A Physical Activity and Diet Just-in-Time Adaptive Intervention to Reduce Blood Pressure: The myBPmyLife Study Rationale and Design

BACKGROUND

Smartphone applications and wearable devices are promising mobile health interventions for hypertension self-management. However, most mobile health interventions fail to use contextual data, potentially diminishing their impact. The myBPmyLife Study is a just-in-time adaptive intervention designed to promote personalized self-management for patients with hypertension.

METHODS AND RESULTS

The study is a 6-month prospective, randomized-controlled, remotely administered trial. Participants were recruited from the University of Michigan Health in Ann Arbor, Michigan or the Hamilton Community Health Network, a federally qualified health center network in Flint, Michigan. Participants were randomized to a mobile application with a just-in-time adaptive intervention promoting physical activity and lower-sodium food choices as well as weekly goal setting or usual care. The mobile study application encourages goal attainment through a central visualization displaying participants' progress toward their goals for physical activity and lower-sodium food choices. Participants in both groups are followed for up for 6 months with a primary end point of change in systolic blood pressure. Exploratory analyses will examine the impact of notifications on step count and self-reported lower-sodium food choices. The study launched on December 9, 2021, with 484 participants enrolled as of March 31, 2023. Enrollment of participants was completed on July 3, 2023. After 6 months of follow-up, it is expected that results will be available in the spring of 2024.

CONCLUSIONS

The myBPmyLife study is an innovative mobile health trial designed to evaluate the effects of a just-in-time adaptive intervention focused on improving physical activity and dietary sodium intake on blood pressure in diverse patients with hypertension.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05154929.

Confirm Rx insertable cardiac monitor for primary atrial fibrillation detection in high-risk heart failure patients (Confirm-AF trial)

BACKGROUND

Patients with heart failure (HF) represent a large population of patients who are at high risk for complications related to undiagnosed atrial fibrillation (AF). However, currently there are limited modalities available for early AF detection in this high-risk population. An implantable cardiac monitor (ICM) is inserted subcutaneously and can provide long-term arrhythmia information via remote monitoring.

METHODS AND RESULTS

Confirm-AF is a prospective randomized, nonblinded, two arm, multicenter clinical trial to be performed in the United States, enrolling 477 patients with a history of HF hospitalization and left ventricular ejection fraction >35% from 30 medical sites. Patients will be randomized in a 2:1 fashion to undergo ICM implant with remote monitoring and symptom-triggered mobile app transmissions versus (vs.) Non-ICM management and follow-up. The primary objective of this trial is to compare the time to first detection of AF lasting > 5 min using an Abbott ICM compared to non-ICM monitoring in symptomatic HF patients. This article describes the design and analytic plan for the Confirm-AF trial.

CONCLUSIONS

The Confirm-AF trial seeks to accurately define the burden of AF in high-risk HF patients with LVEF > 35% using an Abbott ICM. A finding showing significantly higher incidence of AF along with improved clinical outcomes with ICM monitoring is expected to have substantial clinical implications and may change the method of monitoring high-risk HF patients.

Proton pump inhibitor use and the risk of peritoneal dialysis associated peritonitis

BACKGROUND

The use of proton-pump inhibitors (PPI) has been associated with an increased risk of developing spontaneous bacterial peritonitis in patients with cirrhosis. Whether PPI use confers a similar risk in developing peritonitis in peritoneal dialysis (PD) patients remains unclear.

METHODS

Patients on PD were retrospectively identified. Data such as PPI use during PD, underlying diagnoses, comorbidities, and baseline serum tests were collected. Univariable and multivariable analysis was conducted using logistic regression to assess whether PPI use and other factors were associated with PD peritonitis.

RESULTS

57 patients were identified with a median(interquartile range(IQR)) age of 65.0(51.5-74.0) years. The median(IQR) time on PD was 29.0(17.5-45.0) months. 28 patients were on a PPI during PD. 57% of the PPI group went on to develop peritonitis, compared to 31% of patients without PPI exposure (OR=2.96, 95% CI:[1.00, 8.78], p=0.050). Months on PD (OR=1.03, 95% CI:[1.00, 1.06], p=0.026), serum urea (OR=0.88, 95% CI:[0.80, 0.97], p=0.017), congestive cardiac failure (OR=5.44, 95% CI:[1.29, 23.00], p=0.021) and renovascular disease (OR=14.59, 95% CI:[1.68, 126.67], p=0.015) were identified as possible risk factors for peritonitis on univariable analysis. Following adjustment for covariates, serum urea, but not PPI use, was associated with PD peritonitis (OR=0.87, 95% CI:[0.78,0.98], p=0.020).

CONCLUSION

PPI use during PD was not associated with peritonitis. Due to the small number of patients and the limited number of studies investigating the effect of PPI use on PD peritonitis, further research is needed. This article is protected by copyright. All rights reserved.

Evaluation of Nicotine Dependence in Adult Population of Eastern Nepal

Background Tobacco consumption is a leading cause of premature death in the world. Tobaccorelated deaths are associated with cardiovascular diseases, pulmonary diseases, oral potentially malignant disorders, cancer, others. Moreover there is also associated nicotine dependence which might result to numerous tobacco-associated diseases. Objective This study was conducted to analyze the degree of nicotine dependence considering its potential health risk, in the Eastern region of Nepal. Method A descriptive questionnaire based study was conducted among current tobacco users of six districts of Eastern Nepal. Fagerstrom Test for Nicotine Dependence (FTND) and Fagerstrom Test for Nicotine Dependency for Smokeless Tobacco (FTNDST) questionnaire were used for tobacco smokers and chewers, respectively. Result Of the total participants, 836 were males and 359 females, among whom 736 were active tobacco smokers and 432 chewers, 34.8% had tried to stop consuming tobacco and 306 (25.6%) had oral lesions in white or red forms. Very low nicotine dependence was found among 244 (31.47%) tobacco smokers and 37 (8.56%) chewers whereas 36 (4.71%) smokers and 103 (23.84%) chewers had very high nicotine dependence. The mean score for FTND was 3.73±2.37 and 5.74±2.12 for FTND-ST. A significant difference in duration and age group with FTND score was observed, however not with FTND-ST. Conclusion The information regarding degree of nicotine dependence can be used as baseline information for planning of preventive strategies and implementation of tobacco cessation and control programs.

ANCA vasculitis and IgA nephropathy linked to silica exposure

There is a recognized association between silica exposure and Antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV); however, no clear association between silica exposure and Immunoglobulin A (IgA) nephropathy. We describe the case of a 26-year-old male stonemason who presents with hilar lymphadenopathy, haematuria and acute kidney injury related to silica exposure, AAV and IgA nephropathy. He was asymptomatic on presentation; urinalysis revealed glomerular haematuria (>1000 red blood cells/L) and proteinuria (protein-to-creatinine ratio 84 mg/mmol). ANCA anti-myeloperoxidase serology was strongly positive. Mediastinal lymph node biopsy revealed multiple necrotizing granulomas with silica inclusions, and renal biopsy demonstrated crescentic glomerulonephritis and mesangial IgA staining. The patient was treated with cyclophosphamide and high-dose prednisolone with subsequent improvement in renal function. To our knowledge, this is the first report of both ANCA vasculitis and IgA nephropathy in the setting of silica exposure. This case highlights the relevance of occupational exposures in renal disease, and the immune-stimulatory effect of silica.

THU0033 ALTERATIONS IN THE PHENOTYPIC LANDSCAPE AND SPECIFICITY OF CD4+ T CELLS IN CCP+ AT RISK SUBJECTS BEFORE THE ONSET OF RHEUMATOID ARTHRITIS

Background:

The “Targeting Immune Responses for Prevention of RA” (TIP-RA) collaboration studies individuals at high risk for developing rheumatoid arthritis (RA) because of serum anti-citrullinated protein antibody (ACPA) positivity in absence of arthritis at baseline, and is focused on defining how they transition from at-risk to classifiable disease. One potential mechanism is the expansion of antigen specific T cells that recognize self-antigens and acquisition of disease associated T cell phenotypes. ACPA emerge years prior to clinically apparent disease and subsequently increase in their titer and breadth of specificity. However, few studies have characterized T cells during this transition.

Objectives:

To identify features associated with progression to RA by examining the specificity and surface phenotype of CD4+ T cells in individuals from the TIP-RA cohort by HLA class II tetramer staining and multi-parameter flow cytometry.

Methods:

Tetramer staining and flow cytometry were performed on peripheral blood samples from a baseline visit from CCP3- controls (n=34), CCP3+ at-risk (n=26), CCP3+ positive individuals who transitioned in the near-term to RA (called “RA converters”, n=4), and seropositive early-RA (n=21). Our staining panel allowed us to measure the frequencies of T cells specific for citrullinated alpha-enolase, aggrecan, cartilage intermediate layer protein (CILP), fibrinogen and vimentin. We then applied both supervised phenotyping and a cluster-based computational approach to compare the phenotypic landscape and specificity of antigen specific and total CD4+ T cells in each cohort.

Results:

We observed higher overall frequencies of T cells that recognize citrullinated epitopes in CCP3+ at-risk subjects than CCP- controls (p< 0.05). Among the individual specificities, elevated frequencies prior to disease onset were most prominent for CILP specific T cells. Supervised phenotypic analysis revealed an increase in CCR4+ CD4+ T cells in CCP3+ at risk subjects (p< 0.001) and a corresponding decrease in CXCR3+ CD4+ T cells that was most pronounced in RA converters and seropositive early-RA (p< 0.05). Cluster-based phenotypic analysis defined ten distinct phenotypic states present within all subjects. Each of these ten immunotypes contained T cells that recognize citrullinated epitopes. However, the predominant immunotype varied for different antigens. During progression, the frequencies of Ag specific T cells diminished when onset was imminent, but rebounded shortly after diagnosis. Concomitantly, Ag specific T cells with memory phenotypes were diminished, but subsequently reverted to TSCM, Th1, and Th1-17 like phenotypes.

Conclusion:

Our data show that disease associated changes in the antigen specificity of CD4+ T cells are present in CCP3+ at-risk subjects. Furthermore, the number of antigen specific T cells and their phenotype are perturbed before the onset of symptoms and development of classified RA. These findings support a continuum of immunologic changes that underlie risk and drive disease, motivating new approaches for early intervention.

Acknowledgments:

We gratefully acknowledge the Targeting Immune Responses for Prevention of Rheumatoid Arthritis (TIP-RA) for designing and executing this collaborative study

Disclosure of Interests:

Cliff Rims: None declared, Virginia Muir: None declared, Kevin Deane Grant/research support from: Janssen, Consultant of: Inova, ThermoFisher, Janseen, BMS and Microdrop, Sunil Nagpal Shareholder of: Janssen Pharmaceuticals, Employee of: Janssen Pharmaceuticals, Navin Rao Shareholder of: Janssen Pharmaceuticals, Employee of: Janssen Pharmaceuticals, Frederic Baribaud Shareholder of: Janssen Research & Development, LLC, Employee of: Janssen Research & Development, LLC, George Vratsanos Shareholder of: Janssen Pharmaceuticals, Employee of: Janssen Pharmaceuticals, V. Michael Holers Grant/research support from: Janssen, Celgene, and BMS, Peter Linsley Consultant of: BMS, Eddie A. James Grant/research support from: Janssen, Pfizer, Sanofi, Novartis, Jane Buckner Grant/research support from: Bristol-Myers Squibb, Janssen

SAT0003 ELEVATED BASELINE AND INCREASING AUTOANTIBODY LEVELS ARE ASSOCIATED WITH INCREASED RISK FOR IMMINENT ONSET OF INFLAMMATORY ARTHRITIS IN A PROSPECTIVELY STUDIED ANTI-CITRULLINATED PROTEIN ANTIBODY POSITIVE COHORT: THE TIP-RA COLLECTIVE

Background:

The Targeting Immune Responses for Prevention of RA (TIP-RA) Collaborative prospectively studies individuals at high risk for developing RA because of serum ACPA positivity in absence of baseline inflammatory arthritis (IA).

Objectives:

The objective of the analyses presented herein is to evaluate the role of baseline and changing levels of ACPA and rheumatoid factor (RF) in relationship to incident IA/RA.

Methods:

ACPA+ subjects and ACPA- controls were identified who did not have baseline historical or examination evidence of IA. ACPA+ was defined by serum elevation of anti-CCP3 ≥20 units (Inova). Subjects were evaluated annually or sooner if they had changes in joint symptoms. Factors including RFIgM and RFIgA (Inova) were also assessed, and relationships between autoantibody levels at baseline and over time and incident IA/RA were evaluated using t-tests, with paired testing where applicable.

Results:

Baseline characteristics of ACPA+ and ACPA- subjects are in Table 1. Sixteen of the 94 (17%) ACPA+ subjects developed IA/RA a mean of 518 days from the baseline visit; 14 of these met 2010 ACR/EULAR criteria for RA at the time of detection of IA. There was a trend for ACPA+ subjects who later developed IA/RA to have higher baseline levels of anti-CCP3 compared to those who did not develop IA/RA (Table 2). In addition, those who developed IA/RA had significantly higher mean levels of RFIgM and RFIgA compared to those who did not. While not statistically significant, in longitudinal analyses in the ACPA+ subjects with incident IA/RA, anti-CCP3 levels increased from baseline to identification of IA (mean [SD] of 119 [102] to 126 [100], p=0.42). Furthermore, RFIgM levels increased from 36 [49] at baseline to 43 [51] at the time of IA (p=0.31), and RFIgA levels increased from 16 [29] to 21 [31] (p=0.10). In contrast, in ACPA+ subjects who did not develop IA/RA, anti-CCP3 levels increased only slightly over follow-up of a mean of 712 days: 75 [75] to 80 [76], p=0.70 while the levels of RFIgM and RFIgA decreased slightly during the same follow-up: for RFIgM mean [SD] levels went from 9 [22] to 8 [19], p=0.74; for RFIgA, 5 [16] to 3 [12], p=0.67.

Table 1.

Baseline characteristics of ACPA+/- subjects

ACPA-(n=162)ACPA+(n=94)p-valueAge, mean58580.90% Female69680.67% Ever smoker33340.87RF-IgM, mean (SD)3.2 (10.0)13.5 (30.2)<0.01RF-IgA, mean (SD)0.3 (0.6)6.5 (19.1)<0.01Table 2.

Baseline characteristics of 16 ACPA+ subjects who developed incident IA/RA vs. 78 ACPA+ who did not

Did not develop IA/RA (n=78)Developed IA/RA (n=16)p-valueDays from baseline to IA/RA or follow-up, mean (SD)712 (124)518 (295)–% Meeting 2010 criteria at time of IA-88–CCP3, mean (SD)74.5 (75.3)119.1 (102.1)0.05RFIgM, mean (SD)9 (22)36 (49)<0.01RFIgA, mean (SD)4 (16)16 (29)0.03

Conclusion:

In this prospectively followed cohort of ACPA+ subjects, higher levels of RFIgM and RFIgA at baseline were significantly associated with development of IA/RA within the follow-up period. Furthermore, there was a trend for rising levels of anti-CCP3 and RFIgM and A to be associated with development of IA/RA. These finding support the use of higher and/or rising levels of autoantibodies as additional features to predict imminent onset of IA/RA in ACPA+ individuals as well as potentially to use as outcomes of success of preventive interventions. Furthermore, the trend of increasing levels of RFIgM and RFIgA over time in individuals who developed IA/RA suggests that targeting pathways of RF development may lead to preventive interventions in a subset of RA.

References:

None

Disclosure of Interests:

Kevin Deane Grant/research support from: Janssen, Consultant of: Inova, ThermoFisher, Janseen, BMS and Microdrop, Gary Firestein Grant/research support from: Lilly, Janssen, Abbvie, David Boyle: None declared, Jane Buckner Grant/research support from: Bristol-Myers Squibb, Janssen, Eddie A. James Grant/research support from: Janssen, Pfizer, Sanofi, Novartis, Sylvia Posso Grant/research support from: Janssen, William Robinson Grant/research support from: Janssen, Laurie K. Moss Grant/research support from: Janssen, Jennifer Seifert Grant/research support from: Janssen, Roger Gilmore Grant/research support from: Janssen, Saman Barzideh Grant/research support from: Janssen, Navin Rao Shareholder of: Janssen Pharmaceuticals, Employee of: Janssen Pharmaceuticals, Frederic Baribaud Shareholder of: Janssen Research & Development, LLC, Employee of: Janssen Research & Development, LLC, Sunil Nagpal Shareholder of: Janssen Pharmaceuticals, Employee of: Janssen Pharmaceuticals, Alyssa Johnsen Employee of: Janssen, V. Michael Holers Grant/research support from: Janssen, Celgene, and BMS

OP0337 DIFFERENTIAL METHYLATION OF PERIPHERAL BLOOD ADAPTIVE IMMUNE CELLS IN INDIVIDUALS AT HIGH RISK FOR RA AND WITH EARLY RA COMPARED WITH CONTROLS IDENTIFIES PATHWAYS IMPORTANT IN TRANSITION TO ARTHRITIS

Background:

The “Targeting Immune Responses for Prevention of RA” (TIP-RA) collaboration studies individuals at high risk for developing RA because of serum anti-citrullinated protein antibody positivity in absence of arthritis, and is focused on defining how they transition from at-risk to classifiable disease. One potential mechanism is through alterations in epigenetics patterns in adaptive immune cells.

Objectives:

Previous studies showed that DNA methylation patterns of early RA (ERA) synoviocytes differ from long-standing RA, suggesting that abnormal methylation occurs early in synovium and evolves over time. To extend these observations, we performed a cross-sectional analysis in TIP-RA of DNA methylation signatures in peripheral blood cells in ERA, at-risk anti-CCP3+ individuals and demographically matched CCP- controls.

Methods:

Genomic DNA was isolated from two independent cohorts of CCP- (cohorts 1 and 2, respectively: B cell: n = 17/34; memory T cell: n = 21/34; and naïve T cell: n = 21/33), CCP3+ (B cell: n = 18/37; memory T cell: n = 20/36; and naïve T cell: n = 20/35), and CCP3+ ERA (B cell: n = 4/18; memory T cell: n = 5/18; and naïve T cell: n = 5/18) after separating PBMCs using antibodies and magnetic beads. Methylation was measured by Illumina Infinium MethylationEPIC chip. Differentially methylated loci (DMLs) were identified using Welch’s t-test and mapped to gene promoter regions to define DM genes (DMGs). Principal component analysis (PCA) was used to represent relationship among groups. Pathway analysis was applied by Reactome.

Results:

For the initial cohort, 1494, 1097 and 1330 DMLs were identified among CCP+, CCP- and ERA in B cells, memory T cells and naïve T cells, respectively. For the confirmatory cohort, 523, 793 and 548 DMLs were found in corresponding cell populations. The DML overlap between the 2 cohorts was highly significant (p= 2.48E-77). The DMLs were combined for both groups and corresponded to 411, 412, and 351 DMGs in B cells, memory T cells and naïve T cells. Of these, we found 246, 198 and 195 DMGs between CCP3+ and ERA in each peripheral blood cell population, respectively. PCA showed separation of CCP+, CCP- and ERA in each of the three blood cell types by DMLs (Fig. 1). DMGs were mapped to biological pathways to identify DM pathways. Although most were not significant, there were several highly significant differences comparing CCP+, ERA and CCP- in memory T cells involving pathways, including “Interferon gamma signaling” (FDR 7.48E-14), “PD-1 signaling” (FDR 8.71E-10), “Translocation of ZAP-70 to Immunological synapse” (FDR 4.75E-10), and “Phosphorylation of CD3 and TCR zeta chains” (FDR 8.71E-10).

Figure 1.

PCA shows the separation of CCP+, CCP- and ERA patients in memory T cells in confirmatory cohort.

Conclusion:

We identified reproducible methylation signatures of CCP-, CCP+, and ERA in peripheral blood B cells, memory T cells and naïve T cells in initial and confirmatory cohorts. The methylome of ERA also demonstrated a distinctive pattern from CCP+, indicating that progression to RA is accompanied by epigenetic remodeling, especially in T cell signaling and interferon responses. These signatures identify critical pathways in CCP positivity and classifiable RA and could provide the basis of novel interventions to prevent disease.

Disclosure of Interests:

Rizi Ai: None declared, David Boyle: None declared, Deepa Hammaker: None declared, Kevin Deane Grant/research support from: Janssen, Consultant of: Inova, ThermoFisher, Janseen, BMS and Microdrop, V. Michael Holers Grant/research support from: Janssen, Celgene, and BMS, Andre Matti: None declared, William Robinson: None declared, Jane Buckner Grant/research support from: Bristol-Myers Squibb, Janssen, Navin Rao Shareholder of: Janssen Pharmaceuticals, Employee of: Janssen Pharmaceuticals, Frederic Baribaud Shareholder of: Janssen Research & Development, LLC, Employee of: Janssen Research & Development, LLC, Alyssa Johnsen Employee of: Janssen, Sunil Nagpal Shareholder of: Janssen Pharmaceuticals, Employee of: Janssen Pharmaceuticals, Wei Wang: None declared, Gary Firestein Grant/research support from: Lilly, Janssen, Abbvie

AB0037 EXPRESSION OF NEGATIVE CHECKPOINT MOLECULES BTLA AND HVEM IS DYSREGULATED IN AUTOIMMUNE DISEASES

Background:

Immune checkpoint blockade with agents targeting CTLA4 and PD-1/PD-L1 alone or in combination has demonstrated exceptional efficacy in multiple cancer types by “unleashing” the cytotoxic action of quiescent, tumor-infiltrating T cells. However, the therapeutic action of these immunotherapies goes hand in hand with the loss of immune tolerance and appearance of immune-related adverse events such as colitis, arthralgia and inflammatory arthritis in responsive patients. Therefore, immune checkpoint molecules have been proposed as targets for the treatment of autoimmune diseases.

Objectives:

Herein, we interrogate the potential of BTLA/HVEM axis as a target for restoring immune homeostasis in rheumatoid arthritis (RA), Systemic Lupus Erythematosus (SLE) and Sjogren’s Syndrome (SjS) by examining their expression patterns in autoimmune disease tissues.

Methods:

Message and protein expression of BTLA and HVEM were examined in RA and SLE synovial tissues, SLE cutaneous lesions, SjS salivary glands and peripheral blood samples of autoimmune disease by RNA sequencing and flow cytometry.

Results:

Tissue dysregulation of the BTLA-HVEM axis was observed: Increased BTLA RNA level in RA synovium, SLE-affected skin, and SjS salivary gland samples, whereas HVEM level was affected only in the RA synovium when compared to unaffected tissues. Detailed immunophenotyping of B, T, and myeloid cell populations in RA, SLE, SjS and healthy control PBMCs revealed differential modulation of the BTLA+ or HVEM+ immune cell subsets in a disease-context dependent manner. SjS patients showed an overall decrease in memory B cells and most of the BTLA+ B cell subsets while a decrease in HVEM+ B cells was observed only in SLE PBMC samples and not RA and SLE samples. Immunophenotyping with a T cell panel exhibited decreased BTLA and HVEM expression on T cell subsets in SjS and SLE but not in RA patients. In addition, protein levels of HVEM were differentially decreased in SLE myeloid cell subsets. Finally, we demonstrate tissue-specific surface expression patterns of BTLA in RA and SLE samples: higher surface BTLA levels on RA and SLE PBMC B cells than matched tissue-derived B cells.

Conclusion:

Our results demonstrate a dysregulation of the BTLA/HVEM axis in either lesional tissue or peripheral blood in an autoimmune disease context-dependent manner. These results also indicate the potential of targeting BTLA-HVEM axis for the treatment of multiple autoimmune diseases.

Disclosure of Interests:

Sunil Nagpal Shareholder of: Janssen Pharmaceuticals, Employee of: Janssen Pharmaceuticals, Suzanne Cole Shareholder of: Janssen Research & Development employee, Employee of: Janssen Research & Development employee, Achilleas Floudas: None declared, Mihir Wechalekar Grant/research support from: Grant from Janssen Research & Development, Qingxuan Song Shareholder of: Employee of Janssen Research, Employee of: Employee of Janssen Research, Tom Gordon: None declared, Roberto Caricchio Grant/research support from: Financial grant from Janssen Research & Development, Douglas Veale: None declared, Ursula Fearon: None declared, Navin Rao Shareholder of: Janssen Pharmaceuticals, Employee of: Janssen Pharmaceuticals, Ling-Yang Hao Shareholder of: Employee of Janssen Research, Employee of: Employee of Janssen Research

Independent risk factors for long-term skeletal relapse after mandibular advancement with bilateral sagittal split osteotomy

The purpose of this retrospective cohort study was to identify the independent risk factors for long-term skeletal relapse following mandibular advancement with bilateral sagittal split osteotomy. Univariate and multivariate linear regression analyses were performed including nine common risk factors for relapse as independent variables and horizontal/vertical long-term (≥2 years) skeletal relapse as dependent variables. Ninety-six patients were analyzed; 66 were female (68.8%) and the average age of the patients was 29.7±10.5 years. Over an average follow-up of 3.8±1.8 years after an initial mandibular advancement of 8.8±2.4 mm, long-term skeletal relapse of 1.6±1.0 mm horizontal and 0.9±0.7 mm vertical was found. Multivariate analysis identified age, preoperative mandibular plane angle (MPA), bimaxillary surgery, counterclockwise mandibular rotation, and the magnitude of mandibular advancement to be significantly associated with horizontal long-term skeletal relapse. Preoperative MPA, counterclockwise mandibular rotation, and the magnitude of mandibular advancement were significantly associated with vertical long-term skeletal relapse. Thus preoperative MPA, the magnitude of mandibular advancement, and counterclockwise mandibular rotation of the mandible were found to be independent risk factors for both horizontal and vertical long-term skeletal relapse. Although long-term skeletal relapse cannot be avoided entirely, understanding the independent risk factors and their contributions will optimize treatment planning and long-term stability.

The oral Janus kinase/spleen tyrosine kinase inhibitor ASN002 demonstrates efficacy and improves associated systemic inflammation in patients with moderate-to-severe atopic dermatitis: results from a randomized double-blind placebo-controlled study

BACKGROUND

ASN002 is an oral dual inhibitor of Janus kinase and spleen tyrosine kinase, which are involved in the pathogenesis of atopic dermatitis (AD) through their regulatory role on T helper (Th)1, Th2 and Th17/Th22 pathways.

OBJECTIVES

The objectives of this study were to evaluate the efficacy, safety, pharmacokinetics and effects on systemic biomarkers of ASN002 in patients with moderate-to-severe AD. Methods A total of 36 patients with moderate-to-severe AD were randomized (3 : 1) to ASN002 or placebo in the phase Ib study. Three dosage cohorts were studied over a 28-day period (20 mg, 40 mg and 80 mg once daily).

RESULTS

ASN002 was superior to placebo for the proportion of patients achieving Eczema Area and Severity Index (EASI) 50 (20 mg 20%, P = 0·93; 40 mg 100%, P = 0·003; 80 mg 83%, P = 0·03; placebo 22%), EASI 75 (20 mg 0%, P = 0·27; 40 mg 71%, P = 0·06; 80 mg 33%, P = 0·65; placebo 22%) and in change from baseline in pruritus (20 mg -1·3 ± 2·1, P = 0·81; 40 mg -3·1 ± 2·7, P = 0·27; 80 mg -4·7 ± 2·1, P = 0·01; placebo -1·6 ± 1·8). Adverse events were generally mild and similar across all groups. ASN002 showed dose-dependent plasma exposure with low interpatient variability, significantly downregulated several serum biomarkers involved in Th1, Th2 and Th17/Th22 immunity, and decreased the atherosclerosis-associated biomarker E selectin/SELE.

CONCLUSIONS

In patients with moderate-to-severe AD, ASN002 showed strong efficacy with rapid onset of action and associated improvements in systemic inflammation.

Diagnostic pathways in Crohn's disease

The management of Crohn's disease (CD) is shifting from a stepwise, incremental approach based on symptom control to more aggressive early combined immunosuppression in an attempt to induce remission more rapidly and avoid long-term bowel damage. Accurately defining disease activity is a major challenge, as there is often a disconnect between symptomatology and underlying disease status. The role of imaging in CD has evolved such that it now plays a central role establishing the initial diagnosis, characterising disease phenotype, activity assessment, disease surveillance, and assessing response to therapy. Furthermore, the "treat-to-target" approach is being investigated in CD, with resolution of transmural inflammation on cross-sectional imaging being the treatment goal. In this review, we summarise the principal imaging techniques available to the radiologist, the key findings, and provide some guidance on the preferred imaging option in the diagnostic pathway. We consider the relative merits and drawbacks of each imaging technique before offering a brief discussion of some current developments and research avenues in CD imaging. We discuss how imaging may be useful in a "treat-to-target" approach. Finally, we highlight some practical considerations around service configuration and delivery to optimise imaging in CD in an accurate, cost-effective manner.

Utility of the microcolony method for evaluation of multidrug-resistant tuberculosis patients in Karachi, Pakistan

OBJECTIVE: To compare the microcolony method (MCM) with the reference culture method to evaluate culture conversion in multidrug-resistant tuberculosis (MDR-TB) patients.MATERIAL AND METHODS: Adult patients with Mycobacterium tuberculosis culture-positive MDR-TB undergoing second-line anti-tuberculosis treatment were recruited from two tertiary care chest clinics from January 2013 to October 2014. The MCM was performed in addition to MGIT™ and Löwenstein-Jensen medium (reference method) on sputum samples submitted on a monthly basis.RESULTS: Of 140 patients, culture conversion could be evaluated in 95 patients. The MCM showed 100% agreement with the reference M. tuberculosis culture in 83 of 95 patients who achieved culture conversion. In smear-positive and smear-negative cases, the mean time to positivity was 9.1 and 11.4 days for the MCM and 16.1 and 23.2 days for the reference M. tuberculosis culture respectively. The contamination rate for the MCM was 4.5% in comparison with 6.1% for the reference M. tuberculosis culture. The cost of MCM was estimated to be 30% that of the reference method.CONCLUSION: The MCM can be used in non-urban laboratories as a safe, rapid and cost-effective substitute for the reference M. tuberculosis culture to assess culture conversion in MDR-TB patients.Note: Abstract has been published in International Journal of Mycobacteriology 2015; 4: 159-160.

India's integrated child development services scheme: challenges for scaling up

BACKGROUND

India had around 158 million children under the age of 6 and about 26 million births in 2015. In the same year, India's Integrated Child Development Services Scheme served about 82 million children under 6 years and over 19 million pregnant women and lactating mothers. These 102 million beneficiaries received services in about 1.3 million centres.

METHOD

This paper reviews the growth of the Scheme and considers challenges to scaling up quality with equity based on results of large-scale national or multistate studies.

RESULTS

The Scheme is associated with decreased malnutrition and better child development. The size and diversity of the country, the policy context, funding mode and lack of community awareness and engagement have hindered scaling up access while the approach to service delivery, low institutional capacity and poor infrastructure have impeded scaling up of implementation quality.

CONCLUSIONS

This review illustrates the challenges associated with scaling-up access and implementation quality of a multicomponent, integrated early childhood programme in a large, diverse country. The future success of the Integrated Child Development Services will depend on how well it adheres to quality standards and how well it evolves to address current weaknesses.

Abstract P6-07-01: Multigene profiling to identify clinically relevant actionable mutations in breast cancer: An Indian study

Background: Numerous chemotherapeutic agents are available against breast cancer (BC), but a vast majority of patients diagnosed with this disease still develop treatment resistance and eventually succumb to disease. It remains an unmet need to identify specific molecular defects against which targeted therapy are available for improving clinical outcomes in BC. Our study aims to identify frequent hotspot mutations in BCs and determine their clinical impact.

Methods: 200 women with BC(early diagnosed and/or metastatic) aged 26-75 yrs (median age 50.5yrs) diagnosed at HCG from April 2013-15 were consented to be profiled by targeted deep sequencing for hotspot mutations in 48 cancer-related genes using Illumina's TSCAP panel and MiSeq technology in an IRB-approved prospective study in a CLIA compliant laboratory. All the cases had pathology review for stage, histological type, hormonal status and Ki67. The average coverage across 220 hot spots was greater than 1000X. Data was processed using Strand Avadis NGS™. Mutations identified in the tumor were assessed for 'actionability' i.e. response to therapy and impact on prognosis. Results: Somatic variants were detected in 75% of cases with direct impact on therapy or prognosis. Genetic aberrations were identified in PI3K/AKT/ mTOR signalling pathway in substantial fraction (27%) of breast cancer cases, out of which 17% had PIK3CA activating mutations,13 and 5 cases had PTEN and AKT deletions or truncating mutations respectively. Aberration in this pathway was more prevalent in HR+ve (53%) and HER2-ve including TNBC (61%) than in HR+/HER2+ve tumors (10.6%) of IDC histology. However, no correlation was found with stage and Ki67 index of the tumor. Notably 80% of BC cases presented with liver metastasis at the time of diagnosis were detected with PIK3CA mutation indicating its role as a surrogate marker of organ specific metastasis. PIK3CA was found to be co mutated with p53 in 16 cases (9%) of which 4 cases showed npCR post NACT. Also disruptive and non-disruptive mutations in TP53 alone were found in 25% of BC, varying widely among different histologies. A follow up of few cases showed shorter PFS and poor outcome in resected BC treated with NACT indicating its robust prognostic value in NACT setting. Furthermore, two patients were detected with cKIT mutations indicating sensitivity to imatinib and therefore enrolled on a clinical trial. The other variants were found in RB1(n=8),Her2 (n=2),FGFR amplification(n=1), KRAS(n=2),NRAS(n=3)CDH1(n=1),FBXW7(n=2) and EGFR(n=1).All these variants detected indicated resistance to conventional therapy and suggested sensitivity to available targeted therapy, either approved or in clinical trials. The response and outcome are being monitored in about 20 (10%) patients who have been enrolled in clinical trials and receiving mutation specific targeted therapy. Conclusions: This study confirms the utility of multigene profiling in early diagnosed and advanced BC patients, to stratify them on their molecular profile who could potentially benefit from targeted therapy. Prospective studies and randomized clinical trials are ongoing to confirm the independent prognostic and therapeutic value of the mutations in a larger cohort of Indian population.

Citation Format: Ghosh M, Sheela ML, Choudhury S, Bahadur U, Patil S, Satheesh CT, Murugan K, Nayak R, Sridhar PS, Rao N, Mahesh B, Shashidhara HP, Krishnamoorthy N, Gupta V, Sankaran S, Subramanian K, Ajaikumar BS. Multigene profiling to identify clinically relevant actionable mutations in breast cancer: An Indian study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-07-01.

Abstract P6-06-06: Comprehensive analysis of BRCA (BRCAm) and other germline mutations (GRm) with a clinicopathological association in breast cancer: An Indian study

Background: BRCAm and other GRm testing using next generation sequencing (NGS) in early diagnosed and/or metastatic breast cancer (BC) helps in the identification of both unambiguously defined deleterious mutations and sequence variants of unknown clinical significance (VUS). The early detection of these mutations in the proband and the family members help in risk stratification and instituting effective monitoring, surveillance and disease management strategies.

Methods: Out of total 200 patients diagnosed with BC (April 2013-15) 77 unrelated individuals were consented to be profiled by NGS on MiSeq platform using TruSight Cancer panel (consisting of 94 genes including 13 genes highly associated with risk of inherited breast and/or ovarian cancer) in an IRB-approved prospective study in a CLIA compliant laboratory. Paired end sequencing was done with an average coverage of &gt; 450X. Data was processed using STRAND software and interpreted using "Strand Omics" platform. The paired tumor samples were analysed for pathological stage, histological type and hormonal status.

Results: GRm were detected in 61 cases (79%). Among all mutations detected, BRCA1/2 were found in 51% (31% in BRCA1, 20% in BRCA2) of cases. BRCA1 was found to be co-mutated with BRCA2 in 2 cases. Out of 37 deleterious mutations in BRCA1/2 genes only 10 were reported to be pathogenic (6 in BRCA1 and 4 in BRCA2) and rest were VUS. Mutation frequencies were higher among high grade IDC with HER2-ve tumors including TNBC (53%, p&lt;0.05) with an early onset of the disease. TNBC with BRCAm were found to have no/incomplete pCR on conventional TAC regimen , subsequently started with platinum therapy and the outcome being monitored. Interestingly, 4 BRCA1 mutations including 3 non-sense and 1 frameshift mutation were found in two unrelated individuals suggesting them to be founder mutations in Indian population. The other GRm frequency (alone/ co-mutated with BRCA) was also found to be significantly high (49%) and include BRIP1, CHEK2, ERCC2, CDH1, SDHB, APC, MSH6, TP53, PALB2 and RAD51C. Stratification based on age of diagnosis(dx) showed a detection rate significantly higher in the age group of 25-50 yrs (74%) as compared to the 50-75 yrs (26%). Also a strong association of GRm status with the family history(Hx) of BC in 1st or 2nd degree relatives was indicated.

Table 1: Correlation of GRm with Dx and HxGenen%Age at dx(yrs)Family Hx (Yes=Y, No=N,Unknown=UK)BRCA1193125-50 (n=23) 50-75(n=8)Y(n=13) N(n=3) UK(n=3)BRCA2122025-50(n=21) 50-75(n=9)Y(n=8) N(n=2) UK(n=2)PALB211.7&gt;50YCHEK258.825-50 (n=4) 50-75(n=1)YATM610.525-50 (n=4) 50-75(n=2)Y(n=5) N(n=1)RAD5111.7&lt;50Y

Conclusions: Our study in a small cohort clearly highlighted the significance of germline testing and classifying the variant in larger cohort of BC patients with a strong family Hx of cancer particularly in BRCA1/2 positive families , and in women &lt;50yrs for early detection and risk assessment. The study also indicates BRCAm to be an important contributor to the etiology of high grade HER2-/ TNBC in Indian patients. Expanded testing of this subtype is warranted to impact management of the disease with PARP inhibitors and/or platinum therapy.

Citation Format: Ghosh M, ML S, Upasana M, Chodhury S, Mannan AU, Southekal S, Manjima C, Patil S, Murugan K, Mahesh B, Nayak R, Sridhar PSS, Rao N, Krishnamoorthy N, Gupta V, Satheesh CT, Subramanian K, Ajaikumar BS. Comprehensive analysis of BRCA (BRCAm) and other germline mutations (GRm) with a clinicopathological association in breast cancer: An Indian study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-06-06.

Mycobacterium tuberculosis Sonicate-Induced IFNγ, CXCL10 and IL10 can Differentiate Severity in Tuberculosis

Improved tools are required to study immunopathogenesis of tuberculosis (TB). Mycobacterium tuberculosis antigen-stimulated T cell-based assays can detect TB but are less effective when responses are compromised such as in severe disease. We investigated immune responses to M. tuberculosis whole sonicate (MTBs), recombinant antigens ESAT6 and CFP10 in whole blood cells of healthy endemic controls (EC, n = 42) and patients with pulmonary (PTB, n = 36) or extrapulmonary (ETB, n = 41) disease. Biomarkers of T cell activation (IFNγ) or modulation (IL10) and chemokines, CXCL9, CXCL10 and CCL2, secretion were measured. MTBs, ESAT6 and CFP10 all induced IFNγ responses in TB. ESAT6-induced IFNγ was elevated in TB as compared with EC. MTBs stimulated the highest IFNγ levels but did not differentiate between TB and EC. However, MTBs-induced CXCL10 (P = 0.004) was reduced, while IL10 (P < 0.001) was raised in TB as compared with EC. Between sites, MTBs-induced CCL2 (P = 0.001) and IL10 secretion was higher in PTB than ETB (P < 0.001). In comparison of disease severity, MTBs-induced IFNγ (P = 0.014) and CXCL10 (P = 0.022) levels were raised in moderate as compared with far advanced PTB. In ETB, MTBs-induced IL10 levels were greater in less-severe (L-ETB) than in severe disseminated (D-ETB) cases, P = 0.035. Within the L-ETB group, MTBs-induced IFNγ was greater in patients with tuberculous lymphadenitis than those with pleural TB (P = 0.002). As immune responses to MTBs were differentially activated in TB of different sites and severity, we propose the utility of MTBs-induced IFNγ, CXCL10 and IL10 as biomarkers in TB.