A command centre implementation before and during the COVID-19 pandemic in a community hospital

INTRODUCTION

The objective of the study was to assess the effects of high-reliability system by implementing a command centre (CC) on clinical outcomes in a community hospital before and during COVID-19 pandemic from the year 2016 to 2021.

METHODS

A descriptive, retrospective study was conducted at an acute care community hospital. The administrative data included monthly average admissions, intensive care unit (ICU) admissions, average length of stay, total ICU length of stay, and in-hospital mortality. In-hospital acquired events were recorded and defined as one of the following: cardiac arrest, cerebral infarction, respiratory arrest, or sepsis after hospital admissions. A subgroup statistical analysis of patients with in-hospital acquired events was performed. In addition, a subgroup statistical analysis was performed for the department of medicine.

RESULTS

The rates of in-hospital acquired events and in-hospital mortality among all admitted patients did not change significantly throughout the years 2016 to 2021. In the subgroup of patients with in-hospital acquired events, the in-hospital mortality rate also did not change during the years of the study, despite the increase in the ICU admissions during the COVID-19 pandemic.Although the in-hospital mortality rate did not increase for all admitted patients, the in-hospital mortality rate increased in the department of medicine.

CONCLUSION

Implementation of CC and centralized management systems has the potential to improve quality of care by supporting early identification and real-time management of patients at risk of harm and clinical deterioration, including COVID-19 patients.

Signaling via a CD28/CD40 chimeric costimulatory antigen receptor (CoStAR™), targeting folate receptor alpha, enhances T cell activity and augments tumor reactivity of tumor infiltrating lymphocytes

Transfer of autologous tumor infiltrating lymphocytes (TIL) to patients with refractory melanoma has shown clinical efficacy in a number of trials. However, extending the clinical benefit to patients with other cancers poses a challenge. Inefficient costimulation in the tumor microenvironment can lead to T cell anergy and exhaustion resulting in poor anti-tumor activity. Here, we describe a chimeric costimulatory antigen receptor (CoStAR) comprised of FRα-specific scFv linked to CD28 and CD40 intracellular signaling domains. CoStAR signaling alone does not activate T cells, while the combination of TCR and CoStAR signaling enhances T cell activity resulting in less differentiated T cells, and augmentation of T cell effector functions, including cytokine secretion and cytotoxicity. CoStAR activity resulted in superior T cell proliferation, even in the absence of exogenous IL-2. Using an in vivo transplantable tumor model, CoStAR was shown to improve T cell survival after transfer, enhanced control of tumor growth, and improved host survival. CoStAR could be reliably engineered into TIL from multiple tumor indications and augmented TIL activity against autologous tumor targets both in vitro and in vivo. CoStAR thus represents a general approach to improving TIL therapy with synthetic costimulation.

Angiotensin receptor blockade with olmesartan alleviates brain pathology in obese OLETF rats

Metabolic syndrome (MetS) is a rapidly increasing health concern during midlife and is an emerging risk factor for the development of neurodegenerative diseases, such as Alzheimer's disease (AD). While angiotensin receptor blockers (ARB) are widely used for MetS-associated hypertension and kidney disease, its therapeutic potential in the brain during MetS are not well-described. Here, we tested whether treatment with ARB could alleviate the brain pathology and inflammation associated with MetS using the Otsuka Long-Evans Tokushima Fatty (OLETF) rat. Here, we report that chronic ARB treatment with olmesartan (10 mg/kg/day by oral gavage for 6 weeks) partially but significantly ameliorated accumulation of oxidized and ubiquitinated proteins, astrogliosis and transformation to neurotoxic astrocytes in the brain of old OLETF rats, which otherwise exhibit the progression of these pathological hallmarks associated with MetS. Additionally, olmesartan treatment restored claudin-5 and ZO-1, markers of the structural integrity of the blood-brain barrier as well as synaptic protein PSD-95, which were otherwise decreased in old OLETF rats, particularly in the hippocampus, a critical region in cognition, memory and AD. These data demonstrate that the progression of MetS in OLETF rats is associated with deterioration of various aspects of neuronal integrity that may manifest neurodegenerative conditions and that overactivation of angiotensin receptor directly or indirectly contributes to these detriments. Thus, olmesartan treatment may slow or delay the onset of degenerative process in the brain and subsequent neurological disorders associated with MetS.

Improved lipogenesis gene expression in liver is associated with elevated plasma angiotensin 1-7 after AT1 receptor blockade in insulin-resistant OLETF rats

Increased angiotensin II (Ang II) signaling contributes to insulin resistance and liver steatosis. In addition to ameliorating hypertension, angiotensin receptor blockers (ARBs) improve lipid metabolism and hepatic steatosis, which are impaired with metabolic syndrome (MetS). Chronic blockade of the Ang II receptor type 1 (AT1) increases plasma angiotensin 1-7 (Ang 1-7), which mediates mechanisms counterregulatory to AT1 signaling. Elevated plasma Ang 1-7 is associated with decreased plasma triacylglycerol (TAG), cholesterol, glucose, and insulin; however, the benefits of RAS modulation to prevent non-alcoholic fatty liver disease (NAFLD) are not fully investigated. To better address the relationships among chronic ARB treatment, plasma Ang 1-7, and hepatic steatosis, three groups of 10-week-old-rats were studied: (1) untreated lean Long Evans Tokushima Otsuka (LETO), (2) untreated Otsuka Long Evans Tokushima Fatty (OLETF), and (3) OLETF + ARB (ARB; 10 mg olmesartan/kg/d × 6 weeks). Following overnight fasting, rats underwent an acute glucose load to better understand the dynamic metabolic responses during hepatic steatosis and early MetS. Tissues were collected at baseline (pre-load; T0) and 1 and 2 h post-glucose load. AT1 blockade increased plasma Ang 1-7 and decreased liver lipids, which was associated with decreased fatty acid transporter 5 (FATP5) and fatty acid synthase (FASN) expression. AT1 blockade decreased liver glucose and increased glucokinase (GCK) expression. These results demonstrate that during MetS, overactivation of AT1 promotes hepatic lipid deposition that is stimulated by an acute glucose load and lipogenesis genes, suggesting that the chronic hyperglycemia associated with MetS contributes to fatty liver pathologies via an AT1-mediated mechanism.

AB0124 EFFECTS OF INHIBITOR K-CARRAGEENAN ON HAECs INFLAMMATORY RESPONSE TO LDLs ISOLATED FROM SLE PATIENTS

Background

Systemic Lupus Erythematosus (SLE) is an autoimmune disease with a high risk of atherosclerosis and cardiovascular events. It was previously reported by our group that low-density lipoprotein (LDL) particles isolated from SLE patients, during an active state of the disease (‘flare’), promoted an exaggerated inflammatory response in human aortic endothelial cells (HAECs). However, the molecular mechanisms underlying this response still remain elusive.

Objectives

The hypothesis of this study is that these SLE-LDLs would be using receptor LOX-1, associated with inflammatory conditions and altered lipoproteins, to generate the proatherogenic response in HAECs.

Methods

LOX-1 pharmacological inhibitor k-carrageenan was used before the stimulation of HAECs with LDLs isolated from healthy controls (10), non-active (13), or active-SLE patients (13). Gene expression, protein, and cell migration assays were performed to evaluate HAECs inflammatory response.

Results

LOX-1 inhibition with k-carrageenan significantly reduced the expression of vascular cell adhesion molecule 1 (VCAM-1) and restored the gene expression of endothelial nitric oxide synthase (eNOS) in HAECs incubated with non-active SLE LDLs.

Conclusion

While VCAM-1 down-regulation was expected, the immediate next step derived from the observed results will be a deeper understanding of how LOX-1 inhibition may restore the endothelial ability to synthetize NO in the presence of altered LDL. This will allow gaining insight not only on the development of atherosclerosis but also on the clue mechanisms involved in the pathogenesis of SLE.

Disclosure of Interests

None declared

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background

Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies.

Methods

In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality.

Findings

Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference –1·69 [–9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5–8] vs 6 [5–8] cm H₂O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52–23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75–0·86]; p<0·0001).

Interpretation

Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status.

Funding

No funding.

SULT1A1 and SULT1A2 Associated Extensive Prolapse-Type Inflammatory Polyposis in Crohn's Colitis

Mucosal prolapse syndrome most commonly involves the rectum and presents as solitary rectal ulcer syndrome and proctitis cystica profunda. Symptoms and endoscopic appearances are nonspecific. Histologically, mucosal prolapse is characterized by fibromuscular obliteration of the lamina propria, and displacement of crypts into submucosa and muscularis mucosae. Mucosal prolapse presenting as polyposis is rare and has only been reported involving the rectosigmoid colon. In this report, we describe a case of mucosal prolapse syndrome presenting as diffuse polyposis and colitis cystica profunda involving the hepatic, splenic flexures and descending colon in a teenage boy suffering from refractory fibrostenosing Crohn's disease. This patient was found to have possibly deleterious homozygous single nucleotide polymorphisms in both SULT1A1 and SULT1A2 genes within a unique polygenic variation of altered cell adhesion.

Chronic AT1 blockade improves hyperglycemia by decreasing adipocyte inflammation and decreasing hepatic PCK1 and G6PC1 expression in obese rats

Inappropriate activation of the renin-angiotensin system decreases glucose uptake in peripheral tissues. Chronic angiotensin receptor type 1 (AT1) blockade (ARB) increases glucose uptake in skeletal muscle and decreases the abundance of large adipocytes and macrophage infiltration in adipose. However, the contributions of each tissue to the improvement in hyperglycemia in response to AT1 blockade are not known. Therefore, we determined the static and dynamic responses of soleus muscle, liver, and adipose to an acute glucose challenge following the chronic blockade of AT1. We measured adipocyte morphology along with TNF-α expression, F4/80- and CD11c-positive cells in adipose and measured insulin receptor (IR) phosphorylation and AKT phosphorylation in soleus muscle, liver, and retroperitoneal fat before (T0), 60 (T60) and 120 (T120) min after an acute glucose challenge in the following groups of male rats: 1) Long-Evans Tokushima Otsuka (LETO; lean control; n = 5/time point), 2) obese Otsuka Long Evans Tokushima Fatty (OLETF; n = 7 or 8/time point), and 3) OLETF + ARB (ARB; 10 mg olmesartan/kg/day; n = 7 or 8/time point). AT1 blockade decreased adipocyte TNF-α expression and F4/80- and CD11c-positive cells. In retroperitoneal fat at T60, IR phosphorylation was 155% greater in ARB than in OLETF. Furthermore, in retroperitoneal fat AT1 blockade increased glucose transporter-4 (GLUT4) protein expression in ARB compared with OLETF. IR phosphorylation and AKT phosphorylation were not altered in the liver of OLETF, but AT1 blockade decreased hepatic Pck1 and G6pc1 mRNA expressions. Collectively, these results suggest that chronic AT1 blockade improves obesity-associated hyperglycemia in OLETF rats by improving adipocyte function and by decreasing hepatic glucose production via gluconeogenesis.NEW & NOTEWORTHY Inappropriate activation of the renin-angiotensin system increases adipocyte inflammation contributing to the impairment in adipocyte function and increases hepatic Pck1 and G6pc1 mRNA expression in response to a glucose challenge. Ultimately, these effects may contribute to the development of glucose intolerance.

Chronic Stimulation of Arcuate Kiss1 Neurons Decreases Bone Mass in Female Mice

Loss of peripheral estrogen in postmenopausal women is often associated with decreased physical activity and loss of bone mass, leading to an increased risk of metabolic diseases, osteoporosis, and skeletal fragility. While it is well-established that loss of peripheral estrogen signaling results in bone loss, we previously found that eliminating central estrogen signaling paradoxically results in an unexpected massive increase in bone mass only in female mice. Specifically, deletion of estrogen receptor alpha (ERα) signaling in kisspeptin 1 (Kiss1) expressing neurons of the arcuate nucleus (ARC^Kiss1) increases bone mass at the expense of reproduction in female mice. Currently, the mechanisms and the neurocircuits that modulate these unexpected responses are unknown. Here, to begin addressing these questions, we asked if changing the neuronal output of ARC^Kiss1 neurons using chemogenetic manipulation of ARC^Kiss1 neurons might also alter bone mass and locomotion in female mice. To do this, we delivered stimulatory (AAV2-hM3Dq-mCherry) designer receptors exclusively activated by designer drugs (DREADDs) to the ARC of wild type and Kiss1-Cre+ (Kiss1-Cre^hM3q-DREADDs) female mice and asked if chronic activation of ARC^Kiss1 neurons might alter bone mass as analyzed by standard ex-vivo µCT imaging. Clozapine N-oxide (CNO) was delivered for 22 days (0.1 mg/mL). We also leveraged the ANY-Maze system to assess home cage activity over an extensive 96-hour period. Acute activation of ARC^Kiss1 tended to decrease home cage activity by nearly 40% in Kiss1-Cre^hM3q-DREADDs mice during the dark period compared to WT females. Interestingly, chronic activation of ARC^Kiss1 neurons significantly lowered trabecular bone volume by nearly 30%. Current studies are underway to ask if inhibiting ARC^Kiss1 neurons results in increased bone mass. Our findings collectively suggest that the neuronal activity of ARC^Kiss1 neurons is sufficient to shift energy allocation away from locomotion and bone-building to maximize reproductive capacity. We speculate that the widely used SERM in breast cancer treatment, Tamoxifen, might exert its bone sparing effect by silencing ARC^Kiss1 neurons.

Use of an Open-Source Software to Examine Low Skeletal Muscle Mass in Penile Cancer Patients: A Cross-Sectional Study

Purpose

Low skeletal muscle mass determined radiographically has emerged as an important prognostic marker in penile cancer patients but may be unrecognized in obese patients with a high comorbid disease burden. Moreover, publicly available software for image segmentation are limited. Thus, we describe the prevalence of radiographically low skeletal muscle mass in an obese penile cancer cohort, using an open-source software and examine its association with comorbid disease burden.

Methods

This is a cross-sectional study, utilizing retrospective data from patients diagnosed with penile squamous cell carcinoma between October 2009 and December 2019. Available digital files of perioperative computerized tomography were analyzed, using CoreSlicer, an open-source image segmentation software. The correlation between radiographically low skeletal muscle mass, defined as a skeletal muscle index (SMI) less than 55 cm2/m2 and a Charlson Comorbidity Index (CCI) greater than 4 was examined, using logistic and linear regression.

Results

Forty two of 59 patients had available digital files. Median SMI and body mass index (BMI) were 54.6cm2/m2 and 30.2kg/m2 respectively for the entire cohort. Of included patients, 54% had radiographically low skeletal muscle mass and a median BMI of 28.9 kg/m2. Radiographically low skeletal muscle mass was associated with a CCI greater than 4 on univariable and multivariable logistic regression with odds ratios of 4.85 (p = 0.041) and 7.32 (p = 0.033), respectively. When CCI was treated as a continuous variable on linear regression, the association between radiographically low skeletal muscle mass and CCI was positive, but not statistically significant with an estimated effect of 1.29 (p = 0.1) and 1.27 (p = 0.152) on univariable and multivariable analysis, respectively.

Conclusion

Our data demonstrate that low skeletal muscle mass can be readily assessed with CoreSlicer and is associated with a CCI greater than 4 in obese penile cancer patients.

0388 Predictors of Incident Reduced Sleep Efficiency in Community-Dwelling Older Women

Introduction

There is a paucity of longitudinal studies with sleep efficiency (SE) as an outcome measure. Our objective was to examine potential risk factors for incident reduced SE among community-dwelling women in late life.

Methods

We studied 700 women (mean age 82.5 [SD=3.0] years) with a SE ≥70% at the Year 16 (2002-04) visit of the Study of Osteoporotic Fractures with a follow-up measure of SE at the Year 20 (2006-08) visit. SE (percentage of time sleeping while in bed) at both visits was measured using a wrist actigraph with data collected for an average of four 24-hour periods. Women were classified as having incident reduced SE if they had SE &lt;70% at Year 20. Logistic regression was used to estimate the associations between potential risk factors (demographics, lifestyle, use of medications, self-reported medical conditions, functional impairment, frailty, mental and physical health) at Year 16 and reduced SE at Year 20. The association of each candidate risk factor with reduced SE at Year 20 was examined in models adjusted for age, clinical site and continuous SE at Year 16. Candidate risk factors with Benjamin Hochberg false-discovery rate q-values &lt;0.10 were included in a final multivariate model.

Results

Among the 700 eligible women, 62 (8.9%) developed incident reduced SE between the Year 16 and Year 20 visits. After adjusting for age, site and baseline SE, antidepressant use [OR=3.06; 95% CI: 1.50-6.25], benzodiazepine use [OR=2.97; 95% CI: 1.30-6.80] and the presence of hypertension [OR=2.83; 95% CI: 1.47-5.45] at Year 16 were independently associated with a higher odds of having reduced SE at follow-up.

Conclusion

These findings suggest that antidepressant use, benzodiazepine use and hypertension are risk factors or markers for the development of reduced sleep efficiency in older women. Future studies are warranted to examine the underlying mechanisms for these associations.

Support

The Study of Osteoporotic Fractures (SOF) is supported by National Institutes of Health funding. The National Institute on Aging (NIA) provides support under the following grant numbers: R01 AG005407, R01 AR35582, R01 AR35583, R01 AR35584, R01 AG005394, R01 AG027574, and R01 AG027576.

Incidence and Predictors of Acute Kidney Injury Following Transcatheter Aortic Valve Replacement: Role of Changing Definitions of Renal Function and Injury

BACKGROUND

Acute kidney injury (AKI) following transcatheter aortic valve replacement (TAVR) is a known complication. The prospective validation of various AKI definitions and estimated baseline renal function equations in the context of TAVR remains an ongoing area of research. This study examined the Valve Academic Research Consortium (VARC) 1 and 2 criteria for AKI, and impact of three estimated glomerular filtration rate (eGFR) equations (CKD-EPI, MDRD, and Cockcroft-Gault) on AKI incidence in TAVR patients.

METHODS

Retrospective review of 120 consecutive TAVR procedures over a 4-year period was performed. AKI, including stage, was defined using the VARC 1 and VARC 2 criteria. Univariate and multivariate analyses were performed for association between AKI and known patient, hemodynamic, and procedural variables. Further logistic regression, stepwise logistic regression, and association plots were performed for the three different eGFR calculations.

RESULTS

AKI occurred in 22% of VARC 1 patients and 23% of VARC 2 patients. On multivariate analysis, baseline eGFR was predictive of stage 1 AKI by CKD-EPI classification (VARC 1: odds ratio [OR], 0.93; 95% confidence interval [CI], 0.88-0.99; P=.02; VARC 2: OR, 0.93; 95% CI, 0.87-0.99; P=.03) and MDRD (OR, 0.93; 95% CI, 0.88-0.99; P=.03). Non-transfemoral approach was predictive of stage 1 AKI by VARC 2 (OR, 33.33; 95% CI, 1.6-696.41; P=.02).

CONCLUSIONS

The risk factor associations for AKI post TAVR vary by definitions used. Decreased GFR at baseline by both MDRD and CKD-EPI and non-transfemoral approach were associated with an increased risk of AKI post TAVR.

Simultaneous angiotensin receptor blockade and glucagon-like peptide-1 receptor activation ameliorate albuminuria in obese insulin-resistant rats

Insulin resistance increases renal oxidant production by upregulating NADPH oxidase 4 (Nox4) expression contributing to oxidative damage and ultimately albuminuria. Inhibition of the renin-angiotensin system (RAS) and activation of glucagon-like peptide-1 (GLP-1) receptor signalling may reverse this effect. However, whether angiotensin receptor type 1 (AT1) blockade and GLP-1 receptor activation improve oxidative damage and albuminuria through different mechanisms is not known. Using insulin-resistant Otsuka Long-Evans Tokushima Fatty (OLETF) rats, we tested the hypothesis that simultaneous blockade of AT1 and activation of GLP-1r additively decrease oxidative damage and urinary albumin excretion (U_alb V) in the following groups: (a) untreated, lean LETO (n = 7), (b) untreated, obese OLETF (n = 9), (c) OLETF + angiotensin receptor blocker (ARB; 10 mg olmesartan/kg/d; n = 9), (d) OLETF + GLP-1 mimetic (EXE; 10 µg exenatide/kg/d; n = 7) and (e) OLETF + ARB +exenatide (Combo; n = 6). Mean kidney Nox4 protein expression and nitrotyrosine (NT) levels were 30% and 46% greater, respectively, in OLETF compared with LETO. Conversely, Nox4 protein expression and NT were reduced to LETO levels in ARB and EXE, and Combo reduced Nox4, NT and 4-hydroxy-2-nonenal levels by 21%, 27% and 27%, respectively. At baseline, U_alb V was nearly double in OLETF compared with LETO and increased to nearly 10-fold greater levels by the end of the study. Whereas ARB (45%) and EXE (55%) individually reduced U_alb V, the combination completely ameliorated the albuminuria. Collectively, these data suggest that AT1 blockade and GLP-1 receptor activation reduce renal oxidative damage similarly during insulin resistance, whereas targeting both signalling pathways provides added benefit in restoring and/or further ameliorating albuminuria in a model of diet-induced obesity.

Volumetric laser endomicroscopy and its application to Barrett's esophagus: results from a 1,000 patient registry

Volumetric laser endomicroscopy (VLE) uses optical coherence tomography (OCT) for real-time, microscopic cross-sectional imaging. A US-based multi-center registry was constructed to prospectively collect data on patients undergoing upper endoscopy during which a VLE scan was performed. The objective of this registry was to determine usage patterns of VLE in clinical practice and to estimate quantitative and qualitative performance metrics as they are applied to Barrett's esophagus (BE) management. All procedures utilized the NvisionVLE Imaging System (NinePoint Medical, Bedford, MA) which was used by investigators to identify the tissue types present, along with focal areas of concern. Following the VLE procedure, investigators were asked to answer six key questions regarding how VLE impacted each case. Statistical analyses including neoplasia diagnostic yield improvement using VLE was performed. One thousand patients were enrolled across 18 US trial sites from August 2014 through April 2016. In patients with previously diagnosed or suspected BE (894/1000), investigators used VLE and identified areas of concern not seen on white light endoscopy (WLE) in 59% of the procedures. VLE imaging also guided tissue acquisition and treatment in 71% and 54% of procedures, respectively. VLE as an adjunct modality improved the neoplasia diagnostic yield by 55% beyond the standard of care practice. In patients with no prior history of therapy, and without visual findings from other technologies, VLE-guided tissue acquisition increased neoplasia detection over random biopsies by 700%. Registry investigators reported that VLE improved the BE management process when used as an adjunct tissue acquisition and treatment guidance tool. The ability of VLE to image large segments of the esophagus with microscopic cross-sectional detail may provide additional benefits including higher yield biopsies and more efficient tissue acquisition. Clinicaltrials.gov NCT02215291.

Angiotensin receptor and tumor necrosis factor-α activation contributes to glucose intolerance independent of systolic blood pressure in obese rats

Pathological activation of the renin-angiotensin system and inflammation are associated with hypertension and the development of metabolic syndrome (MetS). The contributions of angiotensin receptor type 1 (AT1) activation, independent of blood pressure, and inflammation to glucose intolerance and renal damage are not well defined. Using a rat model of MetS, we hypothesized that the onset of glucose intolerance is primarily mediated by AT1 activation and inflammation independent of elevated systolic blood pressure (SBP). To address this hypothesis, we measured changes in SBP, adiposity, plasma glucose and triglyceride levels, and glucose tolerance in six groups of rats: 1) lean, strain control Long-Evans Tokushima Otsuka (LETO; n = 5), 2) obese Otsuka Long-Evans Tokushima Fatty (OLETF; n = 8), 3) OLETF + angiotensin receptor blocker (ARB; 10 mg olmesartan/kg; n = 8), 4) OLETF + tumor necrosis factor-α (TNF-α) inhibitor (ETAN; 1.25 mg etanercept/kg; n = 6), 5) OLETF + TNF-α inhibitor + angiotensin receptor blocker (ETAN+ARB; 1.25 mg etanercept/kg + 10 mg olmesartan/kg; n = 6), and 6) OLETF + calcium channel blocker (CCB; 5 mg amlodipine/kg; n = 7). ARB and ETAN+ARB were most effective at decreasing SBP in OLETF, and ETAN did not offer any additional reduction. Glucose tolerance improved in ARB, ETAN, and ETAN+ARB compared with OLETF, whereas CCB had no detectable effect. Furthermore, all treatments reduced adiposity, whereas ETAN alone normalized urinary albumin excretion. These results suggest that AT1 activation and inflammation are primary factors in the development of glucose intolerance in a setting of MetS and that the associated increase in SBP is primarily mediated by AT1 activation.

Simultaneous GLP-1 receptor activation and angiotensin receptor blockade increase natriuresis independent of altered arterial pressure in obese OLETF rats

Obesity is associated with an inappropriately activated renin-angiotensin-aldosterone system, suppressed glucagon-like peptide-1 (GLP-1), increased renal Na⁺ reabsorption, and hypertension. To assess the link between GLP-1 and angiotensin receptor type 1 (AT₁) signaling on obesity-associated impairment of urinary Na⁺ excretion (U_NaV) and elevated arterial pressure, we measured mean arterial pressure (MAP) and heart rate by radiotelemetry and metabolic parameters for 40 days. We tested the hypothesis that stimulation of GLP-1 signaling provides added benefit to blockade of AT₁ by increasing U_NaV and further reducing arterial pressure in the following groups: (1) untreated Long-Evans Tokushima Otsuka (LETO) rats (n = 7); (2) untreated Otsuka Long-Evans Tokushima Fatty (OLETF) rats (n = 9); (3) OLETF + ARB (ARB; 10 mg olmesartan/kg/day; n = 9); (4) OLETF + GLP-1 receptor agonist (EXE; 10 µg exenatide/kg/day; n = 7); and (5) OLETF + ARB + EXE (Combo; n = 6). On day 2, U_NaV was 60% and 62% reduced in the EXE and Combo groups, respectively, compared with that in the OLETF rats. On day 40, U_NaV was increased 69% in the Combo group compared with that in the OLETF group. On day 40, urinary angiotensinogen was 4.5-fold greater in the OLETF than in the LETO group and was 56%, 62%, and 58% lower in the ARB, EXE, and Combo groups, respectively, than in the OLETF group. From day 2 to the end of the study, MAP was lower in the ARB and Combo groups than in the OLETF rats. These results suggest that GLP-1 receptor activation may reduce intrarenal angiotensin II activity, and that simultaneous blockade of AT₁ increases U_NaV in obesity; however, these beneficial effects do not translate to a further reduction in MAP.

Chronic AT1 blockade improves glucose homeostasis in obese OLETF rats

Obesity is associated with the inappropriate activation of the renin-angiotensin system (RAS), which increases arterial pressure, impairs insulin secretion and decreases peripheral tissue insulin sensitivity. RAS blockade reverses these detriments; however, it is not clear whether the disease state of the organism and treatment duration determine the beneficial effects of RAS inhibition on insulin secretion and insulin sensitivity. Therefore, the objective of this study was to compare the benefits of acute vs chronic angiotensin receptor type 1 (AT₁) blockade started after the onset of obesity, hyperglycemia and hypertension on pancreatic function and peripheral insulin resistance. We assessed adipocyte morphology, glucose intolerance, pancreatic redox balance and insulin secretion after 2 and 11 weeks of AT₁ blockade in the following groups of rats: (1) untreated Long-Evans Tokushima Otsuka (lean control; n = 10), (2) untreated Otsuka Long-Evans Tokushima Fatty (OLETF; n = 12) and (3) OLETF + ARB (ARB; 10 mg olmesartan/kg/day by oral gavage; n = 12). Regardless of treatment duration, AT₁ blockade decreased systolic blood pressure and fasting plasma triglycerides, whereas chronic AT₁ blockade decreased fasting plasma glucose, glucose intolerance and the relative abundance of large adipocytes by 22, 36 and 70%, respectively. AT₁ blockade, however, did not improve pancreatic oxidative stress or reverse impaired insulin secretion. Collectively, these data show that AT₁ blockade after the onset of obesity, hyperglycemia and hypertension improves peripheral tissue insulin sensitivity, but cannot completely reverse the metabolic derangement characterized by impaired insulin secretion once it has been compromised.

Abstract P5-22-10: Intraoperative ultrasound guided surgery after neoadjuvant treatment in breast cancer improves patient´s quality of life

Background: Intraoperative ultrasound guided surgery (IOUS) has shown not only to improve surgical outcomes by achieving higher rates of negative margins and reducing the need for re-excisions, but also showing better cosmetic results and patient's satisfaction in the adjuvant setting. After neoadjuvant treatments (NAT) we have shown that IOUS lowers the volume of resection in patients with pathologic complete response or minimal microscopic disease after NAT without compromising margins and local recurrences when compared to wire localization techniques (WL) The aim of this study was to determine if IOUS after NAT contributes to improve cosmetic outcomes and quality of life (QOL) when compared with WL.

Material and Methods. The pilot study enrolled patients treated with NAT who underwent breast-conserving surgery (BCS) between July 2008 and December 2012. On the follow up visit, cosmetic outcomes were assessed by the patient and surgeon on a 4 point Likert scale, by the Breast Cancer Conservative Treatment cosmetic results (BCCT.core) software, and by an independent panel. QOL was assessed using cancer-specific (EORTC QLQ-C30 and EORTC QLQ-B23) questionnaires.

Results. The study investigated 113 patients: 81 (71.6 %) in the IOUS group and 32 (28.3 %) in the WL group. The patient and tumor characteristics were comparable between the two groups. Mean follow up was 64 months (range, 12-90) in the WL group while 41 months (range, 18-107) in the IOUS group.

Cosmetic outcomes reported by the patient showed a tendency (p=0.07) for better results in the IOUS group. Patient reported cosmetic outcomes and the independent panel cosmetic evaluation significantly correlated with lumpectomy volume excised (p= 0.04, p = 0.02 respectively). The BCCT.core did not correlate with volume of tissue excised (p &lt; 0.14). IOUS achieved better cosmetic outcomes compared to WL, with excellent outcomes of 30% and 19% respectively, although poor cosmetic outcomes were 3% and 0% respectively. Correlation between patients and surgeons evaluation regarding cosmetic outcomes and satisfaction was low (0.38 and 0.40 respectively). A comparison of the QOL scores of 113 patients showed a significantly better global health status (p = 0.03), better emotional and role function (p = 0.004), for patients with IOUS compared to WL patients.

Conclusions. This is the first study to show that breast volume excised significantly correlates with cosmetic outcomes in the neoadjuvant setting. These results suggest that IOUS after NAT contributes to a better quality of life and may influence cosmetic outcomes in breast cancer patients. Patient reported outcomes should be included in the quality assessment in breast surgery as the correlation with surgeons' evaluation is low.

Citation Format: Rubio IT, Rodriguez R, Esgueva-Colmenarejo A, Suarez M, Espinosa-Bravo M, Siso C, Cordoba O, Alvarado S, Volders J, Van Den Tol P. Intraoperative ultrasound guided surgery after neoadjuvant treatment in breast cancer improves patient´s quality of life [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-22-10.

Enhancement of Quasistationary Shocks and Heating via Temporal Staging in a Magnetized Laser-Plasma Jet

We investigate the formation of a laser-produced magnetized jet under conditions of a varying mass ejection rate and a varying divergence of the ejected plasma flow. This is done by irradiating a solid target placed in a 20 T magnetic field with, first, a collinear precursor laser pulse (10^{12}  W/cm^{2}) and, then, a main pulse (10^{13}  W/cm^{2}) arriving 9-19 ns later. Varying the time delay between the two pulses is found to control the divergence of the expanding plasma, which is shown to increase the strength of and heating in the conical shock that is responsible for jet collimation. These results show that plasma collimation due to shocks against a strong magnetic field can lead to stable, astrophysically relevant jets that are sustained over time scales 100 times the laser pulse duration (i.e., >70  ns), even in the case of strong variability at the source.

Angiotensin receptor blockade improves cardiac mitochondrial activity in response to an acute glucose load in obese insulin resistant rats

Hyperglycemia increases the risk of oxidant overproduction in the heart through activation of a multitude of pathways. Oxidation of mitochondrial enzymes may impair their function resulting in accumulation of intermediates and reverse electron transfer, contributing to mitochondrial dysfunction. Furthermore, the renin-angiotensin system (RAS) becomes inappropriately activated during metabolic syndrome, increasing oxidant production. To combat excess oxidant production, the transcription factor, nuclear factor erythriod-2- related factor 2 (Nrf2), induces expression of many antioxidant genes. We hypothesized that angiotensin II receptor type 1 (AT1) blockade improves mitochondrial function in response to an acute glucose load via upregulation of Nrf2. To address this hypothesis, an oral glucose challenge was performed in three groups prior to dissection (n = 5–8 animals/group/time point) of adult male rats: 1) Long Evans Tokushima Otsuka (LETO; lean strain-control), 2) insulin resistant, obese Otsuka Long Evans Tokushima Fatty (OLETF), and 3) OLETF + angiotensin receptor blocker (ARB; 10 mg olmesartan/kg/d × 6 weeks). Hearts were collected at T0, T60, and T120 minutes post-glucose infusion. ARB increased Nrf2 binding 32% compared to OLETF at T60. Total superoxide dismutase (SOD) and catalase (CAT) activities were increased 45% and 66% respectively in ARB treated animals compared to OLETF. Mitochondrial enzyme activities of aconitase, complex I, and complex II increased by 135%, 33% and 66%, respectively in ARB compared to OLETF. These data demonstrate the protective effects of AT1 blockade on mitochondrial function during the manifestation of insulin resistance suggesting that the inappropriate activation of AT1 during insulin resistance may impair Nrf2 translocation and subsequent antioxidant activities and mitochondrial function.

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ARB increases cardiac mitochondrial enzyme activity in insulin resistant rats.

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Nrf2 binding activity increases when AT1 receptor activation is blocked.

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Glucose suppresses total cardiac GPx and CAT activities during insulin resistance.

Counterpropagating Radiative Shock Experiments on the Orion Laser

We present new experiments to study the formation of radiative shocks and the interaction between two counterpropagating radiative shocks. The experiments are performed at the Orion laser facility, which is used to drive shocks in xenon inside large aspect ratio gas cells. The collision between the two shocks and their respective radiative precursors, combined with the formation of inherently three-dimensional shocks, provides a novel platform particularly suited for the benchmarking of numerical codes. The dynamics of the shocks before and after the collision are investigated using point-projection x-ray backlighting while, simultaneously, the electron density in the radiative precursor was measured via optical laser interferometry. Modeling of the experiments using the 2D radiation hydrodynamic codes nym and petra shows very good agreement with the experimental results.

Successful treatment of intrauterine cytomegalovirus infection with an intraventricular cyst in a dichorionic diamniotic twin gestation using cytomegalovirus immunoglobulin

Congenital cytomegalovirus (CMV) infection is the leading cause of severe congenital abnormalities. CMV immunoglobulin (CMVIG) may lower risk for symptomatic disease in congenital CMV infection. In a twin pregnancy, only one fetus shows CMV infection, raising a dilemma about intervention since the uninfected fetus would be exposed to treatment unnecessarily. CMVIG (2 × 200 U/kg) was given due to high viral load and development of an intraventricular cyst. The cyst growth plateaued, no other brain damage developed, and at 8 months, the infant was symptom-free. CMVIG appears appropriate to treat intrauterine CMV infection in this setting.

Abstract 4979: Development of KITE-585: A fully human BCMA CAR T-cell therapy for the treatment of multiple myeloma

Background: Multiple myeloma (MM) is a usually fatal malignancy of plasma cells, with no current therapy considered curative. About 15% of patients diagnosed with MM are stratified as high risk with poor treatment outcomes and short (2-3 years) survival from diagnosis. Standard risk patients tend to live longer but undergo chronic and/or high intensity therapy and likely experience a relapsing and remitting disease pattern. Therefore, there is still a considerable unmet need for innovative therapies that improve outcomes in MM. One such approach is to use adoptive transfer of engineered autologous T cells expressing a chimeric antigen receptor (CAR) directed against malignant cells. The efficacy of CAR T cells directed against hematological malignancies, particularly CD19-expressing B cell leukemia and lymphomas, has been demonstrated in multiple clinical studies. KITE-585 was developed as a CAR T cell immunotherapy product candidate directed against B cell maturation antigen (BCMA). BCMA is nearly ubiquitously expressed on MM cells, plasma cells and subsets of mature B cells, but with limited or absent expression on other tissues.

Methods: We generated &gt;50 fully human IgGs directed against BCMA using the BCMA protein as antigen and selection criteria including affinity, cross-reactivity and poly-specificity. Following assessment of the binding of the IgGs to a MM cell line known to express BCMA, &gt;10 IgGs were identified that met the criteria for affinity and selectivity and had a &gt;50-fold binding over background. The 8 IgGs that demonstrated the highest specific binding were then sequence-converted to single-chain variable fragments (scFvs) and incorporated into CARs.

Results: In all but one case, human T cells engineered to express these CAR constructs exhibited specific cytolytic activity against MM cell lines (NCI-H929 and MM.1s). These CAR T cells demonstrated killing efficiencies of &gt;95% at effector:target ratios of 1:1 over a 24-hour period. Similarly antigen-specific production of inflammatory cytokines was observed in response to target cell lines in vitro. Assessment of antigen-dependent proliferation over a 5 day period revealed &gt;80% proliferation in the 7 constructs that showed cytolytic activity in vitro. Multiple different anti-BCMA CAR constructs representing distinct epitope binding bins of BCMA were then selected for in vivo evaluation. In two disseminated tumor models of luciferase labeled NCI-H929 or MM.1s cells injected intravenously (i.v.), a single i.v. injection of anti-BCMA CAR T-cells delayed the progression of disease and significantly increased survival when compared to control treatment.

Conclusions: The results of these studies highlight the potential of targeting BCMA with adoptive transfer of engineered T cells for the treatment of MM. Given these positive findings, progress towards Phase 1 clinical studies in MM patients with KITE-585 is continuing.

Citation Format: Gregor B. Adams, Jun Feng, Atefah Ghogha, Armen Mardiros, Jodi Murakami, Tammy Phung, Ruben Rodriguez, Stuart Sievers, Tassja J. Spindler, Jed Wiltzius, Clare Yarka, Sean C. Yoder, Tony Polverino. Development of KITE-585: A fully human BCMA CAR T-cell therapy for the treatment of multiple myeloma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4979. doi:10.1158/1538-7445.AM2017-4979

Abstract 2135: Selectivity and specificity of engineered T cells expressing KITE-585, a chimeric antigen receptor targeting B-cell maturation antigen (BCMA)

Background: Immunotherapy has provided treatment options for cancers that are otherwise refractory to standard approaches. One such technique is to use adoptive transfer of engineered autologous T cells expressing a chimeric antigen receptor (CAR) directed against a tumor antigen. The efficacy of CAR T cells directed against hematological malignancies, particularly CD19-expressing B cell leukemia and lymphomas, has been demonstrated in multiple clinical studies. The success of this approach has prompted development of CAR T cells directed to different tumor antigens for other tumor types. To ensure the selectivity and specificity of the CAR T cells against their intended target, screening methods need to be employed. Multiple myeloma is an incurable malignancy of plasma cells. B-cell maturation antigen (BCMA), also known as tumor necrosis factor superfamily member 17 (TNFRSF17) is nearly ubiquitously expressed on multiple myeloma cells, plasma cells and subsets of mature B cells.

Methods: In order to screen for the specificity of novel CAR T cells directed against BCMA, we utilized a cell microarray platform developed by Retrogenix. In this screen, approximately 4500 human plasma membrane proteins (representing up to 75% of the human plasma membrane proteome) are individually expressed in human HEK293 cells. Fluorescently labeled CAR T cells, which showed cytolytic activity against MM cell lines expressing BCMA, were applied to the cell microarray and specific binding of the CAR T cells to target cells was determined.

Results: Primary hits were sequenced to confirm identity and secondary specificity screens were performed on the identified hits. Specific binding of both mock transduced and BCMA CAR transduced T cells were confirmed for different plasma membrane proteins expressed from the HEK293 cells. These included known T cell interactors, such as ICOSLG, CD244 and CD86, where binding is proposed to be independent of CAR expression. Subtracting the hits of the mock transduced T cells from the BCMA CAR T cells demonstrated specific binding of the CAR T cells to BCMA. Utilizing the fully human IgGs directed against BCMA from which the single-chain variable fragments (scFvs) of the CARs were derived, we further confirmed specific binding to BCMA in additional secondary screens. Additionally, a lack of off-target binding of the fully human IgGs to normal tissue was demonstrated in a tissue cross reactivity screen.

Conclusions: These studies highlight the tractability of this cell microarray approach for determining the specificity of novel CAR constructs expressed in T cell. Demonstrating the selectivity and specificity of anti-BMCA CAR T cells further supports the progression of KITE-585 towards Phase 1 clinical studies in MM patients.

Citation Format: Gregor B. Adams, Jun Feng, Atefeh Ghogha, Armen Mardiros, Ruben Rodriguez, Tassja J. Spindler, Jed Wiltzius, Tony Polverino. Selectivity and specificity of engineered T cells expressing KITE-585, a chimeric antigen receptor targeting B-cell maturation antigen (BCMA) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 2135. doi:10.1158/1538-7445.AM2017-2135

Differential cardiovascular profiles of sodium-glucose cotransporter 2 inhibitors: critical evaluation of empagliflozin

One of the most feared repercussions of type 2 diabetes mellitus is the risk of adverse cardiovascular outcomes. The current antidiabetic agents on the market have had difficulty in showing cardiovascular outcome improvement. The EMPA-REG OUTCOME trial studied the sodium-glucose cotransporter 2 inhibitor empagliflozin in type 2 diabetic patients at high risk of cardiovascular events. The trial results revealed a decrease in the composite primary end points of death from cardiovascular causes, nonfatal myocardial infarction, and nonfatal stroke in those taking empagliflozin vs placebo. Those taking the medication also had a significant decrease in death from any cause, death from cardiovascular cause, and hospitalization for heart failure. The EMPA-REG trial is paradigm shifting because it demonstrates a clear mortality benefit to cardiovascular outcomes with a low side-effect profile, in contrast to prior outcome studies of hypoglycemic agents. Further studies are required to better clarify the long-term safety and efficacy of this promising class of diabetic drugs.