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OBJECTIVES: To report the epidemiology, treatments, and outcomes of adult patients admitted to the ICU after cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome. DESIGN: Retrospective cohort study SETTING: Nine centers across the U.S. part of the chimeric antigen receptor-ICU initiative. PATIENTS: Adult patients treated with chimeric antigen receptor T-cell therapy who required ICU admission between November 2017 and May 2019. INTERVENTIONS: Demographics, toxicities, specific interventions, and outcomes were collected. RESULTS: One-hundred five patients treated with axicabtagene ciloleucel required ICU admission for cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome during the study period. At the time of ICU admission, the majority of patients had grade 3–4 toxicities (66.7%); 15.2% had grade 3–4 cytokine release syndrome and 64% grade 3–4 immune effector cell-associated neurotoxicity syndrome. During ICU stay, cytokine release syndrome was observed in 77.1% patients and immune effector cell-associated neurotoxicity syndrome in 84.8% of patients; 61.9% patients experienced both toxicities. Seventy-nine percent of patients developed greater than or equal to grade 3 toxicities during ICU stay, however, need for vasopressors (18.1%), mechanical ventilation (10.5%), and dialysis (2.9%) was uncommon. Immune Effector Cell-Associated Encephalopathy score less than 3 (69.7%), seizures (20.2%), status epilepticus (5.7%), motor deficits (12.4%), and cerebral edema (7.9%) were more prevalent. ICU mortality was 8.6%, with only three deaths related to cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome. Median overall survival time was 10.4 months (95% CI, 6.64–not available mo). Toxicity grade or organ support had no impact on overall survival; higher cumulative corticosteroid doses were associated to decreased overall and progression-free survival. CONCLUSIONS: This is the first study to describe a multicenter cohort of patients requiring ICU admission with cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome after chimeric antigen receptor T-cell therapy. Despite severe toxicities, organ support and in-hospital mortality were low in this patient population.

Background and aim The use of endoluminal flow diversion in bifurcation aneurysms has been questioned due to the potential for complications and lower occlusion rates. In this study we assessed outcomes of endovascular treatment of intracranial sidewall and bifurcation aneurysms with flow diverters Methods In July 2020, a literature search for all studies utilizing endoluminal flow diverter treatment for sidewall or bifurcation aneurysms was performed. Data were collected from studies that met our inclusion/exclusion criteria by two independent reviewers and confirmed by a third reviewer. Using random-effects meta-analysis the target outcomes including overall complications (hematoma, ischemic events, minor ischemic stroke, aneurysm rupture, side vessel occlusion, stenosis, thrombosis, transient ischemic stroke, and other complications), perioperative complications, and follow-up (long-term) aneurysm occlusion were intestigated. Results Overall, we included 35 studies with 1084 patients with 1208 aneurysms. Of these aneurysms, 654 (54.14%) and 554 (45.86%) were classified as sidewall and bifurcation aneurysm, respectively, based on aneurysm location. Sidewall aneurysms had a similar total complication rate (R) of 27.12% (95% CI, 16.56%–41.09%), compared with bifurcation aneurysms (R, 20.40%, 95% CI, 13.24%–30.08%) (p = 0.3527). Follow-up angiographic outcome showed comparable complete occlusion rates for sidewall aneurysms (R 69.49%; 95%CI, 62.41%–75.75%) and bifurcation aneurysms (R 73.99%; 95% CI, 65.05%–81.31%; p = 0.4328). Conclusions This meta-analysis of sidewall and bifurcation aneurysms treated with endoluminal flow diverters demonstrated no significant differences in complications or occlusion rates. These data provide new information that can be used as a benchmark for comparison with emerging devices for the treatment of bifurcation aneurysms.

Coccidioidomycosis, or Valley Fever (VF), is a potentially lethal fungal infection that results in more than 200 deaths/year in the United States. Differential diagnosis and timely treatment of VF is made difficult due to presentation of vague symptoms that often mimic other pulmonary conditions. Accurate diagnosis therefore relies on a combination of clinical presentation, serology, radiography, histology and culture. These diagnostic methods are either costly, time‐consuming, invasive, or indeterminate. Previous studies have used MS‐based methods for the accurate diagnosis of similar fungal diseases as well as characterization of host‐fungal interactions. Herein, we present the first targeted plasma and urine liquid chromatography tandem mass spectrometry (LC‐MS/MS) profiling approach for the relatively non‐invasive, rapid and accurate detection of VF. In this targeted approach, 207 plasma metabolites and 231 urine metabolites were reliably detected using LC‐MS/MS. These metabolites, which are representative of more than 35 metabolic pathways of potential biological relevance, were monitored in 59 plasma samples and 88 urine samples acquired from excess clinical specimens taken from two groups of patients (48 VF patients and 99 non‐VF controls) at Mayo Clinic Arizona. Univariate and multivariate statistical analyses were performed to develop predictive plasma and urine biomarker panels. Pathway and enrichment analyses were performed to elucidate potential pathogenic mechanisms and therapeutic targets. Results of our univariate significance testing and multivariate model estimation informed the construction of a 3‐metabolite panel of plasma biomarkers ( q < 0.05 and VIP > 2; Fig 1) and a 9‐metabolite panel of urinary biomarkers ( q < 0.05 and VIP > 1; Fig 2). Receiver operating characteristic (ROC) curves (Fig 3) generated based on enhanced orthogonal partial least squares‐discriminant analysis (OPLS‐DA) models (Fig 4) showed excellent overall classification performance (99.5%), with 94.4% sensitivity and 97.6% specificity for plasma metabolites. Although urine metabolites were less accurate (92.5%), demonstrating 89.7% sensitivity and 88.1% specificity, they represent a substantial increase in diagnostic accuracy over currently available urinary antigen tests, which only report sensitivity of around 70%. Pathway analysis (Fig 5) and enrichment analysis (Fig 6) ubiquitously showed alterations in metabolic pathways related to fungal virulence, DNA/RNA synthesis and energy utilization, and host immune escape mechanisms. These results potentially reveal pathways or markers that could be targeted therapeutically. This study is the first‐ever MS‐based metabolomics approach for rapid and highly accurate diagnosis of VF. Support or Funding Information Support from the College of Health Solutions at Arizona State University, Arizona Biomedical Research Council (ABRC) grant# 16–162513 and American Achievement Rewards for College Scientists (ARCS) Foundation Award is gratefully acknowledged. This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal .

Forensic anthropologists are often tasked with determining skeletal age‐at‐death to assist law enforcement in identifying skeletal remains. If the remains are skeletally mature, degenerative changes in articular surfaces are typically assessed to determine age. If the skeleton is immature tooth eruption, dental development, and/or epiphyseal union are used to estimate age. Forensic anthropologists derive an age‐at‐death estimate by comparing our assessment of skeletal age indicator(s) to standards derived from skeletal collections of known age‐at‐death. Prior to the establishment of modern skeletal collections such at the William M. Bass Donated Collection at the University of Tennessee, anthropologists developed age estimation techniques using late 19 th and early 20 th century anatomical collections (e.g. the Hamann‐Todd Osteology Collection at the Cleveland Museum of Natural History and Terry Anatomical Collection at the Smithsonian Institution). However, research on Bass Collection skeletons has demonstrated remarkable changes in skeletal morphology in modern Americans compared to early 19 th century birth cohorts, illustrating that standards derived from modern populations are imperative for forensic casework; anatomical collections and archaeological samples are not appropriate reference samples. Age estimation in forensic casework is further complicated by the age distribution of the forensic case population. Forensic cases often involve accidental deaths, homicides, and suicides of individuals from a younger age demographic than natural deaths which comprise many of the reference samples used to derive age estimates. This difference between the age distribution of the reference sample and that of the “target” population leads to ‘age mimicry’, whereby skeletal age‐at‐death may be under‐estimated. This presentation will highlight research that illustrates the impact of secular change and reference sample composition on the accuracy and precision of forensic skeletal age‐at‐death estimation. The documentation of significant changes in skeletal morphology illustrates what evolutionary biologists already know—phenotype is dynamic, not static. These short‐term evolutionary changes in skeletal form have implications for anatomical research beyond the hard tissues. Support or Funding Information National Institute of Justice This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal .

Injections of local anesthetic in the fascial planes around the quadratus lumborum muscle (QL blocks) are performed for postoperative pain control after abdominal surgeries. Multiple approaches of injecting anesthetic in and around the QL have been reported (anterior, posterior, transmuscular, intramuscular and lateral QL blocks). These techniques vary in terms of ease of administration and extent of analgesia. The extent of the anesthetic spread from this ultrasound‐guided procedure is influenced by the fascial layers surrounding the QL. A limited number of studies on small samples using varying amounts of anesthetic have left open questions regarding the extent of spread of local anesthetic and the best approach. This study evaluates the local anesthetic spread of two ultrasound‐guided lateral QL block approaches that have proven effective in controlling postoperative pain. A methylene blue‐dyed saline solution (40mL per QL block) is injected into fresh frozen cadavers (n=10). With the patient in supine position, the needle tip is placed at either (1) the anterolateral border of the QL deep to the transversalis fascia or (2) anterior to the transversus abdominus muscle superficial to its aponeurosis. Anatomic dissection of the injection plane is then performed to determine the extent of spread of the dyed saline. We hypothesize that the continuity between the transversalis fascia and the anterior layer of the thoracolumbar fascia (anterior to the QL) facilitates the cranial spread of the anesthetic under the lateral arcuate ligament to the endothoracic fascia. This would explain our observed analgesic effect past the umbilical region to dermatomes in the epigastric region (T7–T8). Understanding how QL fascial planes facilitate anesthetic spread will enable intraoperative administration of these blocks to be tailored to specific procedures and facilitate post‐operative recovery after abdominal operations. Improved methods of intraoperative pain management may reduce post‐operative opioid use and support the medical community in addressing the opioid epidemic in the United States. This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal .

Nagarse (N) is traditionally used to isolate mitochondria (mito) from skeletal muscle (SM). We investigated the effects of N on functional parameters of mechanically liberated mito. Mito from mouse (n = 7) gastrocnemius muscle (119‐175 mg tissue) was isolated using a glass on glass homogenizer followed by differential centrifugation. The 800g supernatant from the first centrifugation, containing mito, was divided into two equal volumes. One was exposed to N and the other was not. In each volume, mito were isolated by standard differential centrifugation. State 3 max ADP‐stimulated O 2 consumption rates (J o ) were measured using polarography with malate + pyruvate + glutamate. N increased state 3 J o , 16.1 ± 1.1 vs. 11.9 ± 1.4 nmol O 2 / ml mito suspension / min; P < 0.004, while it decreased protein concentration in the final mito suspension (typically used to adjust final J o values), 1.9 ± 0.1 vs. 2.5 ± 0.1 mg / ml; P < 0.004. Citrate synthase activity in the final mito suspension, indicative of the available mito, was not different in the preparation treated with N vs. that not treated with N (0.067 ± 0.01 vs. 0.065 ± 0.01μmol / min; P = 0.8). These findings suggest that N treatment: 1) hydrolyzes non‐mito contaminating proteins in the final mito pellet, and 2) induces apparent qualitative changes in mito function. Therefore, calculated functional parameters of mito treated with N are not directly comparable to mito not treated with N. Grant Funding Source : Supported by NIH/NIDDK RO1 DK094062

8030 Background: CARTITUDE-1 is a single arm study of Ciltacabtagene autoleucel (cilta-cel; JNJ-68284528) anti-BCMA CAR-T cell therapy in US patients (pts) with relapsed multiple myeloma (RRMM) refractory to both IMiD and proteasome inhibitor (PI) or with at least 3 prior lines of therapy and previously exposed to anti-CD38 monoclonal antibody (MoAb). While recently reported efficacy results of cilta-cel were encouraging, it is unknown how they compare with similar pts receiving conventional (non CAR-T) treatment. Methods: We utilized a contemporary US-based dataset of pts with MM refractory to anti-CD38 MoAb (MAMMOTH) to identify pts who would meet eligibility for CARTITUDE-1 and who received conventional therapy. We analyzed the intent-to-treat population (ITT) in CARTITUDE-1, defined as pts who underwent apheresis (N=113) and a modified ITT population (mITT) defined as subset of pts who received cilta-cel at the RP2D (N=97). From the MAMMOTH dataset, we identified a population corresponding to CARTITUDE-1 ITT (N=190) and a mITT population, pts without death or progression within 47 days (median time between apheresis and cilta-cel infusion) from onset of therapy (N=122). We calculated propensity scores (PS) with demographics, N of prior therapies, cytogenetics and refractoriness to MM agents as covariates. An analyst blinded to outcomes performed nearest neighbor 1:1 PS matching. We analyzed overall response rate (ORR), progression-free (PFS) and overall survival (OS) for ITT and mITT in CARTITUDE-1 vs matching MAMMOTH cohorts. Results: Ninety-five ITT (75 received bridging therapy, 82 received cilta-cel) and 69 mITT (54 received bridging) CARTITUDE-1 pts matched MAMMOTH pts (Table). Among the pts in the MAMMOTH ITT cohort 34% received pomalidomide, 24% anti-CD38 MoAb, 19% carfilzomib and 35% cytotoxic chemotherapy in next therapy. ORR in the ITT cohorts was higher in CARTITUDE-1 (84% vs. 28%). Compared to their MAMMOTH counterparts, pts in CARTITUDE-1 ITT cohort had improved PFS (12 mo. 73% vs. 12%) and OS (12 mo. 83% vs 39%). Between the mITT cohorts, CARTITUDE-1 pts had superior ORR (96% vs. 30%), PFS (12 mo 79% vs. 15%) and OS (12 mo. 88% vs. 41%). Conclusions: In pts with RRMM beyond therapy with IMID, PI, and anti-CD38 MoAb, treatment with cilta-cel is associated with higher response rate and superior PFS and OS when compared to conventional treatment.[Table: see text]

e18518 Background: Initiatives enhancing equitable oncologic care are an increasingly emphasized priority. Our study aims to identify aspects of breast cancer (BC) care in which differences exist based on insurance coverage status. Methods: We performed a retrospective, case control study consisting of 39 Hispanic ethnicity uninsured patients (UP) with newly diagnosed BC at federally qualified health centers and 119 insured patients (IP) diagnosed at Mayo Clinic Arizona (MCA). Patients were matched 3:1 for age, stage, year of diagnosis, ER and HER2 status. Demographic information, clinical variables, and zip code level specific socioeconomic information were compared. Continuous variables were compared by Wilcoxon rank-sum test and categorical variables by chi-square test. All patients ultimately received their cancer treatment at MCA. Results: Similar treatment patterns with chemotherapy, surgery, and radiation treatment were observed between groups. Primary language was Spanish for 94% of UP and English for 97.5% of IP. The majority of UP were of Hispanic ethnicity (97.4%); IP were 83.2% non-Hispanic White, 9.2% Hispanic, 3.4% African American. Zip code level information reflected more unemployment with a median of 10.6% versus 6.9% p ˂ 0.001, percent of high school or lower (53.0 % v 23.2 %, p ˂ 0.001), and lower income for UP (33733.5 v 64728.0 p values ˂ 0.001). UP BMI was significantly higher (30.6 V 24.7, p=0.005), with presence of more co-morbidities; diabetes (28.2% v 5.0%, p ˂ 0.001), hypertension (35.9 % v 20.2%, p= 0.046), dyslipidemia (28.2% v 12.6%, p = 0.023), metabolic syndrome (p 23.7% v 8.5, p= 0.013), and tobacco use (17.9% v 2.5%, p ˂ 0.001). IP had higher alcohol use (52.9% v 5.3%, p ˂ 0.001). Genetics consultation was performed for 62.2% IP versus 35.9% UP (p=0.004), lower acceptance of oncology nutrition consultation for UP (29.4% vs 7.4%, p= 0.024) Median time from abnormal mammogram to biopsy (25.5 days vs. 14 days, p=0.056), and interval from diagnosis to treatment (62 days vs. 39 days) (p=0.001) were less favorable for UP compared to IP. Conclusions: In comparing the status of UP (primarily Hispanic, Spanish-speaking) and IP (primarily non-Hispanic White, English-speaking) with newly diagnosed BC we identified greater prevalence of co-morbidities and adverse social determinants of health in the former group. We identified access to genetic counseling services, access to oncology nutrition consultation, and timeliness of diagnostic biopsy and initiation of treatment as disparate features in the care pathway. These observations can allow development of tailored interventions to achieve greater equity in delivery of BC care.

4009 Background: IDH1/2 genetic aberrations (GA) occur in 20% of IHCC cases and may be specifically targeted by IDH inhibitors. The genomic and immunologic profile of IHCC with IDH1/2 GA remains undefined. IDH1 mutations impair DNA damage repair (DDR), loss of heterozygosity (LOH) and may represent a biomarker for DDR in these patients. Methods: Comprehensive genomic profiling (CGP) was performed in 3,067 cases of advanced stage IHCC using a hybrid capture-based FDA-approved assay. Tumor mutational burden (TMB) was determined on 0.8 Mbp of sequenced DNA and microsatellite instability (MSI) was determined on 95 loci. PD-L1 expression in tumor cells (Dako 22C3) was measured by immunohistochemistry (IHC). Genomic LOH (gLOH) was assessed for samples meeting quality criteria. Densities of tumor associated immune cells and immune-checkpoint markers expressed in epithelial malignant cells and in the tumor microenvironment of 100 surgical samples from 96 patients were evaluated by IHC using digital image analysis of 14 markers (CD3, CD4, CD8, CD68, PD1,PD-L1, B7-H4, B7-H3, IDO1, ICOS, VISTA, OX40, TIM3, LAG3). Tissue microarrays were generated for multiplex immune panel analysis. A p value < 0.05 was considered statistically significant. Results: 426 (14%) of IHCC were IDH1+ and 125 (4%) were IDH2+ (Table) and were mutually exclusive. All IDH1 GA occurred at the R132 locus and included R132C (69%) and R132L/G/S/H/F (16%/7%/4%/3%/ < 1%) and 119Q ( < 1%) and IDH2 GA at R172 (94.4%) and R140 (6.6%). IDH1+ and IDH2+ IHCC had fewer co-occurring targetable GA than IDH1/2 wildtype (WT, IDHwt) cases including FGFR2 rearrangements (RE) (P <.0001), ERBB2 (P =.0009) and BRAF (P =.04). Median gLOH were not significantly different between IDH1+ IDH2+ IHCC vs. IDHwt IHCC (p = 0.37). Potential biomarkers of immune checkpoint inhibition (ICI) response including MSI High, TMB > 10 mut/Mb, and PD-L1 positivity were more frequent in IDHwt IHCC than IDH1+ IHCC. 29/96 (30%) surgical patients were positive for IDH1/2 mutation though mutational status did not confer a statistically significant difference in the 14 immune biomarker panel expression. Conclusions: CGP reveals significant differences in GA between IDH1+, IDH2+ and IDHwt IHCC consistent with IDH1 and IDH2 being driver oncogenes for IHCC. Immune biomarker expression and gLOH did not differ significantly between IDH mutated and WT cases.[Table: see text]