Research Infrastructure Core Facilities at Research Centers in Minority Institutions: Part I-Research Resources Management, Operation, and Best Practices

Funded by the National Institutes of Health (NIH), the Research Centers in Minority Institutions (RCMI) Program fosters the development and implementation of innovative research aimed at improving minority health and reducing or eliminating health disparities. Currently, there are 21 RCMI Specialized (U54) Centers that share the same framework, comprising four required core components, namely the Administrative, Research Infrastructure, Investigator Development, and Community Engagement Cores. The Research Infrastructure Core (RIC) is fundamentally important for biomedical and health disparities research as a critical function domain. This paper aims to assess the research resources and services provided and evaluate the best practices in research resources management and networking across the RCMI Consortium. We conducted a REDCap-based survey and collected responses from 57 RIC Directors and Co-Directors from 98 core leaders. Our findings indicated that the RIC facilities across the 21 RCMI Centers provide access to major research equipment and are managed by experienced faculty and staff who provide expert consultative and technical services. However, several impediments to RIC facilities operation and management have been identified, and these are currently being addressed through implementation of cost-effective strategies and best practices of laboratory management and operation.

RF35 | PSAT263 Efficacy of Teprotumumab for Thyroid Eye Disease in Hypothyroid Patients

Background

Thyroid eye disease (TED) is an autoimmune inflammatory process that can lead to eye-bulging (proptosis) and double-vision (diplopia). Teprotumumab, an insulin-like growth factor-I receptor inhibitory antibody, has demonstrated improvements in proptosis and diplopia. Thyroid dysregulation has been linked to increased TED severity¹ and may trigger TED flares,² thus, treatment efficacy of hypo- or hyperthyroid patients with teprotumumab is of interest. This post-hoc analysis of pooled phase 2 and 3 trial data3 examined teprotumumab efficacy in patients with low baseline FT4 levels.

Methods

Patients from Phase 2 and 3 teprotumumab trials with low baseline FT4 (≤11.5 pmol/L) were included. Patients received teprotumumab or placebo for 24 weeks (8 infusions). Proportions of proptosis (≥2 mm reduction), clinical activity score (CAS, 7-point scale, CAS 0 or 1), and diplopia (≥1 Gorman diplopia scale grade improvement) responders were determined at Week 24. Additionally, the Graves’ ophthalmopathy- quality of life (GO-QOL) questionnaire measured quality of life.

Results

Nine teprotumumab-treated patients (6 female [67%], 54.6±10.7 years old) and 8 (6 female [75%], 50.0±14.9 years old) patients made up the teprotumumab and placebo groups, respectively. Mean baseline proptosis in the study eye was 25.1±3.9 mm in teprotumumab patients and 21.9±3.8 mm in placebo patients. At Week 24, 78% (7/9) teprotumumab-treated vs. 38% (3/8) placebo-treated patients were proptosis responders. Further, mean proptosis reduction was 2.9±0.6 mm with teprotumumab vs. 1.2±0.7 mm with placebo. 67% (6/9) vs. 13% (1/8) of teprotumumab vs. placebo patients were CAS responders at Week 24. Of those with baseline diplopia, 86% (6/7) vs. 40% (2/5) were diplopia responders, respectively. In the teprotumumab group, the least square mean change from baseline in overall GO-QOL score improved by 23.4±6.4, which was a large clinical change. In contrast, the placebo group improved by 6.9±7.4.

Conclusions

After 24 weeks, responses to teprotumumab were greater versus placebo in patients with low baseline FT4 in two clinical trials. Responses in these mildly hypothyroid patients in this study were consistent with those in the overall pooled population as follows: Proptosis response: 78% and 77%, respectively; mean proptosis reduction: 2.9 mm and 3.14 mm; diplopia response 86% and 70%; CAS response 67% and 62%, respectively. Thus, pretreatment hypothyroid status does not affect clinical responses to teprotumumab in TED.

References

Bartalena L. Best Pract Res Clin Endocrinol Metab 2012; 26: 371-379. Patel P, et al. Ophthalmic Plast Reconstr Surg 2015; 31(6): 445-448. Kahaly et al. Lancet Diabetes and Endocrinol 2021; 9(6): 360-372

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Monday, June 13, 2022 12:26 p.m. - 12:41 p.m.

OR11-4 Teprotumumab Markedly Improves Disease-related Quality of Life: Lessons From Two Randomized, Placebo-controlled Trials

Background

Thyroid eye disease (TED) can result in eye-bulging (proptosis) and double-vision (diplopia) and inflammation, which frequently impacts quality of life (QoL). Teprotumumab, an insulin like growth factor-1 receptor inhibitory antibody, improves TED outcomes and QoL¹ as measured by the Graves Ophthalmopathy-Quality of Life (GO-QoL) questionnaire and its appearance (AP) and visual function (VF) subscales. The primary factors driving QoL improvement in TED are unknown; therefore, we examined outcomes associated with improvement as observed in 2 placebo-controlled trials.

Methods

Data from Phase 2/3 placebo-controlled trials of teprotumumab were examined with a mixed-effect model with change in overall GO-QoL, AP, and VF scores as dependent variables to explain within-patient variability. Independent variables included demographics, visits, treatment, symptoms (Gorman diplopia scores [0-3], proptosis change (mm), spontaneous orbital pain, gaze-evoked orbital pain). Variability between subjects was tested over the 24-week study.

Results

Teprotumumab treatment significantly correlated with improved overall GO-QoL, VF and AP scores. Improvements in diplopia, proptosis, gaze-evoked and spontaneous orbital pain were associated with those in overall GO-QoL score (coefficient -4.01, -1.00, -31.21 and -4.37, respectively, all p<0.001). Improvements in diplopia scores and spontaneous orbital pain were significantly correlated with higher VF scores (coefficients -5.51 and -6.66, respectively, both p<0.001). Improvements in diplopia and proptosis correlated significantly with higher AP scores (coefficients -2.98, -1.62, both p<0.001). Patients with pain had lower AP scores (coefficient -38.21, p<0.001). Increasing age was positively correlated with higher GO-QoL AP scores (coefficient 0.41, p<0.001), but negatively correlated with GO-QoL VF scores (coefficient -0.29, p<0.001). Variability between subjects was considerable, accounting for >60% of random variance.

Conclusions

Improvements in diplopia, proptosis, and pain drove improvements in QoL. In older patients, changes in AP impacted QoL to a lesser degree, while reduced VF had a greater negative impact on QoL.

References

Kahaly et al, Lancet Diabetes and Endocrinol 2021; 9(6): 360-372

Presentation: Sunday, June 12, 2022 11:45 a.m. - 12:00 p.m.

PSAT265 Blood Glucose in Thyroid Eye Disease (TED) in Patients treated with Teprotumumab: Clinical Trials Data

Background

Teprotumumab, an FDA-approved insulin-like growth factor-1 receptor inhibitor for TED, improves proptosis, diplopia, inflammation, and quality of life. In the pooled phase 2 and 3 trial analysis, 8/84 (10%) teprotumumab-treated patients reported hyperglycemia adverse events (AEs) versus 1/86 (1.2%) in placebo. Here, we discuss perturbations in serum glucose data reported in patients from two pivotal clinical trials with teprotumumab.

Methods

Glycemia data from two randomized, double-masked, placebo-controlled multicenter trials were analyzed throughout 8 teprotumumab vs. placebo infusions. Blood glucose was measured at Weeks 1, 4, 15, and 21 in phase 2 study patients. In phase 3, all patients with pre-existing diabetes had blood glucose measured at each study visit. Patients without pre-existing diabetes had fasting blood glucose measurements at Weeks 1 and 4. The remainder of blood glucoses in non-diabetics were non-fasting. HbA1c levels were measured at baseline, 12 and 24 weeks, in all patients.

Results

The mean patient age was 51.4 years, with 73% female. At baseline, diabetic patients were controlled with oral and/or insulin therapies at primary investigator discretion. Mean baseline non-fasting blood glucose in teprotumumab patients was 98.3 mg/dl versus 100.5 mg/dl in placebo. Mean non-fasting blood glucose increased from baseline in teprotumumab-treated patients by 6.9 mg/dl but decreased by 6.5 mg/dl in those receiving placebo at 24 weeks. Nine hyperglycemia AEs were reported in 8 teprotumumab-treated patients; 6 resolved during the treatment period, 2 resolved after the last dose, and 1 continued after study completion. Five of 8 patients who had hyperglycemia had pre-existing diabetes in this pooled analysis. All reported hyperglycemic AEs were Grade 1 (>160mg/dl) or 2 (161 mg/dl to 250 mg/dl). In the teprotumumab group follow-up, two patients had hyperglycemia-related AEs. One resolved without medication. Neither led to study drug discontinuation. HbA1c increased by 0.22% (mean, N=72) with teprotumumab compared to 0.04% (N=71) with placebo. There were no cases of diabetic ketoacidosis or hyperosmolar hyperglycemic state.

Conclusion

Approximately 10% of teprotumumab treated patients compared to 1% receiving placebo had hyperglycemic events. Most hyperglycemic cases were easily controlled with medication. In addition, no treatment discontinuation or complications were associated with these elevated blood glucose levels. This analysis demonstrates no evidence for severe diabetogenesis with teprotumumab treatment, although blood glucose monitoring is recommended for all patients.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Evaluation of data imputation strategies in complex, deeply-phenotyped data sets: the case of the EU-AIMS Longitudinal European Autism Project

An increasing number of large-scale multi-modal research initiatives has been conducted in the typically developing population, e.g. Dev. Cogn. Neur. 32:43-54, 2018; PLoS Med. 12(3):e1001779, 2015; Elam and Van Essen, Enc. Comp. Neur., 2013, as well as in psychiatric cohorts, e.g. Trans. Psych. 10(1):100, 2020; Mol. Psych. 19:659–667, 2014; Mol. Aut. 8:24, 2017; Eur. Child and Adol. Psych. 24(3):265–281, 2015. Missing data is a common problem in such datasets due to the difficulty of assessing multiple measures on a large number of participants. The consequences of missing data accumulate when researchers aim to integrate relationships across multiple measures. Here we aim to evaluate different imputation strategies to fill in missing values in clinical data from a large (total N = 764) and deeply phenotyped (i.e. range of clinical and cognitive instruments administered) sample of N = 453 autistic individuals and N = 311 control individuals recruited as part of the EU-AIMS Longitudinal European Autism Project (LEAP) consortium. In particular, we consider a total of 160 clinical measures divided in 15 overlapping subsets of participants. We use two simple but common univariate strategies—mean and median imputation—as well as a Round Robin regression approach involving four independent multivariate regression models including Bayesian Ridge regression, as well as several non-linear models: Decision Trees (Extra Trees., and Nearest Neighbours regression. We evaluate the models using the traditional mean square error towards removed available data, and also consider the Kullback–Leibler divergence between the observed and the imputed distributions. We show that all of the multivariate approaches tested provide a substantial improvement compared to typical univariate approaches. Further, our analyses reveal that across all 15 data-subsets tested, an Extra Trees regression approach provided the best global results. This not only allows the selection of a unique model to impute missing data for the LEAP project and delivers a fixed set of imputed clinical data to be used by researchers working with the LEAP dataset in the future, but provides more general guidelines for data imputation in large scale epidemiological studies.

AB1051 CLINICAL OUTCOMES AND HEALTHCARE RESOURCE UTILIZATION OF UNCONTROLLED GOUT PRIOR TO PEGLOTICASE THERAPY

Background

By definition, uncontrolled gout (UG) cannot be managed with oral urate lowering therapies (ULTs) and is associated with substantial morbidity. UG, also known as refractory gout, results in escalated treatment and management. Recent American College of Rheumatology guidelines recommend treating gout to serum uric acid targets; if targets are not achieved or patients continue to have symptoms, pegloticase is recommended. There is a paucity of data documenting the clinical and economic burden of UG patients.

Objectives

Assess clinical outcomes and healthcare resource utilization (HCRU) of UG prior to pegloticase initiation.

Methods

A retrospective observational database analysis was conducted among patients initiating pegloticase between April 1, 2011 and August 31, 2020 using the PharMetrics Plus database. Eligible subjects had ≥1 pegloticase claim (first claim = index date) and continuous enrollment for 24 months prior to index. Relevant clinical and economic (HCRU) outcomes were evaluated over a 24-month pre-index period and compared between two different time intervals prior to index: time interval 1 (Day -720 to Day -361) and time interval 2 (Day -360 to Day -1). Assessment of comorbid disease burden included Charlson Comorbidity Index (CCI) and relevant health conditions. Dependent pairwise comparisons were conducted to compare clinical and economic outcomes between time intervals prior to pegloticase initiation. To assess statistical differences, paired t-tests (continuous variables) or McNemar’s tests (categorical variables) were used.

Results

Of the 408 eligible subjects, most were male (88.5%), with an average age (SD) of 55.2 (11.3) years, 66.9% were between the ages of 45-64 years and 78.2% had a preferred provider organization (PPO) health plan. Most often (34.8% of patients), a rheumatologist was associated with initiation of pegloticase therapy, while primary care physicians accounted for 23.8% of initiations. Mean (SD) CCI score was 2.4 (2.4) with 37.3% of subjects having a CCI score of >3. Prevalence of relevant health conditions over the 24-month pre-index period included tophi (62.5%), urolithiasis (8.6%), chronic kidney disease (34.6%) and chronic pain/fibromyalgia (76.5%), all of which significantly increased from time interval 1 (Day -720 to Day -361) to time interval 2 (Day -360 to Day -1) prior to pegloticase initiation (Table 1). Of patients initiating pegloticase, 57.4% had 1 ULT (excluding probenecid), 11.3% had >2 ULT (excluding probenecid), and 10.3% UG patients had ≥1 probenecid claim over the 24-month pre-index period. Most patients (98.3%) had ≥1 physician office visit, 27.2% had ≥1 hospitalization and 45.3% had ≥1 emergency room (ER) visit over the 24-month pre-index period. HCRU significantly increased from time interval 1 to time interval 2, prior to pegloticase (Figure 1).

Table 1.

Relevant Health Conditions and Disease-specific Health Care Resource Utilization (HCRU)

Overall N= 408Time Interval 1Time Interval 2Tophi62.5%15.4%61.5%***Urolithiasis8.6%4.2%6.9%*Chronic kidney disease34.6%22.5%31.6%***Cardiovascular disease32.6%21.3%28.4%**Type 2 diabetes mellitus31.4%23.3%28.9%**Hypertension76.2%58.1%70.3%***≥1 gout flare87.7%48.5%83.8%***Mean number of gout flare (SD)3.5 (2.4)1.02.1***Gout-related medications ≥1 claim for colchicine56%39.5%63.7%***≥1 claim for opioids71%52.9%60.3%*≥1 claim for oral corticosteroids80%50.2%75.7%***≥1 claim for injectable corticosteroids64%38.5%53.7%***

†Time Interval 1: Day -720 to Day -361 prior to pegloticase initiation; ††Time Interval 2: Day -360 to Day -1 prior to pegloticase initiation

***, p<0.0001; **, p<0.001; *, p<0.05

Conclusion

Overall, these data demonstrate the progressive nature of UG as confirmed by significant increases in gout-related conditions and healthcare resource utilization prior to pegloticase initiation. Further research is needed on healthcare resource utilization among patients with UG post-pegloticase use.

Disclosure of Interests

Robert Morlock Consultant of: Horizon Therapeutics, Victoria Divino Grant/research support from: Horizon Therapeutics, Mitchell DeKoven Grant/research support from: Horizon Therapeutics, Brian LaMoreaux Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Atsuko Powers Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Naina Barretto Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Robert Holt Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Stephanie Taylor Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics

Autistic People's Perinatal Experiences II: A Survey of Childbirth and Postnatal Experiences

Qualitative accounts indicate there are sensory and communication related barriers to adequate childbirth and postnatal healthcare for autistic people. However, little quantitative work has explored the topic. This online survey study explored childbirth and postnatal experiences among 384 autistic and 492 non-autistic people. Compared with non-autistic people, autistic people were more likely to find the sensory aspects of birth overwhelming, and experienced lower satisfaction with birth-related and postnatal healthcare. Autistic people were more likely to experience postnatal depression and anxiety. The findings highlight that sensory and communication adjustments should be made to birth and postnatal healthcare for autistic people. The findings indicate the need for greater autism understanding among professionals and greater postnatal mental health support for autistic people.

Brain charts for the human lifespan

Over the past few decades, neuroimaging has become a ubiquitous tool in basic research and clinical studies of the human brain. However, no reference standards currently exist to quantify individual differences in neuroimaging metrics over time, in contrast to growth charts for anthropometric traits such as height and weight1. Here we assemble an interactive open resource to benchmark brain morphology derived from any current or future sample of MRI data ( http://www.brainchart.io/ ). With the goal of basing these reference charts on the largest and most inclusive dataset available, acknowledging limitations due to known biases of MRI studies relative to the diversity of the global population, we aggregated 123,984 MRI scans, across more than 100 primary studies, from 101,457 human participants between 115 days post-conception to 100 years of age. MRI metrics were quantified by centile scores, relative to non-linear trajectories2 of brain structural changes, and rates of change, over the lifespan. Brain charts identified previously unreported neurodevelopmental milestones3, showed high stability of individuals across longitudinal assessments, and demonstrated robustness to technical and methodological differences between primary studies. Centile scores showed increased heritability compared with non-centiled MRI phenotypes, and provided a standardized measure of atypical brain structure that revealed patterns of neuroanatomical variation across neurological and psychiatric disorders. In summary, brain charts are an essential step towards robust quantification of individual variation benchmarked to normative trajectories in multiple, commonly used neuroimaging phenotypes.

Maternal steroid levels and the autistic traits of the mother and infant

BACKGROUND

Prenatal sex steroids have been associated with autism in several clinical and epidemiological studies. It is unclear how this relates to the autistic traits of the mother and how early this can be detected during pregnancy and postnatal development.

METHODS

Maternal serum was collected from pregnant women (n = 122) before or during their first ultrasound appointment [mean = 12.7 (SD = 0.7) weeks]. Concentrations of the following were measured via immunoassays: testosterone, estradiol, dehydroepiandrosterone sulphate, progesterone; and sex hormone-binding globulin which was used to compute the free fractions of estradiol (FEI) and testosterone (FTI). Standardised human choriogonadotropin (hCG) and pregnancy-associated plasma protein A (PAPP-A) values were obtained from clinical records corresponding to the same serum samples. Mothers completed the Autism Spectrum Quotient (AQ) and for their infants, the Quantitative Checklist for Autism in Toddlers (Q-CHAT) when the infants were between 18 and 20 months old.

RESULTS

FEI was positively associated with maternal autistic traits in univariate (n = 108, Pearson's r = 0.22, p = 0.019) and multiple regression models (semipartial r = 0.19, p = 0.048) controlling for maternal age and a diagnosis of PCOS. Maternal estradiol levels significantly interacted with fetal sex in predicting infant Q-CHAT scores, with a positive relationship in males but not females (n = 100, interaction term: semipartial r = 0.23, p = 0.036) after controlling for maternal AQ and other covariates. The opposite was found for standardised hCG values and Q-CHAT scores, with a positive association in females but not in males (n = 151, interaction term: r = -0.25, p = 0.005).

LIMITATIONS

Sample size of this cohort was small, with potential ascertainment bias given elective recruitment. Clinical covariates were controlled in multiple regression models, but additional research is needed to confirm the statistically significant findings in larger cohorts.

CONCLUSION

Maternal steroid factors during pregnancy are associated with autistic traits in mothers and their infants.

Abstract 1647: CAPTIV-8: A prospective trial of atezolizumab using a multivariate model incorporating whole genome and transcriptome analysis

Dramatic and durable responses to immune checkpoint inhibitors (ICIs) have been observed across multiple tumor types, but identifying the patients most likely to respond to these drugs remains challenging, particularly in the context of metastatic and pre-treated disease. Recent clinically approved biomarkers for patient selection are tumor agnostic, but currently all approved markers are evaluated independently. Through the Personalized Onco Genomics (POG) program at BC Cancer, we aimed to study the impact of evaluating multiple biomarkers in a tumor agnostic cohort. We performed whole genome and transcriptome analysis (WGTA) on fresh tumor biopsies from a heterogeneous pan-cancer cohort of 82 patients with advanced metastatic disease subsequently treated with ICIs. Established biomarkers, including tumor mutation burden (TMB) and CD8+ T cell scores, were able to distinguish responders in our advanced and pre-treated cohort. Additionally, we discovered that combining multiple biomarkers provided the best stratification of patients, suggesting a multifaceted approach, such as WGTA, may be suitable for more accurate identification of patients that may benefit from ICIs. As such, we have initiated a Phase II clinical trial, CAPTIV-8 (NCT04273061), which is distinctive in its use of WGTA to evaluate multiple markers including TMB, CD8+ T cell scores, an M1-M2 macrophage score and viral integration to select patients most likely to respond to atezolizumab. Clinical and genomic data prospectively collected from two hundred patients will be evaluated to test the efficacy of combining these biomarkers and identify additional biomarkers of response which can be used to guide treatment with ICIs.

Citation Format: Emma Titmuss, Alexandra Pender, Erin Pleasance, Scott Brown, Cameron J. Grisdale, James Topham, Yaoqing Shen, Melika Bonakdar, Gregory A. Taylor, Laura Williamson, Karen Mungall, Eric Chuah, Andrew J. Mungall, Richard A. Moore, Jean-Michel Lavoie, Stephen Yip, Howard Lim, Daniel J. Renouf, Sophie Sun, Steven J. Jones, Robert Holt, Marco A. Marra, Janessa Laskin. CAPTIV-8: A prospective trial of atezolizumab using a multivariate model incorporating whole genome and transcriptome analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1647.

Hematologists' barriers and enablers to screening and recruiting patients to a chimeric antigen receptor (CAR) T cell therapy trial: a theory-informed interview study

BACKGROUND

Novel therapies often fail to reach the bedside due to low trial recruitment rates. Prior to conducting one of the first chimeric antigen receptor (CAR) T cell therapy trials in Canada, we used the Theoretical Domains Framework, a novel tool for identifying barriers and enablers to behavior change, to identify physician-related barriers and enablers to screening and recruiting patients for an early phase immunotherapy trial.

METHODS

We conducted interviews with hematologists across Canada and used a directed content analysis to identify relevant domains reflecting the key factors that may affect screening and recruitment.

RESULTS

In total, we interviewed 15 hematologists. Physicians expressed "cautious hope"; while expressing safety, feasibility, and screening criteria concerns, 14 out of 15 hematologists intended to screen for the trial (domains: knowledge, goals, beliefs about consequences, intentions). Physicians underscored the "challenging contexts," identifying resources, workload, forgetting, and patient wait times to receive CAR T cells as key practical barriers to screening (domains: environmental context and resources, memory, attention and decision-making, behavioral regulation). They also highlighted "variability in roles and procedures" that may lead to missed trial candidates (domain: social and professional role). Left unaddressed, these barriers may undermine trial recruitment.

CONCLUSIONS

This study is among the first to use the Theoretical Domains Framework from the physician perspective to identify recruitment challenges to early phase trials and demonstrates the value of this approach for identifying barriers to screening and recruitment that may not otherwise have been elicited. This approach can optimize trial procedures and may serve to inform future promising early phase cancer therapy trials.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03765177 . Registered on December 5, 2018.

45 Quality Improvement Project on Delirium Care in Older Patients at Mid Yorkshire Hospitals NHS Trust (MYHT)

Background

To improve delirium care in older patients admitted to a large district general NHS Trust in the UK, a quality improvement project was conducted.

Introduction

The national NICE guidelines (CG103) and recent SIGN guidelines recommend delirium is diagnosed by a clinical assessment based on DSM criteria (e.g. CAM or 4AT) and managed by identifying and treating the causes alongside multicomponent interventions.

The results of MYHT’s 2018 delirium audit showed the use of CAM or 4AT was 32.5% and delirium care plan was 20%. A quality improvement project was developed and implemented for 6 weeks on a frailty admission unit.

Method

The quality improvement project introduced a delirium care checklist sticker for medical notes in cases of suspected delirium, brief education sessions for ward doctors regarding delirium care and use of the sticker and reminder emails, all implemented by the elderly medicine registrar. The target measures were completion of stickers, 4AT and delirium care plan. Data was collected by the registrar once a week for 6 weeks and entered into a run chart. Feedback was collected from staff on barriers to use.

Results

31 patients with suspected delirium has their notes reviewed. The sticker use gradually reduced from 57% of cases in week 1, to 0% in week 6. The 4ATwas completed in 57%, 50% and 100% of cases in the first 3 weeks, but dropped to 40%, 4.2% and 1.3% in the last 3 weeks. A delirium care plan was initiated in 42% and 37% of cases in the first two weeks but ended at 0% by week 6.

Barriers included a lack of education sessions from week 2 onwards due to registrar on call shifts. Also junior doctor changeover in week 3. Feedback indicated barriers were time taken to complete, and confusion over ownership of completing 4AT and care plan between medical and nursing teams.

Conclusion

Although a delirium care checklist sticker and brief education sessions can improve delirium care, sustained improvement requires ongoing education and addressing barriers to completion.

References

1. National Institute for Health and Care Excellence (2019) Delirium: prevention, diagnosis and management (NICE Guideline CG103). Available at: https://www.nice.org.uk/guidance/cg103 Accessed 21/09/2019].

2. Scottish Intercollegiate Guidelines Network (2019) risk reduction and management of delirium (SIGN Guideline 157). Available at https://www.sign.ac.uk/assets/sign157.pdf. Accessed 21/09/2019.

OP0173 IMMUNOMODULATION CO-THERAPY WITH PEGLOTICASE: DATABASE TRENDS 2014-2019

Background:

Pegloticase is a PEGylated biologic therapy for patients with uncontrolled gout who have not improved on or could not tolerate conventional urate-lowering therapies.1All biologics have the ability to engender anti-drug antibodies (ADAs) and it is known that some patients given pegloticase develop ADAs that cause them to stop treatment prior to recieving a complete course of therapy.2-3In other rheumatic autoimmune diseases, DMARDs such as methotrexate or azathioprine are used as standard of care to prevent the development of ADAs to biologics. These DMARDs often allow patients to remain on biologic therapies longer and recieve the full therapeutic benefits while minimizing adverse events.4While pegloticase has been used traditionally as monotherapy, recent case series have demonstrated the therapeutic benefit of immunomodulator co-administration, allowing more patients to receive a full course of pegloticase therapy.5-6Little has been published on how widespread this practice is and whether it has changed over time.

Objectives:

To examine medical claims database from 2014-2019 for trends in immunomodulating therapies being co-prescribed with pegloticase.

Methods:

An IQVIA claims database (November 2014 to October 2019) representing 1.3 billion claims, covering 30 million patients diagnosed with gout or CKD, was utilized to search for patients who had received pegloticase. Patients who had recieved pegloticase were classified as having been on an immunomodulating co-therapy if they were prescribed methotrexate or azathioprine within 60 days before or after initiation of their first pegloticase infusion.

Results:

We found relatively steady low rates of immunomodulation co-therapy with pegloticase from 2014 through 2018 ranging from 1% in 2016 to 4% in 2018 (Figure 1). In 2019 however, the proportion of pegloticase patients that were co-treated with methotrexate or azathioprine therapy increased to 15%. Most patients were started on immunomodulating therapy 20 days before to 10 days after initiation of pegloticase. Methotrexate was the more frequently used immunomodulaton co-therapy as compared to azathioprine.

Conclusion:

We found evidence of a relatively dramatic increasing initiation of immunomodulation therapy with pegloticase beginning soon after a November 2018 presentation of a case series which demonstrated improved response rates of pegloticase when co-administered with methotrexate. These data indicate that clinicians began to more frequently employ a strategy of DMARD co-treatment with pegloticase in 2019 to improve response rates to this important gout medicine.

References:

[1]Sundy JS, et al.JAMA2011;306:711-20.

[2]Abeles AM.Arthritis Research & Therapy2014, 16:112

[3]Strand V, et al.BioDrugs2017; 31:299–316.

[4]Krieckaert CL, et al.Arthritis Res Ther2010;12:217.

[5]Botson J and Peterson J.Ann Rheum Dis.2019; 78: A1289.

[6]Bessen SY, et al.Semin Arthritis Rheum.2019;49:56-61.

Disclosure of Interests:

Brian LaMoreaux Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Megan Francis-Sedlak Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Karl Svensson Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Robert Holt Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics

AB1043 AWARENESS OF THYROID EYE DISEASE, AN AUTOIMMUNE CONDITION, AMONG RHEUMATOLOGISTS

Background:

Autoimmune inflammatory conditions of the eye may be associated with rheumatic diseases such as rheumatoid arthritis, systemic lupus erythematosus, and granulomatosis with polyangiitis. This is also observed with thyroid eye disease (TED). Loss of immune tolerance to the thyroid stimulating hormone receptor has thyroidal consequences and nearly 40% of patients with Graves’ disease also have clinically evident Graves’ orbitopathy or TED.1TED results from tissue inflammation that causes retro orbital fat expansion2and extraocular muscle enlargement2and stiffening.3Because the orbital cavity is bony and of limited volume, proptosis and, in severe cases, optic nerve compression, can result. In many patients, muscle changes also cause ocular motility issues and double-vision. Because TED can have a similar presentation to other inflammatory orbital diseases (e.g., granulomatosis with polyangiitis) and Graves’ disease patients frequently have other autoimmune conditions (10% of Graves’s patients also have rheumatoid arthritis),4rheumatologists are likely to care for, or even diagnose, patients with TED.

Objectives:

This analysis sought to understand rheumatologists’ knowledge, and degree of participation in the treatment, of TED including referral patterns from ophthalmologists and endocrinologists for infusion therapies.

Methods:

Rheumatologists practicing in the United States attended an educational session and agreed to complete a 12-item survey regarding TED awareness, referral patterns, and management.

Results:

Of the 47 rheumatologists surveyed, 45 (96%) were familiar with TED. Ten (21%) physicians reported managing patients with TED, but the majority of physicians (62%) reported that they co-managed other autoimmune diseases in patients who also had TED. Additionally, 98% and 64% of polled rheumatologists had received referrals from ophthalmologists and endocrinologists, respectively, for autoimmune disease management or infusion therapy. Ophthalmology referrals for intravenous (IV) medication administration were most frequently for biologics (82%), but some referrals were also made for corticosteroids (2%) or other medication (13%) infusions. Only 23% of rheumatologists had administered a biologic specifically for TED (rituximab: 17%, tocilizumab: 2%, other: 4%), but 89% expressed an interest in administering a TED-specific monoclonal antibody therapy, awaiting FDA approval.

Conclusion:

Nearly all surveyed rheumatologists were aware of the signs and symptoms of TED, although most did not actively manage or administer medication for TED. Given the high level of interest in infusing novel, TED-specific biologics, rheumatologists may become an integral part of TED patient management with the approval of a new biologic, teprotumumab, for thyroid eye disease.

References:

[1]Bartley GB, et al.Am J Ophthalmol1996;121:284-90.

[2]Forbes G, et al.AJNR Am J Neuroradiol1986;7:651-656.

[3]Simonsz HJ, et al.Strabismus1994;2:197-218.

[4]Cardenas Roldan J, et al.Arthritis2012 2012;864907.

Disclosure of Interests:

Brian LaMoreaux Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Megan Francis-Sedlak Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Robert Holt Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, James Rosenbaum Consultant of: AbbVie, Corvus, Eyevensys, Gilead, Novartis, Janssen, Roche, UCB Pharma; royalties from UpToDate

OP0169 AMPUTATION PROCEDURES IN PATIENTS WITH GOUT COMPARED TO PATIENTS WITH DIABETES

Background:

Gout is the most common inflammatory arthritis in the United States (U.S.) and is associated with specific comorbidities, including hypertension, renal disease, cardiovascular disease, hyperlipidemia, and metabolic syndrome (1). This set of comorbidities is known for carrying an increased risk of macrovascular complications (e.g., myocardial infarction, stroke) and peripheral limb problems (e.g., skin ulcers, amputations). Diabetics are known to have an elevated risk of undergoing ulcer and amputation procedures, which have been shown to increase morbidity and mortality in this population (2,3). It is currently not known if patients with gout have an elevated independent risk for limb amputations or whether gout potentiates amputation rates in patients with diabetes.

Objectives:

To assess and compare the rate of amputation procedures conducted in patients with gout, diabetes, both gout and diabetes, and neither gout nor diabetes.

Methods:

In September 2019, a large U.S. claims database (includes data from 190 million patients over 7 years, TriNetX “Diamond” network) was used to determine amputation rates in patients with gout and diabetes. TriNetX only provides aggregate data and statistical summaries of de-identified patient information. Initial cohorts were developed to understand the amputation rate in patients with gout, regardless of diabetes comorbidity (n=4,467,721), and the amputation rate in patients with diabetes, regardless of gout comorbidity (n= 25,972,726). Subsequently, the following four cohorts were constructed to isolate these two diseases: 1) presence of gout without diabetes (n=2,471,430), 2) presence of diabetes without gout (n=23,976,435), 3) presence of both gout and diabetes (n=1,996,291), and 4) absence of both gout and diabetes (control cohort, n=144,705,645). Demographic features of these groups were tabulated and amputation (foot, toes, hand, fingers) rates were calculated using procedural codes reported in each group.

Results:

The overall rate of amputations in patients with gout (0.434%) was similar to the amputation rate in patients with diabetes (0.484%). However, when separating these patients into distinct, non-overlapping cohorts, the amputation rate in patients with gout but not diabetes (0.162%) differed from the rate in patients with diabetes but not gout (0.461%). The control population (no gout or diabetes) had an amputation rate of 0.035%. Unexpectedly, patients with both gout and diabetes had an amputation rate of 0.770%, the highest of all groups examined.

Conclusion:

Gout is increasingly being linked to unfavorable cardiovascular, renal, and metabolic complications. Our analysis showed that having gout also increased the likelihood of undergoing an amputation procedure. Patients with gout but not diabetes suffered an approximately 3-fold increase in amputations compared to patients without either disease. Additionally, patients with both gout and diabetes had a notably increased risk of amputation compared to patients with only diabetes (no gout). Because amputations are an unfavorable outcome associated with procedural complication risk and long-term sequelae, this apparent increased risk of amputation in patients with gout warrants further exploration.

References:

[1]Dalbeth N, et al.Nature Reviews Disease Primers, 2019;5(69):1-17

[2]Geiss LS, et al.Diabetes Care, 2019;42:50-54

[3]Moulik PK, et al.Diabetes Care, 2003;26:491-494

Disclosure of Interests:

Brian LaMoreaux Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Megan Francis-Sedlak Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Robert Holt Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics

SAT-424 Assessing Content Validity of the Graves’ Ophthalmopathy Quality of Life Questionnaire (GO-QOL) in the United States

Introduction: Thyroid eye disease (TED) is an autoimmune condition that negatively impacts patient’s quality of life (QOL). The GO-QOL questionnaire was originally developed in the Netherlands to quantify how TED and treatments affect patient QOL. This questionnaire includes eight questions each on visual functioning and appearance related QOL; the items are answered on a 3-point Likert scale and transformed to a 0 (worst) to 100 (best) scale. Though widely used and validated outside the US, the questionnaire has not been validated in the United States (US). Here we examine the content validity.

Methods: Patients with moderate or severe TED were identified using an existing market research patient database, clinician referrals, patient groups, and social media. Interested participants were screened for eligibility prior to completing the GO-QOL. Subjects were also questioned about TED-related signs, symptoms, and treatments and underwent a cognitive interview following GO-QOL completion.

Results: Thirteen TED patients completed the assessments (mean age = 44.8 ± 11.5 years, range: 26-67); all were female. Mean TED duration was 4.6 ± 5.5 years (range: 0.4-20.7). Twelve patients (92.3%) had Graves’ disease and one had Hashimoto’s thyroiditis. Descriptions of how TED signs and symptoms impacted quality of life were consistent with GO-QOL items, and qualitative interviews indicated that patients found the GO-QOL content relevant and complete. Responses indicated that minor wording changes may be needed to account for US cultural and language conventions and prevent confusion (specifically related to a bicycling question [12/13 reported not regularly riding a bike before TED symptom onset]). Visual functioning impacts most commonly-reported during the interview were difficulty driving a motor vehicle (92% of participants), difficulty with electronic screens (e.g., televisions, smart phones, and computers; 77%), difficulty moving around outdoors (including issues with light sensitivity, uneven surfaces, and depth perception; 69%), and difficulty doing hobbies or pastimes (69%). Emotional/psychological impacts frequently reported by participants were change in appearance (92%), depression and anxiety (including fear and worry; 77%), and frustration and anger (including moodiness; 69%). Negative reactions from others (staring, asking questions), social impacts and isolation, and lack of self-confidence and embarrassment were also reported (each 62%).

Conclusion: This analysis of US patient interviews offered strong support for GO-QOL content validity. Therefore, the GO-QOL is appropriate to quantify TED-related QOL impact in a US population. However, a few slight wording modifications may be needed for future optimal use in the US.Reference: Terwee CB. Br J Ophthalmol 1998;82:773-779

SAT-432 Pharmacokinetics (PK) and Exposure-Response Relationship of Teprotumumab, an Insulin-Like Growth Factor-1 Receptor (IGF-1R) Blocking Antibody, in Active Thyroid Eye Disease (TED)

Introduction: Teprotumumab treatment resulted in statistically and clinically meaningful improvements across multiple facets of active TED and was generally well-tolerated in Phase 2 and 3 trials.1,2 An initial intravenous infusion of 10 mg/kg followed by 20 mg/kg every 3 weeks was selected based on in vitro activity and clinical PK profile, to maintain pharmacologically active exposures and &gt;90% saturation of IGF-1R over dosing intervals and to achieve efficacy at a well-tolerated dose for this vision-threatening disease.

Methods: Population PK analysis were performed on data from a Phase 1 oncology study (n=60)3 and Phase 2 and 3 trials in active TED (N=83)2,3 and covariate effect on PK was assessed. Exposure-response relationship was evaluated in TED studies for key efficacy endpoints (proptosis response rate, % patients with a clinical activity score value of 0 or 1, and diplopia responder rate) and selected safety variables (hyperglycemia and muscle spasms).

Results: Teprotumumab PK was linear in TED patients and consistent with other immunoglobulin G1 monoclonal antibodies (IgG1 mAbs), with low systemic clearance (0.334 L/day), low volume of distribution (3.9 L for central compartment and 4.2 L for peripheral compartment), and long elimination half-life (19.9 days). 4,5 Model-predicted mean (± standard deviation) steady-state area under the concentration curve (AUCss), peak (Cmax,ss), and trough (Cmin,ss) concentrations in TED patients were 131 (± 30.9) mg∙hr/mL, 643 (± 130) µg/mL and 157 (± 50.6) µg/mL, respectively, suggesting low inter-subject variability.

Population PK analysis indicated no significant impact of baseline age, gender, race, weight, smoking status, renal impairment (mild/moderate), and hepatic function (total bilirubin, aspartate and alanine aminotransferases) on teprotumumab PK. Female patients had 15% higher Cmax,ss but similar AUC compared to male patients, which is not considered clinically relevant.

Exposure-response analysis from the TED dose regimen indicated no meaningful correlations between exposures (AUCss, Cmax,ss and Cmin,ss) and key efficacy endpoints or selected safety variables, supporting the demonstrated, favorable benefit-risk profile of the TED dose regimen.2

Conclusion: Teprotumumab PK was characterized in TED patients by long elimination half-life, low systemic clearance and low volume of distribution, consistent with other IgG1 mAbs. There was no meaningful exposure-response relationship at the selected TED dose regimen for both efficacy and safety endpoints, supporting the teprotumumab dose regimen used in TED patients.

Reference: (1) Smith TJ, et al. N Engl J Med 2017;376:1748-1761. (2) Douglas RS, et al. AACE 2019 late-breaking abstract. (3) ClinicalTrials.gov: NCT00400361. (4) Dirks NL et al. Clin Pharmacokinet. 2010;49(10):633-59. (5) Ryman JT et al. CPT Pharmacometrics Syst Pharmacol. 2017;6(9):576-88.

OR18-01 Effect of Teprotumumab on Proptosis Reduction Across Various Demographic Sub-Groups

Introduction: Teprotumumab, an insulin-like growth factor 1 receptor inhibitory monoclonal antibody, was recently shown to significantly reduce proptosis in patients with active, moderate-to-severe thyroid eye disease (TED) in phase 2 and phase 3 clinical trials.^1,2 Prior analyses have demonstrated a combined trial proptosis response (≥2 mm reduction) rate of 77.4% in the teprotumumab group and 14.9% in the placebo group after 24 weeks of therapy (p < 0.001).³ The current analysis was performed to investigate whether or not patient demographic characteristics influence the teprotumumab proptosis response.

Methods: Data from two 24-week randomized, double-masked, placebo-controlled, parallel-group, multicenter studies (Phase 2 [NCT01868997], Phase 3 [NCT03298867[) were combined. All patients had active TED associated with Graves’ disease. The study eye designated at baseline manifested more severe TED and a clinical activity score of > 4. Subjects were divided into subgroups based on gender, smoking status, and age at baseline (younger: <65, older: ≥65). The percentage of proptosis (≥2 mm) responders and proptosis change from baseline were examined in each of these subgroups. Because most of both teprotumumab (85%) and placebo (87%) subjects were white, there were insufficient numbers of subjects to examine the effect of race on the teprotumumab proptosis response. All analyses were performed on the intent-to-treat (ITT) population using data from the study eye.

Results: A total of 171 patients comprised the population from the two studies. Eighty-four and 87 patients were randomized to the teprotumumab and placebo groups, respectively, and the treatment groups had balanced baseline characteristics. At week 24, significantly more teprotumumab than placebo patients were proptosis responders in all examined subgroups (male: 73.1% vs. 5.0%, female: 79.3% vs. 17.9%, smokers: 70.0% vs. 23.1%, non-smokers 79.7% vs. 11.5%, younger: 76.1% vs. 16.2%, older: 84.6% vs. 7.7%; all p < 0.001). In continuous variable analyses, the mean proptosis reduction from baseline was also significantly greater at week 24 in teprotumumab-treated patients than placebo patients (male: -3.34 vs. -0.07 mm, female: -3.10 vs. -0.42 mm, smokers: -2.99 vs. -0.72 mm, non-smokers: -3.20 vs. -0.31 mm, younger: -3.10 vs. -0.39 mm, older: -3.55 vs. -0.22 mm; all p < 0.001).

Conclusion: Teprotumumab was effective across subgroups of age, gender, and smoking status in the pooled 24-week clinical trials.

Reference: (1) Smith TJ, et al. N Engl J Med 2017;376:1748-1761. (2) Douglas RS, et al. AACE 2019 late-breaking abstract. (3) Kahaly GJ, et al. Thyroid 2019;29(Suppl1):A-1 [abstract].

Intrathecal 99mTc-DTPA imaging of molecular passage from lumbar cerebrospinal fluid to brain and periphery in humans

INTRODUCTION

Cerebrospinal fluid (CSF) molecular exchange with brain interstitial fluid (ISF) and periphery is implicated in neurological disorders but needs better quantitative clinical assessment approaches.

METHODS

Following intrathecal (ITH) dosing via lumbar puncture, Technetium-99 m (99mTc-) diethylenetriaminepentaacetic acid (DTPA) imaging was used to quantify neuraxial spread, CSF-brain molecular exchange, and CSF-peripheral clearance in 15 normal human volunteers. The effect of experimental convection manipulation on these processes was also assessed.

RESULTS

Rostral cranial 99mTc-DTPA exposures were influenced by the volume of artificial CSF in the formulation. Signal translocation to the cranial cisterns and the brain parenchyma was observable by 3 hours. 99mTc-DTPA penetrated cortical ISF but showed lower signal in deeper structures. Urinary 99mTc-DTPA signal elimination was accelerated by higher formulation volumes and mechanical convection.

DISCUSSION

Widely used for detecting CSF leaks, ITH 99mTc-DTPA imaging can also become a useful clinical biomarker for measuring molecular exchange physiology between the CSF, brain, and periphery.

Abstract LB-230: Quantitative immunohistochemistry for melanocortin 1 receptor using phosphor integrated dots

Visual scoring of biomarkers by immunohistochemistry (IHC) on formalin-fixed paraffin embedded tissues constitutes a major part of histopathologic diagnosis and staging of several cancers. To improve sensitivity and linearity of IHC methods, we have developed a quantitative IHC technique using streptavidin coated phosphor integrated dot (PID) fluorescent nanoparticles (Gonda et al, Scientific Reports, 2017). In retrospective analysis of clinically established biomarkers (i.e., PD-L1, HER2, CSF-1R), IHC-PID has provided high-sensitivity quantitative detection of target proteins with a broad dynamic range. The present study examines the utility of IHC-PID in the biomarker discovery and validation process by evaluating melanocortin subtype 1 receptor (MC1R) in cell lines and clinical biopsy samples. MC1R is currently under investigation as a potential diagnostic and therapeutic target for malignant melanoma, a lethal cancer with poor long-term prognosis. MC1R is an endocytic cell-surface G-protein coupled receptor that exhibits relatively high expression in malignant melanoma tumors vs. normal tissues. Notably, current melanoma therapies, including MAPKi (e.g., vemurafenib, dabrafenib) increase MC1R expression pharmacologically on melanoma cells (unpublished results). MC1R expression was determined in cell lines by standard radio-ligand binding assay (125I-NDP-α-MSH). The SK-Mel-28 cell line showed 5-6 fold increased expression of endogenous MC1R when compared to the A375 cell line. Formalin fixed pellets of these two cell lines were used for analytical validation of PID-IHC. By utilizing dedicated image-processing algorithms, the readout of average PID score/cell was determined to be 285 and 98, for SK-Mel-28 and A375 cell lines, respectively. To confirm the increase in sensitivity with the PID technology, enabling quantitative IHC and improved detection of MC1R, de-identified melanoma samples from varying sites were collected by surgical biopsy at The University of Iowa Hospitals and Clinics and scored by a pathologist. Sister sections were stained by conventional IHC or IHC-PID. For IHC-PID, sections were counter stained by hematoxylin; tumor regions were hand annotated by a pathologist; and fluorescent images in 5 microscopic fields were captured and analyzed. Background PID threshold was determined by using no-primary antibody as controls. IHC-PID was performed on MS0759 (T1b N0 M0), MS0045 (T3a N1a M0) and MS0868 (T4b N3 M1a) samples and showed average PID score/cell of 217±38, 68±12, and 160±21, respectively. Ongoing studies are expanding on IHC-PID use to assess MC1R expression on a clinical melanoma panel (n=20) in late stage patients undergoing pharmacological interventions including MAPKi. The overall goal of this project is to develop PID-based quantitative IHC to support the development of MC1R as an imaging biomarker for patient stratification and monitoring clinical response to MC1R-targeted radionuclide therapy for malignant melanoma.

Note: This abstract was not presented at the meeting.

Citation Format: Apollina Goel, Kenji Nishikawa, Etsuko Futaya, Ildiko Poylak, Robert Holt, Mengshi Li, Edwin Sagastum, Brenna Marks, Aaron D. Bossler, Frances L. Johnson, Michael K. Schultz, Hideki Goda, Hisatake Okada, Kelly Orcutt, George Abe, Kenneth Bloom. Quantitative immunohistochemistry for melanocortin 1 receptor using phosphor integrated dots [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr LB-230.

SAT-554 Teprotumumab in Graves' Orbitopathy: Extended Outcome Analyses

Objective A multicenter, double-masked, randomized, placebo-controlled, phase two trial of 88 patients with active, moderate-to-severe Graves’ orbitopathy (GO) has demonstrated a significant and rapid response to teprotumumab, an insulin-like growth factor 1 receptor inhibitory monoclonal antibody, when compared with placebo after 24 weeks (N Engl J Med 2017; 376:1748). We now report extended primary and secondary outcome analyses. Methods Seven weeks after final dose of study medication (week 28), the primary and secondary endpoints were analyzed in teprotumumab intent-to-treat patients as compared with placebo to assess possible relapse. This included the primary composite endpoint of percentage patients with ≥2 points reduction in clinical activity score (CAS, seven-point scale) and a reduction of ≥2 mm in proptosis, secondary endpoints of proptosis, CAS, diplopia grade, specific GO quality of life questionnaire (GO-QoL), and exploratory analyses of clinical severity, all in the study (more severely affected) eye. Results Thirty-one of 42 (74%) teprotumumab- and six of 45 (13%) placebo- treated patients reached the primary outcome at treatment week 28 (p<0.001). Response was maintained from end of treatment period (week 24) in 93% of those teprotumumab-treated patients who responded. Proptosis response was similar to the primary outcome, with 55% of those receiving teprotumumab having a high response (≥3mm decrease). Gender, race, smoking or baseline proptosis values did not impact proptosis response. At week 28, 37/42 (88%) of those receiving teprotumumab and 27/45 (60%) getting placebo reached the CAS outcome (p=0.003). All individual CAS components were different from placebo (p≤0.04) except eyelid erythema (p=0.06). Assessment of CAS and severity of GO favored teprotumumab: chemosis (percent of patients ≥1 grade reduction; p=0.11), swelling of eyelid (percent of patients ≥1 grade reduction; p=0.01) and lid aperture (percent of patients ≥2 mm reduction; p=0.09). From baseline there was a reduction in constant diplopia (36% vs 9.5%) and increase in those with no diplopia (9.5% vs. 50%) in the teprotumumab group. At week 24, significantly more teprotumumab-receiving patients had improved by ≥one grade than placebo (62% vs. 22%, p<0.001). Improvement of diplopia grade remained significant at week 28 off drug. Overall GO-QoL was higher in those receiving teprotumumab than in patients getting placebo (p<0.001). Teprotumumab did not affect thyroid function, which was stable in both study groups through the treatment phase and follow-up. Conclusions Teprotumumab reduced the composite primary outcome of proptosis and CAS, as well as improved diplopia and GO-QoL significantly at seven weeks following study treatment discontinuation. This analysis also indicates that proptosis can serve as a primary and sensitive outcome for future trials of therapeutic response in GO.

Base excision repair deficiency signatures implicate germline and somatic MUTYH aberrations in pancreatic ductal adenocarcinoma and breast cancer oncogenesis

We report a case of early-onset pancreatic ductal adenocarcinoma in a patient harboring biallelic MUTYH germline mutations, whose tumor featured somatic mutational signatures consistent with defective MUTYH-mediated base excision repair and the associated driver KRAS transversion mutation p.Gly12Cys. Analysis of an additional 730 advanced cancer cases (N = 731) was undertaken to determine whether the mutational signatures were also present in tumors from germline MUTYH heterozygote carriers or if instead the signatures were only seen in those with biallelic loss of function. We identified two patients with breast cancer each carrying a pathogenic germline MUTYH variant with a somatic MUTYH copy loss leading to the germline variant being homozygous in the tumor and demonstrating the same somatic signatures. Our results suggest that monoallelic inactivation of MUTYH is not sufficient for C:G>A:T transversion signatures previously linked to MUTYH deficiency to arise (N = 9), but that biallelic complete loss of MUTYH function can cause such signatures to arise even in tumors not classically seen in MUTYH-associated polyposis (N = 3). Although defective MUTYH is not the only determinant of these signatures, MUTYH germline variants may be present in a subset of patients with tumors demonstrating elevated somatic signatures possibly suggestive of MUTYH deficiency (e.g., COSMIC Signature 18, SigProfiler SBS18/SBS36, SignatureAnalyzer SBS18/SBS36).

Advancing Stiffness Measurement in Rheumatic Disease: Report from the Stiffness Special Interest Group at OMERACT 2018

OBJECTIVE

To improve measurement of stiffness in rheumatic disease.

METHODS

Data presented included (1) 2 qualitative projects, (2) the rheumatoid arthritis (RA) stiffness patient-reported outcome measure (RAST), and (3) 3 items assessing stiffness severity, duration, and interference.

RESULTS

Stiffness is multidimensional and includes aspects of stiffness experience such as duration, severity, and effect. Stiffness items showed construct validity in RA. Further efforts are required to develop an instrument that will be taken through the Outcome Measures in Rheumatology (OMERACT) Filter 2.1 for instrument selection.

CONCLUSION

The research agenda for the group includes domain content voting for individual diseases, and development of stiffness item banks and disease-specific short forms.

Abstract 4346: Integrated whole genome profiling of the immune tumour interaction identifies predictive biomarkers of checkpoint inhibitor response in metastatic cancer

Immune checkpoint inhibitors are fast becoming a key therapy in the medical oncologist's toolbox across a diverse array of tumour types. The excitement surrounding the utility of these emerging agents is marred by the heterogeneous response observed among patients, highlighting the urgent need for clinically applicable predictive biomarkers. Significant progress has been made in identifying potentially relevant biomarkers including mutation burden and immune infiltration. However, it is still unclear which biomarkers are most predictive across various disease types, and how to integrate various markers of response and resistance for clinical interpretation. We hypothesized that comprehensive genomic profiling, combined with clinical data, would reveal differences in the immuno-oncologic phenotype that could be used as biomarkers for response to checkpoint inhibitor therapy. The Personalized OncoGenomics (POG) study at BC Cancer performs whole genome and transcriptome sequencing of metastatic disease across a diverse array of cancer types to comprehensively characterize cancers and inform clinical therapeutic decision-making. Here we performed in-depth genomic profiling of 64 POG patients who received immune checkpoint inhibitors encompassing multiple disease types including skin, lung, breast, pancreatic and colorectal cancers and sarcomas. Single nucleotide variants, structural variants, copy number alterations, and RNA expression derived from whole genomic and transcriptomic data were used to characterize genomic instability, neoantigen landscape, immune infiltration, and other potential biomarkers of clinical response to checkpoint inhibitors. This collection of putative immune-oncologic biomarkers were integrated into a multivariate model to stratify markers of the tumour immune response. Our analysis shows limited association between PD-L1 expression and checkpoint inhibitor response, consistent with the inadequate effectiveness of this as a universal marker, and shows stronger association between signatures of T cell infiltration based on RNA-Seq data. We also observed patients with low mutation burden that respond to checkpoint inhibitors and show high levels of immune infiltration, and cases with high mutation burden that harbour mechanisms of resistance including reduction in predicted neoantigen diversity. Additional mechanisms of therapeutic resistance observed in post treatment biopsies highlight disruption of antigen presentation and JAK1 mutations in resistant tumours. Our study helps to define which features distinguish patients most likely to respond to checkpoint inhibitors, and uses these features in selecting patients for immunotherapy treatment within the POG clinical trial.

Citation Format: Hillary Pearson, Laura Williamson, Erin Pleasance, Scott Brown, Emma Titmuss, Martin Jones, Stuart Zong, Payal Sipahimalani, Yussanne Ma, Steve Jones, Robert Holt, Marco Marra, Janessa Laskin. Integrated whole genome profiling of the immune tumour interaction identifies predictive biomarkers of checkpoint inhibitor response in metastatic cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4346.

Abstract LB-329: Multiple-resolution characterization of tumor heterogeneity as associated with disease progression in a mouse model of colorectal cancer

The ability to engineer models to express endogenous fluorophores has become an invaluable tool for studying tumor biology. The utility of these models is limited by the sensitivity and resolution of currently available imaging platforms. In vivo techniques enable longitudinal studies in which changes in fluorescent markers, tumors, and whole organs can be monitored over time. In vivo fluorescence suffers from poor sensitivity and resolution owing to the high absorption and scatter of light in biological tissue. While ex vivo fluorescence techniques allow for high resolution evaluation and characterization, these techniques typically only focus on a small samples of tissue instead of whole animals. Using a Cryo-Fluorescence Tomography (CFT) imaging approach, an imaging modality based on serial slicing and off-the-block fluorescence imaging, we can bridge the gap between in vivo and ex vivo resolution of the entire animal. As proof of concept, a novel mouse model expressing fluorophores was evaluated and characterized. Individual cells were labeled with either EGFP or tdTomato prior to tumor initiation. Intestinal tumors were induced through loss of Apc, the activation of PI3K, or both. Tumor heterogeneity and grade were assessed by traditional histopathology, individual-tissue CFT, and whole-animal CFT. Using CFT, serial sectioning and 3D-reconstruction of whole tissues were achieved at 10-50 µm resolution.The multi-resolution imaging approach of this model enabled visualization of molecular and histopathological information from a common in vivo resolution (1mm) to whole-tissue resolution. The CFT platform enabled a 3D data set at a resolution that was not previously available in traditional histopathology. CFT as a molecular tissue imaging technique has proven its utility as a complimentary assay in preclinical oncology studies allowing several characteristics of tumors including heterogeneity, growth, and malignant spread to be readily assessed.

Citation Format: Mohammed Farhoud, Alyssa Leystra, Dawn M. Albrecht, Mathew Brevard, Hemi Dimant, Robert Holt, Richard B. Halberg. Multiple-resolution characterization of tumor heterogeneity as associated with disease progression in a mouse model of colorectal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr LB-329.

New variant and expression studies provide further insight into the genotype-phenotype correlation in YAP1-related developmental eye disorders

YAP1, which encodes the Yes-associated protein 1, is part of the Hippo pathway involved in development, growth, repair and homeostasis. Nonsense YAP1 mutations have been shown to co-segregate with autosomal dominantly inherited coloboma. Therefore, we screened YAP1 for variants in a cohort of 258 undiagnosed UK patients with developmental eye disorders, including anophthalmia, microphthalmia and coloboma. We identified a novel 1 bp deletion in YAP1 in a boy with bilateral microphthalmia and bilateral chorioretinal coloboma. This variant is located in the coding region of all nine YAP1 spliceforms, and results in a frameshift and subsequent premature termination codon in each. The variant is predicted to result in the loss of part of the transactivation domain of YAP1, and sequencing of cDNA from the patient shows it does not result in nonsense mediated decay. To investigate the role of YAP1 in human eye development, we performed in situ hybridisation utilising human embryonic tissue, and observed expression in the developing eye, neural tube, brain and kidney. These findings help confirm the role of YAP1 and the Hippo developmental pathway in human eye development and its associated anomalies and demonstrate its expression during development in affected organ systems.

Identification and functional characterisation of genetic variants in OLFM2 in children with developmental eye disorders

Anophthalmia, microphthalmia, and coloboma are a genetically heterogeneous spectrum of developmental eye disorders and affect around 30 per 100,000 live births. OLFM2 encodes a secreted glycoprotein belonging to the noelin family of olfactomedin domain-containing proteins that modulate the timing of neuronal differentiation during development. OLFM2 SNPs have been associated with open angle glaucoma in a case-control study, and knockdown of Olfm2 in zebrafish results in reduced eye size. From a cohort of 258 individuals with developmental eye anomalies, we identified two with heterozygous variants in OLFM2: an individual with bilateral microphthalmia carrying a de novo 19p13.2 microdeletion involving OLFM2 and a second individual with unilateral microphthalmia and contralateral coloboma who had a novel single base change in the 5' untranslated region. Dual luciferase assays demonstrated that the latter variant causes a significant decrease in expression of OLFM2. Furthermore, RNA in situ hybridisation experiments using human developmental tissue revealed expression in relevant structures, including the lens vesicle and optic cup. Our study indicates that OLFM2 is likely to be important in mammalian eye development and disease and should be considered as a gene for human ocular anomalies.

Abstract 5226: Genomic analysis of pancreatic ductal adenocarcinoma in a patient with MUTYH-associated polyposis

Biallelic pathogenic germline variants in the DNA repair glycosylase, MUTYH, cause MUTYH-associated polyposis, characterised by an increased susceptibility to colorectal adenomas and carcinomas secondary to defective base excision repair. We report a patient diagnosed with Stage IIB distal pancreatic ductal adenocarcinoma (PDAC) at the age of 45 years. Prior colonoscopy and gastroscopy noted three colonic tubular adenomas and a gastric fundic gland polyp. The patient was consented to whole genome and transcriptome sequencing of the PDAC and matched normal blood DNA through the British Columbia Personalized Onco-Genomics (POG) program. Analysis of germline and somatic variants including single nucleotide variants, copy number determination, loss of heterozygosity detection and mutational signatures was undertaken. Expression fold-changes were calculated against Illumina BodyMap pancreatic tissue averages and compared against The Cancer Genome Atlas PDAC cases. Germline analysis revealed biallelic mutations in the MUTYH gene. In light of this patient's personal and family history of adenomatous colon polyps, clinic-initiated panel testing of 14 cancer susceptibility genes, including MUTYH, via Illumina sequencing with reflex Sanger confirmation revealed the same biallelic MUTYH changes. Analysis of the patient's PDAC revealed a base excision repair pathway signature, demonstrated by an increased frequency of C:G&gt;A:T transversions, consistent with deficient MUTYH activity. This is the first association of germline MUTYH biallelic pathogenic variants with PDAC and provides evidence of the contribution of aberrant MUTYH function to the genomic landscape of a PDAC. Detection of the base excision repair mutational signature may be a sensitive way to screen tumors for aberrant MUTYH function that can reveal potential germline MUTYH-related cancer susceptibility, and allow inference of pathogenicity of detected MUTYH variants, which may have cancer prevention and therapeutic implications.

Citation Format: Kasmintan A. Schrader, Carolyn Chu’ng, Eric Zhao, Hui-li Wong, Yaoqing Shen, Martin Jones, Tom Thomson, Howard Lim, Sean Young, Carol Cremin, Robert Holt, Peter Eirew, Joanna Karasinska, Jacquie Schein, Yongjun Zhao, Andy Mungall, Richard Moore, Yussanne Ma, Alexandra Fok, Robyn Roscoe, Stephen Yip, Gillian Mitchell, Aly Karsan, Steven Jones, David Schaeffer, Janessa Laskin, Marco Marra, Daniel Renouf. Genomic analysis of pancreatic ductal adenocarcinoma in a patient with MUTYH-associated polyposis. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 5226.

Morning stiffness response with delayed-release prednisone after ineffective course of immediate-release prednisone

Objective: To assess morning stiffness in rheumatoid arthritis (RA) patients switched from immediate-release (IR) to delayed-release (DR) prednisone.

Method: Circadian Administration of Prednisone in Rheumatoid Arthritis-1 (CAPRA-1) is a 12-week, randomized, multicentre, active-controlled study of morning stiffness that consisted of a double-blind phase and a 9-month open-label extension. Patients receiving IR prednisone with no significant improvement after the double-blind study were switched to DR prednisone. Morning stiffness duration and median absolute and relative changes in pain and global assessment were evaluated (3, 6, and 9 months).

Results: In patients switched from IR to DR prednisone (n = 110), statistically significant reductions in morning stiffness occurred over 3 months and were sustained for 9 months. Absolute reduction of morning stiffness was ~50 min with > 40% relative reduction at each visit. Interleukin (IL)-6 levels were reduced by the same amount. Statistically significant and clinically meaningful mean reductions in morning stiffness were maintained at > 67 min at each visit along with significant improvements in pain and patient global assessment. There was no evidence of tachyphylaxis seen over the 9-month study.

Conclusions: Patients receiving disease-modifying anti-rheumatic drugs (DMARDs) and IR prednisone who had not had significant reductions in morning stiffness demonstrated statistically significant and clinically meaningful improvements when switched to DR prednisone.

Developmental white matter microstructure in autism phenotype and corresponding endophenotype during adolescence

During adolescence, white matter microstructure undergoes an important stage of development. It is hypothesized that the alterations of brain connectivity that have a key role in autism spectrum conditions (ASCs) may interact with the development of white matter microstructure. This interaction may be present beyond the phenotype of autism in siblings of individuals with ASC, who are 10 to 20 times more likely to develop certain forms of ASC. We use diffusion tensor imaging to examine how white matter microstructure measurements correlate with age in typically developing individuals, and how this correlation differs in n=43 adolescents with ASC and their n=38 siblings. Correlations observed in n=40 typically developing individuals match developmental changes noted in previous longitudinal studies. In comparison, individuals with ASC display weaker negative correlation between age and mean diffusivity in a broad area centred in the right superior longitudinal fasciculus. These differences may be caused either by increased heterogeneity in ASC or by temporal alterations in the group's developmental pattern. Siblings of individuals with ASC also show diminished negative correlation between age and one component of mean diffusivity-second diffusion eigenvalue-in the right superior longitudinal fasciculus. As the observed differences match for location and correlation directionality in our comparison of typically developing individuals to those with ASC and their siblings, we propose that these alterations constitute a part of the endophenotype of autism.

A prospective observational study to investigate the association between abnormal hand movements and delirium in hospitalised older people

OBJECTIVE

to examine the relationship between carphology (aimlessly picking at bedclothes), floccillation (plucking at the air) and delirium in older patients admitted to specialist elderly care wards.

DESIGN

daily observation for behaviours of carphology and floccillation embedded within a 'before' and 'after' study.

SETTING

three specialist elderly care wards in a general hospital.

SUBJECTS

older people admitted to hospital as emergencies.

METHODS

patients recruited into a delirium prevention study were observed daily for delirium using the confusion assessment method (CAM). Occurrences of carphology and/or floccillation were also recorded. Sensitivity, specificity and positive and negative predictive values for carphology/floccillation for the diagnosis of delirium were calculated. Inpatient mortality rates were compared for patients who did, and did not exhibit features of carphology and/or floccillation.

RESULTS

four hundred and thirty-seven patients were recruited into the study. One hundred and ten participants experienced an episode of delirium, 21 exhibited behaviours of carphology and/or floccillation. The sensitivity and specificity of carphology and/or floccillation for the diagnosis of delirium were 14 and 98%, respectively; positive likelihood ratio 6.8. Carphology and floccillation were associated with both hyper- and hypo-active delirium subtypes, and occurred early during incident delirium (67% within 2 days of delirium onset). The inpatient mortality rate in patients with carphology/floccillation was double the rate in patients without the behaviours (23.8 versus 11.2%, Fisher's exact test P = 0.16).

CONCLUSIONS

carphology and floccillation are uncommon physical signs, but their presence is highly suggestive of delirium. The behaviours are unrelated to delirium subtype making their presence particularly useful in the diagnosis of hypo-active delirium.

Subgroup-specific structural variation across 1,000 medulloblastoma genomes

Medulloblastoma, the most common malignant paediatric brain tumour, is currently treated with nonspecific cytotoxic therapies including surgery, whole-brain radiation, and aggressive chemotherapy. As medulloblastoma exhibits marked intertumoural heterogeneity, with at least four distinct molecular variants, previous attempts to identify targets for therapy have been underpowered because of small samples sizes. Here we report somatic copy number aberrations (SCNAs) in 1,087 unique medulloblastomas. SCNAs are common in medulloblastoma, and are predominantly subgroup-enriched. The most common region of focal copy number gain is a tandem duplication of SNCAIP, a gene associated with Parkinson's disease, which is exquisitely restricted to Group 4α. Recurrent translocations of PVT1, including PVT1-MYC and PVT1-NDRG1, that arise through chromothripsis are restricted to Group 3. Numerous targetable SCNAs, including recurrent events targeting TGF-β signalling in Group 3, and NF-κB signalling in Group 4, suggest future avenues for rational, targeted therapy.

Metagenomic and metabolomic characterization of rabies encephalitis: new insights into the treatment of an ancient disease

Rabies virus (RV) infection is a fatal nervous system disorder. We describe a patient who died of rabies despite a neuroprotective intervention. Neuropathology showed neuronal loss with abundant RV antigen, genome, and Negri bodies, accompanied by intense neuroinflammation, including by CD8(+) T lymphocyte infiltrates. Deep sequencing and real-time reverse-transcription polymerase chain reaction revealed RNA encoding a bat RV strain together with inflammatory gene induction. RV-infected brain demonstrated reduced neuronal metabolites with an anaerobic metabolic profile by nuclear magnetic resonance (NMR) spectroscopy. These multiplatform studies highlight the extent of ongoing viral replication coupled with inflammation in treated rabies, indicative of a neurological immune reconstitution inflammatory syndrome.