O-191 Endometriosis is associated with a lowered cumulative live birth rate by alters the macrophage polarization and the cytokine concentrations in follicular fluid

Study question

The impact of endometriosis on the outcomes of ART is still ambiguous and the mechanism by which endometriosis impacts fertility has not been fully elucidated

Summary answer

Endometriosis was associated with low CLBR in IVF, which might be due to the change of follicular microenvironment and compromising the quality of embryos.

What is known already

Despite the great advantages of IVF treatment in endometriosis-linked infertility, the impact of endometriosis on outcomes of infertility management with ART is controversial and few studies focused on the association between endometriosis and CLBR. Numerous mechanisms have been proposed in an effort to delineate the multifaceted pathophysiology that induces impairment of reproductive dynamics in patients with endometriosis. Reactive oxygen species, dysregulation of the immune system and cellular architectural disruption constitute the crucial mechanisms that detrimentally affect oocyte and embryo developmental potential. 

Study design, size, duration

This study retrospectively included 433 patients with endometriosis and 1299 patients with tuber factor infertility to evaluate the impact of endometriosis on IVF pregnancy outcome between January 2016 and December 2018.The basic study prospectively recruited 30 patients with ovarian endometriosis and 35 controls with tubal factor infertility to analyze polarization stage of macrophages in their follicular fluid, and another 20 females with ovarian endometriosis and 30 controls to detect cytokines in their FF. 

Participants/materials, setting, methods

Data on all women undergoing fresh or frozen IVF treatment cycles were analysed to compare the CLBR between endometriosis and tuber factor infertility patients. A cytometry panel of 4 antibodies (CD45, CD3, CD80, CD163) was designed to enumerate the numbers of MI and MII macrophages from the cell sediment from FF samples. Quantibody® array was utilized to determine the concentration of 10 cytokines in FF, including IFN-γ, IL-1α, IL-1β, IL-10,IL-13,IL-4, IL-6, IL-8, MCP-1 and TNF-α. 

Main results and the role of chance

The results showed that patients with endometriosis were associated with noticeably fewer retrievable oocytes, a lower oocyte maturity rate, decreased numbers of available and high-quality embryos (all p < 0.001) in comparison with the control group. The clinical pregnancy and live birth rate of the endometriosis group were lower in the frozen-thawed embryo transfer cycles (p = 0.028 and p = 0.008, respectively), which leading to a declined cumulative live birth rate (CLBR) (p = 0.001). Logistic regression analysis indicated a close association between endometriosis and low CLBR (p = 0.002). Furthermore, the numbers of type I and type II macrophages in follicular fluid (FF) of patients with ovarian endometriosis were significantly increased compared with the control group (p < 0.001). The expressions of IL-1α, IL-1β, TNF-α, IL-6, IL-13, and IL-10 in FF were higher in endometrioma group(p < 0.05). The increased expression of cytokines was negatively correlated with embryo outcomes, including the numbers of total oocytes retrieved, mature oocytes, and fertilized oocytes, and the numbers of high-quality blastocysts and embryos. Additionally, IL-6 and IL-8 were positively correlated with AMH, rate of available blastocysts, number of blastocysts formed and available blastocysts, but were negatively associated with rate of MII oocytes. 

Limitations, reasons for caution

The present study being of a retrospective and monocentric study, may not come to a very convincing conclusion, and some unknown biases might still exist due to possible underestimation of some confounders.

Wider implications of the findings

Collectively, our results indicate that endometriosis does adversely affect pregnancy outcomes of ART, as women with endometriosis produce a lower quantity of oocytes and embryos. Moreover, endometriosis might play a role in oocyte or embryo outcomes via regulating the production of cytokines or the number of immune cells in FF. 

Trial registration number

no

P-620 Hormone replacement therapy with GnRH agonist pretreatment improves pregnancy outcomes in patients with previous intrauterine adhesions

Study question

Is there an optimal endometrial preparation protocol of frozen-thawed embryo transfer (FET) for patients with history of intrauterine adhesions (IUAs)?

Summary answer

Hormone replacement therapy with GnRH agonist pretreatment (HRT+GnRHa) is superior to conventional HRT protocol to improve pregnancy outcomes in patients with IUAs.

What is known already

FET follow hysteroscopic adhesiolysis or therapeutic treatment is being widely adopted in patients with IUAs. Proper endometrial preparation plays a key role to maximize IVF success rate and improve pregnancy results. However, it remains unclear whether there is an optimal endometrial preparation protocol for patients with history of IUAs.

Study design, size, duration

This was a retrospective cohort study of 1002 FET cycles with history IUAs in our fertility center between January 2015 to December 2020. The study was approved by the hospital's Ethics Committee.

Participants/materials, setting, methods

Eight hundred and forty-two conventional HRT cycles and 160 HRT+GnRHa cycles met the inclusion criteria were enrolled. Pregnancy outcomes were compared between the two groups. Logistic regression analysis was performed to adjust for important confounders. P < 0.05 was considered statistically significant.

Main results and the role of chance

The HRT+GnRHa group was associated with higher cycle rank (1.79 vs 2.17, P =0.026) and longer infertility duration (3.04 vs 3.69, P =0.000) compared with conventional HRT group. While the latter had a higher proportion of blastocyst embryo transferred (P =0.024). There were no statistically significant differences regarding the parental age at oocyte retrieval, body mass index (BMI), number of total embryos transferred and top embryo transferred, proportion of nulliparity, indication of IVF treatment and fertilization method, and endometrial thickness. Logistic regression indicated that after controlling for potential confounders, the HRT+GnRHa group achieved higher incidence of clinical pregnancy (aOR 1.474, 95% CI: 1.002-2.170, P =0.049), ongoing pregnancy (aOR 1.823, 95% CI: 1.207-2.753, P =0.004), and live birth (aOR 1.975, 95% CI: 1.306-2.988, P =0.000) than the conventional HRT group. The miscarriage rate was comparable between the two groups (aOR 0.613, 95% CI: 0.293-1.283, P =0.194). Our results suggested that HRT+GnRHa is over conventional HRT protocol to improve pregnancy outcomes of patients with previous IUAs.

Limitations, reasons for caution

The primary limitation of this study was its retrospective nature, and it was difficult to distinguish some confounding factors. Besides, there was no grading of IUA severity as most adhesion separation surgeries were not performed in our hospital, and the detailed medical history was not available.

Wider implications of the findings

Our study offers evidence for the superiority of HRT with GnRH-a pretreatment to conventional HRT protocol in improving the pregnancy prognosis of patients with previous IUAs. Our finding deserves further confirmation in clinical practice.

Trial registration number

2018YFC1003900/2018YFC1003904, SZSM201502035

[Overexpression of NAT10 induced platinum drugs resistance in breast cancer cell]

Objective: To observe the platinum drugs resistance effect of N-acetyltransferase 10 (NAT10) overexpression in breast cancer cell line and elucidate the underlining mechanisms. Methods: The experiment was divided into wild-type (MCF-7 wild-type cells without any treatment) group, NAT10 overexpression group (H-NAT10 plasmid transfected into MCF-7 cells) and NAT10 knockdown group (SH-NAT10 plasmid transfected into MCF-7 cells). The invasion was detected by Transwell array, the interaction between NAT10 and PARP1 was detected by co-immunoprecipitation. The impact of NAT10 overexpression or knockdown on the acetylation level of PARP1 and its half-life was also determined. Immunostaining and IP array were used to detect the recruitment of DNA damage repair protein by acetylated PARP1. Flow cytometry was used to detect the cell apoptosis. Results: Transwell invasion assay showed that the number of cell invasion was 483.00±46.90 in the NAT10 overexpression group, 469.00±40.50 in the NAT10 knockdown group, and 445.00±35.50 in the MCF-7 wild-type cells, and the differences were not statistically significant (P>0.05). In the presence of 10 μmol/L oxaliplatin, the number of cell invasion was 502.00±45.60 in the NAT10 overexpression group and 105.00±20.50 in the NAT10 knockdown group, both statistically significant (P<0.05) compared with 219.00±31.50 in wild-type cells. In the presence of 10 μmol/L oxaliplatin, NAT10 overexpression enhanced the binding of PARP1 to NAT10 compared with wild-type cells, whereas the use of the NAT10 inhibitor Remodelin inhibited the mutual binding of the two. Overexpression of NAT10 induced PARP1 acetylation followed by increased PARP1 binding to XRCC1, and knockdown of NAT10 expression reduced PARP1 binding to XRCC1. Overexpression of NAT10 enhanced PARP1 binding to LIG3, while knockdown of NAT10 expression decreased PARP1 binding to LIG3. In 10 μmol/L oxaliplatin-treated cells, the γH2AX expression level was 0.38±0.02 in NAT10 overexpressing cells and 1.36±0.15 in NAT10 knockdown cells, both statistically significant (P<0.05) compared with 1.00±0.00 in wild-type cells. In 10 μmol/L oxaliplatin treated cells, the apoptosis rate was (6.54±0.68)% in the NAT10 overexpression group and (12.98±2.54)% in the NAT10 knockdown group, both of which were statistically significant (P<0.05) compared with (9.67±0.37)% in wild-type cells. Conclusion: NAT10 overexpression enhances the binding of NAT10 to PARP1 and promotes the acetylation of PARP1, which in turn prolongs the half-life of PARP1, thus enhancing PARP1 recruitment of DNA damage repair related proteins to the damage sites, promoting DNA damage repair and ultimately the survival of breast cancer cells.

AB0894 Efficacy and Safety of Guselkumab in Biologic-Naïve Patients With Active Axial Psoriatic Arthritis: Study Design of a Phase 4, Randomized, Double-Blind, Placebo-Controlled Trial

Background

Established criteria for classifying axial psoriatic arthritis (PsA) are lacking, and assessments of disease activity often rely on measures developed for ankylosing spondylitis (AS). There is an unmet need to systematically identify and measure efficacy of treatments for axial PsA patients (pts). Guselkumab (GUS), a selective interleukin (IL)-23p19 inhibitor, was efficacious in improving signs and symptoms of active PsA in 2 phase 3, randomized, placebo (PBO)-controlled studies: DISCOVER-1 and DISCOVER-2. In a post-hoc pooled analysis of DISCOVER-1&2 pts with investigator-confirmed sacroiliitis, GUS-treated pts had greater improvements in axial symptoms compared with PBO.1 Imaging in DISCOVER-1&2 was restricted to the sacroiliac (SI) joints, occurring prior to/at screening as confirmed by the investigator, and locally read.

Objectives

To design a new, dedicated study to evaluate the effects of GUS on axial PsA prospectively.

Methods

Cumulative evidence from DISCOVER-1&2, including exposure–response relationship, covariate adjustment for modest baseline imbalances across treatment groups, subgroup analyses, and comparisons within and across these studies, was considered in designing a new trial. Data from the pivotal registrational studies suggest similar efficacy with GUS every-4-weeks (Q4W) and Q8W regimens in treating PsA signs and symptoms, including symptoms of axial involvement. Power calculations were based on mean changes in Bath AS Disease Activity Index (BASDAI) scores in DISCOVER-1&2.

Results

The phase 4, randomized, PBO-controlled STAR study is specifically designed to prospectively assess efficacy outcomes in PsA pts with magnetic resonance imaging (MRI)-confirmed axial inflammation. Based on observed mean (SD) changes from baseline in BASDAI score from DISCOVER-1&2 (Table 1), 405 pts, randomized (1:1:1) to GUS Q4W, GUS at W0, W4, then Q8W, or PBO →GUS Q8W at W24, are planned for enrollment (Figure 1). STAR eligibility criteria include PsA ≥6 months and active disease (≥3 swollen & ≥3 tender joints, C-reactive protein [CRP] ≥0.3 mg/dL) despite prior non-biologic disease-modifying antirheumatic drugs, apremilast, and/or non-steroidal anti-inflammatory drugs. Pts will be naïve to biologics and Janus kinase inhibitors and have BASDAI ≥4, spinal pain score (visual analog scale [VAS]) ≥4, and screening MRI-confirmed axial disease (positive spine and/or SI joints defined as centrally read Spondyloarthritis Research Consortium of Canada [SPARCC] score ≥3). Follow-up MRIs of spine and SI joints will be obtained at W0, W24, and W52 and also centrally read, with readers blinded to treatment group and timepoint. Spinal/SI joint inflammation will be scored using the SPARCC method, with the former also assessed using the CAN-DEN method. The primary endpoint is mean change in BASDAI at W24; controlled (hierarchical) secondary endpoints, all at W24, include AS Disease Activity Score (ASDAS-CRP), Disease Activity Index for PsA (DAPSA), ≥40% improvement in Assessment in AS criteria (ASAS40), and mean changes in spine/SI joint SPARCC scores.

Table 1.

Power calculations for the primary endpoint in the Phase 4 STAR study.

Historical trial data*Observed mean (SD) change in BASDAI from W0-24Effect sizePower(N=135; α=0.05)**PBO-1.28 (2.24)GUS 100 mg Q4W-2.51 (2.00)1.23>99%GUS 100 mg Q8W-2.61 (2.47)1.33>99%

* From the pooled DISCOVER-1&2 trials

**Power calculations based on N=135 per study group (1:1:1 randomization) and 2-sided significance of 0.05 using a 2-sample T-test assuming equal variances

BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; GUS, guselkumab; PBO, placebo; Q4W, every 4 weeks; Q8W, every 8 weeks; SD, standard deviation; W, week

Conclusion

The phase 4 STAR study will allow for an in-depth, prospective evaluation of the effects of selectively inhibiting the IL-23p19 subunit with GUS in pts with MRI-confirmed axial PsA.

References

[1]Mease, et al. Lancet Rheum. 2021;3(10):e715-e723.

Disclosure of Interests

Dafna D Gladman Consultant of: AbbVie, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: Abbvie, Amgen, BMS, Celgene, Eli Lilly, Janssen, Novartis, Pfizer and UCB, Philip J Mease Speakers bureau: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Consultant of: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Grant/research support from: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Paul Bird Speakers bureau: AbbVie, Eli Lilly, Gilead, Janssen, MSD, Pfizer, and UCB, Consultant of: Eli Lilly, Gilead, Janssen, Novartis, and Pfizer, Enrique Soriano Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Eli Lilly, Janssen, Novartis, Pfizer, Roche, and UCB, Consultant of: AbbVie, Janssen, Novartis, and Roche, Grant/research support from: AbbVie, Janssen, Novartis, Pfizer, Roche, and UCB, Soumya D Chakravarty Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, May Shawi Shareholder of: Johnson & Johnson, Employee of: Janssen Global Services, LLC, Stephen Xu Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Sean Quinn Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Cinty Gong Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Evan Leibowitz Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Lai-Shan Tam Consultant of: Janssen, Pfizer, Sanofi, AbbVie, Boehringer Ingelheim, and Lilly, Grant/research support from: Amgen, Boehringer Ingelheim, Janssen, GSK, Novartis, and Pfizer, Philip Helliwell Speakers bureau: AbbVie, Janssen, and Novartis, Consultant of: Galapagos and Janssen, Grant/research support from: AbbVie, Janssen, and Pfizer, Arthur Kavanaugh Consultant of: Abbvie, Amgen, Bristol Myers Squibb, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, and UCB, Atul Deodhar Speakers bureau: AbbVie, Eli Lilly, Janssen, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Galapagos, Glaxo Smith & Kline, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Eli Lilly, Glaxo Smith & Kline, Novartis, Pfizer, and UCB, Mikkel Østergaard Speakers bureau: AbbVie, Boehringer-Ingelheim, Bristol Myers Squibb, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Consultant of: AbbVie, Boehringer-Ingelheim, Bristol Myers Squibb, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, and Novartis, Xenofon Baraliakos Speakers bureau: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Consultant of: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche, and UCB

POS1037 EFFECT OF GUSELKUMAB, A SELECTIVE IL-23p19 INHIBITOR, ON AXIAL-RELATED ENDPOINTS IN PATIENTS WITH ACTIVE PsA: RESULTS FROM A PHASE 3, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY THROUGH 2 YEARS

Background

Guselkumab (GUS), a selective IL-23p19 inhibitor, showed greater mean improvements in Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scores vs placebo (PBO) at Week (W) 24 in patients (pts) with active PsA and investigator-confirmed sacroiliitis in pooled post hoc analyses of data from phase 3 DISCOVER (D)-1&2 trials. Improvements in symptoms of axial involvement were maintained through 1 year.1

Objectives

To assess maintenance of GUS effect on symptoms of axial involvement in biologic-naïve PsA pts with investigator-confirmed sacroiliitis through 2 years of D-2.

Methods

In D-2, 739 bio-naïve pts with active PsA (≥5 swollen + ≥5 tender joints, CRP ≥0.6 mg/dL despite standard therapies) were randomized 1:1:1 to GUS 100 mg every 4W (Q4W; n=245), GUS 100 mg at W0, W4, then Q8W (n=248), or PBO (n=246) with PBO→GUS 100 mg Q4W at W24. Pts with investigator-identified axial symptoms and sacroiliitis (prior X-ray or MRI, or pelvic X-ray at screening) were evaluated. Efficacy was assessed by changes in BASDAI, modified BASDAI (mBASDAI, excluding Q3 [peripheral joint pain]), and BASDAI Q2 (Spinal Pain) scores, and proportions of pts achieving BASDAI 50, Spinal Pain score ≤2, and AS Disease Activity Score (ASDAS) responses through W100. Through W24, pts who met treatment failure criteria or had missing data were considered nonresponders. After W24, missing data were imputed as nonresponse for binary endpoints or no change from baseline for continuous endpoints (nonresponder imputation [NRI]). Axial-related outcomes were also summarized by HLA-B27 status (+/-).

Results

246 pts had investigator-confirmed sacroiliitis. Baseline characteristics were similar across treatment groups (62% male; mean age 44.4 years; mean BASDAI scores 6.5-6.6). At W24, LS mean/mean changes in BASDAI (-2.4/-2.6) and ASDAS (-1.3/-1.5) scores were greater in GUS- vs PBO-treated pts. Improvements were maintained through W100 in GUS-treated pts: BASDAI, -3.1; Spinal Pain, -3.1; mBASDAI, -3.1; ASDAS, -1.7. Response patterns were similar for BASDAI 50 response rates in GUS-treated pts (W24 38-40%; W100 49-54%). At W24, GUS-treated pts had higher response rates for achievement of ASDAS inactive disease, major improvement, and clinically important improvement vs PBO; response rates (NRI) were maintained, or in some cases further increased, at 2 years. Results were consistent for achievement of ASDAS LDA and Spinal Pain score ≤2 (data not shown). GUS-related improvements in axial symptoms through W100 were generally consistent in HLA-B27+/- pts (data not shown).

Conclusion

In bio-naïve pts with active PsA and investigator-confirmed sacroiliitis, GUS provided durable improvements in axial symptoms through W100, with substantial proportions of pts achieving and maintaining clinically meaningful improvements.

References

[1]Mease PJ et al. Lancet Rheumatol 2021;3:e715-723

Table 1.

Axial symptom assessments through W100 in PsA pts with investigator-confirmed sacroiliitis in DISCOVER-2 (NRI)

GUS Q4W N=82GUS Q8W N=68PBO→GUS Q4W N=96Change in BASDAI scoreW24, LS mean (95% CI)-2.5 (-2.9, -2.0)-2.4 (-3.0, -1.8)-1.2 (-1.7, -0.7)Mean (SD)-2.5 (2.0)-2.6 (2.4)-1.4 (2.4)W52, mean (SD)-2.9 (2.3)-2.7 (2.5)-2.9 (2.6)W100, mean (SD)-3.0 (2.3)-3.1 (2.6)-3.3 (2.6)Change in mBASDAI (excludes Q3) scoreW24, LS mean (95% CI)-2.4 (-2.9, -1.9)-2.4 (-2.9, -1.8)-1.2 (-1.7, -0.7)Mean (SD)-2.5 (2.1)-2.6 (2.5)-1.3 (2.3)W52, mean (SD)-2.7 (2.6)-2.6 (2.5)-2.9 (2.4)W100, mean (SD)-3.3 (2.6)-3.1 (2.6)-3.0 (2.4)Change in Spinal Pain (BASDAI Q2) scoreW24, LS mean (95% CI)-2.2 (-2.7, -1.7)-2.3 (-2.9, -1.7)-0.9 (-1.5, -0.4)Mean (SD)-2.3 (2.6)-2.5 (2.8)-1.1 (2.5)W52, mean (SD)-2.6 (2.7)-2.5 (2.7)-2.5 (2.7)W100, mean (SD)-2.8 (2.7)-3.1 (2.8)-3.0 (2.8)Change in ASDAS scoreW24, LS mean (95% CI)-1.3 (-1.6, -1.1)-1.3 (-1.6, -1.1)-0.6 (-0.8, -0.4)Mean (SD)-1.4 (1.0)-1.5 (1.2)-0.7 (1.1)W52, mean (SD)-1.5 (1.1)-1.5 (1.3)-1.5 (1.3)W100, mean (SD)-1.6 (1.2)-1.7 (1.2)-1.6 (1.2)

Disclosure of Interests

Philip J Mease Speakers bureau: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Consultant of: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Grant/research support from: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Philip Helliwell Speakers bureau: AbbVie, Janssen, and Novartis, Consultant of: Eli Lilly, Janssen, and Pfizer, Dafna D Gladman Consultant of: AbbVie, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: Abbvie, Amgen, BMS, Celgene, Eli Lilly, Janssen, Novartis, Pfizer and UCB, Denis Poddubnyy Consultant of: AbbVie, Eli Lilly, GlaxoSmithKline, MSD, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Eli Lilly, MDS, Novartis, and Pfizer, Xenofon Baraliakos Speakers bureau: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Consultant of: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Soumya D Chakravarty Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Alexa Kollmeier Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Xie L Xu Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Shihong Sheng Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Stephen Xu Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, May Shawi Shareholder of: Johnson & Johnson, Employee of: Janssen Global Services, LLC, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, Bayer, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, and UCB Pharma, Employee of: Imaging Rheumatology BV, Atul Deodhar Speakers bureau: AbbVie, Eli Lilly, Janssen, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Galapagos, Glaxo Smith & Kline, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Eli Lilly, Glaxo Smith & Kline, Novartis, Pfizer, and UCB

POS0249 FIBROBLAST ACTIVATION PROTEIN AS A LINK BETWEEN INFLAMMATION AND VASCULAR REMODELING IN GIANT CELL ARTERITIS

Background

Giant cell arteritis (GCA) can present with serious complications such as blindness, stroke and aortic aneurysm that are related to both inflammation and remodeling of the vessel wall. GCA frequently overlaps with polymyalgia rheumatica (PMR). The pathogenesis of GCA starts in the adventitia where fibroblasts are the major stromal cell population. A preliminary study [1] reported the migration of adventitial fibroblasts to the intima, contributing to intimal hyperplasia in GCA. Fibroblast activation protein (FAP) is a non-classical serine protease which can be present in both a membrane-bound form and a soluble form and has been demonstrated to promote inflammation and fibrosis in coronary artery disease and rheumatoid arthritis [2-3]. We hypothesize that FAP is involved in GCA vasculopathy due to its pro-inflammatory and pro-fibrotic effects.

Objectives

As a first step to unravel the contribution of FAP to the vasculopathy in GCA, we determined FAP plasma levels and FAP protein expression at the site of vascular inflammation in GCA.

Methods

In our prospective cohort of GCA, PMR and healthy elderly (GPS), we measured the plasma FAP levels with ELISA in new-onset, treatment-naïve GCA (N=62), and PMR (N=63) patients and 42 age-matched healthy controls (HC). In addition, we measured the plasma FAP levels at follow-up (3-months, 1-year, 1.5-year and treatment-free remission (TFR)). Temporal artery biopsies (TAB) from treatment-naïve GCA patients (n=9) and non-GCA patients (n=9), aorta samples from GCA-related aneurysm (n=9) and atherosclerosis (n=11) were stained for FAP using immunohistochemistry. Immunofluorescence staining for CD90, CD68, αSMA and FAP was performed to detect FAP expression in fibroblasts, macrophages and vascular smooth muscle cells (VSMC), respectively.

Results

Baseline plasma FAP levels were significantly lower in GCA patients (52.72±2.93 ng/ml) than in PMR patients (66.42±2.86 ng/ml) and HC (80.47±3.38 ng/ml). FAP levels at baseline correlated inversely with C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), interleukin (IL)-6, macrophage-associated protein YKL-40 (Chitinase 3-like 1/CHI3L1) levels and monocyte counts. Plasma FAP levels in GCA patients decreased even further at 3 months (37.23±2.10 ng/ml) upon glucocorticoid-induced remission, and gradually increased to the level of HC (76.84±5.43 ng/ml) when patients were in TFR. Increased FAP expression in GCA TAB (adventitia, media, intima) and aorta (media) compared with tissues from non-GCA was documented. FAP was abundantly expressed in fibroblast- and macrophage-rich areas but not in VSMC-rich areas in TAB and aorta of GCA patients.

Conclusion

FAP expression is clearly modulated both in plasma and at the site of vascular inflammation in GCA and may represent a pathogenic link between the inflammatory and remodeling processes in GCA. As such, FAP may have utility as a biomarker and should be further investigated as target for therapeutic intervention.

References

[1]Parreau Simon VN, Regent Alexis, et al. (2019). Adventitial fibroblast, an important player in giant cell arteritis. Annual European Congress of Rheumatology, EULAR 2019: Annals of the Rheumatic Diseases), pp. 434.2-5.

[2]Brokopp CE, Schoenauer R, Richards P, et al. Fibroblast activation protein is induced by inflammation and degrades type I collagen in thin-cap fibroatheromata. Eur Heart J. 2011; 32: 2713-22.

[3]Croft AP, Campos J, Jansen K, et al. Distinct fibroblast subsets drive inflammation and damage in arthritis. Nature. 2019; 570: 246-51.

Acknowledgements

No.

Disclosure of Interests

None declared

[Analysis of clinical phenotype and genotype of Chinese children with disorders of sex development]

Objective: To explore the heterogeneity and correlation of clinical phenotypes and genotypes in children with disorders of sex development (DSD). Methods: A retrospective study of 1 235 patients with clinically proposed DSD in 36 pediatric medical institutions across the country from January 2017 to May 2021. After capturing 277 DSD-related candidate genes, second-generation sequencing was performed to analyzed the heterogeneity and correlation combined with clinical phenotypes. Results: Among 1 235 children with clinically proposed DSD, 980 were males and 255 were females of social gender at the time of initial diagnosis with the age ranged from 1 day of age to 17.92 years. A total of 443 children with pathogenic variants were detected through molecular genetic studies, with a positive detection rate of 35.9%. The most common clinical phenotypes were micropenis (455 cases), hypospadias (321 cases), and cryptorchidism (172 cases) and common mutations detected were in SRD5A2 gene (80 cases), AR gene (53 cases) and CYP21A2 gene (44 cases). Among them, the SRD5A2 mutation is the most common in children with simple micropenis and simple hypospadias, while the AMH mutation is the most common in children with simple cryptorchidism. Conclusions: The SRD5A2 mutation is the most common genetic variant in Chinese children with DSD, and micropenis, cryptorchidism, and hypospadias are the most common clinical phenotypes. Molecular diagnosis can provide clues about the biological basis of DSD, and can also guide clinicians to perform specific clinical examinations. Target sequence capture probes and next-generation sequencing technology can provide effective and economical genetic diagnosis for children with DSD.

Knee symptom but not radiographic knee osteoarthritis increases the risk of falls and fractures: results from the Osteoarthritis Initiative

OBJECTIVE

To describe the effect of knee symptoms and radiographic osteoarthritis (ROA) on the risk of falls, recurrent falls, and fractures.

DESIGN

Participants from the Osteoarthritis Initiative were classified as having 'no', 'unilateral' or 'bilateral' knee symptoms (≥19 on a 0-96 Western Ontario and McMaster Universities Osteoarthritis Index) and ROA (Kellgren-Lawrence grade ≥2) for each visit. Self-reported falls and fractures in the past 12 months were extracted at baseline and follow-up visits until month 96. Recurrent falls were defined as having ≥2 falls in the past 12 months. Hazard ratios (HR) with 95% confidence intervals (CI) were estimated using mixed-effects complementary log-log regression.

RESULTS

Of 4465 participants, 3145 (70%), 1681 (38%), and 806 (18%) experienced at least one fall, recurrent fall, and fracture, respectively, over 96 months. Compared to participants without symptomatic knee, unilateral and bilateral knee symptoms were associated with a 17% increased risk of falls and a 36-46% increased risk of recurrent falls, and bilateral knee symptoms increased the risk of fractures (HR 1.45, 95%CI 1.17 to 1.81). Compared to participants with no ROA in either knee, bilateral ROA was associated with a reduced risk of falls (HR 0.87, 95%CI 0.77 to 0.99) and fractures (HR 0.78, 95%CI 0.64 to 0.96). No statistically significant interactions between knee symptoms and ROA were observed.

CONCLUSIONS

This large population-based study showed that knee symptoms but not ROA increased the risk of falls, recurrent falls, and fractures, and that adults with bilateral ROA may have a lower risk of falls and fractures.

222 Robotic Surgery: Public Perceptions and Current Misconceptions

Aim

While surgeons and robotic companies are key stakeholders involved in the adoption of Robotic Surgery (RS), the public's role is often overlooked. However, given that patients hold ultimate power over their healthcare decisions, public acceptance of RS is crucial. This study aims to identify public understanding, opinions and misconceptions on RS and present solutions to facilitate its wider integration.

Method

An online questionnaire distributed via social media platforms between February and May 2021 identified the views of UK adults on RS. The data was evaluated using thematic analysis, descriptive statistics, and statistical analysis. Statistical differences in age, gender, education level, and presence in the medical field were also sought.

Results

263 responses were obtained, with 216 (82.1%) analysed. Demographic differences provided significantly different results. Participants were relatively uninformed about RS, with a median knowledge score of 4.00(2.00–6.00) on a 10-point likert scale. Fears surrounding increased risk, reduced precision and technological failure were identified, alongside misconceptions on what RS entails, including it being autonomous. However, providing factual information in the survey about RS statistically increased participant comfort (p=&lt;0.0001). Most (61.8%) participants believed robot manufacturers were responsible for malfunctions, but doctors were held accountable more by older, less educated, and non-medical participants.

Conclusions

This study highlights the role of negative and inaccurate public perceptions surrounding RS in impeding its widespread adoption. Greater emphasis must be placed on patient education in RS to mitigate misconceptions and ensure greater diffusion of its benefits

219 The Opportunities and Challenges of Robotic Surgery: A Surgeon and Robotic Company Perspective

Introduction

As an increasing number of specialties have begun to adopt robotic surgery (RS), its prevalence within the NHS is continually rising. This study aims to establish stakeholders’ opinions on the opportunities and challenges of the widespread adoption of RS.

Method

Participants were recruited through social media platforms such as LinkedIn or via university affiliations and current RS research. Semi-structured interviews of eight surgeons and five company representatives were conducted online. Transcripts were analysed to formulate themes surrounding the opportunities and challenges of RS.

Results

This study identified six common themes amongst shareholders: Perspective, Ethics, Impact of Robotics, Training, Adoption and Finances. The success rates and quality of results offered by RS make it a recognised future surgical staple amongst interviewees. However, the technology remains a contentious subject amongst surgeons, with many doubting whether the benefits outweigh the costs associated with implementation. Such reservations are further exacerbated by the absence of a formal training pathway. National guidelines are necessary to embed RS within the NHS infrastructure, allowing greater standardisation for patients and surgeons. The importance of patient education to address misconceptions was emphasised. Despite current high costs, robotic technology is forecasted to become cheaper with greater use and increased market competition. Interviewees stressed that responsibility for errors lies with the surgeon, but with the manufacturer for instrument malfunctions.

Conclusions

This study highlights stakeholders’ views on the opportunities and challenges of RS. The identified themes should form the basis of the proposed recommendations to facilitate a more widespread adoption of RS.

Solidification of heavy metals and PCDD/Fs from municipal solid waste incineration fly ash by the polymerization of calcium carbonate oligomers

Calcium carbonate oligomers are gel-state precursors that can be crystallized by low-temperature heat treatments to form an inorganic material with a monolithic and continuous structure, this material can effectively solidify/stabilize heavy metals in municipal solid waste incineration fly ash (MSWI FA). Calcium chloride addition achieves FA stabilization/solidification by the formation and polymerization of calcium carbonate oligomers. The effects of calcium, triethylamine (TEA), and water-washing pretreatment on the solidification of heavy metals by the polymer were studied. Consequently, as more calcium was added, the solidification improved. When the ratio of TEA/Ca²⁺ was increased from 2:1 to 3:1, the solidification efficiency of As and Cd increased, but it decreased when the ratio was continuously increased to 4:1. After the water-washing pre-treatment, the MSWI FA had a significantly improved solidification effect on the heavy metals, and the solidification efficiencies of zinc, copper, cadmium, chromium, lead, and arsenic were 81.9%, 90.0%, 93.5%, 91.8%, 99.6% and 95.5%, respectively. Additionally, the solidification efficiency of PCDD/Fs was 56.5%. The heavy metals and PCDD/Fs in MSWI FA solidified by physical adsorption, wrapping and chemical precipitation. The continuous calcium carbonate structure adsorbed and encased the MSWI FA, and the heavy metals in the MSWI FA were converted from a free state to carbonate precipitates through carbonation, and the carbonate precipitate was more likely to be physical solidification by calcium carbonate.

[Epidemiological characteristics of imported Plasmodium ovale malaria in Jiangsu Province from 2012 to 2020]

OBJECTIVE

To analyze the epidemiological characteristics of imported cases with Plasmodium ovale infections in Jiangsu Province from 2012 to 2020, so as to provide insights into the development of the imported malaria control strategy in the province.

METHODS

All data pertaining to cases with definitive diagnosis of P. ovale malaria in Jiangsu Province from 2012 to 2020 were captured from the National Notifiable Disease Report System and the Information Management System for Parasitic Disease Control in China, including the date of going abroad and returning to China, time of malaria infections overseas, date of malaria onset, initial diagnosis and definitive diagnosis. All data pertaining to epidemic status were descriptively analyzed.

RESULTS

A total of 347 cases of P. ovale malaria were reported in Jiangsu Province from 2012 to 2020, with the highest number seen in 2015 (71 cases). All cases were laboratory-confirmed overseas imported malaria cases, accounting for 14.32% of all reported malaria cases in Jiangsu Province during the period from 2012 to 2020. The 5 cities with the highest number of imported P. ovale malaria cases included Lianyungang City (53 cases, 15.27%), Nantong City (44 cases, 12.68%), Huai'an (44 cases, 12.68%), Taizhou City (44 cases, 12.68%) and Yangzhou City (36 cases, 10.37%). The highest number of imported P. ovale malaria cases was reported in October (39 cases, 11.24%), and the lowest number was seen in December (21 cases, 6.05%). P. ovale infections mainly occurred in were Equatorial Guinea (97 cases, 37.95%), Angola (60 cases, 17.29%) and Nigeria (40 cases, 11.53%). The median duration between returning to China and malaria onset was 64 (144) days, and 7.49% (26/347) of all cases developed malaria one year after returning to China. The initial diagnosis of P. ovale malaria was mainly made at county-level medical institutions (117 cases, 33.72%), and the definitive diagnosis was mainly made at city-level medical institutions (122 cases, 35.16%). The correct rate of initial diagnosis of P. ovale malaria increased from 0 in 2012 to 78.26% in 2020, appearing a tendency towards a rise year by year (χ² = 50.90, P < 0.01).

CONCLUSIONS

Imported P. ovale malaria cases were reported in Jiangsu Province each year from 2012 to 2020, and P. ovale infections predominantly occurred in Africa. Initial and definitive diagnoses of P. ovale malaria were mainly made at city- and county-level medical institutions. Training on the detection ability of malaria parasites is recommended among grassroots microscopists to improve the diagnostic ability of P. ovale malaria, and consolidate the achievements of malaria elimination in Jiangsu Province.

[Adult myofibroma: a clinicopathological analysis of 15 cases]

Objective: To investigate the clinicopathological features and immunophenotype of adult myofibroma with emphasis on its differential diagnosis. Methods: The clinical, pathologic data and immunohistochemical profiles were analyzed in 15 cases of adult myofibroma diagnosed between 2014 and 2020 in Department of Pathology, Fudan University Shanghai Cancer Center. The literature was reviewed. Results: There were seven males and eight females, with age at presentation ranging from 22 to 74 years (mean 54 years; median 57 years). Tumor occurred principally in the extremities (n=9), less frequently involved the head and neck region (n=3) and trunk (n=2); one case was located in the vertebral canal of C6-7. Fourteen cases were solitary; one case was multifocal. Most patients presented with a slowly growing painless subcutaneous nodule, about 1 to 2 cm in size. One patient with multifocal disease and the patient with spinal lesion complained of intermittent pain. The duration of symptoms ranged from 2 months to 10 years. Microscopically, they were well circumscribed. All cases showed biphasic growth pattern, consisting of relatively well-differentiated eosinophilic nodules alternating with dark-staining primitive-appearing areas. The light-staining hypocellular nodules were composed of myofibroblast-like plump spindle cells within an eosinophilic stroma, which assumed pale blue myxochondroid appearance and hyalinization of varying degree. The dark-staining areas were composed of compact short spindled to ovoid cells with hyperchromatic nuclei and low mitotic activity, frequently showing a distinctive hemangiopericytoma-like architecture. By immunohistochemistry, the myoid spindled cells and the primitive cells stained variably for α-SMA, MSA and calponin, but were consistently negative for desmin and β-catenin. Conclusions: Adult myofibroma tends to occur in the middle to old aged patients with a predilection for the dermis or subcutis of the extremities. It is a benign neoplasm which can be cured by excision in most cases. Familiarity with its distinctive clinicopathological features helps in the distinction from other myofibroblastic neoplasms.

Knockdown of Sirt1 Gene in Mice Results in Lipid Accumulation in the Liver Mediated via PGC-1α-Induced Mitochondrial Dysfunction and Oxidative Stress

The study demonstrated the crucial role of Sirt1 gene in the pathogenesis of non-alcoholic fatty liver disease (NAFLD) related to the influence of Sirt1 on oxidative stress and glycolipid metabolism. The 16-week-old genetically diabetic db/db mice were characterized with downregulated expression of Sirt1 in the liver accompanied by hepatomegaly and a larger size of fat vacuoles in hepatocytes. In db/m mice, silencing Sirt1 gene induced hepatic steatosis and significantly increased serum AST. Additionally, the levels of triglycerides in blood and liver of these mice were elevated. However, all pathological changes in the liver of Sirt1-knockdown db/m mice were less pronounced than in 16-week-old db/db mice. Further experiments showed that oxidative stress and PGC-1α-mediated mitochondrial dysfunction are implicated in pathological changes of lipid metabolism in T2DM-induced NAFLD provoked by Sirt1 silencing. This study showed that down-regulation of Sirt1 expression plays the key role in pathological processes developed during T2DM-induced abnormalities of lipid metabolism in the liver. Thus, up-regulation of Sirt1 expression seems to be a promising strategy in early prevention of T2DM-induced NAFLD.

Efficacy of Bifidobacterium animalis subsp. lactis, BB-12® on infant colic - a randomised, double-blinded, placebo-controlled study

To evaluate the administration of Bifidobacterium animalis subsp. lactis, BB-12^® (BB-12) on infant colic in breastfed infants, a double-blind, placebo-controlled randomised study was conducted in Chengdu, China from April 2016 to October 2017 with 192 full-term infants less than 3 months of age and meeting the ROME III criteria for infant colic. After a 1-week run-in the infants were randomly assigned to receive daily BB-12 (1×10⁹ cfu/day) or placebo for 3 weeks. Crying/fussing time were recorded using a 24 h structured diary. The primary endpoint was the proportion of infants achieving a reduction in crying and fussing time of ≥50% from baseline. Parent's/caregiver's health related quality of life was measured using a modified PedsQL^™ 2.0 Family Impact Module and immunological biomarkers were evaluated from faecal samples at baseline and after the 21-day intervention. The percentage of infants achieving a reduction in the daily crying/fussing time ≥50% after the 21-day intervention was significantly higher in the infants supplemented with BB-12 (P<0.001). The mean number of crying episodes was significantly reduced in the BB-12 group compared to the placebo group (10.0±3.0 to 5.0±1.87 vs 10.5±2.6 to 7.5±2.8, respectively) (P<0.001) and the mean daily sleep duration was markedly increased from baseline to end of intervention in the BB-12 group compared to the infants in the placebo group (60.7±104.0 vs 31.9±102.7 min/day, respectively) (P<0.001). The faecal levels of human beta defensin 2, cathelicidin, slgA, calprotectin and butyrate were statistically higher in the BB-12 group compared to the placebo group after the 21-day intervention. At the end of the intervention the parent's/caregiver's physical, emotional and social functioning scores were significantly higher for the BB-12 group compared to the placebo group (all P<0.05). Supplementation of BB-12 is effective in reducing crying and fussing in infants diagnosed with infant colic.