Time Until Proof of Credentials Significantly Decreases With the Use of Blockchain Technology and the Document Management System

Background and objective Physician credentialing and verification in the medical education setting are challenging for the modern workforce. The credentials verification process may be time-consuming and challenging for participants. Blockchain technology is a potential resource for authenticating records with reduced administrative burden and time spent. This study investigates whether the use of blockchain technology reduces the time until verification of a participant's credentials. Methods An anonymous letter designation was assigned to 23 medical students. All students enrolled in, and completed, a course designed and run by the Edward Via College of Osteopathic Medicine at Auburn (VCOM) as part of the routine medical education curriculum. At the completion of the training, a credentials certificate was produced, which showed course completion. The anonymous letter designation was utilized in the creation of the certificates. The letter designations were shared with an anonymous investigator. No student names were shared with the investigator. The investigator posed as an employing/credentialing entity and contacted VCOM to record the time required to verify the credentials certificate indicating course completion. The elapsed time until credentials verification was completed for each student in the current system (CS) was recorded. Subsequently, the credentials certificate was minted as a blockchain-based, non-fungible token (NFT) and uploaded to a document software management system. An investigator again posed as an employing/credentialing entity and utilized this system to verify the credentials of the 23 students in the study using the NFT system. The times elapsed until verification of credentials were recorded as the NFT pathway. Data from the NFT pathway and non-NFT pathway were compiled and reviewed. Results Data were normally distributed per the Andersen-Darling Test. A t-test (Welch's method) was performed. The mean time of 111,214 seconds (30.89 hours or 1.29 days) in the CS varied significantly from the mean time of 14 seconds in the NFT blockchain system (p<0.01). The standard deviation of 56,568 seconds in CS varied significantly from 9.9178 seconds in the NFT blockchain (p<0.01).  Conclusions The NFT/blockchain system reduces the mean time until the credential verification is completed and reduces the variance seen in time until credentialing is completed. The NFT/blockchain system may significantly bring down the administrative burden and time spent in the credentialing process.

Revisiting Anterior Cruciate Ligament Repairs in an Athlete With Combined Grade III Medial Collateral Ligament and High-Grade Posterolateral Anterior Cruciate Ligament Tear: A Case Report

Anterior cruciate ligament tears are primarily treated by reconstruction. The development of novel surgical techniques has led to the reconsideration of this approach. Additionally, Grade III tibial-sided medial collateral ligament tears should be treated surgically due to decreased blood flow and poor healing. We describe the surgical repair of a Grade III tibial-sided tear with partial femoral avulsion of the medial collateral ligament and tear of the posterolateral bundle of the anterior cruciate ligament in a competitive high school athlete. A 17-year-old male presented to the Sports Medicine Clinic after injuring his left knee in a football game. Radiographs suggested normal skeletal anatomical alignment with no acute fractures. Magnetic resonance imaging identified a partial injury of the femoral attachment of the medial collateral ligament and a Grade III medial collateral ligament tear where it attached to the tibia. Arthroscopic evaluation of the knee revealed a posterolateral anterior cruciate ligament tear. Operative management included surgical repair of the Grade III tibial-sided medial collateral ligament tear and the posterolateral anterior cruciate ligament tear. Operative repair of medial collateral ligament and anterior cruciate ligament tears provides an alternative approach to the management of surgical reconstruction.

Association of Plasma Biomarkers of Alzheimer Disease With Cognition and Medical Comorbidities in a Biracial Cohort

BACKGROUND AND OBJECTIVES

Recent advances in blood-based biomarkers offer the potential to revolutionize the diagnosis and management of Alzheimer disease (AD), but additional research in diverse populations is critical. We assessed the profiles of blood-based AD biomarkers and their relationships to cognition and common medical comorbidities in a biracial cohort.

METHODS

Participants were evaluated through the Mayo Clinic Jacksonville Alzheimer Disease Research Center and matched on age, sex, and cognitive status. Plasma AD biomarkers (β-amyloid peptide 1-42 [Aβ42/40], plasma tau phosphorylated at position 181 [p-tau181], glial fibrillary acidic protein [GFAP], and neurofilament light) were measured using the Quanterix SiMoA HD-X analyzer. Cognition was assessed with the Mini-Mental State Examination. Wilcoxon rank sum tests were used to assess for differences in plasma biomarker levels by sex. Linear models tested for associations of self-reported race, chronic kidney disease (CKD), and vascular risk factors with plasma AD biomarker levels. Additional models assessed for interactions between race and plasma biomarkers in predicting cognition.

RESULTS

The sample comprised African American (AA; N = 267) and non-Hispanic White (NHW; N = 268) participants, including 69% female participants and age range 43-100 (median 80.2) years. Education was higher in NHW participants (median 16 vs 12 years, p < 0.001) while APOE ε4 positivity was higher in AA participants (43% vs 34%; p = 0.04). We observed no differences in plasma AD biomarker levels between AA and NHW participants. These results were unchanged after stratifying by cognitive status (unimpaired vs impaired). Although the p-tau181-cognition association seemed stronger in NHW participants while the Aβ42/40-cognition association seemed stronger in AA participants, these findings did not survive after excluding individuals with CKD. Female participants displayed higher GFAP (177.5 pg/mL vs 157.73 pg/mL; p = 0.002) and lower p-tau181 (2.62 pg/mL vs 3.28 pg/mL; p = 0.001) levels than male participants. Diabetes was inversely associated with GFAP levels (β = -0.01; p < 0.001).

DISCUSSION

In a biracial community-based sample of adults, we observed that sex differences, CKD, and vascular risk factors, but not self-reported race, contributed to variation in plasma AD biomarkers. Although some prior studies have reported primary effects of race/ethnicity, our results reinforce the need to account for broad-based medical and social determinants of health (including sex, systemic comorbidities, and other factors) in effectively and equitably deploying plasma AD biomarkers in the general population.

Correlation between Multiparametric MR Imaging and Molecular Genetics in Pontine Pediatric High-Grade Glioma

BACKGROUND AND PURPOSE

Molecular profiling is a crucial feature in the "integrated diagnosis" of CNS tumors. We aimed to determine whether radiomics could distinguish molecular types of pontine pediatric high-grade gliomas that have similar/overlapping phenotypes on conventional anatomic MR images.

MATERIALS AND METHODS

Baseline MR images from children with pontine pediatric high-grade gliomas were analyzed. Retrospective imaging studies included standard precontrast and postcontrast sequences and DTI. Imaging analyses included median, mean, mode, skewness, and kurtosis of the ADC histogram of the tumor volume based on T2 FLAIR and enhancement at baseline. Histone H3 mutations were identified through immunohistochemistry and/or Sanger or next-generation DNA sequencing. The log-rank test identified imaging factors prognostic of survival from the time of diagnosis. Wilcoxon rank-sum and Fisher exact tests compared imaging predictors among groups.

RESULTS

Eighty-three patients had pretreatment MR imaging and evaluable tissue sampling. The median age was 6 years (range, 0.7-17 years); 50 tumors had a K27M mutation in H3-3A, and 11, in H3C2/3. Seven tumors had histone H3 K27 alteration, but the specific gene was unknown. Fifteen were H3 wild-type. Overall survival was significantly higher in H3C2/3- compared with H3-3A-mutant tumors (P = .003) and in wild-type tumors compared with any histone mutation (P = .001). Lower overall survival was observed in patients with enhancing tumors (P = .02) compared with those without enhancement. H3C2/3-mutant tumors showed higher mean, median, and mode ADC_total values (P < .001) and ADC_enhancement (P < .004), with lower ADC_total skewness and kurtosis (P < .003) relative to H3-3A-mutant tumors.

CONCLUSIONS

ADC histogram parameters are correlated with histone H3 mutation status in pontine pediatric high-grade glioma.

Clinical Unmet Needs and Treatment Patterns of Paediatric Psoriasis Patients: A Real-World Evidence Study in Spain

BACKGROUND AND OBJECTIVE

Real-world evidence of paediatric psoriasis (PsO) is lacking in Spain. The purpose of this study was to identify physician-reported disease burden and current treatment patterns in a real-world paediatric PsO patient cohort in Spain. This will enhance our understanding of the disease and contribute to the development of regional guidelines.

MATERIAL AND METHOD

This retrospective analysis of a cross-sectional market research survey assessed the clinical unmet needs and treatment patterns in patients with paediatric PsO in Spain, as reported by their primary care and specialist physicians, using data collected as part of the Adelphi Real World Paediatric PsO Disease-Specific Program (DSP™) between February and October 2020.

RESULTS

Survey data from 57 treating physicians were included (71.9% [N=41] dermatologists, 17.6% [N=10] general practitioners/primary care physicians, and 10.5% [N=6] paediatricians); the final analysis included 378 patients. At sampling, 84.1% (318/378) of patients had mild disease, 15.3% (58/378) had moderate disease and 0.5% (2/378) had severe disease. Retrospectively reported physician-judged severity at the time of PsO diagnosis recorded 41.8% (158/378) of patients with mild disease, 51.3% (194/378) with moderate disease and 6.9% (26/378) with severe disease. Overall, 89.3% (335/375) of patients were currently receiving topical PsO therapy, while 8.8% (33/375), 10.4% (39/375) and 14.9% (56/375) of patients were currently receiving phototherapy, conventional systemics and biologics, respectively.

CONCLUSIONS

These real-world data reflect the current burden and treatment landscape of paediatric PsO in Spain. The management of paediatric PsO patients could be improved by further educating healthcare professionals and developing regional guidelines.

The American Board of Clinical Neuropsychology (ABCN) and American Academy of Clinical Neuropsychology (AACN): Recent milestones and future goals 2014-2023

Objective: The American Board of Clinical Neuropsychology (ABCN) and the American Academy of Clinical Neuropsychology (AACN) have become leading organizations in the credentialing of clinical neuropsychologists and promotion of the field, respectively. This paper updates the literature by summarizing the activities and growth of ABCN and AACN during the period 2014 through 2023. Method: Prior papers have reviewed the history of these organizations up to 2014. In this paper, the authors describe milestones that each organization has reached, provide an update reflecting improved functions and new initiatives, and describe how the organizations have responded to numerous challenges. Conclusions: The past decade has witnessed substantial societal and technological evolution, as well as wrenching events including a global pandemic and public outcry over continued racial injustice. ABCN and AACN have evolved in the face of these changes, positioning each organization well to take on future challenges.

A systematic review of the global prevalence and incidence of shoulder pain

BACKGROUND AND OBJECTIVES

Studies reporting on the population burden of people living with shoulder pain show wide heterogeneity in terms of case definition, study samples, and occurrence. This systematic review aims to summarize evidence pertaining to the prevalence and incidence of shoulder pain, including variability based on sex and geography. We also explored the potential influence of methodological limitations and important sources of heterogeneity (case definition and reference period) on reported estimates of shoulder pain prevalence.

DATABASES AND DATA TREATMENT

The study protocol was registered on Prospero under CRD42021243140. We searched EMBASE, CINAHL, Web of Science and Medline from inception to March 2021. Study selection, data extraction and risk of bias assessment was conducted by a team of three researchers. We performed a narrative synthesis of the data, using forest plots to summarize study findings, and stratified data presentation to explore the potential association of risk of bias, case definition, and reference period with estimates of prevalence and incidence of shoulder pain.

RESULTS

We obtained data from 61 studies reporting data from high-, middle- and low-income countries. The overall risk of bias was low, with most rated as "low-risk" and no studies rated as "high-risk". The community prevalence of shoulder pain varied widely across the countries included in our review, with a median of 16% (range 0.67 to 55.2%). Longer reference periods were typically associated with higher prevalence estimates. Primary care prevalence ranged from 1.01 to 4.84% (median 2.36%). Estimates were generally higher for women than men and were higher in high-income nations. The incidence of shoulder pain ranged from 7.7 to 62 per 1000 persons per year (median 37.8 per 1000 persons per year). Risk of bias did not clearly explain variability in study findings, but there was considerable variation in study samples, methods used, and a relative absence of data from low-income countries.

CONCLUSIONS

Our review demonstrates that a significant proportion of the population across the world will experience shoulder pain daily, yearly, and throughout a lifetime. Regional gaps in evidence and methodological inconsistencies must be addressed in order to establish a more definitive global burden.

CTNI-31. COG ACNS1721: PHASE 2 STUDY OF VELIPARIB AND LOCAL IRRADIATION, FOLLOWED BY MAINTENANCE VELIPARIB AND TEMOZOLOMIDE, IN PATIENTS WITH NEWLY DIAGNOSED HIGH-GRADE GLIOMA WITHOUT H3 K27M OR BRAF MUTATIONS

BACKGROUND

The outcome for pediatric patients with high-grade glioma (HGG) remains poor. Veliparib, a potent oral PARP1/2 inhibitor, enhances the activity of radiotherapy and DNA-damaging chemotherapy. Preclinical data indicates that veliparib crosses the blood-brain-barrier and enhances the efficacy of radiotherapy and temozolomide in IDH mutant and wild-type HGG models. ACNS1721 was a single-arm, non-randomized phase 2 clinical trial designed to determine whether treatment with veliparib and radiotherapy, followed by the poly (ADP-ribose) polymerase (PARP) inhibitor veliparib and temozolomide, improves progression-free survival (PFS) in pediatric patients with newly diagnosed HGG without H3 K27M or BRAF mutations compared to patient level data from historical cohorts with closely matching clinical and molecular features.

METHODS

Following surgical resection, newly diagnosed children with non-metastatic HGG were screened by rapid central pathology review and molecular testing. Eligible patients without somatic H3 K27M or BRAF mutations were enrolled on Stratum 1 (IDH wild-type) or Stratum 2 (IDH mutant). Protocol radiochemotherapy consisted of involved field radiotherapy with concurrent veliparib at 65 mg/m2 twice daily. Adjuvant chemotherapy consisted of up to 10 cycles of veliparib 25 mg/m2 twice daily and temozolomide 135 mg/m2 once daily for 5 days every 4 weeks.

RESULTS

Both strata were closed to accrual for futility after planned interim analyses. Among the 23 eligible patients who enrolled on Stratum 1 and received protocol therapy, the 1-year progression-free survival (PFS) was 0.29 (SE = 0.09) and 1-year overall survival (OS) was 0.67 (SE = 0.10). Among the 14 eligible patients who enrolled on Stratum 2 and received protocol therapy, the 1-year PFS was 0.57 (SE = 0.15) and 1-year OS was 0.90 (SE = 0.09).

CONCLUSION

Rapid central pathology review and molecular testing was feasible. The protocol therapy was well tolerated but failed to improve outcome compared to clinically and molecularly matched historical control cohorts.

Molecular classification and outcome of children with rare CNS embryonal tumors: results from St. Jude Children's Research Hospital including the multi-center SJYC07 and SJMB03 clinical trials

Methylation profiling has radically transformed our understanding of tumors previously called central nervous system primitive neuro-ectodermal tumors (CNS-PNET). While this marks a momentous step toward defining key differences, reclassification has thrown treatment into disarray. To shed light on response to therapy and guide clinical decision-making, we report outcomes and molecular features of children with CNS-PNETs from two multi-center risk-adapted studies (SJMB03 for patients ≥ 3 years; SJYC07 for patients < 3 years) complemented by a non-protocol institutional cohort. Seventy patients who had a histological diagnosis of CNS-PNET or CNS embryonal tumor from one of the new categories that has supplanted CNS-PNET were included. This cohort was molecularly characterized by DNA methylation profiling (n = 70), whole-exome sequencing (n = 53), RNA sequencing (n = 20), and germline sequencing (n = 28). Clinical characteristics were detailed, and treatment was divided into craniospinal irradiation (CSI)-containing (SJMB03 and SJMB03-like) and CSI-sparing therapy (SJYC07 and SJYC07-like). When the cohort was analyzed in its entirety, no differences were observed in the 5-year survival rates even when CSI-containing therapy was compared to CSI-sparing therapy. However, when analyzed by DNA methylation molecular grouping, significant survival differences were observed, and treatment particulars provided suggestions of therapeutic response. Patients with CNS neuroblastoma with FOXR2 activation (CNS-NB-FOXR2) had a 5-year event-free survival (EFS)/overall survival (OS) of 66.7% ± 19.2%/83.3% ± 15.2%, and CIC rearranged sarcoma (CNS-SARC-CIC) had a 5-year EFS/OS both of 57.1% ± 18.7% with most receiving regimens that contained radiation (focal or CSI) and multidrug chemotherapy. Patients with high-grade neuroepithelial tumor with BCOR alteration (HGNET-BCOR) had abysmal responses to upfront chemotherapy-only regimens (5-year EFS = 0%), but survival extended with salvage radiation after progression [5-year OS = 53.6% ± 20.1%]. Patients with embryonal tumor with multilayered rosettes (ETMR) or high-grade glioma/glioblastoma multiforme (HGG/GBM) did not respond favorably to any modality (5-year EFS/OS = 10.7 ± 5.8%/17.9 ± 7.2%, and 10% ± 9.0%/10% ± 9.0%, respectively). As an accompaniment, we have assembled this data onto an interactive website to allow users to probe and query the cases. By reporting on a carefully matched clinical and molecular cohort, we provide the needed insight for future clinical management.

ARMADA: Assessing reliable measurement in Alzheimer's disease and cognitive aging project methods

INTRODUCTION

Early detection of cognitive decline in older adults is a public health priority. Advancing Reliable Measurement in Alzheimer's Disease and Cognitive Aging (ARMADA), a multisite study, is validating cognition, emotion, motor, and sensory modules of the National Institutes of Health Toolbox for Assessment of Neurological and Behavioral Function (NIHTB) in the aging spectrum from cognitively normal to dementia of the Alzheimer's type (DAT).

METHODS

Participants 65 to 85 years old, in demographic groups racially proportional to the general US population, are recruited in one of three groups to validate the NIHTB: cognitively normal, amnestic mild cognitive impairment (aMCI), or mild DAT. Additional special emphasis cohorts include (1) Blacks in the three clinical groups; (2) Spanish-speakers in the three clinical groups; (3) cognitively normal, population-proportional, over age 85.

DISCUSSION

Longitudinal study will determine whether NIHTB can predict cognitive decline and is associated with Alzheimer's disease biomarkers. Here, we detail the methods for the ARMADA study.

P-414 Ultrastructural and functional defects in cilia of endometrial glands from women with reproductive failure

Study question

Do endometrial gland factors influence pregnancy success?

Summary answer

Increased proportion of cilia defects during the window of implantation in endometrial glands from women with reproductive failure compared to controls

What is known already

Endometrial glands are important for embryo implantation and successful pregnancy. There is an unmet clinical need to relate endometrial gland structure to function, identify markers for reproductive failure and targets for therapeutic interventions. Ciliated epithelial cells in the endometrium are a distinct cell type with a particular cell transcriptomic signature. Cilia defects have been reported in endometrial glands from women with reproductive failure however, a quantitative study of cilia defects in endometrial glands is yet to be established.

Study design, size, duration

An observational study comparing women with subfertility, recurrent pregnancy loss and controls

Participants/materials, setting, methods

Endometrial samples were collected during the implantation period from fertile controls (n = 10), women with subfertility (n = 11) and women with recurrent pregnancy loss (n = 15). Ciliated cells in endometrial glands were imaged by transmission electron microscopy and the proportion of cilia defects were quantified and compared between study groups. Endometrial glands were isolated from endometrial biopsies and the cilia beat frequency of ciliated cells was quantified by high-speed video analysis.

Main results and the role of chance

Our study reports a significant increase in the proportion of cilia ultrastructural defects in endometrial glands from women with subfertility versus fertile controls (P &lt; 0.05). Cilia defects included microtubule disarrangement, transposition and loss of cilia inner dynein arm motor proteins. Ciliated cells in endometrial glands from women with recurrent pregnancy loss demonstrated a higher proportion of defects compared to fertile controls but this did not reach statistical significance (P = 0.07). A significant decrease in cilia beat frequency was reported in ciliated cells of endometrial glands from women with subfertility compared to fertile controls (P &lt; 0.05).

Limitations, reasons for caution

This is an observational study with a relatively small sample size however, the participants in the study and control groups were matched for age, BMI and menstrual cycle characteristics.

Wider implications of the findings

This study quantified ultrastructural and functional differences of ciliated cells in endometrial glands from women with reproductive failure. Endometrial glands with perturbed cilia structure and function may be non-conductive to successful pregnancy. Differences in endometrial gland cilia could be used to identify a perturbed endometrium and develop targeted therapies.

Trial registration number

not applicable

A high-throughput HPLC method for simultaneous quantification of pyrethroid and pyriproxyfen in long-lasting insecticide-treated nets

Long-lasting insecticide-treated nets (LLINs) play a crucial role in preventing malaria transmission. LLINs should remain effective for at least three years, even after repeated washings. Currently, monitoring insecticides in LLINs is cumbersome, costly, and requires specialized equipment and hazardous solvents. Our aim was to develop a simple, high-throughput and low-resource method for measuring insecticides in LLINs. To extract insecticides, polyethylene-LLIN samples were heated at 85 °C for 45 min in a non-hazardous solvent mix containing dicyclohexylphthalate as an internal standard. The extraction solvent was reduced from 50 to 5 ml using a 0.2 g sample, 90% smaller than the recommended sample size. By optimizing HPLC chromatography, we simultaneously detected pyrethroid and pyriproxyfen insecticides with high sensitivity in LLIN's extract. The method can quantify levels ≥ 0.0015% permethrin, 0.00045% alpha-cypermethrin and 0.00025% pyriproxyfen (w/w) in polyethylene, allowing for insecticide tracking before and after the use of LLINs. This method can be used to assess LLINs with 1% pyriproxyfen (pyriproxyfen-LLIN) or 2% permethrin (Olyset® Net), 1% pyriproxyfen and 2% permethrin (Olyset® Duo), or 0.55% pyriproxyfen and 0.55% alpha-cypermethrin (Royal Gaurd®). One can run 120 samples (40 nets) simultaneously with high precision and accuracy, improving throughput and reducing labour, costs, and environmental impact.

GCT-08. Patients with Metastatic Central Nervous System Germinoma Involving the Basal Ganglia and Thalami, a Case Series

BACKGROUND: Central nervous system (CNS) germinomas are commonly located in the suprasellar and/or pineal regions. Current treatment strategies include irradiation (RT) alone or chemotherapy with RT to reduce the dose and field of RT. However, given their rarity and poorly defined imaging characteristics, germinomas originating in the basal ganglia/thalami (BGTG) have proven challenging to treat. We present a case series of six patients with metastatic BGTG, given the paucity of published research on patients with metastatic CNS BGTG. METHODS: A retrospective multi-institutional review was performed across four institutions in two countries. RESULTS: Two patients were females, and four were males. The median age at presentation was 14.9 years. Biopsies were performed in all patients except for one patient who underwent subtotal surgical resection of her primary tumor. Three patients received RT only, while the remaining three received chemotherapy with RT. Carboplatin and etoposide were used in all three patients who received chemotherapy. All six patients received craniospinal irradiation (CSI). For patients who received RT only, the CSI dose ranged between (24 – 27.2 Gy) with a total dose to the primary site ranging between (36 – 40 Gy). For patients who received chemotherapy, one patient received 36 Gy with a total dose of 54 Gy to the primary site. The second patient received 24 Gy with a total dose of 40 Gy to the primary site. The CSI dose was not available for the third patient. All patients remain alive with a median event-free survival (EFS) and overall survival (OS) of 49 months (range: 14.3 – 168 months). CONCLUSION: In our series, patients with metastatic CNS BGTG treated with CSI with or without chemotherapy had excellent outcomes. Future larger studies are needed to compare the outcomes between CSI only and chemotherapy with low-dose CSI among patients with metastatic CNS BGTG.

HGG-06. Phase 2 Study of Veliparib and Local Irradiation, Followed by Maintenance Veliparib and Temozolomide, in Patients with Newly Diagnosed High-Grade Glioma without H3 K27M or BRAF Mutations: A Report from the Children's Oncology Group ACNS1721 Study

BACKGROUND: The outcome for pediatric patients with high-grade glioma (HGG) remains poor. Veliparib, a potent oral PARP1/2 inhibitor, enhances the activity of radiotherapy and DNA-damaging chemotherapy. Preclinical data indicates that veliparib crosses the blood-brain-barrier and enhances the efficacy of radiotherapy and temozolomide in IDH mutant and wild-type HGG models. ACNS1721 was a single-arm, non-randomized phase 2 clinical trial designed to determine whether treatment with veliparib and radiotherapy, followed by the poly (ADP-ribose) polymerase (PARP) inhibitor veliparib and temozolomide, improves progression-free survival (PFS) in pediatric patients with newly diagnosed HGG without H3 K27M or BRAF mutations compared to patient level data from historical cohorts with closely matching clinical and molecular features. METHODS: Following surgical resection, newly diagnosed children with non-metastatic HGG were screened by rapid central pathology review and molecular testing. Eligible patients without somatic H3 K27M or BRAF mutations were enrolled on Stratum 1 (IDH wild-type) or Stratum 2 (IDH mutant). Protocol radiochemotherapy consisted of involved field radiotherapy with concurrent veliparib at 65 mg/m2 twice daily. Adjuvant chemotherapy consisted of up to 10 cycles of veliparib 25 mg/m2 twice daily and temozolomide 135 mg/m2 once daily for 5 days every 4 weeks. RESULTS: Both strata were closed to accrual for futility after planned interim analyses. Among the 23 eligible patients who enrolled on Stratum 1 and received protocol therapy, the 1-year progression-free survival (PFS) was 0.29 (SE = 0.09) and 1-year overall survival (OS) was 0.67 (SE = 0.10). Among the 14 eligible patients who enrolled on Stratum 2 and received protocol therapy, the 1-year PFS was 0.57 (SE = 0.15) and 1-year OS was 0.90 (SE = 0.09). CONCLUSION: Rapid central pathology review and molecular testing was feasible. The protocol therapy was well tolerated but failed to improve outcome compared to clinically and molecularly matched historical control cohorts.

POS0300 FACTORS ASSOCIATED WITH SECUKINUMAB (SEC) RETENTION IN AXIAL SPONDYLOARTHRITIS (axSpA): RESULTS OF THE FRENCH RETROSPECTIVE STUDY FORSYA

Background

While data on real-life SEC retention rate in patients (pts) with axSpA is accumulating, there are no data on predictive factors for this retention. Presence of objective sign of inflammation (OSI) are known to be predictive of efficacy of anti-TNFs and their retention in axSpA.

Objectives

To assess whether OSI were predictive of SEC retention at 1 year in axSpA.

Methods

French retrospective study collecting between October 2019 and September 2020 data from axSpA pts a) having initiated and received at least one dose of SEC between August 11th 2016 and August 31st 2018, b)with at least a one year follow-up period. Retention of SEC at 1 year was estimated by the Kaplan Meier (KM) method. OSI were defined by at least one of the following: CRP> N, MRI-inflammation at the sacroiliac or spine level. Preselected factors of SEC retention at 1 year (≥1 OSI, age, sex, BMI, smoking, HLA B27, non-radiographic vs radiographic axSpA, past or present uveitis / Inflammatory Bowel Disease (IBD) / psoriasis / arthritis or synovitis, diagnostic delay, disease duration, SEC line of biologic therapy, SEC maintenance dose, concomitant csDMARD / oral corticosteroids / proton pomp inhibitor, history of depression / fibromyalgia) were analyzed by multivariate cox model regression. Only variables with <20% missing data were included in the model after imputation and stepwise selection (significance level for entering variables = 20%; for removing variables = 10%). OSI was forced into the model whatever its significance level or rate of missing data.

Results

In total, 906 pts from 47 centers (male: 42.2%, mean age: 46.2 ± 11.7 years, mean disease duration: 9,3 ± 9.1 years), were included in the analysis. At initiation of SEC, 86.3% of pts had ≥ 1 OSI and respectively 8.0%, 14.9% and 77.1% were in 1st, 2nd and ≥ 3rd line (L) of biologic/targeted synthetic DMARD. The 1 year KM survival rate for SEC was 59% [95%CI:55%-62%] overall, 58% [54%-62%] and 63% [53%-73%] for pts with or without OSI, and was numerically greater in 1st L vs 2nd and ≥3rd L (70% [59%-81%], 62% [54%-70%], 57% [53%-61%] respectively). In multivariate analysis absence of OSI, lack of prior exposure to anti-TNF inhibitors, absence of IBD, and absence of history of depression were associated with a better SEC retention at 1 year (Table 1).

Table 1.

Predictive factors of SEC 1 year retention identified by multivariate cox regression analysis (multiple imputation + stepwise selection)

Predictive factors (* reference)Still on SEC at 1 Year (%)#HR [95% CI]p vs refp type III≥ 1 objective sign of inflammationNo (N=165)*65.3%yes (N=711)58.8%1.44 [1.08; 1.93]0.014SEC treatment line1st L (N=68)*72.2%0.0842nd L (N=132)62.7%1.53 [0.91; 2.57]0.107≥ 3rd L (N=676)57.6%1.67 [1.06; 2.62]0.028Past or present history of IBDNo (N=854)*59.8%Yes (N=22)40.9%1.76 [1.01; 3.07]0.047History of depression or anti-depressive concomitant treatmentNo (N=716)*60.8%Yes (N=160)54.5%1.25 [0.97; 1.60]0.090

# without imputation for missing data

Interpretation HR > 1: the hazard of discontinuation at 1 year is X times higher vs reference

Conclusion

The overall retention of SEC at 1 year in daily practice at the time of its launch in France was 59% for axSpA patients and OSI, prior exposure to TNF inhibitors, IBD and history of depression were identified as predictive factors of SEC retention.

Acknowledgements

Authors thank the participating investigators, centers and patients. NOVARTIS Pharma France financially supported this study.

Disclosure of Interests

Maxime Dougados Consultant of: Honorarium from Novartis Pharma France, Julien Lucas: None declared, Emilie Desfleurs Employee of: Novartis employee, Pascal Claudepierre Consultant of: Honorarium from Novartis Pharma France, Philippe Goupille Consultant of: Honorarium from Novartis Pharma France, Adeline Ruyssen-Witrand Consultant of: Honorarium from Novartis Pharma France, Alain Saraux Consultant of: Honorarium from Novartis Pharma France, Anne Tournadre Speakers bureau: AbbVie, Fresenius-Kabi, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, Sanofi, Consultant of: AbbVie, Fresenius-Kabi, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, Sanofi, Grant/research support from: AbbVie, Fresenius-Kabi, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, Sanofi, Daniel Wendling Consultant of: Honorarium from Novartis Pharma France, Cédric Lukas Consultant of: Honorarium from Novartis Pharma France

AB0760 Factors associated with the retention of secukinumab (SEC) in patients with psoriatic arthritis (PsA) in real world practice: Results from the retrospective FORSYA study

Background

While data on real-life retention of SEC in patients (pts) with PsA is accumulating, there are no data on predictive factors for this retention.

Objectives

The primary objective of FORSYA study was to assess whether objective signs of inflammation (OSI) were predictive of SEC retention at 1 year.

Methods

French retrospective study collecting between October 2019 and September 2020 data from axSpA pts a) having initiated and received at least one dose of SEC between August 11th 2016 and August 31st 2018, b)with at least a one year follow-up period. Retention of SEC at 1 year was estimated by the Kaplan Meier (KM) method. OSI were defined by at least one of the following within the 3 months before initiation of SEC: CRP> N, confirmed clinical dactylitis, confirmed clinical synovitis or ultrasonography power-Doppler positive synovitis except on MTP of first toe. Preselected factors at initiation of SEC retention at 1 year (≥1 OSI, age, sex, BMI, smoking status, axial feature, past or present psoriasis / uveitis / Inflammatory Bowel Disease (IBD) / active arthritis or synovitis, diagnostic delay, disease duration, SEC line of biologic therapy, SEC maintenance dose, concomitant csDMARD, concomitant oral corticosteroids, ≥1 comorbidity) were analyzed by multivariate cox model regression. Only variables with <20% missing data were included in the model after imputation and stepwise selection (significance level for entering variables = 20%; for removing variables = 10%). OSI was forced into the model whatever its significance level or rate of missing data.

Results

In total, 475 pts (male: 40.2%, mean age: 51.9 ± 12.2 years, mean disease duration: 9.3 ± 8.6 years) from 48 centers were included in the analysis. At initiation of SEC, 62.2% of pts had ≥ 1 OSI and respectively 11.0%, 19.5% and 69.6% were in 1st, 2nd and ≥ 3rd line (L) of biologic/targeted synthetic DMARD. The overall 1 year KM survival rate for SEC was 63% [95%CI: 59%-68%] and was numerically greater in 1st L vs 2nd and ≥3rd L (82% [72%-93%], 62% [52-72%], 61% [56%-66%] respectively). The overall survival rates for PsA pts with or without OSI were 62% [56%-68%] and 71% [62%-80%]. In multivariate analysis, absence of OSI, longer disease duration and lack of prior exposure to anti-TNF inhibitors were associated with a better SEC retention at 1 year (Table 1).

Table 1.

Predictive factors of SEC 1 year retention of SEC identified by multivariate cox regression analysis (multiple imputation + Stepwise selection)

Predictive factors (* reference)HR [95% CI]p vs refp type IIIAt least one objective sign of inflammationNo (N=175)*Yes (N=295)1.46 [1.05; 2.02]0.023Disease duration (years)≤ 7.2 years (N=241)*> 7.2 years (N=229)0.69 [0.51; 0.94]0.017Secukinumab treatment line1st L (N=50)*0.0152nd L (N=92)2.43 [1.17; 5.05]0.018≥ 3rd L (N=328)2.72 [1.38; 5.36]0.004

Interpretation for predictor: HR> 1: the hazard of discontinuation at 1 year is X times higher in category vs reference.

Conclusion

The overall retention of SEC at 1 year in daily practice at the time of its launch in France was 63% for PsA patients and OSI, disease duration and prior exposure to TNF inhibitors were identified as predictive factors of SEC retention.

Acknowledgements

Authors thank all participating investigators, centers and patients. This study was financially supported by NOVARTIS Pharma France.

Disclosure of Interests

Adeline Ruyssen-Witrand Consultant of: honorarium fees from Novartis France, Julien Lucas: None declared, Emilie Desfleurs Employee of: Novartis, Pascal Claudepierre Consultant of: Honorarium fees from Novartis France, Maxime Dougados Consultant of: honorarium fees from Novartis France, Philippe Goupille Consultant of: honorarium fees from Novartis France, Cédric Lukas Consultant of: honorarium fees from Novartis France, Alain Saraux Consultant of: honorarium fees from Novartis France, Anne Tournadre Consultant of: honorarium fees from Novartis France, Daniel Wendling Consultant of: honorarium fees from Novartis France

Major procedure-related complications in a real-world cohort of patients undergoing transvenous lead extraction

Funding Acknowledgements

Type of funding sources: None.

Background

Transvenous lead extraction (TLE) is the mainstay therapy for device-related infections. Though TLE procedures are associated with low complication and high success rates, risk factors for major procedure-related complications remain not well defined.

Purpose

To evaluate the safety and efficacy of TLE in a large single centre cohort and to identify risk factors for major complications.

Methods

All consecutive patients undergoing TLE in our department between May 2012 and December 2021 were included in a prospective registry. Our protocol for TLE followed a stepwise approach according to lead dwell time and estimated complexity of the procedure: use of simple traction ± locking stylet (LS) ± mechanical and/or powered sheaths ± snare technique via a femoral or jugular access. Patient characteristics, procedural data and complications were gathered and analysed. Logistic regression analysis was applied to identify risk factors for major procedure related complications.

Results

A total of 2218 leads (25.7% ICD leads) were targeted for TLE in 1060 patients (67.7 ± 14.8 years; 74% male). The mean lead dwell time was 82 ± 62 months. The leading indication for TLE was cardiac device related infection (CDRI) in 695 patients (65.6%), 373 (35.2%) had systemic and 322 (30.4%) localized infection. Leads were extracted by simple traction in 30%, traction with LS in 3.7%, dilator sheaths with LS in 47.7%, and additional use of powered mechanical sheaths in 14.6%. The snare technique was used in 3.9%, with additional venous entry from femoral in 3.5% and jugular in 1.0% of all targeted leads. TLE was completely successful in 92.6%, partially successful with lead fragments &lt;4cm in 4.2%, and failed in 3.1% of all patients, which translated to a clinical success rate of 96.9%.

Twenty-nine patients (2.7%) experienced minor and 18 patients (1.7%) had major procedure-related complications (cardiac tamponade/perforation) including 2 intraprocedural deaths (0.2%). Presence of abandoned leads (HR 8.41, 95% CI 3.21–22.02; p&lt;0.001), lead-years-per-patient (HR 1.063, 95% CI 1.037–1.090; p&lt;0.001), dwelling time of the oldest lead (HR 1.011, 95% CI 1.006–1.016; p&lt;0.001), and a right-sided implantation (HR 2.68, 95% CI 1.05–6.83; p=0.04) were significant predictors of major complications in logistic regression analysis.

Conclusion

TLE is feasible, effective and safe in our large single centre experience. Overall complication and failure rates are low. Following our TLE protocol, the presence of abandoned leads, a right-sided implantation and dwelling time of the extracted leads were associated with major procedure-related complications.

Pacing electrodes to ablate, not to pace: what settings to use to create lesions even deep in the septum

Funding Acknowledgements

Type of funding sources: None.

Background

Intramural septal ventricular arrhythmia remains challenging, requiring emergent technologies and experimental approaches. Although conduction system pacing (CSP) has allowed us to reach deep in the septum, ablation though pacing electrodes has not been examined yet.

Purpose

To evaluate lesion creation by radiofrequency ablation (RFA) through pacing electrodes.

Methods

A custom ex vivo swine model in a saline bath with an indifferent electrode was used to apply RFA with an 8 mm non-irrigated catheter (SJM, MN, USA) on the proximal end of pacing (CapSureFix 5086) or CSP-electrodes (SelectSecure 3830, Medtronic, MN, USA), screwed in perpendicularly to the slab. A generator (Ampere, SJM, MN, USA) applied RFA at varying settings (1-10 W, 1-20 sec). Lesion depth (D), width (W) and volume (V=3,14*W2*D/4) were assessed and analyzed (SPSS 23).

Results

A total of 80 lesions were used for analysis. Median RFA with 3 W over 6 sec resulted in an impedance drop from 200 to 140 Ω and a lesion of 2x3 mm or 9.4 mm3 (Figure 1). Higher energy settings caused impedance rise with abort (n=3, 4%) or charring (n=3, 4%). Compared to conventional electrodes, lesions with CSP-electrodes had similar volume (9.3±7 vs. 10.8±9 mm3, p=0.45) and width (2±0.8 vs. 2±0.7, p=0.58), but more depth (2.6±0.5 vs. 3±0.6, p=0.0.01). Regression analysis showed final-impedance (FI), power and duration (WS=W*Sec) as independent predictors of lesion volume (V=4.7WS-4.1WS2+4.5FI-4, p&lt;0.001).

Conclusions

Effective ablation through pacing electrodes is possible, but lesion size is limited and low-power settings are necessary. Using CSP-electrodes for effective intramural lesions is possibly a new tool for septal arrhythmias. Further in vivo studies are warranted and bailout use should be considered.

The Residual Efficacy of SumiShield™ 50WG and K-Othrine® WG250 IRS Formulations Applied to Different Building Materials against Anopheles and Aedes Mosquitoes

Insecticides with novel modes of action are required to complement the pyrethroids currently relied upon for controlling malaria vectors. One example of this is the neonicotinoid clothianidin, the active ingredient in the indoor residual spray (IRS) SumiShield™ 50WG. In a preliminary experiment, the mortality of insecticide-susceptible and resistant An. gambiae adults exposed to filter papers treated with this IRS product reached 80% by 3 days post-exposure and 100% by 6 days post-exposure. Next, cement, wood, and mud tiles were treated with the clothianidin or a deltamethrin-based IRS formulation (K-Othrine WG250). Insecticide resistant and susceptible Anopheles and Aedes were exposed to these surfaces periodically for up to 18 months. Pyrethroid resistant Cx. quinquefasciatus was also exposed at 9 months. Between exposures, tiles were stored in heat and relative humidity conditions reflecting those found in the field. On these surfaces, the clothianidin IRS was effective at killing both susceptible and resistant An. gambiae for 18 months post-treatment, while mortality amongst the resistant strains when exposed to the deltamethrin IRS was not above that of the negative control. Greater efficacy of clothianidin was also demonstrated against insecticide resistant strains of An. funestus compared to deltamethrin, though the potency was lower when compared with An. gambiae. In general, higher efficacy of the clothianidin IRS was observed on cement and mud compared to wood, though it demonstrated poorer residual activity against Ae.aegypti and Cx. quinquefasciatus.

Effects of metals and persistent organic pollutants on the fitness and health of juveniles of the endangered european sturgeon Acipenser sturio Exposed to W1ater and sediments of the garonne and dordogne rivers

The last remaining population of European sturgeon (Acipenser sturio) lives in the Gironde-Garonne-Dordogne (France) catchment (GGD). Captive young individuals are released into the GGD hydrosystem each year, as part of a restocking programme. This study aims to assess the health status of juveniles A. sturio to current conditions in the GGD hydrosystem, to evaluate their capacity to survive and grow in a moderately anthropized ecosystems. 3-month-old farmed sturgeons were exposed for one month in experimental conditions that mimic the environmental conditions in the Garonne and Dordogne rivers, followed by five months of depuration. After one month of exposure, fish exposed to Dordogne and Garonne waters bioaccumulated higher levels of metals and persistent organic pollutants, displayed a reduced hepato-somatic index, and had depleted levels of lipids and glycogen content in their liver, when compared with the Reference group. However, metabolic and swimming performance, as well as the costs of swimming were not impaired. After the 5 months depuration, a significant decrease of K was observed for all exposure conditions. HSI also decreased with time. The overall health status and adaptive capacity of juvenile A. sturio appeared to be maintained over the experimental 6 months' period. Juveniles of A. sturio seem to have the adaptive capacity to survive and grow in the GGD hydrosystem, after being released as part of a restocking programme.

3D host cell and pathogen-based bioassay development for testing anti-tuberculosis (TB) drug response and modeling immunodeficiency

Tuberculosis (TB) is a global health threat that affects 10 million people worldwide. Human Immunodeficiency Virus (HIV) remains one of the major contributors to the reactivation of asymptomatic latent tuberculosis (LTBI). Over the recent years, there has been a significant focus in developing in-vitro 3D models mimicking early events of Mycobacterium tuberculosis (Mtb) pathogenesis, especially formation of the granuloma. However, these models are low throughput and require extracellular matrix. In this article, we report the generation of a matrix-free 3D model, using THP-1 human monocyte/macrophage cells and mCherry-expressing Mycobacterium bovis BCG (Bacilli Camille Guérin), henceforth referred as 3D spheroids, to study the host cell-bacterial interactions. Using mCherry-intensity-based tracking, we monitored the kinetics of BCG growth in the 3D spheroids. We also demonstrate the application of the 3D spheroids for testing anti-TB compounds such as isoniazid (INH), rifampicin (RIF), as well as a host-directed drug, everolimus (EVR) as single and combinational treatments. We further established a dual infection 3D spheroid model by coinfecting THP-1 macrophages with BCG mCherry and pseudotype HIV. In this HIV-TB co-infection model, we found an increase in BCG mCherry growth within the 3D spheroids infected with HIV pseudotype. The degree of disruption of the granuloma was proportional to the virus titers used for co-infection. In summary, this 3D spheroid assay is an useful tool to screen anti-TB response of potential candidate drugs and can be adopted to model HIV-TB interactions.

Neuroblastoma

The survival of patients with high-risk neuroblastoma has improved significantly with the use of intensive multimodality treatment regimens, including chemotherapy, surgery, radiation therapy, myeloablative chemotherapy followed by stem cell rescue, and immunotherapy. This report summarizes the current treatment strategies used in the COG and SIOP for children with neuroblastoma. The improved global collaboration and the adoption of a uniform International Neuroblastoma Risk Group Staging System will help facilitate comparison of homogeneous pretreatment cohorts across clinical trials. Future research strategies regarding the indications for and dosages of radiation therapy to the primary and metastatic sites, and the integration of meta-iodobenzyl guanidine therapy into the multimodal treatment program, are discussed.

Non-invasive image-based cytometry for high throughput NK cell cytolysis analysis

Natural Killer (NK) cells are lymphocytes that are the first line of defense against malignantly transformed cells, virally infected cells and other stressed cell types. To study the cytolytic function of NK cells in vitro, a cytotoxicity assay is normally conducted against a target cancerous cell line. Current assay methods are typically performed in mixed 2D cocultures with destructive endpoints and low throughput, thereby limiting the scale, time-resolution, and relevance of the assay to in vivo conditions. Here, we evaluated a novel, non-invasive, quantitative image-based cytometry (qIBC) assay for detection of NK-mediated killing of target cells in 2D and 3D environments in vitro and compared its performance to two common flow cytometry- and fluorescence-based cytotoxicity assays. Similar to the other methods evaluated, the qIBC assay allowed for reproducible detection of target cell killing across a range of effector-to-target ratios with reduced variability. The qIBC assay also allowed for detection of NK cytolysis in 3D spheroids, which enabled scalable measurements of cell cytotoxicity in 3D models. Our findings suggest that quantitative image-based cytometry would be suitable for rapid, high-throughput screening of NK cytolysis in vitro, including in quasi-3D structures that model tissue environments in vivo.

The Multi-Fungicide Resistance Status of Aspergillus fumigatus Populations in Arable Soils and the Wider European Environment

The evolution and spread of pan-azole resistance alleles in clinical and environmental isolates of Aspergillus fumigatus is a global human health concern. The identification of hotspots for azole resistance development in the wider environment can inform optimal measures to counteract further spread by minimizing exposure to azole fungicides and reducing inoculum build-up and pathogen dispersal. We investigated the fungicide sensitivity status of soil populations sampled from arable crops and the wider environment and compared these with urban airborne populations. Low levels of azole resistance were observed for isolates carrying the CYP51A variant F46Y/M172V/E427K, all belonging to a cluster of related cell surface protein (CSP) types which included t07, t08, t13, t15, t19, and t02B, a new allele. High levels of resistance were found in soil isolates carrying CYP51A variants TR₃₄/L98H and TR₄₆/Y121F/T289A, all belonging to CSP types t01, t02, t04B, or t11. TR₄₆/Y121F/M172V/T289A/G448S (CSP t01) and TR₄₆/Y121F/T289A/S363P/I364V/G448S (CSP t01), a new haplotype associated with high levels of resistance, were isolated from Dutch urban air samples, indicating azole resistance evolution is ongoing. Based on low numbers of pan-azole resistant isolates and lack of new genotypes in soils of fungicide-treated commercial and experimental wheat crops, we consider arable crop production as a coldspot for azole resistance development, in contrast to previously reported flower bulb waste heaps. This study also shows that, in addition to azole resistance, several lineages of A. fumigatus carrying TR-based CYP51A variants have also developed acquired resistance to methyl benzimidazole carbamate, quinone outside inhibitor and succinate dehydrogenase (Sdh) inhibitor fungicides through target-site alterations in the corresponding fungicide target proteins; beta-tubulin (F200Y), cytochrome b (G143A), and Sdh subunit B (H270Y and H270R), respectively. Molecular typing showed that several multi-fungicide resistant strains found in agricultural soils in this study were clonal as identical isolates have been found earlier in the environment and/or in patients. Further research on the spread of different fungicide-resistant alleles from the wider environment to patients and vice versa can inform optimal practices to tackle the further spread of antifungal resistance in A. fumigatus populations and to safeguard the efficacy of azoles for future treatment of invasive aspergillosis.

IMG-20. RADIOMIC FEATURES IMPROVE PROGNOSTICATION OVER CONVENTIONAL MR DERIVED QUALITATIVE DESCRIPTORS IN PEDIATRIC SUPRATENTORIAL HIGH GRADE GLIOMA: COMPARISON OF MACHINE LEARNING TECHNIQUES

PURPOSE/OBJECTIVES

Pediatric supratentorial high-grade glioma (stHGG) is a biologically heterogeneous disease defined by unique mutations, natural history and prognosis. Prior work by our group outlined a role for qualitative imaging features in aiding prognostication. We build on that work by evaluating the prognostic utility of radiomic features (RM) when paired with clinical factors. MATERIALS/

METHODS

Ninety-one patients age &lt; 21 years with stHGG treated between 1980–2007 were retrospectively reviewed. Prognostic clinical, qualitative imaging (Visually AcceSAble Rembrandt Images, VASARI), and treatment characteristics were evaluated in concert with manual and automatically segmented (DeepMedic), tumor-derived semi-quantitative radiomic features (Pyradiomics) extracted from MR images. Prognostic RM were limited to stable imaging features which were subsequently selected using bootstrapped least absolute shrinkage and selection operator (LASSO). Nonparametric descriptive statistics and prognostication model evaluation, incorporating RM and clinical variables, were developed using random forest (RF), Cox proportional hazards (CPH), and deep learning (deepsurv) algorithms and assessed for goodness of fit using (c-index).

RESULTS

A subset (N=80) of 386 intensity, shape, and texture derived RM were stable between pre-treatment MR. 28 RM features were independently predictive of survival when compared to models utilizing combinations of clinical, VASARI and had comparable model fit statistics. CPH, RF and deepsurv showed comparable utility in modelling RM features. Combined modelling of clinical, VASARI and RM features using CPH, RF, and deepsurv resulted in c-indices of 0.68, 0.67, 0.68, respectively.

CONCLUSION

RM features are stable and independently prognostic. Combined modelling of clinical, VASARI, and RM features improves prognostication in stHGG.

RARE-12. VASCULOPATHY IN PEDIATRIC CRANIOPHARYNGIOMA PATIENTS TREATED WITH SURGERY AND RADIOTHERAPY

PURPOSE

As much as 40% of pediatric brain tumor patients will experience varied levels of Vasculopathy (VS), however few predictive factors have been described. Here we describe the type and timing of VS and explore the relationship between treatment modality and the timing, location, and distribution of VS.

METHODS

94 pediatric Craniopharyngioma patients underwent surgery and proton radiotherapy. Pre- and post-treatment imaging, cumulative physical and biological proton dose maps, clinical characteristics, and measures of dyslipidemia were evaluated. MR and MRAs were evaluated for pre- and post-radiotherapy VS (type, workup, location, and severity). VS events were segmented and described according to their normal brain region, and vascular territory.

RESULTS

47 patients were found to have 154 confirmed VS of varying severity with a median time to event of 3.41 years 95% CI 3.08–3.88. 22% (N=21) of patients had ≥1 pre-existing instances of VS and 26.6% (N=25) had a dyslipidemia at diagnosis. Forty-six (48.9%) patients had evidence of VS post-RT with 9.5% (N=9) being clinically significant. Aspirin was recommended in 10.6% (N=10) patients. Only 4 (4.2%) patients required revascularization. Clinical characteristics were not predictive of VS. An increased frequency of VS were observed along the operative corridor and high-dose radiotherapy field.

CONCLUSIONS

VS often precedes radiotherapy necessitating appropriate baseline imaging. Surgery type and extent are interrelated to the risk for radiotherapy-induced VS. While the spatial radiotherapy dose distribution approximated most vascular injury events, it was not all-inclusive. Spatial modeling of biological and physical dose may offer insights into therapy related vascular injury.

HGG-57. WHOLE-GENOME SEQUENCING, METHYLATION ANALYSIS, AND SINGLE-CELL RNA-SEQ DEFINE UNIQUE CHARACTERISTICS OF PEDIATRIC TREATMENT-INDUCED HIGH-GRADE GLIOMA AND SUGGEST ONCOGENIC MECHANISMS

BACKGROUND

Pediatric treatment-induced high-grade glioma (TIHGG) is among the most severe late effects observed in childhood cancer survivors and is uniformly fatal. We previously showed that TIHGG are divergent from de novo pediatric high-grade glioma (pHGG) and cluster into two gene expression subgroups, one stemlike and the other inflammatory. Here we systematically compared TIHGG molecular profiles to pHGG and evaluated expression and single cell sequencing profiles in order to identify oncogenic mechanisms and the cellular basis for the observed TIHGG gene expression subgroups. MATERIALS/

METHODS

450/850K methylation and mutational signature analysis was conducted in 36 TIHGG samples. Resultant data were analyzed for the presence of chromothripsis, distinct molecular alterations, and mutational signatures in a subset of 10 samples with whole genome sequencing data. Five TIHGGs underwent single-cell RNA-Seq analysis (scRNAseq).

RESULTS

26/36 TIHGG clustered with the pedRTK1 methylation class. TIHGG were characterized by an increased frequency of chromothripsis relative to pHGG (67% vs. 31%, p=0.036). FISH and WGS revealed frequent PDGFRA amplification secondary to enrichment in ecDNA. TIHGG were enriched for COSMIC mutational signatures 5 and 19 (p=0.0003) relative to pHGG. scRNAseq data showed that TIHGG tumors are composed of stem-like, neuronal, and inflammatory cell populations which may contribute to the previously described dominant expression profiles.

CONCLUSIONS

TIHGG represents a distinct molecular subtype of pHGG. Chromothripsis, leading to enriched expression of genes in extrachromosomal DNA, likely contribute to TIHGG oncogenesis. The dominant cell type (stem-like vs. inflammatory) may define the expression subgroup derived from bulk RNA-seq in heterogeneous tumors.

EPEN-50. THE MANAGEMENT AND TREATMENT OF PEDIATRIC SPINAL CORD EPENDYMOMA: RESULTS FROM A COLLABORATIVE INTERNATIONAL MULTI-INSTITUTIONAL REVIEW

PURPOSE

Pediatric Spinal cord ependymoma (SCE) is rare, and the management is often heterogeneous across centers. We evaluated the impact of clinical, pathologic, and treatment-related factors on outcomes in a multi-institutional, international cohort.

METHODS

SCE patients age <21 years were reviewed across 5 institutions. We utilized nonparametric descriptive statistics, survival, and recursive partitioning analysis (RPA) to examine patient, tumor, histopathologic and treatment characteristics, failure pattern, and cause of death.

RESULTS

125 patients were identified, 18 (14.4%) with metastases. Initial surgery was GTR, and STR in 44, 56% of patients respectively. Histology was grade 1, 2, and 3 in 55, 17.7 and 23.2% respectively. 55 patients with initial GTR were observed (52.7%) or irradiated (43.6%); 60 patients had STR and were observed (40%) or irradiated (60%). The 7-year event-free (EFS) and overall survival (OS) was 60% (95% CI 51.5–71.4) and 79% (95% CI 71.1–87.8) respectively. STR and metastasis increased the hazard for death [HR 1.87, 95% CI 1.02–3.57, p=0.05 (vs. GTR)] and [HR 2.28, 95% CI 1.1–5.2, p=0.048 (vs. localized)] respectively. Across 43 failures, local failure predominated (48.8%). Distant and combined failure occurred in 30.2 and 13.9% respectively. Adjuvant RT offered a 20% absolute improvement (vs. observation) in EFS at 5 years regardless of extent of resection. RPA identified thoracic (vs. non-thoracic), grade (1 & 3 vs. 2), STR (vs. GTR) and metastases as determinants of inferior EFS.

CONCLUSIONS

Tumor and treatment-related factors are predictive of EFS. OS is favorable despite diverse schema and frequent distant failures.

CTNI-27. FIRST-IN-PEDIATRICS PHASE I STUDY OF GDC-0084 (PAXALISIB), A CNS-PENETRANT PI3K/mTOR INHIBITOR, IN NEWLY DIAGNOSED DIFFUSE INTRINSIC PONTINE GLIOMA (DIPG) OR OTHER DIFFUSE MIDLINE GLIOMA (DMG)

BACKGROUND

GDC-0084 is an oral, highly selective and potent inhibitor of class I PI3K and moderate inhibitor of mTOR, with an established adult maximum tolerated dose (MTD) of 60 mg/day and evidence of brain tumor penetration in adult recurrent glioblastoma.

METHODS

We used a rolling-6 design to evaluate the safety and pharmacokinetic (PK) properties and establish the pediatric MTD of once-daily GDC-0084 administered after focal RT in children with newly diagnosed DIPG and histone H3 K27M-mutant DMG. Non-compartmental plasma PK analyses were performed using samples collected on cycle 1 days 1–3 after single-dose and day 28 at steady-state.

RESULTS

Twenty-five patients have been enrolled, 16 of whom were treated at study dosage levels of 27 mg/m2 (n=11) and 35 mg/m2 (n=5). Two dose limiting toxicities (DLTs) observed at 35 mg/m2 were grade 3 mucositis and grade 3 rash. Grade 3 hyperglycemia was the only DLT at 27 mg/m2. The most frequent grade 3 or 4 adverse events attributed to GDC-0084 were rash (5 patients), neutropenia (4), and hyperglycemia (2). After single-dose, GDC-0084 exposures (AUC0-48h) at 27 and 35 mg/m2 were 3399±1301 and 4462±2868 hr·ng/mL, respectively. Mean GDC-0084 half-life was 20.6±9.1 hr, comparable to that observed in adults.

CONCLUSIONS

The dosage of 27 mg/m2 has been established as the pediatric MTD of GDC-0084, which is approximately equivalent to 80% of the adult MTD. At 27 mg/m2, GDC-0084 is well tolerated in children where the spectrum of toxicities is similar to those observed in adults and consistent with this class of agents.

NIMG-51. CONVENTIONAL MRI RADIOMIC FEATURES IMPROVE PROGNOSTICATION AND ARE PREDICTIVE OF H3 K27M STATUS IN DIPG

BACKGROUND

Genomic profiling of DIPG suggests distinct and clinically relevant molecular subgroups based on the presence and isoform of histone H3 K27M mutation. We evaluated the impact of radiomic features on the classification and prognostication of 81 histologically confirmed and centrally reviewed DIPG.

METHODS

We utilized a combination of manual and automatic segmentation (DeepMedic) to define tumor volume and Pyradiomics for computation of radiomic features. Imaging feature stability was assessed by calculating concordance correlation coefficient (CCC) for each radiomic parameter from two separate pretreatment MRIs. Bootstrapped least absolute shrinkage and selection operator (LASSO) was used for feature selection. Classification and prognostication models, incorporating H3 status and clinical variables, were developed using random forest, Cox proportional hazards, and deep learning algorithms and assessed for goodness of fit using the c-index.

RESULTS

Eighty of 386 imaging features demonstrated stability (CCC, p&lt; 0.001) between pretreatment scans. LASSO identified 26 prognostic imaging features and 38 and 57 imaging features predictive of the presence of H3 K27M mutation and H3 K27M isoforms, respectively. Using five-fold cross validation, the accuracy of distinguishing H3 K27M mutant and WT tumors was 85% and 77% for H3.3 K27M, H3.1 K27M, and WT tumors. C-index for prognostication was 0.77 for Cox, 0.55 for random forest, and 0.72 for deep learning. All models were more predictive than the Jansen survival prediction model.

CONCLUSIONS

Stable, predictive radiomic features may be a surrogate for H3 status and enhance current prognostication of DIPG. Model validation in cohorts of prospectively treated patients with DIPG is ongoing.

Incidence and causes of in-hospital mortality in cardiac device-related infections

Introduction

Cardiac device-related infections (CDRI) are associated with increased in-hospital mortality despite effective treatment by transvenous lead extraction (TLE) and antibiotic therapy. Data on mortality and causes of death are scarce and predictors of mortality are not well defined.

Purpose

To analyse the incidence and causes of mortality in CDRI and identify predictors of mortality in a large single centre experience.

Methods

All patients undergoing TLE for CDRI in our department between May 2012 and January 2020 were included in a prospective registry. Patient characteristics, procedural and follow-up data were collected and analysed. A Kaplan-Meier analysis was used to analyse the influence of different infection types on mortality. Univariate and multivariate cox regression analysis was applied to identify risk factors for mortality.

Results

Among 561 consecutive patients (72±12 years; 77% male) treated for CDRI (51.2% systemic and 48.8% localized infection), 61 patients (10.9%) died during the index hospitalization. The most frequent cause of death was severe systemic infection or sepsis in 38 patients (6.8%), followed by end-stage heart failure (9; 1.6%), respiratory insufficiency (3; 0.5%), ventricular arrhythmias (3; 0.5%), asystole (2; 0.4%), pulmonary embolism (2; 0.4%), acute enteric ischemia (2; 0.4%), mechanical ileus (1; 0.2%), and unwitnessed sudden death (1; 0.2%). Patients who died had significantly more often systemic infections (p&lt;0.001), positive blood cultures (p&lt;0.001), severe renal dysfunction (GFR &lt;30ml/min; p&lt;0.001), heart failure with reduced ejection fraction (HFrEF; p=0.001), and diabetes (p=0.004). Kaplan-Meier survival analysis showed a significantly higher mortality in patients with systemic CDRI as compared to localized infection (log-rank p&lt;0.001). Several factors were predictors of mortality in univariate analysis: systemic infection (HR 4.64, 95% CI 2.18–9.84; p&lt;0.001), GFR &lt;30 ml/min (HR 4.27, 95% CI 2.57–7.09; p&lt;0.001), vegetation in TOE (HR 3.68, 95% CI 1.78–7.43; p&lt;0.001), positive blood cultures (HR 2.52, 95% CI 1.46–4.37; p=0.001), diabetes (HR 1.89, 95% CI 1.12–3.18; p=0.018), HFrEF (HR 1.83, 95% CI 1.09–3.05; p=0.021), tricuspid regurgitation (HR 1.79, 95% CI 1.21–2.65, p=0.004), and days from hospital admission to explant (HR 1.04, 95% CI 1.02–1.06; p&lt;0.001). Multivariate analysis revealed severe renal dysfunction (HR 2.71, 95% CI 1.47–5.00; p=0.001) and days from hospital admission to TLE (HR 1.029, 95% CI 1.004–1.055, p=0.021) as independent predictors of in-hospital mortality.

Conclusion

In-hospital mortality in CDRI is particularly high in patients with severe systemic infection and sepsis despite state-of the-art treatment. Delayed TLE is associated with an increased in-hospital mortality. Therefore, TLE should be performed early in the course of CDRI, particularly in patients with severe systemic infection.

Funding Acknowledgement

Type of funding source: None

Predictors of major procedure-related complications in transvenous lead extraction

Background

Transvenous lead extraction (TLE) has become the mainstay therapy for device-related infections. Though TLE procedures are associated with low complication and high success rates, risk factors for major procedure-related complications remain not well defined.

Purpose

To evaluate the safety and efficacy of TLE in a large single centre cohort and to identify risk factors for major complications.

Methods

All consecutive patients who had undergone TLE in our department between May 2012 and January 2020 were included in a prospective registry. Our protocol for TLE followed a stepwise approach according to lead dwell time and estimated complexity of the procedure: use of simple traction ± locking stylet (LS) ± mechanical and/or powered sheaths ± snare technique. In case of unsuccessful extraction from the venous entry site, femoral or jugular access was approached. Patient characteristics, procedural data and complications were gathered and analysed. Logistic regression analysis was applied to identify risk factors for major procedure-related complications.

Results

A total of 1717 leads (443 [25.9%] ICD leads) were targeted for TLE in 810 patients (67±15 years; 76% male). The mean lead dwell time was 83±60 months. The leading indication for TLE was cardiac device related infection (CDRI) in 527 patients (65.1%), of whom 273 (51.8%) had systemic and 254 (48.2%) localized infection. Two hundred eighty-three patients (34.9%) underwent TLE for non-CDRI causes. Leads were extracted by simple traction in 28.2%, traction with LS in 4.1%, dilator sheaths with LS in 50.1%, and additional use of powered mechanical sheaths in 13.0%. The snare technique was used in 4.6%. Venous access for TLE was exclusively from the entry site in 94.8%, combined from femoral in 4.0% and jugular in 1.2%. TLE was completely successful in 96.2%, partially successful in 2.1%, and failed in 1.7% of all attempted leads, which translated to a clinical success rate of 96.8%.

Eighteen patients (2.2%) experienced minor and 12 patients (1.5%) had major procedure-related complications (cardiac tamponade/perforation) including one intraprocedural death (0.1%) from fulminant pulmonary embolism. Lead-years-per-patient (HR 1.064, 95% CI 1.032–1.096; p&lt;0.001), dwelling time of the oldest lead (HR 1.013, 95% CI 1.007–1.019; p&lt;0.001), and BMI (HR 0.877, 95% CI 0.772–0.997; p=0.020) were significant predictors for major complications in logistic regression analysis.

Conclusion

TLE is feasible, effective and safe in our large single centre experience. Overall complication and failure rates are low. Following our TLE protocol, dwelling time of the extracted leads and low BMI were associated with major procedure-related complications.

Funding Acknowledgement

Type of funding source: None

Impact of ferric carboxymaltose in patient blood management in Portuguese hospitals

Background

The use of transfusions leads to excessive blood consumption, implying risks such as infections and immunological reactions, so it should be used only when strictly necessary. Patient Blood Management (PBM) aims to minimize the use of allogeneic blood and improve clinical outcomes, with better cost-effectiveness, using three essential points: improving hematopoiesis, minimize blood loss in and optimize the hemoglobin reserves of each patient. The aim of this work is to assess the preoperative haemoglobin optimization using ferric carboxymaltose as part of PBM implementation, in elective orthopaedic, cardiac and colorectal surgery in Portuguese hospitals.

Methods

This is an observational study materialized in a retrospective and multicenter cohort with data collection from medical records. The population and sample will be patients over 18 years from elective orthopaedic, cardiac and colorectal surgeries, treated according with local standards before PBM implementation were assigned to the pre-PBM cohort and patients after PBM implementation with ferric carboxymaltose to preoperative haemoglobin optimization to the PBM cohort. The criteria for selecting hospitals will be the implementation of PBM during the study period.

Expected Results

Based on a previous review, it is expected that the results of the use of ferric carboxymaltose to correct iron deficiency anaemia for preoperative haemoglobin optimization will contribute positively to reducing the number of transfusions, the length of hospital stays and will have a direct impact on economic results.

Conclusions

The use of ferric carboxymaltose and other ferric compounds, as part of PBM program, has demonstrated a positive impact on patients' outcomes (morbility and mortality), adverse events and on economic results. This study might show that clinical guidelines and programs like PBM are a major contribution not just for hemovigilance and blood safety but also for patient safety and health quality.

Key messages

This work is focused on Portuguese hospitals and aims to assess the impact of ferric carboxymaltose and its benefit on PBM strategy. Specially this study intends to conduct the assessment on health outcomes and costs.

A multinational assessment of work-related productivity loss and indirect costs from a survey of patients with psoriasis

BACKGROUND

Total work productivity loss (WPL) and associated indirect costs contribute to the economic burden of psoriasis.

OBJECTIVES

To estimate total WPL and related indirect costs, and identify predictors of WPL associated with psoriasis severity in France, Germany, Spain, the U.K. and Italy (EU5) and the U.S.A.

METHODS

Data from the 2015 Adelphi Real World Psoriasis Disease Specific Programme, analysed for absenteeism, presenteeism and total WPL, were quantified (0-100%) from participants who completed the Work Productivity and Activity Impairment (WPAI) instrument. These measures were converted to indirect costs using the human capital method. Univariate and multivariate statistical analyses controlling for patient demographic and clinical characteristics were conducted.

RESULTS

Of the 936 respondents (29·6% U.S.A., 70·4% EU5) who completed the WPAI, 32·6%, 40·7% and 26·6% had mild [body surface area (BSA) 0-2%], moderate (BSA 3-10%) and severe (BSA > 10%) psoriasis, respectively. Average age, Dermatology Life Quality Index (DLQI) score and BSA were, respectively, 42·4 years, 5·1 and 9·6%; and 37·2% of respondents were female. Mean percentages of total WPL for respondents with mild, moderate and severe psoriasis were 10·1%, 18·9% and 29·4%, respectively. Presenteeism contributed considerably more to total WPL than did absenteeism across all countries and disease severity classes. Mean annual indirect costs per patient due to WPL ranged from 3742 U.S. dollars in Spain to 9591 U.S. dollars in the U.S.A. Multivariate regression showed that a one-unit increase in DLQI score increases total WPL by 1·8% (P < 0·001).

CONCLUSIONS

WPL increased progressively with increasing DLQI scores and BSA, confirming the relationship between psoriasis severity and its economic burden. What's already known about this topic? The economic burden of psoriasis is exceptionally high given the high prevalence and lifelong nature of the condition. Several studies have attempted to assess the overall economic burden of psoriasis but there is a lack of comparative data from different countries, and issues around inconsistent methodologies, including statistical analyses. Total work productivity loss (WPL) and associated indirect costs are believed to contribute to the economic burden of psoriasis. What does this study add? This study measured total WPL and indirect costs via the same method and at the same time point in the U.S.A., France, Germany, Spain, U.K. and Italy. Total WPL increased progressively with psoriasis disease severity. Disease severity and Dermatology Life Quality Index scores significantly correlated with WPL after controlling for patient demographic and clinical characteristics. The U.S.A. had the highest annual mean indirect costs associated with total WPL. Linked Comment: Drabo et al. Br J Dermatol 2020; 183:420-421.

A versatile dual-use RT-PCR control for use in assays for the detection of peste des petits ruminants virus

Peste des petits ruminants (PPR) is an acute and highly contagious disease with high mortality in small ruminants and significant socioeconomic impact in developing countries. The causative agent is peste des petits ruminants virus (PPRV). The Food and Agriculture Organization of the United Nations (FAO) and the World Organization for Animal Health (OIE) have set up a goal for the global eradication of PPR by 2030. To assist in this effort, an easily produced, specific, non-pathogenic bacteriophage Qβ based real-time RT-PCR (qRT-PCR) PPRV positive control was developed. This control is compatible for use with two previously described PPRV qRT-PCR assays either as singleplex or multiplex platform. Additionally, the control can also be used for assembling proficiency testing panels for competency testing in diagnostic laboratories. Use of the Qβ phage based PPRV control as a positive control or in proficiency testing panels reduces the risk of inadvertent release of pathogenic PPRV from diagnostic laboratories, which would be especially important should PPR be eradicated in the future.

Evaluation of VIDAS® Immuno-Concentration Salmonella/VIDAS Salmonella Immunoassay Method for Detection of Salmonella in Selected Foods: Collaborative Study

The VIDAS Immuno-concentration Salmonella (ICS)/VIDAS Salmonella (SLM) immunoassay method for the detection of Salmonella was compared to the Bacteriological Analytical Manual (BAM)/AOAC culture method in a collaborative study. Thirty-two laboratories participated in the evaluation. Each laboratory tested one or more of the 6 test products: milk chocolate, nonfat dry milk, dried whole egg, soy flour, ground black pepper, and ground raw turkey. The 2 methods were in agreement for 1266 of the 1440 samples. Of the 174 samples not in agreement, 69 were VIDAS ICS/SLM-positive and BAM/AOAC-negative and 105 were VIDAS ICS/SLM-negative and BAM/AOAC-positive.

Evaluation of VIDAS® Immuno-Concentration Salmonella Assay Plus Selective Plate Method (Hektoen Enteric, Bismuth Sulfite, Salmonella Identification) for Detection of Salmonella in Selected Foods: Collaborative Study

The VIDAS Immuno-concentration Salmonella (ICS) plus selective plate method (Hektoen enteric, bismuth sulfite, Salmonella identification) method for the detection of Salmonella was compared to the Bacteriological Analytical Manual (BAM)/AOAC culture method in a collaborative study. Thirty-two laboratories participated in the evaluation. Each laboratory tested one or more of the 6 test products: milk chocolate, nonfat dry milk, dried whole egg, soy flour, ground black pepper, and ground raw turkey. The 2 methods were in agreement for 1283 of the 1440 test samples. Of the 157 test samples not in agreement, 82 were VIDAS ICS plus selective plate-positive and BAM/AOAC-negative, and 75 were VIDAS ICS plus selective plate-negative and BAM/AOAC-positive.

Salmonella in Selected Foods by VIDAS® Immuno-Concentration Salmonella Plus Selective Plate Method (Hektoen Enteric, Xylose Lysine Desoxycholate, Bismuth Sulfite): Collaborative Study

The VIDAS Immuno-concentration Salmonella (ICS) plus selective plate method (Hektoen enteric, xylose lysine desoxycholate, bismuth sulfite) method for the detection of Salmonella was compared to the Bacteriological Analytical Manual (BAM)/AOAC culture method in a collaborative study. Thirty-two laboratories participated in the evaluation. Each laboratory tested one or more of the 6 test products: milk chocolate, nonfat dry milk, dried whole egg, soy flour, ground black pepper, and ground raw turkey. The 2 methods were in agreement for 1297 of the 1455 samples. Of the 158 samples not in agreement, 82 were VIDAS ICS plus selective plate-positive and BAM/AOAC-negative, and 76 were VIDAS ICS plus selective plate-negative and BAM/AOAC-positive.

Propofol Total Intravenous Anesthesia as an Intervention for Severe Radiation-Induced Phantosmia in an Adolescent with Ependymoma

Radiation-induced phantosmia has been reported both in children and adults. A fraction of these patients have nausea and vomiting triggered by phantosmia. Radiation-induced phantosmia, although transient, can be distressing enough to prevent a patient from staying still during radiation therapy. To date, specific interventions for radiation-induced phantosmia, including anesthesia, have not been reported. We report for the first time anesthesia as an intervention for transient severe radiation-induced phantosmia, in a 16-year-old girl with ependymoma undergoing proton therapy, and we discuss the pros and cons of techniques for anesthesia and airway management.