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MiR-181 expression levels increased in hepatocellular carcinoma (HCC) compared to non-cancerous tissues. MiR-181 has been widely reported as a possible driver of tumourigenesis but also acts as a tumour suppressor. In addition, the miR-181 family regulates the development and function of immune and vascular cells, which play vital roles in the progression of tumours. More complicatedly, many genes have been identified as miR-181 targets to mediate the effects of miR-181. However, the role of miR-181 in the development of primary tumours remains largely unexplored. We aimed to examine the function of miR-181 and its vital mediators in the progression of diethylnitrosamine-induced primary liver cancers in mice. The size of liver tumours was significantly reduced by 90% in global (GKO) or liver-specific (LKO) 181ab1 knockout mice but not in hematopoietic and endothelial lineage-specific knockout mice, compared to WT mice. In addition, the number of tumours was significantly reduced by 50% in GKO mice. Whole-genome RNA-seq analysis and immunohistochemistry showed that epithelial-mesenchymal transition was partially reversed in GKO tumours compared to WT tumours. The expression of CBX7, a confirmed miR-181 target, was up-regulated in GKO compared to WT tumours. Stable CBX7 expression was achieved with an AAV/Transposase Hybrid-Vector System and up-regulated CBX7 expression inhibited liver tumour progression in WT mice. Hepatic CBX7 deletion restored the progression of LKO liver tumours. MiR-181a expression was the lowest and CBX7 expression the highest in iClust2 and 3 subclasses of human HCC compared to iClust1. Gene expression profiles of GKO tumours overlapped with low-proliferative peri-portal-type HCCs. Liver-specific loss of miR-181ab1 inhibited primary liver tumour progression via up-regulating CBX7 expression, but tumour induction requires both hepatic and non-hepatic miR-181. Also, miR-181ab1-deficient liver tumours may resemble low-proliferative periportal-type human HCC. Graphical abstract

Myelodysplastic syndromes (MDSs) represent a heterogeneous group of hematological stem cell disorders with an increasing burden on health care systems. Evidence-based MDS guidelines and recommendations (G/Rs) are published but do not necessarily translate into better quality of care if adherence is not maintained in daily clinical practice. Guideline-based indicators (GBIs) are measurable elements for the standardized assessment of quality of care and, thus far, have not been developed for adult MDS patients. To this end, we screened relevant G/Rs published between 1999 and 2018 and aggregated all available information as candidate GBIs into a formalized handbook as the basis for the subsequent consensus rating procedure. An international multidisciplinary expert panel group (EPG) of acknowledged MDS experts (n = 17), health professionals (n = 7), and patient advocates (n = 5) was appointed. The EPG feedback rates for the first and second round were 82% (23 of 28) and 96% (26 of 27), respectively. A final set of 29 GBIs for the 3 domains of diagnosis (n = 14), therapy (n = 8), and provider/infrastructural characteristics (n = 7) achieved the predefined agreement score for selection (>70%). We identified shortcomings in standardization of patient-reported outcomes, toxicity, and geriatric assessments that need to be optimized in the future. Our GBIs represent the first comprehensive consensus on measurable elements addressing best practice performance, outcomes, and structural resources. They can be used as a standardized instrument with the goal of assessing, comparing, and fostering good quality of care within clinical development cycles in the daily care of adult MDS patients.

While direct allorecognition underpins both solid organ allograft rejection and tolerance induction, the specific molecular targets of most directly alloreactive CD8+ T cells have not been defined. In this study, we used a combination of genetically engineered major histocompatibility complex class I (MHC I) constructs, mice with a hepatocyte-specific mutation in the class I antigen-presentation pathway, and immunopeptidomic analysis to provide definitive evidence for the contribution of the peptide cargo of allogeneic MHC I molecules to transplant tolerance induction. We established a systematic approach for the discovery of directly recognized pMHC epitopes and identified 17 strongly immunogenic H-2Kb-associated peptides recognized by CD8+ T cells from B10.BR (H-2k) mice, 13 of which were also recognized by BALB/c (H-2d) mice. As few as 5 different tetramers used together were able to identify a high proportion of alloreactive T cells within a polyclonal population, suggesting that there are immunodominant allogeneic MHC-peptide complexes that can account for a large component of the alloresponse.

The quality of T cell responses depends on the lymphocytes' ability to undergo clonal expansion, acquire effector functions, and traffic to the site of infection. Although TCR signal strength is thought to dominantly shape the T cell response, by using TCR transgenic CD4

While direct allorecognition underpins both solid organ allograft rejection and tolerance induction, the specific molecular targets of most directly-alloreactive CD8+ T cells have not been defined. In this study, we used a combination of genetically-engineered MHC class I (MHC I) constructs, mice with a hepatocyte-specific mutation in the class I antigen-presentation pathway and immunopeptidomic analysis to provide definitive evidence for the contribution of the peptide cargo of allogeneic MHC I molecules to transplant tolerance induction. We established a systematic approach for the discovery of directly-recognised pMHC epitopes, and identified 17 strongly immunogenic H-2Kb-associated peptides recognised by CD8+ T cells from B10.BR (H-2k) mice, 13 of which were also recognised by BALB/c (H-2d) mice. As few as five different tetramers used together were able to identify a high proportion of alloreactive T cells within a polyclonal population, suggesting that there are immunodominant allogeneic MHC-peptide complexes that can account for a large component of the alloresponse.

The quality of T cell responses depends on the lymphocytes’ ability to undergo clonal expansion, acquire effector functions and traffic to the site of infection. Although TCR signal strength is thought to dominantly shape the T cell response, by using TCR transgenic CD4+ T cells with different pMHC binding affinity, we reveal that TCR affinity does not control Th1 effector function acquisition nor the functional output of individual effectors following mycobacterial infection. Rather, TCR affinity calibrates the rate of cell division to synchronize the distinct processes of T cell proliferation, differentiation and trafficking. By timing cell division-dependent IL-12R expression, TCR affinity controls when T cells become receptive to Th1-imprinting IL-12 signals, determining the emergence and magnitude of the Th1 effector pool. These findings reveal a distinct yet cooperative role for IL-12 and TCR signalling in Th1 differentiation and suggests that the temporal activation of clones with different TCR affinity is a major strategy to coordinate immune surveillance against persistent pathogens.

Liver resident-memory CD8+ T cells (TRM cells) can kill liver-stage Plasmodium-infected cells and prevent malaria, but simple vaccines for generating this important immune population are lacking. Here, we report the development of a fully synthetic self-adjuvanting glycolipid-peptide conjugate vaccine designed to efficiently induce liver TRM cells. Upon cleavage in vivo, the glycolipid-peptide conjugate vaccine releases an MHC I-restricted peptide epitope (to stimulate Plasmodium-specific CD8+ T cells) and an adjuvant component, the NKT cell agonist α-galactosylceramide (α-GalCer). A single dose of this vaccine in mice induced substantial numbers of intrahepatic malaria-specific CD8+ T cells expressing canonical markers of liver TRM cells (CD69, CXCR6, and CD101), and these cells could be further increased in number upon vaccine boosting. We show that modifications to the peptide, such as addition of proteasomal-cleavage sequences or epitope-flanking sequences, or the use of alternative conjugation methods to link the peptide to the glycolipid improved liver TRM cell generation and led to the development of a vaccine able to induce sterile protection in C57BL/6 mice against Plasmodium berghei sporozoite challenge after a single dose. Furthermore, this vaccine induced endogenous liver TRM cells that were long-lived (half-life of ~425 days) and were able to maintain >90% sterile protection to day 200. Our findings describe an ideal synthetic vaccine platform for generating large numbers of liver TRM cells for effective control of liver-stage malaria and, potentially, a variety of other hepatotropic infections.

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Aim To investigate hepatitis C virus (HCV) testing patterns and engagement with health care for women positive for HCV antibodies (anti-HCV) in pregnancy and their children through pregnancy and the first 2 years of the child's life. Methods At a large inner-city Australian hospital from 2010 to 2012, anti-HCV positive pregnant women were recruited into a cohort study from pregnancy to 2 years post-delivery. Maternal and child data were collected by questionnaire and medical record extraction. Results During the study 29 women participants delivered 31 children. HCV RNA was detected in 64% (18/28) of pregnancies, with injecting drug use, the most likely route of maternal infection. Relatively high maternal health-care engagement during pregnancy reduced after delivery. There was evidence of ongoing illicit drug use in the majority of women. Of the children, 58% (18/31) had some HCV testing confirmed but complete testing was confirmed for only 10% (3/31). Largely, testing was incomplete or unknown. No vertical transmission was identified. Forty-two percent (13/31) of children were placed in out-of-home-care. Conclusions Potentially, there is a high risk of inadequate or incomplete HCV testing of vulnerable children. Ongoing maternal drug use, poor maternal health-care engagement and placement in out-of-home-care may increase the risk. Complete testing of all children at risk of vertically acquired HCV needs to be ensured.

'MDS with isolated del(5q)' is a subtype of Myelodysplastic Syndrome (MDS) with characteristic morphological and genomic features. Clinically, MDS with isolated del(5q) is uniquely responsive to immunomodulatory agents, with lenalidomide (LEN) approved for treating anemia in this indication. Erythropoiesis Stimulating Agents (ESA) and red cell transfusion (RBCT) are other options for anemia management. The EUMDS Registry is an international prospective registry of newly diagnosed patients (within 100 days of diagnosis) with IPSS Low/Int-1-risk MDS (plus higher-risk MDS from 2017) recruiting since 1 st April 2008, currently at 146 sites in 17 countries. We describe the largest prospective Registry series of 'MDS with del(5q)' patients, with data from diagnosis. Methods Comparative analyses of baseline characteristics for categorical variables compared different groups by chi 2 test, and for continuous variables by Kruskal-Wallis test. p values are given with Bonferonni correction applied. Results Baseline characteristics Of 2469 EUMDS patients, 197 (8%) met the WHO 2016 classification criteria for 'MDS with isolated del5q'. Median follow up is 4.3 yrs. 77% were female (34% for all EUMDS patients), and median age was 73y. In comparison to EUMDS patients lacking del(5q), patients with MDS with isolated del(5q) were lower risk at diagnosis (IPSS and IPSS-R, p Interventional management To date, 168/197 patients received active intervention and the following sequence of interventions was observed, in order of frequency of initial intervention, RBCT>ESA>LEN: RBCT (n=96), - then ESA (42) then LEN (21) - then LEN (32) then ESA (5) ESA (n=55), - then RBCT (30) then LEN (13) - then LEN (9) then RBCT (6) LEN (n=17), - then ESA (3) then RBCT (2) - then RBCT (2) then ESA (2) Ninety-two patients have received LEN. In comparison with those not (yet) treated with LEN, LEN treated patients were younger (mean 70y vs 75y, p Adverse events were considered but proved too difficult to evaluate from the Registry data. For example, anticoagulant treatment data was collected, but not the specific indication. Outcome No difference in outcome (OS or PFS) was noted for patients treated with LEN vs. not (Figure, OS - adjusted Hazard Ratio, age and sex, 95% Confidence Interval: 0.67 [95% CI:0.35-1.29], lenalidomide treatment as a time-dependent variable). Conclusion EUMDS is uniquely placed to describe 'real-world' management of patients with 'MDS with isolated del(5q)' from diagnosis. To date, the largest (retrospective) case series reported had a median age 5 years younger than EUMDS, most likely representing referral bias(1). EUMDS demonstrates that most patients with MDS with isolated del(5q) require interventional therapy, and that more than half of transfusion dependent patients have received LEN. Further analysis of interventions and response will be presented. 1. Germing U, Lauseker M, Hildebrandt B, Symeonidis A, Cermak J, Fenaux P, et al. Survival, prognostic factors and rates of leukemic transformation in 381 untreated patients with MDS and del(5q): A multicenter study. Leukemia 2012;26(6):1286-92. Figure 1 Figure 1. Disclosures Fenaux: Takeda: Honoraria, Research Funding; Abbvie: Honoraria, Research Funding; JAZZ: Honoraria, Research Funding; Celgene/BMS: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Syros Pharmaceuticals: Honoraria. Symeonidis: Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; GSK: Research Funding; Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; MSD: Consultancy, Research Funding; BMS: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Sanofi: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Demo: Research Funding; WinMedica: Research Funding; Astellas: Consultancy, Research Funding; Sanofi/Genzyme: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; GenesisPharma: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; AbbVie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Kotsianidis: Novartis Hellas: Consultancy, Other: NONE, Research Funding, Speakers Bureau; Abbvie: Consultancy, Other: NONE, Research Funding, Speakers Bureau; Bristol Hellas: Consultancy, Other: NONE, Research Funding, Speakers Bureau; Janssen Hellas: Consultancy, Other: NONE, Speakers Bureau; Genesis: Consultancy, Other: NONE; Astellas: Other: NONE, Research Funding, Speakers Bureau. Mittelman: Janssen · Roche · Novartis · Takeda · Medison / Amgen · Neopharm / Celgene / BMS · Abbvie · Gilead: Research Funding; Novartis · Takeda · Fibrogen · Celgene / BMS · Onconova · Geron: Other: Clini; Onconova · Novartis · Takeda · Silence: Membership on an entity's Board of Directors or advisory committees; MDS HUB: Consultancy; Celgene / BMS · Novartis: Speakers Bureau. Sanz: Helsinn Healthcare: Consultancy, Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees; Roche: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel, accommodations, and expenses; Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees; Boehringer Ingelheim: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Takeda: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel, accommodations, and expenses, Speakers Bureau; Gilead Sciences: Other: Travel, accommodations, and expenses; Abbvie: Consultancy, Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel, accommodations, and expenses, Research Funding. Stauder: Celgene/BMS: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel support; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees. Germing: Janssen: Honoraria; Celgene: Honoraria; Novartis: Honoraria, Research Funding; Bristol-Myers Squibb: Honoraria, Other: advisory activity, Research Funding; Jazz Pharmaceuticals: Honoraria. van Marrewijk: EUMDS Registry: Current Employment; Novartis: Other: Educational Grants; BV Oncology Europe: Other: Educational Grants; Amgen Limited: Other: Educational Grants; Celgene International: Other: educational grants; Janssen Pharmaceuticals: Other: educational grants; Takeda Pharmaceuticals: Other: educational grants; MDS-RIGHT: Other: project budgets. de Witte: Amgen: Research Funding; Celgene: Research Funding; Takeda: Research Funding; Novartis: Research Funding; Janssen: Research Funding.

Background The assessment of health-related quality of life (HRQoL) in patients with myelodysplastic syndromes (MDS) is critical to organize more robustly patient-centered care. Therefore, availability of well-validated disease-specific HRQoL measures in this area is important. Objectives We investigate the validity of the Quality of Life in Myelodysplasia Scale (QUALMS), to assess HRQoL in MDS patients reported to the European MDS (EUMDS) Registry. A prior validation effort has been reported (Abel G, et al. Haematologica, 2016 June; 781-88), but this was largely a North American cohort and subscales suggested by the original principal components analysis had not been validated. Patients and Methods The QUALMS questionnaire was included in the EUMDS Registry (de Swart L, et al. Br J Haematol. 2015 Aug;170:372-83), a large international initiative including several European countries and Israel. We used proportions, median and interquartile range (IQR) to summarize patients' characteristics at baseline. We also assessed internal consistency and test-retest reliability by Cronbach's alpha (threshold for acceptability Cronbach's alpha ≥0.70). Confirmatory factor analysis (CFA) was used to examine the model fit for the underlying scale structure. The model performance was evaluated by Comparative Fit Index (CFI), the Tucker-Lewis Index (TLI), and the Root Mean Squared Error of Approximation (RMSEA), where acceptable values were >0.90 for CFI and TLI and RMSEA Results Overall, 270 MDS patients completed the QUALMS questionnaire, from 17 centers across four countries: Austria (N = 61), Israel (N = 67), The Netherlands (N = 37) and United Kingdom (N = 105). The majority of patients were male (67.4%) with a median age at diagnosis of 74 years (IQR =68.0-80.0) and a low MDS-CI score (n=158). CFA indicated acceptable model fit, respectively CFI=0.93, TLI=0.93 and RMSEA=0.07. For all analyses, the scales QUALMS-physical burden (P), QUALMS-emotional burden (E) and the total score showed satisfactory results, while the scale QUALMS-benefit finding (BF) showed worse results. Internal consistency and test-retest reliability were acceptable for the total score (TS) and all scales but BF (see figure). Pairwise correlations between QUALMS-P, QUALMS-E, TS and all the scales from EQ-5D-3L (including VAS) showed satisfactory concurrent validity (range from -0.67 to 0.60). Only the QUALMS-BF did not correlate with any of the EQ-5D-3L scales (range from -0.07 with EQ-VAS to 0.14 with EQ-5D Anxiety/ Depression). As per discriminant validity, all known-group comparisons were statistically significant and consistent with the underlying clinical construct for all scales apart for the QUALMS-BF. For example, the QUALMS-P mean scores were 75.8 vs 54.6 (p< 0.001) for patients with a higher vs lower KPS, while the corresponding QUALMS-BF mean scores were 49.4 vs 50.9 (p=0.829). The same profile resulted for responsiveness to change, where all scales reflected significant changes in Hb levels and in EQ-VAS score in the expected direction, while QUALMS-BF did not. For example, those patients who experienced a clinically meaningful deterioration in the VAS score also had also a worsening in QUALMS-P (Δ=-6, p=0.003), QUALMS-E (Δ=-1.8, p=0.075) and TS (Δ=-3, p=0.003). Conclusions Current findings provide novel evidence-based data that support the validity of the QUALMS for its use in European and Israeli patients with MDS. Implementation of the QUALMS in MDS research may further raise PRO standards in this area. Figure 1 Figure 1. Disclosures Efficace: Takeda: Consultancy; Janssen: Consultancy; Abbvie: Consultancy, Other: Grants (to Institution); Amgen: Consultancy, Other: Grants (to Institution). Mittelman: Janssen · Roche · Novartis · Takeda · Medison / Amgen · Neopharm / Celgene / BMS · Abbvie · Gilead: Research Funding; Novartis · Takeda · Fibrogen · Celgene / BMS · Onconova · Geron: Other: Clinical Trial Support; Onconova · Novartis · Takeda · Silence: Membership on an entity's Board of Directors or advisory committees; MDS HUB: Consultancy; Celgene / BMS · Novartis: Speakers Bureau. Van Marrewijk: Novartis Pharmacy B.V. Oncology Europe: Other: project manager of the EUMDS Registry, is funded from the EUMDS (educational grants from Novartis Pharmacy B.V. Oncology Europe); Amgen Limited: Other: project manager of the EUMDS Registry, is funded from the EUMDS (educational grants from Amgen Limited); Celgene International: Other: project manager of the EUMDS Registry, is funded from the EUMDS (educational grants from Celgene International); Janssen Pharmaceutical: Other: project manager of the EUMDS Registry, is funded from the EUMDS (educational grants from Janssen Pharmaceutical); Takeda Pharmaceuticals International: Other: project manager of the EUMDS Registry, is funded from the EUMDS (educational grants from Takeda Pharmaceuticals International); EU's Horizon 2020 program: Other: MDS-RIGHT (grant from EU's Horizon 2020 program) project budgets. de Witte: Takeda: Research Funding; Novartis: Research Funding; Janssen: Research Funding; Celgene: Research Funding; Amgen: Research Funding. Stauder: Celgene/BMS: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Travel support; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees.

Background and Aim Alterations in nutrient metabolism, nutritional requirements, and reduced dietary intakes are common in chronic liver disease (CLD). These result in malnutrition, sarcopenia, and exacerbate progression to decompensation and ascites. We aimed to investigate the effects of continuous tube feeding (TF) on nutritional status and levels of ascites in malnourished individuals with decompensated cirrhosis. Methods Fourteen malnourished patients with decompensated cirrhosis and ascites who failed to respond to standard oral nutritional interventions received supplementary continuous nasogastric TF for 7 ± 1 weeks. Liver disease severity was assessed by model for end-stage liver disease (MELD) and Child-Turcotte-Pugh (CTP) scores. Results Continuous TF occurred at home for 7 weeks (1.5-12 weeks). Prior to feeding, 12 patients had severe ascites, 10 required paracentesis, and 13 were severely malnourished. At completion of TF, five patients did not have ascites, four had mild ascites, four had moderate ascites, and only one had severe ascites and 10 no longer required paracentesis (P

Background Red blood cell (RBC) transfusion dependence (TD) and anemia are associated with inferior quality of life (QOL) and survival in myelodysplastic syndromes (MDS). As part of a research programme to identify the optimal transfusion hemoglobin (Hb) threshold that translates into significantly improved QOL, we conducted a pilot randomized study of two transfusion algorithms (liberal versus restrictive) to determine the feasibility of a larger study. This trial was aligned with the REDDS study (ISRCTN26088319, Stanworth et al., BJH 2019) and followed the same pre-defined statistical analysis plan. Methods The study was undertaken at 3 cancer centers (NCT02099669). We included patients with MDS, CMML, low blast AML (20-30%) or myeloproliferative neoplasms who were TD (> 1 RBC/8 weeks x 16 weeks). Patients on disease modifying therapy for > 6 months were permitted only if they had remained stably RBC-TD with a life expectancy of > 3 months. Central randomization was to one of two RBC transfusion strategies over a 12-week period: Restrictive strategy to maintain Hb between 85 and 105g/L. To achieve this, 2 RBC units were transfused when Hb < 85 g/LLiberal strategy to maintain Hb between 110 and 120 g/L. To achieve this, 2 RBC units were transfused when Hb < 105 g/L and 1 unit for Hb 105-110 g/L. The first 4 weeks were considered a run-in period to achieve the target Hb. The primary outcomes of this feasibility study were The percentage compliance of Hb being within or above the target range of the assigned transfusion threshold (after the 4 week run-in). Feasibility was set at 70%.Achievement of at least a 15 g/L difference between the mean pre-transfusion Hb of the liberal and restrictive strategy groups. Secondary outcomes included changes and differences in QOL scores, rates of transfusion reactions and alloimmunizations, overall blood utilization and visit numbers and impact on serum ferritin. The primary analysis was intention to treat. The study was closed early due to COVID-19, with 28 patients randomized of planned 30. Results 30 patients were enrolled over 5 years and 28 patients randomized (n=15, liberal; n=13 restrictive). Median age was 74 (range 58-84), 26/28 had MDS or CMML and there were no significant imbalances in baseline disease and patient characteristics although patients in the restrictive group tended to have lower risk disease (IPSS-R very low + low 69% versus 53% liberal). Compared with the restrictive arm, liberal arm patients had more complete blood counts, were transfused more RBC units (only during the 4-week run-in) and were transfused at shorter intervals (Table 1). There were no differences in adverse events. Over the 12 weeks, the mean Hb value was 90 ± 4 g/L (restrictive) versus 101 ± 4 g/L (liberal), (p Adherence with QOL completion (minimum of 4 serial) was 93%. While sample sizes are small and comparisons exploratory, the area under the curve for several serial quality of life scores was numerically higher and the curve more stable for the liberal arm (EQ5D (figure 2), EORTC cognitive and emotional functioning). Similarly, a higher % of patients in the liberal arm achieved pre-defined clinically meaningful increases in several symptom and function domains (emotional, social, fatigue, dyspnea, financial problems). Discussion Whilst our study results did not meet our feasibility endpoints, this small randomized trial in MDS patients demonstrated clinically important differences in mean Hb achievable with different transfusion thresholds. Poor rates of compliance with Hb targets were clearly identified for patients in the liberal arm, suggesting a need to understand the barriers to protocol adherence in this arm prior to embarking on larger trials. Compared with the REDDS trial, we did not document a significant excess of RBC transfusions needed (post run-in period) to maintain the higher Hb threshold. Similar to REDDS, we did observe some signals of improved QOL with a liberal transfusion strategy. A formal analysis of pooled results with REDDS study patients is planned. (Funding, CCSRI grant QOLL-14 and MOSPI Fund 2014). Disclosures Buckstein: Novartis: Honoraria; Astex: Honoraria; Celgene: Honoraria; Celgene: Research Funding; Takeda: Research Funding. Prica:seattle genetics: Honoraria; Gilead: Honoraria; astra zeneca: Honoraria. Leber:Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; BMS/Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Abbvie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Pfizer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Otsuka Pharmaceutical: Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Lundbeck: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Alexion: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Takeda/Palladin: Honoraria, Membership on an entity's Board of Directors or advisory committees; Treadwell: Honoraria, Membership on an entity's Board of Directors or advisory committees. Chodirker:Hoffman Laroche: Honoraria. Lin:Novartis: Research Funding; Pfizer: Honoraria. Callum:Octapharma: Research Funding; Canadian Blood Services: Research Funding.

Background Treatments for 'accelerated phase' MPNs (MPN-AP, 10-19% blasts)/post-MPN AML (MPN-BP, ≥20% blasts) are limited. Most patients are precluded from potentially curative haematopoietic stem cell transplantation (HSCT). For HSCT ineligible patients, azacitidine (AZA) is licensed to treat high-risk MDS or AML. Whilst dose and toxicity profile of AZA is well understood, the response of MPNs and post-MPN AML to monotherapy is limited. AZA-based doublet chemotherapy may however result in improved clinical responses. The phase Ib single-arm PHAZAR trial was established to determine maximum tolerated dose (MTD), safety profile and clinical activity of the selective JAK1/2 inhibitor ruxolitinib (RUX) used in combination with AZA to treat MPN-AP and MPN-BP patients. Methods A modified two-stage continual reassessment method with an expansion cohort at the MTD, was used to establish the MTD of RUX in combination with AZA. Successive flexible cohorts of 3-5 patients were enrolled at a fixed AZA dose of 75 mg/m2 s/c for 7 days (excluding weekends, on a 5-2-2 schedule) of a 28-day cycle with continuous administration of an allocated oral RUX dose (dose levels 0, 1, 2 and 3 = 10, 15, 20 and 25 mg BD respectively), and a formal response assessment recorded after 6 cycles. Toxicities were prospectively recorded as per CTCAE v4.0 with dose limiting toxicity (DLT) defined as a grade 3 or 4 non-haematological toxicity during treatment cycle 1. Clinical activity was evaluated over 12 months through assessment of bone marrow response after 3 and 6 treatment cycles, progression free survival (PFS), leukaemia free survival (LFS) and overall survival (OS). Results Thirty four advanced phase MPN patients were recruited from 12 Trials Acceleration Programme sites (19 MPN-AP; 15 MPN-BP). Baseline characteristics are summarized in Table 1. Driver mutation status was available for 25/34(74%) patients. 17/25(68%) carried canonical mutations in JAK2, 4/25 (16%) in CALR, and 4/25(16%) were triple negative. Three patients each received 10 and 15 mg of RUX BD, 4 patients received 20 mg RUX BD, 21 patients received 25 mg RUX BD and 3 did not begin treatment. Median number of cycles received was 3 RUX and 4 AZA. The MTD of RUX in combination with AZA was determined at 25 mg BD, with no DLTs reported during phase 1 of the study. During the expansion phase, 1 DLT at dose level 3 was reported as grade 3 febrile neutropenia; with this patient's RUX dose reduced from 25 to 20 mg BD. Overall, 601 adverse events were reported of which 16.3% were grade 3 and 3.5% grade 4, with anaemia and febrile neutropenia the most common grade 3 and 4 events. There were 77 serious adverse events reported with 50.6% believed trial treatment related; febrile neutropenia, sepsis and, infections and infestations were the most common affecting 29.4%, 14.7% and 14.7% of patients respectively. In total, 20 of 34 patients were evaluable for disease response. IWG MDS criteria were used for blasts Conclusions The combination of RUX and AZA is well tolerated in MPN-AP and MPN-BP patients with toxicities comparable to the individual agents. Of evaluable patients 10 of 20 achieved a PR or CR. The OS compares favourably with historical cohorts and clinically meaningful responses were achieved for transfusion independence. In 1 patient the regimen permitted successful bridge to transplant. Such combinations should be further explored, potentially with higher dose RUX. An expanded molecular analysis including responses is presented as a separate abstract. Disclosures Drummond: Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Gilead: Membership on an entity's Board of Directors or advisory committees; Takeda: Membership on an entity's Board of Directors or advisory committees; Blueprint Medicine Corporation: Research Funding; Jazz: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Bristol Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Astellas: Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees. Harrison:Shire: Honoraria, Speakers Bureau; Gilead Sciences: Honoraria, Speakers Bureau; Incyte Corporation: Speakers Bureau; Promedior: Honoraria; AOP Orphan Pharmaceuticals: Honoraria; CTI Biopharma Corp: Honoraria, Speakers Bureau; Novartis: Honoraria, Research Funding, Speakers Bureau; Celgene: Honoraria, Research Funding, Speakers Bureau; Sierra Oncology: Honoraria; Roche: Honoraria; Janssen: Speakers Bureau. Mead:Celgene/BMS: Consultancy, Honoraria, Other: travel, accommodations, expenses, Research Funding; Novartis: Consultancy, Honoraria, Other: travel, accommodations, expenses, Research Funding, Speakers Bureau; Gilead: Consultancy; CTI: Consultancy; Abbvie: Consultancy. Yap:Bristol-Myers Squibb: Honoraria, Speakers Bureau; Faron Pharmaceuticals: Consultancy. Narayanan:Takeda: Other: Educational support to attend conferences; Alexion: Speakers Bureau; MSD: Speakers Bureau; Celgene: Other: Educational support to attend conferences; Novartis: Other: Educational support to attend conferences. Somervaille:Novartis: Consultancy, Honoraria; Imago Bioscience: Research Funding. Gudgin:Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees. Milojkovic:Incyte: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Bristol-Myers Squibb: Consultancy, Honoraria. Knapper:Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. OffLabel Disclosure: 5-azacitidine is licensed and approved for treatment of adult patients who are not eligible for HSCT with high risk myelodyplastic syndromes. Ruxolitinib is licensed and approved for use in Myelofibrosis and for Polycythaemia Vera resistant/intolerant to hydroxyurea

Liver resident-memory CD8

Hepatitis C virus (HCV) is a significant contributor to the global disease burden, and development of an effective vaccine is required to eliminate HCV infections worldwide. CD4(+) and CD8(+) T cell immunity correlates with viral clearance in primary HCV infection, and intrahepatic CD8(+) tissue-resident memory T (T(RM)) cells provide lifelong and rapid protection against hepatotropic pathogens. Consequently, we aimed to develop a vaccine to elicit HCV-specific CD4(+) and CD8(+) T cells, including CD8(+) T(RM) cells, in the liver, given that HCV primarily infects hepatocytes. To achieve this, we vaccinated wild-type BALB/c mice with a highly immunogenic cytolytic DNA vaccine encoding a model HCV (genotype 3a) nonstructural protein (NS5B) and a mutant perforin (pVAX-NS5B-PRF), as well as a recombinant adeno-associated virus (AAV) encoding NS5B (rAAV-NS5B). A novel fluorescent target array (FTA) was used to map immunodominant CD4(+) T helper (T(H)) cell and cytotoxic CD8(+) T cell epitopes of NS5B in vivo, which were subsequently used to design a K(d)NS5B(451-459) tetramer and analyze NS5B-specific T cell responses in vaccinated mice in vivo. The data showed that intradermal prime/boost vaccination with pVAX-NS5B-PRF was effective in eliciting T(H) and cytotoxic CD8(+) T cell responses and intrahepatic CD8(+) T(RM) cells, but a single intravenous dose of hepatotropic rAAV-NS5B was significantly more effective. As a T-cell-based vaccine against HCV should ideally result in localized T cell responses in the liver, this study describes primary observations in the context of HCV vaccination that can be used to achieve this goal. IMPORTANCE There are currently at least 71 million individuals with chronic HCV worldwide and almost two million new infections annually. Although the advent of direct-acting antivirals (DAAs) offers highly effective therapy, considerable remaining challenges argue against reliance on DAAs for HCV elimination, including high drug cost, poorly developed health infrastructure, low screening rates, and significant reinfection rates. Accordingly, development of an effective vaccine is crucial to HCV elimination. An HCV vaccine that elicits T cell immunity in the liver will be highly protective for the following reasons: (i) T cell responses against nonstructural proteins of the virus are associated with clearance of primary infection, and (ii) long-lived liver-resident T cells alone can protect against malaria infection of hepatocytes. Thus, in this study we exploit promising vaccination platforms to highlight strategies that can be used to evoke highly functional and long-lived T cell responses in the liver for protection against HCV.

Liver-resident memory CD8

BackgroundChronic inflammation is the driver of liver injury resulting in progressive fibrosis and eventual cirrhosis. The consequences include both liver failure and liver cancer. We have previously described increased expression of the highly multifunctional glycoprotein CD147 in liver injury. This work describes a novel role of CD147 in liver inflammation and the importance of leukocyte aggregates in determining the extent of liver injury.MethodsNon-diseased, progressive injury and cirrhotic liver from humans and mice were examined using mAb targeting CD147. Inflammatory cell subsets were assessed by multicolor flow cytometry.ResultsIn liver injury, we observe abundant intrahepatic leukocyte clusters defined as ≥5 adjacent CD45+cells which we have labelled “leukocyte aggregates”. We have shown that these leukocyte aggregates are significant in determining the extent of liver injury. If CD147 is blockedin vivo,these leukocyte aggregates diminish in size and number together with a marked significant reduction in liver injury including fibrosis. This accompanied by no change in overall intrahepatic leukocyte numbers. Further, blocking aggregation formation occurs prior to an appreciable increase in inflammatory markers or fibrosis. Additionally, there were no observed, “off-target” or unpredicted effects in targeting CD147.ConclusionCD147 mediates leukocyte aggregation which is associated with the development of liver injury. This is not a secondary effect, but a cause of injury as aggregate formation proceeds other markers of injury. Leukocyte aggregation has been previously described in inflammation dating back over many decades but till now been shown to determine the extent of injury.

The heterogeneity of myelodysplastic syndromes (MDSs) has made evaluating patient response to treatment challenging. In 2006, the International Working Group (IWG) proposed a revision to previously published standardized response criteria (IWG 2000) for uniformly evaluating clinical responses in MDSs. These IWG 2006 criteria have been used prospectively in many clinical trials in MDSs, but proved challenging in several of them, especially for the evaluation of erythroid response. In this report, we provide rationale for modifications (IWG 2018) of these recommendations, mainly for “hematological improvement” criteria used for lower-risk MDSs, based on recent practical and reported experience in clinical trials. Most suggestions relate to erythroid response assessment, which are refined in an overall more stringent manner. Two major proposed changes are the differentiation between “procedures” and “criteria” for hematologic improvement–erythroid assessment and a new categorization of transfusion-burden subgroups.

BackgroundChronic inflammation is the driver of liver injury and results in progressive fibrosis and eventual cirrhosis with consequences including both liver failure and liver cancer. We have previously described increased expression of the highly multifunctional glycoprotein CD147 in liver injury. This work describes a novel role of CD147 in liver inflammation and the importance of leukocyte aggregates in determining the extent of liver injury.MethodsNon-diseased, progressive injury, and cirrhotic liver from humans and mice were examined using a mAb targeting CD147. Inflammatory cell subsets were assessed by multiparameter flow cytometry.ResultsIn liver injury, we observe abundant, intrahepatic leukocyte clusters defined as ≥5 adjacent CD45+ cells which we have termed "leukocyte aggregates". We have shown that these leukocyte aggregates have a significant effect in determining the extent of liver injury. If CD147 is blocked in vivo, these leukocyte aggregates diminish in size and number, together with a marked significant reduction in liver injury including fibrosis. This is accompanied by no change in overall intrahepatic leukocyte numbers. Further, blocking of aggregation formation occurs prior to an appreciable increase in inflammatory markers or fibrosis. Additionally, there were no observed, "off-target" or unpredicted effects in targeting CD147.ConclusionCD147 mediates leukocyte aggregation which is associated with the development of liver injury. This is not a secondary effect, but a cause of injury as aggregate formation proceeds other markers of injury. Leukocyte aggregation has been previously described in inflammation dating back over many decades. Here we demonstrate that leukocyte aggregates determine the extent of liver injury.

In recent years, various intervention strategies have reduced malaria morbidity and mortality, but further improvements probably depend upon development of a broadly protective vaccine. To better understand immune requirement for protection, we examined liver-stage immunity after vaccination with irradiated sporozoites, an effective though logistically difficult vaccine. We identified a population of memory CD8+ T cells that expressed the gene signature of tissue-resident memory T (Trm) cells and remained permanently within the liver, where they patrolled the sinusoids. Exploring the requirements for liver Trm cell induction, we showed that by combining dendritic cell-targeted priming with liver inflammation and antigen recognition on hepatocytes, high frequencies of Trm cells could be induced and these cells were essential for protection against malaria sporozoite challenge. Our study highlights the immune potential of liver Trm cells and provides approaches for their selective transfer, expansion, or depletion, which may be harnessed to control liver infections or autoimmunity.

Background & Aims Acute hepatitis is often mediated by cytotoxic T lymphocytes (CTLs); however, the intrinsic parameters that limit CTL-mediated liver injury are not well understood. Methods To investigate whether acute liver damage is limited by molecules that decrease the lifespan or effector function of CTLs, we used a well-characterized transgenic (Tg) mouse model in which acute liver damage develops upon transfer of T cell receptor (TCR) Tg CD8 T cells. Recipient Tg mice received donor TCR Tg T cells deficient for either the pro-apoptotic molecule Bim, which regulates CTL survival, or suppressor of cytokine signaling-1 (SOCS-1), which controls expression of common gamma chain cytokines; the effects of anti-PD-L1 neutralizing antibodies were also assessed. Results Use of Bim-deficient donor T cells and/or PD-L1 blockade increased the number of intrahepatic T cells without affecting the degree and kinetic of acute hepatitis. In contrast, SOCS-1-deficient T cells induced a heightened, prolonged acute hepatitis caused by their enhanced cytotoxic function and increased expansion. Although they inflicted more severe acute liver damage, SOCS-1-deficient T cells never precipitated chronic hepatitis and became exhausted. Conclusions The degree of acute hepatitis is regulated by the function of CD8 T cells, but is not affected by changes in CTL lifespan. Although manipulation of the examined parameters affected acute hepatitis, persistent hepatitis did not ensue, indicating that, in the presence of high intrahepatic antigen load, changes in these factors in isolation were not sufficient to prevent T cell exhaustion and mediate progression to chronic hepatitis.

In 2015, there are a few absolute contraindications to liver transplantation. In adult patients, survival post-liver transplant is excellent, with 1-year survival rate >90% and 5-year survival rates >80% and predicted median allograft survival beyond 20 years. Patients with a Child-Turcotte Pugh score ≥9 or a model for end-stage liver disease (MELD) score >15 should be referred for liver transplantation, with patients who have a MELD score >17 showing a 1-year survival benefit with liver transplantation. A careful selection of hepatocellular cancer patients results in excellent outcomes, while consideration of extra-hepatic disease (reversible vs irreversible) and social support structures are crucial to patient assessment. Alcoholic liver disease remains a challenge, and the potential to cure hepatitis C virus infection together with the emerging issue of non-alcoholic fatty liver disease-associated chronic liver failure will change the landscape of the who in the years ahead. The when will continue to be determined largely by the severity of liver disease based on the MELD score for the foreseeable future.

Background: Azacitidine (AZA) based therapy is a standard of care in IPSS INT-2/High MDS/low blast count AML and CMML-2. Thrombocytopenia is an adverse prognostic factor in MDS; increased severity correlates with haemorrhagic complications and shorter AML progression time, and early platelet recovery after AZA is linked to better outcomes. Accumulation of AZA doses is important to patient response, but initial treatment with AZA can aggravate thrombocytopenia and impact outcome. Eltrombopag (ELT) is a thrombopoietin receptor (TpoR) agonist approved for adult chronic immune thrombocytopenic purpura. ELT has shown efficacy in low risk MDS and reduces thrombocytopenic events in advanced MDS and AML. The ELASTIC trial (ISRCTN05858391) is a single-arm phase 1b dose-finding study examining the safety and tolerability of ELT/AZA in patients with MDS/AML with expansion cohort (n=10) at MTD. We investigated if ELT/AZA would lead to earlier platelet recovery and improve AZA efficacy. Although a Phase 3 study testing ELT/AZA (SUPPORT) was terminated due to futility during the ELASTIC trial, we reasoned that drug sequencing may affect outcome. As ELASTIC patients received an ELT pre-phase, ELASTIC was run to completion. Methods: Patients with IPSS INT-2 or High MDS/CMML-2/AML The primary outcome was safety and tolerability (including establishing the MTD) of ELT in combination with AZA. Key secondary outcomes were the effect of ELT on platelet counts, platelet transfusions and marrow blast percentage. Full blood count was measured weekly over the first 13 weeks and monthly thereafter; bone marrow was taken on day 8 of ELT and at the end of cycles 3 and 6. Results: Thirty-one patients were recruited from November 2014 to August 2018. Thirty (median age 74, range: 62-86) were evaluable for analysis in the safety population (AML=5, IPSS INT-2 MDS=12, IPSS High MDS=12, CMML-2=1); 1 patient was ineligible post registration. 11/30 (37%) were IPSS good risk, 3/30 (10%) intermediate risk and 14/30 (47%) high risk (2 unknown). ELT was well tolerated up to 300mg (25mg=5, 50mg=3, 100mg=4, 200mg=4, 300mg=14) and was safely combined with AZA. There were no DLTs in the DLT evaluable patients (n=15). The MTD was established as 300mg (n=14). There were 3 SUSARs, 19 SAEs, 28 SARs and 87 episodes of grade 3/4 AEs. There were 16 episodes of grade 3/4 neutropenia and 11 episodes of grade 3/4 anaemia. Five patients discontinued treatment due to toxicity (25mg=2, 300mg=3), 6 due to death (pneumonia=2, disease-related=4, ischaemic heart disease=1) and 1 withdrew. Platelet responses were seen at ELT 50mg and higher. At the MTD, median platelet count at baseline was 37 (IQR: 25-52), rising to 77 (IQR 50-108.5) and 74 (IQR: 32-430) at cycle 2 and 3 respectively. The median platelet nadir was 20.5 (IQR: 11-25) and 42 (IQR 18.5-51.5) after cycle 1 and 2 dropping to 20 (IQR: 9-160) after cycle 3 when ELT was stopped. Mean platelet transfusions did not change with ELT dose. There was no increase in delays to AZA dosing across the ELT dose cohorts. There was no change in bleeding incidents when patients received ELT. Overall, there was no increase in bone marrow blast percentage from baseline. The cycle 3 marrow aspirate was reached by 27/30 (90%) and 11/30 (37%) reached the cycle 6 marrow aspirate. At the end of 3 cycles there were 21 non-responders and 10 responders (CR=3, marrow CR=4, PR=3, SD=9). At the end of 6 cycles there were 22 non-responders and 9 responders (CR=3, marrow CR=4, PR=2, SD=5). 6/14 (43%) treated at the MTD responded while 3/16 (19%) treated at below the MTD responded. Conclusions: The combination of ELT with AZA is safe and tolerable. Clinically meaningful responses in platelets were seen in patients receiving 50mg or more ELT. At the MTD, there was a noticeable drop in platelet nadir in cycle 3 when patients were not receiving ELT. No change in platelet transfusion was identified across cohorts. The results suggest that an ELT pre-phase may improve platelet responsiveness in patients treated with AZA and warrants further exploration. Disclosures Sternberg: Celgene/BMS: Honoraria, Research Funding; GSK/Novartis: Honoraria, Research Funding. Raghavan:Celgene UK: Speakers Bureau. Culligan:Celgene: Consultancy, Honoraria, Speakers Bureau; Jazz: Consultancy, Honoraria; Abbvie: Consultancy, Honoraria, Speakers Bureau; Diiachi-Sankyo: Consultancy, Honoraria; Pfizer: Consultancy; Novartis: Consultancy, Honoraria. Cargo:Novartis: Honoraria. Vyas:Celgene: Research Funding, Speakers Bureau; Novartis: Research Funding, Speakers Bureau; Forty Seven: Research Funding; Pfizer: Speakers Bureau; Daiichi Sankyo: Speakers Bureau; Astellas: Speakers Bureau; AbbVie: Speakers Bureau. OffLabel Disclosure: Eltrombopag is a second generation thrombopoietin receptor (TpoR) agonist approved for adult chronic immune thrombocytopenic purpura.

Background. The severity of hematopoietic impairment and the kinetics of disease progression in lower risk myelodysplastic syndromes (LR-MDS) are extremely variable. Genomic profiling has the potential to inform the clinical management of these disorders, including improved classification, risk assessment and therapeutic choice. In the present study, based on a comprehensive mutation analysis in a large and clinically well-characterized cohort of LR-MDS patients, either recruited into the European MDS Registry or referred to European excellence centers involved in the MDS-RIGHT project, we adopted unsupervised hierarchical clustering analyses to identify relevant genetically defined disease subtypes within early stage MDS. Methods. The dataset comprised 856 cases identified as LR-MDS based on IPSS risk low or intermediate-1. Median age was 73 years (range 36-98); IPSS-R risk was very low in 30.1% of patients, low in 50.4%, intermediate in 19.5%. We investigated possible sub-structure amongst patients according to their mutational profiles, and correlated this sub-structure with relevant endpoints. For this analysis, unsupervised clustering was used, based on a mixture model of multivariate Bernoulli distributions. The optimal number of clusters was chosen using the Bayes Information Criterion (BIC), with secondary structure identified with the Akaike Information Criterion (AIC). Results. This analysis identified three distinct clusters within LR-MDS. Cluster 1 comprised exclusively patients with SF3B1 mutation, either isolated or associated with other mutations (SF3B1-mutant cluster) (37% of patients). Cluster 2 was characterized by excess mutations associated with higher risk disease (high-risk (HR) cluster) (27% of patients), including a significantly higher prevalence of ASXL1, IDH1/IDH2, SRSF2, RUNX1, CBL and EZH2 mutations (P The three recognized clusters showed distinct clinical features and outcome measures. Patients within HR cluster were significantly older (P=.008) and showed significant enrichment in WHO categories with multi-lineage dysplasia and excess blasts (P HR-cluster showed significantly lower overall survival (OS) compared to CHIP-like and SF3B1-mutant clusters (median 2.6 vs 6.8 or 6.4 years; P Conclusion. Mutation profiling identifies meaningful clusters of lower risk MDS with distinct molecular pathways, clinical features and endpoints. These results represent a robust basis to inform genetic ontogeny-based classification and individual risk assessment, as well as to inspire biology-driven clinical trials in lower risk MDS. Disclosures Symeonidis: Bristol-Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Merck Sharp & Dohme: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Sanofi/Genzyme: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; WinMedica: Research Funding; Celgene: Honoraria, Research Funding; Astellas: Research Funding; Abbvie: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Gilead: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; GenesisPharma: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Stauder:Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Teva: Research Funding. Fenaux:Novartis: Honoraria, Research Funding; Abbvie: Honoraria, Research Funding; Jazz: Honoraria, Research Funding; BMS: Honoraria, Research Funding. Van Marrewijk:EUMDS and MDS-RIGHT (Providing the right care to the right patient with MyeloDysplastic Syndrome at the right time) project: Other: Project manager of the EUMDS Registry.

Liver-resident memory CD8+ T (TRM) cells remain in and constantly patrol the liver to elicit rapid immunity upon antigen encounter and can mediate efficient protection against liver-stage Plasmodium infection. This finding has prompted the development of immunization strategies where T cells are activated in the spleen and then trapped in the liver to form TRM cells. Here, we identify PbRPL6120-127, a H2-Kb-restricted epitope from the putative 60S ribosomal protein L6 (RPL6) of Plasmodium berghei ANKA, as an optimal antigen for endogenous liver TRM cell generation and protection against malaria. A single dose vaccination targeting RPL6 provided effective and prolonged sterilizing immunity against high dose sporozoite challenges. Expressed throughout the parasite life cycle, across Plasmodium species, and highly conserved, RPL6 exhibits strong translation potential as a vaccine candidate. This is further advocated by the identification of a broadly conserved, immunogenic HLA-A∗02:01-restricted epitope in P. falciparum RPL6.

Adeno-associated viral vector–mediated (AAV-mediated) expression of allogeneic major histocompatibility complex class I (MHC class I) in recipient liver induces donor-specific tolerance in mouse skin transplant models in which a class I allele (H-2Kb or H-2Kd) is mismatched between donor and recipient. Tolerance can be induced in mice primed by prior rejection of a donor-strain skin graft, as well as in naive recipients. Allogeneic MHC class I may be recognized by recipient T cells as an intact molecule (direct recognition) or may be processed and presented as an allogeneic peptide in the context of self-MHC (indirect recognition). The relative contributions of direct and indirect allorecognition to tolerance induction in this setting are unknown. Using hepatocyte-specific AAV vectors encoding WT allogeneic MHC class I molecules, or class I molecules containing a point mutation (D227K) that impedes direct recognition of intact allogeneic MHC class I by CD8+ T cells without hampering the presentation of processed peptides derived from allogeneic MHC class I, we show here that tolerance induction depends upon recognition of intact MHC class I. Indirect recognition alone yielded a modest prolongation of subsequent skin graft survival, attributable to the generation of CD4+ Tregs, but it was not sufficient to induce tolerance.

Prognosis of lower-risk (International Prognostic Scoring System [IPSS] low/intermediate-1) myelodysplastic syndrome (MDS) is heterogeneous and relies on steady-state assessment of cytopenias. We analyzed relative drops in neutrophil and platelet counts during the first 6 months of follow-up of lower-risk MDS patients. We performed a landmark analysis of overall survival (OS) of lower-risk MDS patients prospectively included in the European LeukaemiaNet MDS registry having a visit at 6 +/- 1 month from inclusion to assess the prognostic relevance of relative drops in neutrophils and platelets, defined as (count at landmark - count at inclusion)/count at inclusion. Of 2102 patients, 807 were eligible for the stringent 6-month landmark analysis. Median age was 73 years. Revised IPSS was very low, low, and intermediate/higher in 26%, 43%, and 31% of patients, respectively. A relative drop in platelets >25% at landmark predicted shorter OS (5-year OS, 21.9% vs 48.6% with platelet drop 25% had no significant impact on OS. We built a classifier based on red blood cell transfusion dependence (RBC-TD) and relative platelet drop >25% at landmark. Patients with none (62%), either (27%), or both criteria (11%) had 5-year OS of 53.3%, 32.7%, and 9.0%, respectively (P < 10(-4)). This classifier was validated in an independent cohort of 335 patients. Combining relative platelet drop >25% and RBC-TD at 6 months from diagnosis provides an inexpensive and noninvasive way to predict outcome in lower-risk MDS. This study was registered at www.clinicaltrials.gov as #NCT00600860.

The liver is known for its tolerogenic properties. This unique characteristic is associated with persistent infection of the liver by the hepatitis B and C viruses. Improper activation of cellular adaptive immune responses within the liver and immune exhaustion over time both contribute to ineffective cytotoxic T cell responses to liver-expressed antigens in animal models, and likely play a role in incomplete clearance of chronic hepatitis virus infections in humans. However, under some conditions, functional immune responses can be elicited against hepatic antigens, resulting in control of hepatotropic infections. In order to develop improved therapeutics in immune-mediated chronic liver diseases, including viral hepatitis, it is essential to understand how intrahepatic immunity is regulated. This review focuses on CD8 T cell immunity directed towards foreign antigens expressed in the liver, and explores how the liver environment dictates the outcome of intrahepatic CD8 T cell responses. Potential strategies to rescue unresponsive CD8 T cells in the liver are also discussed.

Hepatitis C virus (HCV) reinfection of the liver allograft after transplantation is universal, with some individuals suffering severe disease recurrence. Predictive markers of recurrent disease severity are urgently needed. In this study, we used a cluster of differentiation (CD) microarray to predict the severity of HCV recurrence after transplantation.The CD antibody microarray assays of live leukocytes were performed on peripheral blood taken in the first year after transplantation. The results were grouped into phases defined as; Pre-transplant (day 0), Early (day 3 to week 2), Mid (week 4 to week 10), and Late (week 12 to week 26). Hepatitis C virus severity was based on fibrosis stages in the first 2 years (F0-1 mild and F2-4 severe).Serial blood samples from 16 patients were taken before and after liver transplantation. A total of 98 assays were performed. Follow-up was 3 years or longer. Comparing recurrence severity, significantly greater numbers of CD antigens were differentially expressed on the pretransplant samples compared to any posttransplant timepoints. Five differentially expressed CD antigens before transplantation (CD27 PH, CD182, CD260, CD41, and CD34) were significantly expressed comparing severe to mild recurrence, whereas expression of only CD152 was significant in the late phase after transplantation. No relationship was observed between the donor or recipient interleukin-28B genotypes and HCV recurrence severity.This study shows that circulating leukocyte CD antigen expression has utility in assessing recurrent HCV disease severity after liver transplantation and serves as a proof of principle. Importantly, pretransplant CD antigen expression is most predictive of disease outcome.