Fluoropyrimidine type, patient age, tumour sidedness and mutation status as determinants of benefit in patients with metastatic colorectal cancer treated with EGFR monoclonal antibodies: individual patient data pooled analysis of randomised trials from the ARCAD database

BACKGROUND

KRAS mutations in metastatic colorectal cancer (mCRC) are used as predictive biomarkers to select therapy with EGFR monoclonal antibodies (mAbs). Other factors may be significant determinants of benefit.

METHODS

Individual patient data from randomised trials with a head-to-head comparison between EGFR mAb versus no EGFR mAb (chemotherapy alone or best supportive care) in mCRC, across all lines of therapy, were pooled. Overall survival (OS) and progression-free survival (PFS) were compared between groups. Treatment effects within the predefined KRAS biomarker subsets were estimated by adjusted hazard ratio (HRadj) and 95% confidence interval (CI). EGFR mAb efficacy was measured within the KRAS wild-type subgroup according to BRAF and NRAS mutation status. In both KRAS wild-type and mutant subgroups, additional factors that could impact EGFR mAb efficacy were explored including the type of chemotherapy, line of therapy, age, sex, tumour sidedness and site of metastasis.

RESULTS

5675 patients from 8 studies were included, all with known mCRC KRAS mutation status. OS (HRadj 0.90, 95% CI 0.84-0.98, p = 0.01) and PFS benefit (HRadj 0.73, 95% CI 0.68-0.79, p < 0.001) from EGFR mAbs was observed in the KRAS wild-type group. PFS benefit was seen in patients treated with fluorouracil (HRadj 0.75, 95% CI 0.68-0.82) but not with capecitabine-containing regimens (HRadj 1.04, 95% CI 0.86-1.26) (pinteraction = 0.002). Sidedness also interacted with EGFR mAb efficacy, with survival benefit restricted to left-sided disease (pinteraction = 0.038). PFS benefits differed according to age, with benefits greater in those under 70 (pinteraction = 0.001). The survival benefit was not demonstrated in those patients with mutations found in the KRAS, NRAS or BRAF genes. The presence of liver metastases interacted with EGFR mAb efficacy in patients with KRAS mutant mCRC (pinteraction = 0.004).

CONCLUSION

The benefit provided by EGFR mAbs in KRAS WT mCRC is associated with left-sided primary tumour location, younger patient age and absence of NRAS or BRAF mutations. Survival benefit is observed with fluorouracil but not capecitabine. Exploratory results support further research in KRAS mutant mCRC without liver metastases.

Human papillomavirus negative high grade cervical lesions and cancers: Suggested guidance for HPV testing quality assurance

BACKGROUND

Some high-grade cervical lesions and cervical cancers (HSIL+) test negative for human papillomavirus (HPV). The HPV-negative fraction varies between 0.03 % and 15 % between different laboratories. Monitoring and extended re-analysis of HPV-negative HSIL+ could thus be helpful to monitor performance of HPV testing services. We aimed to a) provide a real-life example of a quality assurance (QA) program based on re-analysis of HPV-negative HSIL+ and b) develop international guidance for QA of HPV testing services based on standardized identification of apparently HPV-negative HSIL+ and extended re-analysis, either by the primary laboratory or by a national HPV reference laboratory (NRL).

METHODS

There were 116 initially HPV-negative cervical specimens (31 histopathology specimens and 85 liquid-based cytology samples) sent to the Swedish HPV Reference Laboratory for re-testing. Based on the results, an international QA guidance was developed through an iterative consensus process.

RESULT

Standard PCR testing detected HPV in 55.2 % (64/116) of initially "HPV-negative" samples. Whole genome sequencing of PCR-negative samples identified HPV in an additional 7 samples (overall 61.2 % HPV positivity). Reasons for failure to detect HPV in an HSIL+ lesion are listed and guidance to identify cases for extended re-testing, including which information should be included when referring samples to an NRL are presented.

CONCLUSION

Monitoring the proportion of and reasons for failure to detect HPV in HSIL+ will help support high performance and quality improvement of HPV testing services. We encourage implementation of QA strategies based on re-analysis of "HPV negative" HSIL+ samples.

A Multifaceted Approach for Evaluating Hepatitis E Virus Infectivity In Vitro: Cell Culture and Innovative Molecular Methods for Integrity Assessment

Hepatitis E virus is a prominent cause of viral hepatitis worldwide. In Western countries, most infections are asymptomatic. However, acute self-limiting hepatitis and chronic cases in immunocompromised individuals can occur. Studying HEV is challenging due to its difficulty to grow in cell culture. Consequently, the detection of the virus mainly relies on RT-qPCR, which cannot differentiate between infectious and non-infectious particles. To overcome this problem, methods assessing viral integrity offer a possible solution to differentiate between intact and damaged viruses. This study aims at optimizing existing HEV cell culture models and RT-qPCR-based assays for selectively detecting intact virions to establish a reliable model for assessing HEV infectivity. In conclusion, these newly developed methods hold promise for enhancing food safety by identifying approaches for inactivating HEV in food processing, thereby increasing food safety measures.

Hepatitis E virus in pork meat products and exposure assessment in Belgium

Zoonotic hepatitis E virus (HEV) genotype 3 infections are the predominant cause of acute viral hepatitis in Europe, mostly associated with the consumption of HEV contaminated pork meat. In this study we looked at the HEV RNA positivity rate of pork meat products readily available from Belgian supermarkets and evaluated the overall HEV consumer exposure in a Belgian context. Two basic assessments were performed in a 'worst-case' scenario setting: one solely focusing on the contamination level of the product itself (ingredients and processing parameters) and another estimating the overall consumer exposure, taking into account consumption habits in Belgium. Non-thermal-processed ready-to-eat (i.e. ready for consumption without additional cooking step by consumer) pork meat products (e.g. raw dried sausages), had a high estimated HEV contamination level, while thermal-processed ready-to-eat pork meat products (e.g. pork liver pâté) had the highest overall consumer exposure estimates. Following these assessments, pork liver pâtés, raw dried hams and raw dried sausages (n = 54) were purchased from Belgian supermarkets (n = 3) and analyzed for HEV RNA by RT-PCR. In total, 31 % (n = 17) products tested positive. HEV RNA was found in 65 % of the pork liver pâtés, 15 % of raw dried hams and 0 % of raw dried sausages. Phylogenetic analysis of four isolates (all gt3c) from pork liver pâté samples showed similarities with human clinical cases from Germany and Belgium.

Viral clade is associated with severity of symptomatic genotype 3 hepatitis E virus infections in Belgium, 2010-2018

BACKGROUND & AIMS

HEV genotype (gt) 3 infections are prevalent in high-income countries and display a wide spectrum of clinical presentations. Host - but not viral - factors are reported to be associated with worse clinical outcomes.

METHODS

Demographic, clinical, and biochemical data laboratory-confirmed HEV infections (by PCR and/or a combination of IgM and IgG serology) at the Belgian National Reference Centre between January 2010 and June 2018 were collected using standardised case report forms. Genotyping was based on HEV open reading frame 2 sequences. Serum CXCL10 levels were measured by a magnetic bead-based assay. H&E staining was performed on liver biopsies.

RESULTS

A total of 274 HEV-infected individuals were included. Subtype assignment was possible for 179/218 viraemic cases, confirming gt3 as dominant with an almost equal representation of clades abchijklm and efg. An increased hospitalisation rate and higher peak serum levels of alanine aminotransferase, bilirubin, and alkaline phosphatase were found in clade efg-infected individuals in univariate analyses. In multivariable analyses, clade efg infections remained more strongly associated with severe disease presentation than any of the previously identified host risk factors, being associated with a 2.1-fold higher risk of hospitalisation (95% CI 1.1-4.4, p = 0.034) and a 68.2% higher peak of bilirubin levels (95% CI 13.3-149.9, p = 0.010), independently of other factors included in the model. In addition, acute clade efg infections were characterised by higher serum CXCL10 levels (p = 0.0005) and a more pronounced liver necro-inflammatory activity (p = 0.022).

CONCLUSIONS

In symptomatic HEV gt3 infections, clade efg is associated with a more severe disease presentation, higher serum CXCL10 levels, and liver necro-inflammatory activity, irrespective of known host risk factors.

CLINICAL TRIAL REGISTRATION

The protocol was submitted to clinicaltrials.gov (NCT04670419).

IMPACT AND IMPLICATIONS

HEV genotype (gt) 3 infections display a wide spectrum of clinical presentations currently ascribed to host factors. Here we examined the role of viral factors on liver disease outcomes by combining viral phylogeny with clinical, biochemical, cytokine, and histological data from 274 Belgian adults infected with HEV presenting between 2010 and 2018. HEV gt 3 clade efg infections were associated with a more severe disease presentation, higher serum CXCL10 levels and liver necro-inflammatory activity, irrespective of known host risk factors. HEV gt3 clade-dependent clinical outcomes call for broad HEV gt3 subtyping in clinical practice and research to help identify those at higher risk for worse outcomes and to further unravel underlying virus-host interactions.

Country-level social mobility and inequalities in adolescent health behaviours in 32 countries

Background

Higher family affluence is associated with healthier behaviours in adolescents, but the strength of this association varies across countries. Differences in social mobility at the country-level, i.e. the extent to which adolescents develop a different socioeconomic status (SES) than their parents, may partially explain why the association between family affluence and adolescent health behaviours is stronger in some countries than in others.

Methods

Using data from adolescents aged 11-15 years from 32 different countries, participating in the 2017/2018 wave of the Health Behaviour in School-aged Children (HBSC) study (N = 185,086), we employed multilevel regression models with cross-level interactions to examine whether country-level social mobility moderates the association between family affluence and adolescent health behaviours (i.e. moderate-to-vigorous physical activity, vigorous physical activity, healthy foods consumed, unhealthy foods consumed, having breakfast regularly, weekly smoking).

Results

Higher family affluence was more strongly associated with higher levels of physical activity in countries characterized by high levels of social mobility (cross-level interaction linear regression coefficient 0.34; 95% CI 0.08 to 0.60; p = 0.009 for moderate-to-vigorous physical activity, and 0.31; 0.11 to 0.50; p = 0.002 for vigorous physical activity). No cross-level interactions were found for any of the other health behaviours.

Conclusions

Our findings suggest that differences in social mobility at the country-level may contribute to cross-national variations in socioeconomic inequalities in adolescent physical activity. Further research can shed light on the mechanisms linking country-level social mobility to inequalities in adolescent physical activity to identify targets for policy and interventions.

Key messages

• This is one of the first studies to investigate country-level social mobility in relation to health equity. Inequalities in adolescent physical activity were steeper in socially mobile countries.

• Stronger efforts to engage adolescents from low-affluent families in physical activity may be necessary in countries characterized by high levels of social mobility.

Prestatiedruk en schoolstress bekeken vanuit verschillende perspectieven

Jongeren ervaren de laatste jaren steeds meer schoolstress en druk door school. Om goed inzicht te krijgen in de factoren die ten grondslag liggen aan deze toename en mogelijk een schakel zijn voor verandering, is het van belang om dit maatschappelijke probleem vanuit verschillende perspectieven te bekijken. In dit onderzoek verbinden we wetenschappelijke kennis (systematisch literatuuronderzoek) met praktijk- en ervaringskennis van professionals, beleidsmedewerkers, ouders en jongeren (diepte-interviews, n = 60). De resultaten van dit onderzoek laten zien dat de beschermende factoren op verschillende niveaus (systeem, directe omgeving, individu) met elkaar interacteren. De maatschappij legt veel nadruk op resultaat en prestaties, wat invloed heeft op de verwachtingen van jongeren en ouders, en de inrichting van ons onderwijssysteem. Scholen kunnen jongeren ondersteunen bij hun ontwikkeling door aandacht te besteden aan bredere talentontwikkeling, alternatieve beoordelingsvormen, goed mentorschap en de sociaal-emotionele ontwikkeling. Om de ervaren schoolstress en druk door school te verminderen is het belangrijk om niet alleen het individu weerbaarder te maken, maar ook de directe omgeving en de school/maatschappij mee te nemen in preventieve maatregelen om schoolstress en ervaren druk te minderen.

Escherichia coli from urine samples of pregnant women as an indicator for antimicrobial resistance in the community: a field study from rural Burkina Faso

Background

In low- and middle-income countries, surveillance of antimicrobial resistance (AMR) is mostly hospital-based and, in view of poor access to clinical microbiology, biased to more resistant pathogens. We aimed to assess AMR among Escherichia coli isolates obtained from urine cultures of pregnant women as an indicator for community AMR and compared the AMR results with those from E. coli isolates obtained from febrile patients in previously published clinical surveillance studies conducted within the same population in Nanoro, rural Burkina Faso. We furthermore explored feasibility of adding urine culture to standard antenatal care in a rural sub-Saharan African setting.

Methods

Between October 2016–September 2018, midstream urine samples collected as part of routine antenatal care in Nanoro district were cultured by a dipslide method and screened for antibiotic residues. Significant growth was defined as a pure culture of Enterobacterales at counts of ≥ 104 colony forming units/ml.

Results

Significant growth was observed in 202/5934 (3.4%) cultures; E. coli represented 155 (76.7%) of isolates. Among E. coli isolates, resistance rates to ampicillin, cotrimoxazole and ciprofloxacin were respectively 65.8%, 64.4% 16.2%, compared to 89.5%, 89.5% and 62.5% among E. coli from clinical isolates (n = 48 of which 45 from blood cultures). Proportions of extended spectrum beta-lactamase producers and multidrug resistance were 3.2% and 5.2% among E. coli isolates from urine in pregnant women versus 35.4%, and 60.4% respectively among clinical isolates.

Conclusions

The E. coli isolates obtained from healthy pregnant women had significantly lower AMR rates compared to clinical E. coli isolates, probably reflecting the lower antibiotic pressure in the pregnant women population. Adding urine culture to the routine urine analysis (dipstick) of antenatal care was feasible. The dipslide culture method was affordable and user-friendly and allowed on-site inoculation and easy transport; challenges were contamination (midstream urine sampling) and the semi-quantitative reading. Provided confirmation of the present findings in other settings, E. coli from urine samples in pregnant women may be a potential indicator for benchmarking, comparing, and monitoring community AMR rates across populations over different countries and regions.

Iatrogenic retroposition of the lips sequel after bicuspid extraction-a retrospective study

AIM

This study aims to explore the prevalence of Iatrogenic retroposition of the lips sequel (IRLS) after bicuspid extraction, associated dentofacial characteristics and the effectiveness of surgical treatment.

MATERIAL

and methods: Patients with bicuspid extraction as part of an orthodontic treatment plan were retrospectively included. IRLS was identified by clinical evaluation and cephalometric Legan and Burstone analysis. Association of demographic and cephalometric variables were assessed. The effectiveness of combined orthodontic-orthognathic correction of the retroposition of the lips was evaluated.

RESULTS

Out of 144 patients with extracted bicuspids, eight Class I patients, nine Class II patients and five Class III patients were seeking treatment because their lips had retruded as a consequence of compensating orthodontic treatment. Lower jaw bicuspid extraction and a decreased vertical facial height in Class II patients correlated significantly more with IRLS development. Postoperative cephalometric analysis of orthodontic-orthognathic treated patients reported improvement in lip projection and naso-labial angle. Only two Class I patients reported postoperative normalization of the lip position according to Legan and Burstone.

CONCLUSION

The consequence of bicuspid extractions on soft tissue profile differs according to skeletal jaw relation. The impact of orthognathic surgery on IRLS is beneficial, although insufficient to completely correct the facial profile when judged on cephalometric standards.

PRECISION: the Belgian molecular profiling program of metastatic cancer for clinical decision and treatment assignment

PRECISION is an initiative from the Belgian Society of Medical Oncology (BSMO) in collaboration with several stakeholders, encompassing four programs that aim to boost genomic and clinical knowledge with the ultimate goal to offer patients with metastatic solid tumors molecularly guided treatments. The PRECISION 1 study has led to the creation of a clinico-genomic database. The Belgian Approach for Local Laboratory Extensive Tumor Testing (BALLETT) and GeNeo studies will increase the number of patients with advanced cancer that have comprehensive genotyping of their cancer. The PRECISION 2 project consists of investigator-initiated phase II studies aiming to provide access to a targeted drug for patients whose tumors harbor actionable mutations in case the matched drug is not available through reimbursement or clinical trials in Belgium.

Hepatitis of unknown aetiology in children - epidemiological overview of cases reported in Europe, 1 January to 16 June 2022

Following the report of an excess in paediatric cases of severe acute hepatitis of unknown aetiology by the United Kingdom (UK) on 5 April 2022, 427 cases were reported from 20 countries in the World Health Organization European Region to the European Surveillance System TESSy from 1 January 2022 to 16 June 2022. Here, we analysed demographic, epidemiological, clinical and microbiological data available in TESSy. Of the reported cases, 77.3% were 5 years or younger and 53.5% had a positive test for adenovirus, 10.4% had a positive RT-PCR for SARS-CoV-2 and 10.3% were coinfected with both pathogens. Cases with adenovirus infections were significantly more likely to be admitted to intensive care or high-dependency units (OR = 2.11; 95% CI: 1.18–3.74) and transplanted (OR = 3.36; 95% CI: 1.19–9.55) than cases with a negative test result for adenovirus, but this was no longer observed when looking at this association separately between the UK and other countries. Aetiological studies are needed to ascertain if adenovirus plays a role in this possible emergence of hepatitis cases in children and, if confirmed, the mechanisms that could be involved.

ESMO Congress 2021: highlights from the EORTC gastrointestinal tract cancer group's perspective

There has been no major change of practice in gastrointestinal oncology at the European Society for Medical Oncology (ESMO) symposium 2021, but confirmation that immunotherapy in combination with chemotherapy has become standard of care in several indications. The European Organisation for Research and Treatment of Cancer (EORTC) Gastrointestinal Track Cancer Group has selected important phase II and III trials presented during the symposium across all gastrointestinal cancers as well as early reports on new drugs or new combinations that may change practice in the future.

Educational level, attention problems, and externalizing behaviour in adolescence and early adulthood

Background

Social causation as well as health-related selection may contribute to educational gradients in adolescents' attention problems (AP) and externalizing behaviour (EB). From past studies it is unclear which of these mechanisms predominates, as AP and EB have the potential to disrupt adolescents' educational careers, but may also be affected by differences in their social environment. Furthermore, gradients in AP and EB may reflect ‘third variables' already present in childhood, such as parental socioeconomic status (SES) and IQ. We investigated social causation and health-related selection in the development of educational differences in EB and AP.

Methods

We used data from a Dutch population-based cohort (TRAILS Study; n = 2,229), including measurements of educational level, EB, and AP at ages around 14, 16, 19, 22, and 26 years. First, we evaluated the directionality in longitudinal associations between education, EB, and AP with cross-lagged panel models, with and without adjusting for pre-existing individual differences using fixed effects. Second, we assessed the role of parental SES and IQ in childhood both as confounders in longitudinal associations, and as predictors of AP, EB, and educational level around age 14.

Results

In fixed effects models, AP, but not EB, consistently predicted decreases in educational level throughout all of adolescence and young adulthood. Regarding social causation, differences in parental SES contributed to increases in EB amongst the lower educational tracks in mid-adolescence. Childhood IQ and parental SES strongly predicted education around age 14. Parental SES, but not IQ, also predicted early adolescent AP and EB.

Conclusions

We found health-related selection attributable to AP throughout all phases of adolescence and young adulthood. Further, our results highlight the role of social causation from parental SES in determining adolescent educational level, AP, and EB.

Key messages

AP have the potential to negatively impact adolescents’ educational careers and may trigger downward mobility in the educational system in all phases of adolescence and young adulthood. The results of this study call for actions to reduce the impact of AP on education. Further, it is essential to address the effects of insufficient economic resources on education and mental health.

Factors associated with organized and non-organized colorectal cancer screening

Background

Data on non-organized colorectal cancer screening using fecal occult blood tests (FOBTs) is currently lacking. We identified factors associated with organized and non-organized FOBT screening.

Methods

Data of 308 municipalities in Flanders (6.6 million residents, 57% of Belgium) during 2015-2017 were analyzed. Logistic regression with generalized estimating equations was used to assess associations between municipal characteristics and organized and non-organized screening coverages.

Results

Median organized screening coverage increased (36.4% to 40.1%) while non-organized screening coverage decreased (4.8% to 3.3%) in 2015-2017. Organized screening coverage was negatively associated with average income (OR = 0.97, 95%CI: 0.96-0.98) and percentage of people with a non-Belgian/Dutch nationality (OR = 0.962, 95%CI: 0.957-0.967). More older people (70-74) in the target screening population were related to lower coverages by both organized (OR = 0.98, 95%CI: 0.97-0.99) and non-organized screening (OR = 0.98, 95%CI: 0.96-0.999). Education level was positively associated with organized screening coverage (OR = 1.010, 95%CI: 1.008-1.011). While GP visit was positively associated with both organized and non-organized screening coverages, average number of patients per GP and having a global medical dossier handled by preferred GP showed more pronounced associations with non-organized screening (OR = 1.021, 95%CI: 1.016-1.026 and OR = 1.025, 95%CI: 1.018-1.031, respectively) compared to organized screening coverage.

Conclusions

Higher average income, lower average education level, more older people and people with foreign nationality were associated with lower organized screening coverage. GP involvement showed a positive association with non-organized screening. It seems that some GPs and screening-invited individuals are still not fully aware of the benefits of organized screening. Available instruments in screening programs should be optimized to fill this gap in knowledge.

Key messages

We identified factors associated with both organized and non-organized colorectal cancer screening using fecal occult blood tests (FOBTs). Based on this knowledge, strategies can be developed to promote screening among non-participants and encourage non-organized participants to switch to organized screening.

Reduced humoral immune response after BNT162b2 coronavirus disease 2019 messenger RNA vaccination in cancer patients under antineoplastic treatment

Background

Cancer patients are at a higher risk of developing severe coronavirus disease 2019 (COVID-19). However, the safety and efficacy of COVID-19 vaccination in cancer patients undergoing treatment remain unclear.

Patients and methods

In this interventional prospective multicohort study, priming and booster doses of the BNT162b2 COVID-19 vaccine were administered 21 days apart to solid tumor patients receiving chemotherapy, immunotherapy, targeted or hormonal therapy, and patients with a hematologic malignancy receiving rituximab or after allogeneic hematopoietic stem cell transplantation. Vaccine safety and efficacy (until 3 months post-booster) were assessed. Anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) receptor-binding domain (RBD) antibody levels were followed over time (until 28 days after the booster) and in vitro SARS-CoV-2 50% neutralization titers (NT50) toward the wild-type Wuhan strain were analyzed 28 days after the booster.

Results

Local and systemic adverse events (AEs) were mostly mild to moderate (only 1%-3% of patients experienced severe AEs). Local, but not systemic, AEs occurred more frequently after the booster dose. Twenty-eight days after the booster vaccination of 197 cancer patients, RBD-binding antibody titers and NT50 were lower in the chemotherapy group {234.05 IU/ml [95% confidence interval (CI) 122.10-448.66] and 24.54 (95% CI 14.50-41.52), respectively} compared with healthy individuals [1844.93 IU/ml (95% CI 1383.57-2460.14) and 122.63 (95% CI 76.85-195.67), respectively], irrespective of timing of vaccination during chemotherapy cycles. Extremely low antibody responses were seen in hematology patients receiving rituximab; only two patients had RBD-binding antibody titers necessary for 50% protection against symptomatic SARS-CoV-2 infection (<200 IU/ml) and only one had NT50 above the limit of detection. During the study period, five cancer patients tested positive for SARS-CoV-2 infection, including a case of severe COVID-19 in a patient receiving rituximab, resulting in a 2-week hospital admission.

Conclusion

The BNT162b2 vaccine is well-tolerated in cancer patients under active treatment. However, the antibody response of immunized cancer patients was delayed and diminished, mainly in patients receiving chemotherapy or rituximab, resulting in breakthrough infections.

•

The BNT162b2 vaccine is well-tolerated in cancer patients, including patients under immunotherapy.

•

Full BNT162b2 vaccination results in a blunted humoral immune response in cancer patients under active treatment.

•

The humoral immune response after BNT162b2 vaccination varies between different antineoplastic treatments.

•

Two doses of BNT162b2 vaccination may insufficiently protect patients receiving chemotherapy or rituximab against SARS-CoV-2.

Clinical implications of isolated troponinemia following immune checkpoint inhibitor therapy

Cardiovascular adverse events induced by immune checkpoint inhibitors (ICIs) have gained significant interest over the past decade due to their impact on short- and long-term outcomes. They were initially thought to be rare, but the increasing use of ICIs in the treatment of both advanced and early stages of various malignancies has resulted in a substantial increase in their incidence. Different guidelines have proposed screening measures for ICI-induced myocarditis by incorporating troponin measurements at baseline and during the first few weeks of treatment. However, no specific guidelines have been developed yet regarding the interpretation of an asymptomatic rise in troponins. This state-of-the art review aims to provide an overview of the clinical relevance of elevated troponins during checkpoint inhibition and recommendations on how to manage elevated troponin levels during ICI therapy.

Soil-transmitted helminth infections in free-ranging non-human primates from Cameroon and Gabon

BACKGROUND

Zoonotic diseases are a serious threat to both public health and animal conservation. Most non-human primates (NHP) are facing the threat of forest loss and fragmentation and are increasingly living in closer spatial proximity to humans. Humans are infected with soil-transmitted helminths (STH) at a high prevalence, and bidirectional infection with NHP has been observed. The aim of this study was to determine the prevalence, genetic diversity, distribution and presence of co-infections of STH in free-ranging gorillas, chimpanzees and other NHP species, and to determine the potential role of these NHP as reservoir hosts contributing to the environmental sustenance of zoonotic nematode infections in forested areas of Cameroon and Gabon.

METHODS

A total of 315 faecal samples from six species of NHPs were analysed. We performed PCR amplification, sequencing and maximum likelihood analysis of DNA fragments of the internal transcribed spacer 2 (ITS2) nuclear ribosomal DNA to detect the presence and determine the genetic diversity of Oesophagostomum spp., Necator spp. and Trichuris spp., and of targeted DNA fragments of the internal transcribed spacer 1 (ITS1) to detect the presence of Ascaris spp.

RESULTS

Necator spp. infections were most common in gorillas (35 of 65 individuals), but also present in chimpanzees (100 of 222 individuals) and in one of four samples from greater spot-nosed monkeys. These clustered with previously described type II and III Necator spp. Gorillas were also the most infected NHP with Oesophagostomum (51/65 individuals), followed by chimpanzees (157/222 individuals), mandrills (8/12 samples) and mangabeys (7/12 samples), with O. stephanostomum being the most prevalent species. Oesophagostomum bifurcum was detected in chimpanzees and a red-capped mangabey, and a non-classified Oesophagostomum species was detected in a mandrill and a red-capped mangabey. In addition, Ternidens deminutus was detected in samples from one chimpanzee and three greater spot-nosed monkeys. A significant relative overabundance of co-infections with Necator and Oesophagostomum was observed in chimpanzees and gorillas. Trichuris sp. was detected at low prevalence in a gorilla, a chimpanzee and a greater spot-nosed monkey. No Ascaris was observed in any of the samples analysed.

CONCLUSIONS

Our results on STH prevalence and genetic diversity in NHP from Cameroon and Gabon corroborate those obtained from other wild NHP populations in other African countries. Future research should focus on better identifying, at a molecular level, the species of Necator and Oesophagostomum infecting NHP and determining how human populations may be affected by increased proximity resulting from encroachment into sylvatic STH reservoir habitats.

Neutropenia and survival outcomes in metastatic colorectal cancer patients treated with trifluridine/tipiracil in the RECOURSE and J003 trials

Background:

The phase II J003 (N = 169) and phase III RECOURSE (N = 800) trials demonstrated a significant improvement in survival with trifluridine (FTD)/tipiracil (TPI) versus placebo in patients with refractory metastatic colorectal cancer. This post hoc analysis investigated pharmacokinetic data of FTD/TPI exposure and pharmacodynamic markers, such as chemotherapy-induced neutropenia (CIN) and clinical outcomes.

Patients and methods:

A total of 210 patients from RECOURSE were enrolled in this substudy. A limited sampling approach was used, with three pharmacokinetic samples drawn on day 12 of cycle 1. Patients were categorized as being above or below the median area under the plasma concentration–time curve (AUC) for FTD and TPI. We conducted a post hoc analysis using the entire RECOURSE population to determine the correlations between CIN and clinical outcome. We then carried out a similar analysis on the J003 trial to validate the results.

Results:

In the RECOURSE subset, patients in the high FTD AUC group had a significantly increased CIN risk. Analyses of the entire population demonstrated that FTD/TPI-treated patients with CIN of any grade in cycles 1 and 2 had significantly longer median overall survival (OS) and progression-free survival (PFS) than patients who did not develop CIN and patients in the placebo group. Patients who required an FTD/TPI treatment delay had increased OS and PFS versus those in the placebo group and those who did not develop CIN. Similar results were obtained in the J003 cohort.

Conclusions:

In RECOURSE, patients with higher FTD drug exposure had an increased CIN risk. FTD/TPI-treated patients who developed CIN had improved OS and PFS versus those in the placebo group and those who did not develop CIN. Similar findings were reported in the J003 cohort, thus validating the RECOURSE results. The occurrence of CIN may be a useful predictor of treatment outcomes for FTD/TPI-treated patients.

ClinicalTrials.gov identifier:

NCT01607957 (RECOURSE).

Japan Pharmaceutical Information Center number:

JapicCTI-090880 (J003).

Testing sampling bias in estimates of adolescent social competence and behavioral control

In 5 of the 6 large Dutch developmental cohorts investigated here, lower SES adolescents are underrepresented and higher SES adolescents overrepresented. With former studies clearly revealing differences between SES strata in adolescent social competence and behavioral control, this misrepresentation may contribute to an overestimation of normative adolescent competence. Using a raking procedure, we used national census statistics to weigh the cohorts to be more representative of the Dutch population. Contrary to our expectations, in all cohorts, little to no differences between SES strata were found in the two outcomes. Accordingly, no differences between weighted and unweighted mean scores were observed across all cohorts. Furthermore, no clear change in correlations between social competence and behavioral control was found. These findings are most probably explained by the fact that measures of SES in the samples were quite limited, and the low SES participants in the cohorts could not be considered as representative of the low SES groups in the general population. Developmental outcomes associated with SES may be affected by a raking procedure in other cohorts that have a sufficient number and sufficient variation of low SES adolescents.

Education and alcohol use in adolescence – The role of social causation and health-related selection

Background

Both social causation and health-related selection may influence educational gradients in alcohol use in adolescence. From past studies it is unclear which of these mechanisms predominates, as drinking may be both a cause and consequence of low educational attainment. Furthermore, gradients in alcohol use may reflect 'third variables' already present in childhood, such as parental socioeconomic status (SES), effortful control, and IQ. We investigated social causation and health-related selection in the development of educational gradients in alcohol use.

Methods

We used data from a Dutch population-based cohort (TRAILS Study; n = 2,229), including measurements of educational level and drinking at ages around 14, 16, 19, 22, and 26 years. First, we evaluated the directionality in longitudinal associations between education and alcohol use with cross-lagged panel models, with and without adjusting for pre-existing individual differences using fixed effects. Second, we assessed the role of childhood characteristics around age 11, i.e. IQ, effortful control, and parental SES, both as confounders in these longitudinal associations, and as predictors of educational level and drinking around age 14.

Results

In fixed effects models, lower education at age 14 strongly predicted increases in drinking at 16. From age 19 onward, we found a non-significant tendency towards opposite associations, with higher education predicting increases in alcohol use. Alcohol use was not associated with subsequent changes in education. All childhood characteristics strongly predicted education around age 14 and, to a lesser extent, early drinking.

Conclusions

We found conclusive evidence for social causation from education to alcohol use in early adolescence only, and no evidence for selection attributable to alcohol use. By determining initial educational level, childhood characteristics also predict subsequent trajectories in alcohol use.

Key messages

Our findings illustrate the importance of social causation in relation to alcohol use in early adolescence, while no support was found for health-related selection from alcohol use to education. Parental SES, effortful control, and IQ in childhood strongly predicted educational level in early adolescence, which subsequently predicted trajectories in alcohol use during adolescence.

Thermistors coated with molecularly imprinted nanoparticles for the electrical detection of peptides and proteins

In this communication, molecularly imprinted nanoparticles (nanoMIPs) that are produced by solid-phase synthesis are functionalised onto thermistors via dip-coating. These thermistors are soldered onto a printed-circuit board to facilitate electrical detection. Subsequently, these are inserted into a home-made thermal device that can measure the selective binding of biomolecules to the nanoMIP layer via monitoring the thermal resistance (R_th) at the solid-liquid interface. This thermal analysis technique, referred to as the Heat-Transfer Method, has previously been used for detection of proteins with MIP-based binders. While offering the advantages of low-cost and label free analysis, this method is limited by the high noise on the feedback loop and not being commercially available. These disadvantages can be overcome by the use of thermistors, which offer superior temperature sensitivity compared to thermocouples, and its electrical read-out can be easily integrated into portable devices. To our knowledge, this is the first report where MIPs are directly integrated onto thermistors for detection purposes. Measurements were conducted with an epitope of epidermal growth factor receptor (EGFR) and trypsin, where the electrical resistance was correlated to the biomolecule concentration. For both EGFR and trypsin, an enhanced signal to noise ratio for the electrical measurements was observed compared to previous analysis that was based on thermal resistance. The sensitivity of the sensors in buffered solution was in the nanomolar range, which is compatible with physiologically relevant concentrations. Upon exposure of the nanoMIP for EGFR towards pepsin no significant change in the resistance was yielded, establishing the selectivity of the developed sensor platform. Besides the enhanced sensitivity, the use of thermistors will enable miniaturisation of the device and has potential for in vivo measurements since specified electrochemical measurements are compatible with human use. To highlight the versatility of the nanoMIPs, this work should be extended to a set of biomolecules with various structures, with the possibility of extending this to an array format.

Regorafenib after failure of gemcitabine and platinum-based chemotherapy for locally advanced/metastatic biliary tumors: REACHIN, a randomized, double-blind, phase II trial

BACKGROUND

There is a high unmet clinical need for treatments of advanced/metastatic biliary tract cancers after progression on first-line chemotherapy. Regorafenib has demonstrated efficacy in some gastrointestinal tumors that progress on standard therapies.

PATIENTS AND METHODS

REACHIN was a multicenter, double-blind, placebo-controlled, randomized phase II study designed to evaluate the safety and efficacy of regorafenib in patients with nonresectable/metastatic biliary tract cancer that progressed after gemcitabine/platinum chemotherapy. Patients were randomly assigned 1 : 1 to best supportive care plus either regorafenib 160 mg once daily 3 weeks on/1 week off or placebo until progression or unacceptable toxicity. No crossover was allowed. The primary objective was progression-free survival (PFS). Secondary objectives were response rate, overall survival, and translational analysis.

RESULTS

Sixty-six patients with intrahepatic (n = 42), perihilar (n = 6), or extrahepatic (n = 9) cholangiocarcinoma, or gallbladder carcinoma (n = 9) were randomized, 33 to each treatment group (33 per group). At a median follow-up of 24 months, all patients had progressed and six patients were alive. Median treatment duration was 11.0 weeks [95% confidence interval (CI): 6.0-15.9] in the regorafenib group and 6.3 weeks (95% CI: 3.9-7.0) in the placebo group (P = 0.002). Fourteen of 33 patients (42%) in the regorafenib group had a dose reduction. Stable disease rates were 74% (95% CI: 59-90) in the regorafenib group and 34% with placebo (95% CI: 18-51; P = 0.002). Median PFS in the regorafenib group was 3.0 months (95% CI: 2.3-4.9) and 1.5 months (95% CI: 1.2-2.0) in the placebo group (hazard ratio 0.49; 95% CI: 0.29-0.81; P = 0.004) and median overall survival was 5.3 months (95% CI: 2.7-10.5) and 5.1 months (95% CI: 3.0-6.4), respectively (P = 0.28). There were no unexpected/new safety signals.

CONCLUSION

Regorafenib significantly improved PFS and tumor control in patients with previously treated metastatic/unresectable biliary tract cancer in the second- or third-line setting.

CLINICAL TRIAL REGISTRATION

The trial is registered in the European Clinical Trials Register database (EudraCT 2012-005626-30) and at ClinicalTrials.gov (NCT02162914).

Allogeneic chondrogenically differentiated human bone marrow stromal cells do not induce dendritic cell maturation

Bone marrow stromal cell (BMSC)‐mediated endochondral bone formation may be a promising alternative to the current gold standards of autologous bone transplantation, in the development of novel methods for bone repair. Implantation of chondrogenically differentiated BMSCs leads to bone formation in vivo via endochondral ossification. The success of this bone formation in an allogeneic system depends upon the interaction between the implanted constructs and the host immune system. The current study investigated the effect of chondrogenically differentiated human bone marrow stromal cell (hBMSC) pellets on the maturation and function of dendritic cells (DCs) by directly coculturing bone forming chondrogenic hBMSC pellets and immature or lipopolysaccharide (LPS)‐matured DCs in vitro. Allogeneic chondrogenic hBMSC pellets did not affect the expression of CD80, CD86, or HLADR on immature or LPS‐matured DCs following 24, 48, or 72 hr of coculture. Furthermore, they did not induce or inhibit antigen uptake or migration of the DCs over time. IL‐6 was secreted by allogeneic chondrogenic hBMSC pellets in response to LPS‐matured DCs. Overall, this study has demonstrated that maturation of immature DCs was not influenced by allogeneic chondrogenic hBMSC pellets. This suggests that allogeneic chondrogenic hBMSC pellets do not stimulate immunogenic responses from DCs in vitro and are not expected to indirectly activate T cells via DCs. For this reason, allogeneic chondrogenic bone marrow stromal cell pellets are promising candidates for future tissue engineering strategies utilising allogeneic cells for bone repair.

Key components of international and European governance for quality of care

The legal status and binding nature of various international governance and guidance instruments to foster and support quality strategies in European countries differs substantially. This presentation introduces and discusses the four main elements of an integrated international governance framework for quality in health care: i) raising political awareness of the relevance of health care quality and creating a common vision on how to improve it; ii) implementing this vision into actual policy frameworks by sharing experience and practice between countries; iii) developing and providing standards and models (voluntary or mandatory) that can be transposed into national policy; iv) measuring, assessing and comparing quality by developing better information, better indicators and methodologies as well as dissemination strategies.

The presentation will also focus on how quality in health care is addressed through EU policy, first through EU provisions and policies that are meant to ensure free movement of citizens and goods and establish an internal market, and by means of more horizontal and generic EU policies on quality and safety that stem from the mandate to support, coordinate or supplement national policies. It will further highlight how EU integration and policy touch upon quality in health care and how the approach has evolved over time.

A10 Presence and frequency of M184V mutation in the MOBIDIP trial

The MOBIDIP trial evaluated the simplification by protease (PI/r) monotherapy for HIV infection versus dual therapy and boosted protease inhibitor plus lamivudine (PI/r + 3TC) in controlled patients under second-line regimens. MOBIDIP was interrupted because of a significant number of patients with virological failure (VF) at week 48 (W48) in PI/r (33/133, ∼25%) versus in PI/r + 3TC (4/132, ∼3%). At the time of first-line VF, 96 per cent of patients harbored the M184V mutation. The presence of the M184V mutation was related to a protective effect against VF in the PI/r + 3TC arm. We developed a methodology that allows to determine the frequency of M184V/I mutations in the HIV reverse transcriptase (RT) gene in peripheral blood mononuclear cells (PBMC) obtained before MOBIDIP simplification. Paired-end sequences were obtained from 252 PBMC samples covering the first 855 bp of the RT gene (HXB2: 2485–3405) by MiSeq technology. These sequences were subjected to an in-house Bioinformatics pipeline. The results of our pipeline were compared to the output of PASeq (https://www.paseq.org), an open web-tool for the identification of drug resistance mutations. The M184V mutation was identified at a frequency greater than 1 per cent in 178 individuals (∼71%). The M184I mutation was observed in 34 patients (∼13%), always in the presence of stop codons, and is in agreement with expectations, as this mutation is a known APOBEC-targeted site. Sixty-seven patients (∼27%) had a frequency of the M184V mutation with values greater than 75 per cent. PASeq confirmed the presence of M184V mutation in 173 patients. The frequencies estimated by the PASeq tool and in-house pipeline were correlated up to 99.5 per cent. We found a significant loss of the M184V mutation archived in PBMC between the first-line regimen treatment failure and the beginning of the MOBIDIP trial. In patients under long-term antiretroviral therapy, as in our case, viral sub-populations could be lost, reducing the presence, and frequency of a mutation. In the next step, we will evaluate the association between the presence and frequency of M184V mutation and MOBIDIP results.

Hotspot DAXX, PTCH2 and CYFIP2 mutations in pancreatic neuroendocrine neoplasms

Mutations in DAXX/ATRX, MEN1 and genes involved in the phosphoinositide-3-kinase/Akt/mammalian target of rapamycin (PI3K/Akt/mTOR) pathway have been implicated in pancreatic neuroendocrine neoplasms (pNENs). However, mainly mutations present in the majority of tumor cells have been identified, while proliferation-driving mutations could be present only in small fractions of the tumor. This study aims to identify high- and low-abundance mutations in pNENs using ultra-deep targeted resequencing. Formalin-fixed paraffin-embedded matched tumor-normal tissue of 38 well-differentiated pNENs was sequenced using a HaloPlex targeted resequencing panel. Novel amplicon-based algorithms were used to identify both single nucleotide variants (SNVs) and insertion-deletions (indels) present in >10% of reads (high abundance) and in <10% of reads (low abundance). Found variants were validated by Sanger sequencing. Sequencing resulted in 416,711,794 reads with an average target base coverage of 2663 ± 1476. Across all samples, 32 high-abundance somatic, 3 germline and 30 low-abundance mutations were withheld after filtering and validation. Overall, 92% of high-abundance and 84% of low-abundance mutations were predicted to be protein damaging. Frequently, mutated genes were MEN1, DAXX, ATRX, TSC2, PI3K/Akt/mTOR and MAPK-ERK pathway-related genes. Additionally, recurrent alterations on the same genomic position, so-called hotspot mutations, were found in DAXX, PTCH2 and CYFIP2. This first ultra-deep sequencing study highlighted genetic intra-tumor heterogeneity in pNEN, by the presence of low-abundance mutations. The importance of the ATRX/DAXX pathway was confirmed by the first-ever pNEN-specific protein-damaging hotspot mutation in DAXX. In this study, both novel genes, including the pro-apoptotic CYFIP2 gene and hedgehog signaling PTCH2, and novel pathways, such as the MAPK-ERK pathway, were implicated in pNEN.

Early changes in the extracellular matrix of the degenerating intervertebral disc, assessed by Fourier transform infrared imaging

OBJECTIVE

Mechanical overloading induces a degenerative cell response in the intervertebral disc. However, early changes in the extracellular matrix (ECM) are challenging to assess with conventional techniques. Fourier Transform Infrared (FTIR) imaging allows visualization and quantification of the ECM. We aim to identify markers for disc degeneration and apply these to investigate early degenerative changes due to overloading and katabolic cell activity.

DESIGN

Three experiments were conducted; Exp 1.: In vivo, lumbar spines of seven goats were operated: one disc was injected with chondroitinase ABC [cABC (mild degeneration)] and compared to the adjacent disc (control) after 24 weeks. Exp 2a: Ex vivo, caprine discs received physiological loading (n = 10) or overloading (n = 10) in a bioreactor. Exp 2b: Cell activity was diminished prior to testing by freeze-thaw cycles, 18 discs were then tested as in Exp 2a. In all experiments, FTIR images (spectral region: 1000-1300 cm^-1) of mid-sagittal slices were analyzed using multivariate curve resolution.

RESULTS

In vivo, FTIR was more sensitive than biochemical and histological analysis in identifying reduced proteoglycan content (P = 0.046) and increased collagen content in degenerated discs (P < 0.01). Notably, FTIR analysis additionally showed disorganization of the ECM, indicated by increased collagen entropy (P = 0.011). Ex vivo, the proteoglycan/collagen ratio decreased due to overloading (P = 0.047) and collagen entropy increased (P = 0.047). Cell activity affected collagen content only (P = 0.044).

CONCLUSION

FTIR imaging allows a more detailed investigation of early disc degeneration than traditional measures. Changes due to mild overloading could be assessed and quantified. Matrix remodeling is the first detectable step towards intervertebral disc degeneration.

Engineering molecularly imprinted polymers (MIPs) for the selective extraction and quantification of the novel psychoactive substance (NPS) methoxphenidine and its regioisomers

In this communication, we present the first developed Molecularly Imprinted Polymers (MIPs) for the specific detection of a New Psychoactive Substance (NPS); namely, methoxphenidine (MXP) and its regioisomers. Selectivity of the MIP towards MXP is studied by analysing mixtures and an acquired street sample with High Performance Liquid Chromatography coupled to UV detection. The study demonstrates that the engineered polymers selectively extract MXP from heterogeneous samples, which makes for a very powerful diagnostic tool that can detect traces of MXP in complicated NPS samples.