A quality improvement curriculum for the neurology clerkship: A practice-based approach to discharge education

In the Neurology Clerkship at our institution, we introduced a medical education curriculum to increase student competency in providing discharge education to patients with neurologic disease, and to increase knowledge of QI principles. The curriculum was peer-based, in that it was developed by medical students, experienced by medical student clerks, and modified over time with their feedback, which was tracked using exit surveys. Patients counseled were predominantly male (67%) and white (55%), with stroke or TIA together representing the most common diagnoses (58%). A high proportion of students (>85%) agreed that the clerkship project was effective in teaching discharge education, the risk factors for readmission, and increased confidence in providing discharge education. We conclude that medical students are poised to learn QI principals through practice-based curricula, and through practice may improve the quality and safety of care for patients with neurologic disease. This curriculum can be implemented within other services, and with different learners.

Associations between movement synchrony and outcome in patients with social anxiety disorder: Evidence for treatment specific effects

Background: Studies with heterogeneous samples in naturalistic treatment settings suggest that movement synchrony (MS) between therapists and patients correlates with therapeutic success. In this study, we examined a homogeneous sample of patients with social anxiety disorder and investigated whether MS in sessions 3 and 8 would be associated with therapy outcome and therapeutic alliance, and whether these associations depend on the therapeutic approach. Methods: The patients (N = 267) were treated with either manual-guided cognitive behavior therapy (CBT), manual-guided psychodynamic therapy (PDT), or naturalistic CBT. The Helping Alliance Questionnaire (HAQ), the Inventory of Interpersonal Problems (IIP) and the Beck-Depression-Inventory (BDI) were used as measures. Body motions were coded with motion energy analysis. MS was quantified using time series analysis methods. Results: MS was observed more frequently in both CBT conditions than in PDT. In both CBT groups, more synchrony was predictive of lower IIP scores at the end of therapy. If the patient lead synchrony more often than the therapist, higher IIP and BDI scores were observed at the end of treatment. PDT showed the largest effect size for the synchrony-alliance-association. Conclusion: Movement synchrony and therapeutic success are associated. The effect of therapeutic approach and leading/following are relevant for this association.

First evidence of a therapeutic effect of miransertib in a teenager with Proteus syndrome and ovarian carcinoma

Proteus syndrome (PS) is an ultra-rare disease characterized by progressive, disproportionate, segmental overgrowth caused by a somatic gain-of-function mutation p.Glu17Lys in the oncogene AKT1. The disease has high morbidity and mortality rates due to the increased risk for patients to develop cancer and progressive overgrowth. A teenage patient with severe PS phenotype developed a pelvic recurrence of low-grade serous ovarian carcinoma (LGSOC). Taking into consideration, recent results of the use of AKT inhibitors both in PS and AKT-mutant cancers, we treated the patient on a compassionate basis, with miransertib (ARQ 092), a potent, selective, allosteric AKT inhibitor. Targeted deep sequencing assay of PI3K/AKT pathway genes of the affected overgrowth lesion (cerebriform connective tissue nevus) and the tumor tissues detected the same activating AKT1 mutation in both. Treatment with miransertib led to a complete remission of the cancer and a significant improvement in the patients' everyday life. The treatment is still ongoing at 22 months. This is the first report showing the therapeutic effects of an AKT inhibitor on both benign and malignant tissues that harbor the same pathogenic AKT1 mutation. The present article showed that personalized medicine is feasible in ultra-rare diseases.

Evidence synthesis - Evaluating risk communication during extreme weather and climate change: a scoping review

INTRODUCTION

Communicating risk to the public continues to be a challenge for public health practitioners working in the area of climate change. We conducted a scoping literature review on the evaluation of risk communication for extreme weather and climate change to inform local public health messaging, consistent with requirements under the Ontario Public Health Standards (OPHS), which were updated in 2018 to include effective communication regarding climate change and extreme weather.

METHODS

Search strategies were developed by library information specialists and used to retrieve peer-reviewed academic and grey literature from bibliographic databases (Medline, Embase, Scopus and CINAHL) and Google country specific searches, respectively. The search strategy was validated through a workshop with experts and community stakeholders, with expertise in environment, health, emergency management and risk communication.

RESULTS

A total of 43 articles were included. These articles addressed issues such as: climate change (n = 22), flooding (n = 12), hurricane events (n = 5), extreme heat (n = 2), and wild fires (n = 2). Studies were predominantly from the US (n = 14), Europe (n = 6) and Canada (n = 5).

CONCLUSION

To meet the OPHS 2018, public health practitioners need to engage in effective risk communication to motivate local actions that mitigate the effects of extreme weather and climate change. Based on the scoping review, risk communication efforts during short-term extreme weather events appear to be more effective than efforts to communicate risk around climate change. This distinction could highlight a unique opportunity for public health to adapt strategies commonly used for extreme weather to climate change.

Applications of Unmanned Aerial Vehicle Based Imagery in Turfgrass Field Trials

Recent advances in remote sensing technology, especially in the area of Unmanned Aerial Vehicles (UAV) and Unmanned Aerial Systems (UASs) provide opportunities for turfgrass breeders to collect more comprehensive data during early stages of selection as well as in advanced trials. The goal of this study was to assess the use of UAV-based aerial imagery on replicated turfgrass field trials. Both visual (RGB) images and multispectral images were acquired with a small UAV platform on field trials of bermudagrass (Cynodon spp.) and zoysiagrass (Zoysia spp.) with plot sizes of 1.8 by 1.8 m and 0.9 by 0.9 m, respectively. Color indices and vegetation indices were calculated from the data extracted from UAV-based RGB images and multispectral images, respectively. Ground truth measurements including visual turfgrass quality, percent green cover, and normalized difference vegetation index (NDVI) were taken immediately following each UAV flight. Results from the study showed that ground-based NDVI can be predicted using UAV-based NDVI (R ² = 0.90, RMSE = 0.03). Ground percent green cover can be predicted using both UAV-based NDVI (R ² = 0.86, RMSE = 8.29) and visible atmospherically resistant index (VARI, R ² = 0.87, RMSE = 7.77), warranting the use of the more affordable RGB camera to estimate ground percent green cover. Out of the top ten entries identified using ground measurements, 92% (12 out of 13 in bermudagrass) and 80% (9 out of 11 in zoysiagrass) overlapped with those using UAV-based imagery. These results suggest that UAV-based high-resolution imagery is a reliable and powerful tool for assessing turfgrass performance during variety trials.

Nonverbal synchrony predicts premature termination of psychotherapy for social anxiety disorder

Premature termination is a problem in psychotherapy. In addition to the examination of demographic and clinical variables as predictors of dropout, research indicates the importance of dyadic variables. Nonverbal synchrony (e.g., movement synchrony) operationalizes the coordination of patient and therapist and is a promising candidate for predicting premature termination. This secondary data analysis included data on patients with social anxiety disorder (N = 267) that were treated with > 20 sessions of cognitive-behavioral therapy or psychodynamic therapy. Therapy outcome was measured by the Inventory of Interpersonal Problems and the Beck Depression Inventory. Individual movements in the third session were assessed by motion energy analysis. Movement synchrony was identified with a windowed cross-lagged correlation and peak-picking algorithm. We performed logistic regressions and mixed effects Cox regressions to investigate synchrony as a predictor of premature termination. Therapist-patient dyads that included a patient who terminated psychotherapy prematurely had significantly lower movement synchrony at the beginning of therapy than patients who completed therapy. Gender-matching and therapeutic approach had a (marginally) significant effect in moderating the relationship. Therefore, low movement synchrony in early therapy sessions may contain clues to premature termination and reflect a mismatch between the patient and therapist or problems in the therapeutic alliance. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Pharmacodynamic Study of Miransertib in Individuals with Proteus Syndrome

Proteus syndrome is a life-threatening segmental overgrowth syndrome caused by a mosaic gain-of-function AKT1 variant. There are no effective treatments for Proteus syndrome. Miransertib is an AKT1 inhibitor that, prior to this study, has been evaluated only in adult oncology trials. We designed a non-randomized, phase 0/1 pilot study of miransertib in adults and children with Proteus syndrome to identify an appropriate dosage starting point for a future efficacy trial using a pharmacodynamic endpoint. The primary endpoint was a 50% reduction in the tissue levels of AKT phosphorylation from biopsies in affected individuals. We also evaluated secondary efficacy endpoints. We found that a dose of 5 mg/m²/day (1/7 the typical dose used in oncology) led to a 50% reduction in phosphorylated AKT (pAKT) in affected tissues from five of six individuals. This dose was well tolerated. Two of the six efficacy endpoints (secondary objectives) suggested that this agent may be efficacious. We observed a decrease in a cerebriform connective tissue nevus and a reduction in pain in children. We conclude that 5 mg/m²/day of miransertib is an appropriate starting point for future efficacy trials and that this agent shows promise of therapeutic efficacy in children with Proteus syndrome.

Public Health Efforts Can Impact Adoption of Current Susceptibility Breakpoints, but Closer Attention from Regulatory Bodies Is Needed

Microbiological testing, including interpretation of antimicrobial susceptibility testing results using current breakpoints, is crucial for clinical care and infection control. Continued use of obsolete Enterobacteriaceae carbapenem breakpoints is common in clinical laboratories. The purposes of this study were (i) to determine why laboratories failed to update breakpoints and (ii) to provide support for breakpoint updates. The Los Angeles County Department of Public Health conducted a 1-year outreach program for 41 hospitals in Los Angeles County that had reported, in a prior survey of California laboratories, using obsolete Enterobacteriaceae carbapenem breakpoints. In-person interviews with hospital stakeholders and customized expert guidance and resources were provided to aid laboratories in updating breakpoints, including support from technical representatives from antimicrobial susceptibility testing device manufacturers. Forty-one hospitals were targeted, 7 of which had updated breakpoints since the prior survey. Of the 34 remaining hospitals, 27 (79%) assumed that their instruments applied current breakpoints, 17 (50%) were uncertain how to change breakpoints, and 10 (29%) lacked resources to perform a validation study for off-label use of the breakpoints on their systems. Only 7 hospitals (21%) were familiar with the FDA/CDC Antibiotic Resistance Isolate Bank. All hospitals launched a breakpoint update process; 16 (47%) successfully updated breakpoints, 12 (35%) received isolates from the CDC in order to validate breakpoints on their systems, and 6 (18%) were planning to update within 1 year. The public health intervention was moderately successful in identifying and overcoming barriers to updating Enterobacteriaceae carbapenem breakpoints in Los Angeles hospitals. However, the majority of targeted hospitals continued to use obsolete breakpoints despite 1 year of effort. These findings have important implications for the quality of patient care and patient safety. Other public health jurisdictions may want to utilize similar resources to bridge the patient safety gap, while manufacturers, the FDA, and others determine how best to address this growing public health issue.

Mild blast-related TBI in a mouse model alters amygdalar neurostructure and circuitry

Traumatic brain injury (TBI) continues to be a signature injury of our modern conflicts. Due in part to increased use of improvised explosive devices (IEDs), we have seen blast trauma make up a significant portion of TBIs sustained by deployed troops and civilians. In addition to the physical injury, TBI is also a common comorbidity with post-traumatic stress disorder (PTSD). Previous research suggests that PTSD is often associated with increased signaling within the amygdala, leading to feelings of fear and hyperarousal. In our study, we utilized a mouse model of mild blast-related TBI (bTBI) to investigate how TBI induces changes within the amygdala, which may provide favorable conditions for the development of PTSD. To do this, we performed Golgi staining on the stellate neurons of the basolateral amygdala and quantified dendritic amount, distribution, and complexity. We found increases in dendritic branching and in the density of dendritic spines in injured mice. Increases in spine density appears to be primarily due to increases in memory associated mushroom type dendritic spines. These changes observed in our bTBI model that are consistent with chronic stress models, suggesting an important connection between the physical changes induced by TBI and the neurological symptoms of PTSD.

Derazantinib (ARQ 087) in advanced or inoperable FGFR2 gene fusion-positive intrahepatic cholangiocarcinoma

BACKGROUND

Next-generation sequencing has identified actionable genetic aberrations in intrahepatic cholangiocarcinomas (iCCA), including the fibroblast growth factor receptor 2 (FGFR2) fusions. Derazantinib (ARQ 087), an orally bioavailable, multi-kinase inhibitor with potent pan-FGFR activity, has shown preliminary therapeutic activity against FGFR2 fusion-positive iCCA.

METHODS

This multicentre, phase 1/2, open-label study enrolled adult patients with unresectable iCCA with FGFR2 fusion, who progressed, were intolerant or not eligible to first-line chemotherapy (NCT01752920). Subjects received derazantinib in continuous daily doses. Tumour response was assessed according to RECIST 1.1 every 8 weeks.

RESULTS

Twenty-nine patients (18 women/11 men; median age, 58.7 years), 2 treatment-naive and 27 who progressed after at least one prior systemic therapy, were enrolled. Overall response rate was 20.7%, disease control rate was 82.8%. Estimated median progression-free survival was 5.7 months (95% CI: 4.04-9.2 months). Treatment-related adverse events (AE) were observed in 27 patients (93.1%, all grades), including asthenia/fatigue (69.0%), eye toxicity (41.4%), and hyperphosphatemia (75.9%). Grade ≥ 3 AEs occurred in 8 patients (27.6%).

CONCLUSION

Derazantinib demonstrated encouraging anti-tumour activity and a manageable safety profile in patients with advanced, unresectable iCCA with FGFR2 fusion who progressed after chemotherapy. A pivotal trial of derazantinib in iCCA is ongoing (NCT03230318).

Public health emergency preparedness: a framework to promote resilience

Background

Emergencies and disasters impact population health. Despite the importance of upstream readiness, a persistent challenge for public health practitioners is defining what it means to be prepared. There is a knowledge gap in that existing frameworks lack consideration for complexity relevant to health systems and the emergency context. The objective of this study is to describe the essential elements of a resilient public health system and how the elements interact as a complex adaptive system.

Methods

This study used a qualitative design employing the Structured Interview Matrix facilitation technique in six focus groups across Canada. Focus group participants were practitioners from public health and related sectors. Data collection generated qualitative data on the essential elements, and interactions between elements, for a resilient public health system. Data analysis employed qualitative content analysis and the lens of complexity theory to account for the complex nature of public health emergency preparedness (PHEP). The unit of study was the local/regional public health agency. Ethics and values were considered in the development of the framework.

Results

A total of 130 participants attended the six focus groups. Urban, urban-rural and rural regions from across Canada participated and focus group size ranged from 15 to 33 across the six sites. Eleven elements emerged from the data; these included one cross-cutting element (Governance and leadership) and 10 distinct but interlinked elements. The essential elements define a conceptual framework for PHEP. The framework was refined to ensure practice and policy relevance for local/regional public health agencies; the framework has ethics and values at its core.

Conclusions

This framework describes the complexity of the system yet moves beyond description to use tenets of complexity to support building resilience. This applied public health framework for local/regional public health agencies is empirically-derived and theoretically-informed and represents a complex adaptive systems approach to upstream readiness for PHEP.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6250-7) contains supplementary material, which is available to authorized users.

1332. West Coast Transplant ID Conferences, A Model for Building Community in ID Disciplines?

Background

Transplant infectious diseases (TID) is a young and rapidly changing field. Providers need to make patient care decisions with limited clinical data. Challenges faced by TID providers may be different than others in their local ID community. We describe a model where TID faculty from six major transplant centers on the West Coast held periodic web-based conferences to discuss challenging cases and controversial topics in TID.

Methods

In 2011, faculty from six major transplant centers in the states of Washington, Oregon, and California began participating in web-based conferences. To assess impact, we distributed a 30-item survey generated in Qualtrics via email in Spring 2018. Participants were invited if they had ever attended one of the conferences. The survey collected quantitative and qualitative data on how the conferences changed clinical practice and helped build community. Data on conference topics was also collected.

Results

West Coast Transplant ID Conferences were held 12 times between 2011 and 2018 with TID topics covered including management of RSV, antifungal prophylaxis, CMV, and LTBI among others. Sixteen participants responded to the survey representing all six institutions. eight (50%) of respondents spent at least half of their time in the practice of TID. Six (37%) of respondents worked for <5 years and five (31%) reported working more than 10 years in TID. 56% of participants attended ≥4 conferences in the last 3 years. 93% of participants included trainees on the conference call. All respondents agreed or strongly agreed that the topics covered were relevant to their practice. 87.5% felt that the calls generate consensus about difficult or controversial topics. 62.5% reported that they had changed their practice because of the conferences. Only 1 respondent reported that they collaborated on research because of the conference. 100% agreed or strongly agreed that the conferences built a sense of community within TID.

Conclusion

Given improvements in web-based technologies, a community of practice can be easily created despite geographic distance allowing for TID providers to discuss relevant topics that impact practice and enhance sense of community. This model could be reproduced in other areas of infectious diseases.

Disclosures

All authors: No reported disclosures.

977. An Innovative 3-Year Medical Student Spiral Curriculum in Antimicrobial Stewardship and Infectious Diseases

Background

By 2050, infections due antimicrobial-resistant organisms are predicted to account for 10 million deaths/year worldwide. Physician antibiotic prescribing patterns are a significant factor in the development of antibiotic resistance organisms. Early, continual, and integrated medical student education may help students develop a framework for responsible antimicrobial use as they develop prescribing patterns.

Methods

We designed a spiral antimicrobial stewardship curriculum (defined as revisiting the same concept but with increasing complexity) for medical students in years 2–4. Data provided by the Graduation Questionnaire (GQ) administered by the US Association of American Colleges were used. We compared student responses during the curriculum rollout in 2013–2015 between students at our institution and other schools. We also surveyed graduating seniors in 2015 about antimicrobial stewardship training.

Results

Using GQ data for the class of 2013 (preintervention), a similar proportion of UCSF medical students compared with other US medical students rated microbiology clinical preparation as excellent (43.6% vs. 45.1%, P > 0.20). For the 2014 class, we developed interactive case-based sessions at the beginning of years 3 and 4. After this first intervention, a higher proportion of UCSF students rated the microbiology clinical preparation as excellent (51.3%) compared with responses at all schools (39.8%, odds ratio [OR] 1.59, 95% confidence interval [CI] 1.1–2.3, P = 0.013). For the class of 2015, we added content during the medicine clerkship and 1 week before graduation. For the 2015 class, an even higher proportion of UCSF students rated microbiology preparation as excellent (57.6%), compared with all schools (41.2%, OR 2.23, 95% CI 1.54–3.22, P < 0.0001). From our survey, 88% were very or extremely satisfied with antimicrobial stewardship training.

Conclusion

A spiral curriculum focusing on antimicrobial stewardship and infectious diseases increases student perception of clinical preparation prior to graduation. As the curriculum was incrementally introduced, students’ knowledge increased indicating a dose–response pattern. Based on these positive results, we plan to introduce more content throughout UME, and link to curriculum for GME and practicing clinicians.

Disclosures

All authors: No reported disclosures.

979. Standardizing Medical Student Learning for Infectious Diseases Consult Electives: Prioritizing Content

Background

The goals of 4th-year medical student electives vary, and students’ learning during clinical electives may occur solely through the subspecialty cases that students encounter. We aim to standardize learning during electives by creating a toolkit to guide elective directors in the development of curricula that reinforce basic science principles, highlight areas for high-value care, and provide opportunities for further inquiry. The first step is to determine the core specialty topics applicable to students regardless of career choice. Here, we describe this content prioritization process within the context of an infectious diseases (ID) elective pilot curriculum.

Methods

We conducted a modified, 2-round Delphi process to develop consensus on ID topics that all graduating medical students should know. Through review of the literature for common diagnoses and high value care, and the medical school curriculum, the authors generated an initial list of 16 topics. An interdisciplinary group of 90 expert faculty educators from Internal Medicine, Family Medicine, Emergency Medicine, and Surgery rated these topics’ importance using a 5-point Likert scale, from 0 (absolutely do not include) to 4 (very important). We considered items rated at least 3 (important) by at least 80% of participants to have reached consensus.

Results

Sixty of 90 (67%) educators responded to the initial survey, and 48/60 (80%) completed both surveys. Nine additional topics were proposed by first-round participants. After the second round, 14 topics met the consensus criterion. Many common conditions, several dangerous infections, and infectious issues overrepresented in the local population met consensus. However, while many of the topics failing to meet consensus addressed rare conditions or those typically managed by subspecialists, some were also common conditions.

Conclusion

Standardizing medical student learning during elective rotations begins with identifying key topics. Our process included a diverse group of educators to determine key topics. We will use this list to guide the content of a new asynchronous, online ID elective curriculum, and we will describe our process as part of a curriculum development toolkit for other elective directors.

Disclosures

All authors: No reported disclosures.

Miransertib (ARQ 092), an orally-available, selective Akt inhibitor is effective against Leishmania

Leishmaniasis is amongst the most important neglected diseases, afflicting more than 12 million people in 88 countries. There is an urgent need for safe orally bioavailable and cost-effective drugs for the treatment of leishmaniasis. It has recently been shown that Leishmania activates host macrophage serine/threonine kinase Akt, to promote survival of both parasites and infected cells. Here, we sought to evaluate a compound, Miransertib (ARQ 092), an orally bioavailable and selective allosteric Akt inhibitor currently in clinical trials for patients with PI3K/Akt-driven tumors or Proteus syndrome. Miransertib was tested against Leishmania donovani and Leishmania amazonensis, causative agents of visceral and cutaneous leishmaniasis, respectively. Cultured promastigotes were susceptible to Miransertib. In addition, Miransertib was markedly effective against intracellular amastigotes of L. donovani or L. amazonensis-infected macrophages. Miransertib also enhanced mTOR dependent autophagy in Leishmania-infected macrophages, which may represent one mechanism of Miransertib-mediated killing of intracellular Leishmania. Whereas parasite clearance in the spleen of mice infected with L. donovani and treated with Miransertib was comparable to that when treated with miltefosine, Miransertib caused a greater reduction in the parasite load in the liver. In the cutaneous leishmaniasis infection model, lesions were reduced by 40% as compared to mock treated mice. Together, these results provide direct evidence to support the conclusion that Miransertib is an excellent lead compound for the development of a new oral drug therapy for visceral and cutaneous leishmaniasis.

Phase 1 study of ARQ 761, a β-lapachone analogue that promotes NQO1-mediated programmed cancer cell necrosis

BACKGROUND

NAD(P)H:quinone oxidoreductase 1 (NQO1) is a two-electron oxidoreductase expressed in multiple tumour types. ARQ 761 is a β-lapachone (β-lap) analogue that exploits the unique elevation of NQO1 found in solid tumours to cause tumour-specific cell death.

METHODS

We performed a 3+3 dose escalation study of 3 schedules (weekly, every other week, 2/3 weeks) of ARQ 761 in patients with refractory advanced solid tumours. Tumour tissue was analysed for NQO1 expression. After 20 patients were analysed, enrolment was restricted to patients with NQO1-high tumours (H-score ≥ 200).

RESULTS

A total of 42 patients were treated. Median number of prior lines of therapy was 4. Maximum tolerated dose was 390 mg/m² as a 2-h infusion every other week. Dose-limiting toxicity was anaemia. The most common treatment-related adverse events were anaemia (79%), fatigue (45%), hypoxia (33%), nausea (17%), and vomiting (17%). Transient grade 3 hypoxia, reflecting possible methemoglobinaemia, occurred in 26% of patients. Among 32 evaluable patients, best response was stable disease (n = 12); 6 patients had tumour shrinkage. There was a trend towards improved efficacy in NQO1-high tumours (P = 0.06).

CONCLUSIONS

ARQ 761 has modest single-agent activity, which appears associated with tumour NQO1 expression. Principal toxicities include anaemia and possible methemoglobinaemia.

Relation between opioid-related harms and socioeconomic inequalities in Ontario: a population-based descriptive study

BACKGROUND

Negative health outcomes associated with the use of both prescribed and nonprescribed opioids are increasingly prevalent. We examined long-term trends in opioid-related harms in Ontario across a set of 6 indicators and the relation between harms and neighbourhood income in 2016.

METHODS

We examined rates of neonatal abstinence syndrome, opioid poisoning (fatal and nonfatal) and nonpoisoning opioid-related events from 2003 to 2016 in Ontario using population-based health administrative databases. We conducted descriptive analyses for harm indicators across neighbourhood income quintiles in 2016 (2015 for death). We examined social inequalities in opioid-related harms on both relative (prevalence ratio) and absolute (potential rate reduction) scales.

RESULTS

Rates of opioid-related harms increased dramatically between 2003 and 2016. In 2016, neonatal abstinence syndrome and opioid poisoning and nonpoisoning events showed a strong social gradient, with harm rates being lowest in higher-income neighbourhoods and highest in lower-income neighbourhoods. Prevalence ratios for the lowest-income neighbourhoods compared to the highest-income neighbourhoods ranged from 2.36 (95% confidence interval [CI] 2.15-2.58) for emergency department visits for opioid poisoning to 3.70 (95% CI 2.62-5.23) for neonatal abstinence syndrome. Potential rate reductions for opioid-related harms ranged from 34.8% (95% CI 29.1-40.1) to 49.9% (95% CI 36.7-60.5), which suggests that at least one-third of all harmful events could be prevented if all neighbourhoods had the same socioeconomic profile as the highest-income neighbourhoods.

INTERPRETATION

Rates of opioid-related harms increased in Ontario between 2003 and 2016, and people in lower-income neighbourhoods experienced substantially higher rates of opioid-related harms than those in higher-income neighbourhoods. This finding can inform planning for opioid-related public health interventions with consideration of health equity.

What happens when the therapist leaves? The impact of therapy transfer on the therapeutic alliance and symptoms

BACKGROUND

The therapeutic alliance is an important factor in psychotherapy, affecting both therapy processes and outcome. Therapy transfers may impair the quality of the therapeutic alliance and increase symptom severity. The aim of this study is to investigate the impact of patient transfers in cognitive behavioural therapy on alliance and symptoms in the sessions after the transfer.

METHOD

Patient- and therapist-rated therapeutic alliance and patient-reported symptom severity were measured session-to-session. Differences in the levels of alliance and symptom severity before (i.e., with the original therapist) and after (i.e., with the new therapist) the transfer session were analysed. The development of alliance and symptom severity was explored using multilevel growth models.

RESULTS

A significant drop in the alliance was found after the transfer, whereas no differences were found with regard to symptom severity. After an average of 2.93 sessions, the therapeutic alliance as rated by patients reached pretransfer levels, whereas it took an average of 5.05 sessions for therapist-rated alliance levels to be at a similar level as before the transfer. Inter-individual differences were found with regard to the development of the therapeutic alliance over time.

CONCLUSIONS

Therapy transfers have no long lasting negative effects on either symptom impairment or the therapeutic alliance.

Retrospective Assessment of a Serum Proteomic Test in a Phase III Study Comparing Erlotinib plus Placebo with Erlotinib plus Tivantinib (MARQUEE) in Previously Treated Patients with Advanced Non-Small Cell Lung Cancer

BACKGROUND

The VeriStrat test provides accurate predictions of outcomes in all lines of therapy for patients with non-small cell lung cancer (NSCLC). We investigated the predictive and prognostic role of VeriStrat in patients enrolled on the MARQUEE phase III trial of tivantinib plus erlotinib (T+E) versus placebo plus erlotinib (P+E) in previously treated patients with advanced NSCLC.

METHODS

Pretreatment plasma samples were available for 996 patients and were analyzed by matrix-assisted laser desorption/ionization-time of flight mass spectrometry to generate VeriStrat labels (good, VS-G, or poor, VS-P).

RESULTS

Overall, no significant benefit in overall survival (OS) and progression-free survival (PFS) were observed for the addition of tivantinib to erlotinib. Regardless of treatment arm, patients who were classified as VS-G had significantly longer PFS (3.8 mo for T+E arm, 2.0 mo for P+E arm) and OS (11.6 mo for T+E, 10.2 mo for P+E arm) than patients classified as VS-P (PFS: 1.9 mo for both arms, hazard ratio [HR], 0.584; 95% confidence interval [CI], 0.468-0.733; p < .0001 for T+E, HR, 0.686; 95% CI, 0.546-0.870; p = .0015 for P+E; OS: 4.0 mo for both arms, HR, 0.333; 95% CI, 0.264-0.422; p < .0001 for T+E; HR, 0.449; 95% CI, 0.353-0.576; p < .0001 for P+E). The VS-G population had higher OS than the VS-P population within Eastern Cooperative Oncology Group (ECOG) performance score (PS) categories. VS-G patients on the T+E arm had longer PFS, but not OS, than VS-G patients on the P+E arm (p = .0108). Among EGFR mutation-positive patients, those with VS-G status had a median OS more than twice that of any other group (OS: 31.6 mo for T+E and 22.8 mo for P+E), whereas VS-P patients had similar survival rates as VS-G, EGFR-wild type patients (OS: 13.7 mo for T+E and 6.5 mo for P+E).

CONCLUSION

In these analyses, VeriStrat showed a prognostic role within EGOC PS categories and regardless of treatment arm and EGFR status, suggesting that VeriStrat could be used to identify EGFR mutation-positive patients who will have a poor response to EGFR tyrosine kinase inhibitors.

IMPLICATIONS FOR PRACTICE

This study suggests that VeriStrat testing could enhance the prognostic role of performance status and smoking status and replicates findings from other trials that showed that the VeriStrat test identifies EGFR mutation-positive patients likely to have a poor response to EGFR tyrosine kinase inhibitors (TKIs). Although these findings should be confirmed in other populations, VeriStrat use could be considered in EGFR mutation-positive patients as an additional prognostic tool, and these results suggest that EGFR mutation-positive patients with VeriStrat "poor" classification could benefit from other therapeutic agents given in conjunction with TKI monotherapy.

The BTK Inhibitor ARQ 531 Targets Ibrutinib-Resistant CLL and Richter Transformation

Targeted inhibition of Bruton tyrosine kinase (BTK) with the irreversible inhibitor ibrutinib has improved outcomes for patients with hematologic malignancies, including chronic lymphocytic leukemia (CLL). Here, we describe preclinical investigations of ARQ 531, a potent, reversible inhibitor of BTK with additional activity against Src family kinases and kinases related to ERK signaling. We hypothesized that targeting additional kinases would improve global inhibition of signaling pathways, producing more robust responses. In vitro treatment of patient CLL cells with ARQ 531 decreases BTK-mediated functions including B-cell receptor (BCR) signaling, viability, migration, CD40 and CD86 expression, and NF-κB gene transcription. In vivo, ARQ 531 was found to increase survival over ibrutinib in a murine Eμ-TCL1 engraftment model of CLL and a murine Eμ-MYC/TCL1 engraftment model resembling Richter transformation. Additionally, ARQ 531 inhibits CLL cell survival and suppresses BCR-mediated activation of C481S BTK and PLCγ2 mutants, which facilitate clinical resistance to ibrutinib.Significance: This study characterizes a rationally designed kinase inhibitor with efficacy in models recapitulating the most common mechanisms of acquired resistance to ibrutinib. Reversible BTK inhibition is a promising strategy to combat progressive CLL, and multikinase inhibition demonstrates superior efficacy to targeted ibrutinib therapy in the setting of Richter transformation. Cancer Discov; 8(10); 1300-15. ©2018 AACR. This article is highlighted in the In This Issue feature, p. 1195.

Abstract LB-018: ARQ 531, a novel and reversible inhibitor of Bruton's tyrosine kinase, displays favorable oral bioavailability and exposure in patients with B-cell malignancies

Background: ARQ 531 is a novel, ATP competitive reversible inhibitor Bruton's tyrosine kinase (BTK). BTK is a key regulator of the B cell receptor (BCR) signaling pathway that mediates signaling from the cell surface to the cytoplasm and into the nucleus. ARQ 531 is not metabolized by any of the major drug metabolizing CYP450 enzymes. Here we report pharmacokinetic profile of ARQ 531 in a phase I study evaluating safety, pharmacokinetics and pharmacodynamics activity and clinical activity of ARQ 531 in selected subjects with relapsed/refractory B-cell malignancies. Preclinical studies in rats, dogs and monkeys are also described.

Methods: Oral and intravenous single dose pharmacokinetic studies of ARQ 531 were conducted in rats, dogs, and monkeys to determine oral bioavailability and drug exposure. In a standard ‘3+3' dose-escalation study design, ARQ 531 was given orally once per day beginning at 5 mg/dose and escalating for 4 weeks [NCT03162536]. Plasma samples were collected to determine ARQ 531 concentrations and whole blood / PBMCx to quantify pBTK inhibition. Plasma samples from each species were analyzed by liquid chromatography-mass spectrometry/ mass spectrometry (LC-MS/MS).

Results: Consistent with preclinical studies, patients enrolled in the phase I study showed favorable exposures, the steady state peak to trough ratio was generally 3:1 or lower. ARQ 531 had an elimination half-life at steady state of ~24 hr and Cmax occurred 2 to 3 hours after dosing. Pharmacodynamic changes included suppression of BTK phosphorylation. No drug related AEs or DLTs have been observed thus far in the study.

Conclusions: ARQ 531 demonstrates a favorable PK profile in humans supporting once daily dosing. Sufficient plasma levels are attained and high levels of pBTK inhibition in peripheral blood can be achieved following oral dosing. Additional dose and schedule evaluations continue, and updated clinical and biomarker results will be presented.

Citation Format: Terence Hall, Yi Yu, Sudharshan Eathiraj, Deborah Stephens, Ian Flinn, Jennifer Woyach, Brian Schwartz, Ronald E. Savage. ARQ 531, a novel and reversible inhibitor of Bruton's tyrosine kinase, displays favorable oral bioavailability and exposure in patients with B-cell malignancies [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr LB-018.

Abstract 2943: In vivo combination of miransertib (ARQ 092) with anti-PD-1 antibody, trametinib, lapatinib, trastuzumab and paclitaxel

Dysregulation of the PI3K-AKT signaling pathway has been implicated as a key driver in cancer initiation and progression. AKT is a serine/threonine kinase and a critical component mediating the PI3K-AKT signaling axis. Although AKT inhibitors have been extensively studied, clinical outcome has not been impressive. Interestingly, it has been shown that PI3K/AKT pathway has been involved in resistance to conventional chemotherapy, and inhibition of AKT enhances targeted therapy and sensitizes radiation therapy. Miransertib is a potent and selective pan-AKT inhibitor and currently in early clinical studies. In this study, we assessed combined effect of Miransertib with immune checkpoint inhibitor, anti-MEK and anti-HER2 agents, and a chemotherapeutic agent in vivo. Miransertib at doses of range from 20mg/kg to 120mg/kg was tested in combination with anti-PD-1 antibody, trametinib, lapatinib, trastuzumab, or paclitaxel. Anti-tumor efficacy was assessed in syngeneic mouse CT-26 colon and 4T1 breast tumor models and xenografts models with endometrial (AN3CA) and breast (HCC1954, KPL-4, ZR-75-1) tumors, two patient-derived (PDX) models of endometrial cancer (with PIK3CAH1047R and R93W+D350G mutations) and in one vemurafenib-resistant melanoma PDX (with BRAFV600E and PIK3CA H1047R mutations). Combinability and efficacy of Miransertib and anti-PD-1 antibody was assessed in syngeneic mouse CT-26 colon tumor model. Miransertib at 60 mg/kg and anti-PD-1 antibody at 10mg/kg were combinable. Combined dosing of Miransertib with Anti-PD-1 antibody exerted superior anti-tumor activity in comparison to the single agents (TGI: 65% for combination, 50% for Miransertib and 55% for anti-PD-1 antibody after dosing for 9 days and more significant difference after 12 day dosing). In 4T1 breast tumor model, combination of Miransertib and anti-PD-1 antibody showed a very modest anti-tumor activity whereas there is no effect as single agents. In one of the endometrial PDX models, the combination of Miransertib with trametinib enhanced anti-tumor activity of each drug alone, reducing tumor growth by 67% compared to single-agent tumor reductions by 43% for either Miransertib or trametinib. In a vemurafenib-resistant melanoma PDX model, tumor growth was reduced by 73% when Miransertib was combined with trametinib, while trametinib alone only reduced tumor growth by 26% for trametinib and by 16% by Miransertib. Miransertib enhanced efficacy of in combination with trastuzumab, lapatinib, or paclitaxel, by reducing tumor growth as much as 92%, 73% and 85% respectively, while single agent comparators reduced tumors by less than 50%. Miransertib is combinable with anti-PD-1 antibody, trametinib, lapatinib, trastuzumab, and paclitaxel and exhibits enhanced anti-tumor activity. These results provide us rationale for the combination study of Miransertib in a clinical setting.

Citation Format: Yi Yu, Terence Hall, Sudharshan Eathiraj, Ron E. Savage, Brian Schwartz. In vivo combination of miransertib (ARQ 092) with anti-PD-1 antibody, trametinib, lapatinib, trastuzumab and paclitaxel [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2943.