Induction Phase Research Articles

Differentiation Syndrome Presenting as Acute Kidney Injury in a Patient of Acute Promyelocytic Leukemia on All-trans Retinoic Acid and Arsenic Trioxide Regimen: A Case Report

Introduction: Acute promyelocytic leukemia (APL), classified as Subtype M3 of acute myeloid leukemia, is known for its relatively favorable prognosis, primarily due to the high effectiveness of all-trans retinoic acid (ATRA) in treating the maturation block. However, it is essential to be aware of potential complications such as ATRA syndrome, which can affect 5%–25% of patients and manifest with symptoms such as fever, interstitial pulmonary infiltration, pleural/pericardial effusion, and acute renal failure. Methods: We present the case of a 47-year-old female with a history of hypertension, who experienced rash, fever, and reduced urine output during the induction phase with ATRA. Her serum creatinine levels exhibited a rapid increase from 2.63 mg/dL on October 07, 2022, to 7 mg/dL on October 18, 2022, despite having normal-sized kidneys and normal corticomedullary differentiation. A renal biopsy conducted on October 20, 2022, revealed features consistent with active tubulointerstitial nephritis, with direct immunofluorescence showing no significant glomerular immune deposits. A total of 17 hemodialysis sessions were performed. Results: A subsequent bone marrow examination conducted on October 26, 2022, demonstrated a hypercellular aspirate with normal morphology. However, due to the persistence of renal failure, a repeat biopsy was performed, revealing severe acute tubular injury. Pulse steroids were initiated, and ATRA was discontinued, resulting in an improvement in renal function. Conclusion: This case highlights an instance of acute, early, and severe differentiation syndrome (DS) occurring after induction therapy in a patient with APL. The DS in this case was particularly severe, leading to renal failure necessitating hemodialysis. The prompt initiation of pulse steroids and discontinuation of ATRA proved to be effective in managing this complication. Clinicians should remain vigilant for DS and its potential complications, including acute kidney injury and acute tubulointerstitial nephritis, when treating patients with APL.

Association between Serum Lactate Dehydrogenase Level and 30-day Mortality in Patients with Intracranial Hemorrhage with Acute Leukemia in the Induction Phase: A Cohort Study.

Objectives  This study aimed to identify the association between lactate dehydrogenase (LDH) levels and 30-day mortality in patients with intracranial hemorrhage (ICH) with acute leukemia during the induction phase. Methods  This cohort study included patients with acute leukemia with ICH during induction. We evaluated serum LDH levels upon admission. Multivariable Cox regression analyzed the LDH 30-day mortality association. Interaction and stratified analyses based on factors like age, sex, albumin, white blood cell count, hemoglobin level, and platelet count were conducted. Results  We selected 91 patients diagnosed with acute leukemia and ICH. The overall 30-day mortality rate was 61.5%, with 56 of the 91 patients succumbing. Among those with LDH levels ≥ 570 U/L, the mortality rate was 74.4% (32 out of 43), which was higher than the 50% mortality rate of the LDH < 570 U/L group (24 out of 48) ( p  = 0.017). In our multivariate regression models, the hazard ratios and their corresponding 95% confidence intervals for Log2 and twice the upper limit of normal LDH were 1.27 (1.01, 1.58) and 2.2 (1.05, 4.58), respectively. Interaction analysis revealed no significant interactive effect on the relationship between LDH levels and 30-day mortality. Conclusions  Serum LDH level was associated with 30-day mortality, especially in patients with LDH ≥ 570 U/L.

Ustekinumab or Vedolizumab after Failure of Anti-TNF Agents in Crohn’s Disease: A Review of Comparative Effectiveness Studies

Background: Anti-tumour necrosis factor (TNF) agents are effective in Crohn’s disease (CD), but some patients lose responsiveness and require alternative biologic therapy. Until recently, ustekinumab and vedolizumab were the only other biological agents approved for use in CD. There are no randomised trials which compare the efficacy of these two agents in patients with anti-TNF refractory disease, but several retrospective cohort studies have compared their effectiveness in this setting. Aim: To review the effectiveness of ustekinumab and vedolizumab in anti-TNF refractory patients with CD. Methods: We included studies that compared the effectiveness of ustekinumab and vedolizumab in treating patients with anti-TNF refractory CD. We recorded the sample size, primary and secondary outcome measures and whether the studies employed adjustments for appropriate confounders. Results: Fourteen studies were included with a total sample size of 5651, of whom 2181 (38.6%) were treated with vedolizumab and the rest were treated with ustekinumab (61.4%). Of the fourteen studies included, eight found ustekinumab to be more effective in achieving clinical remission/steroid-free remission in the induction phase or during maintenance therapy (at least 1-year post-treatment) or that treatment persistence rates with ustekinumab were higher than with vedolizumab. Only one study reported vedolizumab to be superior during the maintenance phase in terms of clinical remission or treatment persistence rates. Biochemical outcomes were reported in five studies, two of which showed superiority for ustekinumab at 14 weeks and the other at 52 weeks. Only two studies reported endoscopic and/or radiologic outcomes; of these, one study showed ustekinumab to be significantly better at achieving endoscopic and radiologic responses. Adverse outcomes were broadly comparable, barring a single study which reported a lower hospitalisation rate for severe infection with ustekinumab. Conclusions: Most studies found ustekinumab to be more effective or non-inferior to vedolizumab in treating patients with anti-TNF refractory CD. Although many studies adjusted appropriately for confounders, the possibility of residual confounding remains and further data from prospective studies are warranted to confirm these findings. Further studies are required to compare these two therapies to other emerging therapies, such as Janus-kinase inhibitors.

THE SIGNIFICANCE OF MINIMAL RESIDUAL DISEASE IN ACUTE LYMPHOBLASTIC LEUKAEMIA: A SINGLE CENTRE STUDY

In Acute lymphoblastic Leukemia (ALL) assessment of molecular response to treatment, assessing minimal residual disease (MRD) is a major independent predictor of treatment outcome. Consequently, MRD is implemented in all ALL-treatment protocols to fill up or to redefine stratification of multifactorial risk with optional intensity of customized treatment. Aim: to specify the significance of MRD in the assessment of remission in children with ALL with results discordant between morphology and flow cytometry at the end of induction phase of therapy. Materials and Methods: A descriptive cross-sectional study was conducted at Jin Oncology Center from March 2019 through November 2023. Data were taken out of the records of 58 patients who had ALL less than 16 years old. All patients were less than 16 years old and treated by ukall. They were diagnosed using peripheral blood morphology, bone marrow study and/or flow cytometry when lymphoblasts in peripheral blood or bone marrow aspirate are ≥20% and was confirmed by flow cytometry. On 29th day of induction therapy, bone marrow was examined for morphology and flow cytometry. The presence or absence of MRD was determined, and CD19, CD10 and tdt were tested. By morphologic assessment they were divided patients into: Category 1, C1 (&lt;5% blasts), Category 2, C2 (5-20% blasts), and Category 3, C3 (&gt;20% blasts). Statistical analysis was made using SPSS version 25. P value of less than 0.05 was considered significant. Results: The study involved 58 patients who had ALL. with a median age of 6.5 years, male to females ratio of 1.76:1, mean platelet count of 96.6 x 10⁹/L ,mean hemoglobin of 8.6 g/dL, mean leucocyte count of 74.3 x 10⁹/L), 48 cases (82.7%) of B-cell lineage and 10 cases (17.3%) of T-cell lineage, 94.6% of the B-cell cases were of the common B-ALL and the rest Pro-BALL type, 54.6% of the T-cell ALL was cortical T-ALL  and 44.4% Early T-cell ALL.  They were tested for MRD by morphology and flow cytometry on day 29. By morphology, 46 patients had remission but by flow only 24 cases. Seventeen cases had residual blasts &gt;5%. In 19 cases there was a discrepancy between the results of morphology and flow. Twenty-five cases (52.08% of B-cell cases) were positive for MRD by flow results. Eight of the ten cases of T-ALL (80%), were positive for MRD by flow cytometry. Among 48 cases of B-ALL, 36 were in C1 category (morphologically in remission), 11 cases were in C2 category and one case in the C3 category. Of cases in C1 category, 17 were MRD +ve and 19 were MRD –ve by flow cytometry. In the C2 category, only 2 out of the 11 cases (18.18%) had discordant results between morphology and flow results. The correlation between morphology and flow results was 100% in the C3 category. Conclusion: MRD should not be the surrogate of morphology but to be used in conjunction in order to give us a more accurate representation of status of remission.

Mathematical Model of a Nonlinear Power Transformer for Needs of Relay Protection

In this work, a mathematical model of a three-phase nonlinear transformer is suggested. The model enables simulating the transformer operation with allowance for its nonlinearity and covers needs of the relay protection. Our model has been developed on the basis of a mathematical model with phase coordinates, where differential equations are composed by the Kirchhoff’s phase-voltage law. Based on this model, we first compose a mathematical model for simulating steady-state operation modes of a transformer, taking into account the asymmetry and nonlinearity of its ferromagnetic core. In this model, the initial values of inductances and mutual inductances of loops are determined from the main phase inductance calculated by the experimentally found no-load current, and their current values are determined from the currents in windings and the magnetic fluxes in legs of the transformer core. The magnetic fluxes are calculated by the nodal-pair method. This improved mathematical model is verified through a comparison between the calculated harmonic components of the phase currents and the experimental results. The harmonic components are calculated with the use of Fourier expansion of the calculated phase currents. Their experimental values are determined with a spectrum analyzer. The calculated and experimental harmonic components of the currents of phase A during no-load and rated-load operation of the transformer are tabulated. The comparison of these results shows that the mathematical model of a three-phase transformer we suggest makes it possible to simulate currents in transformer windings under steady-state operation modes with accuracy acceptable for relay protection.

Etrolizumab as an induction and maintenance therapy for ulcerative colitis: A systematic review and meta‐analysis of randomized controlled trials

AbstractBackground and AimEtrolizumab is a gut‐targeted anti‐β7 integrin monoclonal antibody. However, the evidence of etrolizumab efficacy and safety in ulcerative colitis remains inconclusive. Therefore, we aim to evaluate the safety and efficacy of etrolizumab as an induction and maintenance therapy for active moderate to severe ulcerative colitis.MethodsWe synthesized randomized controlled studies (RCTs) from MEDLINE, Scopus, EMBASE, PubMed, Web of Science, and Cochrane Library until April 2023. The risk ratio (RR) for dichotomous outcomes with the corresponding 95% confidence interval (CI) was used. The study protocol was registered in PROSPERO with ID: CRD42023437040.ResultsFive RCTs with 1849 participants were included. The etrolizumab group had a significant clinical response (RR: 1.28 with 95% CI [1.08, 1.51], P = 0.005), clinical remission rates during the induction phase (RR: 2.47 with 95% CI [1.48, 4.11], P = 0.0005), compared with the placebo group in ulcerative colitis; however, there was no statistically significant difference between the two groups, regarding the corticosteroids‐free remission rate (RR: 1.92 with 95% CI [0.94, 3.92], P = 0.07). Moreover, endoscopic improvement, endoscopic remission, and histologic remission rates were observed more in the etrolizumab group during both the induction and maintenance phases. For safety outcomes, etrolizumab was significantly safer, but any adverse event was higher in the etrolizumab group than in the placebo.ConclusionEtrolizumab shows its effectiveness as both an induction and maintenance therapy for moderate or severe UC. The findings demonstrate its positive impact on clinical, endoscopic, and histologic remission rates. Regarding safety, other than any side effects, etrolizumab showed a good safety than a placebo.

Long-term dynamics of natural killer cells in response to SARS-CoV-2 vaccination: Persistently enhanced activity postvaccination.

Natural Killer (NK) cells play a significant role in the early defense against virus infections and cancer. Recent studies have demonstrated the involvement of NK cells in both the induction and effector phases of vaccine-induced immunity in various contexts. However, their role in shaping immune responses following SARS-CoV-2 vaccination remains poorly understood. To address this matter, we conducted a comprehensive analysis of NK cell phenotype and function in SARS-CoV-2 unexposed individuals who received the BNT162b2 vaccine. We employed a longitudinal study design and utilized a panel of 53 15-mer overlapping peptides covering the receptor binding domain (RBD) of the SARS-CoV-2 Spike protein to assess NK cell function at 0 and 20 days following the first vaccine, and 30 and 240 days following booster. Additionally, we evaluated the levels of total IgG anti-Spike antibodies and their potential neutralizing ability. Our findings revealed an increased NK cell activity upon re-exposure to RBD when combined with IL12 and IL18 several months after booster. Concurrently, we observed that the frequencies of NKG2A + NK cells declined over the course of the follow-up period, while NKG2C increased only in CMV positive subjects. The finding that NK cell functions are inducible 9 months after vaccination upon re-exposure to RBD and cytokines, sheds light on the role of NK cells in contributing to SARS-CoV-2 vaccine-induced immune protection and pave the way to further studies in the field.

Elderly Patients with Newly Diagnosed Multiple Myeloma: Continuous or Fixed Duration Treatment?

Multiple myeloma (MM) presents unique challenges in the elderly population due to increased frailty and comorbidities. Balancing treatment efficacy, safety, and quality of life is essential in managing elderly patients. While two-drug regimens were often favored for elderly patients, recent studies show promising outcomes with anti-CD38 antibody-based therapies, particularly daratumumab and lenalidomide with minimal dexamethasone. Continuous low-intensity treatments have shown improved progression-free survival and overall survival, with significant benefits observed in elderly patients. The DRd combination has now emerged as the standard of care for elderly MM patients, offering a favorable balance of efficacy, safety, and convenience. Ongoing trials are evaluating the addition of bortezomib in an induction phase for fit patients. New-generation immunotherapies hold promise for further refining treatment approaches, potentially leading to treatment discontinuation in select patient populations with sustained minimal residual disease negativity.

Smooth Low-Speed Sensorless Control of Switched Reluctance Machine With Heavy Load

For the switched reluctance machine (SRM) with heavy load, the inductance of the conduction phase is nonlinear, which makes the sensorless control method based on the linear region of the phase inductance no longer applicable. Meanwhile, in the case of light or no load, the estimated rotor position will abruptly change at the connection points between neighboring segments, which has an impact on the estimation of the speed. In this paper, a low-speed sensorless control method for the SRM with heavy load is proposed. The idle-phase inductance is modeled over a wide rotor position range for position estimation, and a proportional gain decreasing type second-order generalized integrator based on a frequency-locked loop (SOGI-FLL) is constructed to estimate the speed while performing rotor position filtering. The effectiveness of the proposed method is experimentally verified with a 3-phase 12/8-pole SRM prototype, and the results show that the estimated rotor position and speed are accurate and smooth, which is beneficial to performance improvement of the sensorless control.

Modified boost converter for renewable energy powered battery charger

In view of the tremendous electrification of transportation sector, development and management of an integrated charging unit has been under research focus for last few decades. Therefore, this paper deals with the development of an integrated battery charging unit in which a modified DC-DC boost converter has been proposed for electric vehicles (EVs). With a nominal number of components (one inductor, one capacitor, one diode, and three switches) in proposed converter, charging unit is suitable to charge the batteries in a wide voltage range. A simplified control scheme is also developed to regulate the output DC link voltage of proposed converter which is used to charge a connected battery during plug-in operation. Propulsion system is developed by using a three phase induction machine (as propulsion motor) of vehicle, which has been controlled by using indirect field-oriented scheme to ensure higher performance. Operation of the motor drive has been investigated during propulsion and regeneration operation. Complete system has been developed and investigated by using Matlab/Simulink.

Analisis Pengontrolan Water Treatment Bandara Djalaluddin Menggunakan Sistem Kerja Star Delta

In knowing how efficient the use of the Star Delta circuit is, the need for a circuit on a 3 Phase motor and how to apply the circuit to a 3 Phase water pump motor. The research was conducted at Gorontalo Djalaluddin Airport which is located in Isimu Sel, Tolotio, Tibawa District, Gorontalo Regency, Gorontalo, Indonesia. The research was carried out using data collection methods. An example of the application of a star delta circuit to a water pump motor. An electric motor is included in the category of dynamic electric machines and is an electromagnetic device that converts electrical energy into mechanical energy. Electric motors in the industrial world are often referred to as the industrial "work horse" because it is estimated that in an industry the average electricity consumption for electric motors is around 65-70% of the total electrical load in the industry. Three-phase electric motors have initial current characteristics that are 5 to 7 times the nominal current of the electric motor itself, but can be overcome by a star (Y) - triangle (Δ) starting system. The aim of this study was to examine how the triangular (Δ) star (Y) starting system works for 3 phase induction motors. The methods used include literature studies, collection of tools and materials, design, tool testing and data collection. From the results of testing the triangular (Y) star starting system (Δ) effectively suppresses the high starting current of the electric motor operation with the value of the measurement results of electric current using a star connection (Y) in the R phase of 0.6 A, the S phase of 0.8 A and the T phase of 0.6 A. And using a triangular relationship (Δ) in the R phase of 7.5 A, the S phase of 8.5 A and the T phase of 8.3 A.

[Cost per Responder Analysis of Filgotinib in Patients Suffering from Ulcerative Colitis]

OBJECTIVE: To evaluate the costs and benefits associated with the use of biologics and Janus kinase inhibitors (JAKi) for the treatment of bio-experienced patients suffering from ulcerative colitis in Italy.METHODS: This pharmacoeconomic analysis compared JAKi (filgotinib, tofacitinib and upadacitinib) and biologics (vedolizumab and ustekinumab). A decision tree model with a 1-year time horizon was built in MS Excel in order to estimate treatment cost and clinical efficacy expressed in terms of clinical response (CR), clinical remission (CRe) and mucosal healing (MH). Efficacy of each treatment was estimated using relative risks elaborated from a recent network meta-analysis of 17 RCTs. The investigated population concerned patients previously treated with biologic drugs (bio-experienced). Both induction and maintenance phases were considered and dose escalation (when allowed) was planned for patients not reaching an appropriate response after induction. Outcomes included total treatment cost (acquisition and administration), overall response rate, and cost per responder at one year.RESULTS: According to the model results, the treatment associated with the best clinical response at 1 year was vedolizumab (69.6%) followed by filgotinib (60.9%) and upadacitinib (60.1%). Despite differences in efficacy, filgotinib resulted in the lowest cost per responder, in every outcome, compared with all the other alternatives. The same trend applies when observing results at the end of the induction phase only. Results were robust to probabilistic sensitivity analyses, filgotinib has a posterior probability to be better than the other alternatives higher than 96% according to all the three response definitions (CR, CRe, and MH).CONCLUSIONS: Generally, JAKis and vedolizumab were associated with higher treatment response. Among the alternatives included in the analysis, filgotinib has the lowest cost per responder for all the outcomes included. These findings could help deliver more effective and efficient healthcare in the NHS. 

Comparative efficacy and safety of subcutaneous infliximab and vedolizumab in patients with Crohn’s disease and ulcerative colitis included in randomised controlled trials

BackgroundWhile indirect comparison of infliximab (IFX) and vedolizumab (VDZ) in adults with Crohn’s disease (CD) or ulcerative colitis (UC) shows that IFX has better effectiveness during induction, and comparable efficacy during maintenance treatment, comparative data specific to subcutaneous (SC) IFX (i.e., CT-P13 SC) versus VDZ are limited.AimPooled analysis of randomised studies to compare efficacy and safety with IFX SC and VDZ in moderate-to-severe inflammatory bowel disease.MethodsParallel-group, randomised studies evaluating IFX SC and VDZ in patients with moderate-to-severe CD or UC were identified. Eligible studies reported ≥ 1 prespecified outcome of interest at Week 6 (reflecting treatment during the induction phase) and/or at 1 year (Weeks 50-54; reflecting treatment during the maintenance phase). Prespecified efficacy and safety outcomes considered in this pooled analysis included the proportions of patients achieving disease-specific clinical responses, clinical remission, or discontinuing due to lack of efficacy, and the proportions of patients experiencing adverse events (AEs), serious AEs, infections, serious infections, or discontinuing due to AEs. Data from multiple studies or study arms were extracted and pooled using a random-effect model; comparative analyses were performed separately for patients with CD and UC.ResultsWe identified three eligible CD trials and four eligible UC trials that assigned over 1200 participants per disease cohort to either IFX SC or VDZ. In patients with CD, intravenous induction therapy with IFX demonstrated better efficacy (non-overlapping 95% confidence intervals [CIs]) compared with VDZ; during the maintenance phase, IFX SC showed numerically better efficacy (overlapping 95% CIs) than VDZ. A lower proportion of IFX SC-treated patients discontinued therapy due to lack of efficacy over 1 year. In patients with UC, efficacy profiles were similar with IFX SC and VDZ during the induction and maintenance phases, and a lower proportion of IFX SC-treated patients discontinued therapy due to lack of efficacy over 1 year. In both cohorts, safety profiles for IFX SC and VDZ were generally comparable during 1 year.ConclusionIFX SC demonstrated better efficacy than VDZ in patients with CD, and similar efficacy to VDZ in patients with UC; 1-year safety was comparable with IFX SC and VDZ.

Abstract 5186: Spatial single-cell deconvolution of the bone marrow microenvironment to define predictive biomarker for response to immunotherapy in patients treated with a check point inhibitor in smoldering multiple myeloma, phase II trial of nivolumab in combination with lenalidomide and low dose dexamethasone

Abstract Background:The immune system is critical for response and resistance in all cancer types and therapies. Patients with Smoldering Multiple Myeloma (SMM) have altered immune cell composition in the bone marrow (BM). However, little is known about the role of BM spatial immune profiling in patients treated with checkpoint inhibitors in MM. Methods: We performed spatial profiling with imaging mass cytometry of trephine biopsies of the BM (n=15; pre-treatment n=7 and post-treatment n=8) from patients with high-risk SMM enrolled in a phase II trial of nivolumab in combination with lenalidomide and low dose dexamethasone (NCT02903381). Patients received 6 cycles of induction therapy of nivolumab (240mg) at days 1 and 15, in combination with lenalidomide (25mg) at days 1-21 and dexamethasone at days 1, 8, and 15. The induction phase was followed by nivolumab (240mg) and lenalidomide (25mg) maintenance for another 6 cycles. A treatment cycle was defined as 28 consecutive days for a total of 12 months period. Event monitoring was performed up to 3 years. The primary efficacy outcome was progression-free survival 2 years after treatment. Results: Eight patients were enrolled on this study from January 2017 to June 2017. The study was put on hold due to the toxicity of checkpoint inhibitors observed in other trials of MM. The median age for all patients at enrolment was 60 years (range 49 to 81), with 5 males (62%) and 3 females (38%). All patients met criteria for high risk SMM disease. Median follow-up for all 8 patients was 38.7 months. Median overall survival was not reached; median progression-free survival was 33.8 months. Seven total patients had a response of Minimal Response (MR) or better, and 4 patients who initially responded eventually progressed. The total number of patients who were followed for at least two years and remained progression-free was 4 of 8 evaluable patients (50%; 90% CI: 19 - 81%).Spatial profiling with a panel of 37 markers on the pre-treatment samples allowed us to assess the states and abundances of multiple immune subpopulations, including rare regulatory NK cells. To assess the accuracy of our cell type annotation, we correlated the proportion of malignant plasma cells identified per patient with the value determined by pathologists for clinical diagnosis. These measures were significantly positively correlated (R=0.92, p&amp;lt;0.01). Spatial neighborhood analysis revealed statistically significant interactions enriched in the responders, even with our small sample size (t-test; p &amp;lt; 0.05). Conclusions and future directions: This pilot study suggests that BM spatial immune profiling before receiving immune check point inhibitors can be a biomarker for response in patients with SMM. Citation Format: Yoshinobu Konishi, Giuseppe Tarantino, Yiwen He, Romanos Sklavenitis-Pistofidis, Sujal I. Shah, Katherine Towle, Christian J. Cea-Curry, Oksana Zavidij, Ruben D. Carrasco, Scott J. Rodig, Jon C. Aster, David Liu, Gad Getz, Irene M. Ghobrial. Spatial single-cell deconvolution of the bone marrow microenvironment to define predictive biomarker for response to immunotherapy in patients treated with a check point inhibitor in smoldering multiple myeloma, phase II trial of nivolumab in combination with lenalidomide and low dose dexamethasone [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 5186.

Effect of proactive combination therapy with peritoneal dialysis and hemodialysis on technique survival and mortality.

Clinically relevant evidence for the timing of starting combination therapy with peritoneal dialysis and hemodialysis remains scarce. We retrospectively examined whether combination therapy during the induction phase of dialysis prolongs peritoneal dialysis duration. This retrospective study includes 160 patients who underwent combination therapy from 20 dialysis facilities. Four groups were categorized: combination at peritoneal dialysis induction (n = 12, Proactive combination group), and combination following peritoneal dialysis durations of < 2years (n = 65), 2-5years (n = 70), or > 5years (n = 13). Differences in technique survival of dialysis, mortality, and hospitalization due to cardiovascular events in the groups were observed. The Proactive combination group had the longer mean duration of combination therapy (3.18years) comparing to that of combination therapy following peritoneal dialysis (1.45years), but total peritoneal dialysis duration was shorter than in control groups (4.02years). Of the 160 cases in the entire cohort, there were 8 deaths, 18 ischemic heart disease hospitalizations, and 18 stroke hospitalizations. The Proactive group had lower crude mortality rate (0/12 cases, 0.0%) and crude hospitalization rate for ischemic heart disease (1/11, 8.3%) than the other groups. However, this cohort study did not have enough statistical power to adjust for patients' background, and we were unable to fully examine the differences in such clinical outcomes by the timing of initiation of combination therapy. Use of combination therapy in the induction phase might prolong the duration of combination therapy, but is not necessarily effective for prolonging peritoneal dialysis technique survival.

Abstract 2828: Combining neratinib with trastuzumab deruxtecan to treat HER2;TP53 co-mutated breast cancers

Abstract In metastatic breast cancer, HER2 activating mutations frequently co-occur with mutations in the TP53 gene and patients with these two co-occuring mutations have a lower response rate to neratinib. In order to address this clinical problem, we bred HER2 activating mutant transgenic mice with two different alleles of TP53. We used mice with the TP53 R172H mutation, which is the murine homolog of the human hotspot TP53 R175H mutation, and mice with TP53flox/flox allele, which mimics TP53 truncating mutations seen in human breast cancers. All three H53 genotypes (H53null, H53172/WT, and H53172/null) developed breast cancers faster than H mice, with H53172/null mice developing breast tumors the fastest, at just 6 weeks after adenoviral-Cre injection into the mammary fat pad. We developed organoids from these murine breast cancers and found that all H53 genotype organoids were less sensitive to neratinib compared to H, however, neratinib was able to synergize with trastuzumab deruxtecan (T-DXd), likely through neratinib mediated increased internalization of T-DXd. Prior literature studies suggest TP53 mutant cancer cells may have therapeutic vulnerabilities to the topoisomerase 1 (Top1) inhibitors. Organoids from all three H53 genotypes were sensitive to the Top1 inhibitor, exatecan. H53172/WT behaved like H organoids with G1 phase cell cycle arrest and induction of p21 expression after exatecan treatment. In contrast, H53null and H53172/null failed to induce p21 and arrested at late-S/G2 phase. Additional animal experiments with these H53 genotypes are in progress and results will be presented at the AACR Annual Meeting. Abbreviation Genotype Median tumor formation (weeks) Neratinib IC50 (nM) Neratinib +T-DXd H HER2V777L 28 10 Not determined H53null HER2V777L;TP53flox/flox 10 240 Synergy H53172/WT HER2V777L;TP53R172H/WT 11 100 Synergy H53172/null HER2V777L;TP53R172H/flox 6 150 Synergy Citation Format: Xiaoqing (Cathy) Cheng, Maureen Highkin, Jacob Hsia, Julie L. Prior, Ian S. Hagemann, Ron Bose. Combining neratinib with trastuzumab deruxtecan to treat HER2;TP53 co-mutated breast cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2828.

Abstract 5472: Direct cytotoxicity of hu14.18K.322A in high-risk neuroblastoma

Abstract Background: Neuroblastoma is a childhood cancer of the sympathetic nervous system and is associated with disialoganglioside GD2 overexpression. The main goal of this study is to investigate the involvement of GD2 targeting humanized antidisialoganglioside monoclonal antibody hu14.18K.322A (hu14) in high-risk neuroblastoma direct cell cytotoxicity, assess for synergy with induction chemotherapy agents, and delineate the mechanisms involved in cell death. Methods: For this study, we used a panel of GD2 expressing cell lines [SK-N-BE (2), SK-N-BE (1), LAN5, CHLA15] and a GD2 non-expressing cell line LAN6. We measured surface expression of GD2 and performed cell cycle analysis using flow cytometry. The role of hu14 in neuroblastoma cell death was assessed using cell viability assays, proliferation assays, real time PCR and western blot analysis. We measured synergy between hu14 and induction phase chemotherapy drugs. Further, we employed next generation sequencing (NGS) to analyze the transcriptomic changes in human neuroblastoma cell lines in response to hu14 treatment to understand the pathways involved and the molecular mechanisms of hu14-mediated cellular response. Results: Using a cell viability assay, we found that CHLA15 and SK-N-BE (1) cell lines were sensitive to hu14 treatment whereas SK-N-BE (2), LAN5, LAN6 were resistant. Hu14 treatment resulted in a dose dependent reduction in cell proliferation in these cell lines. We also found that hu14 treatment resulted in increased expression of apoptotic and autophagy pathway proteins, but not ferroptosis or necroptosis pathways proteins. Hu14 induced cell death was partially inhibited by a pan-caspase inhibitor, confirming that caspase-dependent pathways are involved. Western blot analysis also showed decreased levels of p53 phosphorylation in both sensitive cell lines upon hu14 treatment suggesting an important control mechanism centered on the p53 pathway. Hu14 treatment reduced the surface expression of GD2 in the sensitive cells suggesting direct inhibition of the GD2 synthesis pathway. However, PCR analysis of GD2 synthesis genes did not show any significant difference upon treatment suggesting posttranscriptional control of these genes. Furthermore, NGS analysis revealed alterations in several pathways, but these changes were distinct between the cell lines reconfirming the complexity of therapy response in high-risk Neuroblastoma. Conclusion: Taken together, our findings suggest that hu14.18K322A induces direct cell cytotoxicity in a subset of high-risk Neuroblastoma and synergizes well with standard chemotherapy drugs. Furthermore, our research highlights the complex nature of signaling pathways involved in hu14-mediated cytotoxicity that can be harnessed towards targeted therapy. Citation Format: Manu Gnanamony, Maria Thomas, Thu Hien Nguyen, Amber M. D'Souza, Pedro de Alarcon. Direct cytotoxicity of hu14.18K.322A in high-risk neuroblastoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 5472.

The Effect of Polymorphisms and Other Biomarkers on Infliximab Exposure in Paediatric Inflammatory Bowel Disease: Development of a Population Pharmacokinetic Model.

Therapeutic drug monitoring (TDM) of infliximab has been shown to be a effective strategy for inflammatory bowel disease (IBD). Population pharmacokinetic (PopPK) modeling can predict trough concentrations for individualized dosing. The aim of this study was to develop a PopPK model of infliximab in a paediatric population with IBD, assessing the effect of single nucleotide polymorphisms (SNPs) and other biomarkers on infliximab clearance. This observational and ambispective single-centre study was conducted in paediatric patients with IBD treated with infliximab between July 2016 and July 2022 in the Paediatric Gastroenterology Service of the Hospital Universitari Vall d'Hebron (HUVH) (Spain). Demographic, clinical, and analytical variables were collected. Twenty SNPs potentially associated with variations in the response to infliximab plasma concentrations were analysed. infliximab serum concentrations and antibodies to infliximab (ATI) were determined by ELISA. PopPK modelling was performed using nonlinear mixed-effects analysis (NONMEM). Thirty patients (21 males) were included. The median age (range) at the start of infliximab treatment was 13 years (16 months to 16 years). A total of 190 samples were obtained for model development (49 [25.8%] during the induction phase). The pharmacokinetics (PK) of infliximab were described using a two-compartment model. Weight, erythrocyte sedimentation rate (ESR), faecal calprotectin (FC), and the SNP rs1048610 (ADAM17) showed statistical significance for clearance (CL), and albumin for inter-compartmental clearance (Q). Estimates of CL1 (genotype 1-AA), CL2 (genotype 2-AG), CL3 (genotype 3-GG), Q, Vc, and Vp (central and peripheral distribution volumes) were 0.0066L/h/46.4kg, 0.0055L/h/46.4kg, 0.0081L/h/46.4kg, 0.0029L/h/46.4kg, 0.6750L/46.4kg, and 1.19L/46.4kg, respectively. The interindividual variability (IIV) estimates for clearance, Vc, and Vp were 19.33, 16.42, and 36.02%, respectively. A popPK model utilising weight, albumin, FC, ESR, and the SNP rs1048610 accurately predicted infliximab trough concentrations in children with IBD.

Attention to cryptococcal meningitis in patients with primary nephrotic syndrome

Madam, An important opportunistic pathogen called cryptococcus neoformans typically affects those who have compromised immune systems.1 AIDS-associated cryptococcal infections now account for 80 – 90% of all patients with cryptococcosis. Among HIV-negative patients with cryptococcal infection, studies indicated that 41 – 61% of these patients received immunosuppressive drugs, most had systemic lupus erythematosus and cancer, and only a few patients had primary nephrotic syndrome (PNS).2 In PNS patients, steroid or immunosuppressive medication results in immunologic dysfunction, which enhances the risk of infection. Cryptococcal meningitis (CM) is an unusual and frequently fatal complication in patients with PNS.3 Because the clinical features of CM are normally atypical and the diagnosis is usually neglected, the infection develops and neurological injury arises. Furthermore, limited information is available about the clinical characteristics of PNS with CM to date. Usual clinical features include nausea, vomiting, headache, meningeal irritation indications, and fever, the latter of which was the early and common sign of CM.4 The CM diagnosis were based on the extracting cryptococcus neoformans from the cerebrospinal fluid (CSF) or a positive India ink staining. The opportunistic fungus pathogen Cryptococcus neoformans or Cryptococcus gattii, with C. neoformans predominating worldwide, causes CM, an infection of the meninges. CM is typically an immune-compromised condition with high morbidity and death rates, especially in those patients with HIV. Without anti-fungal therapy, the mortality rate in CM patients was reported to exceed 100%, and even after taking widely available anti-fungal medications, it can still be relatively high (20–60%).5 Moreover, the widespread use of corticosteroids and other immunosuppressive medications, particularly broad-spectrum antibiotics, by medical practitioners has steadily raised concerns about the occurrence of CM in HIV-negative patients. Although immunosuppressive medications and corticosteroids are the primary treatment for PNS, these agents enhance immune system impairment. As a result, among those patients with PNS, infection is one of the most frequent complications, even CM and invasive fungal infections. There have been some case reports of CM in PNS patients from various countries, with China having the majority of these reports due to the country's high NS patient population.5 The induction, consolidation, and maintenance phases of CM treatment are designated in the updated Infectious Diseases Society of America recommendations published in 2010. For non-HIV and non-transplant patients, amphotericin B liposome plus 5-fluorocytosine is the optimum therapy option during the induction period.4 But during the treatment, these medications need to be cared for their side effects. ---Continue

Adjuvant Wilms’ tumour 1-specific dendritic cell immunotherapy complementing conventional therapy for paediatric patients with high-grade glioma and diffuse intrinsic pontine glioma: protocol of a monocentric phase I/II clinical trial in Belgium

IntroductionDiffuse intrinsic pontine glioma (DIPG) and paediatric high-grade glioma (pHGG) are aggressive glial tumours, for which conventional treatment modalities fall short. Dendritic cell (DC)-based immunotherapy is being investigated as a...