.

Oxidized Low-Density Lipoprotein Accumulation in Macrophages Impairs Lipopolysaccharide-Induced Activation of AKT2, ATP Citrate Lyase, Acetyl-Coenzyme A Production, and Inflammatory Gene H3K27 Acetylation

The accumulation of lipid and the formation of macrophage foam cells is a hallmark of atherosclerosis, a chronic inflammatory disease. To better understand the role of macrophage lipid accumulation in inflammation during atherogenesis, we studied early molecular events that follow the accumulation of oxidized low-density lipoprotein (oxLDL) in cultured mouse macrophages. We previously showed that oxLDL accumulation downregulates the inflammatory response in conjunction with downregulation of late-phase glycolysis. In this study, we show that within hours after LPS stimulation, macrophages with accumulated oxLDL maintain early-phase glycolysis but selectively downregulate activation of AKT2, one of three AKT isoforms. The inhibition of AKT2 activation reduced LPS-induced ATP citrate lyase activation, acetyl-CoA production, and acetylation of histone 3 lysine 27 (H3K27ac) in certain inflammatory gene promoters. In contrast to oxLDL, multiple early LPS-induced signaling pathways were inhibited in macrophages with accumulated cholesterol, including TBK1, AKT1, AKT2, MAPK, and NF-κB, and early-phase glycolysis. The selective inhibition of LPS-induced AKT2 activation was dependent on the generation of mitochondrial oxygen radicals during the accumulation of oxLDL in macrophages prior to LPS stimulation. This is consistent with increased oxidative phosphorylation, fatty acid synthesis, and oxidation pathways found by comparative transcriptomic analyses of oxLDL-loaded versus control macrophages. Our study shows a functional connection between oxLDL accumulation, inactivation of AKT2, and the inhibition of certain inflammatory genes through epigenetic changes that occur soon after LPS stimulation, independent of early-phase glycolysis.

JSI-124 inhibits cell proliferation and tumor growth by inducing autophagy and apoptosis in murine malignant mesothelioma

Malignant pleural mesothelioma (MPM), mainly caused by asbestos exposure, has a poor prognosis and lacks effective treatment compared with other cancer types. The intracellular transcription factor signal transducer and activator of transcription 3 (STAT3) is overexpressed and hyperactivated in most human cancers. In this study, the role of STAT3 in murine MPM was examined. Inhibition of the Janus kinase 2 (JAK2)/STAT3 pathway with the selective inhibitor JSI-124 has an antitumor effect in murine MPM. Specifically, we demonstrated that JSI-124 inhibits murine MPM cell growth and induces apoptotic and autophagic cell death. Exposure of RN5 and AB12 cells to JSI-124 resulted in apoptosis via the Bcl-2 family of proteins. JSI-124 triggered autophagosome formation, accumulation, and conversion of LC3I to LC3II. Autophagy inhibitors, Chloroquine (CQ) and Bafilomycin A1 (Baf-A1), inhibited autophagy and sensitized RN5 and AB12 cells to JSI-124-induced apoptosis. Our data indicate that JSI-124 is a promising therapeutic agent for MPM treatment.

Isolation of tumour-reactive lymphocytes from peripheral blood via microfluidic immunomagnetic cell sorting

The clinical use of tumour-infiltrating lymphocytes for the treatment of solid tumours is hindered by the need to obtain large and fresh tumour fractions, which is often not feasible in patients with unresectable tumours or recurrent metastases. Here we show that circulating tumour-reactive lymphocytes (cTRLs) can be isolated from peripheral blood at high yield and purity via microfluidic immunomagnetic cell sorting, allowing for comprehensive downstream analyses of these rare cells. We observed that CD103 is strongly expressed by the isolated cTRLs, and that in mice with subcutaneous tumours, tumour-infiltrating lymphocytes isolated from the tumours and rapidly expanded CD8+CD103+ cTRLs isolated from blood are comparably potent and respond similarly to immune checkpoint blockade. We also show that CD8+CD103+ cTRLs isolated from the peripheral blood of patients and co-cultured with tumour cells dissociated from their resected tumours resulted in the enrichment of interferon-γ-secreting cell populations with T-cell-receptor clonotypes substantially overlapping those of the patients' tumour-infiltrating lymphocytes. Therapeutically potent cTRLs isolated from peripheral blood may advance the clinical development of adoptive cell therapies.

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.

Conversion of leftover ice cream into bakery product for food sustainability

Food sustainability has become so important nowadays not only in order to ensure all raw materials are converted into food for consumption, but also to recycle leftover food for gastronomy. The innovative product created from leftover or unfinished food is a good alternative to throwing away food by-products. In this study, the unutilized ice cream post -selling or post-production process was reformulated with other ingredients to produce bakery products such as cake. Four different cake formulations were used which consisted of melted leftover ice cream, instant cake mix and eggs. The physical qualities of the samples were investigated, and sensory evaluation was also conducted. Cake made conventionally from instant cake mix without the addition of the leftover ice cream was used as a control sample in this study. Cake produced from melted ice cream using three eggs (sample A) had the highest moisture content among all samples which was 39.09%. The control sample had the highest specific volume (2.99 cm3 /g) which indicated a high amount of air remained in the structure after baking. All samples showed a positive symmetry index which indicated good expansion except for cake produced from melted ice cream with no egg (sample D). Cake produced from melted ice cream with no egg (sample D) had the lowest firmness as compared to other cake samples. Cake produced using melted ice cream which contained two eggs (Sample B) had the highest value of springiness which was 0.94 mm. A plot of chewiness as a function of firmness with an R 2 value of 0.9887 confirms the positive correlation between firmness and chewiness. From the sensory evaluation conducted, the cake produced from melted ice cream using three eggs (sample A) scored the highest mark for colour, aroma, sweetness, taste and overall acceptability among the formulated cakes. The results suggested that using melted ice cream as the base ingredient for cake making would tremendously help in solving food waste created by the by-product of the ice cream business and turn it into profit.

Macrophage Jak2 deficiency accelerates atherosclerosis through defects in cholesterol efflux

Atherosclerosis is a chronic inflammatory condition in which macrophages play a major role. Janus kinase 2 (JAK2) is a pivotal molecule in inflammatory and metabolic signaling, and Jak2^V617F activating mutation has recently been implicated with enhancing clonal hematopoiesis and atherosclerosis. To determine the essential in vivo role of macrophage (M)-Jak2 in atherosclerosis, we generate atherosclerosis-prone ApoE-null mice deficient in M-Jak2. Contrary to our expectation, these mice exhibit increased plaque burden with no differences in macrophage proliferation, recruitment or bone marrow clonal expansion. Notably, M-Jak2-deficient bone marrow derived macrophages show a significant defect in cholesterol efflux. Pharmacologic JAK2 inhibition with ruxolitinib also leads to defects in cholesterol efflux and accelerates atherosclerosis. Liver X receptor agonist abolishes the efflux defect and attenuates the accelerated atherosclerosis that occurs with M-Jak2 deficiency. Macrophages of individuals with the Jak2^V617F mutation show increased efflux which is normalized when treated with a JAK2 inhibitor. Together, M-Jak2-deficiency leads to accelerated atherosclerosis primarily through defects in cholesterol efflux from macrophages.

Pityriasis rubra pilaris-like eruption following administration of the BNT163b2 (Pfizer-BioNTech) mRNA COVID-19 vaccine

We describe a case of a pityriasis rubra pilaris (PRP)-like eruption occurring following administration of the Pfizer-Biontech mRNA COVID-19 vaccine, with worsening of the condition following the second dose. To our knowledge, this is the first reported case of a PRP-like eruption as a cutaneous adverse event of the Pfizer-Biontech mRNA COVID-19 vaccine.

Immunohistochemical expression of PCNA, STRO-1 and CD 44 in the healing of experimentally induced periapical lesions in rats

OBJECTIVE

The aim of the study was to determine the expression of cell proliferating marker, anti-proliferating cell nuclear antigen (anti-PCNA) and mesenchymal stem cell (MSC) markers (anti-STRO-1 and anti-CD44) in periapical periodontitis and their role in the healing of periapical lesion in periapical periodontitis.

MATERIALS AND METHODS

Ninety Sprague-Dawley male rats (100 g) were divided into 3 groups: Experimental group I (EG I: n = 30), experimental group II (EG II: n=30) and control group (CG: n = 30). Periapical lesions were experimentally developed by leaving the dental pulp of maxillary first molars mesial root open to oral environment for 4 weeks. Conventional root canal treatment was performed in EG II. Maxillary first molars along with alveolar bone were resected and fixed. The processed samples were stained with routine hematoxylin and eosin (H&E), and evaluated immunohistochemically using antibodies against anti-PCNA, anti-STRO-1, and anti-CD44 polyclonal antibodies. Data were analyzed using Chi-square test and a p-value of <0.05 was considered significant.

RESULTS

Immunostaining of anti-PCNA showed 30%, 70% and 53.3% positive staining in CG, EG I, and EG II, respectively (p<0.001). Moreover, the CD44 staining was 20% in CG in contrast to 63.6% in EG I and 43.3 in EG II. STRO-1 staining in CG was 10%, 50% in the EG I and 36.6% in the EG II (p<0.001).

CONCLUSIONS

Periapical inflammatory tissues expressed significant proliferative cell marker PCNA and mesenchymal stem cell markers STRO-1, and CD44. These findings further reaffirm the promising role of mesenchymal stem cells in the healing of periapical periodontitis.

Illusion of coronary artery chronic total occlusion-associated ventricular arrhythmia: results from a multi-centre study

Background/Introduction

Coronary artery chronic total occlusion (CTO) is frequently encountered in patients with established coronary artery disease (CAD) with a reported incidence of more than thirty percent in this population (1). A previous large single-centre study established CTO as an independent risk factor for occurrence of ventricular arrhythmia in patients with ICD and ischemic heart disease (2). The significance of CTO in all-comers has not been investigated. In this large retrospective data, it was analysed that there is no significant difference in ventricular arrhythmia occurrence in patients with CTO versus those with CAD and no CTO.

Purpose

The purpose of this study is to examine the association between CTO and ventricular arrhythmia in patients with CAD using a pooled de-identified database.

Methods

This retrospective observational study used IBM Explorys, which is a pooled de-identified multi-institutional database of more than 60 million unique patients in the United States. A search was done to identify patients with CTO and those with CAD with the exclusion of CTO diagnosis. The data were analysed for ventricular tachycardia (VT) and/or ventricular fibrillation (VF) occurrence. The data were stratified by presence of systolic HF to identify possible effect modification. Statistical analysis was performed by calculating odds ratios (OR) with associated confidence intervals.

Results

Among the 190 patients with the diagnosis of CTO, 11.8% had VT/VF. Of the 2,796,600 patients with CAD and no CTO, 6.9% had VT/VF. The diagnosis of CTO was associated with an increased risk for VT/VF with OR 1.7143 (1.0786, 2.7247), p&lt;0.05. Upon stratification by presence or absence of systolic HF, there was no statistically significant difference in occurrence of VT/VF in the two strata. In the systolic HF group, the OR was 1.4331 (0.6708, 3.0619), p=0.47; the no systolic HF group had OR 0.9717 (0.5123, 1.843), p=0.92. In patients with CAD, the diagnosis of systolic HF was associated with an increased risk of CTO with OR 2.5616 (1.7268, 3.7999), p&lt;0.05.

Conclusion

Stratification by presence or absence of systolic HF yielded inconsistent and statistically insignificant odds ratios compared to the all-comers group, suggesting effect modification by HF with no statistically significant association between CTO and VT/VF. These findings from this large multicentre retrospective data suggest that CTO itself is not an independent risk factor for ventricular arrhythmia in patients with CAD. Limitations of this study include that it is a retrospective pooled analysis without individualised data on ejection fraction and the inability to distinguish if the CTO was infarct-related. Further prospective studies are needed to evaluate the significance of CTO in patients with CAD as it pertains to ventricular arrhythmia.

Funding Acknowledgement

Type of funding sources: None.

1600 Assessing Necessity and Cost-Effectiveness of Routine Pre-Thyroidectomy Group and Save Tests

Aim

To determine the necessity and cost effectiveness of routine blood group and save tests (G&S) before thyroidectomy

Background

Sub-total or total thyroidectomy is the mainstay of treatment for several thyroid disorders. The incidence of post-thyroidectomy haemorrhage has been reported between 0.36% and 4.3% in the literature. Many patients undergo routine G&S testing in anticipation of a peri-operative haemorrhage requiring blood transfusion.

Method

Retrospective review identified 276 patients undergoing an elective total or sub-total thyroidectomy at a London University Teaching Hospital between February 2018 and August 2020. Electronic medical and transfusion department records were audited to identify patients who had pre-operative G&S tests, pre-operatively reserved blood products and peri-operative transfusions.

Results

261 (94.6%) patients had a valid pre-operative group and save test. 17 (6.16%) patients had a total of 61 units of blood products ordered pre-operatively. Only 2 patients required transfusion.

Conclusions

The blood transfusion rate for elective thyroidectomies at this centre was 0.72%. Routine G&S tests cost the trust thousands of pounds and create unnecessary burden on healthcare providers’ time and hospital resources. We propose that routine pre-operative G&S tests are unnecessary for elective thyroidectomies.

1384 Managing Peri-Orbital and Orbital Cellulitis: A New Multi-Specialty Care Pathway

Aim

1) To review current practice in the diagnosis and management of peri-orbital and orbital cellulitis in children at a London University Teaching Hospital. 2) To design and implement a streamlined, multi-specialty care pathway to improve the quality of care.

Background

Clinical differentiation between peri-orbital cellulitis and orbital cellulitis is often difficult, especially in young children. Early recognition and aggressive, multi-specialty treatment are required in order to prevent any vision and life-threatening sequelae.

Method

A retrospective case note analysis was performed for all paediatric patients with suspected peri-orbital or orbital cellulitis over a nineteen-month period. Extensive literature review was undertaken to ascertain current best practice in diagnosis and management. A streamlined, multi-specialty care pathway was developed, ratified by specialist departments, and introduced to optimise safety and quality of care.

Results

The results correlate with trends found in recent literature. 94.3% of patients had a blood culture taken with only 9.1% being positive. There were inadequate eye (37.1%) and endonasal (17.1%) cultures. Wide variation was noted in the criteria for imaging and in the antibiotic regimen used. 25.7% of patients received any nasal treatment. Suboptimal specialist review was identified in both orbital (60%) and peri-orbital (50.0%) cellulitis.

Conclusions

The new care pathway clearly informs investigation and empiric treatment based on initial risk stratification. The paediatric team is now the main, named care provider responsible for coordinating specialist input.

925 Is Routine Bloods Group and Save Required for Emergency Appendicectomy?

Introduction

Appendicectomy is commonly a safe and low bleeding risk procedure. However, some hospital guidelines stipulate a requirement for routine pre-operative blood group and save (G&S).We aim to determine if pre-operative G&S is required for appendicectomies by looking at the number of tests vs transfusion conducted.The cost of G&S is £4.14 per sample in our trust.

Method

A retrospective review was conducted over a 3-month period. Patient data and demographics were identified using the hospital coding, theatre records and transfusion departments.

Results

118 consecutive appendicectomies were identified. Of which, 99 laparoscopic vs 19 open (13 started open vs 6 converted to open) operations were performed. No patients required a blood transfusion during their admission. There was a total of 219 G&S conducted. Cross matching tests for these procedures cost a total of £906. We estimate a cost projection of £3624 for G&S tests over a year and £18120 over 3 years.

Conclusions

Bleeding complications requiring transfusion following appendicectomies are very uncommon. In our unit, 0% of patients identified required a transfusion during their admission. We suggest stopping routine pre-operative G&S for these patients would be clinically safe and would lead to financial savings and reduce pre-operative waiting time.

902 Too Hot to Handle? Acute Cholecystitis (‘Hot Gallbladder’) Management and Compliance with NICE Guidelines in A District General Hospital

Introduction

Current NICE guidelines recommend that patients with acute cholecystitis should be offered laparoscopic cholecystectomy within 1 week of diagnosis. However, the recommendation is often not met within our trust. We aim to investigate our compliance with these guidelines while outlining the complications and cost effects associated with delayed operation.

Method

A retrospective study identifying emergency patients presenting with image proven uncomplicated acute cholecystitis was performed. Hospital coding and finance departments were used to obtain this information.

Results

166 patients were identified within a 3-month period. Of which, 85 patients were diagnosed with acute uncomplicated cholecystitis and fulfilled the inclusion criteria. On average, patients waited 108 days for their cholecystectomies (range 14-281). No patients received a cholecystectomy within 1 week of diagnosis. 33 patients re-presented to hospital at least once and the total number of repeated admissions was 51. The average length of stay during readmissions was 6 days (range 1-27). The total cost incurred for those readmissions was £117,118.

Conclusion

Role of myeloid-derived chemokine CCL5/RANTES at an early stage of atherosclerosis

One of the hallmarks of atherosclerosis is ongoing accumulation of macrophages in the artery intima beginning at disease onset. Monocyte recruitment contributes to increasing macrophage abundance at early stages of atherosclerosis. Although the chemokine CCL5 (RANTES) has been studied in atherosclerosis, its role in the recruitment of monocytes to early lesions has not been elucidated. We show that expression of Ccl5 mRNA, as well as other ligands of the CCR5 receptor (Ccl3 and Ccl4), is induced in the aortic intima of Ldlr^-/- mice 3 weeks after the initiation of cholesterol-rich diet (CRD)-induced hypercholesterolemia. En face immunostaining revealed that CCL5 protein expression is also upregulated at 3 weeks of CRD. Blockade of CCR5 significantly reduced monocyte recruitment to 3-week lesions, suggesting that chemokine signaling through CCR5 is critical. However, we observed that Ccl5-deficiency had no effect on early lesion formation and CCL5-blockade did not affect monocyte recruitment in Ldlr^-/- mice. Immunostaining of the lesions in Ldlr^-/- mice and reciprocal bone marrow transplantation (BMT) of Ccl5^+/+ and Ccl5^-/- mice revealed that CCL5 is expressed by both myeloid and endothelial cells. BMT experiments were carried out to determine if CCL5 produced by distinct cells has functions that may be concealed in Ccl5^-/-Ldlr^-/- mice. We found that hematopoietic cell-derived CCL5 regulates monocyte recruitment and the abundance of intimal macrophages in 3-week lesions of Ldlr^-/- mice but plays a minor role in 6-week lesions. Our findings suggest that there is a short window in early lesion formation during which myeloid cell-derived CCL5 has a critical role in monocyte recruitment and macrophage abundance.

A population-based study of pulmonary monitoring and toxicity for patients with testicular cancer treated with bleomycin

Background

Bleomycin is commonly used to treat advanced testicular cancer and can be associated with severe pulmonary toxicity. The primary objective of the present study was to describe the use of pulmonary function tests (pfts) and chest imaging before, during, and after treatment with bleomycin.

Methods

To identify all incident cases of testicular cancer treated with bleomycin-based chemotherapy in the Canadian province of Ontario during 2005-2010, the Ontario Cancer Registry was linked with chemotherapy treatment records. Health administrative databases were used to describe use of pfts, chest imaging, and physician visits for respiratory complaints.

Results

Of 394 patients treated with orchiectomy and chemotherapy who received at least 1 dose of bleomycin, 93% had complete chemotherapy records available. In the 4 weeks before, during, and within 2 years after finishing bleomycin-based chemotherapy, pfts were performed in 17%, 17%, and 29% of patients respectively. Chest imaging was performed in 68%, 62%, and 98% of patients in the same time periods. In the 2 years after bleomycin-based chemotherapy, 23% of treated patients had a physician visit for respiratory symptoms. That rate was substantially higher for men with greater exposure to bleomycin: 40% (24 of 60) for 10-12 doses bleomycin compared with 21% (53 of 250) for 7-9 doses and with 14% (8 of 58) for 1-6 doses (p = 0.002).

Conclusions

Quality improvement initiatives are needed to increase baseline rates of chest imaging within 4 weeks of starting chemotherapy for testicular cancer; to understand why such a high proportion of men have chest imaging during bleomycin-based chemotherapy; and to mitigate the excess pulmonary toxicity seen with increasing exposure to bleomycin.

Prognostic utility of cardiopulmonary exercise testing indices in arrhythmogenic right ventricular cardiomyopathy

Introduction

Cardiopulmonary exercise testing (CPET) has an established role in the clinical evaluation of exercise intolerance and in the risk stratification of patients with heart failure. There is limited data assessing its prognostic utility in the evaluation of patients with Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC). The predisposition of patients with ARVC for ventricular arrhythmias and sudden cardiac death has led to recommendations for exercise restrictions and limits our understanding of how the impairment in oxygen extraction and cardiac output impact disease progression and outcomes in these patients.

Purpose

We examined the association between CPET indices and event free survival (time to mortality or cardiac transplantation) in patients with Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC).

Methods

Patients with definite ARVC based on 2010 task force criteria and genetically positive were enrolled into our institutional ARVC registry. 43 patients underwent CPET and have been included in our analyses. Indications for testing included: Evaluation of exercise-induced palpitations/arrhythmias or syncope (37%), pharmacotherapy optimization (28%), heart failure evaluation (19%), and ARVC management decisions (16%). CPET data (peak oxygen consumption (pVO2), respiratory exchange ratio (RER), and ventilatory efficiency (VE/VCO2) were assessed in patients at time of initial evaluation. Median follow-up time was 4.9 years (IQR 9 years).

Results

126 patients were studied (age 43.7+ 15 yrs; 41% women; LVEF 57+ 11%; 15% with LVEF &lt;50%) and 43 underwent CPET evaluation. 41 patients (95%) performed at near maximal effort (RER &gt;1) and no fatal events were reported during testing. During the follow up period, the outcome (death or cardiac transplantation) occurred in 31 patients. On Kaplan Meier analysis, pVO2 ≤14 mL/kg/min was associated with worse outcomes (unadjusted p&lt;0.001). Peak oxygen consumption (pVO2) ≤14 mL/kg/min and ventilatory efficiency (VE/VCO2) &gt;34 were associated with shorter event free survival (HR 5.58, p=0.002 and HR 5.56 p=0.005, respectively). After adjusting for age, sex, and right ventricular function, the association between peak oxygen consumption (pVO2) and event free survival remained significant (p=0.02).

Conclusions

In patients with ARVC, peak oxygen consumption (pVO2) was a prognostic indicator of worse outcomes. Our findings suggest a potential role for pVO2 in disease surveillance and early assessment for advanced heart failure therapies.

Figure 1. KM plot pVO2 & event free survival

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Mayo Clinic

Venous Thromboembolism During Chemotherapy for Testicular Cancer: A Population-Based Study

AIMS

Venous thromboembolism (VTE) is a potential complication among germ cell tumour patients. We evaluated the incidence rate, timing and factors associated with VTE among patients with germ cell cancer in routine practice.

MATERIALS AND METHODS

The Ontario Cancer Registry was linked to electronic records of treatment to identify all cases of testicular cancer treated in Ontario during 2000-2010. Administrative databases were used to identify VTE in the 3 months before and 5 years after orchiectomy. We explored patient-, disease- and treatment-related factors associated with VTE among all patients as well as those with detailed chemotherapy records available.

RESULTS

During 2000-2010, 2650 patients underwent orchiectomy for testicular cancer; among this cohort, 920 (33%) received chemotherapy. The VTE rate was 8% (69/920) among patients treated with chemotherapy and 0.6% (11/1730) among those without chemotherapy. Among the patients treated with chemotherapy who had VTE, 13% (9/69) occurred in the month before starting chemotherapy, 62% (42/69) in the first 3 months after starting and 25% thereafter. For patients who received three and four cycles, VTE rates were 8% (21/258) and 16% (19/121), respectively. In adjusted analyses, the only factor independently associated with VTE was increasing number of cycles (odds ratio 3.91 for four cycles, odds ratio 1.63 for three cycles (P = 0.022) compared with one to two cycles).

CONCLUSION

This population-based study confirms findings from institutional case series regarding the high rate of VTE among patients with germ cell tumours treated with chemotherapy. Future studies should evaluate the extent to which VTE prophylactic strategies might mitigate this risk.

Generalisability of Common Oncology Clinical Trial Eligibility Criteria in the Real World

AIMS

Strict oncology clinical trial eligibility criteria can contribute to low accrual and result in poorly generalisable study findings. Using common eligibility criteria, we sought to (i) determine how many patients would be eligible versus ineligible and (ii) describe real-world patterns of treatments and outcomes between those considered trial eligible and ineligible.

MATERIALS AND METHODS

The Alberta Cancer Registry was used to assemble a population-based cohort of patients diagnosed with 11 common malignancies between 2004 and 2015. We considered age >75 years, anaemia, comorbid conditions (heart disease, uncontrolled diabetes, kidney disease, liver disease) and history of a prior malignancy or immunosuppression to be exclusion criteria. Logistic regression was used to characterise the likelihood of receiving treatment. Cox regression models were constructed to determine cancer-specific and overall survival.

RESULTS

We identified 125 316 cancer patients, of whom 53% were men; the median age was 66 (interquartile range 48-84) years. Approximately 38% of patients were considered trial ineligible. The most common reasons for ineligibility were advanced age (24%) and heart disease (16%). In this ineligible group, 12, 47 and 19% still underwent chemotherapy, surgery and radiotherapy, respectively. Compared with ineligible patients, eligible patients were more likely to undergo chemotherapy (odds ratio 1.98, 95% confidence interval 1.89-2.07, P < 0.0001), surgery (odds ratio 1.39, 95% confidence interval 1.32-1.46, P < 0.0001) and radiotherapy (odds ratio 1.46, 95% confidence interval 1.4-1.52, P < 0.0001). Compared with ineligible patients who did not receive treatment, those considered ineligible but who still received treatment experienced improved cancer-specific survival (hazard ratio 0.75, 95% confidence interval 0.74-0.77, P < 0.0001) and overall survival (hazard ratio 0.89, 95% confidence interval 0.87-0.90, P < 0.0001).

CONCLUSIONS

A significant proportion of real-world patients are unable to participate in clinical trials due to stringent exclusion criteria, but many still receive treatment in routine practice. The eligibility criteria of oncology clinical trials should be broadened.

Toward improved goals-of-care documentation in advanced cancer: report on the development of a quality improvement initiative

Background

Documentation of advance care planning for patients with terminal cancer is known to be poor. Here, we describe a quality improvement initiative.

Methods

Patients receiving palliative chemotherapy for metastatic lung, pancreatic, colorectal, and breast cancer during 2010-2015 at the Cancer Centre of Southeastern Ontario were identified from electronic pharmacy records. Clinical notes were reviewed to identify documentation of care plans in the event of acute deterioration. After establishing baseline practice, we sought to improve documentation of goals of care and referral rates to palliative care. Using quality improvement methodology, we developed a guideline, a standardized documentation system, and a process to facilitate early referral to palliative care.

Results

During 2010-2015, 456 patients were included in the baseline cohort: 63% with lung cancer, 16% with colorectal cancer, 13% with pancreatic cancer, and 7% with breast cancer. Care goals in the event of an acute illness were documented by medical oncologists in 6% of cases (26 of 456). Of the 456 patients, 47% (n = 214) were seen by palliative care; care goals were documented by palliative care in 48% of the patients seen (103 of 214). With those baseline data in hand, a local practice guideline and process was developed to facilitate the identification of patients for whom advance care planning and early palliative care referral should be considered. A system was also established so that goals-of-care documentation will be supported with a written framework and broadly accessible in the electronic medical record.

Conclusions

Low rates of documentation of advance care planning and referral to palliative care persist and have stimulated a local quality improvement initiative.

The predictive effect of primary tumour location in the treatment of metastatic colorectal cancer: a Canadian consensus statement

In recently published data, the predictive value of primary tumour location for the treatment of metastatic colorectal cancer with available biologic therapies has been explored. Recognizing the potential effect of those data on clinical practice, we convened a meeting of Canadian experts who treat metastatic colorectal cancer to develop a set of national, evidence-based treatment guidelines based on primary tumour location. This report summarizes the relevant evidence and presents the consensus recommendations of those experts.

Uptake and Effectiveness of FOLFIRINOX for Advanced Pancreatic Cancer: a Population-based Study

AIMS

Although FOLFIRINOX is a standard treatment option for advanced pancreas cancer, there are few data describing utilisation and effectiveness in routine clinical practice. Here we report practice patterns and outcomes in the general population of Ontario, Canada.

MATERIALS AND METHODS

Using the Ontario Cancer Registry and New Drug Funding Program, we identified all patients with pancreas cancer treated with palliative intent gemcitabine or FOLFIRINOX in Ontario during 2006-2014. FOLFIRINOX became available in Ontario's single-payer health system in November 2011. Gemcitabine cases were classified as pre-FOLFIRINOX era (2006-2010) or post-FOLFIRINOX era (2011-2014). Cases treated with perioperative chemotherapy were excluded. Comparisons of proportions between study groups were made using the chi-square test. Overall survival was measured from the date of chemotherapy initiation.

RESULTS

During 2006-2014, 3826 patients in Ontario were treated with gemcitabine (n = 3042) or FOLFIRINOX (n = 784) chemotherapy for advanced pancreas cancer. Uptake of FOLFIRINOX increased from 41% (206/505) of treated cases in 2012 to 56% (274/486) of treated cases in 2014. The median overall survival of patients treated with gemcitabine was 5.0 months in 2006-2010 and 4.8 months in 2011-2014. The median overall survival of FOLFIRINOX patients treated in 2011-2014 was 8.2 months.

CONCLUSION

The use of FOLFIRINOX in the general population has increased since 2011. Survival outcomes show a substantial efficacy-effectiveness gap between the pivotal Prodige 4/ACCORD 11 clinical trial and routine practice.

Chemotherapy for resected colorectal cancer pulmonary metastases: Utilization and outcomes in routine clinical practice

BACKGROUND

The role of chemotherapy in the setting of resected colorectal cancer pulmonary metastases (CRCPM) is not well defined. Here we describe utilization of peri-operative chemotherapy and outcomes among patients with resected CRCPM in the general population.

METHODS

All cases of CRCPM who underwent resection from 2002 to 2009 were identified using the Ontario Cancer Registry (OCR). Electronic treatment records identified peri-operative chemotherapy delivered within 16 weeks before or after pulmonary metastasectomy (PM). Modified Poisson regression was used to evaluate factors associated with chemotherapy delivery. Cox proportional models were used to explore the association between post-operative chemotherapy and cancer-specific (CSS) and overall survival (OS).

RESULTS

The study population included 420 patients. Thirty-six percent of patients (151/420) received peri-operative chemotherapy. Among these patients, 75% (113/151) received post-operative chemotherapy. Factors that were independently associated with use of post-operative chemotherapy included higher socioeconomic status (SES) and no prior adjuvant chemotherapy (p < 0.01). In adjusted analyses post-operative chemotherapy was not associated with improved CSS (HR 0.99, 95% CI 0.67-1.47) or OS (HR 0.93 95% CI 0.66-1.31). In exploratory analyses, among those patients who did not receive previous adjuvant therapy for the primary colorectal cancer, post-operative chemotherapy following lung metastasectomy was associated with HR 0.50 (95% CI 0.27-0.95) for OS and HR 0.59 (95% CI 0.27-1.27) for CSS.

CONCLUSION

One third of patients with resected CRCPM in routine practice receive peri-operative chemotherapy. A randomized controlled trial is warranted to evaluate whether chemotherapy following resection of CRCPM is associated with improved survival.

Multimodality Treatment Outcome of Hepatoblastoma in a Resource Limited Country

Our objective is to review the records of management of hepatoblastoma (HB) at the Paediatric Haematology and Oncology (PHO) department in the Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from January 2004 to December 2012. This is a retrospective study of clinical, radiological and pathological data of hepatoblastoma patients treated at our institution. Thirteen patients were treated for HB between 2004 and 2012. The records of clinical presentations, chemotherapy tolerance and response, surgical procedure undertaken, and complications were analyzed. Median age of the study population was 12 months (3-60 months) and male: female was 3.3:1. Nine patients were treated with neoadjuvant chemotherapy consists of cisplatin and adriamycin. Primary surgery was done in four patients. Extent of hepatic resection in the operated patients varied. Mixed type was the predominant histopathological diagnosis. Adjuvant chemotherapy was well tolerated with no morbidity or mortality. Five-year event-free survival (EFS) and overall survival (OS) of all the 13 patients is 76.9%. All the nine patients who could complete multimodality treatment are alive with no evidence of disease or complications with median follow-up of 63 months (46-122 months). Treatment of HB with multidisciplinary approach was well tolerated. OS and EFS of patients were comparable with published studies.

Cancer care in South India: perspectives from visiting Canadian oncologists

Cancer is recognized as an increasing threat to public health in low- and middle-income countries (lMICS).[...]

Evaluation of Iron Store by Serum Ferritin in Healthy Blood Donors of Bangladesh

Iron stores in the body exist primarily in the form of ferritin. Small amounts of ferritin secreted into the plasma and plasma ferritin is positively correlated with the size of the total body iron stores. The present study conducted to determine the iron status using the serum ferritin level among healthy Bangladeshi blood donors. The present cross sectional study was conducted in the Department of Transfusion Medicine, Dhaka Medical College, Dhaka, Bangladesh from July 2011 to June 2012. Blood donor signed informed consent and has satisfactory pre-donation health assessment and satisfactory post-donation blood test results were included in the study. Full blood counts were performed within 4 hours of collection using an automated haematology analyzer. Serum ferritin was measured using a validated enzyme immunoassay. Data were analyzed using SPSS version 16 (SPPS Incorporation, Chicago, IL, USA). P value <0.05 was considered as statistically significant. Total 100 blood donors were included in the study, among them 88 were male and 12 were female. Mean±SD of the age of the respondents was 26.8±5.9 years with a range of 19 to 45 years. Mean±SD of heamoglobin level (gm/dl) and total count of Red Blood Cell (million/cmm) were 14.1±1.4 and 5.1±0.4 respectively. Mean±SD of serum ferritin level (ng/ml) was 96.4±69.0ng/ml with a range of 4.1ng/ml to 298.7ng/ml. Among the respondents 9.0% had depleted iron store, 7.0 reduced iron store and 84.0% had normal iron store. Among the respondents 5.0% had iron deficiency anaemia in term of serum ferritin level. Statistically significant difference of serum ferritin level observed between male and female and donors with and without history of previous blood donation. Among the healthy blood donors of Bangladesh abnormal serum ferritin is highly prevalent among blood donors specially among female. Monitoring of iron stores by serum ferritin seems justified in order to identify those with depleted iron stores who will benefit from iron supplementation.

Relationship between Serum Iron Profile and Blood Groups among the Voluntary Blood Donors of Bangladesh

Blood donation results in a substantial iron loss and subsequent mobilization from body stores. Chronic iron deficiency is a well-recognized complication of regular blood donation. The present study conducted to compare the level of serum ferritin, serum iron, total iron binding capacity (TIBC) and percentage transferrin saturation in different ABO and Rhesus type blood groups among the voluntary blood donors of Bangladesh. The present prospective study included 100 healthy voluntary donors attending at Department of Blood Transfusion, Dhaka Medical College, Dhaka between the periods of July 2013 to Jun 2014. From each donor 10mL venous blood sample was taken and divided into heparinized and non-heparinized tubes for determination of hemoglobin (Hb), hematocrit (Hct), serum iron (SI), total iron binding capacity (TIBC) and serum ferritin by standard laboratory methods. Percentage of transferrin saturation (TS) calculated from serum iron and TIBC. Data were analyzed with SPSS (version 16) software and comparisons between groups were made using student's t-test and one way ANOVA. In the present study mean±SD of age of the respondents was 27.2±6.5 years with a range of 18 to 49 years and 81.0% were male and 19.0% were female. Among the donors 18.0% had blood group A, 35.0% had blood group B, 14.0% had blood group AB and 33.0% had blood group O. Among the donors 91.0% had rhesus positive and 9.0% had rhesus negative. Donors with blood group O had lowest haemoglobin, serum iron and transferring saturation levels. Donors with blood group A had highest TIBC level. Donors with blood group B had lowest serum ferritin level. An independent samples 't' test showed statistically significant difference in serum ferritin and percentage transferrin saturation between blood group AB and blood group O and in percentage transferrin saturation between blood group B and blood group O. One way ANOVA showed that there is no significant difference in haemoglobin, serum iron, serum ferritin and percentage transferring saturation in different ABO and Rh blood grouping categories. Blood donors with blood group O had lowest haemoglobin, serum iron and transferring saturation levels and donors with blood group A had highest TIBC level. Blood donors with blood group B had lowest serum ferritin level. The understanding of the different blood groups ability to retain iron in their system can give an insight into their ability to handle the disease iron deficiency anaemia.

An insight into the functional role of thioredoxin reductase, a selenoprotein, in maintaining normal native microbiota in the Gulf Coast tick (Amblyomma maculatum)

Tick selenoproteins have been associated with antioxidant activity in ticks. Thioredoxin reductase (TrxR), also a selenoprotein, belongs to the pyridine nucleotide-disulphide oxidoreductase family of proteins and is an important antioxidant. Molecular interactions between native microbiota and tick hosts have barely been investigated to date. In this study, we determined the functional role of TrxR in tick feeding and in maintenance of the native microbial community. TrxR transcript levels remained high and microbial load was reduced throughout tick attachment to the vertebrate host. RNA interference (RNAi) showed that depletion of TrxR activity did not interfere with tick haematophagy or phenotype but did reduce the viability of the microbiome within the tick tissues, presumably by perturbing redox homeostasis. The transcriptional activity of various antioxidant genes remained unaffected whereas the antioxidant genes Manganese superoxide dismutase (MnSOD), copper/zinc superoxide dismutase (Cu/Zn SOD) and selenoprotein M (SelM) were significantly down-regulated in salivary glands of the ticks subjected to RNAi. The perturbed TrxR enzymatic activity in the knocked-down tick tissues negatively affected the bacterial load as well. Furthermore, we observed the altered bacterial profiles in TrxR-silenced tick tissues. Taken together, these results indicate an essential functional role for TrxR in maintaining the bacterial community associated with ticks.