Overestimation of Balance Ability Among Older Adults at Risk for Falls

Objective: This study examined alignment of subjective balance confidence with Stopping Elderly Accidents, Deaths and Injuries (STEADI) fall risk. Methods: Cross-sectional analysis of 155 community-dwelling adults (60 + y/o) from 2016 to 2018 who completed a STEADI fall assessment. Descriptive statistics, Chi-Square analysis, and biserial point correlations were applied. Results: Adults who overestimate balance confidence, 55.6% (n = 50) reported a fall in the past year, 62.2% (n = 56) were worried about falling, 48.9% (n = 44) felt unsteady when standing/walking, and 70.0% (n = 63) had a score of ≥4 on the Stay Independent Questionnaire (SIQ). Physical performance for these adults were mean TUG score 10.9s (SD = 3.4), mean 30 second chair stands 10.8 (SD = 3.5), and mean 4-stage balance score 3.1 (SD = .76). Discussion: Older adults are more likely to overestimate their subjective balance confidence. Individuals are equally likely to have reported a fall in the past year if they were "at fall risk," regardless of their subjective balance confidence.

Lifestyle and incident dementia: A COSMIC individual participant data meta‐analysis

INTRODUCTION

The LIfestyle for BRAin Health (LIBRA) index yields a dementia risk score based on modifiable lifestyle factors and is validated in Western samples. We investigated whether the association between LIBRA scores and incident dementia is moderated by geographical location or sociodemographic characteristics.

METHODS

We combined data from 21 prospective cohorts across six continents (N = 31,680) and conducted cohort-specific Cox proportional hazard regression analyses in a two-step individual participant data meta-analysis.

RESULTS

A one-standard-deviation increase in LIBRA score was associated with a 21% higher risk for dementia. The association was stronger for Asian cohorts compared to European cohorts, and for individuals aged ≤75 years (vs older), though only within the first 5 years of follow-up. No interactions with sex, education, or socioeconomic position were observed.

DISCUSSION

Modifiable risk and protective factors appear relevant for dementia risk reduction across diverse geographical and sociodemographic groups.

HIGHLIGHTS

A two-step individual participant data meta-analysis was conducted. This was done at a global scale using data from 21 ethno-regionally diverse cohorts. The association between a modifiable dementia risk score and dementia was examined. The association was modified by geographical region and age at baseline. Yet, modifiable dementia risk and protective factors appear relevant in all investigated groups and regions.

COVID-19 Stroke Apical Lung Examination Study 2: a national prospective CTA biomarker study of the lung apices, in patients presenting with suspected acute stroke (COVID SALES 2)

BACKGROUND

Apical ground-glass opacification (GGO) identified on CT angiography (CTA) performed for suspected acute stroke was developed in 2020 as a coronavirus-disease-2019 (COVID-19) diagnostic and prognostic biomarker in a retrospective study during the first wave of COVID-19.

OBJECTIVE

To prospectively validate whether GGO on CTA performed for suspected acute stroke is a reliable COVID-19 diagnostic and prognostic biomarker and whether it is reliable for COVID-19 vaccinated patients.

METHODS

In this prospective, pragmatic, national, multi-center validation study performed at 13 sites, we captured study data consecutively in patients undergoing CTA for suspected acute stroke from January-March 2021. Demographic and clinical features associated with stroke and COVID-19 were incorporated. The primary outcome was the likelihood of reverse-transcriptase-polymerase-chain-reaction swab-test-confirmed COVID-19 using the GGO biomarker. Secondary outcomes investigated were functional status at discharge and survival analyses at 30 and 90 days. Univariate and multivariable statistical analyses were employed.

RESULTS

CTAs from 1,111 patients were analyzed, with apical GGO identified in 8.5 % during a period of high COVID-19 prevalence. GGO showed good inter-rater reliability (Fleiss κ = 0.77); and high COVID-19 specificity (93.7 %, 91.8-95.2) and negative predictive value (NPV; 97.8 %, 96.5-98.6). In subgroup analysis of vaccinated patients, GGO remained a good diagnostic biomarker (specificity 93.1 %, 89.8-95.5; NPV 99.7 %, 98.3-100.0). Patients with COVID-19 were more likely to have higher stroke score (NIHSS (mean +/- SD) 6.9 +/- 6.9, COVID-19 negative, 9.7 +/- 9.0, COVID-19 positive; p = 0.01), carotid occlusions (6.2 % negative, 14.9 % positive; p = 0.02), and larger infarcts on presentation CT (ASPECTS 9.4 +/- 1.5, COVID-19 negative, 8.6 +/- 2.4, COVID-19 positive; p = 0.00). After multivariable logistic regression, GGO (odds ratio 15.7, 6.2-40.1), myalgia (8.9, 2.1-38.2) and higher core body temperature (1.9, 1.1-3.2) were independent COVID-19 predictors. GGO was associated with worse functional outcome on discharge and worse survival after univariate analysis. However, after adjustment for factors including stroke severity, GGO was not independently predictive of functional outcome or mortality.

CONCLUSION

Apical GGO on CTA performed for patients with suspected acute stroke is a reliable diagnostic biomarker for COVID-19, which in combination with clinical features may be useful in COVID-19 triage.

Long waitlists for outpatient drug allergy referrals: An Australian tertiary centre experience

Drug allergy clinic waitlist time data are limited. A 24-month retrospective study of drug allergy referrals was undertaken at a tertiary hospital in Australia. One hundred six patients were reviewed with a median age of 50 years (IQR 40.5-67.3) and a female predominance (n = 76, 71%). Face-to-face consultations were common (n = 83, 78.3%) with the remainder being telephone consultations. General practitioners comprised just over one-third (n = 38, 35.9%) of the referrers but majority being from within the hospital, such as the emergency department (n = 22, 20.8%). Most patients (n = 100, 94.3%) were triaged as Category 1 or urgent. Antibiotic allergies were common (n = 75, 70.8%), of which majority were beta-lactam antibiotics (n = 71, 95%): 55 (73.3%) for penicillins and 16 (15.1%) for cephalosporins. The median waitlist time was 178 days (IQR 48.5-502.5) and only 18 (17%) of Category 1 were seen within urgent timeframe. Telephone consultation had a significantly shorter waitlist time (median 47 days; IQR 6-245) compared to face-to-face consultations (median 267 days; IQR 69-519) (p = 0.026). Large waitlist times are present for drug allergy, and given the majority of referrers are from hospitals, inpatient drug allergy assessment remains paramount. Beta-lactam antibiotic drug allergy labels remain common, and given their negative implications, further work is needed. Economic and human resources evaluations are required to address this shortfall.

TTK/MPS1 inhibitor OSU-13 targets the mitotic checkpoint and is a potential therapeutic strategy for myeloma

Despite substantial recent advances in treatment, multiple myeloma (MM) remains an incurable disease, with a shortage of treatment options for patients with high-risk disease, warranting the need for novel therapeutic targets and treatment approaches. Threonine and tyrosine kinase (TTK), also known as monopolar spindle 1 (MPS1), is a kinase essential for the mitotic spindle checkpoint whose expression correlates to unfavorable prognosis in several cancers. Here, we report the importance of TTK in MM, and the effects of the TTK inhibitor OSU-13. Elevated TTK expression correlated with amplification/ gain of 1q21 and decreased overall and event-free survival in MM. Treatment with OSU-13 inhibited TTK activity efficiently and selectively at a similar concentration range to other TTK inhibitor clinical candidates. OSU-13 reduced proliferation and viability of primary human MM cells and cell lines, especially those with high 1q21 copy numbers, and triggered apoptosis through caspase 3 and 7 activation. In addition, OSU-13 induced DNA damage and severe defects in chromosome alignment and segregation, generating aneuploidy. In vivo, OSU-13 decreased tumor growth in mice with NCI-H929 xenografts. Collectively, our findings reveal that inhibiting TTK with OSU-13 is a potential therapeutic strategy for MM, particularly for a subset of high-risk patients with poor outcome.

Antenatal care of women who use opioids: a qualitative study of practitioners' perceptions of strengths and challenges of current service provision in Scotland

BACKGROUND

The increasing rise of women using opioids during pregnancy across the world has warranted concern over the access and quality of antenatal care received by this group. Scotland has particularly high levels of opioid use, and correspondingly, pregnancies involving women who use opioids. The purpose of this study was to investigate the different models of antenatal care for women using opioids during pregnancy in three Scottish Health Board Areas, and to explore multi-disciplinary practitioners' perceptions of the strengths and challenges of working with women who use opioids through these specialist services.

METHODS

Thirteen semi-structured interviews were conducted with health and social care workers who had experience of providing antenatal and postnatal care to women who use drugs across three Scottish Health Board Areas: NHS Greater Glasgow and Clyde, NHS Lothian, and NHS Tayside. Framework Analysis was used to analyse interview data. The five stages of framework analysis were undertaken: familiarisation, identifying the thematic framework, indexing, charting, and mapping and interpretation.

RESULTS

Each area had a specialist antenatal pathway for women who used substances. Pathways varied, with some consisting of specialist midwives, and others comprising a multidisciplinary team (e.g. midwife, mental health nurse, social workers, and an obstetrician). Referral criteria for the specialist service differed between health board areas. These specialised pathways presented several key strengths: continuity of care with one midwife and a strong patient-practitioner relationship; increased number of appointments, support and scans; and highly specialised healthcare professionals with experience of working with substance use. In spite of this, there were a number of limitations to these pathways: a lack of additional psychological support for the mother; some staff not having the skills to engage with the complexity of patients who use substances; and problems with patient engagement.

CONCLUSIONS

Across the three areas, there appears to be high-quality multi-disciplinary antenatal services for women who use opioids during pregnancy. However, referral criteria vary and some services appear more comprehensive than others. Further research is needed into the perceptions of women who use opioids on facilitators and barriers to antenatal care, and provision in rural regions of Scotland.

Immune checkpoint inhibitor-associated hemophagocytic lymphohistiocytosis in a patient with chronic lymphocytic leukemia

Haemophagocytic lymphohistiocytosis (HLH) is a rare complication of immune checkpoint inhibitor therapy. A 55-year-old male with stable chronic lymphocytic leukemia presented with fevers and symptomatic anaemia after nine cycles of nivolumab for metastatic melanoma. Investigations were consistent with autoimmune haemolytic anemia and corticosteroids were initiated. Thrombocytopenia and elevated liver enzymes without evidence of chronic lymphocytic leukaemia transformation was present. Ferritin was elevated, and thus HLH was considered and subsequently confirmed on a bone marrow biopsy. Corticosteroid monotherapy was continued, with resolution of fevers and improvement in cytopenias and liver enzymes. A six month corticosteroid tapering regimen was initiated, and he remains in HLH remission. This case highlights the importance of prompt recognition of immune checkpoint inhibitor-related HLH in patients with concurrent haematological malignancy.

Tocilizumab in grade 4 hepatitis secondary to immune checkpoint inhibitor: a case report and review of the literature

First- and second-line treatments for immune checkpoint inhibitor-related hepatotoxicity (IRH) are well established; however, evidence for third-line therapies is limited. We present a 68-year-old female with relapsed metastatic non-small-cell lung carcinoma despite multiple treatments. A fortnight after the second cycle of CTLA-4 inhibitor immunotherapy, she developed scleral icterus and mild jaundice with significant elevation in liver enzymes. A diagnosis of IRH was made, and despite corticosteroids, mycophenolate and tacrolimus, liver enzymes continued to worsen. One infusion of tocilizumab was given, which resulted in a remarkable improvement. Prednisolone and tacrolimus were then tapered over the ensuing months, and mycophenolate was continued. Given the rapid improvement in liver enzymes with tocilizumab, this treatment should be considered as a third-line treatment in IRH.

A case of T-cell-Epstein-Barr virus-haemophagocytic lymphohistiocytosis and sustained remission following ruxolitinib therapy

Objectives

Epstein-Barr virus (EBV) is a common cause of secondary haemophagocytic lymphohistiocytosis (HLH). While B cells are reservoirs for EBV, infection within T cells and NK cells in this disease can be difficult to treat.

Methods

A 19-year-old female presented with a 6-week history of coryzal symptoms on a background of Crohn's disease. On examination, she was febrile and tachycardic with mild tonsillar enlargement and splenomegaly. New trilineage cytopenias and elevation in liver enzymes were detected, with acute EBV subsequently confirmed on whole blood PCR. A diagnosis of EBV-associated HLH was supported further with elevated serum ferritin, triglycerides and soluble CD25, low fibrinogen and the presence of haemophagocytosis in the bone marrow.

Results

Corticosteroids, IVIG and rituximab were given, and anakinra was subsequently added due to ongoing fevers. EBV infection was then demonstrated within CD8⁺ T cells on EBER Flow-FISH assay. Ruxolitinib was commenced and her fevers abated on day 5, with improvement in other HLH parameters. She was discharged after a 39-day hospital admission. To date, she has remained in remission of HLH, despite developing COVID-19 infection during the convalescence phase of HLH.

Conclusion

EBV viraemia requires adequate treatment to control EBV-associated HLH as rituximab may be insufficient, and corticosteroid resistance can result in continued EBV infection in CD8⁺ T cells. This entity is known as T-cell-EBV-HLH. Ruxolitinib is a novel treatment strategy in this specific context and has several advantages, including inhibition of corticosteroid resistance to promote apoptosis of EBV-infected T cells.

Characterization of monoclonal gammopathy of undetermined significance progression to multiple myeloma through meta-analysis of GEO data

The etiology of monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma (MM) is still obscure as are the processes that enable the progression of MGUS to MM. Understanding the unique vs. shared transcriptomes can potentially elucidate why individuals develop one or the other. Furthermore, highlighting key pathways and genes involved in the pathogenesis of MM or the development of MGUS to MM may allow the discovery of novel drug targets and therapies. We employed STARGEO platform to perform three separate meta-analysis to compare MGUS and MM transcriptomes. For these analyses we tagged (1) 101 MGUS patient plasma cells from bone marrow samples and 64 plasma cells from healthy controls (2) 383 MM patient CD138+ cells from bone marrow and the 101 MGUS samples in the first analysis as controls (3) 517 MM patient peripheral blood samples and 97 peripheral blood samples from healthy controls. We then utilized Ingenuity Pathway Analysis (IPA) to analyze the unique genomic signatures within and across these samples. Our study identified genes that may have unique roles in MGUS (GADD45RA and COMMD3), but also newly identified signaling pathways (EIF2, JAK/STAT, and MYC) and gene activity (NRG3, RBFOX2, and PARP15) in MGUS that have previously been shown to be involved in MM suggesting a spectrum of molecular overlap. On the other hand, genes such as DUSP4, RN14, LAMP5, differentially upregulated in MM, may be seen as tipping the scales from benignity to malignancy and could serve as drug targets or novel biomarkers for risk of progression. Furthermore, our analysis of MM identified newly associated gene/pathway activity such as inhibition of Wnt-signaling and defective B cell development. Finally, IPA analysis, suggests the multifactorial, oncogenic qualities of IFNγ signaling in MM may be a unifying pathway for these diverse mechanisms and prompts the need for further studies.

THE VALUE OF BALANCE CONFIDENCE IN OLDER ADULT FALL RISK ASSESSMENT

Fall risk assessment traditionally focuses on objective physical performance. Balance confidence, a subjective measure of physical function, may provide important information to better predict fall risk and guide assessment and intervention strategies. This study examines the associations of balance confidence congruency with physical performance measures and fall occurrence. One-hundred-fifty-five community-dwelling adults aged 60 and over completed a comprehensive fall risk assessment including physical performance tests (timed up and go, 4-stage balance, 30-second chair stand, and 4-M gait speed), activities-specific balance confidence (ABC) scale, and self-reported falls in the past year. Four groups were created based on congruency between balance confidence (low vs. high) and each physical performance measure or overall fall risk category (at fall risk vs. not at fall risk, based on the STEADI tool kit). Poison regression analyses, adjusted for age and gender, tested the association between group membership and number of falls in the past year. Participants with high balance confidence and at fall risk based on 4-stage balance performance (Estimate=0.88, p < 0.001), or high balance confidence and at fall risk following the STEADI screening algorithm (Estimate=0.69, p = 0.003) were at increased risk of more falls compared to participants in the group with high balance confidence and not at fall risk. These results suggest that older adults who overestimate their balance relative to their physical performance may be at increased fall risk, and that participant subjective reporting of physical performance should be paired with objective physical performance measures to better identify older adults at fall risk.

Associations of segment-specific pulse wave velocity with vascular calcification: the Atherosclerosis Risk in Communities (ARIC) Study

Background

Pulse wave velocity (PWV) is a non-invasive measure of arterial stiffness and a predictor of cardiovascular disease (CVD). Vascular calcification, especially coronary artery calcium (CAC) measured by computed tomography (CT), is one of the strongest predictors of CVD but requires radiation for measurement. PWV may be helpful to identify persons with vascular calcification who may benefit from formal assessment of vascular calcification with CT. However, the associations between PWV and vascular calcification across different vascular beds have not been fully investigated.

Purpose

The aims of this study were to quantify the association between PWV and calcification at different segments and to explore whether PWV can identify individuals with vascular calcification beyond traditional risk factors.

Methods

Among 1486 ARIC Study participants (mean age 79.3 [SD 4.2] years), we measured PWV by OMRON VP1000plus at the following segments: heart-carotid (hcPWV), heart-femoral (hfPWV), carotid-femoral (cfPWV), heart-ankle (haPWV), brachial-ankle (baPWV) and femoral-ankle (faPWV). Participants were stratified into four groups based on quartiles of each PWV measure. Dependent (i.e., outcome) variables were high calcium score (≥75th percentile of Agatston score by CT) of the following vascular beds (including valves): coronary arteries, aortic valve ring, aortic valve, mitral valve, ascending aorta, and descending aorta. We ran multivariable logistic regression models and assessed c-statistics as a measure of prediction discrimination.

Results

Only cfPWV was significantly positively associated with high CAC (adjusted odds ratio [OR] for the highest vs. lowest quartile: 1.73 [95% CI: 1.17–2.55]) (green dot in figure). The associations were overall most evident for descending aorta calcification, with significantly positive results for hfPWV (gold dot in figure), cfPWV (green dot), haPWV (emerald dot), and baPWV (blue dot). For example, adjusted OR for the highest vs. lowest quartile of cfPWV was 4.08 (2.70–6.24). hfPWV and cfPWV were significantly associated with mitral valve calcification as well. In contrast, faPWV (purple dots) was inversely associated with calcification of aortic valve ring, ascending aorta, and descending aorta. For descending aorta calcification, even the second highest quartile of the following measures demonstrated significant adjusted OR: hfPWV (3.21 [2.11–4.95]), cfPWV (2.11 [1.40–3.20]), and baPWV (1.75 [1.14–2.69]). Simultaneously adding cfPWV and hfPWV improved c-statistic for CAC (Δc-statistic 0.011 [0.0007–0.022]) and descending aorta calcification (0.035 [0.017–0.053]).

Conclusions

The associations of PWV with vascular calcification varied substantially across segments, with descending aorta calcification most closely linked to PWV measures and cfPWV most robustly associated with calcification of multiple vascular beds. cfPWV and hfPWV, together, improved discrimination of high CAC beyond traditional risk factors.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The National Heart, Lung, and Blood Institute, National Institutes of Health

Realist analysis of whether emergency departments with primary care services generate 'provider-induced demand'

Background

It is not known whether emergency departments (EDs) with primary care services influence demand for non-urgent care (‘provider-induced demand’). We proposed that distinct primary care services in EDs encourages primary care demand, whereas primary care integrated within EDs may be less likely to cause additional demand. We aimed to explore this and explain contexts (C), mechanisms (M) and outcomes (O) influencing demand.

Methods

We used realist evaluation methodology and observed ED service delivery. Twenty-four patients and 106 staff members (including Clinical Directors and General Practitioners) were interviewed at 13 EDs in England and Wales (240 hours of observations across 30 days). Field notes from observations and interviews were analysed by creating ‘CMO’ configurations to develop and refine theories relating to drivers of demand.

Results

EDs with distinct primary care services were perceived to attract demand for primary care because services were visible, known or enabled direct access to health care services. Other influencing factors included patients’ experiences of accessing primary care, community care capacity, service design and population characteristics.

Conclusions

Patient, local-system and wider-system factors can contribute to additional demand at EDs that include primary care services. Our findings can inform service providers and policymakers in developing strategies to limit the effect of potential influences on additional demand when demand exceeds capacity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00709-2.

Redefining CD56 as a biomarker and therapeutic target in Multiple Myeloma

Multiple myeloma (MM) cells aberrantly express surface antigens compared to normal plasma cells. Among others, CD56 is present at variable levels in approximately 70% of MM patients; however very little is known about CD56 role in MM. We demonstrated that MM patients with more than 10 percent of CD56-expressing clonal MM cells have inferior clinical outcomes. By gain-of and loss-of function models, we revealed that CD56 promotes MM cell growth, survival, and adhesion to stromal cells. These protumoral effects are induced by the activation of the RSK2/CREB1 signaling pathway, with increased mRNA and protein levels of the anti-apoptotic genes BCL2 and MCL1. Consequently, the genomic and pharmacological inhibition of RSK2 or CREB1 specifically induced MM cell death in CD56-expressing MM cells. Finally, we observed that CD56 signaling decreases CRBN expression, reducing responses to lenalidomide. RSK2 or CREB1 inhibition increased CRBN levels and were synergic with lenalidomide in inducing cell death, especially in CD56-expressing MM cells. In conclusion, our findings demonstrate that CD56 promotes MM cell growth, and pave the way to novel therapies based on targeting CD56, along with the use of CD56 as a predictive biomarker for MM therapies. Implications: Multiple myeloma (MM) is an incurable, genetically heterogeneous disease, without available tailored therapeutic approaches. CD56 signaling promotes MM growth and adhesion, by activating CREB1 target genes, MCL1 and BCL2. Inhibition of CREB1 alone or in combination with lenalidomide is an unexplored synthetic lethal approach in CD56-expressing MM patients.

49 Accurate Hip Reduction and SPICA Application for DDH – the Case for Intraoperative CT

Aim

Accurate reduction of the hip joint and SPICA application for treatment of developmental dysplasia of the hip (DDH) is crucial for long term success – for those undergoing surgical intervention, or closed reduction only. In Alder Hey Children’s Hospital we compared two methods of confirming reduction for patients undergoing SPICA application for DDH. Those receiving either post-operative departmental computed tomography (CT) or an intra-operative CT. Specific outcome assessed were, need for repeat CT and SPICA application, return to theatre (RTT), repeat general anaesthetic (GA) (with associated risks), as well as effect on overall length of stay (LOS).

Method

Patient lists were attained from the radiography department, information regarding RTT and LOS were derived from Meditech V6. CT scans were checked on PACS imaging system.

Results

Retrospective analysis of all SPICA application cases performed, included 102 patients from 2015–2018 undergoing a departmental CT, after GA. Of these, 6 patients required a second GA, 1 patient required 3 GA’s. Mean LOS was 6 days in those requiring repeat SPICA application.

Analysis of the second group of intra-operatively CT scanned patients, included 72 patients from 2018–2020. Of these, 0 patients required a repeat GA and RTT, despite 1 patient requiring change of SPICA. Mean LOS was 4 days for these patients.

Conclusions

Intra-operative CT is crucial for getting it right first time, reducing risks of GA and cost of theatre time. It reduced the LOS for those requiring SPICA change from 6 to 4 days and reduced mean LOS by 1 day overall.

Utilising clinical data to personlaise boundary conditions significantly improves the accuracy of angiography based virtual FFR

Background

Angiography-derived computed (virtual) fractional flow reserve (vFFR) permits the assessment of coronary physiology without the need for a pressure wire or hyperaemia. However, accuracy is limited by assumptions made about coronary microvascular resistance (CMVR) [1]. We hypothesised that machine learning may allow us to “tune” our estimate of the CMVR to increase the accuracy of vFFR.

Purpose

To determine whether routine clinical data can personalise CMVR and improve the accuracy of vFFR on an individual case basis.

Methods

Patients with chronic coronary syndromes underwent coronary angiography with FFR assessment. Vessel-specific CMVR was computed using a 3D- computational fluid dynamics simulation with invasively measured proximal and distal pressures. Predictive models were created using non-linear autoregressing moving average with exogenous inputs (NARMAX) modelling with computed CMVR as the dependent variable. vFFR was computed using previously described methods [2]. Three simulations were run, using: 1) a generic CMVR value (Model A); 2) a NARMAX-predicted CMVR based upon a panel of simple clinical data (Model B); and 3) a NARMAX-predicted CMVR incorporating echocardiographic data (Model C). The diagnostic and quantitative accuracy of each model was compared with directly measured FFR.

Results

Eighty four patients underwent coronary angiography with FFR assessment in 157 vessels. Mean age was 64 (±0.1) years and 64 (76%) were male. Mean FFR was 0.79 (±0.15). Mean CMVR was 1.01e+10 Pa/m3 s–1. vFFR error with Model A was ±0.10, with Model B was ±0.07 (p&lt;0.001) and with Model C was ±0.05 (p&lt;0.001) (Table 1).

Conclusion

vFFR is dependent upon not only the epicardial stenosis, but also the CMVR, estimation of which can be personalised based upon clinical and echocardiographic data. This can be used to increase the accuracy of vFFR.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): British Heart Foundation Clinial Research Training FellowshipNIHR i4i grant Table 1

SURPRISINGLY FEW WOMEN WITH SEVERE OSTEOPOROSIS BY BONE DENSITOMETRY UNDERGO WORKUP FOR SECONDARY CAUSES - A RETROSPECTIVE EVALUATION

We describe clinical features of women with extremely low bone density, and investigate secondary causes of osteoporosis. Our hypothesis was that this population would be enriched in identifiable causes of osteoporosis. We performed a retrospective review of medical records of all women seen at our university over 4 years with T-score on bone densitometry at/below -4 at any site. Historical and fracture details were abstracted. We considered a thorough work up to include Vitamin D, PTH, CBC, chemistry panel, cortisol, transglutaminase, myeloma screen, tryptase and 24-hour urine calcium.

RESULTS

137 women were identified with T-score at/below -4. Percent identified as Asian was 26% (higher than local prevalence of 8%). Average BMI was 21.6 kg/m². Clearly identifiable causes of osteoporosis were noted in 57% (inflammatory disorder, glucocorticoid or antacid exposure, prolonged immobilization and alcoholism were most prevalent). Of the remainder, full work up was performed only in 8%. Endocrine consultation and white race predicted thoroughness of secondary work-up.

CONCLUSION

Fragility fractures, leanness and Asian race were common in women with very low T-score. However, few new causes were identified. Underlying etiology was either immediately evident or inadequately studied, especially in minorities.

Functional expression of aryl hydrocarbon receptor as a potential novel therapeutic target in human multiple myeloma

The etiology of multiple myeloma (MM) remains incompletely understood; however, epidemiologic studies have suggested a possible link between exposure to environmental aromatic hydrocarbons-which serve as exogenous ligands for the aryl hydrocarbon receptor (AHR), which has been implicated in cancer biology-and development of monoclonal gammopathy of undetermined significance (MGUS) and MM. Herein, we demonstrate the functional expression of AHR in MM cell lines and primary human MM samples. AHR is expressed in putative MM 'stem cells' and advanced clinical stages of MM, and functionally contributes to MM tumor cell phenotype and proliferation. Antagonism of AHR directly impairs MM cell viability and increases MM cell susceptibility to immune-mediated clearance. Furthermore, our findings indicate that AHR antagonism may represent an effective means to enhance the function of other drugs, such as anti-CD38 antibodies, in future clinical studies. Taken together, these data identify AHR as a novel target for MM therapy.

IgG4-related Disease Presenting as Isolated Cicatrising Conjunctivitis

A 46-year-old male presented with a 12-month history of trichiasis and was found to have significant, progressive cicatrization of the tarsal conjunctiva causing entropion of the upper and lower eyelids. A biopsy confirmed the diagnosis of IgG4-related cicatrizing conjunctivitis in the absence of any other organ involvement, a previously unreported manifestation of this immune-mediated disease.

Prevalence of SARS-CoV-2 antibodies in pediatric healthcare workers

Objectives

To determine SARS-CoV-2-antibody prevalence in pediatric healthcare workers (pHCWs).

Design

Baseline prevalence of anti-SARS-CoV-2-IgG was assessed in a prospective cohort study from a large pediatric healthcare facility. Prior SARS-CoV-2 testing history, potential risk factors and anxiety level about COVID-19 were determined. Prevalence difference between emergency department (ED)-based and non-ED-pHCWs was modeled controlling for those covariates. Chi-square test-for-trend was used to examine prevalence by month of enrollment.

Results

Most of 642 pHCWs enrolled were 31-40years, female and had no comorbidities. Half had children in their home, 49% had traveled, 42% reported an illness since January, 31% had a known COVID-19 exposure, and 8% had SARS-CoV-2 PCR testing. High COVID-19 pandemic anxiety was reported by 71%. Anti-SARS-CoV-2-IgG prevalence was 4.1%; 8.4% among ED versus 2.0% among non-ED pHCWs (p < 0.001). ED-work location and known COVID-19 exposure were independent risk factors. 31% of antibody-positive pHCWs reported no symptoms. Prevalence significantly (p < 0.001) increased from 3.0% in April–June to 12.7% in July–August.

Conclusions

Anti-SARS-CoV-2-IgG prevalence was low in pHCWs but increased rapidly over time. Both working in the ED and exposure to a COVID-19-positive contact were associated with antibody-seropositivity. Ongoing universal PPE utilization is essential. These data may guide vaccination policies to protect front-line workers.

Physiotherapy rehabilitation for osteoporotic vertebral fracture-a randomised controlled trial and economic evaluation (PROVE trial)

The trial compared three physiotherapy approaches: manual or exercise therapy compared with a single session of physiotherapy education (SSPT) for people with osteoporotic vertebral fracture(s). At 1 year, there were no statistically significant differences between the groups meaning there is inadequate evidence to support manual or exercise therapy.

INTRODUCTION

To evaluate the clinical and cost-effectiveness of different physiotherapy approaches for people with osteoporotic vertebral fracture(s) (OVF).

METHODS

>Prospective, multicentre, adaptive, three-arm randomised controlled trial. Six hundred fifteen adults with back pain, osteoporosis, and at least 1 OVF participated.

INTERVENTIONS

7 individual physiotherapy sessions over 12 weeks focused on either manual therapy or home exercise compared with a single session of physiotherapy education (SSPT). The co-primary outcomes were quality of life and back muscle endurance measured by the QUALEFFO-41 and timed loaded standing (TLS) test at 12 months.

RESULTS

At 12 months, there were no statistically significant differences between groups. Mean QUALEFFO-41: - 1.3 (exercise), - 0.15 (manual), and - 1.2 (SSPT), a mean difference of - 0.2 (95% CI, - 3.2 to 1.6) for exercise and 1.3 (95% CI, - 1.8 to 2.9) for manual therapy. Mean TLS: 9.8 s (exercise), 13.6 s (manual), and 4.2 s (SSPT), a mean increase of 5.8 s (95% CI, - 4.8 to 20.5) for exercise and 9.7 s (95% CI, 0.1 to 24.9) for manual therapy. Exercise provided more quality-adjusted life years than SSPT but was more expensive. At 4 months, significant changes above SSPT occurred in endurance and balance in manual therapy, and in endurance for those ≤ 70 years, in balance, mobility, and walking in exercise.

CONCLUSIONS

Adherence was problematic. Benefits at 4 months did not persist and at 12 months, we found no significant differences between treatments. There is inadequate evidence a short physiotherapy intervention of either manual therapy or home exercise provides long-term benefits, but arguably short-term benefits are valuable.

TRIAL REGISTRATION

ISRCTN 49117867.

4325Change in left atrial function predicts incident atrial fibrillation: the multi-ethnic study of atherosclerosis

Background

Longitudinal change in left atrial (LA) structure and function could be helpful in predicting risk for incident AF. We used cardiac magnetic resonance (CMR) imaging to explore the relationship between change in LA structure and function and incident AF in a multi-ethnic population free of clinical cardiovascular disease at baseline.

Methods and results

In the Multi-Ethnic Study of Atherosclerosis (MESA), 2338 participants, free at baseline of clinically recognized AF and cardiovascular disease, had LA volume and function assessed with CMR imaging, at baseline (2000–02), and at Exam 4 (2005–07) or 5 (2010–12). Free of AF, 124 participants developed AF over 3.8±0.9 years (to 2015) following the second imaging. In adjusted Cox regression models, an average annualized change in all LA parameters were significantly associated with an increased risk of AF. An annual decrease of 1–SD unit in total LA emptying fractions (LAEF) was most strongly associated with risk of AF after adjusting for AF clinical risk factors, baseline LA parameters and left ventricular mass-to-volume ratio (hazard ratio per SD=1.91,95% confidence interval=1.53–2.38, P<0.001). The addition of change in total LAEF to an AF risk score improved model discrimination and reclassification (net reclassification improvement=0.107, P=0.017; integrative discrimination index=0.049, P<0.001).

Model discrimination, NRI and IDI Model: CHARGE-AF risk factors# + Baseline LA variable + ΔLA variable CHARGE-AF ΔLAVImin (mL/m2/y) ΔTotal LAEF (%/y) ΔPeak LA Strain (%/y) C-statistic (95% CI) 0.757 (0.721–0.794) 0.787 (0.749–0.824) 0.779 (0.737–0.820) 0.770 (0.732–0.808) NRI† (p-value) – 0.000 (0.991) 0.107 (0.017) 0.017 (0.634) IDI (p-value) – 0.049 (<0.001) 0.049 (<0.001) 0.018 (<0.001) Calibration chi2* (p-value) 19.3 (0.02) 11.68 (0.232) 5.751 (0.765) 3.673 (0.932) AF: atrial fibrillation; LA: left atrium; EF: emptying fractions; Δ: annual change; VImin: minimum indexed volume; CI: confidence interval; NRI: net reclassification improvement; IDI: integrative discrimination index #CHARGE-AF risk factors: age, race, height, weight, systolic and diastolic blood pressure, use of antihypertensive medication, smoking status, diabetes, MI and CHF by the second imaging. † Categories for NRI: <2.5%, 2.5%-5% and >5%. *Model calibration: Grønnesby and Borgan's modified Hosmer-Lemeshow chi-square statistic for survival analysis.

Kaplan-Meier curves of ΔTotal LAEF

Conclusion

In this multi-ethnic study population free of clinical cardiovascular disease at baseline, a greater increase in LA volumes and decrease in LA function were associated with incident AF. The addition of change in total LAEF to risk prediction models for AF improved model discrimination and reclassification of AF risk.

Acknowledgement/Funding

This research was supported by contracts HHSN2682015ehz745.01623I,N01-HC-95159-69 from the NHLBI and UL1-TR-ehz745.016240,UL1-TR-001079,R01-HL-127659 from NIH

T Cell Transcriptional Profiling and Immunophenotyping Uncover LAG3 as a Potential Significant Target of Immune Modulation in Multiple Myeloma

Autologous stem cell transplant (ASCT) is the standard of care for patients with multiple myeloma (MM). The clinical significance of peripheral blood T lymphocyte (PBTL) immunologic changes associated with ASCT is poorly understood. Here we evaluated T cell transcriptional messenger RNA profiles and immunophenotypes to correlate immunologic senescence, exhaustion, and anergy with clinical endpoints in a cohort of patients with MM undergoing ASCT. ASCT induced global transcriptional T cell changes and altered molecular levels of markers of T cell subtypes, T cell activation, and exhaustion. These included reduced CD4/CD8 ratio, skewing toward the Th1 subset, reduced expression of costimulatory receptors CD27 and CD28, heightened T cell activation, and increased expression of immune modulatory molecules LAG3 and PD1. Multicolor flow cytometry experiments confirmed altered circulating CD4 and CD8 subsets and skewing toward differentiated effector cells. Moreover, ASCT promoted an exhausted immunophenotype in CD3⁺CD4⁺ subsets and a senescent immunophenotype in CD3⁺CD8⁺ subsets. Subset-specific altered expression was also seen for surface molecules with immunomodulatory function. ASCT affected soluble levels of molecules with immunomodulatory function by increasing plasma HVEM and TIM3. High molecular LAG3 level was associated with inferior event-free survival post-ASCT (hazard ratio = 5.44; confidence interval, 1.92 to 15.46; P = .001; adjusted P [controlling for false discovery rate] = .038). Using a comprehensive evaluation of PBTLs on a molecular and phenotypic level, we have identified that ASCT induces global T cell alterations with CD4 and CD8 subset-specific changes. Moreover, LAG3 emerged as an early biomarker of adverse events post-ASCT. These findings will support the development of treatment strategies targeting immune defects in MM to augment or restore T cell responses.

Abstract P3-06-19: MUC17 and PCNX1 as mediators of chemotherapy response in breast cancer

Breast cancer is a heterogeneous disease and accumulating evidence suggests that treatment failure may be driven by intra-tumour heterogeneity (ITH). Utilising the current protocol for neoadjuvant (pre-surgery) chemotherapy (NAC) provides the opportunity to study molecular genetic changes between pre- and post-therapy by assessing pre-therapy biopsies and post-therapy surgical resections.

Whole exome sequencing was performed on matched pre- and post-treatment cancer cells from 6 patients with oestrogen receptor positive breast cancers that showed partial responses to the chemotherapeutic epirubicin. Data analysis was performed to determine differences in genetic aberrations between pre- and post-NAC, and in particular to identify evidence of consistent selection by therapy of aberrations that therefore may define chemotherapy resistance or sensitivity.

There were extensive differences in the range of genetic aberrations between pre- and post-NAC. 48 genes were identified for further study based on evidence of mutations conferring a selective advantage or disadvantage during chemotherapeutic response. The relevance of these was screened using siRNA knock-down and assessment of response to chemotherapeutic drug using cell viability assays in vitro. Two genes were taken forward. Potential loss-of-function mutations in the MUC17 gene were selected against during therapy in patients, and in accordance with this MUC17 knock-down was associated with increased sensitivity in vitro. Potential loss-of-function mutations in the PCNX1 gene were selected for during therapy in patients, and in accordance with this PCNX1 knock-down was associated with resistance. Further work was done to investigate mechanisms by which these genes modify cellular chemotherapy response, by examining drug loading and ABC transporter expression levels. Data indicate that both genes impact on drug loading, potentially through modulating ABC transporter activities. Using available transcriptomic datasets, expression of neither gene correlated with breast cancer outcomes in mixed cohorts that received a wide-range of therapies, however, analysis of correlations between protein expression and outcomes specifically after chemotherapy are on-going. We conclude that MUC17 and PCNX1 are potential markers of response to chemotherapy in breast cancer, and therapeutic modulation of their activities could enhance chemotherapy responses.

Citation Format: Al Amri W, Verghese E, Stead L, Hanby A, Sharma N, Hughes T. MUC17 and PCNX1 as mediators of chemotherapy response in breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-06-19.

Photocuring of 4-arm coumarin-functionalised monomers to form highly photoreversible crosslinked epoxy coatings

Highly photoreversible photocurable crosslinked epoxy coatings that can heal substantial surface damage were formed by the synthesis of unique monomers.

Crosstalks between mTORC1 and mTORC2 variagate cytokine signaling to control NK maturation and effector function

The metabolic checkpoint kinase mechanistic/mammalian target of rapamycin (mTOR) regulates natural killer (NK) cell development and function, but the exact underlying mechanisms remain unclear. Here, we show, via conditional deletion of Raptor (mTORC1) or Rictor (mTORC2), that mTORC1 and mTORC2 promote NK cell maturation in a cooperative and non-redundant manner, mainly by controlling the expression of Tbx21 and Eomes. Intriguingly, mTORC1 and mTORC2 regulate cytolytic function in an opposing way, exhibiting promoting and inhibitory effects on the anti-tumor ability and metabolism, respectively. mTORC1 sustains mTORC2 activity by maintaining CD122-mediated IL-15 signaling, whereas mTORC2 represses mTORC1-modulated NK cell effector functions by restraining STAT5-mediated SLC7A5 expression. These positive and negative crosstalks between mTORC1 and mTORC2 signaling thus variegate the magnitudes and kinetics of NK cell activation, and help define a paradigm for the modulation of NK maturation and effector functions.

The metabolic regulator protein family, mTOR, regulate natural killer (NK) cell development and function, but the underlying mechanism is unclear. Here, the authors show that Raptor/mTORC1 and Rictor/mTORC2 form a feedback crosstalk network to variegate cytokine and cellular signaling and modulate NK maturation and effector functions.

Human AML activates the aryl hydrocarbon receptor pathway to impair NK cell development and function

Acute myeloid leukemia (AML) can evade the mouse and human innate immune system by suppressing natural killer (NK) cell development and NK cell function. This is driven in part by the overexpression of microRNA (miR)-29b in the NK cells of AML patients, but how this occurs is unknown. In the current study, we demonstrate that the transcription factor aryl hydrocarbon receptor (AHR) directly regulates miR-29b expression. We show that human AML blasts activate the AHR pathway and induce miR-29b expression in NK cells, thereby impairing NK cell maturation and NK cell function, which can be reversed by treating NK cells with an AHR antagonist. Finally, we show that inhibition of constitutive AHR activation in AML blasts lowers their threshold for apoptosis and decreases their resistance to NK cell cytotoxicity. Together, these results identify the AHR pathway as a molecular mechanism by which AML impairs NK cell development and function. The results lay the groundwork in establishing AHR antagonists as potential therapeutic agents for clinical development in the treatment of AML.

Fratricide of NK Cells in Daratumumab Therapy for Multiple Myeloma Overcome by Ex Vivo-Expanded Autologous NK Cells

Purpose: Daratumumab and its use in combination with other agents is becoming a new standard of care for the treatment of multiple myeloma. We mechanistically studied how daratumumab acts on natural killer (NK) cells.Experimental Design: Quantities of NK cells in peripheral blood and/or bone marrow of patients with multiple myeloma or healthy donors were examined by flow cytometry. NK-cell apoptosis and the associated mechanism were assessed by flow cytometry and immunoblotting. Patients' NK cells were expanded in vitro using feeder cells. Combination treatment of daratumumab and expanded NK cells was performed using an MM.1S xenograft animal model.Results: CD38^-/low NK cells survived, whereas CD38⁺ NK cells were almost completely eliminated, in peripheral blood and bone marrow of daratumumab-treated multiple myeloma patients. NK-cell depletion occurred due to daratumumab-induced NK-cell fratricide via antibody-dependent cellular cytotoxicity. Consequently, CD38^-/low NK cells were more effective for eradicating multiple myeloma cells than were CD38⁺ NK cells in the presence of daratumumab. Blockade of CD38 with the F(ab)₂ fragments of daratumumab inhibited the antibody-mediated NK-cell fratricide. CD38^-/low NK cells displayed a significantly better potential for expansion than CD38⁺ NK cells, and the expanded NK cells derived from the former population were more cytotoxic than those derived from the latter against multiple myeloma cells. Therefore, infusion of ex vivo-expanded autologous NK cells from daratumumab-treated patients may improve the antibody therapy.Conclusions: We unravel a fratricide mechanism for daratumumab-mediated NK-cell depletion and provide a potential therapeutic strategy to overcome this side effect in daratumumab-treated patients with multiple myeloma. Clin Cancer Res; 24(16); 4006-17. ©2018 AACR.

Is the timed loaded standing test a valid measure of back muscle endurance in people with vertebral osteoporosis?

Timed loaded standing (TLS) is a suggested measure of back muscle endurance for people with vertebral osteoporosis. Surface electromyography revealed back muscles work harder and fatigue during TLS. The test end-point and total time were associated with back fatigue. The findings help demonstrate the concurrent validity of the TLS test.

INTRODUCTION

The TLS test is suggested as a measure of back muscle endurance for patients with vertebral osteoporosis. However, to date, no study has demonstrated that TLS does measure back extensor or erector spinae (ES) muscle endurance. We used surface electromyography (sEMG) to investigate the performance of the thoracic ES muscles during TLS.

METHODS

Thirty-six people with vertebral osteoporosis with a mean age of 71.6 (range 45-86) years participated. sEMG recordings were made of the ES at T3 and T12 bilaterally during quiet standing (QS) and TLS. The relative (%) change in sEMG amplitude between conditions was compared. Fatigue was evaluated by analysing the change in median frequency (MF) of the sEMG signal during TLS, and the correlation between maximal TLS time and rate of MF decline was examined.

RESULTS

Activity in the ES increased significantly during TLS at all electrode locations. During TLS, the MF declined at a mean rate of -24.2% per minute (95% C.I. -26.5 to -21.9%). The MF slope and test time were strongly correlated (r² = 0.71), and at test end, the final MF dropped to an average 89% (95% C.I. 85 to 93%) of initial MF. Twenty-eight participants (78%) reported fatigue was the main reason for stopping, and for eight (22%), it was pain.

CONCLUSIONS

This study demonstrates that TLS challenges the ES muscles in the thoracic region and results in ES fatigue. Endurance time and the point at which the TLS test ends are strongly related to ES fatigue.

FOXOs in cancer immunity: Knowns and unknowns

In the tumor microenvironment (TME), cancer cells, stromal cells, and immune cells, along with their extracellular factors, have profound effects on either promoting or repressing anti-cancer immunity. Accumulating evidence has shown the paradoxical intrinsic role of the Forkhead box O (FOXO) family of transcription factors in cancer, which can act as a tumor repressor while also maintaining cancer stem cells. FOXOs also regulate cancer immunity. FOXOs promote antitumor activity through negatively regulating the expression of immunosuppressive proteins, such as programmed death 1 ligand 1 (PD-L1), and vascular endothelial growth factor (VEGF) in tumor cells or stromal cells, which can shape an immunotolerant state in the TME. FOXOs also intrinsically control the anti-tumor immune response as well as the homeostasis and development of immune cells, including T cells, B cells, natural killer (NK) cells, macrophages, and dendritic cells. As a cancer repressor, reviving the activity of Foxo1 forces tumor-infiltrating activated regulatory T (T_reg) cells to egress from tumor tissues. As a promoter of cancer development, Foxo3 and Foxo1 negatively regulate cytotoxicity of both CD8⁺ T cells and NK cells against tumor cells. In this review, we focus on the complex role of FOXOs in regulating cancer immunity due to the various roles that they play in cancer cells, stromal cells, and immune cells. We also speculate on some possible additional roles of FOXOs in cancer immunity based on findings regarding FOXOs in non-cancer settings, such as infectious disease.

Improvement and tuning of the performance of light-healable polymers by variation of the monomer content

High-performing crosslinked epoxy coatings that possess room temperature self-healing ability by the use of a newly synthesised dynamic diamine crosslinker.

IL-18 Drives ILC3 Proliferation and Promotes IL-22 Production via NF-κB

Group 3 innate lymphoid cells (ILC3s) are important regulators of the immune system, maintaining homeostasis in the presence of commensal bacteria, but activating immune defenses in response to microbial pathogens. ILC3s are a robust source of IL-22, a cytokine critical for stimulating the antimicrobial response. We sought to identify cytokines that can promote proliferation and induce or maintain IL-22 production by ILC3s and determine a molecular mechanism for this process. We identified IL-18 as a cytokine that cooperates with an ILC3 survival factor, IL-15, to induce proliferation of human ILC3s, as well as induce and maintain IL-22 production. To determine a mechanism of action, we examined the NF-κB pathway, which is activated by IL-18 signaling. We found that the NF-κB complex signaling component, p65, binds to the proximal region of the IL22 promoter and promotes transcriptional activity. Finally, we observed that CD11c+ dendritic cells expressing IL-18 are found in close proximity to ILC3s in human tonsils in situ. Therefore, we identify a new mechanism by which human ILC3s proliferate and produce IL-22, and identify NF-κB as a potential therapeutic target to be considered in pathologic states characterized by overproduction of IL-18 and/or IL-22.

Prevalence of infraocclusion of primary molars determined using a new 2D image analysis methodology

BACKGROUND

The reported prevalence of infraocclusion varies widely, reflecting differences in definitions and measurement/scoring approaches. This study aimed to quantify the prevalence and extent of infraocclusion in singletons and twins during the late mixed dentition stage of dental development using a new diagnostic imaging method and objective criteria. The study also aimed to determine any associations between infraocclusion and gender, arch type, arch side and tooth type.

METHODS

Two samples were analysed, 1454 panoramic radiographs of singletons and 270 dental models of twins. Both samples ranged in age from 8 to 11 years. Adobe Photoshop CS5 was used to measure the extent of infraocclusion. Repeatability tests showed systematic and random errors were small.

RESULTS

The prevalence in the maxilla was low (<1%), whereas the prevalence in the mandible was 22% in the singleton sample and 32% in the twin sample. The primary mandibular first molar was affected more often than the second molar. There was no significant difference in the expression between genders or sides.

CONCLUSIONS

A new technique for measuring infraocclusion has been developed with high intra- and interoperator reproducibility. This method should enhance early diagnosis of tooth developmental abnormalities and treatment planning during the late mixed dentition stage of development.

Abstract 5663: A potential role for NKG2A to influence post-transplant outcomes in multiple myeloma

While there is currently no clear consensus regarding optimal maintenance therapy after autologous stem cell transplant (autoSCT), the early post-transplant setting is a potential site of augmentation to improve post-transplant outcomes. We previously characterized stem cell graft lymphocytes in association with progression free survival (PFS) after autoSCT in multiple myeloma (MM), and showed that there was an inverse correlation between NKG2A expression on CD56dim NK cells and PFS. Therefore, we aimed to investigate a potential role for NKG2A modulation, especially in the post-transplant setting with maintenance chemotherapy. We performed immunophenotypic analyses of NK cells from patients in the immediate post-transplant setting as well as from patients at various time points after transplant on lenalidomide maintenance therapy. In the immediate post-transplant setting (mean time since transplant=13 days) NKG2A was upregulated on NK cells when compared with KIR2DL1 (p=0.001) and KIR2DL2 (p=0.002). Additionally, in immunophenotypic analyses of PBMC from MM patients on various treatments, patients receiving lenalidomide maintenance therapy that recently underwent stem cell transplant (mean time since transplant=0.53 years) had elevated NKG2A expression compared to patients receiving no treatment (p=0.029). Conversely, patients receiving lenalidomide maintenance therapy over years (mean time since transplant=4.21 years) after transplant showed reduced NKG2A expression compared to patients receiving no treatment (p=0.0161). In bone marrow aspirates from patients with MM, primary CD138-positive myeloma cells in the bone marrow express HLA-E, the cognate antigen for NKG2A, which makes the overexpression of NKG2A biologically relevant. These data suggest that the NKG2A/HLA-E checkpoint axis may be more biologically relevant than KIR in myeloma, particularly in the post-transplant setting. This has important potential implications for treatment, as it demonstrates that NKG2A could serve as a potential target for modulation in the immediate post-transplant setting to improve survival, especially in the setting of maintenance chemotherapy. Further investigation should be aimed delineating the potential effect of NKG2A modulation on immune recovery and tumor surveillance to increase survival in the post-transplant setting.

Citation Format: Jennifer Cooperrider, Paul D. Ciarlariello, Tiffany Hughes, Nita Williams, Craig Hofmeister, Robert Baiocchi, Don M. Benson. A potential role for NKG2A to influence post-transplant outcomes in 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 5663. doi:10.1158/1538-7445.AM2017-5663

Prognostic factors for musculoskeletal injury identified through medical screening and training load monitoring in professional football (soccer): a systematic review

OBJECTIVES

To identify prognostic factors and models for spinal and lower extremity injuries in adult professional/elite football players from medical screening and training load monitoring processes.

METHODS

The MEDLINE, AMED, EMBASE, CINAHL Plus, SPORTDiscus electronic bibliographic databases and the Cochrane Database of Systematic Reviews were searched from inception to July 2016. Searches were limited to original research, published in peer reviewed journals of any language. The Quality in Prognostic Studies (QUIPS) tool was used for appraisal and the modified GRADE approach was used for synthesis. Prospective and retrospective cohort study designs of spinal and lower extremity injury incidence were found from populations of adult professional/elite football players, between 16 and 40 years. Non-football or mixed sports were excluded.

RESULTS

858 manuscripts were identified. Removing duplications left 551 studies, which were screened for eligibility by title and abstract. Of these, 531 studies were not eligible and were excluded. The full text of the remaining 20 studies were obtained; a further 10 studies were excluded. 10 studies were included for appraisal and analysis, for 3344 participants.

CONCLUSIONS

Due to the paucity and heterogeneity of the literature, and shortcomings in methodology and reporting, the evidence is of very low or low quality and therefore cannot be deemed robust enough to suggest conclusive prognostic factors for all lower limb musculoskeletal injury outcomes identified. No studies were identified that examined spinal injury outcomes or prognostic models.