Impact of HLA-B51 on Uveitis and Retinal Vasculitis: Data from the AIDA International Network Registries on Ocular Inflammatory Disorders

PURPOSE

The clinical relevance of human leukocyte antigen (HLA) subtypes such as HLA-B51 on Behçet's disease (BD)-related uveitis and non-infectious uveitis (NIU) unrelated to BD remains largely unknown.

METHODS

Data were prospectively collected from the International AIDA Network Registry for BD and for NIU. We assessed differences between groups (NIU unrelated to BD and positive for HLA-B51, BD-related uveitis positive for HLA-B51 and BD-related uveitis negative for HLA-B51) in terms of long-term ocular complications, visual acuity (VA) measured by best corrected visual acuity (BCVA), anatomical pattern, occurrence of retinal vasculitis (RV) and macular edema over time.

RESULTS

Records of 213 patients (341 eyes) were analyzed. No differences in complications were observed (p = 0.465). With regard to VA, a significant difference was detected in median BCVA (p = 0.046), which was not maintained after Bonferroni correction (p = 0.060). RV was significantly more prevalent in NIU-affected patients who tested positive for HLA-B51, irrespective of the systemic diagnosis of BD (p = 0.025). No differences emerged in the occurrence of macular edema (p = 0.99).

CONCLUSIONS

Patients with NIU testing positive for HLA-B51 exhibit an increased likelihood of RV throughout disease course, irrespective of a systemic diagnosis of BD. The rate of complications as well as VA are comparable between NIU cases unrelated to BD testing positive for HLA-B51 and uveitis associated with BD. Therefore, it is advisable to perform the HLA-B typing in patients with NIU or retinal vasculitis, even in the absence of typical BD features.

The laminar organization of cell types in macaque cortex and its relationship to neuronal oscillations

The canonical microcircuit (CMC) has been hypothesized to be the fundamental unit of information processing in cortex. Each CMC unit is thought to be an interconnected column of neurons with specific connections between excitatory and inhibitory neurons across layers. Recently, we identified a conserved spectrolaminar motif of oscillatory activity across the primate cortex that may be the physiological consequence of the CMC. The spectrolaminar motif consists of local field potential (LFP) gamma-band power (40-150 Hz) peaking in superficial layers 2 and 3 and alpha/beta-band power (8-30 Hz) peaking in deep layers 5 and 6. Here, we investigate whether specific conserved cell types may produce the spectrolaminar motif. We collected laminar histological and electrophysiological data in 11 distinct cortical areas spanning the visual hierarchy: V1, V2, V3, V4, TEO, MT, MST, LIP, 8A/FEF, PMD, and LPFC (area 46), and anatomical data in DP and 7A. We stained representative slices for the three main inhibitory subtypes, Parvalbumin (PV), Calbindin (CB), and Calretinin (CR) positive neurons, as well as pyramidal cells marked with Neurogranin (NRGN). We found a conserved laminar structure of PV, CB, CR, and pyramidal cells. We also found a consistent relationship between the laminar distribution of inhibitory subtypes with power in the local field potential. PV interneuron density positively correlated with gamma (40-150 Hz) power. CR and CB density negatively correlated with alpha (8-12 Hz) and beta (13-30 Hz) oscillations. The conserved, layer-specific pattern of inhibition and excitation across layers is therefore likely the anatomical substrate of the spectrolaminar motif.

Significance Statement

Neuronal oscillations emerge as an interplay between excitatory and inhibitory neurons and underlie cognitive functions and conscious states. These oscillations have distinct expression patterns across cortical layers. Does cellular anatomy enable these oscillations to emerge in specific cortical layers? We present a comprehensive analysis of the laminar distribution of the three main inhibitory cell types in primate cortex (Parvalbumin, Calbindin, and Calretinin positive) and excitatory pyramidal cells. We found a canonical relationship between the laminar anatomy and electrophysiology in 11 distinct primate areas spanning from primary visual to prefrontal cortex. The laminar anatomy explained the expression patterns of neuronal oscillations in different frequencies. Our work provides insight into the cortex-wide cellular mechanisms that generate neuronal oscillations in primates.

The Systemic Score May Identify Life-Threatening Evolution in Still Disease: Data from the GIRRCS AOSD-Study Group and the AIDA Network Still Disease Registry

OBJECTIVE

We aimed to evaluate the clinical usefulness of the systemic score in the prediction of life-threatening evolution in Still disease. We also aimed to assess the clinical relevance of each component of the systemic score in predicting life-threatening evolution and to derive patient subsets accordingly.

METHODS

A multicenter, observational, prospective study was designed including patients included in the Gruppo Italiano Di Ricerca in Reumatologia Clinica e Sperimentale Adult-Onset Still Disease Study Group and the Autoinflammatory Disease Alliance Network Still Disease Registry. Patients were assessed to see if the variables to derive the systemic score were available. The life-threatening evolution was defined as mortality, whatever the clinical course, and/or macrophage activation syndrome, a secondary hemophagocytic lymphohistiocytosis associated with a poor prognosis.

RESULTS

A total of 597 patients with Still disease were assessed (mean ± SD age 36.6 ± 17.3 years; male 44.4%). The systemic score, assessed as a continuous variable, significantly predicted the life-threatening evolution (odds ratio [OR] 1.24; 95% confidence interval [CI] 1.07-1.42; P = 0.004). A systemic score ≥7 also significantly predicted the likelihood of a patient experiencing life-threatening evolution (OR 3.36; 95% CI 1.81-6.25; P < 0.001). Assessing the clinical relevance of each component of the systemic score, liver involvement (OR 1.68; 95% CI 1.48-2.67; P = 0.031) and lung disease (OR 2.12; 95% CI 1.14-4.49; P = 0.042) both significantly predicted life-threatening evolution. The clinical characteristics of patients with liver involvement and lung disease were derived, highlighting their relevance in multiorgan disease manifestations.

CONCLUSION

The clinical utility of the systemic score was shown in identifying Still disease at a higher risk of life-threatening evolution in a large cohort. Furthermore, the clinical relevance of liver involvement and lung disease was highlighted.

Equated hospitalization rate of patients with inflammatory rheumatic diseases as compared to normal population in 2°wave SARSCoV2 infection

OBJECTIVE

To investigate the clinical manifestations and outcome of COVID-19 in patients with inflammatory rheumatic and musculoskeletal disease (iRMD) as compared with the general population.

METHODS

This is a case-control study of patients selected from the South-Tyrol public health service-Italy with and without iRMD affected by COVID-19. We included patients ≥18 years and with a positive SARS-CoV-2 PCR test between 1.10.2020 and 01.03.2021. Cases were identified by linking the diagnosis of a rheumatic disease with PCR test positivity; these were matched in a 1:1.8 (planned 1:2) ratio for age, sex, and date of COVID-19 diagnosis with people from the general population. The outcomes of primary interest were hospitalization and severe course (intensive care unit, mechanical ventilation/extracorporeal membrane oxygenation, death).

RESULTS

The study population consisted of 561 COVID-19 patients, of which 201 (mean age 60.4 years; 65.2% female) were patients with iRMD and 360 were controls from the general population (59.8 years; 64.7% female). The majority of iRMD patients (88.6%) received an immunosuppressive drug at time of COVID-19 diagnosis, 36.3% were under glucocorticoids. COVID-19 related hospitalization (12.4% vs 10.6%, p= 0.49), severe course (5.0% vs 5.3%, p= 1.00), and mortality (3.5% vs 4.4%, p= 0.66) were similar between groups. Among hospitalized patients, mechanic ventilation was more common in iRMD patients than in controls [n = 5 (20.0%) vs n = 1 (2.6%), p= 0.035].

CONCLUSIONS

Our study indicates similar rates for admission, severe course and mortality between patients with iRMD and controls affected by COVID-19. Among hospitalized patients, mechanical ventilation was more frequently required in the iRMD group.

Still's disease continuum from childhood to elderly: data from the international AIDA Network Still's disease registry

OBJECTIVE

Still's disease is more frequently observed in the paediatric context, but a delayed onset is not exceptional both in the adulthood and in the elderly. However, whether paediatric-onset, adult-onset and elderly-onset Still's disease represent expressions of the same disease continuum or different clinical entities is still a matter of controversy. The aim of this study is to search for any differences in demographic, clinical features and response to treatment between pediatric-onset, adult-onset and elderly-onset Still's disease.

METHODS

Subjects included in this study were drawn from the International AutoInflammatory Disease Alliance Network registry for patients with Still's disease.

RESULTS

A total of 411 patients suffering from Still's disease were enrolled; the disease occurred in the childhood in 65 (15.8%) patients, in the adult 314 (76.4%) patients and in the elderly in 32 (7.8%) patients. No statistically significant differences at post-hoc analysis were observed in demographic features of the disease between pediatric-onset, adult-onset and elderly-onset Still's disease. The salmon-coloured skin rash (p=0.004), arthritis (p=0.009) and abdominal pain (p=0.007) resulted significantly more frequent among paediatric patients than in adult cases, while pleuritis (p=0.015) and arthralgia (p<0.0001) were significantly more frequent among elderly-onset patients compared with paediatric-onset subjects. Regarding laboratory data, thrombocytosis was significantly more frequent among paediatric patients onset compared with adult-onset subjects (p<0.0001), while thrombocytopenia was more frequent among elderly-onset patients although statistical significance was only bordered. No substantial differences were observed in the response to treatments.

CONCLUSIONS

Despite some minor difference between groups, overall, demographic, clinical, laboratory and treatments aspects of Still's disease were similarly observed in patients at all ages. This supports that pediatric-onset, adult-onset and elderly-onset Still's disease is the same clinical condition arising in different ages.

Clinical and laboratory features associated with macrophage activation syndrome in Still's disease: data from the international AIDA Network Still's Disease Registry

To characterize clinical and laboratory signs of patients with Still's disease experiencing macrophage activation syndrome (MAS) and identify factors associated with MAS development. Patients with Still's disease classified according to internationally accepted criteria were enrolled in the AutoInflammatory Disease Alliance (AIDA) Still's Disease Registry. Clinical and laboratory features observed during the inflammatory attack complicated by MAS were included in univariate and multivariate logistic regression analysis to identify factors associated to MAS development. A total of 414 patients with Still's disease were included; 39 (9.4%) of them developed MAS during clinical history. At univariate analyses, the following variables were significantly associated with MAS: classification of arthritis based on the number of joints involved (p = 0.003), liver involvement (p = 0.04), hepatomegaly (p = 0.02), hepatic failure (p = 0.01), axillary lymphadenopathy (p = 0.04), pneumonia (p = 0.03), acute respiratory distress syndrome (p < 0.001), platelet abnormalities (p < 0.001), high serum ferritin levels (p = 0.009), abnormal liver function tests (p = 0.009), hypoalbuminemia (p = 0.002), increased LDH (p = 0.001), and LDH serum levels (p < 0.001). At multivariate analysis, hepatomegaly (OR 8.7, 95% CI 1.9-52.6, p = 0.007) and monoarthritis (OR 15.8, 95% CI 2.9-97.1, p = 0.001), were directly associated with MAS, while the decade of life at Still's disease onset (OR 0.6, 95% CI 0.4-0.9, p = 0.045), a normal platelet count (OR 0.1, 95% CI 0.01-0.8, p = 0.034) or thrombocytosis (OR 0.01, 95% CI 0.0-0.2, p = 0.008) resulted to be protective. Clinical and laboratory factors associated with MAS development have been identified in a large cohort of patients based on real-life data.

Derivation and validation of four patient clusters in Still's disease, results from GIRRCS AOSD-study group and AIDA Network Still Disease Registry

BACKGROUND

Different patient clusters were preliminarily suggested to dissect the clinical heterogeneity in Still's disease. Thus, we aimed at deriving and validating disease clusters in a multicentre, observational, prospective study to stratify these patients.

METHODS

Patients included in GIRRCS AOSD-study group and AIDA Network Still Disease Registry were assessed if variables for cluster analysis were available (age, systemic score, erythrocyte sedimentation rate (ESR), C reactive protein (CRP) and ferritin). K-means algorithm with Euclidean metric and Elbow plot were used to derive an adequate number of clusters.

RESULTS

K-means clustering assessment provided four clusters based on means standardised according to z-scores on 349 patients. All clusters mainly presented fever, skin rash and joint involvement. Cluster 1 was composed by 115 patients distinguished by lower values of age and characterised by skin rash myalgia, sore throat and splenomegaly. Cluster 2 included 128 patients identified by lower levels of ESR, ferritin and systemic score; multiorgan manifestations were less frequently observed. Cluster 3 comprised 31 patients categorised by higher levels of CRP and ferritin, they were characterised by fever and joint involvement. Cluster 4 contained 75 patients derived by higher values of age and systemic score. Myalgia, sore throat, liver involvement and life-threatening complications, leading to a high mortality rate, were observed in these patients.

CONCLUSIONS

Four patient clusters in Still's disease may be recognised by a multidimensional characterisation ('Juvenile/Transitional', 'Uncomplicated', 'Hyperferritinemic' and 'Catastrophic'). Of interest, cluster 4 was burdened by an increased rate of life-threatening complications and mortality, suggesting a more severe patient group.

The administration of methotrexate in patients with Still's disease, "real-life" findings from AIDA Network Still Disease Registry

OBJECTIVES

To describe clinical characteristics of patients with Still's disease treated with methotrexate (MTX) and to assess drug effectiveness evaluating change in disease activity, reduction of inflammatory markers, and glucocorticoid (GC)-sparing effect.

METHODS

Patients with Still's disease treated with MTX were assessed among those included in AIDA Network Still Disease Registry.

RESULTS

In this registry, 171 patients with Still's disease were treated with MTX (males 43.3%, age 37.1 ± 16.0 years). They were mainly characterised by joint features and fever without a prominent multiorgan involvement. MTX was administered with GCs in 68.4% of patients, with other conventional synthetic DMARDs in 6.4%, and with biologic DMARDs in 25.1%. A significant reduction of the modified systemic score was observed, and 38.6% patients were codified as being in clinical remission at the end of follow-up. The concomitant administration of a biologic DMARD resulted a predictor of the clinical remission. Furthermore, a reduction of inflammatory markers and ferritin levels was observed following the administration of MTX. Additionally, a marked reduction of the dosage of concomitant GCs was identified, while 36.7% discontinued such drugs. Male gender appeared as a predictor of GC discontinuation. MTX was discontinued in 12.3% of patients because of adverse effects, and in 12.3% for lack of efficacy.

CONCLUSIONS

Clinical characteristics of patients with Still's disease treated with MTX were described, mainly joint features and fever without a prominent multiorgan involvement. The clinical usefulness of MTX was reported in reducing the disease activity, decreasing the inflammatory markers, and as GC-sparing agent.

Method for comparison of data driven gating algorithms in emission tomography

Objective.Multiple algorithms have been proposed for data driven gating (DDG) in single photon emission computed tomography (SPECT) and have successfully been applied to myocardial perfusion imaging (MPI). Application of DDG to acquisition types other than SPECT MPI has not been demonstrated so far, as limitations and pitfalls of current methods are unknown.Approach.We create a comprehensive set of phantoms simulating the influence of different motion artifacts, view angles, moving objects, contrast, and count levels in SPECT. We perform Monte Carlo simulation of the phantoms, allowing the characterization of DDG algorithms using quantitative metrics derived from the data and evaluate the Center of Light (COL) and Laplacian Eigenmaps methods as sample DDG algorithms.Main results.View angle, object size, count rate density, and contrast influence the accuracy of both DDG methods. Moreover, the ability to extract the respiratory motion in the phantom was shown to correlate with the contrast of the moving feature to the background, the signal to noise ratio, and the noise in the data.Significance.We showed that reporting the average correlation to an external physical reference signal per acquisition is not sufficient to characterize DDG methods. Assessing DDG methods on a view-by-view basis using the simulations and metrics from this work could enable the identification of pitfalls of current methods, and extend their application to acquisitions beyond SPECT MPI.

A patient-driven registry on Behçet's disease: the AIDA for patients pilot project

Introduction

This paper describes the creation and preliminary results of a patient-driven registry for the collection of patient-reported outcomes (PROs) and patient-reported experiences (PREs) in Behçet's disease (BD).

Methods

The project was coordinated by the University of Siena and the Italian patient advocacy organization SIMBA (Associazione Italiana Sindrome e Malattia di Behçet), in the context of the AIDA (AutoInflammatory Diseases Alliance) Network programme. Quality of life, fatigue, socioeconomic impact of the disease and therapeutic adherence were selected as core domains to include in the registry.

Results

Respondents were reached via SIMBA communication channels in 167 cases (83.5%) and the AIDA Network affiliated clinical centers in 33 cases (16.5%). The median value of the Behçet's Disease Quality of Life (BDQoL) score was 14 (IQR 11, range 0-30), indicating a medium quality of life, and the median Global Fatigue Index (GFI) was 38.7 (IQR 10.9, range 1-50), expressing a significant level of fatigue. The mean Beliefs about Medicines Questionnaire (BMQ) necessity-concern differential was 0.9 ± 1.1 (range - 1.8-4), showing that the registry participants prioritized necessity belief over concerns to a limited extent. As for the socioeconomic impact of BD, in 104 out of 187 cases (55.6%), patients had to pay from their own pocket for medical exams required to reach the diagnosis. The low family socioeconomic status (p < 0.001), the presence of any major organ involvement (p < 0.031), the presence of gastro-intestinal (p < 0.001), neurological (p = 0.012) and musculoskeletal (p = 0.022) symptoms, recurrent fever (p = 0.002), and headache (p < 0.001) were associated to a higher number of accesses to the healthcare system. Multiple linear regression showed that the BDQoL score could significantly predict the global socioeconomic impact of BD (F = 14.519, OR 1.162 [CI 0.557-1.766], p < 0.001).

Discussion

Preliminary results from the AIDA for Patients BD registry were consistent with data available in the literature, confirming that PROs and PREs could be easily provided by the patient remotely to integrate physician-driven registries with complementary and reliable information.

[Ultrasound examination of nerves of the upper extremities]

The ultrasound examination of peripheral nerves has been further developed in recent years and is recognized as an independent discipline by the German Society of Ultrasound in Medicine (DEGUM). A systematic ultrasound examination of the musculoskeletal system is not limited to the joints, muscles and bones but should also include the examination of nerves and blood vessels. Therefore, in the practice of ultrasound examination every rheumatologist should have at least a basic knowledge of the ultrasound examination of the peripheral nerves. In this article the authors present a landmark-based concept in which the three large nerves of the upper extremities can be completely visualized from proximal to distal and evaluated.

Multidimensional immunoimaging to characterize the inflammatory reaction after permanent and temporary coronary artery occlusion in mice

Background

The immune response following acute myocardial infarction encompasses a delicate balance between inflammatory and reparative programs. Our knowledge of these complex mechanisms is mainly derived from studies using a murine model of permanent coronary artery occlusion. In this study we developed, validated and implemented multiparametric imaging methods to investigate cardiac function and the systemic immune response in transient or permanent coronary artery occlusion mouse models.

Methods

The myocardial infarction models encompassed either transient (40 min) or permanent LAD occlusion in C57BL/6 mice, and non-infarcted mice were used as controls. Two or seven days later, the animals subjected to systemic immunoimaging of the bone marrow, spleen and myocardium with late gadolinium enhancement cardiac MRI (LGE cMRI), 18F-fluorodeoxyglucose (18F-FDG) PET, 18F-Fluorothymidine (18F-FLT) PET, 64Cu-CCR2 PET targeting inflammatory monocytes, 89Zr-CD11b nanobody PET and 19F-HDL-PERFECTA MRI, both targeting myeloid cells. In addition, the same myocardial infarction models were applied to atherosclerosis-prone Apoe−/− and systemic inflammation and plaque progression were assessed by flow cytometry and immunohistochemistry four weeks after infarction.

Results

Through LGE cMRI and 18F-FDG PET, we observed that temporary coronary occlusion resulted in a smaller infarct size, better cardiac function and viability compared to permanent occlusion. Multiparametric immunoimaging targeting CD11b+ cells by 89Zr-CD11b nanobody PET and Ly6Chi inflammatory monocytes by 64Cu-CCR2 PET demonstrated that mice subjected to transient coronary occlusion had less immune cell influx to the ischemic myocardium. This finding was confirmed by flow cytometry analysis of the infarct zone. In contrast, both myocardial infarction models cause a similar systemic immune response in the bone marrow and spleen as observed with multimodal imaging with subsequent similar numbers of CD11b+ cells in the blood. Both permanent and temporary coronary artery occlusion aggravate atherosclerosis in Apoe−/− mice with higher macrophage and Ly6Chi monocyte numbers in aortas and larger plaque size compared to Apoe−/− mice without myocardial infarction.

Conclusions

We developed and employed multimodal, multiparametric imaging protocols to characterize the immune response in the heart, bone marrow and spleen in two models of myocardial infarction. While cardiac function was superior in the ischemia reperfusion model, both types of myocardial infarction accelerated atherosclerosis.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): NIH and DFG

Development and implementation of the AIDA International Registry for patients with Behçet's disease

Purpose of the present paper is to point out the design, development and deployment of the AutoInflammatory Disease Alliance (AIDA) International Registry dedicated to pediatric and adult patients with Behçet's disease (BD). The Registry is a clinical physician-driven non-population- and electronic-based instrument implemented for the retrospective and prospective collection of real-life data about demographics, clinical, therapeutic, laboratory, instrumental and socioeconomic information from BD patients; the Registry is based on the Research Electronic Data Capture (REDCap) tool, which is thought to collect standardised information for clinical real-life research, and has been realised to change over time according to future scientific acquisitions and potentially communicate with other existing and future Registries dedicated to BD. Starting from January 31st, 2021, to February 7th, 2022, 110 centres from 23 countries in 4 continents have been involved. Fifty-four of these have already obtained the approval from their local Ethics Committees. Currently, the platform counts 290 users (111 Principal Investigators, 175 Site Investigators, 2 Lead Investigators, and 2 data managers). The Registry collects baseline and follow-up data using 5993 fields organised into 16 instruments, including patient's demographics, history, clinical manifestations and symptoms, trigger/risk factors, therapies and healthcare access. The development of the AIDA International Registry for BD patients will facilitate the collection of standardised data leading to real-world evidence, enabling international multicentre collaborative research through data sharing, international consultation, dissemination of knowledge, inclusion of patients and families, and ultimately optimisation of scientific efforts and implementation of standardised care.Trial registration NCT05200715 in 21/01/2022.

Fully automatic AI-based valve motion parameter extraction on long axis CINE images - application on N=11000 patient datasets

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Research support from Siemens Healthineers GmbH.

Background

Mitral valve (MV) motion parameters, assessable using CMR [1, 2], have been shown to help the diagnosis of cardiac dysfunction. To extract valve motion parameters, we propose a fully automatic AI-based prototype system that tracks annulus and apex landmarks by the registration network on time-resolved two- and four-chamber CMR cine views. Parameters such as displacements, velocities, mitral annular plane systolic excursion (MAPSE), or longitudinal shortening (LS) are automatically extracted and evaluated on a large CMR dataset (N=11000).

Methods

The system consists of two sequential neural networks with a processing step in between (Fig. 1a) [3]. Initially, a 2D UNet is applied to localize both MV annulus insertion points as well as the apex. Based on these points, the image processing step consists of rotating, cropping, and interpolating the images, allowing a standardized image impression for both long axis views. Finally, the registration network (VoxelMorph framework [4]) is applied to the processed series and tracks the MV annulus insertion points and apex over the cardiac cycle by the deformation fields obtained by the network. The system was trained on (N=166) multivendor, multi-field strength, ground-truth annotated datasets [5].

A total of 11000 datasets, acquired on a 1.5T scanner (MAGNETOM Aera, Siemens Healthcare, Erlangen, Germany) from January 2016 to September 2017 [6], were used for parameter extraction. 200 of these datasets were additionally annotated semi-automatically for the performance evaluation of the system.

Five motion parameters were automatically derived by the system that are defined as follows (Fig. 1b): (1) The atrioventricular plane displacement (AVPD) as the distance of the plane spanned by the MV annulus points relative to the first frame, (2) the atrioventricular plane velocity (AVPV) as the discrete temporal derivate of the AVPD, (3) the diameter of the annulus as the maximum distance between the MV annulus points, (4) the lateral/inferior and septal/superior MAPSE, as the maximum MV points’ excursion, and (5) the LS as the percentage size difference of the distance between the mid valvular point and the apex point at end-systole and end-diastole.

Results

The accuracy of the system resulted in deviations on the annotated dataset of 1.02 ± 0.87 mm, 0.01 ± 0.02 mm/s, 1.54 ± 1.21 mm, 2.30 ± 1.35 mm, 2.1 ± 1.8 mm for AVPD, AVPV, diameter, MAPSE, and LS respectively. Initial statistics on all datasets (Fig. 2) revealed a mean lateral/inferior, septal/superior MAPSE and LS of 8.7 ± 2.7 mm, 10.5 ± 3.2 mm and 16.3 ± 4.2 % for two-chamber and 9.6 ± 2.6 mm, 8.7 ± 2.6 mm and 15.5 ± 3.9 % for four-chamber views, respectively.

Conclusions

The results demonstrate the versatility of the proposed system for automatic extraction of various MV motion parameters. The proposed system enables automatic extraction of clinically relevant parameters and can improve the automation of MV-based analyses. System overview & Parameter of interestsAnalysis of the extracted parameters

Fully automated machine learning-based selection of optimal bSSFP frequency offset for artifact reduction in cardiac MRI

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Research Support from Siemens Healthineers GmbH.

Background

In bSSFP sequences commonly used for cardiac MRI, signal modulation (e.g. banding artifacts) due to B0 inhomogeneity is often observed, especially at higher field strengths. The spatial position of these artifacts can be shifted by a frequency offset to reduce artifacts in a region of interest (ROI), e.g. the heart. To this end, frequency scout (FS) scans are acquired to visually select the optimal frequency offset [1,2]. In this work, we propose a fully automated image-based system for selecting the optimal frequency offset on FS images based on machine learning.

Methods

The proposed prototype system consists of four main steps (Fig.1). First, a pre-trained deep-learning-based whole heart segmentation network is applied on a four chamber-view FS image to localize the ROI where artifacts should be reduced. Second, high frequency components within the ROI (for each frequency offset in the FS series) are extracted by successive processing of Fourier transformation, high-pass filtering, inverse Fourier transformation and subtraction over series. and N images with the lowest high-frequency content are selected. Third, an adaptive weighting map for each FS image is generated which penalizes signal deviations from a pixel-wise median that is calculated based on the selected images [3]. By averaging the maps and selecting the frame with maximum percentage, the optimal frequency offset is selected.

A total of 38 datasets, acquired on multiple clinical 3T MRI scanners (MAGNETOM Skyra, Vida, Prisma, Lumina; Siemens Healthcare, Erlangen, Germany), were used to evaluate the proposed system. All FS series were annotated manually and used to compare with the system output. The experts were allowed to select multiple possible optimal FS images within a FS series. In case of multiple annotations, the system output was labelled as correct when it selected one of the offsets chosen by the expert. Further, the generated weighting maps were visually evaluated.

Results

The proposed system achieved an accuracy of 92.1% compared to experts’ ground truth annotations. From the failed cases (n=3), the maximum difference was off by 2 frames. Based on the generated weighting maps, a reasonable decision on the selection of the optimal frequency offset is made. The algorithm successfully selects an FS image with minimized banding and flow artifacts within the ROI (Fig. 2a). Further, it reveals that the generated weighting map correctly suppress areas containing artifacts (Fig. 2b).

Conclusions

Initial results demonstrate the feasibility of the proposed system to automatically select the optimal frequency offset on FS scans. Therefore, it can improve the automation of a cardiac MRI workflow. An example of the result of each step

Source-detector trajectory optimization in cone-beam computed tomography: a comprehensive review on today’s state-of-the-art

Cone-beam computed tomography (CBCT) imaging is becoming increasingly important for a wide range of applications such as image-guided surgery, image-guided radiation therapy as well as diagnostic imaging such as breast and orthopaedic imaging. The potential benefits of non-circular source-detector trajectories was recognized in early work to improve the completeness of CBCT sampling and extend the field of view (FOV). Another important feature of interventional imaging is that prior knowledge of patient anatomy such as a preoperative CBCT or prior CT is commonly available. This provides the opportunity to integrate such prior information into the image acquisition process by customized CBCT source-detector trajectories. Such customized trajectories can be designed in order to optimize task-specific imaging performance, providing intervention or patient-specific imaging settings. The recently developed robotic CBCT C-arms as well as novel multi-source CBCT imaging systems with additional degrees of freedom provide the possibility to largely expand the scanning geometries beyond the conventional circular source-detector trajectory. This recent development has inspired the research community to innovate enhanced image quality by modifying image geometry, as opposed to hardware or algorithms. The recently proposed techniques in this field facilitate image quality improvement, FOV extension, radiation dose reduction, metal artifact reduction as well as 3D imaging under kinematic constraints. Because of the great practical value and the increasing importance of CBCT imaging in image-guided therapy for clinical and preclinical applications as well as in industry, this paper focuses on the review and discussion of the available literature in the CBCT trajectory optimization field. To the best of our knowledge, this paper is the first study that provides an exhaustive literature review regarding customized CBCT algorithms and tries to update the community with the clarification of in-depth information on the current progress and future trends.

Development and Implementation of the AIDA International Registry for Patients With VEXAS Syndrome

Objective

The aim of this paper is to present the AutoInflammatory Disease Alliance (AIDA) international Registry dedicated to Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic (VEXAS) syndrome, describing its design, construction, and modalities of dissemination.

Methods

This Registry is a clinical, physician-driven, population- and electronic-based instrument designed for the retrospective and prospective collection of real-life data. Data gathering is based on the Research Electronic Data Capture (REDCap) tool and is intended to obtain real-world evidence for daily patients' management. The Registry may potentially communicate with other on-line tools dedicated to VEXAS syndrome, thus enhancing international collaboration and data sharing for research purposes. The Registry is practical enough to be easily modified to meet future needs regarding VEXAS syndrome.

Results

To date (April 22^nd, 2022), 113 Centers from 23 Countries in 4 continents have been involved; 324 users (114 Principal Investigators, 205 Site Investigators, 2 Lead Investigators, and 3 data managers) are currently able to access the registry for data entry (or data sharing) and collection. The Registry includes 4,952 fields organized into 18 instruments designed to fully describe patient's details about demographics, clinical manifestations, symptoms, histologic details about skin and bone marrow biopsies and aspirate, laboratory features, complications, comorbidities, therapies, and healthcare access.

Conclusion

This international Registry for patients with VEXAS syndrome will allow the achievement of a comprehensive knowledge about this new disease, with the final goal to obtain real-world evidence for daily clinical practice, especially in relation to the comprehension of this disease about the natural history and the possible therapeutic approaches. This Project can be found on https://clinicaltrials.gov NCT05200715.

Binocular Integration in the Primate Primary Visual Cortex

binocular vision, binocular fusion, binocular combination, LGN, V1.

OP0292 CLASSIFICATION OF PSORIATIC ARTHRITIS, SERONEGATIVE RHEUMATOID ARTHRITIS, AND SEROPOSITIVE RHEUMATOID ARTHRITIS USING DEEP LEARNING ON MAGNETIC RESONANCE IMAGING

Background

While MRI evaluation of joints has been primarily used to quantify inflammation at a cross-sectional and longitudinal level, less is known about the potential of MRI in distinguishing different patterns of inflammation in the various forms of arthritis.

Objectives

To evaluate (i) whether deep learning using neural networks can be trained to distinguish between seropositive rheumatoid arthritis (RA+), seronegative RA (RA-), and psoriatic arthritis (PsA) based on structural inflammatory patterns on hand magnetic resonance imaging and (ii) to assess if psoriasis patients with subclinical inflammation fit into such patterns.

Methods

ResNet 3D [1] neural networks were trained to distinguish (i) RA+ vs. PsA, (ii) RA- vs. PsA and (iii) RA+ vs. RA- with respect to hand MRI data. Diagnosis of patients was determined using the following guidelines: ACR/EULAR 2010 [2] for RA and CASPAR [3] for PsA. Results from T1 coronal, T2 coronal, T1 coronal and axial fat suppressed contrast-enhanced (CE) and T2 fat suppressed axial sequences were used. The performance of such trained networks was analyzed by the area-under-the-receiver-operating-characteristic curve (AUROC) with and without imputation of demographic and clinical parameters (Figure 1A). Additionally, the trained networks were applied to psoriasis patients without clinical signs of PsA.

Figure 1.

(A) Neural network combining MR sequences with optional additional clinical data. The prediction for a single case is formed by averaging the prediction of all sequences and the clinical data. (B) Plot of the AUROC for increasing percentages (0.6 – 60%) of training data for the differentiation between RA+ and PsA by the neural network. The light blue area around the dark blue mean indicates the uncertainty measured using a 5-fold cross-validation.

Results

MRI scans from 649 patients (135 RA-, 190 RA+, 177 PsA, 147 psoriasis) were included (Table 1). The AUROC for differentiation between disease entities was 75% (SD 3%) for RA+ vs. PsA, 74% (SD 8%) for RA- vs. PsA, and 67% (6%) for RA+ vs. RA-. All MRI sequences were relevant for classification, however, when deleting CE sequences, the loss of performance was only marginal. The addition of patient-specific data to the networks did not provide significant improvements. Increasing amounts of training data demonstrated improved performance of the networks (Figure 1B). Psoriasis patients were mostly assigned to PsA by the neural networks, suggesting that PsA-like MRI pattern may be present early in the course of psoriatic disease.

Table 1.

Overview of demographic and clinical information.

RA+RA-PsAPsoriasisTotal Number (N)649Number (N)190135177147Age (years), mean±SD56.9±12.660.5±10.356.3±12.049.6±13.8Sex (female/male)126/6493/4292/8571/76BMI (kg/m2), mean±SD26.6±10.527.6 ±9.329.1±11.326.7±6.9Disease duration (years), mean±SD2.6±4.91.3±2.30.8±2.34.2±5.1DAS28, mean±SD3.3±1.33.4±1.23.2±1.3-CRP (mg/L), mean±SD0.9±2.50.7±1.20.5±0.80.5±1.3HAQ, mean±SD0.8±0.60.9±0.80.6±0.60.3±0.4MedicationbDMARD88.46%83.87%81.32%35.01%csDMARD89.52%88.89%80.54%12.28%

Conclusion

Deep learning can be successfully applied to differentiate MRI inflammatory patterns related to RA+, RA-, and PsA. Early changes in psoriasis patients can be recognized by neural networks and are characterized by a pattern that allowed the networks to classify them as PsA.

References

[1]Kensho Hara, Hirokatsu Kataoka, and Yutaka Satoh 2018. Can Spatiotemporal 3D CNNs Retrace the History of 2D CNNs and ImageNet? In Proceedings of the IEEE Conference on Computer Vision and Pattern Recognition (CVPR) (pp. 6546–6555).

[2]Aletaha D, Neogi T et al. 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010 Sep;62(9):2569-81.

[3]Helliwell PS, Taylor WJ. Classification and diagnostic criteria for psoriatic arthritis. Annals of the Rheumatic Diseases 2005;64:ii3-ii8.

Acknowledgements

The study was supported by the Deutsche Forschungsgemeinschaft (DFG-FOR2886 PANDORA and the CRC1181 Checkpoints for Resolution of Inflammation). Additional funding was received by the Bundesministerium für Bildung und Forschung (BMBF; project MASCARA), the ERC Synergy grant 4D Nanoscope, the IMI funded projects HIPPOCRATES and RTCure, the Emerging Fields Initiative MIRACLE of the Friedrich-Alexander-Universität Erlangen-Nürnberg and the Else Kröner-Memorial Scholarship (DS, no. 2019_EKMS.27). Furthermore, infrastructural and hardware support was provided by the d.hip Digital Health Innovation Platform.

Disclosure of Interests

None declared

Basic knowledge in child protection– evaluation of an online-course for webbased transfer of interprofessional basic knowledge in child protection

Introduction

Insufficient or faulty cooperation between the various child protection professions can have an extremly negative impact on the well-being of the concerned children. Communication problems that were revealed when dealing with cases of child abuse show the importance of adequate cooperation and common language of the involved professions in child protection.

Objectives

An online-course adressing medical-therapeutic professionals, youth welfare as well as judiciary and police was developed to impart skills and knowledge in child protection to create interdisciplinary understanding and improve cooperation between the involved professions.

Methods

The acquisition of competencies, the transfer of learning content into everyday work and the quality of the online-course are determined using an online-survey before starting (t1) and after completing (t2) the course. T1-assessment is currently being evaluated with 1034 datasets, t2-assessment will take place 03/2022.

Results

Intended target groups could be accessed and participated in the online-course, although the ratio of medical-therapeutic participants was greater than of judiciary professionals. Specific results of T1- and T2- assesssment and comparing analyses are expected in March 2022 and will be presented.

Conclusions

Based on existing online-courses developed by the Universityhospital Ulm, the suitability of online-education for training professionals in the field of child protection could be proven. If comparable effects can be shown for this online-course, there is an increase in evaluated offers of high quality. These enable comprehensive and low-threshold access to the subject of interdisciplinary communication and cooperation in child protection for involved professionals.

Disclosure

No significant relationships.

Development and Implementation of the AIDA International Registry for Patients With Still's Disease

Objective

Aim of this paper is to present the design, construction, and modalities of dissemination of the AutoInflammatory Disease Alliance (AIDA) International Registry for patients with systemic juvenile idiopathic arthritis (sJIA) and adult-onset Still's disease (AOSD), which are the pediatric and adult forms of the same autoinflammatory disorder.

Methods

This Registry is a clinical, physician-driven, population- and electronic-based instrument implemented for the retrospective and prospective collection of real-world data. The collection of data is based on the Research Electronic Data Capture (REDCap) tool and is intended to obtain evidence drawn from routine patients' management. The collection of standardized data is thought to bring knowledge about real-life clinical research and potentially communicate with other existing and future Registries dedicated to Still's disease. Moreover, it has been conceived to be flexible enough to easily change according to future scientific acquisitions.

Results

Starting from June 30th to February 7th, 2022, 110 Centers from 23 Countries in 4 continents have been involved. Fifty-four of these have already obtained the approval from their local Ethics Committees. Currently, the platform counts 290 users (111 Principal Investigators, 175 Site Investigators, 2 Lead Investigators, and 2 data managers). The Registry collects baseline and follow-up data using 4449 fields organized into 14 instruments, including patient's demographics, history, clinical manifestations and symptoms, trigger/risk factors, therapies and healthcare access.

Conclusions

This international Registry for patients with Still's disease will allow a robust clinical research through collection of standardized data, international consultation, dissemination of knowledge, and implementation of observational studies based on wide cohorts of patients followed-up for very long periods. Solid evidence drawn from “real-life” data represents the ultimate goal of this Registry, which has been implemented to significantly improve the overall management of patients with Still's disease. NCT 05200715 available at https://clinicaltrials.gov/.

Health professionals' perspectives on child protection capacities, training and need for action

Background

Child maltreatment is because of its prevalence and consequences one of the main reasons for global health inequalities and a major public health problem. The medical field offers many opportunities to support affected children. However, there is often very limited awareness concerning child protection beyond a few engaged professionals. The present work aims to survey the state of knowledge and capacities in view of child protection in the medical field and explores health professionals' perspectives on a potential need for action.

Methods

From 06/2016 until 02/2021 3,360 health professionals were interviewed. Using quantitative and qualitative items the questionnaire gathered demographic and professional background information as well as assessments regarding the awareness of child protection, capacities in child protection among health professionals and training offers in medicine.

Results

The analysis indicated that the topic child protection in medicine is not as present as the high prevalence demands it. The majority (94.0%; n = 3,159) of the probands stated that they need more knowledge and capacities regarding child protection in medicine. More than half of the probands assessed the importance of the issue child protection as low among health professionals. The reasons cited included child protection as being an uncomfortable topic, unwillingness among managers, and a lack of training on the topic.

Conclusions

It turned out that there is too little awareness and importance regarding child protection in the medical field. Hence, it is difficult to ensure an adequate care for those affected. Child protection topics should be made mandatory in the training curricula of all health professionals as well as quality standards for prevention and intervention should be implemented in medical institutions.

Key messages

Too little attention is paid to child protection in the medical field. More training in child protection and quality standards must be established in the medical field.

OP0145 DIFFERENTIAL DIAGNOSIS OF RA AND PSA USING NEURAL NETWORKS ON THREE-DIMENSIONAL BONE SHAPE OF FINGER JOINTS

Background:

Early diagnosis and reliable differentiation between rheumatic diseases (RMDs) are crucial to start an adequate therapy and prevent irreversible damage. Since finger joints are commonly affected in rheumatoid arthritis (RA) and psoriatic arthritis (PsA), imaging of the peripheral skeleton is an essential step of diagnosis at a rheumatologist. High resolution peripheral quantitative computed tomography (HR-pQCT) allows an even more detailed and three-dimensional (3D) illustration of the peripheral bone than conventional radiographs. Segmented scans contain further information, such as the density, microstructure, and shape of the bones, which can be further analyzed by neural networks.

Objectives:

We hypothesize that, based on the shape of the second metacarpophalangeal (MCP) joint from HR-pQCT images, a neural network can be trained to differentiate between RA, PsA, and healthy controls and to reveal regions in the bone shape characteristic for the diseases.

Methods:

HR-pQCT images of MCP joints from patients with classified CCP positive RA, classified PsA, and healthy controls with low motion artifacts and appropriate scan region were selected as reported previously [3]. Scans were performed as part of the clinical routine and patients gave their informed consent to use pseudonymized data (Ethics approval 334_16B). Based on the assumption that pathognomonic changes develop over time, only images were used, where the period between classification and imaging exceeded one year.

Based on previous work [4], a pixel-wise mask of the second metacarpal bone was generated using a neural network based on the HR-pQCT scans of patients. Supervised auto-encoder [1] networks were used to predict the correct class given the bone mask only. For the neural network experiment, the patient scans were split on a patient-level into training (70%), validation (20%), and testing (10%). Guided backpropagation [2] was used as a method to investigate the regions influencing the class prediction most.

Results:

In total, images of 331 patients were included in the experiments. The evaluation of the model on the 33 test cases yielded a high accuracy for the healthy control with 94%, RA patients with 84%, and PsA patients with 89%. An area under the receiver operator curve of 91% could be achieved. The regions of the bone mask influencing the network´s decision most are highlighted exemplary in Figure 1.

Figure 1.

Visualization of the HR-pQCT slices with gradient maps. Higher values (red) represent regions that had a stronger contribution to the classification result. The HR-pQCT images are displayed for reference only. (a) Healthy patient, (b) RA diagnosed patient, and (c) PsA diagnosed patient. The first row shows the single slices with the highest values corresponding to the 3D bone masks in the second row.

Conclusion:

For the first time, a neural network-based approach successfully provides a differential diagnosis of RA and PsA based only on the shape of the second MCP in HR-pQCT images. The evaluation of the test set suggests that high curvatures of the bone surface in the joint region significantly influence the prediction of the network, suggesting an in-depth investigation of these regions for patients affected by RA and PsA. Based on these promising findings, we aim to extend the approach to seronegative RA as well as early RA and PsA.

References:

[1]Le, L. et al. (2018). Supervised autoencoders: Improving generalization performance with unsupervised regularizers. In Advances in Neural Information Processing Systems.

[2]Springenberg, J. T. et al. (2015). Striving for simplicity: The all convolutional net. 3rd International Conference on Learning Representations, ICLR 2015 - Workshop Track Proceedings.

[3]Simon, D. et al. (2017). Age- and Sex-Dependent Changes of Intra-articular Cortical and Trabecular Bone Structure and the Effects of Rheumatoid Arthritis. Journal of Bone and Mineral Research, 32(4), 722–730.

[4]Folle, L. et al. (2021). Fully Automatic Bone Mineral Density Measurements using Deep Learning. Manuscript submitted for publication.

Acknowledgements:

This work was supported by the emerging field initiative (project 4 Med 05 “MIRACLE”) of the University Erlangen-Nürnberg and MASCARA - Molecular Assessment of Signatures Characterizing the Remission of Arthritis grant 01EC1903A.

Disclosure of Interests:

Lukas Folle: None declared, Chang Liu: None declared, David Simon Speakers bureau: Lilly, Novartis, Consultant of: Lilly, Novartis, Gilead, BMS, Abbvie, Grant/research support from: Lilly, Novartis, Timo Meinderink: None declared, Anna-Maria Liphardt Consultant of: Mylan/Meda Pharma, Grant/research support from: Novartis, Gerhard Krönke Speakers bureau: Lilly, Novartis, Consultant of: Lilly, Novartis, Gilead, BMS, Abbvie, Grant/research support from: Lilly, Novartis, Georg Schett Speakers bureau: Lilly, Novartis, Consultant of: Lilly, Novartis, Gilead, BMS, Abbvie, Grant/research support from: Lilly, Novartis, Andreas Maier: None declared, Arnd Kleyer Speakers bureau: Lilly, Novartis, Consultant of: Lilly, Novartis, Gilead, BMS, Abbvie, Grant/research support from: Novartis, Lilly

[Rehabilitation of orphan diseases in adulthood: osteogenesis imperfecta]

Osteogenesis imperfecta (brittle bone disease) is an orphan disease caused by a genetic mutation in collagen metabolism. Bone fractures are the most common symptoms; however, the clinical manifestation can vary widely. Additional features can include blue sclera, dwarfism, bone deformities, muscular weakness, scoliosis, hearing loss and hypermobility of joints. Most patients show a reduction of skeletal function. This leads to an increased risk of being unable to continue their former work and to participate in social life. A comprehensive treatment includes drug therapy, surgery and rehabilitation. This article gives an overview of the current status of rehabilitation in adult patients with osteogenesis imperfecta.

Abstract 2813: Tumor models driven by EGFR: Optimizing the preclinical profiling of EGFR-targeting agents

The epidermal growth factor receptor (EGFR, HER1, ERBB1) is a driver of many human cancers. Standard of care treatment for colon, head and neck and non-small cell lung cancer includes drugs targeting EGFR. Numerous molecular alterations activating the oncogenic potential of the EGFR gene have been described including activating point mutations, point mutations causing resistance against EGFR-targeting drugs, activating deletions and truncations as well as overexpression of EGFR and its ligands, occasionally induced by gene amplification. In other situations, EGFR has been identified as a driver in the absence of any obvious molecular alterations of the EGFR gene. The discovery and development of EGFR-targeting agents depends on the availability of relevant tumor models. We provide an overview of our collection of EGFR-driven tumor models, including PDXs along with PDX-derived cell lines and human tumor cell lines. We compare sensitivity profiles of tumor models for EGFR-targeting agents obtained in vivo and in vitro and demonstrate that for EGFR-targeting agents, data obtained in 2D and 3D assays are predictive for the in vivo situation. We propose an optimized strategy for the preclinical profiling of EGFR-targeting anti-cancer agents.

Citation Format: Markus Posch, Hagen Klett, Anne-Lise Peille, Gerhard Kelter, Armin Maier, Julia Schüler, Thomas M. Metz. Tumor models driven by EGFR: Optimizing the preclinical profiling of EGFR-targeting agents [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2813.

Three-dimensional Monte Carlo-based voxel-wise tumor dosimetry in patients with neuroendocrine tumors who underwent 177Lu-DOTATOC therapy

Background

Patients with advanced neuroendocrine tumors (NETs) of the midgut are suitable candidates for ¹⁷⁷Lu-DOTATOC therapy. Integrated SPECT/CT systems have the potential to help improve the accuracy of patient-specific tumor dosimetry. Dose estimations to target organs are generally performed using the Medical Internal Radiation Dose scheme. We present a novel Monte Carlo-based voxel-wise dosimetry approach to determine organ- and tumor-specific total tumor doses (TTD).

Methods

A cohort of 14 patients with histologically confirmed metastasized NETs of the midgut (11 men, 3 women, 62.3 ± 11.0 years of age) underwent a total of 39 cycles of ¹⁷⁷Lu-DOTATOC therapy (mean 2.8 cycles, SD ± 1 cycle). After the first cycle of therapy, regions of interest were defined manually on the SPECT/CT images for the kidneys, the spleen, and all 198 tracer-positive tumor lesions in the field of view. Four SPECT images, taken at 4 h, 24 h, 48 h and 72 h after injection of the radiopharmaceutical, were used to determine their effective half-lives in the structures of interest. The absorbed doses were calculated by a three-dimensional dosimetry method based on Monte Carlo simulations. TTD was calculated as the sum of all products of single tumor doses with single tumor volumes divided by the sum of all tumor volumes.

Results

The average dose values per cycle were 3.41 ± 1.28 Gy (1.91–6.22 Gy) for the kidneys, 4.40 ± 2.90 Gy (1.14–11.22 Gy) for the spleen, and 9.70 ± 8.96 Gy (1.47–39.49 Gy) for all ¹⁷⁷Lu-DOTATOC-positive tumor lesions. Low- and intermediate-grade tumors (G 1–2) absorbed a higher TTD compared to high-grade tumors (G 3) (signed-rank test, p =  < 0.05). The pre-therapeutic chromogranin A (CgA) value and the TTD correlated significantly (Pearson correlation:  = 0.67, p = 0.01). Higher TTD resulted in a significant decrease of CgA after therapy.

Conclusion

These results suggest that Monte Carlo-based voxel-wise dosimetry is a very promising tool for predicting the absorbed TTD based on histological and clinical parameters.

[Raynaud's phenomenon : Practical management]

Raynaud's phenomenon (RP) is a frequent and painful vasospasm of small arteries localized in acral body regions (most frequently the fingers). The more frequent so-called primary RP is caused merely by a functional dysregulation of the tonus of vascular walls. In contrast, the rarer secondary RP is additionally associated with structural abnormalities of blood vessels. Knowledge of RP is important for rheumatologists because secondary RP can be associated with the presence or development of severe underlying diseases, especially with systemic sclerosis. Thus, the rheumatologist has to be aware of this condition. In this article the diagnostic procedures and the most important treatment approaches are summarized.

Abstract LB-B05: Characterization of a panel of 79 PDX-derived cell lines with a focus on the EGFR exon 20 insertion mutation-driven NSCLC model LXFE 2478

Patient-derived tumor xenograft (PDX) models have become indispensable for the preclinical profiling of novel anti-cancer agents as they retain histological, molecular and pharmacological characteristics of the parental patient tumors and for many tumor types collectively replicate the diversity of patient tumors. To make PDX models available for in vitro assays, we have established a panel of 79 low passage cell lines derived from PDXs representing 15 different tumor histologies. Using, among others, the non-small cell lung cancer model LXFE_2478 which is driven by the exon 20 insertion EGFR mutation M766_A767insASV as an example, we demonstrate the following similarities of PDX models and the corresponding PDX-derived cell lines. (i) Subcutaneous xenografts established from PDX-derived cell lines mirror the histology of the corresponding PDX models and usually also patient tumors. (ii) For LXFE_2478 both the PDX model and the corresponding PDX-derived cell line express high levels of EGFR, suggesting that the oncogenic driver is still present. (iii) For LXFE_2478 the PDX and the PDX-derived cell line subcutaneously implanted in mice display comparable sensitivity to a variety of EGFR inhibitors and cytotoxics. (iv) For LXFE_2478 the sensitivity of the PDX-derived cell line to a variety of EGFR inhibitors in an in vitro 2D cell survival and proliferation assay in general corresponds to the EGFRi sensitivity of the corresponding PDX model in vivo. (v) For several additional PDX models representing various histotypes the sensitivity to first generation EGFR inhibitors of PDX-derived cell lines in the 2D assay is in line with the in vivo EGFR inhibitor sensitivity of the corresponding PDXs. In conclusion, at least for some mechanisms of action in vitro data obtained with PDX-derived cell lines can predict the in vivo behavior of the corresponding PDX model and can thereby accelerate, and reduce the costs of, the discovery of novel anticancer agents.

Citation Format: Gerhard Kelter, Anne-Lise Peille, Jutta Fehr, Hagen Klett, Armin Maier, Markus Posch, Thomas M Metz. Characterization of a panel of 79 PDX-derived cell lines with a focus on the EGFR exon 20 insertion mutation-driven NSCLC model LXFE 2478 [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics; 2019 Oct 26-30; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2019;18(12 Suppl):Abstract nr LB-B05. doi:10.1158/1535-7163.TARG-19-LB-B05

Abstract C021: Validation of the interaction between a candidate compound and the intended drug target by a phenotypic rescue approach

New targets for cancer treatment frequently emerge in literature, but the thorough target validation required to consider these targets for a drug discovery program is often lacking. In pharmacological or genetic perturbation studies using complex biological assays, undesired off-target effects cannot be easily distinguished from the intended mode of action at the desired target. This is especially evident in cancer drug development where it is important to discriminate on-target effects on cell viability from off-target effects resulting in non-specific loss of cellular fitness. Neglecting the possibility of being deceived by off-target effects can have tremendous scientific and financial impact on a drug discovery program. Ideally, confidence in a preclinical drug target and a modulating compound is boosted in an early stage by more extensive analysis and validation of the actual drug-target relationship. Rescue of a disease-relevant phenotype by genetic restoration of a target mutation is a gold standard approach in drug discovery by which target validation can be achieved. We aim to follow this approach targeting the BRAF V600E mutation in a number of well described melanoma lines as well as the MAP2K1 Q56P mutation in the non-small cell lung cancer cell line H1437. Target validation for both BRAF and MAP2K1 will be addressed by assessing viability, phenotypic changes and sensitivity to compound modulation upon CRISPR/Cas9 repair of the target mutation or by exogenous re-expression of the wild type variant. Compounds tested will be Vemurafenib for BRAF and Trametinib for MAP2K1. Further investigation into target validity will be done using a physiologically relevant 3D spheroid based co-culture system. Mimicking the tumor microenvironment increases the knowledge about “drug-ability” of a target and sustainability of the target modulation at an early time point in the development process. Such early in-depth validation of the relationship between a compound and the drug target is vital to mitigate the risk of failure at later steps of drug development.

Citation Format: Laure Grandmoursel, Lieke Geerts, Geraldine Servant, Miranda van der Ham, Armin Maier, Jamil Aarbiou, Marijn Vlaming, Jeroen DeGroot, Julia Schuler, Ian Waddell, Anne-Marie Zuurmond. Validation of the interaction between a candidate compound and the intended drug target by a phenotypic rescue approach [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics; 2019 Oct 26-30; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2019;18(12 Suppl):Abstract nr C021. doi:10.1158/1535-7163.TARG-19-C021

Child protection in medicine - closing gaps in continuing education through e-learning

Background

Child abuse is a major problem across Europe. The consequences are often serious and long-lasting disorders which, in addition to the individual burden, are extremely costly for the national health system. It is important to prevent or recognize child abuse at an early stage and to provide adequate help to those affected. Health professionals are privileged first contact persons for the victims. However, the WHO assumes that about 90% of cases of child abuse in medical institutions remain unknown. It is therefore important to train health professionals in this field. For this reason, in Germany an E-Learning course on child protection in medicine is currently being developed and evaluated. This article is intended to present the results of the accompanying evaluation of the E-Learning course.

Methods

The accompanying evaluation collected and analyzed the graduates’ opinion on the course, its contents and the topic of child protection in medicine in general. Knowledge and competence levels were surveyed before and after the course and evaluated with a t-test for related samples.

Results

The evaluation of the course showed a high relevance of the topic of child protection in medicine and the rather low attention paid to the topic in the medical field. The course was, however, assessed very positively and the majority of graduates were already able to apply what they had learnt in their daily work. The pre-post design showed a significant increase in knowledge and skills as a result of the course.

Conclusions

It turned out that the E-Learning course on child protection in medicine closes an existing gap in the continuing medical education system. The evaluation also shows a success of the program and thus a reduction of uncertainties in child protection procedures among health professionals. A corresponding E-Learning offer for other European countries should be considered in order to address the comprehensive problem of child abuse across the whole of Europe.

Key messages

Too little attention is paid to child protection in the medical field. E-Learning can effectively train health professionals in child protection, has a wide reach and is flexible in use.

4323Detection of early inflammation in myocarditis by molecular magnetic resonance imaging of activated platelets

Introduction

A noninvasive imaging strategy for diagnosis and localization of early myocarditis would be of great clinical interest. However, resolution of current imaging techniques is limited. Platelets play an important role in inflammatory processes but the role in myocarditis is unknown. Therefore, the aim of this project was to examine the role of platelets in myocarditis and establish a sensitive non-invasive molecular MRI in-vivo imaging strategy for diagnosis of myocarditis with a contrast agent against activated platelets in mice.

Methods

Myocarditis was induced by subcutaneous injection of an emulsion of porcine cardiac myosin and complete freud's adjuvant (CFA) in Balb/c mice. Inflammatory activity was targeted with a contrast agent against activated platelets consisting of microparticles of iron oxide (MPIO) conjugated to a single chain antibody directed against ligand-induced binding sites (LIBS) on activated glycoprotein IIb/IIIa (=LIBS-MPIO). In comparison, we applied an unspecific control antibody linked to microparticles of iron oxide (control-MPIO) and injected LIBS-MPIO to mice subjected to incomplete freud's adjuvant (iCFA). All imaging results were correlated to immunohistochemistry findings.

Results

Histological evaluation showed significantly higher binding of LIBS-MPIOs to platelet enriched, CD41-positive inflamed myocardium two days after induction of myocarditis in comparison to later time points (7d, 14d, 21d) (p<0.05) and control-MPIO (p<0.05) injection. In iCFA injected mice no significant LIBS-MPIO binding was found (p<0.05). In 3D in-vivo MRI we could specifically detect focal signal effects in LIBS-MPIO injected mice 2 days after induction of myocarditis, whereas in control-MPIO injected mice no signal effect was visible. Quantification of the myocardial MRI signal confirmed a signal decrease after LIBS-MPIO injection and significant fewer signals in comparison to control-MPIO injection (p<0.05).

As a perspective, we also found CD41 positive areas in histology of human myocarditis specimens.

Conclusions

Platelets are involved in the inflammation of myocarditis. Molecular MRI with LIBS-MPIO can image them at an early time point. This noninvasive imaging strategy is of clinical interest for both diagnostic and prognostic purposes, and highlights the potential of molecular MRI for characterization of cardiovascular pathologies such as myocardial inflammation.

Anakinra Drug Retention Rate and Predictive Factors of Long-Term Response in Systemic Juvenile Idiopathic Arthritis and Adult Onset Still Disease

Background and Objective: Only a few studies have reported long-term efficacy of interleukin (IL)-1 inhibition in systemic juvenile idiopathic arthritis (sJIA) and adult-onset Still disease (AOSD). Herein we report on the effectiveness of anakinra (ANA), expressed in terms of drug retention rate (DRR), and evaluate the predictive factors of drug survival in a cohort of patients with sJIA and AOSD.

Patients and Methods: This is a multicenter study reviewing retrospectively the medical records from 61 patients with sJIA and 76 with AOSD, all treated with ANA in 25 Italian tertiary referral centers.

Results: The cumulative retention rate of ANA at 12-, 24-, 48-, and 60-month of follow-up was 74.3%, 62.9%, 49.4%, and 49.4%, respectively, without any significant differences between sJIA and AOSD patients (p = 0.164), and between patients treated in monotherapy compared with the subgroup coadministered with conventional disease-modifying antirheumatic drugs (cDMARDs) (p = 0.473). On the other hand, a significant difference in DRR was found between biologic-naïve patients and those previously treated with biotechnologic drugs (p = 0.009), which persisted even after adjustment for pathology (p = 0.013). In the regression analysis, patients experiencing adverse events (AEs) {hazards ratio (HR) = 3.029 [confidence interval (CI) 1.750–5.242], p < 0.0001} and those previously treated with other biologic agents [HR = 1.818 (CI 1.007–3.282), p = 0.047] were associated with a higher HR of ANA discontinuation. The median treatment delay was significantly higher among patients discontinuing ANA (p < 0.0001). Significant corticosteroid-sparing (p = 0.033) and cDMARD-sparing effects (p < 0.0001) were also recorded. Less than one-third of our cohort developed AEs, and 85% were deemed mild in nature, with 70% of them involving the skin.

Conclusions: Our findings display an overall excellent DRR of ANA on the long run for both sJIA and AOSD, that may be further optimized by closely monitoring patient’s safety issues and employing this IL-1 inhibitor as a first-line biologic as early as possible. Moreover, ANA allowed a significant drug-sparing effect and showed an overall good safety profile.

Abstract 2709: Modulation of the tumor-infiltrating lymphocyte population by PARP inhibitor talazoparib in combination with anti-PD1 treatment significantly enhances overall survival in a murine BRCA1-/- breast cancer model

Targeted therapy of BRCA-deficient cancers has been achieved using poly(ADP-ribose) polymerase (PARP) inhibitors, which block BRCA-independent DNA repair. With first approval in 2014 of Olaparib the concept of tumor-specific synthetic lethality was added to the treatment portfolio of cancer patients. Although the effects of PARPi have shown promising results in multiple cancer types, how and whether patients might benefit from combination with compounds modulating the immune landscape of a tumor is largely unknown. In the current study, we investigate the cross-talk between PARPi and immune checkpoint inhibition, in particular, anti PD-1 and anti CTLA-4, as the most advanced targets in the field. PARP inhibitors Niraparib, Rucaparib, Talazoparib and Olaparib were investigated in vivo using the murine EMT6/BRCA1-/- model in monotherapy as well as in combination with anti-CTLA-4 or anti-PD1 treatment. The four PARPi showed distinct activity profiles in the two breast cancer models. Talazoparib was the most active compound in the BRCA1-/- model (optimal T/C (test/control) of 60%), followed by Niraparib and Rucaparib (65% and 67%, respectively). Olaparib was considered inactive with a T/C value of 80% in monotherapy. The EMT6/BRCA1-/- turned out to be sensitive towards anti CTLA-4 treatment (optimal T/C of 35% - 38% in three independent experiments). Anti PD-1 treatment in monotherapy induced no significant reduction in tumor growth (optimal T/C of 80% - 82%, in two independent experiments). The combination of PARPi and anti CTLA-4 induced a transient but significant reduction of tumor load early in the treatment phase (p&lt; 0.002, one-way ANOVA, day 8). However, anti PD-1 treatment significantly prolonged overall survival in combination with Talazoparib (p&lt; 0.011 log-rank test). The analysis of tumor infiltrating lymphocytes (TILs) by flow cytometry revealed that Talazoparib as monotherapy and in combination with checkpoint (CP) inhibitors enhanced the number of gMDSC as well as the number of CD3/CD11b double positive T cells. Weekly cytokine analysis in the serum of tumor bearing mice will elucidate possible interactions between PARP and CP inhibitors and give guidance to optimal combination and schedules. First results indicate that PARPi as well as CPi induce unique cytokine profiles correlating well with the modified TIL composition of the respective treatment groups. Further mechanistic studies as well as comparative studies with the EMT6/BRCAwt model will elucidate the tumor biology behind these observations and might lead to beneficial combination strategies in patients suffering from triple negative and BRCA1-/- breast cancer.

Citation Format: Anya Avrutskaya, Cordula Tschuch, Astrid Jensen, William Durham, Maycee Robinson, Charles Krause, Emily O’Koren, Gerhard Kelter, Anne-Lise Peille, Armin Maier, Anne-Marie Zuurmond, Julia Schüler. Modulation of the tumor-infiltrating lymphocyte population by PARP inhibitor talazoparib in combination with anti-PD1 treatment significantly enhances overall survival in a murine BRCA1-/- breast cancer model [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2709.

Abstract 52: PDX-derived 3D InSightTM tumor microtissues as ex-vivo human experimental models for evaluating therapeutic responses

Background The selection of appropriate preclinical models comes always with the major question on how accurately and robustly they can represent the complexity of human disease. Patient-derived xenograft (PDX) models faithfully preserve the biological features and the genetic expression profile of human tumor specimens. However, one limiting aspect of patient-derived models is the replacement of the human host microenvironment by murine stroma within the tumor. Lack of cross-species compatibility compromises the induction of a broad range of signaling pathways that cannot be entirely recapitulated. With our in vitro 3D InSightTMTumor Microtissues derived from PDX lines, we provide a relevant physiological environment and a strategy to assess candidate drugs for novel therapeutic approaches.

Aim Development of in vitro 3D InSightTM Tumor Microtissues from PDX lines aimed to retain the cellular heterogeneity found in the original human tumor tissue.

Material & Methods and Results PDX cell suspensions of lung, breast and melanoma origin were successfully used to assess 3D aggregation in 96-well format and characterized over 10 days in culture. After careful removal of mouse cell contaminants in each PDX sample, 3D PDX cell cultures were supplied with exogenous normal human dermal fibroblasts (nHDF). Furthermore, to provide a more physiological cancer niche, PDX cells were also co-cultured with tumor-matched cancer-associated fibroblasts (CAFs). 3D in vitro tumors were analyzed histologically and cancer phenotypic alterations were evaluated through the analysis of epithelial-to-mesenchymal transition (EMT) markers. The morphology, viability and growth rate of PDX-derived microtumors were assessed by size analysis (cell scanner) and ATP assay. To assess the distribution of various cell populations within the tumor, 3D PDX samples were screened for standard stromal vs. epithelial-tumor cells markers (e.g. FAP, pan-CK, E-Cadherin), and diagnostic cancer type-specific biomarkers. 3D PDX samples were also employed to investigate the efficacy of specific targeted therapies based on distinct molecular signatures of PDX tumor models. Immunohistochemistry assessment of 3D microtumors validated the resemblance with their respective PDX tumor models. 3D tumor growth rate and cell behavior observations reflected the diversity of disease progression in vivo.

Conclusion Further efforts will focus on employing this platform to establish more complex co-cultures with integration of additional relevant stromal and immune cells, to enable a reliable preclinical translational research of tumor/immune cell interactions. We suggest that in vitro 3D PDX models offer a more suitable and robust approach to expedite faithful efficacy assessment of immunomodulators and approval of optimal drug candidates.

Citation Format: Francesca Chiovaro, Irina Agarkova, Nicole Buschmann, Chloe' Pichon, Teresa Langova, Armin Maier, Julia Schueler, Patrick Guye. PDX-derived 3D InSightTM tumor microtissues as ex-vivo human experimental models for evaluating therapeutic responses [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 52.

Probe-based confocal laser endomicroscopy in detecting malignant lesions of vocal folds

Probe-based confocal laser endomicroscopy (CLE) is an innovative technique for real-time, non-invasive analysis of the surface epithelium. While being successfully used for diagnosis by experts, this method has not yet been established in clinical routine, partly due to the lack of standards and criteria for classifying various lesions. Our aim was to determine the diagnostic value and inter-rater reliability of CLE in detecting malignant lesions of the vocal cords. 58 video sequences were extracted from the probe-based CLE (GastroFlex probe with a Cellvizio^® laser system) examinations of 3 patients with squamous cell carcinomas and 4 patients with benign alterations of the vocal folds. Two ENT surgeons, who were blinded to the histological result, were asked to identify the sequences representing a carcinoma. We showed an accuracy, sensitivity, specificity, PPV and NPV of 91.38-96.55%, 100%, 87.8-95.2%, 77.27-89.47% and 100%, respectively, with an inter-rater reliability of k = 0.89 (“almost perfect agreement”). Probe-based CLE is a promising method for diagnosis and assessment of vocal fold lesions in vivo. Our results suggest that, with adequate training, the diagnostic value of this technique can be improved and potentially provide important information during oncological surgery.

Ärztliche Kompetenzentwicklung im Kinderschutz durch E-Learning

Gegenstand und Ziel: Kindesmisshandlung stellt eine individuelle und gesellschaftliche Belastung dar. Gesundheitsfachkräfte sind hierbei wichtige Akteure, haben aber häufig unzureichende Kompetenzen. Deshalb fördert das Bundesministerium für Gesundheit die Entwicklung eines Online-Kurses zu Kinderschutz in der Medizin. Diese Arbeit stellt erste Ergebnisse der Kursevaluation für die ärztlichen Teilnehmenden vor. Material und Methoden: Vor und nach Bearbeitung des Kurses wurde Bedarf, Qualität und Kompetenzvermittlung des Online-Kurses mittels Fragebögen evaluiert. An der Befragung beteiligten sich 178 ärztliche Absolventen. Ergebnisse: 74,2% der Befragten empfanden die Inhalte des Kurses als genau angemessen. Wissen und Handlungskompetenz nahmen durch Bearbeitung des Kurses signifikant zu (Cohen’s d = 1,28 und 1,06). Der häufigste Grund für den Abbruch des Kurses waren mangelnde zeitliche Ressourcen (68,4%). Schlussfolgerungen: Der Online-Kurs stellt eine gute Möglichkeit dar, notwendige Kenntnisse zu Kinderschutz in der Medizin zu erwerben oder diese auszubauen. Klinische Relevanz: Es müssen Möglichkeiten geschaffen werden, um die Verbreitung der Kursinhalte noch weiter voranzutreiben.

The Dermal Exposure Risk Management and Logic eTookit: Characterizing and managing dermal exposure during emergency management operations

OBJECTIVE

Emergency management and operations (EMO) personnel require up-to-date information to make informed decisions during natural and man-made disasters. However, information gaps present challenges for accessing human health risk assessment and risk management strategies for dermal exposure. This article describes the development of a decision support system, the Dermal Exposure Risk Management and Logic (DERMaL) eToolkit.

DESIGN

The DERMaL eToolkit provides information on key resources used in emergency incidents. Resources were classified according to response phase, resource categories, and information category and evaluated on reliability, accessibility, and preference by subject matter experts in emergency management fields. These rankings were used to generate a value of information score, unique for each resource, which aids in developing reference lists for users during each incident phase.

RESULTS

This tool will identify and prioritize information resources on dermal risks, and can readily find the most relevant information to suit EMO needs.

CONCLUSION

The DERMaL eToolkit can be used as an aid in finding information resources targeted to scenario-driven needs by providing well-vetted and prioritized resources related to dermal hazards, exposure, and risk assessments for EMO.