Two-stage Study Design Research Articles

Using gene and gene-set association tests to identify lethal prostate cancer genes.

Recent advances in the detection and treatment of prostate cancer (PCa) have reduced morbidity and mortality from this common cancer. Despite these improvements, PCa remains the second leading cause of cancer death in men in the United States. Further understanding of the genetic underpinnings of lethal PCa is required to drive risk detection and prevention and ultimately reduce mortality. We therefore set out to identify germline variants associated with cases of lethal prostate cancer (LPCa). Using a two-stage study design, we compared whole-exome sequencing data of 550 LPCa patients to 488 healthy male controls. Men were classified as having LPCa based on medical record review. Candidate genes were identified using gene- and gene-set-based rare truncating variant association tests. Case-control burden testing through Firth's penalized logistic regression and case-gnomAD allelic burden testing through a one-sided mid-p Fisher's exact test were conducted. Each gene's p-values from these tests were combined into an omnibus p-value for candidate gene selection. In the subsequent validation stage, genes were assessed using the UK Biobank and Firth's penalized logistic regression for each ancestry, combined through meta-analysis. Gene-based rare variant association tests identified 12 genes nominally associated with LPCa. Rare-variant association tests identified a gene set with a significantly higher burden of truncating germline mutations in LPCa patients than controls. Combining gene- and gene-set test results, four nominally significant genes (PPP1R3A, TG, PPFIBP2, and BTN3A3) were selected as candidates. Subsequent validation using the UK Biobank found that PPP1R3A was significantly associated with LPCa risk (odds ratio 2.34, CI 1.20-4.59). Specifically, pGln662ArgfsTer7 was identified as the predominant variant in PPP1R3A among LPCa patients in our dataset. Both individual gene and gene-set analyses identified candidates associated with LPCa. The novel association of PPP1R3A and LPCa risk merits further investigation.

Correlation of ctDNA and LDH levels in patients with soft tissue sarcoma: A single-center experience.

e23535 Background: Our study aims to examine the relationship between the presence of circulating tumor DNA (ctDNA) and lactate dehydrogenase (LDH) in patients diagnosed with soft tissue sarcoma (STS). There is emerging yet limited data on the applicability of ctDNA in STS. LDH is a cheaper readily available test that has been associated with unfavorable overall survival in different malignancies. This research aims to understand the correlation between ctDNA and LDH as a tool to assess its utility as indirect markers of response to treatment in STS. Methods: This was a single-center retrospective chart review on patients diagnosed with STS. Eligibility criteria included a confirmed diagnosis and available measurements of both ctDNA and LDH levels. Correlation was compared between Non-hispanic whites (NHW) and Hispanics (H). Data was sourced from our electronic medical record and Signatera™ assay to obtain the primary endpoints. Specimens were standardized in accordance to Natera’s™ specifications. Study endpoints included the correlation coefficients between ctDNA and LDH levels. A two-stage study design was applied for a robust analysis. Spearman's rank correlation coefficient (denoted as r) was employed for statistical analysis, assessing the strength and direction of the monotonic relationship between ctDNA and LDH levels. Marker values were treated as continuous variables in these analyses. All analyses were executed in GraphPad Prism software. Results: The cohort comprised 33 patients with STS (14 NHW, 19 H). The median LDH in H was 189 (interquartile range (IQR) = 184) vs 184 (IQR = 105) in NHW. Comparatively, the median ctDNA in H was 0 (IQR = 39.3) and also 0 (IQR = 11.1) in NHW. The overall correlation between ctDNA and LDH levels was moderate positive (r = 0.5, p = 0.002), indicating a consistent, though not necessarily linear, relationship. Subgroup analysis showed r = 0.19 (p = 0.52) in NHW and r = 0.43 (p = 0.1) in H groups, suggesting ethnic variability in the ctDNA-LDH correlation. These findings were statistically significant within the predefined confidence limits and probability values. Conclusions: Our study demonstrated a significant correlation between ctDNA levels and LDH in STS patients, implying that higher ctDNA may be associated with higher LDH levels. This association can lead clinicians in monitoring LDH more frequently as an indirect marker of response to treatment in STS. This correlation suggests an increased tumor burden with a higher inflammatory response, with variations across different racial groups. The wider availability of LDH testing compared to ctDNA in many centers highlights LDH's potential as an indirect marker for STS. Further research with larger prospective cohorts is essential to confirm LDH's role paired with ctDNA in guiding treatment decisions in STS, enhancing its utility in clinical practice.

Analyzing the effects of drought at different time scales on cause-specific mortality in South Africa

South Africa (SA) is highly vulnerable to the effects of drought on the environment, economy, and society. However, its effect on human health remains unclear. Understanding the mortality risk associated with different types of droughts in different population groups and by specific causes would help clarify the potential mechanisms involved. The study aims to comprehensively assess the effect of droughts of varying time scales on cause-specific mortality (all; infectious and parasitic; endocrine, nutritional, and metabolic; cardiovascular; respiratory) in SA (from 2009–2016) and identify more vulnerable profiles based on sex and age. We also evaluated the urbanicity and district-level socioeconomic deprivation as potential risk modifiers. We used a two-stage time-series study design, with the weekly standardized precipitation-evapotranspiration index (SPEI) calculated at 1, 6, 12, and 15 months of accumulation to identify droughts of different duration (SPEI1, 6, 12, 15, respectively). We applied a quasi-Poisson regression adjusted by mean temperature to assess the association between each type of drought and weekly mortality in all district municipalities of SA, and then pooled the estimates in a meta-regression model. We reported relative risks (RRs) for one unit increase of drought severity. Overall, we found a positive association between droughts (regardless the time scale) and all causes of death analyzed. The strongest associations were found for the drought events more prolonged (RR [95%CI]: 1.027 [1.018, 1.036] (SPEI1); 1.035 [1.021, 1.050] (SPEI6); 1.033 [1.008, 1.058] (SPEI12); 1.098 [1.068, 1.129] (SPEI15)) and respiratory mortality (RRs varied from 1.037 [1.021, 1.053] (SPEI1) to 1.189 [1.14, 1.241] (SPEI15)). An indication of greater vulnerability was found in younger adults for the shortest droughts, in older adults for medium-term and long-term droughts, and children for very long-term droughts. However, differences were not significant. Further evidence of the relevance of urbanicity and demographic and socioeconomic conditions as potential risk modifiers is needed.

Novel Genetic Variants Distinguishing Myelin Oligodendrocyte Glycoprotein-IgG-Positive From Myelin Oligodendrocyte Glycoprotein-IgG-Negative Pediatric Acute Disseminated Encephalomyelitis in Northern China

BackgroundAcute disseminated encephalomyelitis (ADEM) is a common phenotype in children with myelin oligodendrocyte glycoprotein IgG (MOG-IgG)-associated disease. We aimed to identify novel genetic variants that distinguish children with MOG-IgG-positive ADEM (MOG-IgG+ ADEM) from children with MOG-IgG-negative ADEM (MOG-IgG− ADEM) using whole exome sequencing (WES) analysis. MethodsWe conducted a two-stage study design. First, we performed WES on five patients with MOG-IgG+ ADEM and five patients with MOG-IgG− ADEM. Following bioinformatics analysis, the candidate variant list was constructed. Second, 29 children with MOG-IgG+ ADEM and 27 children with MOG-IgG− ADEM, together with discovery cohort, were genotyped to identify the novel variants. ResultsWES resulted in 33,999 variants, and 5388 nonsynonymous variants were selected for downstream analysis. In total, 118 protein-affecting variants that were significantly different between the two groups were identified. Together with the five variants extracted from the literature, 49 variants were selected as the candidate variant list for genotyping in the replication cohort. Finally, we identified three variants: rs11171951 in NACα, rs231775 in CTLA4, and rs11171951 in GOLGA5, which were significantly different between MOG-IgG+ ADEM and MOG-IgG− ADEM. Only rs12440118 in NACα remained significant after Bonferroni correction for multiple testing (Padj < 0.001). ConclusionsWe identified strong associations between NACα, CTLA4, and GOLGA5 variants and MOG-IgG+ ADEM in a Han Chinese population of Northern China, which may present novel genetic risk factor distinguishing patients with MOG-IgG+ ADEM from those with MOG-IgG− ADEM.

Cross-Cultural Adaptation and Psychometric Evaluation of the Chinese Version of the Authentic Nurse Leadership Questionnaire

Aims. To adapt the Authentic Nurse Leadership Questionnaire (ANLQ) to the Chinese cultural context and evaluate its psychometric properties. Background. Authenticity serves as a pivotal factor in the dynamic interaction between nurse leaders and nurse staff, exerting a profound influence on the growth of nurse individuals, healthcare teams, and organizations. However, there is still a dearth of research instruments to assess nurses’ perception of authentic leadership in China. Methods. After authorization from the original author and technical support had been secured, a systematic process of initial translation, back translation, expert panel review, and pretesting was employed to ensure cross-cultural adaptation in accordance with established guidelines. A two-stage study design was implemented. In stage 1, 189 nurses were sampled for psychometric validation, during which the internal consistency reliability, split-half reliability, and test-retest reliability were tested and exploratory factor analysis was performed. In stage 2, 255 nurses were sampled for confirmatory factor analysis and assessment of convergent and discriminant validity, to further validate the constructs. Results. In stage 1, the validated instrument showed a Cronbach’s alpha value of 0.973, a split-half coefficient of 0.888, and a test-retest reliability coefficient of 0.912. The exploratory factor analysis extracted five dimensions that accounted for 82.629% of the overall variance. The findings in stage 2 showed that the observed data were well fitted to the five-factor theoretical model, with acceptable levels of convergent and discriminant validity. Conclusions. The Chinese version of the ANLQ demonstrated appropriate psychometric properties, as evidenced by its good reliability and validity. Implications for Nursing Management. This study offers nurse administrators and executives a valuable instrument, enabling them to establish leadership evaluation criteria, conduct nurse leader performance appraisals, and assist in selecting new nurse leaders. Ultimately, this contributes to the cultivation and development of exceptional managers capable of providing positive leadership to their followers.

Policy implications of heterogeneous demand reactions to changes in cost-sharing: Patient-level evidence from Austria

Cost-sharing is a prominent tool in many healthcare systems, both for raising revenue and steering patient behaviour. Although the effect of cost-sharing on demand for healthcare services has been heavily studied in the literature, researchers often apply a macro-perspective to these issues, opening the door for policy makers to the fallacy of assuming uniform demand reactions across a spectrum of different forms of treatments and diagnostic procedures. We use a simple classification system to categorize 11 such healthcare services along the dimensions of urgency and price to estimate patients’ (anticipatory) demand reactions to a reduction in the co-insurance rate by a sickness fund in the Austrian social health insurance system. We use a two-stage study design combining matching and two-way fixed effects difference-in-differences estimation. Our results highlight how an overall joint estimate of an average increase in healthcare service utilization (0.8%) across all healthcare services can be driven by healthcare services that are deferrable (+1%), comparatively costly (+1.4%) or both (+1.6%) and for which patients also postponed their consumption until after the cost-sharing reduction. In contrast, we do not find a clear demand reaction for inexpensive or urgent services. The detailed analysis of the demand reaction for each individual healthcare service further illustrates their heterogeneity. We show that even comparatively minor changes to the costs borne by patients may already evoke tangible (anticipatory) demand reactions. Our findings help policy makers better understand the implications of heterogeneous demand reactions across healthcare services for using cost-sharing as a policy tool.

Adherence to recommended guidelines for low back pain presentations to an Australian emergency department: Barriers and enablers

ObjectiveThis study sought to evaluate the adherence to guidelines for the management of mechanical Low Back Pain within a single tertiary metropolitan Emergency Department setting. Our objectives were:1.To identify the proportion of patients presenting to a single Emergency Department with mechanical Low Back Pain who received management in line with the guidelines; and2.To understand and describe factors that can influence clinicians’ (non-) adherence to the guidelines. MethodsA two-stage multi-methods study design was undertaken. Stage 1 involved a retrospective chart audit of patients presenting with a diagnosis of mechanical Low Back Pain to establish documented adherence to clinical guidelines. Stage 2 explored clinicians’ perspectives towards factors influencing adherence to the guidelines via a study-specific survey and follow up focus groups. ResultsThe audit demonstrated low adherence to the following guidelines: (i) appropriate prescription of analgesia, (ii) targeted education and advice, and (iii) attempts to mobilise. Three major themes were identified as factors influencing adherence to the guidelines: (1) clinician driven influences and factors, (2) workflow processes, and (3) patient expectations and behaviours. ConclusionThere was low adherence to some published guidelines and factors influencing adherence to the guidelines were multi-factorial. Understanding the factors that influence care decisions and developing strategies to address these can improve Emergency Department management of mechanical Low Back Pain.

Brain proteome-wide association study linking-genes in multiple sclerosis pathogenesis.

To identify genes that confer MS risk via the alteration of cis-regulated protein abundance and verify their aberrant expression in human brain. Utilizing a two-stage proteome-wide association study (PWAS) design, MS GWAS data (N= 41,505) was respectively integrated with two distinct human brain proteomes from the dorsolateral prefrontal cortex, including ROSMAP (N=376) in the discovery stage and Banner (N=152) in the confirmation stage. In the following, Bayesian colocalization analysis was conducted for GWAS and protein quantitative trait loci signals to prioritize candidate genes. Differential expression analysis was then used to verify the dysregulation of risk genes in white matter and gray matter for evidence at the transcription level. A total of 51 genes whose protein abundance had association with the MS risk were identified, of which 18 genes overlapped in the discovery and confirmation PWAS. Bayesian colocalization indicated six causal genes with genetic risk variants for the MS risk. The differential expression analysis of SHMT1 (PFDR =4.82 × 10-2 ), FAM120B (PFDR =8.13 × 10-4 ) in white matter and ICA1L (PFDR =3.44 × 10-2 ) in gray matter confirmed the dysregulation at the transcription level. Further investigation of expression found SHMT1 significantly up-regulated in white matter lesion, and FAM120B up-regulated in both white matter lesion and normal appearing white matter. ICA1L was down-regulated in both gray matter lesion and normal appearing gray matter. Dysregulation of SHMT1, FAM120B and ICA1L may confer MS risk. Our findings shed new light on the pathogenesis of MS and prioritized promising targets for future therapy research.

Maternal pre-pregnancy body mass index and offspring with overweight/obesity at preschool age: The possible role of epigenome-wide DNA methylation changes in cord blood.

Epigenome-wide association studies have identified some DNA methylation sites associated with body mass index (BMI) or obesity. Studies in the Asian population are lacking. To examine the association of cord blood genome-wide DNA methylation (GWDm) changes with maternal pre-pregnancy BMI and children's BMI-z score at preschool age. Additionally, we also explored the genome-wide differentially methylated regions and differentially methylated probes between preschoolers with overweight/obesity and normal-weight counterparts. This two-stage study design included (1) a GWDm analysis of 30 mother-child pairs from 633 participants of the Zhuhai birth cohort with data on newborn cord blood, maternal pre-pregnancy BMI, and children's BMI at 3 years of age; and (2) a targeted validation analysis of the cord blood of ten children with overweight/obesity and ten matched controls to validate the CpG sites. In the first stage, no significant CpG sites were found to be associated with children's BMI-z score at preschool age after FDR correction with the p-values of the CpG sites in FOXN3 (cg23501836) and ZNF264 (cg27437574) being close to 1 × 10-6 . In the second stage, a significant difference of CpG sites in AHRR (chr5:355067-355068) and FOXN3 (chr14: 89630264-89630272 and chr14: 89630387-89630388) was found between the ten children with overweight/obesity and ten controls (p < 0.05). The CpG sites in FOXN3 (chr14:89630264-89630272 and chr14:89630295-89630296) and ZNF264 (chr19: 57703104-57703107 and chr19: 57703301-57703307) were associated with children's BMI-z score; and the CpG sites in FOXN3 (chr14: 89630264-89630272 and chr14: 89630387-89630388) were associated with maternal pre-pregnancy BMI. DNA methylation in FOXN3 and AHRR is associated with overweight/obesity in preschool-aged children, and the methylation in FOXN3 and ZNF264 might be associated with children's BMI-z score. FOXN3 methylation may be associated with maternal pre-pregnancy BMI, suggesting its potential role in the children's BMI-z score or overweight/obesity. Our results provide novel insights into the mechanisms of children's obesity.

Progression and survival of MBL: a screening study of 10 139 individuals

AbstractMonoclonal B-cell lymphocytosis (MBL) is a common hematological premalignant condition that is understudied in screening cohorts. MBL can be classified into low-count (LC) and high-count (HC) types based on the size of the B-cell clone. Using the Mayo Clinic Biobank, we screened for MBL and evaluated its association with future hematologic malignancy and overall survival (OS). We had a two-stage study design including discovery and validation cohorts. We screened for MBL using an eight-color flow-cytometry assay. Medical records were abstracted for hematological cancers and death. We used Cox regression to evaluate associations and estimate hazard ratios and 95% confidence intervals (CIs), adjusting for age and sex. We identified 1712 (17%) individuals with MBL (95% LC-MBL), and the median follow-up time for OS was 34.4 months with 621 individuals who died. We did not observe an association with OS among individuals with LC-MBL (P = .78) but did among HC-MBL (hazard ratio, 1.8; 95% CI, 1.1-3.1; P = .03). Among the discovery cohort with a median of 10.0 years follow-up, 31 individuals developed hematological cancers with two-thirds being lymphoid malignancies. MBL was associated with 3.6-fold risk of hematological cancer compared to controls (95% CI, 1.7-7.7; P < .001) and 7.7-fold increased risk for lymphoid malignancies (95% CI:3.1-19.2; P < .001). LC-MBL was associated with 4.3-fold risk of lymphoid malignancies (95% CI, 1.4-12.7; P = .009); HC-MBL had a 74-fold increased risk (95% CI, 22-246; P < .001). In this large screening cohort, we observed similar survival among individuals with and without LC-MBL, yet individuals with LC-MBL have a fourfold increased risk of lymphoid malignancies. Accumulating evidence indicates that there are clinical consequences to LC-MBL, a condition that affects 8 to 10 million adults in the United States.

Metabolic signatures in human follicular fluid identify lysophosphatidylcholine as a predictor of follicular development

In order to investigate the metabolic characteristics of human follicular fluid (FF) and to reveal potential metabolic predictors of follicular development (FD) with clinical implications, we analyzed a total of 452 samples based on a two-stage study design. In the first stage, FF samples from both large follicles (LFs) and matched-small follicles (SFs) of 26 participants were analyzed with wide-spectrum targeted metabolomics. The metabolic signatures were described by multi-omics integration technology including metabolomic data and transcriptomic data. In the second stage, the potential biomarkers of FD were verified using enzyme-linked immunoassay with FF and blood serum from an independent 200 participants. We describe the FF metabolic signatures from ovarian follicles of different developmental stages. Lysophosphatidylcholine (LPC) can be used as a biomarker of FD and ovarian sensitivity, advancing the knowledge of metabolic regulation during FD and offering potential detection and therapeutic targets for follicle and oocyte health improvements in humans.

Age-related DNA methylation on Y chromosome and their associations with total mortality among Chinese males.

In view of the sex differences in aging‐related diseases, sex chromosomes may play a critical role during aging process. This study aimed to identify age‐related DNA methylation changes on Y chromosome (ChrY). A two‐stage study design was conducted in this study. The discovery stage contained 419 Chinese males, including 205 from the Wuhan‐Zhuhai cohort panel, 107 from the coke oven workers panel, and 107 from the Shiyan panel. The validation stage contained 587 Chinese males from the Dongfeng‐Tongji sub‐cohort. We used the Illumina HumanMethylation BeadChip to determine genome‐wide DNA methylation in peripheral blood of the study participants. The associations between age and methylation levels of ChrY CpGs were investigated by using linear regression models with adjustment for potential confounders. Further, associations of age‐related ChrY CpGs with all‐cause mortality were tested in the validation stage. We identified the significant associations of 41 ChrY CpGs with age at false discovery rate (FDR) <0.05 in the discovery stage, and 18 of them were validated in the validation stage (p < 0.05). Meta‐analysis of both stages confirmed the robust positive associations of 14 CpGs and negative associations of 4 CpGs with age (FDR<0.05). Among them, cg03441493 and cg17816615 were significantly associated with all‐cause mortality risk [HR(95% CI) = 1.37 (1.04, 1.79) and 0.70 (0.54, 0.93), respectively]. Our results highlighted the importance of ChrY CpGs on male aging.

Propensity score-integrated power prior approach for augmenting the control arm of a randomized controlled trial by incorporating multiple external data sources

ABSTRACT In this paper, a propensity score-integrated power prior approach is developed to augment the control arm of a two-arm randomized controlled trial (RCT) with subjects from multiple external data sources such as real-world data (RWD) and historical clinical studies containing subject-level outcomes and covariates. The propensity scores for the subjects in the external data sources versus the subjects in the RCT are first estimated, and then subjects are placed in different strata based on their estimated propensity scores. Within each propensity score stratum, a power prior is formulated with the information contributed by the external data sources, and Bayesian inference on the treatment effect is obtained. The proposed approach is implemented under the two-stage study design framework utilizing the outcome-free principle to ensure the integrity of a study. An illustrative example is provided to demonstrate the implementation of the proposed approach.

Effect of zinc and vitamin A supplementation on immune responses in Indonesian pre-schoolers.

Vitamin A and zinc are interrelated, but the effects of zinc on vitamin A supplementation on morbidity are inconsistent and not well understood. We investigated the effects of zinc and vitamin A supplementation on immune responses in Indonesian pre-schoolers. In a twostage study design, 826 children (2-5year old) were randomly assigned to receive daily zinc supplement (10 mg) or placebo for 4 months. At 2 months, both groups received a 200,000 IU vitamin A capsules through national vitamin A program. Data were collected at baseline, two and four months, resulting in 4 groups for comparisons: - no zinc no vitamin A (Placebo), zinc only, vitamin A only, and zinc plus vitamin A. Hair, blood and saliva samples were collected to measure hair zinc and serum retinol (vitamin A) concentration, ex-vivo IFN-γ, serum IgG and salivary IgA from 81 children selected randomly from each group. At baseline, there were no differences between treatment groups. Zinc supplementation increased ex-vivo IFN-γ production, greatest amongst boys, younger (<3.5 years), normal weight and children with low baseline retinol concentration. Vitamin A supplementation increased IFN-γ only in those with low baseline retinol, with no effect on serum IgG and salivary IgA. After vitamin A supplementation, zinc had an effect on salivary IgA among younger and underweight children. Zinc supplementation increased IFN-γ (cellular immune responses) and modified the effect of vitamin A supplementation on salivary IgA (mucosal innate immune response) in younger and underweight children.

532 - A Multicenter, Multicohort, Open-Label, Single Arm per Cohort, Phase II Study to Assess the Efficacy and Safety of Tabelecleucel in Patients with EBV-Associated Diseases Using an Adaptive Two-Stage Study Design

Background Epstein-Barr virus infection is associated with a variety of life-threatening malignant and non-malignant diseases. In immunocompromised individuals where T-cell function is impaired, loss of immune control of Epstein-Barr virus (EBV) can lead to proliferation of EBV-transformed B cells and result in immunodeficiency-associated lymphoproliferative diseases (IA-LPD). EBV-driven IA-LPDs are a heterogenous group of diseases with variable clinical and pathologic features, including primary immunodeficiency-associated LPD (EBV+ PID-LPD), acquired immunodeficiency-associated LPD (EBV+ AID-LPD), and post-transplant lymphoproliferative disorder (EBV+ PTLD). In addition, EBV-infection of mesenchymal cells can cause sarcomas, including leiomyosarcoma (EBV+ sarcoma). In rare instances, EBV viremia (ie, persistent EBV infection) can lead to non-malignant yet life-threatening complications such as chronic active EBV (CAEBV) or hemophagocytic lymphohistiocytosis (HLH). During the transition from primary EBV infection to latent state, only a subset of viral genes is expressed. The resulting latency proteins are a target of CD8+ T cells, making EBV+ malignancies good candidates for treatment with EBV-targeted cytotoxic lymphocytes. Tabelecleucel (tab-cel) is an off-the-shelf, partially human leukocyte antigen (HLA)-matched, allogeneic EBV-specific T-cell immunotherapy generated from screened EBV+ donors. Tabelecleucel is characterized by both HLA genotype and HLA restriction, the HLA allele(s) through which tab-cel exerts cytotoxic activity. Tab-cel is selected for each patient from an inventory based on the HLA restriction(s) and partial HLA matching. Initial safety and efficacy data support that tab-cel was well tolerated and showed clinical activity in patients with each of the EBV-associated diseases being proposed in study 205 [Nikiforow S et al. ESMO 2020; Kurlander LS et al. Ann Oncol 2018; Prockop S et al. JCI 2020]. These data encourage investigation to further evaluate the safety and efficacy of tab-cel in these populations. Study design and objectives This is a multicenter, multicohort, open-label, single-arm per cohort, phase II study to assess the efficacy and safety of tab-cel in patients with EBV-associated diseases (ATA129-EBV-205). The primary objective of the study is to assess the clinical benefit of tab-cel as measured by objective response rate. This study will also evaluate clinically relevant disease-specific outcomes and will characterize the safety profile of tab-cel in these patient populations. This study will enroll patients who are relapsed/refractory or newly diagnosed and ineligible for first-line therapy in the following cohorts: EBV+ AID-LPD, EBV+ PID-LPD, EBV+ sarcoma, including LMS, CAEBV/HLH and EBV+ PTLD with central nervous system [CNS]-involvement. In addition, a cohort of patients with previously untreated EBV+ PTLD where first-line therapy is not appropriate is planned to start enrollment in 2021. A Phase III study of tab-cel for solid organ or allogeneic hematopoietic cell transplant patients with EBV+ PTLD after failure of rituximab or rituximab plus chemotherapy (NCT03394365) is ongoing. Patients in each cohort will receive tab-cel in 35-day cycles. During each cycle, patients will receive intravenous tab-cel at a dose of 2 × 106 cells/kg on days 1, 8, and 15, followed by an observation period through day 35 (Figure 1). An adaptive two-stage design will be used for each cohort in this study, and for each, a maximum of eight patients will be enrolled in stage 1. The decision to move to stage 2 enrollment for any given cohort will be based on an analysis of the first eight evaluable patients in the cohort using investigator's assessment (per defined radiologic, clinical, and/or laboratory response criteria). If at least two among the first eight evaluable patients in stage 1 are responders W(ie, complete response or partial response), additional patients may be enrolled in stage 2 of that cohort. The number of patients enrolled in stage 2 will depend on the number of observed responders in stage 1 (Table 1). This design will allow for minimization of the expected number of patients required to evaluate the efficacy of tab-cel in each disease cohort independently. Figure 1. Study design schema Download : Download high-res image (589KB) Download : Download full-size image Disclosures Prockop: Jasper Pharmaceuticals: Research Funding; Mesoblast: Consultancy, Research Funding; Atara Biotherapeutics: Research Funding; Memorial Sloan Kettering: Patents & Royalties: IP related to the development of third party viral specific T cells with all of my interests assigned to MSK. Dinavahi: Atara Biotherapeutics: Current Employment, Current equity holder in publicly-traded company. Navarro: Atara Biotherapeutics: Current Employment, Current equity holder in publicly-traded company. Guzman-Becerra: Atara Biotherapeutics: Current Employment, Current equity holder in publicly-traded company. Sun: Atara Biotherapeutics: Current Employment, Current equity holder in publicly-traded company. Gamelin: Atara Biotherapeutics: Current Employment, Current equity holder in publicly-traded company.

Delphi Approach to explore ways to optimize case manager services in inpatient wards of Sanglah General Hospital

Background and purpose: Case manager services in inpatient rooms have gained popularity in many hospitals in Indonesia, however there are challenges in its implementation. This study aims to explore ways to optimize the characteristics of the case manager, case management practice and outcome of the case manager in cases in inpatient wards based on the Sanglah Hospital standards.Methods: The study utilized a two-stage Delphi study design, started with a qualitative data collection and followed by a quantitative survey. Data collection was done in May-June 2020 based on the concept of case manager characteristics, practice and outcomes. The qualitative data collection through in-depth interviews involved 9 key informants. It aimed to explore case manager services based on qualifications, competencies, ethical standards, workload, hierarchy and guidelines, implementation of case management and indicators of effectiveness of case management at Sanglah General Hospital. The results of the in-depth interviews with thematic analysis informed the Delphi survey instrument development. The Delphi survey aimed to generate agreement on the characteristic of the case manager, case management practice and outcome of the case manager among 21 expert panelists (case managers) in the inpatient wards of Sanglah Hospital. This Delphi survey was conducted in 3 rounds, the results were analyzed based on the median value and quartile deviation (QD).Results: The three rounds of the Delphi survey showed that there was an agreement regarding the qualifications of the case manager, competency development, mechanism for appointment and placement of case managers, case manager guidelines, organizational structure, job descriptions and authorities, information of the presence and role of case managers, screening indicators according to characteristics of inpatient cases, case management target measurement tools, case manager service evaluation indicators as well as the activity feedback loop.Conclusion: Optimization of the case manager service should focus on aspects of human resources, developing guidelines and work systems as well as evaluation indicators and feedback mechanism.

A Multicenter, Multicohort, Open-Label, Single-Arm per Cohort, Phase II Study to Assess the Efficacy and Safety of Tabelecleucel in Patients with EBV-Associated Diseases Using an Adaptive Two-Stage Study Design

Background Epstein-Barr virus infection is associated with a variety of life-threatening malignant and non-malignant diseases. In immunocompromised individuals where T-cell function is impaired, loss of immune control of Epstein-Barr virus (EBV) can lead to proliferation of EBV-transformed B cells and result in immunodeficiency-associated lymphoproliferative diseases (IA-LPD). EBV-driven IA-LPDs are a heterogenous group of diseases with variable clinical and pathologic features, including primary immunodeficiency-associated LPD (EBV+ PID-LPD), acquired immunodeficiency-associated LPD (EBV+ AID-LPD), and post-transplant lymphoproliferative disorder (EBV+ PTLD). In addition, EBV-infection of mesenchymal cells can cause sarcomas, including leiomyosarcoma (EBV+ sarcoma). In rare instances, EBV viremia (ie, persistent EBV infection) can lead to non-malignant yet life-threatening complications such as chronic active EBV (CAEBV) or hemophagocytic lymphohistiocytosis (HLH). During the transition from primary EBV infection to latent state, only a subset of viral genes is expressed. The resulting latency proteins are a target of CD8+ T cells, making EBV+ malignancies good candidates for treatment with EBV-targeted cytotoxic lymphocytes. Tabelecleucel (tab-cel) is an off-the-shelf, partially human leukocyte antigen (HLA)-matched, allogeneic EBV-specific T-cell immunotherapy generated from screened EBV+ donors. Tabelecleucel is characterized by both HLA genotype and HLA restriction, the HLA allele(s) through which tab-cel exerts cytotoxic activity. Tab-cel is selected for each patient from an inventory based on the HLA restriction(s) and partial HLA matching. Initial safety and efficacy data support that tab-cel was well tolerated and showed clinical activity in patients with each of the EBV-associated diseases being proposed in study 205 [Nikiforow S et al. ESMO 2020; Kurlander LS et al. Ann Oncol 2018; Prockop S et al.JCI 2020]. These data encourage investigation to further evaluate the safety and efficacy of tab-cel in these populations. Study design and objectives This is a multicenter, multicohort, open-label, single-arm per cohort, phase II study to assess the efficacy and safety of tab-cel in patients with EBV-associated diseases (ATA129-EBV-205). The primary objective of the study is to assess the clinical benefit of tab-cel as measured by objective response rate. This study will also evaluate clinically relevant disease-specific outcomes and will characterize the safety profile of tab-cel in these patient populations. This study will enroll patients who are relapsed/refractory or newly diagnosed and ineligible for first-line therapy in the following cohorts: EBV+ AID-LPD, EBV+ PID-LPD, EBV+ sarcoma, including LMS, CAEBV/HLH and EBV+ PTLD with central nervous system [CNS]-involvement. In addition, a cohort of patients with previously untreated EBV+ PTLD where first-line therapy is not appropriate is planned to start enrollment in 2021. A Phase III study of tab-cel for solid organ or allogeneic hematopoietic cell transplant patients with EBV+ PTLD after failure of rituximab or rituximab plus chemotherapy (NCT03394365) is ongoing. Patients in each cohort will receive tab-cel in 35-day cycles. During each cycle, patients will receive intravenous tab-cel at a dose of 2 × 106 cells/kg on days 1, 8, and 15, followed by an observation period through day 35 (Figure 1). An adaptive two-stage design will be used for each cohort in this study, and for each, a maximum of eight patients will be enrolled in stage 1. The decision to move to stage 2 enrollment for any given cohort will be based on an analysis of the first eight evaluable patients in the cohort using investigator's assessment (per defined radiologic, clinical, and/or laboratory response criteria). If at least two among the first eight evaluable patients in stage 1 are responders W(ie, complete response or partial response), additional patients may be enrolled in stage 2 of that cohort. The number of patients enrolled in stage 2 will depend on the number of observed responders in stage 1 (Table 1). This design will allow for minimization of the expected number of patients required to evaluate the efficacy of tab-cel in each disease cohort independently. Figure 1. Study design schema Disclosures Prockop: Jasper Pharmaceuticals: Research Funding; Mesoblast: Consultancy, Research Funding; Atara Biotherapeutics: Research Funding; Memorial Sloan Kettering: Patents &amp; Royalties: IP related to the development of third party viral specific T cells with all of my interests assigned to MSK. Dinavahi:Atara Biotherapeutics: Current Employment, Current equity holder in publicly-traded company. Navarro:Atara Biotherapeutics: Current Employment, Current equity holder in publicly-traded company. Guzman-Becerra:Atara Biotherapeutics: Current Employment, Current equity holder in publicly-traded company. Sun:Atara Biotherapeutics: Current Employment, Current equity holder in publicly-traded company. Gamelin:Atara Biotherapeutics: Current Employment, Current equity holder in publicly-traded company.

Identification of novel risk loci and causal insights for sporadic Creutzfeldt-Jakob disease: a genome-wide association study

Human prion diseases are rare and usually rapidly fatal neurodegenerative disorders, the most common being sporadic Creutzfeldt-Jakob disease (sCJD). Variants in the PRNP gene that encodes prion protein are strong risk factors for sCJD but, although the condition has similar heritability to other neurodegenerative disorders, no other genetic risk loci have been confirmed. We aimed to discover new genetic risk factors for sCJD, and their causal mechanisms. We did a genome-wide association study of sCJD in European ancestry populations (patients diagnosed with probable or definite sCJD identified at national CJD referral centres) with a two-stage study design using genotyping arrays and exome sequencing. Conditional, transcriptional, and histological analyses of implicated genes and proteins in brain tissues, and tests of the effects of risk variants on clinical phenotypes, were done using deep longitudinal clinical cohort data. Control data from healthy individuals were obtained from publicly available datasets matched for country. Samples from 5208 cases were obtained between 1990 and 2014. We found 41 genome-wide significant single nucleotide polymorphisms (SNPs) and independently replicated findings at three loci associated with sCJD risk; within PRNP (rs1799990; additive model odds ratio [OR] 1·23 [95% CI 1·17-1·30], p=2·68 × 10-15; heterozygous model p=1·01 × 10-135), STX6 (rs3747957; OR 1·16 [1·10-1·22], p=9·74 × 10-9), and GAL3ST1 (rs2267161; OR 1·18 [1·12-1·25], p=8·60 × 10-10). Follow-up analyses showed that associations at PRNP and GAL3ST1 are likely to be caused by common variants that alter the protein sequence, whereas risk variants in STX6 are associated with increased expression of the major transcripts in disease-relevant brain regions. We present, to our knowledge, the first evidence of statistically robust genetic associations in sporadic human prion disease that implicate intracellular trafficking and sphingolipid metabolism as molecular causal mechanisms. Risk SNPs in STX6 are shared with progressive supranuclear palsy, a neurodegenerative disease associated with misfolding of protein tau, indicating that sCJD might share the same causal mechanisms as prion-like disorders. Medical Research Council and the UK National Institute of Health Research in part through the Biomedical Research Centre at University College London Hospitals National Health Service Foundation Trust.

Development and feasibility of a multidisciplinary education program on adherence to treatment in persons with venous leg ulcers in the clinical setting: A pilot study.

The aim of this study is to: (a) develop an evidence-based multidisciplinary educational intervention for patients with a venous leg ulcer; and (b) conduct a pilot study to assess the feasibility of the intervention in the clinical setting. A two-stage study design was used: (a) an multidisciplinary expert committee designed an educational intervention including support materials; and (b) a pilot randomized controlled trial was conducted to assess the feasibility of the intervention in one wound care outpatient clinic in Western Switzerland. A multidisciplinary expert committee identified evidence for effective care interventions to improve venous leg ulcer patients' wound healing and recurrences rates. They subsequently designed the educational intervention and support materials. In this pilot study venous leg ulcer patients were then randomly assigned to receive multidisciplinary education or standard care from March-July 2018. The objective was to evaluate the feasibility of the intervention in the clinical setting. Allocation to groups was achieved to concealed, simple randomization. Participants and study nurses were not blinded, data analyst was blinded. The intervention, including support material was developed. Twelve of 16 invited venous leg ulcer patients were recruited and randomized (control group N=6; intervention group N=6). Participation rate was 75%. The implementation of the intervention was feasible in the clinical setting. The performance of the Venous Leg Ulcer Self Efficacy Tool for measuring adherence to therapy and the Mini Nutritional Assessment and Frequent Food Questionnaire for the assessment of the nutritional intake was satisfactory. However, Fitbit smartwatch for measuring activity was not a suitable device in this study population. The implementation of the designed multidisciplinary educational program was feasible. The pilot study identified weaknesses in the study protocol, which will be amended for the full-size clinical trial. Findings of the pilot study informed the improvement of the design of the main study.

Abstract 5790: An epigenome-wide gene-age interaction analysis reveals opposite effects of PRODH DNA methylation on survival between young and elderly early-stage NSCLC patients

Abstract Introduction: Aging has become a global public health concern. The number of elderly lung cancer patients increased and elderly comprise the majority (81%) of non-small cell lung cancer (NSCLC) patients. DNA methylation is a potential prognostic biomarker for NSCLC, while it is also associated with aging. However, whether the association between DNA methylation and NSCLC survival is modified by aging is not known. Methods: After quality control procedures, we used a two-stage study design to identify DNA methylation-age interaction that associated with overall survival (OS) for early-stage adenocarcinoma (LUAD) and lung squamous cell carcinoma (LUSC) patients from four international collaborating study centers. In the discovery phase, we investigated the interaction effect in LUAD and LUSC using Cox proportional hazards model, adjusted for covariates. We confirmed the significant interactions with Bonferroni adjusted P ≤ 0.05 were further confirmed in the validation phase using The Cancer Genome Atlas (TCGA) database. Results: A total of 1,230 LUAD and LUSC patients were eligible for the study and 311,981 DNA methylation loci were evaluated. There were 613 (NLUAD = 492 and NLUSC = 121) patients in the discovery phase, and 617 (NLUAD = 332 and NLUSC = 285) patients in the validation phase, respectively. We identified one LUAD-specific CpG probe cg14326354PRODH, the effect on OS was significantly modified by age (HRinteraction = 0.989; 95% CI: 0.986-0.994; P = 9.18 × 10−7). The effect of DNA methylation on OS was different in young and elderly patients (young: HR = 2.44; 95% CI: 1.26-4.72; P = 8.34 × 10−3; elderly: HR = 0.58; 95% CI: 0.42-0.82; P = 1.67 × 10−3). Low methylation level benefited elderly LUAD patients. Moreover, there was an antagonistic interaction between low methylation of cg14326354PRODH and elder age (HRinteraction = 0.21; 95% CI: 0.11-0.40; P = 2.20 × 10−6). Conclusion: Low methylation of cg14326354PRODH may benefit the survival of elderly LUAD patients, providing new insight into only age-specific prediction, but also potential methylation-specific drug targeting. Citation Format: Li Su. An epigenome-wide gene-age interaction analysis reveals opposite effects of PRODH DNA methylation on survival between young and elderly early-stage NSCLC patients [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5790.