AllergoOncology: Biomarkers and refined classification for research in the allergy and glioma nexus-A joint EAACI-EANO position paper

Epidemiological studies have explored the relationship between allergic diseases and cancer risk or prognosis in AllergoOncology. Some studies suggest an inverse association, but uncertainties remain, including in IgE-mediated diseases and glioma. Allergic disease stems from a Th2-biased immune response to allergens in predisposed atopic individuals. Allergic disorders vary in phenotype, genotype and endotype, affecting their pathophysiology. Beyond clinical manifestation and commonly used clinical markers, there is ongoing research to identify novel biomarkers for allergy diagnosis, monitoring, severity assessment and treatment. Gliomas, the most common and diverse brain tumours, have in parallel undergone changes in classification over time, with specific molecular biomarkers defining glioma subtypes. Gliomas exhibit a complex tumour-immune interphase and distinct immune microenvironment features. Immunotherapy and targeted therapy hold promise for primary brain tumour treatment, but require more specific and effective approaches. Animal studies indicate allergic airway inflammation may delay glioma progression. This collaborative European Academy of Allergy and Clinical Immunology (EAACI) and European Association of Neuro-Oncology (EANO) Position Paper summarizes recent advances and emerging biomarkers for refined allergy and adult-type diffuse glioma classification to inform future epidemiological and clinical studies. Future research is needed to enhance our understanding of immune-glioma interactions to ultimately improve patient prognosis and survival.

COVID-19 and chronic rhinosinusitis: management and comorbidity - what have we learned?

INTRODUCTION

Approximately 5%-12% of the population worldwide suffer from chronic rhinosinusitis (CRS). CRS is defined as a chronic respiratory disease and is considered to be a risk factor for COVID-19 patients.

AREAS COVERED

A non-systematic literature research was conducted on COVID-19 and treatment options for CRSwNP. The latest international publications in medical databases, international guidelines, and the internet were reviewed. Since there were no publications on all aspects of this topic during the pandemic, we included our own experience in this report. Based on the conducted literature research in addition to our previously reported experience, we discuss the treatment of CRSwNP during the COVID-19 pandemic and what can be taken for future pandemics.

EXPERT OPINION

Intranasal corticosteroids remain the standard treatment for CRS in patients with SARS-CoV-2 infection. Indications for surgical treatment of CRS should be critically evaluated and reserved for patients with complications and those with no other treatment options. For this purpose, COVID-19 status should be known if possible and, in case of unclear status (emergency), using appropriate personal protective equipment. Systemic corticosteroids should be avoided were possible. Biological treatment should be continued under careful monitoring in uninfected patients and should be temporarily interrupted during COVID-19 infection.

Symptoms of Long-COVID 1-Year after a COVID-19 outbreak among sailors on a French aircraft carrier

OBJECTIVES

While persistent symptoms have been reported after the coronavirus disease-2019 (COVID-19), long-term data on outpatients with mild COVID-19 are lacking. The objective was to describe symptoms persisting for 12 months.

METHODS

This prospective cohort study on 1767 sailors of an aircraft carrier in which a Covid-19 outbreak occurred during a mission in April 2020 described predefined self-reported symptoms of Long-COVID at 6, 9 and 12 months. Logistic-regression analyses were used to identify correlates for Long-COVID at months 6, 9 and 12.

RESULTS

Among the 641 participants, 619 (35%) completed at least one follow-up questionnaire (413 COVID-positive and 206 COVID-negative). Symptoms of Long-COVID were reported by 53.7%, 55.2% and 54.3% of COVID-positive participants vs 31.2%, 23.3% and 40.0% in COVID-negative patients, at 6 (p <.002), 9 (p <.002) and 12 months (p =.13), respectively. The most frequent symptoms reported were concentration and memory difficulties, asthenia and sleep disorders.

CONCLUSION

In this study more than half of COVID-positive outpatients reported persistent symptoms up to 12 months post-quarantine. These findings suggests that all patients, including those with mild disease, can be affected by Long-COVID. A lack of difference at 12 months with COVID-negative patienys prompts caution. The symptoms of Long-COVID are so non-specific that they may be viewed as the consequence of multiple intercurrent factors.

[Neuroimmunology of allergic rhinitis part 2 : Interactions of neurons and immune cells and neuroimmunological units]

Allergic rhinitis is an IgE-mediated, type‑2 inflammatory disease. neuropeptides are released by neurons and interact with immune cells. Via colocalization, neuroimmune cell units such as nerve-mast cell units, nerve-type 2 innate lymphoid cell (ILC2) units, nerve-eosinophil units, and nerve-basophil units are formed. Markedly elevated tryptase levels were found in nasal lavage fluid and were strongly associated with neuropeptide levels. A close anatomical connection allows bidirectional communication between immune and neuronal cells. Transient receptor potential vanilloid 1 (TRPV1) and transient receptor potential ankyrin repeat 1 (TRPA1) are critically involved in immunological reactions in the setting of allergic rhinitis. Neuroimmunological communication plays an important role in the inflammatory process, so that allergic rhinitis can no longer be considered a purely immunological disease, but rather a combined neuroimmunological disease.

[Neuroimmunology of allergic rhinitis : Part 1: Cellular and humoral basic principles]

Allergic rhinitis (AR) is a very common disease with a high prevalence worldwide. It is an IgE-mediated type 2 inflammatory disease following exposure to inhalant allergens. A multitude of different neuropeptides including substance P, vasoactive intestinal peptide (VIP), calcitonin gene-related peptide (CGRP), nerve growth factor (NGF), and neuromedin U (NMU) can be released via peripheral axon or central reflexes, interact with immune cells, and thus contribute to neurogenic inflammation which causes the nasal hyperreactivity (NHR) characteristic of AR. Independent production of neuroendocrine hormones and neuropeptides by immune cells has also been demonstrated. Neuro-immune cell units arise when immune and neuronal cells colocalize, for which typical anatomic regions are, e.g., the mast cell-nerve functional unit. The focus of this review is the elucidation of neuroimmune communication mechanisms in AR.

Positionspapier: ICD-Codierung der chronischen Rhinosinusitis mit Nasenpolypen (CRSwNP) im ICD-10-GM als Grundlage für eine Therapie mit Biologika – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA), der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC) und des Deutschen CRS-Registers

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung der Schleimhäute von Nase und Nasennebenhöhlen. In Deutschland sind 3 verschiedene monoklonale Antikörper für die Indikation „Zusatztherapie zu intranasalen Glukokortikosteroiden für die Behandlung Erwachsener mit schwerer chronischer Rhinosinusitis mit Nasenpolypen“ zugelassen. Um die Verordnung in der zugelassenen Indikation (In-Label) zu dokumentieren, ist neben einer Dokumentation zahlreicher medizinischer Parameter die korrekte Auswahl der ICD-10-GM-Codierung entscheidend. Hierfür existieren in Deutschland bislang keine konsentierten Empfehlungen.

Methoden Basierend auf der internationalen Literatur und bisherigen Erfahrungen werden von einem Expertengremium von AeDA, DGHNO-KHC und Deutschem CRS-Register Codierungsmöglichkeiten von CRS und CRSwNP analysiert und auf dieser Basis eine konsentierte Empfehlung für die ICD-10-GM-Codierung in Deutschland ausgesprochen.

Ergebnis Die Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme ICD-10-GM (International Classification of Diseases, 10. Revision, German Modification) ist die amtliche Klassifikation zur Verschlüsselung von Diagnosen in der ambulanten und stationären Versorgung in Deutschland. Der ICD-10-GM unterscheidet nicht adäquat zwischen heute anerkannten klinischen und immunologischen Differenzierungen der CRSsNP und der CRSwNP. Dennoch wird insbesondere bei indiziertem Einsatz von Biologika in der Therapie der schweren CRSwNP eine möglichst exakte Verschlüsselung mit den Codes J33.8 (im Einzelfall J33.1 oder J33.9) empfohlen.

Schlussfolgerungen Das Verständnis über die immunologischen Grundlagen der CRSwNP eröffnet neue Behandlungsansätze mit monoklonalen Antikörpern für Patienten mit schwerer, unkontrollierter Erkrankung. Hier geben wir Empfehlungen für eine adäquate ICD-10-GM-Codierung in Deutschland.

Empfehlungen zur Überprüfung der Wirksamkeit und Verlaufsdokumentation von Mepolizumab bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the mucous membranes of the nose and sinuses. Eosinophilic inflammation is described as a common endotype. The anti-IL5 antibody mepolizumab was approved in November 2021 as an add-on therapy to intranasal glucocorticosteroids for the treatment of adults with severe chronic rhinosinusitis with nasal polyps when systemic glucocorticosteroids or surgery do not provide adequate disease control. While national and international recommendations exist for the use of mepolizumab in CRSwNP, it has not yet been adequately specified how this therapy is to be monitored, what follow-up documentation is necessary, and when it should be terminated if necessary.

METHODS

A literature search was performed to analyze previous data on the treatment of CRSwNP with mepolizumab and to determine the available evidence by searching Medline, Pubmed, the national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to and including 10/2022 were considered.

RESULTS

Based on the international literature and previous experience by an expert panel, recommendations for follow-up, adherence to therapy intervals and possible therapy breaks, as well as termination of therapy when using mepolizumab for the indication CRSwNP in the German health care system are given on the basis of a documentation sheet.

CONCLUSIONS

Understanding the immunological basis of CRSwNP opens up new non-surgical therapeutic approaches with biologics for patients with severe, uncontrolled courses. Here, we provide recommendations for follow-up, adherence to therapy intervals, possible therapy pauses, or discontinuation of therapy when mepolizumab is used as add-on therapy with intranasal glucocorticosteroids to treat adult patients with severe CRSwNP that cannot be adequately controlled with systemic glucocorticosteroids and/or surgical intervention.

Empfehlungen zur Überprüfung der Wirksamkeit und Verlaufsdokumentation von Dupilumab bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

BACKGROUND

 Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the nasal and paranasal mucosa. A Type-2 inflammation is described as the most common endotype. Since October 2019 the anti-IL-4/-IL-13 antibody dupilumab has been approved in Germany as an add-on therapy to intranasal corticosteroids for the treatment of adults with severe chronic rhinosinusitis with nasal polyps, when systemic corticosteroids alone or surgery do not provide adequate disease control. While recommendations for the use of dupilumab in CRSwNP exist at both national and international levels, until now it has not been adequately established, how therapy should be monitored and when it should be discontinued in the German Health Care System.

METHODS

 A literature search was performed analyzing previous data on the treatment of CRSwNP with dupilumab and to determine the available evidence by searching Medline, Pubmed, the national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to 05/2022 were included.

RESULTS

 Based on international literature and previous experience, recommendations are given by an expert panel for follow-up and possible therapy breaks, therapy intervals or termination of therapy when using dupilumab for the indication CRSwNP in the German health care system based on a documentation form.

CONCLUSIONS

 Understanding the immunological basis of CRSwNP opens new non-surgical therapy approaches with biologics for patients with severe courses. The authors give recommendations for follow-up, possible therapy breaks, therapy intervals and a termination for dupilumab treatment as add-on therapy with intranasal corticosteroids for the treatment of adult patients with severe CRSwNP that cannot be adequately controlled with systemic corticosteroids and/or surgical intervention.

AllergoOncology: Danger signals in allergology and oncology: A European Academy of Allergy and Clinical Immunology (EAACI) Position Paper

The immune system interacts with many nominal 'danger' signals, endogenous danger-associated (DAMP), exogenous pathogen (PAMP) and allergen (AAMP)-associated molecular patterns. The immune context under which these are received can promote or prevent immune activating or inflammatory mechanisms and may orchestrate diverse immune responses in allergy and cancer. Each can act either by favouring a respective pathology or by supporting the immune response to confer protective effects, depending on acuity or chronicity. In this Position Paper under the collective term danger signals or DAMPs, PAMPs and AAMPs, we consider their diverse roles in allergy and cancer and the connection between these in AllergoOncology. We focus on their interactions with different immune cells of the innate and adaptive immune system and how these promote immune responses with juxtaposing clinical outcomes in allergy and cancer. While danger signals present potential targets to overcome inflammatory responses in allergy, these may be reconsidered in relation to a history of allergy, chronic inflammation and autoimmunity linked to the risk of developing cancer, and with regard to clinical responses to anti-cancer immune and targeted therapies. Cross-disciplinary insights in AllergoOncology derived from dissecting clinical phenotypes of common danger signal pathways may improve allergy and cancer clinical outcomes.

AB0130 DEREGULATION OF TFAM EXPRESSION PROMOTES MITOCHONDRIAL DAMAGE AND FIBROBLAST ACTIVATION IN SYSTEMIC SCLEROSIS

Background

Transcription factor A, mitochondrial (TFAM) is a transcription factor with essential function in the mitochondrial homeostasis, such as mitochondria biogenesis and mtDNA replication. Deregulation of TFAM expression has been linked to mitochondrial dysfunction. However, its role in the pathogenesis of rheumatic diseases has not been studied so far.

Objectives

We aimed to study the role of TFAM in the pathological fibroblast activation in SSc.

Methods

The expression of TFAM in SSc skin fibroblast and skin biopsies was analyzed by immunofluorescence and Western blot. The role of TFAM in fibroblast activation was investigated by TFAM knockdown in cultured fibroblasts. The role of TFAM in skin and lung fibrosis was further studied in mice with fibroblast specific knockout of TFAM in three independent mouse models: Bleomycin-induced skin and lung fibrosis as well as TβRIact-induced skin fibrosis.

Results

Dermal fibroblasts from SSc patients express lower level of TFAM in the skin and also after prolonged culture in vitro. The downregulation of TFAM impairs mitochondria homeostasis with decreased mitochondrial number, accumulation of damaged mitochondria with release of mtDNA, accumulation of deletions in mtDNA, metabolic reshaping with impaired OXPHOS and release of the mitokine GDF15. Long time, but not acute exposure of normal fibroblasts to TGFβ mimicked the finding in SSc fibroblasts with downregulation of TFAM and mitochondrial homeostasis disruption and damage. Knockdown TFAM of normal fibroblasts promotes fibroblast activation with increased myofibroblast differentiation and collagen release in a SMAD3 dependent manner. RNA sequencing demonstrated upregulation of pro-fibrotic genes and pathways. Mice with fibroblast-specific knockout of TFAM demonstrate are more sensitive to fibrotic stimuli such as bleomycin injection and TβRIact-overexpression and even demonstrate responses to NaCl instillation.

Conclusion

Alterations in the key mitochondrial transcription factor TFAM in response to prolonged activation of TGFβ and associated mitochondrial damage induce transcriptional programs that promote fibroblast activation and tissue fibrosis.

Disclosure of Interests

Xiang Zhou: None declared, Thuong Trinh-Minh: None declared, Cuong Tran Manh: None declared, Andreas Giessl: None declared, Christina Bergmann: None declared, Andrea-Hermina Györfi: None declared, Georg Schett: None declared, Jörg H.W. Distler Consultant of: Actelion, Active Biotech, Anamar, Bayer Pharma, Boehringer Ingelheim, Celgene, Galapagos, GSK, Inventiva, JB Therapeutics, Medac, Pfizer, RuiYi and UCB.,, Grant/research support from: Anamar, Active Biotech, Array Biopharma, aTyr, BMS, Bayer Pharma, Boehringer Ingelheim, Celgene, Galapagos, GSK, Inventiva, Novartis, Sanofi-Aventis, RedX, UCB.

POS0864 ASSESSMENT OF SYSTEMIC SCLEROSIS RELATED MYOCARDIAL FIBROSIS BY 68Ga-FAPI-04 PET/CT

Background

Myocardial fibrosis is a poor prognostic factor and a relevant cause of SSc-related mortality. Current non-invasive screening methods for myocardial fibrosis (MF) include echocardiography, electrocardiography and serum Nt-pro-BNP, which are not specific for MF and not sensitive for early changes. Cardiac MRI predominately visualizes extracellular space changes as consequence of long-standing fibroblast activation. Direct visualization of the remodeling fibrotic remodeling process has not been feasible so far.

Objectives

Here, we use a tracer labeled probe directed against Fibroblast-Activation-Protein (FAP) to visualize activated fibroblasts in the myocardium of SSc patients and healthy individuals to test the hypothesis that FAPI-based PET imaging might enable the assessment of disease activity in SSc-related MF.

Methods

In this exploratory trial, 7 patients with SSc-related myocardial fibrosis (MF) confirmed by cardic MRI and 8 SSc patients without myocardial involvement were enrolled. All participants underwent 68Ga-FAPI-04 PET/CT imaging and cardiac MRI as well as echocardiography, electrocardiogram, and serum NT-pro-BNP. Patients were followed for at least 6 months including a follow-up cardiac MRI. Regional mapping of 68Ga-FAPI-04-uptake, late gadolinium enhancement (LGE) and T1-relaxation times were performed according to the American Heart Association 17 regions model. Myocardial tissue was analysed by immunofluorescence- (aSMA and FAP) and Sirius-Red staining.

Results

Myocardial FAPI-04-accumulation was significantly increased in SSc patients with myocardial fibrosis as defined by LGE in MRI compared to SSc patients without LGE. Consistent with the previously reported widespread remodeling in SSc-associated myocardial disease, the distribution of FAPI uptake was observed across multiple areas and did not correspond to the supply areas of the coronary arteries. Histological analyses of myocardial tissue biopsied from a LGE and 68Ga-FAPI-04-positive region revealed the accumulation of FAP+; SMA+ myofibroblasts in regions of pronounced collagen deposition. Slightly increased 68Ga-FAPI-04 -uptake values were observed in SSc patients without LGE, but with cardiovascular risk factors.

Comparing 68Ga-FAPI-04-uptake with cardiac MRI based mapping techniques, we observed a partial overlap for certain regions and differences in others. These observations suggest, that 68Ga-FAPI-PET/CT and cMRI could visualize different aspects of the disease process.

To confirm that 68Ga-FAPI-04-uptake assesses current molecular fibroblast activity rather than accumulating disease damage, we analyzed associations of 68Ga-FAPI-04-uptake with changes of clinical parameters of SSc-MF on follow-up: Here we observed different dynamics of change of 68Ga-FAPI-04-uptake and cardiac MRI-based, e.g. in response to start of immunosuppressive therapy.

Conclusion

Our study presents first in human evidence on a limited number of patients that FAPI-04-uptake correlates with fibrotic activity in SSc-associated myocardial fibrosis and that 68Ga-FAPI-04-PET/CT may thus improve risk stratification in this population.

Disclosure of Interests

None declared

Epithelial immune regulation of inflammatory airway diseases: Chronic rhinosinusitis with nasal polyps (CRSwNP)

BACKGROUND

The epithelial immune regulation is an essential and protective feature of the barrier function of the mucous membranes of the airways. Damage to the epithelial barrier can result in chronic inflammatory diseases, such as chronic rhinosinusitis (CRS) or bronchial asthma. Thymic stromal lymphopoietin (TSLP) is a central regulator in the epithelial barrier function and is associated with type 2 (T2) and non-T2 inflammation.

MATERIALS AND METHODS

The immunology of chronic rhinosinusitis with polyposis nasi (CRSwNP) was analyzed in a literature search, and the existing evidence was determined through searches in Medline, Pubmed as well as the national and international study and guideline registers and the Cochrane Library. Human studies or studies on human cells that were published between 2010 and 2020 and in which the immune mechanisms of TSLP in T2 and non-T2 inflammation were examined were considered.

RESULTS

TSLP is an epithelial cytokine (alarmin) and a central regulator of the immune reaction, especially in the case of chronic airway inflammation. Induction of TSLP is implicated in the pathogenesis of many diseases like CRS and triggers a cascade of subsequent inflammatory reactions.

CONCLUSION

Treatment with TSLP-blocking monoclonal antibodies could therefore open up interesting therapeutic options. The long-term safety and effectiveness of TSLP blockade has yet to be investigated.

Positionspapier: Empfehlungen zur Anwendung von Mepolizumab bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Hals-Chirurgie (DGHNO-KHC)

BACKGROUND

 Chronic rhinosinusitis with nasal polyps (CRSwNP) is a multifactorial inflammatory disease of the paranasal sinus mucosa with eosinophilic inflammation as the most common endotype. The anti-IL5 antibody mepolizumab was approved for the treatment of severe CRSwNP in the EU in November 2021.

METHODS

 A literature search was performed to analyze the immunology of CRSwNP and determine the available evidence by searching Medline, Pubmed, and the German national and international trial and guideline registries and the Cochrane Library. Human studies published in the period up to and including 12/2021 that investigated the effect of mepolizumab in CRSwNP were considered.

RESULTS

 Based on the international literature and previous experience, recommendations for the use of mepolizumab in CRSwNP in the German health care system are given by an expert panel on the basis of a documentation form.

CONCLUSIONS

 Understanding about the immunological basis of CRSwNP opens new non-surgical therapeutic approaches with biologics for patients with severe courses. Mepolizumab is approved since November 2021 for add-on therapy with intranasal corticosteroids for the treatment of adult patients with severe CRSwNP who cannot be adequately controlled with systemic corticosteroids and/or surgical intervention.

Positionspapier: Empfehlungen zur Anwendung von Omalizumab bei chronischer Rhinosinusitis mit Polyposis nasi (CRSwNP) im deutschen Gesundheitssystem – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der AGs Klinische Immunologie, Allergologie und Umweltmedizin und Rhinologie und Rhinochirurgie der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung der paranasalen Schleimhäute, der als Endotyp meistens eine TH2-Inflammation zugrunde liegt. IgE-Antikörper spielen dabei eine wichtige Rolle. Der anti-IgE-Antikörper Omalizumab wurde im August 2020 für die Therapie der schweren CRSwNP zugelassen.

Methoden In einer Literatursuche wurde die Immunologie der CRSwNP analysiert und die Evidenz zur Wirkung von Omalizumab bei dieser Erkrankung ermittelt durch Recherchen in Medline, Pubmed sowie den nationalen und internationalen Studien- und Leitlinien-Registern und der Cochrane Library.

Ergebnisse Basierend auf diesen Angaben aus der internationalen Literatur werden von einem Expertengremium Empfehlungen für die Anwendung von Omalizumab bei CRSwNP im deutschen Gesundheitssystem gegeben.

Schlussfolgerung Omalizumab ist zugelassen für Patienten ab 18 Jahren mit schwerer chronischer Rhinosinusitis mit Nasenpolypen als Zusatztherapie zu intranasalen Kortikosteroiden (INCS), wenn durch eine Therapie mit INCS keine ausreichende Krankheitskontrolle erzielt werden kann.

Positionspapier: Hinweise zur Patienteninformation und -aufklärung vor Anwendung von Biologika bei chronischer Rhinosinusitis mit Nasenpolypen (CRSwNP) – Teil 2: Omalizumab – Empfehlungen des Ärzteverbandes Deutscher Allergologen (AeDA) und der Deutschen Gesellschaft für HNO-Heilkunde, Kopf- und Halschirurgie (DGHNOKHC)

Hintergrund Die chronische Rhinosinusitis mit Nasenpolypen (CRSwNP) ist eine multifaktorielle entzündliche Erkrankung, oftmals auf der Grundlage einer Typ-2-Inflammation. Für die Behandlung von Patienten mit einer schweren Ausprägung ohne ausreichendes Ansprechen auf die Standardtherapie mit topischen nasalen Steroiden und/oder Zustand nach endonasaler Operation sind als Biologika aktuell Dupilumab und Omalizumab für die Therapie zugelassen. Nachdem wir in einer früheren Publikation für Dupilumab bereits entsprechende Hinweise gegeben haben, ist das Ziel der vorliegenden Arbeit die Standardisierung von Patienteninformation und -aufklärung vor einer Therapie mit Omalizumab.

Methoden Auf Grundlage des aktuellen Wissensstandes zur Immunologie der CRSwNP und zu den erwünschten und möglichen unerwünschten Wirkungen von Omalizumab werden Empfehlungen für die Patienteninformation entwickelt.

Ergebnisse Basierend auf der internationalen Literatur, der aktuellen Fachinformation und Erfahrungen aus der praktischen Anwendung und den derzeitigen Pharmakovigilanz-Daten hat ein Expertengremium Empfehlungen für die Patienteninformation und -aufklärung zur Anwendung von Omalizumab bei CRSwNP entwickelt und auf dieser Grundlage einen Patienteninformations- und Aufklärungsbogen erstellt.

Schlussfolgerung Die Information und Einwilligung des Patienten wird vor der Verordnung bzw. Verabreichung von allen Biologika, damit auch Omalizumab, empfohlen. Das vorliegende Positionspapier enthält wichtige Informationen zur praktischen Umsetzung und einen Vorschlag für eine Patienteninformation.

POS0423 NCOA3 AMPLIFIES PROFIBROTIC TRANSCRIPTIONAL PROGRAMS IN SYSTEMIC SCLEROSIS

Background:

Excessive activation of fibroblasts with a TGFβ-biased gene signature and deposition of extracellular matrix are key features of fibrotic diseases. The mechanisms underlying these transcriptional changes remain poorly understood. Deregulation, mutations and malfunctions of transcriptional co-regulators, which can interact with multiple transcription factors and enable a broad-spectrum regulation of transcriptional networks, have been implicated as driving factors in a large number of diseases and pathologies.

Objectives:

In the present study, we aimed to analyze the role of the co-regulator Nuclear Receptor Co-Activator 3 (NCOA3) in fibroblast activation and tissue fibrosis, and to evaluate a potential interaction of NCOA3 with fibrosis-relevant transcription factors.

Methods:

NCOA3 was inhibited genetically by siRNA transfection and pharmacologically by the SRC3 inhibitor-2 (SI-2). We performed bulk RNASeq of human dermal fibroblasts and in silico transcription factor binding site screening of differentially expressed genes (DEGs). The interaction of NCOA3 and TGFβ-SMAD signaling was analyzed by reporter and CoIP assays.

Results:

The expression of NCOA3 in skin biopsies of SSc patients compared to normal controls demonstrated that SSc fibroblasts express modestly, but significantly reduced levels of NCOA3, which persisted in cultured SSc fibroblasts. Stimulation of normal fibroblasts with chronically high levels of TGFβ as they also occur in fibrotic tissue remodeling strongly decreased NCOA3 expression to a similar extent as in SSc fibroblasts. Furthermore, NCOA3 expression is also deregulated in different murine models of skin fibrosis. To investigate the functional effects of decreased NCOA3 levels, we targeted the expression of NCOA3 in normal fibroblasts. SiRNA-mediated knockdown of NCOA3 ameliorated TGFβ-induced gene expression, collagen release, myofibroblast differentiation and cell proliferation. In contrast, knockdown of NCOA3 had no effects on collagen release, expression of contractile proteins or gene expression in unstimulated fibroblasts, suggesting that NCOA3 is not required for cellular homeostasis. To characterize the molecular mechanisms, we performed RNASeq upon NCOA3 knockdown. We identified 343 significant differentially expressed genes (220 downregulated and 123 upregulated with a Benjamini-Hochberg false discovery rate FDR < 0.25 and fold change > 1.5) between TGFβ-stimulated fibroblasts with and without NCOA3 knockdown (NCOA3-DEGs) including the fibrosis-relevant genes EDNRB, COL5A3, HES1, IL11 or IL33. Functional analysis of the NCOA3-DEGs showed enrichment of pathway terms such as collagen binding and extracellular matrix organization. In silico screening of the promoters of the NCOA3-DEGs for potential transcription factor binding motifs revealed binding motifs of core transcription factors of fibroblast activation and tissue fibrosis such as SMAD2/3/4, RBPJ, ZEB1, TCF4, REL, and SNAIL2 amongst the downregulated NCOA3-DEGs. Experimental validation of our biostatistical results using SMAD3 as example demonstrated a higher percentage of NCOA3-pSMAD3 double-positive fibroblasts in skin sections of SSc patients compared to healthy controls. In addition, knockdown of NCOA3 reduced TGFβ-induced SMAD-reporter activity. Furthermore, stimulation with TGFβ increased the interaction of NCOA3 with SMAD3 as analyzed by co-immunoprecipitation. Simultaneous knockdown of NCOA3 and SMAD3 showed no additional reductions compared to the single knockdowns, suggesting that NCOA3 controls SMAD3-dependent gene transcription under fibrotic conditions. Finally, inhibition of NCOA3 showed anti-fibrotic effects in different murine models of experimental skin and lung fibrosis.

Conclusion:

Our findings characterize NCOA3 as regulator of multiple pro-fibrotic transcription programs. Pharmaceutical inhibition of NCOA3 might be a strategy to interfere simultaneously with several core pro-fibrotic mediators in fibrotic diseases such as SSc.

Acknowledgements:

We thank Lena Summa, Vladyslav Fedorchenko, Wolfgang Espach and Regina Kleinlein for excellent technical assistance.

The study was funded by grants DI 1537/7-1, DI 1537/8-1, DI 1537/9-1 and -2, DI 1537/11-1, DI 1537/12-1, DI 1537/13-1, DI 1537/14-1, DI 1537/17-1, DE 2414/2-1, DE 2414/4-1, and RA 2506/3-1 of the German Research Foundation, SFB CRC1181 (project C01) and SFB TR221/ project number 324392634 (B04) of the German Research Foundation, grants J39, J40 and A64 of the IZKF in Erlangen, grant 2013.056.1 of the Wilhelm-Sander-Foundation, grants 2014_A47, 2014_A248 and 2014_A184 of the Else-Kröner-Fresenius-Foundation, grant 14-12-17-1-Bergmann of the ELAN-Foundation Erlangen, BMBF (Era-Net grant 01KT1801), MASCARA program, TP 2 and a Career Support Award of Medicine of the Ernst Jung Foundation.

Disclosure of Interests:

Clara Dees: None declared, Sebastian Poetter: None declared, Maximilian Fuchs: None declared, Christina Bergmann: None declared, Alexandru-Emil Matei: None declared, Andrea-Hermina Györfi: None declared, Alina Soare: None declared, Andreas Ramming: None declared, Paolo Ceppi: None declared, Georg Schett: None declared, Meik Kunz: None declared, Jörg H.W. Distler Consultant of: Actelion, Active Biotech, Anamar, ARXX, Bayer Pharma, Boehringer Ingelheim, Celgene, Galapagos, GSK, Inventiva, JB Therapeutics, Medac, Pfizer, RuiYi and UCB, Grant/research support from: Anamar, Active Biotech, Array Biopharma, ARXX, aTyr, BMS, Bayer Pharma, Boehringer Ingelheim, Celgene, Galapagos, GSK, Inventiva, Novartis, Sanofi-Aventis, RedX, UCB

POS0328 ENGRAILED 1 COORDINATES CYTOSKELETAL ORGANIZATION TO PROMOTE MYOFIBROBLAST DIFFERENTIATION AND FIBROTIC TISSUE REMODELING

Background:

Engrailed 1 (EN1) is a homeodomain-containing transcription factor with essential roles in embryonic development. In most cell types, the expression of EN1 is restricted to embryonic development. However, under pathological conditions, EN1 can be re-expressed to promote phenotypical adaptation. En1 is transiently expressed in the developing dermis of murine embryos in a distinct fibroblast lineage and silenced before birth (1). Former EN1-expressing cells give rise to a subpopulation of fibroblasts that has a high capacity for extracellular matrix production in adult murine skin. The role of EN1 in systemic sclerosis (SSc) was previously not explored.

Objectives:

To study the role of EN1 in the pathological activation of fibroblasts in tissue fibrosis.

Methods:

Bulk RNA-Seq and EN1 or SP1 ChIP-Seq were performed from cultured human dermal fibroblasts. The expression of EN1 was inhibited by siRNA. Cytoskeletal drugs paclitaxel, vinblastin and ROCK inhibitor (Y27632) were used to modulate the cytoskeleton in EN1 knockdown or overexpressing dermal fibroblasts. The role of EN1 in fibroblast activation was evaluated by functional experiments with EN1 knockdown or overexpression in standard 2D culture systems as well as in 3D skin equivalent models. The role of EN1 in skin fibrosis was further studied in En1fl/fl X Col6Cre mice, with fibroblast-specific knockout of En1 in three complementary mouse models: overexpression of a constitutively active TGFß-receptor I (TBRICA), bleomycin-induced skin fibrosis and TSK1 mice.

Results:

Pathologically activated dermal fibroblasts from SSc patients express higher levels of EN1 compared with age and sex matched healthy individuals in the skin and in vitro. TGFβ induces EN1 expression in fibroblasts in a SMAD3-dependent manner both in cultured fibroblasts and in murine skin. Knockdown of EN1 prevents TGFβ-induced fibroblast activation, whereas overexpression of EN1 fosters the pro-fibrotic effects of TGFβ with increased expression of αSMA, stress fibers and collagen. RNA sequencing demonstrates that EN1 induces a pro-fibrotic gene expression profile functionally related to cytoskeleton organization and ROCK activation. In silico analyses of the promoters of En1 target genes coupled with siRNA-mediated knockdown demonstrated that EN1 regulates these pro-fibrotic target genes by modulating the activity of regulatory modules that contain transcription factors of the specificity protein (SP) family. Functional experiments with selective modulators of ROCK and of microtubule polymerization confirm the coordinating role of EN1 on ROCK activity and the re-organization of cytoskeleton during myofibroblast differentiation in both conventional culture systems and 3D skin equivalents. Consistently, mice with fibroblast-specific knockout of En1 demonstrate impaired fibroblast-to-myofibroblast transition, reduced dermal thickening and impaired collagen deposition in the TBRICA, bleomycin-induced and TSK1 models.

Conclusion:

We characterize the homeodomain transcription factor EN1 as a molecular amplifier of TGFβ signaling in myofibroblast differentiation that coordinates cytoskeletal organization in a SP-dependent manner. EN1 might thus be a novel candidate for molecular targeted therapies to interfere with myofibroblast differentiation in fibrotic diseases.

References:

[1]Rinkevich Y, Walmsley GG, Hu MS, Maan ZN, Newman AM, Drukker M, et al. Skin fibrosis. Identification and isolation of a dermal lineage with intrinsic fibrogenic potential. Science. 2015;348(6232):aaa2151.

Disclosure of Interests:

Andrea-Hermina Györfi: None declared, Alexandru-Emil Matei: None declared, Maximilian Fuchs: None declared, Aleix Rius Rigau: None declared, Xuezhi Hong: None declared, ZHU Honglin: None declared, Markus Luber: None declared, Christina Bergmann: None declared, Clara Dees: None declared, Ingo Ludolph: None declared, Raymund Horch: None declared, Oliver Distler Consultant of: Actellion, AbbVie, Acceleron Pharma, Anamar, Amgen, Blade Therapeutics, CSL Behring, ChemomAb, Ergonex, Glenmark Pharma, GSK, Inventiva, Italfarmaco, iQvia, Medac, Medscape, Lilly, Sanofi, Target BioScience, UCB, Bayer, Boehringer Ingelheim, Catenion, iQone, Menarini, Mepha, Novartis, Mitsubishi, MSD, Roche, Pfizer, Georg Schett: None declared, Meik Kunz: None declared, Jörg H.W. Distler Consultant of: Actelion, Active Biotech, Anamar, ARXX, Bayer Pharma, Boehringer Ingelheim, Celgene, Galapagos, GSK, Inventiva, JB Therapeutics, Medac, Pfizer, RuiYi and UCB., Grant/research support from: Anamar, Active Biotech, Array Biopharma, aTyr, BMS, Bayer Pharma, Boehringer Ingelheim, Celgene, Galapagos, GSK, Inventiva, Novartis, Sanofi-Aventis, RedX, UCB

OP0272 68GA-FAPI-04 PET/CT STUDY EXTENSION FOR THE ASSESSMENT OF FIBROBLAST ACTIVATION AND RISK EVALUATION IN SYSTEMIC SCLEROSIS-RELATED INTERSTITIAL LUNG DISEASE

Background:

Interstitial lung disease (ILD) is the most common cause of death in systemic sclerosis (SSc). To date, the progression of SSc-ILD is judged by the accrual of lung damage on computed tomography (CT) and functional decline (forced vital capacity). However, this approach does not directly assess the activity of tissue remodeling. Moreover, prediction of the course of ILD in individual SSc patients remains challenging. Fibroblast Activation Protein (FAP) is a specific, ex vivo validated marker for activated fibroblasts.

Objectives:

The aims of this study were: 1. To assess differences in the uptake of 68GA-FAPI 04 in SSc-ILD patients compared to controls, to analyze 2. whether 68GA-FAPI 04 uptake at baseline correlates with other risk factors of disease progression and 3. Whether 68GA-FAPI 04 uptake is associated with the course of SSc-ILD.

Methods:

Between September 2018 and April 2020, 21 patients with SSc-ILD confirmed by HRCT and onset of SSc-ILD within ≤ 5 years or signs of progressive ILD and 21 controls without ILD were consecutively enrolled. All participants underwent 68Ga-FAPI-04 PET/CT imaging and standard-of-care procedures including HRCT and lung function testing (PFT) at baseline. Patients with SSc-ILD patients were followed-up for 6 months with HRCT and PFT. Follow-up 68Ga-FAPI-04 PET/CT scans were obtained in a subset of patients treated with nintedanib. We compared baseline 68Ga-FAPI-04 PET/CT uptake to standard diagnostic tools and currently used predictors of ILD progression. The association of 68Ga-FAPI-04 uptake with changes in FVC was analyzed using mixed-effects models.

Results:

68Ga-FAPI-04 accumulated in fibrotic areas of the lungs in SSc-ILD compared to controls with a median (q1-q3 interval) wlSUVmean of 0.8 (0.6 to 2.1) in the SSc-ILD group and 0.5 (0.4 to 0.5) in the control group (p<0.0001 with Mann-Whitney test) and a median whole lung maximal standardized uptake value (wlSUVmax) of 4.4 (3.05 to 5.2) in the SSc-ILD group compared to 0.7 (0.65 to 0.7) in the control group (p<0.0001). wlFAPI-MAV and wlTL-FAPI were not measurable in control subjects, as no 68Ga-FAPI-04 uptake above background level was observed. In the SSc-ILD group the median wlFAPI-MAV was 254cm3 (163.4 to 442.3) and the median wlTL-FAPI was 183.6 cm3 (98.04 to 960.7). 68Ga-FAPI-04 uptake was higher in patients with extensive disease, with previous ILD progression or high EUSTAR activity scores. Increased 68Ga-FAPI-04 uptake at baseline was associated with progression of ILD independently of extent of involvement on HRCT scan and the forced vital capacity at baseline. In consecutive 68Ga-FAPI-04-PET/CTs, changes in 68Ga-FAPI-04 uptake was concordant with the observed response to the fibroblast-targeting antifibrotic agent nintedanib.

Conclusion:

Our study presents first in human evidence that 68Ga-FAPI-04-fibroblast uptake correlates with fibrotic activity and disease progression in the lungs of SSc-ILD patients and that 68Ga-FAPI-04-PET/CT may be of potential to improve risk assessment of SSc-ILD.

Figure 1.

A and B:68Ga-FAPI-04 PET/CT scan from a patient with SSc-ILD with selective 68Ga-FAPI-04 uptake in fibrotic areas of the left- and right lower lung lobes (red arrows), but not in non-fibrotic areas such as the middle lobe (green arrow). B Corresponding CT component.

Acknowledgements:

We gratefully acknowledge Prof. Uwe Haberkorn (University Hospital Heidelberg and DKFZ, Heidelberg, Germany) and iTheranostics Inc. (Dulles, VA, USA) for providing the precursor FAPI-04.

Disclosure of Interests:

Christina Bergmann: None declared, Jörg H.W. Distler Speakers bureau: Actelion, Anamar, ARXX, Pharma, Boehringer Ingelheim, Celgene, Galapagos, GSK, Inventiva, JB Therapeutics, and UCB, Grant/research support from: Anamar, Active Biotech, Array Biopharma, ARXX, aTyr, BMS, Bayer Pharma, Boehringer Ingelheim, Celgene, Galapagos, GSK, Inventiva, Novartis, Sanofi-Aventis, RedX, UCB, Christoph Treutlein: None declared, Koray Tascilar Speakers bureau: Gilead sciences GmbH, Pfizer Turkey, UCB Turkey, Anna-Theresa Mueller: None declared, Armin Atzinger: None declared, Alexandru-Emil Matei: None declared, Johannes Knitza: None declared, Andrea-Hermina Györfi: None declared, Anja Lueck: None declared, Clara Dees: None declared, Alina Soare: None declared, Andreas Ramming: None declared, Verena Schönau: None declared, Oliver Distler Speakers bureau: Arxx Therapeutics, Baecon Discovery, Blade Therapeutics,Bayer, Böhringer Ingelheim, Catenion,Competitive Drug Development International Ltd, Corbuspharma, CSL Behring, ChemomAb, Horizon Pharmaceuticals, Ergonex, Galaapagos NV, Glenmark Pharmaceuticals,GSK, Inventiva, Italfarmaco, IQvia, Kymera, Lilly, Medac, Medscape, MSD, Novartis, Pfizer, Roche, Sanofi, Taget Bio Sciencec, UCB, Grant/research support from: Bayer,Böhringer Ingelheim, Mitsubishi Tanabe Pharma, Olaf Prante: None declared, Philipp Ritt: None declared, Theresa Ida Goetz: None declared, Markus Koehner: None declared, Michael Cordes: None declared, Tobias Baeuerle: None declared, Torsten Kuwert Speakers bureau: Honoraria for occasional lectures by Siemens Healthineers, Grant/research support from: Research grant to the Clinic of Nuclear Medicine by this entity covering projects in the field of SPECT/CT, Georg Schett: None declared, Christian Schmidkonz: None declared

AB0091 INHIBITION OF AUTOPHAGY PREVENTS PROGRESSION OF FIBROSIS IN MURINE MODELS OF SYSTEMIC SCLEROSIS

Background:

Autophagy is catabolic process allowing cells to degrade unnecessary or dysfunctional cellular organelles. Failure of appropriate regulation of autophagy, however, can severely perturb tissue homeostasis. Recent studies demonstrate that autophagy is activated in several fibrotic diseases such as liver fibrosis, renal interstitial fibrosis, cardiac fibrosis.

Objectives:

The objective of this work was to characterize the activation of autophagy in systemic sclerosis (SSc) and to decipher its role in the pathogenesis of SSc.

Methods:

Activation of autophagy in skin samples of patients and murine models of SSc was assessed by co-staining of LC3B and P62 with the lysosomal marker LAMP2. The role of the autophagy was investigated in the model of bleomycin-induced dermal fibrosis. Beclin1 was overexpressed using adenovirus encoding for Beclin1. To knockdown Atg7 in vivo was achieved by subcutaneous injections of Atg7 siRNA or non-targeting siRNA. In vivo, 3-methyladenine (3-MA) was administered i.p. in a concentration of 15 mg/kg ones daily. Protein expression was measured by Western blot. Target genes were analyzed by qPCR. To monitor the autophagic flux, we generated adenoviral vectors encoding for tandem fluorescent-tagged LC3 (mRFP-EGFP-LC3).

Results:

In the present study, we demonstrate that autophagy is activated in fibroblasts in SSc skin and also in experimental fibrosis models as compared to respective non-fibrotic control tissue with enhanced activity in in vivo and in vitro autophagy reporter studies. The aberrant activation of autophagy had profound stimulatory effects on fibroblasts. Activation of autophagy by forced expression of BECLIN1 promoted fibroblast-to-myofibroblast transition and stimulated the collagen release by cultured human fibroblasts and induced fibrosis in murine model. Nevertheless, inhibition of autophagy can deactivate myofibroblasts and induce regression of tissue fibrosis. Knockdown of ATG7 or BECLIN1 in human fibroblasts reduced the expression of αSMA and the number of stress fibers in myofibroblasts, indicating re-differentiation of myofibroblasts into resting fibroblasts upon inhibition of autophagy. Similar results were obtained with the autophagy inhibitors CQ and 3-MA. In vivo, siRNA mediated knockdown of Atg7 effectively prevented progression of fibrosis in a model of established bleomycin-induced skin fibrosis. Inactivation of autophagy decreased dermal thickness, myofibroblast counts and hydroxyproline content to below pretreatment levels, indicating regression of bleomycin-induced skin fibrosis. In addition, treatment of mice with the autophagy inhibitor 3-MA ameliorated bleomycin-induced skin fibrosis.

Conclusion:

We demonstrate that autophagy activity is enhanced in fibroblasts of SSc patients and in murine models of SSc. The increased activation of autophagy induces fibroblast-to-myofibroblast transition and promotes fibrotic tissue remodeling. However, inhibition of autophagy can deactivate myofibroblasts and induce regression of tissue fibrosis.

References:

[1]Wynn, T. Cellular and molecular mechanisms of fibrosis. J Pathol 214, 199-210 (2008).

[2]Klionsky DJ, Abeliovich H, Agostinis P, et al. Guidelines for the use and interpretation of assays for monitoring autophagy in higher eukaryotes. Autophagy 4, 151-175 (2008).

[3]Wang, CW & Klionsky, DJ. The molecular mechanism of autophagy. Mol Med 9, 65-76 (2003).

[4]Hernández-Gea V, Ghiassi-Nejad Z, Rozenfeld R, et al. Autophagy releases lipid that promotes fibrogenesis by activated hepatic stellate cells in mice and in human tissues. Gastroenterology 142, 938-946 (2012).

Disclosure of Interests:

Ariella Zehender: None declared, Yi-Nan Li: None declared, Neng-Yu Lin: None declared, Andrea-Hermina Györfi: None declared, Alina Soare: None declared, Christina Bergmann: None declared, Andreas Ramming: None declared, Georg Schett: None declared, Jörg H.W. Distler Consultant of: Actelion, Active Biotech, Anamar, ARXX, Bayer Pharma, Boehringer Ingelheim, Celgene, Galapagos, GSK, Inventiva, JB Therapeutics, Medac, Pfizer, RuiYi and UCB., Grant/research support from: Anamar, Active Biotech, Array Biopharma, aTyr, BMS, Bayer Pharma, Boehringer Ingel-heim, Celgene, Galapagos, GSK, Inventiva, Novartis, Sanofi-Aventis, RedX, UCB., Employee of: stock owner of 4D Science and Scientific head of FibroCure

Establishing an objective biomarker for corneal cystinosis using a threshold-based Spectral domain optical coherence tomography imaging algorithm

PURPOSE

The purpose of the present study was to establish a semi-automated threshold-based image segmentation algorithm to detect and objectively quantify corneal cystine crystal deposition in ocular cystinosis with anterior segment optical coherence tomography (AS-OCT).

METHODS

This prospective, observational, comparative study included 88 eyes of 45 patients from the German Cystinosis Registry Study as well as 68 eyes of 35 healthy control subjects. All eyes were imaged with AS-OCT (Cirrus HD-OCT 5000, Carl Zeiss Meditec AG, Jena, Germany). As an initial step, B-scan images were subjectively analysed for typical changes in morphology in comparison to healthy controls. Based on the experience gained, an objective semi-automated B-scan image segmentation algorithm was developed using a grey scale value-based threshold method to automatically quantify corneal crystals.

RESULTS

On AS-OCT B-scans, corneal crystals appeared as hyperreflective deposits within the corneal stroma. The crystals were distributed either in all stromal layers (43 eyes, 49%) or confined to the anterior (23 eyes, 26%) or posterior stroma (22 eyes, 25%), respectively. The novel automatic B-scan image segmentation algorithm was most efficient in delineating corneal crystals at higher grey scale thresholds (e.g. 226 of a maximum of 255). Significant differences in suprathreshold grey scale pixels were observable between cystinosis patients and healthy controls (p < 0.001). In addition, the algorithm was able to detect an age-dependent depth distribution profile of crystal deposition.

CONCLUSION

Objective quantification of corneal cystine crystal deposition is feasible with AS-OCT and can serve as a novel biomarker for ocular disease control and topical treatment monitoring.

Renal cystic diseases during the perinatal and neonatal period

Renal cystic diseases are a clinically and genetically diverse group of renal diseases that can manifest in utero, infancy, or throughout childhood and adulthood. These diseases may be unilateral or bilateral with a single cyst or multiple cysts, or with increased echogenicity of the renal cortex without macroscopic cysts. Certain cystic renal diseases are life-threatening, with many developing chronic kidney and hepatic disease if not recognized early enough. Therefore, due to the prevalence and life-altering complications of this specific group of diseases in vulnerable populations, it is crucial for clinicians and healthcare providers to have an overall understanding of cystic diseases and how to pre-emptively detect and manage these conditions. In this review, we discuss in detail the epidemiology, genetics and pathophysiology, diagnosis, presentation, and management of numerous genetic and sporadic renal cystic diseases, such as polycystic kidney disease, multicystic dysplastic kidney, and calyceal diverticula, with an emphasis on prenatal care and pregnancy counseling.

AllergoOncology: ultra-low IgE, a potential novel biomarker in cancer-a Position Paper of the European Academy of Allergy and Clinical Immunology (EAACI)

Elevated serum IgE levels are associated with allergic disorders, parasitosis and specific immunologic abnormalities. In addition, epidemiological and mechanistic evidence indicates an association between IgE-mediated immune surveillance and protection from tumour growth. Intriguingly, recent studies reveal a correlation between IgE deficiency and increased malignancy risk. This is the first review discussing IgE levels and links to pathological conditions, with special focus on the potential clinical significance of ultra-low serum IgE levels and risk of malignancy. In this Position Paper we discuss: (a) the utility of measuring total IgE levels in the management of allergies, parasitosis, and immunodeficiencies, (b) factors that may influence serum IgE levels, (c) IgE as a marker of different disorders, and d) the relationship between ultra-low IgE levels and malignancy susceptibility. While elevated serum IgE is generally associated with allergic/atopic conditions, very low or absent IgE may hamper anti-tumour surveillance, indicating the importance of a balanced IgE-mediated immune function. Ultra-low IgE may prove to be an unexpected biomarker for cancer risk. Nevertheless, given the early stage of investigations conducted mostly in patients with diseases that influence IgE levels, in-depth mechanistic studies and stratification of malignancy risk based on associated demographic, immunological and clinical co-factors are warranted.

OP0142 FIBROBLAST GROWTH FACTOR RECEPTOR 3 REGULATES THE ACTIVITY OF PROFIBROTIC CYTOKINE AND GROWTH FACTOR PATHWAYS TO DRIVE FIBROBLAST ACTIVATION AND TISSUE FIBROSIS IN SYSTEMIC SCLEROSIS

Background:

Fibroblast growth factor receptor 3 (FGFR3) is a member of the family of different fibroblast growth factor receptors with several ligands called fibroblast growth factors (FGFs) in humans. Each FGFR has different isoforms resulting from natural alternative splice variants. Upon binding FGF ligands, fibroblast growth factor receptors (FGFRs) trigger various intracellular signaling pathways to regulate important biological processes. Systematic evaluation of FGF/FGFR signaling in the context of SSc has not been performed so far.

Objectives:

The aim of this study was to characterize FGFR3/FGF9 signaling in the context of fibroblast activation and to evaluate FGFR3 as a potential molecular target for antifibrotic treatment in SSc.

Methods:

Differential expression profiling of dermal cells from SSc patients and healthy volunteers were performed employing GEArray cDNA microarray. Real-time PCR, Western Blot, immunohistochemistry and immunofluorescence were done in skin tissues and fibroblasts from SSc patients. Selective inhibitors in conjunction with genetic knockdown and knockout strategies were used to target FGFR3 signalingin vitroand in mouse models of SSc: skin fibrosis induced by bleomycin and by overexpression of a constitutively active transforming growth factor receptor 1 (TBR) and tight skin-1 (TSK) mice. Affymetrix gene arrays in dermal fibroblasts from mice with constitutive FGFR3 signaling and mice lacking FGFR3.

Results:

Expression of FGFR3, specifically the isoform FGFR3IIIb and its ligand FGF9, was significantly upregulated in the dermis and dermal fibroblasts of SSc patients as compared to healthy volunteers. Furthermore, an increase of FGFR3 IIIb/FGF9 expression comparable to that in SSc fibroblasts could also be obtained by stimulating normal healthy dermal fibroblasts with transforming growth factor (TGFβ)in vitroand in mice constitutively overexpressing active TGFβ receptor type I.

Transcriptome profiling,in silicoanalysis and functional experiments revealed that FGFR3 synergistigically induces multiple profibrotic pathways including Endothelin-, Interleukin-4- and CTGF-signaling in a CREB-dependent manner. FGFR3 exerts profibrotic effects by modulating phosphorylation of CREB by ERK-, AKT-, CAMK2- and p38-kinases. Activation of FGFR3 in healthy or SSc dermal fibroblasts by stimulation with recombinant FGF9 was sufficient to induce resting fibroblast-to-myofibroblast differentiation along with increased collagen secretion and alpha-SMA production.

Genetic knockout of Fgfr3 abrogates myofibroblast differentiationin vitroand ameliorates skin fibrosis in TSK and TBR mice and in bleomycin-induced fibrosis. Further confirming the translational potential of these findings in the preclinical models of SSc, we demonstrate that pharmacological inactivation of FGFR3 by PD173074 could induce the regression of experimental fibrosis invitroand in bleomycin-challenged, TSK and TBR mice.

Conclusion:

Our findings characterize FGFR3 as an upstream regulator of a network of profibrotic mediators in SSc and thus, we could demonstrate successfully that the targeted inhibition of FGFR3 could inhibit multiple signaling pathwaysin vitroand ameliorated fibrosis in different preclinical models of SSc. These findings may have direct translational implications as FGFR3 inhibitors are currently in development.

Disclosure of Interests:

Debomita Chakraborty: None declared, Honglin Zhu: None declared, Astrid Juengel: None declared, Lena Summa: None declared, Yi-Nan Li: None declared, Christina Bergmann: None declared, Alexandru-Emil Matei: None declared, Thuong Trinh-Minh: None declared, Chih-Wei Chen: None declared, Clara Dees: None declared, Andreas Ramming: None declared, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche, Jörg Distler Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Paid instructor for: Boehringer Ingelheim, Speakers bureau: Boehringer Ingelheim

SAT0291 THE ROLE OF X-LINKED INHIBITOR OF APOPTOSIS PROTEIN (XIAP) IN SYSTEMIC SCLEROSIS

Background:

Pathologic activation of fibroblasts is a central feature of fibrotic tissue disease in Systemic Sclerosis (SSc). Although individual key signaling pathways of fibroblast activation such as transforming growth factor β (TGFβ) and WNT/β-catenin signaling have been identified, the consequences of the concomitant upregulation of these pathways and their crosstalk are incompletely characterized. Given the high medical need, the identification of mutual activation and amplification loops of profibrotic signals is essential to identify novel candidates for antifibrotic therapies. XIAP (X-linked inhibitor of apoptosis protein) is a ubiquitously expressed member of the IAP protein family which are implicated in the regulation of various cellular functions and tissue turnover. XIAP was recently described to be implicated in WNT/β-catenin signaling and TGFβ signaling.

Objectives:

The aim of this study is to characterize the role of XIAP in fibrotic disease.

Methods:

XIAP-expression was analyzed by qPCR, IF and Western blot. XIAP was targeted pharmacologically and with siRNA. The activation of WNT/β-catenin signaling was assessed by analyses of WNT target genes, by TOPflash/FOPflash luciferase reporter assay and in reporter mice.In vivo,XIAP inhibition was analysed in two different models of fibrosis.

Results:

The expression of XIAP is increased in the skin of SSc patients compared to matched healthy individuals with a particular prominent expression in fibroblasts. The overexpression of XIAP is more pronounced in SSc patients with diffuse and active skin fibrosis compared to SSc patients with limited and inactive disease. The overexpression of XIAP is also reflected in several experimental fibrosis models: the model of sclerodermatous graft versus host disease, the model of bleomycin induced skin fibrosis and Topoisomerase I induced fibrosis (TopoI) mice. TGFβ induces the expression of XIAP in vitro and in vivo and treatment with the TGFβ1 receptor antagonist SD208 reverses the TGFβ induced expression of XIAP. Inhibition of XIAP with embelin or siRNA reduces the TGFβ induced activation of fibroblasts with reduced collagen release and reduced expression of myofibroblast markers. In addition, XIAP inhibition reverted the activated fibroblast phenotype in SSc fibroblasts with reduced expression of stress fibers and αSMA. The antifibrotic effects of XIAP inhibition occurred in non-toxic doses as demonstrated by MTT and by TUNEL staining. In vivo, inhibition of XIAP reduced skin fibrosis in the models of bleomycin induced skin fibrosis and in TopoI-induced skin and lung fibrosis as demonstrated by analysis of dermal thickening, dermal hydroxyproline content and by analysis of myofibroblast differentiation. Mechanistically, XIAP inhibition reduced the activation of WNT/β-catenin signaling as demonstrated by TOPflash reporter assays and by the analysis of WNT target genes.

Conclusion:

XIAP is upregulated in SSc fibroblasts and murine SSc models in a TGFβ-dependent manner and promotes fibroblast activation by fostering canonical WNT signaling. Our data suggest that XIAP mediates an amplification loop between TGFβ and WNT/β-catenin signaling. Inhibition of XIAP may thus be a novel approach to target aberrant WNT/β-catenin signaling in fibrotic diseases.

Disclosure of Interests:

Christina Bergmann: None declared, Ludwig Hallenberger: None declared, Benita Merlevede: None declared, Clara Dees: None declared, Chih-Wei Chen: None declared, Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, Jörg Distler Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Paid instructor for: Boehringer Ingelheim, Speakers bureau: Boehringer Ingelheim

SAT0284 EPIGENETIC DEREGULATION OF AUTOPHAGY PROMOTES FIBROSIS IN SYSTEMIC SCLEROSIS

Background:

Autophagy is catabolic process allowing cells to degrade unnecessary or dysfunctional cellular organelles. Failure of appropriate regulation of autophagy, however, can severely perturb tissue homeostasis. Several stimuli present in fibrosis such as pro-fibrotic cytokines are known to activate autophagy.

Objectives:

The objective of this work was to characterize the regulation of autophagy in systemic sclerosis (SSc) and to decipher its role in the pathogenesis of SSc.

Methods:

Activation of autophagy in SSc skin and matched tissue samples from healthy individuals was assessed by immunofluorescence staining for ATG7, BECLIN1 and P62. We generatedAtg7fl/flxCol1a2;CreER mice to selectively disable autophagy in fibroblasts. The role of the autophagy was investigated in the model of bleomycin- and TβRIact-induced dermal and pulmonary fibrosis. Overexpression of Myst1 was achieved by adenovirus encoding forMyst1. Collagen release and protein expression were measure by Western blot. Target genes were analyzed by RT-PCR. Co-immunoprecipitation and reporter assay were performed to study physical and functional interactions between MYST1 and SMAD3. To monitor the autophagic fluxin vitroandin vivowe generated adenoviral vectors encoding for tandem fluorescent-tagged LC3 (mRFP-EGFP-LC3).

Results:

Transforming growth factor-β (TGFβ) activates autophagy by an epigenetic mechanism to amplify its profibrotic effects. TGFβ induces autophagy in fibrotic diseases by SMAD3-dependent downregulation of the H4K16 histone acetyltransferase MYST1, which regulates the expression of core components of the autophagy machinery such as ATG7 and BECLIN1. Activation of autophagy in fibroblasts promotes collagen release and is both, sufficient and required, to induce tissue fibrosis. Forced expression of MYST1 abrogates the stimulatory effects of TGFβ on autophagy and re-establishes the epigenetic control of autophagy in fibrotic conditions. Interference with the aberrant activation of autophagy inhibits TGFβ-induced fibroblast activation and ameliorates experimental dermal and pulmonary fibrosis. These findings link uncontrolled TGFβ signaling to aberrant autophagy, deregulated epigenetics in fibrotic diseases and may open new avenues for therapeutic intervention in fibrotic diseases.

Conclusion:

We demonstrate that the epigenetic control of autophagy is disturbed by a TGFβ-dependent downregulation of the H4K16 histone acetyltransferase MYST1. The increased activation of autophagy induces fibroblast-to-myofibroblast transition and promotes fibrotic tissue remodeling. Re-expression of MYST1 prevents aberrant autophagy, limits the profibrotic effects of TGFβ and ameliorates experimental fibrosis. Restoration of the epigenetic control of autophagy might thus be a novel approach to ameliorate fibrotic tissue remodeling.

References:

[1]Wynn, T.A. Cellular and molecular mechanisms of fibrosis. J Pathol 214, 199-210 (2008).

[2]Distler, J.H., et al. Review: Frontiers of Antifibrotic Therapy in Systemic Sclerosis. Arthritis & rheumatology (Hoboken, N.J.) 69, 257-267 (2017).

[3]Gyorfi, A.H., Matei, A.E. & Distler, J.H.W. Targeting TGF-beta signaling for the treatment of fibrosis. Matrix biology: journal of the International Society for Matrix Biology 68-69, 8-27 (2018).

[4]Wang, C.W. & Klionsky, D.J. The molecular mechanism of autophagy. Mol Med 9, 65-76 (2003).

[5]Hernandez-Gea, V., et al. Autophagy releases lipid that promotes fibrogenesis by activated hepatic stellate cells in mice and in human tissues. Gastroenterology 142, 938-946 (2012).

Disclosure of Interests:

Ariella Zehender: None declared, Neng Yu Lin: None declared, Yi-Nan Li: None declared, Andrea-Hermina Györfi: None declared, Christina Bergmann: None declared, Andreas Ramming Grant/research support from: Pfizer, Novartis, Consultant of: Boehringer Ingelheim, Novartis, Gilead, Pfizer, Speakers bureau: Boehringer Ingelheim, Roche, Janssen, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, Jörg Distler Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Paid instructor for: Boehringer Ingelheim, Speakers bureau: Boehringer Ingelheim

SAT0287 AMPLIFICATION OF THE PRO-FIBROTIC JAK2-STAT3 SIGNALING AXIS BY TGFΒ-INDUCED EPIGENETIC SILENCING OF SOCS3

Background:

Tissue fibrosis caused by a pathological activation of fibroblasts is a major hallmark of systemic sclerosis (SSc). Epigenetic gene silencing of anti-fibrotic genes is thought to play a central role to establish the persistently activated phenotype of fibroblasts independent of external stimuli such as TGFβ, which has been identified as key-mediator of fibroblast activation.

Objectives:

The aims of the present study were to investigate whether the aberrant activation of JAK2-STAT3 signaling in fibrosis might be caused by epigenetic silencing of SOCS expression and whether re-establishment of the endogenous, SOCS-dependent control of JAK / STAT signaling may prevent aberrant fibroblast activation and ameliorate tissue fibrosis.

Methods:

The methylation status of SOCS3 in fibroblasts was evaluated by methylation-specific PCR and MeDIP assays. 5-aza-2-deoxycytidine (5-aza) and siRNA was used to inhibit DNA methyltransferases (DNMTs)in vitroandin vivo. Knockdown and overexpression experiments served to analyze the mechanism of action in cultured fibroblasts. Fibroblast-specific knockout mice were additionally used to analyze the role of SOCS3 and DNMTsin vivo.

Results:

Chronically increased levels of TGFβ reduced the expression of SOCS3 in normal fibroblasts to a level also found in SSc fibroblasts. Consistently, the expression of SOCS3 was severely downregulated in skin of SSc patients compared to healthy individuals with only minor differences between limited and diffuse cutaneous SSc. Methylation analyses demonstrated a prominent promoter hypermethylation of SOCS3 in SSc fibroblasts and in normal fibroblasts exposed to persistently high levels of TGFβ. Increased DNMT activity and a time-dependent induction of DNMT3A and DNMT1 expression upon chronic exposure to TGFβ resulted in promoter hypermethylation of SOCS3. Knockdown of SOCS3 induced an SSc-like phenotype in normal dermal fibroblasts with increased activation of JAK2-STAT3 signaling, enhanced expression of myofibroblast markers, increased collagen release, and aggravated experimental tissue fibrosis with increased activation of JAK2-STAT3 signaling. This effect was mimicked by overexpression of mutant JAK2 with mutations in the SOCS3 binding motif. Vice versa, forced overexpression of SOCS3 reduced TGFβ-mediated fibroblast activation and ameliorated the endogenous activation of SSc fibroblasts. Pharmacological inhibition or selective knockdown of DNMTs restored the normal expression of SOCS3, reduced fibroblast activation and collagen release, blocked STAT3-responsive transcription, and exerted potent antifibrotic effects in bleomycin- and TBRIact-induced dermal fibrosis. In addition, treatment with 5-aza or knockdown of either DNMT1 or DNMT3A induced regression of established fibrosis.

Conclusion:

These findings identify a novel pathway of epigenetic imprinting of fibroblasts in fibrotic disease with translational implications for the development of new targeted therapies in fibrotic diseases. We demonstrate that the chronic activation of TGFβ signaling in fibrotic diseases perturbs the epigenetic control of STAT signaling by DNMT-induced silencing of SOCS3 expression. Our data might thus strengthen the scientific rational for targeting DNA methylation in fibrotic diseases.

Disclosure of Interests:

Clara Dees: None declared, Sebastian Poetter: None declared, Yun Zhang: None declared, Christina Bergmann: None declared, xiang zhou: None declared, Markus Luber: None declared, Emmanuel Karouzakis: None declared, Andreas Ramming Grant/research support from: Pfizer, Novartis, Consultant of: Boehringer Ingelheim, Novartis, Gilead, Pfizer, Speakers bureau: Boehringer Ingelheim, Roche, Janssen, Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, Jörg Distler Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Paid instructor for: Boehringer Ingelheim, Speakers bureau: Boehringer Ingelheim

AB0172 PGC-1Α REGULATES AUTOPHAGY TO PROMOTE FIBROBLAST ACTIVATION AND TISSUE FIBROSIS

Background:

Peroxisome proliferator-activated receptor gamma coactivator-1α (PGC-1α) is the best studied member of the family of coactivators. PGC-1α was initially identified through its interaction with PPARγ in brown adipose tissue. Recent evidence further indicates that PGC-1α may also modulate the transcription of autophagy-related genes, which has recently been shown to be required for fibroblast-to-myofibroblast differentiation under fibrotic conditions. However, the role of PGC-1α in the pathogenesis of SSc has not been investigated.

Objectives:

The aim of the present study was to evaluate the role of the coactivator PGC-1α on autophagy and to evaluate its role in the pathologic activation of fibroblasts in SSc.

Methods:

Expression of PGC-1α was analyzed by RT-PCR, Western blot and immunofluorescence. Modulation of autophagy was analyzed by reporter studies by expression of autophagy related genes. The effects of PGC-1α knockdown on collagen production and myofibroblast differentiation were analyzed in cultured human fibroblasts and in two mouse models with fibroblast-specific knockout of PGC-1α.

Results:

PGC-1α overexpression was detected by immunohistochemistry in skin sections of SSc patients and in experimental fibrotic murine skin, particularly in fibroblasts. Knockdown of PGC-1α inhibited the stimulatory effects of TGFβ on fibroblast activation with impaired induction of collagen as compared to control fibroblasts. Fibroblasts specific knockout of PGC-1α ameliorates experimental fibrosis in bleomycin-induced and adTBR-induced murine dermal fibrosis with decreased dermal thickness, hydroxyproline and myofibroblast counts compared to wild-type fibrotic mice. Incubation of dermal fibroblasts with TGFβ activated autophagy in control fibroblasts with increased expression of the autophagy-related genes ATG7 and BECLIN-1, enhanced conversion of LC3 I to LC3 II and decreased ratios of ILC3 I EGFP to LC3 II RFP in LC3 reporter assays. The expression levels of ATG7, BECLIN-1 and ILC3 II of TGFβ-stimulated PGC-1α knockout fibroblasts decreased compare to TGFβ stimulated wild-type fibroblasts. The ratio of ILC3 I EGFP to LC3 II RFP of TGFβ-stimulated PGC-1α knockout fibroblasts in reporter assays were comparable to unstimulated fibroblasts.

Conclusion:

PGC-1α is upregulated in SSc and promotes autophagy to foster TGFβ-induced fibroblast activation. Targeting of PGC-1α prevents aberrant autophagy, inhibits fibroblast activation and tissue fibrosis.

References:

[1]Finck BN, Kelly DP. PGC-1 coactivators: inducible regulators of energy metabolism in health and disease. The Journal of clinical investigation. 2006 Mar; 116(3):615-622

[2]Lindholm D, Eriksson O, Makela J, Belluardo N, Korhonen L. PGC-1alpha: a master gene that is hard to master. Cellular and molecular life sciences: CMLS. 2012 Aug; 69(15):2465-2468.

[3]Li SY, Susztak K. The Role of Peroxisome Proliferator-Activated Receptor gamma Coactivator 1alpha (PGC-1alpha) in Kidney Disease. Semin Nephrol. 2018 Mar; 38(2):121-126.

[4]Vainshtein A, Tryon LD, Pauly M, Hood DA. Role of PGC-1alpha during acute exercise-induced autophagy and mitophagy in skeletal muscle. American journal of physiology Cell physiology. 2015 May 1; 308(9):C710-719.

[5]Zehender A LN, Stefanica A, Chen CW, Soare A, Wohlfahrt T, Rauber S, Bergmann C, Ramming A, Distler O, Schett G, Distler J. TGFβ Promotes Fibrosis By MYST1-Dependent Epigenetic Regulation of Autophagy [abstract]. Arthritis Rheumatol 2017; 69 (suppl 10).

Disclosure of Interests:

Yun Zhang: None declared, Katja Dreißigacker: None declared, Diana Distler: None declared, Andrea-Hermina Györfi: None declared, Christina Bergmann: None declared, xiang zhou: None declared, Lichong Shen: None declared, Ingo Ludolph: None declared, Raymund Horch: None declared, Andreas Ramming Grant/research support from: Pfizer, Novartis, Consultant of: Boehringer Ingelheim, Novartis, Gilead, Pfizer, Speakers bureau: Boehringer Ingelheim, Roche, Janssen, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, Jörg Distler Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Paid instructor for: Boehringer Ingelheim, Speakers bureau: Boehringer Ingelheim

AB1346-HPR REAL-WORLD EFFECTIVENESS AND PERCEIVED USEFULNESS OF SYMPTOM CHECKERS IN RHEUMATOLOGY: INTERIM REPORT FROM THE PROSPECTIVE MULTICENTER BETTER STUDY

Background:

Symptom checkers (SC) promise to reduce diagnostic delay, misdiagnosis and effectively guide patients through healthcare systems. They are increasingly used, however little evidence exists about their real-life effectiveness.

Objectives:

The aim of this study was to evaluate the diagnostic accuracy, usage time, usability and perceived usefulness of two promising SC, ADA (www.ada.com) and Rheport (www.rheport.de). Furthermore, symptom duration and previous symptom checking was recorded.

Methods:

Cross-sectional interim clinical data from the first of three recruiting centers from the prospective, real-world, multicenter bETTeR-study (DKRS DRKS00017642) was used. Patients newly presenting to a secondary rheumatology outpatient clinic between September and December 2019 completed the ADA and Rheport SC. The time and answers were recorded and compared to the patient’s actual diagnosis. ADA provides up to 5 disease suggestions, Rheport calculates a risk score for rheumatic musculoskeletal diseases (RMDs) (≥1=RMD). For both SC the sensitivity, specificity was calculated regarding RMDs. Furthermore, patients completed a survey evaluating the SC usability using the system usability scale (SUS), perceived usefulness, previous symptom checking and symptom duration.

Results:

Of the 129 consecutive patients approached, 97 agreed to participate. 38% (37/97) of the presenting patients presented with an RMD (Figure 1). Mean symptom duration was 146 weeks and a mean number of 10 physician contacts occurred previously, to evaluate current symptoms. 56% (54/96) had previously checked their symptoms on the internet using search engines, spending a mean of 6 hours. Rheport showed a sensitivity of 49% (18/37) and specificity of 58% (35/60) concerning RMDs. ADA’s top 1 and top 5 disease suggestions concerning RMD showed a sensitivity of 43% (16/37) and 54% (20/37) and a specificity of 58% (35/60) and 52% (31/60), respectively. ADA listed the correct diagnosis of the patients with RMDs first or within the first 5 disease suggestions in 19% (7/37) and 30% (11/37), respectively. The average perceived usefulness for checking symptoms using ADA, internet search engines and Rheport was 3.0, 3.5 and 3.1 on a visual analog scale from 1-5 (5=very useful). 61% (59/96) and 64% (61/96) would recommend using ADA and Rheport, respectively. The mean SUS score of ADA and Rheport was 72/100 and 73/100. The mean usage time for ADA and Rheport was 8 and 9 minutes, respectively.

Conclusion:

This is the first prospective, real-world, multicenter study evaluating the diagnostic accuracy and other features of two currently used SC in rheumatology. These interim results suggest that diagnostic accuracy is limited, however SC are well accepted among patients and in some cases, correct diagnosis can be provided out of the pocket within few minutes, saving valuable time.

Figure:

Acknowledgments:

This study was supported by an unrestricted research grant from Novartis.

Disclosure of Interests:

Johannes Knitza Grant/research support from: Research Grant: Novartis, Jacob Mohn: None declared, Christina Bergmann: None declared, Eleni Kampylafka Speakers bureau: Novartis, BMS, Janssen, Melanie Hagen: None declared, Daniela Bohr: None declared, Elizabeth Araujo Speakers bureau: Novartis, Lilly, Abbott, Matthias Englbrecht Grant/research support from: Roche Pharma, Chugai Pharma Europe, Consultant of: AbbVie, Roche Pharma, RheumaDatenRhePort GbR, Speakers bureau: AbbVie, Celgene, Chugai Pharma Europe, Lilly, Mundipharma, Novartis, Pfizer, Roche Pharma, UCB, David Simon Grant/research support from: Else Kröner-Memorial Scholarship, Novartis, Consultant of: Novartis, Lilly, Arnd Kleyer Consultant of: Lilly, Gilead, Novartis,Abbvie, Speakers bureau: Novartis, Lilly, Timo Meinderink: None declared, Wolfgang Vorbrüggen: None declared, Cay-Benedict von der Decken: None declared, Stefan Kleinert Shareholder of: Morphosys, Grant/research support from: Novartis, Consultant of: Novartis, Speakers bureau: Abbvie, Novartis, Celgene, Roche, Chugai, Janssen, Andreas Ramming Grant/research support from: Pfizer, Novartis, Consultant of: Boehringer Ingelheim, Novartis, Gilead, Pfizer, Speakers bureau: Boehringer Ingelheim, Roche, Janssen, Jörg Distler Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Paid instructor for: Boehringer Ingelheim, Speakers bureau: Boehringer Ingelheim, Peter Bartz-Bazzanella: None declared, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, Axel Hueber Grant/research support from: Novartis, Lilly, Pfizer, Consultant of: Abbvie, BMS, Celgene, Gilead, GSK, Lilly, Novartis, Speakers bureau: GSK, Lilly, Novartis, Martin Welcker Grant/research support from: Abbvie, Novartis, UCB, Hexal, BMS, Lilly, Roche, Celgene, Sanofi, Consultant of: Abbvie, Actelion, Aescu, Amgen, Celgene, Hexal, Janssen, Medac, Novartis, Pfizer, Sanofi, UCB, Speakers bureau: Abbvie, Aescu, Amgen, Biogen, Berlin Chemie, Celgene, GSK, Hexal, Mylan, Novartis, Pfizer, UCB

Very regular high-frequency pulsation modes in young intermediate-mass stars

Asteroseismology probes the internal structures of stars by using their natural pulsation frequencies¹. It relies on identifying sequences of pulsation modes that can be compared with theoretical models, which has been done successfully for many classes of pulsators, including low-mass solar-type stars², red giants³, high-mass stars⁴ and white dwarfs⁵. However, a large group of pulsating stars of intermediate mass-the so-called δ Scuti stars-have rich pulsation spectra for which systematic mode identification has not hitherto been possible^6,7. This arises because only a seemingly random subset of possible modes are excited and because rapid rotation tends to spoil regular patterns^8-10. Here we report the detection of remarkably regular sequences of high-frequency pulsation modes in 60 intermediate-mass main-sequence stars, which enables definitive mode identification. The space motions of some of these stars indicate that they are members of known associations of young stars, as confirmed by modelling of their pulsation spectra.

AllergoOncology: Microbiota in allergy and cancer-A European Academy for Allergy and Clinical Immunology position paper

The microbiota can play important roles in the development of human immunity and the establishment of immune homeostasis. Lifestyle factors including diet, hygiene, and exposure to viruses or bacteria, and medical interventions with antibiotics or anti-ulcer medications, regulate phylogenetic variability and the quality of cross talk between innate and adaptive immune cells via mucosal and skin epithelia. More recently, microbiota and their composition have been linked to protective effects for health. Imbalance, however, has been linked to immune-related diseases such as allergy and cancer, characterized by impaired, or exaggerated immune tolerance, respectively. In this AllergoOncology position paper, we focus on the increasing evidence defining the microbiota composition as a key determinant of immunity and immune tolerance, linked to the risk for the development of allergic and malignant diseases. We discuss novel insights into the role of microbiota in disease and patient responses to treatments in cancer and in allergy. These may highlight opportunities to improve patient outcomes with medical interventions supported through a restored microbiome.

Fibroblast growth factor receptor 4 single nucleotide polymorphism Gly388Arg in head and neck carcinomas

BACKGROUND

Head and neck squamous cell carcinoma (HNSCC) is considered to be a progressive disease resulting from alterations in multiple genes regulating cell proliferation and differentiation like receptor tyrosine kinases (RTKs) and members of the fibroblast growth factor receptors (FGFR)-family. Single-nucleotide polymorphism (SNP) Arg388 of the FGFR4 is associated with a reduced overall survival in patients with cancers of various types. We speculate that FGFR4 expression and SNP is associated with worse survival in patients with HSNCC.

AIM

To investigate the potential clinical significance of FGFR4 Arg388 in the context of tumors arising in HNSCC, a comprehensive analysis of FGFR4 receptor expression and genotype in tumor tissues and correlated results with patients’ clinical data in a large cohort of patients with HNSCC was conducted.

METHODS

Surgical specimens from 284 patients with HNSCC were retrieved from the Institute of Pathology at the Ludwig-Maximilian-University in Germany. Specimens were analyzed using immunohistochemistry and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). The expression of FGFR4 was analyzed in 284 surgical specimens of HNSCC using immunohistochemstry. FGFR4 polymorphism was detected by PCR-RFLP. Patients’ clinical data with a minimum follow-up of 5 years were statistically evaluated with a special emphasis on survival analysis employing Kaplan-Meier estimator and Cox regression analysis.

RESULTS

Concerning the invasive tumor areas the intensity of the FGFR4 expression was evaluated in a four-grade system: no expression, low expression, intermediate and high expression. FGFR4 expression was scored as “high” (+++) in 74 (26%), “intermediate” (++) in 103 (36.3%), and “low” (+) in 107 (36.7%) cases. Analyzing the FGFR4 mutation it was found in 96 tumors (33.8%), 84 of them (29.6%) having a heterozygous and 12 (4.2%) homozygous mutated Arg388 allele. The overall frequency concerning the mutant alleles demonstrated 65% vs 34% mutated alleles in general. FGFR4 Arg388 was significantly associated with advanced tumor stage (P < 0.004), local metastasis (P < 0.0001) and reduced disease-free survival (P < 0.01). Furthermore, increased expression of FGFR4 correlated significantly with worse overall survival (P < 0.003).

CONCLUSION

In conclusion, the FGFR4 Arg388 genotype and protein expression of FGFR4 impacts tumor progression in patients with HNSCC and may present a useful target within a multimodal therapeutic intervention.

Increased dermal expression of chromatin-associated protein HMGB1 and concomitant T-cell expression of the DNA RAGE in patients with psoriasis vulgaris

Purpose

Psoriasis vulgaris (PV) is an autoimmune-related chronic inflammatory disease of the skin, with both vascular and metabolic effects. Aggravating factors have been identified that initiate and maintain inflammation, including expression of Th1-, Th17-, and Th22-cell derived cytokines. Recently, we showed that the evolutionarily ancient and highly conserved damage-associated molecular pattern molecule “high mobility group box 1 (HMGB1)” is significantly increased in the serum of PV patients with disease progression and is decreased under standard therapies.

Materials and methods

To better understand the role of HMGB1 in the pathogenesis of PV, we recruited 22 untreated psoriatic patients with either mild or severe disease, defined by the Psoriasis Area Severity Index. We assessed HMGB1 and receptor for advanced glycation end products (RAGE) expression in the skin by immunohistochemistry and analyzed the immune-phenotype of Treg and Th17 cells by flow cytometry.

Results

We found increased staining for HMGB1 in the dermis of psoriatic plaques in comparison to uninvolved skin of patients with PV. In addition, the major histocompatibility complex class III-encoded DNA and HMGB1 RAGE, induced by HMGB1, were highly expressed on psoriatic CD8+ T cells and CD4+ Treg. High expression of HMGB1 in the lesional skin was associated with even higher expression of its receptor, RAGE, on the cell surface of keratino-cytes in patients with severe PV.

Conclusion

The presence of HMGB1 and RAGE signaling may impact orchestration of chronic inflammation in PV which might have implications for Treg and Th17 cells.

The formation of CdS quantum dots and Au nanoparticles

We report on microsecond-resolved in-situ SAXS experiments of the early nucleation and growth behavior of both cadmium sulfide (CdS) quantum dots in aqueous solution including the temperature dependence and of gold (Au) nanoparticles. A novel free-jet setup was developped to access reaction times as early as 20 μs. As the signal in particular in the beginning of the reaction is weak the containment-free nature of this sample environment prooved crucial. The SAXS data reveal a two-step pathway with a surprising stability of a structurally relaxed cluster with a diameter of about 2 nm. While these develop rapidly by ionic assembly, a further slower growth is attributed to cluster attachment. WAXS diffraction confirms, that the particles at this early stage are not yet crystalline. This growth mode is confirmed for a temperature range from 25°C to 45°C. An energy barrier for the diffusion of primary clusters in water of 0.60 eV was experimentally observed in agreement with molecular simulations. To access reaction times beyond 100 ms, a stopped-drop setup -again contaiment- free is introduced. SAXS experiments on the growth of Au nanoparticles on an extended time scale provide a much slower growth with one population only. Further, the influence of ionizing X-ray radiation on the Au particle fromation and growth is discussed.

[Hemolytic kidney failure and transient ischemic attack in a 32-year-old female]

We report on the case of a 32-year-old female patient who initially presented with oliguric acute renal failure, hemolytic anemia with moderate thrombocytopenia and subsequently developed a transient ischemic attack in the cerebellum. The kidney biopsy revealed clinically suspected atypical hemolytic-uremic syndrome (aHUS), which was confirmed by intraglomerular thrombotic microangiopathy (TMA). Treatment with plasmapheresis and sustained administration of the C5 inhibitor eculizumab resulted in hematological remission but without improvement of kidney function. Further etiological investigations led to reduced plasma levels of inhibitory complement factor I on the basis of a heterozygous CFI mutation. In patients with aHUS molecular genetic investigations are indicated in order to determine the underlying cause, to regulate the therapeutic regimen and to allow prognostic statements with respect to a potential kidney transplantation.

MKS1 mutations cause Joubert syndrome with agenesis of the corpus callosum

Joubert syndrome (JS) is a clinically and genetically heterogeneous ciliopathy characterized by episodic hyperpnea and apnea, hypotonia, ataxia, cognitive impairment and ocular motor apraxia. The "molar tooth sign" is pathognomonic of this condition. Mutations in the MKS1 gene are a major cause of Meckel-Gruber syndrome (MKS), the most common form of syndromic neural tube defects, frequently resulting in perinatal lethality. We present the phenotype and genotype of a child with severe JS and agenesis of the corpus callosum (ACC). In our patient, a next generation sequencing (NGS) approach revealed the following two variants of the MKS1 gene: first, a novel missense variant [ c.240G > T (p.Trp80Cys)], which affects a residue that is evolutionarily highly conserved in mammals and ciliates; second, a 29 bp deletion in intron 15 [c.1408-35_1408-7del29], a founder mutation, which in a homozygous state constitutes the major cause of MKS in Finland. We review the MKS1-variants in all of the eleven JS patients reported to date and compare these patients to our case. To our knowledge, this is the first patient with Joubert syndrome and agenesis of the corpus callosum where a potentially causal genotype is provided.

Evaluation of the application of rhino-septal splints in endoscopic transsphenoidal skull base surgery

The endoscopic transnasal route for the surgical removal of tumors in the sellar region is frequently associated with nasal complications such as synechiae or impaired nasal breathing. In this study, we investigated the impact of septal splints on avoiding surgery-related co-morbidities. 49 patients in whom endoscopic transnasal, transsphenoidal surgery for sellar tumors was performed between 2012 and 2014 were studied. In 30 of these, nasal septal splints were applied at the end of surgery to both sides of the septum and left in situ for 10 days (group 1), 19 patients received no splints (group 2). A standardized postsurgical follow-up investigation with endoscopic nasal examination, rhinomanometry and olfactory testing was performed on average 2 months postoperatively. Patients' subjective nose-related discomfort at follow-up was assessed descriptively using a set of standardized self-rating statements on nasal problems. Synechias occurred less likely with nasal septal splints (n = 15; 50 %) than without (n = 16; 84.2 %). Moreover, multiple synechiae were predominantly observed in the group without septal splints (n = 10 vs. n = 2). Rhinomanometry showed improved flow-V150-inspiration scores when splints were used (with significant differences between groups for the left nostril: p = 0.039 and p = 0.022, resp.). In accordance, impaired nasal breathing after surgery was reported more frequently by 76.9 % of patients without splints, but only 56 % of patients with splints. Our results provide support for the application of nasal septal splints when operating endoscopically on tumors in the sellar region to reduce postoperative synechias and to improve nasal breathing.

Biopanel identifies expression status of targetable proteins in sinonasal melanoma

BACKGROUND

Advanced stage at presentation, lack of BRAF mutations and overall rarity pose unique challenges to the therapy and trial design in sinonasal melanoma.

METHODS

Here, we assessed the expression status of 12 proteins in two independent cohorts of sinonasal melanoma (n = 20).

RESULTS

Each case showed expression of at least one protein (KIT, TP53, MYC, HER2, EGFR, MET, VEGFR, BRAF V600E and/or MDM2), whereas lack of ALK, FLI1 and PDGFRα expression underscores differences to cutaneous melanoma. Comparison of marker frequencies to a metareview of the literature indicates that MYC, HER2, EGFR and MET had not been previously assessed.

CONCLUSION

Expression of at least one potentially targetable protein per case illustrates proteome pathway profiling as one starting point for marker stratified trial design.

Until Death Do Us Part: Necrosis and Oxidation Promote the Tumor Microenvironment

Tumor proliferation is concomitant with autophagy, limited apoptosis, and resultant necrosis. Necrosis is associated with the release of damage-associated molecular pattern molecules (DAMPs), which act as 'danger signals', recruiting inflammatory cells, inducing immune responses, and promoting wound healing. Most of the current treatment strategies for cancer (chemotherapy, radiation therapy, hormonal therapy) promote DAMP release following therapy-induced tumor death by necroptosis and necrosis. Myeloid cells (monocytes, dendritic cells (DCs), and granulocytes), as well as mesenchymal stromal cells (MSCs) belong to the early immigrants in response to unscheduled cell death, initiating and modulating the subsequent inflammatory response. Responding to DAMPs, MSCs, and DCs promote an immunosuppressive milieu, while eosinophils induce oxidative conditions limiting the biologic activity of DAMPs over time and distance. Regulatory T cells are strongly affected by pattern recognition receptor signaling in the tumor microenvironment and limit immune reactivity coordinately with myeloid-derived suppressor cells. Means to 'aerobically' oxidize DAMPs provide a novel strategy for limiting tumor progression. The present article summarizes our current understanding of the impact of necrosis on the tumor microenvironment and the influence of oxidative conditions found within this setting.

High mobility group box 1 is increased in the sera of psoriatic patients with disease progression

BACKGROUND

Psoriasis vulgaris (PV) is an autoimmune-related chronic inflammatory disease, which appears mostly in skin, but also affects the vascular and metabolic system. The incidence of PV is 2-3% in the general population and there is still no possibility to cure. Trigger factors have been identified to initiate and maintain inflammation in the skin, which is characterized by Th1-, Th17- and Th22- cells.

OBJECTIVE

We hypothesize that the damage-associated molecular pattern (DAMP) molecule high mobility group box 1 (HMGB1) plays a role in the pathogenesis of PV. HMGB1 is a DNA-binding protein located in the nucleus, which acquires cytokine-like properties once released from the cell upon necrotic cell death or actively secreted by immune cells in inflammation and cancer.

METHODS

We recruited 90 psoriatic patients under and without therapy with mild, intermediate and severe progression of disease, defined by the Psoriasis Area Severity Index. Serum levels of HMGB1 in patients with PV were detected by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Our results show an increased level of HMGB1 in the sera of patients with PV in comparison to healthy donors. Furthermore, our analyses reveal that HMGB1 levels are significantly increased with disease progression and are downregulated after standard therapies for PV have been conducted.

CONCLUSION

Our data provide insights into a possible role of HMGB1 for inflammation in PV.

Locoregional tumour evaluation of squamous cell carcinoma in the head and neck area: a comparison between MRI, PET/CT and integrated PET/MRI

PURPOSE

To evaluate the accuracy of integrated (18)F-FDG PET/MR imaging for locoregional tumour evaluation compared to (18)F-FDG PET/CT and MR imaging in initial tumour and recurrence diagnosis in histopathologically confirmed head and neck squamous cell carcinoma (HNSCC).

METHODS

(18)F-FDG PET/CT and integrated (18)F-FDG PET/MR imaging were performed for initial tumour staging or recurrence diagnosis in 25 patients with HNSCC. MR, fused (18)F-FDG PET/CT and fused (18)F-FDG PET/MR images were analysed by two independent readers in separate sessions in random order. In initial tumour staging, T and N staging was performed while individual lesions were analysed in patients with suspected cancer recurrence. In T and N staging, histopathological results after tumour resection served as the reference standard while histopathological sampling as well as cross-sectional and clinical follow-up were accepted in cancer recurrence diagnosis. The diagnostic accuracy of each modality was calculated separately for T and N staging as well as for tumour recurrence, and compared using McNemar's test. Values of p <0.017 were considered statistically significant after Bonferroni correction.

RESULTS

In 12 patients undergoing (18)F-FDG PET/CT and (18)F-FDG PET/MR for initial tumour staging, T staging was accurate in 50 % with MRI, in 59 % with PET/CT and in 75 % with PET/MR while N staging was accurate in 75 % with MRI, in 77 % with PET/CT and in 71 % with PET/MR in relation to the reference standard. No significant differences were observed in T and N staging among the three modalities (p > 0.017). In 13 patients undergoing hybrid imaging for cancer recurrence diagnosis, diagnostic accuracy was 57 % with MRI and in 72 % with (18)F-FDG PET/CT and (18)F-FDG PET/MR, respectively. Again, no significant differences were found among the three modalities (p > 0.017).

CONCLUSION

In this initial study, no significant differences were found among (18)F-FDG PET/MR, (18)F-FDG PET/CT and MRI in local tumour staging and cancer recurrence diagnosis.

ESLAV/ECLAM/LAVA/EVERI recommendations for the roles, responsibilities and training of the laboratory animal veterinarian and the designated veterinarian under Directive 2010/63/EU

Directive 2010/63/EU was adopted in September 2010 by the European Parliament and Council, and became effective in January 2013. It replaces Directive 86/609/EEC and introduces new requirements for the protection of animals used for scientific purposes. In particular, it requires that establishments that breed, supply or use laboratory animals have a designated veterinarian (DV) with expertise in laboratory animal medicine, or a suitably qualified expert where more appropriate, charged with advisory duties in relation to the well-being and treatment of the animals. This paper is a report of an ESLAV/ECLAM/LAVA/EVERI working group that provides professional guidance on the role and postgraduate training of laboratory animal veterinarians (LAVs), who may be working as DVs under Directive 2010/63/EU. It is also aimed at advising employers, regulators and other persons working under the Directive on the role of the DV. The role and responsibilities of the DV include the development, implementation and continuing review of an adequate programme for veterinary care at establishments breeding and/or using animals for scientific purposes. The programme should be tailored to the needs of the establishment and based on the Directive’s requirements, other legislations, and current guidelines in laboratory animal medicine. Postgraduate laboratory animal veterinary training should include a basic task-specific training module for DVs to complement veterinary competences from graduation, and continuing professional development on the basis of a gap analysis. A tiered approach to further training in laboratory animal veterinary medicine and science offers career development pathways that are mutually beneficial to LAVs and establishments.