Tumorigenesis driven by the BRAFV600E oncoprotein requires secondary mutations that overcome its feedback inhibition of migration and invasion

BRAFV600E mutation occurs in 46% of melanomas and drives high levels of ERK activity and ERK-dependent proliferation. However, BRAFV600E is insufficient to drive melanoma in GEMM models, and 82% of human benign nevi harbor BRAFV600E mutations. We show here that BRAFV600E inhibits mesenchymal migration by causing feedback inhibition of RAC1 activity. ERK pathway inhibition induces RAC1 activation and restores migration and invasion. In cells with BRAFV600E, mutant RAC1, overexpression of PREX1, PREX2, or PTEN inactivation restore RAC1 activity and cell motility. Together, these lesions occur in 48% of BRAFV600E melanomas. Thus, although BRAFV600E activation of ERK deregulates cell proliferation, it prevents full malignant transformation by causing feedback inhibition of cell migration. Secondary mutations are, therefore, required for tumorigenesis. One mechanism underlying tumor evolution may be the selection of lesions that rescue the deleterious effects of oncogenic drivers.

[Ophthalmic agents during pregnancy]

The use of ophthalmic agents during pregnancy and breastfeeding always represents an off-label use. Therefore, the use of drugs must be particularly carefully assessed with respect to the risk-benefit assessment. In this overview the literature databank of the PubMed library, pharmaceutical lists (Red List, Swiss pharmaceutical compendium), guidelines of the specialist societies the German Society of Ophthalmology (DOG), the Swiss Society of Ophthalmology (SOG), the European Glaucoma Society (EGS), the American Academy of Ophthalmology (AAO) and internet portals (embryotox, reprotox) were inspected and recommendations for the use of ophthalmic agents during pregnancy and breastfeeding were derived. More attention should be dedicated to this topic in the specialist societies.

Prospective Longitudinal Assessment of Quality of Life After Stereotactic Ablative Radiotherapy for Oligometastases: Analysis of the Population-based SABR-5 Phase II Trial

AIMS

To evaluate longitudinal patient-reported quality of life (QoL) in patients treated with stereotactic ablative radiotherapy (SABR) for oligometastases.

MATERIALS AND METHODS

The SABR-5 trial was a population-based single-arm phase II study of SABR to up to five sites of oligometastases, conducted in six regional cancer centres in British Columbia, Canada from 2016 to 2020. Prospective QoL was measured using treatment site-specific QoL questionnaires at pre-treatment baseline and at 3, 6, 9, 12, 15, 18, 21, 24, 30 and 36 months after treatment. Patients with bone metastases were assessed with the Brief Pain Inventory (BPI). Patients with liver, adrenal and abdominopelvic lymph node metastases were assessed with the Functional Assessment of Chronic Illness Therapy-Abdominal Discomfort (FACIT-AD). Patients with lung and intrathoracic lymph node metastases were assessed with the Prospective Outcomes and Support Initiative (POSI) lung questionnaire. The two one-sided test procedure was used to assess equivalence between the worst QoL score and the baseline score of individual patients. The mean QoL at all time points was used to determine the trajectory of QoL response after SABR. The proportion of patients with 'stable', 'improved' or 'worsened' QoL was determined for all time points based on standard minimal clinically important differences (MCID; BPI worst pain = 2, BPI functional interference score [FIS] = 0.5, FACIT-AD Trial Outcome Index [TOI] = 8, POSI = 3).

RESULTS

All enrolled patients with baseline QoL assessment and at least one follow-up assessment were analysed (n = 133). On equivalence testing, the patients' worst QoL scores were clinically different from baseline scores and met MCID (BPI worst pain mean difference: 1.8, 90% confidence interval 1.19 to 2.42]; BPI FIS mean difference: 1.68, 90% confidence interval 1.15 to 2.21; FACIT-AD TOI mean difference: -8.76, 90% confidence interval -11.29 to -6.24; POSI mean difference: -4.61, 90% confidence interval -6.09 to -3.14). However, the mean FIS transiently worsened at 9, 18 and 21 months but eventually returned to stable levels. The mean FACIT and POSI scores also worsened at 36 months, albeit with a limited number of responses (n = 4 and 8, respectively). Most patients reported stable QoL at all time points (range: BPI worst pain 71-82%, BPI FIS 45-78%, FACIT-AD TOI 50-100%, POSI 25-73%). Clinically significant stability, worsening and improvement were seen in 70%/13%/18% of patients at 3 months, 53%/28%/19% at 18 months and 63%/25%/13% at 36 months.

CONCLUSIONS

Transient decreases in QoL that met MCID were seen between patients' worst QoL scores and baseline scores. However, most patients experienced stable QoL relative to pre-treatment levels on long-term follow-up. Further studies are needed to characterise patients at greatest risk for decreased QoL.

Predictors of Quality of Life Decline in Patients with Oligometastases treated with Stereotactic Ablative Radiotherapy: Analysis of the Population-Based SABR-5 Phase II Trial

AIMS

Most patients experience stable quality of life (QoL) after stereotactic ablative radiotherapy (SABR) treatment for oligometastases. However, a subset of patients experience clinically relevant declines in QoL on post-treatment follow-up. This study aimed to identify risk factors for QoL decline.

MATERIALS AND METHODS

The SABR-5 trial was a population-based single-arm phase II study of SABR to up to five sites of oligometastases. Prospective QoL was measured using treatment site-specific tools at pre-treatment baseline and 3, 6, 9, 12, 15, 18, 21, 24, 30 and 36 months after treatment. The time to persistent QoL decline was calculated as the time from SABR to the first decline in QoL score meeting minimum clinically important difference with no improvement to baseline score on subsequent assessments. Univariable and multivariable logistic regression analyses were carried out to determine factors associated with QoL decline.

RESULTS

One hundred and thirty-three patients were included with a median follow-up of 32 months (interquartile range 25-43). Thirty-five patients (26%) experienced a persistent decline in QoL. The median time until persistent QoL decline was not reached. The cumulative incidence of QoL decline at 2 and 3 years were 22% (95% confidence interval 14.0-29.6) and 40% (95% confidence interval 28.0-51.2), respectively. In multivariable analysis, disease progression (odds ratio 5.23, 95% confidence interval 1.59-17.47, P = 0.007) and adrenal metastases (odds ratio 9.70, 95% confidence interval 1.41-66.93, P = 0.021) were associated with a higher risk of QoL decline. Grade 3 or higher (odds ratio 3.88, 95% confidence interval 0.92-16.31, P = 0.064) and grade 2 or higher SABR-associated toxicity (odds ratio 2.24, 95% confidence interval 0.85-5.91, P = 0.10) were associated with an increased risk of QoL decline but did not reach statistical significance.

CONCLUSIONS

Disease progression and adrenal lesion site were associated with persistent QoL decline following SABR. The development of grade 3 or higher toxicities was also associated with an increased risk, albeit not statistically significant. Further studies are needed, focusing on the QoL impact of metastasis-directed therapies.

Therapy-Induced Senescence Contributes to the Efficacy of Abemaciclib in Patients with Dedifferentiated Liposarcoma

PURPOSE

We conducted research on CDK4/6 inhibitors (CDK4/6i) simultaneously in the preclinical and clinical spaces to gain a deeper understanding of how senescence influences tumor growth in humans.

PATIENTS AND METHODS

We coordinated a first-in-kind phase II clinical trial of the CDK4/6i abemaciclib for patients with progressive dedifferentiated liposarcoma (DDLS) with cellular studies interrogating the molecular basis of geroconversion.

RESULTS

Thirty patients with progressing DDLS enrolled and were treated with 200 mg of abemaciclib twice daily. The median progression-free survival was 33 weeks at the time of the data lock, with 23 of 30 progression-free at 12 weeks (76.7%, two-sided 95% CI, 57.7%-90.1%). No new safety signals were identified. Concurrent preclinical work in liposarcoma cell lines identified ANGPTL4 as a necessary late regulator of geroconversion, the pathway from reversible cell-cycle exit to a stably arrested inflammation-provoking senescent cell. Using this insight, we were able to identify patients in which abemaciclib induced tumor cell senescence. Senescence correlated with increased leukocyte infiltration, primarily CD4-positive cells, within a month of therapy. However, those individuals with both senescence and increased TILs were also more likely to acquire resistance later in therapy. These suggest that combining senolytics with abemaciclib in a subset of patients may improve the duration of response.

CONCLUSIONS

Abemaciclib was well tolerated and showed promising activity in DDLS. The discovery of ANGPTL4 as a late regulator of geroconversion helped to define how CDK4/6i-induced cellular senescence modulates the immune tumor microenvironment and contributes to both positive and negative clinical outcomes. See related commentary by Weiss et al., p. 649.

Defining the concept of mental dysregulation in patients requiring ambulance and/or emergency department care: protocol for a Delphi consensus study

INTRODUCTION

From the patient and staff perspective, care delivery for patients experiencing a mental health problem in ambulance and emergency department (ED) settings is challenging. There is no uniform and internationally accepted concept to reflect people with a mental health problem who require emergency care, be it for, or as a result of, a mental health or physical health problem. On initial presentation to the emergency service provider (ambulance or ED), the cause of their healthcare condition/s (mental health and/or physical health) is often initially unknown. Due to this (1) the prevalence and range of underlying causes (mental and/or physical) of the patients presenting condition is unknown; (2) misattribution of physical symptoms to a mental health problem can occur and (3) diagnosis and treatment of the initial somatic complaint and cause(s) of the mental/physical health problem may be hindered.This study will name and define a new concept: 'mental dysregulation' in the context of ambulance and ED settings.

METHODS AND ANALYSIS

A Delphi study, informed by a rapid literature review, will be undertaken. For the literature review, a steering group (ie, persons with lived experience, ED and mental health clinicians, academics) will systematically search the literature to provide a working definition of the concept: mental dysregulation. Based on this review, statements will be generated regarding (1) the definition of the concept; (2) possible causes of mental dysregulation and (3) observable behaviours associated with mental dysregulation. These statements will be rated in three Delphi rounds to achieve consensus by an international expert panel (comprising persons with lived experience, clinicians and academics).

ETHICS AND DISSEMINATION

This study has been approved by the Medical Ethical Committee of the University of Applied Sciences Utrecht (reference number: 258-000-2023_Geurt van der Glind). Results will be disseminated via peer-reviewed journal publication(s), scientific conference(s) and to key stakeholders.

GABA Regulates Electrical Activity and Tumor Initiation in Melanoma

Oncogenes can initiate tumors only in certain cellular contexts, which is referred to as oncogenic competence. In melanoma, whether cells in the microenvironment can endow such competence remains unclear. Using a combination of zebrafish transgenesis coupled with human tissues, we demonstrate that GABAergic signaling between keratinocytes and melanocytes promotes melanoma initiation by BRAFV600E. GABA is synthesized in melanoma cells, which then acts on GABA-A receptors in keratinocytes. Electron microscopy demonstrates specialized cell-cell junctions between keratinocytes and melanoma cells, and multielectrode array analysis shows that GABA acts to inhibit electrical activity in melanoma/keratinocyte cocultures. Genetic and pharmacologic perturbation of GABA synthesis abrogates melanoma initiation in vivo. These data suggest that GABAergic signaling across the skin microenvironment regulates the ability of oncogenes to initiate melanoma.

SIGNIFICANCE

This study shows evidence of GABA-mediated regulation of electrical activity between melanoma cells and keratinocytes, providing a new mechanism by which the microenvironment promotes tumor initiation. This provides insights into the role of the skin microenvironment in early melanomas while identifying GABA as a potential therapeutic target in melanoma. See related commentary by Ceol, p. 2128. This article is featured in Selected Articles from This Issue, p. 2109.

Location of Local Recurrences Post-Prostatectomy Detected by 18F-DCPFyL and Implications for Salvage Radiotherapy Target Volumes

PURPOSE/OBJECTIVE(S)

The use of prostate-specific membrane antigen (PSMA) PET scans have improved detection of recurrent prostate cancer for biochemical failure post-prostatectomy. The primary aim of this study is to assess the location of local recurrences for PSMA PET positive disease post-prostatectomy relative to anatomical landmarks and to inform salvage radiotherapy contouring guidelines.

MATERIALS/METHODS

This is a retrospective study of patients who underwent a staging PSMA PET-CT scan with 18F-DCFPyL tracer. Eligible patients included men with biochemical recurrence (PSA >0.2ng/mL) post-prostatectomy for prostate adenocarcinoma. PSMA positive local disease (GTV) was marked on the CT scan of the PSMA PET/CT, using the PSMA PET scan fused as the secondary dataset. Reference structures were contoured to compare the positional relationship to the GTV local recurrence. Centroids of each GTV position were measured to the closest border of the reference structures and distance measured.

RESULTS

Forty-five patients had a local recurrence on PSMA PET, 28/45 with prostate bed recurrence and 17/45 with seminal vesicle bed recurrence. The median age was 72.7 years, median pre-treatment PSA 0.515 ng/ml (0.2-11.1), pT2 in 37.8% and pT3 in 62.2, ISUP G2-3 was 66.7%, ISUP 4-5 29.6%, 67% ECE, 15.4% SV involvement and 40% positive margin. For prostate bed recurrences, 93.6% of GTVs were within 15mm from the inferior border of pubic symphysis (median 3.3mm [-9.8-15.4]), 83.9% within 10mm from the VUA (median 3.3mm [-17.4-15.9]), and 80.6% were greater than 10mm from the most superior slice of the penile bulb (median 16.4mm [1-29.5]). Laterally, 83.9% of recurrences were within 10mm of midline and 41.9% within 5mm (median 3.3mm [-13.56-11.59]) and all were contained within levator, 35.5% within 5mm (median 7.7 [1-22.6]) of the medial muscle border. 29.0% were within 5mm from the anterior edge of the rectal wall (median -7mm [-32.3-0.5]). Seminal vesicle bed recurrences were within 17.5mm of upper border of pubic symphysis for 88.9% of patients (median -4.69mm[-30.8to18.2]), 100% were more than 7.5mm inferiorly from the vas deferens (median-22.1mm[-32.7to-7.7]). Laterally, 100% recurrences were more than 7.5mm medial from obturator internus (median 5.37mm [-23.1to37.8]), and 88.9% were more than 10mm from midline (median 23.1mm [2.0-36.6]).

CONCLUSION

The 18F-DCFPyL PSMA PET local recurrences can provide detailed localization of prostate bed and seminal vesicle recurrences. Our data can inform contouring guidelines for salvage radiotherapy to the prostate bed, particularly when using anatomical landmarks to define cranio-caudal extent of target volumes. For target volume laterally, the medial wall of levator ani would encompass all prostate bed recurrences, and no seminal vesicles recurrences were seen at the medial border of the obturator internus muscle.

Apoptotic contraction drives target cell release by cytotoxic T cells

Cytotoxic T lymphocytes (CTLs) fight intracellular pathogens and cancer by identifying and destroying infected or transformed target cells1. To kill, CTLs form a specialized cytotoxic immune synapse (IS) with a target of interest and then release toxic perforin and granzymes into the interface to elicit programmed cell death2-5. The IS then dissolves, enabling CTLs to search for additional prey and professional phagocytes to clear the corpse6. While the mechanisms governing IS assembly have been studied extensively, far less is known about target cell release. Here, we applied time-lapse imaging to explore the basis for IS dissolution and found that it occurred concomitantly with the cytoskeletal contraction of apoptotic targets. Genetic and pharmacological perturbation of this contraction response indicated that it was both necessary and sufficient for CTL dissociation. We also found that mechanical amplification of apoptotic contractility promoted faster CTL detachment and serial killing. Collectively, these results establish a biophysical basis for IS dissolution and highlight the importance of mechanosensory feedback in the regulation of cell-cell interactions.

Evaluation in a porcine wound model and long-term clinical assessment of an autologous heterogeneous skin construct used to close full-thickness wounds

Acute and chronic wounds involving deeper layers of the skin are often not adequately healed by dressings alone and require therapies such as skin grafting, skin substitutes, or growth factors. Here we report the development of an autologous heterogeneous skin construct (AHSC) that aids wound closure. AHSC is manufactured from a piece of healthy full-thickness skin. The manufacturing process creates multicellular segments, which contain endogenous skin cell populations present within hair follicles. These segments are physically optimized for engraftment within the wound bed. The ability of AHSC to facilitate closure of full thickness wounds of the skin was evaluated in a swine model and clinically in 4 patients with wounds of different etiologies. Transcriptional analysis demonstrated high concordance of gene expression between AHSC and native tissues for extracellular matrix and stem cell gene expression panels. Swine wounds demonstrated complete wound epithelialization and mature stable skin by 4 months, with hair follicle development in AHSC-treated wounds evident by 15 weeks. Biomechanical, histomorphological, and compositional analysis of the resultant swine and human skin wound biopsies demonstrated the presence of epidermal and dermal architecture with follicular and glandular structures that are similar to native skin. These data suggest that treatment with AHSC can facilitate wound closure.

Abstract 5185: Intratumoral Escherichia is associated with response to single-agent immune checkpoint inhibition in patients with advanced non-small cell lung cancer

The impact of the intratumoral microbiome on immune checkpoint inhibitor (ICI) efficacy in patients (pts) with non-small cell lung cancer (NSCLC) is unknown. In preclinical studies, the presence of lung intratumoral Escherichia was associated with a proinflammatory tumor microenvironment and decreased metastases within lung tissue. We sought to detect intratumoral bacteria in pts with advanced NSCLC using hybrid capture-based, next generation sequencing (NGS). We studied 849 pts treated with ICI-based therapy who underwent NGS at our center. We extracted unmapped reads from BAM files, and these were queried for bacteria (blastn alignment using the NCBI database). Putative environmental contaminants were subtracted from the analysis using “no template” controls (n=2,539) to exclude possible artifactual false positives. A custom E.Coli fluorescence in situ hybridization (FISH) probe was used to visualize Escherichia within the tumors after co-registration with H&E. In 849 pts, a median of 30 bacterial reads was detected per sample (inter-quartile range (18-85)). Among 68 pts with paired primary/metastatic samples, the bacterial spectra were similar in both sites, suggesting that tumor resident bacteria might travel with cancer cells to distant sites. Antibiotic use within 30 days of tumor sampling was associated with decreased intratumoral bacterial diversity (p=0.023 by Inverse Simpson, p=0.038 by Shannon). Intratumoral Escherichia was associated with better PFS (HR 0.78, 95% CI 0.62-0.98, p=0.036), and OS (HR 0.74, 95% CI 0.58-0.95, p=0.017) in pts treated with single-agent ICI, but not combination Chemo/ICI. In a multivariable model adjusting for prognostic features in NSCLC including PD-L1 tumor proportion score, the presence of intratumoral Escherichia was associated with better PFS (p=0.040) and OS (p=0.045) upon single-agent ICI therapy. Escherichia appeared to be intracellular based on co-registration of FISH staining and serial H&E sections. These findings warrant further investigation of the possible inter-relationships between intratumoral Escherichia, tumor immune micro-environment, and ICI therapeutic outcomes.

Citation Format: Arielle Elkrief, Anita S. Bowman, Ayyuce Begum Bektas, Wenfei Kang, Katia Manova-Todorova, Jacklynn V. Egger, Hira Rizvi, Daniel Kelly, Eric Chan, Eric Rosiek, Fan Ning, Gregory J. Riely, Álvaro Quintanal Villalonga, Snjezana Dogan, Umesh Bhanot, Mithat Gonen, Matthew D. Hellmann, Adam J. Schoenfeld, Charles M. Rudin, Marc Ladanyi, Chad M. Vanderbilt. Intratumoral Escherichia is associated with response to single-agent immune checkpoint inhibition in patients with advanced non-small cell lung cancer. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5185.

A145 PEDIATRIC PATIENTS’ & PARENTS’ PERSPECTIVES ON TREATMENT PREFERENCE IN EOSINOPHILIC ESOPHAGITIS: A CROSS SECTIONAL, QUALITATIVE RESEARCH STUDY

Background

Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus which impairs quality of life in children and adolescents. Given the wide variety of symptomatic presentations in pediatrics, the varying time to diagnosis, and differing severity (including stricturing phenotype) initial treatments are not standardized. An important part of this individualization, beyond the health care practitioner counseling involves the patients’ and parents’ preferences which incorporates personal beliefs and attitudes.

Purpose

The study aim was to qualitatively describe parental and patient preferences regarding treatment options in EoE.

Method

This was a cross-sectional qualitative research study conducted in the EoE clinic at BC Children’s Hospital, Vancouver. Parents and their children completed semi-structured survey questions regarding treatment preference in EoE. Patients along with their parents who completed their survey questions were included in the study. Incomplete forms were excluded from the study.

Result(s)

The survey was attempted by 15 children, 7-11yrs of age, and 42 children, 12-18yrs of age, along with their parents. Completed response by both parent and their children were seen in 47 patients, 40 were adolescents 12-18yrs of age and 7 were 7-11yrs of age. Parent treatment preferences were diet in 17/47(36.2%), medications in 21/47 (44.7%) and 9/47 (19%) were unsure. 75% of parents who preferred dietary management thought it was less risky than medication. Parents who chose medication thought it would be easier (8/21) and more effective (8/21). Most of the parents’ decisions were influenced by the physician (35/47; 74.5%) and more so by the gastroenterologist (28/47; 59.6%). In 12–18-yr olds, 6/40 (15%) had preference for diet, 25/40 (62.5%) preferred medication and 9/40 (22.5%) were unsure. 3/6 adolescents thought that diet was less risky and 4/6 thought it was more effective than medication. Among the teens who preferred medication, 17/25 (68%) felt it to be easier and 9/25 (36%) thought it would work better than diet. Teenagers found their parents to be helpful for deciding (50%) and doctor (50%) with the gastroenterologist again playing a prominent role. In the 7 to 11yr old age group, 4/7 (57.1%) predominantly had preference for dietary treatment.

Conclusion(s)

The overall preference in the adolescent age group is for medication supported by patients’ and parents’, with ease of use being a primary driver for adolescents, whereas ease of use and effectiveness were drivers for the parents. Parents were more often interested in dietary therapy than the adolescents. With regards to parents of younger children and younger children themselves, dietary management was the preference as they felt it to be less risky. The numbers, though small, represent one of the few studies done on patient preference in EoE. Future studies should include formal qualitative studies and preferences could ultimately be tied to better counseling and tracking adherence to therapy.

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Disclosure of Interest

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Multiplex Spatial Protein Detection by Combining Immunofluorescence with Immunohistochemistry

Technologies for staining and imaging multiple antigens in single tissue sections are developing rapidly due to their potential to uncover spatial relationships between proteins with cellular resolution. Detections are performed simultaneously or sequentially depending on the approach. However, several technologies can detect limited numbers of antigens or require expensive equipment and reagents. Another serious concern is the lack of flexibility. Most commercialized reagents are validated for defined antibody panels, and introducing any changes is laborious and costly. In this chapter, we describe a method where we combine, for the first time, multiplexed IF followed by sequential immunohistochemistry (IHC) with AEC chromogen on Leica Bond staining processors with paraffin tissue sections. We present data for successful detection of 10 antigens in a single tissue section with preserved tissue integrity. Our method is designed for use with any combination of antibodies of interest, with images collected using whole slide scanners. We include an image viewing and image analysis workflow using nonlinear warping to combine all staining passes in a single full-resolution image of the entire tissue section, aligned at the single cell level.

Short-term risk prediction after major lower limb amputation: PERCEIVE study

BACKGROUND

The accuracy with which healthcare professionals (HCPs) and risk prediction tools predict outcomes after major lower limb amputation (MLLA) is uncertain. The aim of this study was to evaluate the accuracy of predicting short-term (30 days after MLLA) mortality, morbidity, and revisional surgery.

METHODS

The PERCEIVE (PrEdiction of Risk and Communication of outcomE following major lower limb amputation: a collaboratIVE) study was launched on 1 October 2020. It was an international multicentre study, including adults undergoing MLLA for complications of peripheral arterial disease and/or diabetes. Preoperative predictions of 30-day mortality, morbidity, and MLLA revision by surgeons and anaesthetists were recorded. Probabilities from relevant risk prediction tools were calculated. Evaluation of accuracy included measures of discrimination, calibration, and overall performance.

RESULTS

Some 537 patients were included. HCPs had acceptable discrimination in predicting mortality (931 predictions; C-statistic 0.758) and MLLA revision (565 predictions; C-statistic 0.756), but were poor at predicting morbidity (980 predictions; C-statistic 0.616). They overpredicted the risk of all outcomes. All except three risk prediction tools had worse discrimination than HCPs for predicting mortality (C-statistics 0.789, 0.774, and 0.773); two of these significantly overestimated the risk compared with HCPs. SORT version 2 (the only tool incorporating HCP predictions) demonstrated better calibration and overall performance (Brier score 0.082) than HCPs. Tools predicting morbidity and MLLA revision had poor discrimination (C-statistics 0.520 and 0.679).

CONCLUSION

Clinicians predicted mortality and MLLA revision well, but predicted morbidity poorly. They overestimated the risk of mortality, morbidity, and MLLA revision. Most short-term risk prediction tools had poorer discrimination or calibration than HCPs. The best method of predicting mortality was a statistical tool that incorporated HCP estimation.

Olfactory dysfunction is common in classical infratentorial superficial siderosis of the central nervous system

Background

Established features of classical infratentorial superficial siderosis (iSS) include hearing loss, impaired balance, myelopathy and, less commonly, cognitive compromise. Olfactory function may be affected but dedicated studies are lacking. This study aimed to assess the prevalence of olfactory dysfunction in iSS and correlate it with auditory and cognitive functions.

Methods

Ten participants with iSS completed the University of Pennsylvania Smell Identification Test (UPSIT). The scores were compared with population norms; regression analysis was performed to evaluate associations between the scores and hearing thresholds (3-frequency average, 3FA) or the number of cognitive domains impaired. Imaging was reviewed for haemosiderin distribution and to exclude other causes of olfactory and hearing dysfunction.

Results

Eight of ten participants were male; the mean (standard deviation, SD) age was 52.5 (14.5) years. Olfactory hypofunction was identified in all participants and in six (60%) was moderate or completely absent. The mean UPSIT score of 25.5 (7.8) was significantly worse than population norms (difference in means − 10.0; 95% CI − 15.6 to − 4.4). Linear regression identified an association between UPSIT and hearing thresholds (R = 0.75; p = 0.013). The score decreases by 0.157 units (95% CI − 0.31 to − 0.002; p = 0.048) per unit increase in 3FA, after adjusting for hearing loss risk factors. There was no statistically significant association between UPSIT and cognitive function (R = 0.383; p = 0.397).

Conclusion

We report a high prevalence of olfactory dysfunction in iSS, the severity of which correlated with hearing loss. Olfaction appears to be a core feature of the iSS clinical syndrome that should be assessed routinely.

Recurrent WWTR1 S89W mutations and Hippo pathway deregulation in clear cell carcinomas of the cervix

Clear cell carcinoma (CCC) of the cervix (cCCC) is a rare and aggressive type of human papillomavirus (HPV)-negative cervical cancer with limited effective treatment options for recurrent or metastatic disease. Historically, CCCs of the lower genital tract were associated with in utero diethylstilbestrol exposure; however, the genetic landscape of sporadic cCCCs remains unknown. Here we sought to define the molecular underpinning of cCCCs. Using a combination of whole-exome, targeted capture, and RNA-sequencing, we identified pathogenic genetic alterations in the Hippo signaling pathway in 50% (10/20) of cCCCs, including recurrent WWTR1 S89W somatic mutations in 40% (4/10) of the cases harboring mutations in the Hippo pathway. Irrespective of the presence or absence of Hippo pathway genetic alterations, however, all primary cCCCs analyzed in this study (n = 20) harbored features of Hippo pathway deregulation at the transcriptomic and protein levels. In vitro functional analysis revealed that expression of the WWTR1 S89W mutation leads to reduced binding of TAZ to 14-3-3, promoting constitutive nuclear translocation of TAZ and Hippo pathway repression. WWTR1 S89W expression was found to lead to acquisition of oncogenic behavior, including increased proliferation, migration, and colony formation in vitro as well as increased tumorigenesis in vivo, which could be reversed by targeted inhibition of the TAZ/YAP1 complex with verteporfin. Finally, xenografts expressing WWTR1 S89W displayed a shift in tumor phenotype, becoming more infiltrative as well as less differentiated, and were found to be composed of cells with conspicuous cytoplasmic clearing as compared to controls. Our results demonstrate that Hippo pathway alterations are likely drivers of cCCCs and likely contribute to the clear cell phenotype. Therapies targeting this pathway may constitute a new class of treatment for these rare, aggressive tumors. © 2022 The Pathological Society of Great Britain and Ireland.

Abstract 2422: Migration of V600E-expressing cells is suppressed by ERK-dependent feedback inhibition of RAC1 and rescued in melanoma by secondary mutations

Oncogenic activation of ERK occurs in as many as 50% of human tumors and in the majority of melanomas. Activated BRAF V600E hyperactivates ERK signaling and causes ERK dependent dysregulation of proliferation. However, BRAF V600E alone is insufficient to drive melanoma formation in genetically engineered mice models. Moreover, 82% of benign nevi harbor BRAF V600E mutations. In contrast, in BRAF V600E/PTEN-/- GEMM models, rapid onset of aggressive and disseminated melanomas occurs. We show here that cell migration and invasion of melanocytes expressing BRAFV600E is depressed in vitro and in vivo and significantly accelerated by pharmacologic inhibition of ERK signaling or by deletion of PTEN. Upon ERK inhibition, cells lose their cell-cell junctions and become single cells with actin rich protrusions and a mesenchymal morphology. ERK pathway activation affects each step of the migration cycle, impeding cell spreading, assembly of stress fibers, and focal contact formation, all of which are associated with decreased mobility and invasion. Hyperactivation of ERK signaling by BRAF V600E has been shown to cause potent feedback inhibition of RTK signaling and wild type RAS. We now show that this is associated with feedback inhibition of RAC1, a RAS-like small GTPase required for cell migration. Moreover, ERK pathway inhibition reactivates RAC in an RTK-dependent manner. Consistent with these findings, expression of RAC1 P29S, an activating mutant, and overexpression of PREX2, an activator of RAC1, both rescue migration in BRAF V600E cells, as does loss of PTEN expression, which converges with RAC1 activation downstream. Taken together, these data suggest that whereas hyperactivation of ERK signaling by BRAFV600E dysregulates proliferation, ERK dependent feedback inhibition of RAC1 inhibits cell mobility and invasiveness and prevents full transformation. Selection of secondary genetic events that overcome or bypass RAC1 feedback is thus required for full transformation. In support of this view, RAC1 mutation, PTEN loss, or PREX2 amplification occurs in 38% of human melanomas. Thus, oncogene induced feedback may be deleterious and directs tumor evolution by causing selection of mutations that restore functions necessary for transformation

Citation Format: Sunyana Gadal, Jacob A. Boyer, Hongyan Li, Ning Fan, Eric Chan, Yevgeniy Romin, Elisa De Stanchina, Rona Yeager, Marcus Bosenberg, Katia M. Todorova, Neal Rosen. Migration of V600E-expressing cells is suppressed by ERK-dependent feedback inhibition of RAC1 and rescued in melanoma by secondary mutations [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2422.

LB14. Efficacy and Immunogenicity of an Ad26.RSV.preF-based Vaccine in the Prevention of RT-PCR-confirmed RSV-mediated Lower Respiratory Tract Disease in Adults Aged ≥65 Years: A Randomized, Placebo-controlled, Phase 2b Study

Background

Respiratory syncytial virus (RSV) can cause serious lower respiratory tract disease (LRTD) in older adults. Despite a high burden of disease, there is currently no licensed vaccine for RSV. Here, we report the primary efficacy and immunogenicity results from a Phase 2b proof-of-concept trial of an Ad26.RSV.preF-based vaccine for the prevention of RSV-mediated LRTD in adults aged ≥65 years.

Methods

CYPRESS (NCT03982199) is a randomized, double-blind, placebo-controlled Phase 2b trial. Adults ≥65 years of age were randomized 1:1 prior to the RSV season to receive an Ad26.RSV.preF-based vaccine or placebo. Symptoms of acute respiratory infection (ARI) were collected through an RSV-specific patient-reported Respiratory Infection Intensity and Impact Questionnaire (RiiQ) and/or by a clinician assessment until the end of the RSV season. The primary endpoint was the first occurrence of RT-PCR-confirmed RSV-mediated LRTD according to any of 3 case definitions: (1) ≥3 symptoms of lower respiratory tract infection (LRTI), (2) ≥2 symptoms of LRTI, or (3) ≥2 symptoms of LRTI or ≥1 symptom of LRTI with ≥1 systemic symptom. The secondary endpoint was the first occurrence of any RT-PCR-confirmed RSV-mediated ARI. Immunogenicity assessments were performed in a subset of approximately 200 participants.

Results

A total of 5782 participants (2891 in each study arm) received study treatment (92.5% white, 57.7% female, median age 71 years). Vaccine efficacy was 80% (94.2% CI, 52.2–92.9%), 75% (50.1–88.5%), and 69.8% (43.7–84.7%) for case definition 1, 2, and 3, respectively (all P values < 0.001). Efficacy for any RSV-mediated ARI was 69.8% (95% CI, 42.7–85.1%). In the vaccine arm of the immunogenicity subset, geometric mean fold increase in antibody titers 14 days after vaccination was 13.5 for RSV neutralizing antibodies and 8.6 for RSV prefusion F-specific binding antibodies. Median frequency of RSV-F-specific INFγ T-cells increased from 34 to 444 SFC/10⁶ PBMC 14 days after vaccination in the vaccine arm; no relevant changes were observed in the placebo arm.

Conclusion

In CYPRESS, the Ad26.RSV.preF-based vaccine was highly effective against RSV-mediated LRTD through the first RSV season and elicited robust humoral and cellular immune responses in adults aged ≥65 years.

Disclosures

Ann R. Falsey, MD, AstraZeneca (Individual(s) Involved: Self): Grant/Research Support; BioFire Diagnostics (Individual(s) Involved: Self): Grant/Research Support; Janssen (Individual(s) Involved: Self): Grant/Research Support; Merck, Sharpe and Dohme (Individual(s) Involved: Self): Grant/Research Support; Novavax (Individual(s) Involved: Self): Other Financial or Material Support, Paid DSMB member; Pfizer (Individual(s) Involved: Self): Grant/Research Support Kristi Williams, PhD, Janssen R&D US (Employee) Efi Gymnopoulou, MSc, Janssen Infectious Diseases BV (Employee) Arangassery Rosemary Bastian, PhD, Janssen Vaccines & Prevention BV (Employee) Joris Menten, n/a, Janssen Infectious Diseases BV (Employee) Els De Paepe, MSc, Janssen Infectious Diseases BV (Employee) Hilde de Boer, MSc, Janssen-Cilag (Employee) Sjoukje Vandenberghe, n/a, Janssen Infectious Diseases BV (Employee) Eric Chan, PhD, Janssen Global Services, LLC (Employee) Jerald Sadoff, MD, Johnson & Johnson (Employee, Shareholder) Macaya Douoguih, MD, MPH, Janssen (Employee) Benoit Callendret, PhD, Janssen Vaccines & Prevention BV (Employee) Christy Comeaux, MD, Janssen Vaccines & Prevention BV (Employee) Esther Heijnen, MD, Janssen Vaccines & Prevention BV (Employee)

Comparative assessment of reported symptoms of influenza, respiratory syncytial virus, and human metapneumovirus infection during hospitalization and post-discharge assessed by Respiratory Intensity and Impact Questionnaire

Background

The hospitalized acute respiratory tract infection (HARTI) study used the Respiratory Intensity and Impact Questionnaire (RiiQ™) Symptom Scale, derived from FluiiQ™, to assess and compare the burden of respiratory infection symptoms for patients with influenza, respiratory syncytial virus (RSV), and human metapneumovirus (hMPV) infection, with or without core risk factors (CRF) (age ≥65; chronic heart, renal, obstructive pulmonary disease; asthma).

Methods

This was a prospective cohort study in adult patients hospitalized with acute respiratory tract infection (40 centers, 12 countries) during two consecutive influenza/RSV/hMPV seasons (2017–2019). The RiiQ™ Symptom Scale and EuroQol 5‐Dimensions 5‐Levels (EQ‐5D‐5L) were assessed by interview at two timepoints during hospitalization and at 1, 2, and 3 months post‐discharge.

Results

Mean lower respiratory tract (LRT) symptom scores were higher for RSV and hMPV participants compared to influenza at 48 h after enrollment/early discharge (p = 0.001) and 3 months post‐discharge (p = 0.007). This was driven by LRT symptoms, including shortness of breath (SOB) (p < 0.01) and wheezing (p < 0.01) during hospitalization, and SOB (p < 0.05) and cough (p < 0.05) post‐discharge. Participants with CRF reported more moderate‐to‐severe SOB (p < 0.05) and wheezing (p < 0.05) compared to CRF(−) participants post‐discharge. EQ‐5D‐5L scores were moderately associated with RiiQ™ LRT and systemic symptoms domains.

Conclusions

Results from the HARTI study suggest that in the study population, LRT symptoms were more severe for RSV and hMPV groups and for patients with CRF. RiiQ™ Symptom Scale scores shows a moderate association with EQ‐5D‐5L indicating that the RiiQ™ may provide useful insights and offer advantages over other measures for use in interventional RSV adult clinical studies.

Abstract 1451: AN3025: A novel anti-human TNFR2 antibody that exhibits immune activation and strong anti-tumor activity in vivo

Background:

The unique biology and expression pattern of tumor necrosis factor receptor-2 (TNFR2) make it an attractive therapeutic target for immuno-oncology. TNFR2 highly expresses on a subset of regulatory T cells (Tregs) and MDSCs within tumor microenvironment that can activate these cells through nuclear factor kappa B (NF-kB) pathway. TNFR2+ Treg has been shown to be most suppressive among all Treg populations in tumor. On the other hand, TNFR2 is also abundantly expressed on the surface of many human tumors. TNFR2 blocking antibody is expected to relieve TNFR2-mediated immunosuppression and inhibit TNFR2-expressing tumor cell survival. AN3025 is a novel humanized IgG1 (variant) anti-hTNFR2 antibody under preclinical development. The immunomodulatory and anti-tumor activity of AN3025 were evaluated both in vitro and in vivo.

Materials and methods:

AN3025 was generated through rabbit immunization followed by phage display, then humanized by CDRs grafting. The binding affinity and specificity were studied by ELISA and FACS. The ability of AN3025 to mitigate TNF/TNFR2 signaling pathway was characterized using TNFR2 overexpressing Jurkat cell line in vitro. The in vivo anti-tumor activity was evaluated in TNFR2 humanized mouse model bearing MC38 tumor. The tumor samples from control and AN3025 treated mice were taken for further FACS and RNA seq analysis.

Results:

AN3025 binds to the extracellular domain of human TNFR2 with sub-nanomolar affinity and specificity. It cross-reacts with cynomolgus TNFR2 with similar affinity, but not with mouse or rat TNFR2. Mechanistically, AN3025 partially competes with TNFα for binding to TNFR2 receptor and inhibits TNFα induced hTNFR2 overexpressing Jurkat cell death, however it lacks of agonist activity towards TNFR2 even in the presence of hFC crosslinking. In vivo AN3025 significantly inhibits MC38 tumor growth as a monotherapy in hTNFR2 mouse model, while no impact on body weight. Subsequent FACS analysis suggests decreased Tregs% in AN3025 treated tumor. RNA seq suggests immune activation such as increased IFN-gamma and Granzyme expression. In addition, AN3025 enhances anti-tumor efficacy of mPD-1 antibody in a combination study.

Conclusions:

AN3025 is a novel anti-hTNFR2 antibody and demonstrates immunomodulatory activity and potent anti-tumor efficacy in vivo, supporting its clinical development for the treatment of human cancers.

Citation Format: Yonglin Chen, Manxue Jia, Sherry Xu, Yanhui Zhao, Eric Chan, Meng Zhang, Emma Chen, Yi Zhang. AN3025: A novel anti-human TNFR2 antibody that exhibits immune activation and strong anti-tumor activity in vivo [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 1451.

POS0494 AN INVESTIGATION OF JOINT INFLAMMATION DEFINED BY COMPREHENSIVE ULTRASOUND ASSESSMENT AND PAIN SENSITISATION IN PATIENTS WITH ACTIVE RA

Background:

Treat-to-target strategies have improved outcomes in patients with RA. Targets based on clinical assessments of tender (TJC) and swollen joints (SJC) were developed when most patients had active inflammatory disease. It is now recognised some patients have pain sensitisation often termed fibromyalgia (FM), making clinical assessment of inflammatory disease more complex. An indicator of pain sensitisation is the difference between TJC and SJC, an observation we described in a pilot study (1).

Objectives:

To study patients with RA to describe the relationships between enhanced clinical and patient-reported outcome measures (PROMS) and active inflammatory joint disease detected by comprehensive PDUS.

Methods:

158 sequential patients with RA with a DAS28ESR score >¬3.2 were enrolled from GSTT Rheumatology after informed consent. They were assessed by a rheumatologist for 66SJC, 68TJC, fibromyalgia tender points & physician global. Recorded PROMS were: patient global, widespread pain index (WPI), symptom severity score (somatic & fatigue), FACIT fatigue, HAQ, EQ5D QoL, GAD7, PHQ9 and PHQ15. All patients had a 44 joint US scored for PD and grey scale by the EULAR scale blind to all patient data. Data were recorded on MedSciNet and statistical analysis used STATA.

Results:

Patients meeting the ACR 2010 criteria for FM2(n=72) vs those that did not(n=86) had similar demographics. SJC and US doppler scores were higher in the non-FM group, whereas rheumatoid factor, DAS28 and PROMs were higher in the FM group. Analysis of group differences using multinomial logistic regression and subsequent regularised (lasso) logistic regression, showed the FM group related to higher 28TJC, FACIT-F and PHQ15, with the non-FM group related to higher 28SJC, logESR, and lower Differences in 28S/TJC, Physician Global and FACIT-F. Patients were divided into four groups based on presence or absence of at least one PDUS+ joint and FM criteria; -FM-PD, -FM+PD, +FM-PD and +FM+PD, data summarised Table 1. The -FM-PD and -FM+PD groups related to Physician Global and negatively related to FACIT-F, Difference in 28S/TJC, and PHQ15 (-FM-PD). The +FM-PD group related positively to FACIT-F, Difference 28S/TJC, PHQ15, and negatively to Physician Global with +FM+PD related to PHQ9, FACIT-F and DAS28ESR.

TABLE 1.

-FM -PD -FM +PD +FM -PD +FM +PD p-value

Female34 (79%)33 (77%)35 (83%)22 (73%)0.77Total power doppler score0.0 (0.0-1.0)16.0 (10.0-25.0)0.0 (0.0-0.0)9.0 (8.0-20.0)<0.001Total gray scale score40.0(34.0-48.0)57.5(45.0-82.0)34.5(20.0-43.0)60.0(46.0-84.0)<0.001Total Swollen JC3.0 (1.0-5.0)6.0 (3.0-9.0)2.0 (0.0-5.0)5.5 (2.0-10.5)<0.001Total Tender5.5 (3.0-12.0)8.0 (4.0-11.0)13.0 (8.0-20.0)15.0 (8.0-20.0)<0.001Tender-Swollen JC Difference4.0 (0.0-8.0)2.0 (0.0-4.0)8.0 (4.0-18.0)5.5 (2.5-13.5)<0.001ESR mm/hour10.0 (8.0-16.0)14.0 (10.0-30.0)12.0 (7.0-23.0)19.5 (11.5-42.5)0.021Pain VAS50.0 (40.0-65.0)50.0 (30.0-60.0)60.0 (47.5-77.5)67.5 (55.0-80.0)<0.001Patient VAS50.0 (30.0-70.0)40.0 (30.0-70.0)60.0 (40.0-80.0)65.0 (50.0-80.0)0.006Physician VAS30.0 (20.0-50.0)50.0 (40.0-60.0)30.0 (20.0-40.0)50.0 (32.5-70.0)<0.001DAS28 (ESR)4.2 (3.7-4.9)4.7 (4.1-5.2)4.7 (3.9-5.8)5.6 (4.9-6.6)<0.001

Conclusion:

These data using comprehensive US assessment to detect inflammatory joint disease, demonstrate that active inflammation defined as at least 1PDUS+ joint, may account for disease activity in slightly less than half of unselected patients with RA with a DAS28ESR score >3.2. This study shows how frequently pain sensitisation accounts for symptoms and signs in RA. We suggest in addition to central sensitisation, often called FM, another group identified here as -FM-PD, may have pain from joint damage or peripheral pain sensitisation of joints, likely due to different mechanisms than central pain sensitisation.

References:

[1]Mian A et al, BMC Musculoskelet Disord. 2016;17: 404

[2]Wolfe F et al, Arth Care & Res 2010; 62:600

Disclosure of Interests:

Khaldoun Chaabo: None declared, Estee Chan: None declared, Toby Garrood: None declared, Zoe Rutter-Locher: None declared, Alexandra Vincent: None declared, James Galloway Speakers bureau: Dr Galloway has received speaker fees / honoraria from Abbvie, BMS, Celgene, Chugai, Gilead, Janssen, Lilly, Novartis, Pfizer, Roche, Sanofi, Sobi and UCB, Sam Norton: None declared, Bruce Kirkham Speakers bureau: Professor Bruce Kirkham has received speaker fees / honoraria from Abbvie, Gilead, Janssen, Lilly, Novartis, Pfizer,and UCB., Grant/research support from: Professor Bruce Kirkham has received research support from Lilly, Novartis and UCB.

Professor Bruce Kirkham has received speaker fees / honoraria from Abbvie, Gilead, Janssen, Lilly, Novartis, Pfizer and UCB.

Sex-based differences in program completion and clinical outcomes in patients following outpatient cardiac rehabilitation

Funding Acknowledgements

Type of funding sources: None.

Background

Females have greater reduction in mortality compared to males, following completion of a cardiac rehabilitation (CR) program, yet they continue to have lower referral rates and program completion. Since 1996, a local rehabilitation program has been the main provider of CR in our health zone. A standardized rapid referral program was implemented in 2008 to improve referral rates of hospitalized patients. Since then, the relationship between sex and CR completion is unknown.

Purpose

To evaluate the relationship between sex and CR completion and to evaluate the association between CR completion and clinical outcomes, stratified by sex.

Methods: We included consecutive patients who were referred to CR and who

1) were hospitalized for an acute coronary syndrome (ACS) or stable angina between 2008 and 2016; 2) had angiographic evidence of at least one-vessel coronary disease; and 3) had revascularization with percutaneous intervention, coronary artery bypass or medical management. The outcomes of interest were CR completion, anxiety and depression categories, exercise capacity, death, and need for revascularization. Logistics regression models were used to determine the association between sex and CR completion. The association between sex, CR completion, and the outcomes of interest were assessed using multivariable cox proportional hazards models.

Results

A total of 726 females and 2645 males were included in this study. The rate of CR completion was lower in females compared to males (64.6% vs 69.98%, p = 0.006). Following adjustment for baseline characteristics, female sex independently predicted lower rates of CR completion, OR 0.81 (95%CI 0.67-0.97).

Both sexes displayed improvements in peak metabolic equivalents (METs) achieved during exercise testing (W: initial 5.99 ± 1.93; 12-week 7.22 ± 1.92; M: initial 7.62 ± 2.04; 12-week 8.81 ± 1.93, p = 0.001). Amongst CR completers, one-year mortality was similar between sex (W: 1.84% vs M: 3.27%, p = 0.118), as was revascularization (W: 14.29% vs M: 11.97%, p = 0.193), however both sexes had higher one-year mortality in CR non-completers.

Conclusion

Despite a standardized CR referral protocol, a sex-difference in CR completion remains. In CR completers, one-year mortality and revascularization was similar in both sexes, however mortality was higher in CR non-completers. Our study suggests that addressing the causes of female CR non-completion following ACS or stable angina may improve outcomes.

Outcomes by CR Completion and Sex All NC (n = 1051) W-NC (n = 257) M-NC (n = 794) p-value All C (n = 2320) W-C (n = 469) M-C (n = 1851) p-value Revascularization-1 year (%) 146 (14.94) 28 (11.72) 118 (15.59) 0.107 267 (12.44) 62 (14.29) 205 (11.97) 0.193 Death-1 year (%) 67 (6.86) 19 (7.95) 48 (6.50) 0.442 64 (2.98) 8 (1.84) 56 (3.27) 0.118 W = Women;M = Men;NC = Non-Completers;C = Completers

A new respiratory scoring system for evaluation of respiratory outcomes in children with spinal muscular atrophy type1 (SMA1) on SMN enhancing drugs

Nusinersen (NUS), the first treatment approved for Spinal Muscular Atrophy type 1 (SMA1), was made available in the UK for SMA1 through the Expanded Access Program (EAP) in 2017. The Great Ormond Street Respiratory (GSR) score was developed as an objective respiratory assessment for children with SMA1 during their treatment. Aims: Track respiratory status of SMA1 children over the course of Nusinersen treatment and compare GSR scores amongst SMA1 sub-types. Single centre study on SMA1 patients using the GSR score at set time points: prior to first NUS dose; 2 weeks post end of loading doses; 2 weeks post-subsequent doses. GSR score ranges 1-28, being 1-9 = Stable minimal support, thorough to 23-28 = Poor reserve with maximum support. 20 SMA1 children underwent NUS treatment between January 2017 - November 2018. Median age of diagnosis was 5.0 months. NUS started at median of 9.57 months. From 5th dose onwards, GSR scores were significantly lower for Type 1C patients compared to Type 1B By month 18, irrespective of subtypes, the whole cohort appears to stabilise GSR Scores. As treatment duration increases, an overall stabilisation of respiratory status across the cohort was observed. Further longitudinal studies are needed to validate the GSR.

An elevated C-reactive protein level in an inpatient rehabilitation setting after joint replacement: To act or not to act? - that is the question

C-reactive protein (CRP) is part of a battery of "routine bloods" performed by residents on patients when they are admitted into a rehabilitation unit. Generally, an elevated CRP is considered to be an indicator of an acute infective process. Numerous studies have indicated that the CRP peaks on the 2nd or 3rd day post total hip arthroplasty (THR) and total knee arthroplasty (TKR) and returns to normal by day 7. When the CRP level remains elevated, it is generally felt that infection should be excluded.We performed a prospective study on 45 consecutive patients admitted into a rehabilitation unit post hip and knee arthroplasty over a 6 months period, to evaluate the incidence of an elevated CRP on admission, to determine whether an isolated elevated CRP on admission to a rehabilitation setting should not be considered as an indicator of an infective process.We found all patients (100%) had elevated CRP's on admission, ranging from 8.6 mg/L to 139.2 mg/L, between days 5-7 post-operatively. By day 14, CRP's reduced, but 91% of patients still had elevated CRP's, ranging from 2.1 mg/L to 47.3 mg/L after THR and 4.8 mg/L to 40 mg/L after TKR at day 14.These results suggest that even in uncomplicated elective joint arthroplasty, CRP's can remain elevated up to 14 days post-procedure, in the absence of an infective process.An isolated elevated CRP on admission to a rehabilitation setting should not be considered as an indicator of an infective process, but rather part of the normal post-operative inflammatory response. The elevated CRP should be monitored and only an upward trend requires further investigation and management.

What are the key success factors for strategy formulation and implementation? Perspectives of managers in the hotel industry

This study investigates how hotel managers describe strategy and identify key success factors for its formulation and implementation. The study analyzes qualitative data collected through semi-structured interviews with property level top managers of hotels in Hong Kong. The findings show that hotel managers prioritize competition analysis and macro-environmental conditions over internal characteristics such as teamwork in strategy formulation. In the implementation phase, however, internal considerations such as employee involvement and strategic consensus are given prominence. This study provides a significant contribution by examining how top level practitioners in the industry interpret success factors in their strategic management efforts, and it highlights a largely neglected area in the hospitality and tourism management literature.

Fast understanding of phases and phase separation in liquid crystal drug delivery systems using deuterium solid-state NMR

Characterization of lipid based (SPC/GDO/H₂O) liquid crystal (LC) drug delivery system is non-trivial and highly complex, especially when multiple and intermediate phases are present. The phase behavior of such mixtures during hydration or delivery is still poorly understood and therefore, characterizing these systems is crucially important towards controlling their function and enhancing the understanding of their drug release behavior. Current work has established an easy way to identify liquid crystal phases and phase mixtures using deuterium (²H) solid-state nuclear magnetic (NMR) spectroscopy under static conditions without disrupting the three dimensional structure and phases, as magic-angle spinning (MAS) could lead to disruption of the phases. Small angle X-ray scattering (SAXS) technique and optical microscopy were also employed to corroborate the study.

Student nurses' ethical views on responses to the severe acute respiratory syndrome outbreak

BACKGROUND

Fifteen years have passed since the outbreak of severe acute respiratory syndrome in Hong Kong. At that time, there were reports of heroic acts among professionals who cared for these patients, whose bravery and professionalism were highly praised. However, there are concerns about changes in new generation of nursing professionals.

OBJECTIVE

We aimed to examine the attitude of nursing students, should they be faced with severe acute respiratory syndrome patients during their future work.

RESEARCH DESIGN

A questionnaire survey was carried out to examine the attitude among final-year nursing students to three ethical areas, namely, duty of care, resource allocation, and collateral damage.

ETHICAL CONSIDERATIONS

This study was carried out in accordance with the requirements and recommendations of the Central Research and Ethics Committee, School of Health Sciences at Caritas Institute of Higher Education.

FINDINGS

Complete responses from 102 subjects were analyzed. The overwhelming majority (96.1%) did not agree to participate in the intubation of severe acute respiratory syndrome patients if protective measures, that is, N95 mask and gown, were not available. If there were insufficient N95 masks for all the medical, nursing, and allied health workers in the hospital (resource allocation), 37.3% felt that the distribution of N95 masks should be by casting lot, while the rest disagreed. When asked about collateral damage, more than three-quarters (77.5%) said that severe acute respiratory syndrome patients should be admitted to intensive care unit. There was sex difference in nursing students' attitude toward severe acute respiratory syndrome care during pregnancy and influence of age in understanding intensive care unit care for these patients. Interestingly, 94.1% felt that there should be a separate intensive care unit for severe acute respiratory syndrome patients.

CONCLUSION

As infection control practice and isolation facilities improved over the years, relevant knowledge and nursing ethical issues related to infectious diseases should become part of nursing education and training programs, especially in preparation for outbreaks of infectious diseases or distress.

A198 EOSINOPHILIC ESOPHAGITIS WITH STRICTURE PRESENTING SHORTING AFTER INITIATION OF ORAL PEANUT IMMUNOTHERAPY

Background

Oral immunotherapy (OIT) is increasingly practiced outside of research settings with reasonable success (Soller 2019).

With OIT, a patient eats their food allergen daily, gradually increasing the dose, with the goal to prevent or reduce the severity of an anaphylactic reaction.

One of the described adverse events of OIT is a risk of developing Eosinophilic Esophagitis (EoE), with cited frequency of 2.7% (Lucendo 2014). In addition, OIT is typically contraindicated in patients with known EoE but patients are not routinely screened for EoE prior to initiation of OIT.

Aims

To present a case of a 12 year old boy with peanut anaphylaxis who developed eosinophilic esophagitis and an esophageal stricture shortly after starting peanut immunotherapy

Methods

Patient chart review was conducted. A literature review was done using the words “eosinophilic esophagitis” and “immunotherapy”.

Results

A12 year old boy with asthma, allergic rhinitis and multiple anaphylactic food allergies, started peanut OIT with an allergist. Prior to OIT, the patient had no symptoms suggestive of EoE such as dysphagia, heartburn, chest pain or washing of food. Approximately 3.5 weeks into treatment, the patient developed daily vomiting. The patient was advised to stop the peanut OIT three days after symptom onset, but the vomiting continued for another 8 days. By the time of endoscopy (16 days after onset of vomiting), the vomiting had completely subsided for the previous five days.

The upper GI endoscopy demonstrated signs of EoE throughout the length of the esophagus. In the mid esophagus there was resistance where the 9.8 mm gastroscope was unable to pass. A smaller gastroscope with a 5.9 mm width was easily able to pass through the stricture. Histology showed marked eosinophilia throughout the esophagus with basal cell hyperplasia, spongiosis, superficial microabscesses and stromal fibrosis consistent with EoE. The patient continued to be ‘asymptomatic’ at the time of endoscopy and after despite the presence of a stricture. After discussion, the patient was started on oral viscous budesonide (OVB) 1mg PO BID.

The patient was re-scoped 4 weeks into OVB therapy with complete resolution of the stricture with neither macroscopic nor histologic findings of EoE. Patient is now off OVB for over a month, remains asymptomatic, and will undergo repeat endoscopy in the upcoming month to ensure normal histology

Conclusions

This is the first case describing EoE with an esophageal stricture shortly after initiation of OIT. Pediatric Gastroenterologists need to be increasingly aware that patients undergoing OIT are at an increasing risk of ‘developing’ or at least ‘unmasking’ EoE. More research is required to evaluate whether EoE screening, by symptom questionnaire or endoscopy is warranted prior to beginning OIT, and whether OIT is truly needed.

Funding Agencies

CAG

Evaluation and Clinical Course of Keratomalacia With Descemetocele in a Child With Autism and Vitamin A Deficiency

Autistic children with selective diets have an elevated risk for vitamin A deficiency. The authors present the case of a 7-year-old boy with keratomalacia resulting from dietary vitamin A deficiency. Optical coherence tomography and ultrasound biomicroscopy can provide useful details of the cornea and underlying structures. Vitamin A supplementation can result in significant resolution, obviating the need for surgical intervention. [J Pediatr Ophthalmol Strabismus. 2020;57:e1-e3.].

Autoimmune glial fibillary acidic protein astrocytopathy associated meningoencephalomyelitis and bilateral sensorineuronal deafness

Autoimmune encephalitis is an important group of disease that can mimic infectious encephalitis, with one of the most severe forms being meningoencephalomyelitis. One of the recently identified biomarkers, glial fibillary acidic protein (GFAP), targets the cytosolic intermediate filament protein of astrocytes and causes a variety of clinical symptoms. Here, we report an adult Chinese woman presented with acute onset of confusion, CSF lymphocytosis, markedly elevated total protein mimicking tuberculosis meningitis with rapid deterioration resulted in coma and respiratory failure. She was diagnosed with anti-GFAP meningoencephalomyelitis, which later developed tetraplegia, sensorineural hearing loss, brainstem, bulbar and respiratory dysfunction. Intravenous immunoglobulin and methylprednisolone resulted in partial improvement. Further immunotherapy with plasma exchange and rituximab resulted in marked recovery.

Perioperative anaphylaxis and investigations: a local study in Hong Kong

INTRODUCTION

Data on local intraoperative anaphylaxis in Hong Kong is scarce, with few reviews available. We aimed to study the characteristics, presentations and workup results of cases referred to a local allergy clinic.

METHODS

A retrospective review was performed of patient referrals and workup results for suspected intraoperative anaphylaxis at Queen Mary Hospital drug allergy clinic in 2012-2016.

RESULTS

Tryptase was checked in only 81.7% (49/60) of the cases, most of which showed elevation (71.4%, 35/49). Among the 59 patients who received a workup, 47 (79.7%) showed positive findings, with a particularly high yield in the tryptase-positive subgroup (88.6%, 31/35). Among the 54 patients who consented to skin tests (the most sensitive investigation), 43 (79.6%) cases were positive. Overall, neuromuscular blockers were the commonest cause (25.0%, 15/60) of intraoperative anaphylaxis, while antibiotics ranked second (23.3%, 14/60). The timing of reactions was an important indication of potential allergens. For example, the majority of the neuromuscular blocker allergies occurred during the induction phase, while all gelofusine allergic events were in the maintenance phase of anaesthesia. 13 (21.7%) out of 60 cases received subsequent general anaesthesia procedures, with no recurrence of allergic reactions.

CONCLUSION

Proper workup after an intraoperative anaphylactic event has a fairly good chance of identifying the causative allergen. These results are useful for patient management and the planning of subsequent anaesthetic procedures.