Quest Diagnostics Research Articles

Functional Consequence and Therapeutic Targeting of Cryptic ALK Fusions (ALK fus) in Monosomy7 AML

Monosomy 7 (Mono7) AML is one of the most established adverse prognostic markers in AML with over four decades of data on response and outcome in varied clinical trials. However, despite intensive and myeloablative therapies, outcome for this subtype of AML remains dismal with no meaningful advances in therapy in decades. As part of our recently completed discovery efforts in childhood AML (TARGET Pediatric AML; TpAML), we interrogated the transcriptome of 1068 children and young adults treated on COG AAML1031, including 28 cases of Mono7. We discovered novel cryptic fusions involving the Anaplastic Tyrosine Kinase (ALK) gene that were exclusively seen in 4 of 28 Mono7 patients (14.3%) and not detected in the remaining 1064 patients (p<0.001). These ALK fusions (ALK fus) included SPTBN1-ALK (n=3) or RANBP2-ALK (n=1) (figure 1A) and all 4 cases included the entire kinase domain of the ALK gene. Expression of ALK transcript was evaluated in Mono7 patients with and without ALK fus to determine whether these fusions lead to induction/upregulation of ALK. As demonstrated in figure 1B, the only patients with any ALK expression were those with ALK fus positive Mono7.Expression of the resultant onco-proteins of the ALK fus was confirmed by transfection of parental HEK293T cells with the oncofusion and western blot analysis of the protein lysates. As shown in the western blot in figure 1C, immunoblotting of the lysates from ALK fus cells with ALK antibody confirmed expression of the appropriate ALK+ fusion oncoprotein. Under experimental conditions, fusion involving SPTBN1-ALK appeared to generate higher levels of the fusion onco-protein compared to that of RANBP2-ALK fusion. Confirmation of the fusion onco-protein expression further validates the possibility of the functional significance and potential targetability of these fusions.The ALK gene codes for a receptor tyrosine kinase belonging to a family of protein kinases linked to unregulated cell growth which play a key role in CNS development. Alterations of the ALK gene are commonly seen in Non-Small Cell Lung Cancer (NSCLC), Anaplastic Large-Cell Lymphomas, and Neuroblastomas. We further inquired about the functionality of the ALK fus and whether they may confer cytokine-independent proliferation. The ALK fus were cloned from patient samples into pCSII, a direct GFP-tagged lentiviral backbone under the Ef1α promoter; followed by Sanger sequencing to verify the insert. IL-3 dependent Ba/F3 cells were transduced with the GFP tagged lentiviral vectors containing the SPTBN1-ALK or RANBP2-ALK fusion transcripts.Transduced cells were sorted to GFP homogeneity and growth parameters evaluated post-IL-3 withdrawal. In contrast to the parental line, which rapidly died in the absence of cytokines, cells expressing either SPTBN1-ALK or RANBP2-ALK sustained growth and rapidly proliferated in cytokine-free media, suggesting a conferred transformation event by the fusions, figure 1D. SPTBN1-ALK fusion appears to show more transforming potential with more rapid cytokine-free proliferation compared to that of RANBP2-ALK fusion. The observed differential growth pattern with the two ALK fus correlates with the differential expression of the two oncoproteins as presented above.We then sought to evaluate the efficacy of Crizotinib as a potential therapy for aberrant ALK fus positive Mono7 AML. Crizotinib has been FDA-approved and demonstrated efficacy in treating ALK positive NSCLC. ALK fus -positive cells were treated with varying doses of Crizotinib in cytokine-free media and cell viability and cell death were determined with the Promega Cell Titer Glow assay after 48 hours in culture. Fusion positive cells show sensitivity to Crizotinib with IC50s of 144nM and 95nM for the SPTBN1-ALK or RANBP2-ALK fusions, respectively.Here we demonstrate experimental data that when newly discovered cryptic ALK fus in Mono7 AML are functional (translation to fusion onco-protein, conferring cytokine independence) and show susceptibility to the ALK inhibitor crizotinib. This data may support effective therapeutic targeting of a subset of this highly refractory AML. [Display omitted] DisclosuresHylkema: Quest Diagnostics Inc: Current equity holder in publicly-traded company; Moderna: Current equity holder in publicly-traded company. OffLabel Disclosure:Crizotinib is a first-generation ALK inhibitor that is FDA-approved for the treatment of Non-Small Cell Lung Cancer, Anaplastic Lymphoma, and Neuroblastoma.

S3639 Two’s a Crowd: Case Report of Hepatitis C Genotype Mixed Pattern

Introduction: We present a clinical case of an unusual laboratory abnormality, mixed pattern Hepatitis C genotype. The incidence of “mixed genotype HCV infections has been assessed across numerous geographical regions with estimates between 1.2% and 25.3% reported” (McNaughton et al, 2017, p. 524). This case highlights the importance of accurate identification of HCV genotype, subtype,and resistance-associated substitutions. Case Description/Methods: A 30-year-old male presented with a chief complaint of postprandial nausea/vomiting occurring daily for 3 weeks as well as episodes of heartburn and unintentional weight loss. He had a past history of substance abuse: intranasal and IV drug use of both heroin and cocaine. He tested positive for hepatitis C. There was remote use of alcohol (Cessation of use > 1 year),as well as a history of bipolar/depression, suicidal ideations, and self-mutilation. On physical examination BMI was 30.6. There were multiple body piercings. The liver was not palpable. Laboratory: Hepatitis C genotype-1B/3(method used: RT-PCR and reverse hybridization of the 5' UTR and core region of the HCV genome performed by Quest Diagnostics).Viral load-199,000 , Alk. Phos-86, AST-75, ALT-186, Tbil-0.5, PLT-238,000. Negative for HIV. Urine toxicology-positive for benzodiazepine& cocaine. Ultrasound elastography revealed F1 fibrosis. He was lost to care due to incarceration. Discussion: This case report highlights the unusual existence of mixed HCV genotype and the importance of accurate determination of viral genotypes and subtypes for determination of treatment with DAA. In this situation there tends to be a major and a minor genotype presumably because one is more replicatively fit. This may make selection of the appropriate DAA difficult and may explain some treatment failures.

Population Mental Health during the COVID-19 Pandemic: Experiences from a Drive-thru Testing Center

International Journal of Medicine and Public Health,2021,11,3,168-169.DOI:10.5530/ijmedph.2021.3.31Published:August 2021Type:Letter to the EditorPopulation Mental Health during the COVID-19 Pandemic: Experiences from a Drive-thru Testing CenterKenneth Andrew Hoekstra Kenneth A Hoekstra Quest Diagnostics, C/o Peace Health United General Medical Center, Sedro- Wooley, WA, USA. Abstract:Aim/Background: Public health has a unique opportunity to connect with the psychology of the population during the COVID-19 pandemic. Materials and Methods: Beginning May 2020 and ending March 12, 2021, the Skagit County Health Department provided a drivethru COVID-19 testing center during the weekdays for community members and healthcare workers. Test results were typically returned in 1-3 days. Results: The drive-thru COVID-19 testing model provided the healthcare worker the opportunity to consult with individuals presenting for COVID-19 testing. Public health listened closely, answered the public’s questions and provided additional healthcare information when needed and requested. Conclusion: Throughout the COVID-19 pandemic, COVID-19 drive-thru testing centers have emerged world-wide. For healthcare and public health workers, these centers have allowed for additional conversation on topics related to community mental health. Keywords:COVID-19, Drive-thru, Psychological, Stress, TestingView:PDF (70.52 KB)

Retrospective Performance Analyses of over Two Million U.S. QuantiFERON Blood Sample Results.

ABSTRACTBoth the QuantiFERON-TB Gold Plus (QFT-Plus) and the QuantiFERON-TB Gold In-Tube (QFT-GIT) tests are interferon gamma (IFN-γ) release assays (IGRAs) intended to detect in vitro cell-mediated immune responses to Mycobacterium tuberculosis antigens. In this study, we retrospectively analyzed performance data for both the QFT-GIT and QFT-Plus test systems from over 2 million samples. QFT-Plus and QFT-GIT testing was performed as specified in the respective package inserts at 23 Quest Diagnostics sites. Blood specimens were collected from individuals in all 50 states from November 2018 through December 2019. Retrospective analyses compared the proportion of positive, indeterminate, and conversion/reversion results. The overall proportion of QFT-positive results was 7% for both the QFT-Plus and QFT-GIT. The proportion of positive results was highest for QFT-GIT (7.5%) followed by the heparin 1-tube QFT-Plus (7.2%); a lower proportion of positives was observed with the 4-tube (all four QFT tubes were used in blood collection) QFT-Plus (6.0%). The proportions of indeterminate results for the 1-tube (heparin-only tube collection) and 4-tube QFT-Plus methods were less than 1% and 4%, respectively. This study indicates a higher proportion of positive results for M. tuberculosis than data from other studies. Additionally, the proportion of indeterminate QFT results were markedly lower when the sample was transported in one lithium-heparin tube instead of direct inoculation into 4 QFT-Plus tubes at the site of blood collection.IMPORTANCE In this study, we retrospectively analyzed results from both the QFT-GIT and QFT-Plus test systems from over 2 million blood specimens. The variables analyzed were (i) QFT positivity rates among various U.S. populations, (ii) indeterminate rates among various types of blood draws and how often an indeterminate result was resolved within 30 days after the initial draw, and (iii) the association of TB1 and TB2 antigen tubes with IGRA reversion and conversion events from serial QFT testing. This is, to our knowledge, the largest QFT study representing patients from an extensive geographic coverage across the United States and U.S. territories.

Carfilzomib-Based Combination Regimens Are Highly Effective Frontline Therapies for Multiple Myeloma and Waldenström's Macroglobulinemia

Introduction:Multiple myeloma (MM) and Waldenström's macroglobulinemia (WM) are related plasma cell disorders that respond to treatment with proteasome inhibitors. Several early phase studies have shown that carfilzomib (Cz) is highly effective as the initial treatment of MM and results in deep remissions in most patients. A randomized phase III study is evaluating the efficacy of Cz or bortezomib with lenalidomide and dexamethasone as frontline therapy in MM and could lead to changes in the treatment of choice (NCT01863550). A clinical trial also showed good tolerance and efficacy of Cz in the frontline treatment of WM. In this study we aim to report the efficacy and safety of frontline Cz-based combinations in MM and WM in a standard of care setting.Methods:In this retrospective, single center study, we queried our ambulatory and inpatient (IPATC) database to identify subjects who were diagnosed with MM or WM and received Cz as initial therapy from 4/1/2014 to 11/30/2016. Investigational Cz was excluded. We identified 54 patients with MM (including one with concurrent lambda AL amyloidosis) and 6 patients with WM. Responses were assessed based on guidelines published by the International Myeloma Working Group (Kumar et al. Lancet 2016) and the VI international workshop on WM (Owen et al. BJH 2013). The Kaplan-Meier method was used to estimate time-to-event endpoints including progression free survival (PFS). Statistical software SAS 9.3 (SAS, Cary, NC) and S-Plus 8.2 (TIBCO Software Inc., Palo Alto, CA) were used for all the analyses.Results:All MM patients were treated with either KRd (Cz, lenalidomide, dexamethasone) (n=52, 96%) or KCd (Cz, cyclophosphamide and dexamethasone) (n=2, 4%). Median age at diagnosis was 66 years (range 60-70 years). Revised International Staging System (R-ISS) stage I, II or III was present in 20 (37%), 28 (52%) and 6 (11%) patients, respectively. Patients presented with either CRAB criteria (n=48, 89%) or biomarkers of malignancy (n=4, 7%) and 22% had extramedullary disease. Gene expression profiling-70 (GEP-70, Quest Diagnostics) was available for 25 patients (Table 1a). Patients with both high-risk GEP and FISH had early relapse (Table 1b). The maximum doses of Cz used were 36 mg/m2 (n=44), 27 mg/m2 (n=6) and not available (n=4). After a median of 3 cycles, eligible patients underwent autologous stem cell transplant (ASCT) (n= 36, 77%). Fifty-two patients were evaluable for response. After a median of 3 cycles of initial treatment, overall response (ORR) was 98% [complete remission (CR; n=9, 17%), very good partial response (VGPR; n=27, 52%) and partial response (PR; n=15, 29%)]. After ASCT, responses deepened to CR (n=18, 50%), VGPR (n=9, 25%) and PR (n=4, 11%). Eleven patients did not undergo ASCT (comorbidities: 6, insurance issues: 1, patient preference: 3, progression: 1). The median number of cycles received in this group was 4 and best responses were CR (n=3, 30%), VGPR (n=2, 20%), PR (n=5, 50%) while 1 not evaluable. At a median follow up of 7.4 months, overall survival (OS) is 100% while median PFS has not been reached (Figure 1). Five patients discontinued therapy due to toxicity (one of each with pericarditis, shortness of breath, pulmonary toxicity, neuropathy, retroperitoneal bleeding) and 3 due to progressive disease. There were no reported cases of heart failure.Patients with WM, n=6, [MYD88 mutation positive (n=5, 83%), CXCR4 mutation positive (n=0)] were treated with Cz, rituximab and dexamethasone induction followed by maintenance as described by Treon et al. (Blood 2014). Median age was 57 years (range 52-74 years). Patients presented with B symptoms (n=6, 100%) and anemia (n=5, 83%). After a median of 6 cycles of therapy, ORR was 66% [CR: n=1 (17%), PR: n=3 (50%)] while 2 (33%) had minimal response. All patients had resolution of B symptoms and anemia after treatment. One patient (MYD88 positive, CXCR4 negative) relapsed 27 months after starting initial treatment. Only one patient had severe toxicity (debilitating neuropathy attributed to rituximab) prompting therapy discontinuation after 3 cycles (Alfaraj et al, Ann Hematol. 2016). At a median follow up of 33.5 months, OS is 100%. Mutational status did not seem to impact response to therapy.Conclusion:Cz based regimens are generally well tolerated and offer a neuropathy sparing approach with excellent responses in newly diagnosed MM and WM making them a good choice for frontline treatment of these diseases. [Display omitted] DisclosuresLee:Celgene: Consultancy; Eutropics Pharmaceuticals: Research Funding; Adaptive: Membership on an entity's Board of Directors or advisory committees; Pimera Inc: Consultancy; Daiichi Sankyo: Research Funding; Takeda: Consultancy. Orlowski:BioTheryX: Consultancy, Membership on an entity's Board of Directors or advisory committees. Manasanch:quest diagnostics: Research Funding; merck: Research Funding; celgene: Consultancy; takeda: Consultancy; sanofi: Research Funding; adaptive biotechnologies: Consultancy.

B-Cell Maturation Antigen (BCMA)-Specific, CentyrinTM-Based, PiggyBacTM-Transposed CAR-T Memory Stem Cells Are Effective Against p53-/- and Patient-Derived Multiple Myeloma Tumors

B-Cell Maturation Antigen (BCMA)-Specific, CentyrinTM-Based, PiggyBacTM-Transposed CAR-T Memory Stem Cells Are Effective Against p53-/- and Patient-Derived Multiple Myeloma Tumors

Interim Results from the Phase 1a/1b Dose-Finding Study of CWP232291 (CWP291) in Relapsed or Refractory Myeloma (RRMM) Alone or in Combination with Lenalidomide and Dexamethasone

Background: CWP291, a novel peptidomimetic small molecule, has potent and selective inhibitory activity on a Wnt gene reporter and decreases expression of the β-catenin target genes, cyclin D1 and survivin. It has broad anti-cancer efficacy in vitro, outperforming lenalidomide and bortezomib in MM murine xenografts, and improving survival in combination vs. single agents alone in bone marrow engraftment models.Methods: Subjects with RRMM were infused CWP291 IV over at least 30 minutes twice weekly for 3 weeks out of a 4-week cycle in a 3+3 dose-escalation, Phase 1 design. In Phase 1a, CWP291 was delivered as a single agent. In Phase 1b, which started at a dose lower than a demonstrably well-tolerated dose in Phase 1a, allowing for more rapid initiation of this phase of the study (J Clin Oncol 35:2017 Suppl Abstr TPS8058), subjects received CWP291 in combination with lenalidomide and dexamethasone.Results: As of July 25, 2017, 21 subjects (13M, 8F), ages 44-79 (median 61 years) were enrolled; twelve in Phase 1a at doses from 198 - 446 mg/m2 and 8 in Phase 1b at 198 - 263 mg/m2. The median duration of treatment was 2 cycles (range 1 - 6 cycles) with 5 subjects ongoing. The most common (≥20% of subjects) drug-related adverse events (AEs) were due to GI toxicities, with diarrhea in 16 subjects (76%) and nausea in 10 subjects (48%); toxicities were grade ≤2 except grade 3 in 1 subject each. Asthenia/fatigue was seen in 10 subjects (48%) with 1 grade 3. Thrombocytopenia was reported in 6 subjects (29%), 5 of which were grade ≥3. Anemia was seen in 4 subjects (29%), and in 3 subjects were grade ≥3. Serious adverse events were recorded for 11 subjects with 18 separate events, the most frequent (9 events in 6 subjects) considered unrelated were hospitalizations for infections (pneumonia and parainfluenza virus) and only 3 events (urinary tract infection, grade 3 hypotension and grade 2 hypoxia) were considered possibly related. Three dose-limiting toxicities (DLT) occurred in Phase 1a in 2 subjects at 446 mg/m2, which were hypoxia (grade 3), neutropenia (grade 4) and thrombocytopenia (grade 4). The 335 mg/m2 cohort has now been initiated in which 1 DLT (grade 3 hypoxia) has been seen, and accrual is ongoing. One DLT (hypotension grade 3) was seen in Phase 1b at 198 mg/m2 however no additional DLTs were seen and accrual is now ongoing at 263 mg/m2. Fourteen subjects were evaluable for efficacy as per IMWG criteria. Six subjects had progressive disease (1 in Phase 1b), 4 subjects had stable disease, and responses were seen in 4 subjects (2 minor). There was also documentation of a 34.6% decrease in bone marrow plasma cells in one subject for whom a bone marrow aspirate was available in Phase 1a. Changes in targeted genes in blood and BM, as well as PK, will be provided from expanded and escalated dosing cohorts.Conclusions: CWP291, a novel and first in class molecule with significant preclinical activity, shows safety as a single agent as well as in combination with standard of care for patients with relapsed/refractory multiple myeloma Early evidence of efficacy in these subjects suggests that this is an active drug in this indication, and is continuing to be explored. DisclosuresManasanch:sanofi: Research Funding; celgene: Consultancy; adaptive biotechnologies: Consultancy; takeda: Consultancy; quest diagnostics: Research Funding; merck: Research Funding. Hauptschein:Theriac, Inc.: Employment. Choi:JW Pharmaceuticals, Inc.: Employment. Lee:JW Pharmaceuticals: Employment.

Update on a Phase II Study of Ixazomib with Lenalidomide As Maintenance Therapy Following Autologous Stem Cell Transplant in Patients with Multiple Myeloma

Update on a Phase II Study of Ixazomib with Lenalidomide As Maintenance Therapy Following Autologous Stem Cell Transplant in Patients with Multiple Myeloma

Gene Expression Profiling Is a Strong Predictor of Clinical Outcomes in Newly Diagnosed Multiple Myeloma

Introduction: Gene expression profiling (GEP) of purified CD138+ bone marrow plasma cells (PC) in patients with newly diagnosed multiple myeloma (MM) has proven to be a reliable prognostic tool. In this study, we aimed to describe the clinical outcomes of all consecutive NDMM patients with available GEP pre-treatment and compare GEP with standard FISH in determining relapse free survival (RFS) and overall survival (OS).Methods: From April 2014 until January 2017, we identified 104 patients with NDMM who had baseline GEP70 analysis at our institution. GEP70 was performed using CD138+ cells from bone marrow samples at diagnosis through MyPRS® (Signal Genetics, Little Rock, AR). Fisher's exact test was used to evaluate the associations between two categorical variables. The Wilcoxon rank sum test was used to evaluate the difference in continuous variables between patient groups. Kaplan-Meier method was used to estimate the time to event endpoints including RFS and overall survival (OS). The log-rank test was used to evaluate the differences in the time to event endpoints between different risk group categories. Univariate Cox proportional hazards model was used to evaluate the association between a continuous variable and RFS/OS. Statistical software SAS 9.3 (SAS, Cary, NC) and S-Plus 8.2 (TIBCO Software INc., Palo Alto, CA) were used for all analysis.Results: Median age was 63 (37-89) (Table 1a). Patients presented with lytic lesions (78%), anemia (78%), kidney dysfunction (13%) and hypercalcemia (31%). One patient did not meet CRAB criteria or biomarkers of malignancy, but had severe recurrent infections attributed to underlying myeloma requiring initiation of systemic therapy which prompted resolution of infections. One patient was initiated on therapy based on an i:u sFLC ratio of 165. All patients with available data for initial treatment (n=101), were treated either with bortezomib (63%), carfilzomib (37%) in combination with lenalidomide (86%) or cyclophosphamide (14%) and dexamethasone (100%). All patients received at least a three-drug combination as initial treatment, with 73% of patients receiving an upfront autologous transplant. Upfront autoSCT improved RFS (n=9/66; 14%) compared to non- or delayed autoSCT (n=8/25; 32%; p=0.03) but did not affect OS (p=0.86). Two patients (2 %) proceeded to an upfront allogeneic transplant as part of a clinical trial. With up to 36 months of follow up (range 0.9-35.9 months), 74% of patients are relapse free and 86% of patients are alive (Table 1b). GEP risk category predicted RFS (p=0.0005) in this series of patients (Figure 1). Table 1c shows GEP risk subtypes with clinical outcomes and association to FISH abnormalities. Uniformly, patients with high risk FISH abnormalities and low risk GEP had better clinical outcomes than patients with high risk GEP. High risk GEP patients represented 20% of all NDMM in this cohort. At one year, about 50% of these patients had relapsed or died compared to only 5% of patients in all of the other categories of GEP. By FISH, only t(14;16) predicted RFS (p=0.0001). Neither FISH nor GEP significantly predicted OS (P>0.05) although there were trends for worse survival for high risk GEP and FISH t(14;16).Conclusion: In this cohort of NDMM patients treated with modern therapies with most patients having received an autoSCT, GEP risk profiling was one of the best predictors of RFS. Longer follow up will be needed to determine prediction of OS in this cohort of patients. [Display omitted] DisclosuresLee:Eutropics Pharmaceuticals: Research Funding; Adaptive: Membership on an entity's Board of Directors or advisory committees; Pimera Inc: Consultancy; Celgene: Consultancy; Takeda: Consultancy; Daiichi Sankyo: Research Funding. Patel:Pfizer: Membership on an entity's Board of Directors or advisory committees, Research Funding; Juno: Consultancy; Celgene: Consultancy. Thomas:Celgene: Research Funding; Bristol Myers Squibb: Research Funding. Neelapu:Merck: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Bristol-Myers Squibb: Research Funding; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Karus: Research Funding; Cellectis Inc.: Research Funding; Kite Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Poseida Therapeutics, Inc: Research Funding. Orlowski:BioTheryX: Consultancy, Membership on an entity's Board of Directors or advisory committees. Manasanch:adaptive biotechnologies: Consultancy; quest diagnostics: Research Funding; sanofi: Research Funding; merck: Research Funding; celgene: Consultancy; takeda: Consultancy.

A Phase I/II Study of Pomalidomide and Dexamethasone with Growth Factor Support in Patients with Relapsed/Refractory Multiple Myeloma

A Phase I/II Study of Pomalidomide and Dexamethasone with Growth Factor Support in Patients with Relapsed/Refractory Multiple Myeloma

Pilot Study of Pembrolizumab for Immunoprevention in Smoldering Multiple Myeloma

Background: The current management of patients with smoldering multiple myeloma (SMM) is watchful waiting. However, a fraction of these patients are at significant risk of progression to symptomatic multiple myeloma (MM). In a recent study, expression of PD-L1 on tumor cells correlated with increased risk of progression from SMM to MM (Dhodapkar et al Blood. 2015; 126(22): 2475-2478) suggesting a role for immune checkpoint blockade for immunoprevention of MM. Pembrolizumab is a humanized monoclonal antibody against programmed death receptor-1 (PD-1) and blocks the interaction between PD-1 and PD-L1. Here, we report the results of a pilot study evaluating the safety and efficacy of pembrolizumab in intermediate- and high-risk SMM patients (I-HR-SMM). Methods: Patients with I-HR-SMM by PETHEMA, Mayo or SWOG criteria were eligible. Permbrolizumab was administered at a dose of 200 mg IV every 21 days for up to 8 cycles. Patients were eligible to continue treatment for up to 24 cycles if they achieved ≥ minor response after 8 cycles. The primary objective was the overall response rate (ORR) after 8 cycles. The target ORR was 25%. The trial was conducted by the Simon's Minimax design and the ORR was estimated accordingly (Simon, 1989). Twelve patients were planned for the first stage. If at least one patient had ≥ partial response, 4 more patients could enroll for a total of 16 patients. Serial peripheral blood mononuclear cells and bone marrow samples were collected for comprehensive immunophenotyping using multiparametric flow cytometry, and molecular profiling with gene expression profiling (GEP) and exome sequencing. Results: Twelve patients with I-HR-SMM were dosed on the first stage between 08/2016 and 06/2017 (Table 1a/b). Median age was 67.5 years (range 49-74). Median number of cycles received was 8 (range 3-8) and all 12 were evaluable for safety and efficacy. Median follow up was 8.54 months (4.7 to 9.6 months). One patient achieved a stringent complete remission (sCR) (8%), ten patients had stable disease (83%), and one patient had progressive disease (8%). The patient with sCR had HR-SMM by GEP70 and FISH (deletion 17p and amplification of CKS1B) and 50% plasma cells infiltration in the bone marrow at study entry. The sCR with negative flow cytometry on bone marrow was noted in this patient after only 3 cycles of therapy and response is ongoing 8 months after the end of treatment. Five patients discontinued therapy due to related adverse events: grade 2 elevation in LFT (n=2), grade 3 myalgia (n=1), and grade 3 acute kidney injury (AKI) due to tubulo-interstitial nephritis (n=2) [all resolved with discontinuation of treatment or prednisone administration]. There were no grade 4/5 adverse events. Enrollment on second stage is ongoing. Imunophenotyping of paired baseline and end of treatment bone marrow samples showed that the patient who achieved sCR had high levels of PD-1 expression on CD4+ and CD8+ T cells at baseline and showed evidence of CD8+ T-cell activation after therapy with greater upregulation of CD69, CTLA-4, PD-1, TIM-3, 4-1BB, and ICOS relative to non-responders. In contrast, expression of other immune checkpoint molecules such as TIM-3, LAG-3, and CD244 were greater on T cells in non-responders at baseline relative to the responder suggesting greater exhaustion of T cells in non-responders. Molecular profiling including GEP, exome sequencing, and neoantigens analysis is ongoing and will be presented at the meeting. Conclusions: This pilot study of pembrolizumab monotherapy showed that it is tolerable and can induce sCR in patients with SMM. More importantly, it suggested that immunoprevention to prevent progression of SMM to MM is possible. Additional biomarker studies are needed to identify patients that are most likely to respond to this approach. Our correlative studies also provide insights into potential future combination approaches to further improve efficacy of immunoprevention strategies in SMM. [Display omitted] DisclosuresManasanch:takeda: Consultancy; celgene: Consultancy; sanofi: Research Funding; quest diagnostics: Research Funding; merck: Research Funding; adaptive biotechnologies: Consultancy. Lee:Eutropics Pharmaceuticals: Research Funding; Adaptive: Membership on an entity's Board of Directors or advisory committees; Pimera Inc: Consultancy; Celgene: Consultancy; Daiichi Sankyo: Research Funding; Takeda: Consultancy. Patel:Pfizer: Membership on an entity's Board of Directors or advisory committees, Research Funding; Juno: Consultancy; Celgene: Consultancy. Thomas:Celgene: Research Funding; Bristol Myers Squibb: Research Funding. Neelapu:Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Karus: Research Funding; Cellectis Inc.: Research Funding; Poseida Therapeutics, Inc: Research Funding; Merck: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Kite Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Bristol-Myers Squibb: Research Funding. Orlowski:BioTheryX: Consultancy, Membership on an entity's Board of Directors or advisory committees.

Adult Hemophagocytic Lymphohistiocytosis-a Quality Improvement Initiative

Introduction: Hemophagocytic lymphohistiocytosis (HLH) is a frequently fatal severe inflammatory syndrome. HLH evaluations are conducted by multiple inpatient services due to the protean manifestations of the disease in adults. We observed difficulty identifying HLH precipitating conditions, hemorrhage, and erroneous testing as impediments to optimal care. We embarked on a HLH quality improvement project to examine strategies of precipitant identification, quantify hemorrhagic complications, and decrease erroneous test ordering.Methods: The Johns Hopkins Institutional Review Board approved this single-institution retrospective review. Patients were identified from billing and laboratory databases at The Johns Hopkins Hospital. Patients were included if they were evaluated for HLH during an inpatient hospitalization by their treating clinicians between January 1, 2009 and July 30, 2016. Patients <18 years of age at the time of evaluation were excluded. Clinical, laboratory, and imaging findings were obtained by chart review (SAM). HLH was defined as patients meeting at least 5 of 8 HLH-2004 criteria (Henter et al 2007); Hscore during the first inpatient week was also computed (Fardet et al 2014).Interventions occurred in 2015 and consisted of: 1) a review of HLH diagnostic testing, 2) presentation of findings to hematology staff, 3) development of an evidence-based HLH consult template, and 4) consultation on suspected HLH cases. Ordering interleukin-2 levels (IL2) or quantitative natural killer cell (NK) flow cytometry, instead of soluble interleukin-2 receptor (sIL2R) or NK functional assays were defined as erroneous testing in HLH evaluations. Test costs were obtained from Quest Diagnostics. Test ordering between 2014-2016 were compared before and after the interventions.Practices identifying the HLH precipitant were determined by chart review. Major hemorrhage was defined as bleeding 1) into a critical site, 2) requiring modification of blood product support, 3) requiring procedural intervention, or 4) leading to death. Coagulation parameters were examined in the 24hrs before hemorrhage was clinically evident. Overall survival was defined as date of hospital admission until death. Descriptive statistics were computed with percentages and frequencies. Survival analysis was performed with STATA14. Quality metrics were evaluated with either Fisher's exact test or unpaired t-test; statistical analysis used two-tailed significance testing and P<0.05.Results: During the study period, 86 patients were evaluated for HLH, and 63 fulfilled HLH-2004 diagnostic criteria (Table 1). Most patients (64%) were initially admitted to a non-hematology/oncology service. Serologic testing and bone marrow biopsy were most likely to identify the HLH-precipitating illness in 27% and 17.5% of cases, respectively. Major hemorrhage occurred in 41.3% of patients and occurred at the time of at least two coagulation abnormalities. HLH median survival ranged from 45 days with malignancy to not reached with autoimmune diseases and non-EBV infections (Figures 1 & 2).The interventions significantly decreased the occurrence of erroneous testing from 74.3% to 23.5% of patients (P=0.0008), and decreased costs of erroneous testing from $338 to $34 per patient during the evaluation period (Table 2). The interventions also significantly reduced the time to fulfillment of HLH criteria (38 vs 5.7 days, P<.0001), and reduced the delay in obtaining sIL2R testing after initial erroneous ordering (10.3 vs 0 days, P=0.0005). There were no significant differences in time to steroid administration, time to definitive HLH treatment, or in patient number without treatment.Conclusions: Adults with HLH initially present to non-hematology/oncology inpatient services. Diagnostic uncertainty, hemorrhage, and erroneous testing impair patient care. We observed that serological testing and bone marrow biopsy were most likely to identify the HLH precipitant. Major hemorrhage was common and occurred when multiple coagulation abnormalities were evident. Our quality improvement project significantly decreased erroneous testing and improved time to diagnosis. With these data, we are developing an internal HLH decision support tool to facilitate identification of HLH precipitant illness, curtail erroneous testing, and minimize morbidity from major hemorrhage. [Display omitted] DisclosuresMerrill:True North Therapeutics: Consultancy. Streiff:Roche: Research Funding; Portola: Research Funding; Janssen Scientific Affairs, LLC: Consultancy, Research Funding; CSL Behring: Consultancy, Research Funding. Lanzkron:HRSA: Research Funding; Bayer: Research Funding; Global Blood Therapeutics: Research Funding; Pfizer: Research Funding; PCORI: Research Funding; Prolong: Research Funding. Brodsky:Alexion Pharmaceuticals, Inc.: Membership on an entity's Board of Directors or advisory committees, Other: Grant Funding.

A Clinical Model of Progression to Multiple Myeloma in Solitary Plasmacytoma

Introduction: Solitary plasmacytoma is a malignant collection of plasma cells (PC) in the soft tissue (EP) or skeleton (BP) without multiple myeloma (MM). Treatment is based on excision and/or radiation therapy. A proportion of patients with EP/BP progress to MM. In this study we describe the baseline characteristics/clinical outcomes and create a clinical model of progression in a large cohort of 98 plasmacytoma patients diagnosed between 1986 and 2015.Methods: We retrospectively searched our PC database from 1986-2015. 218 patients were identified, of whom 120 were excluded due to incorrect diagnosis (n=40)/lack of baseline data (n=78)/duplicate patient (n=2). Summary statistics were given for categorical and continuous variables. Chi-squared and Fisher's exact tests were used to examine the associations between categorical variables and Wilcoxon's rank sum test was used for continuous variables. The primary outcomes were time to myeloma (TTM:time from diagnosis to myeloma progression), progression free survival (PFS:time from diagnosis to myeloma progression or death) and overall survival (OS:time from diagnosis to death of any cause). Kaplan-Meier curves were plotted for PFS/OS/TTM. Univariate cox proportional hazard models were used to determine the effects of potential risk factors (RF) on TTM, PFS and OS. Multi-covariable Cox proportional hazard models were used to identify RF on time to myeloma. A multi-covariable Cox regression model was fitted using backwards variable selection with a p-value of ≤ 0.05 as limit for inclusion. All tests are two-sided. All analyses were conducted using SAS 9.4 (SAS, Cary, NC) and S-Plus 8.0 (TIBCO Software Inc., Palo Alto, CA) software.Results: Figure 1a shows baseline patient/treatment characteristics. Most patients (n=88/98; 90%) had advanced imaging (MRI, PETCT, CT scan) and bone marrow biopsy at diagnosis (n=97/98; 99%). The median follow-up time was 7.64 years (range 0.2-23.5) among the 64 alive patients. There were 42 myeloma progressions among the 98 patients. BP (n=34/67; 50%) progressed at a significantly higher rate than EP (n=8/31; 25%; p=0.02) (Figure 1b). On univariate analysis baseline bone plasmacytoma, lower hemoglobin, immunoparesis, presence of blood paraprotein and increased light chains in blood were associated with unfavorable TTM outcome (p<0.05). Advanced age, increased Bence Jones in urine and being male at diagnosis were associated with worse OS (p<0.05). Lower hemoglobin, higher LDH, presence of immunoparesis and blood paraprotein at diagnosis were associated with worse PFS (p<0.05). There were no statistical differences in PFS (p=0.09) and OS (p=0.33) between EP and BP, although there was a trend for improved PFS with EP. There were 18 deaths for BP and 12 deaths for EP. Cause-specific mortality showed that for BP: n=6/18 (33%) died of MM, n=7/18 (39%) had unknown cause of death, n=5/18 (27.8%) died of other malignancies. For EP patients, cause of death was unknown [n=6/12 (50%)], MM [n=4/12 (33%)], bladder cancer [n=1/12 (9%)] or infection [n=1/12 (9%)]. Baseline calcium, hemoglobin, and presence of positive immunofixation, immunoparesis, blood paraprotein, Bence Jones ≥ 50 mg, BP vs EP and tumor size were included in the multi-covariate analysis for TTM. The reduced final model showed that presence of immunoparesis (p=0.004) and blood paraprotein (p=0.02) at baseline were significantly associated with TTM. We then created a model using 0 (no risk factors), 1 (either having baseline immunoparesis or presence of blood paraprotein) or 2 risk factors (having both immunoparesis and blood paraprotein at baseline). The rates of progression to myeloma for all BP/EP patients at 10 years with 0, 1 and 2 risk factors were 29%, 66% and 100% (p=0.006) (Figure 1c/d).Conclusion: BP and EP are precursors of MM. At a median follow up of 7.64 years, 26% of EP and 51% of BP patients progressed to MM. These rates are similar to those reported for low and intermediate risk smoldering myeloma, emphasizing the need for continued follow up and prevention strategies (i.e., study NCT02516423 of systemic treatment with ixazomib, lenalidomide, dexamethasone, zoledronic acid). Clinical models such as the one presented here may guide clinicians in optimal follow up or inclusion in clinical trials for prevention of progression to MM. [Display omitted] DisclosuresManasanch:takeda: Consultancy; sanofi: Research Funding; adaptive biotechnologies: Consultancy; merck: Research Funding; celgene: Consultancy; quest diagnostics: Research Funding. Lee:Takeda: Consultancy; Celgene: Consultancy; Pimera Inc: Consultancy; Adaptive: Membership on an entity's Board of Directors or advisory committees; Eutropics Pharmaceuticals: Research Funding; Daiichi Sankyo: Research Funding. Thomas:Celgene: Research Funding; Bristol Myers Squibb: Research Funding. Patel:Juno: Consultancy; Celgene: Consultancy; Pfizer: Membership on an entity's Board of Directors or advisory committees, Research Funding. Orlowski:BioTheryX: Consultancy, Membership on an entity's Board of Directors or advisory committees.

A Randomized Phase III Trial of Busulfan + Melphalan Vs Melphalan Alone for Multiple Myeloma

Background: High-dose melphalan (Mel) 200 mg/m2 is considered the standard of care preparative regimen for autologous hematopoietic stem cell transplantation (auto-HCT) for multiple myeloma. Two recent retrospective analyses suggested that a combination of busulfan (Bu) and Mel (Bu-Mel) may be associated with a longer progression-free survival (PFS) compared to Mel alone. In this randomized phase III trial we compared the safety and efficacy of Bu-Mel vs. Mel.Methods: Patients were randomized to either Bu-Mel or Mel using the Pocock-Simon method within 12 months of the start of induction therapy. In the Bu-Mel arm, Bu 130 mg/m2 was infused daily for 4 days, either as a fixed dose or to target an average daily area under the curve of 5000 μmol-min, followed by 2 daily doses of Mel at 70 mg/m2. Mel 200 mg/m2 was given as a single dose in the Mel only arm. The trial was designed to detect a 14-month increase in median PFS in the Bu-Mel arm with two-sided tests having nominal overall type I error .029 and power .80, with up to 3 tests using O'Brien-Fleming decision boundaries. The primary objective was to compare PFS between the two arms. Secondary objectives were to compare the response rates, toxicity and overall survival (OS).Results: Two-hundred and four patients (Bu-Mel: 104, Mel: 100) were enrolled from October 2011 to March 2017. Patient characteristics are summarized in Table 1. There was no significant difference between the two arms in age, gender, race, cytogenetic risk status, ISS stage, serum LDH, induction regimens, response to induction, or maintenance therapy. One-hundred-day non-relapse mortality (NRM) was 0% in both arms and 1-year NRM was 2% vs. 0% in Bu-Mel vs. Mel (p=0.11). NCICTCv3.0 grade 1-3 diarrhea was seen in 59 (57%) and 78 (78%) patients in Bu-Mel vs. Mel, respectively (p=0.002). Grade 1-3 mucositis (96% vs. 49%, p <0.001), rise in ALT (33% vs 1%, p <0.001) and neutropenic fever (71% vs. 30%, p <0.001) were seen at a higher rate in the Bu-Mel arm. No second primary malignancies have been seen in either arm to date. At day 90 after auto-HCT, 27 (26%) and 33 (33%) patients had achieved complete remission (CR; p=0.29), and 49 (47%) and 55 (55%) patients had achieved at least near CR (nCR; p=0.27) in Bu-Mel and Mel, respectively. Minimal residual disease (MRD) analysis by multiparametric flow cytometry (MFC) was performed at day 100 in 86 and 77 patients in Bu-Mel and Mel, respectively. Fifty (58%) and 47 (61%) achieved MRD negative status in Bu-Mel and Mel arms, respectively (p=0.75). At last evaluation, 52 (51%) and 49 (49%) patients had achieved a CR (p=0.89), and 70 (67%) and 67 (67%) patients had achieved at least nCR (p=1.00) in Bu-Mel and Mel, respectively. Median follow up was 22.1 months (range 0.7 - 64.8). Kaplan-Meier estimates of median PFS was 64.7 months in the Bu-Mel arm, and 34.4 months in the Mel only arm (p=0.013) (Figure 1). This significant difference in PFS was maintained after adjusting for the type of maintenance therapy received (p=0.019). With a median follow up of 28.1 months, there was no difference in OS between the Bu-Mel or Mel only arms (p=0.94). In a fitted Bayesian regression model, the posterior probability that patients receiving Bu-Mel had a smaller risk of progression and/or death compared with patients receiving Mel alone is 0.982, which is highly significant.Conclusions: In this phase III trial, Bu-Mel regimen was safe, and associated with a significantly longer PFS than Mel alone. This significant difference in PFS continued even after adjusting for maintenance therapy. Potential explanations for a longer PFS without a significant difference in response rates include a deeper MRD negativity or selective targeting of clonogenic myeloma progenitor cells by Bu-Mel. [Display omitted] DisclosuresShah:Indapta Therapeutics: Other: Stock Ownership; Celgene: Research Funding; Celgene, Indapta Therapeutics, Takeda: Consultancy; TeneoBio, Inc.: Honoraria. Patel:Juno: Consultancy; Celgene: Consultancy; Pfizer: Membership on an entity's Board of Directors or advisory committees, Research Funding. Thomas:Celgene: Research Funding; Bristol Myers Squibb: Research Funding. Manasanch:celgene: Consultancy; quest diagnostics: Research Funding; adaptive biotechnologies: Consultancy; sanofi: Research Funding; takeda: Consultancy; merck: Research Funding. Lee:Adaptive: Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy; Eutropics Pharmaceuticals: Research Funding; Daiichi Sankyo: Research Funding; Pimera Inc: Consultancy; Takeda: Consultancy. Orlowski:BioTheryX: Consultancy, Membership on an entity's Board of Directors or advisory committees.

Results of a Protocol for Targeted Testing of Congenital Cytomegalovirus Infection in Babies who Fail the Newborn Hearing Screen

<strong>Background and objectives:</strong> Cytomegalovirus (CMV) is a major cause of sensorineural hearing loss in children [1]. Universal screening is controversial due to the low risk of CMV-related hearing loss [2]. The prevalence of CMV related hearing loss is 0.5 in 1000 children and is thought to be responsible for 15% to 20% of moderate-to-severe hearing loss in children [3, 4]. Since 2018, New York state law requires targeted CMV testing for newborns who “refer” on the Newborn Hearing Screen (NBHS) prior to discharge from the hospital at birth [5]. This is a report of a CMV testing protocol implemented at a community hospital for newborns who “refer” on the NBHS. <strong>Methods:</strong> Clinical records of all neonates born at BronxCare Health System (BCHS) who did not pass the NBHS between March 2019 and September 2020 were retrospectively reviewed. All newborns are screened using Auditory Brainstem Response (ABR) and those who do not pass are referred for audiology evaluation. Newborns who failed NBHS were tested for CMV prior to hospital discharge using Salivary Real-time Polymerase Chain Reaction (PCR) (Quest Diagnostics). Positive results were confirmed with serum PCR. We analyzed NBHS, audiology evaluation and CMV testing results. <strong>Results:</strong> A total of 3555 newborns had NBHS performed; 44 did not pass and were referred for audiology evaluation within 2 weeks of hospital discharge. Of these 44, CMV testing was done for 37 (84%) while 7 (16%) were not tested for CMV. Of those tested, salivary PCR detected CMV in two patients: the first had negative confirmatory serum PCR test; the second was confirmed positive and treated with ganciclovir. This patient, who is confirmed positive, had inconclusive results on follow-up audiology evaluation and was referred for Early Intervention services. Of the original cohort of 44 patients who were referred to audiology; thirty-three (75%) passed audiology evaluation and eleven did not. Of these eleven, two cases were followed successfully and have confirmed hearing loss, while 9 were lost to subsequent audiology follow-up. Of the two hearing loss cases; one was the confirmed CMV positive baby who started treatment with valganciclovir, while the other was CMV negative. Of the nine newborns who were lost to audiology follow up, 8 were tested negative for CMV while one baby was not tested for CMV. <strong>Conclusion:</strong> At BCHS, the prevalence of CMV related hearing loss is 0.28/1000 as compared to the reported prevalence of 0.5/1000. Eighteen months of targeted CMV testing in newborns who did not pass the NBHS found only one confirmed case of congenital CMV infection. This suggests that targeted CMV screening based on NBHS results misses some cases of congenital CMV infection. Of the eligible newborns who failed NBHS; seven were not tested for CMV. The testing protocol will need further refinement to avoid missing patients in the future.

Implementation of a Machine-Learning Algorithm in the Electronic Health Record for Targeted Screening for Familial Hypercholesterolemia: A Quality Improvement Study.

Implementation of a Machine-Learning Algorithm in the Electronic Health Record for Targeted Screening for Familial Hypercholesterolemia: A Quality Improvement Study.

Peripheral Insulin Resistance Is Unrelated to Cognition in Highly Educated, Cognitively Normal Adults

ObjectivesPeripheral insulin resistance (IR) and impaired glucose metabolism increase the risk for cognitive decline. However, data looking at peripheral IR’s relationship with cognition in cognitively normal adults is limited. This study aimed to assess the relationship between peripheral IR and tests of executive function, attention, and processing speed in cognitively normal older adults using a novel IR measure. MethodsBaseline data from 81 cognitively normal older adults participating in a nutrition intervention study (Nutrition Interventions for Cognitive Enhancement study; NICE study) were analyzed. Fasting blood draws were attained, and peripheral IR was measured using Quest Diagnostics’ Cardio IQ Insulin Resistance Panel (Test Code: 36,509). The NIH Toolbox Cognition Battery was conducted by a trained psychometrician. Executive function was measured by the Flanker Inhibitory Control and Dimensional Change Card Sort tests. The Flanker test also measures attention. Processing Speed was measured by the Pattern Comparison Processing Speed test. We constructed ordinary least squares regression models to assess IR’s relationships with the individual cognitive tests, including age, education, and gender as covariates. Statistical analyses were performed using R (v. 3.6.2; R Foundation, Vienna, Austria). Statistical significance was set at p < 0.05. ResultsParticipants were 83% female and had a mean age of 72 ± 4.9 years. The mean IR score was 29.9 ± 29.83. There was no statistically significant relationships with IR and any of the cognitive tests: Flanker Inhibitory Control (β = -0.03, P = 0.12), Dimensional Change Card Sort (β = -0.03, P = 0.16), Pattern Comparison Processing Speed (β = -0.10, P = 0.15). ConclusionsThere were no statistically significant relationships between IR scores and performance on the different cognitive tests. Although the tests were not significantly correlated with IR scores, directionality of the relationships indicated trend for higher IR being related to poorer scores. Consequently, maintaining insulin sensitivity with healthy lifestyle choices may be important for healthy brain aging. Future analyses with a larger sample size will be more informative for understanding the relationship between IR and various cognitive tests at baseline and over time. Funding SourcesNational Institutes on Aging.

317-OR: Efficacy and Safety of Dapagliflozin by Glycemic Status in the DAPA-CKD Trial

There is robust evidence that sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk of adverse cardiovascular and kidney outcomes. The DAPA-CKD trial (NCT03036150) demonstrated a significant risk reduction in participants with chronic kidney disease (CKD), with and without type 2 diabetes, treated with dapagliflozin 10 mg once daily compared with placebo, as an adjunct to standard care. In this prespecified analysis, we compared the efficacy and safety of dapagliflozin according to baseline glycemic status. The trial included individuals with CKD with an estimated glomerular filtration rate (eGFR) of 25 to 75 mL/min/1.73 m2 and a urinary albumin-to-creatinine ratio of 200 to 5000 mg/g. The primary outcome was a composite of sustained decline in eGFR of at least 50%, end-stage kidney disease, or death from renal or cardiovascular causes. We analyzed results by baseline glycemic status based on the American Diabetes Association criteria for HbA1c level &amp;lt;5.7% (normoglycemia) vs. ≥5.7 to &amp;lt;6.5% (prediabetes) vs. ≥6.5% or a history of type 2 diabetes. Of the 4304 participants in the trial, 738 had normoglycemia at baseline; 660, prediabetes; and 2906, type 2 diabetes. The relative risk reduction for the primary composite outcome with dapagliflozin (hazard ratio [HR], 0.61; 95% CI, 0.51−0.72) was consistent in participants with normoglycemia (HR, 0.62; 95% CI, 0.39−1.01), prediabetes (HR, 0.37; 95% CI, 0.21−0.66) and type 2 diabetes (HR, 0.64; 95% CI, 0.52−0.79; p-interaction = 0.19). Similarly, we found no evidence of effect modification by glycemic status on secondary or exploratory outcomes. The safety profile of dapagliflozin was similar across glycemic groups, with no events of major hypoglycemia or ketoacidosis in participants with normoglycemia or prediabetes, and no ketoacidosis in any participant treated with dapagliflozin. In conclusion, dapagliflozin reduced the risk of kidney and cardiovascular events independent of baseline glycemic status. Disclosure F. Persson: Advisory Panel; Self; AstraZeneca, Bayer AG, Boehringer Ingelheim International GmbH, Mundipharma International, Novo Nordisk, Advisory Panel; Spouse/Partner; AstraZeneca, Bristol-Myers Squibb Company, Research Support; Self; Amgen Inc., AstraZeneca, Boehringer Ingelheim International GmbH, Novo Nordisk, Speaker’s Bureau; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Mundipharma International, Novo Nordisk. R. D. Toto: Consultant; Self; AstraZeneca, Bayer AG, Boehringer Ingelheim Pharmaceuticals, Inc., Medscape Education, Otsuka America Pharmaceutical, Inc., Quest Diagnostics, Reata Pharmaceuticals, Inc., Relypsa Inc. A. Langkilde: Employee; Self; AstraZeneca, Stock/Shareholder; Self; AstraZeneca. D. C. Wheeler: Advisory Panel; Self; Merck Sharp &amp; Dohme Corp., Consultant; Self; AstraZeneca, Bayer AG, Boehringer Ingelheim International GmbH, GlaxoSmithKline plc., Janssen Global Services, LLC., Mundipharma International, Tricida, Inc., Speaker’s Bureau; Self; Amgen Astellas BioPharma, Astellas Pharma Inc., Napp Pharmaceuticals, Vifor Pharma Management Ltd. H. L. Heerspink: Consultant; Self; AbbVie Inc., Astellas Pharma Inc., AstraZeneca, Bayer AG, Boehringer Ingelheim International GmbH, Chinook, CSL Behring, Fresenius Medical Care, Gilead Sciences, Inc., Janssen Research &amp; Development, LLC, Merck &amp; Co., Inc., Mitsubishi Corporation Life Sciences Limited, Mundipharma International, Novo Nordisk, Retrophin, Inc., Research Support; Self; AbbVie Inc., AstraZeneca, Boehringer Ingelheim International GmbH, Janssen Research &amp; Development, LLC. Dapa-ckd study group: n/a. P. Rossing: Advisory Panel; Self; Astellas Pharma Inc., AstraZeneca, Bayer AG, Boehringer Ingelheim International GmbH, Gilead Sciences, Inc., Merck KGaA, Merck Sharp &amp; Dohme Corp., Novo Nordisk A/S, Sanofi, Vifor Pharma Management Ltd. P. Vart: None. G. M. Chertow: Advisory Panel; Self; Ardelyx, Baxter, Cricket Health, DURECT Corporation, Gilead Sciences, Inc., Reata Pharmaceuticals, Inc., Other Relationship; Self; Akebia Therapeutics, Inc., AstraZeneca, Vertex Pharmaceuticals Incorporated. F. Hou: Consultant; Self; AstraZeneca. J. J. Mcmurray: Other Relationship; Self; AbbVie Inc., Amgen Inc., AstraZeneca, Bayer AG, Cytokinetics Inc., DalCor Pharmaceuticals, Merck &amp; Co., Inc., Novartis AG, Servier Laboratories, Theracos, Inc. R. Correa-rotter: Consultant; Self; GlaxoSmithKline plc., Other Relationship; Self; AstraZeneca, Boehringer Ingelheim (Canada) Ltd., Novo Nordisk Inc., Speaker’s Bureau; Self; AbbVie Inc., Janssen Pharmaceuticals, Inc., Takeda Pharmaceutical Co. H. S. Bajaj: Other Relationship; Self; Eli Lilly and Company, Novo Nordisk, Research Support; Self; Amgen Inc., AstraZeneca, Boehringer Ingelheim International GmbH, Gilead Sciences, Inc., Kowa Pharmaceuticals America, Inc., Merck &amp; Co., Inc., Sanofi, Tricida, Inc. B. Stefansson: Employee; Self; AstraZeneca. Funding AstraZeneca

181-LB: Hyperglycemia at Hospital Presentation Associated with Severity and Mortality in COVID-19 Patients without Type 2 Diabetes

There is a bidirectional association between hyperglycemia (HG) and COVID-19 severity. We conducted a retrospective cohort study in COVID-19 patients aged ≥18 years hospitalized at the Boston Medical Center during March 1 - August 4, 2020 with the aim to determine the relationships among HG, presence of type 2 diabetes (T2D) and outcomes of COVID-19. Blood glucose levels (BG) measured on admission were extracted from the hospital database. HG was defined as BG &amp;gt;200 mg/dL. Patients with type 1 diabetes or BG &amp;lt;70 mg/dL were excluded. Outcomes were in-hospital death and intensive care unit (ICU) admission. Multivariate analysis was used to determine the associations between exposures and outcomes. A total of 1,434 patients were included in the analysis. The mean ± SD age was 56 ± 17 years, 642 (45%) were female and 458 (32%) had a history of T2D. HG occurred in 193 patients with T2D (42%) and 42 patients without T2D (4%). The rates of death and ICU admission were 9% and 19%, respectively. Among patients without T2D, after adjusting for age, sex, body mass index, race and comorbidities, patients with HG had a significantly higher odds of death (aOR 4.5, 95%CI 1.8 - 11.2) and ICU admission (aOR 3.7, 95%CI 1.8 - 7.5) than patients without HG. Among patients with T2D, patients with HG had a significantly higher odds of ICU admission (aOR 1.7, 95%CI 1.0 - 2.8) and tended to have a higher odds of death (aOR 1.6, 95%CI 0.8-3.0) than patients without HG after adjusting for potential confounders. Among the 235 patients with HG, the odds of death and ICU admission were higher in the 42 HG patients without T2D than the 193 patients with T2D (death: aOR 5.1, 95%CI 1.3 - 19.0; ICU admission: aOR 2.7, 95%CI 1.1 - 6.7) after adjusting for potential confounders including BG. HG in the subset of patients without T2D could be a marker of high inflammatory burden leading to higher mortality or undiagnosed diabetes leading to increased severity of COVID-19 due to metabolic dysfunction. Disclosure N. Charoenngam: None. M. F. Holick: Consultant; Self; Biogena Inc, Ontometrics Inc, Other Relationship; Self; Quest Diagnostics, Speaker’s Bureau; Self; Abbott. C. Apovian: Board Member; Self; Abbott, Allergan plc, Gelesis, Novo Nordisk, Nutrisystem, Tivity Health, Xeno Bioscience, Zafgen, Inc. Funding National Institutes of Health (2T32DK7201-42 to N.C.), (P30DK046200 to C.A.)

203-OR: Measurement of Intact Insulin by Mass Spectrometry Identifies Nonalcoholic Fatty Liver Disease (NAFLD)

Patients with NAFLD are characterized by insulin resistance (IR) and hyperinsulinism. However, prior studies have been unable to predict NAFLD based on IR measurements. The aim of this study was to explore the application of a newly validated measurement of intact insulin by mass spectrometry to predict NAFLD in patients without diabetes. Ninety-eight patients were recruited and underwent: a 2-hour OGTT with measurements of insulin every 30 min, and a liver magnetic resonance spectroscopy (1H-MRS) to measure liver fat and diagnose NAFLD. A mass spectrometry method was used to measure intact molecules of insulin. A total of 62 patients had NAFLD (48±11 yr, 66% male, BMI: 34.4±4.6kg/m2, A1c: 5.8±0.4%); and 36 did not have NAFLD (52±12 yr, 56% male, BMI: 30.5±6.8kg/m2, A1c: 5.5±0.4%). Fasting insulin levels were higher in NAFLD patients (17±10 vs. 7±3 μU/ml, p&amp;lt;0.001), but showed similar excursions during the OGTT (120 min incremental AUC: 7.4 [4.4-14.5] vs. 5.7 [4.2-8.9], p=0.22). Fasting intact insulin measurements had an AUROC of 0.90 (0.84-0.96) to predict NAFLD. This was significantly better than measuring insulin by radioimmunoassay (RIA) (AUC 0.80 [0.71-0.89], p=0.007). Using a cut-off of 10.5 μU/ml, we observed a sensitivity, specificity, PPV, and NPV of 92% (87-98%), 71% (62-80%), 79% (71-87%), and 89% (83-95%), respectively. Intact fasting insulin was better than other clinical variables (e.g., ALT, AST, triglycerides, HDL, glucose, A1c, and BMI) to predict NAFLD. When combined with ALT (intact insulin x ALT), it detected NAFLD with AUC 0.94 (0.89-0.99) and PPV and NPV of 93 and 88%, respectively. This newly described approach was significantly better than previously validated non-invasive scores such as NAFLD-LFS (p=0.009), HIS (p&amp;lt;0.001) and TyG index (p=0.039). Conclusions: In patients without diabetes, accurate measurement of fasting intact insulin levels by mass spectrometry constitutes an easy and non-invasive strategy to predict presence of NAFLD. Disclosure F. Bril: None. M. J. Mcphaul: Employee; Self; Quest Diagnostics. S. Kalavalapalli: None. R. Lomonaco: None. D. Barb: None. E. Godinez: None. K. Cusi: None. Funding The Obesity Society; University of Florida