Children´s priorities to improve the acceptability of MDR-TB treatment: qualitative data from South Africa

BACKGROUND: Multidrug-resistant TB (MDR-TB) treatment for children frequently includes unpalatable drugs with low overall acceptability. This can negatively impact children and their caregivers´ treatment experiences and is an important contributor to poor adherence, and potentially, poor treatment outcomes. Children and their caregivers´ preferences for MDR-TB treatment are not well documented. We describe children and caregivers´ priorities to inform future MDR-TB treatment regimens.METHODS: We conducted a cross-sectional qualitative study at a TB hospital in South Africa using semi-structured interviews and participatory research activities with caregivers and children routinely diagnosed and treated for MDR-TB between June and August 2018.RESULTS: We conducted 15 interviews with children and their caregivers. Children ranged from 2 to 17 years of age (median age: 8.3 years). Children and caregivers had an overall negative experience of MDR-TB treatment. Children and caregivers described how future MDR-TB drugs and regimens should prioritise sweeter flavours, fewer pills, brighter colours, and formulations that are easy to prepare and administer and dispensed in colourful, small and discrete packaging.CONCLUSIONS: MDR-TB treatment acceptability remains low, and negatively impacts children and their caregivers´ treatment experiences. Improving the overall acceptability of MDR-TB treatment requires engaging with children and their caregivers to better understand their priorities for new treatment regimens and child-friendly formulations.

Implementation of behaviour change training in practice amongst pharmacy professionals in primary care settings: Analysis using the COM-B model

BACKGROUND

The Pharmacy Integration Fund (PhIF) was established in England in 2016, with funded learning programmes or 'pathways' designed to support the development of clinical pharmacy practice in a range of settings. Despite pharmacy staff being well positioned to provide more clinical work, limited research has investigated behaviour change training targeted at widespread practice transformation.

OBJECTIVE(S)

To investigate implementation of PhIF learning in practice, using the COM-B model of behaviour change.

METHODS

An online survey distributed in February and October 2020 included questions on motivations for learning, confidence in target behaviours and impact of PhIF training on behaviour. The October 2020 survey also included questions exploring the effect of the COVID-19 pandemic. Quantitative data were analysed in SPSS. v.27 (IBM). Inferential statistics were used to compare between the pathways (Primary care pathways [PCP], Post-registration pathway [PRP] and Accuracy Checking Pharmacy Technician [ACPT] pathway). Free text comments were categorised and themed.

RESULTS

Three-hundred and eighty-three responses were received (49% PRP learners, 39% PCP learners and 12% ACPT learners). Learners generally had the capacity and opportunities to apply learning, and were strongly motivated to implement behaviours in practice, although learners based in community pharmacy (those on the PRP) were less likely to report receiving employer support. Enhanced knowledge/skills (capacity) were more commonly reported than change to patient-facing activities, leading clinical services and conducting medication reviews with patients with complex needs (clinical practice behaviours targeted by the pathways). The COVID-19 pandemic heightened barriers to implementing practice change.

CONCLUSIONS

Implementation of a range of clinical practice behaviours following at scale training appears to have been largely successful. Despite this, the community pharmacy context, where funded service opportunities may be lacking, continues to present challenges to workforce transformation plans. More work is needed to understand how training can be implemented to promote practice change for pharmacy professionals in all settings.

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.

Posaconazole inhibits multiple steps of the alphavirus replication cycle

Repurposing drugs is a promising strategy to identify therapeutic interventions against novel and re-emerging viruses. Posaconazole is an antifungal drug used to treat invasive aspergillosis and candidiasis. Recently, posaconazole and its structural analog, itraconazole were shown to inhibit replication of multiple viruses by modifying intracellular cholesterol homeostasis. Here, we show that posaconazole inhibits replication of the alphaviruses Semliki Forest virus (SFV), Sindbis virus and chikungunya virus with EC₅₀ values ranging from 1.4 μM to 9.5 μM. Posaconazole treatment led to a significant reduction of virus entry in an assay using a temperature-sensitive SFV mutant, but time-of-addition and RNA transfection assays indicated that posaconazole also inhibits post-entry stages of the viral replication cycle. Virus replication in the presence of posaconazole was partially rescued by the addition of exogenous cholesterol. A transferrin uptake assay revealed that posaconazole considerably slowed down cellular endocytosis. A single point mutation in the SFV E2 glycoprotein, H255R, provided partial resistance to posaconazole as well as to methyl-β-cyclodextrin, corroborating the effect of posaconazole on cholesterol and viral entry. Our results indicate that posaconazole inhibits multiple steps of the alphavirus replication cycle and broaden the spectrum of viruses that can be targeted in vitro by posaconazole, which could be further explored as a therapeutic agent against emerging viruses.

An affinity-enhanced, broadly neutralizing heavy chain-only antibody protects against SARS-CoV-2 infection in animal models

Broadly neutralizing antibodies are an important treatment for individuals with coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Antibody-based therapeutics are also essential for pandemic preparedness against future Sarbecovirus outbreaks. Camelid-derived single domain antibodies (VHHs) exhibit potent antimicrobial activity and are being developed as SARS-CoV-2–neutralizing antibody-like therapeutics. Here, we identified VHHs that neutralize both SARS-CoV-1 and SARS-CoV-2, including now circulating variants. We observed that the VHHs bound to a highly conserved epitope in the receptor binding domain of the viral spike protein that is difficult to access for human antibodies. Structure-guided molecular modeling, combined with rapid yeast-based prototyping, resulted in an affinity enhanced VHH-human immunoglobulin G1 Fc fusion molecule with subnanomolar neutralizing activity. This VHH-Fc fusion protein, produced in and purified from cultured Chinese hamster ovary cells, controlled SARS-CoV-2 replication in prophylactic and therapeutic settings in mice expressing human angiotensin converting enzyme 2 and in hamsters infected with SARS-CoV-2. These data led to affinity-enhanced selection of the VHH, XVR011, a stable anti–COVID-19 biologic that is now being evaluated in the clinic.

The impact of obstructive sleep apnea on endothelial function during weight loss in an obese pediatric population

BACKGROUND

Childhood obesity is an increasing problem with substantial comorbidities such as obstructive sleep apnea (OSA) and increased cardiovascular morbidity. Endothelial dysfunction is an underlying mechanism related to both obesity and OSA.

RESEARCH QUESTION

To investigate the effect of weight loss on endothelial function and OSA in obese children and to determine whether a change in endothelial function can be linked to an improvement in OSA.

METHODS

Obese children between 8 and 18 years of age were recruited while entering a 12-month inpatient weight loss program. Patients were followed at 3 study visits: baseline, after 10 months of weight loss, and 6 months after ending the program (18 months). Anthropometry and endothelial function (EndoPAT) were determined at all study visits. At baseline, sleep screening with a portable device (ApneaLink) was performed. This was repeated after 10 months if OSA was diagnosed at baseline.

RESULTS

At baseline, 130 children were included, of which 87 had OSA (67%). Seventy-two patients attended the follow-up visit at 10 months, and 28 patients attended the follow-up visit at 18 months. The BMI z-score decreased after 10 months (from 2.7 (1.4-3.4) to 1.7 (0.5-2.7); p < 0.001) and remained stable at 18 months. Endothelial function improved significantly after weight loss, evidenced by a shorter time to peak response (TPR) and higher reactive hyperemia index (p = 0.02 and p < 0.001), and remained improved after 18 months (p < 0.001 and p = 0.007). After 10 months of weight loss, 10 patients had residual OSA. These patients had a higher TPR at 10 months (225 (75-285)s) than those without OSA (135 (45-225)s) and patients with a normalized sleep study (105 (45-285)s; p = 0.02). Linear mixed models showed that more severe OSA was associated with a worse TPR at baseline and less improvement after weight loss.

CONCLUSION

Weight loss improves endothelial function in an obese pediatric population. However, even after weight loss, endothelial function improved less in the presence of OSA.

Itraconazole for COVID-19: preclinical studies and a proof-of-concept randomized clinical trial

BACKGROUND

The antifungal drug itraconazole exerts in vitro activity against SARS-CoV-2 in Vero and human Caco-2 cells. Preclinical and clinical studies are required to investigate if itraconazole is effective for the treatment and/or prevention of COVID-19.

METHODS

Due to the initial absence of preclinical models, the effect of itraconazole was explored in a clinical, proof-of-concept, open-label, single-center study, in which hospitalized COVID-19 patients were randomly assigned to standard of care with or without itraconazole. Primary outcome was the cumulative score of the clinical status until day 15 based on the 7-point ordinal scale of the World Health Organization. In parallel, itraconazole was evaluated in a newly established hamster model of acute SARS-CoV-2 infection and transmission, as soon as the model was validated.

FINDINGS

In the hamster acute infection model, itraconazole did not reduce viral load in lungs, stools or ileum, despite adequate plasma and lung drug concentrations. In the transmission model, itraconazole failed to prevent viral transmission. The clinical trial was prematurely discontinued after evaluation of the preclinical studies and because an interim analysis showed no signal for a more favorable outcome with itraconazole: mean cumulative score of the clinical status 49 vs 47, ratio of geometric means 1.01 (95% CI 0.85 to 1.19) for itraconazole vs standard of care.

INTERPRETATION

Despite in vitro activity, itraconazole was not effective in a preclinical COVID-19 hamster model. This prompted the premature termination of the proof-of-concept clinical study.

FUNDING

KU Leuven, Research Foundation - Flanders (FWO), Horizon 2020, Bill and Melinda Gates Foundation.

Cross-sector pre-registration pharmacist placements in general practice in England: lessons from a national evaluation

Introduction

In 2019/2020, the Pharmacy Integration Fund commissioned delivery of cross-sector pre-registration pharmacist training incorporating 3–6 month placements in general practice (GP). GP placements were managed by Health Education England (HEE) and organised as one (or more) blocks, or as spilt weeks/days across base sector (hospital/community) and GP. Trainees had a pharmacist tutor at base and in GP.

Aim

to evaluate the implementation of cross-sector pre-registration pharmacy placements in GP in England, and to identify barriers and enablers of a successful placement.

Methods

A qualitative approach was taken, with case study sites purposively sampled for maximum variation: pharmacy base (hospital/community), number of pre-registration pharmacist trainees in base doing GP placement, length of GP placement, organisation of GP placement and geographical location. With consent, trainees and tutors identified as meeting sampling criteria were emailed invitation letters and participant information sheets. Where the trainee and their tutor(s) agreed to participate, semi-structured telephone interviews were conducted January - July 2020. Questions developed from literature(1, 2) and the HEE handbook were tailored to understanding trainees’ and tutors’ views on the implementation of pre-registration pharmacist placements in GP, including benefits, unintended consequences and impacts. Thematic analysis across sites was undertaken with a focus on exploring inter and intra group themes.

Results

Thirty-four interviews were completed in 11 study sites (5 GP/hospital; 6 GP/community pharmacy). Trainees and tutors considered GP placements had been successful. Contributing factors were: placement planning (induction, contingency arrangements for cover should GP tutor be unavailable); tutors working together (good communication and collaboration); GP tutor support (regular contact, reflection; identifying learning needs; opportunities for learning); integration of GP placements within training year (specific learning/training activities at base during GP placement); and GP tutors having backing of their organisation to supervise effectively. A lack of these impacted negatively. Trainees completed a wide spectrum of activities and gradually moved from administrative to clinical tasks. They built up confidence to undertake patient-facing activities, with more direct supervision at the beginning moving to indirect supervision using debriefing. Thirteen weeks in GP was considered an appropriate minimum duration by all trainees and tutors; those based in community felt that 26 weeks in GP provided more opportunities for clinical and consultation skills learning. Cross-sector experience facilitated a better understanding of patient pathways and the importance of holistic patient care. All trainees considered working in GP in future but highlighted the lack of a cross-sector GP foundation programme. Base tutors felt the time commitment was comparable to single sector placements. Base and GP tutors felt that a clear set of competencies for GP placements and a broader governance framework would ensure standards and consistency.

Conclusion

This is the first national evaluation of cross-sector pre-registration pharmacists in general practice placements in England. Sampling as case studies enabled data triangulation and generated a multi-faceted understanding on factors impacting GP placements. A key limitation was the volunteer bias associated with recruitment. Key attributes of a successful pre-registration cross-sector training experience are highlighted and can inform policy reforms including change from pre-registration to foundation year training.

References

1. Gray N. Review of Experience of Pre-registration Pharmacist Placements in the General Practice Setting – Final Report. 2019.

2. Jee SD, Schafheutle EI, Noyce PR. Is pharmacist pre-registration training equitable and robust? Higher Education, Skills and Work-Based Learning. 2019;9(3):347–58.

Recent African strains of Zika virus display higher transmissibility and fetal pathogenicity than Asian strains

The global emergence of Zika virus (ZIKV) revealed the unprecedented ability for a mosquito-borne virus to cause congenital birth defects. A puzzling aspect of ZIKV emergence is that all human outbreaks and birth defects to date have been exclusively associated with the Asian ZIKV lineage, despite a growing body of laboratory evidence pointing towards higher transmissibility and pathogenicity of the African ZIKV lineage. Whether this apparent paradox reflects the use of relatively old African ZIKV strains in most laboratory studies is unclear. Here, we experimentally compare seven low-passage ZIKV strains representing the recently circulating viral genetic diversity. We find that recent African ZIKV strains display higher transmissibility in mosquitoes and higher lethality in both adult and fetal mice than their Asian counterparts. We emphasize the high epidemic potential of African ZIKV strains and suggest that they could more easily go unnoticed by public health surveillance systems than Asian strains due to their propensity to cause fetal loss rather than birth defects.

Here, the authors compare seven low passage Zika virus (ZIKV) strains representing the recently circulating viral genetic diversity of African and Asian strains and find that African ZIKV strains have higher transmissibility in mosquitoes and higher lethality in both adult and fetal mice.

Left heart Impella-device to bridge acute mitral regurgitation to MitraClip-procedure: a novel implementation of percutaneous mechanical circulatory support

Background

Acute mitral regurgitation (MR) is an emergency, often requiring urgent surgery. Severe acute MR presenting with hemodynamic collapse is usually caused by papillary muscle rupture or dysfunction after acute myocardial infarction (AMI) or chordal rupture, resulting in flail mitral leaflet(s). Preoperative stabilization is complex due to concomitant hemodynamic collapse and hypoxic respiratory failure. Finding the right balance between both preload and inotropic support is challenging. When patients are too sick for immediate surgical intervention, mechanical circulatory support can be considered because of its ability to both unload and reduce of cardiac work while increasing coronary perfusion and cardiac output. Nevertheless, even after initial stabilization, surgical risk remains high in critically ill acute severe MR patients and transcatheter treatments such as MitraClip are increasingly being explored.

Methods

Between August 2017 and September 2019, patients presenting with acute severe mitral regurgitation and considered too ill for immediate surgical intervention (EURO-II score &gt;11.2% plus pulmonary oedema necessitating mechanical ventilation and/or hemodynamic instability), were selected for an Impella-assisted LV unloading technique as bridge to MitraClip-procedure. Five patients were selected for the combined left Impella/MitraClip-procedure in two tertiary cardiac ICUs.

Results

The mean age was 72 years. The cause of MR was ischemic in 20% and all patients presented in cardiogenic shock state, necessitating mechanical ventilation. The overall cardiac operative risk assessment (Euro-II) score predicted a 35% chance of in-hospital mortality. Cardiac output was severely impaired (mean LVOT VTI 8.2 cm). All patients were on inotropic support and supported by an Impella-CP pVAD (mean flow 2.5 Liter per minute; mean 6.3 days of support). In all cases, we managed to reduce the LVEDP below 15 mmHg using the combination of medical therapy (afterload reduction, inotropes), mechanical ventilation and pVAD-therapy. The MR was significantly reduced by a MitraClip-procedure in each Impella supported patient. The overall survival at discharge was 80%. One patient with late referral and multiple organ failure at presentation deceased due to refractory cardiogenic shock. Overall, severe MR was reduced to grade 1+ and all four patients survived 6 months after discharge with only one readmission for decompensated heart failure.

Conclusions

A combined strategy of Impella and MitraClip appears to be a novel, feasible alternative for patients presenting with acute, severe MR unable to proceed to a corrective surgical procedure at presentation due to severe left ventricular forward flow failure. In these cases, the early initiation of pVAD-support may reduce the risk of development of irreversible end- organ damage and dysfunction. Exploration in a larger, randomised population is warranted to investigate this strategy further.

Funding Acknowledgement

Type of funding source: None

Favipiravir at high doses has potent antiviral activity in SARS-CoV-2-infected hamsters, whereas hydroxychloroquine lacks activity

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) rapidly spread around the globe after its emergence in Wuhan in December 2019. With no specific therapeutic and prophylactic options available, the virus has infected millions of people of which more than half a million succumbed to the viral disease, COVID-19. The urgent need for an effective treatment together with a lack of small animal infection models has led to clinical trials using repurposed drugs without preclinical evidence of their in vivo efficacy. We established an infection model in Syrian hamsters to evaluate the efficacy of small molecules on both infection and transmission. Treatment of SARS-CoV-2-infected hamsters with a low dose of favipiravir or hydroxychloroquine with(out) azithromycin resulted in, respectively, a mild or no reduction in virus levels. However, high doses of favipiravir significantly reduced infectious virus titers in the lungs and markedly improved lung histopathology. Moreover, a high dose of favipiravir decreased virus transmission by direct contact, whereas hydroxychloroquine failed as prophylaxis. Pharmacokinetic modeling of hydroxychloroquine suggested that the total lung exposure to the drug did not cause the failure. Our data on hydroxychloroquine (together with previous reports in macaques and ferrets) thus provide no scientific basis for the use of this drug in COVID-19 patients. In contrast, the results with favipiravir demonstrate that an antiviral drug at nontoxic doses exhibits a marked protective effect against SARS-CoV-2 in a small animal model. Clinical studies are required to assess whether a similar antiviral effect is achievable in humans without toxic effects.

Pan-viral protection against arboviruses by activating skin macrophages at the inoculation site

Arthropod-borne viruses (arboviruses) are important human pathogens for which there are no specific antiviral medicines. The abundance of genetically distinct arbovirus species, coupled with the unpredictable nature of their outbreaks, has made the development of virus-specific treatments challenging. Instead, we have defined and targeted a key aspect of the host innate immune response to virus at the arthropod bite that is common to all arbovirus infections, potentially circumventing the need for virus-specific therapies. Using mouse models and human skin explants, we identify innate immune responses by dermal macrophages in the skin as a key determinant of disease severity. Post-exposure treatment of the inoculation site by a topical TLR7 agonist suppressed both the local and subsequent systemic course of infection with a variety of arboviruses from the Alphavirus, Flavivirus, and Orthobunyavirus genera. Clinical outcome was improved in mice after infection with a model alphavirus. In the absence of treatment, antiviral interferon expression to virus in the skin was restricted to dermal dendritic cells. In contrast, stimulating the more populous skin-resident macrophages with a TLR7 agonist elicited protective responses in key cellular targets of virus that otherwise proficiently replicated virus. By defining and targeting a key aspect of the innate immune response to virus at the mosquito bite site, we have identified a putative new strategy for limiting disease after infection with a variety of genetically distinct arboviruses.

Bayesian strategy selection identifies optimal solutions to complex problems using an example from GP prescribing

Complex health problems require multi-strategy, multi-target interventions. We present a method that uses machine learning techniques to choose optimal interventions from a set of possible interventions within a case study aiming to increase General Practitioner (GP) discussions of physical activity (PA) with their patients. Interventions were developed based on a causal loop diagram with 26 GPs across 13 clinics in Geelong, Australia. GPs prioritised eight from more than 80 potential interventions to increase GP discussion of PA with patients. Following a 2-week baseline, a multi-arm bandit algorithm was used to assign optimal strategies to GP clinics with the target outcome being GP PA discussion rates. The algorithm was updated weekly and the process iterated until the more promising strategies emerged (a duration of seven weeks). The top three performing strategies were continued for 3 weeks to improve the power of the hypothesis test of effectiveness for each strategy compared to baseline. GPs recorded a total of 11,176 conversations about PA. GPs identified 15 factors affecting GP PA discussion rates with patients including GP skills and awareness, fragmentation of care and fear of adverse outcomes. The two most effective strategies were correctly identified within seven weeks of the algorithm-based assignment of strategies. These were clinic reception staff providing PA information to patients at check in and PA screening questionnaires completed in the waiting room. This study demonstrates an efficient way to test and identify optimal strategies from multiple possible solutions.

Antiviral drug discovery against arthritogenic alphaviruses: Tools and molecular targets

Alphaviruses are (mainly) arthropod-borne viruses that belong to the family of the Togaviridae. Based on the disease they cause, alphaviruses are divided into an arthritogenic and an encephalitic group. Arthritogenic alphaviruses such as the chikungunya virus (CHIKV), the Ross River virus (RRV) and the Mayaro virus (MAYV) have become a serious public health concern in recent years. Epidemics are associated with high morbidity and the infections cause in many patients debilitating joint pain that can persist for months to years. The recent (2013-2014) introduction of CHIKV in the Americas resulted in millions of infected persons. Massive outbreaks of CHIKV and other arthritogenic alphaviruses are likely to occur in the future. Despite the worldwide (re-)emergence of these viruses, there are no antivirals or vaccines available for the treatment or prevention of infections with alphaviruses. It is therefore of utmost importance to develop antiviral strategies against these viruses. We here review the possible molecular targets in the replication cycle of these viruses for the development of antivirals. In addition, we provide an overview of the currently available in vitro systems and mouse infection models that can be used to assess the potential antiviral effect against these viruses.

"Knowing Me, Knowing You" the Importance of Networking for Freelancers' Careers: Examining the Mediating Role of Need for Relatedness Fulfillment and Employability-Enhancing Competencies

Research has shown the importance of engaging in networking behaviors for employees' career success. Networking behaviors can be seen as a proactive way of creating access to career-related social resources and we argue that this type of proactive career behaviors might be particularly relevant for freelancers who cannot depend on an organizational career system supporting their further development, yet whose careers are characterized by high levels of uncertainty and unpredictability. To date, however, our understanding of how freelancers, being a category of workers that are deprived of an organizational context of support for career development, can safeguard their employability, is limited. Therefore, this study addresses this gap and investigates whether freelancers' networking behaviors are positively associated with career outcomes, through the mediating role of the need for relatedness fulfillment and employability-enhancing competencies. Hypotheses are tested via Structural Equation Modeling using a sample of 1,874 freelancers from Belgium, France, Germany, the Netherlands, and the United Kingdom. The results generally support our hypotheses, providing evidence for a significant association between networking behaviors and need for relatedness fulfillment, and between networking behaviors and employability-enhancing competencies. Moreover, we found a significant association between need for relatedness fulfillment and employability-enhancing competencies, being the mediators in our research model and the outcomes of career satisfaction and perceived future career opportunities. Implications for career development in the contemporary workplace are discussed, with particular attention for need for relatedness fulfillment, employability-enhancing competencies, and sustainable careers of freelance workers.

A-58 Rare Case of Klinefelter Syndrome with 13/14 Balanced Translocation and Absence Epilepsy: Impact of Combined Genotypes on Cognitive Neuropsychological Phenotype

Objective

Klinefelter syndrome (KS) and Robertsonian translocation of 13/14 [rob t(13;14)] are the most common sex-chromosome disorder and chromosome rearrangement, respectively (Engels et al., 2008; Skakkebæk, Wallentin, & Gravholt, 2015). Both are associated with increased risk of cognitive/intellectual disability (ID). A case of KS and de novo (i.e., unbalanced) rob t(13;14) was previously reported (Gül & Şayli, 1994). A case of KS with balanced rob t(13;14) and well-controlled generalized absence epilepsy will be presented with consideration for pediatric neuropsychological practice.

Method

Neuropsychological evaluation of a 12-year-old, right-handed boy diagnosed with comorbid KS, rob t(13;14), and generalized absence epilepsy. Particular attention was given to language given his KS diagnosis. The patient is in a 12:1:1 self-contained classroom with speech-language therapy and social skills groups in place. The patient’s mother is confirmed to have rob t(13;14), whereas paternal contribution is unknown.

Results

Adolescent with a history of language difficulties, especially comprehension. Recent school-based WISC-V FSIQ was in the extremely low range (SS = 53), with weaker verbal comprehension and working memory. Academic achievement was globally very low. Expressive and receptive language, visual perception and motor coordination were extremely low to low average. Verbal list learning and visual attention were near average to average.

Conclusions

This case contributes to the very limited body of pediatric neuropsychological data on the combined genotype of KS with rob t(13;14) and absence epilepsy. Both the KS and rob t(13;14) cognitive phenotypes have been characterized as highly variable, with the comorbidity a likely increased risk for ID.

B-32 The Use of Repeat Neuropsychological Assessment to Guide Treatment of Possible Normal Pressure Hydrocephalus in a Complex Case

Objective

Normal Pressure Hydrocephalus (NPH) is a condition that is characterized by the buildup of cerebrospinal fluid (CSF) in the brain that can cause urinary incontinence, gait disturbance, and cognitive impairment. NPH can be progressive but may be managed or reversed with shunt placement. External Lumbar Drainage (ELD) trials in determining if shunt placement is appropriate are common, but the role of repeat neuropsychological assessments during ELD procedures is not well documented in the literature. Repeat, pre-, peri and post- ELD trial, assessment in a complex case of possible NPH is presented.

Method

33-year-old Hispanic English-Speaking female with cognitive/memory complaints following intraventricular hemorrhage (IVH) secondary to vasculopathy was initially seen for post IVH outpatient neuropsychological evaluation. MRI showed enlarged ventricles/communicating hydrocephalus and workup for NPH was initiated. Repeat inpatient evaluations were completed during the ELD trial, with annual outpatient neuropsychological follow-up.

Results

Gait evaluation was inconclusive. Inpatient testing demonstrated minor improvement immediately following ELD opening, but performances were variable across the 4 days of re-evaluation. Shunt placement was rejected due to neuropsychological findings. Outpatient follow-up of patient over several years has demonstrated mild improvement and not evidence of cognitive decline since ELD trial.

Conclusions

Assessment of cognitive functioning in outpatient and inpatient settings before, during, and for several years following ELD testing was beneficial to ascertain the decision not to place a shunt. Repeat neuropsychological assessment in inpatient and outpatient settings provided crucial information for guiding treatment decisions.

A-34 An Atypical Case of Primary Progressive Aphasia: Implications for Differentiating the Semantic Variant

Objective

Primary progressive aphasia is a neurodegenerative condition consisting of three primary variants. The semantic variant (svPPA) is typically associated with anomia and word-finding issues paired with fluent speech, although other symptoms can arise over time including non-verbal deficits and behavioral changes. A complex case of svPPA with evidence of robust impairment across multiple domains in the presence of notable psychosocial and medical factors is presented.

Method

Sixty-year-old woman with complaints of worsening memory and language changes in the context of marked behavioral disinhibition, deterioration of daily functioning, and indication of delusions was seen for outpatient neuropsychological evaluation. Medical history includes severe depression, anxiety, hypertension, and rheumatic heart disease. CT scan was significant for frontal and temporal atrophy and chronic right cerebellar infarct.

Results

Neuropsychological evaluation revealed uniformly extremely low scores. Presentation was notable for inappropriate behaviors, and expressive and receptive language difficulties. Significant confusion and functional impairment were evident. Her time awareness varied and she at some moments spoke about events from 20-30 years ago as if they were recent. Global language impairment was evident on formal testing and clearly moderated all other performances, including tasks of memory which were impaired. Notable weakness in visual-spatial processing and executive function were also present.

Conclusions

Complex medical and psychosocial history, and atypical decline patterns complicated the diagnosis of a patient with profound progressive expressive language impairment. SvPPA is offered as the diagnosis.

A Viral Polymerase Inhibitor Reduces Zika Virus Replication in the Reproductive Organs of Male Mice

In humans, Zika virus and viral RNA have been detected in semen up to 2.2 months and 6 months post infection (pi), respectively. Although the contribution of sexual transmission to the spread of ZIKV is too low to sustain an outbreak, it can increase the risk of infection and the epidemic size as well as prolong the duration of an outbreak. In this study, we explored the potential of antivirals to serve as an effective strategy to prevent sexual transmission. Male AG129 mice infected with a ZIKV isolate from Suriname were treated with the nucleoside analog, 7-deaza-2′-C-methyladenosine (7DMA), that was previously shown to be efficacious in reducing ZIKV viremia and delaying ZIKV-induced disease in mice. Following treatment, viral RNA and infectious virus titers were consistently reduced in the male reproductive organs compared to vehicle-treated mice. This reduction of ZIKV loads in the testis was confirmed by the detection of lower levels of ZIKV antigens. Our data illustrate the value of this mouse model to validate the efficacy of new potential ZIKV drugs at the level of the male reproductive system.

Abstract GS3-02: PALLET: A neoadjuvant study to compare the clinical and antiproliferative effects of letrozole with and without palbociclib

Background: CDK4/6 inhibitors, such as palbociclib, are used to treat ER+ metastatic breast cancer in combination with endocrine therapy with trials ongoing in patients with primary disease. No biomarkers exist to identify those who do/do not benefit from added CDK4/6 inhibition. PALLET is an investigator-initiated/led phase II randomized trial collaboration between UK and NSABP investigators evaluating the biological and clinical effects of palbociclib with letrozole combination as neoadjuvant therapy.

Methods: Postmenopausal women with ER+ primary breast cancer and tumors &gt;2.0cm (ultrasound) were randomized to one of 4 treatment groups (3:2:2:2 ratio): Group A: letrozole (2.5mg/d) for 14 weeks; Group B: letrozole for 2 weeks followed by letrozole + palbociclib to 14 weeks; Group C: palbociclib for 2 weeks followed by letrozole + palbociclib to 14 weeks; Group D: letrozole + palbociclib for 14 weeks. Palbociclib was given 125mg/d PO on a 21 days on, 7 days off schedule. Post-14 week treatment was at the discretion of the treating clinician including letrozole until surgery. Core-cut biopsies were taken at baseline, 2 weeks and 14 weeks. Co-primary endpoints for letrozole alone vs palbociclib groups (Group A vs Groups B+C+D) were: (i) change in Ki67 (IHC) between baseline and 14 weeks (log-fold change, Mann-Whitney test); (ii) clinical response (ultrasound) after 14 weeks (4 group, ordinal, Mann-Whitney test). Complete cell-cycle arrest (CCCA) (Ki67≤2.7%) was analyzed using a logistic regression model adjusting for recruitment region. Pre-specified exploratory biomarkers included c-PARP (apoptosis).

Results: 307 patients were recruited between 27 Feb 2015 and 08 Mar 2018; 103 were randomized to letrozole alone and 204 to letrozole + palbociclib. 279 (90.9%) patients were evaluable for 14 week clinical response. Clinical response was not significantly different between letrozole vs letrozole + palbociclib groups [(p=0.20; CR+PR 49.5% (46/93) vs 54.3% (101/186) and PD 5.4% (5/93) vs 3.2% (6/186)] nor was the small proportion of patients with pathological CR (1/87, 1.1% vs 6/180, 3.3%; p=0.43). 190 (61.9%) patients were evaluable for 14 week change in Ki67. The median log-fold change in Ki67 was greater with letrozole + palbociclib vs letrozole alone (-4.1 vs -2.2; p&lt;0.001) corresponding to a geometric mean change of -97.4% vs -88.5%. Similarly, a greater proportion of patients who received letrozole + palbociclib achieved CCCA (90% vs 59%, p&lt;0.001). 146 (47.6%) patients were evaluable for c-PARP and the log-fold change (suppression) was greater with letrozole + palbociclib vs letrozole alone (-0.80 vs -0.42; p=0.003) corresponding to a geometric mean change of -56.8% vs -31.4%. Other biomarkers of response / resistance are being evaluated. A higher proportion of patients had a grade ≥3 toxicity on letrozole + palbociclib than letrozole alone (49.8% vs 17.0%; p&lt;0.001) mainly due to asymptomatic neutropenia.

Conclusion: Adding palbociclib to letrozole markedly enhanced the suppression of malignant cell proliferation as assessed by Ki67 but did not substantially increase the clinical response of primary ER+ breast cancer over a 14-week period. Concurrent reductions in cell death may have reduced the speed of tumor shrinkage.

Citation Format: Dowsett M, Jacobs S, Johnston S, Bliss J, Wheatley D, Holcombe C, Stein R, McIntosh S, Barry P, Dolling D, Snowdon C, Perry S, Batten L, Dodson A, Martins V, Modi A, Cornman C, Puhalla S, Wolmark N, Julian T, Pogue-Geile K, Robidoux A, Provencher L, Boileau JF, Shalaby I, Thirlwell M, Fisher K, Huang Bartlett C, Koehler M, Osborne K, Rimawi M. PALLET: A neoadjuvant study to compare the clinical and antiproliferative effects of letrozole with and without palbociclib [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 GS3-02.

Inhibition of the Replication of Different Strains of Chikungunya Virus by 3-Aryl-[1,2,3]triazolo[4,5- d]pyrimidin-7(6 H)-ones

The re-emergence of chikungunya virus (CHIKV) is a serious global health threat. CHIKV is an alphavirus that is transmitted to humans by Aedes mosquitoes; therefore, their wide distribution significantly contributes to the globalization of the disease. Unfortunately, no effective antiviral drugs are available. We have identified a series of 3-aryl-[1,2,3]triazolo[4,5- d]pyrimidin-7(6 H)-ones as selective inhibitors of CHIKV replication. New series of compounds have now been synthesized with the aim to improve their physicochemical properties and to potentiate the inhibitory activity against different CHIKV strains. Among these newly synthesized compounds modified at position 3 of the aryl ring, tetrahydropyranyl and N- t-butylpiperidine carboxamide derivatives have shown to elicit potent antiviral activity against different clinically relevant CHIKV isolates with 50% effective concentration (EC₅₀) values ranging from 0.30 to 4.5 μM in Vero cells, as well as anti-CHIKV activity in human skin fibroblasts (EC₅₀ = 0.1 μM), a clinically relevant cell system for CHIKV infection.

Forest cover correlates with good biological water quality. Insights from a regional study (Wallonia, Belgium)

Forested catchments are generally assumed to provide higher quality water in opposition to agricultural and urban catchments. However, this should be tested in various ecological contexts and through the study of multiple variables describing water quality. Indeed, interactions between ecological variables, multiple land use and land cover (LULC) types, and water quality variables render the relationship between forest cover and water quality highly complex. Furthermore, the question of the scale at which land use within stream catchments most influences stream water quality and ecosystem health remains only partially answered. This paper quantifies, at the regional scale and across five natural ecoregions of Wallonia (Belgium), the forest cover effect on biological water quality indices (based on diatoms and macroinvertebrates) at the riparian and catchment scales. Main results show that forest cover - considered alone - explains around one third of the biological water quality at the regional scale and from 15 to 70% depending on the ecoregion studied. Forest cover is systematically positively correlated with higher biological water quality. When removing spatial, local morphological variations, or population density effect, forest cover still accounts for over 10% of the total biological water quality variation. Partitioning variance shows that physico-chemical water quality is one of the main drivers of biological water quality and that anthropogenic pressures often explain an important part of it (shared or not with forest cover). The proportion of forest cover in each catchment at the regional scale and across all ecoregions but the Loam region is more positively correlated with high water quality than when considering the proportion of forest cover in the riparian zones only. This suggests that catchment-wide impacts and a fortiori catchment-wide protection measures are the main drivers of river ecological water quality. However, distinctive results from the agricultural and highly human impacted Loam region show that riparian forests are positively linked to water quality and should therefore be preserved.

UV-filters and musk fragrances in seafood commercialized in Europe Union: Occurrence, risk and exposure assessment

In the framework of the FP7 ECsafeSeafood project, 62 seafood samples commercialized in Europe Union from several representative species - mackerel, tuna, salmon, seabream, cod, monkfish, crab, shrimp, octopus, perch and plaice - were analysed for residues of 21 personal care products (PCPs), including 11 UV-filters (UV-Fs) and 10 musk fragrances (musks). PCPs analysis were performed by Quick, Easy, Cheap, Effective Rugged, Safe (QuEChERS), combined with liquid-liquid extraction (LLE) or dispersive solid-phase extraction (dSPE), followed by gas chromatography-tandem mass spectrometry (GC-MS/MS). The results showed the presence in a wide range of samples of nine out of eleven UV-Fs compounds analysed, namely 2-ethylhexyl salicylate (EHS), 2-ethylhexyl,4-methoxycinnamate (EHMC), 4-methylbenzylidenecamphor (4-MBC), benzophenone-1 (BP1), benzophenone-3 (BP3), isoamyl-4-methoxycinnamate (IMC), 2,2'-dihydroxy-4,4'-dimethoxybenzophenone (DHMB), homosalate (HS), and octocrylene (OC), whereas galaxolide (HHCB), galaxolide lactone (HHCB-lactone), and tonalide (AHTN) were the most found musks. The potential risks to human health associated with the exposure to eight of the more prevalent PCPs - EHS, EHMC, 4-MBC, BP1, BP3, IMC, HHCB, and AHTN - through seafood consumption were assessed for consumers from five European countries (Belgium, Ireland, Italy, Portugal and Spain). Results showed that the human exposure to UV-Fs and musks estimated from the concentration values found in seafood and the daily consumption of concerned seafood species, were far below toxicological reference values.

Relative bioavailability of carnitine delivered by ruminal or abomasal infusion or by encapsulation in dairy cattle

Two studies were designed to evaluate the relative bioavailability of l-carnitine delivered by different methods in dairy cattle. In experiment 1, 4 Holstein heifers were used in a split-plot design to compare ruminally or abomasally infused l-carnitine. The study included 2 main-plot periods, with infusion routes allocated in a crossover design. Within main-plot periods, each of 3 subplot periods consisted of 4-d infusions separated with 4-d rest periods. Subplot treatments were infusion of 1, 3, and 6 g of l-carnitine/d in conjunction with 6 g/d of arabinogalactan given in consideration of eventual product manufacturing. Doses increased within a period to minimize carryover risk. Treatments were solubilized in 4 L of water and delivered in two 10-h infusions daily. Blood was collected before the start of infusion period and on d 4 of each infusion period to obtain baseline and treatment l-carnitine concentrations. There was a dose × route interaction and route effect for increases in plasma carnitine above baseline, with increases above baseline being greater across all dose levels when infused abomasally compared with ruminally. Results demonstrated superior relative bioavailability of l-carnitine when ruminal exposure was physically bypassed. In experiment 2, 56 lactating Holstein cows (143 ± 72 d in milk) were used in 2 cohorts in randomized complete block designs (blocked by parity and milk production) to evaluate 2 rumen-protected products compared with crystalline l-carnitine. Treatments were (1) control, (2) 3 g/d of crystalline l-carnitine (crystalline), (3) 6 g/d of crystalline, (4) 5 g/d of 40COAT (40% coating, 60% l-carnitine), (5) 10 g/d of 40COAT, (6) 7.5 g/d of 60COAT (60% coating, 40% l-carnitine), and (7) 15 g/d of 60COAT. Treatments were top-dressed to diets twice daily. Each cohort used 14-d and included a 6-d baseline measurement period with the final 2 d used for data and sample collection, and an 8-d treatment period with the final 2 d used for data and sample collection. Plasma, urine, and milk samples were analyzed for l-carnitine. Crystalline and 40COAT linearly increased plasma l-carnitine, and 60COAT tended to linearly increase plasma l-carnitine. Total excretion (milk + urine) of l-carnitine averaged 1.52 ± 0.04 g/d in controls, increased linearly with crystalline and 40COAT, and increased quadratically with 60COAT. Crystalline increased plasma l-carnitine and l-carnitine excretion more than 40COAT and 60COAT. In conclusion, preventing ruminal degradation of l-carnitine increased delivery of bioavailable carnitine to cattle, but effective ruminal protection and postruminal bioavailability is challenging.