OP0074 DISTINCT CIRCULATING LYMPHOCYTE SUBSETS DISTINGUISH FLARE FROM DRUG-FREE REMISSION IN RHEUMATOID ARTHRITIS

Background

Rheumatoid arthritis (RA) is characterised by relapsing joint and systemic inflammation, yet the immunopathological basis of these disease flares and their clinical prediction remain uncertain.

Objectives

Using mass cytometry and single cell RNA sequencing, we aimed to identify circulating lymphocyte subsets associated with RA flare, and identify potential cellular biomarkers to predict flare versus drug-free remission (DFR).

Methods

We analysed peripheral blood mononuclear cells (PBMCs) from patients recruited to the BioRRA study (Figure 1), a prospective clinical trial of conventional synthetic disease-modifying anti-rheumatic drug (csDMARD) cessation.[1] Patients with RA in clinical (DAS28-CRP < 2.4) and ultrasound (absence of power Doppler signal in 7 joints) remission stopped csDMARDs, with flare defined as DAS28-CRP ≥ 2.4 during 6 month follow-up. A 44-marker mass cytometry panel was used to profile PBMCs from 36 patients (20 flare, 16 DFR) at two time points each (baseline, and flare onset / month 6 DFR). In a subset of patients (n = 12: 8 flare, 4 DFR), fluorescence-activated cell sorting of T and B cells was followed by single cell sequencing (n = 81,923 cells) incorporating 320 immune genes, 34 oligo-tagged surface protein antibodies, and TCR/BCR CDR3 sequence. Clones were defined as ≥2 cells with identical CDR3 nucleotide sequence, and clonal expansion as a significant increase in proportion from baseline to final study visit. Statistical significance was assessed after Benjamini-Hochberg multiple test correction (adj p < 0.05).

Figure 1.

Results

Mass cytometry revealed 31 distinct cell clusters: notably, greater proportions of memory (CD45RO+/PD1hi) CD4+ and CD8+ T cells, and memory (CD27+/CD21-) B cells, were observed at onset of flare versus baseline (Table 1).

Table 1.Mass cytometry (n = 20 flare + 16 DFR)ContrastClusterMedian %Adj. p (GLMM)Flare onset vs baseline: Flare patientsCD4+/CD45RO+/PD1+ memory T cells2.14 vs 0.24<0.001CD8+/CD45RO+/PD1+ memory T cells6.64 vs 0.07<0.001CD19+/CD27+/CD21- memory B cells2.39 vs 0.03<0.001Single cell RNAseq (n = 8 flare + 4 DFR)ContrastClusterMedian %Adj. p (Wilcoxon)Flare onset vs baseline: Flare patientsIgA+ plasma cells0.37 vs 0.210.020Flare vs DFR patients: BaselineCD4+/CD25+/Foxp3+ Treg cells0.55 vs 1.270.022

To better characterise these flare-associated subsets, single cell sequencing of CD45RO+/PD1hi CD4+ and CD8+ T cells, and CD19+ B cells, was performed and identified 21 distinct clusters. CDR3 sequencing revealed significant clonal expansion (Fisher exact, adj. p < 0.05) at flare onset within five unique CD8+ clones (4 patients), one CD4+ clone (1 patent), and no B clones. Overall, there was a significantly greater proportion of IgA+ plasma cells at flare onset versus baseline. In contrast, a significantly lower proportion of CD25+/FoxP3+ regulatory T cells were present at csDMARD cessation (baseline) in subsequent flare versus DFR patients (Table 1), suggesting biomarker potential.

To further assess the predictive performance of CD4+ Tregs as a biomarker for flare versus DFR, we analysed PBMCs from an independent cohort of 50 patients (25 flare, 25 DFR) stopping csDMARDs in the ongoing BIO-FLARE study.[2] By flow cytometry, we confirmed a lower proportion of CD4+/CD25hi Tregs at baseline in flare vs DFR (median 4.74 versus 6.37%, Wilcoxon p = 0.037; AUC: 0.67). In this cohort, stopping csDMARDs only in patients with elevated (> 6.11% total CD4) baseline Tregs would have prevented drug cessation in 18/25 (72%) of flare patients; 9/25 (36%) of DFR patients would have continued csDMARDs unnecessarily.

Conclusion

We present a detailed longitudinal characterisation of circulating lymphocyte surface phenotype, gene expression, and clonal expansion in RA flare vs DFR. Furthermore our data, across two independent cohorts, suggests a role for CD4+ Tregs in promoting drug-free remission meriting further investigation, with potential for future clinical biomarker development.

References

[1]Baker et al; J Autoimmunity; 105:102298

[2]Rayner et al; BMC Rheumatology; 5:22

Acknowledgements

This work was funded by research grants from Wellcome Trust [102595/Z/13/A to KFB], Newcastle NIHR Biomedical Research Centre [BH136167/PD0045 to KFB], British Society for Rheumatology [KFB], Academy of Medical Sciences [SGL022\1074 to KFB], Newcastle University Wellcome Trust Translational Partnership [KFB], Newcastle Hospitals Charity [8033 to KFB], and a National Institute for Health Research Clinical Lectureship [CL-2017-01-004 to KFB]. Our work is supported by the Research into Inflammatory Arthritis Centre Versus Arthritis (RACE) (grant number 20298), and Rheuma Tolerance for Cure (European Union Innovative Medicines Initiative 2, grant number 777357). AGP and JDI are named as inventors on a patent application by Newcastle University (“Prediction of Drug-Free Remission in Rheumatoid Arthritis”; International Patent Application Number PCT/GB2019/050902). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

Disclosure of Interests

Kenneth F Baker Consultant of: Modern Biosciences Ltd, Grant/research support from: Pfizer, Genentech, Fiona Rayner: None declared, Henrique Lemos: None declared, David McDonald: None declared, Gillian Hulme: None declared, Rafiqul Hussain: None declared, Jonathan Coxhead Speakers bureau: Tesaro, Arthur Pratt Grant/research support from: Pfizer, Gilead, Amy E. Anderson: None declared, Andrew Filby Grant/research support from: Becton Dickinson, John Isaacs Speakers bureau: Abbvie, Gilead, Roche, UCB, Grant/research support from: GSK, Janssen, Pfizer.

A cost-effectiveness analysis of endoscopic eradication therapy for management of dysplasia arising in patients with Barrett's oesophagus in the United Kingdom

BACKGROUND AND AIMS

Endoscopic eradication therapy (EET) is the first line approach for treating Barrett's oesophagus (BE) related neoplasia globally. The British Society of Gastroenterology (BSG) recommend EET with combined endoscopic resection (ER) for visible dysplasia followed by endoscopic ablation in patients with both low and high grade dysplasia (LGD and HGD). The aim of this study is to perform a cost-effectiveness analysis for EET for treatment of all grades of dysplasia in BE patients.

METHODS

A Markov cohort model with a lifetime time horizon was used to undertake a cost-effectiveness analysis. A hypothetical cohort of UK patients diagnosed with BE entered the model. Patients in the treatment arm with LGD and HGD received EET and patients with non-dysplastic BE (NDBE) received endoscopic surveillance only. In the comparator arm, patients with LGD, HGD and NDBE received endoscopic surveillance only. A UK National Health Service (NHS) perspective was adopted and the incremental cost-effectiveness ratio (ICER) was calculated. Sensitivity analysis was conducted on key input parameters.

RESULTS

EET for patients with LGD and HGD arising in BE is cost-effective compared to endoscopic surveillance alone (lifetime ICER £3006 per quality adjusted life year [QALY] gained). The results show that, as the time horizon increases, the treatment becomes more cost-effective. The 5 year financial impact to the UK NHS of introducing EET is £7.1m.

CONCLUSIONS

EET for patients with low and high grade BE dysplasia, following updated guidelines from the BSG, has been shown to be cost-effective for patients with BE in the UK.

The surface chemistry of sapphire-c: A literature review and a study on various factors influencing its IEP

A wide range of isoelectric points (IEPs) has been reported in the literature for sapphire-c (α-alumina), also referred to as basal plane, (001) or (0001), single crystals. Interestingly, the available data suggest that the variation of IEPs is comparable to the range of IEPs encountered for particles, although single crystals should be much better defined in terms of surface structure. One explanation for the range of IEPs might be the obvious danger of contaminating the small surface areas of single crystal samples while exposing them to comparatively large solution reservoirs. Literature suggests that factors like origin of the sample, sample treatment or the method of investigation all have an influence on the surfaces and it is difficult to clearly separate the respective, individual effects. In the present study, we investigate cause-effect relationships to better understand the individual effects. The reference IEP of our samples is between 4 and 4.5. High temperature treatment tends to decrease the IEP of sapphire-c as does UV treatment. Increasing the initial miscut (i.e. the divergence from the expected orientation of the crystal) tends to increase the IEP as does plasma cleaning, which can be understood assuming that the surfaces have become less hydrophobic due to the presence of more and/or larger steps with increasing miscut or due to amorphisation of the surface caused by plasma cleaning. Pre-treatment at very high pH caused an increase in the IEP. Surface treatments that led to IEPs different from the stable value of reference samples typically resulted in surfaces that were strongly affected by subsequent exposure to water. The streaming potential data appear to relax to the reference sample behavior after a period of time of water exposure. Combination of the zeta-potential measurements with AFM investigations support the idea that atomically smooth surfaces exhibit lower IEPs, while rougher surfaces (roughness on the order of nanometers) result in higher IEPs compared to reference samples. Two supplementary investigations resulted in either surprising or ambiguous results. On very rough surfaces (roughness on the order of micrometers) the IEP lowered compared to the reference sample with nanometer-scale roughness and transient behavior of the rough surfaces was observed. Furthermore, differences in the IEP as obtained from streaming potential and static colloid adhesion measurements may suggest that hydrodynamics play a role in streaming potential experiments. We finally relate surface diffraction data from previous studies to possible interpretations of our electrokinetic data to corroborate the presence of a water film that can explain the low IEP. Calculations show that the surface diffraction data are in line with the presence of a water film, however, they do not allow to unambiguously resolve critical features of this film which might explain the observed surface chemical characteristics like the dangling OH-bond reported in sum frequency generation studies. A broad literature review on properties of related surfaces shows that the presence of such water films could in many cases affect the interfacial properties. Persistence or not of the water film can be crucial. The presence of the water film can in principle affect important processes like ice-nucleation, wetting behavior, electric charging, etc.

Long-term in vitro maintenance of clonal abundance and leukaemia-initiating potential in acute lymphoblastic leukaemia

Lack of suitable in vitro culture conditions for primary acute lymphoblastic leukaemia (ALL) cells severely impairs their experimental accessibility and the testing of new drugs on cell material reflecting clonal heterogeneity in patients. We show that Nestin-positive human mesenchymal stem cells (MSCs) support expansion of a range of biologically and clinically distinct patient-derived ALL samples. Adherent ALL cells showed an increased accumulation in the S phase of the cell cycle and diminished apoptosis when compared with cells in the suspension fraction. Moreover, surface expression of adhesion molecules CD34, CDH2 and CD10 increased several fold. Approximately 20% of the ALL cells were in G0 phase of the cell cycle, suggesting that MSCs may support quiescent ALL cells. Cellular barcoding demonstrated long-term preservation of clonal abundance. Expansion of ALL cells for >3 months compromised neither feeder dependence nor cancer initiating ability as judged by their engraftment potential in immunocompromised mice. Finally, we demonstrate the suitability of this co-culture approach for the investigation of drug combinations with luciferase-expressing primograft ALL cells. Taken together, we have developed a preclinical platform with patient-derived material that will facilitate the development of clinically effective combination therapies for ALL.

Examining the implementation of NICE guidance: cross-sectional survey of the use of NICE interventional procedures guidance by NHS Trusts

Background

In the UK, NHS hospitals receive large amounts of evidence-based recommendations for care delivery from the National Institute for Health and Care Excellence (NICE) and other organisations. Little is known about how NHS organisations implement such guidance and best practice for doing so. This study was therefore designed to examine the dissemination, decision-making, and monitoring processes for NICE interventional procedures (IP) guidance and to investigate the barriers and enablers to the implementation of such guidance.

Methods

A cross-sectional survey questionnaire was developed and distributed to individuals responsible for managing the processes around NICE guidance in all 181 acute NHS hospitals in England, Scotland, Wales and Northern Ireland. A review of acute NHS hospital policies for implementing NICE guidance was also undertaken using information available in the public domain and from organisations’ websites.

Results

The response rate to the survey was 75 % with 135 completed surveys received. Additionally, policies from 25 % of acute NHS hospitals were identified and analysed. NHS acute hospitals typically had detailed processes in place to implement NICE guidance, although organisations recognised barriers to implementation including organisational process barriers, clinical engagement and poor targeting with a large number of guidance issued. Examples of enablers to, and good practice for, implementation of guidance were found, most notably the value of shared learning experiences between NHS hospitals. Implications for NICE were also identified. These included making improvements to the layout of guidance, signposting on the website and making better use of their shared learning platform.

Conclusions

Most organisations have robust processes in place to deal with implementing guidance. However, resource limitations and the scope of guidance received by organisations create barriers relating to organisational processes, clinician engagement and financing of new procedures. Guidance implementation can be facilitated through encouragement of shared learning by organisations such as NICE and open knowledge transfer between organisations.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0283-4) contains supplementary material, which is available to authorized users.

Heterogeneity in patient diagnostic pathways: an example from contrast-enhanced ultrasound diagnostic scans for focal liver lesions

Background

The UK’s National Institute for Health and Care Excellence (NICE) has recommended contrast-enhanced ultrasound (CEUS) for the characterisation of focal liver lesions where the results of standard unenhanced ultrasound are inconclusive. A further recommendation is for CEUS to replace other imaging modalities. However, little is currently known about the diagnostic pathways in the National Health Service (NHS) followed by patients with potential liver lesions. The aim of this study was to identify the diagnostic pathways for a number of representative hospital trusts and record the clinicians’ views on patient experiences of these processes through a series of semi-structured interviews with UK clinicians (radiologists and sonographers) (N = 7). This study was undertaken in the broader context of a larger research project where the overarching research question is focused on patient preferences for CEUS and other imaging modalities, and how these impact on patient quality of life (QOL).

Results

The results from the semi-structured interviews with UK clinicians revealed that there is a great deal of heterogeneity in diagnostic pathways followed by patients with potential liver lesions which differ both within and between hospitals. In terms of the patient experience, the clinicians believed that a combination of the more patient-friendly ultrasound process, and the fact that scan results are given to patients in 80-90% of cases on the day, as well as the problems inherent to other scan modalities (claustrophobia, anxiety) would lead to patients preferring ultrasound compared with other imaging modalities (CT or MR). However, current clinical practice means that patient choice is virtually non-existent.

Conclusions

The significant variation in diagnostic pathways across the NHS will require further standardisation through local agreements if contrast-enhanced ultrasound is to replace other imaging modalities in characterising focal liver lesions in line with NICE Diagnostics Guidance. The gradual development of patient choice of modalities may necessitate a change of practice in radiology processes.

Comprehensive analysis of karyotypic mosaicism between trophectoderm and inner cell mass

Aneuploidy has been well-documented in blastocyst embryos, but prior studies have been limited in scale and/or lack mechanistic data. We previously reported preclinical validation of microarray 24-chromosome preimplantation genetic screening in a 24-h protocol. The method diagnoses chromosome copy number, structural chromosome aberrations, parental source of aneuploidy and distinguishes certain meiotic from mitotic errors. In this study, our objective was to examine aneuploidy in human blastocysts and determine correspondence of karyotypes between trophectoderm (TE) and inner cell mass (ICM). We disaggregated 51 blastocysts from 17 couples into ICM and one or two TE fractions. The average maternal age was 31. Next, we ran 24-chromosome microarray molecular karyotyping on all of the samples, and then performed a retrospective analysis of the data. The average per-chromosome confidence was 99.95%. Approximately 80% of blastocysts were euploid. The majority of aneuploid embryos were simple aneuploid, i.e. one or two whole-chromosome imbalances. Structural chromosome aberrations, which are common in cleavage stage embryos, occurred in only three blastocysts (5.8%). All TE biopsies derived from the same embryos were concordant. Forty-nine of 51 (96.1%) ICM samples were concordant with TE biopsies derived from the same embryos. Discordance between TE and ICM occurred only in the two embryos with structural chromosome aberration. We conclude that TE karyotype is an excellent predictor of ICM karyotype. Discordance between TE and ICM occurred only in embryos with structural chromosome aberrations.

An attempt to explain bimodal behaviour of the sapphire c-plane electrolyte interface

A tentative picture for the charging of the sapphire basal plane in dilute electrolyte solutions allows reconciliation of the available experimental observations within a dual charging model. It includes the MUltiSIte Complexation (MUSIC) model and auto-protolysis of interfacial water. The semi-empirical MUSIC model predicts protonation and deprotonation constants of individual surface functional groups based on crystal structure and bond-valence principles: on the ideal sapphire c-plane only doubly co-ordinated hydroxyl groups exist which cause quasi zero surface potential (defined as the potential in the plane of the surface hydroxyl groups) from pH 5 to 7 and rather weak charging beyond (compared to typical oxide behaviour). MUSIC predictions concur strikingly with recently published sum frequency data for the pH dependence of the so-called "ice-like" water band (interfacial water) and contact angle titrations. Zeta potential as well as second harmonic generation data reveal a sharp IEP of around 4 and a negative surface charge at the pristine point of zero charge predicted by the MUSIC model. New zeta-potential data corroborate (i) the low IEP and its insensitivity to salt concentration and (ii) the second harmonic results. We thus establish two groups of conflicting results arising from different techniques. A conventional model of the mineral electrolyte interface such as the MUSIC model is at odds with the negative zeta potentials in the pH range 5 to 7. Therefore an additional charging mechanism is invoked to explain all the observations. Enhanced auto-protolysis of interfacial water is the most probable candidate for this additional mechanism, in agreement with net water orientation observed with sum frequency generation and second harmonic generation. Our phenomenological explanation is further corroborated by the similarity of the zeta potential vs. pH curves of the c-plane with those of hydrophobic surfaces. Additional support comes from infrared spectroscopic data on thin water films on sapphire c-plane samples. Most stunningly, theoretical calculations on basal planes of this kind suggest a 2D water bilayer that makes such surfaces hydrophobic towards further adsorption of water. The proposed dual charging mode approach comprises the MUSIC model for protonation/deprotonation of the surface aluminols affecting the surface potential and the currently advocated enhanced auto-protolysis picture for hydrophobic surfaces controlling the zeta-potential and can explain the available information in a qualitative way. The respective contributions from the two components of this dual charging mechanism may be different for different single crystal cuts of alumina. Thus interplay between protonation/deprotonation of surface functional groups and auto-protolysis of interfacial water will cause the observed zeta potentials and isoelectric points. Repercussions of one mechanism on the other will result in the most favourable interfacial water structure, which can be followed by non-linear optic techniques like sum frequency generation.

128. A ROLE FOR SIRTUIN 3 IN THE DEVELOPING MAMMALIAN EMBRYO

Pre-implantation embryo development relies critically on the balance between cytoplasmic and mitochondrial metabolism for the generation of metabolic intermediates such as NAD+. SIRT3 is a mitochondrial sirtuin with NAD+-dependant deacetylase activity that, targets glutamate dehydrogenase (GDH). In this study we characterised SIRT3 mRNA, protein and activity through pre-implantation development and determined whether modulation of SIRT3 activity influenced GDH activity. Embryos (zygotes, 2-cell, 8-cell and blastocyst stages) were recovered from female CBA/C57Bl6 mice following ovarian stimulation and mating with CBA/C57Bl6 males. Expression of SIRT3 mRNA was measured using real-time RTPCR, protein localisation examined using immunohistochemistry and SIRT3 activity measured using a Fluor-de-Lys SIRT3 fluorescentassay. Functional GDH activity was assessed in 2-cell embryos indirectly by measuring glutamine oxidation, following culture from zygote to 2-cell in the presence of nicotinamide, (a sirtuin inhibitor), G1.2 media, or simpleG1 media, compared to in vivo controls. SIRT3 mRNA was detected at all stages of development, with significantly greater levels expressed in the blastocyst. SIRT3 protein was localised predominantly around the nucleus of zygote and 2-cell embryos, and was mainly cytoplasmic in 8-cell embryos and blastocysts. SIRT3 activity remained constant throughout pre-implantation development, and tended to increase at the blastocyst stage. Glutamine oxidation was reduced for embryos cultured in G1.2 media relative to in vivo controls (0.14 pmol/e/hr vs 0.21pmol/e/hr), and this was further reduced by the addition of nicotinamide (0.07pmol/e/hr). Embryo culture in perturbing simpleG1 increased glutamine metabolism (0.33pmol/e/hr). In conclusion, SIRT3 mRNA, protein and activity was detected throughout pre-implantation development. Modulation of sirtuins by nicotinamide decreased glutamine metabolism, likely as a result of decreased deacetylation, thus decreased activity of GDH. SIRT3 can translocate to the mitochondria during cellular stress, thus the increased glutamine metabolism in simpleG1 conditions may be caused by translocation of SIRT3 to mitochondria, potentially increasing GDH deacetylation and enzymatic activity.

130. MICROARRAY ANALYSIS OF FOETAL MOUSE BRAIN FOLLOWING INDUCTION OF MITOCHONDRIAL DYSFUNCTION DURING PRE-IMPLANTATION EMBRYO DEVELOPMENT

Environmental stress can disrupt mitochondrial function in the pre-implantation embryo, subsequently hindering embryo viability. Brain tissue is also sensitive to developmental perturbations, and we have previously discovered genes involved in neurological function and epigenetic modification are differentially expressed in blastocysts following mitochondrial dysfunction by amino-oxyacetate (AOA). In this study CBAxC57Bl6 2 cell stage mouse embryos were cultured in 5μM-AOA without pyruvate for 72h to induce mitochondrial dysfunction. Blastocyst stage embryos were then transferred to pseudopregnant recipients and the expression profile of day 18 foetal brains was interrogated using microarray. mRNA from mouse whole brain (4 per treatment) was extracted and analysed using an Affymetrix gene array. Ingenuity Pathway Analysis software identified persistent alterations in gene expression pathways in foetal brain after AOA treatment during embryo culture, that were subsequently confirmed by qPCR. Expression was significantly increased by both array and qPCR (>1.5 fold, p<0.05) for; 1) Eomes (1.9, 2.9 fold respectively), a T-box transcription factor involved in differentiation, cell death and development, 2) Nr4a3 (1.8, 2.2 fold respectively), a steroid hormone receptor and putative transcriptional activator and 3) Nola3 (1.7, 1.9 fold respectively), a small nucleolar ribonucleoprotein involved in rRNA processing. Neurological disease, behavioural disorders, carbohydrate metabolism, cellular growth and proliferation, cell death, DNA replication, recombination and repair pathways also showed altered gene expression (>1.25 fold). qPCR was performed on 28 genes exhibiting the greatest change in expression. 24/28 genes confirmed the array data, and of the 4 genes that did not; two had expression not detected by qPCR (Snhg1, Speer6-ps1), and two contradicted array results (Atp1b3 p=0.05, Stk38l p=0.06). This study links mitochondrial dysfunction during early embryo development and persistent molecular changes in the developing foetal brain. This indicates that insults incurred during early embryo development can cause permanent changes that we predict results from aberrant epigenetic modification.

Interaction of latex colloids with mineral surfaces and Grimsel granodiorite

Bentonite clay is considered as possible backfill material for nuclear waste repositories in crystalline rock. The same material may also be a source of clay colloids, which may act as carriers for actinide ions possibly released from the repository. Depending on the geochemical parameters, these colloids may be retained by interaction with mineral surfaces of the host rock. In the present study interaction of carboxylated fluorescent latex colloids, used as a model for bentonite colloids, with natural Grimsel granodiorite and some of its component minerals is studied by fluorescence microscopy and SEM/EDX. The experiments are carried out by varying the pH from 2-10. Strong adsorption is observed at pH values close to or below the points of zero charge (pHpzc) of the mineral surfaces. The influence of Eu(III), used as a chemical homologue for trivalent actinide ions, on colloid adsorption is investigated. Depending on mineral phase and pH, a significant increase of colloid adsorption is observed in the presence of Eu(III).