Cardiovascular toxicities associated with bispecific T-cell engager therapy

BACKGROUND

Bispecific T-cell engagers (BTEs) are novel agents used to treat hematological malignancies. Early trials were underpowered to define cardiovascular adverse events (CVAE) and no large-scale studies systematically examined the CVAEs associated with BTEs.

METHODS

Leveraging the US Food and Drug Administration's Adverse Event Reporting System-(FAERS), we identified the relative frequency of CVAEs after initiation of five BTE products approved by the Food and Drug Administration between 2014 and 2023 for the treatment of hematological malignancies. Adjusted reporting ORs (aROR) were used to identify disproportionate reporting of CVAEs with BTEs compared with background rates in the database. Fatality rates and risk ratios (RRs) for each adverse event (AE) were calculated.

RESULTS

From 3668 BTE-related cases reported to FAERS, 747 (20.4%) involved CVAEs. BTEs as a class were associated with fatal CVAEs (aROR 1.29 (95% CI 1.12 to 1.50)), an association mainly driven by teclistamab (aROR 2.44 (95% CI 1.65 to 3.60)). Teclistamab was also associated with a disproportionate risk of myocarditis (aROR 25.70 (95% CI 9.54 to 69.23)) and shock (aROR 3.63 (95% CI 2.30 to 5.74)), whereas blinatumomab was associated with a disproportionate risk of disseminated intravascular coagulation (aROR 3.02 (95% CI 1.98 to 4.60)) and hypotension (aROR 1.59 (95% CI 1.25 to 2.03)). CVAEs were more fatal compared with non-CVAEs (31.1% vs 17.4%; RR 1.76 (95% CI 1.54 to 2.03)). Most CVAEs (83.3%) did not overlap with cytokine release syndrome.

CONCLUSION

In the first postmarketing surveillance study of BTEs, CVAEs were involved in approximately one in five AE reports and carried a significant mortality risk.

Effect of variable left ventricular ejection fraction assessed by equilibrium radionuclide angiocardiography using different software packages on the diagnosis of cardiotoxicity in patients with cancer

BACKGROUND

The equilibrium radionuclide angiocardiography (ERNA) scan is an established imaging modality for assessing left ventricular ejection fraction (LVEF) in oncology patients. This study aimed to explore the interchangeability of two commercially available software packages (MIM and JS) for LVEF measurement for a cancer-therapy-related cardiac dysfunction (CTRCD) diagnosis.

METHODS

This is a single-center retrospective study among 322 patients who underwent ERNA scans. A total of 582 scans were re-processed using MIM and JS for cross-sectional and longitudinal LVEF measurements.

RESULTS

The median LVEF for MIM and JS were 56% and 66%, respectively (P < 0.001). LVEF processed by JS was 9.91% higher than by MIM. In 87 patients with longitudinal ERNA scans, serial studies processed by MIM were classified as having CTRCD in a higher proportion than serial studies processed by JS (26.4% vs 11.4%, P = 0.020). There were no significant differences in intra- or inter-observer LVEF measurement variability (R = 0.99, P < 0.001).

CONCLUSIONS

Software packages for processing ERNA studies are not interchangeable; thus, reports of ERNA studies should include details on the post-processing software. Serial ERNA studies should be processed on the same software when feasible to avoid discrepancies in the diagnosis and management of CTRCD.

Nomogram for Predicting Risk of Cancer Therapy-Related Cardiac Dysfunction in Patients With Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer

BACKGROUND

Cancer therapy-related cardiac dysfunction (CTRCD) is an important treatment-limiting toxicity for patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer that adversely affects cancer and cardiovascular outcomes. Easy-to-use tools that incorporate readily accessible clinical variables for individual estimation of CTRCD risk are needed.

METHODS AND RESULTS

From 2004 to 2013, 1440 patients with stage I to III HER2-positive breast cancer treated with trastuzumab-based therapy were identified. A multivariable Cox proportional hazards model was constructed to identify risk factors for CTRCD and included the 1377 patients in whom data were complete. Nine clinical variables, including age, race, body mass index, left ventricular ejection fraction, systolic blood pressure, coronary artery disease, diabetes, arrhythmia, and anthracycline exposure were built into a nomogram estimating risk of CTRCD at 1 year. The nomogram was validated for calibration and discrimination using bootstrap resampling. A total of 177 CTRCD events occurred within 1 year of HER2-targeted treatment. The nomogram for prediction of 1-year CTRCD probability demonstrated good discrimination, with a concordance index of 0.687. The predicted and observed probabilities of CTRCD were similar, demonstrating good model calibration.

CONCLUSIONS

A nomogram composed of 9 readily accessible clinical variables provides an individualized 1-year risk estimate of CTRCD among women with HER2-positive breast cancer receiving HER2-targeted therapy. This nomogram represents a simple-to-use tool for clinicians and patients that can inform clinical decision-making on breast cancer treatment options, optimal frequency of cardiac surveillance, and role of cardioprotective strategies.

Biomarkers and cardiovascular outcomes in chimeric antigen receptor T-cell therapy recipients

AIMS

Chimeric antigen receptor T-cell therapy (CAR-T) harnesses a patient's immune system to target cancer. There are sparse existing data characterizing death outcomes after CAR-T-related cardiotoxicity. This study examines the association between CAR-T-related severe cardiovascular events (SCE) and mortality.

METHODS AND RESULTS

From a multi-centre registry of 202 patients receiving anti-CD19 CAR-T, covariates including standard baseline cardiovascular and cancer parameters and biomarkers were collected. Severe cardiovascular events were defined as a composite of heart failure, cardiogenic shock, or myocardial infarction. Thirty-three patients experienced SCE, and 108 patients died during a median follow-up of 297 (interquartile range 104-647) days. Those that did and did not die after CAR-T were similar in age, sex, and prior anthracycline use. Those who died had higher peak interleukin (IL)-6 and ferritin levels after CAR-T infusion, and those who experienced SCE had higher peak IL-6, C-reactive protein (CRP), ferritin, and troponin levels. The day-100 and 1-year Kaplan-Meier overall mortality estimates were 18% and 43%, respectively, while the non-relapse mortality (NRM) cumulative incidence rates were 3.5% and 6.7%, respectively. In a Cox model, SCE occurrence following CAR-T was independently associated with increased overall mortality risk [hazard ratio (HR) 2.8, 95% confidence interval (CI) 1.6-4.7] after adjusting for age, cancer type and burden, anthracycline use, cytokine release syndrome grade ≥ 2, pre-existing heart failure, hypertension, and African American ancestry; SCEs were independently associated with increased NRM (HR 3.5, 95% CI 1.4-8.8) after adjusting for cancer burden.

CONCLUSION

Chimeric antigen receptor T-cell therapy recipients who experience SCE have higher overall mortality and NRM and higher peak levels of IL-6, CRP, ferritin, and troponin.

Tumor Genomic Profile Is Associated With Arterial Thromboembolism Risk in Patients With Solid Cancer

Background

Patients with cancer have an increased risk for arterial thromboembolism (ATE). Scant data exist about the impact of cancer-specific genomic alterations on the risk for ATE.

Objectives

The aim of this study was to determine whether individual solid tumor somatic genomic alterations influence the incidence of ATE.

Methods

A retrospective cohort study was conducted using tumor genetic alteration data from adults with solid cancers who underwent Memorial Sloan Kettering-Integrated Mutation Profiling of Actionable Cancer Targets testing between 2014 and 2016. The primary outcome, ATE, was defined as myocardial infarction, coronary revascularization, ischemic stroke, peripheral arterial occlusion, or limb revascularization and identified through systematic electronic medical record assessments. Patients were followed from date of tissue-matched blood control accession to first ATE event or death, for up to 1 year. Cause-specific Cox proportional hazards regression was used to determine HRs of ATE for individual genes adjusted for pertinent clinical covariates.

Results

Among 11,871 eligible patients, 74% had metastatic disease, and there were 160 ATE events. A significantly increased risk for ATE independent of tumor type was noted for the KRAS oncogene (HR: 1.98; 95% CI: 1.34-2.94; multiplicity-adjusted P = 0.015) and the STK11 tumor suppressor gene (HR: 2.51; 95% CI: 1.44-4.38; multiplicity-adjusted P = 0.015).

Conclusions

In a large genomic tumor-profiling registry of patients with solid cancers, alterations in KRAS and STK11 were associated with an increased risk for ATE independent of cancer type. Further investigation is needed to elucidate the mechanism by which these mutations contribute to ATE in this high-risk population.

Differentiation syndrome-induced Myopericarditis in the induction therapy of acute Promyelocytic leukemia: a case report

Background

All trans retinoic acid (ATRA) has revolutionized the treatment and outcomes of patients with Acute Promyelocytic Leukemia (APL). Induction therapy with ATRA is associated with the rare but potentially fatal complication of differentiation syndrome. While the presentation of this syndrome is varied, myopericarditis as a manifestation of differentiation syndrome is often fatal and rarely reported in literature. We present a case of myopericarditis as the sole manifestation of differentiation syndrome in a patient on induction therapy with ATRA and arsenic trioxide for APL.

Clinical presentation

A 62 year old woman with remote history of breast and uterine cancer presented to the hospital for expedited work up of easy bruising and expanding hematomas. She was diagnosed with APL with peripheral blood and bone marrow cytogenetics revealing t (15;17) translocation and initiated on induction therapy with ATRA and ATO as well as steroids for differentiation syndrome prophylaxis. Eighteen days into induction therapy, patient developed pleuritic chest pain, elevated cardiac biomarkers, ECG changes suggestive of pericarditis. Cardiac magnetic resonance imaging showed patchy multifocal sub-epicardial late gadolinium enhancement and elevated T2 signal consistent with acute myopericarditis. Given the timing of symptom onset and lack of other identifiable cause, patient was diagnosed with differentiation syndrome- induced myopericarditis and promptly initiated on high dose steroids with rapid improvement in symptoms, ECG, and cardiac biomarkers. Patient successfully resumed dose-reduced ATRA and arsenic trioxide without complication.

Conclusion

Myopericarditis can be the sole manifestation of differentiation syndrome and the presentation may be atypical owing to the use of prophylactic steroids as illustrated in our patient’s case. A high index of suspicion for differentiation syndrome, multimodality imaging, and prompt input from multidisciplinary providers is crucial for making the timely diagnosis and initiating life-saving treatment.

Cardio-oncology Training in the COVID-19 Era

Cardio-oncology is a field dedicated to the prevention, diagnosis, and management of cardiovascular disease in cancer patients before, during, and after cancer therapy. It is an emerging field with limited opportunities for structured education and training. In the year 2021, we cannot define the requirements of cardio-oncology training without acknowledging the impact of the global coronavirus disease 19 (COVID-19) pandemic. While this pandemic poses significant health risks to patients with cancer and cardiovascular disease as well as the providers who care for them, it also allows novel opportunities for the nascent field of cardio-oncology to readily adapt. In this article, we detail how the COVID-19 pandemic has impacted all aspects of cardio-oncology training, how programs and trainees can adapt to these challenges, and how lessons learned from the COVID-19 era can continue to positively impact cardio-oncology training for the foreseeable future.

Persistence and clearance of high-risk human papillomavirus and cervical dysplasia at 1 year in women living with human immunodeficiency virus: a prospective cohort study

OBJECTIVE

Evaluate 1-year outcomes of cervical cancer screening and treatment using primary high-risk human papillomavirus (HPV) testing in women living with human immunodeficiency virus (HIV).

DESIGN

Prospective cohort study.

SETTING

HIV treatment centre in Botswana.

POPULATION

Women living with HIV.

METHODS

Participants underwent cervical cancer screening with high-risk HPV testing and triage evaluation at baseline and 1-year follow up. Excisional treatment was offered as indicated. Histopathology was the reference standard.

MAIN OUTCOME MEASURES

Persistence, clearance and incidence of high-risk HPV infection; and persistence, progression, regression, cure and incidence of cervical dysplasia.

RESULTS

Among 300 women screened at baseline, 237 attended follow up (79%). High-risk HPV positivity significantly decreased from 28% at baseline to 20% at 1 year (P = 0.02). High-risk HPV persistence was 46% and clearance was 54%; incidence was high at 9%. Prevalence of cervical intraepithelial neoplasia Grade 2 (CIN2) or higher was most common in participants with incident high-risk HPV (53%). CIN2 or higher was also common in those with persistent high-risk HPV (32%) and even in those who cleared high-risk HPV (30%). Of the high-risk HPV-positive participants at baseline with <CIN2, 40% progressed to CIN2 or higher at follow up.

CONCLUSION

The high incidence of high-risk HPV and high-grade cervical dysplasia in women living with HIV after one round of high-risk HPV-based screening and treatment raises concern about the rate of progression of high-risk HPV infection to dysplasia. Persistent disease is common. Caution in spacing cervical cancer screening intervals using high-risk HPV testing in women living with HIV is warranted.

TWEETABLE ABSTRACT

High incidence and persistence of HPV and CIN2+ in women living with HIV 1 year after screening and treatment.

Approaches to training multiclass semantic image segmentation of damage in concrete

This paper addresses the problem of creating a large quantity of high-quality training segmentation masks from scanning electron microscopy (SEM) images. The images are acquired from concrete samples that exhibit progressive amounts of degradation resulting from alkali-silica reaction (ASR), a leading cause of deterioration, cracking and loss of capacity in much of the nation's infrastructure. The target damage classes in concrete SEM images are defined as paste damage, aggregate damage, air voids and no damage. We approached the SEM segmentation problem by applying convolutional neural network (CNN)-based methods to predict the damage classes due to ASR for each image pixel. The challenges in using the CNN-based methods lie in preparing large numbers of high-quality training labelled images while having limited human resources. To address these challenges, we designed damage- and context-assisted approaches to lower the requirements on human resources. We then evaluated the accuracy of CNN-based segmentation methods using the datasets prepared with these two approaches. LAY DESCRIPTION: This work is about automated segmentation of Scanning Electron Microscopy (SEM) images taken from core and prism samples of concrete. The segmentation must detect several damage classes in each image in order to understand properties of concrete-made structures over time. The segmentation problem is approached with an artificial network (AI) based model. The training data for the AI model are created using damage- and context-assisted approaches to lower the requirements on human resources. The access to all training data and to a web-based validation system for scoring segmented images is available at https://isg.nist.gov/deepzoomweb/data/concreteScoring.

Patient engagement in clinical guidelines development: input from > 1000 members of the Canadian Osteoporosis Patient Network

Patient engagement in clinical guidelines development is essential. The results of a self-administered online survey identified themes important to people living with osteoporosis and will inform the development of Osteoporosis Canada clinical guidelines recommendations.

INTRODUCTION

Patient engagement is essential in the development of high-quality and relevant guidelines for osteoporosis management. Osteoporosis Canada (OC) is updating its national clinical practice guidelines in collaboration with people living with osteoporosis in the process.

METHODS

Using electronic mail, we contacted 6937 members of the Canadian Osteoporosis Patient Network (COPN) to provide input on the selection of relevant content, outcomes, and research questions via a self-administered online survey. Close-ended questions were analyzed using descriptive statistics, and conventional content analysis was conducted for open-ended questions.

RESULTS

A total of 1108 individuals completed the survey (97% women, 86% stated they lived with osteoporosis). Most participants considered it critical to have recommendations on physical activity and exercise (74%), fall prevention (69%), nutrition (68%), and initial bone mineral density testing (67%). In addition to preventing fractures, over 75% of respondents stated that consideration of preserving quality of life and ability to perform daily activities, preventing admission to long-term care and fracture-related death, and avoiding serious harms from medications were essential outcomes to consider in evaluating the evidence. In terms of selection of research questions, seven themes emerged from the content analysis including pharmacotherapy, screening and monitoring, diet and supplements, education, exercise, alternative therapies, and pain management.

CONCLUSIONS

Patients emphasized that autonomy, mobility, and quality of life are highly valued outcomes and must be integral to practice guideline development. As expected, guidance on pharmacotherapy, screening and monitoring, and fracture prevention were priorities identified to be included in osteoporosis management guidelines.

Phase-retrieval method for measuring small contact angles of pentane on water

Pentane drops on a water surface are predicted to have contact angles of the order of 1 degree or less in the phase of frustrated complete wetting. We have developed an optical method of measuring such small contact angles, applicable to cases where the refractive indices of the substrate and adsorbate are very similar and the fluid dynamics do not allow delay between image acquisitions, by using phase retrieval to map the surface profile of the drops. It is empirically shown that, with our method, a difference of nanometer order can be achieved for the phase-retrieved dimensions relative to their expected value. Results agree with numerical predictions by Weiss and Widom [Physica A292, 137 (2001)PHYADX0378-437110.1016/S0378-4371(00)00619-1].

Outpatient health care 30 days after hospitalization for heart failure in France

Background

Recommendations for heart failure (HF) outpatient follow-up have been published. The SNDS offers the opportunity to confront them to real-life, including geographical disparities. Moreover, estimation variation has to be explored when population excludes institutionalized patients (IP) that have specific healthcare use and refund: rehabilitation (SSR), psychiatric hospitalization (psy), skilled nursing home (EHPAD) which is not usually done.The Purpose is to study outpatient healthcare use variations in France after hospitalization for HF, using SNDS data.

Methods

The first stay for HF (&gt;0days) in 2015 of patients over 18 yo covered by the general scheme (RG/SLM 88% of population) was considered. Healthcare use 30 days after was compared with (RG/SLM) or without IP (RG/SLM eIP). Regional outpatient care use rates were standardized by age and sex.

Results

Among 104 984 alive patients 30 days after HF hospitalization (RG/SLM, female 52%, mean age 79 yo), 16% stayed in SSR, 9% in cardiologic SSR, 12% in EHPAD, 0.2% in psy and 75% returning home and not institutionalized (RG/SLM eIP; n = 70367). Among all RG/SLM patients vs RG/SLM eIP (mean age 79 yo vs 78 yo), a cardiologist was seen at least once in 30 days post hospitalization 20% vs 21% (median delay 14 days IQR 7-23 vs 16 IQR 9-24), a general practitioner 69% vs 78% (8 IQR 3-16 vs 7 IQR 3-15), a nurse 58% vs 69% (3 IQR 1-9 vs 2 IQR 1-7). ACE inhibitors were reimbursed at least once for 34% vs 39%, ARBs 14% vs 17%, and diuretics 69% vs 77%. Among RG/SLM eIP patients, departmental disparities were high: cardiologist (3% to 46%), GP (59% to 93%), nurse visit (49% to 82%). Lower rates for GP were found in the center of France but with higher rates for nurse visits.

Conclusions

We recommend using RG/SLM eIP when studying outpatient healthcare use in the SNDS. Low visit rates and high delays regarding the recommendations point out the need of a multidisciplinary community health care in France.

Key messages

Low visit rates and high delays regarding the recommendations point out the need of a multidisciplinary community health care in France. We recommend using RG/SLM eIP when studying outpatient healthcare use in the SNDS.

Increased circulating regulatory T cells in medicated people with schizophrenia

Immunological abnormalities are increasingly reported in people with schizophrenia, but no clear functional biomarkers associated with genetic correlates of the disease have been found. Regulatory T cells (Tregs) are key immunoregulatory cells involved in the control of inflammatory processes and their functions are directly related to the human leucocyte antigen (HLA) gene, which has been implicated in schizophrenia genetic studies. However, there is a lack of studies reporting Treg status in people with schizophrenia. In the current study, the proportion of circulating Tregs was examined using flow cytometry in 26 medicated participants with schizophrenia and 17 healthy controls. Psychiatric symptoms and cognitive function were evaluated using the Scale for the Assessment of Negative Symptoms, the Brief Psychiatric Rating Scale, and the MATRICS Consensus Cognitive Battery. The proportion of Tregs was found to be significantly greater in the schizophrenia group compared to healthy controls. No differences were observed in total lymphocyte counts or CD3+ and CD4+ T cells, confirming a specific effect for Tregs. Elevated Tregs in schizophrenia correlated with fewer negative symptoms, a core domain of the illness. These results suggest that Tregs may contribute to improved negative symptoms in schizophrenia, possibly by counteracting on-going inflammatory processes.

Clozapine in Reducing Aggression and Violence in Forensic Populations

Popular media often portray people with a mental illness as being aggressive, violent, and incarcerated as a result of their behavior. Despite exaggeration in the media, risks for some aggressive behaviors are in fact higher in individuals with schizophrenia. This is often the case with influence of comorbid substance use disorders. It is essential that mental health professionals are aware of treatments that may help with attenuating and treating behaviors that contribute to violence, aggression and incarceration. This paper reviews violence and incarceration in individuals with schizophrenia as well as recommendations, guidelines and benefits for the use of clozapine in this population. Clozapine remains one of the most underutilized evidence-based medications available in the psychiatric arena in the United States. It is a viable and recommended option in the forensic population and it may be helpful on the path to recovery as well as bring substantial savings to the criminal justice system.

Prognostic Predictors of Visual Outcome in Open Globe Injury: Emphasis on Facial CT Findings

BACKGROUND AND PURPOSE

The present prognostic models for open globe injuries have a limited ability to predict visual outcome before a comprehensive ophthalmologic examination or operation because they depend on the data derived from the ophthalmologic examination and intraoperative findings. The purpose of our study was to determine the specific CT and preoperative clinical data that can predict the prognosis of open globe injury.

MATERIALS AND METHODS

We analyzed the relationship of 29 variables derived from clinical and CT data from 97 globe injuries with visual acuity at 1 month. A prediction model was derived from 49 globe injuries by regression analysis, followed by receiver operating characteristic curve analysis of the best CT predictor.

RESULTS

Four variables with significance on a regression model were the following: posterior segment hemorrhage (β = -0.93, P < .0001), presenting visual acuity (β = 0.28, P = .042), orbital emphysema (β = 0.46, P = .0018), and complex facial fracture (β = -0.43, P = .009). Receiver operating characteristic analysis of the posterior segment hemorrhage predicted profound vision loss (light perception or no light perception) with an area under the curve of 0.97. The receiver operating characteristic table indicated that grade III posterior segment hemorrhage has a strong positive predictive value of 100% for profound vision loss. On the other hand, the absence of posterior segment hemorrhage has a strong positive predictive value of 93% for mild-to-severe vision loss (visual acuity better than light perception).

CONCLUSIONS

Radiologists, with the help of CT and preoperative clinical data, can predict visual acuity after open globe injury.

Measurement of the equation of state of solid-density copper heated with laser-accelerated protons

We present equation of state (EOS) measurements of solid-density copper heated to 5-10 eV. A copper sample was heated isochorically by hydrogen ions accelerated from an adjacent foil by a high intensity pulsed laser, and probed optically. The measured temperature and expansion are compared against simulations using the most up-to-date wide range EOS tables available.

Abstract OT3-02-08: Open label, phase 2 safety, efficacy, and pharmacokinetic study of pre-surgical intramuscular and intraductal fulvestrant in women with invasive breast cancer or DCIS undergoing mastectomy or lumpectomy

BACKGROUND: Breast cancer (BC) is the leading cause of cancer in women in the United States and the second leading cause of cancer-related death. Currently available options for prevention are oophorectomy, bilateral mastectomy, or medical therapy, such as tamoxifen, raloxifene or aromatase inhibitors. None of these options for prevention are without significant side effects with low patient uptake. This study proposes fulvestrant instilled directly into the breast via the nipple orifices as intraductal therapy. Providing a local therapy into the ducts could reduce the morbidity associated with prevention while potentially better targeting the carcinoma cell. Building on prior studies with cytotoxic agents, this study utilizes the pure anti-estrogen fulvestrant to be injected in up to 5 ducts to determine its effect on BC as well as the safety of this method of administration.

TRIAL DESIGN: An open-label, non-randomized PK study of pre-surgical fulvestrant in women scheduled for mastectomy or lumpectomy. Eligible subjects will be undergoing mastectomy or lumpectomy. The first 6 subjects will be treated with the standard dose of 500 mg intramuscular fulvestrant to establish the reference PK curve. The subsequent 24 subjects will receive fulvestrant by intraductal instillation. Subjects where at least 1 suitable duct is identified will undergo nipple aspiration in order to facilitate duct identification and intraductal infusion of a fulvestrant. A maximum of 5 ducts will receive intraductal infusion of fulvestrant. Across all ducts, the total dose will not exceed 500 mg (10 mL). Subsequent to mastectomy or lumpectomy subjects will undergo serial blood draws to determine fulvestrant blood concentration levels and tissue drug levels.

ELIGIBILITY: Female, age &gt; 18, mastectomy/lumpectomy scheduled within 30 days, Stage 1/2, ER+ low grade invasive BC or DCIS, ECOG scale 0-1.

Primary Objective: The safety and tolerability of intraductal administration of fulvestrant in women with Stage 1 or 2 invasive ductal carcinoma or DCIS, prior to mastectomy or lumpectomy.

Secondary Objectives: The pathological effects, specifically changes in Ki67, ER/PgR expression between pre-fulvestrant biopsy and post-fulvestrant surgical specimen.

STATISTICAL METHODS: Aim of this study is to assess safety and tolerability in subjects receiving intraductal fulvestrant. In addition this trial aims to characterize the PK of this alternative route of administration, and compare the intraductal PK profile to that of standard intramuscular administration. Finally, the 6 study subjects who receive intramuscular fulvestrant will be qualitatively compared with the main study cohort of 24 subjects who receive intraductal fulvestrant. Change in Ki67 labeling index will be compared between the two time points (baseline or time of diagnostic biopsy v. time of the surgically excised specimen collection).

CONTACT INFO: Sheldon Marc Feldman MD Columbia University Medical Center sf2388@cumc.columbia.edu 212-305-9676.

Citation Format: Feldman S, Gomberawalla A, Alonso A, Rea J, Quay S, Lawrence R. Open label, phase 2 safety, efficacy, and pharmacokinetic study of pre-surgical intramuscular and intraductal fulvestrant in women with invasive breast cancer or DCIS undergoing mastectomy or lumpectomy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT3-02-08.

Chronic airway inflammation provides a unique environment for B cell activation and antibody production

BACKGROUND

B cells play many roles in health and disease. However, little is known about the mechanisms that drive B cell responses in the airways, especially in humans. Chronic rhinosinusitis (CRS) is an inflammatory disease of the upper airways that affects 10% of Europeans and Americans. A subset of CRS patients develop nasal polyps (NPs), which are characterized by type 2 inflammation, eosinophils and group 2 innate lymphoid cells (ILC2s). We have reported that NP contain elevated levels of B cells and antibodies, making NP an ideal system for studying B cells in the airways.

OBJECTIVE

We sought to determine the mechanisms that drive B cell activation and antibody production during chronic airway inflammation.

METHODS

We analysed B cells from NP or tonsil, or after ILC2 coculture, by flow cytometry. Antibody production from tissue was measured using Luminex assays and the frequency of antibody-secreting cells by ELISpot. Formation of B cell clusters was assessed using immunohistochemistry. Expression of genes associated with B cell activation and class switch recombination was measured by qRT-PCR.

RESULTS

NP contained significantly elevated frequencies of plasmablasts, especially those that expressed the extrafollicular marker Epstein-Barr virus-induced protein 2 (EBI2), but significantly fewer germinal centre (GC) B cells compared with tonsil. Antibody production and the frequency of antibody-secreting cells were significantly elevated in NP, and there was evidence for local class switch recombination in NP. Finally, ILC2s directly induced EBI2 expression on B cells in vitro.

CONCLUSIONS AND CLINICAL RELEVANCE

Our data suggest there is a unique B cell activation environment within NP that is distinct from classic GC-mediated mechanisms. We show for the first time that ILC2s directly induce EBI2 expression on B cells, indicating that ILC2s may play an important role in B cell responses. B cell-targeted therapies may provide new treatment options for CRSwNP.

Antipsychotic Treatment and Tobacco Craving in People With Schizophrenia

OBJECTIVE

Nicotine dependence is high in schizophrenia, and craving is known to impact relapse during quit attempts.

METHODS

We compared tobacco craving in smokers with schizophrenia treated with different antipsychotics.

RESULTS

Mean craving scores were lowest in participants receiving first-generation antipsychotics, although these differences were not statistically significant. Craving with clozapine was not lower than with other antipsychotics.

CONCLUSIONS

Further research is needed to determine whether differences in craving exist between antipsychotic classes.

Predictors of the Perception of Smoking Health Risks in Smokers With or Without Schizophrenia

OBJECTIVE

This study sought to examine the predictors of health risk perception in smokers with or without schizophrenia.

METHODS

The health risk subscale from the Smoking Consequences Questionnaire was dichotomized and used to measure health risk perception in smokers with (n = 67) and without schizophrenia (n = 100). A backward stepwise logistic regression was conducted using variables associated at the bivariate level to determine multivariate predictors.

RESULTS

Overall, 62.5% of smokers without schizophrenia and 40.3% of smokers with schizophrenia completely recognize the health risks of smoking (p ≤ .01). Multivariate predictors for smokers without schizophrenia included: sex (Exp (B) = .3; p < .05), Smoking Consequences Questionnaire state enhancement (Exp (B) = .69; p < .01), and craving relief (Exp (B) = 1.8; p < .01). Among smokers with schizophrenia, predictors were education (Exp (B) = .7; p < .05), nicotine dependence (Exp (B) = .5; p < .01), motivation to quit (Exp (B) = 1.8; p < .01), and Smoking Consequences Questionnaire craving relief (Exp (B) = 1.8; p < .01).

CONCLUSIONS

There was overlap and differences between predictors in smokers with and without schizophrenia. Commonly used techniques for education on the health consequences of cigarettes may work in smokers with schizophrenia, but intervention efforts specifically tailored to smokers with schizophrenia might be more efficacious.

Risk of high-grade cervical dysplasia and cervical cancer in women with systemic lupus erythematosus receiving immunosuppressive drugs

Objective Prior studies suggest an increased risk of cervical cancer among women with systemic lupus erythematosus. However, the relationship with immunosuppressive drugs is not well studied in US nationwide cohorts. We compared the risk of high-grade cervical dysplasia and cervical cancer among women with systemic lupus erythematosus who started immunosuppressive drugs versus hydroxychloroquine. Methods We identified systemic lupus erythematosus patients initiating immunosuppressive drugs or hydroxychloroquine using claims data from two US commercial health plans and Medicaid (2000-2012). We used a validated claims-based algorithm to identify high-grade cervical dysplasia or cervical cancer. To account for potential confounders, including demographic factors, comorbidities, medication use, HPV vaccination status, and health care utilization, immunosuppressive drugs and hydroxychloroquine initiators were 1:1 matched on the propensity score. We used inverse variance-weighted, fixed effect models to pool hazard ratios from the propensity score-matched Medicaid and commercial cohorts. Results We included 2451 matched pairs of immunosuppressive drugs and hydroxychloroquine new users in the commercial cohort and 7690 matched pairs in Medicaid. In the commercial cohort, there were 14 cases of cervical dysplasia or cervical cancer among immunosuppressive drugs users and five cases among hydroxychloroquine users (hazard ratio 2.47, 95% CI 0.89-6.85, hydroxychloroquine = ref). In Medicaid, there were 46 cases among immunosuppressive drugs users and 29 cases in hydroxychloroquine users (hazard ratio 1.24, 95% CI 0.78-1.98, hydroxychloroquine = ref). The pooled hazard ratio of immunosuppressive drugs was 1.40 (95% CI 0.92-2.12). Conclusion Among women with systemic lupus erythematosus, immunosuppressive drugs may be associated with a greater, albeit not statistically significant, risk of high-grade cervical dysplasia and cervical cancer compared to patients receiving hydroxychloroquine alone.

Pharmacokinetics and Safety Assessment of l-Tetrahydropalmatine in Cocaine Users: A Randomized, Double-Blind, Placebo-Controlled Study

Cocaine use disorder (CUD) remains a significant public health challenge. l-Tetrahydropalmatine (l-THP), a well-tolerated and nonaddictive compound, shows promise for the management of CUD. Its pharmacologic profile includes blockade at dopamine and other monoamine receptors and attenuation of cocaine self-administration, reinstatement, and rewarding properties in rats. This study evaluated the safety of l-THP in human cocaine users and its influence on the safety and pharmacokinetics (PK) of cocaine. Twenty-four cocaine-using adult men were randomized to receive l-THP (30 mg twice a day orally) or placebo double-blind for 4 days, with an intranasal cocaine (40 mg) challenge on the fourth day. Safety and tolerability were evaluated using vital signs, ECG, clinical laboratory tests, and standardized self-report instruments. Peripheral venous blood was collected periodically and later assayed for l-THP and cocaine using highly sensitive and specific ultraperformance liquid chromatography-fluorescence detection (UPLC-FLD) methods. Twenty subjects completed the study, of whom 19 provided complete PK data. The short 3.5-day course of l-THP was safe and well tolerated and did not affect cocaine's PK or its acute cardiovascular effects. The cocaine AUC_0→∞ was 211.5 and 261.4 h·ng/mL, and the C_max was 83.3 and 104.5 ng/mL for the l-THP and placebo groups, respectively. In addition there were no significant differences in the number of side effects reported in each group (l-THP group 22 [48%], placebo group 24 [52%]) or vital signs including, heart rate, blood pressure, complete blood count, or ECG. These findings suggest that oral THP has promise for further development as a treatment for CUD.

The Safety, Pharmacokinetics, and Nervous System Effects of Two Natural Sources of Caffeine in Healthy Adult Males

This double‐blind crossover clinical trial randomized 12 adult males to receive 200 mg of caffeine from a green coffee extract, a guayusa leaf extract, and a synthetic control to compare their safety, absorption, and effect on neurotransmitters. The results showed no statistically significant changes in blood pressure or heart rate from baseline to 120 min postdose of each natural source compared with changes from baseline in the control (0.094 < = P < = 0.910). The ratios of C_max, AUC_0‐4, and AUC_0‐∞ of each natural source to the control were bioequivalent by US Food and Drug Administration standards (90% CI within 80–125%). The guayusa leaf extract stimulated a significantly lower increase in epinephrine compared with the control (+0.5 vs. +2.78 μg/gCr, P = 0.04), while the green coffee extract provoked an increase in epinephrine similar to the control (+3.21 vs. +2.78 μg/gCr, P = 0.569). Implications for future clinical research are discussed.

Schizophrenia clinical symptom differences in women vs. men with and without a history of childhood physical abuse

BACKGROUND

Childhood abuse has been implicated as an environmental factor that increases the risk for developing schizophrenia. A recent large population-based case-control study found that abuse may be a risk factor for schizophrenia in women, but not men. Given the sex differences in onset and clinical course of schizophrenia, we hypothesized that childhood abuse may cause phenotypic differences in the disorder between men and women.

METHODS

We examined the prevalence of childhood physical abuse in a cohort of men and women with schizophrenia and schizoaffective disorder. Specifically, we examined differences in positive, negative, cognitive and depressive symptoms in men and women who reported a history of childhood physical abuse. We recruited 100 subjects for a single visit and assessed a history of childhood physical abuse using the childhood trauma questionnaire (CTQ) and clinical symptoms and cognition using the brief psychiatric rating scale (BPRS), the calgary depression scale (CDS) and the repeatable battery of the assessment of neuropsychological status (RBANS) for cognition.

RESULTS

Ninety-two subjects completed the full CTQ with abuse classified as definitely present, definitely absent or borderline. Twelve subjects who reported borderline abuse scores were excluded. Of the 80 subjects whose data was analyzed, 10 of 24 (41.6 %) women and 11 of 56 (19.6 %) men reported a history of childhood physical abuse (χ(2) = 4.21, df = 1, p = 0.04). Women who reported such trauma had significantly more psychotic (sex by abuse interaction; F = 4.03, df = 1.76, p = 0.048) and depressive (F = 4.23, df = 1.76, p = 0.04) symptoms compared to women who did not have a trauma history and men, regardless of trauma history. There were no differences in negative or cognitive symptoms.

CONCLUSIONS

Women with schizophrenia and schizoaffective disorder may represent a distinct phenotype or subgroup with distinct etiologies and may require different, individually tailored treatments.