Investigating the Intrinsic Role of Programmed Death-Ligand 1 in Human Cancers.

Programmed death-ligand 1 (PD-L1) expression is a survival mechanism employed by tumours to mediate immune evasion and tumour progression. PD-1/PD-L1-targeted therapies have revolutionised the cancer therapy landscape due to their ability to promote durable anti-tumour immune responses in select patients with advanced cancers. However, some patients are unresponsive, hyperprogressive or develop resistance. The exact mechanisms for this are still unclear. Recently, a pro-tumorigenic role of PD-L1 to send pro-survival signals in cancer cells is becoming apparent in some cancers. Better characterisation of the three-dimensional (3D) architecture of solid tumours by utilising 3D cell culture could provide an environment that more closely recapitulates in vivo human tumours for investigating tumour-intrinsic PD-L1 signalling and immunotherapy responses. The role of PD-L1 and how approved immunotherapies may influence its role needs to be fully explored in all cancer types using in vitro cell culture systems that better model tumour heterogeneity compared to standard monolayer cell culture. Within this thesis, human breast prostate and colorectal cancer cell lines were firstly characterised for their expression of immune-inhibitory proteins (PD-L1, PD-1 and PD-L2), immunological proteins (DR4, DR5 and Fas) and tumorigenic proteins (CD44 and HIF1α) at basal level in two-dimensional (2D) monolayer cell culture, before being investigated in two different 3D cell culture models (hanging drop and alginate hydrogel beads) of varying in vitro complexity. In doing this, we were able to demonstrate that cancer cells alter their gene and protein expression levels and develop hypoxia in a 3D environment that more closely mimics human in vivo solid tumours. Cancer cells in 3D reduced their expression of death receptors and antigen presenting machinery which would reduce their susceptibility to immune-mediated cell death and could ultimately hinder their response to immunotherapy. Thereafter, we investigated the biological effects of therapeutically approved anti-PD-L1 monoclonal antibody Atezolizumab, before comparing PD-L1 blockade with PD-L1 knockdown in high PD-L1 expressing breast cancer cells cultured in 2D monolayer and 3D cell culture models. PD-L1 blockade using Atezolizumab demonstrated modest effects on breast cancer cell growth, proliferation, viability, and metabolism in our functional assays, but did reduce the phosphorylation of molecules involved in the PI3K/AKT and MAPK/ERK signalling pathways. PD-L1 knockdown, on the other hand, revealed the importance of PD-L1 expression for the spheroid-forming capabilities of breast cancer cells in our 3D cell culture models. PD-L1 knockdown also potentiated the modest biological effects on breast cancer cell growth, proliferation, viability, and metabolism observed by Atezolizumab treatment. Additionally, cytokine modulation of PD-L1 expression was investigated in combination with PD-L1 blockade and PD-L1 knockdown in our studies. Utilising the 3D alginate model for the culture of breast cancer cells revealed a potential benefit of combining cytokines with PD-L1 targeting for the treatment of breast cancer which warrants further investigation. Altogether this thesis provides new insights into: (1) the expression of immunological and tumorigenic proteins by diverse human cancer cells; (2) how PD-L1 blockade with Atezolizumab may influence PD-L1 intrinsic signalling in breast cancer cells; and (3) how PD-L1 may exhibit a pro-tumour role in breast cancer cells, not only in 2D monolayer but for the first time in two different 3D cell culture models

Effectiveness of conservative management versus laparoscopic cholecystectomy in the prevention of recurrent symptoms and complications in adults with uncomplicated symptomatic gallstone disease (C-GALL trial) : pragmatic, multicentre randomised controlled trial

Acknowledgments This project will be published in full in the National Institute for Health and Care Research (NIHR) Health Technology Assessment (HTA) programme series. Data monitoring committee: Catherine Hewitt (University of York), Jonathan Lund (University of Nottingham), Tim McAdam (Belfast Health and Social Care Trust), and Amir Nisar (Maidstone and Tunbridge Wells NHS Trust). Trial steering group: David Beard (University of Oxford), Ian Beckingham (Nottingham University Hospitals NHS Trust), John Leeds (Newcastle Hospitals NHS Foundation Trust), and Dee McDonald (patient representative). Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment (HTA) programme (project No 14/192/71). The Health Services Research Unit of the University of Aberdeen is funded in part by the chief scientist’s office of the Scottish government’s health and social care directorates. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the chief scientist’s office, HTA programme, NIHR, NHS, or Department of Health. The funder had no role in the study design, data collection, data analysis, data interpretation, or writing of the report.Peer reviewedPublisher PD

Laparoscopic cholecystectomy versus conservative management for adults with uncomplicated symptomatic gallstones : the C-GALL RCT

Acknowledgements The authors wish to thank the men and women who participated in C-GALL. We also thank the CHaRT data coordinators and trials managers who helped support the study: Zoe Batham, Louise Campbell, Janice Cruden, Dianne Dejean, Jackie Ellington, Andrea Fraser and Bev Smith (data coordinators), Tracey Davidson and Alison McDonald (Trial managers). We are grateful to Kirsty McCormack and John Norrie for their help and advice in developing the grant proposal, to the Programming Team in CHaRT for developing and maintaining the study website. We thank Juliette Snow and Rachael West for their help with contracting, and Louise Cotterell, Kerry Duffus and Anne Buckle for their assistance in managing the budget. Our thanks go also to the Research Governance team (Louise King, Stacey Dawson, Lynn McKay) at the University of Aberdeen for their advice and support during the study. Thanks to Jamie McAllister (NHS Grampian) for providing unit cost data for the within trial economic analysis. Thanks to the Chen et al. for allowing the C-GALL group the use of the Otago ConditionSpecific Questionnaire (OCSQ) for gallstone disease, developed by Chen et al. in the University of Otago, New Zealand.1,2 1. Chen TY, Landmann MG, Potter JC, van Rij AM. Questionnaire to aid priority and outcomes assessment in gallstone disease. ANZ J Surg. 2006;76(7):569-74. 2. Chen TY. A novel set of condition-specific quality of life questionnaires in elective general surgical patient prioritization and outcome assessment [dissertation]. Dunedin (NZ): University of Otago; 2012. Retrieved from http://hdl.handle.net/10523/2588 Members of the PMG for their ongoing support and advice. The independent members of the TSC and DMC, and the staff at the recruiting sites (listed below) who facilitated recruitment, treatment and follow up of trial participants. Trial funding This project was funded by the National Institute for Health Research (NIHR) XXX programme and will be published in full in HTA journal; Vol. XX, No. XXPeer reviewe

Adjunctive rifampicin for Staphylococcus aureus bacteraemia (ARREST): a multicentre, randomised, double-blind, placebo-controlled trial.

BACKGROUND: Staphylococcus aureus bacteraemia is a common cause of severe community-acquired and hospital-acquired infection worldwide. We tested the hypothesis that adjunctive rifampicin would reduce bacteriologically confirmed treatment failure or disease recurrence, or death, by enhancing early S aureus killing, sterilising infected foci and blood faster, and reducing risks of dissemination and metastatic infection. METHODS: In this multicentre, randomised, double-blind, placebo-controlled trial, adults (≥18 years) with S aureus bacteraemia who had received ≤96 h of active antibiotic therapy were recruited from 29 UK hospitals. Patients were randomly assigned (1:1) via a computer-generated sequential randomisation list to receive 2 weeks of adjunctive rifampicin (600 mg or 900 mg per day according to weight, oral or intravenous) versus identical placebo, together with standard antibiotic therapy. Randomisation was stratified by centre. Patients, investigators, and those caring for the patients were masked to group allocation. The primary outcome was time to bacteriologically confirmed treatment failure or disease recurrence, or death (all-cause), from randomisation to 12 weeks, adjudicated by an independent review committee masked to the treatment. Analysis was intention to treat. This trial was registered, number ISRCTN37666216, and is closed to new participants. FINDINGS: Between Dec 10, 2012, and Oct 25, 2016, 758 eligible participants were randomly assigned: 370 to rifampicin and 388 to placebo. 485 (64%) participants had community-acquired S aureus infections, and 132 (17%) had nosocomial S aureus infections. 47 (6%) had meticillin-resistant infections. 301 (40%) participants had an initial deep infection focus. Standard antibiotics were given for 29 (IQR 18-45) days; 619 (82%) participants received flucloxacillin. By week 12, 62 (17%) of participants who received rifampicin versus 71 (18%) who received placebo experienced treatment failure or disease recurrence, or died (absolute risk difference -1·4%, 95% CI -7·0 to 4·3; hazard ratio 0·96, 0·68-1·35, p=0·81). From randomisation to 12 weeks, no evidence of differences in serious (p=0·17) or grade 3-4 (p=0·36) adverse events were observed; however, 63 (17%) participants in the rifampicin group versus 39 (10%) in the placebo group had antibiotic or trial drug-modifying adverse events (p=0·004), and 24 (6%) versus six (2%) had drug interactions (p=0·0005). INTERPRETATION: Adjunctive rifampicin provided no overall benefit over standard antibiotic therapy in adults with S aureus bacteraemia. FUNDING: UK National Institute for Health Research Health Technology Assessment

Proceedings of the Thirteenth International Society of Sports Nutrition (ISSN) Conference and Expo

Meeting Abstracts: Proceedings of the Thirteenth International Society of Sports Nutrition (ISSN) Conference and Expo Clearwater Beach, FL, USA. 9-11 June 201

PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK

Abstract Background Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment. Methods All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals. Results A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death. Conclusion Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions. </jats:sec

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

Background: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding: National Institute for Health Research Health Services and Delivery Research Programme

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

BACKGROUND: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. METHODS: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. FINDINGS: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28). INTERPRETATION: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. FUNDING: National Institute for Health Research Health Services and Delivery Research Programme

Dimethyl fumarate in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial

Dimethyl fumarate (DMF) inhibits inflammasome-mediated inflammation and has been proposed as a treatment for patients hospitalised with COVID-19. This randomised, controlled, open-label platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing multiple treatments in patients hospitalised for COVID-19 (NCT04381936, ISRCTN50189673). In this assessment of DMF performed at 27 UK hospitals, adults were randomly allocated (1:1) to either usual standard of care alone or usual standard of care plus DMF. The primary outcome was clinical status on day 5 measured on a seven-point ordinal scale. Secondary outcomes were time to sustained improvement in clinical status, time to discharge, day 5 peripheral blood oxygenation, day 5 C-reactive protein, and improvement in day 10 clinical status. Between 2 March 2021 and 18 November 2021, 713 patients were enroled in the DMF evaluation, of whom 356 were randomly allocated to receive usual care plus DMF, and 357 to usual care alone. 95% of patients received corticosteroids as part of routine care. There was no evidence of a beneficial effect of DMF on clinical status at day 5 (common odds ratio of unfavourable outcome 1.12; 95% CI 0.86-1.47; p = 0.40). There was no significant effect of DMF on any secondary outcome

Laparoscopic cholecystectomy versus observation/conservative management for preventing recurrent symptoms and complications in adults with uncomplicated symptomatic gallstones (C-GALL):a pragmatic, multicentre randomised controlled trial

Background: In the adult population, gallstones have a global prevalence of 10-15%, although around 80% remain asymptomatic. Cholecystectomy remains the default treatment option for symptomatic gallstones. We assessed the clinical and cost-effectiveness of observation/conservative management compared with cholecystectomy for preventing symptoms and complications in adults with uncomplicated symptomatic gallstones. Methods: A parallel group, pragmatic randomised, superiority trial in 20 UK centres. All adults with uncomplicated symptomatic gallstone disease referred to secondary care were considered for inclusion and randomly assigned (1:1) to receive observation/conservative management or cholecystectomy. The primary outcome was quality of life measured by area under the curve (AUC) over 18 months using the short form 36 (SF-36) bodily pain domain. NHS costs, quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio were calculated. Findings: Between August 2016-November 2019, 434 participants were randomised: 217 in each group. By 18 months, 54 (24·9%) in the observation/conservative management arm and 146 (67·3%) in the cholecystectomy arm had received surgery. The mean SF-36 norm-based bodily pain score was 49·4 (SD 11·7) in the observation/conservative management arm and 50·4 (SD 11·6) in the cholecystectomy arm. The SF-36 bodily pain AUC up to 18 months showed no difference (mean difference 0·0, 95% CI -1·7 to 1·7; p=1·00). Observation/conservative management was less costly (mean difference -£1,033 95% Credible Interval (CrI) -£1,413 to -£632) and no evidence of QALY difference was observed (mean difference -0.019, 95% CrI: -0.06 to 0.02). Interpretation: In the short term (up to 18 months), surgery is no more effective than observation/conservative management, as such observation/conservative management should be considered as an alternative strategy to surgery, and may be (from a UK NHS perspective) cost-effective for uncomplicated symptomatic gallstones. As costs, complications and benefits will continue to be incurred in both groups beyond 18 months, future research should focus on longer-term follow-up to establish effectiveness and lifetime cost-effectiveness and identify the cohort of patients that should be routinely offered surgery. <br/