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Background Patients with Tetralogy of Fallot with pulmonary stenosis (ToF/PS), the most common form of cyanotic congenital heart disease (CHD), develop adverse right ventricular (RV) remodeling, leading to late heart failure and arrhythmia. We recently demonstrated that overactive β-adrenergic receptor signaling inhibits cardiomyocyte division in ToF/PS infants, providing a conceptual basis for the hypothesis that treatment with the β-adrenergic receptor blocker, propranolol, early in life would increase cardiomyocyte division. No data are available in ToF/PS infants on the efficacy of propranolol as a possible novel therapeutic option to increase cardiomyocyte division and potentially reduce adverse RV remodeling. Methods Using a randomized, double-blind, placebo-controlled trial, we will evaluate the effect of propranolol administration on reactivating cardiomyocyte proliferation to prevent adverse RV remodeling in 40 infants with ToF/PS. Propranolol administration (1 mg/kg po QID) will begin at 1 month of age and last until surgical repair. The primary endpoint is cardiomyocyte division, quantified after 15N-thymidine administration with Multi-isotope Imaging Mass Spectrometry (MIMS) analysis of resected myocardial specimens. The secondary endpoints are changes in RV myocardial and cardiomyocyte hypertrophy. Conclusion This trial will be the first study in humans to assess whether cardiomyocyte proliferation can be pharmacologically increased. If successful, the results could introduce a paradigm shift in the management of patients with ToF/PS from a purely surgical approach, to synergistic medical and surgical management. It will provide the basis for future multi-center randomized controlled trials of propranolol administration in infants with ToF/PS and other types of CHD with RV hypertension. Clinical trial registration: The trial protocol was registered at clinicaltrials.gov (NCT04713657).

We introduce a model for auto-complete of general queries via Bayesian inference. To that end, we address three issues: First, the problem of predicting a word given previous words in a text. Usually, the context words are treated as a directional sequence. In our approach, we introduce a set-based class language model with order-independence, modeling the context words as a set of classes. Second, towards the task of predicting the next word’s class based on the classes of previous words plus an incomplete word prefix, we present a Bayesian framework that incorporates the set-based class language model in conjunction with an ontology. Third, regarding the auto-complete problem, we provide complete query suggestions via abstract class-space search which determines similar historical queries that contain the classes of previous words plus the next word’s predicted class. Subsequently, we apply the model to auto-complete inference in a system setting, in which users can access data via natural language queries.

HLA haplotype mismatches have been associated with an elevated risk of acute graft-versus-host disease (aGVHD) in patients undergoing HLA-matched unrelated donor (URD) hematopoietic cell transplantation (HCT). The gamma block (GB) is located in the central MHC region between beta and delta blocks (encoding HLA-B and -C and HLA-DQ and -DR antigens, respectively) and contains numerous inflammatory and immune regulatory genes, including Bf, C2, and C4 genes. A single-center study showed that mismatches in SNPs c.2918+98G, c.3316C, and c.4385C in the GB block (C4 SNPs) were associated with higher risk of grade III-IV aGVHD. We investigated the association of GB SNP (GBS) mismatches with outcomes after 10/10 and 9/10 URD HCT (n = 714). The primary outcome was acute GVHD. Overall survival, disease-free survival, transplantation-related mortality, relapse, chronic GVHD, and engraftment were also analyzed. DNA samples were GBS genotyped by identifying 338 SNPs across 20 kb using the Illumina NGS platform. The overall 100-day incidence of aGVHD grade II-IV and II-IV were 41% and 17%, respectively. The overall incidence of matching at all GBSs tested and at the C4 SNPs were 23% and 81%, respectively. Neither being matched across all GB SNPs tested (versus mismatched) nor having a higher number of GBS mismatches was associated with transplantation outcomes. There was no association between C4 SNP mismatches and outcomes except for an unexpected significant association between having 2 C4 SNP mismatches and a higher hazard ratio (HR) for relapse (association seen in 15 patients only; HR, 3.38, 95% confidence interval, 1.75 to 6.53; P = .0003). These data do not support the hypothesis that mismatching at GB is associated with outcomes after HCT.

Natural killer (NK) cells are regulated by killer immunoglobulin-like receptor (KIR) interactions with human leukocyte antigen class I ligands. Various models of NK cell alloreactivity have been associated with outcomes after allogeneic hematopoietic cell transplant (alloHCT), but results have varied widely. We hypothesized that somatic mutations in acute myeloid leukemia (AML) in the context of KIR profiles may further refine their association with transplant outcomes. In this single-center, retrospective, observational study, 81 AML patients who underwent matched-related donor alloHCT were included. Post-HCT outcomes were assessed based on mutational status and KIR profiles with the Kaplan–Meier method and log-rank test. On multivariable analysis those with any somatic mutations and C1/C2 heterozygosity had less acute graft-versus-host disease (GvHD) (hazard ratio [HR], 0.32; 95% confidence interval [CI], 0.14-0.75; P = .009), more relapse (HR, 3.02; 95% CI, 1.30-7.01; P = .010), inferior relapse-free survival (RFS; HR, 2.22; 95% CI, 1.17-4.20; P = .014), and overall survival (OS; HR, 2.21; 95% CI, 1.17-4.20; P = .015), whereas those with a missing KIR ligand had superior RFS (HR, 0.53; 95% CI, 0.30-0.94; P = .031). The presence of a somatic mutation and donor haplotype A was also associated with less acute GvHD (HR, 0.38; 95% CI, 0.16-0.92; P = .032), more relapse (HR, 2.72; 95% CI, 1.13-6.52; P = .025), inferior RFS (HR, 2.11; 95% CI, 1.07-4.14; P = .030), and OS (HR, 2.20; 95% CI, 1.11-4.38; P = .024). Enhanced NK cell alloreactivity from more KIR activating signals (donor B haplotype) and fewer inhibitory signals (recipient missing KIR ligand or C1 or C2 homozygosity) may help mitigate the adverse prognosis associated with some AML somatic mutations. These results may have implications for improving patient risk stratification prior to transplant and optimizing donor selection.

Quantification of cellular proliferation in humans is important for understanding biology and responses to injury and disease. However, existing methods require administration of tracers that cannot be ethically administered in humans. We present a protocol for the direct quantification of cellular proliferation in human hearts. The protocol involves administration of non-radioactive, non-toxic stable isotope 15Nitrogen-enriched thymidine (15N-thymidine), which is incorporated into DNA during S-phase, in infants with tetralogy of Fallot, a common form of congenital heart disease. Infants with tetralogy of Fallot undergo surgical repair, which requires the removal of pieces of myocardium that would otherwise be discarded. This protocol allows for the quantification of cardiomyocyte proliferation in this discarded tissue. We quantitatively analyzed the incorporation of 15N-thymidine with multi-isotope imaging spectrometry (MIMS) at a sub-nuclear resolution, which we combined with correlative confocal microscopy to quantify formation of binucleated cardiomyocytes and cardiomyocytes with polyploid nuclei. The entire protocol spans 3–8 months, which is dependent on the timing of surgical repair, and 3–4.5 researcher days. This protocol could be adapted to study cellular proliferation in a variety of human tissues. The dynamics of cardiomyocyte cell cycle activity and proliferation in humans are poorly understood. This protocol describes how to measure cell division in infant hearts by multi-isotope imaging spectrometry after incorporation of 15N-thymidine.

Natural language query understanding for unstructured textual sources has seen significant progress over the last couple of decades. For structured data, while the ecosystem has evolved with regard to data storage and retrieval mechanisms, the query language has remained predominantly SQL (or SQL-like). Towards making the latter more natural there has been recent research emphasis on Natural Language Interface to DataBases (NLIDB) systems. Piggybacking on the rise of 'deep learning' systems, the state-of-the-art NLIDB solutions over large parallel and standard benchmarks (viz, WikiSQL and Spider) primarily rely on attention based sequence-to-sequence models. Building industry grade NLIDB solutions for making big data ecosystem accessible by truly natural and unstructured querying mechanism presents several challenges. These include lack of availability of parallel corpora, diversity in underlying data schema, wide variability in the nature of queries to context and dialog management in interactive systems. In this paper, we present an end-to-end system Query Enterprise Data (QED) towards making enterprise descriptive analytics and reporting easier and natural. We elaborate in detail how we addressed the challenges mentioned above and novel features such as handling incomplete queries in incremental fashion as well as highlight the role of an assistive user interface that provides a better user experience. Finally, we conclude the paper with observations and lessons learnt from the experience of transferring and deploying a research solution to industry grade practical deployment.

With seven billion mobile phone subscriptions and a third of the world's population going online, digital information and communication technologies present untapped platforms for communication, learning and empowerment. Newer technologies such as mobile phones, the internet and computers have the potential to contribute significantly to the prevention of violence against children. Yet, efforts to date have focused primarily on the risks associated with them. It is important to consider how digital technologies can enhance social and behaviour change interventions to prevent and respond to violence against children. We conducted a systematic review of social and behaviour change interventions addressing violence against children. We searched five databases for peer-reviewed and grey literature published between 2000 and 2015, which yielded 18 manuscripts relevant to the use of computers, the internet or mobile phones. Digital technologies were typically combined with other communication channels in order to reach children, parents, teachers or service providers. We are unable to draw any conclusions on the direct effectiveness of digital technologies, indicating the need for more rigorous evaluations to assess their added value. Future work should explore how digital technologies can be integrated into programmes disseminating information, raising awareness, helping individuals report violence and mobilising communities to action. Copyright © 2017 John Wiley & Sons, Ltd. Key Practitioner Messages Successful violence prevention programmes are not taking full advantage of digital technologies. Adapting programmes and messages for computer, internet or mobile phone delivery would broaden their scope and reach. The interactive nature of digital technologies makes them ideally suited to involve and empower individuals and entire communities for change. The effectiveness of digital technologies in preventing violence against children is still unclear. More investment in research and evaluation is needed. ‘A systematic review of social and behaviour change interventions addressing violence against children’ ‘The effectiveness of digital technologies in preventing violence against children is still unclear’

Objective/Background: Cytomegalovirus (CMV) infection and disease are common infectious complications after allogeneic hematopoietic cell transplantation (alloHCT). Major histocompatibility complex (MHC) class I chain-related gene A (MICA) is a ligand of the natural killer (NKG2D) receptor on immune effector cells that helps mediate NK cell alloreactivity. We hypothesized that MICA polymorphisms may influence CMV infection and disease incidence after alloHCT. Methods: We conducted a retrospective analysis of 423 adults at the Cleveland Clinic with hematologic malignancies treated with a matched related or unrelated donor alloHCT. CMV cases analyzed included a compositive of instances of viral copy replication above detection limits as well as any biopsy-proven tissue invasive disease episodes. Genotypes at the MICA-129 position have been categorized as weak (valine/valine; V/V), intermediate (methionine/valine; M/V), or strong (methionine/methionine; M/M) receptor affinity. Results: In multivariable analysis, V/V donor MICA-129 genotype was associated with CMV infection and disease (hazard ratio [HR] = 1.40; 95% confidence interval [CI], 1.00–1.96; p = .05), but not MICA mismatch (HR = 1.38; 95% CI, 0.83–2.29; p = .22). There was no association of acute or chronic GVHD with MICA donor–recipient mismatch (HR = 1.05; 95% 95% CI, 0.66–1.68; p = .83 and HR = 0.94; 95% CI, 0.51–1.76; p = .85, respectively) or V/V donor MICA-129 genotypes (HR = 1.02; 95% CI, 0.79–1.31; p = .89 and HR = 0.89; 95% CI, 0.65–1.22; p = .47, respectively). Conclusion: These findings suggest that the donor MICA-129 V/V genotype with weak NKG2D receptor binding affinity is associated with an increased risk of CMV infection and disease after alloHCT. Keywords: Allogeneic hematopoietic cell transplantation, Cytomegalovirus, Killer cell immunoglobulin-like receptors, Major histocompatibility complex class I chain-related gene A

De novo steatosis after liver transplant is common and can occur in up to one-third of patients who are transplanted for liver disease other than for nonalcoholic fatty liver disease. Genetic factors may influence posttransplant steatosis; in a posttransplant setting, donor or recipient genetic factors could also play roles. Genetic polymorphisms in the adiponectin gene have been associated with metabolic syndrome in the pretransplant setting. We aimed to assess the association between donor and recipient adiponectin polymorphisms and early posttransplant hepatic steatosis identified on liver biopsies.Clinical data were collected for 302 liver transplant patients who underwent protocol biopsies for hepatitis C. Of these, 111 patients had available biopsies and donor/recipient DNA. Patients with grade 1 steatosis or greater (35% of patients) were compared with patients without posttransplant steatosis with respect to clinical features and donor/recipient adiponectin polymorphism genotypes.Patients who developed posttransplant steatosis and those without steatosis were similar with respect to individual components of metabolic syndrome. The adiponectin polymorphisms rs1501299 G/G and rs17300539 G/G genotypes in recipients were associated with early posttransplant graft steatosis. We found no associations between graft steatosis and donor adiponectin polymorphisms.Genetic polymorphisms in the adiponectin gene of recipients (but not donors) are associated with early de novo posttransplant hepatic steatosis, independent of components of metabolic syndrome.

We report a case of primary renal allograft dysfunction and early acute cell-mediated rejection after a 12/12 HLA antigen zero-mismatch (0MM) transplant. The recipient was a 40-year-old white man who was highly allosensitized, with a calculated panel reactive antibody score of 100%. In posteroperative day 1 the recipient remained anuric and underwent dialysis because of hyperkalemia. Graft biopsy showed early acute cellular rejection, Banff grade 2B. No evidence of antibody-mediated rejection was observed. To our knowledge, this case is the 1st to report early cell-mediated rejection after 12/12 HLA antigen 0MM kidney transplantation. This case suggests that highly sensitized candidates are at high immunologic risk even in the context of 0MM kidney transplantation.

Background Menopausal hormone therapy (MHT) increases breast cancer risk; however, most cohort studies omit MHT use after enrolment and many infer menopausal age. Methods We used information from serial questionnaires from the UK Generations Study cohort to estimate hazard ratios (HRs) for breast cancer among post-menopausal women with known menopausal age, and examined biases induced when not updating data on MHT use and including women with inferred menopausal age. Results Among women recruited in 2003–2009, at 6 years of follow-up, 58 148 had reached menopause and 96% had completed a follow-up questionnaire. Among 39 183 women with known menopausal age, 775 developed breast cancer, and the HR in relation to current oestrogen plus progestogen MHT use (based on 52 current oestrogen plus progestogen MHT users in breast cancer cases) relative to those with no previous MHT use was 2.74 (95% confidence interval (CI): 2.05–3.65) for a median duration of 5.4 years of current use, reaching 3.27 (95% CI: 1.53–6.99) at 15þ years of use. The excess HR was underestimated by 53% if oestrogen plus progestogen MHT use was not updated after recruitment, 13% if women with uncertain menopausal age were included, and 59% if both applied. The HR for oestrogen-only MHT was not increased (HR¼1.00; 95% CI: 0.66–1.54). Conclusions Lack of updating MHT status through follow-up and inclusion of women with inferred menopausal age is likely to result in substantial underestimation of the excess relative risks for oestrogen plus progestogen MHT use in studies with long follow-up, limited updating of exposures, and changing or short durations of use.

BACKGROUND: A simplified protocol for HLA-typing -by NGS, developed for use with the Illumina MiSeq, was performed by technologists with varying NGS experience to assess accuracy and reproducibility.METHODS: Technologists from six laboratories typed the same 16 samples at HLA-A, B, C, DRB1, and DQB1. The protocol includes long range PCR, library preparation, and paired-end 250bp sequencing. Two indexing strategies were employed: locus-specific indexing whereby each locus was tagged uniquely and sample-specific indexing whereby all 5 loci for a sample were pooled prior to library preparation. Sequence analysis was performed with two software packages, Target HLA (Omixon) and NGSengine (GenDx).RESULTS: The average number of sequence reads per library was 387,813; however, analysis was limited to 40,000 reads for locus-indexed libraries and 200,000 reads for sample-indexed libraries resulting in an average depth of coverage of 1444 reads per locus. Sufficient reads for genotype analysis were obtained for 98.4% of libraries. Genotype accuracy was >97% in pooled amplicons and >99% in individual amplicons by both software analysis. Inter-laboratory reproducibility was 99.7% and only cause of discordance was cross-contamination of a single amplicon.CONCLUSIONS: This NGS HLA-typing protocol is simple, reproducible, scalable, highly accurate and amenable to clinical testing.

The clinical relevance of mismatches at the MHC class I–related chain A (MICA) in hematopoietic stem cell transplantation (HSCT) remains unclear. We investigated the association of MICA donor/recipient mismatch and whether there is an interaction between these and HLA-DPB1 mismatch on clinical outcomes after unrelated donor HSCT. Our study included 227 patients who underwent unrelated donor allogeneic HSCT at our institution between 2000 and 2010. Among these, 177 (78%) received HSCT from a 10/10 HLA-matched donor. MICA genotyping was performed using commercially available kits. In univariable analysis, the risk of grade II to IV acute graft-versus-host disease (GVHD) was greater for patients with MICA mismatch (hazard ratio [HR], 1.73; P = .02) than for those with HLA-DPB1 mismatch (HR, 1.62; P = .07). When MICA and HLA-DPB1 were assessed simultaneously, patients mismatched at both loci had the greatest risk (HR, 2.51; P < .01) and those mismatched at only 1 locus had somewhat greater risk (HR, 1.53; P = .12) than patients matched at both loci; this remained significant in multivariable analysis. The 100-day incidence was 66%, 45%, and 31%, respectively (P = .03). Results were similar for grade III and IV acute GVHD, with 100-day incidence 34%, 16%, and 8% (P = .01). These results are clinically pertinent to donor selection strategies and indicate that patients with mismatch at both MICA and HLA-DPB1 are at increased risk for acute GVHD.

Aim Development of de novo HLA donor-specific antibody (dnDSA) after lung transplant (LuTx) is prevalent and associated with poorer transplant outcomes. Understanding pre-LuTx determinants helps to minimize dnDSA. The aim of this study was to investigate the impact of HLA-Epitope Mismatch Load (EpiMML) in the development of dnDSA in LuTx recipients. Methods 572 recipients received LuTx during 10/2012–10/2017 and were retrospectively analyzed for the formation of dnDSA (Mean Fluorescence Intensity ⩾ 1000). Antigenic mismatches were recorded among 422 recipients. EpiMMLs were determined by HLA-Matchmaker (Version 02) among 168 recipients who had four-digit high resolution typing. There were 18 recipients who were typed by both high and low resolution. Acute Cellular Rejection (ACR) and Antibody Mediated Rejection (AMR) were assessed for LuTx outcomes. Results Of the 572 patients, 55% developed dnDSA; 25% Class I, 39% Class II, and 36% both Class I and II. In Class II, the most prevalent dnDSA was DQ (216/235; 92%). EpiMMLs for Class I, Class II, as well as single loci of HLA-A, B, C, DR, and DQ were all significantly higher from patients with positive dnDSA than from patient with negative dnDSA (Table 1a). However, for antigen-level mismatches, only HLA-A and DQ correlated with the development of dnDSA. As shown in Table 1b, certain mismatched epitopes were more frequent among patients who developed dnDSA than those who did not. Among a subgroup of 120 recipients, EpiMMLs of Class II, especially DQ, were significantly associated with the occurrence of ACR (p = 0.02 and 0.005, respectively). There was no remarkable relevance between EpiMMLs and AMR. Conclusions Compared to HLA antigen mismatching, EpiMML is a better predictor of dnDSA development in LuTx recipients. Increasing EpiMMLs, particularly for HLA-DQ, identify patients at the highest risk to develop dnDSA and ACR. Collectively, these data support the use of EpiMML assessment especially for optimizing post-transplantation immunosuppression in LuTx recipients. Download : Download high-res image (242KB) Download : Download full-size image Download : Download high-res image (182KB) Download : Download full-size image

Background: Graft-versus-leukemia (GVL) responses after allogeneic hematopoietic cell transplantation (alloHCT) for AML are mediated by alloreactive donor-derived immune effector cells including T lymphocytes and natural killer (NK) cells. The function of NK cells is regulated by inhibitory and activating signals mediated through cell-surface receptors, including KIRs. Various models of NK cell alloreactivity have been associated with post-transplant outcomes, including leukemia relapse. However, these results have varied widely between different investigators employing similar models of NK cell alloreactivity. Assessment of somatic mutations in AML on post-transplant outcomes has not been investigated in the context of KIR profiles. Methods: In this single-institution retrospective cohort study, we investigated KIR haplotypes (haplotype AA vs. Bx [associated with multiple activating KIRs]; Cooley S., et al. Blood. 113:726-732. 2009) in the context of somatic mutations. We included 34 adult patients with AML who underwent alloHCT from a matched related donor from 2006 to 2013. A targeted multi-amplicon deep NGS panel of 79 commonly mutated genes in myeloid neoplasia was performed. Post-HCT outcomes were assessed based on mutational status and KIR haplotype with Kaplan-Meier method and log-rank test. Results: Median age at transplant was 54 (range 31-73). Cytogenetic risk groups were 9% favorable, 56% intermediate, and 35% poor based on 2017 ELN classification. HCT-CI scores included 26% low, 32% intermediate, and 41% high. Disease risk group defined by ASTCT included 71% low, 26% intermediate, and 3% high. Disease status at HCT included 74% CR1 and 26% CR2. Frequencies of somatic mutations prior to HCT were: 21% DNMT3A, 18% IDH2, 9% each for STAG2 and NRAS, 6% each for ASXL1, JAK2, PHF6, RUNX1, TET2, and 3% each for CBL, FLT3, NPM1, and U2AF1. Overall, 53% of patients had at least 1 mutation: 24%, 18%, 9%, and 3% of patients had 1, 2, 3, and 4 mutations, respectively. 41% were carriers of KIR haplotype AA, and 59% were haplotype Bx. Relapse (p=0.40), relapse-free (p=0.33), and overall survival (p=0.30) between haplotypes AA and Bx were not statistically different. However, when considering somatic mutations in the context of KIR haplotypes, those with any somatic mutation (n= 18) present had inferior relapse-free (p=0.002) and overall survival (p=0.002; figures A-B) as compared to those with none. Further assessment of outcomes was then considered for those who had the following poor prognostic mutations (n=12): ASXL1, DNMT3A, FLT3, NRAS, RUNX1, and TET2. KIR haplotype AA with one or more of these mutations was associated with inferior relapse-free (p=0.05) and overall survival (p=0.008). At median follow-up of 83 (range 66-137) months, 38% were alive. Non-relapse mortality rates were 21% (9-36) at 1 year and 29% (15-39) at 3 years. The most common causes of death for all patients were relapse (48%) followed by infection (33%). Conclusion: In presence of somatic mutations, carrying KIR haplotypes Bx was associated with better survival in AML post-alloHCT. The presence of multiple activating KIRs may also help mitigate the worse prognosis associated with some of the more deleterious somatic mutations in AML. These observations may have implications for improving patient risk stratification prior to transplant and optimizing donor selection. Future investigation with larger cohorts interrogating KIR haplotypes in the context of pre-transplant AML somatic mutations on post-transplant outcomes may further elucidate which patients may benefit most from transplant. Disclosures Nazha: Tolero, Karyopharma: Honoraria; Abbvie: Consultancy; Daiichi Sankyo: Consultancy; Novartis: Speakers Bureau; Jazz Pharmacutical: Research Funding; Incyte: Speakers Bureau; MEI: Other: Data monitoring Committee. Mukherjee:Bristol-Myers Squibb: Speakers Bureau; Projects in Knowledge: Honoraria; Celgene Corporation: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Partnership for Health Analytic Research, LLC (PHAR, LLC): Consultancy; McGraw Hill Hematology Oncology Board Review: Other: Editor; Pfizer: Honoraria; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Takeda: Membership on an entity's Board of Directors or advisory committees. Advani:Pfizer: Honoraria, Research Funding; Macrogenics: Research Funding; Glycomimetics: Consultancy, Research Funding; Kite Pharmaceuticals: Consultancy; Amgen: Research Funding; Abbvie: Research Funding. Gerds:Sierra Oncology: Research Funding; Incyte: Consultancy, Research Funding; CTI Biopharma: Consultancy, Research Funding; Imago Biosciences: Research Funding; Celgene Corporation: Consultancy, Research Funding; Roche: Research Funding; Pfizer: Consultancy. Sekeres:Celgene: Membership on an entity's Board of Directors or advisory committees; Syros: Membership on an entity's Board of Directors or advisory committees; Millenium: Membership on an entity's Board of Directors or advisory committees. Majhail:Mallinckrodt: Honoraria; Atara Bio: Consultancy; Anthem, Inc.: Consultancy; Nkarta: Consultancy; Incyte: Consultancy. Maciejewski:Novartis: Consultancy; Alexion: Consultancy.

The National Lung Screening Trial (NLST) is a randomized multicenter study comparing low-dose helical computed tomography (CT) with chest radiography in the screening of older current and former heavy smokers for early detection of lung cancer, which is the leading cause of cancer-related death in the United States. Five-year survival rates approach 70% with surgical resection of stage IA disease; however, more than 75% of individuals have incurable locally advanced or metastatic disease, the latter having a 5-year survival of less than 5%. It is plausible that treatment should be more effective and the likelihood of death decreased if asymptomatic lung cancer is detected through screening early enough in its preclinical phase. For these reasons, there is intense interest and intuitive appeal in lung cancer screening with low-dose CT. The use of survival as the determinant of screening effectiveness is, however, confounded by the well-described biases of lead time, length, and overdiagnosis. Despite previous attempts, no test has been shown to reduce lung cancer mortality, an endpoint that circumvents screening biases and provides a definitive measure of benefit when assessed in a randomized controlled trial that enables comparison of mortality rates between screened individuals and a control group that does not undergo the screening intervention of interest. The NLST is such a trial. The rationale for and design of the NLST are presented.

Background MHC class I chain-related gene A (MICA) is a polymorphic ligand of the natural killer (NKG2D) receptor on immune effector cells. The activating NKG2D receptor controls immune responses by regulating NK cells, NKT cells and γδ-T cells. Dimorphisms at sequence position 129 of the MICA gene confers varying levels of binding affinity to NKG2D receptor. MICA previously has been associated with post-allogeneic hematopoietic cell transplantation (alloHCT) outcomes including graft-versus-host-disease (GvHD), infection, and relapse. However, it is unclear how MICA interacts with cytogenetic and somatic mutations in regards to these outcomes in acute myeloid leukemia (AML). Methods We conducted a single center, retrospective analysis of adult AML patients in first or second complete remission (CR1, CR2), who underwent T-cell replete matched related or unrelated donor alloHCT. Analysis was limited to those who had MICA data available for donors and recipients. In addition to cytogenetic risk group stratification by European LeukemiaNet criteria (Döhner H, et al, Blood 2016), a subset of patients had a 36-gene somatic mutation panel assessed prior to alloHCT by next-generation sequencing. Dimorphisms at the MICA-129 position have previously been categorized as weaker (valine/valine: V/V), heterozygous (methionine/valine: M/V), or stronger (methionine/methionine: M/M) receptor binding affinity. Fine and Gray or Cox regression was used to identify the association of MICA and outcomes with results as hazard ratios (HR) and 95% confidence intervals (CI). Results From 2000 - 2017, 131 AML patients were identified meeting inclusion criteria. Median age at transplant was 54 years (18-74), with 98% Caucasian. Disease status at transplant included 78% CR1 and 22% CR2. Cytogenetic risk stratification showed 13% of patients as favorable, 56% as intermediate, and 31% as adverse-risk. The five most common somatic mutations were FLT3 (15%), NPM1 (14%), DNMT3A (11%), TET2 (7%), and NRAS (6%). 60% of patients had a related donor. A myeloablative transplant was performed in 84% of patients and 53% had a bone marrow graft source. The most common conditioning regimen used was busulfan/cyclophosphamide (52%). 12% of patients were MICA mismatched with their donor. The distribution of donor MICA-129 polymorphisms were 41% V/V, 53% M/V, and 6% M/M. In univariable analysis, donor-recipient MICA mismatch tended to be associated with a lower risk of infection (HR 0.49, CI 0.23-1.02, P=0.06) and grade 2-4 acute GvHD (HR 0.25, CI 0.06-1.04, P=0.06) but was not associated with other post-transplant outcomes. In multivariable analysis, donor MICA-129 V/V was associated with a higher risk of non-relapse mortality (NRM) (HR 2.02, CI 1.01-4.05, P=0.047) (Figure 1) along with increasing patient age at transplant (HR 1.46, CI 1.10-1.93, p=0.008) and the presence of a TET2 mutation (HR 6.00, CI 1.77-20.3, P=0.004). There were no differences between the V/V and the M/V+M/M cohorts regarding somatic mutational status, cytogenetics and other pre-transplant characteristics and post-transplant outcomes. With a median follow-up of 65 months for both cohorts, 45% vs. 49% of patients remain alive, respectively. The most common causes of death between the V/V and the M/V+M/M cohorts was relapse (38% vs. 62%) and infection (31% vs. 8%), respectively. Conclusion While previous studies have demonstrated associations of somatic mutations and cytogenetics with survival outcomes after alloHCT for AML, we observed mutations in TET2 and the V/V donor MICA-129 polymorphism to be independently prognostic for NRM. Mechanistic studies may be considered to assess for possible interactions of TET2 mutations with NK cell alloreactivity. The weaker binding affinity to the NKG2D receptor by the V/V phenotype may diminish immune responses against pathogens that subsequently contribute to higher NRM. These observations may have implications for enhancing patient risk stratification prior to transplant and optimizing donor selection. Future investigation with larger cohorts interrogating pre-transplant AML somatic mutations with MICA polymorphisms on post-transplant outcomes may further elucidate which subsets of patients may benefit most from transplant. Disclosures Nazha: MEI: Consultancy. Mukherjee:Pfizer: Honoraria; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Projects in Knowledge: Honoraria; BioPharm Communications: Consultancy; Bristol Myers Squib: Honoraria, Speakers Bureau; Takeda Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Takeda: Membership on an entity's Board of Directors or advisory committees; LEK Consulting: Consultancy, Honoraria; Aplastic Anemia & MDS International Foundation in Joint Partnership with Cleveland Clinic Taussig Cancer Institute: Honoraria. Advani:Amgen: Research Funding; Pfizer: Honoraria, Research Funding; Glycomimetics: Consultancy; Novartis: Consultancy. Carraway:Novartis: Speakers Bureau; Balaxa: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Jazz: Speakers Bureau; FibroGen: Consultancy; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Amgen: Membership on an entity's Board of Directors or advisory committees; Agios: Consultancy, Speakers Bureau. Gerds:Apexx Oncology: Consultancy; Celgene: Consultancy; Incyte: Consultancy; CTI Biopharma: Consultancy. Sekeres:Celgene: Membership on an entity's Board of Directors or advisory committees; Opsona: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Opsona: Membership on an entity's Board of Directors or advisory committees. Maciejewski:Apellis Pharmaceuticals: Consultancy; Ra Pharmaceuticals, Inc: Consultancy; Alexion Pharmaceuticals, Inc.: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Ra Pharmaceuticals, Inc: Consultancy; Alexion Pharmaceuticals, Inc.: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Apellis Pharmaceuticals: Consultancy. Majhail:Incyte: Honoraria; Anthem, Inc.: Consultancy; Atara: Honoraria.

Background While allogeneic hematopoietic cell transplantation (alloHCT) can be curative for patients with acute myeloid leukemia (AML), relapse remains a significant challenge. Previous work has suggested that disease status at time of transplant and cytogenetics are important predictors of relapse. However, it is unclear if common somatic mutations or dimorphisms of MHC class I chain-related gene A (MICA), a ligand of the natural killer (NKG2D) receptor on immune effector cells that helps mediate NK cell alloreactivity, also contribute. Moreover, the mechanisms of early relapse are an area of ongoing investigation. We assessed risk factors for relapse within 6 and 12 months after alloHCT. Methods We conducted a single center, retrospective analysis of adults with AML who underwent a first alloHCT. Analysis was restricted to patients with T-cell replete HLA-8/8 matched related or unrelated donor. In addition to cytogenetic risk group stratification by European LeukemiaNet criteria (Döhner H, et al, Blood 2016), a subset of patients had a 36-gene somatic mutation panel assessed prior to alloHCT by next-generation sequencing. Dimorphisms at the MICA-129 position have previously been categorized as weaker (valine/valine: V/V), heterozygous (methionine/valine: M/V), or stronger (methionine/methionine: M/M) receptor binding affinity. Risk factors for early relapse were assessed with Fine and Gray competing risk regression with results as hazard ratios (HR) and 95% confidence intervals (CI). Results From 2000 - 2017, 319 adult AML patients were identified meeting inclusion criteria. Median age at transplant was 51 years (range, 18-74), with 95% Caucasian. The distribution of low, intermediate, and high HCT-CI scores was 28%, 28%, and 44%, respectively. 75% of patients were transplanted ≤12 months from diagnosis. Disease status at transplant included 48% in first complete remission (CR1), 19% in second CR (CR2), 33% in third CR or relapsed/refractory or untreated (collectively, In univariable analysis, non-Caucasian race, disease status Conclusion Relapse after alloHCT for AML remains a challenge. In our study, the strongest risk factors for early relapse after alloHCT remains absence of CR1 disease status at transplant and adverse-risk cytogenetics. We observed no prognostic effect of somatic mutations nor MICA dimorphisms prior to transplant on 6 or 12-month relapse post-transplant. Further interrogation of pre-transplant or post-transplant persistence of somatic mutations in a larger series may better risk stratify subjects who may benefit from more intensive or innovative approaches to prevent post-transplant relapse. Disclosures Nazha: MEI: Consultancy. Advani:Amgen: Research Funding; Pfizer: Honoraria, Research Funding; Novartis: Consultancy; Glycomimetics: Consultancy. Carraway:Novartis: Speakers Bureau; Amgen: Membership on an entity's Board of Directors or advisory committees; Balaxa: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; FibroGen: Consultancy; Jazz: Speakers Bureau; Agios: Consultancy, Speakers Bureau. Gerds:Celgene: Consultancy; Apexx Oncology: Consultancy; Incyte: Consultancy; CTI Biopharma: Consultancy. Sekeres:Celgene: Membership on an entity's Board of Directors or advisory committees; Opsona: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Opsona: Membership on an entity's Board of Directors or advisory committees. Maciejewski:Apellis Pharmaceuticals: Consultancy; Alexion Pharmaceuticals, Inc.: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Apellis Pharmaceuticals: Consultancy; Ra Pharmaceuticals, Inc: Consultancy; Ra Pharmaceuticals, Inc: Consultancy; Alexion Pharmaceuticals, Inc.: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Majhail:Atara: Honoraria; Incyte: Honoraria; Anthem, Inc.: Consultancy.

HLA typing using Next Generation Sequencing (NGS) for bone marrow transplant (BMT) patients has been recognized to outperform traditional molecular typing methodologies in detecting contaminating alleles from malignancy. Here we report a case with ambiguous HLA typing that was clearly resolved by NGS. A 61 year old female with atypical chronic myeloid leukemia was evaluated for allogeneic BMT. Initial HLA typing by NGS on peripheral blood (PB) of the patient and her 2 siblings showed that one sibling was most likely HLA identical, and the other was haplo-identical to the patient, except an extra HLA-DRB1* allele was detected in the patient. NGS presented a mixture of DRB1*03:01 and 03:16 for the patient and DRB1*03:01 only for both siblings (Table 1a). The difference between DRB1*03:01 and 03:16 is located in Exon 2 at NT 229 as C and T, respectively. The number of NGS reads (R#345) from the patients’ PB at this position showed 10 reads mapping to DRB1*03:01 and 335 to DRB1*03:16, indicating 2.9% DRB1*03:01 and 97.1% DRB1*03:16. To investigate the possible involvement of malignant cells, DNA from the patients’ buccal swab (BS) was typed by NGS and also revealed a mixture of DRB1*03:01 and 03:16. The number of NGS reads (R#543) showed 420 and 123 reads (77.3% and 22.7%) mapped to the DRB1*03:01 and 03:16, respectively (Table 1b). Confirmatory typing of the patients’ PB and BS verified the initial typing result, thus concluding the DRB1*03:16 allele originated in the malignancy of the patient. BMT was performed with the HLA identical sibling. Parallel testing by NGS typing and engraftment monitoring by short tandem repeat (STR) was performed with post-BMT PB. Interestingly, NGS analysis indicated 63.1% of DRB1*03:01 and 36.9% of DRB1*03:16, which presented a close correlation with 61% and 39% donor and recipient chimerism, respectively, as detected by STR (Table 1c). This case study highlights the great potential of NGS in detecting minor component alleles from malignancy in a semi-quantitative manner.

Aim Autoantibodies have been implicated in the chronic rejection process after Lung Transplantation (LuT), but it is less certain if preformed non-HLA autoantibody (pAuAb) is the pre-LuT determinant for De Novo Donor Specific Antibody (dDSA) development. This study aims to investigate the relationship of pAuAb to dDSA fomation and the clinical impact of dDSA to LuT. Methods 124 recipients underwent LuT during 10/2012 −2/2014 at our center were retrospectively analyzed for dDSA (Mean Fluorescence Intensity ⩾1000). pAuAbs were detected among a subgroup of 118 patients using LABScreen™ Autoantibody (Thermofisher, panel coverage is listed in Table 1a). Cut-offs for pAuAbs were set up using 85% reference background values, which were calculated of lower than 85% population from a group of random selected non-transplanted and non-transfused individuals. Acute Cellular Rejection (ACR), Antibody Mediated Rejection (AMR) were recorded to assess LuT outcomes. Results 71 out of 124 (57%) recipients were identified with dDSA. Among dDSA recipients, Class I only, Class II only, and combined Class I and Class II were 16 (23%), 30 (42%), and 25 (35%), respectively. 53 (75%) of total dDSA was from DQ. pAuAbs to Angiotensinogen and Vimentin were clearly related to the formation of dDSA (p Conclusions The significant relevance of multiple pAuAbs to the formation of dDSA may provide a new perspective for evaluating the possibility of pAuAbs in eliciting dDSA at pre-LuT, which may help to reduce the risk of ACR and AMR related negative impact to LuT.

Background: Emotion processing abnormalities are considered among the core deficits in schizophrenia. Subjects at high risk (HR) for schizophrenia also show these deficits. Structural neuroimaging studies examining unaffected relatives at high risk for schizophrenia have demonstrated neuroanatomical abnormalities involving neo-cortical and sub-cortical brain regions related to emotion processing. The brain functional correlates of emotion processing in these HR subjects in the context of ecologically valid, real-life dynamic images using functional Magnetic Resonance Imaging (fMRI) has not been examined previously. Aim: To examine the neurohemodynamic abnormalities during emotion processing in unaffected subjects at high risk for schizophrenia in comparison with age-, sex-, handedness- and education-matched healthy controls, using fMRI. Materials and Methods: HR subjects for schizophrenia (n=17) and matched healthy controls (n=16) were examined. The emotion processing of fearful facial expression was examined using a culturally appropriate and valid tool for Indian subjects. The fMRI was performed in a 1.5-T scanner during an implicit emotion processing paradigm. The fMRI analyses were performed using the Statistical Parametric Mapping 2 (SPM2) software. Results: HR subjects had significantly reduced brain activations in left insula, left medial frontal gyrus, left inferior frontal gyrus, right cingulate gyrus, right precentral gyrus and right inferior parietal lobule. Hypothesis-driven region-of-interest analysis revealed hypoactivation of right amygdala in HR subjects. Conclusions: Study findings suggest that neurohemodynamic abnormalities involving limbic and frontal cortices could be potential indicators for increased vulnerability toward schizophrenia. The clinical utility of these novel findings in predicting the development of psychosis needs to be evaluated.

Killer immunoglobulin-like receptors (KIRs) expressed on natural killer and natural killer T cells are involved in activation of these cells and can influence antiviral immunity in the liver. This study investigated the association between KIR genetic diversity and sustained virologic response (SVR) to Peginterferon and Ribavirin (Peg/RBV) therapy in liver transplant (LT) recipients with hepatitis C virus (HCV) recurrence. We tested KIR genotypes in 44 HCV-infected LT recipients treated with Peg/RBV for 48 weeks. Patients were categorized as having KIR genotypes A/A or B/x and analyzed for association with SVR. Fifteen of 44 (34%) patients had SVR. Only 2 of 18 (11%) who lacked KIR2DS2/KIR2DL2 achieved SVR compared to 13 of 26 (50%) who carried these two genes (odds ratio: 8.0, 95% confidence interval: 1.5-42.0, P = 0.008). The association between lack of KIR2DS2/KIR2DL2 and SVR remained significant after exclusion of 10 patients with non-genotype 1 HCV. No correlation was found with other activating or inhibitory KIR genes. Absence of KIR2DS2 and/or KIR2DL2 is associated with failure of Peg/RBV therapy in patients with recurrent HCV after LT. These findings support the role of natural killer and natural killer T cells in HCV clearance after LT and might be generalizable to treatment of HCV infection outside the setting of LT.

Angiotensin II receptor sub-type 1 (AGTR1) plays an important role in the regulation of the cellular immune process. We hypothesized that recurrent acute rejection is associated with increased gene expression of AGTR1 in human heart transplantation.We identified a group of 14 heart transplant recipients who had recurrent acute cellular rejection (RAR), defined as three consecutive episodes of acute rejection (Gradeor =3A). These patients were matched to a control group (n = 15). mRNA gene expression of AGTR1 was measured in heart biopsy specimens of controls at 1 week post-transplant. AGTR1 mRNA was determined serially in the RAR group at baseline, each rejection episode, and after resolution of rejection. Angiotensin-converting enzyme (ACE) polymorphism was also evaluated.Both the control and RAR groups had similar mRNA AGTR1 expression at baseline. Compared with baseline, the RAR group had significantly increased mRNA expression of AGTR1 at the first episode of rejection (9-fold, p0.001), which increased further at the second episode (12-fold, p0.001) and peaked at the third episode (35-fold, p0.001). After resolution of rejection, AGTR1 expression was decreased significantly (p0.001), but remained elevated above baseline (6-fold, p0.001). No difference in ACE polymorphism was noted between the two groups. Compared with controls, the RAR patients had an increased incidence of hypertension, diabetes mellitus, chronic renal insufficiency and transplant vasculopathy during a mean follow-up period of 51.5 +/- 12 months.This is the first report to describe increased mRNA expression of AGTR1 in response to recurrent cellular rejection. Up-regulation of AGTR1 responds to treatment of rejection but not to complete recovery, a phenomenon that may potentially explain the link between rejection and subsequent clinical outcome.

Autoimmune sensorineural hearing loss (ASNHL) is the most common cause of sudden hearing loss in adults. Although autoimmune etiopathogenic events have long been suspected in ASNHL, inner ear-specific Ags capable of targeting T cell autoreactivity have not been identified in ASNHL. In this study, we show by ELISPOT analysis that compared with normal hearing age- and sex-matched control subjects, ASNHL patients have significantly higher frequencies of circulating T cells producing either IFN-γ (p = 0.0001) or IL-5 (p = 0.03) in response to recombinant human cochlin, the most abundant inner ear protein. In some patients, cochlin responsiveness involved both CD4+ and CD8+ T cells whereas other patients showed cochlin responsiveness confined to CD8+ T cells. ASNHL patients also showed significantly elevated cochlin-specific serum Ab titers compared with both normal hearing age- and sex-matched control subjects and patients with noise- and/or age-related hearing loss (p < 0.05 at all dilutions tested through 1/2048). Our study is the first to show T cell responsiveness to an inner ear-specific protein in ASNHL patients, and implicates cochlin as a prominent target Ag for mediating autoimmune inner ear inflammation and hearing loss.

A key to supporting a child's emerging literacy is building relationships with adults and peers through interactions around literacy activities. The development of sustained relationships with adults who engage a child in authentic conversations increases the opportunities for the child to build literacy connections. Robust relationships with caring adults are especially important in meeting the social and emotional needs of children who may be unable to benefit from traditional, curriculum-driven, academic instruction. This article focuses on strategies that support social relationships around literacy learning in malleable environments that mold to the continually developing child, especially young children who struggle to learn the skills needed to read and write.

Objective Limited by unavailable calculated panel reactive antibody (cPRA) for HLA-DP, it is impossible to predict the opportunity for a patient to receive a donor with compatible DP from a donor pool.The aim of this study is to provide a DPB1 allele typing frequency (TF) from a larger cohort as a reference for donor selection. Methods This study retrospectively reviewed 1354 patients and donors from solid organ and stem cell transplant registration at Cleveland Clinic who had been typed for HLA-DPB1 by high resolution sequence based typing.Four major US populations: Caucasian, African American, Hispanic, and Asian, along with mixed race were analyzed for DPB1 allele TF from total individuals and 234 normal related/unrelated donors. Results 35 DPB1 alleles were identified from this study.The total cohort analysis demonstrated that among the top 18 selected DPB1 alleles with the TF greater than 0.5%, HLA-DPB1 ∗ 04:01 was the most common allele in the population possessed by 69% of subjects, followed by ∗ 02:01 (27%), ∗ 04:02 (20%), ∗ 03:01 (19%), ∗ 01:01 (13%), which were present in subjects at TF greater than 10%.Sixteen alleles had high distribution TF in Caucasian.DPB1 ∗ 105:01 and ∗ 18:01 are the only alleles with highest TF in African American.Of the top 18 alleles, Asian subjects were found to have relatively higher TF with DPB1 ∗ 05:01 and ∗ 19:01 (Table 1a).Analysis of 234 normal individuals showed that DPB1 ∗ 04:01 was also found to be the most frequent (40%), followed by ∗ 02:01 (31%), ∗ 03:01 (18%), ∗ 04:02 (16%), ∗ 01:01 (9.8%), ∗ 05:01 (4.7%) (Table1b). Conclusion Our data provides DPB1 allele TF based on a larger cohort. The DPB1 allele TF calculated from the total cohort and from healthy donors had similar TF orders, which are in broad agreement with other published DPB1 allele frequency studies. Download : Download high-res image (402KB) Download : Download full-size image

Background Cytomegalovirus (CMV) is a common infectious complication after allogeneic hematopoietic cell transplantation (alloHCT). Efforts to enhance immune reconstitution post-transplant have been pursued to help facilitate clearance of such infections. Assessment of natural killer (NK) cell allo-reactivity with investigation of killer cell immunoglobulin-like receptors has been reported to be associated with protection from CMV infection after alloHCT (Davis ZB et al, BBMT 2015). In addition, the activating NKG2D receptor controls immune responses by regulating NK cells, NKT cells and γδ-T cells. MHC class I chain-related gene A (MICA) is a polymorphic ligand of the NKG2D receptor on these immune effector cells. Given the potential benefit of NK cell allo-reactivity for protection from CMV infection after alloHCT we hypothesized that MICA polymorphisms may influence CMV infection rates after such transplants. Methods We conducted a single center, retrospective analysis of allogeneic HCTs for adults with hematologic malignancies in which MICA data were available for donors and recipients. Analysis was restricted to patients with T-cell replete HLA-8/8 matched related or unrelated donor. Fine and Gray regression was used to identify risk factors for CMV infection. The first episode of graft-versus-host-disease (GVHD) was analyzed relative to CMV as a time-dependent covariate. An analysis was performed examining dimorphisms at the MICA-129 position, which previously has been categorized as weaker (valine/valine: V/V), heterozygous (methionine/valine: M/V), or stronger (methionine/methionine: M/M) receptor binding affinity. Results From 2000-2016, 423 alloHCT patients were identified who had MICA data. Diagnoses included 197 AML, 82 MDS, 34 ALL, 34 NHL, 22 CML, 12 CMML, 9 CLL, 9 myelofibrosis, 9 plasma cell myeloma, 9 other leukemias, and 6 Hodgkin lymphoma. High, intermediate, and low co-morbidity index was seen in 42%, 33%, and 25% of patients, respectively. Median age at transplant was 52 years (range, 18-76), with 95% Caucasian. A myeloablative transplant was performed in 80% of patients and 52% had a bone marrow graft source. CMV infection occurred in 141 (33%) of patients at a median time of 46 days post-transplant (range, 0-609 days) with 29 (21%) occurring within 30 days, 108 (77%) within 100 days and 33 (23%) after day 100. Thirty-three (8%) patients were MICA mismatched with their donor. Donor MICA-129 dimorphisms included 203 (48%) V/V, 190 (45%) M/V and 30 (7%) M/M. Baseline donor(d)/recipient(r) CMV serostatus for V/V vs. M/V + M/M cohorts were 25% vs. 28% for d+/r+, 11% vs 9% for d+/r-, 39% vs. 37% for d-/r+, and 25% vs. 26% for d-/r- (P=0.75). In univariate analysis, MICA mismatch was associated with a higher risk of CMV (HR 1.64, CI 1.00-2.69, P=0.049), and V/V donor MICA-129 dimorphism with a marginally higher risk of CMV (HR 1.32, CI 0.85-1.83, P=0.10). In multivariable analysis, MICA mismatch was not associated with CMV infection (HR 1.38, CI 0.83-2.29, P=0.22) while V/V donor MICA-129 dimorphism was associated (HR 1.40, CI 1.00-1.96, P=0.05) (Figure 1). Other significant variables in multivariable analysis were year of transplant (HR 0.95, CI 0.92-0.99 P=0.01), non-Caucasian race (HR 2.15, CI 1.18-3.91, P=0.01), high-risk disease (HR 1.62, CI 1.13-2.32 P=0.008), baseline CMV serostatus (HR 7.51, CI 3.76-15.0, P Conclusion We conclude that the donor MICA-129 V/V dimorphism with weak NKG2D receptor binding affinity is associated with increased risk of CMV infection after alloHCT. The presence of at least one M residue encoding allele may confer enhanced NK cell anti-viral reactivity. These observations potentially may have implications in optimizing donor selection. Further investigation of MICA may also help better predict which patients are at higher risk of CMV infection in order to consider intervening sooner with CMV specific therapy or more rapid tapering of immunosuppression. Figure 1 Figure 1. Disclosures Gerds: CTI BioPharma: Consultancy; Incyte: Consultancy. Majhail: Sanofi: Honoraria; Anthem, Inc.: Consultancy.

Aim The incidence of HLA de novo donor specific antibody (dDSA) after lung transplant (LuTx) is prevalent and related to negative transplant outcomes. In the first large cohort study of its kind, we aim to assess pre-transplant predictors that are associated with development of dDSA afterLuTx. Methods We retrospectively recorded the development of dDSA among 422 recipients who underwent LuTx between 10/2012 and 12/2016 at our center. Recipient demographic characteristics including gender, age ( 65), race, blood type, histocompatibility factors of ⩾30% pre-transplant total panel reactive antibody (PRA), mean fluorescence intensity (MFI) of dDSA at the time of pre-transplant (0–500; >500 * , B * , C * , DRB1 * , DQB1 * , DPB1 * loci were analyzed for the development of dDSA. Results A total of 222 out of 422 (53%) recipients were identified with dDSA. Among 6 studied loci, HLA-A * and DQB1 * MMs were remarkably associated with the occurrence of dDSA (p Conclusions MMs in HLA-A * and DQB1 * loci, as well as pre-transplant PRA ⩾30% are associated with dDSA production after LuTx and should be considered as the secondary pre-transplant histocompatibility risk factors that warrant closer post-transplant DSA monitoring.

Aim The human leukocyte antigen (HLA) gene family encodes the major histocompatibility complex (MHC) proteins in humans. Being the most polymorphic region of the human genome, it has proven difficult to fully characterize. NGS has shown that it is able overcome this challenge and provide unambiguous and accurate HLA typings. NGS typing of all patients and donors is now standard practice for our center. Previously, high resolution typing would be provided by Sanger sequencing (SBT) with many ambiguous allele pairs ruled out by RSSOP. This study seeks to show the difference in typing assignments between our previous strategy of combined SBT & RSSOP vs typing by NGS for two proficiency samples. Methods We typed two proficiency samples by SBT/RSSOP and NGS. This provided us with the typing resolution that we previously would have reported. These same samples were tested by NGS using Omixon’s Holotype HLA kit. A DNA library was created by pooling 24 samples total and sequenced on the Illumina Miseq using a Micro Kit. NGS analysis was performed with Omixon’s HLA Twin 2.1.0. Results NGS provided a higher resolution and less ambiguous typing than SBT/RSSOP. In Sample 1, the HLA typing was not A∗02:380, A∗30:01:01, but in fact A∗02:01:01 and a novel variant of A∗30:01:01. The variant produced a missense SNP in codon 139 from GCG to GTG which resulted in an amino acid change from alanine to valine. In Sample 2, with SBT/RSSOP, we were not able to obtain a common 4 digit typing for HLA-B and therefore were not sure if the B∗15 or B∗46 was the common allele. NGS was able to unambiguously assign B∗15:58, B∗46:01:01. Conclusions SBT/RSSOP was not able to provide the correct typing for HLA-A for Sample 1. By utilizing NGS, we were able to determine that this sample had a novel allele that was not characterized by SBT/RSSOP. In addition, NGS has been useful for us in obtaining more accurate and unambiguous typings as can be seen in both samples described here. Download : Download high-res image (236KB) Download : Download full-size image

DNA-based typing of HLA alleles occasionally results in the inability to assign a specific allele because of ambiguity in associating two or more polymorphisms to the same or to alternate homologs (cis/trans ambiguity). Since most individuals are heterozygous at a given HLA locus, the highest level of confidence in definition is obtained when the alleles are tested in isolation. By using single-strand conformation polymorphisms (SSCP) to separate heterozygous HLA-DRB1 alleles, followed by sequencing of separated conformers, we have achieved resolution of previously ambiguous assignments without the need for additional probes or primers.

Objective Management of acute Graft versus Host Disease (aGvHD) following liver transplant (LT) is critical for reducing mortality from this life-threatening disease. The aim of this study was to examine how Donor Lymphoid Chimerism (DLC) determinants associate with the diagnosis and prediction of clinical outcome of aGvHD after LT. Methods We retrospectively analyzed 17 LT patients (2007-2015) who were clinically suspected and DLC supportive of aGvHD. The DLC was tested by short tandem repeat with an initial 5% as positive cut off. The DLC determinants were: initial positive DLC after 30 days post-LT (InPD > 30D); initial positive DLCs in whole blood, T, NK, and CD8+ cells; peak DLCs of > 5% in whole blood, > 50% in each of T, NK, CD8+ cells respectively; positive DLC in both CD8+ and NK cells at initial phase, DLC 50% in both CD8+ and NK cells at peak phase. Clinical outcome was determined over the following 40-day duration of treatment and/or aGvHD related motility ( > 40D DuT/M). Logistic regression was used to analyze > 40D DuT/M in response to all the variables of DLC determinants. Results Of 17 aGvHD patients, the prevalence of 100% (16/16) in CD8+ cell was markedly higher than the prevalence of 41% (7/17) in whole blood, 59% (10/17), in T cell, and 38% (6/16) in NK cell at the initial detection of positive DLC. Amongst all analyzed variables of DLC determinants, InPD > 30D and DLC 50% in both CD8+ and NK cells at peak phase were all significantly associated with > 40D DuT/M. There was a mildly significant association with the individual variables of initial phase positive DLC in T and NK cells, and peak phase > 50% DLC in T and NK cells. Regardless of initial phase or peak phase, the individual variables of DLC in whole blood and CD8+ cell had no significant relationship with > 40D DuT/M (Figure 1). Conclusion Initial positive DLC of CD8+ cell is a sensitive and reliable indicator supporting the diagnosis of aGvHD. Both delayed diagnosis and/or peak phase DLC over 50% in both CD8+ and NK cells strongly predicts aGvHD related negative impact following LT. Download : Download full-size image

In this case we describe a Hematopoietic cell transplantation (HCT) African American recipient whose typing included a novel allele initially assigned incorrectly after utilizing 3 traditional Methods Sanger sequence based typing (SBT, Conexio), rSSOP (One Lambda) and SSP (Invitrogen). The correct typing was assigned by Next Generation Sequencing (NGS, MiSeq platform, Omixon reagents and analysis software) and supported by a family study. Initial HLA-C typing in duplicate was assigned as C∗06:44, 08:XX based on rSSOP (positive bead 9 with recognition site highlighted in Fig. 1A) and SBT result of 06:44, 08:05 (0 nucleotide mismatches) or 06:02:01:01, 08:02:01:01 (1 nucleotide mismatch, Fig. 1B). High resolution HLA-C SSP testing assigned 06:44, 08:XX (excluded the 08:05). Two siblings of the patient were HLA typed but neither of them shared any HLA haplotypes with the patient. The typing was reported as 06:44, 08:XX. There was no consistent high resolution assignment by all 3 methods. NGS provided phased information with an unambiguous typing of C∗06:02:01:01, 08:02:01:01v (80 and 93 reads mapping to these alleles respectively, 0 reads mapping to 06:44, Fig. 1C). Subsequent HLA typing of the father ruled out 06:44 and confirmed the NGS results. This novel C∗08:02:01:01v has a non-synonymous substitution at the 3rd nucleotide of codon 66 (AAG > AAC) in exon2 (Fig. 1A) which translates to one amino acid (AA) difference Lys > Asn. This AA resides in the α -1 helix of the HLA molecule, is accessible to antibody recognition and is a T-cell receptor (TCR) and peptide binding site. This novel allele also has intronic substitution at position 1578 (G > A) of intron 3. Currently, IMGT database has no intron 3 or exon 4 sequence information for 06:44 and 08:05 which would be helpful in determining whether the allele stemmed from recombination or point mutation. This case demonstrates that NGS is a powerful tool applicable to HLA-typing in HCT with the capability to resolve typing ambiguity and identify potential clinically relevant novel alleles. Download : Download full-size image

Summary This report describes the project to identify the global distribution of extended HLA haplotypes, a component of 16th International HLA and Immunogenetics Workshop (IHIW), and summarizes the initial analyses of data collected. The project aims to investigate extended HLA haplotypes, compare their distribution among different populations, assess their frequency in hematopoietic stem cell unrelated donor registries and initiate an international family studies database and DNA repository to be made publicly available. HLA haplotypes compiled in immunogenetics laboratories during the evaluation of transplant candidates and related potential donors were analysed. Haplotypes were determined using the pedigree analysis tool publicly available from the National Marrow Donor Program (NMDP) website. Nineteen laboratories from 10 countries (11 laboratories from North America, five from Asia, two from Latin America and one from Australia) contributed data on a total of 1719 families comprised of 7474 individuals. We identified 10 393 HLA haplotypes, of which 1682 haplotypes included high-resolution typing at HLA-A, B, C, DRB1 and DQB1 loci. We also present haplotypes containing MICA and other HLA loci and haplotypes containing rare alleles seen in these families. The project will be extended through the 17th IHIW, and investigators interested in joining the project may communicate with the first author.

Head Start is the largest program providing comprehensive educational, health, and social services to young children and their families in poverty and is an important player in the early childhood service delivery system. This article summarizes the results of a needs assessment of Head Start programs in one region in the nation. Three important challenges were identified: (a) serving young children with emotional-behavior issues, (b) working with families, and (c) working with community institutions. The paper focuses on a midwestern state, presenting interview information that confirms trends found in survey data from the whole region. As collaboration between early childhood programs serving children with disabilities becomes more prevalent, the challenges facing Head Start are a concern for the early childhood community.

Background and Aims Early post-transplant hepatic fibrosis is associated with poor outcomes and may be influenced by donor/recipient genetic factors. The rs368234815 IFNL4 polymorphism is related to the previously described IL28B polymorphism, which predicts etiology-independent hepatic fibrosis. The aim of this study was to identify the impact of donor and/or recipient IFNL4 genotype on early fibrosis among patients transplanted for hepatitis C (HCV). Methods Clinical data were collected for 302 consecutive patients transplanted for HCV. 116 patients who had available liver biopsies and donor/recipient DNA were included. 28% of these patients with stage 2 fibrosis or greater were compared to patients without significant post-transplant fibrosis with respect to clinical features as well as donor/recipient IFNL4 genotype. Results The IFNL4 TT/TT genotype was found in 26.0% of recipients and 38.6% of donors. Patients who developed early post-transplant fibrosis had a 3.45 adjusted odds of having donor IFNL4 TT/TT genotype (p = 0.012). Donor IFNL4 TT/TT genotype also predicted decreased overall survival compared to non-TT/TT genotypes (p = 0.016). Conclusions Donor IFNL4 TT/TT genotype, a favorable predictor of spontaneous HCV clearance pre-transplant, is associated with increased early post-transplant fibrosis and decreased survival.

Objective It has been widely recognized that donor specific antibody (DSA) is correlated with antibody-mediated rejection (AMR) and graft loss in solid organ transplant (Tx). However, the impact of HLA-DP DSA in Tx has been poorly understood, especially in lung Tx. Here we analyze the association of DP DSA with lung Tx clinical outcomes. Methods This study retrospectively analyzed 213 individuals selected from 720 recipients who underwent lung Tx at Cleveland Clinic from 2008 to 2015. 213 patients were analyzed in three groups: G1- without HLA antibody (n = 144), G2- with DP antibodies (n = 69), G3- with DP DSAs among the individuals in G2 (n = 20). Two year graft survival (GS), AMR, acute cellular rejection (ACR), and bronchiolitis obliterans syndrome (BOS), were recorded as deleterious clinical outcomes. Luminex single antigen assay was used for HLA antibody testing. Results DP antibodies were detected in 10% (69/720) lung Tx patients. DP DSAs were identified in 29% (20/69) of the patients with DP antibodies. De novo DP DSA was identified in 90% (18/20) of the patients with DP DSAs. In G3, 15% (3/20) had other class I DSA, 35% (7/20) had other class II DSA, and 50% (10/20) had only DP DSAs. Compared to patients in G1, patients in G2 showed higher occurrence of AMR (p = 0.019), but there was no remarkable difference in 2 year graft survival, ACR, and BOS. A comparison between G1 and G3 showed that patients with DP DSAs (G3) presented with significantly more AMR and poor GS (p = 0.010 and 0.003 , respectively) than patients who had no HLA antibodies. However, ACR, and BOS were equivalent (Table 1a). There was higher incidence of AMR and lower rate of GS in patients with DP DSA combined with class I or class II than in patients who only had DP DSA (Table 1b). Download : Download high-res image (212KB) Download : Download full-size image Conclusion DP DSA is associated with negative impact following lung Tx by increasing the incidence of AMR and reducing GS. DP DSA combined with other HLA-DSAs demonstrates increased adverse clinical outcomes. This finding warrants further investigation with larger cohort studies.