The impact of daily mean air temperature on the proportion of time in hypoglycemia in 2,582 children and adolescents with type 1 diabetes - Is this association clinically relevant?

OBJECTIVES

To study the potential association between increases in daily mean air temperature and time below range (TBR <54 mg/dl) and time above range (TAR >250 mg/dl) in children and adolescents with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Individuals with type 1 diabetes <21 years with information on daily glucose profiles from the diabetes prospective follow-up study (DPV) were included (n = 2582). Further inclusion criteria were age at least 6 months at diabetes onset, diabetes duration for at least one year and treatment years 2020-2021. Mean daily air temperature and other meteorological parameters from 78 measurement stations in Germany were linked to the individual glucose sensor profile via the five-digit postcode areas of residency. We used multivariable repeated measures fractional logistic regression models with a compound symmetry covariance structure to study the association between a 1 °C increase in daily mean temperature and time in specific glucose ranges.

RESULTS

A 1 °C increase in daily mean temperature was associated with an acute (Odds Ratio (OR) 1.009 (95%-CI 1.007, 1.011)) and up to 7 days delayed (OR 1.003 (1.001, 1.005)) increase in TBR <54 mg/dl. Moreover, an acute decrease in TAR >250 mg/dl (OR 0.997 (0.996, 0.997)) was found.

CONCLUSIONS

Results of the DPV registry showed small, but statistically significant changes in TBR and TAR in association with a short-term temperature increase. Higher blood flow and faster insulin absorption might be one possible mechanism. In times of increasing temperature fluctuations meteorological impacts on time in range could become even more relevant.

Programmatic Precision Oncology Decision Support for Patients With Gastrointestinal Cancer

PURPOSE

With the growing number of available targeted therapeutics and molecular biomarkers, the optimal care of patients with cancer now depends on a comprehensive understanding of the rapidly evolving landscape of precision oncology, which can be challenging for oncologists to navigate alone.

METHODS

We developed and implemented a precision oncology decision support system, GI TARGET, (Gastrointestinal Treatment Assistance Regarding Genomic Evaluation of Tumors) within the Gastrointestinal Cancer Center at the Dana-Farber Cancer Institute. With a multidisciplinary team, we systematically reviewed tumor molecular profiling for GI tumors and provided molecularly informed clinical recommendations, which included identifying appropriate clinical trials aided by the computational matching platform MatchMiner, suggesting targeted therapy options on or off the US Food and Drug Administration-approved label, and consideration of additional or orthogonal molecular testing.

RESULTS

We reviewed genomic data and provided clinical recommendations for 506 patients with GI cancer who underwent tumor molecular profiling between January and June 2019 and determined follow-up using the electronic health record. Summary reports were provided to 19 medical oncologists for patients with colorectal (n = 198, 39%), pancreatic (n = 124, 24%), esophagogastric (n = 67, 13%), biliary (n = 40, 8%), and other GI cancers. We recommended ≥ 1 precision medicine clinical trial for 80% (406 of 506) of patients, leading to 24 enrollments. We recommended on-label and off-label targeted therapies for 6% (28 of 506) and 25% (125 of 506) of patients, respectively. Recommendations for additional or orthogonal testing were made for 42% (211 of 506) of patients.

CONCLUSION

The integration of precision medicine in routine cancer care through a dedicated multidisciplinary molecular tumor board is scalable and sustainable, and implementation of precision oncology recommendations has clinical utility for patients with cancer.

MatchMiner: an open-source platform for cancer precision medicine

Widespread, comprehensive sequencing of patient tumors has facilitated the usage of precision medicine (PM) drugs to target specific genomic alterations. Therapeutic clinical trials are necessary to test new PM drugs to advance precision medicine, however, the abundance of patient sequencing data coupled with complex clinical trial eligibility has made it challenging to match patients to PM trials. To facilitate enrollment onto PM trials, we developed MatchMiner, an open-source platform to computationally match genomically profiled cancer patients to PM trials. Here, we describe MatchMiner’s capabilities, outline its deployment at Dana-Farber Cancer Institute (DFCI), and characterize its impact on PM trial enrollment. MatchMiner’s primary goals are to facilitate PM trial options for all patients and accelerate trial enrollment onto PM trials. MatchMiner can help clinicians find trial options for an individual patient or provide trial teams with candidate patients matching their trial’s eligibility criteria. From March 2016 through March 2021, we curated 354 PM trials containing a broad range of genomic and clinical eligibility criteria and MatchMiner facilitated 166 trial consents (MatchMiner consents, MMC) for 159 patients. To quantify MatchMiner’s impact on trial consent, we measured time from genomic sequencing report date to trial consent date for the 166 MMC compared to trial consents not facilitated by MatchMiner (non-MMC). We found MMC consented to trials 55 days (22%) earlier than non-MMC. MatchMiner has enabled our clinicians to match patients to PM trials and accelerated the trial enrollment process.

POS1103 “WHAT MATTERS”: PATIENT AND CLINICIAN PERSPECTIVES IN PSORIATIC ARTHRITIS CARE

Background

Recent psoriatic arthritis (PsA) treatment recommendations (1) highlight the importance of shared decision making; this ideally requires the clinician understands “what matters” to each patient regarding their disease. Concurrently, patient research partners have been incorporated into projects for the OMERACT core domain set (2) and measures of physical function and (health related) quality of life (3). Currently, less is known about the similarities and differences between patient and clinician perspectives.

Objectives

To interrogate and deliniate commonalities and discrepancies in “what matters” to patients and to physicians in routine clinical care.

Methods

A comprehensive list of items describing the PsA patient experience was generated in medical anthropologist-designed (CH) peer-to-peer discussions in 4 patient focus groups across the United States (Seattle, Cleveland, Washington, DC). These items were combined with those from the GRAPPA-OMERACT PsA Outcomes patient-physician consensus project (2). A PsA physician and patient steering committee reviewed and revised the list with additional topics considered to be of importance. The final list of 51 items went through a 3 round Delphi process starting with 53 PsA patients and a 2 round Delphi with 13 PsA expert rheumatologists. In each round, participants rated each item for level of importance out of 100 total points.

Results

Top priority items for each group are depicted in Figure 1. Both patients and physicians rated ‘Arthritis -Joint pain and swelling’ in the top two. Five additional items were included for both groups but with different scores; all related to disease manifestations or physical consequences. Several items received disparate priority between groups. In this set, patients included two unique items: access to care and future health uncertainty. Other items affecting everyday function were noted. Physician priorities included specific disease manifestations and physical/functional outcomes, and the topic of “disease management goals”, focusing on patient-physician communication regarding a treatment plan.

Figure 1.

Top Patient and Physician Priorities

*Not in set of highest ranked items for that group

Conclusion

Patients and physicians were in consensus that arthritis disease activity, pain and fatigue are key features of the patient’s experience of PsA. Differences appeared in other domains; physicians ranked clinical domains such as enthesitis, dactylitis, and skin disease more highly, patients considered items such as access to care, future health uncertainty and sleep quality to be most important. This study highlights the need for physicians to ask and address “what matters” with patients and to educate patients about potential differences in physicians’ areas of concern to optimize shared decision making.

References

[1]Ogdie A, Coates LC, Gladman D. Treatment guidelines in psoriatic arthritis: Rheumatology 2020;59:i37-i46

[2]Orbai A-M, de Wit M, Mease P, et al. International patient and physician consensus on a psoriatic arthritis core outcome set for clinical trials Ann Rheum Dis 2017;76:673–680.

[3]Gossec L, de Wit M, Kiltz U, et al. A patient-derived and patient-reported outcome measure for assessing psoriatic arthritis: elaboration and preliminary validation of the Psoriatic Arthritis Impact of Disease (PsAID) questionnaire, a 13-country EULAR initiative. Ann Rheum Dis 2014;73: 1012–9.

Disclosure of Interests

Philip J Mease Speakers bureau: AbbVie, Amgen, Eli Lilly, Genentech, Janssen, Pfizer, Novartis, UCB, Consultant of: AbbVie, Amgen, BMS, Eli Lilly, Galapagos, Celgene, Boehringer Ingelheim, Genetech, Novartis, Janssen, Pfizer, Sun Pharma, UCB, GSK, Grant/research support from: AbbVie, Amgen, BMS, Eli Lilly, Galapagos, Genetech, Novartis, Janssen, Sun Pharma, Pfizer, Daniel Furst Speakers bureau: Corbus, GSK, Sanofi, Consultant of: Actelion, Amgen, BMS, Corbus, Galapagos, Sanofi, Novartis, Pfizer, Grant/research support from: Actelion, Amgen, BMS, Galapagos, Sanofi, Roche/Genetech, Novartis, Pfizer, Evan Siegel Speakers bureau: AbbVie, Janssen, UCB, Novartis, Lilly, Consultant of: AbbVie, Janssen, UCB, Novartis, Lilly, BMS, Vibeke Strand Consultant of: Abbvie Amgen Corporation Arena

Aria

AstraZeneca, Bayer, Bioventus, BMS, Boehringer Ingelheim, Celltrion, Chemocentryx, Elsa, EMD Serono, Endo, Equilium, Flexion, Galapagos, Genentech / Roche, Gilead, GSK, Horizon, Ichnos, Inmedix, Janssen, Kiniksa, Kypha, Lilly, Merck, MiMedx, Novartis, Pfizer, Regeneron, Rheos, R-Pharma, Samsung, Sandoz, Sanofi, Scipher, Servier, Setpoint, Sorrento, Spherix, Sun Pharma, Swing, UCB, Melissa Mcilraith Employee of: Past employee at Abbott and Celgene, M Elaine Husni Consultant of: AbbVie, Amgen, Janssen, Novartis, Eli Lilly, UCB, Regeneron, M. Cameron Hay Grant/research support from: Novartis for this IIS

AB0966 Are Current Patient Reported Outcomes Tools Optimized to Capture the Entire Patient Experience?

Background

Psoriatic Arthritis (PsA) affects multiple attributes of patient health; to assess treatment effectiveness a compilation of Patient Reported Outcomes (PRO) have been utilized. While useful, most of these were originally created for other diseases and only later validated or adapted for use in PsA. More recent efforts have focused on development of PsA specific PRO tools, with inclusion of patient input and relevance for use in both clinical research and clinical care (1).

Objectives

To subject a broad set of currently used PROs to patient assessment, giving insight into usefulness in the clinic and informing efforts for optimization of PsA PROs.

Methods

Four focus groups were conducted across three regionally-diverse areas in the United States from March 2016 to October 2016. Patients represented a range of disease history, symptoms, and severity. After trained facilitators encouraged open conversation about PsA, including symptoms, challenges and feelings about disease and treatment, patients reviewed 13 currently utilized PROs and rated relevance of these instruments to reporting their disease experiences on a 3 point scale of Relevant, Somewhat Relevant, and Irrelevant. Verbal discussion followed on the merits and challenges of each rated PRO

Results

PRO instruments ranged from overall global assessments to disease specific assessments (Table 1). The PROs received a variety of ratings, with Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-F) and Psoriatic Arthritis Impact of Disease (PsAID) judged as Very Relevant by the largest number of patients, followed by Health Assessment Questionnaire-Spondyloarthropathies (HAQ-S) and Pain VAS (Figure 1). Instruments receiving the most assessments of Not Really Relevant were Pt Global and PsA Quality of Life (PsAQOL). In the qualitative portion of the research, major patient critiques across PROs were the time frames listed on the questionnaires; some were too restrictive and disallowed reporting important recent disease activity. Preferences were for questions asked as ‘..since your last visit..’. Multiple participants also agreed that a visual tool allowing patients to circle specific joints to indicate pain would be useful.

Table 1.

Outcomes Instruments Assessed in the Study

ToolAbbreviationTime Period QueriedPatient GlobalPt GANone SpecifiedPain Visual Analog ScalePain VASIn the past weekHealth Assessment Questionnaire-SpondyloarthropathiesHAQ-SOver the past weekShort Form - 36SF-36Different periods queried for different questions: Compared to a year ago; None Specified; Over the past 4 weeksFunctional Assessment of Chronic Illness Therapy - FatigueFACIT-FPast 7 DaysEQ-5D and EQ Visual Analog ScaleEQ-5D-5LTodayPsoriatic Arthritis Quality of LifePsAQOLNone specifiedPsoriatic Arthritis Impact of DiseasePsAIDDuring the last weekDermatology Life Quality IndexDLQIOver the last WeekPsoriasis Symptom InventoryPSILast 7 daysWork Productivity and Activity Impairment: General HealthWPAI:GHDuring the past 7 daysWork Productivity Survey - PsAWPS-PsALast monthBeck Depression InventoryBDI-IIDuring the past 2 weeks

Conclusion

Currently utilized PROs in PsA evaluating domains of fatigue, function, pain, and disease specific manifestations were all important regarding new therapeutic agents. However, some are more relevant than others to patients, most notably FACIT-F and PsAID, the latter being an important example of a patient-led and disease-specific development effort. Allowing reporting of items of concern without restrictive time periods is important to patients. These preferences and comments can be utilized to better understand the value of PROs in clinical settings to optimize patient-clinician communications.

References

[1]Gossec L, de Wit M, Kiltz U, et al. A patient-derived and patient-reported outcome measure for assessing psoriatic arthritis: elaboration and preliminary validation of the Psoriatic Arthritis Impact of Disease (PsAID) questionnaire, a 13-country EULAR initiative. Ann Rheum Dis 2014;73: 1012–9.

Disclosure of Interests

Philip J Mease Speakers bureau: AbbVie, Eli Lilly, Genentech, Janssen, Pfizer, Amgen, Novartis, UCB, Consultant of: AbbVie, Eli Lilly, Boehringer Ingelheim, Pfizer, Amgen, GAlapagos, Genentech, Janssen, Sun Pharma, BMS, Celgene, Novartis, UCB, GSK, Grant/research support from: AbbVie, Eli Lilly, Genentech, Janssen, Pfizer, Amgen, Galapagos, Novartis, Sun Pharma, BMS, Vibeke Strand Consultant of: Abbvie, Amgen Corporation, Arena, Aria, AstraZeneca, Bayer, Bioventus, BMS, Boehringer Ingelheim, Celltrion, Chemocentryx, Elsa, EMD Serono, Endo, Equilium, Flexion, Galapagos, Genentech / Roche, Gilead, GSK, Horizon, Ichnos, Inmedix, Janssen, Kiniksa, Kypha, Lilly, Merck, MiMedx, Novartis, Pfizer, Regeneron, Rheos, R-Pharma, Samsung, Sandoz, Sanofi, Scipher, Servier, Setpoint, Sorrento, Spherix, Sun Pharma, Swing, UCB, Daniel Furst Speakers bureau: Corbus, GSK, Sanofi, Consultant of: Actelion, Amgen, BMS, Corbus, Galapagos, Sanofi, Novartis, Pfizer, Grant/research support from: Actelion, Amgen, BMS, Galapagos, Sanofi, Roche/Genentech, Novartis, Pfizer, Evan Siegel Speakers bureau: AbbVie, Janssen, Eli Lilly, Novartis, UCB, Consultant of: BMS, AbbVie, Janssen, Eli Lilly, Novartis, UCB, Melissa Mcilraith Employee of: Past Employee of Abbott and Celgene, M Elaine Husni Consultant of: AbbVie, Amgen, Janssen, Novartis, Eli Lilly, UCB, Regeneron, M. Cameron Hay Grant/research support from: Novartis

Abstract 1198: MatchMiner: An open-source computational platform that accelerates patient enrollment on to precision medicine trials

With the advent of next generation sequencing in cancer care, patients' tumors can be genomically profiled and specific genetic alterations can be targeted with precision medicine drugs. However, the abundance of patient sequencing data coupled with complex clinical trial eligibility has made it challenging to match patients to precision medicine trials. To facilitate interpretation of complex tumor sequencing data and clinical trial genomic eligibility criteria, we developed MatchMiner, an open-source platform to computationally match cancer patients to precision medicine clinical trials. MatchMiner supports two distinct workflows: (1) patient-centric mode, in which an oncologist can find clinical trial matches for a specific patient, and (2) trial-centric mode, in which a clinical trial investigator can identify and recruit patients for a specific trial. In MatchMiner at DFCI, there are currently 330+ precision medicine trials and genomic and genomic and clinical data from 39,000+ patients. Although MatchMiner has been operational at Dana-Farber Cancer Institute since early 2017, its impact on patient care has not yet been extensively studied.

In this study, we analyzed temporal trends of 170 MatchMiner-driven trial enrollments. We compared these 170 MatchMiner-driven trial enrollments to non-MatchMiner-driven trial enrollments to determine how MatchMiner has impacted patient enrollments. To compare MatchMiner-driven trial enrollments to non-MatchMiner-driven enrollments, we limited the non-MatchMiner group by choosing patients who enrolled on the same trials. We also ensured that all patients in both enrollment groups had a genomic report present in MatchMiner before their consent date. We then analyzed temporal trends between genomic report dates, patient consent and on-study dates, and patient views in MatchMiner. MatchMiner-driven enrollments had a significant decrease in time from genomic report date to consent date compared to non-MatchMiner-driven enrollments. Thus, clinical use of MatchMiner decreased time to enroll in a precision medicine study, and suggests that use of precision medicine trial matching tools such as MatchMiner are important for the future of patient care.

The MatchMiner open-source software package is available through GitHub (https://github.com/dfci/matchminer). We are committed to supporting MatchMiner as an open-source software; to our knowledge, at least five cancer centers are implementing MatchMiner.

Citation Format: Harry Klein, Tali Mazor, Priti Kumari, James Lindsay, Andrea Ovalle, Ethan Siegel, Pavel Trukhanov, Joyce Yu, Michael Hassett, Ethan Cerami. MatchMiner: An open-source computational platform that accelerates patient enrollment on to precision medicine trials [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 1198.

Abstract 3382: MatchMiner: An open-source computational platform for genomically-driven matching of cancer patients to precision medicine clinical trials

To facilitate interpretation of complex tumor sequencing data and clinical trial genomic eligibility criteria, we developed MatchMiner, an open-source platform to computationally match cancer patients to precision medicine clinical trials based on clinical and genomic features. MatchMiner supports two distinct workflows: (1) patient-centric mode, in which an oncologist can find clinical trial matches for a specific patient, and (2) trial-centric mode, in which a clinical trial investigator can identify and recruit patients for a specific trial.

MatchMiner has been operational at Dana-Farber Cancer Institute since early 2017. There are currently 275+ trials curated in the system and genomic data from 26,000+ patients. Over 80% of living patients match to at least one open clinical trial, with an average of 6 trial matches per patient. At least 98 patients have enrolled on a clinical trial as a result of MatchMiner.

To enable computational matching, we developed clinical trial markup language (CTML), a structured format to encode detailed information about a trial. CTML utilizes boolean logic to define clinical (e.g. cancer type), demographic (e.g. age) and genomic (e.g. specific mutations, copy number alterations, structural variants or mutational signatures) eligibility, which can be applied to individual arms of a trial.

MatchMiner is an open-source two-tier web application with a Python-based REST API server and an AngularJS front-end. MatchMiner utilizes Security Assertion Markup Language (SAML)-based authentication and is fully HIPAA-compliant when hosted behind a secure institutional firewall. MatchMiner ingests clinical and genomic data, and connects to existing clinical systems, including clinical trial management systems for real-time trial status.

We recently refactored the core matching algorithm (the matchengine), which improves upon the original matchengine in several ways: (1) increased granularity in reporting the reason for a match; (2) can match all patients/trials or individual patients/trials; (3) easily extensible to match based on additional data types.

The MatchMiner open-source software package is available through GitHub (https://github.com/dfci/matchminer). We are committed to supporting MatchMiner as an open-source software; to our knowledge, at least five cancer centers are implementing MatchMiner at their own institutions.

In summary, we have defined a standard for encoding clinical trial information in a structured and computable form, and we have developed an open-source computational trial matching platform to support patient-specific trial identification as well as trial-specific patient recruitment. We are actively collaborating with clinical groups at Dana-Farber Cancer Institute and other institutions to understand the role of MatchMiner in their clinical workflows, and we are committed to continuing to evolve MatchMiner to meet clinical needs.

Citation Format: Tali Mazor, Rachel B. Keller, Priti Kumai, James Lindsay, Eric Marriott, Andrea Ovalle, Ethan Siegel, Joyce Yu, Michael Hassett, Ethan Cerami. MatchMiner: An open-source computational platform for genomically-driven matching of cancer patients to precision medicine clinical trials [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 3382.

Abstract A024: MatchMiner: An open-source computational platform for genomically-driven matching of cancer patients to precision medicine clinical trials

To facilitate interpretation of complex tumor sequencing data and clinical trial genomic eligibility criteria, we developed MatchMiner, an open-source platform to computationally match cancer patients to precision medicine clinical trials based on clinical and genomic features. MatchMiner supports two distinct workflows: (1) a patient-centric mode, in which an oncologist can find clinical trial matches for a specific patient, and (2) a trial-centric mode, in which a clinical trial investigator can identify and recruit patients for a specific trial. MatchMiner has been operational at Dana-Farber Cancer Institute since early 2017. There are currently 250+ trials curated in the system and genomic data from 24,000+ patients. Over 82% of living patients match to at least one open clinical trial, with an average of 6 trial matches per patient. At least 85 patients have enrolled on a clinical trial as a result of MatchMiner. The MatchMiner open-source software package is available through GitHub (https://github.com/dfci/matchminer). MatchMiner is a two-tier web application with a Python-based REST application programming interface (API) server and an AngularJS front-end. MatchMiner utilizes Security Assertion Markup Language (SAML)-based authentication and, when hosted behind a secure institutional firewall, is fully HIPAA-compliant. MatchMiner can connect to existing clinical systems, including clinical trial management systems for real-time trial status. To enable computational matching to clinical trials, we developed clinical trial markup language (CTML), a structured format to encode detailed information about a trial. CTML utilizes boolean logic to define clinical (e.g. cancer type), demographic (e.g. age) and genomic (e.g. specific mutations, copy number alterations, structural variants or mutational signatures) eligibility, which can be applied to individual arms of a trial. We recently refactored the core matching algorithm (the matchengine), which improves upon the original matchengine in several ways. While the original matchengine reported the reason for a patient-trial match, the refactored matchengine provides additional, more granular details. In addition, the original matchengine ran at the cohort level, matching all patients to all trials, whereas the refactored matchengine can also run against individual patients or trials, speeding up the matching process. The refactored matchengine is also easily extensible to match based on additional data types. In summary, we have defined a standard for encoding clinical trial information in a structured and computable form, and we have developed an open-source computational trial matching platform to support patient-specific trial identification as well as trial-specific patient recruitment. We are actively collaborating with clinical groups at Dana-Farber Cancer Institute to understand the role of MatchMiner in their clinical workflows, and we are committed to continuing to evolve MatchMiner to meet clinical needs.

Citation Format: Tali Mazor, Rachel B Keller, Priti Kumari, James Lindsay, Eric Marriott, Andrea Ovalle, Ethan Siegel, Elizabeth H Williams, Joyce Yu, Michael Hassett, Ethan Cerami. MatchMiner: An open-source computational platform for genomically-driven matching of cancer patients to precision medicine clinical trials [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics; 2019 Oct 26-30; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2019;18(12 Suppl):Abstract nr A024. doi:10.1158/1535-7163.TARG-19-A024

Abstract P6-10-06: Inducing immune responses to tumor associated carbohydrate antigens by a carbohydrate mimetic peptide vaccine: Clinical experience in phase I and phase II trials

Active immunization of cancer patients to induce de novo functional anti-tumor immune responses is an alternative/complementary approach to chemotherapy. Tumor vaccines hold the potential to deliver durable, specific and systemic anti-tumor responses in patients. We have been developing active vaccination strategies targeting tumor associated carbohydrate antigens (TACAs) using carbohydrate mimetic peptides. TACAs play roles in initiation and metastasis of cancer and considered as common targets shared by many tumor types. TACA support cell survival that can be interrupted by anti-carbohydrate antibodies. An early-phase 3+3 clinical trial was conducted to evaluate the feasibility, safety and immune functionality of a carbohydrate mimetic-peptide (CMP) vaccine referred to as P10s, which can induce TACA reactive, proapoptotic antibodies. In this trial a dose-escalation trial of vaccine plus adjuvant was conducted in two cohorts of 3 subjects each. Patients were restricted to females of all races with histologically or cytologically confirmed stage IV breast cancer who had stable disease and a positive recall-antigen response. P10s was synthesized with the Pan-T-cell epitope PADRE and formulated at 300 and 500 µg/injection with MONTANIDE™ ISA 51 VG for the 1st and 2nd cohorts, respectively. Doses of the appropriate formulation of the vaccine were administered to research participants subcutaneously on weeks 1, 2, 3, 7 and 19. Blood samples were collected at various time points and tested for presence and functionality of antibodies. Antibody response to P10s and in particular against the ganglioside GD2 was measured by ELISA. Binding of pre-immune and post-immune sera was assessed against breast cancer cell lines. Vaccination generates IgG response with serum antibodies capable of inhibiting tumor growth in spheroid culture of breast cancer cell lines. The vaccine induced antibodies in all 6 subjects, displaying significant cytotoxic activity against several representative human breast-cancer cell lines. Caspase 3 was involved in the postimmune serum-mediated apoptosis. No cytotoxicity toward a normal breast epithelial cell line was detected. Apoptosis and caspase 3 activation seems to be involved in anti-tumor cell activity. Immunization with the P10s vaccine was found to be safe and tolerable, and induces functional antibodies that potentially have a cell-death-mediated therapeutic benefit. Incubation of spheroids with post-immune serum further sensitized cells to drugs, improving the efficacy of drug treatment at lower doses. The data suggest that the vaccine-induced anti-tumor immune response in combination with standard of care chemotherapy may further improve clinical outcome. Consequently, we are testing the vaccine in a Phase II study in the neoadjuvant setting. 5 Cohorts of 5 patients each administered with the vaccine at different schedules of chemotherapy are being assessed for immune response to the vaccine as in the Phase I study and if the combination approach contributes to a difference in pathological complete response (PCR) from chemotherapy alone.

Citation Format: Kieber-Emmons T, Hutchins LF, Emanuel PD, Pennisi A, Siegel E, Jousheghany F, Karbassi BM, Makhoul I. Inducing immune responses to tumor associated carbohydrate antigens by a carbohydrate mimetic peptide vaccine: Clinical experience in phase I and phase II trials [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-10-06.

Interventions to Improve the Oral Health of People with Dementia or Cognitive Impairment: A Review of the Literature

OBJECTIVE

Oral diseases and conditions are prevalent among older people with dementia and cognitive impairment. While many interventions have been advocated for use in this population, evidence for their effectiveness is unclear. Our objective was to review systematically the content and effectiveness of interventions and implementation strategies used to improve or maintain the oral health of people with dementia or cognitive impairment.

METHODS

Original studies published in English at any time until January 2015 were identified through electronic searches of the Medline, Embase, CINAHL, Scopus and Cochrane databases and hand searches of eligible studies and relevant reviews. Two investigators independently abstracted study characteristics and assessed the methodological quality of eligible studies. Results were presented as a narrative review because significant heterogeneity among included studies precluded a meta-analysis.

RESULTS

The 18 included studies varied considerably in terms of size, scope and focus. Only two studies were identified that had been designed specifically for and examined exclusively in people with dementia or cognitive impairment. All studies were in residential care; none was population-based. While several studies reported positive effects, a number of methodological weaknesses were identified and the overall quality of included studies was poor. The specific outcomes targeted varied across studies but most studies focused almost exclusively on proximal clinical oral health outcomes such as levels of dental or denture plaque. Attempts to measure intervention integrity were limited and there was usually little or no effort to evaluate intervention effects over a sustained period.

CONCLUSION

There is a lack of high quality evidence to support the effectiveness of oral health interventions and implementation strategies for older people with dementia or cognitive impairment. More rigorous, large scale research is needed in this area. Recommendations are provided to improve the overall quality of evaluation in this area. Emphasis must be placed on developing evidence-based, achievable and sustainable oral health strategies if the needs of people with dementia and cognitive impairment are to be met into the future.

Gender-specific Effects of Treatment with Lifestyle, Metformin or Sulfonylurea on Glycemic Control and Body Weight: A German Multicenter Analysis on 9 108 Patients

Effects of diabetes treatment are strongly connected to individual factors, but the relevant role of gender has not been addressed so far. This observational study evaluates whether monotherapy with lifestyle, metformin or sulfonylurea has gender-specific effects on glycemic control and/or body weight. Data of 9 108 patients with type 2 diabetes from 129 German diabetes centers were assessed by a standardized, prospective, computer-based diabetes care and outcome documentation system (DPV-Wiss-database; age 63.1±12.8 years, diabetes duration 5.7±7.4 years, HbA1c 55±17.7 mmol/mol [7.2±1.6%], BMI 30.6±6.1 kg/m(2), 49.3% female patients). Antidiabetic concepts included lifestyle intervention (n=5,787), metformin (n=2,180), sulfonylurea (n=943) or other antidiabetic drugs (n=198), respectively. HbA1c and body weight were compared before and after a stable monotherapeutical period of 0.8±0.4 years. Women had a significantly higher reduction of body weight after treatment with lifestyle (women-0.8±0.1 vs. men-0.2±0.1 kg; p<0.05), metformin (women-1.8±0.2 vs. men-1.2±0.2 kg; p<0.05) or sulfonylurea drugs (women-0.9±0.2 vs. men - 0.1±0.2 kg; p<0.05), whereas men displayed significantly higher HbA1c-reductions after treatment with lifestyle (women-6.9±0.2 mmol/mol [- 0.6±0.02%] vs. men-7.5±0.2 mmol/mol [0.7±0.02%]; p<0.05) and metformin only (women-6.3±0.3 mmol/mol [- 0.6±0.03%] vs. men - 7.4±0.3 mmol/mol [- 0.7±0.03%]; p<0.05). No differences were seen for sulfonylurea monotherapy concerning the HbA1c-reduction (women - 5.6±0.5 mmol/mol [- 0.5±0.05%] vs. men-6.4±0.4 mmol/mol [- 0.6±0.04%]; p=0.196). In summary, antidiabetic treatment concepts might result in gender-specific effects on body weight and HbA1c. Gender might therefore represent another important factor in the context of an individualized treatment management of type 2 diabetes.

[Pharmaceutical and insulin therapy of diabetes mellitus type 2. Update]

BACKGROUND

The prevalence of diabetes mellitus type 2 in the adult population is > 7 %. Despite new therapy options and modern insulins, the therapy remains a challenge. Especially in patients with obesity or high insulin resistance it is often difficult to achieve the necessary target values. In most cases the disease is initially asymptomatic so that the aim is the early recognition and avoidance of complications.

MATERIAL AND METHODS

This article provides an update on the approach options of modern therapy forms in diabetes management.

RESULTS

The foundations of every treatment program are lifestyle interventions, including diabetes schooling. When these fail a pharmaceutical therapy must be initiated which among others is oriented to hemoglobin A1c (HbA1c). The HbA1c target value should take patient-specific circumstances into consideration and should be determined together with the patient. If no contraindications or intolerances are present, metformin is the medication of choice. Apart from metformin, the available data which can be used for guidance are limited. A combination therapy with one or two other oral or injectable medications is suitable to keep the side effects as low as possible. The advantages of other substances in individual cases could be a lower risk of hypoglycemia, reduced weight increase, oral administration and compatibility with renal insufficiency. Ultimately, insulin therapy will be necessary for many patients, either as monotherapy or in combination with other substances. Therapy decisions should be made together with the patient, taking personal preferences into consideration and should include age, body weight, comorbidities, occupational situation and compliance.

CONCLUSION

The Reorganization of the Pharmaceutical Market Act represents a momentarily perceived clear barrier. In the interests of an individualized therapy and personalized disease management, a target-aimed flexibility in diabetes management should be possible in the future.

Is there a benefit to use calculated percent body fat or age- and gender-adjusted BMI-SDS(LMS) to predict risk factors for cardiovascular disease? A German/Austrian multicenter DPV-Wiss analysis on 42 048 type 2 diabetic patients

OBJECTIVE

In clinical practice Body Mass Index is generally used to evaluate overweight status in adults. The present multicenter study examines whether Body Mass Index (BMI), age- and gender-adjusted Body Mass Index Standard Deviation Score, or calculated %body fat is a better predictor for cardiovascular disease risk factors, specifically hypertension and dyslipidemia, in a high-risk population.

METHODS

Data of 42 048 adult type 2 diabetic patients (median age: 67.1 years) from 161 centers in Germany (n=158) and Austria (n=3) registered in a standardized, prospective, computer-based documentation program, were included in the study. For each patient body weight, height, blood pressure and blood lipids were documented. Spearman correlation analyses as well as multivariable logistic regression models were used to examine the relationship between anthropometric measurements and cardiovascular disease risk factors.

RESULTS

Correlation and regression analyses revealed minor, non significant differences between the 3 anthropometric measurements (all p>0.05). In both genders, relationships between anthropometric measurements and hypertension or reduced HDL-cholesterol were nearly identical. Only for increased triglycerides, the relations with the 3 anthropometric measurements were significantly stronger in males than in females (p<0.0001, respectively). With increasing age, associations between anthropometric measurements and hypertension, reduced HDL-cholesterol or increased triglycerides became weaker. Spearman correlation coefficients for total cholesterol and LDL-cholesterol revealed weak associations with the 3 anthropometric measurements.

CONCLUSION

Compared to Body Mass Index, age- and gender-adjusted Body Mass Index Standard Deviation Score, or calculation of %body fat, has no further benefit to predict cardiovascular disease risk factors in adult type 2 diabetic patients.

IgG4-related sclerosing cholangitis mimicking cholangiocarcinoma

IgG4-related disease has gained increased attention worldwide. While the initial focus was on autoimmune pancreatitis which was first described in Asian populations and turned out to be of relevance in Western populations too, the scope has recently broadened towards a notion of a multi-systemic disease with very diverse manifestations such as autoimmune pancreatitis, IgG4-related sclerosing cholangitis (IgG4-SC), retroperitoneal fibrosis and tubulointerstitial nephritis. IgG4-SC (also known as IgG4-associated cholangitis, IAC) represents a rare but clinically challenging differential diagnosis in patients with obstructive jaundice and proximal extra- or intrahepatic biliary strictures which can be mistaken for cholangiocarcinoma (CC). We present the case of a 79-year-old male patient who presented with obstructive jaundice and biliary strictures at the hepatic duct bifurcation without any evidence for autoimmune pancreatitis and without elevation of serum IgG4-concentrations who underwent hemihepatectomy for suspected CC. However, on histological examination of the resection specimen CC could not be confirmed. It was only after several episodes of obstructive jaundice had reoccurred that the diagnosis of IgG4-SC could be established by reexamination of the surgical specimen which showed extensive infiltration with IgG4-positive plasma cells. Appropriate medical treatment with steroids and azathioprine led to complete remission of the disease. Early recognition of IgG4-SC can save patients from potential harmful and unnecessary surgical interventions. Here we describe the clinical features of this rare case of IgG4-SC with extensive liver tissue infiltration with IgG4-positive cells but without elevated serum IgG4 concentration or evidence of autoimmune pancreatitis. We describe diagnostic criteria for IgG4-SC and review recent insights in pathophysiology and treatment options.

[Jaundice and pancreatic mass: typical clinical presentation of a rare disease]

HISTORY AND ADMISSION FINDINGS

An 81-year-old man presented with jaundice and a pancreatic tumor. 6 years ago transperitoneal nephrectomy had been performed because of a clear cell renal cancer (pT3b pN0 pM0).

INVESTIGATIONS

Laboratory tests showed normocytic anemia and signs of cholestasis. Abdominal ultrasonography revealed a well-defined mass of the head of the pancreas with a diameter of about 4 cm, and a previously diagnosed adrenal mass which had slightly increased in size. Contrast-enhanced ultrasound demonstrated a hyperenhancing of the pancreatic mass, untypical for primary adenocarcinoma of the pancreas. Endoscopic ultrasound-guided fine-needle aspiration disclosed a metastasis of the previously resected renal cancer.

TREATMENT AND COURSE

Bilary spincterotomy and stent insertion were performed. Because of proven pancreatic metastasis and suspected adrenal metastasis of renal cancer palliative treatment with multi-targeted receptor tyrosine kinase inhibitor sunitinib was initiated.

CONCLUSION

Renal cell carcinomas are the most common primary tumors leading to pancreatic metastasis. In contrast to ductal adenocarcinoma pancreatic metastasis shows hyperenhancement when examined by using contrast-enhanced ultrasonography. Endoscopic ultrasound-guided fine-needle aspiration helps to confirm the suspected diagnosis.