Ezh2 emerges as an epigenetic checkpoint regulator during monocyte differentiation limiting cardiac dysfunction post-MI

Epigenetic regulation of histone H3K27 methylation has recently emerged as a key step during alternative immunoregulatory M2-like macrophage polarization; known to impact cardiac repair after Myocardial Infarction (MI). We hypothesized that EZH2, responsible for H3K27 methylation, could act as an epigenetic checkpoint regulator during this process. We demonstrate for the first time an ectopic EZH2, and putative, cytoplasmic inactive localization of the epigenetic enzyme, during monocyte differentiation into M2 macrophages in vitro as well as in immunomodulatory cardiac macrophages in vivo in the post-MI acute inflammatory phase. Moreover, we show that pharmacological EZH2 inhibition, with GSK-343, resolves H3K27 methylation of bivalent gene promoters, thus enhancing their expression to promote human monocyte repair functions. In line with this protective effect, GSK-343 treatment accelerated cardiac inflammatory resolution preventing infarct expansion and subsequent cardiac dysfunction in female mice post-MI in vivo. In conclusion, our study reveals that pharmacological epigenetic modulation of cardiac-infiltrating immune cells may hold promise to limit adverse cardiac remodeling after MI.

POS1406 EVALUATING THE QUALITY OF CARE FOR HEART FAILURE HOSPITALIZATIONS IN INFLAMMATORY ARTHRITIS- A POPULATION-BASED COHORT STUDY

Background

Individuals with inflammatory arthritis (IA) have an increased risk of heart failure (HF). Little is known if the quality of HF care differs among patients with IA compared to other chronic diseases such as diabetes mellitus (DM).

Objectives

We examined adherence to quality-of-care indicators for HF hospitalizations among patients with IA compared to those with DM but no IA and the general population (without IA or DM).

Methods

We linked multiple population-based health datasets to construct a cohort of adults living in Ontario, Canada on January 1, 2011 and followed to December 2020. The IA cohort was identified using validated case definitions and included patients with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. Comparison cohorts included adults with DM but no IA and general comparators without DM or IA. We included all subjects with a first HF hospitalization and who were alive at the time of discharge. We summarized the percentage of subjects in each of the 3 exposure groups who achieved recommended quality process measures [1]: (1) % receiving echocardiogram, (2) % receiving electrocardiogram, (3) % receiving a chest x-ray; and (4) % seen by a physician within 7 days of discharge. For those over the age of 65 years in whom medication information was universally available, we examined how many were dispensed evidence-based therapies: (5) % prescribed β-blocker, (6) % prescribed angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, (7) % prescribed mineralocorticoid receptor antagonist. We categorized adherence as perfect, moderate, or poor based on the number of measures achieved and compared proportions using pair-wise chi-squared tests.

Results

A first HF hospitalization occurred in 5,836 IA patients, 33,553 DM patients and 62,256 general comparators. The crude incidence rate for HF in IA was 2.70 per 1000/PY and was significantly higher compared to the general population (0.84 per 1000/PY), but lower compared to the DM cohort (5.01 per 1000/PY, p< 0.001). Mean age at time of HF hospitalization was significantly higher in the IA group (78 years) with more females affected (58%) compared to either the DM or general population group (p<0.001). All groups had high achievement of testing process measures and there were no differences in perfect adherence between the IA vs. DM and IA vs. general population comparators (Table 1). For those >65 years of age, patients with IA were less likely to achieve perfect adherence for medication quality indicators compared to either the DM or general population.

Table 1.

Percentage in each of three exposure groups achieving the recommended HF quality measures.

Process MeasureIA GroupDM GroupGeneral Population1.Echocardiogram90.6%91.1%89.5%2.Electrocardiogram97.4%97.4%97.3%3.Chest x-ray99.7%99.6%99.6%4.Health care provider visit within 7 days of discharge39.0%38.9%38.7%Perfect Adherence (achieving 1, 2,3 and 4 above)33.0%33.0% (p=0.43, IA vs. DM)32.2% (p=0.15, IA vs general population)5.Beta-blocker prescribed64.8%70.5%66.6%6.Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker prescribed54.8%61.3%56.2%7.Mineralocorticoid receptor antagonist prescribed20.3%19.9%21.2%Perfect Adherence (achieving 5, 6 and 7 above)10.6%12.0% (p=<0.001, IA vs. DM)12.0% (p=0.02, IA vs general population)

Conclusion

HF quality indicators are adhered to in a high proportion of patients with IA following HF hospitalization. However, reasons for lower HF medication prescribing in IA compared to other high-risk conditions, such as DM, requires further evaluation. It will also be important to determine if adherence to HF quality of care translates to reduced long-term outcomes such as repeat HF hospitalizations and cardiovascular mortality, which we are currently exploring.

References

[1]Ontario HQ. Recommendations for Adoption: Heart Failure Care in the Community 2019 [Available from: http://www.hqontario.ca/Evidence-to-Improve-Care/Quality-Standards

Disclosure of Interests

Bindee Kuriya Speakers bureau: Abbvie, Gilead, Pfizer, Lihi Eder Speakers bureau: Abbvie, UCB, Pfizer, Eli Lily, Novartis and Sandoz, Jessica Widdifield: None declared, Laura Ferreira-Legere: None declared, Irene JH Jeong: None declared, Jiming Fang: None declared, Anna Chu: None declared, Jacob Udell: None declared

Chromatin Reorganization during Myoblast Differentiation Involves the Caspase-Dependent Removal of SATB2

The induction of lineage-specific gene programs are strongly influenced by alterations in local chromatin architecture. However, key players that impact this genome reorganization remain largely unknown. Here, we report that the removal of the special AT-rich binding protein 2 (SATB2), a nuclear protein known to bind matrix attachment regions, is a key event in initiating myogenic differentiation. The deletion of myoblast SATB2 in vitro initiates chromatin remodeling and accelerates differentiation, which is dependent on the caspase 7-mediated cleavage of SATB2. A genome-wide analysis indicates that SATB2 binding within chromatin loops and near anchor points influences both loop and sub-TAD domain formation. Consequently, the chromatin changes that occur with the removal of SATB2 lead to the derepression of differentiation-inducing factors while also limiting the expression of genes that inhibit this cell fate change. Taken together, this study demonstrates that the temporal control of the SATB2 protein is critical in shaping the chromatin environment and coordinating the myogenic differentiation program.

POS0905 ACHIEVEMENT OF PARTIAL REMISSION AND INACTIVE DISEASE IN UPADACITINIB-TREATED PATIENTS WITH ANKYLOSING SPONDYLITIS

Background:

Assessment of SpondyloArthritis international Society (ASAS) response criteria and AS Disease Activity Score (ASDAS) are both commonly used, rigorous composite indices consisting of components with relevance to patients. Clinically meaningful thresholds for these measures have been defined to reflect partial remission (PR), inactive disease (ID), and low disease activity (LDA).

Objectives:

To study the association of ASAS PR and ordinal ASDAS disease categories (including ASDAS ID, which is the most stringent category of this composite score) in upadacitinib (UPA)-treated patients with AS.

Methods:

In the SELECT-AXIS 1 (NCT03178487) study, biologic DMARD naïve-patients (pts; ≥18 y) with active AS and intolerance/contraindication or inadequate response to ≥2 NSAIDs were randomized 1:1 to UPA 15 mg once daily (QD) or placebo (PBO).1 At wk 14, pts entered an open-label extension (OLE) of UPA 15 mg QD; pts randomized to PBO were switched to UPA. This post hoc analysis assessed the responsiveness of individual ASAS and ASDAS core components among pts who achieved ASAS PR. The association of ASAS PR with achievement of ASDAS ID (ASDAS <1.3), ASDAS LDA (ASDAS <2.1 but ≥1.3) or ASDAS high disease activity (HDA)/very HDA (VHDA) (ASDAS ≥2.1 for HDA/VHDA) was also assessed by measures including Youden index, distance to perfect point, and sensitivity/specificity equality. These evaluations were performed in pts randomized to UPA from baseline (BL; continuous UPA, assessed at wk 14) and those who were randomized to PBO and switched to UPA upon entry in the OLE (PBO to UPA; re-baselined at wk 14 and assessed at wk 32, representing 18 wks of UPA exposure).

Results:

At wk 14, for the continuous UPA group, 16 pts (19%) achieved ASAS PR. At wk 32, following 18 wks of UPA exposure for the PBO-to-UPA group, 28 pts (33%) achieved ASAS PR. Among both groups (continuous UPA and PBO-to-UPA), improvements were seen across all core components (Figure 1). Of the 44 total pts who achieved ASAS PR, 91% achieved either ASDAS ID or LDA. The majority of patients who achieved ASAS PR achieved ASDAS ID in the continuous UPA and PBO-to-UPA groups: 11/16 (69%) and 16/28 (57%), respectively. For the continuous UPA group, the remaining 5 pts who achieved ASAS PR also achieved ASDAS LDA (Table 1). ASAS PR was associated with ASDAS categories in the following manner: the highest rate of ASAS PR was achieved for ASDAS ID followed by ASDAS LDA followed by ASDAS HDA/VHDA. The cutoff of 1.3 (the upper threshold for ASDAS ID) was a better discrimination threshold for ASAS PR than the cutoff of 2.1 (the upper threshold for ASDAS LDA).

Conclusion:

Nineteen percent of pts receiving UPA from BL achieved ASAS PR after 14 wks of treatment, with similar results seen in pts who were originally randomized to PBO and switched to UPA at wk 14. A consistent improvement was seen across all core components of ASAS among those who achieved ASAS PR with UPA treatment. The achievement of ASAS PR was most closely associated with the achievement of ASDAS ID, providing further clarity on the reduction of disease activity in AS pts treated with UPA.

References:

[1]van der Heijde, et al. Lancet. 2019;394(10214):2108-2117.

Table 1.

Association Between ASAS PR and ASDAS Clinical Thresholds (ID/LDA/HDA or VHDA)

ASDAS ID(<1.3)ASDAS LDA(1.3 to <2.1)ASDAS HDA or VHDA(≥2.1)Continuous UPA Groupn=15n=31n=39 ASAS PR Responders (n=16)1150 ASAS PR Non-responders (n=69)42639PBO to UPA Groupn=25n=35n=25 ASAS PR Responders (n=28)1684 ASAS PR Non-responders (n=57)92721

P<0.001 for association of ASAS PR with the ordered ASDAS categories of ID-LDA-HDA, for both Continuous UPA Group and PBO to UPA Group. P-value calculated from Cochran-Armitage trend test for association of ordinal categories.

ASAS, Assessment of SpondyloArthritis international Society response criteria; ASDAS, AS Disease Activity Score; HDA, high disease activity; ID, inactive disease; LDA, low disease activity; PBO, placebo; PR, partial remission; UPA, upadacitinib; VHDA, very high disease activity.

Acknowledgements:

AbbVie funded this study and participated in the study design, research, analysis, data collection, interpretation of data, reviewing, and approval of the publication. All authors had access to relevant data and participated in the drafting, review, and approval of this publication. No honoraria or payments were made for authorship. Medical writing support was provided by J Urbanik of AbbVie and M Hovenden and J Matsuura of Complete Publication Solutions, LLC (funded by AbbVie).

Disclosure of Interests:

Atul Deodhar Speakers bureau: Novartis and Pfizer, Consultant of: Novartis, Pfizer, AbbVie, Eli Lilly, UCB Pharma, GlaxoSmithKline, Galapagos, Janssen, Boehringer Ingelheim and Celgene, Amgen., Grant/research support from: AbbVie, Eli Lilly, UCB Pharma, GlaxoSmithKline, Andrew Ostor Consultant of: AbbVie, BMS, Roche, Janssen, Lilly, Novartis, Pfizer, UCB, Gilead, and Paradigm, anna maniccia Shareholder of: AbbVie, Employee of: AbbVie, Fabiana Ganz Shareholder of: AbbVie, Employee of: AbbVie, Tianming Gao Shareholder of: AbbVie, Employee of: AbbVie, Alvina Chu Shareholder of: AbbVie, Employee of: AbbVie, Denis Poddubnyy Speakers bureau: AbbVie, BMS, Lilly, MSD, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Biocad, Gilead, GSK, Lilly, MSD, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Lilly, MSD, Novartis, and Pfizer

OP0144 EFFICACY AND SAFETY OF UPADACITINIB IN PATIENTS WITH ACTIVE ANKYLOSING SPONDYLITIS: 1-YEAR RESULTS FROM A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY WITH OPEN-LABEL EXTENSION

Background:

Upadacitinib (UPA) was efficacious and well tolerated vs placebo (PBO) during the first 14 weeks (wks) of the phase 2/3 SELECT-AXIS 1 study in patients (pts) with active ankylosing spondylitis (AS) who had an inadequate response to NSAIDs.1

Objectives:

To report efficacy and safety of UPA through 1 year in the SELECT-AXIS 1 study.

Methods:

In SELECT-AXIS 1 (NCT03178487) pts were randomized 1:1 to UPA 15 mg once daily (QD) or PBO; at wk 14, pts continued in the 90-wk open-label extension and received UPA 15 mg QD; reported here are data up to wk 64. The study enrolled pts (≥18 y) with active AS (defined as BASDAI ≥4 and pt assessment of back pain ≥4 [numeric rating scale, 0–10] at screening and baseline [BL]) who had inadequate response to ≥2 NSAIDs or intolerance to or contraindication for NSAIDs and were biologic DMARD naive. Efficacy assessments included percentage of pts with Assessment of SpondyloArthritis international Society (ASAS) 20/40 response, ASAS partial remission, BASDAI50, AS Disease Activity Score (ASDAS) and change from BL in ASDAS and BASFI. Data are reported as observed and by using non-responder imputation (NRI). Treatment-emergent adverse events (TEAEs) were reported as events per 100 patient-years (PY) up to January 31, 2020.

Results:

Of 187 pts, 178 pts (each n=89 for UPA and PBO arms) completed wk 14 on study drug and entered the open-label extension; 160 pts completed wk 64. Efficacy was maintained or continued to improve throughout the study in the continuous UPA group: 85% (95% CI, 77%–93%) of pts achieved ASAS40 at wk 64 in the as-observed analysis and 72% (63%–81%) in the NRI analysis (Figure). Pts who switched from PBO to UPA at wk 14 showed similar speed of onset and magnitude of response vs pts initially randomized to UPA: 81% (95% CI, 72%–89%) in the as-observed analysis and 70% (61%–80%) in the NRI analysis achieved ASAS40 at wk 64 (Figure). Similar results were observed for other efficacy endpoints (Figure). Among all 182 pts receiving UPA, 618 AEs were reported. AEs leading to discontinuation and serious AEs were low (Table). No serious infections, active tuberculosis, venous thromboembolic events, gastrointestinal perforation, major adverse cardiovascular events, renal dysfunction, or deaths were reported.

Table 1.

TEAEs per 100 PYs

Events/(E/100 PY)UPA 15 mg QDN=182 (237.6 PY)Any AE618 (260.1)Serious AE14 (5.9)AE leading to discontinuation15 (6.3)Infections205 (86.3) Opportunistic infection*2 (0.8) Herpes zoster†5 (2.1)Creatine phosphokinase elevation‡28 (11.8)Hepatic disorder§24 (10.1)Neutropenia||7 (2.9)Anemia||3 (1.3)Lymphopenia||2 (0.8)Malignancy¶1 (0.4)Death0

AE, adverse event; PY, patient-year; QD, once daily; TEAE, treatment-emergent AE; UPA, upadacitinib.

*Two non-serious events of esophageal candidiasis in the same patient.

†Five events in 4 patients; all non-serious and limited to 1 dermatome.

‡All events were non-serious and none led to study drug discontinuation; majority were asymptomatic.

§Majority based on asymptomatic alanine aminotransferase/aspartate aminotransferase elevations; all were non-serious and none led to study drug discontinuation.

||All events were non-serious and none led to study drug discontinuation.

¶Squamous cell carcinoma of tongue in 61-year-old male former smoker; no reasonable possibility to be study drug related per investigator.

Conclusion:

UPA 15 mg QD showed sustained and consistent efficacy over 1 year. Pts who switched from placebo to UPA at wk 14 showed a similar efficacy response compared with pts who received continuous UPA. No new safety findings were observed compared with safety data from the UPA clinical development program in other indications.2

References:

[1]van der Heijde D, et al. Lancet. 2019;394(10214):2108-2117.

[2]Cohen, et al. Arthritis Rheumatol. 2019;71(suppl 10).

Acknowledgements:

AbbVie funded this study and participated in the study design, research, analysis, data collection, interpretation of data, reviewing, and approval of the publication. All authors had access to relevant data and participated in the drafting, review, and approval of this publication. No honoraria or payments were made for authorship. Medical writing support was provided by M Hovenden and J Matsuura of ICON plc (North Wales, PA) and was funded by AbbVie.

Disclosure of Interests:

Atul Deodhar Speakers bureau: Novartis, Pfizer, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, GlaxoSmithKline, Janssen, Novartis, Pfizer, UCB, Grant/research support from: AbbVie, Eli Lilly, GlaxoSmithKline, Novartis, Pfizer, UCB, Désirée van der Heijde Consultant of: AbbVie, BMS, Cyxone, Eisai, Galapagos, Gilead, GlaxoSmithKline, Lilly, Novartis, Pfizer, and UCB Pharma, Joachim Sieper Speakers bureau: AbbVie, Janssen, Lilly, Merck, and Novartis, Consultant of: AbbVie, Janssen, Lilly, Merck, and Novartis, Filip van den Bosch Speakers bureau: AbbVie, Celgene, Eli Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, and UCB Pharma, Consultant of: AbbVie, Celgene, Eli Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, and UCB Pharma, Walter P Maksymowych Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Galapagos, Gilead, Janssen, Lilly, Novartis, Pfizer, UCB Pharma, Grant/research support from: AbbVie, Novartis and Pfizer, Tae-Hwan Kim Speakers bureau: AbbVie, Celltrion, Kirin, Lilly, and Novartis, Mitsumasa Kishimoto Consultant of: AbbVie, Amgen-Astellas BioPharma, Asahi-Kasei Pharma, Astellas, Ayumi Pharma, BMS, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Janssen, Kyowa Kirin, Novartis, Pfizer, Tanabe-Mitsubishi, Teijin Pharma, and UCB Pharma, Andrew Ostor Consultant of: AbbVie, BMS, Roche, Janssen, Lilly, Novartis, Pfizer, UCB, Gilead, and Paradigm, Bernard Combe Speakers bureau: AbbVie, Lilly, Merck, Consultant of: AbbVie, Lilly, Gilead, Janssen, Novartis, Roche-Chugai, and Sanofi, Grant/research support from: AbbVie and Lilly, Yunxia Sui Shareholder of: AbbVie, Employee of: AbbVie, xin wang Shareholder of: AbbVie, Employee of: AbbVie, Alvina Chu Shareholder of: AbbVie, Employee of: AbbVie, In-Ho Song Shareholder of: AbbVie, Employee of: AbbVie

Designing a continuous data-driven feedback and learning initiative to improve electronic prescribing: an interdisciplinary quality improvement study

Introduction

The WHO Global Patient Safety Challenge aims to reduce severe avoidable medication-related harm by 50% by 2023[1]. Research suggests that providing timely, trusted feedback that incorporates relevant action can improve practice. However, a key barrier is lack of prescribing error data. Hospital electronic prescribing (EP) data may help address this gap.

Aims

To explore approaches for continuously monitoring medication safety signals using existing or new EP data, and to deliver personalised prescribing feedback and learning to improve patient safety.

Methods

We conducted a feasibility study (November 2019 - February 2020) on a 28-bed adult gastroenterology. This ward was chosen because of a high prescribing error rate. All foundation year 1 and 2 doctors, and pharmacists on the ward, participated in the study. The study team comprised pharmacists, doctors, quality improvement experts and clinical analysts, and used a quality improvement approach to design and test (i) methods for extracting electronic data to calculate prescribing accuracy rates, (ii) ways to refine a paper-prototype of an electronic pharmacists’ interventions form, (iii) potential digital medication safety indicators, and (iv) approaches for feedback for doctors to augment existing verbal feedback from pharmacists. Data were documented in accordance with local information governance and analysed using Excel. Acceptability and usability was assessed through verbal feedback from participants during weekly huddles. Outcome measures: feasibility of using EP to determine prescribing accuracy, user acceptability and usability of data collection, feedback and learning by pharmacists and doctors. We also measured changes in prescribing accuracy rate, pharmacists’ interventions, and quality of prescribing for targeted problematic medications.

Results

Extracting EP data required multiple data linkages to be configured and validated, and not all required data were available. Potential digital medication safety indicators: utility of the reason code ‘prescribed in error’ and actions by pharmacists to modify medications were limited by underuse and lack of data granularity. After testing different ways to extract relevant EP data, we eventually used a combination of EP and manual retrospective review of electronic patient records to determine prescribing accuracy rates. An intervention form was redesigned to tally interventions and capture details for contextual learning for email feedback to doctors and weekly prescribing improvement huddles. Doctors reported emails as timely and helpful for gaining new prescribing- and system-related knowledge. Pharmacists reported intervention data as providing invaluable evidence to drive improvement.

Statistical process control charts showed no special cause variation around a mean prescription accuracy rate of 98% for inpatient orders, and 87% for discharge orders. By contrast, pharmacists recorded a mean of 10 interventions/day with 7 special cause variation (above upper control limit of 19) in the first two months. Omission of venous thromboembolism prophylaxis was identified as a priority medication issue. Specific prescriber- and system-based improvements were suggested (Jan 2020), some implemented (Feb 2020) and others fed back to the thrombosis committee (Feb 2020).

Conclusion

Harnessing the potential of EP data to improve medication safety requires the workforce to have a deeper understanding of the EP data structure and processes. Using a quality improvement approach, we developed a feedback and learning model that is acceptable and useful to pharmacists and doctors. Further research should explore adapting the approach to other clinical areas.

Reference

1. Sheikh, A., Dhingra-Kumar, N., Kelley, E., Kieny, M. and Donaldson, L. The Third Global Patient Safety Challenge: Tackling Medication-Related Harm. Bulletin of the World Health Organization. World Health Organisation. 2017;95:546-546A.

Hospital readmissions after catheter ablation for atrial fibrillation among patients with heart failure in the United States

Background

Catheter ablation for atrial fibrillation may improve quality of life and long-term mortality among patients with heart failure.

Purpose

The rates of hospital readmission after catheter ablation for atrial fibrillation among patients with an established diagnosis of heart failure are largely unknown. We aimed to assess the rates and causes of 30-day readmission among patients with heart failure undergoing catheter ablation vs. medical therapy for atrial fibrillation in the United States.

Methods

The 2016 Nationwide Readmissions Database was screened for patients with diagnosis of heart failure and atrial fibrillation using the 10th Revision of International Classification of Diseases codes. Patients undergoing catheter ablation for atrial fibrillation were grouped separately from those treated medically for atrial fibrillation. Thirty-day readmissions were assessed for both groups.

Results

The analytical cohort included 749,776 (national estimate of 1,421,673) patients with heart failure and atrial fibrillation. This included 2,204 patients that underwent catheter ablation. Patients treated with catheter ablation had lower 30-day readmissions compared to the medical therapy group (16.8% vs 20.1%, p&lt;0.001). Fifty-five percent of all readmissions among the catheter ablation cohort were related to cardiac events. Heart failure exacerbation (40%) and arrhythmia (36%) were the most common cardiac causes for readmission after catheter ablation (Figure).

Conclusions

In a contemporary nationwide analysis of patients with heart failure and atrial fibrillation, compared to medical therapy those treated with catheter ablation for atrial fibrillation had fewer 30-day readmissions after index hospital discharge. The most common cause for readmission among patients treated with catheter ablation was heart failure exacerbation and arrhythmia.

Causes of readmission

Funding Acknowledgement

Type of funding source: None

Implications of pacemaker implantation after TAVR: insights from the Nationwide Readmissions Database

Introduction

Conduction disturbances after transcatheter aortic valve replacement (TAVR) requiring permanent pacemaker (PPM) implantation are a well-known procedural complication. Data on the effect of post-TAVR PPM implantation on 30-day readmissions is scarce.

Methods

The Nationwide Readmissions Database (NRD) is a nationally representative sample of all US hospitalizations, representing over 35 million discharges. The 2016 NRD was used to identify patients who underwent TAVR and PPM implantation from January to November 2016. Propensity matching was used to balance baseline clinical characteristics.

Results

Of the 44,607 patients who underwent TAVR, 4,878 (10.9%) required permanent pacemaker implantation during their index hospitalization. Patients requiring PPM during their index admission for TAVR had a higher crude median length of stay (LOS) (5d vs. 3d, p&lt;0.001), median cost of index admission ($61,604 vs. $45,513, p&lt;0.001) and rate of 30-day readmission (14.5% vs 11.2%, p&lt;0.001). After 2:1 propensity matching, PPM patients still had a higher median LOS (5d vs. 3d, p&lt;0.001), median cost of index admission ($61,902 vs. $41,162, p&lt;0.001), and rate of 30-day readmission (13.8% vs 11.1%, p=0.003). Patients who received PPM were more likely to be older (81.1 vs 80.3, OR 1.01, CI 1.01–1.02), diabetic (OR 1.27, 1.13–1.44), obese (OR 1.22, 1.05–1.43), and have right (OR 4.35, 3.72–5.09) or left (OR 1.80, 1.51–2.15) bundle branch blocks on multivariate analysis. Causes of readmission in patients with and without PPM were predominantly non-cardiac (62.9% vs 68.0%). Heart failure was the most common cause of readmission for both groups (18.4% vs 14.6%). Median cost of readmissions ($8716 vs $8250, p=0.34) and LOS (4d vs 4d, p=1) were not significantly different during readmissions.

Conclusions

Based on a nationally representative sample, 10.9% of patients undergoing TAVR required PPM implantation during the index hospitalization. Age, diabetes, obesity, and right or left bundle branch blocks were significant predictors of PPM implantation. PPM implantation resulted in significantly higher LOS, costs, and 30-day readmissions on propensity-matched analysis.

Funding Acknowledgement

Type of funding source: None

Efficient Ground-State Cooling of Large Trapped-Ion Chains with an Electromagnetically-Induced-Transparency Tripod Scheme

We report the electromagnetically-induced-transparency (EIT) cooling of a large trapped ^{171}Yb^{+} ion chain to the quantum ground state. Unlike conventional EIT cooling, we engage a four-level tripod structure and achieve fast sub-Doppler cooling over all motional modes. We observe simultaneous ground-state cooling across the complete transverse mode spectrum of up to 40 ions, occupying a bandwidth of over 3 MHz. The cooling time is observed to be less than 300  μs, independent of the number of ions. Such efficient cooling across the entire spectrum is essential for high-fidelity quantum operations using trapped ion crystals for quantum simulators or quantum computers.

Dysregulated expression of monoacylglycerol lipase is a marker for anti-diabetic drug metformin-targeted therapy to correct impaired neurogenesis and spatial memory in Alzheimer's disease

Rationale: Monoacylglycerol lipase (Mgll), a hydrolase that breaks down the endocannabinoid 2-arachidonoyl glycerol (2-AG) to produce arachidonic acid (ARA), is a potential target for neurodegenerative diseases, such as Alzheimer's disease (AD). Increasing evidence shows that impairment of adult neurogenesis by perturbed lipid metabolism predisposes patients to AD. However, it remains unknown what causes aberrant expression of Mgll in AD and how Mgll-regulated lipid metabolism impacts adult neurogenesis, thus predisposing to AD during aging. Here, we identify Mgll as an aging-induced factor that impairs adult neurogenesis and spatial memory in AD, and show that metformin, an FDA-approved anti-diabetic drug, can reduce the expression of Mgll to reverse impaired adult neurogenesis, prevent spatial memory decline and reduce β-amyloid accumulation.

Methods: Mgll expression was assessed in both human AD patient post-mortem hippocampal tissues and 3xTg-AD mouse model. In addition, we used both the 3xTg-AD animal model and the CbpS436A genetic knock-in mouse model to identify that elevated Mgll expression is caused by the attenuation of the aPKC-CBP pathway, involving atypical protein kinase C (aPKC)-stimulated Ser436 phosphorylation of histone acetyltransferase CBP through biochemical methods. Furthermore, we performed in vivo adult neurogenesis assay with BrdU/EdU labelling and Morris water maze task in both animal models following pharmacological treatments to show the key role of Mgll in metformin-corrected neurogenesis and spatial memory deficits of AD through reactivating the aPKC-CBP pathway. Finally, we performed in vitro adult neurosphere assays using both animal models to study the role of the aPKC-CBP mediated Mgll repression in determining adult neural stem/progenitor cell (NPC) fate.

Results: Here, we demonstrate that aging-dependent induction of Mgll is observed in the 3xTg-AD model and human AD patient post-mortem hippocampal tissues. Importantly, we discover that elevated Mgll expression is caused by the attenuation of the aPKC-CBP pathway. The accumulation of Mgll in the 3xTg-AD mice reduces the genesis of newborn neurons and perturbs spatial memory. However, we find that metformin-stimulated aPKC-CBP pathway decreases Mgll expression to recover these deficits in 3xTg-AD. In addition, we reveal that elevated Mgll levels in cultured adult NPCs from both 3xTg-AD and CbpS436A animal models are responsible for their NPC neuronal differentiation deficits.

Conclusion: Our findings set the stage for development of a clinical protocol where Mgll would serve as a biomarker in early stages of AD to identify potential metformin-responsive AD patients to restore their neurogenesis and spatial memory.

P6572Sinus arrest post-cardioversion

Introduction

Sinus arrest remains a recognized but likely underreported complication of cardioversion, with incidence ranging widely in the literature, from virtually 0% to 1.5%. After a case of elective cardioversion resulting in the need for ECMO support, we investigated possible risk factors that could help predict adverse outcomes after cardioversion.

Hypothesis

Cardioversion, while generally benign, is not without risks, and further study may help elucidate predictors of morbidity and mortality.

Methods

We retrospectively reviewed data of all patients who underwent cardioversion at three hospitals within the Lifespan health system, Rhode Island Hospital, Newport Hospital, and the Miriam Hospital, between 2000 and 2015. 23 patients who experienced sinus arrest after cardioversion, and characteristics of these patients were compared with those of 3:1 age-and-gender matched controls using binomial logistic regression analysis on Stata.

Results

Of 12,156 patients who underwent cardioversion, 23 patients (57% male, mean age 78±14), or 0.18%, experienced immediate post-cardioversion sinus arrest, defined as absence of sinus activity for greater than five seconds. Compared with 3:1 age-and-gender-matched controls who underwent cardioversion without incident, binomial logistic regression revealed that paroxysmal atrial fibrillation (OR 11.8; 95% CI 1.85–75.72; p=0.009), beta-blocker use (OR 58.0; 95% CI 2.4–1404.48; p=0.013), Amiodarone use (OR 19.9; 95% CI 2.0–198.32; p=0.011), and elevated ventricular rate (CV 0.028; 95% CI 0.0031–0.053; p=0.027) were statistically significant predictors of sinus arrest after cardioversion. Calcium-channel blocker use, Digoxin use, age, gender, PR interval, QRS duration, and corrected QT interval were not significant associations.

Conclusions

Sparse data exists regarding characteristics predisposing patients to adverse outcomes following cardioversion, and further risk stratification is warranted, given the potential for significant morbidity and mortality. Our findings raise questions that demand elucidation, such as whether beta-blockers or Amiodarone should be held prior to cardioversion.

Characterization of proximal femoral anatomy in the skeletally-immature patient

PURPOSE

The morphology of the proximal femur has been extensively studied in the adult population. However, no literature providing a comprehensive evaluation of the anatomy in paediatric patients exists. The current study aims to characterize such anatomy in skeletally-immature patients, examine potential differences between genders, and analyze how these anatomical parameters change with age.

METHODS

Cadaveric femurs from the Hamann-Todd Osteological Collection were examined. Specimens with open physes and no skeletal disease or deformity were included for analysis. Age and gender were recorded for each specimen. Each femur was photographed in standardized modified axial and anteroposterior views. In all, 14 proximal femoral anatomical parameters were measured from these photographs. Comparisons between genders and age were calculated.

RESULTS

A total of 43 femurs from ages four to 17 years met inclusion criteria. The majority were female (56%); no difference existed in age between genders (p = 0.62). The specimens had a neutral mean neck-shaft angle (130.7º) and anteversion (12.8º), and the sphericity of the ossified femoral heads was symmetrical. Male specimens had significantly higher alpha angles (p = 0.01), posterior offset (p = 0.02), neck width (p = 0.04) and head-neck length ratio (p = 0.02) values than female specimens. Strong positive correlations exist between length/size parameters and age, while negligible correlations were noted for angular measurements.

CONCLUSIONS

This study establishes reference values for a comprehensive list of anatomical parameters for the skeletally-immature ossified proximal femur. It highlights gender differences in morphology and demonstrates that angular characteristics remain relatively stable while length parameters generally increase with age.

LEVEL OF EVIDENCE

Level III Diagnostic.

Epigenetic Activation of Pro-angiogenic Signaling Pathways in Human Endothelial Progenitors Increases Vasculogenesis

Human endothelial colony-forming cells (ECFCs) represent a promising source of adult stem cells for vascular repair, yet their regenerative capacity is limited. Here, we set out to understand the molecular mechanism restricting the repair function of ECFCs. We found that key pro-angiogenic pathways are repressed in ECFCs due to the presence of bivalent (H3K27me3/H3K4me3) epigenetic marks, which decreases the cells' regenerative potential. Importantly, ex vivo treatment with a combination of epigenetic drugs that resolves bivalent marks toward the transcriptionally active H3K4me3 state leads to the simultaneous activation of multiple pro-angiogenic signaling pathways (VEGFR, CXCR4, WNT, NOTCH, SHH). This in turn results in improved capacity of ECFCs to form capillary-like networks in vitro and in vivo. Furthermore, restoration of perfusion is accelerated upon transplantation of drug-treated ECFCs in a model of hindlimb ischemia. Thus, ex vivo treatment with epigenetic drugs increases the vascular repair properties of ECFCs through transient activation of pro-angiogenic signaling pathways.

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Pro-angiogenic pathways are maintained in a poised state in ECFCs

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Epigenetic drugs resolve bivalently marked genes toward an active state in ECFCs

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Treatment with epigenetic drugs activates multiple pro-angiogenic pathways in ECFCs

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Ex vivo treatment with epigenetic drugs increases ECFC-mediated vasculogenesis

Activating transcription factor 3 promotes loss of the acinar cell phenotype in response to cerulein-induced pancreatitis in mice

Pancreatitis is a debilitating disease of the exocrine pancreas that, under chronic conditions, is a major susceptibility factor for pancreatic ductal adenocarcinoma (PDAC). Although down-regulation of genes that promote the mature acinar cell fate is required to reduce injury associated with pancreatitis, the factors that promote this repression are unknown. Activating transcription factor 3 (ATF3) is a key mediator of the unfolded protein response, a pathway rapidly activated during pancreatic insult. Using chromatin immunoprecipitation followed by next-generation sequencing, we show that ATF3 is bound to the transcriptional regulatory regions of >30% of differentially expressed genes during the initiation of pancreatitis. Of importance, ATF3-dependent regulation of these genes was observed only upon induction of pancreatitis, with pathways involved in inflammation, acinar cell differentiation, and cell junctions being specifically targeted. Characterizing expression of transcription factors that affect acinar cell differentiation suggested that acinar cells lacking ATF3 maintain a mature cell phenotype during pancreatitis, a finding supported by maintenance of junctional proteins and polarity markers. As a result, Atf3-/- pancreatic tissue displayed increased tissue damage and inflammatory cell infiltration at early time points during injury but, at later time points, showed reduced acinar-to-duct cell metaplasia. Thus our results reveal a critical role for ATF3 as a key regulator of the acinar cell transcriptional response during injury and may provide a link between chronic pancreatitis and PDAC.

A Simple Automated Method for Detecting Recurrence in High-Grade Glioma

Our aim was to develop an automated multiparametric MR imaging analysis of routinely acquired imaging sequences to identify areas of focally recurrent high-grade glioma. Data from 141 patients treated with radiation therapy with a diagnosis of high-grade glioma were reviewed. Strict inclusion/exclusion criteria identified a homogeneous cohort of 12 patients with a nodular recurrence of high-grade glioma that was amenable to focal re-irradiation (cohort 1). T1WI, FLAIR, and DWI data were used to create subtraction maps across time points. Linear regression was performed to identify the pattern of change in these 3 imaging sequences that best correlated with recurrence. The ability of these parameters to guide treatment decisions in individual patients was assessed in a separate cohort of 4 patients who were treated with radiosurgery for recurrent high-grade glioma (cohort 2). A leave-one-out analysis of cohort 1 revealed that automated subtraction maps consistently predicted the radiologist-identified area of recurrence (median area under the receiver operating characteristic curve = 0.91). The regression model was tested in preradiosurgery MRI in cohort 2 and identified 8 recurrent lesions. Six lesions were treated with radiosurgery and were controlled on follow-up imaging, but the remaining 2 lesions were not treated and progressed, consistent with the predictions of the model. Multiparametric subtraction maps can predict areas of nodular progression in patients with previously treated high-grade gliomas. This automated method based on routine imaging sequences is a valuable tool to be prospectively validated in subsequent studies of treatment planning and posttreatment surveillance.

UTX inhibition as selective epigenetic therapy against TAL1-driven T-cell acute lymphoblastic leukemia

Benyoucef et al. reveal the existence of a subtype-specific epigenetic vulnerability in T-cell acute lymphoblastic leukemia (T-ALL) by which a particular subgroup of T-ALL characterized by expression of the oncogenic transcription factor TAL1 is uniquely sensitive to variations in the dosage and activity of the histone 3 Lys27 (H3K27) demethylase UTX/KDM6A.

T-cell acute lymphoblastic leukemia (T-ALL) is a heterogeneous group of hematological tumors composed of distinct subtypes that vary in their genetic abnormalities, gene expression signatures, and prognoses. However, it remains unclear whether T-ALL subtypes differ at the functional level, and, as such, T-ALL treatments are uniformly applied across subtypes, leading to variable responses between patients. Here we reveal the existence of a subtype-specific epigenetic vulnerability in T-ALL by which a particular subgroup of T-ALL characterized by expression of the oncogenic transcription factor TAL1 is uniquely sensitive to variations in the dosage and activity of the histone 3 Lys27 (H3K27) demethylase UTX/KDM6A. Specifically, we identify UTX as a coactivator of TAL1 and show that it acts as a major regulator of the TAL1 leukemic gene expression program. Furthermore, we demonstrate that UTX, previously described as a tumor suppressor in T-ALL, is in fact a pro-oncogenic cofactor essential for leukemia maintenance in TAL1-positive (but not TAL1-negative) T-ALL. Exploiting this subtype-specific epigenetic vulnerability, we propose a novel therapeutic approach based on UTX inhibition through in vivo administration of an H3K27 demethylase inhibitor that efficiently kills TAL1-positive primary human leukemia. These findings provide the first opportunity to develop personalized epigenetic therapy for T-ALL patients.

UTX demethylase activity is required for satellite cell-mediated muscle regeneration

The X chromosome-encoded histone demethylase UTX (also known as KDM6A) mediates removal of repressive trimethylation of histone H3 lysine 27 (H3K27me3) to establish transcriptionally permissive chromatin. Loss of UTX in female mice is embryonic lethal. Unexpectedly, male UTX-null mice escape embryonic lethality due to expression of UTY, a paralog that lacks H3K27 demethylase activity, suggesting an enzyme-independent role for UTX in development and thereby challenging the need for active H3K27 demethylation in vivo. However, the requirement for active H3K27 demethylation in stem cell-mediated tissue regeneration remains untested. Here, we employed an inducible mouse KO that specifically ablates Utx in satellite cells (SCs) and demonstrated that active H3K27 demethylation is necessary for muscle regeneration. Loss of UTX in SCs blocked myofiber regeneration in both male and female mice. Furthermore, we demonstrated that UTX mediates muscle regeneration through its H3K27 demethylase activity, as loss of demethylase activity either by chemical inhibition or knock-in of demethylase-dead UTX resulted in defective muscle repair. Mechanistically, dissection of the muscle regenerative process revealed that the demethylase activity of UTX is required for expression of the transcription factor myogenin, which in turn drives differentiation of muscle progenitors. Thus, we have identified a critical role for the enzymatic activity of UTX in activating muscle-specific gene expression during myofiber regeneration and have revealed a physiological role for active H3K27 demethylation in vivo.

Abstract P4-01-06: Microcalcifications as imaging biomarker in breast cancer: High-throughput radiogenomic analysis using microarrya data

Purpose: To investigate relationships between microcalcifications and gene expression pattern using microarray analysis in breast cancer.

Materials and methods: The institutional review board approved this retrospective study and waived the informed consent. Clinicopathologic finding, mammographic features, and gene expression data were evaluated in 133 women (mean age, 50.1 years; range, 21-79 years) with stage I-III breast cancer. Women with microcalcifications (n=33) and without microcalcifications (n=100) were compared. Immunohistochemical analysis of estrogen receptor, progesterone receptor, HER-2, and Ki-67 expression was performed. Differentially expressed genes (DEGs) using Affymetrix GeneChip® Human Gene 2.0 ST arrays (53,427 probes) were identified in tissue with microcalcifications versus without microcalcifications. In addition, genes included in the prediction analysis of PAM50, MammaPrint® and OncotypeDX® were also compared between two groups (microcalcifications versus no calcification). To further investigate the functions and underlying biology of DEGs, we performed enrichment analysis using the Gene Ontology database and pathway anlyais using the Kyoto Encyclopedia of Genes and Genomes database and Ingenuity Pathway Analysis.

Results: Among clinicopathologic varibales, HER2 positivity (p&lt;0.001) and presence of comedo necrosis (p=0.024) are significantly higher in the calcification group. About 128 genes had differential expression (&gt; 1.5 fold difference, adjusted p value&lt;0.05). Among known gene signatures, GRB7 (fold change=2.26, p=0.006) and ERBB2 (fold change=2.13, p=0.001) which are known as associated with recurrence, cell invasion and poor survival were highly expressed. In contrast, ZNF385B which is associated with p53-mediated apoptosis and good prognosis was underexpressed (fold change=0.39, p=0.001) in calcification group. Significant gene ontology terms included response to wounding, coagulation, wound healing, and response to hypoxia. Network and canonical pathway analysis indicated that increased cellular movement, cellular growth and proliferation, cellular develoment, coagulation and atherosclerosis signaling in breast cancer with microcalcifications, suggesting biological aggressiveness.

Conclusion: Gene expression patterns are different according to microcalcifications status in breast cancer. Breast cancers with mammographic microcalcifications are associated with metabolic aggressiveness and poor prognosis.

Citation Format: Shin SU, Kim W, Song SE, Chu A, Han W, Moon WK. Microcalcifications as imaging biomarker in breast cancer: High-throughput radiogenomic analysis using microarrya data. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-01-06.