The use of procedural kits may reduce unscheduled central line dressing changes: A matched pre-post intervention study

Background

Unscheduled dressing changes for central venous lines (CVLs) have been shown to increase the risk of bloodstream infections.

Objective

The objective of this study is to determine if the use of an innovative dressing change kit reduces the rate of unscheduled dressing changes.

Methods

This pre-post interventional study took place at a large, academic, tertiary care center in metro Detroit, Michigan, the United States. We assessed the impact of the interventional dressing change procedure kit on the rate of unscheduled dressing changes for adult patients who underwent placement of a CVL inclusive of a central catheter, peripherally inserted central catheter, or hemodialysis catheter. Data was collected for the pre-intervention cohort through electronic health records (EHRs), while data for the post-intervention cohort were collected by direct observation by trained research staff in combination with EHR data. The primary outcome was the rate of unscheduled dressing changes. Secondary outcomes included rate of unscheduled dressing changes based on admission floor type, etiology of unscheduled dressing changes, and central line-associated bloodstream infections (CLABSIs).

Results

The study included a convenience sample of 1548 CVLs placed between May 2018 and June 2022 with a matched analysis including 488 catheters in each of the pre- and post-intervention groups. The results showed that the unadjusted rate of unscheduled dressing evaluations was significantly reduced from the pre-intervention group (0.21 per day) to the post-intervention group (0.13 per day) (p < .001). The adjusted rate ratio demonstrated the same trend at 1.00 pre- and 0.60 post-intervention (p < .001). Stratifying the analysis based on the highest level of care showed that the intervention was effective in reducing the unadjusted rate of unscheduled dressing evaluations for both the advanced and regular medical floor subgroups pre- to post-intervention; the advanced subgroup had an reduction from 0.22 to 0.15 per day (p = .001), while the regular medical floor subgroup had a reduction from 0.21 to 0.09 per day (p < .001). CLABSIs were similar in both groups (0.6% vs 0.8%; p = 1.00) in pre- and post-intervention groups, respectively.

Discussion

Procedural kits for central line dressing changes are effective in reducing unscheduled dressing changes and may have a role in reducing CLABSI. Further studies assessing the impact of dressing change kits on cost, procedural compliance, and the precise impact on CLABSI are needed.

Germline homozygosity and allelic imbalance of HLA-I are common in esophagogastric adenocarcinoma and impair the repertoire of immunogenic peptides

BACKGROUND

The individual HLA-I genotype is associated with cancer, autoimmune diseases and infections. This study elucidates the role of germline homozygosity or allelic imbalance of HLA-I loci in esophago-gastric adenocarcinoma (EGA) and determines the resulting repertoires of potentially immunogenic peptides.

METHODS

HLA genotypes and sequences of either (1) 10 relevant tumor-associated antigens (TAAs) or (2) patient-specific mutation-associated neoantigens (MANAs) were used to predict good-affinity binders using an in silico approach for MHC-binding (www.iedb.org). Imbalanced or lost expression of HLA-I-A/B/C alleles was analyzed by transcriptome sequencing. FluoroSpot assays and TCR sequencing were used to determine peptide-specific T-cell responses.

RESULTS

We show that germline homozygosity of HLA-I genes is significantly enriched in EGA patients (n=80) compared with an HLA-matched reference cohort (n=7605). Whereas the overall mutational burden is similar, the repertoire of potentially immunogenic peptides derived from TAAs and MANAs was lower in homozygous patients. Promiscuity of peptides binding to different HLA-I molecules was low for most TAAs and MANAs and in silico modeling of the homozygous to a heterozygous HLA genotype revealed normalized peptide repertoires. Transcriptome sequencing showed imbalanced expression of HLA-I alleles in 75% of heterozygous patients. Out of these, 33% showed complete loss of heterozygosity, whereas 66% had altered expression of only one or two HLA-I molecules. In a FluoroSpot assay, we determined that peptide-specific T-cell responses against NY-ESO-1 are derived from multiple peptides, which often exclusively bind only one HLA-I allele.

CONCLUSION

The high frequency of germline homozygosity in EGA patients suggests reduced cancer immunosurveillance leading to an increased cancer risk. Therapeutic targeting of allelic imbalance of HLA-I molecules should be considered in EGA.

Evolutionary trajectories of small cell lung cancer under therapy

The evolutionary processes that underlie the marked sensitivity of small cell lung cancer (SCLC) to chemotherapy and rapid relapse are unknown1-3. Here we determined tumour phylogenies at diagnosis and throughout chemotherapy and immunotherapy by multiregion sequencing of 160 tumours from 65 patients. Treatment-naive SCLC exhibited clonal homogeneity at distinct tumour sites, whereas first-line platinum-based chemotherapy led to a burst in genomic intratumour heterogeneity and spatial clonal diversity. We observed branched evolution and a shift to ancestral clones underlying tumour relapse. Effective radio- or immunotherapy induced a re-expansion of founder clones with acquired genomic damage from first-line chemotherapy. Whereas TP53 and RB1 alterations were exclusively part of the common ancestor, MYC family amplifications were frequently not constituents of the founder clone. At relapse, emerging subclonal mutations affected key genes associated with SCLC biology, and tumours harbouring clonal CREBBP/EP300 alterations underwent genome duplications. Gene-damaging TP53 alterations and co-alterations of TP53 missense mutations with TP73, CREBBP/EP300 or FMN2 were significantly associated with shorter disease relapse following chemotherapy. In summary, we uncover key processes of the genomic evolution of SCLC under therapy, identify the common ancestor as the source of clonal diversity at relapse and show central genomic patterns associated with sensitivity and resistance to chemotherapy.

Unintended consequences of using collars with occipital extensions in neck support - Snapshot assessment at the largest tertiary spinal referral centre in the UK

INTRODUCTION

Upper cervical spine fractures are commonplace in the elderly following low energy trauma. These injuries carry high mortality rates, similar to patients sustaining hip fractures. A key aspect affecting clinical outcome is effective management in the first 12 weeks following injury. This study aims to assess the understanding of healthcare staff that may be required to care for such patients.

MATERIALS AND METHODS

A survey was carried out over a single day at the UK's largest Spine Specialist referral centre (Salford Royal Foundation Trust, SRFT) assessing the understanding of healthcare staff of the term, 'Collar with occipital extension', by asking staff to identify the safe position of the neck when looking at clinical images of a model in a collar in various different neck positions. The participants demographics were then taken, including profession, grade, spinal/post graduate experience, if English is their first language and their understanding of the term 'Collar with occipital extension'.

RESULTS

102 participants were interviewed and the results showed almost half (45.1%) of participants selecting an incorrect hyperextended neck to be a safe position for conservative treatment and only 37.3% selecting the neutral position as satisfactory. The only positive predictors identified for those selective the neutral safe cervical spine alignment was if participants had >5 years of previous spinal experience (p = 0.0006) or if they understood the term 'Collar with occipital extension' to be describing the collar component (p = 0.000013) and not neck position.

CONCLUSION

Management of spinal injuries are classically poorly managed in non-spinal centres, possibly due to the lack of training and understanding within the spinal speciality. This study shows the importance of clearly communicating with referring hospitals exactly how to conservatively manage patients with high cervical injuries to best improve clinical outcome.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Informal gold miners with mercury toxicity: Novel asymmetrical neurological presentations

Mercury is a highly toxic heavy metal that may cause neurological, respiratory, gastrointestinal and dermatological illnesses. Previously described neurological manifestations of mercury toxicity are symmetrical, and include a pancerebellar syndrome, generalised seizures and encephalopathy. Mercury is used in the gold mining process, and in artisanal or illicit gold mining, often without necessary protection. Here we describe the cases of two artisanal gold miners from western Johannesburg, South Africa, who presented with atypical neurological manifestations of mercury toxicity. Patient 1 presented with focal seizures, an asymmetrical cerebellar syndrome and an acute encephalopathy. Patient 2 had unilateral cerebellar ataxia. Both patients had toxic mercury levels, with no other cause identified for their symptoms. Patient 1 responded well to chelation therapy, but patient 2 refused admission and further medical treatment. The neurological manifestations of mercury toxicity are typically symmetrical, whereas our two patients presented with markedly asymmetrical features. It is important to maintain a high index of suspicion for mercury poisoning, even in patients with atypical and unilateral or asymmetrical presentations. A prompt diagnosis and the commencement of early chelation therapy have the potential to produce good outcomes.

Role of demographics in noninvasive testing for colorectal cancer screening: do targeted cut-off values improve detection?

BACKGROUND

Fecal immunochemical test (FIT) is a yearly alternative colorectal screening modality for average risk individuals unwilling or unable to undergo invasive colorectal cancer (CRC) screening due to cost and accessibility. This study aimed to determine whether FIT should be interpreted within the context of patient demographics and medical history.

METHODS

Patients >50 years old who had a FIT followed by colonoscopy within 1 year were analyzed based on age, race, BMI, social and medical comorbidities. False positive (FP) and false negative (FN) FIT results within each patient demographic and medical history variable were determined by comparing with the gold standard of colonoscopy using χ2 analysis.

RESULTS

One thousand twenty-five patients were reviewed. 21.8% of FIT results were positive. Factors which differed in positive FIT rates were age (P=0.003), smoking (P<0.001), alcohol (P=0.001), and hypertension (P<0.001). The difference in rates of FP and FN FIT outcomes among each variable underwent further subanalysis. The FP was 66.8% and the FN rate was 12.8%. Higher FN outcomes were noted in those above 70, males and smokers, though the result was only statistically significant for males (P=0.009). Females were observed to have higher FP rates (P=0.019).

CONCLUSIONS

Females had higher FP FIT rates compared to males, indicating that sex may influence FIT outcomes and should be accounted for when interpreting FIT results. This information can be utilized to identify populations at higher risk of FP or FN FIT results to target CRC screening. Additionally, recalculating the FP and FN rates for each variable may help determine new FIT targets.

Somatic rearrangements causing oncogenic ectodomain deletions of FGFR1 in squamous cell lung cancer

The discovery of frequent 8p11-p12 amplifications in squamous cell lung cancer (SQLC) has fueled hopes that FGFR1, located inside this amplicon, might be a therapeutic target. In a clinical trial, only 11% of patients with 8p11 amplification (detected by FISH) responded to FGFR kinase inhibitor treatment. To understand the mechanism of FGFR1 dependency, we performed deep genomic characterization of 52 SQLCs with 8p11-p12 amplification, including 10 tumors obtained from patients who had been treated with FGFR inhibitors. We discovered somatically altered variants of FGFR1 with deletion of exons 1-8 that resulted from intragenic tail-to-tail rearrangements. These ectodomain-deficient FGFR1 variants (ΔEC-FGFR1) were expressed in the affected tumors and were tumorigenic in both in vitro and in vivo models of lung cancer. Mechanistically, breakage-fusion-bridges were the source of 8p11-p12 amplification, resulting from frequent head-to-head and tail-to-tail rearrangements. Generally, tail-to-tail rearrangements within or in close proximity upstream of FGFR1 were associated with FGFR1 dependency. Thus, the genomic events shaping the architecture of the 8p11-p12 amplicon provide a mechanistic explanation for the emergence of FGFR1-driven SQLC. Specifically, we believe that FGFR1 ectodomain-deficient and FGFR1-centered amplifications caused by tail-to-tail rearrangements are a novel somatic genomic event that might be predictive of therapeutically relevant FGFR1 dependency.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Comparison of the clinical characteristics of SARS-CoV-2 Delta (B.1.617.2) and Omicron (B.1.1.529) infected patients from a single hospitalist service

BACKGROUND

While existing evidence suggests less severe clinical manifestations and lower mortality are associated with the Omicron variant as compared to the Delta variant. However, these studies fail to control for differences in health systems facilities and providers. By comparing patients hospitalized on a single medical service during the Delta and Omicron surges we were able to conduct a more accurate comparison of the two varaints' clinical manifestations and outcomes.

METHODS

We conducted a prospective study of 364 Omicron (BA.1) infected patients on a single hospitalist service and compared these findings to a retrospective analysis of 241 Delta variant infected patients managed on the same service. We examined differences in symptoms, laboratory measures, and clinical severity between the two variants and assessed potential risk drivers for case mortality.

FINDINGS

Patients infected with Omicron were older and had more underlying medical conditions increasing their risk of death. Although they were less severely ill and required less supplemental oxygen and dexamethasone, in-hospital mortality was similar to Delta cases, 7.14% vs. 4.98% for Delta (q-value = 0.38). Patients older than 60 years or with immunocompromised conditions had much higher risk of death during hospitalization, with estimated odds ratios of 17.46 (95% CI: 5.05, 110.51) and 2.80 (1.03, 7.08) respectively. Neither vaccine history nor variant type played a significant role in case fatality. The Rothman score, NEWS-2 score, level of neutrophils, level of care, age, and creatinine level at admission were highly predictive of in-hospital death.

INTERPRETATION

In hospitalized patients, the Omicron variant is less virulent than the Delta variant but is associated with a comparable mortality. Clinical and laboratory features at admission are informative about the risk of death.

Measurement of the Positive Muon Anomalous Magnetic Moment to 0.20 ppm

We present a new measurement of the positive muon magnetic anomaly, a_{μ}≡(g_{μ}-2)/2, from the Fermilab Muon g-2 Experiment using data collected in 2019 and 2020. We have analyzed more than 4 times the number of positrons from muon decay than in our previous result from 2018 data. The systematic error is reduced by more than a factor of 2 due to better running conditions, a more stable beam, and improved knowledge of the magnetic field weighted by the muon distribution, ω[over ˜]_{p}^{'}, and of the anomalous precession frequency corrected for beam dynamics effects, ω_{a}. From the ratio ω_{a}/ω[over ˜]_{p}^{'}, together with precisely determined external parameters, we determine a_{μ}=116 592 057(25)×10^{-11} (0.21 ppm). Combining this result with our previous result from the 2018 data, we obtain a_{μ}(FNAL)=116 592 055(24)×10^{-11} (0.20 ppm). The new experimental world average is a_{μ}(exp)=116 592 059(22)×10^{-11} (0.19 ppm), which represents a factor of 2 improvement in precision.

Evaluation of Interprofessional Quality Improvement Interventions Led by an Ambulatory Care Pharmacist on Adherence to a Controlled Substance Agreement Policy

Background: A controlled substance agreement (CSA) is a risk mitigation strategy for patients managed on controlled substance medications such as opioids and benzodiazepines. Limited literature exists to describe the role of the clinic pharmacy team to promote adherence to CSA monitoring parameters. Objective: The objective of this study is to evaluate the impact of interprofessional educational and clinical interventions led by an ambulatory care pharmacist on adherence to monitoring parameters within a CSA policy. Methods: This retrospective observational study included patients on long-term controlled substances who had a clinic visit every 3 months during the study period. The primary outcomes were the proportion of patients with a signed CSA in the electronic medical record (EMR), urine drug screen (UDS) completion, and documentation of review of the statewide prescription drug monitoring program (PDMP) in the EMR 8 months prior to as compared to 8 months after implementation of pharmacist interventions. Results: Among 79 patients (mean age 55.7 years, 65.8% female, 54.4% African American), 8.9% pre- vs 88.6% post-interventions had a signed CSA (p<0.001), 35.4% pre- vs 65.8% post-interventions had a UDS completed (p<0.001), and 32.9% pre- vs 57% post-interventions had documentation of PDMP review (p=0.002). Conclusion: Adherence to monitoring parameters within a CSA policy significantly improved after educational and clinical interventions led by an ambulatory care pharmacist.

Impact of Ambulatory Care Pharmacist-Led Management on Hemoglobin A1c Values among Patients with Uncontrolled Diabetes in a Primary Care Clinic vs Usual Care over Two Years

Background: Literature has shown the positive impact of ambulatory care pharmacists on diabetes management, yet additional research on clinical outcomes compared to traditional care models is warranted. Objective: The objective of this study is to evaluate the impact of an ambulatory care pharmacist on glycemic control over two years compared to patients who received usual care. Methods: This retrospective cohort study matched patients with a baseline hemoglobin A1c (HgbA1c) ≥8% managed by the ambulatory care pharmacist to patients who received usual care. The primary outcome was the mean change in HgbA1c over two years. The secondary outcomes were to evaluate the difference in (1) the proportion of patients achieving HgbA1c <8%, (2) the proportion of patients achieving blood pressure <130/80 mmHg, (3) mean LDL, (4) the proportion of patients prescribed SGLT2 inhibitors, GLP-1RA, and sulfonylureas, and (5) severe hypoglycemia after two years. Results: Data for 180 patients was analyzed over two years. The mean HgbA1c was 10% at baseline vs 8.2% after two years (adjusted mean change -1.92) among pharmacist-managed patients, compared to 9.9% vs 9% respectively for usual care patients (adjusted mean change -0.98) (p=0.004). Among pharmacist-managed patients, 53.5% achieved HgbA1c <8% compared with 34.2% of usual care patients (p=0.014). There were no statistically significant differences in proportion of patients at goal blood pressure, mean LDL, or hypoglycemia between the two groups. After two years, 18.3% of pharmacist-managed and 5.8% of usual care patients were on an SGLT2 inhibitor (p=0.008), and 46.7% of pharmacist-managed and 9.2% of usual care patients were on a GLP-1RA (p<0.001). No difference was found in sulfonylurea utilization. Conclusion: Patients with HgbA1c >8% managed by an ambulatory care pharmacist had twice the HgbA1c reduction and significantly more utilization of GLP-1RA and SGLT2 inhibitors as compared to controls provided usual care.

Outcomes of Brain Metastases with Suspicious Imaging Undergoing Resection to Evaluate for Radionecrosis vs. Tumor Progression

PURPOSE/OBJECTIVE(S)

In patients treated with stereotactic radiosurgery (SRS) for brain metastases, radiographic changes on surveillance imaging may result from treatment effect/radionecrosis (RN) or tumor progression. Distinguishing between these processes is critical to appropriate management. We report long-term outcomes for a cohort of patients who demonstrated radiographic progression on serial imaging after initial radiation and ultimately underwent resection to inform further management.

MATERIALS/METHODS

A retrospective chart review identified 76 patients with an associated 82 brain lesions between 2009 and 2022 that were initially treated with SRS, then demonstrated suspicious imaging changes developing through at least two scan time points that led to pathologic confirmation of either tumor or RN. We report clinical outcomes and details of further treatments.

RESULTS

Of the 82 lesions, 55 (67.1%) were found to be pathologically-confirmed viable tumor and were treated with repeat radiation and 27 (32.9%) were found to be strictly RN and conservatively managed. Over half of the lesions (14/27) ultimately found to be radionecrotic required use of steroids pre-operatively due to neurologic symptoms. Among the 27 that were found to be RN, the most common histology was melanoma (33.3%, n = 9). The most common dose fractionation regimen was 20 Gy in 1 fx (n = 11, 40.7%; range: 16-20 Gy x 1Fx), and the median BED (10) was 50.4 Gy (IQR 41.6 - 50 Gy). None of these lesions required further intervention with median post-surgery follow up of 24.4 months (range 1-104 months). There were 55 instances (in 51 patients) of pathologically-confirmed recurrent/progressive tumor who were consequently treated with repeat radiation with either Cs-131 brachytherapy (12 (21.8%)) or SRS (43 (78.2%)). The most common histology was NSCLC (37.2%, n = 19). The most common fractionation for repeat irradiation with SRS was 8 Gy x 3 fx (n = 15, 27.3%), followed by 5 Gy x 5 fx (n = 10, 18.2%), and 4 Gy x 5 fx (n = 8, 14.6%). Four individuals each had two lesions that were re-irradiated for local recurrence. Among patients treated with re-irradiation, the median follow-up to local failure was 15.2 months (95% CI 7.3-26.6 months). Radionecrosis was confirmed on pathology in 4/55 (7.2%) of lesions. The median follow-up from date of SRS2 to local failure was 14.1 months (95% CI 7.6-24.3 months). The 2-yr local control rate was 74.8% (95% CI 61.7-90.7%).

CONCLUSION

We recommend cautious monitoring of possible progression after radiosurgery, with consideration of resection for continuous progression, as a significant proportion of radiographic progression are ultimately pure RN. Management determined by pathology (observation for RN; additional radiation for confirmed tumor) leads to excellent control.

[ctHPV-DNA based precision oncology for patients with oropharyngeal cancer - Where are we?]

Human papillomavirus (HPV) is an established etiologic factor for cancers in the head and neck region, specifically for Oropharyngeal Squamous Cell Carcinoma (OPSCC). The comparatively good overall survival justifies the current discussion regarding therapy de-escalation for patients with a low-risk profile. In addition to the immunohistochemistry-based biomarker p16INK4a, there is still a need for diagnostic and prognostic biomarkers that allow risk stratification and monitoring during therapy and follow-up of these patients. In recent years, liquid biopsy, especially in the form of plasma samples, has gained importance and is already used to monitor viral DNA in patients with Epstein-Barr virus-associated nasopharyngeal carcinoma. Circulating DNA (ctDNA) released by the tumor into the bloodstream is particularly suitable for a high specificity in detecting virus-associated tumors. Detection of viral E6 and E7 oncogenes in HPV-positive OPSCC is predominantly performed by droplet digital/quantitative PCR as well as next generation sequencing. Detection of circulating HPV-DNA derived from tumor cells (ctHPV-DNA) at diagnosis is associated with advanced tumor stage, locoregional and distant metastases. Longitudinal studies have further demonstrated that detectable and/or increasing ctHPV-DNA levels are associated with treatment failure and disease relapse. However, a standardization of the diagnostic procedure is necessary before introducing liquid biopsy into the clinical routine. In the future, this might allow a valid reflection of disease progression in HPV-positive OPSCC.

Predicting HPV association using deep learning and regular H&E stains allows granular stratification of oropharyngeal cancer patients

Human Papilloma Virus (HPV)-associated oropharyngeal squamous cell cancer (OPSCC) represents an OPSCC subgroup with an overall good prognosis with a rising incidence in Western countries. Multiple lines of evidence suggest that HPV-associated tumors are not a homogeneous tumor entity, underlining the need for accurate prognostic biomarkers. In this retrospective, multi-institutional study involving 906 patients from four centers and one database, we developed a deep learning algorithm (OPSCCnet), to analyze standard H&E stains for the calculation of a patient-level score associated with prognosis, comparing it to combined HPV-DNA and p16-status. When comparing OPSCCnet to HPV-status, the algorithm showed a good overall performance with a mean area under the receiver operator curve (AUROC) = 0.83 (95% CI = 0.77-0.9) for the test cohort (n = 639), which could be increased to AUROC = 0.88 by filtering cases using a fixed threshold on the variance of the probability of the HPV-positive class - a potential surrogate marker of HPV-heterogeneity. OPSCCnet could be used as a screening tool, outperforming gold standard HPV testing (OPSCCnet: five-year survival rate: 96% [95% CI = 90-100%]; HPV testing: five-year survival rate: 80% [95% CI = 71-90%]). This could be confirmed using a multivariate analysis of a three-tier threshold (OPSCCnet: high HR = 0.15 [95% CI = 0.05-0.44], intermediate HR = 0.58 [95% CI = 0.34-0.98] p = 0.043, Cox proportional hazards model, n = 211; HPV testing: HR = 0.29 [95% CI = 0.15-0.54] p < 0.001, Cox proportional hazards model, n = 211). Collectively, our findings indicate that by analyzing standard gigapixel hematoxylin and eosin (H&E) histological whole-slide images, OPSCCnet demonstrated superior performance over p16/HPV-DNA testing in various clinical scenarios, particularly in accurately stratifying these patients.

Exploring the artificial intelligence "Trust paradox": Evidence from a survey experiment in the United States

Advances in Artificial Intelligence (AI) are poised to transform society, national defense, and the economy by increasing efficiency, precision, and safety. Yet, widespread adoption within society depends on public trust and willingness to use AI-enabled technologies. In this study, we propose the possibility of an AI "trust paradox," in which individuals' willingness to use AI-enabled technologies exceeds their level of trust in these capabilities. We conduct a two-part study to explore the trust paradox. First, we conduct a conjoint analysis, varying different attributes of AI-enabled technologies in different domains-including armed drones, general surgery, police surveillance, self-driving cars, and social media content moderation-to evaluate whether and under what conditions a trust paradox may exist. Second, we use causal mediation analysis in the context of a second survey experiment to help explain why individuals use AI-enabled technologies that they do not trust. We find strong support for the trust paradox, particularly in the area of AI-enabled police surveillance, where the levels of support for its use are both higher than other domains but also significantly exceed trust. We unpack these findings to show that several underlying beliefs help account for public attitudes of support, including the fear of missing out, optimism that future versions of the technology will be more trustworthy, a belief that the benefits of AI-enabled technologies outweigh the risks, and calculation that AI-enabled technologies yield efficiency gains. Our findings have important implications for the integration of AI-enabled technologies in multiple settings.

Reshaping surveillance for infectious diseases: less chasing of pathogens and more monitoring of drivers

Animal health surveillance, despite its name, tends to focus on looking for disease. Often this involves searching for cases of infection with known pathogens (‘pathogen chasing'). Such an approach is both resource intensive and limited by the requirement for prior knowledge of disease likelihood. In this paper, the authors propose the gradual reshaping of surveillance towards the systems level, focusing on the processes (‘drivers') that promote disease or health, rather than on the presence or absence of specific pathogens. Examples of relevant drivers include land-use change, increasing global interconnectedness, and finance and capital flows. Importantly, the authors suggest that surveillance should focus on detecting changes in patterns or quantities associated with such drivers. This would generate systems-level, risk-based surveillance information to identify areas where additional attention may be needed, and, over time, inform the implementation of prevention efforts. The collection, integration and analysis of data on drivers is likely to require investment in improving data infrastructures. A period of overlap would allow the two systems (traditional surveillance and driver monitoring) to be compared and calibrated. This would also lead to a better understanding of the drivers and their linkages, and thereby generate new knowledge that can improve surveillance and inform mitigation efforts. Since surveillance of drivers may give signals when changes are occurring, which could act as alerts and enable targeted mitigation, this might even enable disease to be prevented before it happens by directly intervening in the drivers themselves. Such surveillance focused on the drivers could be expected to bring additional benefits, since the same drivers promote multiple diseases. Further, focusing on drivers rather than pathogens should enable control of currently unknown diseases, making this approach particularly timely, given the increasing risk of emergence of new diseases.

Impact of P16 Positivity on Clinical Outcomes in Nasopharyngeal Carcinoma: A Single Institution Study

Introduction Nasopharyngeal carcinoma (NPC) is a rare malignancy with unique geographical distribution. It is prevalent in East and Southeast Asia and rare in non-endemic countries like the USA. P16 is a tumor suppressor gene and there are limited studies with inconsistent results describing the association of its positivity in immunohistochemistry and clinical outcomes. In this retrospective study, we compared progression-free survival (PFS) and overall survival (OS) based on p16 positivity in 60 patients with NPC. Materials and methods Patients aged above 18 years and followed between July 2015 and December 2020 were included in the study. P16 positivity was based on the immunohistochemistry of the biopsy sample. We compared PFS and OS among all p16-positive and negative patients, and then among patients with advanced disease (stage III or IV), and between p16-positive, negative, and unknown status patients. Results There were 15 p16-positive, and 28 p16-negative, with a median age of 54.3 years and 55.7 years respectively. Most patients in both groups were male, Caucasian, and had advanced disease (stage III or stage IV). Both median PFS (p=0.838) and OS (p=0.776) were 84 months in the p16-negative group but were not reached during the study period in the p16-positive group. Among advanced-stage patients, the PFS (p=0.873), and OS (p=0.773) of both groups were not statistically significant. P16 status was unknown for 17 patients, and PFS (p=0.785) and OS (p=0.901), when compared among patients with p16-positive, negative, and unknown status, were also statistically non-significant. Discussion and conclusion Our analysis suggests that p16 status does not predict clinical outcomes in NPC patients. Our sample size was limited but is larger than most studies describing this association. With different studies in the literature reporting disparate findings, we recommend larger prospective studies to better illustrate the impact of p16 positivity on clinical outcomes in NPC.

Optical Coherence Tomography (OCT) evaluation of culprit lesions in patients with Non-ST Elevation Acute Coronary Syndromes (NSTE-ACS)

Funding Acknowledgements

Type of funding sources: None.

Background

OCT is an excellent tool to determine plaque morphology in Acute Coronary Syndromes. While plaque rupture has been determined to be the dominant morphology in ST Elevation Myocardial Infarction, there is paucity of literature in NSTE-ACS, which includes Non–ST Segment Elevation Myocardial Infarction (NSTEMI) and Unstable angina (UA).

Purpose

To characterize culprit lesion morphology by OCT in NSTE-ACS and to evaluate the frequency of each type of lesion in patients presenting with NSTEMI and UA.

Methods

In this single-centre observational study, OCT imaging of culprit lesion was acquired during coronary angioplasty of culprit lesions of 50 patients presenting with NSTE-ACS between August 2020 to July 2021. A comparison of the frequency of each type of lesion between NSTEMI and UA was performed.

Results

OCT of culprit vessel in the entire cohort of NSTE-ACS showed plaque erosion in 32% (n=16), plaque rupture in 32% (n=16), tight stenosis in 26% (n=13) and calcific nodule in 10% (n= 5) patients. Lipid plaque was seen in a higher number of patients with plaque erosion and plaque rupture (93.8% and 87.5% respectively). Comparison of the frequency of these lesions in NSTEMI and UA, revealed that among NSTEMI patients (n=25), 48% had plaque erosion, 36% had plaque rupture, 12% had tight stenosis and 4% had calcific nodule whereas, among UA patients (n=25), 16% had plaque erosion, 28% had plaque rupture, 40% had tight stenosis and 16% had calcific nodule. There was a statistically significant increase in plaque erosion in NSTEMI compared to UA (p=0.015) while tight stenosis was significantly more common in UA (p=0.024). Similarly, red thrombus and spotty calcium (p=0.002 and 0.008 respectively) were higher in NSTEMI compared to UA. There was no significant difference in frequency of thin cap fibroatheroma, macrophages, cholesterol crystals, white thrombus, and neovascularization among the two groups.

Conclusions

OCT provides unique insights into the mechanisms of NSTE-ACS. In our study plaque erosion and plaque rupture were both equally seen in patients presenting with NSTE- ACS. However, NSTEMI patients had a higher frequency of plaque erosion, red thrombus, and spotty calcium when compared to UA. While UA patients had a higher incidence of tight stenosis.

287. Procalcitonin and D-dimer levels at baseline, but not CRP, were informative of COVID-19 hospitalization outcomes

Background

The WHO estimates 512 million cases of COVID-19 and 6.2 million deaths globally as of May 4^th, 2022. In Michigan (MI), the first case was diagnosed March 10^th, 2020. We describe here outcomes of COVID-19 patients cared for in a large tertiary hospital in 2020 spanning two surges based on baseline lab values for C-reactive protein (CRP), Procalcitonin (PC), and D-Dimer (DD).

Methods

After IRB approval, adult patients diagnosed via PCR with COVID-19 during the two surges in 2020 and admitted to Beaumont Hospital, Royal Oak, an 1,131 beds tertiary care referral center in MI, were reviewed. Demographic, clinical and laboratory characteristics were obtained from the EMR. ICD-10 classification diagnoses were utilized to identify comorbidities, and patient BMIs were based on the admission values in the EMR. Outcomes were defined as death during current admission, transfer to nursing home or other facility, or discharge home. Using a tree-based model and the combined levels of the three labs we defined a hierarchy of four lab levels, each progressively having increased risk of death. We then analyzed the outcome for the four levels, adjusting for time period (surge), age, sex, race, BMI and comorbidities. Data was analyzed using SAS statistical software version 9.4 (SAS Institute).

Results

A total of 2197 patients were identified from March through December 2020, of whom 1118 had CRP, PC and DD available at baseline. The mean age was 66.7 years (SD 16.1) for the cohort in first surge (March-June), and 66.4 (15.6) in the latter surge (July-December, Table1). More patients had a PC of >0.5 in the first surge (25.7%) than the second (13.2%). After adjusting for all other factors, the hierarchical lab levels are significantly associated with outcomes. Of note, baseline CRP value was not informative. Compared to the 2nd level (Table 2), the lowest level (PC < 0.1) has significantly lower odds of death [OR=0.37, 95% CI (0.19, 0.73)], while the highest level, (DD >1000 and PC ≥ 0.26) has significantly higher odds of death [OR=3.01, 95% CI (1.59, 5.72)].

Conclusion

Baseline PC and DD, but not CRP, were informative in determining risk of death and can assist clinicians determine possible outcomes during COVID-19 hospitalization.

Disclosures

Christopher F. Carpenter, MD, MHSA, Atox Bio: Advisor/Consultant|GSK: Advisor/Consultant|Iterum Therapeutics: Advisor/Consultant|Takeda: Advisor/Consultant.

Impact of Ambulatory Care Pharmacist-Led Diabetes Mellitus Management on Hemoglobin A1c Values Among Patients With Diabetes in a Primary Care Clinic Over Two Years

Background: Previous evaluation in the literature of ambulatory care pharmacist management on glycosylated hemoglobin (HgbA1c) has been positive, but often limited to 6 to 12 months of follow up. Objective: The objective of this study is to evaluate the impact of an ambulatory care pharmacist on HgbA1c among patients with diabetes in a primary care clinic over two years. Methods: Retrospective chart review was conducted on patients with type 2 diabetes managed by the ambulatory care pharmacist. Patients with at least one HgbA1c value ≥7% in the two-year pre-intervention period were included. The primary outcome was the change in mean HgbA1c from baseline to two years post-intervention. The secondary outcome was the change in mean of all HgbA1c values over two years pre-intervention compared to two years post-intervention. Results: Data for 116 patients was analyzed two years prior to and two years after ambulatory care pharmacist service initiation. The mean HgbA1c at baseline pre-intervention was 8.8% compared to a mean HgbA1c of 7.8% two years post-intervention. A total of 12.9% of patients (n=15) had a baseline HgbA1c of less than 7% pre-intervention, compared to 42.2% of patients (n=49) two years post-intervention (p<0.001). The overall mean HgbA1c was 8.8% in the two-year pre-intervention period and 8.2% in the two-year post-intervention period (p<0.001). Among patients with an overall mean HgbA1c ≥8% in the pre-intervention period, the mean HgbA1c was 9.8% pre-intervention and 8.7% post-intervention. Conclusion: Ambulatory care pharmacist interventions demonstrated a significant impact on HgbA1c reduction over two years of follow up.

Large multicenter evaluation of clinical outcomes of transcatheter aortic valve implantation in different age groups: results from the Israeli TAVI registry

Introduction

Transcatheter aortic valve implantation (TAVI) is becoming the preferred treatment for elderly patients with severe aortic stenosis. Clinical outcomes of these patients according to different age groups and especially in the very old population are under reported.

Purpose

To describe clinical characteristics at baseline, according to different age groups, and to compare clinical outcomes in the very old population with other patients undergoing the procedure.

Methods

Data was extracted from the Israeli National TAVI Registry. Clinical outcomes in very old patients (above the age of 90 years) were compared with younger patients. Multivariable analysis for 30-day and 1-year mortality were performed. Procedural complication was defined as one or more of the following: need for permanent pacemaker, major vascular complication, severe acute kidney injury and major stroke.

Results

A total of 5,936 patients who underwent TAVI from 2008 to 2021 were analyzed (age 81.6±7.1 years, 50.6% female). Patients older than 90 years of age had more comorbidities than the younger population (STS score for mortality 6.4%±3.8% vs. 4.1%±4.8%, p&lt;0.001). Independent correlates for 30-day mortality included STS score (OR=1.01, 95% CI [1.03–1.13], p&lt;0.001) and procedural complication (OR=4.29, 95% CI [2.24–8.20], p&lt;0.0001). Independent correlates for 1-year mortality included chronic obstructive pulmonary disease (OR=1.83, 95% CI [1.28–2.60]; p=0.001), atrial fibrillation (OR=1.71, 95% CI [1.31–2.23]; p&lt;0.001 (STS score); OR=1.13 95% CI [1.09–1.18]; p&lt;0.001), and procedural complication) OR=2.58, 95% [1.89–3.50]; p&lt;0.001).

Conclusions

Although older patients undergoing TAVI had a higher risk profile, short- and long-term survival of these patients were associated significantly more with procedural complications than with patient age. It seems that extreme patient age alone should not be viewed as a consideration for not performing valve replacement, as long as the risk for procedural complications does not seem to be severely elevated.

Funding Acknowledgement

Type of funding sources: None.

Navigating Paths to Wellness: A Strengths-Based Photovoice Study Conducted with One First Nation in Southern Ontario, Canada

Research on substance use challenges in First Nations communities is often deficit-focused and can reinforce paternalistic stereotypes that lead to further discrimination. In this article, we report on findings of a strengths-based Photovoice project done in collaboration with a First Nations' community in southern Ontario, Canada to better understand experiences with substance use challenges in the community. We analyzed interview data collected with seventeen individuals who have lived experience or are supporting a loved one with lived experience with a substance use challenge. Participants described sources of strength that characterized their path to wellness, including strong family and social connections, cultural practices, identity, spirituality, day-to-day activities, and helpful supports and services. Furthermore, participants made several suggestions for improving services, including the need for integrated and flexible systems of care and trustful client-provider relationships. At its core, nurturing wellness involved a transformative process involving social and/or cultural connections. The stories shared by participants demonstrate the unique and varied strengths drawn from by individuals dealing with a substance use challenge.

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Abstract 6028: Patient derived organoids demonstrate hallmark characteristics of small cell lung cancer

Small cell lung cancer (SCLC) accounts for approximately 15% of all lung cancers with an overall 5-year survival rate of 5-10%. Although transgenic mouse models and patient derived xenograft models have been shown to capture the heterogeneity and complexity of SCLC, the costs involved and timeframe of generating these models can be extensive. Furthermore, these models lack the ability to study the patients’ immune components and tumor microenvironment. Alternatively, in other cancer types in vitro methods to generate organoids have been successful in the hope to develop personalized patient derived organoids for screening and further downstream analyses. Here, we have generated and characterized small cell lung cancer patient-derived tumor organoids and confirmed that the organoids possess similar molecular characteristics, genetic profiles and morphological architectures to the corresponding patient tumor tissue. Organoids were shown to express hallmark features for SCLC, which included expression of neuroendocrine markers CD56, CHGA, INSM1 and SYP shown by immunohistochemistry. We suggest utilizing these organoids as SCLC patient models would be ideal for investigating the tumor microenvironment in SCLC, mechanisms between tumor immune cell interactions as well as assessing patients’ responses to therapy.

Citation Format: Joshua D'Rozario, Julie George, Roman Thomas. Patient derived organoids demonstrate hallmark characteristics of small cell lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 6028.

Abstract 6291: Integrative single-cell tracking of genome evolution and tumor cell plasticity in small cell lung cancer (SCLC)

SCLC is the deadliest type of lung cancer, which is mostly diagnosed at late stages and accounts for 15% of pulmonary tumors. Even though chemotherapy is initially effective, SCLC patients relapse quickly with therapy resistant tumors. Genome studies revealed universal loss of TP53 and RB1; recent transcriptional studies categorized SCLC tumors based on the expression of 4 lineage transcription factors (TFs). We aimed to dissect how genomic cues impact transcriptional phenotypes, tumor cell plasticity and the dynamics of tumor and immune cell interactions, to thus decipher molecular mechanisms of phenotypic divergence and therapy resistance in SCLC.

We performed genome sequencing and single cell transcriptome profiling on 61 SCLC patient tumors, including primary tumors, metastases and paired relapse tumors acquired throughout therapy. Single cell RNA-seq was performed with the 10x Genomics platform for patient tumors to study cancer cells and the tumor micro-environment (TME)(n=17), and on xenograft models to study tumor cell intrinsic heterogeneity (n=44). Single cell and genome sequencing data were processed with an in-house pipeline. To further validate our findings on the transcriptional level, we performed imaging mass cytometry (IMC) of matched tissue samples to delineate the spatial context of cellular subsets.

Single cell transcriptome profiles were determined for 211,446 cells from 61 tumors. Transcriptome profiling at single cell levels revealed co-expression of at least two of the lineage TFs ASCL1, NEUROD1 or POU2F3 for each SCLC tumor. Furthermore, tumor subsets without any expression of the four described TFs were found. Instead of distinct subgroups, our data points to a concerted regulation of a multitude of lineage factors and transcriptional programs in each SCLC tumor. To specifically investigate how underlying genetic alterations affect molecular phenotypes, integrative studies across all patients were performed. This revealed shared transcriptional programs in tumors with MYC family member amplifications; trajectory inference for cases with low and high-level copy gains of MYCN pointed to distinct transcriptional states. We performed multi-regional and longitudinal studies of matched patient cases. We reconstructed genomic patterns of clonal evolution from bulk genome sequencing data, and projected genomic subsets to transcriptional trajectories at single cell level, thus analyzing the effect of genome diversity on the transcriptional landscape. Additionally, tumor intrinsic profiles of heterogeneity were mapped to single cell data of patient tumors to elucidate the effects on the TME, focusing on tumor-immune cell interactions. All together our data provides a first comprehensive framework for the study of underlying genetic alterations that shape the transcriptional landscape and phenotypic plasticity in SCLC.

Citation Format: Marcel Schmiel, Roman K. Thomas, Julie George. Integrative single-cell tracking of genome evolution and tumor cell plasticity in small cell lung cancer (SCLC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 6291.

LB0003 WITHDRAWING METHOTREXATE AFTER BOTH VERSUS ONLY SECOND DOSE OF THE ChAdOx1 nCoV-19 VACCINE IN PATIENTS WITH AUTOIMMUNE INFLAMMATORY ARTHRITIS: TWO INDEPENDENT RANDOMIZED CONTROLLED TRIALS (MIVAC I AND II)

Background

Pausing methotrexate (MTX) for two to four weeks, improved immunogenicity of influenza vaccination in patients with rheumatoid arthritis (RA), albeit a risk of disease flare (1). This guided the framing of guidelines on MTX withdrawal for COVID-19 vaccination (2). However, evidence for MTX withdrawal for COVID-19 vaccination is limited to observational studies only.

Objectives

To compare the efficacy and safety of holding MTX after each (MIVAC 1) and only after the second dose (MIVAC II) of the ChAdOx1 vaccine versus continuation of MTX in two randomized controlled trials (RCTs).

Methods

Two single centre, investigator-blinded, RCTs were conducted in patients with RA or Psoriatic arthritis (PsA) on stable doses of MTX without prior COVID-19 (CTRI reg. no. MIVAC I: CTRI/2021/07/03463 & MIVAC II: CTRI/2021/07/035307). In MIVAC I, unvaccinated patients were randomised (1:1) to hold or continue MTX for two weeks after each dose of the vaccine. MIVAC II included patients who had continued MTX during the first dose of ChAdOx1 and were randomised (1:1) to hold or continue MTX for 2 weeks after the second vaccine dose. The primary outcome for both the trials was the anti-Receptor Binding Domain (RBD) antibody titres measured four weeks after the second vaccine dose (per protocol analysis). Secondary outcome was the flare rate, defined as an increase in disease activity scores (DAS28/cDAPSA) or physician intent to hike DMARDs.

Results

250 patients were randomized for MIVAC 1 and 178 for MIVAC II and after due exclusions, 158 and 157 were eligible for analysis respectively (Figure 1). In MIVAC I, median anti-RBD titres were significantly high in the MTX hold group [2484 (1050-4388) versus 1147(433-2360), p=0.001] but the flare rate was higher in the hold group [20 (25%) versus 6(8%) p=0.005] compared to continue group. In MIVAC II median anti-RBD titres were significantly high for the MTX hold group [2553 (1792-4823) versus 990 (356-2252), p=0.001] when compared to continue group but there was no difference in the flare rate between the groups [9(11.8%) and 4(7.9%), p=0.15] (Table 1). Since both were parallel studies in similar population, MTX hold arms across both the trials were compared for anti-RBD titres and flare. There was no difference in the anti-RBD titres [p=0.2] between the groups. In MIVAC I, 29(36.25%) patients had reported flare (19 in either first or second dose, 10 for both doses) when compared to MIVAC II where only 9(11.84%) patients had reported flare after the second dose (P <0.001).

Table 1.

Baseline demographics and key results

VariableMIVAC IMIVAC IIMTX HoldMTX ContinuePMTX HoldMTX ContinueP valueN=80N=78valueN=76N=81Age†48 (38-53.3)49 (39-59)0.1953 (42.3-59)53(50-62)0.14Female (%) ‡73 (91.3)75 (96.2)0.3365 (85.5)70 (86.4)>0.99RA (%) ‡69(86.3)69 (93.2)70 (85.6)80 (87.7)PsA (%) ‡11(13.8)6 (8.1)0.316 (7.9)1 (1.2)0.057DAS28†2.7 (2.4-3.2)2.6 (2-3.3)0.62.7(2.3-3.4)2.8 (2.1-3.5)0.78cDAPSA †2(3-4.5)2.5(1.3-3.8)0.463(2.8-3)30.15Prednisolone (%) ‡29 (36.3)23(31.1)0.424(31.6)26 (32.1)>0.99MTX mg/week†17.5 (10-25)15 (10-20)0.05715 (9.4-25)17.5(7.5-25)0.92Anti- RBD antibody titres post second dose (IU/mL) †2484 (1050-4388.8)1147.5 (433.5-2360.3)<0.0012553.5 (1792.5-4823.8)990.5 (356.1-2252.5)<0.001Flare (N%) ‡Post first dose20 (25)6 (8)0.005NANAPost second dose19 (23.8)10(13.3)0.19 (11.8)4 (7.9)0.15

All analysis as per protocol population.

†Median (interquartile range): Mann Whitney U test.

‡ N (%): Fisher Exact test

. Bolded if p<0.05.

Conclusion

Holding MTX after both the doses or only after the second dose of ChAdOx1 yields higher anti-RBD antibody titres as compared to continuing MTX. Comparing across the trials, holding MTX only after the second dose appears to be non-inferior to holding MTX after both doses of the vaccine with a lesser risk of flare.

References

[1]Park JK et al. Clin Rheumatol. 2020 Feb; 39(2):375-379.

[2]Curtis JR, et al. Arthritis & Rheumatology. 2021 Oct;73(10): e60-75.

Acknowledgements

Acknowledgments to all participating investigators, patients and their families

Disclosure of Interests

Anu Sreekanth: None declared, Teny Skaria: None declared, Sneha Joseph: None declared, Rashwith Umesh: None declared, Manju Mohanan: None declared, Aby Paul: None declared, Sakir Ahmed Speakers bureau: Sakir Ahmed had received honorarium as speaker from Pfizer, Dr Reddy’s, Cipla, and Novartis unrelated to this Comment, Pankti Mehta: None declared, Seena Oomen: None declared, Janet Benny: None declared, Justin George: None declared, Anagha Paulose: None declared, K Narayanan: None declared, Sanjana Joseph: None declared, Anuroopa Vijayan: None declared, Kaveri Nalianda: None declared, Padmanabha Shenoy: None declared

667 EFFECT OF LEUCINE SUPPLEMENTATION ON PHYSICAL PERFORMANCE, MUSCLE MASS AND QUALITY OF LIFE IN OLDER PEOPLE WITH SARCOPENIA

Introduction

Leucine supplementation improves muscle protein synthesis in physiological studies and has been proposed as a treatment to improve muscle mass and physical performance. We tested the effects of leucine supplementation in a randomised controlled trial enrolling patients with sarcopenia.

Methods

We conducted a placebo-controlled, parallel group, double-blind, randomised two-by-two factorial trial. Participants aged 70 and over with low muscle mass by bioimpedance and either low grip strength or low walk speed, were recruited from 14 UK sites. Participants were randomised to receive one year of leucine powder 2.5 g three times a day or matching placebo, plus perindopril 4 mg once daily or matching placebo. The primary outcome was the between-group difference in the Short Physical Performance Battery, measured at baseline, 6 and 12 months, analysed using repeated-measures mixed models. Secondary outcomes included grip strength, quadriceps strength, six-minute walk distance, appendicular muscle mass measured by dual x-ray absorptiometry, quality of life measured using the EQ5D tool, falls rates and adverse events.

Results

We screened 320 people and randomised 145 participants, mean age 79 (SD 6) years; 78 (54%) were women and the mean SPPB was 7.0 (SD 2.4). 72 were randomised to leucine and 73 to placebo. Median adherence was the same in both groups (76% vs 76%; p &lt; 0.001). Leucine had no significant effect on the primary outcome (adjusted treatment effect 0.1 points [95%CI -1.0 to 1.1]). No significant treatment effect was seen for any secondary outcome. There were similar numbers of adverse events in both groups (leucine 187, placebo 196) and falls rates were similar (leucine 1.9 [95%CI 0.9 to 2.9] per year; placebo 2.9 [95%CI 0.8 to 5.0] per year).

Conclusion

Leucine did not improve measures of physical performance, muscle mass or quality of life in older people with sarcopenia.

666 EFFECT OF PERINDOPRIL ON PHYSICAL PERFORMANCE, MUSCLE MASS AND QUALITY OF LIFE IN OLDER PEOPLE WITH SARCOPENIA: RESULTS: FROM THE

Introduction

Angiotensin-converting enzyme inhibitors such as perindopril have been proposed as treatments to improve muscle mass and physical performance but have not been tested in randomised controlled trials enrolling patients with sarcopenia.

Methods

We conducted a placebo-controlled, parallel group, double-blind, randomised two-by-two factorial trial. Participants aged 70 and over with low muscle mass by bioimpedance and either low grip strength or low walk speed, were recruited from 14 UK sites. Participants were randomised to receive one year of perindopril 4 mg once daily or matching placebo, and to receive leucine powder 2.5 g three times a day or matching placebo. The primary outcome was the between-group difference in the Short Physical Performance Battery, measured at baseline, 6 and 12 months, analysed using repeated-measures mixed models. Secondary outcomes included grip strength, quadriceps strength, six-minute walk distance, appendicular muscle mass measured by dual x-ray absorptiometry, quality of life measured using the EQ5D tool, falls rates and adverse events.

Results

We screened 320 people and randomised 145 participants, mean age 79 (SD 6) years; 78 (54%) were women and the mean SPPB was 7.0 (SD 2.4). 73 were randomised to perindopril and 72 to placebo. Median adherence was lower for perindopril (76% vs 96%; p &lt; 0.001). Perindopril had no significant effect on the primary outcome (adjusted treatment effect −0.1 points [95%CI -1.2 to 1.0]). No significant treatment effect was seen for any secondary outcome except for worse EQ5D thermometer scores in the perindopril group (treatment effect −12 points [95%CI -21 to −3]). More adverse events were seen in the perindopril group (218 vs 165) but falls rates were similar (perindopril 2.0 [95%CI 1.1 to 3.0] per year; placebo 2.8 [95%CI 0.6 to 5.1] per year).

Conclusion

Perindopril did not improve measures of physical performance, muscle mass or quality of life in older people with sarcopenia.

(Mis)Information on Digital Platforms: Quantitative and Qualitative Analysis of Content From Twitter and Sina Weibo in the COVID-19 Pandemic

BACKGROUND

Misinformation about COVID-19 on social media has presented challenges to public health authorities during the pandemic. This paper leverages qualitative and quantitative content analysis on cross-platform, cross-national discourse and misinformation in the context of COVID-19. Specifically, we investigated COVID-19-related content on Twitter and Sina Weibo-the largest microblogging sites in the United States and China, respectively.

OBJECTIVE

Using data from 2 prominent microblogging platform, Twitter, based in the United States, and Sina Weibo, based in China, we compared the content and relative prevalence of misinformation to better understand public discourse of public health issues across social media and cultural contexts.

METHODS

A total of 3,579,575 posts were scraped from both Sina Weibo and Twitter, focusing on content from January 30, 2020, within 24 hours of when WHO declared COVID-19 a "public health emergency of international concern," and a week later, on February 6, 2020. We examined how the use and engagement measured by keyword frequencies and hashtags differ across the 2 platforms. A 1% random sample of tweets that contained both the English keywords "coronavirus" and "covid-19" and the equivalent Chinese characters was extracted and analyzed based on changes in the frequencies of keywords and hashtags and the Viterbi algorithm. We manually coded a random selection of 5%-7% of the content to identify misinformation on each platform and compared posts using the WHO fact-check page to adjudicate accuracy of content.

RESULTS

Both platforms posted about the outbreak and transmission, but posts on Sina Weibo were less likely to reference topics such as WHO, Hong Kong, and death and more likely to cite themes of resisting, fighting, and cheering against coronavirus. Misinformation constituted 1.1% of Twitter content and 0.3% of Sina Weibo content-almost 4 times as much on Twitter compared to Sina Weibo.

CONCLUSIONS

Quantitative and qualitative analysis of content on both platforms points to lower degrees of misinformation, more content designed to bolster morale, and less reference to topics such as WHO, death, and Hong Kong on Sina Weibo than on Twitter.

Cold and heterogeneous T cell repertoire is associated with copy number aberrations and loss of immune genes in small-cell lung cancer

Small-cell lung cancer (SCLC) is speculated to harbor complex genomic intratumor heterogeneity (ITH) associated with high recurrence rate and suboptimal response to immunotherapy. Here, using multi-region whole exome/T cell receptor (TCR) sequencing as well as immunohistochemistry, we reveal a rather homogeneous mutational landscape but extremely cold and heterogeneous TCR repertoire in limited-stage SCLC tumors (LS-SCLCs). Compared to localized non-small cell lung cancers, LS-SCLCs have similar predicted neoantigen burden and genomic ITH, but significantly colder and more heterogeneous TCR repertoire associated with higher chromosomal copy number aberration (CNA) burden. Furthermore, copy number loss of IFN-γ pathway genes is frequently observed and positively correlates with CNA burden. Higher mutational burden, higher T cell infiltration and positive PD-L1 expression are associated with longer overall survival (OS), while higher CNA burden is associated with shorter OS in patients with LS-SCLC.

MAPK-pathway inhibition mediates inflammatory reprogramming and sensitizes tumors to targeted activation of innate immunity sensor RIG-I

Kinase inhibitors suppress the growth of oncogene driven cancer but also enforce the selection of treatment resistant cells that are thought to promote tumor relapse in patients. Here, we report transcriptomic and functional genomics analyses of cells and tumors within their microenvironment across different genotypes that persist during kinase inhibitor treatment. We uncover a conserved, MAPK/IRF1-mediated inflammatory response in tumors that undergo stemness- and senescence-associated reprogramming. In these tumor cells, activation of the innate immunity sensor RIG-I via its agonist IVT4, triggers an interferon and a pro-apoptotic response that synergize with concomitant kinase inhibition. In humanized lung cancer xenografts and a syngeneic Egfr-driven lung cancer model these effects translate into reduction of exhausted CD8+ T cells and robust tumor shrinkage. Overall, the mechanistic understanding of MAPK/IRF1-mediated intratumoral reprogramming may ultimately prolong the efficacy of targeted drugs in genetically defined cancer patients.

Breast Angiosarcoma Surveillance Study: UK national audit of management and outcomes of angiosarcoma of the breast and chest wall

BACKGROUND

Breast angiosarcomas are rare tumours of vascular origin. Secondary angiosarcoma occurs following radiotherapy for breast cancer. Angiosarcomas have high recurrence and poor survival rates. This is concerning owing to the increasing use of adjuvant radiotherapy for the treatment of invasive breast cancer and ductal cancer in situ (DCIS), which could explain the rising incidence of angiosarcoma. Outcome data are limited and provide a poor evidence base for treatment. This paper presents a national, trainee-led, retrospective, multicentre study of a large angiosarcoma cohort.

METHODS

Data for patients with a diagnosis of breast/chest wall angiosarcoma between 2000 and 2015 were collected retrospectively from 15 centres.

RESULTS

The cohort included 183 patients with 34 primary and 149 secondary angiosarcomas. Median latency from breast cancer to secondary angiosarcoma was 6 years. Only 78.9 per cent of patients were discussed at a sarcoma multidisciplinary team meeting. Rates of recurrence were high with 14 of 28 (50 per cent ) recurrences in patients with primary and 80 of 124 (64.5 per cent ) in those with secondary angiosarcoma at 5 years. Many patients had multiple recurrences: total of 94 recurrences in 162 patients (58.0 per cent). Median survival was 5 (range 0-16) years for patients with primary and 5 (0-15) years for those with secondary angiosarcoma. Development of secondary angiosarcoma had a negative impact on predicted breast cancer survival, with a median 10-year PREDICT prognostic rate of 69.6 per cent, compared with 54.0 per cent in the observed cohort.

CONCLUSION

A detrimental impact of secondary angiosarcoma on breast cancer survival has been demonstrated. Although not statistically significant, almost all excess deaths were attributable to angiosarcoma. The increased use of adjuvant radiotherapy to treat low-risk breast cancer and DCIS is a cause for concern and warrants further study.

Constraints on Cosmic Strings Using Data from the Third Advanced LIGO-Virgo Observing Run

We search for gravitational-wave signals produced by cosmic strings in the Advanced LIGO and Virgo full O3 dataset. Search results are presented for gravitational waves produced by cosmic string loop features such as cusps, kinks, and, for the first time, kink-kink collisions. A template-based search for short-duration transient signals does not yield a detection. We also use the stochastic gravitational-wave background energy density upper limits derived from the O3 data to constrain the cosmic string tension Gμ as a function of the number of kinks, or the number of cusps, for two cosmic string loop distribution models. Additionally, we develop and test a third model that interpolates between these two models. Our results improve upon the previous LIGO-Virgo constraints on Gμ by 1 to 2 orders of magnitude depending on the model that is tested. In particular, for the one-loop distribution model, we set the most competitive constraints to date: Gμ≲4×10^{-15}. In the case of cosmic strings formed at the end of inflation in the context of grand unified theories, these results challenge simple inflationary models.