The Effect of Asset Degradation on Trust in Swarms: A Reexamination of System-Wide Trust in Human-Swarm Interaction

OBJECTIVE

The effects of asset degradation on trust in human-swarm interaction were investigated through the lens of system-wide trust theory.

BACKGROUND

Researchers have begun investigating contextual features that shape human interactions with robotic swarms-systems comprising assets that coordinate behavior based on their nearest neighbors. Recent work has begun investigating how human trust toward swarms is affected by asset degradation through the lens of system-wide trust theory, but these studies have been marked by several limitations.

METHOD

In an online study, the current work manipulated asset degradation and measured trust-relevant criteria in a within-subjects design and addressed the limitations of past work.

RESULTS

Controlling for swarm performance (i.e., target acquisition), asset degradation and trust (i.e., reliance intentions) in swarms were negatively related. In addition, as degradation increased, perceptions of swarm cohesion, obstacle avoidance, target acquisition, and terrain exploration efficiency decreased, the latter two of which (coupled with the reliance intentions criterion) support the tenets of system-wide trust theory as well as replicate and extend past work on the effects of asset degradation on trust in swarms.

CONCLUSION

Human-swarm interaction is a context in which system-wide trust is relevant, and future work ought to investigate how to calibrate human trust toward swarm systems.

APPLICATIONS

Based on these findings, design professionals should prioritize ways to depict swarm performance and system health such that humans do not abandon trust in systems that are still functional yet not over-trust those systems which are indeed performing poorly.

Potential Sources of Moral Injury for Healthcare Workers in Forensic and Psychiatric Settings: A Systematic Review and Meta-ethnography

The current research examines potentially morally injurious events (PMIEs) faced by healthcare professionals working in forensic and psychiatric environments. A systematic literature review was conducted to identify peer-reviewed articles reporting on sources of moral injury or similar concepts (e.g., moral distress) for healthcare workers in such settings. Thirty articles were included and analyzed using a meta-ethnographic approach. Synthesis yielded three third-order factors, each reflecting a moral dichotomy: (a) "between profession and system," (b) "between relations with patients and relations with others," and (c) "between principles and practices." Findings illustrated the hierarchical relationships between dichotomies, with discordance between values of the healthcare profession and features of the healthcare system providing the conditions for PMIEs to occur. The review advances conceptual understandings of PMIEs in forensic and psychiatric settings, illustrating the multilayered dimensions within which morally injurious events are experienced. Theoretical and practical implications are offered that may support the early detection and prevention of moral injury in healthcare professionals.

Cancer-related cells and oncosomes in the liquid biopsy of pancreatic cancer patients undergoing surgery

Pancreatic ductal adenocarcinoma (PDAC) has a five-year survival rate of less than 10% due to its late diagnosis, rapid metastasis, and chemotherapeutic resistance. For a small proportion (10-20%) of early-stage patients however, surgical resection of the pancreatic tumor offers the best chance for survival but the effect of surgery on disease dissemination is unknown. The primary objective of this study was to characterize cellular and acellular blood-based analytes in portal and peripheral blood before pancreatic manipulation, during tumor dissection and immediately after surgical resection to determine the effects of the surgery. This study used the non-enriching third generation High-Definition Single Cell Assay (HDSCA3.0) workflow to investigate heterogeneous circulating rare cell population in the blood. Blood from both sites taken before surgical manipulation of the pancreas had significantly greater incidence of total rare cellular and acellular analytes than normal donor samples. Post-surgery portal and peripheral blood had significantly greater incidence of specific cellular and acellular subtypes compared to the matched pre- and during-surgery samples. Our results reveal that in patients with PDAC liquid biopsy analytes are increased in both the portal and peripheral blood; portal blood contains a higher frequency of analytes than in the peripheral blood; total analytes in the portal and peripheral blood samples were significantly associated with the tumor volume and pathological T stage; and the surgical procedure increased the blood levels of circulating cellular and acellular analytes, but not Epi.CTCs or Mes.CTCs. This study demonstrates liquid biopsy's utility in monitoring patients with PDAC with surgically resectable disease.

The impact of preoperative sarcopenia on postoperative ileus following colorectal cancer surgery

PURPOSE

Sarcopenia is associated with poor short- and long-term patient outcomes following colorectal surgery. Despite postoperative ileus (POI) being a major complication following colorectal surgery, the predictive value of sarcopenia for POI is unclear. We assessed the association between sarcopenia and POI in patients with colorectal cancer.

METHODS

Elective colorectal cancer surgery patients were retrospectively included (2018-2022). The cross-sectional psoas area was calculated using preoperative staging imaging at the level of the 3rd lumbar vertebrae. Sarcopenia was determined using gender-specific cut-offs. The primary outcome POI was defined as not achieving GI-2 by day 4. Demographics, operative characteristics, and complications were compared via univariate and multivariate analyses.

RESULTS

Of 297 patients, 67 (22.6%) were sarcopenic. Patients with sarcopenia were older (median 74 (IQR 67-82) vs. 69 (58-76) years, p < 0.001) and had lower body mass index (median 24.4 (IQR 22.2-28.6) vs. 28.8 (24.9-31.9) kg/m2, p < 0.001). POI was significantly more prevalent in patients with sarcopenia (41.8% vs. 26.5%, p = 0.016). Overall rate of complications (85.1% vs. 68.3%, p = 0.007), Calvien-Dindo grade > 3 (13.4% vs. 10.0%, p = 0.026) and length of stay were increased in patients with sarcopenia (median 7 (IQR 5-12) vs. 6 (4-8) days, p = 0.013). Anastomotic leak rate was higher in patients with sarcopenia although the difference was not statistically significant (7.5% vs. 2.6%, p = 0.064). Multivariate analysis demonstrated sarcopenia (OR 2.0, 95% CI 1.1-3.8), male sex (OR 1.9, 95% CI 1.0-3.5), postoperative hypokalemia (OR 3.2, 95% CI 1.6-6.5) and increased opioid use (OR 2.4, 95% CI 1.3-4.3) were predictive of POI.

CONCLUSION

Sarcopenia demonstrates an association with POI. Future research towards truly identifying the predictive value of sarcopenia for postoperative complications could improve informed consent and operative planning for surgical patients.

Rational optimization of a transcription factor activation domain inhibitor

Transcription factors are among the most attractive therapeutic targets but are considered largely 'undruggable' in part due to the intrinsically disordered nature of their activation domains. Here we show that the aromatic character of the activation domain of the androgen receptor, a therapeutic target for castration-resistant prostate cancer, is key for its activity as transcription factor, allowing it to translocate to the nucleus and partition into transcriptional condensates upon activation by androgens. On the basis of our understanding of the interactions stabilizing such condensates and of the structure that the domain adopts upon condensation, we optimized the structure of a small-molecule inhibitor previously identified by phenotypic screening. The optimized compounds had more affinity for their target, inhibited androgen-receptor-dependent transcriptional programs, and had an antitumorigenic effect in models of castration-resistant prostate cancer in cells and in vivo. These results suggest that it is possible to rationally optimize, and potentially even to design, small molecules that target the activation domains of oncogenic transcription factors.

PACAP and VIP Neuropeptides' and Receptors' Effects on Appetite, Satiety and Metabolism

The overwhelming increase in the prevalence of obesity and related disorders in recent years is one of the greatest threats to the global healthcare system since it generates immense healthcare costs. As the prevalence of obesity approaches epidemic proportions, the importance of elucidating the mechanisms regulating appetite, satiety, body metabolism, energy balance and adiposity has garnered significant attention. Currently, gastrointestinal (GI) bariatric surgery remains the only approach capable of achieving successful weight loss. Appetite, satiety, feeding behavior, energy intake and expenditure are regulated by central and peripheral neurohormonal mechanisms that have not been fully elucidated yet. Pituitary Adenylate Cyclase-Activating Polypeptide (PACAP) and Vasoactive Intestinal Polypeptide (VIP) are members of a family of regulatory peptides that are widely distributed in parallel with their specific receptors, VPAC1R, VPAC2R and PAC1R, in the central nervous system (CNS) and in the periphery, such as in the gastrointestinal tract and its associated organs and immune cells. PACAP and VIP have been reported to play an important role in the regulation of body phenotype, metabolism and homeostatic functions. The purpose of this review is to present recent data on the effects of PACAP, VIP, VPAC1R, VPAC2R and PAC1R on the modulation of appetite, satiety, metabolism, calorie intake and fat accumulation, to evaluate their potential use as therapeutic targets for the treatment of obesity and metabolic syndrome.

Study on emotion recognition bias in different regional groups

Human-machine communication can be substantially enhanced by the inclusion of high-quality real-time recognition of spontaneous human emotional expressions. However, successful recognition of such expressions can be negatively impacted by factors such as sudden variations of lighting, or intentional obfuscation. Reliable recognition can be more substantively impeded due to the observation that the presentation and meaning of emotional expressions can vary significantly based on the culture of the expressor and the environment within which the emotions are expressed. As an example, an emotion recognition model trained on a regionally-specific database collected from North America might fail to recognize standard emotional expressions from another region, such as East Asia. To address the problem of regional and cultural bias in emotion recognition from facial expressions, we propose a meta-model that fuses multiple emotional cues and features. The proposed approach integrates image features, action level units, micro-expressions and macro-expressions into a multi-cues emotion model (MCAM). Each of the facial attributes incorporated into the model represents a specific category: fine-grained content-independent features, facial muscle movements, short-term facial expressions and high-level facial expressions. The results of the proposed meta-classifier (MCAM) approach show that a) the successful classification of regional facial expressions is based on non-sympathetic features b) learning the emotional facial expressions of some regional groups can confound the successful recognition of emotional expressions of other regional groups unless it is done from scratch and c) the identification of certain facial cues and features of the data-sets that serve to preclude the design of the perfect unbiased classifier. As a result of these observations we posit that to learn certain regional emotional expressions, other regional expressions first have to be "forgotten".

GEMC1 and MCIDAS interactions with SWI/SNF complexes regulate the multiciliated cell-specific transcriptional program

Multiciliated cells (MCCs) project dozens to hundreds of motile cilia from their apical surface to promote the movement of fluids or gametes in the mammalian brain, airway or reproductive organs. Differentiation of MCCs requires the sequential action of the Geminin family transcriptional activators, GEMC1 and MCIDAS, that both interact with E2F4/5-DP1. How these factors activate transcription and the extent to which they play redundant functions remains poorly understood. Here, we demonstrate that the transcriptional targets and proximal proteomes of GEMC1 and MCIDAS are highly similar. However, we identified distinct interactions with SWI/SNF subcomplexes; GEMC1 interacts primarily with the ARID1A containing BAF complex while MCIDAS interacts primarily with BRD9 containing ncBAF complexes. Treatment with a BRD9 inhibitor impaired MCIDAS-mediated activation of several target genes and compromised the MCC differentiation program in multiple cell based models. Our data suggest that the differential engagement of distinct SWI/SNF subcomplexes by GEMC1 and MCIDAS is required for MCC-specific transcriptional regulation and mediated by their distinct C-terminal domains.

The association between iron deficiency and outcomes: a secondary analysis of the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial

In the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial, the use of intravenous iron did not reduce the need for blood transfusion or reduce patient complications or length of hospital stay. As part of the trial protocol, serum was collected at randomisation and on the day of surgery. These samples were analysed in a central laboratory for markers of iron deficiency. We performed a secondary analysis to explore the potential interactions between pre-operative markers of iron deficiency and intervention status on the trial outcome measures. Absolute iron deficiency was defined as ferritin <30 μg.l^-1 ; functional iron deficiency as ferritin 30-100 μg.l^-1 or transferrin saturation < 20%; and the remainder as non-iron deficient. Interactions were estimated using generalised linear models that included different subgroup indicators of baseline iron status. Co-primary endpoints were blood transfusion or death and number of blood transfusions, from randomisation to 30 days postoperatively. Secondary endpoints included peri-operative change in haemoglobin, postoperative complications and length of hospital stay. Most patients had iron deficiency (369/452 [82%]) at randomisation; one-third had absolute iron deficiency (144/452 [32%]) and half had functional iron deficiency (225/452 [50%]). The change in pre-operative haemoglobin with intravenous iron compared with placebo was greatest in patients with absolute iron deficiency, mean difference 8.9 g.l^-1 , 95%CI 5.3-12.5; moderate in functional iron deficiency, mean difference 2.8 g.l^-1 , 95%CI -0.1 to 5.7; and with little change seen in those patients who were non-iron deficient. Subgroup analyses did not suggest that intravenous iron compared with placebo reduced the likelihood of death or blood transfusion at 30 days differentially across subgroups according to baseline ferritin (p = 0.33 for interaction), transferrin saturation (p = 0.13) or in combination (p = 0.45), or for the number of blood transfusions (p = 0.06, 0.29, and 0.39, respectively). There was no beneficial effect of the use of intravenous iron compared with placebo, regardless of the metrics to diagnose iron deficiency, on postoperative complications or length of hospital stay.

Perception of audio-visual synchrony in infants at elevated likelihood of developing autism spectrum disorder

The inability to perceive audio-visual speech as a unified event may contribute to social impairments and language deficits in children with autism spectrum disorder (ASD). In this study, we examined and compared two groups of infants on their sensitivity to audio-visual asynchrony for a social (speaking face) and non-social event (bouncing ball) and assessed the relations between multisensory integration and language production. Infants at elevated likelihood of developing ASD were less sensitive to audio-visual synchrony for the social event than infants without elevated likelihood. Among infants without elevated likelihood, greater sensitivity to audio-visual synchrony for the social event was associated with a larger productive vocabulary.

CONCLUSION

Findings suggest that early deficits in multisensory integration may impair language development among infants with elevated likelihood of developing ASD.

WHAT IS KNOWN

•Perceptual integration of auditory and visual cues within speech is important for language development. •Prior work suggests that children with ASD are less sensitive to the temporal synchrony within audio-visual speech.

WHAT IS NEW

•In this study, infants at elevated likelihood of developing ASD showed a larger temporal binding window for adynamic social event (Speaking Face) than TD infants, suggesting less efficient multisensory integration.

Infective endocarditis: Do we have an effective risk score model? A systematic review

Background

Infective endocarditis (IE) is a rare, highly morbid condition with 17% in-hospital mortality. A total of 25-30% require surgery and there is ongoing debate with regard to markers predicting patient outcomes and guiding intervention. This systematic review aims to evaluate all IE risk scores currently available.

Methods

Standard methodology (PRISMA guideline) was used. Papers with risk score analysis for IE patients were included, with attention to studies reporting area under the receiver-operating characteristic curve (AUC/ROC). Qualitative analysis was carried out, including assessment of validation processes and comparison of these results to original derivation cohorts where available. Risk-of-bias analysis illustrated according to PROBAST guidelines.

Results

Of 75 articles initially identified, 32 papers were analyzed for a total of 20 proposed scores (range 66-13,000 patients), 14 of which were specific for IE. The number of variables per score ranged from 3 to 14 with only 50% including microbiological variables and 15% including biomarkers. The following scores had good performance (AUC > 0.8) in studies proposing the score (often the derivation cohort); however fared poorly when applied to a new cohort: PALSUSE, DeFeo, ANCLA, RISK-E, EndoSCORE, MELD-XI, COSTA, and SHARPEN. DeFeo score demonstrated the largest discrepancy with initial AUC of 0.88, compared to 0.58 when applied to different cohorts. The inflammatory response in IE has been well documented and CRP has been found to be an independent predictor for worse outcomes. There is ongoing investigation on alternate inflammatory biomarkers which may assist in IE management. Of the scores identified in this review, only three have included a biomarker as a predictor.

Conclusion

Despite the variety of available scores, their development has been limited by small sample size, retrospective collection of data and short-term outcomes, with lack of external validation, limiting their transportability. Future population studies and large comprehensive registries are required to address this unmet clinical need.

The Development of Disgust and Its Relationship to Adolescent Psychosocial Functioning

Experiences of excessive disgust have been implicated in several psychopathologies. Research, however, has rarely examined disgust and its role in psychosocial functioning from a developmental standpoint. This study examines the relationship between disgust expression in early life and subsequent adolescent psychosocial functioning. Data from 165 children were collected as part of a longitudinal study. Disgust propensity in infancy and childhood was assessed using a facial expressivity task and food aversion task, respectively. Adolescent psychosocial functioning was measured through several self-report measures. Results suggest that there exists a degree of consistency in disgust expression within the first year of life, and that childhood disgust propensity may be related to impairment in early adolescent psychosocial functioning. These findings highlight the potential importance of identifying early disgust expression as a marker for later psychopathology.

Humoral Immunogenicity of the mRNA-1273 Vaccine in the Phase 3 Coronavirus Efficacy (COVE) Trial

BACKGROUND

Messenger RNA (mRNA)-1273 vaccine demonstrated 93.2% efficacy against coronavirus disease 2019 (COVID-19) in the Coronavirus Efficacy (COVE) trial. The humoral immunogenicity results are now reported.

METHODS

Participants received 2 mRNA-1273 (100 µg) or placebo injections, 28 days apart. Immune responses were evaluated in a prespecified, randomly selected per-protocol immunogenicity population (n = 272 placebo; n = 1185 mRNA-1273). Serum binding antibodies (bAbs) and neutralizing antibodies (nAbs) to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-spike protein were assessed at days 1, 29, and 57 by baseline SARS-CoV-2-negative (n = 1197) and SARS-CoV-2-positive (n = 260) status, age, and sex.

RESULTS

SARS-CoV-2-negative vaccinees had bAb geometric mean AU/mL levels of 35 753 at day 29 that increased to 316 448 at day 57 and nAb inhibitory dilution 50% titers of 55 at day 29 that rose to 1081 at day 57. In SARS-CoV-2-positive vacinees, the first mRNA-1273 injection elicited bAb and nAb levels that were 11-fold (410 049) and 27-fold (1479) higher than in SARS-CoV-2-negative vaccinees, respectively, and were comparable to levels after 2 injections in uninfected participants. Findings were generally consistent by age and sex.

CONCLUSIONS

mRNA-1273 elicited robust serologic immune responses across age, sex, and SARS-CoV-2 status, consistent with its high COVID-19 efficacy. Higher immune responses in those previously infected support a booster-type effect. Clinical Trials Registration. NCT04470427.

Perfect Polar Alignment of Parallel Beloamphiphile Monolayers: Synthesis, Characterization, and Crystal Architectures of Unsymmetrical Phenoxy-Substituted Acetophenone Azines

It remains a great challenge to achieve polar order in organic molecular crystals because anti-parallel alignment of side-by-side molecules is intrinsically preferred. We have addressed this problem with a rational design that focuses on the polar stacking of parallel beloamphiphile monolayers (PBAMs) with strong lateral quadrupole-quadrupole attractions. We employ arene-arene interactions as lateral synthons. The first successes were achieved with unsymmetrical donor (X), acceptor (Y) substituted acetophenone azines which form polar PBAMs with double T-contacts between the azines. Near-perfect alignment was achieved with the methoxy series of (MeO, Y)-azines with Y=Cl, Br, I. Here, we report on the synthesis, the characterization (GC/MS, ¹ H NMR, ¹³ C NMR, FTIR), the crystallization, and the single-crystal X-ray analyses of the phenoxy series of (PhO, Y)-acetophenone azines with Y=F, Cl, Br, I. Properties of (RO, Y) azines were computed at the APFD/6-311G* level and are discussed with reference to p-nitroaniline (PNA). This (PhO, Y) series embodies an improved PBAM design based on triple T-contacts which is shown to facilitate faster crystallization and to produce larger crystals. Perfect polar-alignment has been achieved for the phenoxy series of (PhO, Y)-azines with Y=Cl, Br, I and the (PhO, F)-azine also features near-perfect dipole alignment.

The deviation-from-familiarity effect: Expertise increases uncanniness of deviating exemplars

Humanlike entities deviating from the norm of human appearance are perceived as strange or uncanny. Explanations for the eeriness of deviating humanlike entities include ideas specific to human or animal stimuli like mate selection, avoidance of threat or disease, or dehumanization; however, deviation from highly familiar categories may provide a better explanation. Here it is tested whether experts and novices in a novel (greeble) category show different patterns of abnormality, attractiveness, and uncanniness responses to distorted and averaged greebles. Greeble-trained participants assessed the abnormality, attractiveness, uncanniness of normal, averaged, and distorted greebles and their responses were compared to participants who had not previously seen greebles. The data show that distorted greebles were more uncanny than normal greebles only in the training condition, and distorted greebles were more uncanny in the training compared to the control condition. In addition, averaged greebles were not more attractive than normal greebles regardless of condition. The results suggest uncanniness is elicited by deviations from stimulus categories of expertise rather than being a purely biological human- or animal-specific response.

The uncanniness of written text is explained by configural deviation and not by processing disfluency

Deviating from human norms in human-looking artificial entities can elicit uncanny sensations, described as the uncanny valley. This study investigates in three tasks whether configural deviation in written text also increases uncanniness. It further evaluates whether the uncanniness of text is better explained by perceptual disfluency and especially deviations from specialized categories, or conceptual disfluency caused by ambiguity. In the first task, lower sentence readability predicted uncanniness, but deviating sentences were more uncanny than typical sentences despite being just as readable. Furthermore, familiarity with a language increased the effect of configural deviation on uncanniness but not the effect of non-configural deviation (blur). In the second and third tasks, semantically ambiguous words and sentences were not uncannier than typical sentences, but deviating, non-ambiguous sentences were. Deviations from categories with specialized processing mechanisms thus better fit the observed results as an explanation of the uncanny valley than ambiguity-based explanations.

SAGE-718: A First-in-Class N-Methyl-d-Aspartate Receptor Positive Allosteric Modulator for the Potential Treatment of Cognitive Impairment

N-Methyl-d-aspartate receptor (NMDAR) positive allosteric modulators (PAMs) have received increased interest as a powerful mechanism of action to provide relief as therapies for CNS disorders. Sage Therapeutics has previously published the discovery of endogenous neuroactive steroid 24(S)-hydroxycholesterol as an NMDAR PAM. In this article, we detail the discovery of development candidate SAGE-718 (5), a potent and high intrinsic activity NMDAR PAM with an optimized pharmacokinetic profile for oral dosing. Compound 5 has completed phase 1 single ascending dose and multiple ascending dose clinical trials and is currently undergoing phase 2 clinical trials for treatment of cognitive impairment in Huntington's disease.

Relevance of necroptosis in the hearts subjected to acute versus chronic ischemia/reperfusion injury

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Slovak Research and Development Agency

Medical Research Council Grant

Necroptosis, a necrosis-like programmed cell death modality dependent on the activity of receptor-interacting protein kinase 3 (RIP3) and mixed lineage domain kinase domain-like pseudokinase (MLKL), plays a prominent role in mediating myocardial ischemia/reperfusion injury. However, the extent to which necroptosis contributes to such damage under short and long reperfusion has not been evaluated in detail. In Wistar rat hearts, subjected to global 30-min ischemia followed by an acute 10-min reperfusion period, with compromised cardiac function, no changes in the protein expression of the main necroptotic markers (pThr231/Ser232-RIP3, MLKL) were found. Likewise, the non-canonical pathways of necroptosis involving Ca2+/calmodulin dependent protein kinase II–mitochondrial permeability transition pore (CaMKII–mPTP) or phosphoglycerate mutase 5–dynamin-related protein 1 (PGAM5–Drp1) axes were unlikely affected by such short reperfusion. In contrast, hearts subjected to global 30-min ischemia followed by a prolonged 40-min reperfusion period exhibited worsened hemodynamic parameters what was accompanied by the increased levels of RIP3, pSer229-RIP3 and MLKL. Moreover, this reperfusion period induced MLKL translocation to the plasma membrane, indicating necroptosis execution with resultant very likely cell disruption. Similarly, activated necroptosis, evidenced by the higher levels of proteins of the canonical pathway, has been suggested to contribute to the pathogenesis of post-infarction heart failure (30-min ischemia, 42-day reperfusion). Collectively, these findings suggest that short reperfusion seems to be insufficient to induce necroptosis in the heart and the molecular mechanisms being activated during the longer reperfusion phase are needed to promote necroptotic cell dying. Therefore, inhibition of necroptosis might represent a cardioprotective strategy in the settings of chronic, but not acute myocardial ischemia/reperfusion injury.

POS0145 CLINICAL RESPONSE TO RITUXIMAB IS ASSOCIATED WITH PREVENTION OF B-CELL DRIVEN SALIVARY GLAND INFLAMMATION AND EPITHELIAL RESTORATION AS REVEALED BY MOLECULAR PATHOLOGY: RESULTS FROM THE TRACTISS TRIAL IN PRIMARY SJOGREN’S SYNDROME

Background

The TRial for Anti-B-Cell Therapy In patients with pSS (TRACTISS) is the largest multi-centre, placebo-controlled, phase-III trial with the administration of 2 cycles of Rituximab (RTX) or placebo at week 0 and 24, with trial clinical endpoints at week 48. Despite the primary endpoints (30% reduction in fatigue or oral dryness) were not met, RTX treated patients showed an improvement in secondary endpoints, such as unstimulated whole salivary flow (UWSF), and salivary gland (SG) total ultrasound score1,2. Additionally, recent post-hoc analysis of TRACTISS using novel CRESS composite endpoints3, highlighted a significantly increased response rate in the RTX vs placebo arm.

Objectives

To perform the first longitudinal analysis of matched transcriptomic and histological data of SG biopsies of pSS patients treated with RTX vs placebo at 3 time points, over 48 weeks, from the TRACTISS cohort, in order to identify mechanisms of response/resistance to B cell depletion.

Methods

29 pSS patients randomised to RTX or placebo arm consented for labial SG biopsies at week 0, 16 and 48. Patients received two 1000mg cycles of RTX or placebo at week 0 and 24. SG focus score, inflammatory aggregate area fraction, B-cells (CD20+), T-cells (CD3+), follicular dendritic cells (FDCs) (CD21+) and plasma cells (CD138+) density were assessed using quantitative digital image analysis. RNA sequencing with deconvolution and pathway analysis was performed to identify genes signatures and consensus gene modules as biomarkers of disease evolution and response/resistance to therapy.

Results

Placebo-treated SGs showed worsening of SG inflammation highlighted by the increment of aggregate size, B-cell density, development of new FDC networks, and a higher ectopic GC prevalence over 48 weeks, compared to RTX-treated patients. No difference in focus score, total T-cell and plasma cell infiltration was observed. RTX downregulated genes involved in immune cell recruitment and inflammatory aggregate organisation (e.g. CXCL13, CCR7 and PDCD1). Gene signature-based analysis of 35 immune cell types using XCell highlighted how RTX blocked class-switched and memory-B-cells accumulation in SGs over 48 weeks. Pathway analyses confirmed the downregulation of leukocyte migration, MHC-II antigen presentation, and T-cell co-stimulation immunological pathways, such as the CD40 receptor complex pathway. Among RTX-treated patients, only CRESS-responders demonstrated prevention of worsening B cell-driven molecular pathology signatures over time and a significant improvement in UWSF, in parallel with the upregulation of molecular pathways associated to SG restoration of the glandular epithelium. None of the above effects were observed at week 16 after the first RTX cycle.

Conclusion

Two RTX infusions repeated at week 24 exerted beneficial effects on labial SG inflammatory infiltration in pSS by downregulating genes involved in immune cell recruitment, activation and organisation in ectopic GCs. Conversely, all the above parameters showed significant evolution in placebo treated patients over 48 weeks demonstrating progression of SG immunopathology. Clinical responders to RTX based on CRESS response criteria were characterised by preservation of exocrine function which appear driven by SG epithelial restoration.

References

[1]Fisher, B. A. et al. Effect of rituximab on a salivary gland ultrasound score in primary Sjögren’s syndrome: results of the TRACTISS randomised double-blind multicentre substudy. Ann. Rheum. Dis.77, 412–416 (2018).

[2]Bowman, S. J. et al. Randomized Controlled Trial of Rituximab and Cost-Effectiveness Analysis in Treating Fatigue and Oral Dryness in Primary Sjögren’s Syndrome. Arthritis Rheumatol.69, 1440–1450 (2017).

[3]Arends, S. et al. Composite of Relevant Endpoints for Sjögren’s Syndrome (CRESS): development and validation of a novel outcome measure. Lancet Rheumatol.3, e553–e562 (2021).

Disclosure of Interests

None declared

The Burnout Epidemic Within A Viral Pandemic: Impact of a Wellness Initiative

Background

Anesthesiologists are at high risk of developing burnout, a condition which can lead to many deleterious effects for the physician, and far-reaching effects on their patients and hospital systems. The COVID-19 pandemic has presented new challenges that have further exacerbated the risk of burnout in anesthesiologists. It is critical to develop effective strategies to promote well-being and decrease burnout for physicians in this specialty. The purpose of this observational study was to evaluate the impact of a Physician Well-Being Initiative on distress and well-being in anesthesiologists. It was hypothesized that the wellness intervention would promote an improvement in well-being scores.

Methods

The Physician Well-Being Initiative was launched in August 2019 in the Department of Anesthesiology, Pain Management and Perioperative Medicine at Henry Ford Hospital in Detroit, Michigan. The Physician Well-Being Initiative was designed to address several of the key factors that improve physician wellness, including 1) a sense of autonomy; 2) positive view of leadership; and 3) flexible schedule opportunities. To assess the impact of the Physician Well-Being Initiative on the well-being and distress scores of participating anesthesiologists, the physicians were emailed the validated Well-Being Index survey at baseline and 3, 6 and 12 months. The Well-Being Index evaluates multiple items of distress in the healthcare setting. The sample size was limited to the 54 anesthesiologists at Henry Ford Hospital.

Results

Forty-four of the 54 anesthesiologists completed the baseline questionnaire. A total of 44 physicians answered the questionnaire at baseline, with more male than female physicians (35 males and 7 females) and the majority (17/44) in practice for 5-10 years. Thirty-two physicians completed the survey at 3 and 6 months, and 31 physicians at 12 months after the launch of the Physician Well-Being Initiative. Twenty-one physicians completed the questionnaire at all 4 time points. Although the COVID-19 pandemic started shortly after the 6-month surveys were submitted, results indicated that there was a 0.05 decrease in the Well-Being Index sum score for every 1-month of time (coefficient -0.05, 95% CI -0.01, -0.08, P = 0.013). This study shows that, with the wellness initiative in place, the department was able to maintain and potentially even reduce physician distress despite the concurrent onset of the pandemic.

Conclusions

Following the launch of a sustained wellness initiative, this study demonstrates that physician wellness improved with time. This suggests that it takes time for a wellness initiative to have an effect on well-being and distress in anesthesiologists.

OP0085 CELL LINEAGE-SPECIFIC TRANSCRIPT DECONVOLUTION OF SYNOVIAL BIOPSIES FROM THE R4RA TRIAL IDENTIFIES CELL POPULATIONS ASSOCIATED WITH RESPONSE TO RITUXIMAB AND TOCILIZUMAB

Background

The R4RA trial, the first biopsy-based randomised trial in TNF-i inadequate responder patients with Rheumatoid Arthritis, showed that molecular stratification of RA synovial tissue was associated with clinical response, demonstrating that, in patients with low/absent B-cell lineage signature in synovial-tissue, tocilizumab is superior to rituximab1.

Objectives

Here, we aimed to perform cell-transcript deconvolution of pre-and post-treatment synovial biopsies from the R4RA trial.

Methods

A total of 164 patients underwent pre-treatment synovial biopsy (US-guided or arthroscopic) prior to randomization 1:1 to rituximab (83) or tocilizumab (81). 65 patients had a repeat biopsy at 16 weeks when clinical response was assessed using Clinical Disease Activity Index (CDAI) 50% improvement. RNA extracted from a minimum of 6 synovial samples/patient underwent RNA-sequencing and the abundance of tissue-infiltrating immune and stromal cell populations was estimated using the Microenvironment Cell Populations-counter (MCP-counter) method (Figure 1a).

Results

At baseline, while synovial semiquantitative immunohistochemistry scores did not differ between CDAI50% responders and non-responders, both for rituximab and tocilizumab, MCP-counter analysis showed significantly higher CD8 T-cells in responders to rituximab and higher macrophage-monocytes and myeloid dendritic cells (mDC) in responders to tocilizumab (Figure 1b). Moreover, when patients were classified according to MCP-counter scores, B-cell poor patients (MCP-counter B cell score <median value) showed significantly higher response rates to tocilizumab, while no difference was found in B-cell rich patients (Figure 1c). In contrast, macrophage and myeloid dendritic cell (mDC) rich individuals showed higher responses to tocilizumab (Figure 1d). Combined scores for lymphoid and myeloid cells demonstrated that patients poor in B-cells but rich in macrophages/mDC had a significantly higher response to tocilizumab (77% responders to tocilizumab vs 14% responders to rituximab, p=0.017, OR 16.48, 95%CI 1.29-1000.5) (Figure 1e). By analysing disease activity over time from baseline to week 16, we found a statistically significant interaction effect between treatments and time in B-cell poor (p=0.003), T-cell poor (p=0.022), mDC rich (p=0.029) and B-cell poor/Macrophages-mDC rich patients (p=0.006) (Figure 1f-g-h). Finally, by applying MCP-counter on matched pre-and post-treatment biopsies, rituximab-treated patients showed a significant reduction of B-cells, T-cells and monocyte/macrophages, while tocilizumab-treated patients showed a significant reduction of monocyte/macrophages, T-cells, but also neutrophils, myeloid dendritic cells and, interestingly, an increase in fibroblast signature (Figure 1i).

Conclusion

In silico deconvolution of the synovial tissue identify pre-treatment lymphoid cell lineages associated with response to rituximab and myeloid cells for tocilizumab. The longitudinal analysis of matched pre- and post-treatment synovial biopsies indicated that both medications have an effect on synovial immune cells, but tocilizumab can also affect stromal cells.

References

[1]Humby et al. Rituximab versus tocilizumab in anti-TNF inadequate responder patients with rheumatoid arthritis (R4RA): 16-week outcomes of a stratified, biopsy-driven, multicentre, open-label, phase 4 randomised controlled trial Lancet. 2021 Jan 23;397(10271):305-317. doi: 10.1016/S0140-6736(20)32341-2.

Acknowledgements

We would like to thank all patients and the R4RA recruiting centres and principal investigators http://www.r4ra-nihr.whri.qmul.ac.uk/recruiting_centres.php We would also like to acknowledge the UK National Institute of Health Research for funding the R4RA trial (grant reference: 11/100/76) and Versus Arthritis for providing infrastructure support through the Experimental Arthritis Treatment Centre (grant number: 20022).

Disclosure of Interests

None declared.

OP0077 SYNOVIAL RNA-SEQ ANALYSIS OF THE R4RA TRIAL IDENTIFIES SIGNATURES OF TREATMENT RESISTANCE AND REFRACTORY STATE IN RHEUMATOID ARTHRITIS

Background

Although up to 5-20% of rheumatoid arthritis (RA) patients do not respond to all current medications including biologic therapies, relatively little is known about the underlying pathogenic mechanisms driving non-response. In the first biopsy-driven randomized clinical trial in RA (R4RA)1, patients, in whom synthetic-DMARDs and at least one anti-TNF drug were not effective, were randomised 1:1 to rituximab (RTX) or tocilizumab (TOC) with a balanced stratification based on their synovial B-cell rich/poor signature, and response was assessed at 16 weeks. Non-responders were subsequently allowed to switch to the alternative drug with 48-week follow-up.

Objectives

Investigate mechanisms of response and non-response to RTX and TOC through deep molecular (RNA-Sequencing) profiling of synovial tissue.

Methods

RNA-Seq from baseline synovial tissue biopsies of patients who received RTX (n=88) or TOC (n=94) at any point in the trial was analysed for differentially expressed genes and associated modules between responders and non-responders. Response was defined as 50% improvement in clinical disease activity index (CDAI) score. Patients who had received both drugs during the trial were subdivided into RTX only responders (pro-RTX, n=9), TOC only responders (pro-TOC, n=12) and refractory patients (no response to both RTX & TOC, n=32) and analysed for differential gene expression and performed gene module analysis.

Results

6625 genes were significantly differentially expressed between RTX responders compared to non-responders, with a predominance of antigen presentation as well as T- and B-cell genes being associated with response, while non-response was linked to fibroblast associated genes. Comparison between TOC responders and non-responders identified fewer (85) differentially expressed genes, however lymphocyte and immunoglobulin genes were also high in the synovial tissue of TOC responders similar to RTX responders, while non-responder genes and modules also included a fibroblast signature.

The cross-over study design enabled comparison of rituximab-specific responders (pro-RTX), tocilizumab-specific responders (pro-TOC) and refractory patients (non-responders to both RTX & TOC, n=32) in a 3-way analysis (see Figure 1). This identified 1980 genes upregulated both in pro-RTX and pro-TOC patients, 175 genes exclusive to the pro-RTX group and 306 to the pro-TOC group, while 1277 genes were exclusive to the refractory group. While leukocyte modules and genes dominated RTX & TOC response, the refractory state was strongly associated with fibroblast genes and modules. We confirmed the observed expansion of fibroblasts from the RNA-Seq data by immunohistochemistry showing the presence of DKK3+ sublining fibroblasts in refractory rather than responder patients.

Conclusion

We provide novel insights into the cellular and molecular pathways underpinning multi-biologic resistance that define a refractory RA phenotype, characterised by a stromal/fibroblast signature.

References

[1]Humby, F., et al. Lancet (2021)

Acknowledgements

We would like to thank all patients and the R4RA recruiting centres and principal investigators http://www.r4ra-nihr.whri.qmul.ac.uk/recruiting_centres.php We would also like to acknowledge the UK National Institute of Health Research for funding the R4RA trial (grant reference: 11/100/76) and Versus Arthritis for providing infrastructure support through the Experimental Arthritis Treatment Centre (grant number: 20022).

Disclosure of Interests

None declared.

POS0138 RHEUMATOID SYNOVIAL FIBROBLASTS DISPLAY IMPRINTED MEMORY OF THEIR SYNOVIAL ENDOTYPE WHICH CAN BE PLASTICALLY MODULATED BY B-CELLS CROSSTALK

Background

Despite advances in the treatment of Rheumatoid Arthritis (RA), synthetics and biologicals drugs are ineffective in ~40% of patients. The origin of this refractoriness is unclear, but several clues point at the synovial microenvironment (SE) and the relative cellular heterogeneity between patients. We previously described the existence of different RA endotypes such as the lympho-myeloid, LM, which is B-cell rich and the fibroid-paucimmune, FPI, which is devoid of B-cells. While there is clear evidence that the crosstalk between stromal and immune cells in rheumatoid joints is critical for the perpetuation of chronic inflammation and autoimmunity, it is currently unknown whether transcriptional signatures identified in synovial fibroblasts (SFs) derived from different RA endotypes are driven by “imprinted” properties of the SFs or are shaped by the interaction with infiltrating immune cells in the RA joints.

Objectives

I) to identify “imprinted” vs “inducible” RASFs signatures trough the comparison of freshly isolated SFs and primary established SFs cultures obtained from LM vs FPI RA synovial biopsies and ii) to investigate the identified RASF signature as predictive biomarkers of disease evolution and of response to conventional and biological DMARDs.

Methods

We performed flowcytometry and single cell RNA sequencing (sc-RNAseq) on SFs obtained from LM and FPI biopsies, in isolation or in co-culture with RA B cells. Next, supernatant has been screened trough Multiplex and ELISA. Furthermore, we compared our results to publicly available sc-RNAseq datasets on freshly isolated SFs and to our bulk-RNAseq data from clinical trials patients.

Results

Hierarchical clustering from sc-RNAseq transcriptional profiling of LM vs FPI RASF - after several cell passages - identified profoundly different gene signatures: whereby LM-RASF were characterised by genes involved in inflammation, proteoglycan formation and integrin binding, FPI-RASF were defined by genes related to collagen biosynthesis. Comparing the above signatures with those of freshly isolated RASF we identified both imprinted (i.e. maintained through several in vitro passages) and inducible (i.e. loss after long term culture) gene signatures. Notably, RA B-cells co-cultured with FPI-RASF profoundly altered the FPI-RASF transcriptional profile including the ex-novo expression of gene signatures typical of LM-RASF. Consensus gene modules constructed on LM vs FPI RASF imprinted gene signatures could be tracked in longitudinal whole tissue bulk RNA-seq data obtained from both early arthritis and established RA and were associated with synovial pathotype-specific histological and clinical features. Finally, modulation of FPI-RASF related genes following B-cell depletion identified poor responders to Rituximab in the R4RA randomised clinical trial.

Conclusion

Our work demonstrates that RASFs from different endotypes display imprinted memory of their original synovial tissue when maintained in culture over several months. We also demonstrated that imprinted memory typical of RASF isolated from B-cell rich LM synovial tissues can be dynamically modulated in FPI RASF following crosstalk with RA B cells. Finally, consensus gene modules based on FPI vs LM RASF-gene signatures were able inform on response/resistance to targeted biologic therapies.

References

[1]Lewis, M. J. et al. Molecular Portraits of Early Rheumatoid Arthritis Identify Clinical and Treatment Response Phenotypes. Cell Rep (2019)

[2]Humby, F. et al. Synovial cellular and molecular signatures stratify clinical response to csDMARD therapy and predict radiographic progression in early rheumatoid arthritis patients. Ann Rheum Dis (2019)

[3]Zhang, F. et al. Defining inflammatory cell states in rheumatoid arthritis joint synovial tissues by integrating single-cell transcriptomics and mass cytometry. Nat Immunol (2019)

[4]Humby, F. et al. Rituximab versus tocilizumab in anti-TNF inadequate responder patients with rheumatoid arthritis (R4RA). Lancet (2021)

Disclosure of Interests

None declared

Targeting kinome reprogramming in ESR1 fusion-driven metastatic breast cancer

1085

Background: Genomic analysis has recently identified multiple ESR1 gene translocations in estrogen receptor-alpha positive (ERα+) metastatic breast cancer (MBC) that encode chimeric proteins whereby the ESR1 ligand binding domain is replaced by C-terminal sequences from many different gene partners. Transcriptionally active ESR1 fusions promoted hormone-independent cell growth, motility and resistance to endocrine therapy. The diversity of partner genes creates a considerable diagnostic challenge and no targeted treatments exist for ESR1 translocated tumors. Thus, we have established a transcriptional signature to diagnose the presence of an active ESR1 fusion (PMID: 34711608) and developed novel targeted therapies against ESR1 fusion-driven biology. Methods: Fifteen ESR1 fusion cDNA constructs were expressed in ER+ breast cancer cell lines by lentiviral transduction. Cell growth was assayed by Alamar blue assay. A mass spectrometry (MS)-based Kinase Inhibitor Pulldown Assay (KIPA) and tandem mass tag-based proteomics were performed to identify ESR1 fusion-driven druggable kinases for subsequent pharmacological inhibition. Results: KIPA profiling demonstrated an increase of multiple receptor tyrosine kinases including RET in T47D cells expressing active ESR1 fusions. Inhibition of RET by repurposing an FDA-approved drug significantly suppressed ESR1 fusion-driven cell growth in vitro, suggesting that despite marked diversity in the 3’ partners, common kinase activities were elevated and targetable. Proteogenomic profiling, including whole exome sequencing, RNA sequencing, and MS-based proteomics and phosphoproteomics were further performed on 22 ER+ patient-derived xenograft (PDX) tumors, which demonstrated different degrees of estradiol dependence. These integrated “omic” profiles defined targetable genes/pathways and predict tumor subsets that could be responsive to kinase inhibition therapy from this biologically heterogeneous panel of PDX tumors. WHIM18, a PDX naturally harboring the ESR1-YAP1 fusion showed elevated level of RET and CDK4/6 pathways. The tumor volumes were significantly reduced by the RET inhibitor. CDK4/6 inhibitor treatment showed similar tumor reductions to RET inhibition. Interestingly, WHIM9 PDX that expressed wild-type ESR1 conferred a comparable kinome profile to WHIM18. The tumor growth was significantly suppressed by RET or CDK4/6 inhibition. Therefore, pharmacological experiments validated proteogenomics-predicted drug response in two tested ER+ PDX models. Conclusions: Proteogenomics characterization of PDX tumors can drive clinical trial hypotheses. Here, we reveal therapeutic kinase vulnerabilities in ESR1 fusion-driven tumors as exemplified by RET inhibition, which will lay the framework for future clinical trials.

POS0441 IN-DEPTH ANALYSIS OF Axl AND MerTK EXPRESSION PATTERNS AND REGULATION BY BIOLOGIC TREATMENTS IN RHEUMATOID ARTHRITIS

Background

Tyrosine kinases receptors MerTK and Axl have been implicated in the pathogenesis of several autoimmune diseases. Despite sharing significant structural homology and having common ligands, Axl and MerTK have distinct features and biological functions [1]. A growing body of evidence suggests that both Axl and MerTK play a crucial role in Rheumatoid Arthritis (RA) pathogenesis and progression and may be exploited as novel therapeutic targets [2]. However, numerous unanswered questions remain to be addressed.

Objectives:

i.To define common and distinct gene-partners of Axl/MerTK and quantify their expression in RA synovial tissue.

ii.To assess the co-expression of Axl/MerTK by synovial cells.

iii.To outline the longitudinal variation in Axl/MerTK expression upon treatment intervention.

Methods

Synovial tissue samples were collected by US-guided synovial biopsy from: i. Patients with early (<12 months) RA DMARDs/steroid-naïve [n=87]; and ii. RA patients who failed the first-line biologic with TNF-inhibitors (TNFi) before and 16 weeks after receiving either Rituximab (RTX) or Tocilizumab (TOC) [n=164] [3]. Gene expression was obtained by bulk RNAseq performed on an Illumina HiSeq2500 platform. Axl-/MerTK-modules were defined using STRING networks and the module expression determined by the mean z-score of regularized log transformed expression for all genes in the set. Axl, MerTK, CD55, CD90, CD68 protein expression was analysed by multiplex immunofluorescence staining.

Results

Using STRING network analysis, we defined an Axl- and a MerTK-module composed of 31 predicted gene-partners of either Axl or MerTK. Thirteen genes were common to both modules and included the ligands Gas6 and ProteinS, and EGFR. Conversely, eighteen genes were uniquely present in the Axl-module (e.g., PIK3-family, IGF1R, IFNAR1 and STAT3) or the MerTK-module (e.g., Galectin3 and TULP, recently discovered MerTK ligands, FCGR1A/CD64, PTPN1and MEGF10). Axl/MerTK-modules quantified in the early-arthritis treatment-naïve RNAseq dataset showed a significant negative correlation with the synovitis score (Axl r=−0.33, p=0.0032; MerTK r=-0.33, p=0.003). At protein level, CD68+macrophages of the Lining showed notable heterogeneity between patients: they could express either Axl or MerTK alone, or co-express both. Axl was also present in most CD55+ Lining Fibroblast-Like-Cells (FLS) but not by CD90+ Sublining FLS while MerTK, as expected, was restricted to macrophages, including intra-aggregate tingible-body-macrophages.

To define how Axl and MerTK vary depending on disease stage and treatment exposure, we quantified their gene expression in active RA patients inadequately responding to TNFi, prior and 16 weeks after starting second-line biologic (RTX or TOC) [3]. Differently from the early-arthritis cohort, MerTK was significantly up-regulated in synovia characterised by higher degree of tissue inflammation (lympho-myeloid > diffuse-myeloid > pauci-immune, p<0.0001) and significantly positively correlated with several cytokines’ genes such as TNF, IL-6, CCL8 and IL-10. MerTK expression was dependent on clinical response to RTX but not TOC as assessed by EULAR response (DAS28CRP, good vs none/mod, FDRresp 0.048). Conversely, Axl expression significantly increased upon IL-6 blockade by TOC independently of the clinical response (FDRtime 0.016).

Conclusion

Our data further corroborate that Axl and MerTK constitute a dynamic axis influenced by the synovial tissue inflammatory features, the disease stage, the exposure and the response to targeted treatment and the blockade of critical inflammatory pathways over time. A better understanding of the individual features of these tyrosine kinases as well as their interaction would be beneficial to define novel treatment approaches.

References

[1]Zagórska A, et al. Nat Immunol. 2014 Oct;15(10):920-8

[2]Kemble S, Croft AP. Front Immunol. 2021 Sep 3;12:715894

[3]Humby F et al. Lancet. 2021 Jan 23;397(10271):305-317

Acknowledgements

Versus Arthritis.

Disclosure of Interests

None declared.

POS0431 PDGF-BB, TNF-α, AND LT-β REGULATE FOLLICULAR DENDRITIC CELL DEVELOPMENT IN THE RHEUMATOID SYNOVIUM

Background

Follicular dendritic cells (FDCs) fundamentally contribute to the formation of synovial ectopic lymphoid-like structures in rheumatoid arthritis (RA) which is associated with poor clinical prognosis. Despite this critical role in RA pathogenesis, FDC development in the RA synovium has not been fully elucidated.

Objectives

To investigate the role of TNF-α/LT-β and PDGF-BB in the ontogeny of RA synovial FDCs and the differentiation of lymphoid and fibroid RA synovitis.

Methods

RA Synovial tissues were obtained from the Pathobiology of Early Arthritis Cohort (PEAC) of the Centre for Experimental Medicine and Rheumatology of Queen Mary University of London. RNA-Seq analysis and confocal imaging of early and late FDC differentiation markers were carried out and the stromal cell subsets were sorted by flow cytometry. The stromal cell subsets were treated with TNF-α/LT-β and/or PDGF-BB and the expression of FDC differentiation genes was assessed by qPCR. Germinal centre reactions were setup in vitro using TNF-α/LT-β activated stromal cells, and antibody production by naive human B cells stimulated with anti IgM was measured by ELISA.

Results

Our results indicate that PDGF-BB induces the FDC marker CNA.42+ on NG2+/αSMA+ type-1 pericytes, stimulates THY-1 and αSMA gene expression, and strongly correlates with fibroid synovitis using RNA-Seq analysis. On the other hand, TNF-α/LT-β downregulate PDGFR-β, THY-1, αSMA; induce CD21, FcɣRIIB expression, and significantly correlate with lymphoid synovial pathotype. Ultrastructural examination of antigen trapping on TNF-α/LT-β-activated RA synovial fibroblasts (RASFs) showed periodically retained surface antigens and these fibroblasts were able to induce T cell independent B cell activation in in vitro germinal centre reactions. The transition from an early PDGFR-β+ pre FDCs to a late TNF-α/LT-β-responsive mature FDCs is promoted by PDGF-BB. PDGF-BB induces TNF-αR expression in RASFs and facilitates B cell recruitment via pericyte CXCL13 expression and stromal cell migration.

Conclusion

To the best of our knowledge, this is the first report describing the crosstalks between PDGF-BB and TNF-α/LT-β in FDC development in the rheumatoid synovium and its association with the evolution of lymphoid and fibroid synovitis. Selective targeting of this interplay could inhibit FDC differentiation and potentially ameliorate RA in clinically severe and drug-resistant patients.

Disclosure of Interests

None declared.

OP0109 EXPRESSION QUANTITATIVE TRAIT LOCI IN EARLY TREATMENT-NAÏVE RHEUMATOID ARTHRITIS

Background

To date more than 100 genetic loci have been associated with rheumatoid arthritis (RA), particularly in the human leukocyte antigen (HLA) region. Our understanding of the functional consequences of genetic variation in RA causality, however, is limited and it has been shown that a substantial portion of complex disease risk alleles modify gene expression in a cell-specific manner [1]. The Pathobiology of Early Arthritis Cohort (PEAC) is a longitudinal study looking at treatment-naiv̈e RA patients with genotyped data as well as both synovial and blood RNA-sequenced biopsies prior to treatment with disease modifying anti-rheumatic drugs (DMARDs).

Objectives

To explore expression quantitative trait loci (eQTL) in synovium and blood within PEAC and characterise the effects of genetic variation on gene expression measured by RNA-sequencing. A further goal was to investigate the role of these variants in RA disease severity and response variables.

Methods

Genotypes were generated by Illumina Human CoreExome-24 version 1-0 array in 118 RA patients. Single nucleotide polymorphisms (SNPs) in the HLA region were imputed using HLA-TAPAS. A candidate gene study was performed on variants within the HLA region using Plink v2.0. Synovial (n=85) and blood (n=51) RNA-sequenced samples then underwent cis-eQTL analysis (loci within ±5x105Mb of the variant) based on linear regression models with the matrixeQTL R package using PEER [2] and PCA eigenvectors as covariates. Differences in eQTL between tissues were determined using a linear interaction term.

Results

The candidate gene study determined several amino acids around HLA-DRB1 acting as markers for seropositivity, which replicated findings by Raychaudhuri et. al. [3]. Using eQTL analysis, around 33,000 synovial SNPs were found with genome-wide significance (p ≤ 5x10-8) and around 29,000 in blood. This corresponded to 279 unique significant genes in synovium and 417 in blood (Figure 1). There were 100 genes common to both synovium and blood, including PSORS1C3, HLA-DRB9 and ERAP2, which have known associations with autoimmune diseases and inflammatory arthritis. Notably, 92 genes showed significantly different patterns of QTL expression between synovial tissue and blood (p ≤ 5x10-8). eQTL data also confirmed the triad of genetic variants significantly driving tissue gene expression of HLA-DPB2, while both HLA-DPB2 SNPs and HLA-DPB2 RNA-sequencing synovial expression correlated highly with erythrocyte sedimentation rate (ESR).

Figure 1.

Manhattan plots for cis-expression quantitative trait loci (eQTL) analysis performed on 85 synovial samples (top) and 51 blood samples (middle). Tissue interaction eQTL (bottom) show significant differences between tissues (p ≤ 5x10-8).

Conclusion

The high significance of genes in the HLA region in both tissues is in-keeping with the strong association between HLA and susceptibility to RA, as well as other autoimmune diseases. Most notably variants linked to HLA-DPB2 synovial expression were found to be a marker for disease severity through ESR association. Additionally, the significant differences between eQTL in blood and synovium highlight the need to explore functional consequences of genetic associations in the diseased tissue directly.

References

[1]Thalayasingam et. al. (2018). CD4+ and B lymphocyte expression quantitative traits at rheumatoid arthritis risk loci in patients with untreated early arthritis: implications for causal gene identification. Arthritis & Rheumatology, 70(3), 361-370.

[2]Stegle et al. (2012). Using probabilistic estimation of expression residuals (PEER) to obtain increased power and interpretability of gene expression analyses. Nature protocols, 7(3), 500-507.

[3]Raychaudhuri et al. (2012). Five amino acids in three HLA proteins explain most of the association between MHC and seropositive rheumatoid arthritis. Nature genetics, 44(3), 291-296.

Disclosure of Interests

None declared

Extreme Stress Events in a Forensic Hospital Setting: Prevalence, Impact, and Protective Factors in Staff

The current research explored the prevalence of stressful events in a forensic hospital setting, and their impact on staff. A systematic review of the literature on responses following exposure to extreme stress comprised 46 articles. This was followed by a Delphi study of professionals based in a forensic hospital (n = 43) to explore views on the factors that affect responses to extreme stress. This comprised three rounds to build consensus. Finally, a study of forensic hospital staff was conducted (n = 153, 47% male) to capture current trauma symptoms. The systematic review indicated three superordinate themes: outcomes adversely impacting staff and patients; personal characteristics moderating the impact of events; and organisational and interpersonal support moderating the impact of events. The Delphi supported these themes and noted the importance of factors external to the workplace and internal factors, such as self-blame. The final study demonstrated how a fifth of the workforce showed at least some trauma symptomology. Those who experienced less burnout reported lower trauma symptoms, while staff who experienced higher levels of secondary trauma at work reported higher levels of trauma symptoms. A higher level of resilience was related to lower levels of trauma symptomology. Findings are discussed in relation to the importance of recognising trauma in staff and implementing strategies to reduce and/or buffer the impact of stress on wellbeing. In doing so, the research presents a new model for consideration and development, the Impact and Amelioration of extreme stress events Model (IA-Model).

Familiarity, orientation, and realism increase face uncanniness by sensitizing to facial distortions

The uncanny valley predicts aversive reactions toward near-humanlike entities. Greater uncanniness is elicited by distortions in realistic than unrealistic faces, possibly due to familiarity. Experiment 1 investigated how familiarity and inversion affect uncanniness of facial distortions and the ability to detect differences between the distorted variants of the same face (distortion sensitivity). Familiar or unfamiliar celebrity faces were incrementally distorted and presented either upright or inverted. Uncanniness ratings increased across the distortion levels, and were stronger for familiar and upright faces. Distortion sensitivity increased with increasing distortion difference levels, again stronger for familiar and upright faces. Experiment 2 investigated how face realism, familiarity, and face orientation interacted for the increase of uncanniness across distortions. Realism increased the increase of uncanniness across the distortion levels, further enhanced by upright orientation and familiarity. The findings show that familiarity, upright orientation, and high face realism increase the sensitivity of uncanniness, likely by increasing distortion sensitivity. Finally, a moderated linear function of face realism and deviation level could explain the uncanniness of stimuli better than a quadratic function. A re-interpretation of the uncanny valley as sensitivity toward deviations from familiarized patterns is discussed.

Self-Recognition and Emotional Knowledge

Self-recognition emerges during the second year of life and represents the emergence of a reflective self, a metacognition which underlies self-conscious emotions such as embarrassment and shame, perspective taking, and emotional knowledge of others. In a longitudinal study of 171 children, two major questions were explored from an extant database: 1) Do early factors, including IQ, general environmental risk, mother-child attachment interaction, drug exposure, gender, and neonatal risk, relate to self-recognition?; 2) Does self-recognition, along with these earlier factors, predict the child's subsequent emotional knowledge? Consistent with previous data, 39% of children exhibited self-recognition by 18-months and few early factors explored were related to this ability. Moreover, path analysis revealed few effects of the earlier factors predicting self-recognition on children's emotional knowledge. Self-recognition did predict emotional knowledge at 4.5 years, such that children who showed early self-recognition showed greater emotional knowledge. Children from high risk environments also showed lower emotional knowledge. These findings indicate that self-recognition and environmental risk are related to children's later knowledge of emotions.

On the Measurement of Self-Conscious Emotions

Self-conscious emotions, like shame and pride, are thought to have an evaluative component in which the self is posited against a set of standards, rules, and goals of society. This study compares the two methods used to examine self-conscious emotions: a self-report questionnaire, the Test of Self-Conscious Affect in Children (TOSCA-C), and a direct observation of behaviors in response to particular tasks, developed by Lewis, Alessandri and Sullivan (1992). 126 young children participated in both tasks at ages 6 and 7. For the observation data, we found that the tendency to be self-evaluative in terms of success were not related to be self-evaluative in failure, and individual consistency across age was found for self-conscious emotions but not for the primary emotions. The questionnaire data showed that children who scored high in shame also scored high in failure, and there were no consistencies across age. There were weak, inconsistent associations between shame measured by the questionnaire technique and sadness observed in the experiment.

Comparison of impedance cardiography and cardiac magnetic resonance imaging for the evaluation of cardiac function in early-stage breast cancer patients

Objective.Breast cancer treatment can negatively impact cardiac function in some breast cancer patients. Current methods (MUGA, echocardiography) used in clinical practice to detect abnormal cardiac changes as a result of treatment suffer from important limitations. Use of alternative techniques that would offer safe, inexpensive and non-invasive cardiac function assessment in this population would be highly advantageous. The aim of this study was to examine the agreement between impedance cardiography (ICG) and cardiac magnetic resonance imaging (CMR) in quantifying stroke volume (SV), cardiac output (CO) and end-diastolic volume (EDV) in this population.Approach.Sixteen breast cancer patients underwent ICG and CMR assessments at three time-points (before treatment, immediately after chemotherapy, and four months after chemotherapy). Bland-Altman analysis was used to quantify the accuracy and precision of ICG (relative to CMR) in estimating absolute values of SV, CO and EDV. Four methods (concordance rate, polar concordance rate, clinical concordance rate and trend interchangeability rate) were also used to assess ICG performance in tracking changes in these variables.Main results.Bland-Altman analysis showed that the accuracy of ICG relative to CMR was -3.1 ml (SV), 0.2 l·min^-1(CO) and -26.0 ml (EDV) and precision was 13.2 ml (SV), 1.1 l·min^-1(CO) and 20.1 ml (EDV), respectively. Trending ability assessment showed that (1) the concordance rate was 87% (SV), 73% (CO) and 73% (EDV), (2) the polar concordance rate was 67% (SV), 53% (CO) and 33% (EDV), (3) the clinical concordance rate was 33% (SV), 40% (CO) and 20% (EDV) and (4) the trend interchangeability rate was 29% (SV), 43% (CO) and 17% (EDV), respectively.Significance.Our findings show that, although ICG showed good accuracy for absolute SV and CO measurements and for CO and EDV changes, precision was poor for all variables in terms of both absolute measurements and trend tracking performance. This suggests that ICG cannot be used interchangeably with CMR in breast cancer patients.

Prenatal drug exposure and executive function in early adolescence

PURPOSE

Study of the relationship between prenatal cocaine exposure (PCE) and executive function (EF) has yielded inconsistent results. The purpose of the current study is to examine whether PCE, biological sex, environmental risk, and their interaction predicted EF in early adolescence.

METHODS

135 12-year-old adolescents (40.7% with PCE), who were followed prospectively from birth, attempted up to 8 Tower of Hanoi (ToH) puzzle trials of increasing complexity. The number of correctly completed puzzles served as the main outcome measure. Survival analysis was used to examine predictors of the number of successfully completed trials.

RESULTS

As trial difficulty increased, fewer adolescents were able to solve the TOH puzzle. Adolescents from high risk environments and with either prenatal alcohol or prenatal cannabis exposure completed fewer puzzles (p < .05). In addition, a hypothesized 3-way interaction of PCE x sex x environmental risk was found such that cocaine-exposed males with high environmental risk had the worst performance (p < .01).

CONCLUSIONS

The current findings are consistent with prior research indicating that males with PCE may be at particular risk of poorer functioning and highlight the potential importance of examining adolescent's sex and environmental risk as moderators of PCE effects.

Comparison of deep learning with traditional models to predict preventable acute care use and spending among heart failure patients

 

Recent health reforms have created incentives for cardiologists and accountable care organizations to participate in value-based care models for heart failure (HF). Accurate risk stratification of HF patients is critical to efficiently deploy interventions aimed at reducing preventable utilization. The goal of this paper was to compare deep learning approaches with traditional logistic regression (LR) to predict preventable utilization among HF patients. We conducted a prognostic study using data on 93,260 HF patients continuously enrolled for 2-years in a large U.S. commercial insurer to develop and validate prediction models for three outcomes of interest: preventable hospitalizations, preventable emergency department (ED) visits, and preventable costs. Patients were split into training, validation, and testing samples. Outcomes were modeled using traditional and enhanced LR and compared to gradient boosting model and deep learning models using sequential and non-sequential inputs. Evaluation metrics included precision (positive predictive value) at k, cost capture, and Area Under the Receiver operating characteristic (AUROC). Deep learning models consistently outperformed LR for all three outcomes with respect to the chosen evaluation metrics. Precision at 1% for preventable hospitalizations was 43% for deep learning compared to 30% for enhanced LR. Precision at 1% for preventable ED visits was 39% for deep learning compared to 33% for enhanced LR. For preventable cost, cost capture at 1% was 30% for sequential deep learning, compared to 18% for enhanced LR. The highest AUROCs for deep learning were 0.778, 0.681 and 0.727, respectively. These results offer a promising approach to identify patients for targeted interventions.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): internally funded by Diagnostic Robotics Inc.

63 The “Brighton Connector”: A Simple, Reproducible and Cost-Effective Technique for Bilateral Antegrade Cerebral Perfusion During Aortic Arch Surgery

Aim

Surgery of the aortic arch presents significant technical and physiological challenges. Selective antegrade cerebral perfusion (SACP) during arch surgery has been shown to improve mortality and neurological outcomes in these patients. At our centre, we aimed to develop a safe, reliable, and cost-effective technique to provide bilateral antegrade cerebral perfusion without the need of another pump head.

Method

We developed our system using equipment that is included in the accessory packaging for the Sorin Xtra cell saver system, which is readily available in cardiac surgical units nationwide, but often discarded as it is not required. An EOPA arterial return cannula and the TRUE FLOW RDB SACP cannula were joined using our novel connection.

Results

A single surgeon has used the “Brighton Connector” for 6 patients in the last two years. All patients made a satisfactory recovery with a 0% rate of mortality or permanent neurological deficit.

Conclusions

All components in our circuit are already approved for use in cardiac theatres, and the connection tubing would normally be discarded, making our method cost neutral. We demonstrate through a case series that mortality and neurological outcomes are good and comparable with other techniques.