AbstractMedication can affect the gut microbiota composition and function. The aim of this study was to investigate connections between use of common non-antibiotic medicines and the gut microbiota composition and function in a large Swedish cohort (N = 2223). Use of 67 medications and polypharmacy (≥ 5 medications), based on self-reported and prescription registry data, were associated with the relative abundance of 881 gut metagenomic species (> 5% prevalence) and 103 gut metabolic modules (GMMs). Altogether, 97 associations of 26 medications with 40 species and of four medications with five GMMs were observed (false discovery rate < 5%). Several earlier findings were replicated like the positive associations of proton pump inhibitors (PPIs) with numerous oral species, and those of metformin with Escherichia species and with lactate consumption I and arginine degradation II. Several new associations were observed between, among others, use of antidepressants, beta-blockers, nonsteroidal anti-inflammatory drugs and calcium channel blockers, and specific species. Polypharmacy was positively associated with Enterococcus faecalis, Bacteroides uniformis, Rothia mucilaginosa, Escherichia coli and Limosilactobacillus vaginalis, and with 13 GMMs. We confirmed several previous findings and identified numerous new associations between use of medications/polypharmacy and the gut microbiota composition and functional potential. Further studies are needed to confirm the new findings.

BACKGROUND Disruptions in gut microbiota have been implicated in cardiometabolic disorders and other health outcomes. Antibiotics are known gut microbiota disruptors, but their long-term consequences on taxonomic composition of the gut microbiome remain underexplored. METHODS We investigated associations between register-based oral antibiotic use over 8 years and gut microbiota composition assessed with fecal shotgun metagenomics in 15,131 adults from the Swedish population-based studies SCAPIS, MOS, and SIMPLER. We applied multivariable regression models with the number of prescriptions in three pre-specified periods before fecal sampling (<1 year, 1-4, 4-8 years) as the main exposures and adjusted for sociodemographics, lifestyle, and comorbidities. Secondary analyses included participants with only one antibiotic course or none. RESULTS Antibiotic use <1 year before fecal sampling was associated with the greatest reduction in gut microbiota species diversity; however, antibiotic use 1-4 years and 4-8 years earlier was also associated with decreased diversity. Clindamycin, fluoroquinolones, and flucloxacillin accounted for most of the associations between antibiotic use and the abundance of individual species across all periods. Use of these three antibiotics 4-8 years earlier was associated with altered abundance of 10-14% of the species studied; use of penicillin V, extended-spectrum penicillins, and nitrofurantoin were associated with altered abundance of only a few species. Similar results were found when comparing one antibiotic course 4-8 years before sampling vs. none in the past 8 years. CONCLUSION Commonly prescribed antibiotics like clindamycin, fluoroquinolones, and the narrow-spectrum flucloxacillin appear to have long-lasting consequences for the gut microbiota. ### Competing Interest Statement J.S. reports direct or indirect stock ownership in companies (Anagram Kommunikation AB, Sence Research AB, Symptoms Europe AB, MinForskning AB) that provide services not related to the present work to companies and authorities in the health sector, including Amgen, AstraZeneca, Bayer, Boehringer, Eli Lilly, Gilead, GSK, Göteborg University, Itrim, Ipsen, Janssen, Karolinska Institutet, LIF, Linköping University, Novo Nordisk, Parexel, Pfizer, Region Stockholm, Region Uppsala, Sanofi, STRAMA, Takeda, TLV, Uppsala University, Vifor Pharma, and WeMind. J.Ä. has served on the advisory boards for Astella, AstraZeneca, and Boehringer Ingelheim and has received lecturing fees from AstraZeneca and Novartis, all unrelated to the present work. J.F.L. has also received financial support from M.S.D. to develop a paper reviewing national healthcare registers in China, has ongoing discussions with M.S.D. about unrelated IBD research, and receives funding for celiac disease research from Takeda. The remaining authors declare no competing interests. The remaining authors declare no competing interests. ### Funding Statement Financial support was obtained in the form of grants from the European Research Council [ERC-STG-2018-801965 (T.F.); ERC-CoG-2014-649021 (M.O.-M.); ERC-STG-2015-679242 (J.G.S.)], the Swedish Heart-Lung Foundation [Hjärt-Lungfonden, 2019-0505 (T.F.); 2018-0343 (J.Ä.); 2020-0711 (M.O.-M.)], the Swedish Research Council [VR, 2019-01471 (T.F.), 2018-02784 (MO-M), 2018-02837 (M.O.-M.), 2019-01015 (J.Ä.), 2020-00243 (J.Ä.), 2022-01460 (S.A.), and EXODIAB 2009-1039 (M.O.-M.)], the Swedish Research Council for Sustainable Development [FORMAS, 2020-00989 (S.A.)], Göran Gustafsson foundation [2016 (T.F.)], Axel and Signe Lagerman's foundation (T.F.), the A.L.F. governmental grant 2018-0148 (M.O.-M.), The Novo Nordic Foundation NNF20OC0063886 (M.O.-M.), The Swedish Diabetes Foundation DIA 2018-375 (M.O.-M.), Center of Clinical Research (CKF) in Region Dalarna (J.Ä.), Epihealth (S.A.), and governmental funding of clinical research within the Swedish National Health Service (J.G.S.). B.K. is supported by a Gullstrand fellow grant from the Uppsala University Hospital. We acknowledge the Swedish Heart-Lung Foundation, the main funding body of SCAPIS. Funding for the SCAPIS study was also provided by the Knut and Alice Wallenberg Foundation, the Swedish Research Council and VINNOVA (Sweden's innovation agency), the University of Gothenburg and Sahlgrenska University Hospital, Karolinska Institutet and Stockholm County Council, Linköping University and University Hospital, Lund University and Skåne University Hospital, Umeå University and University Hospital, Uppsala University and University Hospital. We thank SIMPLER for the providing facilities and experimental support and Anna-Karin Kolseth and Niclas Håkansson for assistance. SIMPLER receives funding through the Swedish Research Council under grant no 2017-00644, 2017-06100, 2021-00160, and Stiftelsen Olle Engkvist Byggmästare. The computations and data handling were enabled by resources in project sens2019512 and simp2023007 provided by the National Academic Infrastructure for Supercomputing in Sweden (NAISS) at Uppsala Multidisciplinary Center for Advanced Computational Science (UPPMAX), funded by the Swedish Research Council through grant agreement no. 2022-06725. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval was obtained from the Swedish Ethical Review Authority (DNR 2018-315 B and amendments 2020-06597 and 2022-06460-02, DNR 2012-594 and the amendment 2017-768 and 2020-05611, DNR 2022-06137-01 and amendment DNR 2023-04785-02). All participants from each of the three studies provided written informed consent. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data supporting the conclusions of this article were provided by the SCAPIS, SIMPER, and MOS and are not shared publicly due to confidentiality. Data will be shared upon reasonable request to the corresponding author only after permission from the Swedish Ethical Review Authority (https://etikprovningsmyndigheten.se) and from the boards of SCAPIS, (https://www.scapis.org/data-access), SIMPER (https://www.simpler4health.se), and MOS (https://www.malmo-kohorter.lu.se/malmo-offspring-study-mos). The code used for the statistical analysis and .csv files of the supplementary tables will be available at https://github.com/MolEpicUU/antibiot_gut.

Background: Metabolic syndrome (MetS) is characterized by coexisting risk factors for type 2 diabetes and cardiovascular disease. Diet is of importance in their aetiology, and gut microbiota (GM) may constitute a link between diet and metabolic health. Understanding the interplay between diet and GM could contribute novel insights for future dietary guidelines, and aid in preventive actions to motivate adherence to dietary guidelines. Objective: We intended to create a Swedish dietary guideline index (SweDGI) measuring adherence to 12 Swedish dietary guidelines and examine whether SweDGI and its components are associated with GM α-diversity (Shannon index) and prevalent MetS, and if the association between the Shannon index and MetS differs depending on SweDGI. Design: SweDGI was based on food-frequency data assessed 2014–2018 in 10,396 diabetes-free participants from the Malmö and Uppsala-sites of the Swedish CArdioPulmonary bioImage Study (SCAPIS) (50–64 y, 53% women). We estimated the Shannon index from shotgun metagenomic sequencing-data to assess microbial richness and evenness. We used a general linear model to examine cross-sectional SweDGI-Shannon associations and logistic regression for associations with MetS. Results: Most guidelines were followed by less than half of the participants. Men showed poorer adherence. Higher SweDGI was linked to higher Shannon index (P-trend across five SweDGI-groups = 1.7 × 10-12). Most guidelines contributed to this observation. Higher SweDGI and Shannon index were associated with lower MetS-prevalence, where the lowest prevalence was observed among those with both high SweDGI and high Shannon index (odds ratio:0.43; 95% confidence interval:0.35, 0.52). Both the Shannon index and SweDGI were associated with MetS, independently of the level of the other factor (P-interaction = 0.82). Conclusions: We created a new index to comprehensively reflect adherence to the Swedish dietary guidelines in sub-cohorts within the large multicentre SCAPIS study. Better adherence was associated with a richer and more even GM and lower prevalence of MetS. The inverse association between the Shannon index and MetS was consistent at different levels of adherence to dietary guidelines

BACKGROUND: Gut microbiota have been implicated in atherosclerotic disease, but their relation with subclinical coronary atherosclerosis is unclear. This study aimed to identify associations between the gut microbiome and computed tomography–based measures of coronary atherosclerosis and to explore relevant clinical correlates. METHODS: We conducted a cross-sectional study of 8973 participants (50 to 65 years of age) without overt atherosclerotic disease from the population-based SCAPIS (Swedish Cardiopulmonary Bioimage Study). Coronary atherosclerosis was measured using coronary artery calcium score and coronary computed tomography angiography. Gut microbiota species abundance and functional potential were assessed with shotgun metagenomics sequencing of fecal samples, and associations with coronary atherosclerosis were evaluated with multivariable regression models adjusted for cardiovascular risk factors. Associated species were evaluated for association with inflammatory markers, metabolites, and corresponding species in saliva. RESULTS: The mean age of the study sample was 57.4 years, and 53.7% were female. Coronary artery calcification was detected in 40.3%, and 5.4% had at least 1 stenosis with >50% occlusion. Sixty-four species were associated with coronary artery calcium score independent of cardiovascular risk factors, with the strongest associations observed for Streptococcus anginosus and Streptococcus oralis subsp oralis ( P <1×10 –5 ). Associations were largely similar across coronary computed tomography angiography–based measurements. Out of the 64 species, 19 species, including streptococci and other species commonly found in the oral cavity, were associated with high-sensitivity C-reactive protein plasma concentrations, and 16 with neutrophil counts. Gut microbial species that are commonly found in the oral cavity were negatively associated with plasma indole propionate and positively associated with plasma secondary bile acids and imidazole propionate. Five species, including 3 streptococci, correlated with the same species in saliva and were associated with worse dental health in the Malmö Offspring Dental Study. Microbial functional potential of dissimilatory nitrate reduction, anaerobic fatty acid β-oxidation, and amino acid degradation were associated with coronary artery calcium score. CONCLUSIONS: This study provides evidence of an association of a gut microbiota composition characterized by increased abundance of Streptococcus spp and other species commonly found in the oral cavity with coronary atherosclerosis and systemic inflammation markers. Further longitudinal and experimental studies are warranted to explore the potential implications of a bacterial component in atherogenesis.

Background Despite EU regulatory standards, many workers suffer injury as a result of working with hand-held vibrating tools. Our aim of this study was to confirm whether carpenters, a highly exposed group, suffer more injuries to their hands than painters, a group assumed to be less exposed to vibration. Methods 193 carpenters (participation rate 100%) and 72 painters (participation rate 67%), all men, answered a questionnaire and underwent a clinical examination to identify manifestations of neural and vascular origin in the hands. Neurosensory affection was defined as having at least one symptom in the fingers/hands (impaired perception of touch, warmth, or cold, impaired dexterity, increased sensation of cold, numbness or tingling, or pain in the fingers/hands when cold) and at least one clinical finding (impaired perception of touch, warmth, cold, vibration, or two-point discrimination). Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI). Results Neurosensory affection was fulfilled for 31% of the carpenters and 17% of the painters , age-adjusted OR 3.3 (CI 1.6–7.0). Among carpenters with neurosensory affection 18% reported interference with daily life activities, the most common symptoms being increased sensation of cold, numbness and pain in the fingers/hands when cold, the most common clinical findings were impaired perception of touch and vibration. Neurosensory affection was found in 12% of young carpenters (≤ 30 years old) . No difference was found in the prevalence of white fingers between carpenters and painters. Conclusions Carpenters showed more symptoms and clinical findings of neurosensory affection than painters, probably due to vibration exposure. Also young carpenters showed signs of neurosensory affection, which indicates that under current conditions workers at these companies are not protected against injury. This underlines the importance of reducing exposure to vibration and conducting regular medical check-ups to detect early signs of neural and vascular manifestations indicating hand-arm vibration injuries. Special attention should be given to symptoms of increased sensation of cold, pain in the fingers when cold, and numbness, as these were the most common initiating ones, and should be addressed as early as possible in the preventive sentinel process. It is also important to test clinically for small- and large-fibre neuropathy, as the individual may be unaware of any pathology.

The outcome of periampullary adenocarcinomas remains poor with few treatment options. Podocalyxin-like protein (PODXL) is an anti-adhesive protein, the high expression of which has been shown to confer a poor prognosis in numerous malignancies. A correlation and adverse prognostic synergy between PODXL and the epidermal growth factor receptor (EGFR) has been observed in colorectal cancer. Here, we investigated whether this also applies to periampullary adenocarcinomas. We analyzed the immunohistochemical expression of PODXL and EGFR in tissue microarrays with tumors from two patient cohorts; (Cohort 1, n = 175) and (Cohort 2, n = 189). The effect of TGF-β-induced expression and siRNA-mediated knockdown of PODXL and EGFR, were investigated in pancreatic cancer cells (PANC-1) in vitro . We found a correlation between PODXL and EGFR in these cancers, and a synergistic adverse effect on survival. Furthermore, silencing PODXL in pancreatic cancer cells resulted in the down-regulation of EGFR, but not vice versa. Consequently, these findings suggest a functional link between PODXL and EGFR, and the potential combined utility as biomarkers possibly improving patient stratification. Further studies examining the mechanistic basis underlying these observations may open new avenues of targeted treatment options for subsets of patients affected by these particularly aggressive cancers.

Background Being born small for gestational age (SGA) or large for gestational age (LGA) has short and long term metabolic consequences. There is a growing interest in the extent to which body composition, both in the short and the long term, differs in infants born at the extremes of these birth weights. Methods Body composition in 25 SGA and 25 LGA infants were assessed during the first days of life and at 3-4 months of age using air displacement plethysmography. Results SGA infants had significantly lower body fat (%) at birth compared to LGA infants. SGA infants increased their body weight and length at a significantly higher rate between birth and 3-4 months than LGA infants. Fat mass (g) in SGA infants increased 23 times between birth and 3-4 months of age compared to 2.8 times for LGA infants. At 3-4 months of age LGA infants reached a threshold in body fat (%) while SGA infants were still gaining body fat (%). Conclusion Several significant differences have been identified between SGA and LGA infants, indicating that the effects of intrauterine life continues to play an important role in body composition and growth during the first 3-4 months of life.

Obesity is a well-established risk factor for colorectal cancer (CRC), but the association with the tumor microenvironment has been sparsely described. Herein, we examined the relationship between pre-diagnostic anthropometry and CRC risk according to tumor immune cell composition, with particular reference to potential sex differences. The density of different immune cell subsets was assessed by immunohistochemistry in tissue microarrays with tumors from 584 incident CRC cases in a prospective, population-based cohort (n = 28098). Multivariable Cox regression models, adjusted for age, smoking, alcohol intake, and educational level, were applied to calculate risk of immune marker-defined CRC in relation to quartiles of pre-diagnostic height, weight, body mass index (BMI), waist and hip circumferences, waist-hip ratio (WHR), and body fat percentage (BFP). Obesity was all over significantly associated with risk of CRC with low density of FoxP3(+) T cells and low programmed cell-death protein 1 (PD-L1) expression on tumor cells, but with high density of CD8(+) T cells and CD20(+) B cells. In women, obesity was significantly associated with risk of PD-L1 high tumors (p= 0.009 for weight, p= 0.039 for BMI). Contrastingly, in men, obesity defined by all anthropometric factors was significantly associated with PD-L1 low tumors (p= 0.005 for weight, p = 0.002 for BMI, p<0.001 for waist, p= 0.011 for hip, p<0.001 for WHR, and p= 0.004 for BFP). In summary, obesity appears to influence the immune landscape of CRC, possibly in a sex-dependent manner. Thus, anthropometry and sex may be important factors to take into account when assessing the prognostic or predictive value of relevant complementary immune biomarkers.

e15587 Background: Podocalyxin-like 1 (PODXL) is an anti-adhesive transmembrane protein associated with an aggressive tumor phenotype and poor prognosis in numerous malignancies, including colorectal cancer (CRC). An intercorrelation and synergistic adverse prognostic impact of PODXL and epidermal growth factor receptor (EGFR) expression has previously been demonstrated in CRC. The aim was to investigate the prognostic role of PODXL and EGFR in metastatic CRC (mCRC), and the potential functional link between the two proteins. Methods: PODXL and EGFR expression was analyzed by immunohistochemistry in tissue microarrays with tumors from a prospective cohort including 454 mCRC patients from three Scandinavian countries diagnosed 2003-2006, before implementation of routine RAS testing to preclude anti-EGFR treatment. Cox regression analyzes were applied to demonstrate the impact of PODXL and EGFR expression on overall survival (OS). The effects of small interfering RNA (siRNA)-mediated downregulation of PODXL and EGFR were examined in CRC cells in vitro. Results: There was a strong correlation between high expression of PODXL and EGFR (p < 0.001). Both high expression of PODXL and EGFR was significantly associated with a reduced OS (HR = 1.86; 95% CI 1.29-2.69, and HR = 1.39; 95% CI 1.06-1.84, respectively). High expression of both proteins signified the shortest OS (HR = 2.56; 95% CI 1.18-5.59), and there was a significant prognostic interaction between EGFR and PODXL (p = 0.018). In the entire cohort, 68 (15.0%) patients received anti-EGFR treatment in any line. Median OS for patients with PODXL positive tumors was 33 vs 3 months in the anti-EGFR treated vs untreated group (p = 0.001). Interestingly, a majority of PODXL high tumors in the treated group had RAS mutations. Knockdown of PODXL resulted in downregulation of EGFR, whereas PODXL was not affected by silencing of EGFR. Conclusions: The results from this study demonstrate a functional link between PODXL and EGFR, and a synergistic adverse prognostic effect in mCRC. The potential value of PODXL as a predictive biomarker for anti-EGFR therapy merits further investigation.

Expression of programmed cell death protein 1 (PD-1) and its ligand PD-L1 has been demonstrated to confer a prognostic value in colorectal cancer (CRC), but no studies have investigated whether this association differs according to tumour location. In this study, immunohistochemical expression of PD-1 and PD-L1 was analysed in tissue microarrays with primary tumours from 557 incident CRC cases from a prospective population-based cohort. Univariable and multivariable Cox regression analyses, adjusted for age, sex, TNM stage, differentiation grade and vascular invasion, were applied to determine the impact of biomarker expression on 5-year overall survival (OS), in the entire cohort and in subgroup analysis of right colon, left colon, and rectum. High PD-L1 expression on tumour-infiltrating immune cells was an independent factor of a prolonged OS in the entire cohort (hazard ratio [HR] = 0.49; 95% confidence interval [CI] CI 0.35 - 0.68), and in tumours of the right colon (HR = 0.43; 95% CI 0.25 - 0.74) and the left colon (HR = 0.28; 95% CI 0.13 - 0.61), but not in rectal cancer. Tumour-specific PD-L1-expression was not prognostic, neither in the full cohort nor according to tumour location. High immune cell-specific PD-1 expression was associated with a prolonged OS in the entire cohort and in tumours of the right colon, but not in the left colon or rectum, and only in univariable analysis. In conclusion, these results demonstrate that immune cell-specific PD-L1 and PD-1 expression is prognostic in a site-dependent manner, whereas tumour-specific PD-L1-expression is not prognostic in CRC.

628 Background: A plethora of studies report abundant expression of programmed death-ligand 1 (PD-L1) on tumors to be associated with poor outcome in several cancer forms, whereas immune cell-specific expression of PD-L1 has been associated with improved prognosis in colorectal cancer. However, none of these studies have investigated the association with prognosis according to primary tumor location. This study aimed to investigate the clinicopathological correlates and prognostic impact of PD-L1 and its receptor PD-1 in colorectal cancer, with particular reference to the anatomical subsite of the primary tumor. Methods: Immunohistochemical expression of PD-L1 and PD-1 was analysed in tissue microarrays with tumors from 557 incident cases of CRC from a prospective population-based cohort. Kaplan-Meier and Cox regression analyses were applied to determine the impact of biomarker expression on 5-year overall survival (OS), in the entire cohort and in subgroup analysis of right colon, left colon, and rectum. Results: High PD-L1 expression on tumor-infiltrating immune cells correlated significantly with an improved 5-year OS in univariable and multivariable analysis, adjusted for age, sex, TNM stage, differentiation grade, and vascular invasion, in the full cohort (HR = 0.49; 95 % CI 0.35-0.68), and in primary tumors of the right (HR = 0.43; 95 % CI 0.25-0.74) and the left colon (HR = 0.28; 95 % CI 0.13-0.61), but not in rectal cancer. High tumor-specific PD-L1-expression was not significantly associated with prognosis in neither the full cohort nor according to primary tumor location. High expression of PD-1 on tumor-infiltrating immune cells was significantly associated with an improved 5-year overall survival in the entire cohort (HR = 0.42; 95 % CI 0.21-0.87), but not in subsite analysis according to primary tumor location. Conclusions: This study is, to the best of our knowledge, the first to investigate the prognostic impact of PD-L1 and PD-1 expression according to primary tumor site in colorectal cancer. Dense infiltration of PD-L1+ immune cells was found to be an independent favorable prognostic factor in primary tumors of the right and left colon, but not in the rectum.

We have previously shown that podocalyxin-like protein (PODXL) is a prognostic biomarker for poor survival in gastric and esophageal adenocarcinoma treated with surgery up-front. The aim of the present study was to assess PODXL expression in tumors from patients treated with neoadjuvant ± adjuvant (i.e. preoperative with or without postoperative) chemotherapy, with regard to histopathologic response, time to recurrence (TTR) and overall survival (OS).

Accumulating evidence demonstrates an association between dense infiltration of lymphocytes and prognosis in colorectal cancer (CRC), but whether this prognostic impact differs by tumour location remains unknown. This study investigated the prognostic impact of cytotoxic and regulatory T cells in CRC, with particular reference to the anatomical subsite of the primary tumour. The density of CD3+ , CD8+ and FoxP3+ tumour-infiltrating T cells was calculated in tissue microarrays with tumours from 557 incident CRC cases from a prospective population-based cohort. Kaplan-Meier and Cox regression analyses were applied to determine the impact of high and low lymphocyte density on 5-year overall survival, in subgroup analysis of right colon, left colon and rectum. High CD8+ cell density was a favourable prognostic factor for patients with right-sided colon tumours (hazard ratio [HR]=0.53, 95% confidence interval [CI] 0.29-0.95), independent of age, sex, TNM stage, differentiation grade and vascular invasion, with a significant prognostic interaction between CD8+ cells and right-sidedness (p = 0.031). High FoxP3+ cell density was an independent favourable prognostic factor only in patients with rectal tumours (HR = 0.54, 95% CI 0.30-0.99), and CD3+ cell density was an independent favourable prognostic factor for tumours in the right colon and rectum, but there was no significant prognostic interaction between CD3+ or FoxP3+ cells and sidedness. These results demonstrate that the prognostic impact of tumour-infiltrating lymphocytes in CRC differs by primary tumour site, further indicating that tumour location may be an important factor to take into consideration in therapeutic decisions, including eligibility for immunotherapy.

Background Human epidermal growth factors 2 and 3 (HER2 and HER3) are members of the EGFR family that drives oncogenesis mainly through activation of the RAS-RAF-MEK-ERK pathway. While the prognostic value of HER2 and HER3 alterations in colorectal cancer (CRC) remains uncertain, KRAS and BRAF mutations confer resistance to targeted therapies and poor prognosis. Sidedness of the primary tumour has also been shown to be an important prognostic and predictive factor. Herein, we examined the prognostic value of HER2 and HER3 expression in CRC, with reference to sidedness, KRAS and BRAF mutational status. Methods The study cohort encompassed 557 incident CRC cases from the prospective, population-based Malmo Diet and Cancer study. Immunohistochemistry and dual-in situ hybridization were applied on tissue microarrays to assess HER2 and HER3 expression and HER2 gene copy number (GCN) alterations. Kaplan-Meier and Cox regression analyses were applied to determine their impact on 5-year overall survival (OS) in different strata. Results We found a significant, gradual increase in HER2 GCN alterations and HER3 overexpression from the right colon to the rectum (p=0.010 and p<0.001, respectively). In the full cohort, HER3 expression was not prognostic. However, a significant prognostic interaction between HER3 and KRAS status was observed in that high HER3 expression was significantly associated with a reduced OS in KRAS wild-type (wt) and with a prolonged OS in KRAS-mutated tumours (pinteraction = 0.001). HER3 overexpression was also significantly associated with a reduced OS in BRAF-mutated tumours but was not prognostic in BRAF wt tumours (pinteraction =0.014). In addition, HER3 overexpression was significantly associated with a reduced OS in patients with right-sided tumours (HR= 1.64, 95% CI 1.06-2.55). No prognostic significance was found for HER2 overexpression or GCN alterations. Conclusions These novel findings of significant prognostic interactions between HER3 overexpression and mutational status of KRAS and BRAF in CRC are potentially highly relevant in the clinical setting. Speculatively, HER3 overexpression may influence the efficacy of EGFR-inhibitors in metastatic CRC.

Podocalyxin-like 1 (PODXL) is an anti-adhesive transmembrane protein that has been demonstrated to be an independent factor of poor prognosis in colorectal cancer (CRC). The gene encoding PODXL is located to chromosome 7, which also harbours the gene for the epidermal growth factor receptor (EGFR). The aim of this study was to examine the associations between PODXL and EGFR expression in CRC in vitro and in vivo.

BACKGROUND:Disseminated intravascular coagulopathy (DIC) relates to the consumption of coagulation factors and platelets with bleeding and micro thrombosis events. AIM:The aim of this study was to compare haemostasis parameters in critically ill patients with DIC versus patients without DIC, and in survivors versus non-survivors over time. Correlations between the DIC-score, the degree of organ failure and the haemostasis were assessed. METHOD:Patients admitted to the intensive care unit with a condition known to be associated with DIC and with an expected length of stay of >3 days were included. Routine laboratory tests, prothrombin time, activated partial thromboplastin time, platelet count, fibrinogen concentration and D-dimer were measured. Coagulation and platelet function were assessed with two point-of-care devices; Multiplate and ROTEM. DIC scores were calculated according to the International Society on Thrombosis and Haemostasis and Japanese Association for Acute Medicine. RESULTS:Blood was sampled on days 0-1, 2-3 and 4-10 from 136 patients with mixed diagnoses during 290 sampling events. The point-of-care assays indicated a hypocoagulative response (decreased platelet aggregation and reduced clot strength) in patients with DIC and, over time, in non-survivors compared to survivors. Patients with DIC as well as non-survivors had decreased fibrinolysis as shown by ROTEM. DIC scores were higher in non-survivors than in survivors. CONCLUSIONS:Patients with DIC displayed signs of a hypocoagulative response and impaired fibrinolysis, which was also evident over time in non-survivors. Patients with DIC had a higher mortality rate than non-DIC patients, and DIC scores were higher in non-survivors than in survivors.

Background: Podocalyxin-like protein (PODXL) is a cell surface transmembrane glycoprotein, the expression of which has been associated with poor prognosis in a range of malignancies. The aim of this study was to investigate the impact of PODXL expression on survival in esophageal and gastric adenocarcinoma.Methods: The study cohort consists of a consecutive series of 174 patients with esophageal (including the gastroesophageal junction) or gastric adenocarcinoma, surgically treated between 2006 and 2010 and not subjected to neoadjuvant treatment. Immunohistochemical expression of PODXL was assessed in tissue microarrays with cores from primary tumors, lymph node metastases, intestinal metaplasia and adjacent normal epithelium. Survival analyses were performed on patients with no distant metastases and no macroscopic residual tumor.Results: In the majority of cases, expression of PODXL was significantly higher in cancer cells compared to normal epithelial cells and was significantly associated with lymph node metastases and high grade tumors. In esophageal adenocarcinoma, Kaplan-Meier analyses revealed that patients with PODXL negative tumors had a superior time to recurrence (TTR) and overall survival (OS) compared to patients with PODXL positive tumors. In gastric adenocarcinoma, patients with PODXL negative tumors had a superior TTR and a trend towards an improved OS. In esophageal and gastric adenocarcinoma combined, the prognostic significance of PODXL expression on TTR was confirmed in unadjusted Cox regression analysis (HR = 5.36, 95 % CI 1.68-17.06, p = 0.005) and remained significant in the adjusted model (HR = 3.39, 95 % CI 1.01-11.35, p = 0.048). Moreover, the impact of PODXL expression on OS was also confirmed in unadjusted analysis (HR = 2.52, 95 % CI 1.31-4.85, p = 0.006) and remained significant in the adjusted model (HR = 2.03, 95 % CI 1.04-3.98, p = 0.039).Conclusions: In esophageal and gastric adenocarcinoma, PODXL expression is an independent prognostic biomarker for reduced time to recurrence and poor overall survival. This is the first report on the prognostic role of PODXL in esophageal adenocarcinoma and validates recent findings in gastric cancer.

Monitoring low molecular weight heparins (LMWH’s) in the perioperative period is prudent in patients at high risk of coagulative complications, especially when the patient has an epidural catheter requiring withdrawal, which is associated with the risk of spinal haematoma. The aim of this study was to evaluate the in vitro dose-responses of two different LMWH’s on two different viscoelastic haemostatic tests, using blood sampled from patients with normal routine coagulation parameters, on the day after major surgery when their epidural catheters were due to be withdrawn.