mRNA Display Identifies Potent, Paralog-Selective Peptidic Ligands for ARID1B

The ARID1A and ARID1B subunits are mutually exclusive components of the BAF variant of SWI/SNF chromatin remodeling complexes. Loss of function mutations in ARID1A are frequently observed in various cancers, resulting in a dependency on the paralog ARID1B for cancer cell proliferation. However, ARID1B has never been targeted directly, and the high degree of sequence similarity to ARID1A poses a challenge for the development of selective binders. In this study, we used mRNA display to identify peptidic ligands that bind with nanomolar affinities to ARID1B and showed high selectivity over ARID1A. Using orthogonal biochemical, biophysical, and chemical biology tools, we demonstrate that the peptides engage two different binding pockets, one of which directly involves an ARID1B-exclusive cysteine that could allow covalent targeting by small molecules. Our findings impart the first evidence of the ligandability of ARID1B, provide valuable tools for drug discovery, and suggest opportunities for the development of selective molecules to exploit the synthetic lethal relationship between ARID1A and ARID1B in cancer.

Identification of Brain-Penetrant ATP-Competitive mTOR Inhibitors for CNS Syndromes

The allosteric inhibitor of the mechanistic target of rapamycin (mTOR) everolimus reduces seizures in tuberous sclerosis complex (TSC) patients through partial inhibition of mTOR functions. Due to its limited brain permeability, we sought to develop a catalytic mTOR inhibitor optimized for central nervous system (CNS) indications. We recently reported an mTOR inhibitor (1) that is able to block mTOR functions in the mouse brain and extend the survival of mice with neuronal-specific ablation of the Tsc1 gene. However, 1 showed the risk of genotoxicity in vitro. Through structure-activity relationship (SAR) optimization, we identified compounds 9 and 11 without genotoxicity risk. In neuronal cell-based models of mTOR hyperactivity, both corrected aberrant mTOR activity and significantly improved the survival rate of mice in the Tsc1 gene knockout model. Unfortunately, 9 and 11 showed limited oral exposures in higher species and dose-limiting toxicities in cynomolgus macaque, respectively. However, they remain optimal tools to explore mTOR hyperactivity in CNS disease models.

Discovery of Potent Pyrazoline-Based Covalent SARS-CoV-2 Main Protease Inhibitors

Among the various genes and proteins encoded by all coronaviruses, one particularly "druggable" or relatively easy-to-drug target is the coronavirus Main Protease (3CLproor Mpro), an enzyme that is involved in cleaving a long peptide translated by the viral genome into its individual protein components that are then assembled into the virus to enable viral replication in the cell. Inhibiting Mpro with a small-molecule antiviral would effectively stop the ability of the virus to replicate, providing therapeutic benefit. In this study, we have utilized activity-based protein profiling (ABPP)-based chemoproteomic approaches to discover and further optimize cysteine-reactive pyrazoline-based covalent inhibitors for the SARS-CoV-2 Mpro. Structure-guided medicinal chemistry and modular synthesis of di- and tri-substituted pyrazolines bearing either chloroacetamide or vinyl sulfonamide cysteine-reactive warheads enabled the expedient exploration of structure-activity relationships (SAR), yielding nanomolar potency inhibitors against Mpro from not only SARS-CoV-2, but across many other coronaviruses. Our studies highlight promising chemical scaffolds that may contribute to future pan-coronavirus inhibitors.

Crystal Structures of Inhibitor-Bound Main Protease from Delta- and Gamma-Coronaviruses

With the spread of SARS-CoV-2 throughout the globe causing the COVID-19 pandemic, the threat of zoonotic transmissions of coronaviruses (CoV) has become even more evident. As human infections have been caused by alpha- and beta-CoVs, structural characterization and inhibitor design mostly focused on these two genera. However, viruses from the delta and gamma genera also infect mammals and pose a potential zoonotic transmission threat. Here, we determined the inhibitor-bound crystal structures of the main protease (M^pro) from the delta-CoV porcine HKU15 and gamma-CoV SW1 from the beluga whale. A comparison with the apo structure of SW1 M^pro, which is also presented here, enabled the identification of structural arrangements upon inhibitor binding at the active site. The cocrystal structures reveal binding modes and interactions of two covalent inhibitors, PF-00835231 (active form of lufotrelvir) bound to HKU15, and GC376 bound to SW1 M^pro. These structures may be leveraged to target diverse coronaviruses and toward the structure-based design of pan-CoV inhibitors.

Defining the substrate envelope of SARS-CoV-2 main protease to predict and avoid drug resistance

Coronaviruses can evolve and spread rapidly to cause severe disease morbidity and mortality, as exemplified by SARS-CoV-2 variants of the COVID-19 pandemic. Although currently available vaccines remain mostly effective against SARS-CoV-2 variants, additional treatment strategies are needed. Inhibitors that target essential viral enzymes, such as proteases and polymerases, represent key classes of antivirals. However, clinical use of antiviral therapies inevitably leads to emergence of drug resistance. In this study we implemented a strategy to pre-emptively address drug resistance to protease inhibitors targeting the main protease (M^pro) of SARS-CoV-2, an essential enzyme that promotes viral maturation. We solved nine high-resolution cocrystal structures of SARS-CoV-2 M^pro bound to substrate peptides and six structures with cleavage products. These structures enabled us to define the substrate envelope of M^pro, map the critical recognition elements, and identify evolutionarily vulnerable sites that may be susceptible to resistance mutations that would compromise binding of the newly developed M^pro inhibitors. Our results suggest strategies for developing robust inhibitors against SARS-CoV-2 that will retain longer-lasting efficacy against this evolving viral pathogen.

Endothelial lipase: regulation and biological function

Endothelial lipase is synthetized almost exclusively in endothelial cells and then fixed on the luminal surface of the endothelium by means of heparan sulphate proteoglycans. The enzyme is expressed in the endothelium of nearly all tissues and the degree of expression is higher in richly vascularized tissues than in the less vascularized ones. The endothelial lipase expression in tissues is upregulated by shear and cyclic stress, angiotensin II and hypertension. The plasma enzyme level is elevated by pro-inflammatory cytokines, in metabolic syndrome and obesity. Prolonged exercise reduces the plasma enzyme level in the rat. The activity of the enzyme is inhibited by: sphingomyelin, angiopoietin-like protein 3 and 4, and insulin. Endothelial lipase reduces the plasma high density lipoprotein concentration and changes its properties. The enzyme is considered to be the main regulator of the plasma high density lipoprotein concentration. The plasma endothelial lipase concentration is elevated in coronary atherosclerosis and it is inversely correlated with the plasma high density lipoprotein level. The enzyme is considered to exert mostly pro-atherogenic effects. Its action as triglyceride lipase is important in hypertriglyceridemia.

Identification of NVP-CLR457 as an Orally Bioavailable Non-CNS-Penetrant pan-Class IA Phosphoinositol-3-Kinase Inhibitor

Balanced pan-class I phosphoinositide 3-kinase inhibition as an approach to cancer treatment offers the prospect of treating a broad range of tumor types and/or a way to achieve greater efficacy with a single inhibitor. Taking buparlisib as the starting point, the balanced pan-class I PI3K inhibitor 40 (NVP-CLR457) was identified with what was considered to be a best-in-class profile. Key to the optimization to achieve this profile was eliminating a microtubule stabilizing off-target activity, balancing the pan-class I PI3K inhibition profile, minimizing CNS penetration, and developing an amorphous solid dispersion formulation. A rationale for the poor tolerability profile of 40 in a clinical study is discussed.

MiRNA-149 as a Candidate for Facial Clefting and Neural Crest Cell Migration

Nonsyndromic cleft lip with or without palate (nsCL/P) ranks among the most common human birth defects and has a multifactorial etiology. Human neural crest cells (hNCC) make a substantial contribution to the formation of facial bone and cartilage and are a key cell type in terms of nsCL/P etiology. Based on increasing evidence for the role of noncoding regulatory mechanisms in nsCL/P, we investigated the role of hNCC-expressed microRNAs (miRNA) in cleft development. First, we conducted a systematic analysis of miRNAs expressed in human-induced pluripotent stem cell-derived hNCC using Affymetrix microarrays on cell lines established from 4 unaffected donors. These analyses identified 152 candidate miRNAs. Based on the hypothesis that candidate miRNA loci harbor genetic variation associated with nsCL/P risk, the genomic locations of these candidates were cross-referenced with data from a previous genome-wide association study of nsCL/P. Associated variants were reanalyzed in independent nsCL/P study populations. Jointly, the results suggest that miR-149 is implicated in nsCL/P etiology. Second, functional follow-up included in vitro overexpression and inhibition of miR-149 in hNCC and subsequent analyses at the molecular and phenotypic level. Using 3'RNA-Seq, we identified 604 differentially expressed (DE) genes in hNCC overexpressing miR-149 compared with untreated cells. These included TLR4 and JUNB, which are established targets of miR-149, and NOG, BMP4, and PAX6, which are reported nsCL/P candidate genes. Pathway analyses revealed that DE genes were enriched in pathways including regulation of cartilage development and NCC differentiation. At the cellular level, distinct hNCC migration patterns were observed in response to miR-149 overexpression. Our data suggest that miR-149 is involved in the etiology of nsCL/P via its role in hNCC migration.

The crystal growth and properties of novel magnetic double molybdate RbFe5(MoO4)7 with mixed Fe3+/Fe2+ states and 1D negative thermal expansion

Single crystals of new composition RbFe₅(MoO₄)₇ were successfully grown by the flux method, and their crystal structure was determined using the X-ray single-crystal diffraction technique.

'TB or not TB': the conundrum of pre-European contact tuberculosis in the Pacific

Tuberculosis (TB) is a major global health threat, infecting one-third of the world's population. Despite this prominence, the age, origin and spread of the disease have been topics of contentious debate. Molecular studies suggest that Mycobacterium tuberculosis 'sensu stricto', the most common strain of TB infecting humans today, originated in Africa and from there spread into Europe and Asia. The M. tuberculosis strains most commonly found across the Pacific and the Americas today are most closely related to European strains, supporting a hypothesis that the disease only reached these regions relatively recently via European sailors or settlers. However, this hypothesis is inconsistent with palaeopathological evidence of TB-like lesions in human remains from across the Pacific that predate European contact. Similarly, genetic evidence from pre-European South American mummies challenges the notion of a European introduction of the disease into the Pacific. Here, we review the complex evidence for the age and origin of TB in the Pacific, and discuss key gaps in our knowledge and how these may be addressed. This article is part of the theme issue 'Insights into health and disease from ancient biomolecules'.

A systematic review and meta-analysis of dementia prevalence in seven developing countries: A STRiDE project

The STRiDE project sets out to support the development of effective dementia policy in middle-income countries (Brazil, India, Indonesia, Jamaica, Kenya, Mexico, and South Africa). As part of this it will generate new data about the prevalence of dementia for a subset of these countries. This study aims to identify the current estimates of dementia prevalence in these countries and where the gaps lie in the current literature. A systematic review was completed on 30th April 2019 across electronic databases, identifying dementia prevalence literature originating from any of the seven countries. Four hundred and twenty-nine records were identified following de-duplication; 28 studies met the inclusion criteria and were included in the systematic review. Pooled estimates of dementia prevalence ranged from 2% to 9% based on DSM-IV criteria; these figures were generally higher in studies using other diagnostic criteria (e.g. the 10/66 algorithm). Available prevalence data varied between countries. Only Brazil, Mexico and India had data derived from studies judged as having a low risk of bias. Irrespective of country, studies often were not explicit in detailing the representativeness of their sample, or whether there was non-response bias. Further transparent and externally valid dementia prevalence research is needed across the STRiDE countries.

The state of the art in European research on reducing social exclusion and stigma related to mental health: A systematic mapping of the literature

Stigma and social exclusion related to mental health are of substantial public health importance for Europe. As part of ROAMER (ROAdmap for MEntal health Research in Europe), we used systematic mapping techniques to describe the current state of research on stigma and social exclusion across Europe. Findings demonstrate growing interest in this field between 2007 and 2012. Most studies were descriptive (60%), focused on adults of working age (60%) and were performed in Northwest Europe—primarily in the UK (32%), Finland (8%), Sweden (8%) and Germany (7%). In terms of mental health characteristics, the largest proportion of studies investigated general mental health (20%), common mental disorders (16%), schizophrenia (16%) or depression (14%). There is a paucity of research looking at mechanisms to reduce stigma and promote social inclusion, or at factors that might promote resilience or protect against stigma/social exclusion across the life course. Evidence is also limited in relation to evaluations of interventions. Increasing incentives for cross-country research collaborations, especially with new EU Member States and collaboration across European professional organizations and disciplines, could improve understanding of the range of underpinning social and cultural factors which promote inclusion or contribute toward lower levels of stigma, especially during times of hardship.

Cost-benefit analysis of psychological therapy

At present six million people are suffering from clinical depression or anxiety disorders, but only a quarter of them are in treatment. NICE Guidelines prescribe the offer of evidence-based psychological therapy, but they are not implemented, due to lack of therapists within the NHS. We therefore estimate the economic costs and benefits of providing psychological therapy to people not now in treatment. The cost to the governement would be fully covered by the savings in incapacity benefits and extra taxes that result from more people being able to work. On our estimates, the cost could be recovered within two years - and certainly within five. And the benefits to the whole economy are greater still. This is not because we expect the extra therapy to be targeted especially at people with problems about work. It is because the cost of the therapy is so small (£750 in total), the recovery rates are so high (50 per cent) and the cost of a person on IB is so large (£750 per month). These findings strongly reinforce the humanitatian case for implementing the NICE Guidelines. Current proposals for doing this would require some 8,000 extra psychological therapists withing the NHS over the six years.

The combination of ibrutinib and rituximab demonstrates activity in first-line follicular lymphoma

This phase 2 study evaluated the activity and safety of ibrutinib, a Bruton’s tyrosine kinase inhibitor, plus rituximab in adults with previously untreated follicular lymphoma. Patients received once‐daily ibrutinib 560 mg continuously plus once‐weekly rituximab 375 mg/m² for 4 weeks beginning Week 1 (Arm 1, n = 60) or Week 9 (following an 8‐week ibrutinib lead‐in) to explore biomarkers (Arm 2, n = 20). The primary endpoint was the best overall response rate (ORR). The median age was 58 years; most had an Eastern Cooperative Oncology Group Performance Status of 0 (74%) and Stage III/IV disease (84%). At a median study follow‐up of 34 months in Arm 1 and 29 months in Arm 2, ORRs were 85% [95% confidence interval (CI) 73–93] and 75% (95% CI 51–91), respectively, with complete responses in 40% and 50%. The median duration of response was not reached in either arm; 30‐month progression‐free and overall survival rates were 67% and 97% (Arm 1) and 65% and 100% (Arm 2). The most common adverse events were fatigue, diarrhoea and nausea. Higher grade (Grade 3/4) haematological, haemorrhagic and cardiac events occurred infrequently. Ibrutinib plus rituximab was active and tolerable in first‐line follicular lymphoma.

A polyomavirus peptide binds to the capsid VP1 pore and has potent antiviral activity against BK and JC polyomaviruses

In pursuit of therapeutics for human polyomaviruses, we identified a peptide derived from the BK polyomavirus (BKV) minor structural proteins VP2/3 that is a potent inhibitor of BKV infection with no observable cellular toxicity. The thirteen-residue peptide binds to major structural protein VP1 with single-digit nanomolar affinity. Alanine-scanning of the peptide identified three key residues, substitution of each of which results in ~1000 fold loss of binding affinity with a concomitant reduction in antiviral activity. Structural studies demonstrate specific binding of the peptide to the pore of pentameric VP1. Cell-based assays demonstrate nanomolar inhibition (EC₅₀) of BKV infection and suggest that the peptide acts early in the viral entry pathway. Homologous peptide exhibits similar binding to JC polyomavirus VP1 and inhibits infection with similar potency to BKV in a model cell line. Lastly, these studies validate targeting the VP1 pore as a novel strategy for the development of anti-polyomavirus agents.

P1789 Stress echocardiography in patients with pulmonary arterial hypertension - a pilot study

INTRODUCTION

Pulmonary arterial hypertension (PAH) is a rare, progressive disease with poor prognosis. Stress echocardiography (SE) gives an important data on hemodynamic response to exercise. In patients with PAH SE may be useful for the diagnosis and risk assessment but data are lacking.

AIM OF STUDY

The aim of the study was to analyze exercise-induced response of right heart function and pulmonary artery pressure in patients with PAH.

MATERIALS AND METHODS

Study group consisted of 15 hemodynamically stable patients, 9 women, aged 22-73 (median- 50), diagnosed with PAH treated at Cardiology Department. The patients were subjected to stress echocardiography on supine cycloergometer and underwent assessment before and at peak-exercise. Moreover the standard parameters of clinical assessment: NT-proBNP, WHO functional class, and 6-minute walk test were analyzed.

RESULTS

Nine patients were in WHO class III, 4 of them- WHO class II and 2- WHO class I. The median NT-proBNP concentration was 169.3 (IQR 151.2-989.5) pg/ml. 6-Minute Walk Test distance was 455 (428-489) meters. The median workload was 75 (IQR 50-100) Watts and it was the median 54% (IQR 37-62%) of predicted.

The echocardiographic parameters assessed in SE at rest and shortly after peak-exercise revealed that RV systolic volume did not significantly differ: 70 (49.8-112.3) vs 71.5 (36.6-110) ml, p = 0.3. Right atrial area decreased from median 21.9 (17.4-27.3) to 19.8 (16.4-22.1) cm2, p = 0.05, whereas right atrial volume did not significantly changed - 80 (47.5-99.5) vs 68 (47.3-78.8) ml, p = 0.13. Further, shortly after exercise tricuspid regurgitation peak gradient (TRPG) significantly increased - 43 (25-76.5) vs 71 (50.5-102) mmHg, p = 0.002.

CONCLUSIONS

In stable PAH patients supine SE is feasible. Even in advanced WHO functional classes patients were able to exercise. Among echocardiographic parameters TRPG reflecting systolic pulmonary artery pressure showed the biggest difference between baseline and peak-exercise values. SE and seems to be a valuable tool in PAH patients’ assessment.

408 The relationship between right ventricle-arterial coupling and cardiac metabolism in pulmonary arterial hypertension - multimodal study

Background

Right ventricular (RV) function is a major determinant of survival in patients with pulmonary arterial hypertension (PAH). The concept of coupling mainly refers to the relationship between ventricular contractility and afterload. In advanced PAH, to maintain cardiac output, RV dilates and the uncoupling occurs with wall stress and increased metabolic demand. We previously confirmed that impaired RV function is associated with increased glucose uptake of RV myocytes estimated by PET, which marks patients with worse prognosis.

Purpose

Whether echocardiographic approach of coupling parameters in PAH patients has relationship with RV metabolic alterations.

Methods

Twenty-six stable PAH patients (mean age 49.92 ± 15.94 years) and sixteen healthy subjects (control group) were enrolled into the study. The TAPSE, reflecting RV contractility, was obtained by mono-dimensional echo in standard technique. The echo estimation of the sPAP was reflecting RV afterload. Ventricular-arterial coupling was evaluated by the ratio between those two parameters. All PAH patients had also right heart catheterization (RHC) and PET performed during baseline visit. Heart glucose metabolism was assessed with fluorodeoxyglucose (FDG) as a tracer in PET. Its uptake was quantified as mean standardized uptake value (SUV) for both left ventricle (LV) and RV. Mean follow-up time of this study was 16.6 ± 7.5 months and the clinical end-point (CEP) was defined as death or clinical deterioration.

Results

Most of enrolled patients were in the WHO functional Class III (61%, 16). There were significant correlations between echo-derived hemodynamic parameters and RHC-derived values e.g. emPAP vs mPAP (RHC), r = 0.86, p < 0.001. Echo-estimated RV ventricular-arterial coupling parameter (TAPSE/sPAP) was 0.35 ± 0.20 in PAH group and 1.51 ± 0.22 in control group, p < 0.001. Mean SUV RV/LV ratio was 1.03 ± 0.68 in PAH group and 0.19 ± 0.08 in controls, p < 0.005.

Echo-derived TAPSE/sPAP significantly correlated with hemodynamic parameters from RHC – cardiac output and pulmonary vascular resistance. Interestingly, we also observed significant correlations of TAPSE/sPAP with glucose uptake in PET - SUV RV as well as with SUV RV/LV (r=-0.63, p = 0.0006; r=-0.50, p = 0.0009), confirming higher metabolic demand in uncoupled heart in case of PAH.

Furthermore, patients who reached CEP (n = 15, 57%) had a significantly lower TAPSE/esPAP ratio (0.29 ± 0.17 vs 0.43 ± 0.21, p = 0.04) and higher SUV RV/LV (1.39 ± 0.79 vs 0.55 ± 0.45, p = 0.01). ROC analysis revealed significant cut-off value of TAPSE/esPAP in predicting CEP (AUC 0.72 (95% CI 0.52-0.92), p = 0.03). Patients with TAPSE/esPAP lower than 0.25 mm/mmHg had worse prognosis, log-rank test, p = 0.001 (Figure 1).

Conclusions

Simple echocardiographic parameter reflecting RV coupling (TAPSE/esPAP) related to altered myocardium metabolism in PAH may predict outcome in patients with PAH.

Abstract 408 Figure 1

Non-ischemic heart preconditioning

Ischemic heart conditioning has been shown to protect the organ against ischemia/reperfusion injury. Animal studies have revealed that the heart can also be conditioned by non-ischemic procedures, namely physical exercise and tachycardia. Long and short term endurance training, sprint training, resistance or interval training and even one bout of exercise induce cardiac preconditioning, which is manifested by a reduction in post ischemia/reperfusion infarct size, ventricular arrhythmia and improved heart function. Several factors contribute to the exercise-induced heart preconditioning, among which the most important can be: increased activity of the anti-radical defense system, opioids, interleukin-6, nitric oxide, ATP dependent potassium channels, heat shock protein 72 and sphingosine-1-phosphate. A few studies have also shown that one bout of exercise in patients with stable angina increases tolerated workload. According to some data obtained in swine and dogs, stimulated tachycardia before ischemia/reperfusion reduces the infarct size. Future studies are needed to fully clarify the mechanisms responsible for exercise- or tachycardia-induced heart preconditioning against ischemia/reperfusion. It may lead to the development of new treatment modes of the disease.

Abstract P6-03-11: Differences in serum miRNA signatures in women with pathology-confirmed breast cancer, benign breast diseases and healthy individuals with no cancer history

[INTRODUCTION] Mammography is the principal non-invasive imaging method of screening for breast cancer around the world. Mammography has been shown to be effective in reducing breast cancer deaths in randomized studies (Tabar et al., 2011 and Duffy et al., 2002). However, screening mammography can result in false positives that require subsequent interventions such as biopsy or interval repeat mammography.

Recently, circulating micro RNAs (miRNAs) have been cited as promising minimally invasive markers for breast cancer as well as for various other types of malignancies (Shimomura et al., 2016; Lawrie et al., 2008; Wang et al., 2009; Zhang et al., 2010; Mitchell et al., 2008). In this study, we have developed a new molecular diagnostic platform for the measurement of circulating (serum) miRNAs to assist with the management of women with abnormal screening mammograms.

[METHODS] Peripheral venous blood samples were collected in BD Red/Gray gel barrier tubes from patients with untreated breast cancer, patients with benign breast diseases and healthy individuals with no cancer history. The processing from blood to serum was done within six hours of collection and stored at -80°C. Total RNA was extracted from 300uL of the resulting serum using 3D-Gene®RNA extraction reagent (Toray Industries, Inc). Comprehensive miRNA expression analysis was then performed using 3D-Gene® Human miRNA Oligo Chip (Toray Industries, Inc). The average of three pre-selected internal control miRNA (miR-149-3p, miR-2861 and miR-4463) was used to normalize the signals across the different microarrays tested.

[RESULTS] RESULTS] All serum specimens used in this study were from subjects enrolled at US clinical sites (83% Caucasian, 15% African American, 2% Asian and others). One hundred fifteen (115) specimens (breast cancer: 40, healthy: 45, benign breast lesions: 30) were selected as a training cohort and used to develop comprehensive discriminants with 1–5 miRNAs using Fisher's linear discriminant analysis. The analysis identified a combination of five miRNAs that could detect breast cancer, and the resulting discriminant equation showed a sensitivity of 90.5%, specificity of 89.5% and accuracy of 89.8%. As test cohorts, (A) 381 subjects (breast cancer: 63, healthy: 160, benign breast lesions: 152), independent from subjects in the training cohort, and (B) 35 subjects who had been referred for breast biopsy were tested. The discrimination performance of the equation for each breast cancer stage (Stage 0: 1, Stage 1: 20, Stage 2: 17, Stage 3: 14, Stage 4: 11) was examined in the test cohorts. Also, information from breast cancer types as well as from benign breast lesions have been used to assess the performance of the discriminant score. The results of these analyses along with a discussion of the potential significance and plans for expanded clinical trials will be presented.

Citation Format: Akiyama H, Manlapaz V, Wong C, Yamazaki Y, Knapp M, Ohara S. Differences in serum miRNA signatures in women with pathology-confirmed breast cancer, benign breast diseases and healthy individuals with no cancer history [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-03-11.

Candidate Genes for Nonsyndromic Cleft Palate Detected by Exome Sequencing

Nonsyndromic cleft palate only (nsCPO) is a facial malformation that has a livebirth prevalence of 1 in 2,500. Research suggests that the etiology of nsCPO is multifactorial, with a clear genetic component. To date, genome-wide association studies have identified only 1 conclusive common variant for nsCPO, that is, a missense variant in the gene grainyhead-like-3 ( GRHL3). Thus, the underlying genetic causes of nsCPO remain largely unknown. The present study aimed at identifying rare variants that might contribute to nsCPO risk, via whole-exome sequencing (WES), in multiply affected Central European nsCPO pedigrees. WES was performed in 2 affected first-degree relatives from each family. Variants shared between both individuals were analyzed for their potential deleterious nature and a low frequency in the general population. Genes carrying promising variants were annotated for 1) reported associations with facial development, 2) multiple occurrence of variants, and 3) expression in mouse embryonic palatal shelves. This strategy resulted in the identification of a set of 26 candidate genes that were resequenced in 132 independent nsCPO cases and 623 independent controls of 2 different ethnicities, using molecular inversion probes. No rare loss-of-function mutation was identified in either WES or resequencing step. However, we identified 2 or more missense variants predicted to be deleterious in each of 3 genes ( ACACB, PTPRS, MIB1) in individuals from independent families. In addition, the analyses identified a novel variant in GRHL3 in 1 patient and a variant in CREBBP in 2 siblings. Both genes underlie different syndromic forms of CPO. A plausible hypothesis is that the apparently nonsyndromic clefts in these 3 patients might represent hypomorphic forms of the respective syndromes. In summary, the present study identified rare variants that might contribute to nsCPO risk and suggests candidate genes for further investigation.

Rationally Designed PI3Kα Mutants to Mimic ATR and Their Use to Understand Binding Specificity of ATR Inhibitors

ATR, a protein kinase in the PIKK family, plays a critical role in the cell DNA-damage response and is an attractive anticancer drug target. Several potent and selective inhibitors of ATR have been reported showing significant antitumor efficacy, with most advanced ones entering clinical trials. However, due to the absence of an experimental ATR structure, the determinants contributing to ATR inhibitors' potency and specificity are not well understood. Here we present the mutations in the ATP-binding site of PI3Kα to progressively transform the pocket to mimic that of ATR. The generated PI3Kα mutants exhibit significantly improved affinity for selective ATR inhibitors in multiple chemical classes. Furthermore, we obtained the X-ray structures of the PI3Kα mutants in complex with the ATR inhibitors. The crystal structures together with the analysis on the inhibitor affinity profile elucidate the roles of individual amino acid residues in the binding of ATR inhibitors, offering key insights for the binding mechanism and revealing the structure features important for the specificity of ATR inhibitors. The ability to obtain structural and binding data for these PI3Kα mutants, together with their ATR-like inhibitor binding profiles, makes these chimeric PI3Kα proteins valuable model systems for structure-based inhibitor design.

The skeletal and heart muscle triacylglycerol lipolysis revisited

For 40 years, the enzyme hormone sensitive lipase was considered to hydrolyze the first ester bond of the triacylglycerol moiety and thus initiate hydrolysis. However, 12 years ago a new lipolytic enzyme, termed adipose triglyceride lipase was discovered. It was further shown that the process of lipolysis of triacylglycerol to diacylglycerol and fatty acid is initiated by adipose triglyceride lipase and not by hormone sensitive lipase, responsible for hydrolysis of diacylglycerol to monoacyglycerol and fatty acid. Adipose triglyceride lipase is present in all types of cells containing neutral fat. The enzyme is activated by a protein called comparative gene identification-58 and inhibited by a protein called G0/G1 switch protein 2. It has also been discovered that perilipins, the main proteins coating lipid droplets in the cells, are involved in the process of triacylglycerol lipolysis. Five perilipins (1-5) were identified, however, up to now their role has been poorly assessed. In skeletal muscles, exercise and training affect the mRNA expression and protein content of adipose triglyceride lipase, comparative gene identification-58, G0/G1 switch protein 2, perilipin 2 and 5. The effect of exercise/training depends on exercise intensity and type of muscle fiber. An interaction between comparative gene identification-58 and adipose triglyceride lipase seems to be responsible for the enzyme activation during contractile activity. Adipose triglyceride lipase is also responsible for the activation of the first step of triacylglycerol lipolysis in the heart. There is substantial evidence that cardiac triacylglycerol metabolism affects the function of the heart. ATGL gene mutations leads to the development of neutral lipid storage diseases.

Childhood bullying victimization is associated with use of mental health services over five decades: a longitudinal nationally representative cohort study

BACKGROUND

Research supports robust associations between childhood bullying victimization and mental health problems in childhood/adolescence and emerging evidence shows that the impact can persist into adulthood. We examined the impact of bullying victimization on mental health service use from childhood to midlife.

METHOD

We performed secondary analysis using the National Child Development Study, the 1958 British Birth Cohort Study. We conducted analyses on 9242 participants with complete data on childhood bullying victimization and service use at midlife. We used multivariable logistic regression models to examine associations between childhood bullying victimization and mental health service use at the ages of 16, 23, 33, 42 and 50 years. We estimated incidence and persistence of mental health service use over time to the age of 50 years.

RESULTS

Compared with participants who were not bullied in childhood, those who were frequently bullied were more likely to use mental health services in childhood and adolescence [odds ratio (OR) 2.53, 95% confidence interval (CI) 1.88-3.40] and also in midlife (OR 1.30, 95% CI 1.10-1.55). Disparity in service use associated with childhood bullying victimization was accounted for by both incident service use through to age 33 years by a subgroup of participants, and by persistent use up to midlife.

CONCLUSIONS

Childhood bullying victimization adds to the pressure on an already stretched health care system. Policy and practice efforts providing support for victims of bullying could help contain public sector costs. Given constrained budgets and the long-term mental health impact on victims of bullying, early prevention strategies could be effective at limiting both individual distress and later costs.

Global patterns of workplace productivity for people with depression: absenteeism and presenteeism costs across eight diverse countries

PURPOSE

Depression is a leading cause of disability worldwide. Research suggests that by far, the greatest contributor to the overall economic impact of depression is loss in productivity; however, there is very little research on the costs of depression outside of Western high-income countries. Thus, this study examines the impact of depression on workplace productivity across eight diverse countries.

METHODS

We estimated the extent and costs of depression-related absenteeism and presenteeism in the workplace across eight countries: Brazil, Canada, China, Japan, South Korea, Mexico, South Africa, and the USA. We also examined the individual, workplace, and societal factors associated with lower productivity.

RESULTS

To the best of our knowledge, this is the first study to examine the impact of depression on workplace productivity across a diverse set of countries, in terms of both culture and GDP. Mean annual per person costs for absenteeism were lowest in South Korea at $181 and highest in Japan ($2674). Mean presenteeism costs per person were highest in the USA ($5524) and Brazil ($5788). Costs associated with presenteeism tended to be 5-10 times higher than those associated with absenteeism.

CONCLUSIONS

These findings suggest that the impact of depression in the workplace is considerable across all countries, both in absolute monetary terms and in relation to proportion of country GDP. Overall, depression is an issue deserving much greater attention, regardless of a country's economic development, national income or culture.

Discovery and Pharmacological Characterization of Novel Quinazoline-Based PI3K Delta-Selective Inhibitors

Inhibition of the lipid kinase PI3Kδ is a promising principle to treat B and T cell driven inflammatory diseases. Using a scaffold deconstruction-reconstruction strategy, we identified 4-aryl quinazolines that were optimized into potent PI3Kδ isoform selective analogues with good pharmacokinetic properties. With compound 11, we illustrate that biochemical PI3Kδ inhibition translates into modulation of isoform-dependent immune cell function (human, rat, and mouse). After oral administration of compound 11 to rats, proximal PD markers are inhibited, and dose-dependent efficacy in a mechanistic plaque forming cell assay could be demonstrated.

Intensity modulated radiation therapy with simultaneous integrated boost based dose escalation on neoadjuvant chemoradiation therapy for locally advanced distal esophageal adenocarcinoma

AIM: To evaluate impact of radiation therapy dose escalation through intensity modulated radiation therapy with simultaneous integrated boost (IMRT-SIB).

METHODS: We retrospectively reviewed the patients who underwent four-dimensional-based IMRT-SIB-based neoadjuvant chemoradiation protocol. During the concurrent chemoradiation therapy, radiation therapy was through IMRT-SIB delivered in 28 consecutive daily fractions with total radiation doses of 56 Gy to tumor and 5040 Gy dose-painted to clinical tumor volume, with a regimen at the discretion of the treating medical oncologist. This was followed by surgical tumor resection. We analyzed pathological completion response (pCR) rates its relationship with overall survival and event-free survival.

RESULTS: Seventeen patients underwent dose escalation with the IMRT-SIB protocol between 2007 and 2014 and their records were available for analysis. Among the IMRT-SIB-treated patients, the toxicity appeared mild, the most common side effects were grade 1-3 esophagitis (46%) and pneumonitis (11.7%). There were no cardiac events. The Ro resection rate was 94% (n = 16), the pCR rate was 47% (n = 8), and the postoperative morbidity was zero. There was one mediastinal failure found, one patient had local failure at the anastomosis site, and the majority of failures were distant in the lung or bone. The 3-year disease-free survival and overall survival rates were 41% (n = 7) and 53% (n = 9), respectively.

CONCLUSION: The dose escalation through IMRT-SIB in the chemoradiation regimen seems responsible for down-staging the distal esophageal with well-tolerated complications.

Value-based mental healthcare: The cost aspect

Economic hardship can be a factor in the incidence and exacerbation of mental health problems, and economic constraints have always constrained availability of resources. But examining the economic case – whether treatment or longer-term preventive strategies are cost-effective – can actually provide strong support for investing more in them. This presentation will provide illustrations of how economic evidence has helped decision-makers (in government and in funding bodies) to recognise the enormous contributions often generated by prevention, treatment and care.

Disclosure of interest

The author has not supplied his declaration of competing interest.

Cost-effectiveness of the Mental Health and Development model for schizophrenia-spectrum and bipolar disorders in rural Kenya

BACKGROUND

The treatment gap for serious mental disorders across low-income countries is estimated to be 89%. The model for Mental Health and Development (MHD) offers community-based care for people with mental disorders in 11 low- and middle-income countries.

METHOD

In Kenya, using a pre-post design, 117 consecutively enrolled participants with schizophrenia-spectrum and bipolar disorders were followed-up at 10 and 20 months. Comparison outcomes were drawn from the literature. Costs were analysed from societal and health system perspectives.

RESULTS

From the societal perspective, MHD cost Int$ 594 per person in the first year and Int$ 876 over 2 years. The cost per healthy day gained was Int$ 7.96 in the first year and Int$ 1.03 over 2 years - less than the agricultural minimum wage. The cost per disability-adjusted life year averted over 2 years was Int$ 13.1 and Int$ 727 from the societal and health system perspectives, respectively, on par with antiretrovirals for HIV.

CONCLUSIONS

MHD achieved increasing returns over time. The model appears cost-effective and equitable, especially over 2 years. Its affordability relies on multi-sectoral participation nationally and internationally.

MMP-9 in atrial remodeling in patients with atrial fibrillation

INTRODUCTION

Atrial fibrillation (AF) is the most common arrhythmia and is associated with significant morbidity and mortality. The impact of matrix metalloproteinases (MMPs) on structural atrial remodeling and sustainment of AF in patients with persistent and permanent AF is unresolved.

OBJECTIVES

The aim was to evaluate MMP-9 and its tissue inhibitor-1 (TIMP-1) as markers of atrial remodeling in patients with persistent AF (PAF) who underwent electrical cardioversion (ECV) and in patients with permanent AF (continuous AF, CAF).

PATIENTS AND METHODS

Plasma levels of MMP-9 and TIMP-1, clinical findings, and echocardiographic parameters were evaluated in 39 patients with AF and in 14 controls with sinus rhythm.

RESULTS

The concentrations of MMP-9 were significantly higher in patients with PAF and CAF compared to controls. There was a significant increase of MMP-9 after ECV in the persistent AF group. The values of TIMP-1 were not significantly different between the groups. In patients with AF, MMP-9 levels were positively related to posterior wall thickness of the LV (r=0.356, P=0.049) and body mass index (r=0.367, P=0.046).

CONCLUSION

Elevated levels of MMP-9 were related to the occurrence and maintenance of AF. This suggests that MMP-9 can be a marker of atrial remodeling in patients with AF. Regulation of the extracellular collagen matrix might be a potential therapeutic target in AF.

Structure-Based Drug Design of Novel, Potent, and Selective Azabenzimidazoles (ABI) as ATR Inhibitors

Compound 13 was discovered through morphing of the ATR biochemical HTS hit 1. The ABI series was potent and selective for ATR. Incorporation of a 6-azaindole afforded a marked increase in cellular potency but was associated with poor PK and hERG ion channel inhibition. DMPK experiments established that CYP P450 and AO metabolism in conjunction with Pgp and BCRP efflux were major causative mechanisms for the observed PK. The series also harbored the CYP3A4 TDI liability driven by the presence of both a morpholine and an indole moiety. Incorporation of an adjacent fluorine or nitrogen into the 6-azaindole addressed many of the various medicinal chemistry issues encountered.

Structure-Based Drug Design of Novel Potent and Selective Tetrahydropyrazolo[1,5-a]pyrazines as ATR Inhibitors

A saturation strategy focused on improving the selectivity and physicochemical properties of ATR inhibitor HTS hit 1 led to a novel series of highly potent and selective tetrahydropyrazolo[1,5-a]pyrazines. Use of PI3Kα mutants as ATR crystal structure surrogates was instrumental in providing cocrystal structures to guide the medicinal chemistry designs. Detailed DMPK studies involving cyanide and GSH as trapping agents during microsomal incubations, in addition to deuterium-labeled compounds as mechanistic probes uncovered the molecular basis for the observed CYP3A4 TDI in the series.

Potent nonimmunosuppressive cyclophilin inhibitors with improved pharmaceutical properties and decreased transporter inhibition

Nonimmunosuppressive cyclophilin inhibitors have demonstrated efficacy for the treatment of hepatitis C infection (HCV). However, alisporivir, cyclosporin A, and most other cyclosporins are potent inhibitors of OATP1B1, MRP2, MDR1, and other important drug transporters. Reduction of the side chain hydrophobicity of the P4 residue preserves cyclophilin binding and antiviral potency while decreasing transporter inhibition. Representative inhibitor 33 (NIM258) is a less potent transporter inhibitor relative to previously described cyclosporins, retains anti-HCV activity in cell culture, and has an acceptable pharmacokinetic profile in rats and dogs. An X-ray structure of 33 bound to rat cyclophilin D is reported.

A cluster randomised controlled trial and economic evaluation of a structured training programme for caregivers of inpatients after stroke: the TRACS trial

BACKGROUND

The majority of stroke patients are discharged home dependent on informal caregivers, usually family members, to provide assistance with activities of daily living (ADL), including bathing, dressing and toileting. Many caregivers feel unprepared for this role and this may have a detrimental effect on both the patient and caregiver.

OBJECTIVE

To evaluate whether or not a structured, competency-based training programme for caregivers [the London Stroke Carer Training Course (LSCTC)] improved physical and psychological outcomes for patients and their caregivers after disabling stroke, and to determine if such a training programme is cost-effective.

DESIGN

A pragmatic, multicentre, cluster randomised controlled trial.

SETTING

Stratified randomisation of 36 stroke rehabilitation units (SRUs) to the intervention or control group by geographical region and quality of care.

PARTICIPANTS

A total of 930 stroke patient and caregiver dyads were recruited. Patients were eligible if they had a confirmed diagnosis of stroke, were medically stable, were likely to return home with residual disability at the time of discharge and had a caregiver available, willing and able to provide support after discharge. The caregiver was defined as the main person--other than health, social or voluntary care provider--helping with ADL and/or advocating on behalf of the patient.

INTERVENTION

The intervention (the LSCTC) comprised a number of caregiver training sessions and competency assessment delivered by SRU staff while the patient was in the SRU and one recommended follow-up session after discharge. The control group continued to provide usual care according to national guidelines. Recruitment was completed by independent researchers and participants were unaware of the SRUs' allocation.

MAIN OUTCOME MEASURES

The primary outcomes were self-reported extended ADL for the patient and caregiver burden measured at 6 months after recruitment. Secondary outcomes included quality of life, mood and cost-effectiveness, with final follow-up at 12 months.

RESULTS

No differences in primary outcomes were found between the groups at 6 months. Adjusted mean differences were -0.2 points [95% confidence interval (CI) -3.0 to 2.5 points; p = 0.866; intracluster correlation coefficient (ICC) = 0.027] for the patient Nottingham Extended Activities of Daily Living score and 0.5 points (95% CI -1.7 to 2.7 points; p = 0.660; ICC = 0.013) for the Caregiver Burden Scale. Furthermore, no differences were detected in any of the secondary outcomes. Intervention compliance varied across the units. Half of the participating centres had a compliance rating of > 60%. Analysis showed no evidence of higher levels of patient independence or lower levels of caregiver burden in the SRUs with better levels of intervention compliance. The economic evaluation suggests that from a patient and caregiver perspective, health and social care costs, societal costs and outcomes are similar for the intervention and control groups at 6 months, 12 months and over 1 year.

CONCLUSIONS

We have conducted a robust multicentre, cluster randomised trial, demonstrating for the first time that this methodology is feasible in stroke rehabilitation research. There was no difference between the LSCTC and usual care with respect to improving stroke patients' recovery, reducing caregivers' burden, or improving other physical and psychological outcomes, nor was it cost-effective compared with usual care. Compliance with the intervention varied, but analysis indicated that a dose effect was unlikely. It is possible that the immediate post-stroke period may not be the ideal time for the delivery of structured training. The intervention approach might be more relevant if delivered after discharge by community-based teams.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49208824.

FUNDING

This project was funded by the MRC and is managed by the NIHR (project number 09/800/10) on behalf of the MRC-NIHR partnership, and will be published in full in Health Technology Assessment; Vol. 17, No. 46. See the NIHR Journals Library website for further project information.

Evidence for a polygenic contribution to androgenetic alopecia

BACKGROUND

Male pattern baldness (androgenetic alopecia, AGA) is a highly heritable trait and the most common form of hair loss in humans. Eight genome-wide significant risk loci for AGA have been identified.

OBJECTIVES

To determine whether a polygenic component contributes to the genetic risk for AGA.

METHODS

This study used a German case-control sample for AGA, which comprised 581 severely affected patients and 617 controls, to determine the contribution of polygenic variance to AGA risk. The sample was divided evenly into discovery and test samples. An additive polygenic risk score was calculated from risk alleles with increasingly liberal P-values in the discovery dataset, which was then used to test for the enrichment of AGA risk score alleles in the independent test samples.

RESULTS

The polygenic score analysis provided significant evidence for a polygenic contribution to AGA where the amount of variance explained was 1·4-4·5%.

CONCLUSION

This study provides evidence for the specific contribution of a polygenic component to the overall heritable risk for AGA. To some degree, the polygenic architecture of AGA might reflect the complexity of the biological pathways involved. Further analyses and strategies that complement conventional genome-wide association studies are needed to identify these factors. These may include pathway-based analyses, the analysis of functional candidate genes and tests for epistatic effects with known loci.

Impact of initial treatment outcome on long-term costs of depression: a 3-year nationwide follow-up study in Taiwan

BACKGROUND

The impact of initial treatment outcome on long-term healthcare costs in depression remains to be determined. We aimed to identify demographic and clinical characteristics associated with initial treatment outcomes and to test whether and how these outcomes influence total healthcare costs over the subsequent 3 years.

METHOD

In this secondary analysis of a large healthcare database, a national cohort of adult patients (n = 126,471) who received antidepressant treatment for depression was identified and factors associated with initial outcomes were examined. Potential predictors of total healthcare costs in the subsequent years were assessed using generalized linear modeling, with a particular focus on initial outcome status after antidepressant treatment and co-morbidities.

RESULTS

Depression type and co-morbid painful physical symptoms (PPS) or mental illnesses were found to be associated with initial outcome status. Having sustained treatment-free status after initial treatment was shown to be associated with a 22-33% reduction in total healthcare costs in the second and third years (compared to those with late recontacts). Although the presence of co-morbid PPS was associated with higher healthcare costs, having certain co-morbid anxiety disorders was associated with lower costs over the 3 years.

CONCLUSIONS

Initial outcome status after antidepressant treatment has a sustained impact on individuals' total healthcare costs over the following 3 years. Future efforts to improve initial treatment outcome of depression are warranted.