Combination of mycological criteria: a better surrogate to identify COVID-19 associated pulmonary aspergillosis patients and evaluate prognosis?

Introduction: Diagnosis of COVID-19 associated pulmonary aspergillosis remains unclear especially in non-immunocompromised patients. The aim of this study was to evaluate seven mycological criteria and their combination in a large homogenous cohort of patients. Methods: All successive patients (n=176) hospitalized for COVID-19 requiring mechanical ventilation and who clinically worsened despite appropriate standard of care were included over a one-year period. Direct examination, culture, Aspergillus qPCR ( Af -qPCR) and galactomannan was performed on all respiratory samples (n=350). Serum galactomannan, ß-D-glucan and plasma Af -qPCR were also assessed. Criteria were analyzed alone or in combination in relation to mortality rate. Results: Mortality was significantly different in patients with 0, ≤2 and ≥3 positive criteria (logrank test, p=0.04) with death rate of 43.1, 58.1 and 76.4% respectively. Direct examination, plasma qPCR and serum galactomannan were associated with a 100% mortality rate. Bronchoalveolar lavage (BAL) galactomannan and positive respiratory sample culture were often found as isolated markers (28.1 and 34.1%) and poorly repeatable when a second sample was obtained. Aspergillus DNA was detected in 13.1% of samples (46/350) with significantly lower Cq when associated with at least one other criteria (30.2 vs 35.8) (p<0.001). Conclusion: Combination of markers and/or blood biomarkers and/or direct respiratory sample examination seems more likely to identify patients with CAPA. Af -qPCR may help identifying false positive results of BAL galactomannan testing and culture on respiratory samples while quantifying fungal burden accurately.

ECM–Receptor Regulatory Network and Its Prognostic Role in Colorectal Cancer

Interactions of the extracellular matrix (ECM) and cellular receptors constitute one of the crucial pathways involved in colorectal cancer progression and metastasis. With the use of bioinformatics analysis, we comprehensively evaluated the prognostic information concentrated in the genes from this pathway. First, we constructed a ECM–receptor regulatory network by integrating the transcription factor (TF) and 5’-isomiR interaction databases with mRNA/miRNA-seq data from The Cancer Genome Atlas Colon Adenocarcinoma (TCGA-COAD). Notably, one-third of interactions mediated by 5’-isomiRs was represented by noncanonical isomiRs (isomiRs, whose 5’-end sequence did not match with the canonical miRBase version). Then, exhaustive search-based feature selection was used to fit prognostic signatures composed of nodes from the network for overall survival prediction. Two reliable prognostic signatures were identified and validated on the independent The Cancer Genome Atlas Rectum Adenocarcinoma (TCGA-READ) cohort. The first signature was made up by six genes, directly involved in ECM–receptor interaction: AGRN, DAG1, FN1, ITGA5, THBS3, and TNC (concordance index 0.61, logrank test p = 0.0164, 3-years ROC AUC = 0.68). The second hybrid signature was composed of three regulators: hsa-miR-32-5p, NR1H2, and SNAI1 (concordance index 0.64, logrank test p = 0.0229, 3-years ROC AUC = 0.71). While hsa-miR-32-5p exclusively regulated ECM-related genes (COL1A2 and ITGA5), NR1H2 and SNAI1 also targeted other pathways (adhesion, cell cycle, and cell division). Concordant distributions of the respective risk scores across four stages of colorectal cancer and adjacent normal mucosa additionally confirmed reliability of the models.

Very long term outcome after linear versus electrogram guided ablation for persistent atrial fibrillation

The optimal ablation strategy for persistent atrial fibrillation (PsAF) remains to be defined. We sought to compare very long-term outcomes between linear ablation and electrogram (EGM)-guided ablation for PsAF. In a retrospective analysis, long-term arrhythmia-free survival compared between two propensity-score matched cohorts, one with pulmonary vein isolation (PVI) and linear ablation including roof/mitral isthmus line (LINE-group, n = 52) and one with PVI and EGM-guided ablation (EGM-group; n = 52). Overall, 99% of patients underwent successful PVI. Complete block following linear ablation was achieved for 94% of roof lines and 81% of mitral lines (both lines blocked in 75%). AF termination by EGM-guided ablation was accomplished in 40% of patients. Non-PV foci were targeted in 7 (13%) in the LINE-group and 5 (10%) patients in the EGM-group (p = 0.76). During 100 ± 28 months of follow-up, linear ablation was associated with superior arrhythmia-free survival after the initial and last procedure (1.8 ± 0.9 procedures) compared with EGM-group (Logrank test: p = 0.0001 and p = 0.045, respectively). In multivariable analysis, longer AF duration and EGM-guided ablation remained as independent predictors of atrial arrhythmia recurrence. Linear ablation might be a more effective complementary technique to PVI than EGM-guided ablation for PsAF ablation.

Modified Seldinger technique for neonatal epicutaneo-caval catheter insertion: A non-randomised retrospective study

Background: Epicutaneo-Caval Catheters (ECCs) are critical for good neonatal care. No previous studies have evaluated which insertion method provides the highest likelihood of success. Methods: This study aimed to compare the success rates and cost of modified Seldinger technique (MST) and split needle technique (SNT). MST was introduced to St Michael’s Neonatal Unit, SNT was already in use. Routinely documented data on ECC insertion was retrospectively collected from the clinical notes. Practitioners were able to use their preferred insertion method. A sub-group analysis of success rates in patients born at ⩾35-weeks GA was performed. Results: There was a significantly higher first pass (53% vs 26%; p = 0.014) and overall (72% vs 40%; p = 0.0046) successful ECC insertion rate with fewer venipunctures per successful ECC with MST (2.5 vs 6.5; p = 0.002). Logrank test demonstrated a significantly higher successful ECC insertion with MST for patients of all GA ( p = 0.003) and for neonates born at ⩾35 weeks ( p = 0.015). The cost per successful MST ECC was £156.41 versus £152.51 for SNT. Conclusion: In this uncontrolled retrospective study, there was a higher chance of successful ECC insertion with MST, with a reduced number of venipunctures and similar costs per successful ECC. Further work in randomised studies is needed to verify this finding and should focus on other clinical outcomes, including rates in central line associated blood stream infections.

The Alternative Splicing Landscape in Multiple Myeloma Is Determined By IGH Translocations and Mutations of RNA Processing Genes

Introduction: Alternative Splicing (AS) plays a key role in regulating numerous cellular processes in both normal and malignant cells. Previous studies have revealed mutations in the spliceosome complex, such as SF3B1, can cause increased AS frequencies in multiple myeloma (MM) patients, and patients with increased levels of AS are associated with a poor prognosis. Other frequently mutated genes involved in RNA processing include DIS3 and FAM46C, thus, systematically investigating other causes of AS abnormalities and pathologies in MM patients is highly necessary. Materials and Methods: RNA-seq data from 598 newly diagnosed MM patients from the MMRF CoMMpass study were utilized to generate AS comparisons. They were previously annotated for cytogenetic, copy number, and mutation data (version IA16). RNA-seq data were aligned to HG38 using STAR and Salmon. SUPPA2 was used for calling AS differences. For each identified AS event, the splicing level was defined by Percentage of Spliced-In (PSI) while the mean difference of splicing levels between two groups was measured by ΔPSI (dPSI) and by the P-value from independent T-tests against PSIs in the two groups. Filtering thresholds were determined to find high-quality differentially spliced events and were filtered for those also present in normal PCs (GSE110486). Geneset enrichment analysis was performed to identify dysregulated pathways caused by differential splicing and differential expression. Survival analysis was performed on clinical annotations of 598 NDMM patients while the Logrank test and Cox regression were used to evaluate the risk of AS and other genomic factors. Kaplan-Meier curves were plotted for various subgroups. Results: We compared 16 major cytogenetic subgroups, including Ig translocations (t(4;14), t(14;16), t(11;14)), hyperdiploidy, mutations in KRAS, NRAS, BRAF, FAM46C, SF3B1, DIS3 and TP53, combined events (t(4;14) plus DIS3 mutation), as well as those with biallelic abnormalities (DIS3, FAM46C, and TP53). Samples with SF3B1 hotspot mutations identified the greatest number of AS events (n=862), and samples with any SF3B1 mutation had approximately half as many. IGH translocations had an equivalent number of AS events to those with SF3B1 mutations, with t(14;16) having the most (n=587) followed by t(11;14) (n=366), and t(4;14) (n=256). We observed an increased number of significant AS events in bi-allelic DIS3 and FAM46C groups (n=404 and 171) compared to their mono-allelic abnormalities (n=114 and 35). As DIS3 mutations are enriched in the t(4;14) subgroup we also examined that interaction and found significantly more AS events (n=481; p&lt;0.01) in the combination compared to either event alone. As expected, KRAS, NRAS and BRAF mutations did not have enrichment for AS events (n=2, 15, 23, respectively). The majority of AS events were unique to each subgroup, exemplifying the AS heterogeneity in these subgroups. Among overlapped events, an alternative first (AF) exon in ACACA was consistently more spliced in t(14;16), t(11;14) and t(4;14) groups (dPSI=0.18, 0.10, 0.12, P=2x10 -5, 2x10 -9, 5x10 -5). ACACA encodes an enzyme that significantly affects MM cell growth and viability, suggesting that similar regulations exist in the three translocation groups. Unique events were also detected including an AF event in MIB2 (E3 Ubiquitin Protein Ligase 2) in the t(11;14) group (dPSI=0.17, P=7x10 -14), and a skipped exon in UBXN4 (related to ER stress) in t(14;16) group (dPSI=0.1, P=3x10 -4). AS heterogeneity also leads to functional heterogeneity in the three groups. Besides commonly downregulated RNA catabolic processes, cell adhesion, migration and mobility related pathways are enriched pathways in t(14;16); cell growth related pathways in t(11;14); and ERK related pathways in t(4;14). High-risk events were identified through survival analysis and included a retained intron in RPS16 in the t(14;16) (Hazard Ratio (HR)=18.81, p=0.004). Similarly, high risk was associated with an AF event in DDX39B in t(11;14) (HR=2.62, p=0.001) and an AF event in COPA in t(4;14) (HR=6.29, p=0.001). Conclusion: AS is defined by multiple genomic events, including primary translocations and mutations in RNA processing genes, DIS3 and FAM46C, and interactions between genomic markers can increase AS. AS events contribute to outcome and some high risk AS events may serve as prognostic marker or potentially novel targets. Disclosures Walker: Sanofi: Speakers Bureau; Bristol Myers Squibb: Research Funding.

BIOM-08. DNA METHYLATION-BASED SUBGROUPING PREDICTS SURVIVAL BENEFIT FROM LOMUSTINE/TEMOZOLOMID COMBINATION THERAPY IN MGMT PROMOTOR-METHYLATED GLIOBLASTOMA

BACKGROUND The CeTeG/NOA-09 trial showed that lomustine/temozolomide chemotherapy prolongs survival for newly diagnosed MGMT-methylated glioblastoma patients. Previous reports on temozolomide monotherapy suggested, that the survival benefit of temozolomide in MGMT-methylated tumors may be restricted to the RTK II methylation subgroup and absent in RTK I and MES subgroups. To identify patients with a particularly strong benefit from CCNU/TMZ, we explored the association of methylation subgroups with outcome after lomustine/temozolomide therapy. METHODS All patients from the CeTeG/NOA-09 trial with sufficiently available tumor tissue (n = 98) underwent 850K methylation array analysis of their tumor and methylation subgroup annotation (Heidelberg brain tumor methylation classifier v11b4; calibrated score &gt; 0.5 required). Overall survival (OS) was compared between a pooled cohort of tumors of the RTK I/MES subgroups and RTK II tumors. RESULTS In the CCNU/TMZ arm of CeTeG/NOA-09, OS was prolonged in RTK I/MES (n = 16; median not reached, 4-year OS 69%) as compared to RTK II patients (n = 14; median 20.6 months, 4-year OS 23%; p = 0.004 logrank test). In the standard temozolomide arm of CeTeG/NOA-09, OS tended to be shorter in RTK I/MES (n = 7; median 23.7 months, 4-year OS 17%) as compared to RTK II patients (n = 17; median 35.2 months; 4-year OS 38%, p = 0.15). CONCLUSION The CCNU/TMZ-dependent survival prolongation in patients with RTK I/MES tumors as opposed to RTK II seen in CeTeG/NOA-09 suggests that methylation-based subgrouping could be predictive for CCNU/TMZ efficacy in newly diagnosed MGMT-methylated glioblastoma.

CTNI-05. PRELIMINARY RESULTS OF THE NERATINIB ARM IN THE INDIVIDUALIZED SCREENING TRIAL OF INNOVATIVE GLIOBLASTOMA THERAPY (INSIGHT): A PHASE II PLATFORM TRIAL USING BAYESIAN ADAPTIVE RANDOMIZATION

BACKGROUND EGFR is amplified in over 50% of glioblastoma and 20-30% have EGFRvIII mutations. Neratinib is a potent inhibitor of EGFR/HER2 approved for metastatic HER2+ breast cancer. To efficiently evaluate the potential impact of neratinib on overall survival (OS) in newly-diagnosed glioblastoma and to simultaneously develop information regarding potential genomic biomarker associations, neratinib was included as an arm on the Individualized Screening Trial of Innovative Glioblastoma Therapy (INSIGhT) trial. INSIGhT is a phase II platform trial using response adaptive randomization and deep genomic profiling to more efficiently test experimental agents in MGMT unmethylated glioblastoma and accelerate identification of novel therapies for phase III testing. Initial randomization was equal between neratinib, control, and two other experimental arms but subsequent randomization was adapted based on efficacy as determined by progression-free survival (PFS). We report preliminary results for the neratinib arm. METHODS Patients with newly diagnosed MGMT-unmethylated glioblastoma were randomized to receive either radiotherapy with concomitant and adjuvant temozolomide or standard radiochemotherapy followed by adjuvant neratinib (240 mg daily). Treatment continued until progression or development of unacceptable toxicities. The primary endpoint was OS. Association between neratinib efficacy and EGFR amplification was also investigated. RESULTS There were 144 patients (70 control; 74 neratinib). Neratinib was reasonably well-tolerated with no new toxicity signals identified. PFS was compared (HR 0.84; p=0.38, logrank test – not significant) between the neratinib (median 6.05 months) and control (median 5.82 months) arms. For patients EGFR pathway activation the PFS HR was 0.53 (p-value=0.03 – significant, median PFS: neratinib, 6.21 months, control, 5.26 months). However, there was no significant improvement in OS in EGFR amplified/mutated patients (HR 1.05; p-value 0.87) between neratinib (median 14.2) compared to the control arm (median 14.6). CONCLUSION Neratinib prolonged PFS in the EGFR positive subpopulation but there was no overall PFS benefit, or any OS improvement.

On the statistical significance of communities from weighted graphs

Community detection is a fundamental procedure in the analysis of network data. Despite decades of research, there is still no consensus on the definition of a community. To analytically test the realness of a candidate community in weighted networks, we present a general formulation from a significance testing perspective. In this new formulation, the edge-weight is modeled as a censored observation due to the noisy characteristics of real networks. In particular, the edge-weights of missing links are incorporated as well, which are specified to be zeros based on the assumption that they are truncated or unobserved. Thereafter, the community significance assessment issue is formulated as a two-sample test problem on censored data. More precisely, the Logrank test is employed to conduct the significance testing on two sets of augmented edge-weights: internal weight set and external weight set. The presented approach is evaluated on both weighted networks and un-weighted networks. The experimental results show that our method can outperform prior widely used evaluation metrics on the task of individual community validation.

Modified CHA2DS2-VASc can predict mortality in COVID-19 patients admitted to the emergency department

Introduction CHA2DS2-VASc score is used to determine the thromboembolic risk, but its prognostic value has been demonstrated in several cardiovascular (CV) diseases. Except for female gender, many CV risk factors comprising this score are recognized as risk factors for mortality in COVID-19. Cetinak G. et al demonstrated the ability of modified CHA2DS2-VASc (M-CHA2DS2-VASc) to predict mortality in COVID-19, which is based on changing gender criteria from female to male. Purpose To evaluate the prognostic value of a M-CHA2DS2-VASc score to predict pulmonary embolism (PE) and mortality in pts with COVID-19 admitted at the emergency department (ED). Methods Retrospective study of pts admitted to the ED between June 2020-January 2021, who underwent computed tomography pulmonary angiography (CTPA) due to PE suspicion. Pts were stratified into 3 M-CHA2DS2-VASc risk groups: lower (0–1), intermediate (2–3) and high risk (≥4). Kruskal-Wallis and X-square test were used to compare score risk groups. Logistic regression was used to determine predictors of PE and mortality. ROC curve was performed to evaluate the discriminative power of the score. Results We included 300 pts: median age 71 years, 59% male. Hypertension (59%) chronic kidney disease (CKD, 33%), dyslipidemia (32%) and diabetes (28%) were the most common comorbidities. PE was diagnosed in 46 pts (15%). We found no difference in PE incidence according to M-CHA2DS2-VASc groups (p=0.531) and it showed no predictive value for PE (OR: 1.050, p=0.596). The AUC of M-CHA2DS2-VASc was 0.52, suggesting no discriminative power to predict PE. Regarding mortality, M-CHA2DS2-VASc score was higher in non-survivors COVID-19 pts than in survivors [4 (IQR 3–5) vs 2 (1–4), respectively, p&lt;0.001]. A multivariate logistic regression analysis was performed for mortality based on M-CHA2DS2-VASC, troponin, CKD and smoking history, and only M-CHA2DS2-VASc was identified as an independent predictor of mortality (OR: 1.406, p=0.007). Kaplan-Meier showed that M-CHA2DS2-VASc score was associated with mortality: the survival rate was 92%, 80% and 63% in the lower, intermediate and higher M-CHA2DS2VASc score risk group (logrank test p&lt;0.001; Fig. A). Most of the pts in the cohort were hospitalized (83%), but 21 pts (17%) discharged from the ED. Among these pts, 33% (n=17) had low risk, 37% (n=19) intermediate risk and 29% (n=15) high risk for mortality according to the M-CHA2DS2VASc score. The Kaplan-Meier individual survival analysis for hospitalized patients (Fig. B) and for those discharged from the ED (Fig. C) showed that M-CHA2DS2-VASc score had a good discriminative ability to predict short-term mortality for both groups (logrank test p&lt;0.001 and p=0.007, respectively). Conclusion Considering the lack of validated scores to predict mortality in COVID-19 pts, the M-CHA2DS2-VASc might be a simple tool to predict short-term mortality in these pts, irrespectively of the need for hospitalization or not. FUNDunding Acknowledgement Type of funding sources: None.

VHL Expression Level in the Pathological Tissue is Significantly Associated with Hematotoxicity of Platinum-based Chemotherapy in Non-Small Cell Lung Cancer Patients.

Objective To investigate the association between expression level of Von Hippel-Lindau(VHL) in pathological tissue and hematotoxicity of platinum-based chemotherapy in non-small cell lung cancer (NSCLC) patients. Methods The pathological samples of NSCLC patients were obtained for immunohistochemical staining to evaluate the expression level of VHL. Furthermore, their clinical data were collected and prognosis was traced by phone. The correlation between gene expression level and the hematotoxicity was evaluated by chi-square test. The influence of VHL expression level on the risk of hematotoxicity was tested by logistic regression model. The survival curve was plotted by Kaplan-Meier method and the survival rate between the two groups was compared by log-rank test. Results A total of 110 NSCLC patients were enrolled in this study, the median follow-up time of these patients was 27.5 months. In the whole group, 31 patients had died by the last date of follow-up to get their survival information (Nov.10,2020), with a median survival time of 24.3 months. Though immunohistochemical analysis,we found that 59 patients(53.6%) had weak expression level of VHL or lack of expression in their tumor tissues,while 51 patients(46.4%) presented moderate or high expression. We found that the patients with weak expression of VHL in their carcinoma tissue or lack of expression had more opportunities to occur neutropenia after platinum-based chemotherapy(OR=0.264,95%CI=0.085-0.818,P-value=0.021).And the expression level of VHL was correlated with OS(Logrank test: P-value= 0.007，HR= 4.219,95%CI: 1.75-10.174, P-value=0.001), while not related with DFS(Logrank test：P-value=0.256，HR= 1.334,95%CI:0.642-2.769, P-value=0.440). Conclusion The expression level of VHL gene in pathological tissue is related with granulocytopenia and leukocytotoxicity after platinum-based chemotherapy in NSCLC patients. It can be used as a biomarker to predict the risk of neutropenia and the prognosis of NSCLC patients.