Bone Proteomics Method Optimization for Forensic Investigations

The application of proteomic analysis to forensic skeletal remains has gained significant interest in improving biological and chronological estimations in medico-legal investigations. To enhance the applicability of these analyses to forensic casework, it is crucial to maximize throughput and proteome recovery while minimizing interoperator variability and laboratory-induced post-translational protein modifications (PTMs). This work compared different workflows for extracting, purifying, and analyzing bone proteins using liquid chromatography with tandem mass spectrometry (LC-MS)/MS including an in-StageTip protocol previously optimized for forensic applications and two protocols using novel suspension-trap technology (S-Trap) and different lysis solutions. This study also compared data-dependent acquisition (DDA) with data-independent acquisition (DIA). By testing all of the workflows on 30 human cortical tibiae samples, S-Trap workflows resulted in increased proteome recovery with both lysis solutions tested and in decreased levels of induced deamidations, and the DIA mode resulted in greater sensitivity and window of identification for the identification of lower-abundance proteins, especially when open-source software was utilized for data processing in both modes. The newly developed S-Trap protocol is, therefore, suitable for forensic bone proteomic workflows and, particularly when paired with DIA mode, can offer improved proteomic outcomes and increased reproducibility, showcasing its potential in forensic proteomics and contributing to achieving standardization in bone proteomic analyses for forensic applications.

Pharmacogene expression during progression of metabolic dysfunction-associated steatotic liver disease: Studies on mRNA and protein levels and their relevance to drug treatment

Metabolic dysfunction-associated steatotic liver disease (MASLD) is common worldwide. Genes and proteins contributing to drug disposition may show altered expression as MASLD progresses. To assess this further, we undertook transcriptomic and proteomic analysis of 137 pharmacogenes in liver biopsies from a large MASLD cohort. We performed sequencing on RNA from 216 liver biopsies (206 MASLD and 10 controls). Untargeted mass spectrometry proteomics was performed on a 103 biopsy subgroup. Selected RNA sequencing signals were replicated with an additional 187 biopsies. Comparison of advanced MASLD (fibrosis score 3/4) with milder disease (fibrosis score 0-2) by RNA sequencing showed significant alterations in expression of certain phase I, phase II and ABC transporters. For cytochromes P450, CYP2C19 showed the most significant decreased expression (30 % of that in mild disease) but significant decreased expression of other CYPs (including CYP2C8 and CYP2E1) also occurred. CYP2C19 also showed a significant decrease comparing the inflammatory form of MASLD (MASH) with non-MASH biopsies. Findings for CYP2C19 were confirmed in the replication cohort. Proteomics on the original discovery cohort confirmed decreased levels of several CYPs as MASLD advanced but this decrease was greatest for CYP2C19 where levels fell to 40 % control. This decrease may result in decreased CYP2C19 activity that could be problematic for prescription of drugs activated or metabolized by CYP2C19 as MASLD advances. More limited decreases for other P450s suggest fewer issues with non-CYP2C19 drug substrates. Negative correlations at RNA level between CYP2C19 and several cytokine genes provided initial insights into the mechanism underlying decreased expression.

Unlearning and relearning sexuality: a qualitative exploration of The Sex Wrap, a sex education podcast

BACKGROUND

Traditional school-based sexuality education has a myriad of problems with its successful delivery, including access to comprehensive sexuality curricula, access to trained facilitators, and community and parental fears. As an alternative form of sexuality education, The Sex Wrap podcast is released in weekly episodes of about 20-45min, providing listeners with diverse, evidence-based sexual health information.

METHODS

Participants in a larger mixed-methods study evaluating The Sex Wrap were invited to participate in qualitative in-depth interviews to explore their experiences with sexuality education, including The Sex Wrap , and how they relate to information received through the podcast. Seventeen interviews were conducted with listeners of The Sex Wrap , aged 20-25years old.

RESULTS

One core category and three axial codes were identified in the interview data. The core category is: sexuality education is an ongoing process that includes learning and unlearning. The three temporally related axial codes are: (1) experiences with formal and informal sexuality education (mostly negative) drove participants to seek more information about sex, (2) participants use The Sex Wrap as a way of exploring and personalising information about sexuality, and (3) participants equipped with comprehensive sexuality education are empowered to educate their peers.

CONCLUSIONS

This study suggests that podcast-based interventions, such as The Sex Wrap , can play a key role in young people's process of sexuality education and should be considered for incorporation into other forms of sex education.

Use of Ultrasound-Guided Tendon Fenestration and Injection Procedures for Treatment of Tendinosis

Introduction

Overuse injuries such as tendinosis are a common complaint at sports medicine clinics. When conservative management for tendinosis has failed, ultrasound-guided tendon fenestration and injection procedures, such as dry needling, needling tenotomy, autologous whole blood injections, and prolotherapy, can be utilized for treatment. This study examined the effectiveness of these procedures for pain improvement and ability to return to activity for patients with tendinosis.

Methods

This study involved a chart review of patients 15 years or older who underwent at least one treatment for tendinosis at a sports medicine clinic between January 1, 2014 and April 17, 2019. Eligible patients had at least one of the following procedures: 1) percutaneous dry needling, 2) percutaneous needle tenotomy, 3) autologous whole blood injection, and/or 4) prolotherapy. A Current Procedural Terminology (CPT) code query was used to screen patient charts for study inclusion.

Results

In total, 680 patients' data were reviewed, and 343 patients met inclusion criteria. Patients underwent a total of 598 unique procedures. Dry needling represented most procedures (62.8%, n = 375). Most patients reported diminished pain at follow up (73.0%, n = 268). Prolotherapy had the highest percentage among the follow up patients reporting diminished pain (81.0%, n = 17). Most patients were able to return to activity at follow-up (47.4%, n = 172). A greater proportion of patients with autologous whole blood injection were able to return to activity (60.7%, n = 85).

Conclusions

Most patients with tendinosis who underwent tendon fenestration or injection procedures reported diminished pain at follow-up. Autologous whole blood injection may be more likely to diminish patient pain and allow return to activity than other procedure types. More research is needed across all anatomical sites to compare the generalized effectiveness of these procedures.

Exploring human papillomavirus vaccination decision making through mother and adolescent dyad interviews

INTRODUCTION

The purpose of our research was to explore how parents and their adolescent children make decisions about the human papillomavirus (HPV) vaccine, and to inform future interventions that aim to facilitate inclusive decision-making processes.

METHOD

Purposive and snowball sampling strategies targeted parents and their adolescent children (ages = 11-13) in a large city in Australia. We conducted separate and joint semistructured interviews in 2013 with six mother-adolescent dyads (50% female adolescents and 50% male). Interviews were analyzed using a grounded theory approach.

RESULTS

Factors that both facilitate and impede decision making emerged, including: background knowledge, values, historical experiences, parenting style, and opinion weights.

DISCUSSION

New interventions, strategies, and tools that are informed by these decision-making factors can be used to aid productive, mutual decision making between parents and adolescents and support adolescent autonomy and self-sufficiency in health decision making. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Tracheostomy in children is associated with neutrophilic airway inflammation

BACKGROUND

Tracheostomies in children are associated with significant morbidity, poor quality of life, excess healthcare costs and excess mortality. The underlying mechanisms facilitating adverse respiratory outcomes in tracheostomised children are poorly understood. We aimed to characterise airway host defence in tracheostomised children using serial molecular analyses.

METHODS

Tracheal aspirates, tracheal cytology brushings and nasal swabs were prospectively collected from children with a tracheostomy and controls. Transcriptomic, proteomic and metabolomic methods were applied to characterise the impact of tracheostomy on host immune response and the airway microbiome.

RESULTS

Children followed up serially from the time of tracheostomy up to 3 months postprocedure (n=9) were studied. A further cohort of children with a long-term tracheostomy were also enrolled (n=24). Controls (n=13) comprised children without a tracheostomy undergoing bronchoscopy. Long-term tracheostomy was associated with airway neutrophilic inflammation, superoxide production and evidence of proteolysis when compared with controls. Reduced airway microbial diversity was established pre-tracheostomy and sustained thereafter.

CONCLUSIONS

Long-term childhood tracheostomy is associated with a inflammatory tracheal phenotype characterised by neutrophilic inflammation and the ongoing presence of potential respiratory pathogens. These findings suggest neutrophil recruitment and activation as potential exploratory targets in seeking to prevent recurrent airway complications in this vulnerable group of patients.

Improving Emergency Medicine Clinician Awareness of Prehospital-Administered Medications

Background/problem: Information transfer between emergency medical services (EMS) and emergency medicine (EM) is at high risk for omissions and errors. EM awareness of prehospital medication administration affects patient management and medication error. In April 2020, we surveyed emergency physicians and emergency department nurse practitioners (NPs) and physician assistants (PAs) regarding the EMS handoff process. Emergency physicians and NPs/PAs endorsed knowing what medications were given, or having received direct verbal handoff from EMS "Often" or "Always" only 20% of the time (n = 71), identifying a need to improve the written handoff process. To assess rates of medication error due to lack of awareness of prehospital administered medications, we measured glucocorticoid redosing in the emergency department (ED) following prehospital dexamethasone administration. In 2020, glucocorticoids were redosed 30% of the time, and our aim was to reduce glucocorticoid redosing to 10% by June 2022. Intervention: We developed and implemented a system innovation where prehospital-administered medications documented in a nursing flowsheet during verbal handoff are pulled directly into the triage note where they are more likely to be reviewed by receiving EM clinicians. Results: Shewhart p-charts were used to evaluate for statistical process change in the process measure of triage note documentation of prehospital medication administration and the outcome measure of glucocorticoid redosing. While the frequency of prehospital dexamethasone administration in the triage note increased, no statistical process change outcome measure of glucocorticoid redosing was observed. However, on repeat survey of EM clinicians in July 2022, 50% now indicated they were aware of prehospital medication administration "Often" or "Always" (n = 61, p = 0.003), 87% maintained they use the triage note as the main source of information regarding prehospital medication administration, and 81% "Always" review the triage note. Conclusions: Innovations that improve accessibility of written documentation of prehospital medication administration were associated with improved subjective assessment of EM clinician awareness of prehospital medications, but not the outcome measure of medication error. Effective error reduction likely requires better system integration between prehospital and EM records.

Did the UK's public health shielding policy protect the clinically extremely vulnerable during the COVID-19 pandemic in Wales? Results of EVITE Immunity, a linked data retrospective study

INTRODUCTION

The UK shielding policy intended to protect people at the highest risk of harm from COVID-19 infection. We aimed to describe intervention effects in Wales at 1 year.

METHODS

Retrospective comparison of linked demographic and clinical data for cohorts comprising people identified for shielding from 23 March to 21 May 2020; and the rest of the population. Health records were extracted with event dates between 23 March 2020 and 22 March 2021 for the comparator cohort and from the date of inclusion until 1 year later for the shielded cohort.

RESULTS

The shielded cohort included 117,415 people, with 3,086,385 in the comparator cohort. The largest clinical categories in the shielded cohort were severe respiratory condition (35.5%), immunosuppressive therapy (25.9%) and cancer (18.6%). People in the shielded cohort were more likely to be female, aged ≥50 years, living in relatively deprived areas, care home residents and frail. The proportion of people tested for COVID-19 was higher in the shielded cohort (odds ratio [OR] 1.616; 95% confidence interval [CI] 1.597-1.637), with lower positivity rate incident rate ratios 0.716 (95% CI 0.697-0.736). The known infection rate was higher in the shielded cohort (5.9% vs 5.7%). People in the shielded cohort were more likely to die (OR 3.683; 95% CI: 3.583-3.786), have a critical care admission (OR 3.339; 95% CI: 3.111-3.583), hospital emergency admission (OR 2.883; 95% CI: 2.837-2.930), emergency department attendance (OR 1.893; 95% CI: 1.867-1.919) and common mental disorder (OR 1.762; 95% CI: 1.735-1.789).

CONCLUSION

Deaths and healthcare utilisation were higher amongst shielded people than the general population, as would be expected in the sicker population. Differences in testing rates, deprivation and pre-existing health are potential confounders; however, lack of clear impact on infection rates raises questions about the success of shielding and indicates that further research is required to fully evaluate this national policy intervention.

Functionalization of polymeric nanoparticles with targeting VNAR ligands using vinyl sulfone conjugation

Actively targeted drug loaded nanoparticles represent an exciting new form of therapeutics for cancer and other diseases. These formulations are complex and in order to realize their ultimate potential, optimization of their preparation is required. In this current study, we have examined the conjugation of a model targeting ligand, conjugated in a site-specific manner using a vinyl sulfone coupling approach. A disulfide-functionalized poly(L-lactide)-b-poly(oligo(ethylene glycol) methacrylate)-stat-(bis(2-methacryloyl)oxyethyl disulfide) (PLA-b-P(OEGMA-stat-DSDMA)) diblock copolymer was synthesized by simultaneous ring opening polymerization (ROP) and reversible addition-fragmentation chain transfer (RAFT) polymerization. Subsequently, the disulfide bonds of the polymer were reduced to thiols and divinyl sulfone was attached to the polymer using thiol-ene chemistry to produce the vinyl sulfone (VS)-functionalized PLA-b-P(OEGMA-stat-VSTEMA) amphiphilic block copolymer. Single emulsion - solvent evaporation was employed using a blend of this polymer with poly(D,L-lactide-co-glycolide) (PLGA) to produce VS-functionalized polymeric nanoparticles. The ability of these novel nanoparticles to attach ligands was then exemplified using a single domain variable new antigen receptor (VNAR) with a free carboxyl terminal cysteine residue. The resulting VNAR-functionalized nanoparticles were found to maintain specific affinity to their cognate antigen (DLL4) for at least 72 h at 4 °C. The simplicity of the degradable amphiphilic block copolymer synthesis and the efficiency of VNAR conjugation to the VS-functionalized nanoparticles show the potential of this platform for therapeutic development.

Retinal pigment epithelium extracellular vesicles are potent inducers of age-related macular degeneration disease phenotype in the outer retina

Age-related macular degeneration (AMD) is a leading cause of blindness. Vision loss is caused by the retinal pigment epithelium (RPE) and photoreceptors atrophy and/or retinal and choroidal angiogenesis. Here we use AMD patient-specific RPE cells with the Complement Factor H Y402H high-risk polymorphism to perform a comprehensive analysis of extracellular vesicles (EVs), their cargo and role in disease pathology. We show that AMD RPE is characterised by enhanced polarised EV secretion. Multi-omics analyses demonstrate that AMD RPE EVs carry RNA, proteins and lipids, which mediate key AMD features including oxidative stress, cytoskeletal dysfunction, angiogenesis and drusen accumulation. Moreover, AMD RPE EVs induce amyloid fibril formation, revealing their role in drusen formation. We demonstrate that exposure of control RPE to AMD RPE apical EVs leads to the acquisition of AMD features such as stress vacuoles, cytoskeletal destabilization and abnormalities in the morphology of the nucleus. Retinal organoid treatment with apical AMD RPE EVs leads to disrupted neuroepithelium and the appearance of cytoprotective alpha B crystallin immunopositive cells, with some co-expressing retinal progenitor cell markers Pax6/Vsx2, suggesting injury-induced regenerative pathways activation. These findings indicate that AMD RPE EVs are potent inducers of AMD phenotype in the neighbouring RPE and retinal cells.

Realist analysis of whether emergency departments with primary care services generate 'provider-induced demand'

Background

It is not known whether emergency departments (EDs) with primary care services influence demand for non-urgent care (‘provider-induced demand’). We proposed that distinct primary care services in EDs encourages primary care demand, whereas primary care integrated within EDs may be less likely to cause additional demand. We aimed to explore this and explain contexts (C), mechanisms (M) and outcomes (O) influencing demand.

Methods

We used realist evaluation methodology and observed ED service delivery. Twenty-four patients and 106 staff members (including Clinical Directors and General Practitioners) were interviewed at 13 EDs in England and Wales (240 hours of observations across 30 days). Field notes from observations and interviews were analysed by creating ‘CMO’ configurations to develop and refine theories relating to drivers of demand.

Results

EDs with distinct primary care services were perceived to attract demand for primary care because services were visible, known or enabled direct access to health care services. Other influencing factors included patients’ experiences of accessing primary care, community care capacity, service design and population characteristics.

Conclusions

Patient, local-system and wider-system factors can contribute to additional demand at EDs that include primary care services. Our findings can inform service providers and policymakers in developing strategies to limit the effect of potential influences on additional demand when demand exceeds capacity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00709-2.

A fast and sensitive absolute quantification assay for the detection of SARS-CoV-2 peptides using parallel reaction monitoring mass spectrometry

The on-going SARS-CoV-2 (COVID-19) pandemic has called for an urgent need for rapid and high-throughput methods for mass testing and early detection, prevention as well as surveillance of the disease. We investigated whether targeted parallel reaction monitoring (PRM) quantification using high resolution Orbitrap instruments can provide the sensitivity and speed required for a high-throughput method that could be used for clinical diagnosis. We developed a high-throughput and sensitive PRM-MS assay that enables absolute quantification of SARS-CoV-2 nucleocapsid peptides with short turn-around times by using isotopically labelled synthetic SARS-CoV-2 concatenated peptides. We established a fast and high-throughput S-trap-based sample preparation method and utilized it for testing 25 positive and 25 negative heat-inactivated clinical nasopharyngeal swab samples for SARS-CoV-2 detection. The method was able to differentiate between negative and some of the positive patients with high viral load. Moreover, based on the absolute quantification calculations, our data show that patients with Ct values as low as 17.8 correspond to NCAP protein amounts of around 7.5 pmol in swab samples. The present high-throughput method could potentially be utilized in specialized clinics as an alternative tool for detection of SARS-CoV-2 but will require enrichment of viral proteins in order to compete with RT-qPCR.

Nuclear alpha-synuclein is present in the human brain and is modified in dementia with Lewy bodies

Dementia with Lewy bodies (DLB) is pathologically defined by the cytoplasmic accumulation of alpha-synuclein (aSyn) within neurons in the brain. Predominately pre-synaptic, aSyn has been reported in various subcellular compartments in experimental models. Indeed, nuclear alpha-synuclein (aSyn^Nuc) is evident in many models, the dysregulation of which is associated with altered DNA integrity, transcription and nuclear homeostasis. However, the presence of aSyn^Nuc in human brain cells remains controversial, yet the determination of human brain aSyn^Nuc and its pathological modification is essential for understanding synucleinopathies. Here, using a multi-disciplinary approach employing immunohistochemistry, immunoblot, and mass-spectrometry (MS), we confirm aSyn^Nuc in post-mortem brain tissue obtained from DLB and control cases. Highly dependent on antigen retrieval methods, in optimal conditions, intra-nuclear pan and phospho-S129 positive aSyn puncta were observed in cortical neurons and non-neuronal cells in fixed brain sections and in isolated nuclear preparations in all cases examined. Furthermore, an increase in nuclear phospho-S129 positive aSyn immunoreactivity was apparent in DLB cases compared to controls, in both neuronal and non-neuronal cell types. Our initial histological investigations identified that aSyn^Nuc is affected by epitope unmasking methods but present under optimal conditions, and this presence was confirmed by isolation of nuclei and a combined approach of immunoblotting and mass spectrometry, where aSyn^Nuc was approximately tenfold less abundant in the nucleus than cytoplasm. Notably, direct comparison of DLB cases to aged controls identified increased pS129 and higher molecular weight species in the nuclei of DLB cases, suggesting putative pathogenic modifications to aSyn^Nuc in DLB. In summary, using multiple approaches we provide several lines of evidence supporting the presence of aSyn^Nuc in autoptic human brain tissue and, notably, that it is subject to putative pathogenic modifications in DLB that may contribute to the disease phenotype.

P295 Establishing adenosine deaminase 2 activity in a cohort of patients with large vessel vasculitis

Background/Aims

Deficiency of adenosine deaminase 2 (DADA2) leads to a broad phenotype; some patients develope vasculitis and strokes, and others have predominantly haematological manifestations. Small, medium and large vessel vasculitis has been described. In contrast, plasma ADA2 activity is elevated in inflammatory conditions including systemic lupus erythematosus and systemic juvenile idiopathic arthritis with macrophage activation syndrome. The role of ADA2 and how its deficiency associates with the vasculitides is not well understood. Using a well-characterised large vessel vasculitis cohort, we sought to establish the potential role of ADA2 activity.

Methods

ADA2 activity was measured in adults with Takayasu arteritis (TA), large vessel giant cell arteritis (LV-GCA), intracranial vasculitis (IV) and healthy control (HC) subjects using a coupled spectrophotometric assay. Plasma from 11 patients with genotyped DADA2 and 10 patients heterozygous for pathogenic variants in ADA2 were used to define thresholds for deficiency and carrier status respectively (DADA2 activity 0 - 0.90 U/L, ADA2 carrier activity 2.02 - 10.62 U/L). Activity levels above the upper limit of normal (ULN) were defined as > 99th percentile of the HC activity (30.3U/L). To assess potential associations with TA disease status, ADA2 was measured prospectively in matched active and remission samples. TA disease activity was determined as active, grumbling or stable using clinical and radiological features, physician impression, CRP, ESR and Indian Takayasu clinical Activity Score (ITAS).

Results

No patients had deficient ADA2 activity while 7 subjects had activity within the carrier range (1 HC [1.9%], 5 TA [3.7%], 1 LV-GCA [2.3%]). Compared to HC levels (17.43 [14.11 - 20.78] U/L), activity in the TA group was significantly increased (TA 19.68U/L, p = 0.0061), while LV-GCA and IV were not significantly different. In 20 cases, activity exceeded the ULN; 16 TA (11.9%, p = 0.044; 4 active, 2 grumbling, 10 stable) and 4 LV-GCA (9.1%, ns). In TA, there was a positive correlation between ADA2 activity and ESR (Spearman R = 0.2863, p = 0.0009) but not with CRP or ITAS score. Subgroup analysis revealed ADA2 activity was most prominently elevated in the stable group relative to HCs (TA stable 20.54 U/L [8.08 - 48.66], median +17.8%, p = 0.0006), but not with active or grumbling disease. Consistent with this, prospective analysis demonstrated a significant increase in ADA2 activity in remission vs active disease (p = 0.024), with activity increasing in 18 (62%) patients achieving remission.

Conclusion

There were no cases of ADA2 deficiency in this cohort. Consistent with other inflammatory conditions, ADA2 activity was elevated in TA compared to HC subjects. Surprisingly, increased ADA2 activity was linked to stable TA in both cross-sectional and prospective analyses. This may suggest a potential role of ADA2 enzyme activity in vascular repair and regrowth - possibly tying in with known elevated levels of ADA2 activity in growing children.

Disclosure

A. Porter: None. R. Maughan: None. C. Pericleous: None. A. Kiprianos: None. H. Jee: None. P. Lee: None. T. Youngstein: None. J. Mason: None.

Semiconducting silicon-phosphorous frameworks for caging exotic polycations

A series of novel semiconductors AAe6Si12P20X (A = Na, K, Rb, Cs; Ae = Sr, Ba; X = Cl, Br, I) is reported. Their crystal structures feature tetrahedral Si-P framework...

Worse outcomes of ACS patients without versus with traditional cardiovascular risk factors

Introduction

Approximately 5–15% patients presenting with acute coronary syndrome were found to have no traditional cardiovascular risk factors (RFs). Data regarding the determinants, management and outcomes of these patients are scarce.

Purpose

To evaluate the management, outcomes and time dependent changes of ACS patients without RFs.

Methods

Evaluation of clinical characteristics, management strategies, and outcomes as well as time dependent changes (by 3 time periods: early [2000–2006], mid [2008–2013], and late [2016–2018]) of ACS patients without RFs (diabetes mellitus, hypertension, dyslipidemia, family history of IHD and current or past smoking) or known coronary artery disease, enrolled in the biennial ACS Israeli Surveys (ACSIS) between 2000 and 2018. We compared ACS patients without RFs (RF−) to those ≥1 RFs (RF+).

Results

Overall 583 out of 10,324 (5.6%) eligible ACS patients did not have any RFs (median age 64 [IQR 52–77], 25% females]. The RF− group were older, more educated, with lower BMI and prevalence of another cardiovascular comorbidity and chronic kidney disease compared with the RF+ group. The in-hospital PCI rates were lower among the RF− vs. the RF+ group (55% vs. 66%, respectively p<0.001). Furthermore, lower rate of guideline-recommended medical therapy upon discharge were prescribed in the RF− vs. the RF+ group. The rate of in-hospital complications was greater in the RF− vs. RF+ group (31.4% vs. 26.1%, respectively p=0.006). The rates of 30-day major adverse cardiac events (MACE) were significantly higher among patients with RF− vs. RF+ (18.1% vs.12.8%, respectively p<0.001). Similarly, the rates of 30-day and 1-year all-cause mortality (figure 1) were higher among patients with RF− vs. RF+ (8.7% vs. 4.2%, p<0.001 and 11.9% vs. 7.7% p<0.001 respectively). A trend of decline in the rate of MACE was observed between the early and the late study period in the RF− group (22% vs. 10.7% p=0.002 respectively). One-year mortality did not decrease significantly in the RF− group during the study periods (13.6% vs. 10% early vs. late period respectively p=0.16).

Conclusions

ACS patients without traditional cardiovascular risk factors comprise a unique group with reduced prevalence of comorbidities yet significantly worse short-and long-term outcomes. Additional research to identify unique risk factors and targets for interventions to improve outcomes of this group of patients is warranted.

Funding Acknowledgement

Type of funding sources: None.

Diacetyl and Other Ketones in e-Cigarette Aerosols: Some Important Sources and Contributing Factors

Background: Concerns over the presence of the diketones 2,4 butanedione (DA) and 2,3 pentanedione (AP) in e-cigarettes arise from their potential to cause respiratory diseases. Their presence in e-liquids is a primary source, but they may potentially be generated by glycerol (VG) and propylene glycol (PG) when heated to produce aerosols. Factors leading to the presence of AP, DA and acetoin (AC) in e-cigarette aerosols were investigated. We quantified direct transfer from e-liquids, examined thermal degradation of major e-liquid constituents VG, PG and 1,3 propanediol (1,3 PD) and the potential for AC, AP and DA production from sugars and flavor additives when heated in e-cigarettes.

Method: Transfers of AC, AP and DA from e-liquids to e-cigarette aerosols were quantified by comparing aerosol concentrations to e-liquid concentrations. Thermal generation from VG, PG or 1,3 PD e-liquids was investigated by measuring AC, AP and DA emissions as a function of temperature in an e-cigarette. Thermal generation of AC, AP and DA from sugars was examined by aerosolising e-liquids containing sucrose, fructose or glucose in an e-cigarette. Pyrolytic formation of AP and DA from a range of common flavors was assessed using flash pyrolysis techniques.

Results: AC transfer efficiency was >90%, while AP and DA were transferred less efficiently (65%) indicating losses during aerosolisation. Quantifiable levels of DA were generated from VG and PG, and to a lesser extent 1,3 PD at coil temperatures >300°C. Above 350°C AP was generated from VG and 1,3 PD but not PG. AC was not generated from major constituents, although low levels were generated by thermal reduction of DA. Aerosols from e-liquids containing sucrose contained quantifiable (>6 ng/puff) levels of DA at all sucrose concentrations tested, with DA emissions increasing with increasing device power and concentration. 1% glucose, fructose or sucrose e-liquids gave comparable DA emissions. Furanose ring compounds also generate DA and AP when heated to 250°C.

Conclusions: In addition to less than quantitative direct transfer from the e-liquid, DA and AP can be present in the e-cigarette aerosol due to thermal decomposition reactions of glycols, sugars and furanonse ring flavors under e-cigarette operating conditions.

The Chemical Complexity of e-Cigarette Aerosols Compared With the Smoke From a Tobacco Burning Cigarette

Background: As e-cigarette popularity has increased, there is growing evidence to suggest that while they are highly likely to be considerably less harmful than cigarettes, their use is not free of risk to the user. There is therefore an ongoing need to characterise the chemical composition of e-cigarette aerosols, as a starting point in characterising risks associated with their use. This study examined the chemical complexity of aerosols generated by an e-cigarette containing one unflavored and three flavored e-liquids. A combination of targeted and untargeted chemical analysis approaches was used to examine the number of compounds comprising the aerosol. Contributions of e-liquid flavors to aerosol complexity were investigated, and the sources of other aerosol constituents sought. Emissions of 98 aerosol toxicants were quantified and compared to those in smoke from a reference tobacco cigarette generated under two different smoking regimes. Results: Combined untargeted and targeted aerosol analyses identified between 94 and 139 compounds in the flavored aerosols, compared with an estimated 72-79 in the unflavored aerosol. This is significantly less complex (by 1-2 orders of magnitude) than the reported composition of cigarette smoke. Combining both types of analysis identified 5-12 compounds over and above those found by untargeted analysis alone. Gravimetrically, 89-99% of the e-cigarette aerosol composition was composed of glycerol, propylene glycol, water and nicotine, and around 3% comprised other, more minor, constituents. Comparable data for the Ky3R4F reference tobacco cigarette pointed to 58-76% of cigarette smoke "tar" being composed of minor constituents. Levels of the targeted toxicants in the e-cigarette aerosols were significantly lower than those in cigarette smoke, with 68.5->99% reductions under ISO 3308 puffing conditions and 88.4->99% reductions under ISO 20778 (intense) conditions; reductions against the WHO TobReg 9 priority list were around 99%. Conclusion: These analyses showed that the e-cigarette aerosols contain fewer compounds and at significantly lower concentrations than cigarette smoke. The chemical diversity of an e-cigarette aerosol is strongly impacted by the choice of e-liquid ingredients.

Improving Discharge Efficiency and Charge Containment on a Pediatric Acute Care Cardiology Unit

BACKGROUND

Hospital discharge delays can negatively affect patient flow and hospital charges. Our primary aim was to increase the percentage of acute care cardiology patients discharged within 2 hours of meeting standardized medically ready (MedR) discharge criteria. Secondary aims were to reduce length of stay (LOS) and lower hospital charges.

METHODS

A multidisciplinary team used quality improvement methods to implement and study MedR discharge criteria in our hospital electronic health record. The criteria were ordered on admission and modified on daily rounds. Bedside nurses documented the time when all MedR discharge criteria were met. A statistical process control chart measured interventions over time. Discharge before noon and 30-day readmissions were also tracked. Average LOS was examined, comparing the first 6 months of the intervention period to the last 6 months. Inpatient charges were reviewed for patients with >2 hours MedR discharge delay.

RESULTS

The mean percentage of patients discharged within 2 hours of meeting MedR discharge criteria increased from 20% to 78% over 22 months, with more patients discharged before noon (19%-32%). Median LOS decreased from 11 days (interquartile range: 6-21) to 10 days (interquartile range: 5-19) (P = .047), whereas 30-day readmission remained stable at 16.3%. A total of 265 delayed MedR discharges beyond 2 hours occurred. The sum of inpatient charges from care provided after meeting MedR criteria was $332 038 (average $1253 per delayed discharge).

CONCLUSIONS

Discharge timeliness in pediatric acute care cardiology patients can be improved by standardizing medical discharge criteria, which may shorten LOS and decrease medical charges.

Robust optimization of SWATH-MS workflow for human blood serum proteome analysis using a quality by design approach

Background

It is not enough to optimize proteomics assays. It is critical those assays are robust to operating conditions. Without robust assays, proteomic biomarkers are unlikely to translate readily into the clinic. This study outlines a structured approach to the identification of a robust operating window for proteomics assays and applies that method to Sequential Window Acquisition of all Theoretical Spectra Mass Spectroscopy (SWATH-MS).

Methods

We used a sequential quality by design approach exploiting a fractional screening design to first identify critical SWATH-MS parameters, then using response surface methods to identify a robust operating window with good reproducibility, before validating those settings in a separate validation study.

Results

The screening experiment identified two critical SWATH-MS parameters. We modelled the number of proteins and reproducibility as a function of those parameters identifying an operating window permitting robust maximization of the number of proteins quantified in human serum. In a separate validation study, these settings were shown to give good proteome-wide coverage and high quantification reproducibility.

Conclusions

Using design of experiments permits identification of a robust operating window for SWATH-MS. The method gives a good understanding of proteomics assays and greater data-driven confidence in SWATH-MS performance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12014-021-09323-z.

Abstract LB096: Development of a next generation ROR1 targeting Protein Drug Conjugate (PDC)

The receptor tyrosine kinase ROR1 is a cell-surface onco-fetal protein expressed on a variety of solid tumours and haematological malignancies, which has limited expression on normal adult tissue. A functional role for ROR1 in tumorigenesis and disease progression has been demonstrated in a number of cancer indications. ROR1 is also involved in mediating drug resistance (for example to chemotherapies as well as to the targeted therapy T-DM1), activation of YAP/TAZ signalling and up-regulation of BMI-1. Consistent with this pleiotropic role, increased ROR1 expression correlates with poor clinical outcome in a number of cancer indications including triple negative breast cancer, ovarian cancer and lung adenocarcinoma. As a result, ROR1 has emerged as a highly attractive target for cancer therapy, and its limited expression on normal tissues make it particularly well suited for antibody and protein-drug conjugate (ADC and PDC) approaches. This has been fuelled by recent Phase I clinical data for the ROR1 ADC, VLS-101, in patients with advanced MCL and DLBCL and the potential of ROR1-targeting drug conjugates for the treatment of ROR1+ solid tumour indications. We report the development of novel, differentiated protein drug conjugates targeting ROR1 based on Variable New Antigen Receptor domains (VNARs). VNARs are the smallest antigen binding domain in the vertebrate kingdom and their small size and modular nature offer a number of potential benefits over full-length antibodies as the payload delivery vehicle in PDC approaches. We have applied our VNAR drug discovery platform, which includes novel linker-toxin combinations, to the development of potent and selective ROR1 targeting PDCs that are highly efficacious in ROR1+ patient derived xenograft (PDX) models of cancer. Homogenous drug conjugates were generated by Fc-fusion reformatting of ROR1 binding VNARs, and novel cleavable linker-toxin conjugates attached in a site-specific fashion. By exploiting proprietary crystal-structure information, a structure-guided approach was used to deliver VNAR-hFc drug conjugates with optimised drug-like properties. Though iterations of this approach, lead PDCs have been developed which cause potent ROR1-dependant killing of selected cancer cell-lines and elicit complete and durable regressions in PDX models of TNBC at doses that are very well tolerated. As the lead Candidate progresses toward clinical development, we anticipate that this excellent pre-clinical profile will translate to a highly differentiated product for the treatment of both solid tumor and haematological cancer indications. In addition, the flexible formatting accessible using our drug discovery platform has allowed us to readily access ROR1-targeting bi-paratopic and bi-specific therapeutic formats.

Citation Format: Graham Cotton, Jennifer Thom, Paul Trumper, Stacey Bell, Mark Wappett, Caroline Barelle, Marina Kovaleva, Andrew Porter, Estelle McLean, Chiara Saladino, Aidan McCann, Aaron Cranston, Tim Harrison. Development of a next generation ROR1 targeting Protein Drug Conjugate (PDC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr LB096.

Ultraviolet light-induced collagen degradation inhibits melanoma invasion

Ultraviolet radiation (UVR) damages the dermis and fibroblasts; and increases melanoma incidence. Fibroblasts and their matrix contribute to cancer, so we studied how UVR modifies dermal fibroblast function, the extracellular matrix (ECM) and melanoma invasion. We confirmed UVR-damaged fibroblasts persistently upregulate collagen-cleaving matrix metalloprotein-1 (MMP1) expression, reducing local collagen (COL1A1), and COL1A1 degradation by MMP1 decreased melanoma invasion. Conversely, inhibiting ECM degradation and MMP1 expression restored melanoma invasion. Primary cutaneous melanomas of aged humans show more cancer cells invade as single cells at the invasive front of melanomas expressing and depositing more collagen, and collagen and single melanoma cell invasion are robust predictors of poor melanoma-specific survival. Thus, primary melanomas arising over collagen-degraded skin are less invasive, and reduced invasion improves survival. However, melanoma-associated fibroblasts can restore invasion by increasing collagen synthesis. Finally, high COL1A1 gene expression is a biomarker of poor outcome across a range of primary cancers.

Treatment of metastatic placental site trophoblastic tumor with surgery, chemotherapy, immunotherapy and coil embolization of multiple pulmonary arteriovenous fistulate

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Placental site trophoblastic tumor can be resistant to chemotherapy.

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Multidisciplinary care is required for management of advanced disease.

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Increased PD-L1 expression can help guide use of immunotherapies.

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Complete responses are possible with aggressive multidisciplinary management.

Placental Site Trophoblastic Tumor (PSTT) is a rare malignancy that often presents with extensive disease and can be resistant to traditional treatments. We present the case of a woman with stage IV PSTT who was initially managed with neoadjuvant chemotherapy followed by tumor debulking. Adjuvant therapy was guided by further pathologic analysis that revealed high levels of staining for PD-L1 as well as the presence of tumor infiltrating lymphocytes (TILs). Subsequently, the patient was treated with traditional chemotherapy with the EP/EMA regimen with the addition of pembrolizumab. The patient’s treatment course was complicated by the development of pulmonary arteriovenous malformations, autoimmune thyroiditis thought to be secondary to immunotherapy, and significant tinnitus secondary to platinum agents. Currently the patient is in follow up and remains in a complete remission.

Posts, Likes, Shares, and DMs: A Qualitative Exploration of How Social Media Is Related to Sexual Agency in Young People

It is well documented that social interactions have a crucial impact on all aspects of personal development for adolescents, however few studies have documented how social interactions affect a young person's sense of sexual agency. The aim of the current qualitative study was to examine young people's perceptions of their own sexual agency in relation to their social media attitudes and behaviors. Participants (n = 31) were recruited from a nonprofit organization and asked to complete a one-hour in-depth interview and a demographic survey. Using an inductive method, involving constant comparison, we identified four overarching themes: (a) Participants utilize different social media platforms for distinct purposes and are cognizant of each audience; (b) Based on past experiences, participants have negotiated and created their own rules of engagement for online behavior; (c) Participants have different expectations about how others should act online versus how they act in relation to flirty or sexual messages; (d) Participants were concerned about the authenticity of online identities and are aware of vulnerability in online interactions. Our results highlight the need for sexual health researchers to observe social network etiquette closely through the lens of autonomy and agency.

Echocardiographic Findings Associated with Transplantation-Free Survival and Left Ventricular Systolic Function at Midterm Follow-Up after Ross Procedure in Infants with Critical Aortic Stenosis

BACKGROUND

The Ross operation is an important option for children with critical aortic stenosis with residual disease, but operation in infancy is associated with significant morbidity and mortality. The aim of this study was to evaluate echocardiographic correlates of transplantation-free survival, reintervention, and left ventricular (LV) function in midterm follow-up.

METHODS

This retrospective, single-center study included all infants with critical aortic stenosis who underwent Ross by 1 year of age from January 2000 to September 2018. Serial echocardiograms were analyzed for LV ejection fraction (LVEF) and systolic and diastolic longitudinal strain. The primary outcome was mortality or transplantation; secondary outcomes were reintervention and abnormal LVEF (≤55%).

RESULTS

Among 40 infants (30 male [75%]; median age at Ross, 51 days) with median follow-up duration of 3.3 years (interquartile range, 1.0-9.4 years), the primary outcome was met in 11 (28%). Rates of transplantation-free survival was 79%, 77%, and 69% at 1, 5, and 10 years after Ross. Predictors of transplantation or death included neonatal surgery, cross-clamp time, and preoperative left atrial dilatation and lower LVEF. Median freedom from reintervention was 7.1 years after Ross, with no identified associations. LV longitudinal strain improved 1 year after Ross (-21.1 ± 3.8% vs -17.4 ± 5.1%, P = .02), although LVEF did not reach significance. Lower LVEF at 1 year was related to pre-Ross left atrial dilatation (P = .02), abnormal LVEF (P = .04), and lower early diastolic longitudinal strain rate (P = .03). LVEF remained stable 3 years after Ross.

CONCLUSIONS

Both transplantation-free survival and normalization of LV function after Ross in infancy are associated with preoperative LV systolic and diastolic measures, highlighting the prognostic value of echocardiography in this population. Further data are necessary in a larger, multicenter cohort to allow more precise risk stratification.

Mechanisms and consequences of dysregulation of the Tiam family of Rac activators in disease

The Tiam family proteins - Tiam1 and Tiam2/STEF - are Rac1-specific Guanine Nucleotide Exchange Factors (GEFs) with important functions in epithelial, neuronal, immune and other cell types. Tiam GEFs regulate cellular migration, proliferation and survival, mainly through activating and directing Rac1 signalling. Dysregulation of the Tiam GEFs is significantly associated with human diseases including cancer, immunological and neurological disorders. Uncovering the mechanisms and consequences of dysregulation is therefore imperative to improving the diagnosis and treatment of diseases. Here we compare and contrast the subcellular localisation and function of Tiam1 and Tiam2/STEF, and review the evidence for their dysregulation in disease.

Psychometric Testing of an Instrument to Measure Cultural Humility

INTRODUCTION

As the world increasingly diversifies, there is a need to prepare nurses to care for individuals, families, and communities with contrasting lifeways. Although education about cultural humility is needed, there is no way to measure the construct. The purpose of this study was to develop, validate, and psychometrically test an instrument designed to measure cultural humility.

METHOD

The lead author extracted key constructs from previous research to develop the instrument. Six expert faculty validated the instrument. An exploratory factor analysis was conducted with 322 health professional students.

RESULTS

All items had an item content validity index of 0.83 or higher. The factor analysis yielded three factors: context for difference in perspective, self-attributes, and outcomes of cultural humility. The instrument was determined reliable (Cronbach's alpha = .85).

DISCUSSION

Foronda's Cultural Humility Scale may help researchers better operationalize and evaluate achievement of cultural humility.

Abstract 538: Exploiting the properties of VNAR domains for the development of novel efficacious protein drug conjugates targeting the oncofetal protein ROR1

The onco-embryonic receptor tyrosine kinase ROR1is a cell-surface protein expressed on a broad range of solid tumours and haematological malignancies but is largely absent from normal adult tissue. Increased ROR1 expression correlates with poor clinical outcome in a number of cancer indications, consistent with its functional role in tumorigenesis and disease progression. In addition, elevated expression has been associated with increased metastatic potential and drug resistance in breast cancer and non-small cell lung cancer. The oncofetal expression pattern of ROR1 coupled with its role in cancer pathology and therapy resistance makes it a highly attractive target for a protein-drug conjugate approach. Shark-derived Variable New Antigen Receptor domains (VNARs) are the smallest antigen binding domain in the vertebrate kingdom. We have developed a platform to enable VNAR-based drug discovery and used it to identify a series of highly potent protein-drug conjugates that target ROR1. Through screening VNAR phage libraries, high affinity ROR1 specific binders were isolated that bind distinct regions of the extracellular domain and showed species cross reactivity (mouse, rat and human). By exploiting the modular nature of the VNAR domains, multiple different therapeutic formats have been engineered, including multimeric binders and Fc fusion proteins. Subsequent site-specific attachment of highly potent toxins yielded homogeneous VNAR-based drug conjugates which demonstrated potent ROR1-dependant killing of selected cancer cell-lines in vitro with IC50 values in the picomolar range. In a series of in vivo studies, VNAR-hFc fusions conjugated with novel linker payloads were well tolerated in mice and showed significant anti-tumor activity in mouse xenograft models of cancer, including complete and sustained tumour regressions in a patient-derived xenograft (PDX) model of triple negative breast cancer. Lead VNAR-hFc conjugates have been successfully ‘humanized' guided by de novo structural biology. These engineered VNAR-hFc drug conjugates represent exciting new candidates for the treatment of a variety of both solid tumor and haematological cancer indications. Additionally, bi-paratopic and bi-specific ROR1 binders have been generated which fully leverage the modular design of VNAR-based therapeutics. These provide second generation drug conjugates which can be tailored to specific additional therapeutic applications, further extending the applicability of this approach.

Citation Format: Graham Cotton, Jennifer Thom, Paul Trumper, Andrei Kamenski, Stacey Bell, Mark Wappett, Caroline Barelle, Marina Kovaleva, Alicia Campion, Elisa Persiani, Andrew Porter, Estelle McLean, Aidan McCann, Chiara Saladino, Aaron Cranston, Tim Harrison. Exploiting the properties of VNAR domains for the development of novel efficacious protein drug conjugates targeting the oncofetal protein ROR1 [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 538.

Anti-DLL4 VNAR targeted nanoparticles for targeting of both tumour and tumour associated vasculature

Whilst there is an extensive body of preclinical nanomedicine research, translation to clinical settings has been slow. Here we present a novel approach to the targeted nanoparticle (NP) concept: utilizing both a novel targeting ligand, VNAR (Variable New Antigen Receptor), a shark-derived single chain binding domain, and an under-investigated target in delta-like ligand 4 (DLL4). We describe the development of an anti-DLL4 VNAR and the site-specific conjugation of this to poly(lactic-co-glycolic) acid PEGylated NPs using surface maleimide functional groups. These nanoconjugates were shown to specifically bind DLL4 with high affinity and were preferentially internalized by DLL4-expressing pancreatic cancer cell lines and endothelial cells. Furthermore, a distinct anti-angiogenic effect endowed by the anti-DLL4 VNAR was evident in in vitro tubulogenic assays. Taken together these findings highlight the potential of anti-DLL4 targeted polymeric NPs as a novel therapeutic approach in pancreatic cancer.

Collegiate Athletes’ Perceptions of Osteopathic Manipulative Treatment

Introduction. Many published studies have examined the effects of osteopathic manipulative treatment (OMT), but none has evaluated its role in treating collegiate athletes. The authors examined collegiate athletes’ perception of OMT. Methods. A cross-sectional survey of a convenience sample of 592 collegiate athletes was conducted from two universities in the midwestern United States during August-September 2019. The athletes completed a 12-item survey during pre-participation physical evaluations at their respective institutions. Main outcome measures included pain, need for pain medication, stress and anxiety associated with injuries, and overall satisfaction with the OMT in recovery and return to sports. Fisher’s exact test was used to evaluate association between the variables. Results. The participation rate was 80.6% (477/592). Slightly fewer than 7% (31/477) of the athletes were familiar with OMT. Eighteen of the 31 athletes (58.1%) had received osteopathic manipulation as part of a treatment plan for injury. Of these athletes, 94.4% (17/18) reported a decreased need for pain medication and 83.3% (15/18) had reduced stress and anxiety related to their injury. One in three of them expressed interest in receiving osteopathic manipulation as a treatment option for an injury. The athletes reported general satisfaction with OMT in their recovery and return to sports. Conclusion. The findings demonstrated the interest and benefits of OMT among collegiate athletes. This evidence supported previous findings about perceived efficacy of OMT in treating patients regardless of injury and diagnosis. Future studies need to establish causal relationship among OMT, stress and anxiety, pain, and use of pain medications.

AB1023 CARDIAC MRI IN HYPERFERRITINAEMIC DISEASE STATES REVEALS MYOCARDIAL INFLAMMATION NOT IDENTIFIED BY ECHOCARDIOGRAPHY

Background:

Acutely unwell adult patients with hyperinflammatory hyperferritinaemic states are typically challenging to diagnose. Case series suggest that cardiac involvement may be common (up to 20%) but the phenotype has not been well characterised1.

The elevation of cardiac biomarkers suggests cardiac involvement, but are non-specific in acute illness. Cardiac MRI (CMR) offers the ability to characterise the myocardium and identify inflammation, and modern motion-corrected sequences now allow the assessment of patients who may struggle to breath-hold in the recovery from acute illness.

Objectives:

We report 3 patients who underwent CMR in the acute phase of illness with raised cardiac biomarkers.

Methods:

Case records of acutely ill patients with hyperferritinaemia from two major London centres were reviewed and cases who had undergone CMR in the acute phase of illness were identified.

Results:

3 cases were identified from a cohort of 22, we report CMR findings from differing aetiologies of hyperferritinaemic states:

Case 1: A female in her 60s presented acutely unwell with fever, swollen joints and salmon pink rash. Ferritin was raised at 50574ug/L (20-300ug/L), troponin I 384ng/L (<34ng/L) and Brain Natriuretic Peptide (BNP) 324ng/L (<159ng/L). Echocardiography was normal. However CMR with T2 mapping revealed several small areas of raised signal consistent with myocardial inflammation. A diagnosis of systemic Adult Onset Stills Disease (AOSD) was made. She received IV methylprednisolone and anakinra with normalisation of cardiac biomarkers.

Case 2: A male in his 20s with known SLE with associated end stage renal failure requiring transplant. He had a previous prolonged admission secondary to HLH. He presented with chest pain and concave shaped ST elevation on ECG. Troponin peak 2168ng/L, BNP 1334ng/L. Peak ferritin 1300ug/l.

He was initiated on colchicine for likely pericarditis. Echocardiography showed a dilated left ventricle and mildly increased wall thickness, but overall systolic function within normal limits.

CMR reported nodular patchy late gadolinium enhancement in the mid inferoseptum and inferior wall associated with areas of raised T2 mapping values. NM cardiac rest gated PET reported abnormal FDG uptake to the myocardium with sites including the apical inferior wall, apical RV insertion point and basal septal/anterior right ventricular walls. Features were deemed in keeping with active myocarditis.

He responded to colchicine with improved troponin, and was discharged with close follow up.

Case 3: A male in his 20s presented with septic shock attributed to meningococcal septicaemia requiring ITU admission. Troponin was elevated at >9000ng/L. Bloods demonstrated raised ferritin and features consistent with HLH were identified.

CMR reported elevated native myocardial T1/T2 signal of the lateral and mid-anterior walls in keeping with myocardial oedema. Pericardium adjacent to the anterolateral wall had elevated T1/T2 signal with hyperenhancement on delayed enhancement imaging. Tissue characterisation was in keeping with an acute myopericarditis process.

In addition to broad spectrum antibiotics to treat his underlying infection, he received therapy for HLH including methylprednisolone, anakinra and IVIG. He subsequently made a good recovery to treatment.

Conclusion:

CMR in acute illness with hyperferritinaemia reveals abnormal tissue characterisation with myocardial inflammation, even when echocardiography is normal. We suggest CMR may be a useful test to expand our understanding of hyperferritinaemic disease states.

References:

[1]M Gerfaud-Valentin et al. Myocarditis in Adult-Onset Still Disease. Medicine (Baltimore) 2014 Oct; 93(17): 280-289

Disclosure of Interests:

None declared

Biologic therapy in supra-aortic Takayasu arteritis can improve symptoms of cerebral ischaemia without surgical intervention

OBJECTIVES

Takayasu arteritis commonly results in severe arterial injury with stenoses, occlusions and occasionally aneurysms. Arterial disease may compromise organ blood flow and result in significant cardiovascular morbidity and premature mortality. Involvement of the supra-aortic arteries is common, and in its most severe form may compromise cerebral blood supply, resulting in signs of cerebral ischaemia including visual impairment, dysphasia, transient hemiparesis, loss of consciousness and stroke. In addition to combination immunosuppression, the management paradigm for symptomatic cerebral ischaemia includes revascularization. The invasive nature of this surgery, the risk of complications and the relatively high rate of re-stenosis is of concern to patients and their physicians alike. The aim of this study was to determine whether combined immunosuppression with early escalation to biologic therapy improved outcomes and reduced the need for high risk surgical intervention.

METHODS

A retrospective review of 145 Takayasu arteritis patients attending Imperial College Healthcare between 2010-2018 was conducted to identify those with cerebral ischaemia secondary to supra-aortic disease and to analyse their treatment and outcomes.

RESULTS

Eight patients (5.5%) were identified. Seven patients received long-term combined immunosuppressive therapy and six were prescribed biologics. The data revealed a higher than expected comprehensive response to therapy, with significant falls in disease activity, the cerebral ischaemia score and the prednisolone dose required, over a median follow-up of 37 months. Serial imaging analysis detected no arterial disease progression after the initiation of optimal therapy. Only one patient required surgical intervention for persistent neurological symptoms.

CONCLUSION

Early use of biologic therapy in those with supra-aortic Takayasu arteritis presenting with cerebral ischaemia may reduce the numbers of patients requiring surgical intervention and improve outcomes.

Case of using mycophenolate in combination with steroids for concurrent macrophage activation syndrome and lupus flare

This report highlights the importance of tailored treatment strategies in severe systemic lupus erythematosus (SLE) flares driving the life-threatening condition, macrophage activation syndrome (MAS). We report the case of a 42-year-old woman with active systemic lupus erythematosus (SLE) who was diagnosed with MAS within 3 days of onset of lethargy, rash, joint pain and significant cytopenias. This early diagnosis meant that her condition was managed with less intensive immunosuppression with only modest doses of steroids and mycophenolate mofetil.

Simultaneous Quantification of Terpenelactones and Flavonol Aglycones in Hydrolyzed Ginkgo biloba Extract by Liquid Chromatography with Inline Ultraviolet and Evaporative Light Scattering Detection

We report here a liquid chromatography (LC) method with inline ultraviolet/evaporative light scattering (UV/ELS) detection for the simultaneous quantification of the terpenelactones and flavonol aglycones in a single sample of hydrolyzed Ginkgo biloba extract (GBE). The sample is hydrolyzed by a rapid and convenient oven heating method for 1 h at 90°C with 10% hydrochloric acid. The 1 h hydrolysis was found to be equivalent to the 2.25 h reflux treatment for dry powder extract, where total flavonol glycosides were 28.4 and 28.1%, respectively. Acceptable precision was achieved for total terpenelactones [relative standard deviation (RSD) = 4.8%] by ELS detection, and total flavonol aglycones (RSD = 2.3%) by UV detection. The analytical range was 1.5 to 7.3% (w/w) for the individual terpenelactones (ELS) and 2.5 to 15.0% (w/w) for the individual glycosides (UV) calculated from the aglycones quercetin, kaempferol, and isorhamnetin. This improved method allows for the first time high throughput sample preparation coupled with the quantification of the predominant compounds generally used for quality control of GBE in a single assay.

Analysis of Flavonol Aglycones and Terpenelactones in Ginkgo biloba Extract: A Comparison of High-Performance Thin-Layer Chromatography and Column High-Performance Liquid Chromatography

Advancements in automated high-performance thin-layer chromatography (HPTLC) have made it feasible to assess its use for the quantitative analysis of marker compounds in botanical preparations. We report here the findings of method comparisons for the terpenelactones and flavonol aglycones by column high-performance liquid chromatography (HPLC) with evaporative light scattering and UV detection, and HPTLC with a scanning densitometer. For the HPTLC assay of terpenelactones, total bilobalide, ginkgolide A, and ginkgolide B consistently achieved &lt;70 of the total determined using HPLC, regardless of variations to postchromatographic derivatization time and temperature. Accuracy testing showed the possibility of a matrix interference. In contrast, a good relationship (95) was determined between HPTLC and HPLC for determination of total flavonol glycosides (calculated from combined quercetin, kaempferol, and isorhamnetin) from an acid-hydrolyzed Ginkgo biloba L. (GBE) sample. The HPTLC flavonol aglycone method also performed well in terms of accuracy (overall average of 96 recovery for the 3 aglycones) and consecutive plate repeatability (overall percent relative standard deviation of 4.4). It is demonstrated that HPTLC can be a time-saving complement to HPLC for routine analysis of the flavonol glycosides in GBE.

A Rapid Cleanup Method for the Isolation and Concentration of Pyrrolizidine Alkaloids in Comfrey Root

Preparations from comfrey (Symphytum officinale and S. x uplandicum) root and leaf contain varying levels of the hepatotoxic pyrrolizidine alkaloids (PAs). Reference compounds for comfrey are not commercially available, and there is currently no rapid extraction or analytical method capable of determining low levels in raw materials or as adulterants in commercially available extracts. A solid-phase extraction (SPE) method was developed using an Ergosil cleanup column that specifically binds the PAs. With this method, powdered comfrey root was extracted by sonication and shaking with basic chloroform. The extract was applied to the cleanup column under vacuum, washed with 2 mL acetone–chloroform (8 + 2, v/v) followed by 2 mL petroleum ether to remove excess chloroform. The column was dried under vacuum, and the PAs were eluted with 2 successive 1 mL aliquots methanol. Percent recoveries of the PAs following Ergosil SPE had an overall average of 96.8%, with RSD of 3.8% over a range of 1.0 to 25.0 g extracted in 100 mL. Average precision of the method (n = 3 over 4 extraction concentrations) gave an overall RSD of 6.0% for the 5 alkaloids, with a range of 0.8% (5 g in 100 mL) to 11.2% (25 g in 100 mL). Recovery optimization testing showed that 1.0 g comfrey root extracted in 100 mL yielded the greatest recovery (% dry weight) of the PAs, with an extraction efficiency and accuracy of 94.2%, and RSD of 1.7% (n = 9). The unique properties of the Ergosil cleanup column provide rapid sample cleanup, volume reduction, and concentration of PAs from comfrey extracts, and allow the eluant to be analyzed directly by traditional chromatographic methods.

Uveitis Therapy With Shark Variable Novel Antigen Receptor Domains Targeting Tumor Necrosis Factor Alpha or Inducible T-Cell Costimulatory Ligand

Purpose

We assess the efficacy of two next-generation biologic therapies in treating experimental autoimmune uveitis.

Methods

Variable binding domains from shark immunoglobulin novel antigen receptors (VNARs) were fused with a mouse IgG2a constant domain (Fc) to generate VNAR-Fc molecules with binding specificity to tumor necrosis factor alpha (TNFα) or inducible T-cell costimulatory ligand (ICOSL). Treatment with VNAR-Fc fusion proteins was compared to treatment with dexamethasone or vehicle in the Lewis rat model of experimental autoimmune uveitis (EAU). Inflammation control was determined by comparing OCT clinical and histologic scores, and aqueous humor protein concentration. The concentration of 27 inflammatory cytokines in the aqueous humor was measured using a multiplex enzyme-linked immunosorbent assay platform.

Results

Administration of S17-Fc significantly decreased clinical, histologic, and aqueous protein levels when compared to vehicle treatment. Inflammation scores and aqueous protein levels in A5-Fc–treated animals were decreased compared to vehicle treatment, but not significantly. The concentration of vascular endothelial growth factor (VEGF), regulated on activation, normal T cell expressed and secreted (RANTES), macrophage inflammatory protein 1 alpha (MIP-1α), interleukin (IL)-1β, LPS-induced CXC chemokine (LIX), monocyte chemoattractant protein-1 (MCP-1), and interferon (IFN)-γ were significantly decreased in the eyes of animals treated with dexamethasone. VNAR treatment demonstrated a trend towards decreased cytokine concentrations, but only VEGF and RANTES were significantly decreased by S17-Fc.

Conclusions

Treatment with the anti-TNFα VNAR S17-Fc ameliorates EAU as effectively as treatment with corticosteroids.

Translational Relevance

VNAR-Fc molecules are a next-generation therapeutic biologic that overcome the limitations of classical biologic monoclonal antibodies, such as complex structure, large size, and limited tissue penetration. This is a novel drug modality that could result in the development of new therapy options for patients with noninfectious uveitis.

Using deterministic record linkage to link ambulance and emergency department data: is it possible without patient identifiers? A case study from the UK

INTRODUCTION

Routine linkage of emergency ambulance records with those from the emergency department is uncommon in the UK. Our study, known as the Pre-Hospital Emergency Department Data Linking Project (PHED Data), aimed to link records of all patients conveyed by a single emergency ambulance service to thirteen emergency departments in the UK from 2012-2016.

OBJECTIVES

We aimed to examine the feasibility and resource requirements of collecting de-identified emergency department patient record data and, using a deterministic matching algorithm, linking it to ambulance service data.

METHODS

We used a learning log to record contacts and activities undertaken by the research team to achieve data linkage. We also conducted semi-structured interviews with information management/governance staff involved in the process.

RESULTS

We found that five steps were required for successful data linkage for each hospital trust. The total time taken to achieve linkage was a mean of 65 weeks. A total of 958,057 emergency department records were obtained and, of these, 81% were linked to a corresponding ambulance record. The match rate varied between hospital trusts (50%-94%). Staff expressed strong enthusiasm for data linkage. Barriers to successful linkage were mainly due to inconsistencies between and within acute trusts in the recording of two ambulance event identifiers (CAD and call sign). Further data cleaning was required on emergency department fields before full analysis could be conducted. Ensuring the data was not re-identifiable limited validation of the matching method.

CONCLUSION

We conclude that deterministic record linkage based on the combination of two event identifiers (CAD and call sign) is possible. There is an appetite for data linkage in healthcare organisations but it is a slow process. Developments in standardising the recording of emergency department data are likely to improve the quality of the resultant linked dataset. This would further increase its value for providing evidence to support improvements in health care delivery.

HIGHLIGHTS

Ambulance records are rarely linked to other datasets; this study looks at the feasibility and resource requirement to use deterministic matching to link ambulance and emergency department data for patients conveyed by ambulance to the emergency department.It is possible to link these data, with an average match rate of 81% across 13 emergency departments and one large ambulance trust.All trusts approached provided match-able data and there was an appetite for data linkage; however, it was a long process taking an average of 65 weeks.We conclude that deterministic matching using no patient identifiers can be used in this setting.

The Generation of a Comprehensive Spectral Library for the Analysis of the Guinea Pig Proteome by SWATH-MS

Advances in liquid chromatography‐mass spectrometry have facilitated the incorporation of proteomic studies to many biology experimental workflows. Data‐independent acquisition platforms, such as sequential window acquisition of all theoretical mass spectra (SWATH‐MS), offer several advantages for label‐free quantitative assessment of complex proteomes over data‐dependent acquisition (DDA) approaches. However, SWATH data interpretation requires spectral libraries as a detailed reference resource. The guinea pig (Cavia porcellus) is an excellent experimental model for translation to many aspects of human physiology and disease, yet there is limited experimental information regarding its proteome. To overcome this knowledge gap, a comprehensive spectral library of the guinea pig proteome is generated. Homogenates and tryptic digests are prepared from 16 tissues and subjected to >200 DDA runs. Analysis of >250 000 peptide‐spectrum matches resulted in a library of 73 594 peptides from 7666 proteins. Library validation is provided by i) analyzing externally derived SWATH files (https://doi.org/10.1016/j.jprot.2018.03.023) and comparing peptide intensity quantifications; ii) merging of externally derived data to the base library. This furnishes the research community with a comprehensive proteomic resource that will facilitate future molecular‐phenotypic studies using (re‐engaging) the guinea pig as an experimental model of relevance to human biology. The spectral library and raw data are freely accessible in the MassIVE repository (MSV000083199).

Oriented attachment of VNAR proteins, via site-selective modification, on PLGA-PEG nanoparticles enhances nanoconjugate performance

Herein we report the construction of a nanoparticle-based drug delivery system which targets a key regulator in tumour angiogenesis. We exploit a Variable New Antigen Receptor (VNAR) domain, conjugated using site-specific chemistry, to direct poly lactic acid-co-glycolic acid-polyethylene glycol (PLGA-PEG) nanoparticles to delta like canonical Notch ligand 4 (DLL4). The importance of site-specific chemistry is demonstrated.