Peppas N, Perreault EJ, Rabbitt R, Setton LA, Shea LD, Shroff SG, Shung K, Tolias AS, van der Meulen MC, Varghese S, Vunjak-Novakovic G, White JA, Winslow R, Zhang J, Zhang K, Zukoski C, Miller MI. Grand Challenges at the Interface of Engineering and Medicine

Over the past two decades Biomedical Engineering has emerged as a major discipline that bridges societal needs of human health care with the development of novel technologies. Every medical institution is now equipped at varying degrees of sophistication with the ability to monitor human health in both non-invasive and invasive modes. The multiple scales at which human physiology can be interrogated provide a profound perspective on health and disease. We are at the nexus of creating "avatars" (herein defined as an extension of "digital twins") of human patho/physiology to serve as paradigms for interrogation and potential intervention. Motivated by the emergence of these new capabilities, the IEEE Engineering in Medicine and Biology Society, the Departments of Biomedical Engineering at Johns Hopkins University and Bioengineering at University of California at San Diego sponsored an interdisciplinary workshop to define the grand challenges that face biomedical engineering and the mechanisms to address these challenges. The Workshop identified five grand challenges with cross-cutting themes and provided a roadmap for new technologies, identified new training needs, and defined the types of interdisciplinary teams needed for addressing these challenges. The themes presented in this paper include: 1) accumedicine through creation of avatars of cells, tissues, organs and whole human; 2) development of smart and responsive devices for human function augmentation; 3) exocortical technologies to understand brain function and treat neuropathologies; 4) the development of approaches to harness the human immune system for health and wellness; and 5) new strategies to engineer genomes and cells.

"There should be one spot that you can go:" BRCA mutation carriers' perspectives on cancer risk management and a hereditary cancer registry

Individuals who carry BRCA1 or BRCA2 pathogenic variants are recommended to have extensive cancer prevention screening and risk-reducing surgeries. Uptake of these recommendations is variable, and there remains room for improvement in the risk management of BRCA carriers. This paper explores female BRCA carriers' experiences with the current model of care and their perspectives on (and interest in) an inherited cancer registry. Findings can inform the development of a dedicated high-risk screening and management program for these patients. Quantitative and qualitative data were gathered through a provincial descriptive survey and semi-structured qualitative interviews to assess BRCA carriers' opinions toward risk management services in the province of Newfoundland and Labrador (NL), Canada. Survey (n = 69) and interview data (n = 15) revealed continuity and coordination challenges with the current system of care of high-risk individuals. Respondents suggested an inherited cancer registry would help identify high-risk individuals and provide a centralized system of risk management for identified carriers. Respondents identified concerns about the privacy of their registry data, including who could access it. Findings suggest BRCA carriers see great value in an inherited cancer registry. Specifically, participants noted it could provide a centralized system to help improve the coordination of burdensome, life-long risk management. Important patient concerns about protecting their privacy and their health data confidentiality must be addressed in patient and public information and informed consent documents about a registry.

A latent class analysis of mental disorders, substance use, and aggressive antisocial behavior among Swedish forensic psychiatric patients

BACKGROUND

Patients in the forensic mental health services (FMHS) with a mental disorder, a co-occurring substance use disorder (SUD), and high risk of aggressive antisocial behavior (AAB) are sometimes referred to as the 'triply troubled'. They suffer poor treatment outcomes, high rates of criminal recidivism, and increased risk of drug related mortality. To improve treatment for this heterogeneous patient group, more insight is needed concerning their co-occurring mental disorders, types of substances used, and the consequent risk of AAB.

METHODS

A three-step latent class analysis (LCA) was used to identify clinically relevant subgroups in a sample of patients (n = 98) from a high-security FMHS clinic in Sweden based on patterns in their history of mental disorders, SUD, types of substances used, and AAB.

RESULTS

A four-class model best fit our data: class 1 (42%) had a high probability of SUD, psychosis, and having used all substances; class 2 (26%) had a high probability of psychosis and cannabis use; class 3 (22%) had a high probability of autism and no substance use; and class 4 (10%) had a high probability of personality disorders and having used all substances. Both polysubstance classes (1 and 4) had a significantly more extensive history of AAB compared to classes 2 and 3. Class 3 and class 4 had extensive histories of self-directed aggression.

CONCLUSIONS

The present study helps disentangle the heterogeneity of the 'triply troubled' patient group in FMHS. The results provide an illustration of a more person-oriented perspective on patient comorbidity and types of substances used which could benefit clinical assessment, treatment planning, and risk-management among patients in forensic psychiatric care.

First Dark Matter Search Results from the LUX-ZEPLIN (LZ) Experiment

The LUX-ZEPLIN experiment is a dark matter detector centered on a dual-phase xenon time projection chamber operating at the Sanford Underground Research Facility in Lead, South Dakota, USA. This Letter reports results from LUX-ZEPLIN's first search for weakly interacting massive particles (WIMPs) with an exposure of 60 live days using a fiducial mass of 5.5 t. A profile-likelihood ratio analysis shows the data to be consistent with a background-only hypothesis, setting new limits on spin-independent WIMP-nucleon, spin-dependent WIMP-neutron, and spin-dependent WIMP-proton cross sections for WIMP masses above 9  GeV/c^{2}. The most stringent limit is set for spin-independent scattering at 36  GeV/c^{2}, rejecting cross sections above 9.2×10^{-48}  cm at the 90% confidence level.

The Current Proposed Total Hip Arthroplasty Surgical Planning Guidelines Based on Classification of Spine Stiffness May be Flawed Due to Incorrect Assumptions

BACKGROUND

The available classifications and preoperative planning tools for total hip arthroplasty assume that: 1) there is no variation in the sagittal pelvic tilt (SPT) if the radiographs are repeated, and 2) there is no significant change in the postoperative SPT postoperatively. We hypothesized that there would be significant differences in postoperative SPT tilt as measured by the sacral slope, thus rendering the current classifications and tools flawed.

METHODS

This study was a multicenter, retrospective analysis of preoperative and postoperative (1.5-6 months) full-body imaging of 237 primary total hip arthroplasty (standing and sitting positions). Patients were categorized as 1) stiff spine (standing sacral slope sitting sacral slope < 10°) and 2) normal spine (standing sacral slope-sitting sacral slope ≥ 10°). Results were compared using the paired t-test. The posthoc power analysis showed a power of 0.99.

RESULTS

The difference in mean standing and sitting sacral slope between the preoperative and postoperative measurements was 1°. However, in standing position, this difference was more than 10° in 14.4% of patients. In the sitting position, this difference was more than 10° in 34.2% of patients and more than 20° in 9.8% of patients. Postoperatively, 32.5% of patients switched groups based on the classification, which rendered the preoperative planning suggested by the current classifications flawed.

CONCLUSION

Current preoperative planning and classifications are based on a single acquisition of preoperative radiographs without the incorporation of possible postoperative changes in SPT. Validated classifications and planning tools should incorporate repeated measurements to determine the mean and variance in SPT and consider the significant postoperative changes in SPT.

The reality of advanced airway management during out of hospital cardiac arrest; why did paramedics deviate from their allocated airway management strategy during the AIRWAYS-2 randomised trial?

Background

AIRWAYS-2 was a large multi-centre cluster randomised controlled trial investigating the effect on functional outcome of a supraglottic airway device (i-gel) versus tracheal intubation (TI) as the initial advanced airway during out-of-hospital cardiac arrest. We aimed to understand why paramedics deviated from their allocated airway management algorithm during AIRWAYS-2.

Methods

This study employed a pragmatic sequential explanatory design utilising retrospective study data collected during the AIRWAYS-2 trial. Airway algorithm deviation data were analysed to categorise and quantify the reasons why paramedics did not follow their allocated strategy of airway management during AIRWAYS-2. Recorded free text entries provided additional context to the paramedic decision-making related to each category identified.

Results

In 680 (11.7%) of 5800 patients the study paramedic did not follow their allocated airway management algorithm. There was a higher percentage of deviations in the TI group (399/2707; 14.7%) compared to the i-gel group (281/3088; 9.1%). The predominant reason for a paramedic not following their allocated airway management strategy was airway obstruction, occurring more commonly in the i-gel group (109/281; 38.7%) versus (50/399; 12.5%) in the TI group.

Conclusion

There was a higher proportion of deviations from the allocated airway management algorithm in the TI group (399; 14.7%) compared to the i-gel group (281; 9.1%). The most frequent reason for deviating from the allocated airway management algorithm in AIRWAYS-2 was obstruction of the patient's airway by fluid. This occurred in both groups of the AIRWAYS-2 trial, but was more frequent in the i-gel group.

Implementing clinical guidelines for co-occurring substance use and major mental disorders in Swedish forensic psychiatry: An exploratory, qualitative interview study with mental health care staff

INTRODUCTION

Patients with substance use disorders (SUD) and co-occurring mental disorders (COD) within forensic psychiatric care often suffer poor treatment outcomes and high rates of criminal recidivism, substance use, and psychiatric problems. This study aimed to describe the conditions for, and mental health care staff's experiences with, implementing integrated SUD-focused clinical guidelines, including assessment and treatment for patients with COD at a high-security forensic mental health services (FMHS) facility in Sweden.

METHODS

Study staff conducted nineteen semi-structured interviews with health care staff experienced in administering the new SUD assessment and treatment. The study conducted a thematic analysis to describe the health care staff's experiences with these guidelines and suggestions for improvement.

RESULTS

Most participants reported appreciation for the implementation of clinical guidelines with an SUD focus, an area they considered to have previously been neglected, but also noted the need for more practical guidance in the administration of the assessments. Participants reported the dual roles of caregiver and warden as difficult to reconcile and a similar, hindering division was also present in the health care staff's attitudes toward SUD. Participants' reports also described an imbalance prior to the implementation, whereby SUD was rarely assessed but treatment was still initiated. One year after the implementation, an imbalance still existed, but in reverse: SUD was more frequently assessed, but treatment was difficult to initiate.

CONCLUSIONS

Despite indications of some ambivalence among staff regarding the necessity of the assessment and treatment guidelines, many participants considered it helpful to have a structured way to assess and treat SUD in this patient group. The imbalance between frequent assessment and infrequent treatment may have been due to difficulties transitioning patients across the "gap" between assessment and treatment. To bridge this gap, mental health services should make efforts to increase patients' insight concerning their SUD, flexibility in the administration of treatment, and the motivational skills of the health care staff working with this patient group. Participants considered important for enhancing treatment quality a shared knowledge base regarding SUD, and increased collaboration between different professions and between in- and outpatient services.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Welfare concerns associated with captive lions (Panthera leo) and the implications for commercial lion farms in South Africa

Breeding and housing wild animals in captive environments can pose challenges for their welfare. In South Africa, thousands of lions (Panthera leo) are bred and raised at commercial captive breeding facilities, so called 'lion farms', for use in tourism, trophy hunting and traditional medicine. To gain a better understanding of the potential welfare challenges faced by lions on farms we reviewed 91 peer-reviewed articles relating to lion welfare, identified via a systematic review of the scientific literature. Across these studies, we identified 170 different terms relating to negative behaviours and physical health afflictions. The majority of these terms were associated with disease and injury (124; 73%), followed by negative behaviours (19; 11%), negative mental experiences (15; 9%), nutritional concerns (7; 4%), and environmental challenges or discomfort arising from the animal's surroundings (5; 3%). Of the 91 articles, 32 (35%) focused on data concerning captive lions. Only two studies focused specifically on data obtained from lion farms in South Africa, whilst the remainder reported on data collected from zoos, wildlife parks, sanctuaries, game reserves and private ownership. Our preliminary review of the scientific literature draws attention to some of the challenges associated with caring for lions in captivity, and outlines the potential significance of these welfare challenges for commercial lion farms. Our data highlight the apparent lack of scientific research involving captive lion welfare generally, particularly data collected at commercial breeding facilities in South Africa and the consequences this could have for the welfare of thousands of lions within the industry.

Tolerogenic Artificial Antigen Presenting Cells for Selective Tolerance in Autoimmune Disease

Autoimmune diseases like multiple sclerosis (MS) and type 1 diabetes develop when autoreactive immune cells attack healthy cells and tissues. Current treatments are non-curative and leave patients immunocompromised. As an alternative, therapies that expand regulatory T cells (Tregs) are being actively explored to establish antigen-specific tolerance. We recently showed that an IL-2 immunocytokine (IL-2_IC), a fusion of an antibody to IL-2, preferentially engages and expands Tregs over effector T cells. As a more targeted approach to tolerize the immune system towards a specific autoantigen, we explored the design and therapeutic efficacy of a microparticle bearing an IL-2_IC and an MHC II/peptide complex on its surface (TolAPC).

Microparticles composed of a blend of PLGA and PBAE were loaded with rapamycin, and then chemically conjugated with IL-2_IC and MHC II I-A(b) tetramers loaded with a peptide derived from myelin oligodendrocyte glycoprotein (MOG). Characterized TolAPC were tested in a mouse model of MS, Experimental Autoimmune Encephalomyelitis (EAE). When administered prophylactically, TolAPC delayed EAE development and reduced severity compared to unconjugated controls, with 36.4% of mice remaining asymptomatic for the duration of the study. When administered therapeutically, TolAPC reversed symptomatic EAE. Clinical improvements correlated with a nearly two-fold increase in Tregs in the brain and spinal cord of TolAPC-treated mice compared to controls six days after treatment. Furthermore, administration of additional booster doses led to sustained amelioration of the disease.

Overall, TolAPC can selectively expand Tregs and provide both protection and treatment in an autoimmune mouse model.

Supported by grants from DoD (W81XWH-18-1-0735; W81XWH-21-1-0892), NIH (R01EB029455), and JDRF (1-INO-2020-923-A-N)

Cambridge hybrid closed-loop algorithm in children and adolescents with type 1 diabetes: a multicentre 6-month randomised controlled trial

BACKGROUND

Closed-loop insulin delivery systems have the potential to address suboptimal glucose control in children and adolescents with type 1 diabetes. We compared safety and efficacy of the Cambridge hybrid closed-loop algorithm with usual care over 6 months in this population.

METHODS

In a multicentre, multinational, parallel randomised controlled trial, participants aged 6-18 years using insulin pump therapy were recruited at seven UK and five US paediatric diabetes centres. Key inclusion criteria were diagnosis of type 1 diabetes for at least 12 months, insulin pump therapy for at least 3 months, and screening HbA1c levels between 53 and 86 mmol/mol (7·0-10·0%). Using block randomisation and central randomisation software, we randomly assigned participants to either closed-loop insulin delivery (closed-loop group) or to usual care with insulin pump therapy (control group) for 6 months. Randomisation was stratified at each centre by local baseline HbA1c. The Cambridge closed-loop algorithm running on a smartphone was used with either (1) a modified Medtronic 640G pump, Medtronic Guardian 3 sensor, and Medtronic prototype phone enclosure (FlorenceM configuration), or (2) a Sooil Dana RS pump and Dexcom G6 sensor (CamAPS FX configuration). The primary endpoint was change in HbA1c at 6 months combining data from both configurations. The primary analysis was done in all randomised patients (intention to treat). Trial registration ClinicalTrials.gov, NCT02925299.

FINDINGS

Of 147 people initially screened, 133 participants (mean age 13·0 years [SD 2·8]; 57% female, 43% male) were randomly assigned to either the closed-loop group (n=65) or the control group (n=68). Mean baseline HbA1c was 8·2% (SD 0·7) in the closed-loop group and 8·3% (0·7) in the control group. At 6 months, HbA1c was lower in the closed-loop group than in the control group (between-group difference -3·5 mmol/mol (95% CI -6·5 to -0·5 [-0·32 percentage points, -0·59 to -0·04]; p=0·023). Closed-loop usage was low with FlorenceM due to failing phone enclosures (median 40% [IQR 26-53]), but consistently high with CamAPS FX (93% [88-96]), impacting efficacy. A total of 155 adverse events occurred after randomisation (67 in the closed-loop group, 88 in the control group), including seven severe hypoglycaemia events (four in the closed-loop group, three in the control group), two diabetic ketoacidosis events (both in the closed-loop group), and two non-treatment-related serious adverse events. There were 23 reportable hyperglycaemia events (11 in the closed-loop group, 12 in the control group), which did not meet criteria for diabetic ketoacidosis.

INTERPRETATION

The Cambridge hybrid closed-loop algorithm had an acceptable safety profile, and improved glycaemic control in children and adolescents with type 1 diabetes. To ensure optimal efficacy of the closed-loop system, usage needs to be consistently high, as demonstrated with CamAPS FX.

FUNDING

National Institute of Diabetes and Digestive and Kidney Diseases.

A systematic review of gut microbiota composition in observational studies of major depressive disorder, bipolar disorder and schizophrenia

The emerging understanding of gut microbiota as 'metabolic machinery' influencing many aspects of physiology has gained substantial attention in the field of psychiatry. This is largely due to the many overlapping pathophysiological mechanisms associated with both the potential functionality of the gut microbiota and the biological mechanisms thought to be underpinning mental disorders. In this systematic review, we synthesised the current literature investigating differences in gut microbiota composition in people with the major psychiatric disorders, major depressive disorder (MDD), bipolar disorder (BD) and schizophrenia (SZ), compared to 'healthy' controls. We also explored gut microbiota composition across disorders in an attempt to elucidate potential commonalities in the microbial signatures associated with these mental disorders. Following the PRISMA guidelines, databases were searched from inception through to December 2021. We identified 44 studies (including a total of 2510 psychiatric cases and 2407 controls) that met inclusion criteria, of which 24 investigated gut microbiota composition in MDD, seven investigated gut microbiota composition in BD, and 15 investigated gut microbiota composition in SZ. Our syntheses provide no strong evidence for a difference in the number or distribution (α-diversity) of bacteria in those with a mental disorder compared to controls. However, studies were relatively consistent in reporting differences in overall community composition (β-diversity) in people with and without mental disorders. Our syntheses also identified specific bacterial taxa commonly associated with mental disorders, including lower levels of bacterial genera that produce short-chain fatty acids (e.g. butyrate), higher levels of lactic acid-producing bacteria, and higher levels of bacteria associated with glutamate and GABA metabolism. We also observed substantial heterogeneity across studies with regards to methodologies and reporting. Further prospective and experimental research using new tools and robust guidelines hold promise for improving our understanding of the role of the gut microbiota in mental and brain health and the development of interventions based on modification of gut microbiota.

STEM-07. PRC2 MAINTAINS A CANCER STEM CELL PHENOTYPE IN GLIOBLASTOMA MULTIFORME VIA CHROMATIN MODIFICATION OF H3K27me3

Multi-potent stem-like cells (i.e. cancer stem cells, CSCs) are critical determinants of tumor propagation, therapeutic resistance, and recurrence in glioblastoma (GBM). Modifications in chromatin architecture play a fundamental role in the tumor cell phenotype of GBM. The polycomb repressor complex 2 (PRC2) is a key histone modifier that supports multi-potency and oncogenesis via H3K27 trimethylation (H3K27me3). Understanding how these epigenetic modifications cooperatively drive cancer cell stemness should unveil new targets for therapeutic development in GBM. Using a combination of next-generation sequencing, bioinformatics, and molecular approaches we identified EZH2, the catalytic domain of the PRC2 complex, as a critical mediator of reprograming events in GBM cells. We found that EZH2 is highly induced in response to transgenic Oct4/Sox2 with global increases in H3K27me3. Pharmacological inhibition of EZH2 diminishes self-renewal capacity of GBM neurospheres concurrent with a reduction in gene expression levels of markers and drivers of stemness. Furthermore, we identified and validated a set of 6 putative tumor suppressor genes repressed by Oct4 and Sox2 in a PRC2-dependent manner. We identified miR-217 as an EZH2 regulator in GBM cells and miR-217 reconstitution using advanced nanoparticle formulations re-activates the PRC2-repressed tumor suppressors, inhibited tumor growth and enhanced the effects of ionizing radiation in an orthotopic model of GBM. Taken together, these data show that PRC2-mediated chromatin changes in H3K27me3 help regulate the stem-cell phenotype induced by Oct4 and Sox2 in GBM cells and predict that targeting EZH2 could have therapeutic benefit in GBM.

222 Genetic reprogramming of merkel cell carcinoma and melanoma leads to increased MHC-I expression and antitumor immune activation in vitro and in vivo

Background

Merkel cell carcinoma (MCC) is a rare skin cancer with 46% disease-associated mortality and half of patients unresponsive to immune checkpoint inhibitors.1 2 MCC and melanomas often display decreased MHC class I (MHC-I) expression on the surface of cells, which prevents antigen recognition by T cells (”signal 1”) and hampers immune activation. We therefore sought to genetically reprogram cells to express their own costimulatory molecules (”signal 2”) and immunostimulatory cytokines (”signal 3”) to increase MHC-I expression and drive a targeted immune response.

Methods

We used biodegradable poly(beta-amino ester) nanoparticles (NPs) to co-deliver plasmids encoding a signal 2 molecule (4-1BBL) and two signal 3 molecules (IL-12 and IFNγ) to cancer cells. For in vitro evaluation of NPs we used two patient-derived MCC cell lines with low baseline MHC-I expression; MCC13 and UISO. Co-culture experiments were performed with human PBMCs or primary human natural killer (NK) cells. All in vitro analysis was performed 7 days following PBMC or NK cell addition. For in vivo evaluation, subcutaneous B16F10 mouse melanoma tumors were implanted in C57BL/6J mice and NPs were administered by direct injection into the tumor with and without intraperitoneal injection of αPD1. Tumors were harvested for analysis on day 16.

Results

Transfection with particles delivering the three plasmids to MCC13 and UISO increased MHC-I expression (mean fluorescence intensity) 1.6- and 5.0-fold, respectively, and MHC-II expression increased 1.6- and 6.3-fold, respectively (figure 1). In co-culture with human PBMCs, signal 2/3 particles resulted in increased leukocyte proliferation (4.6- and 6.1-fold increase, respectively) and led to significantly reduced MCC viability (10.6 and 1.6% vs control particles)(figure 2). When MCC13 cells were co-cultured with primary human NK cells, NK cell expansion increased 355-fold with 4-1BBL/IL-12 particles compared to control particles and was accompanied by 2.5% MCC13 cell viability, indicating a potent innate immune response with signal 2/3 NP administration in vitro (figure 3). Following evaluation of NPs in vivo, assessment of MHC-I and MHC-II expression in the melanoma tumors found increased expression with signal 2/3 NPs compared to control NPs (figure 4). When signal 2/3 NPs were administered in combination with αPD1 treatment, 4-1BBL/IL-12 NPs with αPD1 demonstrated improved survival compared to αPD1 treatment with control NPs (p=0.0010) (figure 5).

Abstract 222 Figure 1

Administration of signal 2/3 NPs to MCC13 and UISO cells led to increases in MHC-I and MHC-II expression after 7 days. MHC-I expression in transfected cells (red) and MHC-II expression in transfected cells (blue) compared to untreated control (black)

Abstract 222 Figure 2

Co-culture of transfected MCC cells with human PBMCs led to increases in CD45+ cells and reduced MCC cell viability after 7 days

Abstract 222 Figure 3

Co-culture of 4-1BBL/IL-12 transfected MCC13 cells with isolated CD56+ NK cells demonstrated robust NK-cell expansion and low MCC cell viability after 7 days

Abstract 222 Figure 4

Direct intratumoral injection with signal 2 and 3 NPs led to increases in MHC-I and MHC-II in cancer cells in vivo.

Abstract 222 Figure 5

NPs were administered intratumorally ± intraperitoneal aPD1 on day 9, 11, and 13 following B16F10 melanoma tumor implantation. 4-1BBL/IL12 particles in combination with αPD1 demonstrated a significant improvement in survival compared to control particles (Luc) with αPD1 (p=0.0010)

Conclusions

Together, these results show the ability of signal 2/3 NPs to reprogram MCC and melanoma cells, leading to increased MHC-I expression in vitro and in vivo, eliciting a productive immune response against cancer cells.

References

Hughes MP, Hardee ME, Cornelius LA, Hutchins LF, Becker JC, Gao L. Merkel cell carcinoma: epidemiology, target, and therapy. Curr Dermatol 2014;46–53.

Nghiem PT, Bhatia S, Lipson EJ, Kudchadkar RR, Miller NJ, Annamalai L, Berry S, Chartash EK, Daud A, Fling SP, Friedlander PA, Kluger HM, Kohrt HE, Lundgren L, Margolin K, Mitchell A, Olencki T, Pardoll DM, Reddy SA, Shantha EM, Sharfman WH, Sharon E, Shemanski LR, Shinohara MM, Sunshine JC, Taube JM, Thompson JA, Townson SM, Yearley JH, Topalian SL, Cheever MA. PD-1 blockade with pembrolizumab in advanced merkel-cell carcinoma. N Engl J Med 2016;374:2542–2552.

Experiences of UK African-Caribbean prostate cancer survivors of discharge to primary care

Objective: Black men are three times more likely to develop prostate cancer (PCa), to do so at a younger age and to experience a more aggressive form than White men. This study aims to understand the experiences of African-Caribbean men with respect to their discharge to primary care following successful PCa treatment and the challenges associated with survivorship.Design: Eight African-Caribbean men, who had been successfully treated for PCa, were recruited through the charity BME Cancer Communities. They participated in a focus group, which took place on the premises of the charity and was audio-recorded. The recording was transcribed and the data were analysed employing thematic analysis.Results: Three overarching themes were developed: Discharge - misconceptions and uncertainties; Survivorship - challenges and ways of coping; Black men and PCa: real and potential discrimination. Participants expressed concerns regarding the lack of information and clarity about what discharge meant, the quality of follow-up care, especially the levels of specialist knowledge among GPs, and the impact of side-effects, particularly erectile dysfunction (ED). Participants linked ED with stereotypes of Black male sexuality, particularly in relation to difficulties of expressing their emotions and psychological distress. African-Caribbean men face particular challenges in dealing with the side-effects of treatment for PCa, which are linked to socially-constructed ideas of masculinity.Conclusion: There needs to be a greater focus in primary care on understanding these issues and providing individualised culturally-sensitive care. In particular, GPs should be aware of sensitivities concerning help-seeking related to culturally-mediated understandings of masculinity.

564 Freedom from Urethral Catherisation – Using QI Methodology to Improve Patient Outcome and Experiences

Aim

To reduce catheter burden on patients who could instead be free of urethral catheter and taught intermittent self-catheterisation (ISC).

Method

2 PDSA (Plan, Do, Study, Act) cycles were performed over a 21-month period from February 2018 to November 2020. Using multiple nurse-led TWOC clinics, data was extracted using nurse-completed proformas and electronic patient records to determine: TWOC rate; urethral catheter-free rate; and ISC rate. Following baseline measurement, interventions were made, such as centralisation of TWOC services, emphasis on ISC teaching and the introduction of industry-nurse led clinics.

Results

At baseline, TWOC rate, urethral catheter-free rate and ISC rate were 55.7%, 68% and 28.2%, respectively. Following centralisation of TWOC services and emphasis on ISC teaching in Cycle 1, urethral catheter-free rate rose to 77.8% whilst ISC rate fell to 25%. Cycle 2 followed the introduction of industry-nurse led clinics. Following this, urethral catheter-free rate rose further to 81.6%, with ISC rate rising dramatically to 56.3%

Conclusions

To those capable, ISC frees patients of catheter burden and its sequalae. Evidently, a greater onus on ISC training will increase the number of patients left catheter-free.

123 Supporting A Learning System in Paediatric Emergency Pathways; Using Organisational Comparisons, Serious Incidents and Near Miss Events To Improve The Diagnosis And Treatment Of Testicular Torsion

Introduction

Scrotal pain is a common presentation to the emergency department requiring prompt investigation and management to identify testicular torsion. Using national data we aim to identify key suboptimal areas in the acute diagnosis and management of testicular torsion with a view to improving outcomes.

Method

A freedom of information request was made to all Trusts in England that manage testicular torsion. Serious Incidents (SI's) were analysed to see if those with Paediatric Emergency Departments fared better than those without. In addition, a qualitative thematic analysis of the NHS England Strategic Executive Information System database from 2007-2019 was undertaken, identifying common themes associated with orchidectomies and ‘near miss’ events in children.

Results

304 serious incidents were returned with 62 Orchidectomies and 242 Near Miss Events. Misdiagnosis of symptomatic testicle was not significant when comparing ED to specialists (OR = 1.46, p = 0.3842). Atypical presentation resulting in orchidectomy was significant when comparing ED to specialists (OR = 6, p = 0.0355). Near miss events are due to a variety of factors. There was no statistical significance in incidents when comparing ED's caring for all ages with Paediatric EDs U = 807.5, z = -1.124, p = 0.261.

Conclusions

There's a need for education in ED about atypical presentation of testicular torsion and examination of scrotum in cases of lower abdominal pain. It's also vital that specialist teams are cognisant of the standard operating procedures relevant to scrotal pain. Finally, there should be a drive for annual audit in Urology and ED units with regards to testicular torsion as SI's may be under-reported.

AB0872-HPR IMPACT OF COVID-19 ON A PHYSICAL ACTIVITY FEASIBILITY PILOT STUDY: THE PIPPRA EXPERIENCE

Background:

The PIPPRA (Physiotherapist-led Intervention to Promote Physical Activity in Rheumatoid Arthritis) project is a feasibility project examining the impact of a physical activity behaviour change intervention in people who have rheumatoid arthritis (RA). The PIPPRA study recruitment commenced in October 2019, with participant assessment and intervention commencing in November 2019. In the Republic of Ireland people who have RA are categorised as high risk category for Covid-19, due to immunosuppression [1], although this categorisation contrasts with EULAR’s provisional recommendations [2].

Objectives:

To examine the impact of the Covid-19 pandemic and public health restrictions on a pilot randomised controlled feasibility study in 2020.

Methods:

Participants (aged 18 years+, diagnosis of RA, independently mobile and low levels of physical activity [3]) were recruited from a rheumatology clinic at an urban hospital. Target recruitment was four participants per month for one year (N=48). Assessments were planned at baseline, eight and twenty-four weeks (N=144). Participants were randomised to intervention group or control group. The intervention group received four 1:1 sixty minute sessions with a physiotherapist (N=96). The intervention was delivered over eight weeks. Intervention and control groups received a physical activity information leaflet.

Results:

The Covid-19 pandemic and associated public health restrictions forced the study to be formally paused in April 2020 and the study formally resumed in August 2020. N=48 participants were recruited between October 2019 and March 2020 (six months). N=20 participants have commenced in the study, N=16 are awaiting baseline assessment, N=6 withdrew and N=6 were lost to follow-up prior to baseline. Trial protocol planned for the delivery of N=55 assessments and N=36 intervention sessions for participants who had commenced in the study. N=22 assessments and N=26 intervention sessions were delivered between November 2019 and March 2020. N=5 assessments and N=6 intervention sessions were conducted between August and October 2020. No assessment or intervention delivery occurred in November-December 2020 due to participant hesitancy in attending for assessment and/or intervention with increased public health restrictions. The impact of Covid-19 restrictions resulted in N=33 (60%) deviations from assessment protocol and N=10 (27%) deviations from intervention delivery protocol (Figure 1).

Figure 1.

Deviations from assessment and intervention protocol in the PIPPRA study

Conclusion:

The Covid-19 pandemic has had a significant impact on the delivery of the PIPPRA study. Feasibility study outcomes, including participant retention rate, and study delivery as per protocol, have been affected due to the Covid-19 pandemic. Participant reluctance to attend face-to-face sessions demonstrates the need to consider alternative methods of delivery, e.g. virtual delivery of interventions, where attending in person is not acceptable to participants [4], in future studies.

References:

[1]Health Service Executive. (2019). People at higher risk from COVID-19.Accessed 5th Jan 2020 https://www2.hse.ie/conditions/coronavirus/people-at-higher-risk.html.

[2]Landewé RB et al (2020). EULAR provisional recommendations for the management of rheumatic and musculoskeletal diseases in the context of SARS-CoV-2. Annals of the Rheumatic Diseases 79:851-858.

[3]Godin, G. (2011). The Godin-Shephard leisure-time physical activity questionnaire. The Health & Fitness Journal of Canada, 4(1):18-22.

[4]Inan, OT et al. (2020). Digitizing clinical trials. npj Digit. Med. 3:10.

Disclosure of Interests:

None declared

92 Reshaping the Diagnostic Pathways for Investigation of Haematuria During and After The COVID-19 Pandemic: Diagnostic Accuracy of Strategies for Detection of Bladder Cancer from The IDENTIFY Cohort Study

Introduction

Diagnostic haematuria services have been reduced due to the COVID-19 pandemic, compromising patient care, and necessitating a more pragmatic pathway.

Method

The IDENTIFY study was an international, prospective, multicentre cohort study of over 11,000 patients referred to secondary care for investigation of haematuria. Using this data, we developed strategies using combinations of imaging and cytology as triage tests to maximise cancer detection within a pragmatic pathway.

Results

8112 patients (74·4%) received an ultrasound or a CT urogram, with or without cytology. 5737 (70·7%) patients had visible haematuria (VH) and 2375 (29·3%) had non-visible haematuria (NVH). Diagnostic test performance was used to determine optimal age cut-offs for four proposed strategies. We recommended proceeding directly to transurethral resection of bladder tumour for patients of any age with positive triage tests for cancer. Patients with negative triage tests under 35-years-old with VH, or under 50-years-old with NVH can safely be discharged without undergoing flexible cystoscopy. The remaining patients may undergo flexible cystoscopy, with a greater priority for older patients to capture high risk bladder cancer.

Conclusions

We suggest diagnostic strategies in patients with haematuria, which focus on detection of bladder cancer, whilst reducing the burden to healthcare services in a resource-limited setting.