Clinical and electrophysiological characteristics of extra-pulmonary vein triggers in patients who underwent catheter ablation for atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Extra-pulmonary vein (PV) triggers play significant roles in atrial fibrillation (AF) recurrence after AF catheter ablation (AFCA).

Purpose

We explore the clinical and electrophysiological characteristics of extra-PV triggers in de novo and repeat-AFCA procedure.

Methods

We included 2,151 patients who had de novo AFCA and 319 repeat AFCA (female 28.0%, 59.1 ± 10.8 years old, paroxysmal AF 65.1%) those underwent post-procedural isoproterenol (ISO) provocation tests. We analysed the clinical, electrophysiological, and procedure-related factors associated with extra-PV triggers.

Results

Extra-PV triggers were documented in 11.9% (1.19 ± 0.42 foci) after de novo-AFCA and 27.0% (1.37 ± 0.65 foci) after repeat-AFCA (p = 0.004). LA volume index (OR 1.02 [1.01-1.03], p = 0.004), history of vascular disease (OR 0.55[0.31-0.91], p = 0.028) and Lead I amplitude of electrocardiogram (OR <0.01 [<0.01-0.62], p = 0.032) were independently associated with the existence of extra-PV triggers in de-novo procedure. Women (OR 1.84 [1.03-3.25], p = 0.037) and LA appendage volume (OR 1.04 [1.01-1.07] p = 0.027) were independently associated with extra-PV triggers during the redo-mapping procedure. Septum (28.4%), coronary sinus (24.0%), and superior vena cava (19.6%) were common extra-PV foci, and septal foci were more commonly found in repeat mapping (38.4% vs. 25.0%, p = 0.025). Among 65 patients who showed extra-PV at the repeat procedures, 19 (29.2%) matched with previous focal or empirical extra-PV ablation sites and 9 (13.8%) were multiple or unmappable sites. AF recurrence rates were significantly higher in both patients with extra-PV triggers after de novo procedures (Log-rank P <0.001; HR 1.93 [1.58-2.36], p= <0.001) and repeat procedures (Log-rank P <0.001, HR 1.87 [1.29-2.70], p= <0.001).

Conclusion

ISO provoked extra-PV triggers commonly found in AF patients with significant remodelling and previous empirical or focal extra-PV ablations. Existence of extra-PV triggers were independently associated with poorer rhythm outcome after both de novo and repeat AFCA. Denovo AF ablation outcome OverallExtra-PV triggers (-)Extra-PV triggers (+)p-value(n = 2151)(n = 1895)(n = 256)Age, yrs58.98 ± 10.9558.73 ± 11.0360.76 ± 10.200.006Male, (%)1550 ( 72.1)1389 ( 73.3)161 ( 62.9)0.001Follow up duration, month50.30 (37.71)51.65 (37.95)40.71 (34.58)<0.001Early recurrence (%)579 ( 27.8)455 ( 24.9)124 ( 48.4)<0.001Clinical recurrence (%)699 ( 33.6)584 ( 32.0)115 ( 44.9)<0.001Abstract Figure. AF free survival according to Extra PVT

Sympathetic predominance before tourniquet deflation is associated with a reduction in arterial blood pressure after tourniquet deflation during total knee arthroplasty

High dependency of arterial blood pressure (ABP) on enhanced sympathetic activity, which maintains vascular tone, leads to hypotension after hemodynamic insults that blunt the sympathetic activity. Therefore, we hypothesized that sympathovagal balance before tourniquet deflation (TD) determines the extent of a reduction in ABP after TD during total knee arthroplasty (TKA). Fifty-four hypertensive female patients undergoing TKA under spinal anesthesia were analyzed. The sympathovagal balance [low-to-high frequency ratio of heart rate variability (LF/HF)] before TD was defined as (LF/HF during 5 min before TD-preanesthetic LF/HF)/preanesthetic LF/HF (%). An increase in its value represents a shift in sympathovagal balance toward sympathetic predominance. The percent change in the mean ABP (MAP) after TD was defined as (minimum MAP during 10 min after TD-averaged MAP during 5 min before TD)/averaged MAP during 5 min before TD (%). Simple linear regression was performed to assess the correlation between the sympathovagal balance before TD and change in MAP after TD. The correlation was also assessed by multiple linear regression controlling for age, duration of tourniquet inflation, and spinal anesthesia-induced hypotension. Thirty-two minutes (on average) after tourniquet inflation, the MAP was decreased by 12.1 (-3.0 to 47.9) % [mean (range)] upon TD (P<0.001). The sympathovagal balance before TD was negatively proportional to the change in MAP after TD in both simple and multiple linear regression models (R2=0.323 and 0.340, P<0.001). A shift in sympathovagal balance toward sympathetic predominance before TD is associated with a decrease in ABP after TD.

317 Why Are We Cancelling Theatre Cases at Ealing Hospital? What Can Be Done?

Introduction

Following a recent spate of on the day cancellation of elective operations being cancelled on the day of surgery, a need for a wider review was felt. Our aim was to identify the causes behind these cancellations.

Method

Retrospective data collection was performed to categorise patients according to the reason for cancellation. Analysis consisted of case presentations being prepared and presented to the surgical consultants.

Results

A total of 130 operations were cancelled on the day of surgery. 22 patients were cancelled due to the procedure not being required and 10 patients were cancelled due to insufficient pre-operative investigations.

Analysis of the 32 cases demonstrated that the majority of cancelled patients were seen and listed for surgery after clinical review by the registrar without involvement of the consultant.

Some cancellations occurred when the consultant responsible for listing the patient was different of the operating consultant.

Both factors lead to differences in opinion arising on the day of surgery.

Conclusions

Ensuring patients are only listed after discussion with the consultant would reduce cancellations arising from lack of experience and clinical misjudgment of the registrar. It would also ensure that cases added to the pooled operating lists are less subjective in their indication and readiness.

Nanophotonics for light detection and ranging technology

Light detection and ranging (LiDAR) technology, a laser-based imaging technique for accurate distance measurement, is considered one of the most crucial sensor technologies for autonomous vehicles, artificially intelligent robots and unmanned aerial vehicle reconnaissance. Until recently, LiDAR has relied on light sources and detectors mounted on multiple mechanically rotating optical transmitters and receivers to cover an entire scene. Such an architecture gives rise to limitations in terms of the imaging frame rate and resolution. In this Review, we examine how novel nanophotonic platforms could overcome the hardware restrictions of existing LiDAR technologies. After briefly introducing the basic principles of LiDAR, we present the device specifications required by the industrial sector. We then review a variety of LiDAR-relevant nanophotonic approaches such as integrated photonic circuits, optical phased antenna arrays and flat optical devices based on metasurfaces. The latter have already demonstrated exceptional functional beam manipulation properties, such as active beam deflection, point-cloud generation and device integration using scalable manufacturing methods, and are expected to disrupt modern optical technologies. In the outlook, we address the upcoming physics and engineering challenges that must be overcome from the viewpoint of incorporating nanophotonic technologies into commercially viable, fast, ultrathin and lightweight LiDAR systems.

Holographic metasurface gas sensors for instantaneous visual alarms

The rapid detection of biological and chemical substances in real time is particularly important for public health and environmental monitoring and in the military sector. If the process of substance detection to visual reporting can be implemented into a single miniaturized sensor, there could be a profound impact on practical applications. Here, we propose a compact sensor platform that integrates liquid crystals (LCs) and holographic metasurfaces to autonomously sense the existence of a volatile gas and provide an immediate visual holographic alarm. By combining the advantage of the rapid responses to gases realized by LCs with the compactness of holographic metasurfaces, we develop ultracompact gas sensors without additional complex instruments or machinery to report the visual information of gas detection. To prove the applicability of the compact sensors, we demonstrate a metasurface-integrated gas sensor on safety goggles via a one-step nanocasting process that is attachable to flat, curved, and flexible surfaces.

Small-molecule inhibitors of histone deacetylase improve CRISPR-based adenine base editing

CRISPR-based base editors (BEs) are widely used to induce nucleotide substitutions in living cells and organisms without causing the damaging DNA double-strand breaks and DNA donor templates. Cytosine BEs that induce C:G to T:A conversion and adenine BEs that induce A:T to G:C conversion have been developed. Various attempts have been made to increase the efficiency of both BEs; however, their activities need to be improved for further applications. Here, we describe a fluorescent reporter-based drug screening platform to identify novel chemicals with the goal of improving adenine base editing efficiency. The reporter system revealed that histone deacetylase inhibitors, particularly romidepsin, enhanced base editing efficiencies by up to 4.9-fold by increasing the expression levels of proteins and target accessibility. The results support the use of romidepsin as a viable option to improve base editing efficiency in biomedical research and therapeutic genome engineering.

Optical spin-symmetry breaking for high-efficiency directional helicity-multiplexed metaholograms

Helicity-multiplexed metasurfaces based on symmetric spin-orbit interactions (SOIs) have practical limits because they cannot provide central-symmetric holographic imaging. Asymmetric SOIs can effectively address such limitations, with several exciting applications in various fields ranging from asymmetric data inscription in communications to dual side displays in smart mobile devices. Low-loss dielectric materials provide an excellent platform for realizing such exotic phenomena efficiently. In this paper, we demonstrate an asymmetric SOI-dependent transmission-type metasurface in the visible domain using hydrogenated amorphous silicon (a-Si:H) nanoresonators. The proposed design approach is equipped with an additional degree of freedom in designing bi-directional helicity-multiplexed metasurfaces by breaking the conventional limit imposed by the symmetric SOI in half employment of metasurfaces for one circular handedness. Two on-axis, distinct wavefronts are produced with high transmission efficiencies, demonstrating the concept of asymmetric wavefront generation in two antiparallel directions. Additionally, the CMOS compatibility of a-Si:H makes it a cost-effective alternative to gallium nitride (GaN) and titanium dioxide (TiO2) for visible light. The cost-effective fabrication and simplicity of the proposed design technique provide an excellent candidate for high-efficiency, multifunctional, and chip-integrated demonstration of various phenomena.

Liposomal irinotecan plus fluorouracil/leucovorin versus FOLFIRINOX as the second-line chemotherapy for patients with metastatic pancreatic cancer: a multicenter retrospective study of the Korean Cancer Study Group (KCSG)

Background

There is no clear consensus on the recommended second-line treatment for patients with metastatic pancreatic cancer who have disease progression following gemcitabine-based therapy. We retrospectively evaluated the clinical outcomes of liposomal irinotecan (nal-IRI) plus fluorouracil/leucovorin (FL) and FOLFIRINOX (fluorouracil, leucovorin, irinotecan, and oxaliplatin) in patients who had failed on the first-line gemcitabine-based therapy.

Patients and methods

From January 2015 to August 2019, 378 patients with MPC who had received nal-IRI/FL (n = 104) or FOLFIRINOX (n = 274) as second-line treatment across 11 institutions were included in this retrospective study.

Results

There were no significant differences in baseline characteristics between groups, except age and first-line regimens. With a median follow-up of 6 months, the median progression-free survival (PFS) was 3.7 months with nal-IRI/FL versus 4.6 months with FOLFIRINOX (P = 0.44). Median overall survival (OS) was 7.7 months with nal-IRI/FL versus 9.7 months with FOLFRINOX (P = 0.13). There was no significant difference in PFS and OS between the two regimens in the univariate and multivariate analyses. The subgroup analysis revealed that younger age (<70 years) was associated with better OS with FOLFIRINOX. In contrast, older age (≥70 years) was associated with better survival outcomes with nal-IRI/FL. Adverse events were manageable with both regimens; however, the incidence of grade 3 or higher neutropenia and peripheral neuropathy was higher in patients treated with FOLFIRINOX than with nal-IRI/FL.

Conclusions

Second-line nal-IRI/FL and FOLFIRINOX showed similar effectiveness outcomes after progression following first-line gemcitabine-based therapy. Age could be the determining factor for choosing the appropriate second-line therapy.

•

This multicenter retrospective study investigated nal-IRI/FL and FOLFIRINOX outcomes after gemcitabine-based therapy.

•

We found no significant differences in outcome between nal-IRI/FL and FOLFIRINOX treatment.

•

Both regimens were well tolerated; however, neutropenia and peripheral neuropathy were more frequent with FOLFIRINOX.

•

Age (cut-off, 70 years) showed differential efficacy between chemotherapy regimens.

Multiplex gene targeting in the mouse embryo using a Cas9-Cpf1 hybrid guide RNA

CRISPR-Cas systems, including Cas9 and Cpf1 (Cas12a), are promising tools for generating gene knockout mouse models. Unlike Cas9, Cpf1 can generate multiple crRNAs from a single concatemeric crRNA precursor, which is favorable for multiplex gene editing. Recently, a hybrid guide RNA (hgRNA) system employing both Cas9 and Cpf1 was developed for multiplex gene editing. As the crRNA of Cpf1 was linked to the 3' end of the sgRNA for Cas9, it can be split into separate guide RNAs by Cpf1. To examine whether this Cas9-Cpf1 hybrid system is suitable for multiplex gene knockouts in the mouse embryo, we generated an hgRNA that simultaneously targets the mouse Il10ra gene by Cas9 and mouse Dr3 (or Tnfrsf25, death receptor3) gene by Cpf1. The expression of hgRNA from a single promoter induced significant indels at each gene in cultured mouse cells upon the co-expression of both Cas9 and Cpf1. Interestingly, the hgRNA exhibited comparable Cas9-mediated indel activity without Cpf1 expression. Similarly, when the hgRNA was co-microinjected with both Cas9 and Cpf1 mRNAs into mouse zygotes at the pronuclear stage, founder mice were generated harboring mutations in both the Il10ra and Dr3 genes. However, when Cas9 mRNA was used alone without Cpf1 mRNA, the mouse Il10ra gene targeting was significantly decreased. These results indicate that the hgRNA system is a possible tool for multiplex gene targeting in the mouse embryo.

Stimuli-Responsive Dynamic Metaholographic Displays with Designer Liquid Crystal Modulators

Flat optics, realized by the artificially created 2D material platform called optical metasurfaces, is currently undergoing a science-to-technology transition. However, "real-time" active operations of such flat optical devices remain yet unresolved. Here, liquid crystals (LCs)-integrated metaholograms for ultracompact dynamic holographic displays are proposed. The anisotropic nature of the LCs allows facile and repeatable manipulation of the polarization of light. Specifically designed ("designer") LCs and efficient helicity-encoded metaholograms are combined to realize stimuli-responsive dynamic displays. The designer LC modulators are used as switches that enable a variety of external stimuli (e.g., electric field, heat, surface pressure) to operate holographic images in real-time. Such a dynamic metaholographic platform will provide a path to external stimuli-driven "smart" sensing and display applications such as hologram labels for temperature/pressure/touch monitoring and interactive holographic displays with haptic motion recognition.

Euchromatin histone methyltransferase II (EHMT2) regulates the expression of ras-related GTP binding C (RRAGC) protein

Dimethylation of the histone H3 protein at lysine residue 9 (H3K9) is mediated by euchromatin histone methyltransferase II (EHMT2) and results in transcriptional repression of target genes. Recently, chemical inhibition of EHMT2 was shown to induce various physiological outcomes, including endoplasmic reticulum stress-associated genes transcription in cancer cells. To identify genes that are transcriptionally repressed by EHMT2 during apoptosis, and cell stress responses, we screened genes that are upregulated by BIX-01294, a chemical inhibitor of EHMT2. RNA sequencing analyses revealed 77 genes that were upregulated by BIX-01294 in all four hepatic cell carcinoma (HCC) cell lines. These included genes that have been impli-cated in apoptosis, the unfolded protein response (UPR), and others. Among these genes, the one encoding the stress-response protein Ras-related GTPase C (RRAGC) was upregulated in all BIX-01294-treated HCC cell lines. We confirmed the regulatory roles of EHMT2 in RRAGC expression in HCC cell lines using proteomic analyses, chromatin immune precipitation (ChIP) assay, and small guide RNA-mediated loss-of-function experiments. Upregulation of RRAGC was limited by the reactive oxygen species (ROS) scavenger N-acetyl cysteine (NAC), suggesting that ROS are involved in EHMT2-mediated transcriptional regulation of stress-response genes in HCC cells. Finally, combined treatment of cells with BIX-01294 and 5-Aza-cytidine induced greater upregulation of RRAGC protein expression. These findings suggest that EHMT2 suppresses expression of the RRAGC gene in a ROS-dependent manner and imply that EHMT2 is a key regulator of stress-responsive gene expression in liver cancer cells.

Planar Achiral Metasurfaces-Induced Anomalous Chiroptical Effect of Optical Spin Isolation

Planar chiral structures respond differently for oppositely handed incident light, and thus can produce extraordinary chiroptical effects such as circular conversion dichroism (CCD) and asymmetric transmission (AT). Such chiroptical effects are powerful tools to realize the fundamental principle of optical spin isolation, which leads to a plethora of applications such as optical conversion diodes, chiral imaging, and sensing. Here, we demonstrate the chiroptical effects of simultaneous CCD and AT through meticulously designed single-layered achiral nanofins. Our metamolecule consists of four achiral hydrogenated amorphous silicon (a-Si:H) nanofins that are carefully oriented and optimized to exhibit considerable CCD and AT. The device demonstrates a circular conversion dichroism of 55% and an asymmetric transmission of 58% at a wavelength of 633 nm. Right-hand circularly polarized light (RHCP) is completely absorbed, while left-hand circularly polarized light (LHCP) is transmitted with a polarization conversion, making it a perfect circular polarization wave isolator with negligible backscattering (due to low reflectance). This unique design and its underlying working mechanism are described comprehensively with three different techniques. These methods validate the proposed design and its methodology. For practical applications such as imaging, the proposed design realizes the Pancharatnam-Berry (PB) phase, achieving a 0-2π phase coverage for transmitted circular polarization. For the proof of concept, a metahologram is designed and demonstrated by employing the achieved full-phase control. The measured response of the fabricated metadevice not only validates the CCD and AT but also exhibits a simulated polarization conversion efficiency of up to 71% and measured efficiency up to 52%, comparable to state-of-the-art metahologram demonstrations.

Molecular mechanisms underlying the effects of the small molecule AMC-04 on apoptosis: Roles of the activating transcription factor 4-C/EBP homologous protein-death receptor 5 pathway

The unfolded protein response (UPR) is an emerging target pathway for cancer treatment owing to its ability to induce cell death. In our previous analysis of UPR-modulating small molecules, we had reported that piperazine oxalate derivative compounds (AMC-01-04) are able to promote increased phosphorylation of eukaryotic translation initiation factor-2 alpha (eIF2α). In this study, we found that AMC-04 induces apoptotic cell death via the activation of UPR in human breast and liver cancer cells. AMC-04 upregulated the expression of activating transcription factor-4 (ATF4)-C/EBP homologous protein (CHOP) and death receptor 5 (DR5) in cancer cells, as revealed by microarray analysis, small-interference RNA assay, and western blotting. From a mechanistic perspective, cytotoxic UPR pathway activation by AMC-04 is mediated by reactive oxygen species (ROS) and p38 mitogen-activated protein kinase (p38 MAPK) signaling. A chemical informatics approach predicted that AMC-04 modulates histone methyltransferase activity. Based on biochemical analysis, the activity of histone methyltransferases, including SUV39H1, SUV39H2, SETDB1, and EHMT1, was inhibited by AMC-04. Furthermore, chemical inhibition of the identified target proteins induced UPR activation and apoptotic cell death, suggesting that inhibition of histone methyltransferases is a promising strategy for cancer therapy. Taken together, we showed that the small molecule AMC-04 modulates epigenetic enzyme activity and mediates the link between cytotoxic UPR and histone modifications.

Demonstration of Spin-Multiplexed and Direction-Multiplexed All-Dielectric Visible Metaholograms

The optical holography technique realized by metasurfaces has emerged as a novel approach to projective volumetric display and information encryption display in the form of ultrathin and almost flat optical devices. Compared to the conventional holographic technique with spatial light modulators, the metahologram has numerous advantages such as miniaturization of optical setup, higher image resolution and larger field of visibility for holographic images. Here, a protocol is reported for the fabrication and optical characterization of optical metaholograms that are sensitive to the spin and direction of incident light. The metasurfaces are composed of hydrogenated amorphous silicon (a-Si:H), which has large refractive index and small extinction coefficient in the entire visible range resulting in high transmittance and diffraction efficiency. The device produces different holographic images when the spin or direction of incident light are switched. Therefore, they can encode multiple types of visual information simultaneously. The fabrication protocol consists of film deposition, electron beam writing and subsequent etching. The fabricated device can be characterized using a customized optical setup that consists of a laser, a linear polarizer, a quarter waveplate, a lens and a charge-coupled device (CCD).

Changes of Neurotransmitters in Youth with Internet and Smartphone Addiction: A Comparison with Healthy Controls and Changes after Cognitive Behavioral Therapy

BACKGROUND AND PURPOSE

Neurotransmitter changes in youth addicted to the Internet and smartphone were compared with normal controls and in subjects after cognitive behavioral therapy. In addition, the correlations between neurotransmitters and affective factors were investigated.

MATERIALS AND METHODS

Nineteen young people with Internet and smartphone addiction and 19 sex- and age-matched healthy controls (male/female ratio, 9:10; mean age, 15.47 ± 3.06 years) were included. Twelve teenagers with Internet and smartphone addiction (male/female ratio, 8:4; mean age, 14.99 ± 1.95 years) participated in 9 weeks of cognitive behavioral therapy. Meshcher-Garwood point-resolved spectroscopy was used to measure γ-aminobutyric acid and Glx levels in the anterior cingulate cortex. The γ-aminobutyric acid and Glx levels in the addicted group were compared with those in controls and after cognitive behavioral therapy. The γ-aminobutyric acid and Glx levels correlated with clinical scales of Internet and smartphone addiction, impulsiveness, depression, anxiety, insomnia, and sleep quality.

RESULTS

Brain parenchymal and gray matter volume-adjusted γ-aminobutyric acid-to-creatine ratios were higher in subjects with Internet and smartphone addiction (P = .028 and .016). After therapy, brain parenchymal- and gray matter volume-adjusted γ-aminobutyric acid-to-creatine ratios were decreased (P = .034 and .026). The Glx level was not statistically significant in subjects with Internet and smartphone addiction compared with controls and posttherapy status. Brain parenchymal- and gray matter volume-adjusted γ-aminobutyric acid-to-creatine ratios correlated with clinical scales of Internet and smartphone addictions, depression, and anxiety. Glx/Cr was negatively correlated with insomnia and sleep quality scales.

CONCLUSIONS

The high γ-aminobutyric acid levels and disrupted balance of γ-aminobutyric acid-to-Glx including glutamate in the anterior cingulate cortex may contribute to understanding the pathophysiology and treatment of Internet and smartphone addiction and associated comorbidities.

Reconfigurable all-dielectric Fano metasurfaces for strong full-space intensity modulation of visible light

Dynamically reconfigurable nanoscale tuning of visible light properties is one of the ultimate goals both in the academic field of nanophotonics and the optics industry demanding compact and high-resolution display devices. Among various efforts incorporating actively reconfigurable optical materials into metamaterial structures, phase-change materials have been in the spotlight owing to their optical tunability in wide spectral regions including the visible spectrum. However, reconfigurable modulation of visible light intensity has been limited with small modulation depth, reflective schemes, and a lack of profound theoretical background for universal design rules. Here, all-dielectric phase-change Fano metasurface gratings are demonstrated for strong dynamic full-space (reflection and transmission) modulation of visible intensities based on Fano resonances. By judicious periodic couplings between densely arranged meta-atoms containing VO₂, phase-change induced thermo-optic modulation of full-space intensities is highly enhanced in the visible spectrum. By providing intuitive design rules, we envision that the proposed study would contribute to nanophotonics-enabled optoelectronics technologies for imaging and sensing.

Nanocatalosomes as Plasmonic Bilayer Shells with Interlayer Catalytic Nanospaces for Solar-Light-Induced Reactions

Interest and challenges remain in designing and synthesizing catalysts with nature-like complexity at few-nm scale to harness unprecedented functionalities by using sustainable solar light. We introduce "nanocatalosomes"-a bio-inspired bilayer-vesicular design of nanoreactor with metallic bilayer shell-in-shell structure, having numerous controllable confined cavities within few-nm interlayer space, customizable with different noble metals. The intershell-confined plasmonically coupled hot-nanospaces within the few-nm cavities play a pivotal role in harnessing catalytic effects for various organic transformations, as demonstrated by "acceptorless dehydrogenation", "Suzuki-Miyaura cross-coupling" and "alkynyl annulation" affording clean conversions and turnover frequencies (TOFs) at least one order of magnitude higher than state-of-the-art Au-nanorod-based plasmonic catalysts. This work paves the way towards next-generation nanoreactors for chemical transformations with solar energy.

CD226hiCD8+ T Cells Are a Prerequisite for Anti-TIGIT Immunotherapy

Clinical trials are evaluating the efficacy of anti-TIGIT for use as single-agent therapy or in combination with programmed death 1 (PD-1)/programmed death-ligand 1 blockade. How and whether a TIGIT blockade will synergize with immunotherapies is not clear. Here, we show that CD226^loCD8⁺ T cells accumulate at the tumor site and have an exhausted phenotype with impaired functionality. In contrast, CD226^hiCD8⁺ tumor-infiltrating T cells possess greater self-renewal capacity and responsiveness. Anti-TIGIT treatment selectively affects CD226^hiCD8⁺ T cells by promoting CD226 phosphorylation at tyrosine 322. CD226 agonist antibody-mediated activation of CD226 augments the effect of TIGIT blockade on CD8⁺ T-cell responses. Finally, mFOLFIRINOX treatment, which increases CD226^hiCD8⁺ T cells in patients with pancreatic ductal adenocarcinoma, potentiates the effects of TIGIT or PD-1 blockade. Our results implicate CD226 as a predictive biomarker for cancer immunotherapy and suggest that increasing numbers of CD226^hiCD8⁺ T cells may improve responses to anti-TIGIT therapy.

Enhanced antimicrobial stewardship based on rapid phenotypic antimicrobial susceptibility testing for bacteraemia in patients with haematological malignancies: a randomized controlled trial

OBJECTIVES

Recently, rapid phenotypic antimicrobial susceptibility testing (AST) based on microscopic imaging analysis has been developed. The aim of this study was to determine whether implementation of antimicrobial stewardship programmes (ASP) based on rapid phenotypic AST can increase the proportion of patients with haematological malignancies who receive optimal targeted antibiotics during early periods of bacteraemia.

METHODS

This randomized controlled trial enrolled patients with haematological malignancies and at least one positive blood culture. Patients were randomly assigned 1:1 to conventional (n = 60) or rapid phenotypic (n = 56) AST. The primary outcome was the proportion of patients receiving optimal targeted antibiotics 72 hr after blood collection for culture.

RESULTS

The percentage receiving optimal targeted antibiotics at 72 hr was significantly higher in the rapid phenotypic AST group (45/56, 80.4%) than in conventional AST group (34/60, 56.7%) (relative risk (RR) 1.42, 95% confidence interval (CI) 1.09-1.83). The percentage receiving unnecessary broad-spectrum antibiotics at 72 hr was significantly lower (7/26, 12.5% vs 18/60, 30.0%; RR 0.42, 95% CI 0.19-0.92) and the mean time to optimal targeted antibiotic treatment was significantly shorter (38.1, standard deviation (SD) 38.2 vs 72.8, SD 93.0 hr; p < 0.001) in the rapid phenotypic AST group. The mean time from blood collection to the AST result was significantly shorter in the rapid phenotypic AST group (48.3, SD 17.6 vs 83.1, SD 22.2 hr).

DISCUSSION

ASP based on rapid phenotypic AST can rapidly optimize antibiotic treatment for bacteraemia in patients with haematological malignancy. Rapid phenotypic AST can improve antimicrobial stewardship in immunocompromised patients.

Biomimetic ultra-broadband perfect absorbers optimised with reinforcement learning

By learning the optimal policy with a double deep Q-learning network (DDQN), we design ultra-broadband, biomimetic, perfect absorbers with various materials, based the structure of a moth's eye. All absorbers achieve over 90% average absorption from 400 to 1600 nm. By training a DDQN with moth-eye structures made up of chromium, we transfer the learned knowledge to other, similar materials to quickly and efficiently find the optimal parameters from the ∼1 billion possible options. The knowledge learned from previous optimisations helps the network to find the best solution for a new material in fewer steps, dramatically increasing the efficiency of finding designs with ultra-broadband absorption.

Capillary-force-induced collapse lithography for controlled plasmonic nanogap structures

The capillary force effect is one of the most important fabrication parameters that must be considered at the micro/nanoscale because it is strong enough to deform micro/nanostructures. However, the deformation of micro/nanostructures due to such capillary forces (e.g., stiction and collapse) has been regarded as an undesirable and uncontrollable obstacle to be avoided during fabrication. Here, we present a capillary-force-induced collapse lithography (CCL) technique, which exploits the capillary force to precisely control the collapse of micro/nanostructures. CCL uses electron-beam lithography, so nanopillars with various shapes can be fabricated by precisely controlling the capillary-force-dominant cohesion process and the nanopillar-geometry-dominant collapse process by adjusting the fabrication parameters such as the development time, electron dose, and shape of the nanopillars. CCL aims to achieve sub-10-nm plasmonic nanogap structures that promote extremely strong focusing of light. CCL is a simple and straightforward method to realize such nanogap structures that are needed for further research such as on plasmonic nanosensors.

Twisted non-diffracting beams through all dielectric meta-axicons

We demonstrate transmission-based all-dielectric, highly efficient (≈73.4%) and polarization-insensitive meta-axicons (for the visible wavelength of 633 nm) to generate zero and higher order Bessel beams without using additional components. The Bessel beams, owing to their diverse applications and non-diffractive properties, attract great interest from the scientific community. It is shown that the propagation length can be increased through a lower numerical aperture (∼2600 λ for NA = 0.1) whereas a higher full width at half maximum (< 0.5 λ) can be obtained for a higher numerical aperture (for NA ≥ 0.7). Our dielectric material, hydrogenated amorphous silicon (a-Si:H), provides a significant efficiency advantage over plasmonic and other high-index all-dielectric (e.g., TiO₂ and GaN) metasurfaces in terms of cost, ease of fabrication, and CMOS compatibility. The finite difference time domain (FDTD) technique based numerically simulated and experimental results show excellent agreement. Due to the technological and scientific importance of the Bessel beams, the recommended material and meta-axicons provide an efficient and compact platform for realizing various advanced applications like optical manipulation, optical alignment, laser fabrication, imaging, and laser machining.

Comparison of the difference between income quintiles with the slope index of inequality

Background

The difference between income quintiles in health is relatively well accepted by the general public as a measure of health inequality. However, the slope index of inequality (SII) in health reflects the patterns of all social groups, including the middle 60%, and it could therefore be considered more academically desirable. If these two measures are closely correlated, the widespread use of the difference between income quintiles in health would be better supported. This study was conducted to compare differences between income quintiles in life expectancy (LE) and healthy life expectancy (HLE) with the SII.

Methods

Data on LE and HLE by income quintile from all 252 subnational districts of Korea were obtained using the National Health Information Database of the National Health Insurance Service and the Korea Community Health Survey. The SII was estimated with linear regression analysis, and Pearson correlation coefficients between differences between income quintiles and the SII were computed.

Results

The correlation coefficients between differences between income quintiles and the SII were generally high: 0.97 (95% CI: 0.96-0.98) for LE in men and women combined and 0.96 (95% CI: 0.94-0.97) for HLE in men and women combined. In most districts, the SII was greater than the difference between income quintiles.

Conclusions

Differences between income quintiles were closely correlated with the SII. The widespread use of differences between income quintiles in health as a measure of health inequality may be preferable for communicating results of health inequality measurements to the public.

Key messages

Differences in life expectancy and health life expectancy between income quintiles were closely correlated with the slope index of inequality in life expectancy and healthy life expectancy. The widespread use of differences between income quintiles in health as a measure of health inequality may be preferable for communicating results of health inequality measurements to the public.

Evaluation of an antibody to α4β7 in the control of SIVmac239-nef-stop infection

Treatment of SIV-infected rhesus macaques with short-term antiretroviral therapy (ART) and partially overlapping infusions of antibody to integrin α4β7 was reported to induce durable posttreatment viral suppression. In an attempt to replicate those observations, we treated macaques infected with the same virus and with the same ART and monoclonal antibody (mAb) regimens (anti-α4β7 versus control mAb). Sequencing demonstrated that the virus used was actually SIVmac239-nef-stop, not wild-type SIVmac239. A positive correlation was found at 2 weeks after infection between the frequency of repair of attenuated Nef-STOP virus to pathogenic Nef-OPEN and plasma SIV RNA levels. Levels of plasma viremia before the first antibody infusion and preinfection levels of α4β7hi CD4+ T cells, but not treatment with antibody to α4β7 , correlated with levels of viral replication upon discontinuation of all treatments. Follow-up plasma viremia, peripheral blood CD4+ T cell counts, and lymph node and rectal tissue viral load were not significantly different between anti-α4β7 and control mAb groups.

Histone deacetylase inhibition has cardiac and vascular protective effects in rats with pressure overload cardiac hypertrophy

Histone deacetylase (HDAC) inhibitors have shown beneficial effects in animal models of cardiovascular diseases. We hypothesized that HDAC inhibitor, sodium valproate (VPA), has cardiac and vascular protective effects in rats with pressure overload cardiac hypertrophy induced by transverse aortic constriction (TAC). Sections of the heart were visualized after hematoxylin and eosin staining, picrosirius red staining and immunohistochemistry. The expression of genes related to cardiac hypertrophy, fibrosis, and oxidative stress was determined by quantitative real-time polymerase chain reaction. The aortic ring tension analysis was conducted using both the ascending aorta and descending thoracic aorta. TAC increased the expression of hypertrophic, fibrotic, and oxidative stress genes, which was attenuated by VPA. In the ascending aorta with intact endothelium, there was a significant decrease in the relaxation response, which was recovered by VPA treatment. These results indicate that VPA has cardiac and vascular protective effects in rats with pressure overload cardiac hypertrophy.

Down-regulation of Survivin by BIX-01294 Pretreatment Overcomes Resistance of Hepatocellular Carcinoma Cells to TRAIL

BACKGROUND/AIM

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) is a cancer-selective, cell-death-inducing agent with little toxicity to normal cells. However, various human cancers and cancer cell lines have been reported to be resistant to TRAIL. Molecular clarification of resistance mechanism is needed.

MATERIALS AND METHODS

Compound screening, proliferation assays, western blotting, and flow cytometry were used to examine the sensitizer activity of methyl transferase inhibitor BIX-01294 in combination with TRAIL, in hepatocellular carcinoma (HCC) cells. RNA sequencing analysis and single guide (sg)RNA-mediated gene deletion were used to investigate the role of survivin in sensitization.

RESULTS

In HCC cells, BIX-01294 enhanced TRAIL sensitivity by reducing survivin expression at the RNA level. Small interference RNA-mediated gene knockdown demonstrated the mechanism of sensitization to be via the reduction of survivin.

CONCLUSION

Euchromatin histone methyltransferase 2 (EHMT2) inhibition by BIX-01294 may be a potent anti-tumor therapeutic strategy for human HCC.

Therapeutic Potential of Rottlerin for Skin Hyperpigmentary Disorders by Inhibiting the Transcriptional Activity of CREB-Regulated Transcription Coactivators

Exposure to UVR stimulates the cAMP signaling pathway, which leads to melanin deposits in skin tissues. Although melanogenesis can be beneficial by protecting skin from UVR-induced damage, excessive or uneven deposits of melanin can cause various skin hyperpigmentation disorders. Because cAMP-responsive element binding protein (CREB) and CREB-regulated transcription coactivators (CRTC) play a major role in conveying cAMP signals that induce transcription of microphthalmia-associated transcription factor and melanin production, we screened for a CREB or CRTC inhibitor and identified rottlerin (Rot) as a potent inhibitor of its transcriptional activity. Rot suppressed melanin production in both basal and cAMP-stimulated cultured melanocytes by downregulating melanogenic gene expression. In addition, topical application of Rot on the tails of mice decreased melanin accumulation. Mechanistically, we showed that Rot decreased the mitochondrial membrane potential, which then activated AMPK, leading to the phosphorylation and nuclear exclusion of CRTC3 and suppressing the expression of CREB target genes, including MITF. Our study demonstrates that Rot is an active antimelanogenic agent and suggests that screening for an inhibitor of CREB or CRTC transcriptional activity is a promising strategy by which to discover better drugs to treat skin hyperpigmentary disorders.

Correction: Polarisation insensitive multifunctional metasurfaces based on all-dielectric nanowaveguides

Correction for 'Polarisation insensitive multifunctional metasurfaces based on all-dielectric nanowaveguides' by Nasir Mahmood et al., Nanoscale, 2018, 10, 18323-18330.

Novel Compound Heterozygote Mutation in IL10RA in a Patient With Very Early-Onset Inflammatory Bowel Disease

BACKGROUND

Very early-onset inflammatory bowel disease (VEO-IBD) is often associated with monogenetic disorders. IL-10RA deficiency is one of the major causal mutations in VEO-IBD. Here, we aimed to identify the causal mutation associated with severe IBD in a 1-year-old patient, validate the pathogenicity of the mutation, and characterize the mutant protein.

METHODS

To identify the causal mutation, targeted exome sequencing (ES) was performed using the genomic DNA from the patient. To validate the pathogenicity, IL-10RA functional tests were performed using the patient's peripheral blood mononuclear cells (PBMCs). Additionally, flow cytometry analysis, confocal microscopy on overexpressed green fluorescent protein-fused mutants, and computational analysis on the structures of IL-10RA proteins were performed.

RESULTS

We identified a novel compound heterozygote mutation p.[Tyr91Cys];[Pro146Alafs*40] in the IL10RA gene of the patient. The missense variant p.Tyr91Cys was previously identified but not functionally tested, and a frameshift variant, p.Pro146Alafs*40, is novel and nonfunctional. PBMCs from the patient showed defective signal transducer and activator of transcription 3 activation. The p.Tyr91Cys mutant protein failed to properly localize on the plasma membrane. The p.Tyr91Cys mutation seems to disrupt the hydrophobic core structure surrounding the tyrosine 91 residue, causing structural instability.

CONCLUSIONS

Targeted ES and linkage analysis identified novel compound heterozygous mutations p.[Tyr91Cys];[Pro146Alafs*40] in the IL10RA gene of a child with severe VEO-IBD. p.Tyr91Cys proteins were functionally defective in IL-10RA signaling and failed to properly localize on the plasma membrane, probably due to its structural instability.

Soluble Prokaryotic Expression and Purification of Bioactive Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) is considered as an antitumor agent owing to its ability to induce apoptosis of cancer cells without imparting toxicity toward most normal cells. TRAIL is produced in poor yield because of its insoluble expression in the cytoplasm of E. coli. In this study, we achieved soluble expression of TRAIL by fusing maltose-binding protein (MBP), b'a' domain of protein disulfide isomerase (PDIb'a'), or protein disulfide isomerase at the N-terminus of TRAIL. The TRAIL was purified using subsequent immobilized metal affinity chromatography and amylose-binding chromatography, with the tag removal using tobacco etch virus protease. Approximately 4.5 mg of pure TRAIL was produced from 125 ml flask culture with a purification yield of 71.6%. The endotoxin level of the final product was 0.4 EU/μg, as measured by the Limulus amebocyte lysate endotoxin assay. The purified TRAIL was validated and shown to cause apoptosis of HeLa cells with an EC₅₀ and Hill coefficient of 0.6 ± 0.03 nM and 2.41 ± 0.15, respectively. The high level of apoptosis in HeLa cells following administration of purified TRAIL indicates the significance and novelty of this method for producing high-grade and high-yield TRAIL.

Abstract P2-08-52: A predictive model for distant metastasis in breast cancer patients using machine learning

Introduction

Tumor metastasis is a major clinical challenge accounting for the vast majority of cancer related deaths.In previous studies, prediction of distant metastasis was based on subtypes,clinical status and sometimes gene expression were used however clinical application was difficult.

In this study, we develop the easy to use prediction tool for distant metastasis using clinical characteristics and gene profiles which came from CancerSCANTM, Next Generation Sequencing based targeted-sequencing platform designed at Samsung Medical Center(SMC).

Methods

We performed a retrospective chart review of 326 breast cancer patients who underwent surgery and CancerSCAN TM between Jan 2001 and Dec 2014 at SMC. Median follow up period was 83 months (Range 1˜190). Cancer scanTM cover 381 genes but 27 genes and 34 occasions (loss of function, mutation or copy number variation) were selected for analysis through gradient boosting and Wilcoxon Signed rank test. Azure Machine Learning is a cloud service that enables the execution of machine learning processes.This was accomplished using the steps of (1) edit the data, (2) split the data, (3) train the model, (4) score the model, and (5) evaluate the model. We split the modeling data into training and testing sets using a randomized 50–50 split. Two-class Decision Forest method was used. After deploying the Azure ML predictive model as a web service, we used a Representational State Transfer application programming interface to send data and obtained predictions in real-time.

Results

No distant metastasis group and distant metastasis group consisted of 267 and 59 patients, respectively. HR-/HER2+ and 50 years old and over patients were higher in metastasis group (p-value = 0.003 and p-value = 0.000). Nuclear grade 3 and N2,3 were higher in metastasis group (p-value = 0.010 and p-value = 0.000, p-value = 0.001 respectively). Stage III was also higher in metastasis group (p-value = 0.000). Among 59 patients with distantmetastasis, multiple sites metastasis was 21 cases (35.6%) and then lung metastasis was 19 cases (32.2%). In the 21 cases of multiple sites metastasis, triple sites was 6 cases (28.6%) and double sites was 15 cases (71.4%). PIK3CA mutation was the most frequent gene variation in all patients (34.5% of no metastasis group and 27.1% of metastasis group) but there was no difference between two groups(p-value = 0.278). BRCA 1 loss of function and BRCA2 loss of function were more frequent in metastasis group than no metastasis group(p-value = 0.033 and p-value = 0.024, respectively) but total counts was too small. We assessed the area under the curve (AUC) of the receiver operating characteristic (ROC) curve for predictive value. The AUC of ROC curve was 1.000 and also accuracy, precision, recall were 1.000. In addition, we conducted internal validation using 83 patients during 2015. When we applied a 0.5 threshold value with our predictive model, true negative was 81 and true positive was 2 among 83 patients. Finally, the accuracy of validation was 1.000.

Conclusion

Our predicted model could represent a useful and easy-to-access tool for the selection of patients with distant metastasis. After additional evaluation with large data and external validation, worldwide use of our model could be expected.

Citation Format: Kim I, Choi HJ, Ryu JM, Lee SK, Yu JH, Kim SW, Nam SJ, Seo SW, Lee JE. A predictive model for distant metastasis in breast cancer patients using machine learning [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-52.

Abstract P1-15-18: Not presented

This abstract was not presented at the conference.

Citation Format: Choi HJ, Kim SW, Ryu JM, Kim I, Nam SJ, Yu J, Lee SK, Lee JE. Not presented [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-15-18.

Abstract P2-08-29: The impact of time interval between diagnosis and surgery in each type and stage of breast cancer

Background: There are many factors that might contribute to the delay of surgery in patients with breast cancer. Previous studies investigate the influence of delay of surgery, but they reported inconsistent results. The purpose of this study was to evaluate the impact of time of surgery on prognosis of breast cancer.

Methods: We performed a retrospective review of the patients with breast cancer, who received surgery between 1992 and 2009, by using data from Korea Breast Cancer Society Registry. Kaplan-Meier survival analysis and Cox regression model were used to evaluate the impact of time to surgery in breast cancer and subgroup analyses were performed for each disease stage and molecular subtype.

Result: A total 14727 patients were included for analysis. Delay of surgery more than 31 days was associated with worse survival for breast cancer [hazard ratio (HR) = 2.16; 95% confidence interval (CI), 1.936-2.408, p&lt;0.001]. Subgroup analyses revealed that over 31 days of surgical delay were significantly associated with worse survival in hormone receptor positive and HER-2 negative (p&lt;0.001), hormone receptor positive and HER-2 positive (p&lt;0.001), hormone receptor negative and HER-2 positive (p&lt;0.001), triple negative (p&lt;0.001) and stage II, III breast cancer patients (p&lt;0.001).

Conclusion: Surgical delay of more than 31 days were independent risk factors for worse outcome of breast cancer in each molecular subtype and breast cancer group except stage 0 and I. Although preoperative evaluation is required, surgical delay should be shortened to enhance survival of breast cancer, especially in patients with tumor size more than 2cm or presence of lymph node metastasis.

Citation Format: Kim J-M, Choi HJ, Kim I, Ryu JM, Yu J, Lee JE, Kim SW, Nam SJ, Lee SK. The impact of time interval between diagnosis and surgery in each type and stage of breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-29.

Abstract P2-09-03: Updated efficacy of first or second-line pembrolizumab (pembro) plus capecitabine (cape) in metastatic triple negative breast cancer (mTNBC) and correlations with baseline lymphocyte and naïve CD4+ T-cell count

Background: In mTNBC, anti-PD-1/L1 monotherapy is most effective when administered early in the course of disease, with recent trials demonstrating overall response rates (ORR) of 23-26% in the first-line setting and 5-6% in later lines. This may reflect iatrogenic lymphopenia from preceding cytotoxic chemotherapy. Furthermore, curative-intent chemotherapy is associated with prolonged suppression of naïve CD4+ cells, a T-cell subset that may play a critical role in the generation of de novo anti-tumor immune responses. We present the final clinical results of a pilot study evaluating the safety and efficacy of combining pembrolizumab plus standard-of-care capecitabine in the first/second-line mTNBC setting. We also explore potential associations between clinical benefit and lymphopenia, preceding chemotherapy, and absolute naïve CD4+ counts.

Methods: In a pilot study, we evaluated the tolerability and preliminary efficacy of concurrent pembro (200mg IV q21 day) plus investigator-selected 1st/2nd line paclitaxel (80mg/m2 IV weekly) or oral cape (2,000mg BID, weekly 1 on/1 off). The primary endpoint was tolerability, defined as the proportion of subjects receiving &gt;6 weeks concurrent therapy without dose discontinuation with toxicities reported per CTCAE v4.0. The secondary endpoint was 12-week objective response rate (ORR) by RECIST1.1. Exploratory endpoints included peripheral blood cell enumeration by real-time flow cytometry and routine clinical laboratory. Naïve CD4+ cells were defined as CD45+ CD3+ TCRab+ CD4+ CD45RA+ CCR7+. Here, we report the results of the pilot phase of the cape cohort (NCT02734290).

Results: Twelve of 14 subjects were treated in the first-line setting. All subjects (14/14, 100%) tolerated cape+pembro for &gt;6 weeks, with toxicities consistent with monotherapy cape experience (diarrhea: grade I-II 50%, grade III 7%; hand-foot: grade I-II 71%) that improved with dose-reduction as needed. At 12 weeks, the ORR was 6/14 (42.9%), and the clinical benefit rate (ORR + stable disease) was 8/14 (57.1%). Depressed absolute lymphocyte count at baseline (ALC&lt;1.0/uL: 33% CBR; ALC≥1.0/uL: 75% CBR) and recent exposure to cytotoxic chemotherapy (&lt;6 months: 33% CBR; &gt;6 months: 75% CBR) were associated with reduced clinical benefit. By flow cytometry, subjects experiencing clinical benefit had higher baseline absolute naïve CD4+ counts (average 283 cells/uL v. 93 cells/uL, p=.069).

Conclusions: This study met the primary endpoint of safety for cape plus pembro in mTNBC, with encouraging clinical activity. These data are supportive of further studies evaluating combination chemotherapy plus anti-PD-1/L1 mTNBC. We observed greater clinical benefit in subjects with non-suppressed ALC, less exposure to recent chemo, and higher baseline naïve CD4+ counts, suggesting that iatrogenic immunosuppression can impair response to immune checkpoint therapy in mTNBC. These findings should be confirmed in ongoing randomized trials of immune checkpoint +/- chemotherapy in mTNBC, and should be considered in the design of future clinical trials.

Citation Format: Page DB, Pucilowska J, Bennetts L, Kim I, Sanchez K, Martel M, Conlin A, Moxon N, Mellinger S, Acheson A, Kemmer K, Mitri Z, Vuky J, Ahn J, Abaya C, Manigault T, Basho R, Urba WJ, McArthur HL. Updated efficacy of first or second-line pembrolizumab (pembro) plus capecitabine (cape) in metastatic triple negative breast cancer (mTNBC) and correlations with baseline lymphocyte and naïve CD4+ T-cell count [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-09-03.