A practical evidence-based approach to management of type 2 diabetes in children and young people (CYP): UK consensus

BACKGROUND

Type 2 diabetes in young people is an aggressive disease with a greater risk of complications leading to increased morbidity and mortality during the most productive years of life. Prevalence in the UK and globally is rising yet experience in managing this condition is limited. There are no consensus guidelines in the UK for the assessment and management of paediatric type 2 diabetes.

METHODS

Multidisciplinary professionals from The Association of Children's Diabetes Clinicians (ACDC) and the National Type 2 Diabetes Working Group reviewed the evidence base and made recommendations using the Grading Of Recommendations, Assessment, Development and Evaluation (GRADE) methodology.

RESULTS AND DISCUSSION

Young people with type 2 diabetes should be managed within a paediatric diabetes team with close working with adult diabetes specialists, primary care and other paediatric specialties. Diagnosis of diabetes type can be challenging with many overlapping features. Diabetes antibodies may be needed to aid diagnosis. Co-morbidities and complications are frequently present at diagnosis and should be managed holistically. Lifestyle change and metformin are the mainstay of early treatment, with some needing additional basal insulin. GLP1 agonists should be used as second-line agents once early ketosis and symptoms are controlled. Glycaemic control improves microvascular but not cardiovascular risk. Reduction in excess adiposity, smoking prevention, increased physical activity and reduction of hypertension and dyslipidaemia are essential to reduce major adverse cardiovascular events.

CONCLUSIONS

This evidence-based guideline aims to provide a practical approach in managing this condition in the UK.

Comparing anti-tumor and anti-self immunity in a patient with melanoma receiving immune checkpoint blockade

BACKGROUND

Tumor regression following immune checkpoint blockade (ICB) is often associated with immune-related adverse events (irAEs), marked by inflammation in non-cancerous tissues. This study was undertaken to investigate the functional relationship between anti-tumor and anti-self immunity, to facilitate irAE management while promoting anti-tumor immunity.

METHODS

Multiple biopsies from tumor and inflamed tissues were collected from a patient with melanoma experiencing both tumor regression and irAEs on ICB, who underwent rapid autopsy. Immune cells infiltrating melanoma lesions and inflamed normal tissues were subjected to gene expression profiling with multiplex qRT-PCR for 122 candidate genes. Subsequently, immunohistochemistry was conducted to assess the expression of 14 candidate markers of immune cell subsets and checkpoints. TCR-beta sequencing was used to explore T cell clonal repertoires across specimens.

RESULTS

While genes involved in MHC I/II antigen presentation, IFN signaling, innate immunity and immunosuppression were abundantly expressed across specimens, irAE tissues over-expressed certain genes associated with immunosuppression (CSF1R, IL10RA, IL27/EBI3, FOXP3, KLRG1, SOCS1, TGFB1), including those in the COX-2/PGE2 pathway (IL1B, PTGER1/EP1 and PTGER4/EP4). Immunohistochemistry revealed similar proportions of immunosuppressive cell subsets and checkpoint molecules across samples. TCRseq did not indicate common TCR repertoires across tumor and inflammation sites, arguing against shared antigen recognition between anti-tumor and anti-self immunity in this patient.

CONCLUSIONS

This comprehensive study of a single patient with melanoma experiencing both tumor regression and irAEs on ICB explores the immune landscape across these tissues, revealing similarities between anti-tumor and anti-self immunity. Further, it highlights expression of the COX-2/PGE2 pathway, which is known to be immunosuppressive and potentially mediates ICB resistance. Ongoing clinical trials of COX-2/PGE2 pathway inhibitors targeting the major COX-2 inducer IL-1B, COX-2 itself, or the PGE2 receptors EP2 and EP4 present new opportunities to promote anti-tumor activity, but may also have the potential to enhance the severity of ICB-induced irAEs.

Immune microenvironment of basal cell carcinoma and tumor regression following combined PD-1/LAG-3 blockade

Systemic treatment options for patients with locally advanced or metastatic basal cell carcinoma (BCC) are limited, particularly when tumors are refractory to anti-programmed cell death protein-1 (PD-1). A better understanding of immune checkpoint expression within the BCC tumor microenvironment may inform combinatorial treatment strategies to optimize response rates. CD3, PD-1, programmed death ligand-1 (PD-L1), lymphocyte activation gene 3 (LAG-3), and T-cell immunoglobulin domain and mucin domain 3 (TIM-3)+ cell densities within the tumor microenvironment of 34 archival, histologically aggressive BCCs were assessed. Tumor infiltrating lymphocyte (TIL) expression of PD-1, PD-L1, and LAG-3, and to a lesser degree TIM-3, correlated with increasing CD3+ T-cell densities (Pearson's r=0.89, 0.72, 0.87, and 0.63, respectively). 100% of BCCs (34/34) demonstrated LAG-3 and PD-1 expression in >1% TIL; and the correlation between PD-1 and LAG-3 densities was high (Pearson's r=0.89). LAG-3 was expressed at ~50% of the level of PD-1. Additionally, we present a patient with locally-advanced BCC who experienced stable disease during and after 45 weeks of first-line anti-PD-1 (nivolumab), followed by a partial response after the addition of anti-LAG-3 (relatlimab). Longitudinal biopsies throughout the treatment course showed a graduated increase in LAG-3 expression after anti-PD-1 therapy, lending support for coordinated immunosuppression and suggesting LAG-3 as a co-target for combination therapy to augment the clinical impact of anti-PD-(L)1.

Do baseline patient reported outcome measures predict changes in self-reported function, following a chronic pain rehabilitation programme?

Background

Interdisciplinary pain management programmes, based on cognitive-behavioural principles, aim to improve physical and psychological functioning and enhance self-management in people living with chronic pain. Currently there is insufficient evidence about whether psychological, biological or social factors are predictive of positive outcomes following pain rehabilitation. This study aims to evaluate predictors of change in Brief Pain Inventory - pain interference score (BPI) in a clinical data set to determine whether age, sex and baseline outcome measures are predictive of improvement in pain interference following pain rehabilitation.

Methods

A retrospective, pragmatic observational analysis of routinely collected clinical data in two pain rehabilitation programmes, Balanced Life Programme (BLP) and Get Back Active (GBA) was conducted. Standard regression and hierarchical regression analyses were used to identify predictors of change to assess temporal changes in BPI. Responder analysis was also conducted.

Results

Standard regression analyses of 208 (BLP) and 310 (GBA) patients showed that higher baseline BPI and better physical performance measures predicted better improvement in BPI across both programmes. Hierarchical regression showed that age and sex accounted for 2.7% (BLP) and 0.002% (GBA) of the variance in change in BPI. After controlling for age and sex, the other measures explained an additional 23% (BLP) and 19% (GBA) of the variance, p = < .001 where BPI and physical performance measures were consistently statistically significant predictors, p < .05. Responder analysis also showed that pain interference and physical performance were significantly associated with improvement (p = < .0005).

Conclusions

The combination of high self-reported pain interference and better physical performance measures may be a useful indicator of who would benefit from interdisciplinary rehabilitation. Further validation of the results is required.

Robust Radiosensitization by Combined Treatment of Cancer Cells with Talazoparib and Polθ Inhibitors

PURPOSE/OBJECTIVE(S)

The PARP inhibitor talazoparib is synthetically lethal with HR-defective tumors and functions as a potent radiosensitizer specifically of cancer cells. Talazoparib exerts this unique radiosensitizing property by shifting ionizing radiation (IR)-induced DNA double strand break (DSB) repair towards error-prone alternative end-joining (alt-EJ). DNA polymerase theta (Polθ, encoded by POLQ) is a key component of alt-EJ. Here, we tested the hypothesis that inhibition of alt-EJ with Polθ ablation or using specific small molecule inhibitors can further increase talazoparib-induced radiosensitization.

MATERIALS/METHODS

U2OS, A549, and their corresponding POLQ ablated/mutant cell lines were treated with talazoparib and/or Polθ inhibitors ART558/novobiocin prior to irradiation. siRNAs against CtIP, MRE11, EXO1; and a specific inhibitor of DNA2 were employed to suppress DNA end resection. Radiosensitization was assessed by clonogenic survival. Olaparib, rucaparib, and veliparib were also tested under similar conditions. DSB repair and end resection were measured by scoring γH2AX and RPA nuclear foci, respectively. Chromosomal abnormalities were assessed using G2-specific cytogenetics analysis.

RESULTS

Genetic ablation or pharmacological inhibition of Polθ robustly enhanced talazoparib mediated radiosensitization by ∼40-70%. Notably, Polθ inhibition had a much lower effect (by ∼7-17%) when combined with other clinically used PARP inhibitors, olaparib, rucaparib, and veliparib. Polθ inhibition significantly suppressed talazoparib-induced translocation formation in irradiated cells. In addition, combined treatment with Polθ inhibitor and talazoparib attenuated DSB repair, resulting in ∼60% unresolved γH2AX foci and ∼40% unresolved chromatid breaks at 5h post IR. Talazoparib promoted resection of DNA ends as demonstrated by an increase in RPA foci. The resection process requires the activities of CtIP and MRE11, but not of DNA2 or EXO1. Finally, CtIP and MRE11 knockdown impaired radiosensitization following a combined talazoparib/Polθ inhibition treatment.

CONCLUSION

Talazoparib increases the reliance of irradiated cancer cells on Polθ-mediated alt-EJ owing to the increased CtIP/MRE11-dependent resection it produces. Combining talazoparib with Polθ inhibitors has therefore great potential in improving radiotherapy of human tumors.

Patient activation and health-related quality-of-life in association with smartwatch alerts for atrial fibrillation detection

Background

Smartwatches with various alert systems are becoming increasingly popular in the detection of atrial fibrillation (AF) post stroke, however their impact on psychological well-being remains unknown.

Purpose

Assess the association between smartwatch alerts for detected atrial fibrillation in older stroke survivors and patient activation as well as health-related quality-of-life.

Methods

Data were used from the Pulsewatch study, a multiphase, randomized controlled trial, which enrolled older adults (≥50 years of age) from the UMass Memorial Health System with history of a stroke and no contraindications to anticoagulation, who were given a smartwatch for AF detection. In Phase I, participants were randomized 3:1 (intervention:control) to receive a smartwatch/smartphone pair and an FDA-approved cardiac patch monitor or only the patch (control) to monitor for AF for 14 days. In Phase II, participants were re-randomized 1:1, with the intervention group being offered the smartwatch/smartphone pair for an extra 30 days. Participants were grouped into those receiving at least one alert of a possible abnormal rhythm versus those who did not receive any alerts from their smartwatch. At baseline, 14 days, and 44 days the Consumer Health Activation Index was used to assess patient activation and the Physical and Mental Component Summary of Short-Form Health Survey were utilized to evaluate physical and mental health-related quality-of-life, respectively. Mixed-effects repeated measures linear regression models were used to examine changes in patient activation and physical and mental health-related quality-of-life, in relation to alerts, adjusting for confounding variables including age, sex, race, history of arrhythmias, history of congestive heart failure, history of coronary artery disease, baseline depression, and baseline cognitive impairment, over the study period.

Results

94 participants (64.6±9.1 years of age, 87.2% non-Hispanic white, and 43.6% female) were included in the analysis; 16 of whom received at least one alert. Specifically, twelve participants received 1 to 3 alerts, three participants received 11 to 18, and one participant received 226. In fully adjusted models, receiving alerts was not associated with changes in patient activation or mental health-related quality-of-life (β −1.70, p-value 0.60 and β 2.85, p-value 0.09 respectively), but was associated with a significant reduction in physical health-related quality-of-life (β −4.67, p-value 0.04).

Conclusions

In a cohort of older stroke survivors who wore smartwatches for up to 44 days, reception of alerts was not significantly associated with changes in patient activation or mental health-related quality-of-life but was significantly related to a decline in physical health-related quality-of-life. Further studies are necessary to explore the use of smartwatches in AF screening and their impact on psychological health and quality-of-life.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): R01HL137734 from the National Heart, Lung, and Blood Institute

AB1409 EVALUATING HOW EFFECTIVELY PATIENTS WITH A NEW INFLAMMATORY ARTHRITIS ARE BEING TRIAGED INTO THE APPROPRIATE CLINIC AT A TERTIARY CARE HOSPITAL IN THE UK: A RETROSPECTIVE AUDIT

Background

Inflammatory arthritis is associated with significant morbidity and costs to the NHS, social care, and wider economy. Early diagnosis and treatment are essential to reduce the impact of the disease. Therefore, it is important that referrals for a new inflammatory arthritis are appropriately triaged to be seen in the early inflammatory arthritis (EIA) clinic so that they can be seen and started on disease modifying anti-rheumatoid drugs (DMARDs) without delay. The British Society of Rheumatology guidance for inflammatory arthritis states that patients must be seen within three weeks of referral and started on DMARDs within six weeks.

Objectives

To evaluate how effectively people referred with a new EIA are currently being triaged.

To evaluate whether we are meeting the national standards.

Methods

We performed a retrospective review of the medical notes of all new patients who were seen in the EIA clinic from 01/09/21-31/11/21. During this same time period, we will also reviewed all the patients who had been newly diagnosed and started on a DMARD in the other Rheumatology clinics (e.g., general rheumatology, vasculitis).

We collected data on referral date, referral source (e.g., GP), date of clinic assessment, clinic type (e.g., EIA clinic or other Rheumatology clinic), diagnoses made, days’ wait from referral to assessment and days’ wait from referral to commencing DMARD.

We then calculated the conversion rate (percentage of referrals triaged to the EIA clinic that have an EIA) and detection rate (percentage of new EIA patients that are seen in the EIA clinic (as opposed to in non-urgent clinics)). The standard for conversation rate (CR) was 50% and for detection rate (DR) was 95%.

Results

Of all the patients seen in the EIA clinic (n=73), 36 had a new diagnosis of an EIA, giving a CR of 49%. Of all the new diagnoses of EIA made during that time-period (n=53), 36 were appropriately triaged to be seen in the EIA clinic, giving a detection rate 68%. Those new referrals who had been appropriately seen in the EIA clinic had an average of 5 weeks wait from referral to assessment/ commencement of DMARD. In contrast, those new referrals who had been seen in other clinics had an average of 10 weeks from referral to assessment/ commencement of DMARD.

A previous audit performed before the COVID-19 pandemic (01/11/19- 01/01/20) showed a CR of 25% (115 patients seen in EIA clinic, 29 new diagnoses) and a DR of 69% (29 new diagnoses, 20 seen in EIA clinic).

Conclusion

Those patients with a new EIA who are appropriately seen in the EIA clinic do not meet the national guidance for being seen within three weeks of referral but do meet the guidance for starting a DMARD withing six weeks. However, those new EIA who are seen outside the EIA clinic do not meet either of these standards, with a delay of 10 weeks to be seen/ started on a DMARD. Given that only 68% of people with a new EIA are being correctly triaged to be seen in the EIA clinics, it highlights that there is a need for an improvement in the triage process (currently being done manually by Rheumatologists). Interestingly, when comparing our findings to the audit done pre-COVID-19 pandemic, the CR has improved whilst the DR has stayed steady. The next steps include exploring using additional data collected from patients electronically to improve the CR/ DR rates, as well as artificial intelligence informed modelling.

Disclosure of Interests

None declared

POS1549-HPR IMPROVING EFFICACY AND SAFETY OF BLOOD MONITORING IN RHEUMATOLOGY PATIENTS ON DISEASE MODIFYING ANTI-RHEUMATIC DRUGS (DMARDs) USING A NEW AUTOMATED ALGORITHM

Background

Most patients in Rheumatology require early management with DMARDs to control their disease. In our department, around two hundred patients start a DMARD therapy every month and monitoring their blood test results whilst on DMARDs play an essential role to detect toxicity and the need for further action. This process has been done manually, which has been prone to error. Over the past six months, a minimum of three patients have had abnormalities which were missed, consequently identifying the need to improve the quality of the blood monitoring.

Objectives

The aim of the project was to develop, test and implement an automated algorithm to review multiple blood test results and highlight any changes, trends or abnormalities in patients starting DMARD therapy efficiently.

Methods

We designed a system to automatically review blood tests from patients newly started on DMARD therapy, following the recommended British Society for Rheumatology (BSR) schedule for blood monitoring. Results are processed in our local laboratory, subsequently uploaded to our unique database and analysed automatically using an algorithm against BSR guided threshold values for each blood test. According to the value, each blood result is identified as normal, mildly abnormal, missing, trending, or abnormal. A trained clinician or pharmacist will review the data and endorse the results after taking any appropriate action. Based on the results, if any actions are needed, patients are contacted either by phone or via a letter automatically generated by this software, recommending them to have a repeat test or temporarily stop the medication as required.

Results

The system was tested on two cohorts, comprised of 100 and 227 blood tests. It was faster and more efficient than the manual alternative. Following this test, each record was compared manually, based on the data stored on a spreadsheet.

This new system led to the identification of more abnormalities versus the manual inspection (29% vs 10%, Chi square P<0.001). Additionally, it took less than a minute compared to the manual method, which took three hours to complete. Follow up manual inspection confirmed that the new system had correctly identified every abnormality, based on test records.

To date, we have analysed 3568 blood results using this technique. 1564 (44%) results have been normal and endorsed within seconds. 374 (10%) were mildly abnormal, 17 (0.5%) results have been abnormal requiring action and 311 (9%) were abnormal requiring no action. 265 (7%) results showed a trend within the blood results. Trending results were defined as being out of range and worsening on two consecutive occasions but not reaching the limits for stoppig a drug. 1032 (29%) results contained missing results, a consequence of the different timings of results uploaded by various laboratory sections.

Conclusion

We have developed an efficient and safe blood monitoring system for Rheumatology patients starting on a DMARD, proven to be more accurate compared to previous manual alternatives and able to process up to 10,000 results at a time.

Disclosure of Interests

None declared

A practical approach to continuous glucose monitoring (rtCGM) and FreeStyle Libre systems (isCGM) in children and young people with Type 1 diabetes

Real-time continuous glucose monitoring (rtCGM) and FreeStyle Libre glucose monitoring systems (isCGM) are new evolving technologies used in the management of Type 1 diabetes. They offer potential to improve diabetes control and reduce hypoglycaemia. rtCGM can be linked to insulin pump providing hybrid closed loop therapy. Families of children and young people are keen to have the benefit from these technologies. These are relatively expensive so it is important that health care professionals, families of children and young people (CYP) with diabetes are adequately trained in the use of these devices. Health care professionals need to be able to make patient selection based on individual needs and preferences to achieve maximum benefit. Association of Children's Diabetes Clinicians (ACDC) developed a comprehensive guideline in 2017 to help identify which patients may be most likely to benefit and how these technologies may be practically implemented. Since then new technologies have been introduced and the use of GCM has expanded in routine clinical practice. This article, aims to provide a practical approach and help identify which patients may be most likely to benefit and how the technology may be implemented in order to maximise the clinical benefits.

Sex-specific differences and how to handle them in early psoriatic arthritis

Objectives

The prevalence of psoriatic arthritis (PsA) is the same in men and women; however, the latter experience a higher burden of disease and are affected more frequently by polyarthritis. Here, we performed an early PsA cohort analysis to assess sex-related differences in demographics, disease characteristics, and evolution over 1 year including applied treatment strategies.

Methods

Our study is embedded in the Dutch south-west Early Psoriatic Arthritis cohoRt. We described patient characteristics and treatment decisions. For the comparison across sexes and baseline and 1 year follow-up, appropriate tests depending on the distribution were used.

Results

Two hundred seventy-three men and 294 women with no significant differences in age and ethnicity were included. Women reported significantly longer duration of symptoms before diagnosis and significantly higher tender joint count, a higher disease activity, higher levels of pain, and lower functional capacity. Although minimal disease activity (MDA) rates increased over time for both sexes, MDA remained significantly more prevalent among men at 1 year (58.1% vs 35.7%, p < 0.00).

Initially, treatment strategies were similar in both sexes with methotrexate being the most frequently used drug during the first year. Women received methotrexate for a shorter period [196 (93–364) vs 306 (157–365), p < 0.00] and therefore received a lower cumulative dose compared to men. Retention time was shorter for all DMARDs, and women had a delayed start on b-DMARDs.

Conclusion

After 1 year of standard-of-care treatment, women did not surpass their baseline disadvantages. Despite the overall improvement, they still presented higher disease activity, higher levels of pain, and lower functional capacity score than men. The nature of these findings may advocate a need for sex specific adjustment of treatment strategies and evaluation in early PsA patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-021-02680-y.

Spatial UMAP and Image Cytometry for Topographic Immuno-oncology Biomarker Discovery

Multiplex immunofluorescence (mIF) can detail spatial relationships and complex cell phenotypes in the tumor microenvironment (TME). However, the analysis and visualization of mIF data can be complex and time-consuming. Here, we used tumor specimens from 93 patients with metastatic melanoma to develop and validate a mIF data analysis pipeline using established flow cytometry workflows (image cytometry). Unlike flow cytometry, spatial information from the TME was conserved at single-cell resolution. A spatial uniform manifold approximation and projection (UMAP) was constructed using the image cytometry output. Spatial UMAP subtraction analysis (survivors vs. nonsurvivors at 5 years) was used to identify topographic and coexpression signatures with positive or negative prognostic impact. Cell densities and proportions identified by image cytometry showed strong correlations when compared with those obtained using gold-standard, digital pathology software (R2 > 0.8). The associated spatial UMAP highlighted "immune neighborhoods" and associated topographic immunoactive protein expression patterns. We found that PD-L1 and PD-1 expression intensity was spatially encoded-the highest PD-L1 expression intensity was observed on CD163+ cells in neighborhoods with high CD8+ cell density, and the highest PD-1 expression intensity was observed on CD8+ cells in neighborhoods with dense arrangements of tumor cells. Spatial UMAP subtraction analysis revealed numerous spatial clusters associated with clinical outcome. The variables represented in the key clusters from the unsupervised UMAP analysis were validated using established, supervised approaches. In conclusion, image cytometry and the spatial UMAPs presented herein are powerful tools for the visualization and interpretation of single-cell, spatially resolved mIF data and associated topographic biomarker development.

Diagnosis of osteoarticular tuberculosis by immuno-PCR assay based on mycobacterial antigen 85 complex detection

Diagnosis of osteoarticular tuberculosis (OATB) exhibits serious challenges owing to paucibacillary nature of specimens and localization of disease at sites that are difficult to access. We recently developed indirect immuno-PCR (I-PCR) and real-time I-PCR (RT-I-PCR) assays for the detection of mycobacterial antigen 85 complex (Ag85) in OATB patients. Detection limits for the purified Ag85 protein were found to be 1 and 41 fg ml^-1 by I-PCR and RT-I-PCR, respectively, which were at least 10⁵ -fold lower than respective ELISA. While spiking synovial fluids of non-TB control subjects with the purified Ag85 protein, LODs of 100 and 120 fg ml^-1 were obtained by I-PCR and RT-I-PCR, respectively, thus demonstrating the sample matrix effect. Sensitivities of 87·5 and 70·5% were observed in bodily fluids of confirmed (n = 8) and clinically suspected (n = 51) OATB cases, respectively, by I-PCR, with a specificity of 93·9% (n = 33). Markedly, the sensitivities obtained by I-PCR/RT-I-PCR were significantly higher (P < 0·05-0·01) than ELISA and GeneXpert assay (n = 30). However, no substantial difference in sensitivity was observed between the I-PCR and RT-I-PCR assays. After further improving the accuracy of I-PCR, this test may lead to development of an attractive diagnostic kit.

Comparison of Bone-Patellar Tendon-Bone Graft, Semitendinosus-Gracilis Graft and Semitendinosus-Gracilis with Preserved Tibial Insertion Graft in Anterior Cruciate Ligament Reconstruction in Sports Persons

Introduction

Bone-patellar tendon-bone (BPTB) and semitendinosus-gracilis (STG) are the commonest grafts used for ACL reconstruction. However even after having been debated for years, there is no consensus about the ideal graft. Moreover, the literature is deficient about STG graft with preserved tibial insertion (STGPI) which preserves the proprioception. Our aim is to compare the outcome of BPTB, free STG and STGPI grafts after ACL reconstruction in professional sports persons. We compared the outcome in terms of mechanical stability, functional outcome, return to sports activity and degenerative changes.

Material and Methods

Professional sports persons aged between 16-50 years operated for ACL tear using BPTB, free STG and STGPI grafts with minimum follow-up of two years were identified from hospital records. Patients with associated knee injuries were excluded. Patients, divided in three groups according to graft used, were compared in terms of mechanical stability (arthrometric examination KT-1000 score), functional outcome (Lysholm Score), return to sports activity (Tegner score and difference in thigh circumference) and degenerative changes (KL grading).

Results

BPTB graft group was found to be better than free STG and STGPI graft groups in terms of KT-1000 score. There was no statistically significant difference among the groups in terms of Lysholm score, Tegner score, difference in thigh circumference and KL grading.

Conclusion

BPTB graft is better than free STG and STGPI grafts in terms of knee stability. When compared for patient reported outcome, return to sports activity, osteoarthritic changes and graft failure there is no significant difference among the three types of grafts.

Integrated hydrochemical and ERT approach for seawater intrusion study in a coastal aquifer: a case study from Jafrabad Town, Gujarat State, India

Hydrochemical and geophysical approach has been adopted to evaluate the seawater intrusion (SWI) in coastal aquifers of Jafrabad Town, Gujarat State, India. Electrical Resistivity Tomography (no. 9) was carried out with spread length of 160-400 m which provided penetration depth of about 23 to 76 m. Very low resistivity zone (0-3 Ω-m range) has been observed in the ERT profiles conducted in the study area. Parameters, namely, TDS, Na, and Cl, have been considered to examine the signature of SWI. The results obtained from ionic ratios, Piper plot, and Chaddha's diagram also confirm the influence of saline water within aquifer. The very low resistivity signature is correlated with the high TDS values in the nearby wells. SWI has been observed up to 9 km from the coast, and it is observed at a depth of 20-22 m in the existing limestone mines near the coast.

POS0152-HPR REMOTE CLINICAL MANAGEMENT: INCORPORATING ELECTRONIC ASSESSMENT OF PATIENTS WITH RHEUMATIC DISEASES INTO STANDARD CLINICAL PATHWAYS DURING THE COVID-19 PANDEMIC: A PILOT STUDY

Background:

Many patients with rheumatic disease require immunosuppressive medication putting them at high risk of COVID-19 infection. Reduced staffing in rheumatology due to redeployment to COVID-19 work, limited out patient capacity and patient vulnerability have had a major impact on our ability to review our patients to assess their condition and treatment (by face-to-face, video or telephone consultations). Novel strategies are essential to safely and effectively treat patients with rheumatic disease whilst minimising their risk of exposure to COVID-19 infection.

Objectives:

The objective was to develop a digital solution to help deliver safe, efficient and effective care for patients with rheumatic diseases. The aim was to produce a system that allowed us to integrate data recorded directly by patients with information held in our electronic health records to provide a virtual review of care.

Methods:

An online questionnaire was used to collect clinical information, including validated disease activity measures, to conduct a remote assessment in 175 patients awaiting follow-up appointments. This assessment was integrated within our electronic health records (EHR). The questionnaire contained measures of disease activity (DAS28 or BASDAI); patient reported outcomes; patient preferences regarding the urgency and type of appointment; any recent problems or changes in medication. This information was imported into a database for clinician review, together with previous clinical records and results of relevant investigations, to inform clinical decisions and to decide on the safest and most appropriate timing for follow-up. Report letters were sent to the patient and their primary care providers.

Results:

Of the 175 patients (149 with RA and 26 with AS), 108 patients (89/149 [60%] with RA [mean age=64; female=65%] and 19/26 [73%] with AS [mean age=45; female=54%]) submitted responses over a 6-week period based on which clinical decisions were made. The mean questionnaire completion time was 19 minutes for RA responders and 16 minutes for AS responders. Non responders (67/175 [mean age=61; female=63%]) remained on our list of patients awaiting follow-up arrangements to be made. Sixty-nine responders (64%) had stable disease therefore did not require any changes to their treatment and were offered an appointment within the next 6 months, of whom 12 (11%) requested face-to-face follow-up. Of the remaining 39 – with less stable disease – requiring more rapid follow-up assessment, 22 patients (56%) required a face-to-face consultation to consider treatment change. So far 9 of these patients have had follow-up, of whom 6 necessitated treatment escalation (Methotrexate increase n=2; anti-inflammatory increase n=2; intramuscular steroid n=1; anti-TNF escalation n=1). Thirty-nine patients (36%) provided feedback on the process of completing the questionnaire, 85% of whom used a mobile phone and the remainder used a computer or tablet. The majority (70%) found it “extremely easy” or “somewhat easy” to complete; remaining responses: “neutral” 20%, “somewhat difficult” 10%, “extremely difficult” 0%.

Conclusion:

We have created and tested a system of remote clinical management for patients with RA and AS. Amongst the 108 responders, just 31% required a face-to-face appointment, with treatment changes made accordingly. With a backlog of 3,800 awaiting allocation to follow-up appointments, remote clinical management will allow us to safely and efficiently prioritise patients requiring urgent follow-up for treatment optimisation. We will integrate this system into our standard care pathway beyond the COVID-19 pandemic to streamline our service, deliver effective care and provide evidence to support the use of costly biologic drugs.1 We plan to investigate the barriers for non-responders.

References:

[1]Holroyd CR, Seth R, Bukhari M, et al. The British Society for Rheumatology biologic DMARD safety guidelines in inflammatory arthritis. Rheumatology. 2019; 58 (2): e3–e42.

Disclosure of Interests:

Tamir Malley: None declared, John Jackman: None declared, Sarah Manderson: None declared, Larissa Saldana Pena Grant/research support from: Pfizer’s Global Medical Grants program, Ellie Evans: None declared, Joe Barrett Grant/research support from: Pfizer’s Global Medical Grants program, Anushka Soni Grant/research support from: Pfizer’s Global Medical Grants program, Raashid Luqmani Grant/research support from: Pfizer’s Global Medical Grants program

Predictors for Anterior Cruciate Ligament (ACL) Re-injury after Successful Primary ACL Reconstruction (ACLR)

Introduction:

Few authors have addressed risk factors related to an ipsilateral graft rupture and contralateral anterior cruciate ligament (ACL) injury after return to sports (RTS) following primary ACL reconstruction.

Material and Methods:

Patients with ACL re-injury to either knee after successful primary ACLR were included in Group I and those with no further re-injury were included in Group II. Variables including age, gender, side, body mass index (BMI), thigh atrophy, anterior knee laxity difference between both knees measured by KT-1000 arthrometer, mean time of return to sports (RTS), graft type, type of game, mode of injury, Tegner Activity Score, hormone levels, femoral tunnel length (FTL), posterior tibial slope (PTS) and notch width index (NWI) were studied. Binary logistic regression was used to measure the relative association.

Results:

A total of 128 athletes were included with 64 in each group. Mean age in Group I and II were 24.90 and 26.47 years respectively. Mean follow-up of Group I and Group II were 24.5 and 20.11 months respectively. Significant correlation was present between ACL re-injury and following risk factors; PTS of >10º, KT difference of >3.0mm, thigh atrophy of >2.50cm and time to RTS <9.50 months P value <0.05). No correlation was found with age, sex, BMI, type of game, Tegner Activity Score, mode of injury, NWI, size of graft, FTL and hormone levels.

Conclusion:

Possible risk factors include PTS of ≥ 10º, KT difference of ≥ 3.0mm at 1 year follow-up, thigh atrophy of ≥ 2.50cm at 1 year follow-up and RTS <9.5 months after primary ACLR.

Excitation Density Dependent Photoluminescence Studies on Homo-Epitaxial GaN Nanowall Networks Grown by Laser Assisted Molecular Beam Epitaxy

The optical properties of laser-assisted molecular beam epitaxy grown homo-epitaxialGaN nanowall networks (NWNs) were investigated using power dependent photoluminescence (PL) spectroscopy and compared with homo-epitaxial GaN thin film. The pore size and tip width of GaN NWN sample is ˜120-180 nm and 10-15 nm, respectively. The ultraviolet-visible spectroscopy study shows that the GaN NWNs have low optical light reflection and minimum Fabry-Perot cavity effect than GaN film. The room temperature PL spectroscopy reveals that the GaN NWNs possesses enhanced band gap of 3.51 eV with blue shift of 90 meV than the GaN film (3.42 eV). The excitation density dependent PL spectroscopy measurements reveal that the GaN NWNs nanowall and near band emission (NBE) peak position and its linewidth invariant. The intensity of NBE peak for GaN film and nanowalls varies linearly whereas NBE to defect related yellow luminescence peak intensity ratio shows a non-linear variation on the excitation density. The excitation density in PL measurements plays a key role when the sample quality compared on the basis of PL data.

OP0057 SEX SPECIFIC DIFFERENCES IN EARLY PSORIATIC ARTHRITIS

Background:

Although the prevalence of Psoriatic Arthritis (PsA) is the same in men and women, women experience a higher burden of disease (pain, disability, fatigue) (1).The persistent belief that women tend to over-report their symptoms compared to men may also contribute to under or delayed diagnosis in women. The clinical pattern of PsA also differs, with men presenting more commonly with peripheral and axial joint damage and women being affected more frequently by polyarthritis (2). Furthermore, most disease activity measures contain pain and quality of life measurement metrics that may perform differently by sex. As a result, this may affect the clinician’s perception of disease severity, influence management decisions and subsequently introduce sex bias in prescribing.

Objectives:

To assess sex-related differences in baseline demographics, disease characteristics and evolution over 1 year in patients with newly diagnosed PsA.

Methods:

Our study is embedded in the Dutch south-west Early Psoriatic Arthritis prospective cohort study. We described patient characteristics using simple descriptive analysis techniques. For the comparison across sexes and baseline and 1 year follow up, appropriate tests depending on the distribution were used.

Results:

273 men and 294 women with no significant differences in age and ethnicity were included. Women reported significantly longer duration of symptoms before diagnosis and significantly fewer of them were in paid employment at baseline. Oligoarthritis was the most common pattern of arthritis in both sexes. Polyarthritis and enthesitis were more prevalent in women who also presented at baseline a significantly higher tender joint count (Fig.1) than men but no difference in swollen joint count.

Figure 1.

Longitudinal evolution of TJC68, Pain, VAS global, BRAF for men and women in the first year of PsA.

All composite indices (CPDAI, DAPSA, GRACE, MDA, Psoriatic ArthritiS Disease Activity Score) showed significantly worse results in women at baseline. Women also suffered more frequently from comorbid medical conditions, fatigue and anxiety, and reported more severe limitations in function and worse quality of life.

At 12 months women, despite the improvement they made, reported significantly higher levels of pain compared to men. Although MDA rates increase over time for both sexes,(Fig.2), it remained significantly more prevalent among men (19.0% vs 11.1% at inclusion,p<0.05, and 58.1% vs 35.7%,p<0.00, at T12). DAPSA was significantly higher in women at both timepoints and a significantly higher percentage of men presented remission according to DAPSA score at 12 months.

Figure 2.

Longitudinal evolution of composite measures for men and women in the first year of PsA.

Conclusion:

After 1 year of follow-up women didn’t surpass their baseline disadvantages and despite the improvement, they still present higher disease activity, more pain and lower functional capacity than men. The nature of these findings may advocate a need for sex specific adjustment of treatment strategies and evaluation in psoriatic arthritis as sex-related difference in outcome persisted over time.

References:

[1]Eder L, Thavaneswaran A, Chandran V, Gladman DD. Gender difference in disease expression, radiographic damage and disability among patients with psoriatic arthritis. Annals of the rheumatic diseases. 2013;72(4):578-82.

[2]Orbai AM, Perin J, Gorlier C, Coates LC, Kiltz U, Leung YY, et al. Determinants of Patient-Reported Psoriatic Arthritis Impact of Disease: An Analysis of the Association with Gender in 458 Patients from 14 Countries. Arthritis care & research. 2019.

Disclosure of Interests:

Evangelia Passia: None declared, Marijn Vis Grant/research support from: Novartis, Pfizer – grant/research support, Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Novartis, Pfizer – consultant, Laura C Coates: None declared, Anushka Soni Grant/research support from: Oxford-UCB prize fellowship, Speakers bureau: Janssen and Abbvie, Ilja Tchetverikov: None declared, Andreas Gerards: None declared, Lindy-Anne Korswagen: None declared, Marc R Kok Grant/research support from: BMS and Novartis, Consultant of: Novartis and Galapagos, Wiebo van der Graaff: None declared, Josien Veris-van Dieren: None declared, Natasja Denissen: None declared, F. Fodili: None declared, M. Starmans: None declared, Yvonne Goekoop-Ruiterman: None declared, M. van Oosterhout: None declared, Jolanda Luime: None declared

Multiplex Immunofluorescence Image Cytometry Combined with Spatially-Resolved UMAP Defines Novel Immune Prognostic Biomarkers in Metastatic Melanoma

Multiplex IF (mIF) provides a detailed characterization of spatial relationships and complex cell phenotypes in the tumor microenvironment. However, the data-analysis and visualization is complex and time-consuming. Here, we developed a platform to analyze mIF data through flow cytometry workflows (image cytometry), while maintaining spatial information, and applied it to tissue microarrays of metastatic melanoma specimens (n=93; 6-plex mIF panel: PD-1, PD-L1, CD163, CD8, FoxP3, Sox10/S100). Then, we used a UMAP-based approach driven by cell-to-cell distances (rather than fluorescence intensity) to display and analyze geographic organization and cell interactions. Our pipeline provided equivalent results to the digital pathology gold standard with faster run times (5-fold reduction) and higher reproducibility. We identified key prognostic immune variables, including CD8PD1Low and CD8PD1Neg cells which associated with longer overall survival (OS, both p&lt;0.01), and CD163PDL1Neg cells which associated with shorter OS (p=0.001). The spatial UMAPs showed that PD-L1 and PD-1 intensities were spatially encoded, and their expression on distinct cell subsets was organized in geographic clusters. Specifically, PD-L1Hi cells co-located to areas of CD8 cells, and PD-1Hi cells were observed near dense collections of tumor cells. Spatial UMAP subtraction analysis (survivors vs. non-survivors at 5 years) identified geographic and co-expression signatures associated with improved prognosis, i.e. CD8-driven PD-L1 expression and lacking CD163PDL1Neg macrophages. These data demonstrate the use of image cytometry and spatial UMAPs for improved visualization and interpretation of single-cell, spatially-resolved mIF data.

Jamun fruit (Syzgium cumini) skin extract based indicator for monitoring chicken patties quality during storage

Natural plant pigment, anthocyanins have the capability to change its color with the change of its structure influenced by changing pH. This feature of anthocyanin has been harnessed to design a meat products quality indicator. In the present experiment anthocyanin rich Jamun fruit (Syzgium cumini) skin extract was used to develop quality indicator by immobilizing on filter paper strips with the purpose of application in chicken patties packets stored at refrigeration temperature (4 ± 1 °C). The indicator changed its color from violet to yellow due to changed pH in it when it was attached inside packet of chicken patties during storage, due to reaction with volatile basic compounds generated from meat. During storage for 21 days, various changes in quality attributes of chicken patties viz., pH, Total volatile basic nitrogen (TVBN), ammonia level, color value, sensory attributes and microbial evaluation were estimated. The pH decreased (P < 0.5) from 6.22 to 6.04. TVBN and ammonia and level increased significantly (P < 0.5) throughout storage. Redness, yellowness, hue and chroma value gradually changed during storage. Sensory scores also decreased significantly (P < 0.5). Microbial count also increased (P < 0.5) during this time. The experiment showed that, during storage, the color changing pattern of quality indicator was well correlated with the changes in quality attributes of chicken meat patties. Therefore, it is expected that the developed quality indicator can provide a convenient, non destructive, visual mean to monitor the meat products quality during refrigerated storage.

PD-L1, PD-1, LAG-3, and TIM-3 in Melanoma: Expression in Brain Metastases Compared to Corresponding Extracranial Tumors

Background

Metastatic melanoma to the brain carries a particularly poor prognosis that may be associated with an attenuated antitumor response in the presence of central nervous system malignancies. Thus, the development of brain metastases could theoretically accelerate cancer progression both locally and systemically. Although dysregulation of checkpoint markers, such as programmed death-ligand 1 (PD-L1), programmed cell death receptor 1 (PD-1), lymphocyte activation gene 3 (LAG-3), and T-cell immunoglobulin and mucin-domain containing-3 (TIM-3), have been implicated in immune dysfunction, the exact relationship between these markers and brain tumor-mediated immune suppression remains unclear. Thus, the objective of this study was to explore whether there exists a differential expression of the above checkpoint markers in the intracranial milieu as compared to tumors in the periphery, which may shed light on the mechanism behind the diminished antitumor response.

Methods

We identified nine patients with extracranial melanomas and matched intracranial metastases. Formalin-fixed, paraffin-embedded slides were stained for PD-L1, PD-1, LAG-3, and TIM-3 via immunohistochemistry. Qualitative analysis was performed to assess the staining of the markers in the neoplastic and lymphocytic cells, which were the two cell lineages in each biopsy. 

Results

Expression of PD-1 and TIM-3 between extracranial and intracranial tumoral sites was conserved. Specifically, in lymphocytes, PD-1 expression was observed in 100% of extracranial and 100% of intracranial slides, whereas TIM-3 expression was seen in 33.33% of extracranial and 33.33% of intracranial slides. Neither marker stained tumor cells, as expected. PD-L1 showed a slight variation in staining between sites, with lymphocyte staining in 100% of extracranial and 88.89% of intracranial slides, and the same percentages per site for tumor cells. The greatest variability was observed in LAG-3 lymphocyte staining, with staining in 77.78% of extracranial and 33.33% of intracranial slides. No LAG-3 staining of tumor cells was noted, as expected.

Conclusion

Preliminary analysis revealed the conservation of PD-L1, PD-1, LAG-3, and TIM-3 expression intra- and extracranially. This could suggest that these markers are important in maintaining an immunosuppressive phenotype at both sites. Another possibility is that this pattern of expression is associated with patients who develop brain metastasis, as this was the only subset of patients included in this study. Interestingly, LAG-3 staining of lymphocytes appeared more prominent in extracranial over intracranial tumors. Future studies should include more samples to draw out potential patterns masked by the small sample size, as well as to compare checkpoint expression in other patient groups, such as those with non-brain metastasis or those with no metastasis at all.

In Situ Fixation of Symptomatic Fibrous Non-union Hoffa Fracture: A Case Report

Femoral condyle fracture in coronal plane, also known as Hoffa fracture, is a rare fracture. Non-union of Hoffa fracture is even rarer. We present a case of fibrous nonunion of a Hoffa fracture in which the fractured fragment, though not freely movable, led to painful walking. Since the fragment was un-displaced and non-movable we fixed the fractured fragment in situ. Patient regained full range of motion of the knee and was asymptomatic on follow-up.

Major pathologic response on biopsy (MPRbx) in patients with advanced melanoma treated with anti-PD-1: evidence for an early, on-therapy biomarker of response

BACKGROUND

With increasing anti-PD-1 therapy use in patients with melanoma and other tumor types, there is interest in developing early on-treatment biomarkers that correlate with long-term patient outcome. An understanding of the pathologic features of immune-mediated tumor regression is key in this endeavor.

MATERIALS AND METHODS

Histologic features of immune-related pathologic response (irPR) following anti-PD-1 therapy were identified on hematoxylin and eosin (H&E)-stained slides in a discovery cohort of pre- and on-treatment specimens from n = 16 patients with advanced melanoma. These features were used to generate an irPR score [from 0 = no irPR features to 3 = major pathologic response on biopsy (MPRbx, ≤10% residual viable tumor)]. This scoring system was then tested for an association with objective response by RECIST1.1 and overall survival in a prospectively collected validation cohort of pre- and on-treatment biopsies (n = 51 on-treatment at 4-week timepoint) from melanoma patients enrolled on the nivolumab monotherapy arm of CA209-038 (NCT01621490).

RESULTS

Specimens from responders in the discovery cohort had features of immune-activation (moderate-high TIL densities, plasma cells) and wound-healing/tissue repair (neovascularization, proliferative fibrosis) compared to nonresponders, (P ≤ 0.021, for each feature). In the validation cohort, increasing irPR score associated with objective response (P = 0.009) and MPRbx associated with increased overall survival (n = 51; HR 0.13; 95%CI, 0.054-0.31, P = 0.015). Neither tumoral necrosis nor pretreatment histologic features were associated with response. Eight of 16 (50%) of patients with stable disease showed irPR features, two of which were MPRbx, indicating a disconnect between pathologic and radiographic features at the 4-week on-therapy timepoint for some patients.

CONCLUSIONS

Features of immune-mediated tumor regression on routine H&E-stained biopsy slides from patients with advanced melanoma correlate with objective response to anti-PD-1 and overall survival. An on-therapy biopsy may be particularly clinically useful for informing treatment decisions in patients with radiographic stable disease. This approach is inexpensive, straightforward, and widely available.

Durable Tumor Regression and Overall Survival in Patients With Advanced Merkel Cell Carcinoma Receiving Pembrolizumab as First-Line Therapy

PURPOSE

Merkel cell carcinoma (MCC) is an aggressive skin cancer often caused by the Merkel cell polyomavirus. Clinical trials of programmed cell death-1 pathway inhibitors for advanced MCC (aMCC) demonstrate increased progression-free survival (PFS) compared with historical chemotherapy data. However, response durability and overall survival (OS) data are limited.

PATIENTS AND METHODS

In this multicenter phase II trial (Cancer Immunotherapy Trials Network-09/Keynote-017), 50 adults naïve to systemic therapy for aMCC received pembrolizumab (2 mg/kg every 3 weeks) for up to 2 years. Radiographic responses were assessed centrally per Response Evaluation Criteria in Solid Tumors (RECIST) v1.1.

RESULTS

Among 50 patients, the median age was 70.5 years, and 64% had Merkel cell polyomavirus-positive tumors. The objective response rate (ORR) to pembrolizumab was 56% (complete response [24%] plus partial response [32%]; 95% CI, 41.3% to 70.0%), with ORRs of 59% in virus-positive and 53% in virus-negative tumors. Median follow-up time was 14.9 months (range, 0.4 to 36.4+ months). Among 28 responders, median response duration was not reached (range, 5.9 to 34.5+ months). The 24-month PFS rate was 48.3%, and median PFS time was 16.8 months (95% CI, 4.6 months to not estimable). The 24-month OS rate was 68.7%, and median OS time was not reached. Although tumor viral status did not correlate with ORR, PFS, or OS, there was a trend toward improved PFS and OS in patients with programmed death ligand-1-positive tumors. Grade 3 or greater treatment-related adverse events occurred in 14 (28%) of 50 patients and led to treatment discontinuation in seven (14%) of 50 patients, including one treatment-related death.

CONCLUSION

Here, we present the longest observation to date of patients with aMCC receiving first-line anti-programmed cell death-1 therapy. Pembrolizumab demonstrated durable tumor control, a generally manageable safety profile, and favorable OS compared with historical data from patients treated with first-line chemotherapy.

PVRIG and PVRL2 Are Induced in Cancer and Inhibit CD8+ T-cell Function

Although checkpoint inhibitors that block CTLA-4 and PD-1 have improved cancer immunotherapies, targeting additional checkpoint receptors may be required to broaden patient response to immunotherapy. PVRIG is a coinhibitory receptor of the DNAM/TIGIT/CD96 nectin family that binds to PVRL2. We report that antagonism of PVRIG and TIGIT, but not CD96, increased CD8⁺ T-cell cytokine production and cytotoxic activity. The inhibitory effect of PVRL2 was mediated by PVRIG and not TIGIT, demonstrating that the PVRIG-PVRL2 pathway is a nonredundant signaling node. A combination of PVRIG blockade with TIGIT or PD-1 blockade further increased T-cell activation. In human tumors, PVRIG expression on T cells was increased relative to normal tissue and trended with TIGIT and PD-1 expression. Tumor cells coexpressing PVR and PVRL2 were observed in multiple tumor types, with highest coexpression in endometrial cancers. Tumor cells expressing either PVR or PVRL2 were also present in numbers that varied with the cancer type, with ovarian cancers having the highest percentage of PVR^-PVRL2⁺ tumor cells and colorectal cancers having the highest percentage of PVR⁺PVRL2^- cells. To demonstrate a role of PVRIG and TIGIT on tumor-derived T cells, we examined the effect of PVRIG and TIGIT blockade on human tumor-infiltrating lymphocytes. For some donors, blockade of PVRIG increased T-cell function, an effect enhanced by combination with TIGIT or PD-1 blockade. In summary, we demonstrate that PVRIG and PVRL2 are expressed in human cancers and the PVRIG-PVRL2 and TIGIT-PVR pathways are nonredundant inhibitory signaling pathways.See related article on p. 244.

Comparative evaluation of antidotal efficacy of 2-PAM and HNK-102 oximes during inhalation of sarin vapor in Swiss albino mice

Efficacy of two oximes treatments evaluated during inhalation of sarin vapor (LCt₅₀, 755.9 mg/min/m³) in simulated real scenario in vivo. Majority of mice either became moribund or died within 1-2 min during exposure to multifold-lethal concentrations of sarin vapor. Protection indices were determined by exposing to sarin vapor in two sessions, 1 min exposure followed by treatments with or without HNK-102 (56.56 mg/kg, im) or 2-PAM (30 mg/kg, im) and atropine (10 mg/kg, ip), and again exposed for remaining 14 min. Protection offered by HNK-102 was found to be four folds higher compared to 2-PAM in the same toxic environment. Secondly, sub-lethal concentration of sarin vapor (0.8 × LCt₅₀ or 605 mg/min/m³), 24 h post investigations revealed that the oximes could not reactivate brain and serum acetylcholinesterase (AChE) activity. The treatments prevented increase in protein concentration (p < .05) and macrophages infiltration compared to sarin alone group in broncho-alveolar lavage fluid. Lung histopathology showed intense peribronchial infiltration and edema with desquamating epithelial lining and mild to moderate alveolar septal infiltration in sarin and atropine groups, respectively. Noticeable peeling-off observed in epithelial lining and sporadic mild infiltration of epithelial cells at bronchiolar region in 2-PAM and HNK-102 groups, respectively. The oximes failed to reactivate AChE activity; however, the mice survived up to 6.0 × LCt₅₀, proved involvement of non-AChE targets in sarin toxicity. Atropine alone treatment was found to be either ineffective or increased the toxicity. HNK-102, exhibited better survivability with lung protection, can be considered as a better replacement for 2-PAM to treat sarin inhalation induced poisoning.

Multidimensional, quantitative assessment of PD-1/PD-L1 expression in patients with Merkel cell carcinoma and association with response to pembrolizumab

Background

We recently reported a 56% objective response rate in patients with advanced Merkel cell carcinoma (MCC) receiving pembrolizumab. However, a biomarker predicting clinical response was not identified.

Methods

Pretreatment FFPE tumor specimens (n = 26) were stained for CD8, PD-L1, and PD-1 by immunohistochemistry/immunofluorescence (IHC/IF), and the density and distribution of positive cells was quantified to determine the associations with anti-PD-1 response. Multiplex IF was used to test a separate cohort of MCC archival specimens (n = 16), to identify cell types expressing PD-1.

Results

Tumors from patients who responded to anti-PD-1 showed higher densities of PD-1+ and PD-L1+ cells when compared to non-responders (median cells/mm², 70.7 vs. 6.7, p = 0.03; and 855.4 vs. 245.0, p = 0.02, respectively). There was no significant association of CD8+ cell density with clinical response. Quantification of PD-1+ cells located within 20 μm of a PD-L1+ cell showed that PD-1/PD-L1 proximity was associated with clinical response (p = 0.03), but CD8/PD-L1 proximity was not. CD4+ and CD8+ cells in the TME expressed similar amounts of PD-1.

Conclusions

While the binomial presence or absence of PD-L1 expression in the TME was not sufficient to predict response to anti-PD-1 in patients with MCC, we show that quantitative assessments of PD-1+ and PD-L1+ cell densities as well as the geographic interactions between these two cell populations correlate with clinical response. Cell types expressing PD-1 in the TME include CD8+ T-cells, CD4+ T-cells, T_regs, and CD20+ B-cells, supporting the notion that multiple cell types may potentiate tumor regression following PD-1 blockade.

Electronic supplementary material

The online version of this article (10.1186/s40425-018-0404-0) contains supplementary material, which is available to authorized users.

Interprofessional working: a spearhead opportunity for dentistry and pharmacy

Dentistry and pharmacy have an opportunity, through interprofessional working, to spearhead a move towards more integrated healthcare provision, in particular for patients with chronic non-communicable diseases such as diabetes. The proposed interprofessional working poses certain challenges, but offers may opportunities and benefits.

Mutations in Coagulation Factor VIII Are Associated with More Favorable Outcome in Patients with Cutaneous Melanoma

Coagulation factor VIII (FVIII), von Willebrand factor (VWF), and ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 repeats 13) play an important role in the regulation of normal hemostasis. However, little is known about their roles in patients with malignancy, particularly with cutaneous melanoma. Whole genome sequencing data are available for 25,719 cases in 126 cancer genomic studies for analysis. All sequencing data and corresponding pathology findings were obtained from The Cancer Genome Atlas. The cBioPortal bioinformatics tools were used for the data analysis. Our results demonstrated that mutations in genes encoding FVIII , VWF , and ADAMTS13 were reported in 92 of 126 cancer genomic studies, and high mutation rates in these three genes were observed in patients with cutaneous melanoma from three independent studies. Moreover, high mutation rates in FVIII , VWF , and ADAMTS13 were also found in patients with diffuse large B cell lymphoma (22.9%), lung small cell carcinoma (20.7%), and colon adenocarcinoma (19.4%). Among 366 melanoma cases from TCGA provisional, the somatic mutation rates of FVIII , VWF , and ADAMTS13 in tumor cells were 15, 14, and 5%, respectively. There was a strong tendency for coexisting mutations of FVIII , VWF , and ADAMTS13 . Kaplan–Meier survival analysis demonstrated that melanoma patients with FVIII mutations had a more favorable overall survival rate than those without FVIII mutations ( p  = 0.02). These findings suggest, for the first time, that the FVIII mutation burden may have a prognostic value for patients with cutaneous melanoma. Further studies are warranted to delineate the molecular mechanisms underlying the favorable prognosis associated with FVIII mutations.

Hepatitis C Virus Genie: A Web 2.0 Interpretation and Analytics Platform for the Versant Hepatitis C Virus Genotype Line Probe Assay Version 2.0

Context:

Hepatitis C virus (HCV) genotyping at our institution is performed using the Versant HCV genotype 2.0 Line Probe Assay (LiPA). The last steps of this procedure are manual, laborious, and error-prone process that involves the comparison of the banding pattern on a test strip to a physical reference table.

Aim:

We developed a web-based HCV genotype interpretation platform that utilizes a scanned image to generate the genotypes, thus minimizing interpretation time and reducing error.

Subjects and Methods:

HCV Genie 2 utilizes a database of banding patterns in conjuncture with image analysis algorithms to determine the genotype for any number of scanned LiPA strips. HCV Genie 2 is built with client-side JavaScript; allowing the program to run in the user' browser rather than on an unknown server, essentially eliminating data and patient privacy concerns.

Results:

HCV Genie 2 was tested over 2 months and proved identical to human expert interpretation for 148 samples (>1000 bands identified). Manual intervention was required only for two faint bands and one false-positive band; this was done utilizing the built-in-user interface. Utilizing the original method, the trained laboratory technician interpretation time for 16 samples was 13.8 (±0.96) min as compared to 5.0 (±1.09) min with HCV Genie 2, a 63.8% decrease. In addition to the time savings, the new method provides an additional validation step, which decreases the potential for errors.

Conclusions:

Our institution has moved exclusively to utilize the new techniques and tools described here. Both experienced technicians and the molecular pathologists at our institution prefer the workflow using HCV Genie. It is easier for the technicians to prepare and document, and the pathologists are more rapidly able to review and confirm results. The use of this tool will lead to increase the quality of patient care delivered through this test methodology by decreasing the potential for error. The algorithms developed here can be ported to similar band identification platforms, most directly to other LiPAs.

Pain in knee osteoarthritis is associated with variation in the neurokinin 1/substance P receptor (TACR1) gene

BACKGROUND

Substance P (SP) is a pain- and inflammation-related neuropeptide which preferentially binds to the neurokinin receptor 1 (NK₁ ). SP and NK₁ receptors have been implicated in joint pain, inflammation and damage in animal models and human studies of osteoarthritis (OA). The aim of this study was to test if genetic variation at the neurokinin 1 receptor gene (TACR1) is associated with pain in individuals with radiographic knee OA.

METHODS

Participants from the Genetics of OA and Lifestyle study were used for the discovery group (n = 1615). Genotype data for six SNPs selected to cover most variation in the TACR1 gene were used to test for an association with symptomatic OA. Replication analysis was performed using data from the Chingford 1000 Women Study, Hertfordshire Cohort Study, Tasmanian Older Adult Cohort Study and the Clearwater OA Study. In total, n = 1715 symptomatic OA and n = 735 asymptomatic OA individuals were analysed.

RESULTS

Out of six SNPs tested in the TACR1 gene, one (rs11688000) showed a nominally significant association with a decreased risk of symptomatic OA in the discovery cohort. This was then replicated in four additional cohorts. After adjusting for age, gender, body mass index and radiographic severity, the G (minor) allele at rs11688000 was associated with a decreased risk of symptomatic OA compared to asymptomatic OA cases (p = 9.90 × 10^-4 , OR = 0.79 95% 0.68-0.90 after meta-analysis).

CONCLUSIONS

This study supports a contribution from the TACR1 gene in human OA pain, supporting further investigation of this gene's function in OA.

SIGNIFICANCE

This study contributes to the knowledge of the genetics of painful osteoarthritis, a condition which affects millions of individuals worldwide. Specifically, a contribution from the TACR1 gene to modulating pain sensitivity in osteoarthritis is suggested.

Impact of Cognition and Clinical Factors on Functional Outcome in Patients with Bipolar Disorder

OBJECTIVE

To examine the role of different clinical variables and cognition on functional outcome in patients with bipolar disorder.

METHODS

A total of 61 euthymic patients with bipolar disorder and 30 healthy individuals were included in the study. The patients were divided into low functioning (n = 30) or high functioning (n = 31) subgroups based on functioning level measured by Global Assessment of Functioning Scale score. Groups were subjected to neurocognitive and clinical assessment.

RESULTS

Clinical variables differed significantly between low and high functioning patient groups, namely total number of episodes, depressive episodes, and time since the last episode. These variables were also correlated significantly with Global Assessment of Functioning Scale score. All 3 groups differed significantly for digit span backward test, verbal learning and memory test, Trail Making Test, and Stroop Colour Test. Digit span backward test, Trail Making Test, and Stroop Colour Test were significantly correlated with Global Assessment of Functioning Scale score.

CONCLUSIONS

Total episodes, depressive episodes, time since the last episode, and cognitive dysfunction correlated with poor functioning. Executive dysfunction was the strongest predictor of psychosocial outcome in euthymic bipolar patients. Long-term therapeutic interventions should target relapse prevention with special consideration given to depressive episodes and cognitive rehabilitation.

Primary Renal Ewing Sarcoma in an Adult

Primary renal Ewing sarcoma is extremely rare and carries a dismal prognosis. It is particularly diagnostically challenging due to its ability to mimic other round cell tumors. Herein we report such a case in a 28-year-old white female. The diagnosis was confirmed by immunophenotyping, fluorescence in situ hybridization, and reverse transcription polymerase chain reaction analyses.