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Fetal alcohol spectrum disorders (FASD) are alarmingly common, result in significant personal and societal loss, and there is no effective treatment for these disorders. Cerebellar neuropathology is common in FASD and causes aberrant cognitive and motor function. Ethanol induced neuroinflammation is believed to contribute to neuropathological sequelae of FASD, and was previously demonstrated in the cerebellum in animal models of FASD. We now demonstrate neuroinflammation persists in the cerebellum several days following cessation of ethanol treatment in an early postnatal mouse model, with meaningful implications for timing of therapeutic intervention in FASD. We also demonstrate by Sholl analysis that ethanol decreases ramification of microglia cell processes in cells located near the Purkinje cell layer but not those near the external granule cell layer. Ethanol did not alter the expression of anti-inflammatory molecules or molecules that constitute NLRP1 and NLRP3 inflammasomes. Interestingly, ethanol decreased the expression of IL-23a (P19) and IL-12Rβ1 suggesting that ethanol may suppress IL-12 and IL-23 signaling. Fractalkine-fractalkine receptor (CX3CL1-CX3CR1) signaling is believed to suppress microglial activation and our demonstration that ethanol decreases CX3CL1 expression suggests that ethanol modulation of CX3CL1-CX3CR1 signaling may contribute to cerebellar neuroinflammation and neuropathology. We demonstrate ethanol alters the expression of specific molecules in the cerebellum understudied in FASD, but crucial for immune responses. Ethanol increases the expression of NOX-2 and NGP and decreases the expression of RAG1, NOS1, CD59a, S1PR5, PTPN22, GPR37, and Serpinb1b. These molecules represent a new horizon as potential targets for development of FASD therapy.

Diffuse large B-cell lymphoma (DLBCL) encompasses a group of aggressive B-cell non-Hodgkin lymphomas with striking genetic heterogeneity and variable clinical presentations. Among these is primary mediastinal B-cell lymphoma (PMBL), which has unique clinical and molecular features resembling Hodgkin lymphoma. Treatment of DLBCL is usually curative, but identifiable subsets at highest risk for treatment failure may benefit from intensified chemotherapy regimens and/or targeted agents added to frontline therapy. Recent comprehensive genomic analyses have identified distinct genetic subtypes of DLBCL with characteristic genetic drivers and signaling pathways that are targetable. Immune therapy with chimeric antigen receptor T cells and checkpoint inhibitors has revolutionized the treatment of relapsed or refractory disease, and antibody drug conjugates have weaponized otherwise intolerable cytotoxic agents. Ongoing clinical trials are further refining the specificity of these approaches in different genetic subtypes and moving them from the setting of recurrent disease to frontline treatment in high-risk patient populations.

The use of Bruton tyrosine kinase (BTK) inhibitors to block B-cell receptor (BCR)–dependent NF-κB activation in lymphoid malignancies has been a major clinical advance, yet acquired therapeutic resistance is a recurring problem. We modeled the development of resistance to the BTK inhibitor ibrutinib in the activated B-cell (ABC) subtype of diffuse large B-cell lymphoma, which relies on chronic active BCR signaling for survival. The primary mode of resistance was epigenetic, driven in part by the transcription factor TCF4. The resultant phenotypic shift altered BCR signaling such that the GTPase RAC2 substituted for BTK in the activation of phospholipase Cγ2, thereby sustaining NF-κB activity. The interaction of RAC2 with phospholipase Cγ2 was also increased in chronic lymphocytic leukemia cells from patients with persistent or progressive disease on BTK inhibitor treatment. We identified clinically available drugs that can treat epigenetic ibrutinib resistance, suggesting combination therapeutic strategies. Significance: In diffuse large B-cell lymphoma, we show that primary resistance to BTK inhibitors is due to epigenetic rather than genetic changes that circumvent the BTK blockade. We also observed this resistance mechanism in chronic lymphocytic leukemia, suggesting that epigenetic alterations may contribute more to BTK inhibitor resistance than currently thought. See related commentary by Pasqualucci, p. 555. This article is highlighted in the In This Issue feature, p. 549

Nurse practitioner (NP) students are required to have a clear understanding of the complexities of the human body. Students enter graduate studies with varying experiences and backgrounds in anatomy and physiology. Evidence suggests that human anatomy laboratories increase learning outcomes when compared with comparative anatomy modalities. The purpose of this evaluation was to determine if teaching with a computed tomography (CT)-based three-dimensional (3D) anatomy table and cadaveric specimens improves Doctor of Nursing Practice (DNP) and NP students' understanding of anatomy in health assessment. Students participated in a hands-on anatomy review using a 3D anatomy table and human cadavers to master the five included body systems. Presurveys and postsurveys were administered to determine how much time had lapsed since our students' most recent anatomy class and the type of dissection laboratory provided within that class; to assess knowledge confidence in pediatric Head, Eyes, Ears, Nose and Throat (HEENT) anatomy; and to assess students' confidence in pediatric anatomical knowledge for all five body systems. Data were analyzed using a Mann-Whitney U test with independent samples. All areas with the exception of HEENT showed clinically significant improvement, including overall scores. Many positive themes were identified using qualitative thematic analysis. Teaching with a CT-based, 3D anatomy table with cadaveric specimens improved DNP and NP students' confidence levels in pediatric anatomy knowledge for all five systems. This innovative combination of human cadavers and virtual technology has the potential to produce advanced anatomical understanding for prospective health care professionals and to validate their capacity to conduct complex health assessments and procedures.

Primary central nervous system lymphoma (PCNSL) is confined to the brain, eyes, and cerebrospinal fluid without evidence of systemic spread. Rarely, PCNSL occurs in the context of immunosuppression (eg, posttransplant lymphoproliferative disorders or HIV [AIDS-related PCNSL]). These cases are poorly characterized, have dismal outcome, and are typically Epstein-Barr virus (EBV)-associated (ie, tissue-positive). We used targeted sequencing and digital multiplex gene expression to compare the genetic landscape and tumor microenvironment (TME) of 91 PCNSL tissues all with diffuse large B-cell lymphoma histology. Forty-seven were EBV tissue-negative: 45 EBV- HIV- PCNSL and 2 EBV- HIV+ PCNSL; and 44 were EBV tissue-positive: 23 EBV+ HIV+ PCNSL and 21 EBV+ HIV- PCNSL. As with prior studies, EBV- HIV- PCNSL had frequent MYD88, CD79B, and PIM1 mutations, and enrichment for the activated B-cell (ABC) cell-of-origin subtype. In contrast, these mutations were absent in all EBV tissue-positive cases and ABC frequency was low. Furthermore, copy number loss in HLA class I/II and antigen-presenting/processing genes were rarely observed, indicating retained antigen presentation. To counter this, EBV+ HIV- PCNSL had a tolerogenic TME with elevated macrophage and immune-checkpoint gene expression, whereas AIDS-related PCNSL had low CD4 gene counts. EBV-associated PCNSL in the immunosuppressed is immunobiologically distinct from EBV- HIV- PCNSL, and, despite expressing an immunogenic virus, retains the ability to present EBV antigens. Results provide a framework for targeted treatment.

Human status epilepticus (SE) is associated with a pathological reduction in cerebral blood flow termed the inverse hemodynamic response (IHR). Canonical transient receptor potential 3 (TRPC3) channels are integral to the propagation of seizures in SE, and vascular smooth muscle cell (VSMC) TRPC3 channels participate in vasoconstriction. Therefore, we hypothesize that cerebrovascular TRPC3 channels may contribute to seizure-induced IHR. To examine this possibility, we developed a smooth muscle-specific TRPC3 knockout (TRPC3smcKO) mouse. To quantify changes in neurovascular coupling, we combined laser speckle contrast imaging with simultaneous electroencephalogram recordings. Control mice exhibited multiple IHRs, and a limited increase in cerebral blood flow during SE with a high degree of moment-to-moment variability in which blood flow was not correlated with neuronal activity. In contrast, TRPC3smcKO mice showed a greater increase in blood flow that was less variable and was positively correlated with neuronal activity. Genetic ablation of smooth muscle TRPC3 channels shortened the duration of SE by eliminating a secondary phase of intense seizures, which was evident in littermate controls. Our results are consistent with the idea that TRPC3 channels expressed by cerebral VSMCs contribute to the IHR during SE, which is a critical factor in the progression of SE. Fil: Cozart, Michael A.. University of Arkansas for Medical Sciences; Estados Unidos Fil: Phelan, Kevin D.. University of Arkansas for Medical Sciences; Estados Unidos Fil: Wu, Hong. University of Arkansas for Medical Sciences; Estados Unidos Fil: Mu, Shengyu. University of Arkansas for Medical Sciences; Estados Unidos Fil: Birnbaumer, Lutz. Pontificia Universidad Católica Argentina "Santa María de los Buenos Aires". Instituto de Investigaciones Biomédicas. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Investigaciones Biomédicas; Argentina Fil: Rusch, Nancy J.. University of Arkansas for Medical Sciences; Estados Unidos Fil: Zheng, Fang. University of Arkansas for Medical Sciences; Estados Unidos

Background Dilated cardiomyopathy may be heritable but shows extensive genetic heterogeneity. The utility of whole exome sequencing as a first‐line genetic test for patients with dilated cardiomyopathy in a contemporary “real‐world” setting has not been specifically established. Using whole exome sequencing with rigorous, evidence‐based variant interpretation, we aimed to identify the prevalence of a molecular diagnosis in patients with dilated cardiomyopathy in a clinical setting. Methods and Results Whole exome sequencing was performed in eligible patients (n=83) with idiopathic or familial dilated cardiomyopathy. Variants were prioritized for curation in up to 247 genes and classified using American College of Medical Genetics and Genomics–based criteria. Ten (12%) had a pathogenic or likely pathogenic variant. Eight (10%) participants had truncating TTN variants classified as variants of uncertain significance. Five (6%) participants had variants of unknown significance according to strict American College of Medical Genetics and Genomics criteria but classified as either pathogenic or likely pathogenic by other clinical laboratories. Pathogenic or likely pathogenic variants were found in 8 genes (all within tier 1 genes), 2 (20%) of which are not included in a standard commercially available dilated cardiomyopathy panel. Using our bioinformatics pipeline, there was an average of 0.74 variants of uncertain significance per case with ≈0.75 person‐hours needed to interpret each of these variants. Conclusions Whole exome sequencing is an effective diagnostic tool for patients with dilated cardiomyopathy. With stringent classification using American College of Medical Genetics and Genomics criteria, the rate of detection of pathogenic variants is lower than previous reports. Efforts to improve adherence to these guidelines will be important to prevent erroneous misclassification of nonpathogenic variants in dilated cardiomyopathy genetic testing and inappropriate cascade screening.

Rationale and Objectives Competency in ultrasound (US) imaging and US-guided procedures is often difficult for medical students and residents to master. The use of simulation training has been strongly encouraged but the quality of phantom models available for US-guided procedures is limited. As a feasible alternative, we describe the innovative use of a lightly embalmed cadaver for realistic practice of common interventional radiology (IR) procedures prior to direct patient care. Materials and Methods Lightly embalmed cadavers were positioned as patients would be in the IR suite: supine, prone, and erect seated position. Lidocaine was injected and visualized under standard percutaneous techniques and sonographic guidance was used to simulate common US-guided procedures performed in IR including liver biopsy, kidney biopsy, thoracentesis, and vascular access. Results The ability to position cadavers was a key factor that allowed entire procedures to be simulated. Medical students with very limited exposure to US imaging and diagnostic radiology residents with minimal exposure to US imaging successfully completed common US-guided procedures. Arterial and venous vascular access was obtained. Wires were passed and catheters easily placed via both access sites. The texture of the tissue layers provided realistic feedback for the trainees as they advanced the needle or dilated the tissues. Images from each simulated procedure resembled images expected in a living patient. Conclusion Lightly embalmed cadavers are an innovative and feasible tool to simulate common IR US-guided procedures in a realistic fashion for deliberate practice in advance of first-attempt encounters with patients.

Background: Medical practice trends and limitations in trainees’ duty hours have diminished the interest and exposure of nephrology fellows to percutaneous kidney biopsy (PKB). We hypothesized that an integrated nephrology-pathology-led simulation may be an effective educational tool. Materials and methods: A 4-hour PKB simulation workshop (KBSW), led by two ultrasonography (US)-trained nephrologists and two nephropathologists, consisted of 6 stations: 1) diagnostic kidney US with live patients, 2) kidney pathology with plasticine models of embedded torso cross-sections, 3) US-based PKB with mannequin (Blue Phantom™), 4) kidney pathology with dissected cadavers, 5) US-based PKB in lightly-embalmed cadavers, and 6) tissue retrieval adequacy examination by microscope. A 10-question survey assessing knowledge acquisition and procedural confidence gain was administered pre- and post-KBSW. Results: 21 participants attended the KBSW and completed the surveys. The overall percentage of correct answers to knowledge questions increased from 55 to 83% (p = 0.016). The number of “extremely confident” answers increased from 0 – 5% to 19 – 28% in all 4 questions (p = 0.02 – 0.04), and the number of “not at all confident” answers significantly decreased from 14 – 62% to 0 – 5% in 3 out of 4 questions (p = 0.0001 – 0.03). Impact of the imparted training on subsequent practice pattern was not assessed. Conclusion: A novel KBSW is an effective educational tool to acquire proficiency in PKB performance and could help regain interest among trainees in performing PKBs.

Background: Follicular lymphoma (FL) shows marked variation in clinical course including spontaneous regression and histologic transformation (HT). Watchful waiting (W&W) is routinely applied to pts with newly diagnosed FL, but monitoring strategies are not standardized. Pts with progression within 1-2y of diagnosis have worse outcomes, but the biologic basis is unclear and biologic-based classifiers are not routinely applied at diagnosis. Circulating tumor DNA (ctDNA) is a highly tumor-specific biomarker that is prognostic in aggressive B-cell lymphomas, but its ability to serially monitor FL remains undefined. We applied a next-generation sequencing assay to identify tumor clonotypes for serial monitoring of peripheral blood in pts with untreated FL as part of an ongoing prospective clinical trial [NCT03190928]. Methods: Pts with grade I-II or 3A FL are eligible if evaluable disease on CT or FDG-PET, age ≥18, ECOG ≤2, no evidence of HT, and no prior systemic therapy. Pts undergo W&W until they meet uniform protocol-defined treatment criteria and remain on study until second-line therapy. Baseline testing includes labs, peripheral blood flow cytometry, BM biopsy/aspirate, CT and FDG-PET scans, and research biopsy. Pt have clinic visits every 4m for 2y, every 6m in years 3-5, then annually. CT scans are every 8m for 2y, then annually. FDG-PET scans are at baseline, at 2y, and any time of suspected progression. Peripheral blood samples including Streck tubes (plasma) and PBMCs are drawn at each clinic visit and stored. For ctDNA analysis, tumor DNA was amplified from FFPE using locus-specific primer sets for the Ig heavy-chain and light-chain loci along with BCL1/BCL2 translocations (Adaptive Biotechnologies). Amplified products were sequenced and tumor clonotypes were identified in plasma and PBMCs. Serial tracking of ctDNA was done in plasma and blinded to clinical outcomes. Results: 77 pts enrolled between July 2017 and July 2021. Median age was 57 (range 24-83) including 14 (18%) low-risk, 29 (38%) intermediate-risk, and 34 (44%) high-risk by FLIPI. Fourteen (18%) pts had stage I-II disease. Forty-three (56%) pts had monoclonal B-cells on peripheral blood flow cytometry. Twenty-nine (38%) pts progressed requiring frontline therapy including 7 (9%) pts with HT. Twenty-five (32%) pts were monitored ≥2y with no progression including 10 (13%) pts with evidence of at least some spontaneous regression by CT. Twenty (26%) pts were on study for Conclusions: ctDNA quantified from plasma in FL mirrors TMTV. Serial monitoring of ctDNA in patients without therapy demonstrated various patterns of fluctuation, including some patients in which ctDNA became undetectable coincident with spontaneous clinical regressions. ctDNA thus provides a non-invasive platform to monitor the natural history of FL, enabling future studies of tumor immune surveillance in this disease. Figure 1 Figure 1. Disclosures Jacob: Adaptive Biotechnologies: Current Employment, Current equity holder in publicly-traded company. Bagaev: BostonGene Corp.: Current Employment, Current holder of stock options in a privately-held company, Patents & Royalties: BostonGene. Meerson: BostonGene: Current Employment, Current holder of stock options in a privately-held company, Patents & Royalties: BostonGene. Postovalova: BostonGene Corp.: Current Employment, Current holder of stock options in a privately-held company, Patents & Royalties: BostonGene. Kudryashova: BostonGene: Current Employment, Current holder of stock options in a privately-held company, Patents & Royalties: BostonGene. Kotlov: BostonGene Corp: Current Employment, Current holder of stock options in a privately-held company, Patents & Royalties. Fowler: BostonGene: Current Employment, Current holder of stock options in a privately-held company.

Introduction: Immune tolerance and evasion plays a significant role in the pathogenesis of EBV+ lymphoproliferative disorders (LPD) and non-Hodgkin lymphomas (NHL). Programmed cell death protein-1 (PD-1) is a signaling molecule on the surface of T-cells that suppresses the cytotoxic effects of T-cells on tumor cells. PD-L1 expression is a marker of poor prognosis in aggressive lymphomas and most EBV+ LPDs demonstrate high levels of PD-L1 expression. Chronic viral infections, such as EBV, also result in T-cell exhaustion that can be reversed by PD-1 blockade. Nivolumab is a fully human IgG4 monoclonal anti-PD-1 antibody which has demonstrated activity and favorable safety in lymphoid malignancies. We hypothesized that PD-1 blockade may reverse the inactivation of tumor-specific effector T-cells and result in anti-tumor responses in EBV+ LPD and NHL. Methods: Relapsed/refractory (R/R) EBV+ LPD and B-cell NHL pts age ≥ 12y with adequate organ function are eligible. Untreated pts are eligible if EBV+ LPD. Exclusions include prior use of PD-1/PD-L1/PD-L2/CD137/CTLA-4 antibodies, prior solid organ transplant and HIV. Pts with immunodeficiency or autoimmune illness are eligible if not requiring steroids or immunosuppression. CNS involvement is permitted if no seizure activity within 4 weeks of study. Nivolumab 480mg IV is given every four weeks for up to 2y. Pts who achieve CR discontinue nivolumab after 1y of treatment. Baseline evaluation includes CT, PET, MRI brain, flow cytometry of peripheral blood and CSF, BM biopsy along with optional tumor biopsy. CT scans are performed after cycles 3, 6, 13 and 19 and end of treatment (EoT). PET is performed after cycles 1, 3 and EoT. Surveillance CT scans are performed q3m for 1y, q6m for yrs 2-5, and annually thereafter. Results: 9 pts, 7 (78%) R/R and 2 (22%) untreated, enrolled between April 2018 and May 2021; 5 (56%) with EBV+ LPD [4 G1-2 lymphomatoid granulomatosis (LYG) and 1 chronic active EBV disease (CAEBV)] and 4 (44%) with EBV+ NHL (all DLBCL, NOS). Median age was 48y (range 30-63) and all pts (100%) had stage III/IV disease. Four pts (44%) had elevated LDH (all DLBCL). Median baseline CD4 and CD8 count (cells/mcL) was 378 (range 99-984) and 86 (range 22-1237), respectively, for LPD and 190 (range 133-255) and 90 (range 9-630), respectively, for NHL. Median EBV VL at baseline (Log10 IU/mL) was 2.55 (range 0-6.78) and 2.53 (range 0-5.33) for LPD and NHL, respectively. Eight (89%) pts had extranodal disease with pulmonary involvement most common in 6 (67%). Median prior therapies were 1 (range 0-1) and 2 (range 1-4) for LPD and NHL pts, respectively. Three (43%) R/R pts were refractory (i.e., Of 9 pts enrolled, 7 were evaluable for response (1 NHL pt died prior to restaging and 1 NHL pt has not yet been restaged). In 6 measurable pts, tumor reduction was observed in 67% (Fig 1A). ORR and CR rate was 57% (4/7) and 43% (3/7), respectively; 60% (3/5) and 40% (2/5) in LPD and 50% (1/2) and 50% (1/2) in NHL. Median TTR was 3.0m with 3 (75%) of 4 responses ongoing from 6.9m to 35.2m after first response (Fig 1B). Most common adverse events (AEs) (% pts) included maculopapular rash (38%), ALT elevation (25%), AST elevation (25%), CPK elevation (25%) and fatigue (25%). One pt discontinued therapy due to G2 immune-mediated myositis that required prolonged steroid therapy. >G3 AEs included AST elevation in 1 (13%) pt with no G4/G5 or serious adverse events. With a median potential follow up of 12.6m, 12-month PFS and OS was 50.8% (95% CI: 15.7-78.1) and 75.0% (95% CI: 31.5-93.1). In LPD pts, 12-month PFS and OS was 80% (95% CI: 20.4-96.9) and 100%. Three (75%) NHL pts progressed and 2 (50%) died of disease progression. One NHL pt stopped therapy due to apparent disease progression after 2 cycles but later developed CR without further therapy and remains in remission 35.2m after stopping therapy. Conclusion: Nivolumab appears safe in pts with EBV+ LPD and NHL without unexpected toxicities. Preliminary clinical activity, including CRs, is noted in pts with EBV+ LPD and NHL. Additional pts are needed for a better assessment of true activity in these rare entities and correlates of response including PD-1/PD-L1 expression and/or 9p24.1 alterations are ongoing and will be presented at the meeting. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: Nivolumab for EBV+ LPD and EBV+ NHL.

Background: Diffuse large B-cell lymphoma (DLBCL) subtypes have differential response to BTK inhibitors (BTKi). Ibrutinib with R-CHOP improves survival in DLBCL subsets, but toxicity is limiting. Precise characterization of BTKi-responsive tumors enhances pt selection. Acalabrutinib (acala) is a BTKi with activity in DLBCL, but the molecular correlates of acala response are unknown. Circulating tumor DNA (ctDNA) is a prognostic biomarker in DLBCL including early changes during chemotherapy. PhasED-Seq is a novel ctDNA method that lowers the error profile of mutation detection by requiring the concordant detection of two separate mutations on an individual cell-free DNA molecule (Kurtz et al. Nat Biotechnol 2021). We employed a response-adapted study of acala for up to 14d prior to frontline therapy for aggressive B-cell lymphoma to determine the molecular profile of BTKi-responsive tumors. We report preliminary results including dynamic changes in ctDNA from this ongoing trial [NCT04002947]. Methods: Pts with untreated aggressive B-cell lymphoma and any HIV status are eligible if age ≥18, ≥stage 2, PS ≤2, and adequate organ function. Pts with PMBL, unmeasurable lesions, or active CNS disease are excluded. Screening includes labs, CT and FDG-PET, BM, and CSF with flow cytometry. Pts first receive acala 100mg twice daily x 14d. Pts with Results: 34 pts enrolled between August 2019 and July 2021 and completed the acala window. Median age was 64 (range 28-85) including 13 (38%) < 60y, 14 (41%) 61-69, and 7 (21%) ≥70y. Three (9%) pts had HIV and 17 (50%) were high-risk by IPI. The median diagnosis to treatment was 22.5d (4-53). IHC subtypes by Hans included 17 (50%) non-GCB, 16 (47%) GCB, and 1 (3%) T-cell/histiocyte-rich large B-cell lymphoma (TRLBCL). Four (12%) pts were high-grade B-cell lymphoma with MYC and BCL2 and/or BCL6 (HGBL-DH). Fifteen (44%) pts responded to acala during the window, while 19 (56%) pts had no response (Figure 1A). Acala responses were seen across DLBCL subtypes including 7 (47%) pts with non-GCB, 7 (47%) pts with GCB, and 1 (7%) pt with TRLBCL. Twenty pts had RNA sequencing to confirm cell-of-origin including 10 responders which included 7 (70%) GCB, 2 (20%) ABC, and 1 (10%) Unclassified. Notably, 13 (86%) BTKi-responsive tumors were CD10 negative and only 2 (18%) CD10+ tumors were BTKi-responsive. ctDNA dynamics strongly correlated with CT response as the log-fold change in ctDNA (hGE/mL) at the end of the window correlated with change on CT (r=0.75, p=0.0013). Remarkably, ctDNA dynamics after only 7d also correlated with change on CT (r=0.82, p=0.00006)(Figure 1B-C). Interestingly, one pt had improved symptoms and a 20-fold drop in ctDNA, but no corresponding CT changes suggesting that ctDNA changes may precede CT changes in some cases. Twenty-nine (85%) pts completed all planned cycles of therapy while 5 pts stopped chemotherapy early due to myelosuppression (n=3), CHF (n=1), and MI (n=1). Toxicity across 156 cycles was mostly hematologic. G3/G4 neutropenia occurred in 50% and 38% of cycles and febrile neutropenia in 10% of cycles. G3/G4 thrombocytopenia occurred in 22% and 12% of cycles. No increase in infections, atrial fibrillation, or bleeding were observed in pts treated with acala. All 27 pts who completed therapy achieved a CR. Two pts (1 acala responder) have relapsed from CR and 1 pt died of an MI. After a median follow-up of 9.2m the estimated 1-year PFS was 84.9% (95% CI: 58-95). Conclusions: Acalabrutinib prior to frontline therapy has activity in GCB, non-GCB, and HGBL-DH: confirmed by gene expression profiling. CD10+ GCB tumors are mostly acala-resistant. Toxicity is mainly hematologic and manageable across age groups including pts with HIV. ctDNA correlates with CT change and may predict response to targeted agents as early as 7 days. Updated clinical results within genetic subtypes will be presented at the meeting. Figure 1 Figure 1. Disclosures Chabon: Foresight Diagnostics: Current Employment, Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company. Lurain: CTI Biopharma: Research Funding; EMD-Serrono: Research Funding; Merck: Research Funding; BMS-Celgene: Research Funding; Janssen: Research Funding. Bagaev: BostonGene Corp.: Current Employment, Current holder of stock options in a privately-held company, Patents & Royalties: BostonGene. Postovalova: BostonGene Corp.: Current Employment, Current holder of stock options in a privately-held company, Patents & Royalties: BostonGene. Meerson: BostonGene: Current Employment, Current holder of stock options in a privately-held company, Patents & Royalties: BostonGene. Kudryashova: BostonGene: Current Employment, Current holder of stock options in a privately-held company, Patents & Royalties: BostonGene. Kotlov: BostonGene Corp: Current Employment, Current holder of stock options in a privately-held company, Patents & Royalties. Fowler: BostonGene: Current Employment, Current holder of stock options in a privately-held company. Kurtz: Roche: Consultancy; Foresight Diagnostics: Consultancy, Current holder of stock options in a privately-held company; Genentech: Consultancy. Alizadeh: CAPP Medical: Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company; Forty Seven: Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company; Foresight Diagnostics: Consultancy, Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company; Roche: Consultancy, Honoraria; Janssen Oncology: Honoraria; Celgene: Consultancy, Research Funding; Gilead: Consultancy; Bristol Myers Squibb: Research Funding; Cibermed: Consultancy, Current holder of individual stocks in a privately-held company, Current holder of stock options in a privately-held company.

Background: Mantle cell lymphoma (MCL) is a biologically and clinically heterogenous B-cell lymphoma that is generally incurable with standard therapies. Novel targeted agents can disrupt key survival pathways in MCL such as regulation of apoptosis (BCL2: venetoclax), B-cell receptor signaling (BTK: ibrutinib), and NF-κB survival pathways (IRF4/SPIB: lenalidomide). As monotherapy, these agents fail to induce deep responses and doublet/triplet regimens often require continuous or maintenance therapy. ViPOR has been shown to be safe and active in non-MCL NHL pts without significant tumor lysis syndrome (TLS) (Melani et al. Blood. 2020; 136(Supplement 1):44-45). We hypothesized that combining agents that target multiple survival pathways with ViPOR will leverage efficacy and time-limited, cyclic dosing will limit toxicities in MCL. Methods: Relapsed/refractory (R/R) and untreated MCL pts with adequate organ function were eligible. In R/R MCL, a phase I "3+3" design was used to determine the maximum tolerated dose (MTD) of 2 dose-levels of dose-escalated venetoclax (200mg and 400mg) PO D2-14 (starting C2) in combination with fixed-dose ibrutinib 560mg PO D1-14, prednisone 100mg PO D1-7, obinutuzumab 1000mg IV D1-2, and lenalidomide 15mg PO D1-14. A phase II expansion in untreated MCL was included at the MTD. ViPOR q21d x 6C was given without maintenance or consolidation. All pts were admitted C2 for 12d venetoclax escalation and TLS monitoring. All pts received TLS prophylaxis (ppx) with IVFs and allopurinol as well as PCP and G-CSF ppx. VTE ppx was per investigator discretion. Baseline CT, PET, BM, and tumor biopsy was performed with CT scans after cycles 1, 2, 4, and 6 and PET after cycle 6 or at time of suspected complete response (CR). Surveillance CT was performed q3m for 1y, q4m x 1y, q6m x 1y, then annually x 2y. Plasma for ctDNA was collected at baseline, prior to each treatment cycle, at each follow-up visit, and at disease progression. Results: 11 pts have been enrolled and treated; 9 (82%) R/R in dose-escalation and 2 (18%) untreated in dose-expansion. Median age was 71y (range 57-79) with 73% >65y and 64% male. Low, intermediate, and high-risk MIPI occurred in 18%, 64%, and 18% of pts, respectively. Stage IV disease was seen in 91%, with BM involvement in 73%, extranodal disease in 82%, and both in 64%. Disease bulk >5cm occurred in 45% of pts. Blastoid morphology, Ki-67 >30%, and TP53 IHC >50% occurred in 27%, 36%, and 18% of pts, respectively. Median prior therapies in R/R pts was 3 (range 1-4) with 44% receiving prior BTKi, 11% receiving prior CAR-T, and 78% refractory (i.e., No dose-limiting toxicities (DLTs) occurred in 9 evaluable pts in the dose-escalation cohort; thus, venetoclax 400mg was used in expansion. G3-4 heme AEs (% cycles) included neutropenia (13%), anemia (11%), and thrombocytopenia (9%). No cases of febrile neutropenia occurred across 46 total cycles. G3-4 non-heme AEs (% pts) included hypokalemia in 3 (33%) pts as well as fatigue, hypomagnesemia, elevated bilirubin, atrial fibrillation, lung infection, and syncope in 1 (11%) pt each. No laboratory or clinical TLS occurred. Dose reductions and delays occurred in 5% and 15% of cycles, respectively. Of 11 pts enrolled, 10 are evaluable for response (1 pt has not yet been restaged) with an overall response rate (ORR) and CR rate of 100% (10/10) and 80% (8/10), respectively (Fig 1A). Of 8 pts who have completed therapy, all 8 (100%) have achieved CR, including all 4 post-BTKi pts, 1 post-CAR-T pt, and 6 refractory pts. With a median potential f/u of 5.2m, median TTR and DOR was 0.7m and not reached, respectively, with 9 (90%) responses ongoing ranging from 0.3m to 14.5m after first response (Fig 1B). One pt with R/R blastoid MCL relapsed in the CNS 9.9m after initial response. Median PFS and OS were both not reached with 10 (91%) pts alive and progression-free and 1 relapse and death from progression at 11.9m. Conclusion: ViPOR is safe in MCL without significant TLS or DLTs using a 12d venetoclax ramp-up on C2 and venetoclax 400mg was taken forward in expansion. Most common G3-4 AEs were hematologic with no febrile neutropenia observed when given with G-CSF ppx. High preliminary activity is noted in MCL pts with fixed-duration ViPOR x 6C, including CRs in refractory, post-BTKi, and post-CAR-T pts. Molecular and ctDNA analyses are ongoing and will be presented at the meeting. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: Off-label use of ViPOR in relapsed/refractory and untreated MCL.

Background: Secondary CNS B-cell lymphomas (SCNSL) are aggressive lymphomas with a very poor prognosis. Genetic subtypes of DLBCL with CNS tropism are enriched for chronic active B-cell receptor signaling and may respond to BTK inhibition (BTKi). CLL, MCL, and transformed lymphomas can also involve the CNS and are BTKi responsive. TEDDI-R achieves durable remissions in relapsed/refractory primary DLBCL of the CNS (PCNSL) but the profile of SCNSL tumors that are ibrutinib-responsive is unknown. We present preliminary results from a response-adapted trial of ibrutinib with TEDD-R in SCNSL. Methods: Pts with aggressive B-cell lymphomas with secondary CNS involvement are eligible if age ≥18 and adequate organ function. Pts must have relapsed after frontline therapy or can be untreated if brain parenchyma involved. Prior BTKi is allowed, but HIVinfection and EBV+ lymphomas are excluded. Baseline tests include brain MRI, FDG-PET brain and body, CSF with flow cytometry, Ommaya, and eye exam. Pts receive isavuconazole starting at 200mg BID x 3d prior to ibrutinib to prevent fungal infections associated with TEDDI-R and then 200mg daily unless ibrutinib stopped. Pts first receive ibrutinib 560mg daily x 14d in a window. If ≥20% reduction after ibrutinib, pts receive TEDDI-R for 4 cycles every 21d with IT cytarabine. Pts with Results: 16 pts with a median age 67 (range 40-79) enrolled between June 2019 and July 2020. 15 (94%) pts had DLBCL comprising 9 (60%) non-GCB, 5 (33%) GCB, and 1 (7%) transformed from MZL. One pt had plasmablastic lymphoma. Eight (50%) pts had a MYC-rearrangement including 4 (25%) with both MYC and BCL2 or BCL6 rearrangements. Eight (50%) pts had isolated CNS disease and 8 (50%) had synchronous CNS and peripheral disease. All pts relapsed after a median of 2 (range 1-4) prior therapies and all (100%) pts received prior anthracycline. Seven pts (44%) had prior CNS prophylaxis and 8 pts (50%) had prior HD-MTX based salvage therapy. Toxicity was evaluated across 35 cycles. G3 and G4 neutropenia occurred in 49% and 29% of cycles, respectively, while febrile neutropenia occurred in 9% of cycles. The median (range) duration of neutropenia was 6 (1-13) days. Five (14%) cycles were complicated by ≥G3 infection, but no opportunistic infections (including Aspergillus) were observed. One pt developed a bacterial infection during cycle 1 and died. G3 and G4 thrombocytopenia occurred in 34% and 23% of cycles, respectively, and 1 pt developed G3 hematuria. G3 mucositis occurred in 9% of cycles and palmar-plantar-erythrodysesthesia led to dose reductions of liposomal doxorubicin in 5 (36%) pts. Of 15 pts who completed the 14d ibrutinib window and were evaluable, 8 (53%) were ibrutinib-responsive and 7 (47%) were ibrutinib-resistant (Figure 1). Clinical responses were concordant across anatomic compartments; of 8 pts with both CNS and peripheral disease, 5 (63%) responded to ibrutinib in both compartments while 3 (37%) did not respond in either compartment. All 8 ibrutinib responders had a non-GCB phenotype and six (75%) achieved CR. One died of treatment-related toxicity after a PR and 1 is still on therapy. Only two (29%) pts with ibrutinib-resistant tumors achieved PR and none have achieved CR. After a median follow-up of 5.1m, a landmark analysis starting after the ibrutinib window demonstrated the PFS for pts with ibrutinib-responsive compared to ibrutinib-resistant tumors was not reached vs. 0.9m (95% CI: 0.1-2m)(p=0.002)(Figure 2). Conclusions: Patients with SCNSL tumors that are ibrutinib-responsive achieve a high rate of complete response to TEDDI-R in both CNS and peripheral disease. Patients with tumors that are ibrutinib-resistant also respond poorly to TEDD-R. Toxicity is mainly hematologic, and no Aspergillus infections have occurred with the use of isavuconazole prophylaxis. Updated clinical results from this ongoing study (NCT03964090) and will be presented at the meeting. Disclosures No relevant conflicts of interest to declare. OffLabel Disclosure: ibrutinib for use in secondary cns lymphoma as part of a clinical trial

Introduction Follicular lymphoma (FL) has a highly variable clinical course. Chemoimmunotherapy can induce durable remissions, but ~20% relapse early. The PI3K pathway is central to FL biology and multiple PI3K inhibitors (PI3Ki) are approved for FL, but the molecular profile of tumors most sensitive to PI3Ki is unknown. Further, PI3Ki are dosed indefinitely which contributes to toxicity and cost. Copanlisib is an IV inhibitor of PI3Kα and δ isoforms with high activity in relapsed FL. We hypothesized that patients with FL tumors most sensitive to PI3Ki will achieve deep and durable remissions after a fixed duration of copanlisib-based therapy. Here we report preliminary results of a response-adapted study using copanlisib and rituximab as frontline therapy for FL. Methods Pts with untreated grade 1-2, 3A FL, ≥stage 2, and any tumor burden are eligible if they meet criteria for need of systemic therapy that includes symptoms, increasing size of nodes, critical organ involvement, or impending organ compromise. No prior systemic therapy other than radiation is permitted. Frozen or archival tissue is required. Eligibility includes age ≥18 and adequate organ function unless involved by FL. Active HIV, CMV, Hep B or C, and autoimmune conditions requiring therapy are excluded. All pts receive PCP prophylaxis. Pts first receive copanlisib 60mg on days 1, 8, and 15 of a 28-day window to test activity of monotherapy. On-treatment tumor biopsies are optional after the window. Following the window, pts receive 6 cycles of copanlisib 60mg on days 1, 8, and 15 of a 28 day cycle along with rituximab 375mg weekly x 4 then on day 1 of each cycle. Streck tubes for circulating tumor DNA (ctDNA) are collected weekly during the window, after each cycle, and during surveillance. FDG-PET and CT scans are performed at baseline, after the window, and after cycles 3 and 6 to determine response. Patients with complete response (CR) after 6 cycles stop therapy. Patients with partial response (PR) after 6 cycles receive another 6 cycles of combination therapy with the copanlisib reduced to day 1 and 15 of each cycle. Non-responding patients will receive standard chemotherapy. The primary endpoint is the overall rate of CR with secondary endpoints of safety and duration of CR. Exploratory objectives include identification of a signature that predicts PI3Ki response. Results Ten pts have been enrolled and completed the copanlisib window. Median age was 50y (range, 28-77) including 3 (30%) over age 70. Seven (70%) pts had high-risk FLIPI scores ≥3 and two (20%) pts had Grade 3A FL. Comorbid conditions included prediabetes in 4 (40%) and hypertension in 4 (40%). All 10 (100%) pts had tumor reductions during copanlisib monotherapy with a median reduction of 41% (range 16-62%) (Figure 1). Four pts have completed 6 cycles of copanlisib and rituximab and all 4 (100%) have responded including 2 (50%) who achieved CR. In the two pts who achieved a PR after 6 cycles, one had a 90% tumor reduction and one had only persistent minimal residual disease in the bone marrow by flow cytometry. Toxicity was evaluated in 10 pts across 58 cycles and the most common have included rash (50%), diarrhea (50%) and mucositis (40%) which have all been G1 or G2 and successfully managed with supportive care and did not recur with subsequent cycles. One pt developed grade 3 neutropenia that responded to growth factors and did not recur. Four pts had dose delays due to rash (N=3) and lung infection (N=1). One pt had copanlisib reduced to 45mg due to recurrent rash and elevated liver tests. No pt has discontinued therapy. One pt required oral diabetic medications during therapy that were stopped after therapy completed. One pt had asymptomatic PCP pneumonia diagnosed during the copanlisib window prior to starting prophylaxis that was successfully treated while therapy continued. Conclusion Copanlisib is highly active in untreated FL and the first 10 (100%) patients all had tumor reductions after the first cycle of copanlisib monotherapy, including patients with high tumor bulk. Combination of copanlisib and rituximab can induce complete responses after only 6 cycles and without indefinite therapy. The safety profile includes rash and diarrhea that respond to supportive care and lessen on subsequent cycles. Updated clinical results from this ongoing trial (NCT03789240) along with the molecular profile of FL tumors will be presented at the meeting. Disclosures No relevant conflicts of interest to declare.

Background: Primary DLBCL of the CNS (PCNSL) relies on chronic active B-cell receptor (BCR) signaling. Ibrutinib targets BCR signaling through BTK inhibition (BTKi), which may also impair innate immunity. We showed that ibrutinib and temozolomide, etoposide, liposomal doxorubicin, dexamethasone, rituximab (TEDDI-R) induces durable remissions in relapsed/refractory PCNSL but 7 (39%) pts developed Aspergillus infections without fungal prophylaxis. Newer triazoles are effective against Aspergillus but inhibit ibrutinib clearance through CYP3A4. Isavuconazole has less effect on CYP3A4 and less hepatotoxicity than voriconazole. We hypothesized that ibrutinib and isavuconazole could be safely co-administered in TEDDI-R and ameliorate the risk of Aspergillus while maintaining efficacy. We studied escalating doses of ibrutinib in TEDDI-R with isavuconazole to determine the safety profile, ibrutinib PK, and clinical activity in relapsed/refractory PCNSL. Methods: Pts with relapsed/refractory PCNSL, age ≥18, ECOG PS ≤2, and adequate organ function were enrolled. Previous BTKi, HIV, EBV+, and pregnancy were excluded. Pts had baseline MRI brain, FDG-PET brain and body, Ommaya placed, CSF with flow cytometry, and eye exam. Isavuconazole 200mg BID x 3d started prior to ibrutinib then 200mg daily. Three dose levels of ibrutinib (280mg, 420mg, 560mg) were given continuously through each cycle. Pts received up to 6 cycles of TEDDI-R with IT cytarabine. No one received maintenance or consolidation. If a DLT occurred in the first 3 pts at a given ibrutinib dose level, 3 more pts were treated before escalating. Full safety and PK data was reviewed after two dose levels prior to escalating. An expansion of 10 pts was planned at the highest ibrutinib dose level to confirm safety and clinical activity. Surveillance for fungal infections included chest CT mid-cycle 1 and after each cycle along with Beta-D glucan and aspergillus galactomannan in blood and CSF. Brain MRI was performed after cycles 1, 2, 4, and 6 to determine response and screen for CNS Aspergillus. All remissions by MRI were confirmed with FDG-PET and CSF analysis. Surveillance brain MRI were q3m for 1y, q4m x 1y, q6m x 1y, then annually. Primary objective was to identify the highest dose of ibrutinib safely co-administered with isavuconazole in TEDDI-R that achieves adequate PK concentrations. Results: 13 relapsed/refractory PCNSL pts enrolled between 11/2018 and 06/2020. 10 (77%) pts were male and the median age was 65 (range 46-77), including 3 pts ≥age 70. 13 (100%) pts had prior high-dose MTX, and 2 (15%) pts had prior autologous stem cell transplant (ASCT). Three evaluable pts received ibrutinib 280mg, 3 pts received ibrutinib 420mg, and 6 pts received ibrutinib 560mg. One pt in the 280mg cohort was not evaluable. Toxicity was evaluated in 13 pts across 49 cycles and the toxicity was mainly hematologic. G3 and G4 neutropenia occurred in 45% and 37% of cycles, respectively, while febrile neutropenia occurred in 8% of cycles. The median (range) duration of neutropenia was 4.5 (1-12) days. One pt with prior ASCT stopped after 4 cycles due to myelosuppression. Four (8%) cycles were complicated by ≥G3 infection, but no opportunistic infections (including Aspergillus) were observed. G3 and G4 thrombocytopenia occurred in 22% and 8% of cycles, respectively, and 1 pt developed melena with no overt GI bleeding. ≥G3 mucositis occurred in 6% of cycles and 1 patient stopped therapy after 5 cycles due to recurrent mucositis. Palmar-plantar-erythrodysesthesia led to dose reductions of liposomal doxorubicin in 9 (69%) pts, but only 1 G3 event occurred. Twelve pts were evaluable for response, and 11 (92%) pts have responded and all after receiving only 1 cycle (Figure 1). All 8 (100%) pts who have completed at least 4 cycles have achieved CR and the other 4 remain on therapy. Six (75%) pts who achieved CR remain in remission while 2 (25%) pts relapsed within 3 months of stopping therapy. After a median potential f/u of 5.2 months, the 1-year PFS is estimated at 60.0% (95% CI, 12.6-88.2) and the OS is 100%. Conclusions: Ibrutinib 560mg was safely co-administered with isavuconazole in TEDDI-R for relapsed/refractory PCNSL. No DLTs were observed, no cases of Aspergillus occurred, and no new safety signals. The first 8 (100%) patients who have completed therapy achieved complete response. Updated clinical results from this ongoing study (NCT02203526) will be presented at the meeting. Disclosures Lai: Abbvie: Consultancy; Agios: Consultancy; Jazz: Speakers Bureau; Macrogenics: Consultancy; Astellas: Speakers Bureau.

Background: Aggressive B-cell non-Hodgkin lymphoma (NHL) can be cured with chemoimmunotherapy; however, those who fail primary therapy and those with indolent NHL are rarely curable. Targeted agents can disrupt key survival pathways in NHL such as regulation of apoptosis (BCL2: venetoclax), B-cell receptor signaling (BTK: ibrutinib), and NF-κB survival pathways (IRF4/SPIB: lenalidomide). These agents are active as monotherapy but fail to induce deep responses and require continuous therapy. Also, genetically defined subtypes of NHL that best respond to these targeted agents are undefined. Synergistic cytotoxicity has been shown with these targeted therapies and corticosteroids in DLBCL cell lines. We hypothesized that combining agents that target multiple survival pathways will leverage efficacy and time-limited, cyclic dosing will limit toxicities. Methods: Relapsed/refractory (R/R) B-cell NHL pts, excluding MCL and CLL/SLL, with adequate organ function were eligible. A phase I "3+3" design was used to determine the maximum tolerated dose (MTD) of 4 dose-levels (DLs) of dose-escalated venetoclax (200mg, 400mg, 600mg, and 800mg) PO D2-14 (starts cycle 2 for DL1) in combination with fixed-dose ibrutinib 560mg PO D1-14, prednisone 100mg PO D1-7, obinutuzumab 1000mg IV D1-2, and lenalidomide 15mg PO D1-14. A phase II expansion in R/R DLBCL and FL was included at the MTD. Up to 6 cycles of ViPOR every 21-days was given without maintenance. TLS and PCP prophylaxis was given to all pts and VTE prophylaxis and G-CSF use was per investigator discretion. Baseline CT, PET, BM and tumor biopsy was performed with CT scans after cycles 1, 2, 4, and 6 and PET after cycle 6 or at time of suspected CR. Surveillance CT was performed q3m for 1y, q4m x 1y, q6m x 1y, then annually x 2y. Results: 53 pts were enrolled and treated; 17 in dose-escalation and 36 in dose-expansion. NHL subtypes included DLBCL (23), FL (19), HGBCL "double-hit" (9), and MZL (2). Of 32 aggressive pts, 34% transformed from indolent NHL. Median age was 57y (range 29-83) with stage III/IV disease in 89%, elevated LDH in 68%, and >2 EN sites in 57%. Median prior therapies was 3 (range 1-9) with 45% of pts refractory (i.e. A single dose-limiting toxicity (DLT) of G3 intracranial hemorrhage occurred at DL1 with concomitant enoxaparin and ASA. No other DLTs occurred and venetoclax 800mg was used in expansion. Heme AEs (% cycles) were most common and included thrombocytopenia (23%), neutropenia (23%) and anemia (7%). G-CSF was used in 92% of pts and 89% of cycles with only 3 (6%) cases of febrile neutropenia. Non-heme AEs (% pts) were mainly G1-2 and included diarrhea (67%), hypokalemia (56%), nausea (52%), and rash (42%). Most common G3-4 non-heme AEs included hypokalemia (19%), diarrhea (8%), and a.fib/flutter (6%). G4 TLS occurred in 1 pt with HGBCL after the first venetoclax dose and was successfully treated without further TLS upon continued treatment. Dose reductions and delays occurred in 8% and 9% of cycles, respectively. Of 53 total patients, 51 completed 1C of therapy with restaging CT and tumor reduction occurred in 90% of pts overall (Fig 1A). Of 44 pts who are now off therapy, 43 were evaluable for response with an ORR of 70% and 49% CR, with responses across all DLs and NHL subtypes. In 27 pts with aggressive NHL, ORR was 56% with 37% CR. Based on DLBCL subtype by IHC, ORR and CR rate was 62% (8/13) and 54% (7/13) in non-GCB and 50% (7/14) and 21% (3/14) in GCB DLBCL, respectively. In 16 pts with indolent NHL, ORR was 94% with 69% CR. ORR and CR rate was 52% (11/21) and 29% (6/21) in refractory pts and 86% (19/22) and 68% (15/22) in relapsed pts, respectively. ORR was 40% with 30% CR in 10 patients who failed prior CAR-T and completed ViPOR therapy. With a median potential f/u of 13m, median TTR and DOR was 0.8m and NR, respectively, with 25 (69%) of 36 responses ongoing. 5 pts relapsed after CR, including 2 non-GCB at 3m and 6m, 1 HGBCL at 5m, 1 FL at 6m, and 1 MZL at 16m. Median PFS and OS was 9m and NR, respectively; 20m and NR in indolent NHL, 3m and 13m in GCB, and 7m and 13m in non-GCB DLBCL (Fig 1B). Conclusions: ViPOR is safe without unexpected toxicities observed. Most common AEs were hematologic with rare febrile neutropenia and no severe infections observed when given with G-CSF prophylaxis. ViPOR induces durable CRs without maintenance therapy, including refractory and post CAR-T pts. Molecular analyses are ongoing and will be presented at the meeting. Disclosures Portell: Infinity: Research Funding; Roche/Genentech: Consultancy, Research Funding; Xencor: Research Funding; Kite: Consultancy, Research Funding; TG Therapeutics: Research Funding; AbbVie: Research Funding; Pharmacyclics: Consultancy; Janssen: Consultancy; Amgen: Consultancy; Bayer: Consultancy; BeiGene: Consultancy, Research Funding; Acerta/AstraZeneca: Research Funding. OffLabel Disclosure: Off-label use of the combination of venetoclax, ibrutinib, prednisone, obinutuzumab and lenalidomide in relapsed/refractory B-cell non-Hodgkin lymphoma.

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BACKGROUND: Diffuse large B-cell lymphomas (DLBCLs) are phenotypically and genetically heterogeneous. Gene-expression profiling has identified subgroups of DLBCL (activated B-cell-like [ABC], germinal-center B-cell-like [GCB], and unclassified) according to cell of origin that are associated with a differential response to chemotherapy and targeted agents. We sought to extend these findings by identifying genetic subtypes of DLBCL based on shared genomic abnormalities and to uncover therapeutic vulnerabilities based on tumor genetics. METHODS: We studied 574 DLBCL biopsy samples using exome and transcriptome sequencing, array-based DNA copy-number analysis, and targeted amplicon resequencing of 372 genes to identify genes with recurrent aberrations. We developed and implemented an algorithm to discover genetic subtypes based on the co-occurrence of genetic alterations. RESULTS: We identified four prominent genetic subtypes in DLBCL, termed MCD (based on the co-occurrence of MYD88L265P and CD79B mutations), BN2 (based on BCL6 fusions and NOTCH2 mutations), N1 (based on NOTCH1 mutations), and EZB (based on EZH2 mutations and BCL2 translocations). Genetic aberrations in multiple genes distinguished each genetic subtype from other DLBCLs. These subtypes differed phenotypically, as judged by differences in gene-expression signatures and responses to immunochemotherapy, with favorable survival in the BN2 and EZB subtypes and inferior outcomes in the MCD and N1 subtypes. Analysis of genetic pathways suggested that MCD and BN2 DLBCLs rely on "chronic active" B-cell receptor signaling that is amenable to therapeutic inhibition. CONCLUSIONS: We uncovered genetic subtypes of DLBCL with distinct genotypic, epigenetic, and clinical characteristics, providing a potential nosology for precision-medicine strategies in DLBCL. (Funded by the Intramural Research Program of the National Institutes of Health and others.).

Lost circulation is a continual problem associated while drilling and cementing during well construction. The failure to provide adequate cement coverage over loss zones can result in costly remediation and/or fines from regulatory agencies. Traditional losses prior to, or during, cement operations are addressed by loss circulation material (LCM) laden pills pumped ahead of the cement treatment as sweeps or spacers. The LCM pills are limited in volume to the size of the mixing tank and can be an insufficient volume compared to the thief zones. The high concentration of LCM in the pill results in higher rheology and can be difficult to properly displace up the annulus by the cement treatment due to inverse friction hierarchy between fluids. The solution being presented consists of using the cement slurry as the carrying fluid along with an inert engineered solid package. A fiber added on-the-fly improves the plugging efficiency of the engineered solid package and the ability to tailor the treatment design to the well conditions up until the treatment is pumped. The results are tangible, with the solution applied successfully in over 300 treatments for multiple operators in the Permian Basin. The Permian Basin is one of the most developed basins in the world with a complex lithology and layered, highly depleted reservoirs. The solution successful performance has been unprecedented in allowing operators to comply with local regulations, avoid remedial work, and extend the life of the completion across corrosive formations. Application of the engineered solid package with fiber is for loss circulation cases in highly depleted zones, permeable formations, and naturally fracture formations for other basins. The progress thus far has been encouraging with additional optimization of the engineered solid package with fiber application could potentially improve the performance further. The final result will be an improved fluid placement and understanding of the effect LCM has on the carrying fluid.

Summary Total cholesterol and low-density lipoprotein (LDL) cholesterol exhibit an independent, strong, continuous correlation with cardiovascular events. The effectiveness of hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) in the treatment and prevention of atherosclerosis is well-established. However, despite the lowering of LDL targets and the increased use of statins, patients with type 2 diabetes mellitus (DM) continue to experience a higher proportion of adverse coronary artery disease events. This is as a result of an atherogenic dyslipidaemia, characterized by low levels of high-density lipoprotein and elevated plasma triglyceride concentrations, often with high levels of cholesterol-rich remnant particles. This article will review dyslipidaemia and its role in DM, and will discuss available treatment modalities that address residual cardiovascular risk in this disease.

Background: In asthma, measurements of airway inflammation correlate poorly with clinical markers and airway hyperresponsiveness. While the relation between determinants of asthma severity is known, that for cough is unknown. We hypothesised that cough sensitivity changes relate to changes in cough scores and objectively measured cough frequency. Aims: To examine the relation between commonly used outcome measurements of cough severity in children. Methods: The concentration of capsaicin causing two and five or more coughs (C2 and C5 respectively), cough frequency objectively measured using an ambulatory cough meter, and parent and child recorded subjective cough scores were determined in 40 children with recurrent cough on two occasions. Results: On occasion one, log cough frequency significantly correlated with parent and child recorded log cough score (rs = 0.32, p = 0.05; and rs = 0.32, p = 0.046 respectively) and significantly negatively correlated with log C2 (rs= -0.5, p = 0.005). Subjective cough scores did not relate to either C2 or C5. On occasion two, the relation between cough frequency and C2 and C5 measures was lost, but C2 had a weak but significant relation to parent recorded cough score (rs = -0.38, p = 0.047). When the changes in the log values were determined, C5 but not C2 significantly related to cough frequency. Conclusion: In children, measures of cough sensitivity have a weak relation with cough frequency. Subjective cough scores have a stronger and consistent relation with cough frequency. These cough severity indices measure different aspects of cough. The choice of indices depends on the reason for performing the measurement.

Objective: To determine High Dependency Unit (HDU) utilization patterns over time and its impact on Intensive Care Unit (ICU) workload. Design: Retrospective analysis of prospectively collected data. Setting: High Dependency and Intensive Care Units of an Irish University Hospital. Subjects: Data prospectively collected on all HDU admissions was analyzed for the first 6 months of operation and comparable 3-month periods during years 2 and 4. ICU workload was assessed by comparing ICU admissions by speciality, length of ICU stay, and need for ventilatory support before and after HDU opening. Interventions: None Measurements and main results: Demographic data, reason for admission, patient source, admitting speciality, length of HDU stay, and discharge destination were analysed. ICU data included casemix, length of stay, and requirement for ventilatory support. Seventy four percent of HDU admissions were from the cardiothoracic, vascular and general surgical specialities. The mean HDU stay was 2.1 days, wit...

A group of children with a past history of wheezing was randomly selected from the Melbourne community at the age of 7 years in 1964, and a further group of children with severe wheezing was selected from the same birth cohort at the age of 10 years. These subjects have been followed prospectively at 7-year intervals, with the last review in 1999, when their average age was 42 years. Eighty-seven percent of the original cohort who were still alive participated in the 1999 review. This study showed that the majority of children who had only a few episodes of wheezing associated with symptoms of a respiratory infection had a benign course, with many ceasing to wheeze by adult life. Most who continued with symptoms into adult life were little troubled by them. Conversely, those children with asthma mostly continued with significant wheezing into adult life, and the more troubled they were in childhood, the more likely symptoms continued. There was a loss in lung function by the age of 14 years in those with severe asthma, but the loss did not progress in adult life. The childhood asthma had been treated before the availability of inhaled steroids. There was no significant loss of lung function in those with milder symptoms.

Background C225 is an antibody to the epidermal growth factor receptor (EGFR), and inhibits growth of various tumour cells. The antibody is currently being used as a therapeutic agent in several clinical trials of patients with carcinomas. Objectives To determine and investigate the cutaneous side-effects in cancer patients treated with C225. Methods We clinically examined 10 patients treated with C225, and performed immunohistochemical and in situ hybridization studies on skin biopsies. Results The most common cutaneous reaction to C225 therapy was the development of an acneiform follicular eruption, which was most pronounced on the face, chest and upper back and typically manifested a week after the onset of treatment. The consistency of the morphology and timing of the clinical findings in 10 different patients following monotherapy with C225 strongly suggested a direct biological effect of the antibody. Additional dermatological side-effects included focal areas of tender paronychial inflammation of toes and fingers and small aphthous ulcers of the oral mucosa. Serial punch biopsies of chest skin before and after treatment (at 8 days) revealed two main reaction patterns: a superficial dermal inflammatory cell infiltrate surrounding hyperkeratotic and ectatic follicular infundibula, and a suppurative superficial folliculitis. In two biopsies focal intraepidermal acantholysis was found, Microbiological cultures failed to reveal an infectious aetiology. Immunohistochemical and in situ hybridization studies on a subset of the biopsies showed an increase in the expression of p27 Kip1 in epidermal keratinocytes after treatment with C225. Conclusions Our findings support the concept that p27 Kip1 plays a part in the in vivo regulation of follicular and epidermal homeostasis by EGFR.

A cohort of 378 asthmatic children was studied from 7 to 35 yr of age at 7-yr intervals. On selection for inclusion in the study sample, the children had a wide range of severity of wheezing. At each 7-yr review, asthma severity, the presence of eczema or hay fever, and skin test reactivity to house dust mite or rye grass were recorded by questionnaire or clinical interview. We report on the course of asthma and these atopic conditions over the study period and discuss associations between the two phenomena. The presence of an atopic condition in childhood was found to increase the odds of more severe asthma in later life (odds ratio [OR] = 1.66, 95% confidence interval [CI]: 1.17 to 2.36 in the case of eczema; OR = 1. 39, 95% CI: 1.00 to 1.92 for hay fever; and OR = 2.25, 95% CI: 1.49 to 3.39 for skin test reactivity). Additionally, the odds of eczema and hay fever in later life increased with severity of asthma in childhood. The findings of this study provide substantially new quantitative information on the extent of association between asthma and atopic conditions from childhood into middle adulthood.

This study aimed to elucidate the relationship between maternal psychosocial factors related to dietary adherence and growth outcomes in their children with cystic fibrosis (CF). Twenty-five children with CF and mild lung disease, aged 7-12 years, were weighed and measured and completed detailed food records. Mothers completed questionnaires that measured general nutritional knowledge, nutritional knowledge specific to CF, coping strategies, dieting behaviors, self-efficacy about the ability to provide the correct diet, and attitudes and beliefs about CF. Of the cohort, only 16% adhered to the dietary recommendations. Dietary adherence was positively correlated with weight. Maternal nutritional knowledge specific to CF significantly predicted children's dietary adherence score. There was a significant negative correlation between the child's weight and mothers who were dieting successfully. Other psychosocial factors assessed were not related to dietary adherence. Improving the mother's knowledge about nutritional needs in CF appears worthwhile and may have an impact on growth.

Recent advances in polymeric electro-optic materials and device fabrication techniques have significantly increased the potential for incorporation of these materials and devices into modern high bandwidth (fiber and wireless) telecommunication, information processing, and radar systems. Charge transfer π-electron chromophores characterized by molecular first hyperpolarizability (second order optical non-linearity) values approaching 3000×10 –30 esu have been synthesized. Elucidation of the role of intermolecular electrostatic interactions in inhibiting the efficient translation of molecular optical non-linearity to macroscopic electro-optic activity has permitted systematic modification of materials to achieve electro-optic coefficients approaching 100 pm V –1 . Improvements in the optical loss of polymeric materials at wavelengths of 1.3 and 1.55 µm have been effected. Mode matching of passive transmission and active electro-optic waveguides has been addressed, permitting a dramatic reduction in insertion loss. The putative ability of polymeric electro-optic materials to be efficiently integrated with very large scale integration semiconductor electronic circuitry and with passive optical circuitry has been demonstrated. Several devices of varying degrees of complexity have been fabricated and evaluated to operational frequencies as high as 150 GHz. The operational stability of polymeric devices is very competitive with devices fabricated from lithium niobate and gallium arsenide.

Limited data in children with cystic fibrosis (CF) suggest that respiratory viral infections during infancy result in substantial morbidity. Eighty of 101 (79%) infants with CF diagnosed by neonatal screening during 1991–1996 were recruited into a prospective, multiple-birth cohort study. We aimed to perform an initial, then annual bronchoalveolar lavage (BAL) for bacterial and viral culture, cytology, IL-8, and elastolytic activity over the following 2 years. When possible, BAL was also performed during any hospitalization for a pulmonary exacerbation, and additional specimens for viral culture were collected by nasopharyngeal aspiration. Thirteen infants undergoing bronchoscopy for congenital stridor served as disease controls. During infancy, 31 children (39%) were hospitalized for respiratory disease and 20 (65%) cases had an etiologic agent identified. Respiratory viruses were detected in 16/31 (52%) cases, including four with simultaneous bacterial infection. Another four were infected with Staphylococcus aureus. Respiratory syncytial virus predominated and was found in seven infants. In the absence of bacteria, those with viral infections had acute onset of respiratory distress, were not treated with antibiotics, and had an uncomplicated hospital course. Compared to noninfected CF subjects and controls, infected infants had elevated BAL inflammatory indices (P < 0.01). Eleven of 31 (35%) hospitalized infants followed for 12–60 months acquired Pseudomonas aeruginosa, compared with only three of 49 (6%) subjects not hospitalized for respiratory symptoms during infancy (risk ratio 5.8, CI 1.9, 24). We conclude that respiratory viruses are important causes of hospitalization in CF infants. While viral infections were self-limited, they were accompanied by airway inflammatory changes, and admission to hospital was associated with early acquisition of Pseudomonas aeruginosa and persistent respiratory symptoms. Pediatr Pulmonol. 1998; 26:371–379. © 1998 Wiley-Liss, Inc.

Objectives: To determine the clinical effects of a change from postural drainage (PD) to positive expiratory pressure chest physiotherapy (PEP) in children with cystic fibrosis (CF) and symptoms of gastro-oesophageal reflux (GOR). To measure the effects of PD on GOR in children with CF. Methods: Study 1: Six adolescents with CF and symptoms of GOR during PD were changed to upright PEP physiotherapy. The effects on lung function, reflux symptom scores and annual hospital days were measured. Study 2: Twenty-four children with CF (mean age 11 years) and symptoms suggestive of GOR underwent 24-h pH monitoring, including periods of chest physiotherapy. Results: Study 1: All six patients reported a reduction in reflux symptoms during PEP therapy (P

This study evaluated adherence to current dietary recommendations of children with cystic fibrosis and mild lung disease and their siblings by comparing energy intake. Fifty children (25with cystic fibrosis) aged between 7 and 12 years completed the study. Energy intake was assessed by weighed dietary intake, resting energy expenditure was used to calculate recommended daily intakes. The children with cystic fibrosis had significant deficits in Z scores for both height and weight compared with their siblings, but there was no difference in percentage of ideal weight for height. The cystic fibrosis group had a significantly higher energy intake per kilogram body weight per day but there was no difference in the percentage of energy derived from fat, protein or carbohydrate. Energy intake (per kg/day) and fat intake (g/kg) were both significant predictors of weight for height in the cystic fibrosis group. Targets for dietary management in cystic fibrosis should perhaps be related to fat intake per kilogram body weight.

Objective: The aim of this study was to determine current Australian practice for the nutritional management of cystic fibrosis (CF) and compare it to USA and UK guidelines. Methodology: A structured questionnaire was completed by dietitians from 15 major CF centres. It was estimated that these centres manage or co-manage 84% of Australians with CF. Results: There was close agreement between UK and USA guidelines and Australian practice for dietary intervention strategies, nutritional monitoring and surveillance, and electrolyte replacement. Infant feeding practices were more closely aligned with the UK. There were some differences in the areas of pancreatic enzyme replacement therapy, vitamin requirements in CF and dietary management of CF- related diabetes. Conclusions: Despite the lack of formal agreement, nutritional management practices of most Australian centres are closely aligned with current published international recommendations. However, there is need for consensus in the area of enzyme replacement therapy, management of CF-related diabetes and vitamin supplementation based on optimal clinical outcomes.

OBJECTIVE: To estimate the prevalence of asymptomatic Mycobacterium tuberculosis infection in Melbourne secondary school students. DESIGN: Cross-sectional Mantoux testing of a partly random and partly targeted sample of secondary school students, designed to enable estimation of prevalence by region of birth. SETTING: Fifty-one State and Catholic secondary schools in metropolitan Melbourne during 1995. PARTICIPANTS: Australian and overseas-born students in Years 9 and 10. OUTCOME MEASURES: Proportions of students with positive Mantoux reactions (defined as induration at 48 hours of > or = 5 mm with a history of recent exposure; > or = 10 mm and no prior BCG vaccination; > or = 15 mm and prior BCG vaccination). RESULTS: Of 2586 students potentially eligible for testing, evaluable results were obtained from 1274 (49%). The overall prevalence of infection for Melbourne students in Years 9 and 10 was 2.5% (95% CI, 1.1-3.9%). Main predictors of a positive test were birth overseas and number of years residing overseas. Prevalence varied considerably by region of birth, and was very low in students born in Australia (0.7%), "other developed countries" (0.7%), and Southern Europe (0). The highest rates were observed in students born in Indochina (15.9%), other countries in South East Asia (10.2%), and Eastern Europe (10.2%). CONCLUSIONS: The risk of a young person becoming infected with M. tuberculosis while living in Melbourne is very low. Our results do not indicate a need for the reintroduction of mass screening in Victorian schools. If targeted screening were to be considered, the group most likely to benefit would be recently arrived migrants from Indochina.

AIM—To establish the incidence of pathological gastro-oesophageal reflux (GOR) in newly diagnosed infants with cystic fibrosis and to identify clinical predictors of increased reflux. METHODS—26 infants with cystic fibrosis less than 6 months of age (14 male, 12 female; mean (SEM) age 2.1 (0.21) months, range 0.8to 5.6 months) underwent prolonged oesophageal pH monitoring (mean duration 27.1 (0.49) hours; range 21.3 to 30.2 hours). Reflux symptoms, anthropometric variables, pancreatic status, meconium ileus, genotype, and chest x ray findings were correlated with pH monitoring data. RESULTS—Five infants (19.2%) had an abnormal fractional reflux time of greater than 10%, seven (26.9%) of 5-10%, and 14 (53.8%) of below 5%. Infants who presented with frequent vomiting had a significantly higher fractional reflux time than infants who had infrequent or no vomiting. There was no significant association between abnormal chest x rays and pathological GOR. Sex, genotype, nutritional status, meconium ileus, and pancreatic enzyme supplementation were not significantly associated with pathological GOR. CONCLUSIONS—About one in five newly diagnosed infants with cystic fibrosis had pathological GOR. Pathologically increased reflux was present before radiological lung disease was established. Apart from frequent vomiting, no useful clinical predictors of pathological reflux were found.

Airway inflammation is an important component of cystic fibrosis (CF) lung disease. To determine whether this begins early in the illness, before the onset of infection, we examined bronchoalveolar lavage (BAL) fluid from 46 newly diagnosed infants with CF under the age of 6 mo identified by a neonatal screening program. These infants were divided into three groups: 10 had not experienced respiratory symptoms or received antibiotics and pathogens were absent in their BAL fluid; 18 had clear evidence of lower respiratory viral or bacterial (or = 10(5) CFU/ml) infection; and the remaining 18 had either respiratory symptoms, taken antibiotics, or had10(5) CFU/ml of respiratory pathogens. Their BAL cytology, interleukin-8, and elastolytic activity were compared with those from 13 control subjects. In a longitudinal study to assess if inflammation develops or persists in the absence of infection, the results of 56 paired annual BAL specimens from 44 CF infants were grouped according to whether they showed absence, development, clearance, or persistence of infection. In newly diagnosed infants with CF, those without infection had BAL profiles comparable with control subjects while those with a lower respiratory infection had evidence of airway inflammation. In older children, the development and persistence of infection was accompanied by increased inflammatory markers, whereas these were decreased in the absence, or with the clearance, of infection. We conclude that airway inflammation follows respiratory infection and, in young children, improves when pathogens are eradicated from the airways.

BACKGROUND: Cough is a major symptom in some children with asthma. The relationship between cough and the severity of asthma is ill defined. A study was undertaken to test the hypotheses that, in children with asthma who cough as a major part of their asthma symptoms, cough receptor sensitivity (CRS) is heightened during an acute severe exacerbation of asthma but not in the non-acute phase and airway calibre or its change correlates with CRS. METHODS: Spirometric measurements and the capsaicin CRS test were performed on children admitted to hospital for an acute severe exacerbation of asthma. Nasal secretions were tested for viruses. The children were grouped into those who usually cough with asthma episodes and those who do not. The tests were repeated 7-10 days and 4-6 weeks later. The CRS outcome measure used was the concentration of capsaicin required to stimulate two (Cth) and five coughs (C5). RESULTS: The CRS of the group who coughed (n = 15) was significantly higher than those who did not cough (n = 16) (mean difference log Cth 0.77 mumol (95% CI 0.35 to 1.18), C5 0.72 mumol (95% CI 0.26 to 1.18)) during acute asthma but not after the exacerbation. CRS was not significantly different between groups based on the presence of a viral infection. Neither forced expiratory volume in one second (FEV1) nor its change correlated with CRS nor its change. CONCLUSIONS: In children with asthma CRS is heightened in acute severe asthma in the subgroup of children who have cough as a significant symptom with their asthma episodes. In acute and non-acute asthma CRS does not correlate with FEV1.

We tested the hypothesis that the composition of bronchial surfactant is normal in infants with cystic fibrosis (CF) in the absence of active lung disease but that it is altered by lower respiratory tract infection and inflammation. We examined the total phospholipid (PL), disaturated phospholipid (DSP), surfactant protein-A (SP-A), surfactant protein B (SP-B), and surface activity in bronchoalveolar lavage fluid from 27 subjects with CF whose mean age was 22.7 (SD 14.5) mo. Six infants with stridor served as non-CF controls. Twelve of the subjects with CF (CF-I group) had evidence of active pulmonary infection or inflammation which was absent in the remaining 15 subjects (CF-NI group). We found no differences in the surfactant composition or activity between controls and the CF-NI group. In contrast, the DSP/PL ratio was lower in the CF-I subjects than in both the CF-NI subjects (p = 0.05) and controls (p < 0.01) suggesting a disturbance of surfactant function. SP-A concentrations were higher in the CF-I group compared to the other two groups (p < 0.05). These results suggest that the bronchial surfactant of infants with CF is altered following lower airway infection and inflammation and is not a primary abnormality associated with this disorder.

Recurrent cough and asthma are common problems in children. In the evaluation of children with recurrent cough, the sequential measurements of airway responsiveness (AR) and capsaicin cough receptor sensitivity may be useful. However, the effect of capsaicin on AR induced by an indirect stimulus such as hypertonic saline (HS) is not known. Current evidence suggests that a common pathway is involved in both capsaicin and HS challenges. This study was designed to determine whether inhalation of capsaicin for the cough receptor sensitivity test before HS challenge will alter AR of asthmatic and non-asthmatic children to that challenge. Twenty-one children (12 asthmatics, 9 non-asthmatics; mean age, 11.3 years) performed the HS challenge alone or 2 min after capsaicin inhalation on 2 different days in random order. The end point of the capsaicin inhalation was when > or = 5 coughs were stimulated from a single inhalation. The power of the study was > 90% at a significance level of 0.05. Capsaicin inhalation prior to HS challenge did not alter the AR of normal children. In the asthmatic group, the PD15 (provocation dose causing a fall in forced expiratory volume in 1 s of > or = 15% from the baseline) without prior inhalation of capsaicin (mean, 2.44 +/- SEM 1.21 ml) was not significantly different from that when HS challenge was performed after capsaicin inhalation (mean, 2.19 +/- SEM 0.83 ml). The mean of the difference in log PD15 of the HS challenge with and without capsaicin was -0.02 (95% CI, -0.16, 0.12), i.e. within the equivalence range of the HS challenge in children with asthma. We conclude that in normal and asthmatic children, capsaicin inhalation does not alter AR to HS; consequently the capsaicin cough sensitivity test can be performed validly before an HS challenge.

In children, recurrent cough is a common presenting symptom that may represent asthma. We tested the hypotheses that children with recurrent cough have increased cough-receptor sensitivity (CRS) or airway hyperresponsiveness (AHR). Skin prick testing, the capsaicin CRS test, and hypertonic saline (HS) challenge were performed in 44 children (median age: 8.9 yr) with recurrent dry cough (> or = 2 episodes of cough, each lasting > or = 2 wk, within a period of 12 mo) and 44 controls. Measures of CRS were the concentration of capsaicin required to stimulate > or = 2 coughs (Cth) and > or = 5 coughs (C5). During the coughing period, Cth (mean log: 0.62 [95% CI: 0.43 to 0.81]) and C5 (mean log: 1.15 [95% CI: 0.86 to 1.44]) of the subjects without AHR were significantly lower (p = 0.0026, 0.027, respectively) than Cth (mean log: 1.27 [95% CI: 0.88 to 1.66]) and C5 (mean log: 1.79 [95% CI: 1.21 to 2.37]) of the subjects with AHR and those of the controls (p = 0.0002 and 0.0001). During the cough-free period, there was no difference in CRS among the groups. In subjects who demonstrated AHR, the provocation dose causing a > or = 15% fall in FEV1 (PD15) during the cough period was significantly lower (p = 0.005) than that during the cough-free period. We conclude that AHR or increased CRS is present during the coughing phase in children with recurrent cough.