Detection, survival, and persistence of Staphylococcus capitis NRCS-A in neonatal units in England

BACKGROUND

The multidrug-resistant Staphylococcus capitis clone, NRCS-A, is increasingly associated with late-onset sepsis in low birthweight newborns in neonatal intensive care units (NICUs) in England and globally. Understanding where this bacterium survives and persists within the NICU environment is key to developing and implementing effective control measures.

AIM

To investigate the potential for S. capitis to colonize surfaces within NICUs.

METHODS

Surface swabs were collected from four NICUs with and without known NRCS-A colonizations/infections present at the time of sampling. Samples were cultured and S. capitis isolates analysed via whole-genome sequencing. Survival of NRCS-A on plastic surfaces was assessed over time and compared to that of non-NRCS-A isolates. The bactericidal activity of commonly used chemical disinfectants against S. capitis was assessed.

FINDINGS

Of 173 surfaces sampled, 40 (21.1%) harboured S. capitis with 30 isolates (75%) being NRCS-A. Whereas S. capitis was recovered from surfaces across the NICU, the NRCS-A clone was rarely recovered from outside the immediate neonatal bedspace. Incubators and other bedside equipment were contaminated with NRCS-A regardless of clinical case detection. In the absence of cleaning, S. capitis was able to survive for three days with minimal losses in viability (<0.5 log10 reduction). Sodium troclosene and a QAC-based detergent/disinfectant reduced S. capitis to below detectable levels.

CONCLUSION

S. capitis NRCS-A can be readily recovered from the NICU environment, even in units with no recent reported clinical cases of S. capitis infection, highlighting a need for appropriate national guidance on cleaning within the neonatal care environment.

Rare ^{40}K Decay with Implications for Fundamental Physics and Geochronology

Potassium-40 is a widespread, naturally occurring isotope whose radioactivity impacts subatomic rare-event searches, nuclear structure theory, and estimated geological ages. A predicted electron-capture decay directly to the ground state of argon-40 has never been observed. The KDK (potassium decay) collaboration reports strong evidence of this rare decay mode. A blinded analysis reveals a nonzero ratio of intensities of ground-state electron-captures (I_{EC^{0}}) over excited-state ones (I_{EC^{*}}) of I_{EC^{0}}/I_{EC^{*}}=0.0095±[over stat]0.0022±[over sys]0.0010 (68% C.L.), with the null hypothesis rejected at 4σ. In terms of branching ratio, this signal yields I_{EC^{0}}=0.098%±[over stat]0.023%±[over sys]0.010%, roughly half of the commonly used prediction, with consequences for various fields [27L. Hariasz et al., companion paper, Phys. Rev. C 108, 014327 (2023)PRVCAN2469-998510.1103/PhysRevC.108.014327].

Safety and efficacy of the tumor-selective adenovirus enadenotucirev, in combination with nivolumab, in patients with advanced/metastatic epithelial cancer: a phase I clinical trial (SPICE)

BACKGROUND

Novel combination therapies to overcome anti-PD-1 resistance are required. Enadenotucirev, a tumor-selective blood stable adenoviral vector, has demonstrated a manageable safety profile and ability to increase tumor immune-cell infiltration in phase I studies in solid tumors.

METHODS

We conducted a phase I multicenter study of intravenous enadenotucirev plus nivolumab in patients with advanced/metastatic epithelial cancer not responding to standard therapy. Co-primary objectives were safety/tolerability and maximum tolerated dose and/or maximum feasible dose (MTD/MFD) of enadenotucirev plus nivolumab. Additional endpoints included response rate, cytokine responses, and anti-tumor immune responses.

RESULTS

Overall, 51 heavily pre-treated patients were treated, 45/51 (88%) of whom had colorectal cancer (35/35 patients with information available were microsatellite instability-low/microsatellite stable) and 6/51 (12%) had squamous cell carcinoma of the head and neck. The MTD/MFD of enadenotucirev plus nivolumab was not reached, with the highest dose level tested (1×10¹² vp day 1; 6×10¹² vp days 3 and 5) shown to be tolerable. Overall, 31/51 (61%) patients experienced a grade 3-4 treatment-emergent adverse event (TEAE), most frequently anemia (12%), infusion-related reaction (8%), hyponatremia (6%), and large intestinal obstruction (6%). Seven (14%) patients experienced serious TEAEs related to enadenotucirev; the only serious TEAE related to enadenotucirev occurring in >1 patient was infusion-related reaction (n=2). Among the 47 patients included in efficacy analyses, median progression-free survival was 1.6 months, objective response rate was 2% (one partial response for 10 months), and 45% of patients achieved stable disease. Median overall survival was 16.0 months; 69% of patients were alive at 12 months. Persistent increases in Th1 and related cytokines (IFNγ, IL-12p70, IL-17A) were seen from ~day 15 in two patients, one of whom had a partial response. Among the 14 patients with matching pre-tumor and post-tumor biopsies, 12 had an increase in intra-tumoral CD8⁺ T-cell infiltration and 7 had increased markers of CD8 T-cell cytolytic activity.

CONCLUSIONS

Intravenously dosed enadenotucirev plus nivolumab demonstrated manageable tolerability, an encouraging overall survival and induced immune cell infiltration and activation in patients with advanced/metastatic epithelial cancer. Studies of next-generation variants of enadenotucirev (T-SIGn vectors) designed to further re-program the tumor microenvironment by expressing immune-enhancer transgenes are ongoing.

TRIAL REGISTRATION NUMBER

NCT02636036.

A protracted outbreak of difficult-to-treat resistant Pseudomonas aeruginosa in a haematology unit: a matched case-control study demonstrating increased risk with use of fluoroquinolone

BACKGROUND

Between September 2016 and November 2020, 17 cases of difficult-to-treat resistant Pseudomonas aeruginosa (DTR-PA) were reported in haematology patients at a tertiary referral hospital in the North of England.

AIM

A retrospective case-control study was conducted to investigate the association between DTR-PA infection and clinical interventions, patient movement, antimicrobial use and comorbidities.

METHODS

Cases were patients colonized or infected with the outbreak strain of DTR-PA who had been admitted to hospital prior to their positive specimen. Exposures were extracted from medical records, and cases were compared with controls using conditional logistic regression. Environmental and microbiological investigations were also conducted.

FINDINGS

Seventeen cases and 51 controls were included. The final model included age [>65 years, adjusted OR (aOR) 6.85, P=0.232], sex (aOR 0.60, P=0.688), admission under the transplant team (aOR 14.27, P=0.43) and use of ciprofloxacin (aOR 102.13, P=0.030). Investigations did not indicate case-to-case transmission or a point source, although a common environmental source was highly likely.

CONCLUSION

This study found that the use of fluoroquinolones is an independent risk factor for DTR-PA in haematology patients. Antimicrobial stewardship and review of fluoroquinolone prophylaxis should be considered as part of PA outbreak investigations in addition to standard infection control interventions.

Exploring barriers to vaccine delivery in adult migrants: a qualitative study in primary care

Background

The COVID-19 pandemic has highlighted shortfalls in the delivery of vaccine programmes to older migrant groups. Guidelines exist, however, little is known around care pathways and engagement of these older cohorts in routine vaccinations in primary care, including catch-up programmes. We explored the views of primary care professionals around barriers and facilitators to catch-up vaccination in adult migrants (defined as foreign born; 18+ years) with incomplete or uncertain vaccination status.

Methods

We did a qualitative interview study with purposive sampling and thematic analysis in UK primary care (50 practices included nationally; 1 hour qualitative interviews) with 64 primary care professionals (PCPs): 48 clinical staff including GPs, Practice Nurses and healthcare assistants (HCAs); 16 administrative staff including practice managers and receptionists (mean age 45 years; 84.4% female; a range of ethnicities).

Results

Participants highlighted direct and indirect barriers to catch-up vaccines in adult migrants who may have missed vaccines as children, missed boosters, and not be aligned with the UK's vaccine schedule, from both a personal and service-delivery level, with themes including: lack of training and knowledge of guidance around catch-up vaccination among staff; unclear or incomplete vaccine records; and lack of incentivization (including financial reimbursement) and dedicated time and care pathways. Adult migrants were reported as being excluded from many vaccination initiatives, most of which focus exclusively on children. PCPs noted that migrants expressed to them a range of views around vaccines, from positivity to uncertainty, to refusal.

Conclusions

Vaccine uptake in adult migrants could be improved through implementing new financial incentives, strengthening care pathways and training, and working directly with local community groups to improve understanding around the benefits of vaccination at all ages.

Key messages

Strategies to increase catch-up vaccination among migrants: a qualitative study and rapid review

Background

WHO’s Immunization Agenda 2030 has placed renewed focus on catch-up vaccination across the life course to meet global targets for reduction in vaccine-preventable diseases through increased vaccine coverage, including among migrant groups who may require catch-up vaccination to align them with host country vaccination schedules.

Methods

We did a global rapid review (01/2010 to 04/2022) to explore drivers of vaccine hesitancy among migrants followed by an in-depth qualitative study (semi-structured, telephone interviews) among recently arrived adult migrants (foreign-born, &gt;18 years old, residing in the UK &lt; 10 years). Interviews explored views on routine vaccination including accessibility, confidence and awareness. Data were analysed iteratively using thematic analysis.

Results

63 papers were included in the rapid review, including data from 22 countries/regions. Multiple factors driving under-immunisation and hesitancy in migrants were reported, including language barriers, low health literacy, social exclusion, low cultural competency and accessibility in healthcare systems. Our qualitative study recruited 40 migrants (mean age: 36.7 years; 62.5% female) resident in the UK (6 refugees, 19 asylum-seekers, 8 undocumented, 7 labour migrants). Major barriers to catch-up vaccination included a lack of provider recommendation and low awareness, with vaccination viewed as only relevant to children. Hesitancy around specific vaccines, such as MMR, was often influenced by misinformation. Participants suggested that novel strategies such as walk-in or mobile access points, consistent provider recommendations, and translation of information into relevant languages, may enhance accessibility and uptake of routine vaccinations.

Conclusions

Targeted and tailored information campaigns, versatile and proactive access pathways and education for healthcare staff on cultural competency will be needed to ensure uptake of catch-up vaccination among marginalised migrant groups.

Key messages

• Newly arrived adult migrants face barriers to catch-up vaccination in host countries, which may hinder immunisation coverage and increase the risk of vaccine-preventable disease outbreaks.

• Health systems must develop novel mechanisms to proactively offer culturally competent and accessible catch-up vaccination services to adult migrants on and after arrival.

Abstract CT213: A multicenter phase 1a/b study of NG-350A, a tumor-selective anti-CD40-antibody expressing adenoviral vector, and pembrolizumab in patients with metastatic or advanced epithelial tumors (FORTIFY)

Background: The efficacy of immune checkpoint inhibitors is often limited by immunosuppressive tumor microenvironments (TME) and novel combination therapies are required to overcome resistance. NG-350A is a novel T-SIGn (Tumor-Specific Immuno Gene) adenoviral vector that expresses a fully human agonistic IgG anti-CD40 antibody to promote innate and adaptive immune responses. Additionally, NG-350A selectively replicates in tumor cells, allowing IV dosing to be coupled with local transgene expression in the TME, thereby targeting all tumor lesions while limiting systemic exposure. Through these immunostimulatory effects the vector is designed to re-program ‘cold’ TMEs to allow functional anti-cancer immune responses. Data from an ongoing study with IV NG-350A monotherapy have shown promising tolerability, as well as prominent and sustained elevations in inflammatory cytokines (IL-2, IFNγ, IL-17A, IL-2 and IFNα2) consistent with the mechanism of action of anti-CD40 in stimulating TME re-programming [Naing 2021]. Based on these promising initial data, we designed a study to further assess the safety, tolerability and preliminary efficacy of NG-350A + pembrolizumab.

Methods: FORTIFY (NCT05165433) is an open-label, dose-escalating, phase 1a/b study of NG-350A + pembrolizumab. Eligible patients have advanced/metastatic epithelial tumors that have progressed after ≥1 line of systemic therapy and are incurable by local therapy. Patients eligible for phase 1a must have experienced failure of prior PD-1/PD-L1 inhibition as part of any prior line of therapy; patients eligible for phase 1b must have primary resistance to PD-1/PD-L1 inhibition. During phase 1a, up to 30 patients will receive escalating doses of IV NG-350A (Bayesian Optimal Interval design) to a maximum of 1 × 1012 viral particles (vp) on Day 1 and 1 × 1013 vp on Days 3 and 5 (1 cycle). Patients will receive a fixed-dose of pembrolizumab (200 mg IV) on Day 15 and then every 3 weeks thereafter for up to 35 cycles. Phase 1b will further investigate the efficacy/safety of the selected regimen in up to 3 tumor-specific cohorts using a Simon 2-stage design. Co-primary objectives are to characterize the safety and tolerability of NG-350A + pembrolizumab and to identify a recommended dose. Preliminary efficacy and immunogenicity are secondary endpoints. Pharmacodynamic outcomes will be assessed using tumor tissues and blood. Analyses of tumor tissue (serial biopsies at baseline and Day 15 of cycles 1-3 [cycles 1-2 only in Phase 1b]) will explore virus replication, transgene expression and immune/inflammatory responses. Analyses of serial blood samples will explore cytokine production and changes in peripheral immune cell subsets. Recruitment is expected to begin in Q1 2022.

Citation Format: Tom Lillie, Mark O'Hara, Christian Ottensmeier, Eileen Parkes, Lee Rosen, David Krige, Marya Chaney, Jo Carter, Vladimir Evilevitch, Matthew Thomas, Aung Naing. A multicenter phase 1a/b study of NG-350A, a tumor-selective anti-CD40-antibody expressing adenoviral vector, and pembrolizumab in patients with metastatic or advanced epithelial tumors (FORTIFY) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT213.

FORTITUDE: Results of a phase 1a study of the novel transgene-armed and tumor-selective vector NG-350A with and without pembrolizumab (pembro)

2559

Background: Stimulating CD40 may support anti-cancer immune responses; however, on-target toxicity limits systemic dosing. NG-350A is a tumor-selective and blood stable adenoviral T-SIGn vector expressing a potent fully human IgG agonistic anti-CD40 antibody (mAb). NG-350A was designed to selectively deliver anti-CD40 to multiple tumor sites via IV delivery, driving immunological tumor re-engineering while avoiding systemic toxicity. We report results from a first-in-human trial after completion of enrollment. Methods: FORTITUDE (NCT03852511) is a phase 1 study of NG-350A ± pembro in patients (pts) with metastatic/advanced epithelial tumors. NG-350A monotherapy (mTx) was dose-escalated in separate intratumoral (IT; increasing numbers of doses) or IV (one cycle; three increasing dose levels) cohorts. IV NG-350A + pembro (200 mg Q3W for ≤8 cycles) was then assessed. Results: As of Jan 2022, 28 heavily pre-treated pts had received NG-350A, either as IT mTx (n=9; two dose levels), IV mTx (n=16; IV dose levels 1, 3 & 4) or IV + pembro (n=3; IV dose level 2). The MTD of NG-350A ± pembro was not reached, with no DLTs at the highest IT and IV dose levels. The safety profile of NG-350A was consistent with acute reactions to viral particles and asymptomatic aPTT prolongations (Table). No systemic CD40 transgene protein was detected at any dose level and the only SAE to occur in >1 pt was pneumonia. No objective responses were observed; however, 3/6 patients treated with NG-350A mTx at IV dose level 4 achieved stable disease (dose not yet tested with pembro). Dose-dependent specific increases in serum IL-12, IFNγ and IL-17a were detected in pts treated with IV NG-350A mTx from ̃Wk 2. Increases were sustained at ≥5x baseline levels 7 wks after dosing in the majority of evaluable pts treated at higher IV dose levels. These responses did not occur with IT dosing (or in prior studies with an unarmed vector); further follow-up is ongoing for NG-350A + pembro. IV NG-350A also led to the expansion of T cell clones in blood; most of these were newly detected. Conclusions: NG-350A ± pembro was well-tolerated, with no evidence of CD40-related toxicity. NG-350A IV mTx led to specific and sustained cytokine responses consistent with the MoA of the encoded anti-CD40 Ab. Peak cytokine elevations were typically higher than reported with systemic anti-CD40 Abs, suggesting NG-350A can drive local immunological tumor changes while avoiding systemic toxicity. A further trial (FORTIFY, NCT05165433) will continue dose-escalation of NG-350A + pembro to identify a dose level for efficacy assessments. Clinical trial information: NCT03852511. [Table: see text]

Safety and tolerability of T-SIGn vectors when administered using “flat” versus “low-high-high” (LHH) dosing regimens

2572

Background: Tumor-selective viruses, particularly those dosed systemically to deliver transgenes, are potentially powerful cancer therapies. However, acute cytokine reactions to viral particle (vp) infusion may affect vector tolerability [Small 2006], thereby limiting the maximum tolerated dose (MTD) and subsequent transgene delivery. T-SIGn vectors (e.g. NG-641 and NG-350A) are transgene-armed variants of the epithelial tumor-selective adenovirus enadenotucirev (EnAd). Acute serum cytokine increases post-dosing have been seen at the MTD of EnAd (“flat” dosing of 3 x 1012 vp on Days [D] 1, 3 and 5) [Machiels 2019]. Following supportive preclinical data [McElwaine-Johnn 2019], we explored if a LHH dosing regimen, in which a lower dose is given on D1 prior to two higher doses on D3 and 5, may improve vector safety/tolerability thereby allowing higher cumulative doses to be given. Methods: Data were pooled from three Phase 1 dose-escalation studies in advanced/metastatic epithelial cancer: SPICE (EnAd + pembrolizumab/nivolumab; NCT02636036), FORTITUDE (NG-350A ± pembrolizumab; NCT03852511) and STAR (NG-641; NCT04053283). Serum cytokines were measured using a 17-analyte Luminex assay. IL-6/MCP-1 data for D1, 3 and 5 (pre- and 6-10 hrs post-dose) were analyzed to examine acute cytokine changes. TNFα/IFNγ were examined due to their association with cytokine release syndrome (CRS). Samples analyzed from SPICE/FORTITUDE were taken before PD-1 inhibitor administration. Results: 84 patients (SPICE n=51; FORTITUDE n=18; STAR n=15) were included in these analyses; 79 had cytokine data. AEs and Gr≥3 AEs within 1 wk of first dose, and DLTs at any time, were less frequent with a LHH vs flat dosing regimen (Tbl). Importantly, a LHH dose of 1-6-6 (1 x 1012 vp on D1; 6 x 1012 vp on D3 and 5; greater than the previous flat MTD) was tolerated. Acute increases in TNFα/IFNγ were limited and no severe CRS was seen. Increases in IL-6/MCP-1 with 1 x 1011 or 1 x 1012 vp flat dosing were negligible, whereas acute increases in IL-6/MCP-1 were seen after the first dose of 3 x 1012 vp when given as a flat dose (negligible increases on D3/5). Notably, cytokine responses with 1-3-3 dosing (1 x 1012 vp on D1; 3 x 1012 vp on D3 and 5), including after the first 3 x 1012 vp dose on D3, were negligible. Cytokine responses after the first dose of 6 x 1012 vp in the 1-6-6 regimen were similar to those seen with the first dose of the flat 3 x 1012 vp regimen. Conclusions: LHH dosing appears to induce a desensitization mechanism allowing higher cumulative doses of T-SIGn vectors to be given without the associated acute reactions to viral infusions. This finding may have implications for optimizing safety-efficacy profiles of viral vectors in cancer. Clinical trial information: NCT02636036, NCT03852511 and NCT04053283. [Table: see text]

383 Introduction of a Burns Admission Proforma to Improve Patient Admission Clerking and Management

Introduction

Patients who suffer burns present with a variation in the cause, depth, and size of their burns. A number of factors are important in determining the successful management of these patients such as age, cause, time since burn, first aid, co-morbidities, medication, burn size, depth and area, associated injuries, and social circumstances. Appropriate documentation, assessment, and examination in order to guide treatment is therefore imperative to good management and positive outcomes. We performed an audit of admission documentation to our burns unit and introduced a proforma to determine whether there was an improvement in important assessment criteria in order to enhance patient care.

Method

We retrospectively assessed burns admission documentation in 25 patients recently admitted against important assessment criteria. We then introduced a burns admission proforma to the unit and collected the results of 25 further patients in which the proforma was used.

Results

Introduction of the proforma showed an improvement in documentation, examination, and recorded management in almost all areas assessed, excluding allergies where there was a reduction.

Conclusions

Use of a proforma is beneficial in enhancing patient admission documentation and assessment, therefore directing appropriate management by focusing on all areas of patient care. However, the content of the proforma results in adherence to the assigned assessment parameters with limited deviation. Therefore, it is important when using a proforma to include all areas which are important to assessment otherwise they may be overlooked. Their use could be expanded to local emergency departments to ensure appropriate initial assessment, resuscitative management, and referral.

Clinicians' experiences of using and implementing a medical mobile phone app (QUiPP V2) designed to predict the risk of preterm birth and aid clinical decision making

Background

As the vast majority of women who present in threatened preterm labour (TPTL) will not deliver early, clinicians need to balance the risks of over-medicalising the majority of women, against the potential risk of preterm delivery for those discharged home. The QUiPP app is a free, validated app which can support clinical decision-making as it produces individualised risks of delivery within relevant timeframes. Recent evidence has highlighted that clinicians would welcome a decision-support tool that accurately predicts preterm birth.

Methods

Qualitative interviews were undertaken as part of the EQUIPTT study (The Evaluation of the QUiPP app for Triage and Transfer) (REC: 17/LO/1802) which aimed to evaluate the impact of the QUiPP app on management of TPTL. Individual semi-structured telephone interviews were used to explore clinicians’ (obstetricians’ and midwives’) experiences of using the QUiPP app and how it was implemented at their hospital sites. Thematic analysis was chosen to explore the meaning of the data, through a framework approach.

Results

Nineteen participants from 10 hospital sites in England took part. Data analysis revealed three overarching themes which were: ‘experience of using the app’, ‘how QUiPP risk changes practice’ and ‘successfully adopting QUiPP: context is everything’. With these final themes we appeared to have achieved our aim of exploring the clinicians’ experiences of using and implementing the QUiPP app.

Conclusion

This study explored different clinician’s experiences of implementing the app. The organizational and cultural context at different sites appeared to have a large impact on how well the QUiPP app was implemented. Future work needs to be undertaken to understand how best to embed the intervention within different settings. This will inform scale up of QUiPP app use across the UK and ensure that clinicians have access to this free, easy-to-use tool which can positively aid clinical decision making when caring for women in TPTL.

Clinical trial registry and registration number

ISRCTN 17846337, registered 08th January 2018, https://doi.org/10.1186/ISRCTN17846337.

342 Combining enadenotucirev and nivolumab increased tumour immune cell infiltration/activation in patients with microsatellite-stable/instability-low metastatic colorectal cancer in a phase 1 study

Background

Microsatellite-stable (MSS) and instability-low (MSI-L) metastatic colorectal cancer (mCRC) are typically characterised as ”immune-excluded/desert” tumour microenvironments lacking T-cell infiltration. Anti-PD-1 monotherapy has little clinical benefit in MSS/MSI-L mCRC1 and knowledge of the effects of PD-1 inhibition on T-cell activation/infiltration in this population is limited. Novel combination therapies to overcome anti-PD-1 resistance are required. SPICE is a multicentre, open-label, phase 1 study of the tumour-selective chimeric Ad11/Ad3 group B oncolytic adenovirus enadenotucirev plus nivolumab in patients with metastatic/advanced epithelial tumours refractory to standard therapy. Preliminary data from patients with MSS/MSI-L mCRC demonstrated a median overall survival of 14 months, manageable tolerability and intratumoural T-cell infiltration.2 Here we characterise the immunological effects of tumour re-engineering with enadenotucirev in combination with nivolumab in patients with MSS/MSI-L mCRC.

Methods

Patients received increasing doses and/or cycles of intravenous enadenotucirev followed by up to 8 cycles of nivolumab as previously described.2 Wherever possible, pre- and post-treatment (~5 weeks post-first enadenotucirev) biopsies were collected; samples were analysed using immunohistochemistry and automated image analysis. Peripheral blood mononuclear cell immunophenotyping (multiparameter flow cytometry) and serum cytokines were assessed at multiple times.

Results

43 patients with mCRC were treated (86% MSS/MSI-L; 14% unknown). Among the 13 patients (12/13 MSS/MSI-L; 1/13 unknown) with matched biopsies, 11 had increased intratumoural and stromal CD8+ T-cell infiltration in post-treatment biopsies (median [Q1-Q3] fold changes 6.5× [1.5–25.4] and 1.9× [1.5–3.9], respectively; figure 1). CD4+ T-cell density increased in 10/13 patients and 8/13 patients had increased proportions of PD-L1+ immune cells. Increases in CD8 T-cell proliferation (Ki67; 7/9 patients) and cytolytic activity (Granzyme B; 7/13 patients) markers were seen. 4/13 patients converted from a ”desert” to an ”inflamed” immune phenotype (pathologist scored CD8/pan-cytokeratin staining). Immunophenotyping showed trends towards increased T-cell activation (CD38+ and HLA-DR+ CD8+ T cell populations) post-treatment (9/10 patients), including in one patient who had only received enadenotucirev prior to sampling. Persistent increases in inflammatory cytokines (IFNγ, IL-12p70, IL-17a) were seen in two patients from ~Day 15, including one who achieved a sustained objective response.

Abstract 342 Figure 1

Tumour immune cell infiltration following treatment with enadenotucirev plus nivolumab

Conclusions

These data show that intravenous enadenotucirev plus nivolumab can induce immune infiltration/activation within MSS/MSI-L mCRC. These encouraging findings suggest that immune activation can be achieved even in ”immune-excluded/desert” tumours. SPICE has been closed following completion of dose-escalation. Efforts are now focused on the development of next-generation variants of enadenotucirev designed to further re-programme the tumour microenvironment by expressing immune-enhancer transgenes (T-SIGn vectors); these studies are ongoing (NCT04830592, NCT04053283, NCT03852511).

Acknowledgements

This study was funded by PsiOxus Therapeutics Limited and Bristol Myers Squibb. Medical writing support: Lola Parfitt, MRes, of PsiOxus Therapeutics Limited.

Trial Registration

EudraCT number

2017-001231-39NCT number: NCT02636036

References

Kawazoe A, Kuboki Y, Shinozaki E, et al. Multicenter phase I/II trial of napabucasin and pembrolizumab in patients with metastatic colorectal cancer (EPOC1503/SCOOP trial). Clin Cancer Res 2020;26:5887–5894.

Fakih M, Wang D, Harb W, et al. SPICE: a phase I multicenter study of enadenotucirev in combination with nivolumab in tumors of epithelial origin: an analysis of the metastatic colorectal cancer patients in the dose escalation phase. Ann Oncol 2019:30(suppl_5):v252.

Ethics Approval

The study was approved by the WCG Institutional Review Board (study approval number 20152656), UCLA Institutional Review Board (study approval number IRB#15-002010), Vanderbilt Institutional Review Board (study approval number IRB #171453) and Henry Ford Institutional Review Board (study approval number IRB #10349).

Analysing drivers of routine and COVID-19 vaccination in migrants to develop tailored interventions

Background

Migrants in Europe are at risk of under-immunisation and may also have lower COVID-19 vaccination intent and uptake. There is an urgent need to better understand the drivers of uptake in these groups to inform the development of migrant-sensitive interventions for COVID-19 vaccination and routine vaccination beyond the pandemic.

Methods

We did a systematic review (PROSPERO: CRD42020219214) following PRISMA guidelines to explore factors influencing vaccine uptake in migrants in the EU/EEA and identify determinants of under-immunisation. We also held 3 participatory workshops with multinational migrant community leaders (n = 23) in London, to explore solutions and approaches to strengthen COVID-19 vaccine roll-out.

Results

We included 66 papers reporting data on 262,761 migrants in the review. Numerous access-related factors (e.g. government policy, communication barriers) influenced uptake. Vaccine hesitancy was attributed to lack of information, concerns about side-effects, and cultural beliefs/stigma around specific vaccinations. Migrants who had recently arrived, were older, female or of African and Eastern Mediterranean origin were at risk for under-immunisation for key vaccine-preventable diseases. Migrant community leaders reported considerable hesitancy towards COVID-19 vaccination in their communities and misinformation circulating via social media. Leaders requested support in producing simple COVID-19 guidance that could be translated and adapted locally, alongside more meaningful engagement and partnership-working.

Conclusions

Access barriers and vaccine hesitancy may affect vaccine uptake in some migrant populations in Europe, which needs to be urgently addressed for COVID-19 vaccine roll-out but also beyond the pandemic to strengthen uptake of routine vaccinations. Actively involving migrant communities in the planning, co-production and implementation of tailored and targeted approaches will be essential.

On behalf of ESGITM.

Key messages

Access barriers and vaccine hesitancy (from information gaps, cultural factors) contribute to low vaccine uptake in some migrant populations in the EU/EEA, with implications for COVID-19 vaccination. Meaningful engagement and co-production of tailored approaches with under-immunised migrants are urgently needed to ensure their inclusion in COVID-19 and routine vaccination programmes.

Digital screening tool (Health Catch-UP!) to promote multi-disease screening in migrants

Background

The ECDC has called for innovative strategies to deliver multi-disease screening (TB, LTBI, HIV, hepatitis B/C, Chagas, Strongyloidiasis and schistosomiasis) and catch-up vaccination (MMR, DTP) to adult migrants within the primary care context. We did a UK i qualitative study to explore current practice and seek views on a novel integrated digital tool to support delivery of screening recommendations for migrants https://emishealth.vids.io/videos/a49ad1bb1a18e4c72c/health-catch-up-with-requested-edits-mp4).

Methods

Phase 1 was conducted via telephone with clinical primary care practitioners (PCPs) (phase 1) and informed data collection and analysis for phase 2 with administrative staff. Data were analysed iteratively, informed by thematic analysis (Ethics no.20/HRA/1674).

Results

64 participants were recruited in Phase 1 (25 general practitioners [GPs], 15 nurses, 7 healthcare assistants, 1 pharmacist); Phase 2 comprised administrative staff (11 Practice-Managers, 5 receptionists). There was lack of consistency in delivery of screening and vaccination. Most GP practices adopted a practice-specific approach, or had no system in place; screening only for HIV and hepatitis B/C. Barriers to screening were perceived lack of knowledge/training and limited financial resources. Facilitators included having an infectious disease/migrant-health champion, incentivisation, and clear protocols. Participants responded positively to the integrated Health Catch-UP! tool, confirming that it would increase screening and vaccination, reduce missed opportunities for preventative healthcare, and raise awareness of migrant health.

Conclusions

Infectious disease screening and catch-up vaccination is not currently delivered well in primary care in high-migrant receiving European countries. Innovative digital tools like Health Catch-UP! could aid clinical decision-making and facilitating improved health outcomes for migrants. Further work is needed to evaluate this intervention.

Key messages

Infectious disease screening and catch-up vaccination is not currently delivered well in primary care in high-migrant receiving European countries. Innovative digital tools could aid clinical decision-making and facilitating improved health outcomes for migrants.

Fractional flow reserve derived from computed tomography coronary angiography in the assessment and management of stable chest pain: the FORECAST randomized trial

Aims 

Fractional flow reserve (FFR_CT) using computed tomography coronary angiography (CTCA) determines both the presence of coronary artery disease and vessel-specific ischaemia. We tested whether an evaluation strategy based on FFR_CT would improve economic and clinical outcomes compared with standard care.

Methods and results 

Overall, 1400 patients with stable chest pain in 11 centres were randomized to initial testing with CTCA with selective FFR_CT (experimental group) or standard clinical care pathways (standard group). The primary endpoint was total cardiac costs at 9 months. Secondary endpoints were angina status, quality of life, major adverse cardiac and cerebrovascular events, and use of invasive coronary angiography. Randomized groups were similar at baseline. Most patients had an initial CTCA: 439 (63%) in the standard group vs. 674 (96%) in the experimental group, 254 of whom (38%) underwent FFR_CT. Mean total cardiac costs were higher by £114 (+8%) in the experimental group, with a 95% confidence interval from −£112 (−8%) to +£337 (+23%), though the difference was not significant (P = 0.10). Major adverse cardiac and cerebrovascular events did not differ significantly (10.2% in the experimental group vs. 10.6% in the standard group) and angina and quality of life improved to a similar degree over follow-up in both randomized groups. Invasive angiography was reduced significantly in the experimental group (19% vs. 25%, P = 0.01).

Conclusion 

A strategy of CTCA with selective FFR_CT in patients with stable angina did not differ significantly from standard clinical care pathways in cost or clinical outcomes, but did reduce the use of invasive coronary angiography.

Ten women's decision-making experiences in threatened preterm labour: Qualitative findings from the EQUIPTT trial

BACKGROUND

Clinical triage of women in threatened preterm labour (TPTL) could be improved through utilising the QUiPP App, as symptoms alone are poor predictors of early delivery. As most women in TPTL ultimately deliver at term, they must weigh this likelihood with their own personal considerations, and responsibilities. The importance of personal considerations was highlighted by the 2015 Montgomery ruling, and the significance of shared decision-making.

AIMS

Through qualitative interviews, the primary aim was to explore women's decision-making experiences in TPTL through onset of symptoms, triage, clinical assessment, and discharge.

METHODS

Qualitative interviews were undertaken as part of the EQUIPTT study (REC: 17/LO/1802) using a semi-structured interview schedule. Descriptive labels of the coding scheme were applied to the raw transcript data. This coding scheme was then increasingly refined into key themes and allowed parallels to be made within and between cases.

RESULTS

Ten ethnically diverse women who presented at six different London hospitals sites in TPTL were interviewed. Three final themes emerged from the data incorporating 10 sub-themes, 'Seeking help', 'Being "assessed" vs making clinical decisions together', and 'End result.'

CONCLUSION

Women described their busy lives and the need to juggle their commitments. Participants drew comparisons between their TPTL symptoms and 'period pain,' contrasting to typical medical terminology. Shared decision-making and the clinician-patient relationship could be improved through clinicians utilizing terminology women understand and relate to. Women used language that highlighted the clinician-patient power balance. While not fully involved in shared decision-making, women were overall satisfied with their care.

Evaluation of urinary chloride dipsticks for the rapid estimation of hydration status in patients receiving artificial nutrition: Feasibility study

BACKGROUND AND AIMS

The home parenteral nutrition (HPN) population face many challenges, especially with respect to fluid balance management. A low urinary sodium concentration of <20 mmol/L is commonly used as an indicator of dehydration that requires clinical assessment in these patients. The Quantab titrator dipstick measures chloride concentration of a solution and correlates with sodium concentration. We assessed whether it would be feasible to use the Quantab dipstick in the HPN population and explored relationships between Quantab dipstick estimated chloride concentration and quality of life (QOL).

METHODS

Patients on HPN were asked to collect urine samples at 5 specific times points (day 0,7,14, 21 and 28) to send to the laboratory for formal electrolyte analysis. The participant and a member of laboratory staff tested these samples with the Quantab dipstick to estimate urinary chloride concentration. Participants were instructed to complete a QOL questionnaire at each of the 5 time-points in addition to a baseline demographic questionnaire and an end-of-study questionnaire. Six participants completed an interview at the end of the study period. The relationship between participant-derived and laboratory-derived data was assessed using rank correlation coefficients. QOL assessment was correlated with urine dipstick measurements.

RESULTS

10 patients on HPN completed the study. Data on chloride concentration as estimated by the dipstick (assessed by participants and by the laboratory) and sodium concentration from the laboratory were available for 47 urine samples. There was a positive relationship between participant dipstick estimated chloride concentration and laboratory sodium (Kendall's τ = 0.45; P < 0.001; Spearman's r_s = 0.58 P < 0.001; 47 pairs). There was a strong correlation between chloride concentrations estimated by dipstick in the laboratory and by participants (Kendall 0.58 p < 0.001, Spearman's 0.69 p < 0.001; 47 pairs). In exploratory analyses, there was no relationship between QOL and dipstick estimated chloride concentration. Participants had no issues collecting urine samples but some difficulties were reported with determining the dipstick reading.

CONCLUSIONS

Patients on HPN are able to collect urine specimens, complete QOL questionnaires, and are capable of using the Quantab dipstick to estimate urinary chloride concentration. The Quantab dipstick correlates with laboratory measured sodium and chloride concentrations. Further work is required to fully establish whether this point-of-care test could be used to guide fluid balance management in the HPN population.

Queensland’s multi-year Wet and Dry periods: implications for grazing enterprises and pasture resources

Year-to-year variability in rainfall has long been recognised as a major issue in managing livestock enterprises across Australia’s grazing lands. Extension products documenting rainfall variability have been developed over the last 30 years and have been keenly sought by producers and their advisors. This paper describes multi-year rainfall variability from 1889 to 2020 and provides the basis for classifying the 131 years of rainfall into 18 discrete Wet (7), Average (2) and Dry (9) periods as presented in the ‘Queensland’s Extended Wet and Dry Periods’ poster. The classification was consistent with: analysis of fluctuations and trends in the long-term time series of reported livestock numbers; drought declarations for government assistance; and documented periods of pasture resource degradation and recovery. Rainfall during the nine Wet and Average periods was +18% above the long-term average annual rainfall (LTAAR), in contrast to the Dry periods with −17% below LTAAR. Wet periods (including Average) were on average 7 years in duration, ranging from 5 to 9 years. Dry periods were on average 8 years in duration and ranged from 5 to 13 years. Detailed analysis of the effects of the El Niño Southern Oscillation (ENSO) phenomenon indicated that: (a) the Wet/Dry periods were dominated by different frequencies and amounts of rainfall in La Niña/El Niño years; (b) rainfall in ENSO neutral years was generally above and below average rainfall for the Wet or Dry periods respectively; (c) the frequency of ENSO year-types was less important than the overall rainfall surplus (or deficit) in La Niña (or El Niño) years within the Wet (or Dry) periods respectively; and (d) the timing of Wet and Dry periods was correlated with indices of quasi-decadal and inter-decadal variability in components (sea surface temperatures and atmospheric pressures) of the global climate system. Climatic risk assessment systems for grazing management at multi-year timescales are yet to be developed.

An online system for calculating and delivering long-term carrying capacity information for Queensland grazing properties. Part 1: background and development

This paper (Part 1) describes the development of a new online system that estimates long-term carrying capacity (LTCC) for grazing properties across Queensland, Australia. High year-to-year and multi-year rainfall variability is a dominating feature of the climate of Queensland’s grazing lands, and poses major challenges for extensive livestock production. The use of LTCC is one approach used by graziers to reduce the impact of rainfall variability on land condition and financial performance. Over the past 30 years, scientists, graziers and their advisors have developed a simple approach to calculating LTCC ((average annual pasture growth × safe pasture utilisation) ÷ annual animal intake). This approach has been successful at a property scale (regional south-west Queensland) and in a wider application through Grazing Land Management (GLM) regional workshops. We have built on these experiences to develop an online system (as described in detail in Part 2; Zhang et al. 2021; this issue) that incorporates the simple LTCC approach with advances in technology and grazing science to provide LTCC information for Queensland grazing properties. Features of the LTCC system are: (1) assimilation of spatial datasets (cadastral data, grazing land types, climate data, remotely-sensed woody vegetation cover); (2) a pasture growth simulation model; (3) land type parameter sets of biophysical attributes; and (4) estimates of safe pasture utilisation. The ‘FORAGE LTCC report’ is a major product of the system, describing individual property information that allows detailed analysis and explanation of the components of the LTCC calculation by land type and land condition. The online system rapidly analyses property spatial data and calculates paddock/property LTCC information. For the 10 months between November 2020 and August 2021, over 4000 grazing property reports have been requested in Queensland, and has proven to be a sound basis for ‘discussion support’ with grazier managers and their advisors.

An online system for calculating and delivering long-term carrying capacity information for Queensland grazing properties. Part 2: modelling and outputs

A combination of field data and models have been used to estimate long-term carrying capacity (LTCC) of domestic livestock in Queensland grazing lands. These methods have been synthesised and coupled with recent developments in science and information technology to provide a fully-automated approach of modelling LTCC through the FORAGE online system. In this study, the GRASP model was used to simulate pasture growth with parameter sets and safe pasture utilisation rates defined for 225 land types across Queensland. Distance to water points was used to assess the accessibility of pastures to livestock. Spatial analysis classified the property into unique areas based on paddock, land type and distance to water points, which estimated pasture growth, pasture utilisation and accessibility at a sub-paddock scale. Thirteen foliage projective cover (FPC) classes were used in modelling the pasture system to deal with the non-linear relationship between tree and grass interactions. As ‘proof of concept’, remotely-sensed individual-date green ground cover data were used to optimise the GRASP model parameters to improve the model performance, and a Monte Carlo analysis provided uncertainty estimates for model outcomes. The framework provides an efficient and standardised method for estimating LTCC. To test the system, LTCCs from 43 ‘benchmark’ properties were compared with simulated LTCCs, and 65% of the modelled LTCCs were within ± 25% of the benchmark LTCCs. Due to uncertainties in model inputs at the property scale and in model simulation, the modelled LTCC should be used as a starting point for further refinement of actual property LTCC.

Predictors for a dementia gene mutation based on gene-panel next-generation sequencing of a large dementia referral series

Next-generation genetic sequencing (NGS) technologies facilitate the screening of multiple genes linked to neurodegenerative dementia, but there are few reports about their use in clinical practice. Which patients would most profit from testing, and information on the likelihood of discovery of a causal variant in a clinical syndrome, are conspicuously absent from the literature, mostly for a lack of large-scale studies. We applied a validated NGS dementia panel to 3241 patients with dementia and healthy aged controls; 13,152 variants were classified by likelihood of pathogenicity. We identified 354 deleterious variants (DV, 12.6% of patients); 39 were novel DVs. Age at clinical onset, clinical syndrome and family history each strongly predict the likelihood of finding a DV, but healthcare setting and gender did not. DVs were frequently found in genes not usually associated with the clinical syndrome. Patients recruited from primary referral centres were compared with those seen at higher-level research centres and a national clinical neurogenetic laboratory; rates of discovery were comparable, making selection bias unlikely and the results generalisable to clinical practice. We estimated penetrance of DVs using large-scale online genomic population databases and found 71 with evidence of reduced penetrance. Two DVs in the same patient were found more frequently than expected. These data should provide a basis for more informed counselling and clinical decision making.

Effects of within-person variability in spot urinary sodium measurements on the associations with blood pressure and risk of cardiovascular disease in 0.5 Million adults in UK Biobank

Background

Randomised control trials have demonstrated direct positive and causal associations of 24-hr measurements of urinary sodium excretion on blood pressure. However, prospective studies, which often used spot (not 24-hr) measurements of urinary sodium, have reported J-shaped associations with higher risks of cardiovascular disease (CVD) at sodium intake &lt;4 g/day. The reasons for the discrepant results are not fully understood, but have prompted some to question the World Health Organisation's recommendations to restrict sodium intake to &lt;2.3g/day.

Purpose

We examined the effects of within-person variability in spot urinary sodium (UNa) measurements on immediate and delayed associations of UNa with blood pressure at baseline and at resurvey, and with incident cardiovascular disease in the UK Biobank (UKB).

Methods

Baseline spot urine samples were measured in 502,619 adults at baseline and in 20,346 participants who were resurveyed at 4 years after baseline. Linear regression was used to assess associations of baseline UNa measurements with systolic blood pressure (SBP; mmHg) at baseline and at resurvey. Cox regression was used estimate the associations between baseline measures of UNa with incident CVD events (recorded from linkage with hospital records). All analyses were adjusted for confounders and corrected for regression dilution bias.

Results

After excluding participants with prevalent diseases, the primary analyses involved 386,060 adults who were followed-up for a median of 7.8 years, during which ∼13,000 CVD events occurred. Estimated mean (SD) urinary sodium excretion was 77.4 mmol/L (SD 44.4, IQR = 42.8–103.7 mmol/L), and mean SBP/DBP were 137.5/82.3 (SD 18.5/10.1) mmHg, respectively. Within-person variability in UNa was high, with a self-correlation of 0.35 at 4 years between measurements. After adjustment for confounders and correction for regression dilution bias, a 100 mmol/L higher UNa was associated with an immediate 3.2 mmHg higher SBP (95% confidence interval [CI]: 2.8–3.6) in cross-sectional analyses (Figure 1). However, the corresponding associations of baseline UNa with SBP at resurvey was completely attenuated (p=0.20). The predicted risk of CVD was 1.06 (95% CI 1.06–1.07, p&lt;0.001) for a 3.2 mmHg higher SBP, but the observed risk for a 100 mmol/L higher UNa was 0.95 (95% CI 0.82–1.10, p=0.47) (Figure 1).

Conclusions

While spot measurements of UNa were strongly associated with immediate effects on SBP, the magnitude of within-person variability in UNa precluded detection of associations with SBP several years after baseline or with risk of CVD. The extreme within-person variability in spot UNa may explain the discrepant results of the trials and observational studies of sodium and blood pressure.

Figure 1. Spot UNa with SBP and CVD in UK Biobank

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Core funding from the Medical Research Council-Population Health Research Unit, British Heart Foundation

Impact of a medical mobile phone app (QUiPP) for predicting preterm birth on the anxiety and decisional conflicts faced by women in threatened preterm labour

BACKGROUND

The QUiPP app is a free, validated mobile phone application (app) that supports clinical decision-making for women in threatened preterm labour by providing an individualised risk of delivery within clinically important time points. Alongside generating a percentage risk score, the QUiPP app also provides the risk score in an infographic donut chart, allowing the clinician to communicate with the woman in an easy to understand format. Informing women of their risk status using the QUIPP app may help to reduce anxiety in women and decrease decisional conflict.

METHOD

A subset of participants from the EQUIPTT study [REC Ref. 17/LO/1802] were asked to complete a questionnaire booklet which was used to evaluate decisional conflict and anxiety. Seven sites were randomised to the QUiPP app intervention (to use as a decision and communication tool) and six sites were randomised to the control (continued their normal practice). The first section of the questionnaire booklet was completed by the woman before her assessment, and the second section after. The pre and postassessment anxiety scores utilised the Visual Analogue Scale for Anxiety (Hornblow and Kidson, 1976). The Decisional Conflict Scale (O'Connor, 1995) measured decisional conflict post assessment. The data were then analysed to determine the impact of the QUiPP App on the anxiety and decisional conflicts faced by women in threatened preterm labour.

RESULTS

Questionnaires were completed by 221 women from 12 of the potential 13 sites. After exclusions 202 questionnaires were included in the analysis. There was a significant reduction in difference between anxiety scores before and after clinical assessment. While there were reductions in anxiety and decisional conflict for women who were aware of the QUiPP app use, this failed to reach statistical significance.

CONCLUSIONS

The QUiPP app has potential to reduce anxiety and decisional conflict in women who are aware that it is being used in their care. Additional work is required to ensure clinicians are aware of the QUiPP app and optimise using it as a communication tool when counselling women.

Migration and outbreaks of vaccine-preventable disease in Europe: a systematic analysis (1990-2019)

Background

Migrant populations (defined as foreign-born) in the EU/EEA may be one of several under-immunised populations yet their role in outbreaks of vaccine-preventable diseases (VPDs) has been poorly defined to date.

Methods

We did both a temporal analysis to map published reports of migrant-related outbreaks against data from the ECDC's Surveillance Atlas of Infectious Disease, and a systematic review (PROSPERO CRD42019157473; 1990-2019) adhering to PRISMA guidelines, to explore whether migrants are involved in outbreaks in Europe and which particular subpopulations may be at increased risk. Studies on VPD outbreaks (measles, mumps, rubella, diphtheria, pertussis, polio, hepatitis A, N meningitidis, and H influenzae) in migrants residing in the EU/EEA were included.

Results

46 studies were included, reporting on 50 VPD outbreaks across 13 EU/EEA countries, of which 98% (n = 49) occured since January 2000. Measles had the highest number of reports of outbreaks involving migrants (n = 21; 5043 cases), followed by varicella (n = 10; 595 cases) and hepatitis A (n = 10; 1226 cases). 21 (40%) of outbreaks were reported from shelters for asylum seekers and refugees (mainly varicella or measles). Of 27 outbreaks where the index case was defined, 20 (74.1%) were migrants, including 9 (33.3%) from Eastern Europe and 6 (22.2%) from Africa. When mapped against the ECDC timeline of measles outbreaks, migrant-related outbreaks coincide with Europe-wide peaks in measles incidence (in 2006, 2010, and 2018).

Conclusions

Migrants represent one key group involved in VPD outbreaks, with refugees/asylum seekers residing in shelters or camps particularly at risk. Measles accounted for 38% of all reported outbreaks. Improved data collection on migrant status across Europe is crucial to understanding the complex relationship between migration and occurrence of VPD outbreaks to inform policy decisions on the most effective strategies to prevent future outbreaks.

Key messages

Migrants represent one key group involved in vaccine-preventable diseases outbreaks in Europe. Refugees and asylum seekers may be particularly at risk.

Development and validation of predictive models for QUiPP App v.2: tool for predicting preterm birth in asymptomatic high-risk women

OBJECTIVES

Accurate mid-pregnancy prediction of spontaneous preterm birth (sPTB) is essential to ensure appropriate surveillance of high-risk women. Advancing the QUiPP App prototype, QUiPP App v.2 aimed to provide individualized risk of delivery based on cervical length (CL), quantitative fetal fibronectin (qfFN) or both tests combined, taking into account further risk factors, such as multiple pregnancy. Here we report development of the QUiPP App v.2 predictive models for use in asymptomatic high-risk women, and validation using a distinct dataset in order to confirm the accuracy and transportability of the QUiPP App, overall and within specific clinically relevant time frames.

METHODS

This was a prospective secondary analysis of data of asymptomatic women at high risk of sPTB recruited in 13 UK preterm birth clinics. Women were offered longitudinal qfFN testing every 2-4 weeks and/or transvaginal ultrasound CL measurement between 18 + 0 and 36 + 6 weeks' gestation. A total of 1803 women (3878 visits) were included in the training set and 904 women (1400 visits) in the validation set. Prediction models were created based on the training set for use in three groups: patients with risk factors for sPTB and CL measurement alone, with risk factors for sPTB and qfFN measurement alone, and those with risk factors for sPTB and both CL and qfFN measurements. Survival analysis was used to identify the significant predictors of sPTB, and parametric structures for survival models were compared and the best selected. The estimated overall probability of delivery before six clinically important time points (< 30, < 34 and < 37 weeks' gestation and within 1, 2 and 4 weeks after testing) was calculated for each woman and analyzed as a predictive test for the actual occurrence of each event. This allowed receiver-operating-characteristics curves to be plotted, and areas under the curve (AUC) to be calculated. Calibration was performed to measure the agreement between expected and observed outcomes.

RESULTS

All three algorithms demonstrated high accuracy for the prediction of sPTB at < 30, < 34 and < 37 weeks' gestation and within 1, 2 and 4 weeks of testing, with AUCs between 0.75 and 0.90 for the use of qfFN and CL combined, between 0.68 and 0.90 for qfFN alone, and between 0.71 and 0.87 for CL alone. The differences between the three algorithms were not statistically significant. Calibration confirmed no significant differences between expected and observed rates of sPTB within 4 weeks and a slight overestimation of risk with the use of CL measurement between 22 + 0 and 25 + 6 weeks' gestation.

CONCLUSIONS

The QUiPP App v.2 is a highly accurate prediction tool for sPTB that is based on a unique combination of biomarkers, symptoms and statistical algorithms. It can be used reliably in the context of communicating to patients the risk of sPTB. Whilst further work is required to determine its role in identifying women requiring prophylactic interventions, it is a reliable and convenient screening tool for planning follow-up or hospitalization for high-risk women. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Development and validation of predictive models for QUiPP App v.2: tool for predicting preterm birth in women with symptoms of threatened preterm labor

OBJECTIVE

To develop enhanced prediction models to update the QUiPP App prototype, a tool providing individualized risk of spontaneous preterm birth (sPTB), for use in women with symptoms of threatened preterm labor (TPTL), incorporating risk factors, transvaginal ultrasound assessment of cervical length (CL) and cervicovaginal fluid quantitative fetal fibronectin (qfFN) test results.

METHODS

Participants were pregnant women between 23 + 0 and 34 + 6 weeks' gestation with symptoms of TPTL, recruited as part of four prospective cohort studies carried out at 16 UK hospitals between October 2010 and October 2017. The training set comprised all women whose outcomes were known in May 2017 (n = 1032). The validation set comprised women whose outcomes were gathered between June 2017 and March 2018 (n = 506). Parametric survival models were developed for three combinations of predictors: risk factors plus qfFN test results alone, risk factors plus CL alone, and risk factors plus both qfFN and CL. The best models were selected using the Akaike and Bayesian information criteria. The estimated probability of sPTB < 30, < 34 or < 37 weeks' gestation and within 1 or 2 weeks of testing was calculated and receiver-operating-characteristics (ROC) curves were created to demonstrate the diagnostic ability of the prediction models.

RESULTS

Predictive statistics were similar between the training and the validation sets at most outcome time points and for each combination of predictors. Areas under the ROC curves (AUC) demonstrated that all three algorithms had good accuracy for the prediction of sPTB at < 30, < 34 and < 37 weeks' gestation and within 1 and 2 weeks' post-testing in the validation set, particularly the model combining risk factors plus qfFN alone (AUC: 0.96 at < 30 weeks; 0.85 at < 34 weeks; 0.77 at < 37 weeks; 0.91 at < 1 week from testing; and 0.92 at < 2 weeks from testing).

CONCLUSIONS

Validation of the new prediction models suggests that the QUiPP App v.2 can reliably calculate risk of sPTB in women with TPTL. Use of the QUiPP App in practice could lead to better targeting of intervention, while providing reassurance and avoiding unnecessary intervention in women at low risk. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

A multicenter, open label, first-in-human study of an oncolytic viral vector expressing an agonistic anti-CD40 antibody (NG-350A) in patients with epithelial tumors (FORTITUDE)

TPS2668

Background: NG-350A is a transgene modified variant of the oncolytic platform virus enadenotucirev (EnAd) which expresses a fully human agonist anti-cluster of differentiation 40 (anti-CD40) antibody. The principal advantage of encoding anti-CD40 within an oncolytic virus is the ability to potentially achieve very high levels within the tumor coupled with direct cytotoxicity due to viral lysis and stimulation of the immune-system. NG-350A infects and selectively replicates in tumor cells. The anti-CD40 antibodies are expected to activate the patient’s own dendritic cells, macrophages and B-cells to drive CD4+ and CD8+ T-cell immuno-inflammatory responses and immune mediated tumor cell killing. EnAd is a tumor-selective chimeric Ad11/Ad3 group B oncolytic adenovirus developed using directed evolution. Phase I clinical studies have identified a well-tolerated systemic dose and regimen for EnAd monotherapy. EnAd shows a high level of selective replication and cell killing for a broad range of carcinoma cell lines (of epithelial origin) with little replication in normal and non-carcinoma cells. Methods: This first in human study will evaluate the safety, tolerability and preliminary efficacy of NG-350A together with virus kinetics, immunogenicity and other pharmacodynamic effects to elucidate the mechanism of action of NG-350A in patients with advanced or metastatic epithelial tumours. In the dose escalation phase up to 33 patients evaluable for dose-limiting toxicity will receive NG-350A by IV infusion on Day 1, 3 and 5 at 6 US sites. The first IV cohort in the dose-escalation phase will utilize the conventional ‘3+3’ design; thereafter dose recommendations will be based on a continual reassessment method. Following determination of the recommended phase 2 dose up to 20 patients will be treated in a dose-expansion cohort. In a parallel cohort, up to 12 patients will receive a single dose of NG-350A by intratumoural (IT) injection on Day 1 for direct delivery of high viral titres to tumor. Up to six patients are planned to undergo surgical resection of a tumor lesion to optimize translational research. Clinical conduct of the study was initiated in February 2019.

Racial differences in myocardial deformation in obese children: Significance of inflammatory state

BACKGROUND AND AIMS

The association between racial differences in myocardial deformation and cardiometabolic risk factors is unknown in obese children. Our objective was to: 1) investigate for racial differences in myocardial deformation between white and black obese children and 2) identify biomarkers associated with these observed racial differences. We hypothesized that decreased myocardial deformation observed in black obese children could be accounted for by the differences in the markers of metabolic syndrome between the groups.

METHODS AND RESULTS

Obese children were recruited prospectively. All clinical and laboratory tests for the metabolic syndrome were conducted during a single assessment using a standardized protocol. Speckle-tracking echocardiography was performed to obtain longitudinal and circumferential measures of deformation. 310 patients were included in the analysis; 158 (51%) white and 152 (49%) black. The median age was 11.3 years (IQR 5.9). Blacks demonstrated worse longitudinal strain (-14.7 ± 2.7% vs. -15.4 ± 2.9%, p = 0.04). There was no difference in circumferential strain between the groups. Multivariable linear regression showed a significant relationship between longitudinal strain and hsCRP (β = 0.16, p = 0.03) and HOMA-IR (β = 0.15, p = 0.04); there was no independent association between longitudinal strain and race.

CONCLUSION

Black subjects demonstrated worse longitudinal strain than whites. Only hsCRP and HOMA-IR levels, not race, had an independent association with longitudinal strain, suggesting that the observed racial differences in longitudinal strain may be secondary to differences in inflammation and insulin resistance between the groups.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Long Paddock: climate risk and grazing information for Australian rangelands and grazing communities

The Queensland Government’s Long Paddock website has been redeveloped on Amazon Web Services cloud computing platform, to provide Australian rangelands and grazing communities (i.e. rural landholders, managers, pastoralists (graziers), researchers, advisors, students, consultants and extension providers) with easier access to seasonal climate and pasture condition information. The website provides free, tailored information and services to support management decisions to maximise productivity, while maintaining the natural resource base. For example, historical rainfall and pasture analyses (i.e. maps, posters and data) have been developed to assist in communicating the risk of multi-year droughts that are a feature of Queensland’s highly variable climate.