Multicenter Evaluation of Ultra-Rapid Lispro (URLi) Insulin with Control-IQ Technology in Adults, Adolescents and Children with Type 1 Diabetes

OBJECTIVE

To evaluate the safety and explore the efficacy of use of ultra-rapid lispro (URLi, Lyumjev) insulin in the Tandem t:slim X2 insulin pump with Control-IQ 1.5 technology in children, teens and adults living with type 1 diabetes (T1D).

METHODS

At 14 U.S. diabetes centers, youth and adults with T1D completed a 16-day lead-in period using lispro in a t:slim X2 insulin pump with Control-IQ 1.5 technology followed by a 13-week period in which URLi insulin was used in the pump.

RESULTS

The trial included 179 individuals with type 1 diabetes (T1D) age 6 to 75 years. With URLi, 1.7% (3 participants) had a severe hypoglycemia event over 13 weeks attributed to override boluses or a missed meal. No DKA events occurred. Two participants stopped URLi use due to infusion site discomfort and one stopped after developing a rash. Mean time 70-180 mg/dL (TIR) increased from 65%±15% with lispro to 67%±13% with URLi (P=0.004). Mean insulin treatment satisfaction questionnaire (ITSQ) score improved from 75±13 at screening to 80±11 after 13 weeks of URLi use (mean difference = 6; 95% CI 4 to 8; P<0.001), with the greatest improvement reported for confidence avoiding symptoms of high blood sugar. Mean treatment related impact measure-diabetes (TRIM-D) score improved from 74±12 to 80±12 (P<0.001), and mean TRIM-Diabetes Device (TRIM-DD) score improved from 82±11 to 86±12 (P<0.001).

CONCLUSIONS

URLi use in the Tandem t:slim X2 insulin pump with Control-IQ 1.5 technology was safe for adult and pediatric participants with type 1 diabetes, with quality of life benefits of URLi use perceived by the study participants.

Diabetes Management in Detention Facilities: A Statement of the American Diabetes Association

This statement provides guidance for diabetes care in detention facilities. It focuses on areas where the processes for delivery of care to people with diabetes in detention facilities may differ from those in the community, and key points are made at the end of each section. Areas of emphasis, which inform multiple aspects discussed in this statement, include 1) timely identification or diagnosis of diabetes treatment needs and continuity of care (at reception/intake, during transfers, and upon discharge), 2) nutrition and physical activity, 3) timely access to diabetes management tools (insulin, blood glucose monitoring, tracking data, current diabetes management technologies, etc.), and 4) treatment of the whole person with diabetes (self-management education, mental health support, monitoring and addressing long-term complications, specialty care, etc.).

Association Between Sarcopenia and Chronic Renal Failure (Overt and Concealed) in Chronic Obstructive Pulmonary Disease (COPD) Patients: A Cross-Sectional Study

Background Sarcopenia, a syndrome characterized by a progressive decline in skeletal muscle mass, strength, and function, is frequently associated with chronic diseases such as chronic obstructive pulmonary disease (COPD). Chronic kidney disease (CKD) is a prevalent condition among patients with sarcopenia. Reports suggest that between 15% and 55% of stable COPD patients have sarcopenia. Therefore, the present study aims to determine the association between sarcopenia and chronic renal failure (overt and concealed) in COPD patients. Methodology This institutional-based cross-sectional study was conducted on patients diagnosed with COPD. Hospitalized adult COPD patients who gave consent were included. Sociodemographic information such as age, gender, residence, and prolonged length of stay in the hospital (categorized by a median of 10 days, considering its data distribution in our sample) was obtained using electronic medical records. Skeletal muscle %, visceral fat %, and body fat % were calculated using a bio-electrical impedance analysis device (Omron Body Composition Monitor, Model HBF-702T). Additionally, the strength of the hand grip was measured using a hand dynamometer. Sarcopenia was assessed following the criteria set by the Asian Working Group on Sarcopenia (AWGS). Chronic renal failure (CRF) was assessed by calculating the glomerular filtration rate (GFR) using the Modification of Diet in Renal Disease (MDRD) Study Group equation. Quantitative data were compared using an independent sample t-test. The association was determined using chi-square and multivariate logistic regression analyses. A p-value of <0.05 was considered significant. Results The study found that the proportion of sarcopenia in COPD patients was 52%, with overt and concealed CRF prevalence rates of 31.5% and 27%, respectively. Sarcopenic individuals had significantly lower FEV1 and FEV1/FVC compared to non-sarcopenic patients. The incidence of sarcopenia significantly increased with rising BODE index (body mass index (BMI, B), airflow obstruction (O) as measured by the post-bronchodilator FEV1 (percentage of predicted value), dyspnea (D) assessed by the modified Medical Research Council (MMRC) score, and exercise tolerance (E) measured by 6-minute walking distance) and mMRC (modified Medical Research Council dyspnea scale) dyspnea scale scores. Both concealed CRF and overt CRF patients had four times higher odds of having sarcopenia (AOR=4). Conclusion The study reveals a high prevalence of sarcopenia and provides evidence for the association between sarcopenia and chronic renal failure in COPD patients. These findings underscore the importance of early detection and management of sarcopenia and CRF in COPD patients to optimize their clinical outcomes.

Common Neuroimaging Findings in Bosch-Boonstra-Schaaf Optic Atrophy Syndrome

Bosch-Boonstra-Schaaf optic atrophy syndrome (BBSOAS) is a rare autosomal dominant syndrome secondary to mutations in NR2F1 (COUP-TF1), characterized by visual impairment secondary to optic nerve hypoplasia and/or atrophy, developmental and cognitive delay, and seizures. This study reports common neuroimaging findings in a cohort of 21 individuals with BBSOAS that collectively suggest the diagnosis. These include mesial temporal dysgyria, perisylvian dysgyria, posterior predominant white matter volume loss, callosal abnormalities, lacrimal gland abnormalities, and optic nerve volume loss.

Factors influencing treatment outcomes in patients with isoniazid-resistant pulmonary TB

INTRODUCTION: Patients with isoniazid (H, INH) resistant pulmonary TB but undetected rifampicin (R, RIF) resistance are treated with a 6-month regimen of levofloxacin-RIF-ethambutol-pyrazinamide (6LvxREZ) under India´s National TB Elimination Programme (NTEP).OBJECTIVE: To describe the profile of and treatment outcomes in patients with pulmonary INH-resistant (INHR) TB initiated on TB treatment, and identify factors associated with unfavourable treatment outcomes (died, failed, treatment changed, lost to follow-up).METHODS: This was a retrospective analysis of NTEP database (Ni-kshay) on pulmonary INHR TB patients initiated on treatment with “H mono/poly regimen” (6LvxREZ) between July 2019 and June 2020 with documented treatment outcomes. Proportions with 95% confidence interval (CI) was calculated and logistic regression analysis was performed.RESULTS: Of the 11,519 patients with pulmonary INHR TB, 9,440 (82%) had treatment success (55.1% cured, 26.9% treatment completed). Unfavourable treatment outcome was observed in 1,901 (16.5%). Male sex, tobacco and alcohol use, HIV reactive status were associated with unfavourable treatment outcome. Patients with katG mutations and resistance to fluoroquinolones were likely to have poor treatment outcomes.CONCLUSION: A levofloxacin-based regimen offers a treatment success rate of 82% in patients with pulmonary INHR TB. Sex-specific strategies, interventions to address smoking and alcohol use, focus on HIV-reactive patients and optimising treatment regimens based on drug susceptibility should be considered for improving treatment outcomes.

Evaluating atmospheric mercury (Hg) uptake by vegetation in a chemistry-transport model

Mercury (Hg), a neurotoxic heavy metal, is transferred to marine and terrestrial ecosystems through atmospheric transport. Recent studies have highlighted the role of vegetation uptake as a sink for atmospheric elemental mercury (Hg⁰) and a source of Hg to soils. However, the global magnitude of the Hg⁰ vegetation uptake flux is highly uncertain, with estimates ranging 1000-4000 Mg per year. To constrain this sink, we compare simulations in the chemical transport model GEOS-Chem with a compiled database of litterfall, throughfall, and flux tower measurements from 93 forested sites. The prior version of GEOS-Chem predicts median Hg⁰ dry deposition velocities similar to litterfall measurements from Northern hemisphere temperate and boreal forests (∼0.03 cm s^-1), yet it underestimates measurements from a flux tower study (0.04 cm s^-1vs. 0.07 cm s^-1) and Amazon litterfall (0.05 cm s^-1vs. 0.17 cm s^-1). After revising the Hg⁰ reactivity within the dry deposition parametrization to match flux tower and Amazon measurements, GEOS-Chem displays improved agreement with the seasonality of atmospheric Hg⁰ observations in the Northern midlatitudes. Additionally, the modelled bias in Hg⁰ concentrations in South America decreases from +0.21 ng m^-3 to +0.05 ng m^-3. We calculate a global flux of Hg⁰ dry deposition to land of 2276 Mg per year, approximately double previous model estimates. The Amazon rainforest contributes 29% of the total Hg⁰ land sink, yet continued deforestation and climate change threatens the rainforest's stability and thus its role as an important Hg sink. In an illustrative worst-case scenario where the Amazon is completely converted to savannah, GEOS-Chem predicts that an additional 283 Mg Hg per year would deposit to the ocean, where it can bioaccumulate in the marine food chain. Biosphere-atmosphere interactions thus play a crucial role in global Hg cycling and should be considered in assessments of future Hg pollution.

Two decades of changing anthropogenic mercury emissions in Australia: inventory development, trends, and atmospheric implications

Mercury is a toxic environmental pollutant emitted into the atmosphere by both natural and anthropogenic sources. In Australia, previous estimates of anthropogenic mercury emissions differ by up to a factor of three, with existing inventories either outdated or inaccurate and several lacking Australia-specific input data. Here, we develop a twenty-year inventory of Australian anthropogenic mercury emissions spanning 2000-2019 with annual resolution. Our inventory uses Australia-specific data where possible and incorporates processes not included in other Australian inventories, such as delayed release effects from waste emissions. We show that Australian anthropogenic mercury emissions have decreased by more than a factor of two over the past twenty years, with the largest decrease from the gold production sector followed by brown coal-fired power plants and commercial product waste. Only the aluminium sector has shown a notable increase in mercury emissions. Using a global 3-D chemical transport model (GEOS-Chem), we show that the reduction in emissions has led to a small decrease in mercury deposition to the Australian continent, with annual oxidised mercury deposition ∼3-4% lower with present day emissions than with emissions from the year 2000. We also find that Australian emissions are not accurately represented in recent global emissions inventories and that differences between inventories have a larger impact than emissions trends on simulated mercury deposition. Overall, this work suggests a significant benefit to Australia from the Minamata Convention, with further reductions to Australian mercury deposition expected from decreases in both Australian and global anthropogenic emissions.

P201 Medicopsis romeroi: an emerging cause of subcutaneous infections

 

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

Objective

Medicopsis romeroi is one of the emerging dematiaceous fungi implicated in subcutaneous human infections. Despite advances in diagnostics, identification of this agent still remains delinquent owing to poor sporulation necessitating molecular modalities. Data on clinical and management profile of M. romeroi are available as case reports. In the present study, we describe an index case of M. romeroi infection and clinical risk factors and management profile of 74 cases of M. romeroi cases from India (n = 32) and those reported in the literature (n = 42) till date.

Methods

A detailed history was obtained from the index patient after informed consent. Aspirated fluid was subjected to microbiological investigations. Identification of isolate was done by molecular technique using Sanger's sequencing. All isolates stored at the National culture collection of pathogenic fungi as M. romeroi were retrieved and identity confirmed by ITS sequencing. Demographic and management details were retrieved. We also conducted a systematic literature review of M. romeroi, as per PRISMA guidelines (Fig. 1).

Results

Index case history: A 59-years-old diabetic female presented with lobulated swelling and sinuses on dorsum of the right hand for 10 months. A provisional diagnosis of mycetoma was made. Calcofluor-potassium hydroxide mount of aspiration fluid revealed dematiaceous septate hyphae and Sabouraud dextrose agar grew non-sporulating greyish black aerial mycelia after 3 days of incubation at 25°C and 37°C (Fig. 2). Molecular identification confirmed isolates as M. romeroi and patient was started on itraconazole with surgical excision. A total of 32 cases of M. romeroi infection from India were included. Mean age of patients was 47.2 years with male:female ratio of 1.3:1. Most common predisposing factors were post-renal transplant (46%) and farming (24%). All the patients presented with nodular or cystic swellings, with frequent involvement of lower limbs (56%). Most of the patients were managed using itraconazole (46%), followed by amphotericin B. All the patients except one responded well to treatment.

Literature review: A total of 42 cases have been reported till date, of which 29% are from India. The mean age was 52.3 years, with male:female ratio of 1.4:1. Most common predisposing factors were post-renal transplant (28.5%) and farming/gardening (16.67%). The mean duration to infection in post-transplant cases was 3.26 years and the mean duration to diagnosis in all the cases was 31 months. The noteworthy finding was the absence of predisposing factors in 21.45% cases. A total of 62% presented with skin nodules on the foot, 21.5% on lower limbs, and 11.8% with ocular affliction. Identification was done using molecular modalities in 80% cases. A total of 34% cases were managed using both surgical excision and antifungals, whereas 21% were merely with surgical excision. Another remarkable finding was spontaneous resolution in 5% cases. Antifungals used include itraconazole (25%), followed by voriconazole (21%). MICs of all antifungals showed wide variation (0.25-8 μg/ml for AMB). All the patients except two responded well to treatment and 3 had residual disease.

Conclusion

Medicopsis romeroi is an emerging cause of subcutaneous infection in India. The present study underlines the significance of molecular tests in the identification of this dematiaceous fungus due to its poor sporulation, hindering the phenotypic characterization.

Effect of divergent continuous glucose monitoring technologies on glycaemic control in type 1 diabetes mellitus: A systematic review and meta-analysis of randomised controlled trials

AIMS

We aimed to conduct a systematic review and meta-analysis of randomised controlled clinical trials (RCTs) assessing separately and together the effect of the three distinct categories of continuous glucose monitoring (CGM) systems (adjunctive, non-adjunctive and intermittently-scanned CGM [isCGM]), compared with traditional capillary glucose monitoring, on HbA1c and CGM metrics.

METHODS

PubMed, Web of Science, Scopus and Cochrane Central register of clinical trials were searched. Inclusion criteria were as follows: randomised controlled trials; participants with type 1 diabetes of any age and insulin regimen; investigating CGM and isCGM compared with traditional capillary glucose monitoring; and reporting glycaemic outcomes of HbA1c and/or time-in-range (TIR). Glycaemic outcomes were extracted post-intervention and expressed as mean differences and 95%CIs between treatment and comparator groups. Results were pooled using a random-effects meta-analysis. Risk of bias was assessed using the Cochrane Rob2 tool.

RESULTS

This systematic review was conducted between January and April 2021; it included 22 RCTs (15 adjunctive, 5 non-adjunctive, and 2 isCGM)). The overall analysis of the pooled three categories showed a statistically significant absolute improvement in HbA1c percentage points (mean difference (95% CI): -0.22% [-0.31 to -0.14], I²  = 79%) for intervention compared with comparator and was strongest for adjunctive CGM (-0.26% [-0.36, -0.16]). Overall TIR (absolute change) increased by 5.4% (3.5 to 7.2), I²  = 71% for CGM intervention compared with comparator and was strongest with non-adjunctive CGM (6.0% [2.3, 9.7]).

CONCLUSIONS

For individuals with T1D, use of CGM was beneficial for impacting glycaemic outcomes including HbA1c, TIR and time-below-range (TBR). Glycaemic improvement appeared greater for TIR for newer non-adjunctive CGM technology.

LB0004 EFFICACY AND SAFETY OF DEUCRAVACITINIB, AN ORAL, SELECTIVE, ALLOSTERIC TYK2 INHIBITOR, IN PATIENTS WITH ACTIVE SYSTEMIC LUPUS ERYTHEMATOSUS: A PHASE 2, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY

Background

Tyrosine kinase 2 (TYK2) mediates signaling of Type I interferons, IL-23, and IL-12, key cytokines involved in lupus pathogenesis. Deucravacitinib (DEUC) is an oral, selective, allosteric TYK2 inhibitor with a unique mechanism of action, distinct from Janus kinase (JAK) 1/2/3 inhibitors, and has shown efficacy in psoriasis and psoriatic arthritis.

Objectives

Assess efficacy and safety of DEUC in patients with active systemic lupus erythematosus (SLE).

Methods

This was a 48-week (wk), randomized, double-blind, placebo (PBO)-controlled, phase 2 trial (NCT03252587). Eligible patients met SLICC criteria, were seropositive (ANA/anti-dsDNA/anti-Sm), and had a SLEDAI-2K score ≥6 and ≥1 BILAG index A or >2 BILAG B manifestations from the musculoskeletal or mucocutaneous domain. Patients on standard background medications were randomized 1:1:1:1 to PBO or DEUC (3 mg BID, 6 mg BID, 12 mg QD). Oral corticosteroid tapering to 7.5 mg/day was required from wks 8-20; further tapering was optional from wks 32-40. The primary endpoint was the proportion of patients achieving SRI(4) at wk 32. Key secondary endpoints at wk 48 included SRI(4), BICLA, LLDAS, CLASI-50, and change from baseline in active (tender and swollen) joint count.

Results

A total of 363 patients were randomized, with baseline demographic and disease characteristics similar across treatment groups. Of randomized patients, 275 (76%) completed 48 wks of treatment. The primary endpoint at wk 32 was met, with significantly greater proportion of patients in DEUC 3 mg BID and 6 mg BID groups vs PBO achieving SRI(4) responses (PBO: 34.4%; DEUC 3 mg BID: 58.2%, P=0.0006; DEUC 6 mg BID: 49.5%, P=0.021; DEUC 12 mg QD: 44.9%, P=0.078). SRI(4) response was sustained across all DEUC groups up to 48 wks (Figure 1). At wk 48, the DEUC 3 mg BID group demonstrated statistical significance in BICLA, LLDAS, CLASI-50, and active joint count, and the two other DEUC groups demonstrated clinically meaningful differences vs PBO (Figure 1). Rates of adverse events (AEs), serious AEs, and AEs of interest were similar between DEUC and PBO groups (Table 1). Most common AEs (≥10%) with DEUC were upper respiratory tract infection, nasopharyngitis, headache, and urinary tract infection. No deaths, major cardiac events, thrombotic events, systemic opportunistic infections, or active tuberculosis occurred. Malignancies were rare with similar rates across all groups. No meaningful abnormalities in mean levels of hematology and chemistry laboratory parameters were observed.

Table 1.

Summary of Adverse Events Through Week 48

AE, na(%)Placebo n = 90DEUC 3 mg BID n = 91DEUC 6 mg BID n = 93DEUC 12 mg QD n = 89AE79 (87.8)85 (93.4)81 (87.1)75 (84.3)SAE11 (12.2)7 (7.7)8 (8.6)7 (7.9)AEs leading to treatment discontinuation3 (3.3)8 (8.8)6 (6.5)11 (12.4)Skin-related AEsb12 (13.3)15 (16.5)32 (34.4)30 (33.7)Overall infections/infestations48 (53.3)60 (65.9)60 (64.5)45 (50.6)Serious infections/infestations1 (1.1)1 (1.1)2 (2.2)1 (1.1)Infections of interest Tuberculosis0000 Herpes zosterc4 (4.4)3 (3.3)3 (3.2)2 (2.2) Influenza1 (1.1)3 (3.3)1 (1.1)3 (3.4) COVID-193 (3.3)3 (3.3)5 (5.4)3 (3.4)Malignancy events1 (1.1)d1 (1.1)e01 (1.1)fMACE0000Thrombotic events0000

an is the number of patients who experienced an event. bIncludes (≤8.6% in any arm) acne, rash, dermatitis acneiform, pruritus, skin lesion, urticaria. cIncludes herpes zoster, herpes ophthalmic, genital herpes zoster. dBasal cell carcinoma. eBreast carcinoma. fVaginal squamous cell carcinoma.

AE, adverse event; COVID-19, coronavirus disease 2019; DEUC, deucravacitinib; MACE, major adverse cardiac events; SAE, serious adverse event.

Conclusion

In patients with active SLE, DEUC showed statistically significant and sustained clinical efficacy in SRI(4), improvement across multiple composite and organ-specific measures up to 48 wks, and was well tolerated. DEUC shows promise as a novel therapy for SLE and warrants further investigation in phase 3 trials.

Acknowledgements

This study was sponsored by Bristol Myers Squibb. Professional medical writing assistance was provided by Julianne Hatfield, PhD at Peloton Advantage, LLC, an OPEN Health company, Parsippany, NJ, USA, and funded by Bristol Myers Squibb. The authors acknowledge Christina Crater, MD, who was employed by Bristol Myers Squibb at the time the study was conducted, for contributions to study conduct.

Disclosure of Interests

Eric Morand Consultant of: AstraZeneca, Bristol Myers Squibb, Biogen, Eli Lilly, EMD Serono, Genentech, Servier, and Novartis , Grant/research support from: AbbVie, Amgen, AstraZeneca, Bristol Myers Squibb, Biogen, Eli Lilly, EMD Serono, Genentech, Janssen, and UCB , Marilyn Pike Consultant of: AstraZeneca, Bristol Myers Squibb, and Pfizer, Joan T. Merrill Consultant of: UCB, GlaxoSmithKline, AbbVie, EMD Serono, Remegen, Celgene/Bristol Myers Squibb, AstraZeneca, Amgen, Janssen, Lilly, Genentech, Aurinia, Astellas, Alexion, Sanofi, Zenas, and Provention , Grant/research support from: GlaxoSmithKline and AstraZeneca , Ronald van Vollenhoven Consultant of: UCB, Pfizer, AbbVie, AstraZeneca, Biogen, Biotest, Celgene, Galapagos, Gilead, Janssen, Servier, Paid instructor for: Roche, Pfizer, Speakers bureau: UCB, Pfizer, AbbVie, Galapagos, Janssen, Grant/research support from: Bristol Myers Squibb, GlaxoSmithKline, Eli Lilly, UCB, , Victoria P. Werth Consultant of: Celgene, Medimmune, Resolve, Genentech, Idera, Janssen, Lilly, Biogen, Bristol Myers Squibb, Gilead, Amgen, Medscape, Nektar, Incyte, EMD Serono, CSL Behring, Principia, Crisalis, Viela Bio, Argenx, Kirin, AstraZeneca, AbbVie, GSK, AstraZeneca, Cugene, UCB, Corcept, Beacon Bioscience , Grant/research support from: Celgene, Janssen, Biogen, Gilead, AstraZeneca, Viela, Amgen, Lupus Research Alliance/BMS , Coburn Hobar Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Nikolay Delev Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vaishali Shah Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Brian Sharkey Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Thomas Wegman Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Ian Catlett Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Subhashis Banerjee Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Shalabh Singhal Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

Acquired Resistance to Antiangiogenic Therapies in Hepatocellular Carcinoma Is Mediated by Yes-Associated Protein 1 Activation and Transient Expansion of Stem-Like Cancer Cells

Induction of neoangiogenesis is a hallmark feature during disease progression of hepatocellular carcinoma (HCC). Antiangiogenetic compounds represent a mainstay of therapeutic approaches; however, development of chemoresistance is observed in the majority of patients. Recent findings suggest that tumor-initiating cells (TICs) may play a key role in acquisition of resistance, but the exact relevance for HCC in this process remains to be defined. Primary and established hepatoma cell lines were exposed to long-term sorafenib treatment to model acquisition of resistance. Treatment effects on TICs were estimated by sphere-forming capacity in vitro, tumorigenicity in vivo, and flow cytometry. Adaptive molecular changes were assessed by whole transcriptome analyses. Compensatory mechanisms of resistance were identified and directly evaluated. Sustained antiproliferative effect following sorafenib treatment was observed in three of six HCC cell lines and was followed by rapid regrowth, thereby mimicking responses observed in patients. Resistant cells showed induction in sphere forming in vitro and tumor-initiating capacity in vivo as well as increased number of side population and epithelial cell adhesion molecule-positive cells. Conversely, sensitive cell lines showed consistent reduction of TIC properties. Gene sets associated with resistance and poor prognosis, including Hippo/yes-associated protein (YAP), were identified. Western blot and immunohistochemistry confirmed increased levels of YAP. Combined treatment of sorafenib and specific YAP inhibitor consistently revealed synergistic antioncogenic effects in resistant cell lines. Conclusion: Resistance to antiangiogenic therapy might be driven by transient expansion of TICs and activation of compensatory pro-oncogenic signaling pathways, including YAP. Specific targeting of TICs might be an effective therapeutic strategy to overcome resistance in HCC.

An Integrative QbD Approach for the Development and Optimization of Controlled Release Compressed Coated Formulation of Water-Soluble Drugs

Controlled release dosage forms maintain regulated pharmacokinetic profile of drug substance within its therapeutic window by ensuring constant plasma concentrations. Controlled release formulations not only increase the therapeutic efficacy of drug substances but also reduce their dose-related side effects. Present investigation was conducted to develop, optimize, and validate compressed coated controlled release tablet formulation for highly water-soluble drug substances which have no rate-controlling factor towards its release from dosage form. Drug dispersed waxy core tablet, press coated within the swellable hydrophilic polymeric barrier layer, was developed and optimized via quality by design approach (QbD) using Box-Behnken design. The optimized formulation was characterized and validated using in vitro quality control parameters. Attributes identified under SUPAC guidelines, such as drug release rates at 30 min, 6 h, and 12 h, were considered as the critical quality attributes (CQAs) that significantly affected efficiency of the compressed coated controlled release tablets. CQAs screened using risk assessment and Pareto chart analyses were used for optimizing controlled release dosage form. Findings revealed that tablets containing drug to wax ratio of 1:1, hydrophilic swellable polymer concentration of 200 mg, and prepared using compression pressure of 6.5 kg/cm² exhibited the highest desirability indices in terms of controlling the release rate of drug substance. Optimized formulation was also evaluated for swelling rate, erosion rate, and other post-compression parameters, including release kinetics. Fickian diffusion-based zero-order controlled release of BCS class I drug substance was achieved through the developed dosage form.

The impact of outdoor walking surfaces on lower-limb coordination and variability during gait in healthy adults

BACKGROUND

Inter-joint coordination and variability during gait provide insight into control and adaptability of the neuromuscular system. To date, coordination research has been restricted to laboratory settings, and it is unclear how these findings translate to real-world, outdoor walking environments.

RESEARCH QUESTION

Compared to flat walking, to what extent do outdoor surfaces impact lower-limb inter-joint coordination and variability during gait, in healthy adults?

METHODS

Data from inertial measurement units placed on the lower-back, thigh, and shank were extracted from thirty healthy young adults (15 females, 23.5 ± 4.2 years) during outdoor walking on flat (paved sidewalk); irregular (cobblestone, grass); sloped (slope-up, slope-down); and banked (banked-right, banked-left) surfaces. Sagittal joint angles for the right knee and hip were computed and partitioned by gait phase (stance and swing). Continuous Relative Phase analysis determined inter-joint coordination and variability for the knee-hip joint pair using Mean Absolute Relative Phase (MARP) and Deviation Phase (DP), respectively. One-way repeated measures ANOVAs tested surface effects. Post-hoc Bonferroni adjusted surface comparisons were assessed.

RESULTS

Significant knee-hip surface effects were seen during all gait phases for MARP (p < 0.001) and DP (p ≤ 0.001). Compared to flat walking, grass prompted more in-phase coordination (smaller MARP) during stance and swing phase (p ≤ 0.003). Slope-up caused more in-phase coordination during stance (p < 0.001), while slope-down caused more out-of-phase coordination during stance and swing (p ≤ 0.003), compared to the flat surface. Sloped surfaces prompted more variable (larger DP) knee-hip coordination (p ≤ 0.001), compared to flat walking during stance and swing phase.

SIGNIFICANCE

Compared to flat walking, changes in knee-hip coordination and variability were greatest on slope-up/slope-down surfaces. This could reflect greater changes in lower-limb kinematics on sloped surfaces and/or a neuromuscular response to the demands of a more challenging task.

Improved Mechanistic Model of the Atmospheric Redox Chemistry of Mercury

We present a new chemical mechanism for Hg⁰/Hg^I/Hg^II atmospheric cycling, including recent laboratory and computational data, and implement it in the GEOS-Chem global atmospheric chemistry model for comparison to observations. Our mechanism includes the oxidation of Hg⁰ by Br and OH, subsequent oxidation of Hg^I by ozone and radicals, respeciation of Hg^II in aerosols and cloud droplets, and speciated Hg^II photolysis in the gas and aqueous phases. The tropospheric Hg lifetime against deposition in the model is 5.5 months, consistent with observational constraints. The model reproduces the observed global surface Hg⁰ concentrations and Hg^II wet deposition fluxes. Br and OH make comparable contributions to global net oxidation of Hg⁰ to Hg^II. Ozone is the principal Hg^I oxidant, enabling the efficient oxidation of Hg⁰ to Hg^II by OH. BrHg^IIOH and Hg^II(OH)₂, the initial Hg^II products of Hg⁰ oxidation, respeciate in aerosols and clouds to organic and inorganic complexes, and volatilize to photostable forms. Reduction of Hg^II to Hg⁰ takes place largely through photolysis of aqueous Hg^II-organic complexes. 71% of model Hg^II deposition is to the oceans. Major uncertainties for atmospheric Hg chemistry modeling include Br concentrations, stability and reactions of Hg^I, and speciation and photoreduction of Hg^II in aerosols and clouds.

951 More Than A Checkbox: Importance of Role-Modelling and Visibility Initiatives in Improving Perceptions of Diversity in Surgical Leadership

Introduction

The Royal College of Surgeons of England have committed themselves to championing diversity in surgery in light of recent socio-political events. Although there are now more trainees from underrepresented backgrounds entering the profession, this is not reflected in leadership roles which are key in establishing attitudes and cultures. This study evaluated whether an event showcasing surgeons from underrepresented groups holding leadership positions could improve student perceptions of diversity in surgical leadership.

Method

Participants attended an online event hosted by a student surgical society, where speakers with surgical leadership experience from a range of marginalised backgrounds highlighted topics of diversity and discrimination in surgery. Pre- and post-event questionnaires comprising Likert scales were completed to evaluate student perceptions of surgeons holding a leadership role from the following underrepresented groups: women (or gender non-conforming), BAME, LGBTQ+ and individuals with disabilities. Statistical significance was assessed using a Mann-Whitney U test with p &lt; 0.05 denoting significance throughout.

Results

The event significantly increased attendee confidence in the idea of a surgeon being seen in a leadership role from all underrepresented groups evaluated: 9.3% for female/gender non-conforming individuals (p &lt; 0.01), 12.3% for BAME individuals (p &lt; 0.01), 7.5% for non-heterosexual individuals (p = 0.04) and 16.0% for individuals with a disability (p &lt; 0.01).

Conclusions

Attendees felt significantly more confident in the belief that surgeons from underrepresented backgrounds could hold leadership positions following the event, indicating the benefit of such role-modelling initiatives. More investment is necessary in exploring factors dissuading specific underrepresented groups from pursuing surgical careers and for novel strategies to support these communities accordingly.

1526 Primary Hip and Knee Arthroplasty Documentation: Do Our Operation Notes Follow New GIRFT/BOA Guidelines? A Closed Loop Audit

Aim

Operation notes provide essential information about the techniques and implants used in surgery. Accurate documentation is important to improve patient outcomes and reduce rising litigation costs within the NHS. The aim of this audit was to assess compliance to recent guidance for hip and knee arthroplasty documentation, issued by the Getting It Right First Time (GIRFT) programme in 2019.

Method

Data was collected retrospectively from operation notes of all primary total/unicompartmental knee and hip arthroplasties during August 2019 and again in October 2019 at a DGH. Documentation was audited against data items from the GIRFT knee and hip arthroplasty ‘best practice’ guidelines. Interventions between timeframes included clinician education and a discussion of the guidelines between local surgeons.

Results

In audit rounds 1 and 2 twenty-six and 34 patients had THRs and 23 and 28 had knee arthroplasties respectively. 100% compliance was seen in 5/23 THR criteria and 9/27 knee criteria. Average compliance for knee documentation rose from 71% to 74% but no improvement was seen for THR (68% vs 64%). Those with least improvement related to assessment of range of movement and vascular status at the end of surgery.

Conclusions

Although compliance was good against the majority of data points there was minimal change following a local education intervention. The development and use of fully compliant departmental operation note templates would provide further clarity about steps performed and surgeon rationale should patient care later be scrutinised. The template would also act as an invaluable educational tool for trainees reflecting on the case.

Challenges in LTBI care in the United States identified using a nationwide TB medical consultation database

BACKGROUND

Identifying and treating individuals with latent TB infection (LTBI) represents a critical and challenging component of national TB elimination. Medical consultations by the Centers for Disease Control and Prevention (CDC) funded TB Centers of Excellence (COEs) are an important resource for healthcare professionals (HCPs) caring for individuals with LTBI. This study aimed to identify the most common clinical concerns regarding LTBI care and to describe epidemiologic and clinical features of patients discussed in these consultations.

METHODS

This mixed-methods study randomly sampled 125 consultation inquiries related to LTBI from the COEs' medical consultation database in 2018. Text from consultation records were reviewed and coded to identify reasons for the inquiries and common epidemiologic and clinical patient characteristics.

RESULTS

The most common topics of inquiry for consultation included accurate LTBI diagnosis (36%), management of LTBI treatment-related issues (22%), and choice of appropriate LTBI treatment regimen (17%). Patients for whom consultations were requested commonly had another medical condition (34%), were non-U.S. born (31%), were children (25%), and had a history of travel to TB-endemic areas (18%).

CONCLUSION

Our findings emphasize the challenge of managing patients with either suspected or confirmed LTBI, highlighting the need for ongoing medical consultation support for nuanced clinical and epidemiologic scenarios.

Prematurity and postnatal alterations in intermittent hypoxaemia

Intermittent hypoxaemia (IH) events are well described in extremely preterm infants, but the occurrence of IH patterns in more mature preterm infants remains unclear. The objective of this study was to characterise the effect of gestational age on early postnatal patterns of IH in extremely (<28 weeks), very (28-<32 weeks) and moderately (32-<34 weeks) preterm infants. As expected, extremely preterm infants had a significantly higher frequency of IH events of longer durations and greater time with hypoxaemia versus very and moderately preterm infants. In addition, the postnatal decrease in IH duration was comparable in the very and moderately preterm infants. This progression of IH events should assist clinicians and families in managing expectations for resolution of IH events during early postnatal life.

US COVID-19 Shutdown Demonstrates Importance of Background NO2 in Inferring NOx Emissions From Satellite NO2 Observations

Satellite nitrogen dioxide (NO2) measurements are used extensively to infer nitrogen oxide emissions and their trends, but interpretation can be complicated by background contributions to the NO2 column sensed from space. We use the step decrease of US anthropogenic emissions from the COVID-19 shutdown to compare the responses of NO2 concentrations observed at surface network sites and from satellites (Ozone Monitoring Instrument [OMI], Tropospheric Ozone Monitoring Instrument [TROPOMI]). After correcting for differences in meteorology, surface NO2 measurements for 2020 show decreases of 20% in March-April and 10% in May-August compared to 2019. The satellites show much weaker responses in March-June and no decrease in July-August, consistent with a large background contribution to the NO2 column. Inspection of the long-term OMI trend over remote US regions shows a rising summertime NO2 background from 2010 to 2019 potentially attributable to wildfires.

Immunogenicity and safety of two quadrivalent influenza vaccines in healthy adult and elderly participants in India - A phase III, active-controlled, randomized clinical study

Background: This study was conducted to compare the immunogenicity and safety profile of two quadrivalent influenza vaccines (QIVs) in healthy adults (18-60 years) and elderly (>61 years) participants.Method: This phase III study was conducted from March 2018 to April 2018 across 12 sites in India. In this randomized, observer-blind, active-controlled study, 480 participants were randomized to receive a single dose of test vaccine (subunit, inactivated influenza vaccine; Influvac® Tetra, Abbott) (n = 240) or reference vaccine (split virion, inactivated influenza vaccine; VaxiFlu-4, Zydus Cadilla Healthcare) (n = 240). The primary objective was to describe and compare the immunogenicity of each vaccination group based on hemagglutination inhibition (HI) assay seroprotection and seroconversion rates, and geometric mean fold increase (GMFI) against four vaccine strains in two age groups. Safety and reactogenicity were also compared for the vaccines in both the age groups.Results: The pre- and post-vaccination HI titers for both the vaccines were comparable. The GMFI varied from 4.3 - 22.7 in the test and 3.7-21.6 in the reference vaccine group. The seroprotection rates were >90% for the A-strains and ranged between >43% and <60% for B-strains for both the vaccines. Seroconversion rates varied between 41.4% and 78.8%. Overall, the reported adverse events (AEs) for both the vaccines were <1% and comparable. Reported local and systemic reactions were comparable.Conclusion: Influvac® Tetra elicited an adequate immune response with a favorable safety profile which was comparable with the reference vaccine. (Clinical trial registry number: CTRI/2018/02/012222).

925 Is Routine Bloods Group and Save Required for Emergency Appendicectomy?

Introduction

Appendicectomy is commonly a safe and low bleeding risk procedure. However, some hospital guidelines stipulate a requirement for routine pre-operative blood group and save (G&S).We aim to determine if pre-operative G&S is required for appendicectomies by looking at the number of tests vs transfusion conducted.The cost of G&S is £4.14 per sample in our trust.

Method

A retrospective review was conducted over a 3-month period. Patient data and demographics were identified using the hospital coding, theatre records and transfusion departments.

Results

118 consecutive appendicectomies were identified. Of which, 99 laparoscopic vs 19 open (13 started open vs 6 converted to open) operations were performed. No patients required a blood transfusion during their admission. There was a total of 219 G&S conducted. Cross matching tests for these procedures cost a total of £906. We estimate a cost projection of £3624 for G&S tests over a year and £18120 over 3 years.

Conclusions

Bleeding complications requiring transfusion following appendicectomies are very uncommon. In our unit, 0% of patients identified required a transfusion during their admission. We suggest stopping routine pre-operative G&S for these patients would be clinically safe and would lead to financial savings and reduce pre-operative waiting time.

Development and Characterization of Saturated Fatty Acid-Engineered, Silica-Coated Lipid Vesicular System for Effective Oral Delivery of Alfa-Choriogonadotropin

The present study was designed to develop an efficient, safe, and patient-friendly dosage form, for oral delivery of alfa-choriogonadotropin, used in the treatment of female reproductive infertility. Silica-coated, saturated fatty acid (dipalmitoylphosphatidylcholine (DPPC))-engineered, nanolipidic vesicular (NLVs) system was developed for systemic delivery of therapeutic peptide, alfa-choriogonadotropin, through oral route. DPPC-based NLVs were formulated using the technique of thin-film hydration and were coated with silica to form a homogeneous surface silica shell. The formulated silica-coated NLVs were evaluated for physicochemical and physiologic stability under simulated conditions and were optimized based on physicochemical parameters like particle size, zeta potential, polydispersity index (PDI), entrapment efficiency, and in vitro release profile. Silica-coated, DPPC-based NLVs imparted physicochemical stability to entrapped alfa-choriogonadotropin against the biological environment prevailing in the human gastrointestinal tract (GIT). In vivo, subchronic animal toxicity studies were performed to assess the safety of the designed dosage form. Results of in vitro characterization and in vivo pharmacokinetic studies of fabricated formulation revealed that the silica-coated, DPPC-based NLV formulation was not only stable in human GIT but was also as efficacious as a marketed parenteral formulation for the systemic delivery of alfa-choriogonadotropin. In vivo toxicity studies revealed that silica-coated NLVs did not alter hematological and serum biochemical parameters. The histopathological studies also depicted no macroscopic changes in major organs; thus, the developed formulation was proven to be nontoxic and equally efficient as a marketed parenteral formulation for the delivery of alfa-choriogonadotropin with added benefits of possible self-medication, more patient acceptability, and no chances of infection.

Bone and body characteristics of freestyle and nonfreestyle skiers

BACKGROUND

Freestyle skiers must optimize their aerial performance by maintaining the strength and coordination to propel themselves in the air and adapt to landings and take-offs on uneven surfaces. The purpose of this study is to investigate the differences in areal bone mineral density (aBMD) and body composition in freestyle skiers and nonfreestyle skiing controls.

HYPOTHESIS

We hypothesized that the unique demands and summation of forces experienced by freestyle athletes would manifest as greater femoral neck aBMD, lower percent body fat, and lower BMI than nonfreestyle skiing controls.

LEVEL OF EVIDENCE

Level 3, Retrospective Cohort Study.

METHODS

18 freestyle skiers (14M 4F, [27.56 ± 5.22 years]) and 15 controls (7M 8F, [26.93 ± 3.54 years]) were measured with dual energy X-ray absorptiometry (DXA) to determine total body composition, hip and lumbar spine aBMD, and bone mineral composition (BMC). Height and weight were measured with an in-office stadiometer and scale. Questionnaires were used to determine physical activity and pertinent medical history. Between-group variations were analyzed with an analysis of variance (ANOVA) and stratified by sex.

RESULTS

Percent body fat, hip and lumbar spine aBMD, BMC, and area were all similar between freeski and nonfreeski athletes (p<0.05 for all). BMI was significantly lower in male freeski athletes (23.97kg/m2, 95% CI [22.75-25.18]) compared to nonfreestyle skiing controls (26.64kg/m2, 95% CI [24.43-28.86]) (p=0.03).

CONCLUSIONS

Freestyle skiers have a lower BMI than nonfreestyle skiers. All skiers in this study has similar percent body fat, aBMD, and BMC. This pilot study supports that there are unique musculoskeletal adaptations based on type of skiing.

CLINICAL RELEVANCE

Skiers endure a variety of intense physical forces yet remain understudied despite high orthopedic injury rates. This study serves to broaden the current sports health literature and explore the physical demands and subsequent physiology of freestyle skiers.

Fatal Cutaneous Zygomycosis caused by Saksaenea Vasiformis

Fungi in the class of zygomycetes usually produce serious infections in diabetics and immunocompromised hosts. Cutaneous zygomycosis is a less common form, with an unpredictable extent of anatomical involvement and clinical course1.¹ Here, we report a case of primary cutaneous zygomycosis caused by saksaenea vasiformis as posttraumatic complications in a diabetic female. Zygomycosis was suspected and specimens from the surgical debridement were examined by microbiological and histopathological studies for conforming the clinical diagnosis. Rapid diagnosis, liposomal amphotericin B, and proper debridement of affected tissue are necessary to avoid a fatal outcome.

Surgical cardiac sympathetic denervation in patients with VT storm: long term follow-up data

Background

Surgical Cardiac Sympathetic Denervation (CSD) is a procedure which involves surgical removal of terminal cervical and thoracic sympathetic ganglion for reducing sympathetic discharge to the heart. CSD is usually performed as a last desperate measure in treatment of ventricular tachycardia (VT). We report here the clinical profile and long-term follow-up of all our patients who underwent CSD (unilateral or bilateral) predominantly upfront prior to considering catheter ablation of VT for VT storm.

Material and methods

We retrospectively collected data of all patients who underwent CSD for VT storm between year 2010 till 2019. Success of CSD was defined as successful discharge of patient from the hospital after the procedure more than 75% decrease in the frequency of VT after two weeks of surgical procedure.

Results

A total of 65 patients underwent CSD in the above-mentioned period and the average duration of follow-up was 28 months. The clinical parameters, demographic data and outcome analysis is provided in details in table 1. Only 14 (21.5%) patients underwent attempt of catheter ablation of VT prior to considering CSD. CSD was successful in 53 (81.5%) of patients. There was a significant decline in the incidence of number of ICD or external shocks before and after CSD (25.2±39.4 vs 1.09±2.9) respectively. There was no significant effect of CSD on ejection fraction. None of the available clinical parameters predicted the success of CSD.

Discussion and conclusion

The current retrospective analysis reemphasize the role of surgical CSD in treatment of patients with VT storm. As in predominant patient's CSD was performed even before the attempting catheter-based ablation, it brings in a new dimension in the treatment of VT. Efficacy of CSD (81.5%) in experienced hand is equivalent or even better than catheter-based ablation in patients with VT storm.

Funding Acknowledgement

Type of funding source: None

Tackling The Challenge Of Opioid Use And Abuse And Treatment Of Chronic Pain Management

Introduction/Objective

Deaths from opioid overdose increased 12% from 2016 to 2017. This major economic burden cost roughly $78.5 billion in the US. This steep increase in drug overdose deaths can be attributed to increased synthetic opioid abuse. To better understand and reduce opioid abuse amongst patients at Henry Ford Health System, Detroit MI, we sought to collaborate with physicians to manage prescribing, interpret test results, improve patient care, and deliver more value.

Primary Aim: To create a directed pain panel for ordering and interpreting pain management drugs to help providers to better manage patients and to assess compliance from test ordering history to serve patients safely and effectively.

Secondary Aim: To streamline the process of prescribing pain medications and to create a patient centered approach to treat chronic non-cancer patients who actually need opioids, to minimize the risk of abuse, diversion and addiction among patients.

Methods

Plan Do Check Act (PDCA) cycles of process improvement were used to achieve our two aims. In the first cycle, a drug screen-ordering guide was developed to facilitate screening (qualitative) and confirmation (quantitative) ordering practices. As part of this, providers prescribing for chronic pain patients were advised to use drugs of abuse panel rather than our emergency drug screen. In the second cycle, a directed pain panel (DPP) was introduced with reflex to confirmation testing. The DPP led to discovery of unexpected fentanyl positives, which were further investigated.

Results

A survey was conducted to investigate provider-ordering practices, which showed that use of the new drugs of abuse panel rose from 57% to 77%. The DPP was accepted by ~60% of physicians and was frequently reordered in follow-up. Analysis of unexpected fentanyl positivity revealed 30% true positivity, thus identifying unknown patient use. A future PDCA cycle is focused on developing, implementing, and measuring the customer value of a laboratory generated interpretive opioid results report at 5 similar organizations with a goal to assist with test selection and simplify provider interpretation of results.

Conclusion

A future PDCA cycle is focused on developing, implementing, and measuring the customer value of a laboratory generated interpretive opioid results report at 5 similar organizations with a goal to assist with test selection and simplify provider interpretation of results.

0906 Identification Of Physical Exam Findings With High Predictive Value For Moderate To Severe Pediatric Obstructive Sleep Apnea(osa) In Overweight/obese Children

Introduction

Obstructive sleep apnea(OSA) is highly prevalent and under-diagnosed in the overweight/obese pediatric population largely due to limitations of existing pediatric OSA screening instruments including lack of efficiency and practical implementation and lack of careful consideration of physical examination(PE) findings with high predictive value for OSA. We sought to identify PE finding(s) predictive of pediatric OSA in overweight/obese patients to inform development of an OSA screening tool.

Methods

Overweight/obese patients presenting to the Cleveland Clinic weight-management clinic between 2013-2018 with polysomnogram (PSG) data were included. The association of PE predictors: age, sex, race (white, black, other), neck (NC), waist circumference (WC), tonsil size (TS), height, systolic and diastolic blood pressure (BP) percentiles) in relation to OSA defined by apnea-hypopnea index (AHI)≥5,i.e. clinically significant pediatric OSA, were assessed using univariate and multivariate logistic regression models (OR,95%CI).

Results

Retrospective analysis of 180 overweight/obese patients (BMI percentile&gt;85th for age and sex) and age 12.5±3.7 years were included. The multivariate model showed that only WC was significantly associated (1.03, 1.00 - 1.07, p=0.038) with OSA defined as AHI≥5. A statistically significant interaction of age and sex was observed such that the likelihood of OSA increased in males with older age and conversely decreased in females with older age. (1.26,1.04 -1.52, p=0.038) The reduced multivariate model, which included age, sex, WC, and age*sex interaction term, correctly discriminated AHI &lt;5 vs. ≥ 5 66.5% of the time.

Conclusion

In this large clinic-based overweight/obese pediatric sample, males, older age and WC were significant predictors of OSA and TS was not. A significant interaction of age and sex was observed supporting increased OSA with increasing age in males. Data generated supports value of PE findings of age, sex and WC to incorporate in development of an OSA screening tool for overweight/obese children.

Support

 

A Machine Learning Enabled Wireless Intracranial Brain Deformation Sensing System

A leading cause of traumatic brain injury (TBI) is intracranial brain deformation due to mechanical impact. This deformation is viscoelastic and differs from a traditional rigid transformation. In this paper, we describe a machine learning enabled wireless sensing system that predicts the trajectory of intracranial brain deformation. The sensing system consists of an implantable soft magnet and an external magnetic sensor array with a sensing volume of 12 × 12 × 4 mm³. Machine learning algorithm predicts the brain deformation by interpreting the magnetic sensor outputs created by the change in position of the implanted soft magnet. Three different machine learning models were trained on calibration data: (1) random forests, (2) k-nearest neighbors, and (3) a multi-layer perceptron-based neural network. These models were validated using both in vitro (a needle inserted into PVC gel) and in vivo (blast exposure to live and dead rat brains) experiments. The in vitro gel deformation predicted by these machine learning models showed excellent agreement with the camera measurements and had absolute error = 138 μm, Fréchet distance = 372 μm with normalized Procrustes disparity = 0.034. The in vivo brain deformation predicted by these models had absolute error = 50 μm, Fréchet distance = 95 μm with normalized Procrustes disparity = 0.055 for dead animal and absolute error = 125 μm, Fréchet distance = 289 μm with normalized Procrustes disparity = 0.2 for live animal respectively. These results suggest that the proposed machine learning enabled sensor system can be an effective tool for measuring in situ brain deformation.

The Contemporary Prevalence of Diabetic Neuropathy in Type 1 Diabetes: Findings From the T1D Exchange

OBJECTIVE

To evaluate the contemporary prevalence of diabetic peripheral neuropathy (DPN) in participants with type 1 diabetes in the T1D Exchange Clinic Registry throughout the U.S.

RESEARCH DESIGN AND METHODS

DPN was assessed with the Michigan Neuropathy Screening Instrument Questionnaire (MNSIQ) in adults with ≥5 years of type 1 diabetes duration. A score of ≥4 defined DPN. Associations of demographic, clinical, and laboratory factors with DPN were assessed.

RESULTS

Among 5,936 T1D Exchange participants (mean ± SD age 39 ± 18 years, median type 1 diabetes duration 18 years [interquartile range 11, 31], 55% female, 88% non-Hispanic white, mean glycated hemoglobin [HbA1c] 8.1 ± 1.6% [65.3 ± 17.5 mmol/mol]), DPN prevalence was 11%. Compared with those without DPN, DPN participants were older, had higher HbA1c, had longer duration of diabetes, were more likely to be female, and were less likely to have a college education and private insurance (all P < 0.001). DPN participants also were more likely to have cardiovascular disease (CVD) (P < 0.001), worse CVD risk factors of smoking (P = 0.008), hypertriglyceridemia (P = 0.002), higher BMI (P = 0.009), retinopathy (P = 0.004), reduced estimated glomerular filtration rate (P = 0.02), and Charcot neuroarthropathy (P = 0.002). There were no differences in insulin pump or continuous glucose monitor use, although DPN participants were more likely to have had severe hypoglycemia (P = 0.04) and/or diabetic ketoacidosis (P < 0.001) in the past 3 months.

CONCLUSIONS

The prevalence of DPN in this national cohort with type 1 diabetes is lower than in prior published reports but is reflective of current clinical care practices. These data also highlight that nonglycemic risk factors, such as CVD risk factors, severe hypoglycemia, diabetic ketoacidosis, and lower socioeconomic status, may also play a role in DPN development.

Anthropogenic control over wintertime oxidation of atmospheric pollutants

During winter in the mid-latitudes, photochemical oxidation is significantly slower than in summer and the main radical oxidants driving formation of secondary pollutants, such as fine particulate matter and ozone, remain uncertain, owing to a lack of observations in this season. Using airborne observations, we quantify the contribution of various oxidants on a regional basis during winter, enabling improved chemical descriptions of wintertime air pollution transformations. We show that 25-60% of NO_x is converted to N₂O₅ via multiphase reactions between gas-phase nitrogen oxide reservoirs and aerosol particles, with ~93% reacting in the marine boundary layer to form >2.5 ppbv ClNO₂. This results in >70% of the oxidizing capacity of polluted air during winter being controlled, not by typical photochemical reactions, but from these multiphase reactions and emissions of volatile organic compounds, such as HCHO, highlighting the control local anthropogenic emissions have on the oxidizing capacity of the polluted wintertime atmosphere.

Drivers of topoisomerase II poisoning mimic and complement cytotoxicity in AML cells

Recently approved cancer drugs remain out-of-reach to most patients due to prohibitive costs and only few produce clinically meaningful benefits. An untapped alternative is to enhance the efficacy and safety of existing cancer drugs. We hypothesized that the response to topoisomerase II poisons, a very successful group of cancer drugs, can be improved by considering treatment-associated transcript levels. To this end, we analyzed transcriptomes from Acute Myeloid Leukemia (AML) cell lines treated with the topoisomerase II poison etoposide. Using complementary criteria of co-regulation within networks and of essentiality for cell survival, we identified and functionally confirmed 11 druggable drivers of etoposide cytotoxicity. Drivers with pre-treatment expression predicting etoposide response (e.g., PARP9) generally synergized with etoposide. Drivers repressed by etoposide (e.g., PLK1) displayed standalone cytotoxicity. Drivers, whose modulation evoked etoposide-like gene expression changes (e.g., mTOR), were cytotoxic both alone and in combination with etoposide. In summary, both pre-treatment gene expression and treatment-driven changes contribute to the cell killing effect of etoposide. Such targets can be tweaked to enhance the efficacy of etoposide. This strategy can be used to identify combination partners or even replacements for other classical anticancer drugs, especially those interfering with DNA integrity and transcription.

CT-Guided Block and Radiofrequency Ablation of the C2 Dorsal Root Ganglion for Cervicogenic Headache

The purpose of this report is to describe the technical aspects of CT-guided C2 dorsal root ganglion diagnostic block and radiofrequency ablation for refractory cervicogenic headache. CT guidance allows precise and safe positioning of a needle adjacent to the C2 dorsal root ganglion. At-risk neural and vascular structures can be avoided with CT, and it can provide a thorough understanding of upper cervical neuroanatomy.

Abstract 5223: Epigenetic silencing mediated by non-phosphorylated STAT5B prevents differentiation in acute myeloid leukemia

STAT5 proteins are transcription factors involved in the regulation of proliferation, apoptosis and differentiation. Upon ligand-mediated activation, phosphorylated STAT5A (pSTAT5A) and pSTAT5B form homo- or heterodimers, translocate to the nucleus and activate transcription. Recent data indicate an important role of un-phosphorylated STAT5 (uSTAT5) in the regulation of differentiation. For example, the presence of uStat5 shifts the balance toward the maintenance of leukemic stem cells, whereas genetic depletion of Stat5induced differentiation. Further, uSTAT5 has been shown to act as a repressor of megakaryocytic differentiation via restricting the access of ERG to its target genes. To further investigate the function of uSTAT5 in mammalian AML, we established several cell line models expressing doxycycline-inducible shRNA directed against either STAT5A or STAT5B. In uSTAT5-expressing AML cells targeting of STAT5A or STAT5B suppressed cell growth and induced differentiation. These effects were significantly stronger upon knockdown of STAT5B compared to STAT5A. Global RNA sequencing demonstrated enrichment of differentiation programs upon downregulation of uSTAT5B. To further explore the biological function of uSTAT5, we performed SILAC-based global proteomics after pulldown of either STAT5A or STAT5B. While uSTAT5A was found to be associated with proteins involved in RNA processing, uSTAT5B primarily co-precipitated with chromatin- and histone-binding proteins, like the transcriptional repressor ETV6 or the histone H3K4 demethylase KDM5C. To dissect the specific roles of pSTAT5B and uSTAT5B, we performed co-immunoprecipitation assay upon treatment of AML cells with GM-CSF or vehicle control. As expected, GM-CSF treatment caused strong phosphorylation of STAT5A/B, however, uSTAT5B-binding of ETV6 was almost completely abolished, indicating a specific association only with uSTAT5B. As depletion of uSTAT5B induced differentiation and uSTAT5B interacts with KDM5C and ETV6, we hypothesized that uSTAT5B prevents transcription of genes involved in differentiation. To address this question, we performed H3K4me3 ChIP-seq analysis in THP-1 cells upon knockdown of STAT5B. Downregulation of uSTAT5B caused strong accumulation of H3K4me3 at promoter regions of previously silenced genes. Finally, we wanted to investigate whether targeting of KDM5C can reverse disturbed differentiation in AML cells. Treatment with the KDM5 inhibitor CPI-455 significantly inhibited proliferation and induced apoptosis, but only in AML samples expressing uSTAT5B. In summary, our data provide evidence that uSTAT5B specifically blocks differentiation in AML cells via its interaction with KDM5C followed by repression of H3K4me3 at distinct promoter regions. Targeting of uSTAT5B or its interacting partners might represent an interesting novel strategy in AML therapy.

Citation Format: Jakub Szybinski, Daniel Sasca, Jan Heidelberger, Karolin Klumb, Viral Shah, Anna Dolnik, Matthias Theobald, Lars Bullinger, Petra Beli, Thomas Kindler. Epigenetic silencing mediated by non-phosphorylated STAT5B prevents differentiation in acute myeloid leukemia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 5223.