ALBERT

Description: Introduction Emerging research suggests key differences in clinical manifestations among people with hemophilia A (HA) and hemophilia B (HB) that may impact health-related quality of life (HRQoL), healthcare utilization and costs. However, HB's low prevalence hinders obtaining study cohorts large enough to be representative and avoid selection bias. This analysis of the Hematology Utilization Group Studies (HUGS) cohorts examined over a 2-year period (1) baseline pain, joint range of motion (ROM), and HRQoL (2) clinical characteristics and treatment outcomes, and (3) costs of care and service utilization among a geographically diverse sample of individuals with HB and HA. Materials and Methods HUGS part Va (enrolling HA) and HUGS part Vb (enrolling HB) are US multicenter observational studies conducted at hemophilia treatment centers (HTCs) serving patients from 15 states. HUGS Va was conducted 2005-2007; HUGS Vb 2009-2014. This analysis included 350 participants with complete medical records and ≥2 follow-up surveys: 243 with HA and 107 with HB. Children (age 2-17 years) and adults (age 18-64 years) were followed prospectively. Mean ages at baseline were 21.3 (HA) and 24.5 (HB); 70% of HA participants were severely affected, as were 46% with HB. HUGS collected data through an initial, in-person interview with participants or parents after informed consent; regularly scheduled web-, mail-, or phone-based follow-up questionnaires; and clinical chart review conducted by HTC staff. Treatment utilization and costs were annualized including direct and indirect costs. Medication cost was obtained from payment allowance limits for Medicare Part B. Costs were adjusted for inflation to reflect costs in 2019. We compared continuous variables using Wilcoxon-Mann-Whitney and Chi-square or Fisher's exact test for categorical variables. Results Quality of Life and Clinical Measures Both severe adults HA (mean±SD: 40.7±10.4) and HB (42.6±11.4) showed lower SF-12 physical composite score than the general US population (50±10). Severe HB children had mean 6 points greater physical health summary score than severe HA children. Pain and joint ROM limitation were reported less often by those with severe HB (63% and 58%, respectively), compared to those with severe HA (81% and 77% respectively). Among HB children with severe hemophilia, 12% reported pain compared to 28% with HA. Joint ROM limitation was reported in 8% of HB children, compared to 16% with HA. HB children having half the burden than HA on reported pain and joint ROM limitation. Median annualized missed work days were significant lower in the HB group (3) than HA (7), P

Description: Autophagy maintains hematopoietic stem cell integrity and prevents malignant transformation. In addition to bulk degradation, selective autophagy serves as an intracellular quality control mechanism and requires autophagy receptors, such as p62 (SQSTM1), to specifically bridge the ubiquitinated cargos into autophagosomes. Here, we investigated the function of p62 in acute myeloid leukemia (AML) in vitro and in murine in vivo models of AML. Loss of p62 impaired expansion and colony-forming ability of leukemia cells and prolonged latency of leukemia development in mice. High p62 expression was associated with poor prognosis in human AML. Using quantitative mass spectrometry, we identified enrichment of mitochondrial proteins upon immunoprecipitation of p62. Loss of p62 significantly delayed removal of dysfunctional mitochondria, increased mitochondrial superoxide levels, and impaired mitochondrial respiration. Moreover, we demonstrated that the autophagy-dependent function of p62 is essential for cell growth and effective mitochondrial degradation by mitophagy. Our results highlight the prominent role of selective autophagy in leukemia progression, and specifically, the importance of mitophagy to maintain mitochondrial integrity.

Description: Background: Allogeneic hematopoietic stem cell transplantation (HSCT) is a potentially curative therapy for pediatric patients with hematologic malignancies. Historically, matched sibling donors (MSD) have been the preferred donor source given ease of availability and lower rates of graft-versus-host-disease (GVHD). However, only 30% of patients have a MSD and relapse rates are high after MSD HSCT, raising the question of best donor choice. As conditioning regimens evolve, GVHD management improves and supportive care advances, it is important to evaluate the role of donor source on short and long-term clinical outcomes to inform donor selection. We performed a single-center retrospective analysis comparing post-HSCT outcomes in a cohort of pediatric patients undergoing MSD, matched unrelated donor (MUD), and umbilical cord blood (CB) transplants from 2006 to 2018. Methods: A retrospective analysis was performed on an IRB-approved protocol through Fred Hutchinson Cancer Research Center. 232 patients were included who received MSD (n=56), MUD (n=89) or CB (n=87) transplants. Of note, 24 CB patients received expanded CB cells in addition to unmanipulated unit(s). GVHD prophylaxis in all patients consisted of a calcineurin inhibitor and MMF or methotrexate. The vast majority received a high-intensity conditioning regimen (86%, 96%, and 82% respectively for MSD, MUD and CB). Overall survival (OS) and disease-free survival (DFS) were evaluated using the Kaplan-Meier method. Probabilities of non-relapse mortality (NRM), relapse, and acute GVHD were evaluated using cumulative incidence (CI) estimates with appropriate competing risks. The Cox regression model was used for adjusted analysis for age, year of transplant, sex, CMV status, MRD status, disease risk, and conditioning regimen. Results: Patient/treatment/donor demographics are shown in Table 1. Median follow-up was 2.6, 3.7 and 3.1 years for MSD, MUD and CB respectively. Patient diagnosis, disease risk, gender, age, and CMV serology were balanced between groups. CI of engraftment was similar as well, with only one graft failure in the MUD group (Fig 1). Median time to platelet recovery was significantly faster in MUD and MSD groups as compared to the CB group (p

Description: Introduction Acute vaso-occlusive pain crises are the most common complications of sickle cell disease (SCD). Pain is a subjective sensation and is often difficult to describe and for practitioners to understand. The complexity and multidimensional nature of pain requires additional evaluation beyond pain intensity. Pain assessment is also influenced by implicit and explicit biases related to race and ethnicity which can negatively influence treatment (Wandner et al J Pain 2012). In this pilot quality improvement study, we studied resident perceptions to a functional assessment tool in adult patients hospitalized with sickle cell vaso-occlusive crises. We used the Youth Acute Pain Functional Ability Questionnaire (YAPFAQ), a validated questionnaire of physical function in youth experiencing acute pain (Zempsky et al J Pain 2014) (Figure 1). Resident responses to using the YAPFAQ were measured as an initial step to implementation of functional pain assessment in hospitalized adults with SCD pain crises. Methods We piloted this study on internal medicine residents. First, residents completed the Resident Acute SCD Pain Assessment Survey regarding their current management of acute pain in SCD (Figure 2). This was done to determine their baseline demographic information, methods of pain assessment, satisfaction with the numerical pain score system, and to understand barriers in assessing acute pain. This survey included a combination of multiple choice, free response, and binary response options. The residents then trialed the YAPFAQ with a patient admitted with vaso-occlusive pain crisis then the residents completed The Post YAPFAQ Evaluation Survey in response to this assessment tool (Figure 3). This survey included a combination of multiple choice, free response, and binary response options. The goal of this survey was to assess resident satisfaction with YAPFAQ, perceived patient receptiveness to YAPFAQ, and feasibility of using this tool during daily assessments. Patients were not surveyed during this pilot study. We performed descriptive statistics to describe the survey results. Results Sixteen residents completed the Acute SCD Pain Management survey prior to using the YAPFAQ. Sixty-nine percent of residents reported dissatisfaction with using numerical pain scores. Reported barriers to assessing pain included: subjectivity of pain scores, concern for malingering, and the ceiling effect of the numeric scale. Seven residents completed the post YAPFAQ evaluation survey. A majority of residents (86%) were extremely satisfied or satisfied with using the YAPFAQ. Fifty seven percent of residents felt that patients were extremely receptive or receptive to using this tool. The majority of residents (85%) felt that the YAPFAQ improved their understanding of patients' pain. All YAPFAQs were completed with patients in 10 minutes or less. Most residents (57%) reported that the tool would be feasible for implementation on rounds. Conclusions Similar to previous studies, our residents felt that numerical pain score systems inadequately describe pain. Residents had generally positive responses to the YAPFAQ. One resident stated that the questionnaire was "structured and easy to compare day to day." Functional pain assessment allows providers to better understand how pain limits daily activities and can provide useful functional targets for safe hospital discharge. Future directions of this project include performing a larger study of patients hospitalized with vaso-occlusive pain crises to validate the YAPFAQ in adult patients, survey patients regarding experiences with the YAPFAQ, and to create tailored pain management plans based on functional pain assessments. Disclosures No relevant conflicts of interest to declare.

Description: Chimeric antigen receptor (CAR) T cells have shown impressive results in refractory B-cell malignancies. Unfortunately, to date, commercially available cells, as well as most products tested in clinical trials, are autologous CAR T cells whose widespread use is limited by the logistical and financial burdens related to their ad hoc generation. The development of universal allogeneic CAR T cell products to be used off-the-shelf across MHC-barriers has faced major limitations, namely the risk of Graft-versus-Host-Disease (GvHD) induction and the rejection of the administered cells by the host immune system. Invariant Natural Killer-T (iNKT) cells are innate lymphocytes that are deprived of any GvHD induction potential but that display antitumor effects both directly, through the production of cytotoxic effector molecules, and indirectly, through the enhancement of NK and CD8 T cell-mediated immune responses. Preclinical studies using xenogeneic mouse models have demonstrated the feasibility of using iNKT cells as a platform for CAR-based therapies, and two clinical trials are currently ongoing. In order to study the interaction of CD19-specific iNKT CAR cells with the host immune system, we transduced iNKT cells ex vivo expanded from FVB/N mice with a CAR composed of the variable region cloned from the 1D3 hybridoma recognizing murine CD19 linked to a portion of the murine CD28 molecule and to the cytoplasmic region of the murine CD3-ζ molecule. The cytotoxic potential of CD19-iNKT CAR was confirmed in an in vitro cytotoxic assay against the CD19-expressing A20 lymphoma cell line, revealing a strong, dose dependent cytotoxic effect of CD19-CAR iNKT cells. Accordingly, and similarly to what was previously reported in xenogeneic studies, FVB/N (H-2Kq) derived iNKT CAR (2x10e6 cells iv) significantly improved survival of mice after administration to major histocompatibility complex (MHC)-mismatched, immunodeficient BALB/c (H-2Kd) Rag2-/- gamma-chain-/- mice receiving A20 cells (2x10e4 cells iv; Figure 1A) without inducing any signs of GvHD. To test the efficacy of iNKT CAR cells in the presence of host immune cells, we tested the antitumor activity mediated by iNKT CAR against A20 cells in BALB/c mice receiving sublethal irradiation (4.4 Gy), resulting in only a partial and transient lymphopenia. In this model, the antitumor effect of iNKT CAR cells was greatly enhanced, leading to long-term survival of the great majority of treated mice (Figure 1B). Such a difference in iNKT CAR effect between mice that genetically lacked lymphocytes and mice with only partial lymphopenia suggested the participation of host derived lymphocytes in the antitumor effect. To test the hypothesis that host CD8 T cell activation via cross-priming could at least partially mediate the indirect antitumor effect of iNKT CAR cells, we repeated the experiment, employing as recipients BALB/c BATF3-/- mice, in which CD8 T cell cross-priming is impaired as a result of the absence of BATF3-dependent CD103+ CD8a+ dendritic cells that are thought to present antigens through CD1d to the invariant T cell receptor expressed by iNKT cells. Interestingly, the iNKT CAR effect was partially abrogated in A20-receiving BATF3-/- mice as compared to WT mice (Figure 1C), supporting the hypothesis that the impact of iNKT CAR cells is mediated at least partially by the activation of host CD8 T cells via their cross-priming. To formally demonstrate the synergistic effect between allogeneic iNKT CAR and autologous CD8 T cells, we employed an autologous bone marrow transplantation model, co-administering allogeneic iNKT CAR with autologous CD8 T cells at the time of transfer of T-cell-depleted autologous bone marrow cells and A20 lymphoma cells into lethally irradiated (8.8 Gy) BALB/c recipients. Co-administration of allogeneic iNKT CAR and autologous CD8 T cells resulted in a synergistic effect, significantly extending animal survival (Figure 1D) compared to mice receiving no treatment, as well as to mice receiving either allogeneic iNKT or autologous CD8 T cells alone. Collectively, these results represent the first demonstration of an immune adjuvant effect exerted by an allogeneic CAR cell product toward the autologous immune system of the host, suggesting that the effect of the administered cells would last longer than the physical persistence of the allogeneic cells after they will be rejected by the host immune system. Figure 1 Disclosures Mackall: Obsidian: Research Funding; Lyell: Consultancy, Equity Ownership, Other: Founder, Research Funding; Nektar: Other: Scientific Advisory Board; PACT: Other: Scientific Advisory Board; Bryologyx: Other: Scientific Advisory Board; Vor: Other: Scientific Advisory Board; Roche: Other: Scientific Advisory Board; Adaptimmune LLC: Other: Scientific Advisory Board; Glaxo-Smith-Kline: Other: Scientific Advisory Board; Allogene: Equity Ownership, Membership on an entity's Board of Directors or advisory committees; Apricity Health: Equity Ownership, Membership on an entity's Board of Directors or advisory committees; Unum Therapeutics: Equity Ownership, Membership on an entity's Board of Directors or advisory committees.

Description: INTRODUCTION: Brentuximab vedotin (Bv) is an antibody-drug conjugate with a CD30-directed antibody linked to the antitubulin agent monomethyl auristatin E (MMAE) which selectively induces apoptosis in CD30-positive malignant Reed-Sternberg cells. The use of Bv is thought to increase the possibility of cure and potentially avoid exposure to subsequent toxic therapies, therefore it is not surprising that Bv is becoming increasingly important in the treatment of Hodgkin lymphoma (HL). Bv has been studied in pediatric patients with relapsed/refractory HL and is currently under investigation as frontline therapy in high risk HL. However, little has been reported on the tolerability and treatment-related toxicity of Bv in the pediatric population. Here we report our experience with Bv in a small cohort of patients and report on the toxicities observed. METHODS: We retrospectively evaluated the toxicity of Bv in children and adolescents with HL. Patients that received Bv either at the time of first diagnosis or relapse were included. Patient characteristics, treatment regimens including cumulative doses of Bv, toxicity and time to toxicity were collected. RESULTS: Ten patients with biopsy proven Hodgkin Lymphoma received treatment with Bv from 2015 to 2019 (Figure 1). Three patient received Bv as part of frontline therapy at the time of diagnosis. Of those, one received Bv for relapse therapy during re-induction and after autologous stem-cell transplant (ASCT). Seven patients received Bv for relapse/progressive disease. Of those 1 received it during re-induction therapy for relapse; 2 during re-induction and consolidation after ASCT; and 4 as consolidation after ASCT only. Five (50%) of the 10 patients developed Bv related toxicities. One patient experienced grade 3 neutropenia causing increased interval between doses. Two patients experienced dyspnea. One of them had mild dyspnea with exertion one month after he completed 16 doses of consolidative Bv. The other one had severe dyspnea with a decrease in pulmonary function (FCV 46, FEV1 〈 50) when compared to baseline pulmonary function test (FCV 74, FEV1 of 70 at diagnosis with mediastinal mass). This patient did not receive any additional doses of Bv. Both of those patient received radiation therapy to the mediastinum during front-line treatment. One patient experienced grade 3 motor and sensory neuropathy requiring Bv to be discontinued at cycle 13. Neuropathy resolved four months after cessation of Bv. One patient had a grade 3 hypersensitivity reaction after second dose of Bv used as re-induction treatment for refractory HL. No clear association between the number of doses of Bv and toxicities was observed. Overall, we found severe neuropathy to be the most significant toxicity. CONCLUSIONS: Our retrospective review highlights that the use of Bv either as frontline, re-induction therapy after relapse or as consolidative treatment following ASCT in children and adolescent patients, carries risk for toxicities. Some of these toxicities have significant impact in the quality of life such as neuropathy and dyspnea. Its use should be implemented with caution and monitored closely for toxicities. Ultimately, prospective studies are needed to evaluate and understand the acute and long term toxicities of the use of Bv in the treatment of HL either in the frontline, re-induction or consolidative therapy. Disclosures No relevant conflicts of interest to declare.

Description: We examined the impact of total body irradiation (TBI) dose and fractionation on risk of subsequent malignant neoplasms (SMNs) in the era of reduced-intensity and nonmyeloablative conditioning regimens for hematopoietic cell transplantation (HCT). Among 4905 1-year survivors of allogeneic HCT for hematologic malignancies (N = 4500) or nonmalignant disorders (N = 405) who received transplants between 1969 and 2014, we identified 581 SMNs (excluding squamous and basal cell of skin) in 499 individuals. With a median length of follow-up of 12.5 years, the cumulative incidence of SMNs by 30 years after HCT was 22.0%. Compared with age-, sex-, and calendar year–matched Surveillance, Epidemiology, and End Results (SEER) population rates, the standardized incidence ratio (SIR) of SMNs was increased 2.8-fold. The highest SIRs were for SMNs of bones (SIR, 28.8), oral cavity (SIR, 13.8), skin (SIR, 7.3), central nervous system (SIR, 6.0), and endocrine organs (SIR, 4.9). The highest excess absolute risks (EARs) were seen with breast cancer (EAR, 2.2) and cancers of the oral cavity (EAR, 1.5) and skin (EAR, 1.5) per 1000 person-years. The highest incidence of SMNs was in survivors exposed to unfractionated (600-1000 cGy) or high-dose fractionated (1440-1750 cGy) TBI. For patients receiving low-dose TBI, the incidence was comparable to myeloablative chemotherapy alone, although still twofold higher than in the general population. These data demonstrate a strong effect of TBI dose, dose fractionation, and risk of SMNs after HCT. The cumulative incidence of SMNs increases with follow-up time; thus, HCT survivors require lifetime monitoring for early detection and effective therapy of SMNs.

Description: The continent-to-ocean supply of phosphorus (P) in the soluble state, recognized as bioavailable P, via the atmosphere is hypothesized to be crucial to the biological cycle in offshore surface seawater. To investigate the solubility of P in aerosol particles moving towards the northwestern Pacific from the Asian continent, we measured the total P (TP), total dissolved P (TDP) and dissolved inorganic P (DIP) in aerosols at Qingdao (36∘06′ N, 120∘33′ E), a coastal city in eastern China. The samples were collected in December 2012 and January 2013 (winter) and in March and April 2013 (spring), when the middle-latitude westerly wind was prevailing. On average, P solubility, i.e., the ratio of TDP to TP, was 32.9±16.7 % in winter and 21.3±9.8 % in spring, and the TP concentrations in the two seasons were similar. This seasonal solubility difference is attributed to the aerosol sources containing the P. Particles in winter were predominantly anthropogenic particles from local and regional areas, and particles in spring were significantly influenced by natural dust from the arid and semiarid areas in the inland part of the continent. Moreover, acidification processes associated with the formation of sulfate and nitrate in the winter samples enhanced P solubility, suggesting that the P in anthropogenic particles was more susceptible to the production of acidic species than that in natural dust particles. There was a strong positive correlation between P solubility and relative humidity (RH). P solubility was usually less than 30 % when RH was below 60 %, even when the content of acidic species and/or anthropogenic particles in the aerosols was high, suggesting humidity had a critical role in the production of TDP. In addition, the proportion of DIP in TDP was high when the particles were predominantly anthropogenic, and the proportion of dissolved organic P (DOP; quantified as TDP minus DIP) in TDP was high when the particles were dominated by natural dust. These results indicate that, as the contents of bioavailable P in Asian continent outflows are closely dependent on the aerosol particle origins, atmospheric acidic processes could convert P into a bioavailable state under certain meteorological conditions. Therefore, the recent severe air pollution over East Asia might have enhanced the input of bioavailable P to downwind marine areas.