Common variation in a long non-coding RNA gene modulates variation of circulating TGF-β2 levels in metastatic colorectal cancer patients (Alliance)

BACKGROUND

Herein, we report results from a genome-wide study conducted to identify protein quantitative trait loci (pQTL) for circulating angiogenic and inflammatory protein markers in patients with metastatic colorectal cancer (mCRC). The study was conducted using genotype, protein marker, and baseline clinical and demographic data from CALGB/SWOG 80405 (Alliance), a randomized phase III study designed to assess outcomes of adding VEGF or EGFR inhibitors to systemic chemotherapy in mCRC patients. Germline DNA derived from blood was genotyped on whole-genome array platforms. The abundance of protein markers was quantified using a multiplex enzyme-linked immunosorbent assay from plasma derived from peripheral venous blood collected at baseline. A robust rank-based method was used to assess the statistical significance of each variant and protein pair against a strict genome-wide level. A given pQTL was tested for validation in two external datasets of prostate (CALGB 90401) and pancreatic cancer (CALGB 80303) patients. Bioinformatics analyses were conducted to further establish biological bases for these findings.

RESULTS

The final analysis was carried out based on data from 540,021 common typed genetic variants and 23 protein markers from 869 genetically estimated European patients with mCRC. Correcting for multiple testing, the analysis discovered a novel cis-pQTL in LINC02869, a long non-coding RNA gene, for circulating TGF-β2 levels (rs11118119; AAF = 0.11; P-value < 1.4e-14). This finding was validated in a cohort of 538 prostate cancer patients from CALGB 90401 (AAF = 0.10, P-value < 3.3e-25). The analysis also validated a cis-pQTL we had previously reported for VEGF-A in advanced pancreatic cancer, and additionally identified trans-pQTLs for VEGF-R3, and cis-pQTLs for CD73.

CONCLUSIONS

This study has provided evidence of a novel cis germline genetic variant that regulates circulating TGF-β2 levels in plasma of patients with advanced mCRC and prostate cancer. Moreover, the validation of previously identified pQTLs for VEGF-A, CD73, and VEGF-R3, potentiates the validity of these associations.

Common variation in a long non-coding RNA gene modulates variation of circulating TGF-β2 levels in metastatic colorectal cancer patients (Alliance)

Background

Herein, we report results from a genome-wide study conducted to identify protein quantitative trait loci (pQTL) for circulating angiogenic and inflammatory protein markers in patients with metastatic colorectal cancer (mCRC).The study was conducted using genotype, protein marker, and baseline clinical and demographic data from CALGB/SWOG 80405 (Alliance), a randomized phase III study designed to assess outcomes of adding VEGF or EGFR inhibitors to systemic chemotherapy in mCRC patients. Germline DNA derived from blood was genotyped on whole-genome array platforms. The abundance of protein markers was quantified using a multiplex enzyme-linked immunosorbent assay from plasma derived from peripheral venous blood collected at baseline. A robust rank-based method was used to assess the statistical significance of each variant and protein pair against a strict genome-wide level. A given pQTL was tested for validation in two external datasets of prostate (CALGB 90401) and pancreatic cancer (CALGB 80303) patients. Bioinformatics analyses were conducted to further establish biological bases for these findings.

Results

The final analysis was carried out based on data from 540,021 common typed genetic variants and 23 protein markers from 869 genetically estimated European patients with mCRC. Correcting for multiple testing, the analysis discovered a novel cis-pQTL in LINC02869, a long non-coding RNA gene, for circulating TGF-β2 levels (rs11118119; AAF = 0.11; P-value < 1.4e-14). This finding was validated in a cohort of 538 prostate cancer patients from CALGB 90401 (AAF = 0.10, P-value < 3.3e-25). The analysis also validated a cis-pQTL we had previously reported for VEGF-A in advanced pancreatic cancer, and additionally identified trans-pQTLs for VEGF-R3, and cis-pQTLs for CD73.

Conclusions

This study has provided evidence of a novel cis germline genetic variant that regulates circulating TGF-β2 levels in plasma of patients with advanced mCRC and prostate cancer. Moreover, the validation of previously identified pQTLs for VEGF-A, CD73, and VEGF-R3, potentiates the validity of these associations.

Retrospective Review of the Factors Limiting Optune Initiation in GBM patients

PURPOSE/OBJECTIVE(S)

Tumor Treating Fields (TTFields) are a proven treatment that prolongs survival in Glioblastoma Multiforme (GBM) patients. The duration of usage of TTFields correlates with its effectiveness. This study aims to identify socioeconomic and clinical factors that prevent GBM patients at a single institution from starting and remaining on TTFields treatment.

MATERIALS/METHODS

This is a retrospective review from a single institution. Data were analyzed for each patient with a diagnosis of GBM that was seen in new patient consultation with a radiation oncologist. Data from 2015 to present were available. 178 patients were included in the study. Insurance status (private vs Medicare/Medicaid vs uninsured), zip code, expected income status, race, ethnicity, preferred primary language, work status, performance status (KPS) at time of diagnosis, and family support at home (Spouse vs Other) were analyzed. For those that initiated TTFields, we examined the duration of treatment, usage rates, patient reported tolerability, and reasons for discontinuation. Early termination of treatment was defined as treatment with TTFields for less than 3 months.

RESULTS

Of the 178 diagnosed GBM patients, 96 (54%) were offered TTFields and 48 (27%) agreed to treatment, with 46 actually starting. Of 89 Non-Hispanic patients, 53 were offered TTFields (60%) whereas of 73 Hispanic patients, 35 were offered TTFields (48%) (no statistically significant difference). The number one reason for refusing TTFields treatment was rapid deterioration (14/48 patients). The next most common reason was the patient feeling overwhelmed by managing or wearing the device (10/48) as well as the patient's decision to participate in any other clinical trial (10/48). The 3-month dropout rate for patients who received TTFields was 35% (17/48). 5 of the 17 stopped early due to skin rash or annoyance with the device. Patient's median income and insurance status did not predict whether they would start TTFields. 33 out of 109 (31%) patients with spousal support at home started treatment with TTFields compared to 13 of 69 (19%) of those without spousal support (p = .0895, Chi-Square test).

CONCLUSION

TTFields were offered to more patients each successive year, but many patients had no documented discussion offering TTFields, which may indicate room for improvement at our institution. Median income and insurance status did not play a role in patient access to TTFields, most likely due to Novocure sponsorship of un- or under-insured patients. Among those who declined treatment, 21% did so because of perceived difficulty managing the device. The strongest single trend predictive of successful initiation of TTFields is spousal support at home. Further interventions may focus on improving patient support at home, such as home health nursing visits or community support.

Myocarditis in Patients With Idiopathic Inflammatory Myopathies: Clinical Presentation and Outcomes

OBJECTIVE

To determine the clinical phenotype and outcomes of patients with idiopathic inflammatory myopathies (IIMs) and myocarditis.

METHODS

Using the Johns Hopkins Myositis Center Research Registry, we identified 31 adult patients with IIM-out of a total of 3082 with confirmed or suspected muscle disease-with an encounter code of myocarditis from 2004 to 2021. Of these, 14 adult patients with IIM were adjudicated to have clinical myocarditis. Information about demographics, autoantibodies, and clinical outcomes was retrospectively collected and analyzed.

RESULTS

Of 14 patients with IIM with clinical myocarditis, the median age at IIM diagnosis was 49 (IQR 35-56) years, and the median age at myocarditis diagnosis was 54 (IQR 36-61) years. The median duration between IIM diagnosis and myocarditis was 3 (IQR 2-9) years. The majority of patients were female (8/14, 57%) and Black (10/14, 71%). Antisynthetase syndrome was the most common IIM subtype (9/14, 64%). Anti-Jo1 (n = 4) and anti-PL12 (n = 3) were the most frequent autoantibodies. At myocarditis diagnosis, most patients (11/14, 79%) had active myositis, defined as elevated creatine kinase and/or muscle weakness; required hospitalization (13/14, 93%); and had reduced left ventricular ejection fraction (LVEF < 50%; 10/14, 71%). Despite intensification of immunosuppression, the 5-year overall survival rate from IIM diagnosis was 84%, and the 5-year overall survival rate from myocarditis diagnosis was 53%. Systolic dysfunction (LVEF < 40%) at final evaluation was observed in all expired patients (n = 6).

CONCLUSION

Clinical presentations of myocarditis in this select cohort of patients with IIM were severe and heterogeneous with poor outcomes despite intensification of immunosuppression, potentially reflecting late detection of myocarditis.

Defining Hearing Loss Severity Based on Pure Tone Audiometry and Self-Reported Perceived Hearing Difficulty, National Health and Nutrition Examination Survey

BACKGROUND

There is a well-known metric to describe average/normal vision, 20/20, but the same agreed upon standard does not exist for hearing. The pure tone average has been advocated for such a metric.

PURPOSE

We aimed to use a data driven approach to inform a universal metric for hearing status based on pure tone audiometry and perceived hearing difficulty (PHD).

RESEARCH DESIGN

Cross-sectional national representative survey of the civilian non-institutionalized population in the United States.

STUDY SAMPLE

Data from the 2011-2012 and 2015-2016 cycles of the National Health and Nutrition Examination Survey (NHANES) was used in our analysis. Of 9,444 participants aged 20-69 years old from the 2011-2012 and 2015-2016 cycles, we excluded those with missing self-reported hearing difficulty (n=8) and pure tone audiometry data (n=1,361). The main analysis sample, therefore, included 8,075 participants. We completed a sub-analysis limited to participants with "normal" hearing based on the WHO standard (pure tone average, PTA of 500, 1000, 2000, 4000 Hz < 20 dBHL).

ANALYSIS

Descriptive analyses to calculate means and proportions were used to describe characteristics of the analysis sample across PHD levels relative to PTA. Four PTAs were compared, low frequency (LF-PTA, 500, 1000, 2000 Hz), four frequency PTA (PTA4, 500, 1000, 2000, 4000 Hz), high frequency (HF-PTA, 4000, 6000, 8000 Hz) and all frequency (AF-PTA, 500, 1000, 2000, 4000, 6000, 8000 Hz). Differences between groups were tested using Rao-Scott χ2 tests for categorical variables and F tests for continuous variables. Logistic regression was used to plot receiver operating characteristic (ROC) curves with PHD as a function of PTA. The sensitivity and specificity for each PTA and PHD was also calculated.

RESULTS

We found that 19.61% of adults aged 20-69 years reported PHD, with only 1.41% reporting greater than moderate PHD. The prevalence of reported PHD increased with higher decibel hearing levels (dBHL) categories reaching statistical significance (p < 0.05 with Bonferroni correction) at 6-10 dBHL for PTAs limited to lower frequencies (LF-PTA and PTA4) and 16-20 dBHL when limited to higher frequencies (HF-PTA). The prevalence of greater than moderate PHD reached statistical significance at 21-30 dBHL when limited to lower frequencies (LF-PTA) and 41-55 dBHL when limited to higher frequencies (HF-PTA). Forty percent of the sample had high frequency loss with normal low frequency hearing, representing nearly 70% of hearing loss configurations. The diagnostic accuracy of the PTAs for reported PHD was poor to sufficient (< 0.70), however the HF-PTA had the highest sensitivity (0.81).

CONCLUSIONS

We provide three basic recommendations for clinical application based on our analysis. 1). A PTA based metric for hearing ability should include frequencies above 4000 Hz. 2). The data driven cutoff for any PHD/normal hearing is 15 dBHL. When considering greater than moderate PHD, the data driven cutoffs were more variable but estimated at 20-30 dBHL for LF-PTA, 30-35 for PTA4, 25-50 for AF-PTA, and 40-65 for HF-PTA. 3). Clinical recommendations and legislative agendas should include consideration beyond pure tone audiometry such as functional assessment of hearing and PHD.

Phase II Investigation of TVB-2640 (denifanstat) with Bevacizumab in Patients with First Relapse High-Grade Astrocytoma

PURPOSE

Glioblastoma (GBM) represents the most common primary brain tumor. Although anti-angiogenics are employed in the recurrent setting, they do not prolong survival. GBM is known to upregulate fatty acid synthase (FASN) to facilitate lipid biosynthesis. TVB-2640, a FASN inhibitor, impairs this activity.

PATIENTS AND METHODS

We conducted a prospective, single-center, open-label, unblinded, phase II study of TVB-2640 plus bevacizumab in patients with recurrent high-grade astrocytoma. Patients were randomized to TVB-2640 (100mg/m2 oral daily) plus bevacizumab (10mg/kg IV, D1 and D15) or bevacizumab monotherapy for cycle 1 only (28 days) for biomarker analysis. Thereafter, all patients received TVB-2640 plus bevacizumab until treatment-related toxicity or progressive disease. The primary endpoint was progression-free survival.

RESULTS

A total of 25 patients were enrolled. The most frequently reported AEs were palmar-plantar erythrodysesthesia, hypertension, mucositis, dry eye, fatigue and skin infection. Most were Grade 1 or 2 in intensity. The ORR for TVB-2640 plus bevacizumab was 56% (CR 17%, PR 39%). PFS6 for TVB-2640 plus bevacizumab was 31.4%. This represented a statistically significant improvement in PFS6 over historical bevacizumab monotherapy (BELOB 16%, p=0.008) and met the primary study endpoint. The observed OS6 was 68%, with survival not reaching significance by log rank test (p=0.56).

CONCLUSIONS

In this phase II study of relapsed high-grade astrocytoma, TVB-2640 was found to be a well-tolerated oral drug that could be safely combined with bevacizumab. The favorable safety profile and response signals support the initiation of a larger multicenter trial of TVB-2640 plus bevacizumab in astrocytoma.

Anti-MDA5-positive dermatomyositis and remission in a single referral centre population

OBJECTIVES

To describe a single-centre North American adult cohort of anti-MDA5-positive dermatomyositis patients, with emphasis on drug-free long-term remission.

METHODS

We conducted an observational retrospective cohort study of anti-MDA5-positive DM patients. All consented patients seen in the Johns Hopkins Myositis Centre from 2003-2020 with suspected muscle disease were routinely screened for myositis-specific autoantibodies. All sera were screened for anti-MDA5 autoantibodies by line blot; positives were verified by enzyme-linked immunoassay. Patients whose sera were anti-MDA5 positive by both assays (n=52) were followed longitudinally. If clinical status was unavailable, structured telephone interviews were conducted. Clinical remission was defined as being off all immunosuppression >1 year while remaining asymptomatic.

RESULTS

38/52 (73%) of the patients were women with a median age at disease-onset of 47 (IQR 40-54). Twenty-five of the patients (48%) were White, 16 (30%) were Black and 3 (6%) were Asian. Most patients (42/52, 80%) had interstitial lung disease, defined by inflammatory or fibrotic changes on high resolution computed tomography (HRCT). 18/52 (35%) of patients required pulse-dose methylprednisolone, 4/52 (8%) experienced spontaneous pneumothorax/pneumomediastinum, 6/52 (12%) required intubation, and 5/52 (10%) died. Over longitudinal follow-up (median 3.5 years), 9 (18%) patients achieved clinical remission. The median time from symptom onset to clinical remission was 4 years, and the median duration of sustained remission was 3.5 years (range 1.4-7.8). No demographic or disease characteristics were significantly associated with remission.

CONCLUSIONS

In this single centre, tertiary referral population of anti-MDA5-positive dermatomyositis, ~20% of patients experienced long-term drug-free remission after a median disease duration of 4 years. No clinical or biologic factors were associated with clinical remission.

Hypermetabolic lymphadenopathy following the administration of COVID-19 vaccine and immunotherapy in a lung cancer patient: a case report

BACKGROUND

Given the current climate of the pandemic, lung cancer patients are especially vulnerable to complications from severe acute respiratory syndrome coronavirus 2 infection. As a high-risk population group, these patients are strongly advised to receive coronavirus disease 2019 vaccination in accordance with Center for Disease Control and Prevention guidelines to minimize morbidity and mortality. In recent years, immunotherapy has taken a preeminent role in the treatment of non-small cell lung cancer with dramatic improvement in overall survival. Reactive lymphadenopathy following the administration of a coronavirus disease 2019 vaccination can confound the radiographic interpretation of positron emission tomography-computed tomography or computed tomography scans from lung cancer patients receiving immunotherapy.

CASE PRESENTATION

Here, we present a case of a 61-year-old Caucasian female and former smoker who developed cervical, hilar, supraclavicular, mediastinal, and left retroauricular lymphadenopathy following her coronavirus disease 2019 booster vaccination. At the time, she had been receiving long-term immunotherapy for the treatment of advanced lung adenocarcinoma. Biopsy was pursued owing to concerns of treatment failure and confirmed recurrent malignancy.

CONCLUSION

This case report highlights the importance of lymph node biopsies in lung cancer patients who present with contralateral lymphadenopathy following coronavirus disease 2019 vaccination to rule out tumor recurrence in this deserving patient population.

Screening for supportive care services in the neuro-oncology patient: A quality improvement project

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Background: On average, 80 to 85% of patients diagnosed with brain tumors qualify for supportive care under the American Society of Clinical Oncology (ASCO) recommendations. The National Comprehensive Cancer Network (NCCN) recommends routine screening, yet in our experience only 39% are screened in-clinic and 8.7% qualifying are referred. Evidence within the literature suggests consistent patient symptom screening and reflexive supportive care referral leads to improved quality of life and treatment plan adherence, and reduced symptom burden, healthcare costs, and less aggressive end-of-life care. This QI/IS project sought to improve quality of life through increased symptom screening via the Edmonton Symptom Assessment Scale (ESAS) and initiation of supportive care referral in Neuro-Oncology patients. Methods: Institutional Review Board (IRB) appraisal deemed this project non-regulatory research. A retrospective chart review assessed pre-implementation consistency of patients screened using the ESAS tool, the number indicating symptom burden and supportive care qualification, and if referral was placed. The Plan-Do-Study-Act (PDSA) Framework guided implementation and process evaluation. Interventions focused on improving ESAS use to identify patients who would benefit from supportive services and decreasing barriers to supportive care such as supportive care misinformation, screening burden, and documentation. From October 2021 to March 2022, data collection included the patient demographics ethnicity, age, diagnosis, and encounter date, as well as patient ESAS scores and supportive care referrals placed. Results: Over a five-month implementation period, 357 ESAS symptom burden tools were completed and documented out of 378 patient encounters in the neuro-oncology outpatient clinic. Clinic ESAS completion rates increased from 39.3% to 94.4%. Symptom burden qualifying for supportive care referral improved in 18% (N = 66), down from 31.2% (N = 102) of patients. Of patients qualifying, referrals increased from 4.9% (N = 5) to 10.7% (N = 7). Conclusions: Consistent use of a patient screening process led to an increase in the number of identified patients with significant symptom burden and referral for supportive care services, meeting all project goals. Initially, qualified rates increased with improved screening processes and clinic education, then steadily decreased to indicate better symptom control. This suggests a process capable of meeting the screening needs of oncology patients and minimal resource needs to maintain long-term sustainability. Future projects aimed at supportive care access and resource availability are recommended.[Table: see text]

Genomic Testing in Localized Prostate Cancer Can Identify Subsets of African Americans With Aggressive Disease

BACKGROUND

Personalized genomic classifiers have transformed the management of prostate cancer (PCa) by identifying the most aggressive subsets of PCa. Nevertheless, the performance of genomic classifiers to risk classify African American men is thus far lacking in a prospective setting.

METHODS

This is a prospective study of the Decipher genomic classifier for National Comprehensive Cancer Network low- and intermediate-risk PCa. Study-eligible non-African American men were matched to African American men. Diagnostic biopsy specimens were processed to estimate Decipher scores. Samples accrued in NCT02723734, a prospective study, were interrogated to determine the genomic risk of reclassification (GrR) between conventional clinical risk classifiers and the Decipher score.

RESULTS

The final analysis included a clinically balanced cohort of 226 patients with complete genomic information (113 African American men and 113 non-African American men). A higher proportion of African American men with National Comprehensive Cancer Network-classified low-risk (18.2%) and favorable intermediate-risk (37.8%) PCa had a higher Decipher score than non-African American men. Self-identified African American men were twice more likely than non-African American men to experience GrR (relative risk [RR] = 2.23, 95% confidence interval [CI] = 1.02 to 4.90; P = .04). In an ancestry-determined race model, we consistently validated a higher risk of reclassification in African American men (RR = 5.26, 95% CI = 1.66 to 16.63; P = .004). Race-stratified analysis of GrR vs non-GrR tumors also revealed molecular differences in these tumor subtypes.

CONCLUSIONS

Integration of genomic classifiers with clinically based risk classification can help identify the subset of African American men with localized PCa who harbor high genomic risk of early metastatic disease. It is vital to identify and appropriately risk stratify the subset of African American men with aggressive disease who may benefit from more targeted interventions.

Recognition of Culturally Diverse Cuisine in Popular Nutrition Apps

Objectives

Nutrition apps have been designed to assist users in determining the nutritional value of their food in alliance with their dietary restrictions and/or health. However, many of these apps do not incorporate or recognize the cuisine of the diverse communities that they serve. In this work we assessed several of the most popular free apps and compared with the most popular dishes in Latin America, Europe, India, East Asia, West Africa, and the American South to determine the rate of recognition of culturally diverse cuisines in popular nutrition apps.

Methods

We built a consensus database of over 150 culturally popular foods via a web scraper for foods from Latin American, Europe, India, East Asia, West Africa, and the American South. Researched & logged popular dishes from International cuisines with their corresponding nutritional data. Each food item was run against Calorie Mama, Lose It, My Fitness Pal and My Plate to determine the recognition and availability of the nutritional value.

Results

European and Indian dishes were better recognized (greater than 70%) across all apps than West African and Latin American dishes. Of the dishes that were recognizable, most were due to manual entry and lacked some of the nutritional information, making the apps less useful.

Conclusions

We note a bias among popular nutrition apps in not taking into account cuisines, from both international and regional American communities, leaving many communities underserved and contributing to health inequalities gap.

Funding Sources

N/A.

Cabozantinib in Combination With Atezolizumab for Advanced Renal Cell Carcinoma: Results From the COSMIC-021 Study

[Figure: see text].

Atraumatic forearm swelling in a patient with poorly controlled asthma

We present a case of sarcoidosis presenting as unilateral forearm swelling. A 65-year-old male with a long history of asthma presented with unexplained left forearm and hand swelling. Over many years, chest imaging had been devoid of adenopathy or parenchymal findings suspicious for sarcoid, until after the extremity findings emerged. The patient was diagnosed based on subcutaneous, dermal and mediastinal lymph node histopathology. Sarcoid presenting with isolated extremity findings prior to more typical pulmonary manifestations is rare even for cutaneous or soft tissue sarcoid, highlighting the need to maintain a high index of suspicion for sarcoidosis.

Prevalence of avascular necrosis in idiopathic inflammatory myositis: a single center experience

OBJECTIVES

To assess the prevalence of avascular necrosis (AVN) in a large cohort of patients with idiopathic inflammatory myopathies (IIM) and define the major associated risk factors.

METHODS

We retrospectively reviewed the electronic medical records of all patients with a definitive diagnosis of IIM enrolled in our registry between 2003-2017 and followed until 2020. Pertinent demographic, clinical, serologic and imaging data were collected. A matched group of patients without AVN was then selected for comparison.

RESULTS

1680 patients were diagnosed with IIM. Fifty-one patients developed AVN, with an overall prevalence of 3%. Musculoskeletal magnetic resonance imaging (MSK MRI) was available for 1085 patients and AVN was present in 46 patients (43 lower extremities and 3 upper extremities MRI studies), with a relative prevalence of 4.2%. Most patients with AVN were Caucasian females (57%) with a mean age at diagnosis of 44.5 ± 12.4 years. 61% had dermatomyositis (DM) and 29% had polymyositis (PM). The median time from onset of IIM to diagnosis of AVN was 46 months. The hip joint was most commonly involved in 76% of cases, followed by the knee joint in 15% and shoulder joint in 9%. 81% of patients were asymptomatic. Established risk factors for AVN were not found to be associated with the development of AVN in IIM patients.

CONCLUSION

Although mostly asymptomatic and incidental, the overall prevalence of AVN in IIM was 3% and the prevalence by MRI was 4.2%. None of the established risk factors were found to be associated with AVN development.

Patient-reported dermatomyositis and polymyositis flare symptoms are associated with disability, productivity loss, and health care resource use

BACKGROUND: Flare activity or worsening symptoms are not well defined for myositis. OBJECTIVES: To (a) characterize dermatomyositis (DM) and polymyositis (PM) flares from the patient perspective and (b) report the corresponding disability and rate of unplanned medical encounters. METHODS: Online survey data were collected from volunteer patients from The Myositis Association and Johns Hopkins Myositis Center. Flare frequency; Health Assessment Questionnaire Disability Index (HAQ-DI), HAQ-Pain Index, Work Productivity and Activity Impairment (WPAI) scales; emergency department/urgent care (ED/UC) visits; and hospital admissions during the past year were examined. RESULTS: 564 individuals with selfreported diagnoses of DM/PM were surveyed between December 2017 and May 2018. Recall of symptom flares was reported by 524 respondents (78.1% were female, mean age of 55 years). Among the respondents, 378 (72.1%) reported ≥ 1 flare in the past year. The pattern of flare frequency was similar for DM and PM respondents. The most common symptoms were muscle weakness (83%), extreme fatigue (78%), and muscle pain/discomfort (64%). Increasing flare frequency was associated with significantly (P < 0.01) greater mean HAQ-DI and HAQ-Pain scores, myositis-related ED/UC visits, hospital admissions, WPAI work productivity loss (among those employed), and WPAI nonwork activity impairment. CONCLUSIONS: DM/PM-related flares are common with exacerbations of muscle weakness and fatigue being the most common flare symptoms. Flare frequency was associated with greater disability, pain, work productivity loss, nonwork activity impairment, and increased ED/UC utilization. Higher frequency of patient-reported flares may serve as a marker of worsening physical functioning and intensifying health care needs and, therefore, suggests their importance in the clinical assessment of patients with DM/PM. DISCLOSURES: This study was supported by Mallinckrodt Pharmaceuticals (Bedminster, NJ) via grants to Vedanta Research and The Myositis Association. Christopher-Stine has received compensation from previous Mallinckrodt Advisory Board meetings, unrelated to this subject matter. Wan is an employee of Mallinckrodt Pharmaceuticals and is a stockholder of the company. Reed and Bostic received grant support from Mallinckrodt Pharmaceuticals for data collection and analysis. McGowan is an employee of The Myositis Foundation, which received grant funding to support study data collection. Kelly has no conflicts to disclose. This study was presented, in part or full, at the 2019 Annual American College of Rheumatology and Association of Rheumatology Professional Meeting (November 8-13, 2018; Atlanta, GA) and at the Third Global Conference on Myositis (March 27, 2019; Berlin, Germany).

Abstract PR09: Gene expression profiling in wild-type and mutant FGFR3 metastatic urothelial cancer treated with combination therapy with vofatamab and pembrolizumab

Background: FGFR3 mutations (mutFGFR3) are present in up to 20-35% of metastatic bladder (mUC) and upper tract urothelial cancer, respectively. Early data suggest that these tumors respond better to FGFR inhibition as compared with immunotherapy.

Methods: Patients who failed prior treatment for mUC were treated with vofatamab, an antibody targeting both wild-type (wtFGFR3) and mutFGFR3. Patients were treated with a loading dose of vofatamab 25 mg/kg with a biopsy pre- and post-treatment, followed by combination therapy with pembrolizumab to cohorts of patients with and without mutFGFR3. We performed gene expression profiling on paired biopsies from patients enrolled to date.

Results: We performed whole-transcriptome RNAseq on 17 matched tumors. The responses to the therapy were 7 partial responses (PR), 4 stable disease (SD), 5 progressed disease (PD), and 1 unknown. Surprisingly, we did not observe any relationships between FGFR3 mutation status and clinical response (ORR:1/3 mutant and 6/14 wild-type). Unsupervised cluster analysis of 17 matched tumors revealed the presence of two clusters: cluster 1 was enriched for responders (6 PR, 1 SD, and 1 PD), compared with cluster 2 (1 PD, 3 SD, and 4 PD). The significantly differentially expressed genes comparing cluster 1 and 2 were extracted and analyzed by Ingenuity Pathway Analysis (Sigma). Immune cell trafficking pathways, including migration of lymphocytes/T cells and phagocytes, were significantly upregulated in cluster 2 (p&lt;0.001). We then used BASE47 (47 gene signature for basal and luminal subtypes) to assign 17 paired tumors to the molecular subtypes. Of the responding tumors, 6 were luminal and 1 was basal. To further explore sensitivity/resistance mechanisms, the differentially expressed genes between pre- and post-treated PR tumors were extracted and were used to perform IPA analysis. Upstream regulators (CEBPA and RXRA) that control luminal biology were significantly activated after treatment (p&lt;0.001, Z score &gt;2).

Conclusions: Luminal biology may sensitize to combination of vofatamab with pembrolizumab regardless of presence of mutFGFR3, suggesting a role for this combination in wtFGFR3 mUC. Larger cohorts are needed to confirm these results.

This abstract is also being presented as Poster B25.

Citation Format: Woonyoung Choi, David McConkey, I-ling Lee, Graeme Currie, Steve Abella, William Kelly, Arlene Siefker-Radtke. Gene expression profiling in wild-type and mutant FGFR3 metastatic urothelial cancer treated with combination therapy with vofatamab and pembrolizumab [abstract]. In: Proceedings of the AACR Special Conference on Bladder Cancer: Transforming the Field; 2019 May 18-21; Denver, CO. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(15_Suppl):Abstract nr PR09.

Proceedings of the Comprehensive Oncology Network Evaluating Rare CNS Tumors (NCI-CONNECT) Adult Medulloblastoma Workshop

BACKGROUND

Medulloblastoma (MB) is a rare brain tumor occurring more frequently in children in whom research has been primarily focused. Treatment recommendations in adults are mainly based on retrospective data and pediatric experience; however, molecular features and treatment tolerance differ between the 2 age groups. In adults, prognostic tools are suboptimal, late recurrences are typical, and long-term sequelae remain understudied. Treatment has not adapted to molecular classification advances; thus, the survival rate of adult MB has not improved.

METHODS

In 2017, the National Cancer Institute (NCI) received support from the Cancer Moonshot℠ to address the challenges and unmet needs of adults with rare central nervous system tumors through NCI-CONNECT, a program that creates partnerships among patients, health care professionals, researchers, and advocacy organizations. On November 25, 2019, NCI-CONNECT convened leading clinicians and scientists in a workshop to review advances in research, share scientific insights, and discuss clinical challenges in adult MB.

RESULTS

Working groups identified unmet needs in clinical trial design, tissue acquisition and testing, tumor modeling, and measurement of clinical outcomes.

CONCLUSIONS

Participants identified opportunities for collaboration; discussed plans to create a working group of clinicians, researchers, and patient advocates; and developed specific action items to expedite progress in adult MB.

Real-world outcomes of underrepresented patient populations treated with immune checkpoint inhibitors (ICIs): African American descent, poor ECOG performance status, and chronic viral infections

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Background: ICIs have now become standard of care treatment for multiple malignancies. However, patients (pts) who are African American decent (AA), have a poor ECOG performance status (PS) or chronic viral infections [human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV)] were underrepresented in early clinical trials with ICIs and outcome data in these pt populations is not well reported. Methods: We performed a retrospective analysis of pts treated with ICIs (anti-PD(L)-1, anti-CTLA-4, or combination ICIs) across five MedStar Health hospitals from January 2011 to April 2018. Investigator-assessed best responses were noted. CTCAE v4.03 was used to capture immune-related adverse events (irAEs). Results: We identified 765 pts treated with 829 unique ICIs therapies across different malignancies. A total of 203 AA pts, 178 pts with a pre-treatment ECOG PS ≥2, 21pts with HIV, and 50 pts with HBV/HCV were noted. Any grade and grade ≥ 3 irAEs in the HIV cohort were 24% and 10% with an ORR of 29%. Any grade and grade ≥ 3 irAEs in HBV/HCV were 50% and 26% with an ORR of 21%. No viral reactivation or changes in pts anti-viral medications were noted during ICIs treatment. The ORR in AA pts was 35%. Any grade and grade ≥ 3 irAEs in the AA cohort were 27% and 8%, respectively. The ORR in pts with ECOG PS ≥2 was 14%. Any grade and grade ≥ 3 irAEs in this cohort were 20% and 4%. Similar trends were seen in the subset of patients with NSCLC treated with anti-PD(L)1 monotherapy (Table). Outcomes of NSCLC pts treated with anti-PD(L)-1 monotherapy. Conclusions: ICI therapy was not associated with any new safety signal in the above underrepresented populations. Prospective studies are needed to validate this data.[Table: see text]

Thymosin beta 4 induces significant changes in the plasma miRNA profile following severe traumatic brain injury in the rat lateral fluid percussion injury model

OBJECTIVES

Thymosin beta 4 (Tβ4) has demonstrated neuroprotective potential in models of neurlogical injury. The neuroprotective potential of Tβ4 has been associated with increased miR-200a and miR-200b within the brain following stroke. Here we tested the hypothesis that Tβ4 treatment could also alter miRNA profiles within the plasma following severe traumatic brain injury (TBI).

METHODS

We used the rat lateral fluid percusion injury model of severe TBI to test this hypothesis. Highly sensitive and quantitative droplet digital polymerase chain reaction (ddPCR) was used to measure the plasma concentrations of miR-200 family members. In addition, we conducted RNAseq analysis of plasma miRNA to further identify changes associated with TBI and treatment with Tβ4.

RESULTS

ddPCR demonstrated that miR-200a-3p andmiR-200b-3p were both significantly increased in plasma following treatment with Tβ4 after severe TBI. RNAseq analysis suggested that miR-300-3p and miR-598-3p increased while miR-450-3p and miR-194-5p significantly decreased following TBI. In contrast, miR-194-5p significantly increased in Tβ4 treated rats following TBI. In addition, we identified nine plasma miRNAs whose expression significantly changed following treatment with Tβ4.

CONCLUSIONS

Tβ4 treatment significantly increased plasma levels of miR-200a-3p and miR-200b-3p, while RNAseq analysis identified miR-194-5p as a candidate miRNA that may be critical for neuroprotection.

Convulsive seizures and EEG spikes after lateral fluid-percussion injury in the rat

The rat lateral fluid-percussion injury (FPI) model has been used extensively to study post-traumatic epilepsy (PTE). Epidemiological studies have reported that the risk of PTE is higher after more severe injury. Adult, male Wistar rats subjected to different atmospheric pressures of injury during FPI showed great variability in injury severity when functional behavior was determined based on the Neurological Severity Score (NSS) assessment. When NSS was used to select rats with the most severe FPI-induced brain injury, 63% of rats experienced at least one convulsive seizure 2-5 weeks after FPI. This same cohort of rats (i.e., selected for severe TBI based on NSS) were significantly more susceptible to PTZ-induced seizures compared to sham controls. Video/EEG recordings from a second cohort of rats with severe FPI-induced injury (based on NSS) showed a similar incidence and frequency of spike wave discharges between rats with severe TBI and sham controls. However, the rate of isolated EEG spikes was greater in rats with severe FPI-induced injury compared to sham controls. These data suggest that convulsive seizures can be obtained in FPI-treated rats when NSS is used as an inclusion criterion to select rats with severe injury. Furthermore, although spike-wave discharges were equally prevalent in rats with severe FPI and sham controls, spontaneous spikes were more prevalent in the rats with severe FPI.

Circulating microRNAs as biomarkers in traumatic brain injury

Preclinical and clinical studies can be greatly improved through the inclusion of diagnostic, prognostic, predictive or pharmacodynamics biomarkers. Circulating microRNAs (miRNAs) represent highly stable targets that respond to physiological and pathological changes. MicroRNA biomarkers can be detected by highly sensitive and absolutely quantitative methods currently available in most clinical laboratories. Here we review preclinical and clinical studies that have examined circulating miRNAs as potential diagnostic and prognostic biomarkers. We also present data that suggests pharmacodynamics biomarkers can be identified that are associated with neuroprotection in general. Although circulating miRNA can serve as useful tools, it is clear their expression profiles are highly sensitive to changing conditions and are influenced by a broad range of parameters including age, sex, body mass index, injury severity, time of collection, as well as methods of processing, purification and detection. Thus, considerable effort will be required to standardize methods and experimental design conditions before circulating miRNAs can prove useful in a heterologous injury like TBI. This article is part of the Special Issue entitled "Novel Treatments for Traumatic Brain Injury".

Sporulation capability and amylosome conservation among diverse human colonic and rumen isolates of the keystone starch-degrader Ruminococcus bromii

Ruminococcus bromii is a dominant member of the human colonic microbiota that plays a 'keystone' role in degrading dietary resistant starch. Recent evidence from one strain has uncovered a unique cell surface 'amylosome' complex that organizes starch-degrading enzymes. New genome analysis presented here reveals further features of this complex and shows remarkable conservation of amylosome components between human colonic strains from three different continents and a R. bromii strain from the rumen of Australian cattle. These R. bromii strains encode a narrow spectrum of carbohydrate active enzymes (CAZymes) that reflect extreme specialization in starch utilization. Starch hydrolysis products are taken up mainly as oligosaccharides, with only one strain able to grow on glucose. The human strains, but not the rumen strain, also possess transporters that allow growth on galactose and fructose. R. bromii strains possess a full complement of sporulation and spore germination genes and we demonstrate the ability to form spores that survive exposure to air. Spore formation is likely to be a critical factor in the ecology of this nutritionally highly specialized bacterium, which was previously regarded as 'non-sporing', helping to explain its widespread occurrence in the gut microbiota through the ability to transmit between hosts.

Ten Years of Chronic Cough in a 64-Year-Old Man With Multiple Pulmonary Nodules

A 64-year-old male former smoker with a history of prostate cancer presented to our pulmonary clinic, complaining of nonproductive cough for 10 years. Prior evaluation included treatment for upper airway cough syndrome and gastroesophageal reflux, stopping angiotensin-converting enzyme inhibitor, and initiation of inhaled β-agonists. Esophageal pH monitoring indicated silent reflux, and proton pump inhibitor therapy was started. He continued to cough and complain of dyspnea. Physical examination produced unremarkable results, with no evidence of lymphadenopathy. Pulmonary function tests showed a pseudo-restrictive pattern with air trapping, hyperreactivity, and incomplete bronchodilator responsiveness: FEV1, 2.48 L (69% of predicted); FVC, 3.57 L (75% of predicted); FEV1/FVC, 92%; total lung capacity, 7.00 L (100% of predicted); and residual volume, 3.05 L (136% of predicted). Laboratory studies, including a complete metabolic panel, prostate-specific antigen test, and complete blood count, yielded normal results.

An investigation of professionalism reflected by student comments on formative virtual patient encounters

BACKGROUND

This study explored the use of virtual patient generated data by investigating the association between students' unprofessional patient summary statements, which they entered during an on-line virtual patient case, and detection of their future unprofessional behavior.

METHOD

At the USUHS, students complete a number of virtual patient encounters, including a patient summary, to meet the clerkship requirements of Internal Medicine, Family Medicine, and Pediatrics. We reviewed the summary statements of 343 students who graduated in 2012 and 2013. Each statement was rated with regard to four features: Unprofessional, Professional, Equivocal (could be construed as unprofessional), and Unanswered (students did not enter a statement). We also combined Unprofessional and Equivocal into a new category to indicate a statement receiving either rating. We then examined the associations of students' scores on these categories (i.e. whether received a particular rating or not) and Expertise score and Professionalism score reflected by a post-graduate year one (PGY-1) program director (PD) evaluation form. The PD forms contained 58 Likert-scale items designed to measure the two constructs (Expertise and Professionalism).

RESULTS

The inter-rater reliability of statements coding was high (Cohen's Kappa = .97). The measure of receiving an Unprofessional or Equivocal rating was significantly correlated with lower Expertise score (r = -.19, P < .05) as well as lower Professionalism score (r = -.17, P < .05) during PGY-1.

CONCLUSION

Incident reports and review of routine student evaluations are what most schools rely on to identify the majority of professionalism lapses. Unprofessionalism reflected in student entries may provide additional markers foreshadowing subsequent unprofessional behavior.

Understanding and modeling retention of mammalian cells in fluidized bed centrifuges

Within the last decade, fully disposable centrifuge technologies, fluidized-bed centrifuges (FBC), have been introduced to the biologics industry. The FBC has found a niche in cell therapy where it is used to collect, concentrate, and then wash mammalian cell product while continuously discarding centrate. The goal of this research was to determine optimum FBC conditions for recovery of live cells, and to develop a mathematical model that can assist with process scaleup. Cell losses can occur during bed formation via flow channels within the bed. Experimental results with the kSep400 centrifuge indicate that, for a given volume processed: the bed height (a bed compactness indicator) is affected by RPM and flowrate, and dead cells are selectively removed during operation. To explain these results, two modeling approaches were used: (i) equating the centrifugal and inertial forces on the cells (i.e., a force balance model or FBM) and (ii) a two-phase computational fluid dynamics (CFD) model to predict liquid flow patterns and cell retention in the bowl. Both models predicted bed height vs. time reasonably well, though the CFD model proved more accurate. The flow patterns predicted by CFD indicate a Coriolis-driven flow that enhances uniformity of cells in the bed and may lead to cell losses in the outflow over time. The CFD-predicted loss of viable cells and selective removal of the dead cells generally agreed with experimental trends, but did over-predict dead cell loss by up to 3-fold for some of the conditions. © 2016 American Institute of Chemical Engineers Biotechnol. Prog., 32:1520-1530, 2016.

Health promotion and health education about diabetes mellitus

Diabetes mellitus, especially if poorly controlled, is a major contributory cause for blindness, heart attacks, amputations, strokes, kidney failure and impotence. The prevalence of diabetes is increasing globally. Fortunately there is compelling evidence from clinical trials that lifestyle modifications and education can minimise the risk of diabetes, and new treatments can reduce the burden of morbidity and mortality. We now have modified insulin, infusion pumps, dialysis, kidney and pancreas transplants, and effective therapies for reducing lipids and blood pressure.

However, important as these advances are, diabetes and its complications can be prevented, or delayed, by modifying risk factors. Persons with diabetes must understand their disease and be empowered to avoid obesity, smoking and unhealthy diets, and encouraged to exercise, and control blood glucose. Good health education, health promotion and access to professional care are essential for persons with diabetes mellitus. Valuable health information is available from Diabetes UK and the Internet.