Effect of Early Parent Participation Program on Physiological Stability in Preterm Infants: A Randomized Controlled Trial

OBJECTIVE

This research aimed to study the impact of early parent participation program (EPPP) for preterm infants in neonatal intensive care unit (NICU) on physiological instability, breastmilk feeding rates, and discharge timing.

STUDY DESIGN

Families of 147 infants born between 28 and 33 weeks' gestation were randomized at birth to EPPP group or conventional care (CC). Families in the EPPP group were trained soon after admission by using a structured education program and encouraged to spend more time with their baby. Soon after enrolment (day of life 1 to 2), they would sequentially participate in daily NICU care processes such as orogastric tube feeding, nesting, oil massages, diaper changes, and daily weight checks. Families in the CC group would undergo the same after their infant was off parenteral nutrition and respiratory support. Proportion of infants having physiological instability (significant apnea, feeding intolerance, or needing investigation for sepsis) in two groups was compared.

RESULTS

There was a significant reduction in the proportion of infants with physiological instability (feeding intolerance) in the EPPP group (relative risk = 0.70 [0.52-0.94], p = 0.016). Infants in EPPP group had a trend toward higher breastmilk feeding rates at discharge (66 vs. 51%, p = 0.076).

CONCLUSION

Very early parent participation was feasible in the NICU and led to decrease in physiological instability in preterm infants.

KEY POINTS

· Family-integrated care is beneficial; however, it is often started later in the NICU course.. · This trial showed that very early involvement of family in NICU care processes is feasible and safe.. · Structured parent participation started very early improves physiological stability in preterm infants (mainly tolerance to feeds)..

Acquired bedaquiline resistance in Karakalpakstan, Uzbekistan

BACKGROUND: The WHO recommends the use of bedaquiline (BDQ) in longer, as well as shorter, multidrug-resistant TB (MDR-TB) treatment regimens. However, resistance to this new drug is now emerging. We aimed to describe the characteristics of patients in Karakalpakstan, Uzbekistan, who were treated for MDR-TB and acquired BDQ resistance during treatment.METHODS: We performed a retrospective study of routinely collected data for patients treated for MDR-TB in Karakalpakstan between January 2015 and December 2020. We included patients on BDQ-containing regimens with baseline susceptibility to BDQ who developed BDQ resistance at any point after treatment initiation. Patients resistant to BDQ at baseline or with no confirmed susceptibility to BDQ at baseline were excluded.RESULTS: Of the 523 patients who received BDQ-containing regimens during the study period, BDQ resistance was detected in 31 patients (5.9%); 20 patients were excluded-16 with no prior confirmation of BDQ susceptibility and 4 who were resistant at baseline. Eleven patients with acquired BDQ resistance were identified. We discuss demographic variables, resistance profiles, treatment-related variables and risk factors for unfavourable outcomes for these patients.CONCLUSION: Our programmatic data demonstrated the acquisition of BDQ resistance during or subsequent to receiving a BDQ-containing regimen in a patient cohort from Uzbekistan. We highlight the need for individualised treatment regimens with optimised clinical and laboratory follow up to prevent resistance acquisition.

COVID-19 DIAGNOSIS BY POINT OF CARE LUNG ULTRASOUND: A NOVEL DEEP LEARNING ARTIFICIAL INTELLIGENCE METHOD

BACKGROUND

METHODS AND RESULTS

CONCLUSION

Rapid review of decision-making for place of care and death in older people: Lessons for COVID-19

Introduction

The coronavirus pandemic (COVID-19) has affected the functioning and capacity of healthcare systems worldwide. COVID-19 has also disproportionately affected older adults, including those living with dementia. In the context of COVID-19, decision-making surrounding place of care and place of death in this population involves significant new challenges.

Objectives

To explore key factors that influence place of care and place of death decisions in older adults. A secondary aim was to investigate key factors that influence the process and outcome of these decisions in older adults. To apply findings from current evidence to the context of COVID-19.

Methods

Rapid review of reviews, undertaken using WHO guidance for rapid reviews. Ten papers were included for full data extraction. These papers were published between 2005-2020. Data extracted was synthesised using narrative synthesis, with thematic analysis and tabulation.

Results

Papers included discussed actual place of death, as well as preferred. Results were divided into papers that explored the process of decision-making, and those that explored decision-making outcomes. Factors such as caregiver capacity, the availability of multidisciplinary teams, cultural appropriateness of care packages and advanced care planning were found to be key.

Conclusions

The process and outcomes of decision-making for older people are affected by many factors – all of which have the potential to influence both patients and caregivers experience of illness and dying. Within the context of COVID-19, such decisions may have to be made rapidly and be reflexive to changing needs of systems and of families and patients.

Rapid development of a decision-aid for people with dementia and their families during COVID-19

Introduction

COVID-19 as a pandemic has disproportionately affected older adults, including those with dementia. The effects on health and social care systems has necessitated a rapid-response approach to care planning and decision-making in this population, with reflexivity and responsiveness to changing individual and system needs at its core. In light of this, a decision-making tool to help families of persons with dementia was developed using a combination of qualitative data and evidence synthesis.

Objectives

To develop a decision-aid using a combination of assessment and evidence-gathering methods for families of persons with dementia.

Methods

Semi-structured interviews with helpline staff from national end-of-life and supportive care organisations formed the basis of the tool design. Co-design with people living with dementia, current and former carers and experts in general practice and social care shaped the next stage. Simultaneously, a rapid review of current evidence on making decisions with older people at the end of life was undertaken.

Results

Output from interviews covered many topics, including trust, agency and confusion in making decisions in the context of COVID-19. The rapid review of existing evidence highlighted the need to consider both process and outcome elements of decision-making.

Conclusions

Combining different sources and forms of evidence was efficient and valuable in creating a novel decision-making tool for persons with dementia and their families within the context of COVID-19. The decision-aid covered care planning, caregiver support systems, access to information and contingency considerations. Upon publication, the tool was adopted by NHS England and other leading healthcare organisations.

Disclosure

No significant relationships.

Setting up pharmacovigilance based on available endTB Project data for bedaquiline

SETTING: Active pharmacovigilance (PV) is recommended for TB programmes, notably for multidrug-resistant TB (MDR-TB) patients treated with new drugs. Launched with the support of UNITAID in April 2015, endTB (Expand New Drug markets for TB) facilitated treatment with bedaquiline (BDQ) and/or delamanid of >2600 patients in 17 countries, and contributed to the creation of a central PV unit (PVU).OBJECTIVE: To explain the endTB PVU process by describing the serious adverse events (SAEs) experienced by patients who received BDQ-containing regimens.DESIGN: The overall PV strategy was in line with the ‘advanced´ WHO active TB drug safety monitoring and management (aDSM) system. All adverse events (AEs) of clinical significance were followed up; the PVU focused on signal detection from SAEs.RESULTS and CONCLUSION: Between 1 April 2015 and 31 March 2019, the PVU received and assessed 626 SAEs experienced by 417 BDQ patients. A board of MDR-TB/PV experts reviewed unexpected and possibly drug-related SAEs to detect safety signals. The experts communicated on clusters of risks factors, notably polypharmacy and off-label drug use, encouraging a patient-centred approach of care. Organising advanced PV in routine care is possible but demanding. It is reasonable to expect local/national programmes to focus on clinical management, and to limit reporting to aDSM systems to key data, such as the SAEs.

Exacerbations of Severe Asthma While on Anti-IL-5 Biologics

Anti-interleukin 5 (IL-5) and anti-IL-5 receptor α monoclonal antibodies markedly decrease airway and peripheral blood eosinophil numbers and are thus highly effective in reducing asthma exacerbations. Nonetheless, these biologics do not completely resolve exacerbations. There is very little information on the cellular nature of exacerbations during treatment with biologics. Using illustrative clinical case scenarios, we highlight the importance of carefully characterizing asthmatics at the time of exacerbation and recognizing neutrophilic causes of exacerbations to ensure optimal management. While an eosinophilic exacerbation may improve with more corticosteroids or by switching to another anti-IL-5 monoclonal antibody, a noneosinophilic exacerbation will likely not. An infective exacerbation needs to be recognized, and the pathogen must be identified and treated with the appropriate antimicrobial agent.

AB0736 SEVERITY OF NAIL PSORIASIS SCORE (SNAPS) IS SENSITIVE TO CHANGE IN A COHORT OF PATIENTS WITH PSORIATIC ARTHRITIS TREATED WITH ETANERCEPT

Background:

The Severity of Nail Psoriasis Score (SNAPS; range 0-40: scored one point each for the presence of pitting, onycholysis, hyperkeratosis and/or severe nail disease#in each fingernail) has been utilised to collect data regarding psoriatic nail dystrophy in the Bath Psoriatic Arthritis (PsA) Longitudinal cohort for many years. SNAPS has construct validity in PsA with the modified Nail Psoriasis Severity Index (mNAPSI) as a comparator instrument and appears to be more feasible than mNAPSI with excellent reliability1.

Objectives:

We aimed to determine if SNAPS could demonstrate longitudinal sensitivity to change in a cohort of patients treated with biological disease modifying anti-rheumatic drugs (bDMARDs) and therefore be utilized prospectively in observational and clinical trial settings.

Methods:

Patients enrolled in the Bath PsA longitudinal cohort routinely undergo clinical assessments including a 66/68 Swollen and Tender Joint Count (SJC/TJC), Psoriasis Area Severity Index (PASI), Patient Global Assessment (PtGA) and Physician Global Assessment (PhGA), as well as complete patient-reported outcome measures such as the Health Assessment Questionnaire (HAQ) and Dermatology Quality of Life (Derm-QoL). All patients who commenced treatment with Etanercept and had available outcome data at baseline, 3 months and 6 months were included in this retrospective analysis. Baseline demographics were recorded and paired t-tests were utilized to assess the change in SNAPS at 3 and 6 months. The effect size and measurement error of SNAPS in this cohort were measured. Correlations between SNAPS and other outcome measures were assessed using Pearson’s r.

Results:

Fifty-seven patients (32 male and 25 female) with available data were retrospectively analysed. The mean (±SD) age of the cohort and duration of disease was 61.3 (±11.55) and 13.3 (±10.82) years respectively. The mean SNAPS at baseline was 3.7 (±6.13) and improved to 2.0 (3.74, p=0.018) at 3 months and 1.2 (2.40) at 6 months (p=0.001 for change from baseline and p=0.039 for change from month 3). The smallest detectable difference at 3 months for SNAPS in this cohort was 1.35, representing 3.37% of the range of the score (Table 2). The standardised response mean (SRM) was 0.32 at 3 months and 0.44 at 6 months. There was a modest correlation between the improvement in the SNAPS score and the improvement in PASI and Derm QOL at 3 months (r = 0.511 and 0.558 respectively, p=0.001) and 6 months (r= 0.672, p<0.001 and r=0.510, p=0.003 respectively).

Conclusion:

SNAPS demonstrates sensitivity to change in response to treatment with a bDMARD and could be a potential outcome measure for the assessment of treatment efficacy in prospective studies.

References:

[1]Antony A, Hart D, Cavill C, Korendowych E, McHugh N, Lovell C, Tillett W. The ‘Severity of Nail Psoriasis Score’ (SNAPS) Is Feasible, Reliable and Demonstrates Construct Validity Against the mNAPSI in an Observational Cohort of Patients with Psoriatic Arthritis [abstract].Arthritis Rheumatol.2019; 71 (suppl 10).

Table 1.

Outcomes at Baseline, 3 months and 6 months

Mean (SD) or Median [IQR]Baseline3 Months(p for change from baseline)6 Months(p for change from baseline)PASI (0-72)3.0 (4.80)1.6 (2.12) p=0.011.3 (1.6) p=0.002SNAPS (0-40)3.7 (6.13)2.0 (3.73) p=0.0181.2 (2.39) p=0.001Derm-QoL (0-30)5.7 (7.07)1.95 (3.23) p=0.001 (n=33)1.9(4.72) p=0.037 (n=31)Table 2.

Measurement Error for SNAPS in an Etanercept Cohort

TimeframeStandardised Response MeanStandard Error of MeanSmallest Detectable ChangeSmallest Detectable Change (% of total score)Smallest Detectable DifferenceSmallest Detectable Difference (% of total score)0-3 months0.320.691.914.771.353.370-6 months0.440.742.065.151.463.64

Disclosure of Interests:

Anna Antony: None declared, Sadaf Saeed: None declared, Darren Hart: None declared, Preeti Nair: None declared, Charlotte Cavill: None declared, Eleanor Korendowych: None declared, Neil McHugh: None declared, Christopher Lovell: None declared, William Tillett Grant/research support from: AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer Inc, UCB, Consultant of: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, MSD, Pfizer Inc, UCB, Speakers bureau: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, Pfizer Inc, UCB

AB0735 SEVERITY OF NAIL PSORIASIS SCORE (SNAPS) DEMONSTRATES LONGITUDINAL CONSTRUCT VALIDITY AGAINST THE MODIFIED NAIL PSORIASIS SEVERITY INDEX (mNAPSI) IN AN OBSERVATIONAL COHORT OF PATIENTS WITH PSORIATIC ARTHRITIS

Background:

Longitudinal observational data on psoriatic nail dystrophy is scarce, in part due to the lack of a validated outcome measure that is feasible in routine care. The Severity of Nail Psoriasis Score (SNAPS; range 0-40: scored one point each for the presence of pitting, onycholysis, hyperkeratosis and/or severe nail disease#in each fingernail) has face validity and has recently demonstrated feasibility, reliability and cross-sectional construct validity against the modified Nail Psoriasis Severity Index (mNAPSI; range 0-130)1.

Objectives:

We aimed to assess the longitudinal construct validity of SNAPS against the mNAPSI and physician nail VAS (PhNVAS), and to determine the effect size and measurement error of these tools.

Methods:

Consenting consecutive patients enrolled in the Bath Psoriatic Arthritis (PsA) longitudinal cohort underwent photography of their fingernails at baseline1and 6 months alongside routine clinical assessments. Dorsal images of individual fingernails were acquired using a tripod mounted DSLR camera. An angled mirror positioned distally aided identification of hyperkeratosis. Photograps were scored using SNAPS, mNAPSI and PhNVAS1. Paired statistical analyses were conducted to assess for change in scores from baseline to follow-up. Pairwise correlations between change in SNAPS and change in mNAPSI and PhyNVAS were assessed using Spearman’s rho. Effect sizes and measurement error were calculated.

Results:

Fifteen patients with a mean (±SD) age of 54.5 (±10.59) were assessed at 6 months. There was a significant reduction in both the mNAPSI and SNAPS scores (p<0.005), with improvements in the most frequently-observed manifestations1i.e. pitting, onycholysis, hyperkeratosis and crumbling (Table 1). No other feature specific to mNAPSI improved over time. There was no significant change using the PhyNVAS. There was a strong correlation between changes in SNAPS and the mNAPSI (Figure 1; rho = 0.838, p<0.001). The correlation between change in SNAPS and PhyNVAS was not statistically significant (rho =0.45, p=0.095) (Figure 1). The change in mNAPSI correlated moderately with the PhNVAS (rho = 0.540, p=0.038). mNAPSI was superior to SNAPS in most parameters of measurement error (Table 2). The mNAPSI and SNAPS had similar effect sizes as measured by the SRM (Table 2).

Conclusion:

SNAPS demonstrates longitudinal construct validity against the mNAPSI in a small observational cohort of PsA patients as evidenced by a strong correlation between the measures, comparable effect sizes and sensitivity to change over time. Whilst measurement error parameters favored the mNAPSI, SNAPS may be a more feasible measure for studying nail disease in cohort studies.

References:

[1]Antony A, Hart D, Cavill C, Korendowych E, McHugh N, Lovell C, Tillett W. The ‘Severity of Nail Psoriasis Score’ (SNAPS) Is Feasible, Reliable and Demonstrates Construct Validity Against the mNAPSI in an Observational Cohort of Patients with Psoriatic Arthritis [abstract].Arthritis Rheumatol.2019; 71 (suppl 10).

Table 1.

Outcomes at Baseline and at Follow-Up:

OutcomeMean (SD) or Median (IQR) N=15t-test or Wilcoxon Sign Rank test (p-value)BaselineFollow-upSNAPS13.0 [8.00-21.00]5.0 [2.00-11.00]0.002*mNAPSI22.0 [12.00-35.00]6.0 [4.00-15.00]0.001*Physician Nail VAS23.3 (22.90)15.8 (15.22)0.147Physician Global VAS18.0 [10.75-32.75]15.0 [10.00-30.00]0.455Table 2.

Measurement error of SNAPS, mNAPSI, PtNVAS and PhyNVAS

SRMSEMSDCSDC % (% of total score)SDDSDD% (% of total score)SNAPS1.151.716.7216.793.368.40mNAPSI1.153.5113.7410.576.875.29Physician Nail VAS0.404.7118.4714.219.237.10Figure 1.

Correlation between changes in SNAPS and changes in mNAPSI

Disclosure of Interests:

Anna Antony: None declared, Sadaf Saeed: None declared, Darren Hart: None declared, Preeti Nair: None declared, Charlotte Cavill: None declared, Eleanor Korendowych: None declared, Neil McHugh: None declared, Christopher Lovell: None declared, William Tillett Grant/research support from: AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer Inc, UCB, Consultant of: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, MSD, Pfizer Inc, UCB, Speakers bureau: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, Pfizer Inc, UCB

Janssen effect in dynamic particulate systems

The Janssen model of stress redistribution within laterally bounded particulate assemblies is a longstanding and valuable theoretical framework, widely used in the design of industrial systems. However, the model relies on the assumption of a static packing of particles and has never been tested in a truly dynamic regime nor for a constraining system whose geometry is dynamically altered. In this paper, we explore the pressure distributions of granular beds housed within a container possessing a laterally mobile sidewall, allowing the depth, height, and cross-sectional areas of the systems studied to be dynamically altered, thus, inducing particle rearrangements and flow in the particulate system constrained thereby. We demonstrate that the systems studied can be successfully described by the Janssen model across a wide range of system expansion rates, including those for which liquidlike flow is clearly observed and propose an extension to the model allowing for an improved characterization of constrained dynamic systems.

Vitamin D status and supplementation in adult patients receiving extracorporeal membrane oxygenation

The prevalence of vitamin D deficiency in critical illness is known to be high and associated with adverse clinical outcomes. Patients receiving extracorporeal membrane oxygenation (ECMO) may be at increased risk of vitamin D deficiency due to high severity of acute illness. Challenges with drug dosing in ECMO patients are recognised due to increased volume of distribution and drug absorption to circuit components. To describe the prevalence of vitamin D deficiency in ECMO patients and the effect of intramuscular dosing of cholecalciferol on levels of vitamin D metabolites, and to compare these data with intensive care unit (ICU) patients not receiving ECMO, two prospective studies were performed sequentially: an observational study of 100 consecutive ICU patients and an interventional study assessing effects of intramuscular cholecalciferol in 50 ICU patients. The subgroup of patients who required ECMO support in each of these studies was analysed and compared to patients who did not receive ECMO. Twenty-four ECMO patients, 12 from the observational study and 12 from the interventional study (who received intramuscular cholecalciferol) were studied-21/24 (88%) ECMO patients were vitamin D deficient at baseline compared to 65/126 (52%) of non-ECMO patients (<i>P</i>=0.006). Of the 12 ECMO patients who received cholecalciferol, six patients (50%) achieved correction of deficiency compared to 36/38 (95%) non-ECMO patients (<i>P</i>=0.001). The prevalence of vitamin D deficiency is higher in ECMO patients compared to other critically ill adults. Correction of deficiency with single dose cholecalciferol is not reliable; higher or repeated doses should be considered to correct deficiency.

Split-graft liver transplantation from an adult donor with an unrecognized UCD to a pediatric and adult recipient

We report the outcomes of an adult and pediatric split liver transplant from an adult male donor who died due to an unrecognized UCD, OTC deficiency. Recognizing inborn errors of metabolism can be challenging, especially in adult centers where such disorders are rarely encountered. Shortage of donors for liver transplantation has led to procedures to maximize donor utilization, such as split and live donor grafts. The cause of death should be ascertained before accepting a cadaveric donor organ.

Revisiting Type 2-high and Type 2-low airway inflammation in asthma: current knowledge and therapeutic implications

Asthma is a complex respiratory disorder characterized by marked heterogeneity in individual patient disease triggers and response to therapy. Several asthma phenotypes have now been identified, each defined by a unique interaction between genetic and environmental factors, including inflammatory, clinical and trigger-related phenotypes. Endotypes further describe the functional or pathophysiologic mechanisms underlying the patient's disease. type 2-driven asthma is an emerging nomenclature for a common subtype of asthma and is characterized by the release of signature cytokines IL-4, IL-5 and IL-13 from cells of both the innate and adaptive immune systems. A number of well-recognized biomarkers have been linked to mechanisms involved in type 2 airway inflammation, including fractional exhaled nitric oxide, serum IgE, periostin, and blood and sputum eosinophils. These type 2 cytokines are targets for pharmaceutical intervention, and a number of therapeutic options are under clinical investigation for the management of patients with uncontrolled severe asthma. Anticipating and understanding the heterogeneity of asthma and subsequent improved characterization of different phenotypes and endotypes must guide the selection of treatment to meet individual patients' needs.

Role of local eosinophilopoietic processes in the development of airway eosinophilia in prednisone-dependent severe asthma

BACKGROUND

In severe asthmatics with persistent airway eosinophilia, blockade of interleukin-5 has significant steroid-sparing effects and attenuates blood and sputum eosinophilia. The contribution of local maturational processes of progenitors within the airways relative to the recruitment of mature cells from the peripheral circulation to the development of airway eosinophilia is not known. We hypothesize that local eosinophilopoiesis may be the predominant process that drives persistent airway eosinophilia and corticosteroid requirement in severe asthmatics.

OBJECTIVES

In a cross-sectional study, the number and growth potential of eosinophil-lineage-committed progenitors (EoP) were assayed in 21 severe eosinophilic asthmatics, 19 mild asthmatics, eight COPD patients and eight normal subjects. The effect of anti-IL-5 treatment on mature eosinophils and EoP numbers was made in severe eosinophilic asthmatics who participated in a randomized clinical trial of mepolizumab (substudy of a larger GSK sponsored global phase III trial, MEA115575) where subjects received mepolizumab (100 mg, n = 9) or placebo (n = 8), as six monthly subcutaneous injections.

RESULTS

Mature eosinophil and EoP numbers were significantly greater in the sputum of severe asthmatics compared with all other subject groups. In colony-forming assays, EoP from blood of severe asthmatics demonstrated a greater response to IL-5 than mild asthmatics. Treatment of severe asthmatics with mepolizumab significantly attenuated blood eosinophils and increased EoP numbers consistent with blockade of systemic eosinophilopoiesis. There was however no significant treatment effect on mature eosinophils, sputum EoP numbers or the prednisone maintenance dose.

CONCLUSIONS AND CLINICAL RELEVANCE

Patients with severe eosinophilic asthma have an exaggerated eosinophilopoeitic process in their airways. Treatment with 100 mg subcutaneous mepolizumab significantly attenuated systemic differentiation of eosinophils, but did not suppress local airway eosinophil differentiation to mature cells. Targeting IL-5-driven eosinophil differentiation locally within the lung maybe of relevance for optimal control of airway eosinophilia and asthma.

Novel SPG20 mutation in an extended family with Troyer syndrome

Troyer Syndrome (TRS) is a rare autosomal recessive complicated spastic paraplegia disorder characterized by various neurological and musculoskeletal manifestations. Pathogenicity stems from mutations in SPG20 which encodes Spartin, a multifunctional protein that is thought to be essential for neuron viability. Here we report on the clinical and molecular characterization of TRS in five patients from an extended consanguineous family in the United Arab Emirates. Molecular analysis involved Whole Exome Sequencing and Sanger sequencing for identification and confirmation of the causative variant respectively. In silico tools including CADD and Polyphen-2 were used to assess pathogenicity of the variant. The clinical description of these patients included spastic paraparesis, motor and cognitive delay, gait abnormalities, musculoskeletal features, as well as white matter abnormalities and emotional liability. Molecular analysis revealed a novel homozygous missense mutation in SPG20 (c.1324G > C; p.Ala442Pro) occurring at an evolutionarily conserved residue in the Plant-Related Senescence domain of Spartin. The mutation segregated with the clinical phenotype in all patients. In silico algorithms predict the mutation to be disease causing, and the variant had not been previously reported in public or ethnic specific variant repositories.

Abstract P3-07-02: Are we missing actionable targets in breast cancer? Novel insights into recurrent Ret alterations

Background: Recurrent gene fusions in breast cancer have been rarely reported suggesting that they either are not present or are not easily detected by standard sequencing methods. Comprehensive genomic profiling (CGP) by hybrid capture-based, high depth next-generation sequencing approaches, can be used to detect recurrent rearrangements and other genomic alterations involving target genes. We found that CGP can identify recurrent alterations involving RET, a known oncogenic tyrosine receptor kinase, in a subset of breast cancer.

Methods: CGP using FoundationOne platform was performed interrogating the entire coding region for up to 315 cancer-related genes and introns of up to 28 genes involved in rearrangements at a depth of 500-1000X in formalin-fixed, paraffin embedded tumor tissue (Foundation Medicine, MA). Engineered representative RET fusion vectors were synthesized and expressed in non-tumorigenic cell lines (breast MCF10A and mouse 3T3 fibroblasts), and cells were evaluated for RET kinase signaling, drug response, and tumorigenicity. Patient-derived xenografts (PDX) generated from two triple negative breast cancers (TNBCs) were used in an ex vivo assay (Response3DXTM, Molecular Response LLC, San Diego, CA).

Results: Twenty-two RET rearrangements were identified in 8119 (0.27%) breast cancer cases. Of these, 5 rearrangements were activating RET fusions including CCDC6-RET (n=4) and NCOA4-RET (n=1), that have been described in other cancer types. Five other cases had clear evidence of genomic rearrangement involving RET, but the 5' partners could not be definitively identified. The remaining twelve cases had complex rearrangements of RET including internal duplications. RET amplification was also observed, both in TNBC and in a HER2+ breast cancer at onset of resistance to HER2-targeted therapy.

Both NCOA4-RET and a novel RASGEF1A-RET fusion were characterized in vitro. Non-tumorigenic cells engineered to stably overexpress either RET fusions demonstrated transformed phenotypes. The fusions were constitutively active, as shown by endogenous phosphorylation of the kinase domain, and drove activation of downstream signaling as shown by increased phosphorylation of ERK and AKT. Cells transformed by RET-fusions were exquisitely sensitive to treatment with RET inhibitors. Interestingly, a PDX model of RET-amplified TNBC was sensitive to treatment with a PIK3CA inhibitor. An index case of ER+/PR-/HER2+, metastatic breast cancer that had radiographic evidence of disease progression while on trastuzumab, pertuzumab, and anastrazole was found to have a NCOA4-RET fusion by CGP. Subsequent treatment with with cabozantinib plus anastrazole led a rapid clinical and radiographic response.

Conclusions: CGP can identify recurrent RET rearrangements in breast cancer that act as primary oncogenic drivers and can be therapeutically targeted. RET alterations may also play a role in acquired resistance to HER2-targeted therapies, suggesting a role for combined RET and HER2-targeted therapy in this setting. Our data demonstrate that RET alterations can be identified by clinical-grade CGP and are promising candidates as therapeutic targets in selected breast cancer patients.

Citation Format: Hirshfield KM, Paratala BS, Hindoyan A, Dolfi SC, Yilmazel B, Schrock A, Gay L, Ali SM, Ross JS, Williams CB, Nair P, Ganesan S, Leyland-Jones B. Are we missing actionable targets in breast cancer? Novel insights into recurrent Ret alterations [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-07-02.

Leech in the Nose - an unusual cause of epistaxis

Leech is an uncommon nasal foreign body, which can cause epistaxis. It is an aquatic segmental worm living in fresh water most commonly in tropical areas. Once it is attached in the nose, it will secrete an anticoagulant enzyme named hirudin, and that will result in continuous bleeding more than from a normal wound even after it is removed. We present a case of a live leech in the nose that caused unilateral epistaxis in a patient with a recent history of jungle trekking.

Human bronchial and parenchymal fibroblasts display differences in basal inflammatory phenotype and response to IL-17A

BACKGROUND

Chronic inflammation, typified by increased expression of IL-17A, together with airway and parenchymal remodelling are features of chronic lung diseases. Emerging evidence suggests that phenotypic heterogeneity of repair and inflammatory capacities of fibroblasts may contribute to the differential structural changes observed in different regions of the lung.

OBJECTIVE

To investigate phenotypic differences in parenchymal and bronchial fibroblasts, either in terms of inflammation and remodelling or the ability of these fibroblasts to respond to IL-17A.

METHODS

Four groups of primary fibroblasts were used: normal human bronchial fibroblast (NHBF), normal human parenchymal fibroblast (NHPF), COPD human bronchial fibroblast (CHBF) and COPD human parenchymal fibroblast (CHPF). Cytokine and extracellular matrix (ECM) expression were measured at baseline and after stimulation with IL-17A. Actinomycin D was used to measure cytokine mRNA stability.

RESULTS

At baseline, we observed higher protein production of IL-6 in NHPF than NHBF, but higher levels of IL-8 and GRO-α in NHBF. IL-17A induced a higher expression of GRO-α (CXCL1) and IL-6 in NHPF than in NHBF, and a higher level of IL-8 expression in NHBF. IL-17A treatment decreased the mRNA stability of IL-6 in NHBF when compared with NHPF. CHPF expressed higher protein levels of fibronectin, collagen-I and collagen-III than CHBF, NHBF and NHPF. IL-17A increased fibronectin and collagen-III protein only in NHPF and collagen-III protein production in CHBF and CHPF.

CONCLUSIONS AND CLINICAL RELEVANCE

These findings provide insight into the inflammatory and remodelling processes that may be related to the phenotypic heterogeneity of fibroblasts from airway and parenchymal regions and in their response to IL-17A.

Histone deacetylase activity and recurrent bacterial bronchitis in severe eosinophilic asthma

An increase in P13 Kinase activity and an associated reduction in histone deacetylase activity may contribute to both relative steroid insensitivity in patients with severe eosinophilic asthma and impaired macrophage scavenger function and susceptibility to recurrent infective bronchitis that may, in turn, contribute to further steroid insensitivity.

Nasal and pharyngeal eosinophil peroxidase levels in adults with poorly controlled asthma correlate with sputum eosinophilia

The objective of the study was to compare nasal, pharyngeal, and sputum eosinophil peroxidase (EPX) levels with induced sputum eosinophil percentage in 10 adults with poorly controlled asthma and 10 normal controls. EPX was measured using an ELISA and normalized for grams of protein for nasal and pharynx specimens and for mL-gram of protein for sputum. Sputum EPX levels were statistically different between asthma and control subjects (P = 0.024). EPX levels measured in the nasal and pharyngeal swab samples derived from the same patients were also different between asthma and control subjects, each displaying a high degree of significance (P = 0.002). Spearman's correlation coefficients for nasal EPX and pharyngeal EPX levels compared to induced sputum eosinophil percentage were 0.81 (P = 0.0007) and 0.78 (P = 0.0017), respectively. Thus, there is a strong association in a given patient between both nasal and pharyngeal EPX levels and the eosinophil percentage of induced sputum.

Association of HLA-DQA1 and -DQB1 alleles with type I diabetes in Arabs: a meta-analyses

This study aimed at assessing the nature and significance of associations between various alleles of HLA-DQA1, HLA-DQB1, and type I diabetes (T1D) in Arab populations. Evidence from literature (published before 20 April 2015) was amassed and analysed through multiple meta-analyses, which yielded effect summary odds ratios and 95% confidence intervals for 24 alleles and 4 haplotypes. A total of 1273 cases and 1747 controls from 16 studies were analysed. High levels of significance were obtained to support higher T1D risk when harbouring DQA1*03:01. The alleles DQB1*02:01 and *03:02 and the haplotypes DR3 and DR4 were significant risk factors, albeit with high publication heterogeneity. The protective effects of DQA1*01:01, DQB1*05:03, *06:02, *06:03, and *06:04 were robustly suggested by all indicators of meta-analyses. The haplotypes DR7 and DR11 were strongly suggested to be protective in Arabs. A relatively small number of studies have emerged from Arab countries, mostly with inadequate power on an individual basis. This study fills the gap by providing significant size effect of human leukocyte antigen (HLA) alleles and completes the continuum of global ethnic differences in this context.

A novel missense mutation in ATRX uncovered in a Yemeni family leads to alpha-thalassemia/mental retardation syndrome without alpha-thalassemia

BACKGROUND

Intellectual disability (ID) features in numerous heritable medical conditions that result from ATRX mutations. Alpha-thalassemia mental retardation syndrome (ATR-X syndrome) is the most notable manifestation of ATRX dysfunction. In addition to ID, genitourinary and craniofacial abnormalities are regularly observed with or without alpha-thalassemia.

AIMS

The study sought to characterize two cases of ATR-X in a Yemeni family clinically and molecularly.

METHODS

PCR amplification and Sanger sequencing were used to study the ATRX gene in a Yemeni family. Also, methylation-sensitive PCR was used to perform X-inactivation studies. CADD, SNAP2 and PolyPhen-2 helped to predict the functional consequences of the variant.

RESULTS

Molecular testing revealed a novel hemizygous missense mutation (c.5666T>G) in the ATRX gene in the two Yemeni brothers. This mutation was found in a heterozygous state in the mother, with the chromosome harboring the mutated allele being under strongly skewed X-inactivation.

CONCLUSIONS

The mutated gene is predicted to have a disrupted SNF-2 domain at a conserved residue; p.Leu1889Trp, which is deemed functionally damaging. This report offers, for the first time, full clinical and molecular characterization of a novel ATRX variant in an Arab family.