Cellular and humoral immunogenicity of the COVID-19 vaccine and COVID-19 disease severity in individuals with immunodeficiency

Background

A well-coordinated adaptive immune response is crucial for limiting COVID-19 disease. Some individuals with immunodeficiency are at a high risk of developing severe COVID-19. Therefore, the development of standardized methods for measuring different arms of the vaccine response in the setting of immunodeficiency is of particular interest. In this study, we compared the vaccine response of individuals living with immunodeficiency with healthy controls in terms of interferon gamma (IFN-γ) production and spike protein-specific antibody level post primary COVID-19 vaccination and booster vaccines. Additionally, the disease severity of those individuals who contracted COVID-19 was assessed.

Methods

Whole blood was stimulated overnight from 71 participants and 99 healthy controls. Commercially available PepTivator^® peptide pool and trimeric spike protein stimulation were used. ELISA was used to analyze IFN-γ levels. The total SARS-CoV-2 spike protein antibody titre was measured using a Roche Elecsys^® S total antibody assay. Patient characteristics, COVID-19 infection status and IDDA 2.1 'Kaleidoscope' scores were recorded. Vaccine responses were scored from zero to three.

Results

99% of healthy controls, 89% of individuals with IEI and 76% with secondary immunodeficiency (SID) had an IFN-γ level above the validated reference range after peptide mix stimulation following primary vaccination. There was an increase in IFN-γ levels in patients with inborn errors of immunity (IEI) following the booster vaccine (p = 0.0156). 100% of healthy controls, 70% of individuals living with IEI and 64% of individuals living with SID had detectable spike protein-specific antibody levels following the primary vaccination. 55% of immunodeficiency patients who had mild COVID-19 and 10% with moderate/severe COVID-19 had detectable antibody and IFN-γ levels post vaccine. The mean pre-infection IDDA 2.1 scores were higher in individuals who developed moderate/severe COVID-19 (25.2 compared to 9.41).

Conclusions

Covid whole-blood IGRA is a highly accurate, straightforward and robust assay and can be easily adapted to measure cellular response to COVID-19. A complete evaluation of the vaccine response may be particularly important for individuals living with immunodeficiency. A clinical immunodeficiency score and a validated vaccine response score may be valuable tools in estimating COVID-19 disease risk and identifying individuals living with immunodeficiency who may benefit from enhanced vaccination schedules.

Oro-Naso-Sino-Orbital-Cutaneous Fistula From Prolonged Cocaine Use

Presentation We present the case of a 48-year-old man with nasal cellulitis and subsequent oro-naso-sino-orbital-cutaneous fistula from prolonged cocaine use. Diagnosis Initial laboratory investigations reported a raised white cell count (WBC) and C-Reactive Protein (CRP) and subsequently a positive atypical anti-neutrophil cytoplasm antibodies (ANCA) and positive anti-proteinase (PR3). Perihilar lung nodularity on chest imaging raised the possibility of a systemic autoimmune response. His urinalysis was positive for cocaine. Treatment He was commenced on Augmentin, Amphotericin B and Prednisolone. An obturator was created to manage the oro-nasal fistula. A subsequent naso-cutaneous defect was re-approximated. Daily nasal saline douche and abstinence of cocaine were recommended. Discussion Cocaine use in the community is rising and poses a challenge to multiple facets of our health care system.

42 EXPLORING THE IMPACT OF AGE AND FRAILTY STATUS ON THE IMMUNE RESPONSE TO COVID-19 ILLNESS USING DETAILED IMMUNO-PHENOTYPING

Background

Methods

Results

Conclusion

A Comparison of the Performance of SARS-CoV-2 Antibody Assays in Healthcare Workers with COVID-19

Aims Since its emergence, significant interest surrounds the use of SARS-CoV-2 serological tests as an alternative or as an adjunct to molecular testing. However, given the speed of this pandemic, paralleled with the pressure to develop and provide serological tests in an expediated manner, not every assay has undergone the rigorous evaluation that is usually associated with medical diagnostic assays. We aimed to examine the performance of several commercially available SARS-CoV-2 IgG antibody assays among participants with confirmed COVID-19 disease and negative controls. Methods Serum taken between day 17 and day 40 post onset of symptoms from 41 healthcare workers with RT-PCR confirmed COVID-19 disease, and pre-pandemic serum from 20 negative controls, were tested for the presence of SARS-CoV-2 IgG using 7 different assays including point-of-care (POC) and laboratory-based assays. Results Assay performance varied. The lab-based Abbott diagnostics SARS-CoV-2 IgG assay proved to be the assay with the best positive and negative predictive value, and overall accuracy. The POC Nal von Minden GmbH and Biozek assays also performed well. Conclusion Our research demonstrates the variations in performance of several commercially available SARS-CoV-2 antibody assays. These findings identify the limitations of some serological tests for SARS-CoV-2. This information will help inform test selection and may have particular relevance to providers operating beyond accredited laboratories.

AB0404 EXTENDED MYOSITIS PANEL AND THE CLINICAL ASSOCIATION IN PATIENT WITH SUSPECTED INFLAMMATORY DISEASE, A RETROSPECTIVE STUDY

Background:

The idiopathic inflammatory myopathies (IIMs) are a heterogeneous group of conditions characterized by proximal muscle weakness. Autoantibodies are identified in more than 80% of patients with polymyositis (PM) or dermatomyositis (DM). Some are also found in other connective tissue diseases (CTD), while others are more specific to IIM. Thus, they are classified into two categories named myositis associated antibodies (MAA) and myositis specific antibodies (MSA). MSA have been reported as being 90% specific for IIM while MAA are found in up to 50% of myositis patients. 1

Objectives:

The aim of the study was to evaluate the myositis antibody prevalence and to assess the associations of these antibodies with clinical manifestations, final diagnosis, medication received and outcomes.

Methods:

A retrospective chart review study was conducted at St. James’s Hospital from 2015-2020. All positive myositis panels were obtained. The MAA evaluated were PMScl (100/75), U1snRNP, Ku and Ro52, while MSA were Mi2a, Mi2b, TIF1, MDA5, NXP2, SAE1, Jo-1, SRP, PL-7, PL-12, EJ and OJ.

Results:

We identified 52 patients who were positive for one or more MSA/MAAs. The mean age was 58.9 years, the majority were female (65.3%).The most prevalent MAA was anti-Ro52 (29/52) followed by anti-PMScl 100/75 (7/52), anti-Ku and anti-U1RNP were seen in (3/52) each. The prevalence of MSA were (4/52) for anti-PL12 and (3/52) for anti-SAE1 followed by (2/52) for each of anti-Mi2b, anti-NXP2, anti-Jo, anti-SRP, anti-PL7, anti-EJ and anti-OJ while only (1/52) for anti-MDA5. The most common observed clinical phenotypes in our cohort were arthralgia (20/52), ILD (18/52) and cutaneous manifestations (15/52). Less than a quarter of the studied population had arthritis (8/52), myositis (7/52), raynauds (7/52) and malignancy (4/52). Various diagnosis were allocated for these patients, while only eight cases were diagnosed with dermatomyositis. Medication received and the final outcome for those with strong positive MSA were summarized in table1.

Conclusion:

IIM was the final diagnosis in only 15% of positive myositis panels and the presence of antisynthetase antibodies didn’t necessarily indicate the presence of antisynthetase syndrome thus signifying low specificity in our cohort.

References:

[1]Ghirardello A, Borella E, Beggio M, Franceschini F, Fredi M, Doria A. Myositis autoantibodies and clinical phenotypes. Auto Immun Highlights. 2014;5(3):69-75. Published 2014 Aug 23.

IIMMAAMSAILDArthritisArthralgiaMyositisRaynaudsCutanousMalignancyFinal diagnosisTreatment OutcomeNXP2++DermatomyositisMyasthenia gravisPrednisolone + IVIG Remission/stable+Azathioprine +pyridostigmineMDA5++Amyopathic dermatomyositisPrednisolone + MTX Remission/stableSAE1++DermatomyositisPrednisolone + MTX Remission/stableILDPL12+IPFNo medication Remission/stableRo52PL12+IPFPrednisolone DiedSAE1/OJ+IPFNo medication Lost follow-upEJ+IPFNo medication Remission/stablePL12+Interstitial pneumonia with autoimmune feature (IPAF)Under evaluation Remission/stableRo52PL7+++++Anti-synthetase syndromePrednisolone +cyclophosphamide Remission/stablethen azathioprinePL7++Anti-synthetase syndromePrednisolone + Remission/stableRituximabJO-1++Anti-synthetase syndromeNo medication Remission/stableRo52JO-1+Anti-synthetase syndromePrednisolone + MMF Remission/stablethen rituximabCTDSAE1/SRP++Progressive pulmonary fibrosis (post COVID, ARDS and recurrent aspiration)Esophageal Ca T1N2M0 s/p esophagectomyAntibiotics +supportive care Remission/stableSRP++Limited cutaneous sclerodermaNifedipine Remission/stableRo52EJ+SjogrenHCQ Remission/stableOthersU1snRNP/ Ro52OJ++++MCTDAutoimmune hepatitisPrednisolone+ Remission/stableAzathioprine+HCQNXP2+Polymyalgia rheumaticaPrednisolone Remission/stablekuMi2b+large vessel vasculitisPrednisolone+ Remission/stableTocilizumabPL12+++PsAMTX Remission/stableMi2bPBCUrsodeoxycholic acid Remission/stable

Disclosure of Interests:

None declared

Leukocyte Adhesion Deficiency Type 1 Due to Novel ITGB2 Mutation

Aim Marked neutrophilia and omphalitis in an infant resulted in the diagnosis of the first case of leukocyte adhesion deficiency type 1 (LAD1) in Ireland. Diagnosis LAD1 requires specific molecular diagnostics for its correct identification. Results Early identification of this disorder allowed for rapid referral for haemotopoeitic stem cell transplant which has resulted in an excellent outcome for this patient. Conclusion The identification of a previously unknown ITGB2 mutation resulting in LAD1 in Ireland should alert physicians to the diagnostic possibility of this extremely rare disorder.

Abstract P5-03-02: Pre-clinical investigation of PP2A inhibitor LB-100 in overcoming and preventing lapatinib resistance in HER2-positive breast cancer

Background: HER2-positive breast cancer (BC) accounts for approximately 15% of all BC. HER2-targeted therapies, such as trastuzumab and lapatinib, have significantly improved the outcome for these patients. However, HER2-targeted therapy resistance is a common clinical issue. We have previously shown that protein phosphatase 2A (PP2A) plays a role in mediating acquired lapatinib resistance in HER2-positive BC and that response to lapatinib is enhancedin vitroby the lab-grade PP2A inhibitor, okadaic acid. The aim of this study was to examine the in vitro and in vivo efficacy of LB-100, a PP2A inhibitor that has completed phase I clinical testing (NCT01837667), in models of HER2-positive BC with acquired resistance to lapatinib.

Methods: HER2-positiveSKBR3 and HCC1954 BC cell lines were treated with 250 nM or 1 μM lapatinib, respectively, for 6 months to generate lapatinib-resistant SKBR3-L and HCC1954-L cell lines. In vitro sensitivity to lapatinib and LB-100 was assessed by 2D acid phosphatase assay. Combination index (CI) values were generated to identify synergistic combinations. Propidium iodide staining was used to determine cell cycle arrest and apoptosis. In order to examine the in vivo efficacy of LB-100, HCC1954-L cells were implanted into the mammary fat pad of BALB/c nude mice and treated with vehicle, lapatinib, LB-100, or lapatinib plus LB-100. To examine the prevention of the development of lapatinib resistance, SKBR3 and HCC1954 cells were treated twice weekly with lapatinib, LB-100 or the combination and stained with crystal violet when confluent.

Results: SKBR3-L and HCC1954-L cells were resistant to lapatinib at clinically relevant concentrations (IC50values = 2.37 ± 0.58 μM and 1.67 ± 0.34 μM). This represents a 46- and 5.2-fold decrease in lapatinib sensitivity. LB-100 had a greater anti-proliferative effect in the lapatinib-resistant SKBR3-L and HCC1954-L cell lines compared to their respective parental cell lines (IC50values = 2.12 ± 0.2 μM v 5.38 ± 0.6 μM, and 2.31 ± 0.19 μM v 5.32 ± 0.82 μM, respectively). LB-100 overcame lapatinib resistance in both models, as lapatinib plus LB-100 was synergistic in both cell lines (CI values = 0.56 ± 0.13 and 0.68 ±0.26). LB-100 caused cell death through the induction of apoptosis in SKBR3- L (p = 0.019) and HCC1954-L (p = 0.046) and the addition of lapatinib to LB-100 increased apoptotic induction in HCC1954-L cells (p=0.046).Lapatinib plus LB-100 was well tolerated in vivo. The HCC1954-L cell line maintained resistance to lapatinib in vivo and the combination of lapatinib and LB-100 significantly reduced HCC1954-L tumour volume compared to all other treatment arms (p = 0.0006). Interestingly, in vitro short-term resistance assays showed that the addition of LB-100 to lapatinib could also block the emergence of lapatinib resistance in both parental SKBR3 and HCC1954 cell lines.

Conclusions: This study indicates that LB-100 has in vitro and in vivo efficacy against lapatinib-resistant HER2-positive BC cell line models and justifies further investigation into its potential to circumvent or prevent lapatinib resistance in HER2-positive BC.

Citation Format: Conlon N, McDermott M, Browne B, Roche S, O'Neill F, Meiller J, Browne A, Eustace A, Collins DM, O'Donovan N, Crown J. Pre-clinical investigation of PP2A inhibitor LB-100 in overcoming and preventing lapatinib resistance in HER2-positive breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-03-02.

Abstract P4-07-08: Budesonide and loperamide do not impact the cytotoxicity of neratinib or HER2-directed monoclonal antibodies in HER2+ breast cancer cell lines

Background: Neratinib is an irreversible pan-HER tyrosine kinase inhibitor with demonstrated clinical activity in HER2+ and HER2-mutated breast cancers. The main toxicity of neratinib is diarrhea, which is common in the absence of prophylaxis. Preclinical models suggest that neratinib-associated diarrhea may involve inflammatory, bile acid malabsorption and secretory factors. The phase II CONTROL study is currently investigating the prophylactic efficacy of the opioid receptor antagonist loperamide in combination with budesonide (a corticosteroid used for inflammatory gastrointestinal conditions) or colestipol (bile acid sequestrant) on neratinib-associated diarrhea in early-stage HER2+ breast cancer (NCT02400476). This in vitro study examines the impact of loperamide and budesonide on the anti-proliferative activity of neratinib or trastuzumab and pertuzumab in HER2+ or HER2-low breast cancer cell lines.

Methods: HER2+ breast cancer cell lines SKBR3 (estrogen receptor [ER]–), BT474 (ER+), HCC1569 (ER–) and HER2-low, pertuzumab-sensitive MDA-MB-175-VII (ER+) breast cancer cells were investigated using a 5-day acid phosphatase-based proliferation assay to determine the concentrations required to inhibit growth by 50% (IC50). Fixed ratios of drugs were utilised in combination assays to generate Combination Index (CI) values (Calcusyn®) where available. Clinically relevant levels of neratinib, trastuzumab and pertuzumab were utilised in all experiments. Physiologically relevant levels of budesonide (˜4.2 nM) and loperamide (˜2.5 nM) were exceeded to provide IC50 values for these compounds.

Results: All cell lines tested had neratinib IC50 values in the nM range (Table). Trastuzumab and the trastuzumab/pertuzumab combination did not exceed 50% inhibition in the HER2+ cell lines. In the HER2+ breast cancer cell lines tested, loperamide had no impact on neratinib activity in BT474, enhanced neratinib activity in SKBR3, and the combination of loperamide and neratinib proved synergistic in HCC1569 (CI = 0.77 +/– 0.2). Budesonide produced strong synergism in combination with neratinib in SKBR3 (CI = 0.27 +/– 0.03), had no impact on neratinib activity in BT474 and improved response to neratinib in HCC1569. Loperamide and budesonide improved the activity of trastuzumab and pertuzumab in all three HER2+ models tested, and had no impact on pertuzumab activity in MDA-MB-175-VII. Interestingly, neratinib proved synergistic in combination with pertuzumab in MDA-MB-175-VII (CI = 0.75 +/– 0.5 nM).

Table.Anti-proliferative effects of agents testedBreast cancer cell lineNeratinib IC50, nMLoperamide IC50, nMBudesonide IC50, nMPertuzumab IC50, nMTrastuzumab (% inhibition, 2.5μg/ml)Trastuzumab/Pertuzumab (% inhibition, 2.5μg/ml)SKBR32.8 +/– 0.47.7 +/– 0.52.7 +/– 0.2NA26.3 +/– 1.3NABT4741.4 +/– 0.12.6 +/– 0.27 +/– 0.6NA40.1 +/– 4.3NAHCC156917.3 +/– 0.79.3 +/– 1.728.7 +/– 0.5No effectNo effect26.1 +/– 2.8MDA-MB-175-VII3 +/– 0.3> 20> 201.2 +/– 0.2NANANA = not acquired.

Conclusions: Our preclinical results suggest that budesonide and loperamide do not antagonise the anti-proliferative activity of neratinib or HER2-directed monoclonal antibodies in HER2+ breast cancer cell lines.

Citation Format: Collins DM, Gaynor N, Conlon N, Gullo G, Eustace AJ, Crown J. Budesonide and loperamide do not impact the cytotoxicity of neratinib or HER2-directed monoclonal antibodies in HER2+ breast cancer cell lines [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-07-08.

Abstract P4-03-15: Targeting Src kinase blocks development of afatinib resistance in HER2-positive breast cancer

Background: Afatinib is an irreversible pan-HER inhibitor approved for non-small cell lung cancer. We have previously shown that afatinib inhibits growth of HER2-positive breast cancer cells and enhances response to trastuzumab. However, we have also shown that long-term exposure to tyrosine kinase inhibitors leads to the development of acquired resistance. To determine if acquired afatinib resistance develops in HER2-positive breast cancer cells, we exposed a HER2-positive breast cancer cell line to afatinib for 6 months and investigated alterations in the cells following long-term exposure.

Methods: SKBR3 cells were treated with 150 nM afatinib twice-weekly for 6 months. Growth response to drug inhibitors was assessed by acid phosphatase assay. Drug sensitivity was examined in four HER2-positive cell lines (SKBR3, EFM192A, BT474 and HCC1954) and three acquired trastuzumab resistant cell lines (SKBR3-T, BT474-T and EFM192A-T). Reverse phase protein array (RPPA) was used to determine alterations in key signaling pathways. Src, p-Src, EGFR, p-EGFR, ERK1/2, p-ERK 1/2 levels were examined by Western blotting. To examine the prevention of the development of afatinib resistance, cells were treated twice weekly with afatinib, dasatinib, or the combination and stained with crystal violet when confluent.

Results: Following 6 months of afatinib treatment, the SKBR3-A cells were more resistant to afatinib compared to parental cells (IC50 SKBR3-A 284 ± 28.2 nM vs SKBR3-Par 10.9 ± 3.4 nM). Furthermore, the resistant cells were cross-resistant to lapatinib, neratinib and trastuzumab. RPPA interrogation of the SKBR3-A cells showed alterations in several pathways, including significantly increased levels of p-Src (Y416). SKBR3-A cells were more sensitive to Src inhibition with dasatinib compared to SKBR3-Par cells and the combination of afatinib and dasatinib was highly synergistic in SKBR3-A cells (CI value = 0.09 ± 0.06). The combination of afatinib and dasatinib was also synergistic in the trastuzumab resistant SKBR3-T cells (Table). Afatinib and dasatinib inhibited EGFR and Src activation and ERK 1/2 signalling in SKBR3-A cells.

Short-term resistance assays showed that the addition of dasatinib to afatinib blocks the emergence of resistant cells in three of four HER2 positive cell lines tested and two of the three acquired trastuzumab resistant cell lines tetsed.

Conclusion: HER2-positive breast cancer cells that are highly sensitive to afatinib can develop acquired resistance to afatinib within six months. Src is a potential target to prevent the development of afatinib resistance and thus combined treatment with afatinib and dasatinib may be beneficial in patients with HER2-positive breast cancer.

Percentage growth in HER2-positive cells treated with afatinib and/or dasatinib for 5 days. 20 nM Afatinib40 nM Dasatinib20 nM Afatinib + 40 nM DasatinibSKBR325.2 ± 6.1109.9 ± 6.222.6 ± 6.2SKBR3-A62.1 ± 0.787.3 ± 11.036.3 ± 0.3*SKBR3-T42.6 ± 4.9107.4 ± 9.729.3 ± 3.5*BT47418.2 ± 3.079.5 ± 5.213.3 ± 1.1BT474-T6.9 ± 2.795.3 ± 2.06.2 ± 2.3EFM192A39.1 ± 4.7105.7 ± 3.135.3 ± 2.7EFM192A-T30.4 ± 5.299.8 ± 2.528.5 ± 4.4HCC195461.8 ± 8.180.5 ± 8.219.4 ± 3.6** indicates enhanced anti-proliferative response for the combination compared to the single agents.

Citation Format: Conlon N, Canonici A, Morgan C, Cremona M, Hennessey BT, Eustace A, O'Brien N, Slamon D, Crown J, O'Donovan N. Targeting Src kinase blocks development of afatinib resistance in HER2-positive breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-03-15.

Alterations in circulating lymphoid cell populations in systemic small vessel vasculitis are non-specific manifestations of renal injury

Innate lymphocyte populations, such as innate lymphoid cells (ILCs), γδ T cells, invariant natural killer T (iNK T) cells and mucosal-associated invariant T (MAIT) cells are emerging as important effectors of innate immunity and are involved in various inflammatory and autoimmune diseases. The aim of this study was to assess the frequencies and absolute numbers of innate lymphocytes as well as conventional lymphocytes and monocytes in peripheral blood from a cohort of anti-neutrophil cytoplasm autoantibody (ANCA)-associated vasculitis (AAV) patients. Thirty-eight AAV patients and 24 healthy and disease controls were included in the study. Patients with AAV were sampled both with and without immunosuppressive treatment, and in the setting of both active disease and remission. The frequencies of MAIT and ILC2 cells were significantly lower in patients with AAV and in the disease control group compared to healthy controls. These reductions in the AAV patients remained during remission. B cell count and frequencies were significantly lower in AAV in remission compared to patients with active disease and disease controls. Despite the strong T helper type 2 (Th) preponderance of eosinophilic granulomatosis with polyangiitis, we did not observe increased ILC2 frequency in this cohort of patients. The frequencies of other cell types were similar in all groups studied. Reductions in circulating ILC2 and MAIT cells reported previously in patients with AAV are not specific for AAV, but are more likely to be due to non-specific manifestations of renal impairment and chronic illness. Reduction in B cell numbers in AAV patients experiencing remission is probably therapy-related.

Immunological efficacy of pneumococcal vaccine strategies in HIV-infected adults: a randomized clinical trial

The aim of this study was to compare the immunologic response to a prime-boost immunization strategy combining the 13-valent conjugate pneumococcal vaccine (PCV13) with the 23-valent polysaccharide pneumococcal vaccine (PPSV23) versus the PPSV23 alone in HIV-infected adults. HIV-infected adults were randomized to receive PCV13 at week 0 followed by PPSV23 at week 4 (n = 31, prime-boost group) or PPSV23 alone at week 4 (n = 33, PPSV23-alone group). Serotype specific IgG geometric mean concentration (GMC) and functional oposonophagocytic (OPA) geometric mean titer (GMT) were compared for 12 pneumococcal serotypes shared by both vaccines at week 8 and week 28. The prime-boost vaccine group were more likely to achieve a ≥2-fold increase in IgG GMC and a GMC >1 ug/ml at week 8 (odds ratio (OR) 2.00, 95% confidence interval (CI) 1.46–2.74, p < 0.01) and week 28 (OR 1.95, 95% CI 1.40–2.70, p < 0.01). Similarly, the prime-boost vaccine group were more likely to achieve a ≥4-fold increase in GMT at week 8 (OR 1.71, 95% CI 1.22–2.39, p < 0.01) and week 28 (OR 1.6, 95% CI 1.15–2.3, p < 0.01). This study adds to evidence supporting current pneumococcal vaccination recommendations combining the conjugate and polysaccharide pneumococcal vaccines in the United States and Europe for HIV-infected individuals.

Predictors of outcome in decompensated liver disease: validation of the SOFA-L score

A growing number of patients with liver disease are being referred for critical care support. We have recently shown that a combination of lactate and SOFA score (SOFA-L score) may provide an accurate, objective measurement of prognosis in a group of patients admitted to ICU with alcoholic liver disease. This score has not been validated in an independent patient cohort. A retrospective study was performed where patients admitted to our ICU with decompensated liver disease (any cause) were included. The SOFA-L score accurately predicted in-hospital mortality in this group of patients with an area under the ROC curve of 0.83. Sensitivity and specificity were 65% and 87% respectively SOFA-L performed superior to SOFA, MELD and MELD-Na scores. This study validates the use of the SOFA-L score in the initial 24 hours of ICU admission as an accurate predictor of mortality in this group of patients with a high mortality.

Abstract P1-02-09: Positive predictive value (PPV) of the diagnosis of atypia in breast core biopsies: An audit of MSKCC breast pathology service

Percutaneous needle core biopsy is the standard of care in the assessment of suspicious breast lesions. The diagnostic term “Atypia” is used in breast biopsy reporting when histologic appearances are suspicious but not diagnostic of malignancy. Multiple histopathological appearances are encompassed by the umbrella term “atypia”, including atypical ductal hyperplasia (ADH), columnar cell change with atypia (CCCWA), which is also known as flat epithelial atypia (FEA), and a miscellaneous group of diagnoses, known as atypia NOS.

A pathologic diagnosis of “atypia” in breast core biopsies usually leads to a recommendation to surgically excise the lesion. Many studies have correlated the diagnosis of “atypia” in core biopsies with the subsequent finding of carcinoma in the surgical excisions, and the percentage of carcinoma found represents the positive predictive value (PPV) of the diagnosis. To date, there is no agreed target PPV for the diagnosis of breast atypia on biopsy, but the most studies have demonstrated a PPV of 20- 40%. Individual “atypia” diagnoses such as CCCWA have an even lower PPV of 10-15%.

One method of performance review is an audit of the average breast-atypia PPV within individual pathology departments, which then can be monitored and studied over time, to detect trends and “diagnostic drift” at an early stage. In addition, assessment of the individual PPV of each breast pathologist allows for analysis of the consistency of the diagnostic practice of each individual with their colleagues. Surprisingly, there have been no major studies assessing the intradepartmental range of PPVs for breast atypia diagnoses to date. In contrast, the American College of Radiology has designed the BIRADS classification system in order to audit and monitor the PPV of breast imaging in diagnosing malignancy.

We undertook to measure the departmental PPV for malignancy following a biopsy diagnosis of breast atypia, and performed an anonymized subanalysis in order to establish the range of PPVs of atypia diagnoses between the sub-specialized breast pathologists within the department.

This study established that the baseline PPV in our department is comparable to previously reported studies at 24%, while the range of PPV for an atypia diagnosis between pathologists is between 22.8 and 25% for 5 of 6 pathologists, with one pathologist demonstrating a higher PPV of 36.8%. ADH was the most common diagnosis of the atypia subtypes, and the PPV for ADH alone was 29.9%. 15% of ADH diagnoses were described as “ADH bordering on low grade DCIS”; within this subgroup the PPV was 48.5%. The PPV for a diagnosis of CCCWA alone was 10%.

This study demonstrates that the PPV for breast atypia in a major tertiary cancer center is approximately 24%. We have demonstrated very reproducible use of this diagnostic term within the department. We plan to use the findings of this study to identify subgroups of patients with a sufficiently low PPV to justify a decision not to proceed to surgical intervention. We aim to develop an algorithm for use in the clinical setting in order to direct further patient management. The ultimate aim of this research is to reduce the number of patients undergoing unnecessary surgical interventions.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-02-09.

Should we stop doing blind transversus abdominis plane blocks?

BACKGROUND

Any landmark-based regional anaesthetic technique raises two important issues. The first is the accuracy of placement of the needle and thus the local anaesthetic in a 'blind' technique and the second is the potential for damage to adjacent structures. We designed a prospective, blinded study in an adult general surgical population to evaluate with ultrasound the placement of the needle tip and local anaesthetic during transversus abdominis plane (TAP) blocks using the landmark-based 'double-pop' technique.

METHODS

After induction of general anaesthesia, 36 adult patients had a TAP block performed bilaterally using the standard landmark-based technique. Ultrasonography was then used to record the actual needle position and local anaesthetic spread. The anaesthetist performing the block was blinded to the ultrasound images.

RESULTS

Thirty-six adult patients were included in the study, which was terminated early due to what was considered an unacceptably high level of peritoneal needle placements. The needle tip and local anaesthetic spread were in the correct plane in only 17 (23.6%) of the injections. In the remaining 55 (76.4%), the needle was in the subcutaneous tissue 1 (1.38%), external oblique muscle 1 (1.38%), plane between the external and internal oblique muscles 5 (6.94%), internal oblique muscle 26 (36.1%), transversus abdominis muscle 9 (12.5%), and peritoneum 13 (18%).

CONCLUSIONS

We conclude that the needle and local anaesthetic placement using the standard landmark-based approach to the TAP block is inaccurate, and the incidence of peritoneal placement is unacceptably high.

Long-term functional outcome and performance status after intensive care unit re-admission: a prospective survey

BACKGROUND

Intensive care unit (ICU) re-admission identifies a high-risk group in terms of hospital mortality, length of stay, and resource utilization. Only hospital and ICU mortality are well described in the literature on critically ill patients needing re-admission.

METHODS

With ethical committee approval, from a prospectively collected database of all admissions to a combined medical and surgical ICU from January 1 to December 31, 2004, we identified all ICU re-admissions from within the hospital and analysed the factors associated with increased incidence of re-admission. At 2-3 yr after discharge, we evaluated the functional outcome of the surviving re-admitted patients as Glasgow Outcome Score (GOS) and Karnofsky index and identified determinants of both mortality and good functional outcome.

RESULTS

Seventy-three (7.4%) of the 1061 patients who survived their first ICU stay were re-admitted during the study period. Of the 73 re-admitted patients, 14 died in ICU, 17 died later in the same hospital stay, and 10 died in the interim. Thus, 32 (43.8%) were alive 2-3 yr after discharge. The median [IQR] GOS of the survivors was 4 (see Mackle and colleagues in One year outcome of intensive care patients with decompensated alcoholic liver disease.

CONCLUSIONS

Although the ICU, hospital, and subsequent mortalities are high in patients after ICU re-admission, most survivors at 2-3 yr had by then made a good functional recovery and were independent.

New lessons: Classic treatments in convulsive status epilepticus

Convulsive status epilepticus is a relatively common life-threatening illness requiring prompt intervention. There has been much debate about the appropriate protocol for management of convulsive status epilepticus. Published data on the management of this condition in Ireland is limited. Our aim was to establish if there was a structured, evidence-based or consensus-based protocol being implemented in the management of status epilepticus in our centre. We retrospectively audited all charts with a diagnosis of 'Status Epilepticus' admitted to our hospital from January 1998 to December 2002. A total of 95 episodes of convulsive status epilepticus were recorded. 34 charts were reviewed. Benzodiazepines were the drug class of first choice in 96% of patients. However, the doses of benzodiazepines used varied widely. The most frequent dose of phenytoin used was 1 gram. No one received continuous EEG monitoring during treatment of refractory status epilepticus. Overall mortality was 18%. The results of this study show that there is no consistent protocol was being followed for the management of convulsive status epilepticus in our centre. The drugs of first choice varied between diazepam and lorazepam in most cases. Although phenytoin was used as second line drug, the dose used was frequently suboptimal. We have developed a protocol for the management for convulsive status in our centre.