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.

Predictors of Long-Term Survival in Patients Treated for Oligometastases

PURPOSE/OBJECTIVE(S)

The purpose of this work is to report the long-term outcomes of patients with oligometastases treated with curative intent radiotherapy in the context of the recently developed ESTRO EORTC classification schema.

MATERIALS/METHODS

This retrospective, single institution study consists of consecutive adult patients with oligometastases from solid tumor malignancy referred to a single high volume radiation oncologist. Oligometastases were defined as 5 or fewer extracranial or intracranial metastatic lesions where all sites of active disease are amenable to treatment. Patients with a history of distant metastases requiring treatment of the primary tumor ± regional lymph nodes were included. Radical local therapies utilized included stereotactic radiotherapy (53% of patients, median dose 27 Gy in 3 fractions), intensity modulated radiotherapy (64% of patients; median dose 50 Gy in 15 fractions), surgery and/or ablation. Overall survival and progression-free survival were estimated using the Kaplan-Meier method. Predictors of survival were assessed using log-rank test for categorical variables and Cox regression for continuous variables for univariable analysis and Cox multivariable analyses.

RESULTS

The study population consists of 130 patients with 207 treated distant metastases referred to radiation oncology between 1/2014 and 12/2021. Key patient characteristics include median age 71, median pre-radiation albumin 3.7 g/dl, 72% ECOG 0-1 performance status, 35% lung primary, 12% prostate primary, median of 1 distant metastasis treated, 31% bone metastases, 30% brain metastases, 47% required treatment to primary tumor ± regional lymph nodes and 71% received systemic therapy after radiation. The most frequent ESTRO EORTC oligometastatic groups were synchronous oligometastases (40%) and metachronous oligorecurrence (29%). At a median follow-up of 28.8 months (IQR 16.0 to 56.3 months), the median overall survival is 37.9 months with a 4-year overall survival of 41.1%. The median progression-free survival was 12.3 months with a 4-year progression-free survival of 22.6%. On multivariable analysis, the strongest predictors of overall survival are age (HR 1.05 [1.02-1.08]; CI: 95%; p<0.001), ECOG performance status (HR 1.69 [1.15-2.47]; CI: 95%; p = 0.007), primary prostate, breast or kidney tumor (HR 2.79 [1.29-6.03]; CI: 95%; p = 0.009) and pre-radiation serum albumin (HR 0.55 [0.35-0.87]; CI: 95%; p = 0.01). The strongest predictors of progression free survival on multivariable analysis are albumin (HR 0.59 [0.39-0.88]; CI: 95%; p = 0.009) and primary prostate, breast or kidney tumor (HR 1.90 [1.06-3.38]; CI: 95%; p = 0.03).

CONCLUSION

Long-term overall survival is not uncommon after radical treatment for oligometastases. The ESTRO EORTC classification provides an enriched nomenclature for oligometastases but is not independently predictive of survival.

Patient ratings in exercise therapy for the management of tendinopathy: a systematic review with meta-analysis

OBJECTIVE

To synthesise exercise therapy intervention data investigating patient rating outcomes for the management of tendinopathy.

DESIGN

A systematic review and meta-analysis of randomized controlled trials investigating exercise therapy interventions and reporting patient rating outcomes.

SETTING

Any setting in any country listed as very high on the human development index.

PARTICIPANTS

People with a diagnosis of any tendinopathy of any severity or duration.

INTERVENTIONS

Exercise therapy for the management of tendinopathy comprising five different therapy classes: 1) resistance; 2) plyometric; 3) vibration; 4) flexibility, and 5) movement pattern retraining modalities, were considered for inclusion.

MAIN OUTCOME MEASURES

Outcomes measuring patient rating of condition, including patient satisfaction and Global Rating of Change (GROC).

RESULTS

From a total of 124 exercise therapy studies, 34 (Achilles: 41%, rotator cuff: 32%, patellar: 15%, elbow: 9% and gluteal: 3%) provided sufficient information to be meta-analysed. The data were obtained across 48 treatment arms and 1246 participants. The pooled estimate for proportion of satisfaction was 0.63 [95%CrI: 0.53-0.73], and the pooled estimate for percentage of maximum GROC was 53 [95%CrI: 38-69%]. The proportion of patients reporting positive satisfaction and perception of change increased with longer follow-up periods from treatment onset.

CONCLUSION

Patient satisfaction and GROC appear similar and are ranked moderately high demonstrating that patients generally perceive exercise therapies positively. Further research including greater consistency in measurement tools is required to explore and where possible, identify patient- and exercise-related moderating factors that can be used to improve person-centred care.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO ID=CRD42020168187 CONTRIBUTION OF PAPER.

Machine learning algorithm improves the detection of NASH (NAS-based) and at-risk NASH: A development and validation study

BACKGROUND AND AIMS

Detecting NASH remains challenging, while at-risk NASH (steatohepatitis and F≥ 2) tends to progress and is of interest for drug development and clinical application. We developed prediction models by supervised machine learning techniques, with clinical data and biomarkers to stage and grade patients with NAFLD.

APPROACH AND RESULTS

Learning data were collected in the Liver Investigation: Testing Marker Utility in Steatohepatitis metacohort (966 biopsy-proven NAFLD adults), staged and graded according to NASH CRN. Conditions of interest were the clinical trial definition of NASH (NAS ≥ 4;53%), at-risk NASH (NASH with F ≥ 2;35%), significant (F ≥ 2;47%), and advanced fibrosis (F ≥ 3;28%). Thirty-five predictors were included. Missing data were handled by multiple imputations. Data were randomly split into training/validation (75/25) sets. A gradient boosting machine was applied to develop 2 models for each condition: clinical versus extended (clinical and biomarkers). Two variants of the NASH and at-risk NASH models were constructed: direct and composite models.Clinical gradient boosting machine models for steatosis/inflammation/ballooning had AUCs of 0.94/0.79/0.72. There were no improvements when biomarkers were included. The direct NASH model produced AUCs (clinical/extended) of 0.61/0.65. The composite NASH model performed significantly better (0.71) for both variants. The composite at-risk NASH model had an AUC of 0.83 (clinical and extended), an improvement over the direct model. Significant fibrosis models had AUCs (clinical/extended) of 0.76/0.78. The extended advanced fibrosis model (0.86) performed significantly better than the clinical version (0.82).

CONCLUSIONS

Detection of NASH and at-risk NASH can be improved by constructing independent machine learning models for each component, using only clinical predictors. Adding biomarkers only improved the accuracy of fibrosis.

Abstract 5411: Efficient development of prognostic tests for detecting cancer risk using proteomic technology

Background: Prognostic models for assessing future health outcomes can be developed using time-to-event (also known as “survival”) data. This methodology is ubiquitous in statistical literature and in the analysis of cancer outcomes, but its use in high-dimensional analyses tends to be limited as the methods are difficult to implement in a machine learning environment. Additionally, development of certified prognostic clinical tests using proteomic biomarkers for detecting future cancer risk can be time-consuming, prone to overfitting issues, and difficult to navigate. We demonstrate the utility of combining SomaScan® proteomic data with pipeline machine learning tools and survival analysis methodology to identify powerful and robust LDT-certifiable prognostic tests for assessing future risk of cancer.

Methods: Data pipeline and analysis tools were developed using R. In addition to standard machine learning techniques, statistical methods include elastic net AFT models, subsampling survival techniques, and metrics for assessing predictive survival models. The pipeline takes the analyst from data processing and QC through identification of optimal models for prediction of clinical endpoints, and then through validation on a hold-out test set. The tools include an assessment of model robustness against sample handling issues, longitudinal stability, the impacts of assay noise on model performance, effects of putative interferents, and risk of failure during CLIA validation in the lab. We demonstrate the utility of the tools and methods for development of a lung cancer risk model.

Results: Analysis time for validation of an optimal clinical model was reduced by at least 80%, resulting in the development of 7 LDT-certified tests within 3 years, including a test for lung cancer risk. Inclusion of methods that allow for subsampling and penalized regression using AFT models show improved predictive performance and identification of top features related to clinical endpoints.

Conclusion: Not only are powerful, prognostic tests do-able, but they can be LDT certified in an efficient manner and made to be robust to real-life lab settings. Survival analysis in a machine-learning setting allow us to leverage proteomic technology in new ways, leading to tests that assess future cancer risk, which can be used for precision medicine applications.

Citation Format: Yolanda Hagar, Leigh Alexander, Jessica Chadwick, Gargi Datta, Joe Gogain, Rachel Ostroff, Clare Paterson, Laura Sampson, Caleb Scheidel, Sama Shrestha, Amy Zhang, Michael Hinterberg. Efficient development of prognostic tests for detecting cancer risk using proteomic technology. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5411.

A proteo-transcriptomic map of non-alcoholic fatty liver disease signatures

Non-alcoholic fatty liver disease (NAFLD) is a common, progressive liver disease strongly associated with the metabolic syndrome. It is unclear how progression of NAFLD towards cirrhosis translates into systematic changes in circulating proteins. Here, we provide a detailed proteo-transcriptomic map of steatohepatitis and fibrosis during progressive NAFLD. In this multicentre proteomic study, we characterize 4,730 circulating proteins in 306 patients with histologically characterized NAFLD and integrate this with transcriptomic analysis in paired liver tissue. We identify circulating proteomic signatures for active steatohepatitis and advanced fibrosis, and correlate these with hepatic transcriptomics to develop a proteo-transcriptomic signature of 31 markers. Deconvolution of this signature by single-cell RNA sequencing reveals the hepatic cell types likely to contribute to proteomic changes with disease progression. As an exemplar of use as a non-invasive diagnostic, logistic regression establishes a composite model comprising four proteins (ADAMTSL2, AKR1B10, CFHR4 and TREM2), body mass index and type 2 diabetes mellitus status, to identify at-risk steatohepatitis.

Defining the serum proteomic signature of hepatic steatosis, inflammation, ballooning and fibrosis in non-alcoholic fatty liver disease

BACKGROUND & AIMS

Despite recent progress, non-invasive tests for the diagnostic assessment and monitoring of non-alcoholic fatty liver disease (NAFLD) remain an unmet need. Herein, we aimed to identify diagnostic signatures of the key histological features of NAFLD.

METHODS

Using modified-aptamer proteomics, we assayed 5,220 proteins in each of 2,852 single serum samples from 636 individuals with histologically confirmed NAFLD. We developed and validated dichotomized protein-phenotype models to identify clinically relevant severities of steatosis (grade 0 vs. 1-3), hepatocellular ballooning (0 vs. 1 or 2), lobular inflammation (0-1 vs. 2-3) and fibrosis (stages 0-1 vs. 2-4).

RESULTS

The AUCs of the four protein models, based on 37 analytes (18 not previously linked to NAFLD), for the diagnosis of their respective components (at a clinically relevant severity) in training/paired validation sets were: fibrosis (AUC 0.92/0.85); steatosis (AUC 0.95/0.79), inflammation (AUC 0.83/0.72), and ballooning (AUC 0.87/0.83). An additional outcome, at-risk NASH, defined as steatohepatitis with NAFLD activity score ≥4 (with a score of at least 1 for each of its components) and fibrosis stage ≥2, was predicted by multiplying the outputs of each individual component model (AUC 0.93/0.85). We further evaluated their ability to detect change in histology following treatment with placebo, pioglitazone, vitamin E or obeticholic acid. Component model scores significantly improved in the active therapies vs. placebo, and differential effects of vitamin E, pioglitazone, and obeticholic acid were identified.

CONCLUSIONS

Serum protein scanning identified signatures corresponding to the key components of liver biopsy in NAFLD. The models developed were sufficiently sensitive to characterize the longitudinal change for three different drug interventions. These data support continued validation of these proteomic models to enable a "liquid biopsy"-based assessment of NAFLD.

CLINICAL TRIAL NUMBER

Not applicable.

IMPACT AND IMPLICATIONS

An aptamer-based protein scan of serum proteins was performed to identify diagnostic signatures of the key histological features of non-alcoholic fatty liver disease (NAFLD), for which no approved non-invasive diagnostic tools are currently available. We also identified specific protein signatures related to the presence and severity of NAFLD and its histological components that were also sensitive to change over time. These are fundamental initial steps in establishing a serum proteome-based diagnostic signature of NASH and provide the rationale for using these signatures to test treatment response and to identify several novel targets for evaluation in the pathogenesis of NAFLD.

Abstract 2227: Development and validation of a blood-based protein-only predictor of 5-year lung cancer risk in ever smokers

Background: Lung cancer is the second most common cancer type and is the leading cause of cancer death globally, with smoking and advancing age as the leading causal risk factors. The USPSTF guidelines for lung cancer screening recommends annual screening for select current or former smokers over 50 years of age. While annual screening via low dose CT has been demonstrated to decrease lung cancer mortality, compliance with screening guidelines remains low. Additional prognostic tools for future lung cancer risk stratification, particularly those without immutable demographic and health history, may be beneficial in increasing screening compliance and monitoring changing risk across time.

Methods: Using modified-aptamer proteomics technology, SomaScan® assay v4.0, we scanned ~5000 proteins in 6085 EDTA plasma samples from “Ever Smokers” (current or former smokers, aged 50-73) with no known prevalent cancer at visit 3 of the Atherosclerosis Risk in Communities (ARIC) study, for a total of ~30 million protein measurements. A total of 348 incident lung cancer diagnoses occurred in this sample set, with 75 occurring within 5 years of visit 3 blood-draw. Time to lung cancer diagnosis events were modeled with protein measurements using machine learning methods in 70% of ARIC visit 3 ever smokers. A model was selected based on performance in a 15% holdout sample subset and validated in the remaining 15% ARIC visit 3 samples not used for model training or selection.

Results: A 7-feature protein-only accelerated failure time (AFT) Weibull model was successfully developed to predict the probability of a lung cancer diagnosis within 5 years of blood draw. Model performance in training, model selection, and validation datasets was AUC equal to 0.76, 0.72, and 0.83, respectively. Based on predicted probabilities from the model, individuals were stratified into 3 risk bins (low, medium, and high) with a 5-year event rate of 0.49% vs 2.74% in low vs high risk bins. Model performance was additionally assessed in an independent Japanese cohort.

Conclusion: We successfully developed a blood-based protein-only model that predicts risk of developing lung cancer in ever smokers. Performance of the protein model out-performs traditional risk factors for lung cancer and given the lack of immutable factors it has the potential to provide real-time risk which can be repeatedly assessed over time. Proteomics-driven risk stratification may have ability to increase adherence to lung cancer screening guidelines and/or influence a positive behavior change in modifiable risk-related behaviors.

Citation Format: Clare Paterson, Leigh Alexander, Rachel Ostroff, Joseph Gogain, Yolanda Hagar, Hannah Biegel, Stephen Williams. Development and validation of a blood-based protein-only predictor of 5-year lung cancer risk in ever smokers [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 2227.

Phase 2 study of anastrozole in rare cohorts of patients with estrogen receptor/progesterone receptor positive leiomyosarcomas and carcinosarcomas of the uterine corpus: The PARAGON trial (ANZGOG 0903)

BACKGROUND

Aromatase inhibitors have been used empirically to treat a subset of patients with hormone receptor positive uterine leiomyosarcomas(LMS) and carcinosarcomas (UCS) mainly supported by retrospective data. We evaluated the activity of anastrozole in two rare cohorts; patients with recurrent/metastatic LMS and UCS enrolled in PARAGON, a basket trial of anastrozole in estrogen receptor (ER+)/progesterone receptor positive (PR+) gynecological cancers.

METHOD

An investigator-initiated, single-arm, prospective open-label trial of anastrozole 1 mg/day in patients with ER &/or PR + ve LMS or UCS with measurable disease, treated until progression or unacceptable toxicity. Primary endpoint was clinical benefit (complete/partial response + stable disease) rate (CBR) at 3 months. Secondary endpoints include progression-free survival (PFS), quality of life and toxicity.

RESULTS

39 eligible patients were enrolled, 32 with LMS and 7 with UCS. For the LMS cohort CBR at 3 months was 35% (95% CI: 21-53%) with a median duration of clinical benefit of 5.8 months. Best response was a partial response in one patient. Two patients remained on treatment for more than one year. The median progression-free survival was 2.8 months (95% CI: 2.6-4.9). For the UCS cohort CBR at 3 months was 43% (95% CI: 16-75%) with a median duration of clinical benefit of 5.6 months. Stable disease was seen in 3 patients but no objective responses were seen. The median progression-free survival was 2.7 months (95% CI, 1.1-8.2). Safety was acceptable with 5/39 evaluable patients showing grade 3 toxicities.

CONCLUSION

Whilst objective response rates with anastrozole are low, the clinical benefit rate and good tolerance suggests that aromatase inhibitor therapy may have a role in a subset of patients with metastatic LMS and UCS.

729 “I Don’t Feel Like I’m Learning How to Be A Doctor:” The Impact of Disruptions Due to Covid-19 On Professional Identity Formation in UK Medical Students

Introduction

Professional identity formation (PIF) is a priority of medical training. Covid-19 caused disruption to medical education. We ask how this disruption impacted PIF through the lens of the activities performed – or not performed – by medical students during the first wave of the covid-19 pandemic, and perceptions of conflicts between activities.

Method

A pragmatic survey was distributed in spring 2020. Thematic analysis was performed of qualitative responses to two open questions. A social constructivist approach linked participants’ comments to PIF theory.

Results

We analysed 928 responses. Three themes surrounding students’ activities during covid-19 and their impact on identity were constructed:

Conflict arose at the intersections between these themes. Students noted lack of clinical exposure was detrimental, implicitly recognising that aspects of PIF require the clinical environment. Participants were keen to volunteer but struggled with balancing academic work. Participants worried about risk to their households and the wider community and wanted their skills to add value in the clinical environment. Volunteers felt frustrated when they were unable to perform tasks aligning with their identity as a future doctor. An exception was participants who worked as interim FY1s, aligned with the role of an FY1.

Conclusions

Medical students feel a duty to help during crises. Conflict arises when different aspects of their identity demand different actions. Care must be taken to nurture PIF during periods of disruption.

Serum Proteomics and Plasma Fibulin-3 in Differentiation of Mesothelioma From Asbestos-Exposed Controls and Patients With Other Pleural Diseases

INTRODUCTION

Malignant pleural mesothelioma (MPM) is difficult to diagnose. An accurate blood biomarker could prompt specialist referral or be deployed in future screening. In earlier retrospective studies, SOMAscan proteomics (Somalogic, Boulder, CO) and fibulin-3 seemed highly accurate, but SOMAscan has not been validated prospectively and subsequent fibulin-3 data have been contradictory.

METHODS

A multicenter prospective observational study was performed in 22 centers, generating a large intention-to-diagnose cohort. Blood sampling, processing, and diagnostic assessment were standardized, including a 1-year follow-up. Plasma fibulin-3 was measured using two enzyme-linked immunosorbent assays (CloudClone [used in previous studies] and BosterBio, Pleasanton, CA). Serum proteomics was measured using the SOMAscan assay. Diagnostic performance (sensitivity at 95% specificity, area under the curve [AUC]) was benchmarked against serum mesothelin (Mesomark, Fujirebio Diagnostics, Malvern, PA). Biomarkers were correlated against primary tumor volume, inflammatory markers, and asbestos exposure.

RESULTS

A total of 638 patients with suspected pleural malignancy (SPM) and 110 asbestos-exposed controls (AECs) were recruited. SOMAscan reliably differentiated MPM from AECs (75% sensitivity, 88.2% specificity, validation cohort AUC 0.855) but was not useful in patients with differentiating non-MPM SPM. Fibulin-3 (by BosterBio after failed CloudClone validation) revealed 7.4% and 11.9% sensitivity at 95% specificity in MPM versus non-MPM SPM and AECs, respectively (associated AUCs 0.611 [0.557-0.664], p = 0.0015) and 0.516 [0.443-0.589], p = 0.671), both inferior to mesothelin. SOMAscan proteins correlated with inflammatory markers but not with asbestos exposure. Neither biomarker correlated with tumor volume.

CONCLUSIONS

SOMAscan may prove useful as a future screening test for MPM in asbestos-exposed persons. Neither fibulin-3 nor SOMAscan should be used for diagnosis or pathway stratification.

986 A Systematic Review of Medical Student Willingness to Volunteer and Preparedness for Pandemics and Disasters

Introduction

We aimed to identify motivators and barriers to volunteering during a disaster and knowledge and medical school curriculum of disaster and pandemic medicine.

Method

We systematically searched the literature on 28/6/2020, following PRISMA guidelines.

Results

A total of 37 studies met inclusion criteria including 11,168 medical students and 91 medical schools. 24 studies evaluated knowledge (64.9%), 16 evaluated volunteering (43.2%), and five evaluated medical school curricula (13.5%). Weighted mean willingness to volunteer during a disaster was 68.4% (SD = 21.7%, n = 2911), and there was a significant difference between those planning to volunteer and those who actually volunteered (P<.001). We identified a number of modifiable barriers which may contribute to this difference. Overall, knowledge of disasters was poor with a weighted mean of 48.9% (SD = 15.1%, n = 2985).

Conclusions

There is a large number of students who are willing to volunteer during pandemics. However, they are likely to be under-prepared for these roles due to poor overall knowledge and limited teaching. During the current COVID-19 pandemic and in future disasters, medical students may be required to volunteer as auxiliary staff. Medical schools need to develop infrastructure to facilitate this process as well as providing education and training to ensure students are adequately prepared for these roles.

967 COVID READY Study: Cross-Sectional Survey of Medical Students Volunteering During the Coronavirus Pandemic (COVID-19) In the United Kingdom

Introduction

We aimed to identify the willingness, attitudes, and practice of medical students towards volunteering in a clinical capacity during the COVID-19 pandemic.

Method

We distributed a cross-sectional survey from 2/5/2020 to 14/6/2020 to all medical students at UK medical schools.

Results

A total of 1145 medical students from 36 medical schools completed the questionnaire. 82.7% of students were willing to volunteer, but only 34.3% had volunteered. The strongest predictors of willingness to volunteer on multiple linear regression were the beliefs that volunteering to work would benefit their medical education (estimate=0.35±0.03, adjusted P < 0.001) and that they would have a positive impact (estimate=0.33±0.03, adjusted P < 0.001). The majority of students were willing to take up a clinical role and were confident in having the necessary skills, but there was a discrepancy between the role’s students were comfortable performing and those they were assigned. Thematic analysis of the issue’s students would face when volunteering identified five themes: safety, professional practice, pressure to volunteer, finances and logistics, and education.

Conclusions

This study identifies areas for consideration from those responsible for workforce planning, healthcare provision, and student safety. We provide recommendations to facilitate a volunteering process that is safer for students, staff, and patients.

Phase 2 study of anastrozole in patients with estrogen receptor/progesterone receptor positive recurrent low-grade endometrial stromal sarcomas: The PARAGON trial (ANZGOG 0903)

BACKGROUND

Aromatase inhibitors are standard of care for low-grade endometrial stromal sarcomas (LGESS), based on very high response rates reported in retrospective studies. We evaluated the activity of anastrozole in recurrent/metastatic LGESS patients enrolled in PARAGON, a basket trial of anastrozole in estrogen receptor (ER±)/progesterone receptor (PR+) gynecological cancers.

METHOD

An investigator-initiated, single-arm, prospective open-label trial of anastrozole 1 mg/day in patients with ER ± PR + ve LGESS with measurable disease, treated until progressive disease or unacceptable toxicity. Primary endpoint was clinical benefit (complete/partial response + stable disease) rate (CBR) at 3 months. Secondary endpoints include progression-free survival (PFS), quality of life and toxicity.

RESULTS

15 eligible patients were enrolled. CBR at 3 months was 73% (95% CI: 48-89.1%); unchanged at 6 months. Best response was 26.7%, including complete response in one (6.7%; 95% CI 1.2-29.8%), partial response in three (20%, 95% CI 7.1-45.2%) and stable disease in seven (46.7%). Four patients ceased treatment by 3 months due to progression. Median PFS was not reached (25th percentile: 2.9 months (95% CI: 1.2-NR)). PFS was 73.3%, 73.3% and 66% at 6, 12, and 18 months, respectively. Six patients remained on treatment for an average of 44.2 months (range 34.5-63.6) up until data cut. Toxicity was as expected, with 3 patients stopping due to adverse effects.

CONCLUSION

The 26.7% objective response rate with anastrozole is lower than reported in retrospective series, but the CBR was high and durable. The results underscore the importance of prospective trials in rare cancers.

Transcriptomic profiling across the nonalcoholic fatty liver disease spectrum reveals gene signatures for steatohepatitis and fibrosis

The mechanisms that drive nonalcoholic fatty liver disease (NAFLD) remain incompletely understood. This large multicenter study characterized the transcriptional changes that occur in liver tissue across the NAFLD spectrum as disease progresses to cirrhosis to identify potential circulating markers. We performed high-throughput RNA sequencing on a discovery cohort comprising histologically characterized NAFLD samples from 206 patients. Unsupervised clustering stratified NAFLD on the basis of disease activity and fibrosis stage with differences in age, aspartate aminotransferase (AST), type 2 diabetes mellitus, and carriage of PNPLA3 rs738409, a genetic variant associated with NAFLD. Relative to early disease, we consistently identified 25 differentially expressed genes as fibrosing steatohepatitis progressed through stages F2 to F4. This 25-gene signature was independently validated by logistic modeling in a separate replication cohort (n = 175), and an integrative analysis with publicly available single-cell RNA sequencing data elucidated the likely relative contribution of specific intrahepatic cell populations. Translating these findings to the protein level, SomaScan analysis in more than 300 NAFLD serum samples confirmed that circulating concentrations of proteins AKR1B10 and GDF15 were strongly associated with disease activity and fibrosis stage. Supporting the biological plausibility of these data, in vitro functional studies determined that endoplasmic reticulum stress up-regulated expression of AKR1B10, GDF15, and PDGFA, whereas GDF15 supplementation tempered the inflammatory response in macrophages upon lipid loading and lipopolysaccharide stimulation. This study provides insights into the pathophysiology of progressive fibrosing steatohepatitis, and proof of principle that transcriptomic changes represent potentially tractable and clinically relevant markers of disease progression.

Plasma protein patterns as comprehensive indicators of health

Proteins are effector molecules that mediate the functions of genes1,2 and modulate comorbidities3-10, behaviors and drug treatments11. They represent an enormous potential resource for personalized, systemic and data-driven diagnosis, prevention, monitoring and treatment. However, the concept of using plasma proteins for individualized health assessment across many health conditions simultaneously has not been tested. Here, we show that plasma protein expression patterns strongly encode for multiple different health states, future disease risks and lifestyle behaviors. We developed and validated protein-phenotype models for 11 different health indicators: liver fat, kidney filtration, percentage body fat, visceral fat mass, lean body mass, cardiopulmonary fitness, physical activity, alcohol consumption, cigarette smoking, diabetes risk and primary cardiovascular event risk. The analyses were prospectively planned, documented and executed at scale on archived samples and clinical data, with a total of ~85 million protein measurements in 16,894 participants. Our proof-of-concept study demonstrates that protein expression patterns reliably encode for many different health issues, and that large-scale protein scanning12-16 coupled with machine learning is viable for the development and future simultaneous delivery of multiple measures of health. We anticipate that, with further validation and the addition of more protein-phenotype models, this approach could enable a single-source, individualized so-called liquid health check.

Quality Improvement of Clinical Handover in a Liaison Psychiatry Department: A Three-Phase Audit

Aims To audit and improve quality of clinical handover in a Liaison Psychiatry Department. Methods An 11-item Handover Checklist was used to carry out a baseline audit and immediate and delayed post-intervention re-audits. The intervention consisted of checklist posters, an electronic database and staff training. Results There was an immediate and sustained improvement in most areas, including baseline demographics and components of SBAR communication (Situation, Background, Assessment, Recommendation). The improvement between baseline and delayed re-audit was statistically significant (P=0.007). Conclusion Poor handover practices contribute to negative outcomes in healthcare but there remains a dearth of guidelines in most specialties.This audit is important as it describes an intervention which improved clinical handover at a time of significant clinical risk. This practice could be applied effectively to other services and is relevant to all specialties. Six to twelve-monthly re-audit and longitudinal assessment of clinical outcomes are recommended to maintain the practices implemented in this audit.

SYSTEMS-2: A randomised phase II study of radiotherapy dose escalation for pain control in malignant pleural mesothelioma

SYSTEMS-2 is a randomised study of radiotherapy dose escalation for pain control in 112 patients with malignant pleural mesothelioma (MPM). Standard palliative (20 Gy/5#) or dose escalated treatment (36 Gy/6#) will be delivered using advanced radiotherapy techniques and pain responses will be compared at week 5. Data will guide optimal palliative radiotherapy in MPM.

Urinary excretion of dietary Maillard reaction products in healthy adult female cats

During processing of foods, the Maillard reaction occurs, resulting in the formation of advanced Maillard reaction products (MRP). Varying amounts of MRP have been found in commercially processed pet foods. Dietary MRP can be absorbed and contribute to the endogenous pool of MRP and possibly the etiology of age-related diseases. The aim of the present study was to determine urinary excretion of dietary MRP in cats fed commercial moist and dry foods. A pilot study with 10 cats, conducted to determine the adaptation time required for stable urinary excretion of MRP when changing to a diet with contrasting MRP content, showed an adaptation time of 1 d for all components. In the main study, 6 commercially processed dry and 6 moist diets were fed to 12 adult female cats in 2 parallel randomized, 36-d Latin square designs. The 24-h urine was collected quantitatively using modified litter boxes, and fructoselysine (FL), carboxymethyllysine (CML), and lysinoalanine (LAL) were analyzed using ultra high performance liquid chromatography (UHPLC) - mass spectrometer. Daily urinary excretion of FL and CML showed a positive relationship with daily intake in the dry ( = 0.03 and < 0.01, respectively) and moist ( < 0.01) foods. For LAL, no significant relationship was observed. Urinary recovery (% ingested) showed a negative relationship with daily intake for FL, CML, and LAL in the dry foods ( < 0.01, < 0.01, and = 0.08, respectively) and for CML and LAL in the moist foods ( < 0.01). The observed increase in urinary excretion with increasing dietary intake indicates that dietary MRP were absorbed from the gastrointestinal tract of cats and excreted in the urine. The adaptation time with change in diet indicates a likely effective excretion of MRP. Minimum apparent absorption of FL, CML, and LAL was found to range between 8% and 23%, 25% and 73%, and 6% and 19%, respectively. The observed decrease in urinary recovery suggests a limiting factor in digestion, absorption, metabolism, or urinary excretion. This study shows that dietary MRP in commercial diets are absorbed and excreted via the kidneys in cats.

Reasons for participation and non-participation in a randomized controlled trial: postal questionnaire surveys of women eligible for TOMBOLA (Trial Of Management of Borderline and Other Low-grade Abnormal smears)

Background Better understanding of motivators for, and barriers to, participation in randomized controlled trials (RCTs) in different study populations and settings has the potential to improve participation of historically under-represented groups (eg, women) in future trials.

Purpose To investigate reasons why women agreed, or declined, to participate in a RCT.

Methods In two postal questionnaire-based studies, we investigated women's reasons for participation or non-participation in TOMBOLA, a RCT comparing management policies for low-grade cervical abnormalities. Four-hundred and ninety-two TOMBOLA participants (response rate 56%) completed questionnaires on reasons for participation. One-hundred and thiry-seven women (38%) who declined TOMBOLA participation completed questionnaires on reasons for this.

Results Eighty percent of women reported that one of their reasons for attending their TOMBOLA recruitment appointment was worries about their smear result. Ninety-four percent participated in the RCT because it was a worthwhile contribution to the cervical screening programme and other women; for 70% this was the most important reason. These proportions did not vary by socio-demographic factors. Thirty-two percent thought participation would result in better care. The most common reason for non-participation was preference for follow-up from the woman's GP. Logistical issues (eg, inconvenient appointments, travel time, arranging time off work or child-care) were commonly cited. Fourteen percent were too frightened to participate; this was unrelated to the grade of the recruitment smear. Limitations Response rates were not high, but there was little evidence of response bias. Structured questionnaires were used.

Conclusions Future research should address how best to deliver information to ensure different social groups appreciate potential benefits of RCT participation and provide reassurance regarding fears about participation. Simple strategies (eg, appealing to the altruism of potential participants or offering flexible recruitment clinic locations and times) might enhance RCT recruitment rates. This in turn would ensure best use of research resources thus bringing the greatest benefits to participants and the population.

Battery-Less Wireless Instrumented Knee Implant

Over 400,000 total knee replacement procedures (TKR) are performed annually in the United States. This paper focuses on the development of a battery-less wireless instrumented tibial tray for performance feedback in TKR implants. The proposed instrumented tibial tray is powered internally by an integrated piezoelectric energy harvesting system. Energy is harvested during the walking of the patient when forces are exerted on the tibial component. The sensors and wireless electronics are entirely powered from the harvested energy. This tibial tray is also instrumented with capacitive force sensors and an ultra low-power method to measure the capacitive force sensors. A bench top test rig is developed for testing the battery-less wireless knee replacement implant. For a person with a body weight of 55 kg, the energy harvesting system can fully charge the storage capacitors in 11 steps and can harvest an average of 1051 μJ per step. To power the force measurement system for ten seconds and to transmit the data, the piezoelectric energy harvesting system must be charged before the force measurement process is initiated by a minimum of 11 steps and a minimum of two steps must be taken during the force measurement process. During the force measurement process, each force sensor is sampled at a frequency of 10 Hz for ten seconds; thereafter, all of the data is transmitted to the RF base station. The resulting capacitive force sensors adequately represented cyclic loads; however, the sensors demonstrated some issues with repeatability.

Breast cancer treatment delay in African American women in Washington, DC

Abstract #4164

Background: Delays in follow-up after a positive breast cancer screen are thought to contribute to racial/ethnic disparities in breast cancer outcomes. The goal of this study was to determine the relative impact of self-identified race and other relevant socio-demographic and logistic variables on time to diagnosis after an abnormal mammogram, and time to first treatment after a cancer diagnosis within the context of data collection for a large research study of the effectiveness of patient navigation.&#x2028; Methods: Our sample includes 168 African-American and non-Hispanic white women with a documented invasive breast cancer diagnosis at an urban academic medical center during 2006 and 2007. The outcome variables were the number of days from abnormal mammogram to cancer diagnosis and from diagnosis to first treatment.&#x2028; Results: The median number of days to breast cancer diagnosis following an abnormal mammogram was 20.5 days for African-Americans compared to 15 days for non-Hispanic white women. Median days to first treatment after diagnosis was 21 days for African-American women compared to 16 days for non-Hispanic white women. Neither difference was statistically significant. In addition, 76% of African-American women had private insurance versus 81% of non-Hispanic white women.&#x2028; Conclusions: The identification of specific risk factors associated with a delay in diagnosis noted elsewhere in the literature and suggested in these preliminary findings could provide useful information regarding characteristics of women who are most likely to benefit from enhanced patient navigation efforts. Thus far, no statistically significant differences have been identified but the variety of factors that could contribute to the longer delay in disease management in African-American women compared to non-Hispanic white women, such as insurance status, provider location, household income, cultural issues, and other barriers to health care access, should be evaluated with a larger patient population.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4164.

The effects of short-term antioxidant supplementation on oxidative stress and flight performance in adult budgerigars Melopsittacus undulatus

Antioxidants are known to play an important role in quenching reactive oxygen species (ROS), thus ameliorating oxidative stress. Since increased metabolism associated with exercise can increase oxidative stress, dietary antioxidants may be a limiting factor in determining aspects of physical performance. Here we tested whether oxidative stress associated with flight exercise of captive adult budgerigars, Melopsittacus undulatus differed after they received a diet containing either enhanced (EQ) or reduced levels (RQ) of a nutritional supplement (Nutrivit) rich in antioxidants for 4 weeks. We also assessed differences in take-off escape time, a potential fitness-determining physiological capability. Oxidative stress was measured in two ways: comet assay to measure DNA damage; and analysis of malondialdehyde (MDA), a by-product of lipid peroxidation. Flight exercise appeared to increase oxidative stress. Moreover, birds had a higher percentage of intact DNA (fewer alkali labile sites) in one comet measure and lower levels of MDA after an EQ diet than after an RQ diet. We found no difference in flight performance between the two diets. Our results suggested that birds exerted maximum effort in escape flights, regardless of diet. However, this was at a cost of increased oxidative stress post-flight when on a reduced quality diet, but not when on an enhanced, antioxidant-rich diet. We suggest that dietary antioxidants may prove important in reducing exercise-related costs through multiple physiological pathways. Further work is necessary to fully understand the effects of antioxidants and oxidative stress on exercise performance in the longer term.

Cellular uptake of fluorescent labelled biotin-streptavidin microspheres

Amino functionalized, cross-linked, polystyrene microspheres were covalently loaded with streptavidin to which was coupled fluorescently labeled biotin and biotinylated-tagged DNA. These biotin-streptavidin microsphere conjugates were then successfully delivered into cells. The application of the streptavidin-biotin technology to these microspheres allows the effective delivery of any biotinylated material into intact mammalian cells, without the need for delicate procedures such as micro-injection.

How physically active are South Asians in the United Kingdom? A literature review

BACKGROUND

Moderate physical activity is protective against coronary heart disease (CHD) and diabetes, both important public health problems among UK South Asian (Indian, Pakistani and Bangladeshi) ethnic groups. We assessed the evidence that physical activity is lower in South Asian groups than in the general population.

METHODS

We carried out a systematic literature review of studies describing levels of physical activity and fitness in UK South Asians using MEDLINE, EMBASE, the Cochrane databases, hand searching of relevant journals and review of reference lists.

RESULTS

We identified 12 studies in adults and five in children. Various methods were used to assess physical activity and fitness, but all the studies reported lower levels among South Asian groups. The differences were substantial, particularly among women and older people. For example, the Health Survey for England found that Indian, Pakistani and Bangladeshi men were 14, 30 and 45 per cent less likely than the general population to meet current guidelines for physical activity. Limited information was provided about translation and adaptation of questionnaires.

CONCLUSION

Levels of physical activity were lower in all South Asian groups than the general population and patterns of activity differed. No studies used validated measures. Insufficient attention has been paid to issues of cross-cultural equivalence. With these caveats, low levels of physical activity among UK South Asian ethnic groups may contribute to their increased risk of diabetes and CHD. Closer attention to validity, translation and adaptation is necessary to monitor changes and assess the effectiveness of interventions to increase physical activity.