Cell-specific Systemic Immune Signatures Associated with Treatment Burden in Neovascular Age-related Macular Degeneration

Purpose

Choroidal neovascularization (CNV) accounts for the majority of severe vision loss in neovascular age-related macular degeneration (AMD). Despite therapies that target VEGF, patients are often under-responsive, require frequent eye injections to control disease, and eventually lose some vision despite chronic therapy implicating a multifactorial etiology in treatment response. Genetic studies implicate systemic immunity in AMD and systemic immune cells accumulate within CNV lesions, yet a role for these cells in anti-VEGF response remains undetermined. The purpose of this study was to identify transcriptional signatures of circulating immune cells that are associated with high anti-VEGF treatment burden.

Design

Experimental pilot study.

Participants

Patients with neovascular AMD seen at Washington University School of Medicine in St. Louis and BJC Health System.

Methods

We profiled by single cell RNA sequencing the peripheral blood mononuclear cells of 27 treatment-experienced patients with wet AMD. We stratified this cohort into 2 groups with low and high treatment burden (≤ 5 or ≥ 6 injections in the past 12 months, respectively).

Main Outcome Measures

Identification of immune cells associated with high treatment burden.

Results

Gene expression signature of CD16+ monocytes may be associated with high treatment burden.

Conclusions

These studies delineate potential signatures of circulating immune cells that may be associated with high treatment burden in neovascular AMD, potentially informing the development of diagnostic predictors of anti-VEGF response and new precision medicine-based approaches to complement anti-VEGF therapies.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Targeting cell-type-specific, choroid-peripheral immune signaling to treat age-related macular degeneration

Age-related macular degeneration (AMD) is a leading cause of blindness featuring pathogenic neovascularization of the choroidal vasculature (CNV). Although systemic immunity plays a role in AMD, the ocular signals that recruit and activate immune cells remain poorly defined. Using single-cell RNA sequencing, we prospectively profile peripheral blood mononuclear cells from 65 individuals including AMD and controls, which we integrate with existing choroid data. We generate a network of choroid-peripheral immune interactions dysregulated in AMD, including known AMD-relevant gene vascular endothelial growth factor (VEGF) receptor 2. Additionally, we find CYR61 is upregulated in choroidal veins and may signal to circulating monocytes. In mice, we validate that CYR61 is abundant in endothelial cells within CNV lesions neighboring monocyte-derived macrophages. Mechanistically, CYR61 activates macrophage anti-angiogenic gene expression, and ocular Cyr61 knockdown increases murine CNV size, indicating CYR61 inhibits CNV. This study highlights the potential of multi-tissue human datasets to identify disease-relevant and potentially therapeutically modifiable targets.

955 ANALYSIS OF RANDOMISED CONTROLLED TRIAL SERIOUS ADVERSE EVENT RATES AS A MARKER OF TRIAL REPRESENTATIVENESS

Introduction

The applicability of randomised controlled trials of pharmacological agents to older people with frailty/multimorbidity is often uncertain, due to concerns that trials are not representative. However, assessing trial representativeness is challenging and complex. We explore an approach assessing trial representativeness by comparing rates of trial Serious Adverse Events (SAEs: most of which reflect hospitalisations/deaths) to rates of hospitalisation/death in routine care (which, in a trial setting, would be SAEs be definition).

Method

We identified 483 trials (n = 636,267) from clinicaltrials.gov across 21 index conditions. A routine care comparison was identified from SAIL databank (n = 2.3 M). SAIL data were used to derive the expected rate of hospitalisations/deaths by age, sex and index condition. We then calculated the expected number of SAEs for each trial compared to the observed number of SAEs (observed/expected SAE ratio). We then re-calculated the observed/expected SAE ratio additionally accounting for comorbidity count in 125 trials for which we accessed individual participant data.

Results

For 12/21 index conditions the observed/expected SAE ratio was <1, indicating fewer SAEs in trials than expected given community rates of hospitalisations and deaths. A further 6/21 had point estimates <1 but the 95% CI included the null. The median observed/expected SAE ratio was 0.60 (95% CI 0.56–0.65; COPD) and the interquartile range was 0.44 (0.34–0.55; Parkinson’s disease) to 0.88 (0.59–1.33; IBD). Higher comorbidity count was associated with SAEs and hospitalisations/deaths across index conditions. For most trials, the observed/expected ratio was attenuated but remained <1 after additionally accounting for comorbidity count.

Conclusion

Trial participants experience fewer SAEs than expected based on age/sex/condition specific hospitalisation/death rates in routine care, confirming the predicted lack of representativeness. This difference is only partially explained by differences in multimorbidity. Assessing observed/expected SAE may help assess applicability of trial findings to older populations in whom multimorbidity and frailty are common.

Appendix as a biliary conduit for choledochal cysts in children

Biliary conduits are constructed in operations for choledochal cysts. A wide variety of options are available for biliary tract reconstruction. We present our experience of treating six children with choledochal cysts by using the appendix as a biliary conduit. After mobilizing the appendix on its vascular pedicle, nonrefluxing, tunneled anastomosis was made with the 2nd part of the duodenum and the appendix. The operative procedure was simple and less time-consuming. Postoperative evaluation was done with the help of HIDA scan and ultrasound examination. Postoperative cholangitis was conspicuously absent in the two years of follow-up. One child has been lost to follow-up. From our preliminary experience, the operation seems simple and satisfying. Though the long-term efficacy still remains to be proven, the appendix should prove durable as a functional conduit.

Evaluation of Freeze-Dried Dura Mater Allograft as a Collagen Based Barrier (an experimental animal study)

Freeze-dried dura mater allograft (FDDMA) was evaluated as a cost-effective collagenous barrier using an experimental animal model to determine its biocompatibility and 'cell-occlusivity' potential. The FDDMA was processed at the Civil Hospital Ahmedabad, in accordance with the guidelines provided by the South-Eastern Organ Procurement Foundation, U.S.A. Fifteen Charles Foster rats were selected for a study period of 9 weeks. The 1st set graft procedure was performed in an abdominal pouch and after 1 week bilateral mandibular defects were created. One defect was covered by the FDDMA barrier (2nd set graft procedure) and the other defect served as the control. The post operative autopsy and morphological and histological assessments were carried out at 2 and 4 weeks for the 1st set graft, and 3, 6 and 9 weeks for the 2nd set graft procedure. There was acceptance of the 2nd set graft in a pre-exposed animal and no significant inflammatory response. The processed FDDMA demonstrated optimal 'cell-occlusivity' potential for guided bone regeneration to take place in Charles Foster rats.

Laparoscopic gastropexy in a neonate for acute gastric volvulus

A 26-day-old male neonate presented with an acute gastric volvulus which was reduced with a nasogastric catheter. The patient was then subjected to laparoscopic anterior gastropexy. Six months after the procedure, the child is thriving and completely free of symptoms. We present this case as the first wherein a laparoscopic gastropexy has been done for gastric volvulus in a neonate. We have found the procedure acceptable for the treatment of neonates with gastric volvulus.

Clinical Evaluation of Irradiated, Freeze-Dried Dura Mater Allograft as a Collagen-Based Barrier in Periodontal Osseous Defects

The objective of this study was to clinically evaluate freeze-dried dura mater allograft (FDDMA) provided by the Tata Memorial Hospital Tissue Bank, in various periodontal osseous defects and to observe any unwanted healing pattern or adverse reaction.Eleven systemically healthy patients with one infrabony/furcation defect and at least 6 mm or more loss of attachment at selected sites, were scheduled for surgery. At base-line, patients had a good maintenance regime, minimal gingival inflammation and mobility not more than 1 mm in the buccolingual plane (grade 2). The measurements taken were probing pocket depth, clinical attachment level, intrasurgical level of bone and radiographic level of bone. Instead of surgical re-entry, transgingival probing was performed after 12 months of surgery. After debridement the defects were filled with demineralised freeze-dried bone allograft and covered with FDDMA barrier. The results after 12 months were satisfactory (mean gain of attachment 4.33 mm and mean defect fill 3.91 mm). No adverse reaction, infection or delayed wound healing was noted throughout the study.

Conformations of large cycloalkanes: cyclooctadecane, cyclononadecane and cycloicosane

The conformations of cyclooctadecane, cyclononadecane, and cycloicosane were generated by a stochastic program that works in conjunction with MM2. The shapes of the rings are analyzed in terms of previous work by Dale and others, and in terms of distributions of energies, torsion angle distributions, and torsion angle sequences. A new shape element called the 'nick' has been discovered, and it seems to be increasingly important with 18-membered and larger rings. Previously suggested relationships between ring size and energy distribution were observed, and a geometrical explanation is provided for the relative distributions of stable conformations in 16-, 18-, and 20-membered rings.

Effect of sublingual isosorbide dinitrate in portal hypertension

Nitrates decrease portal pressure by decreasing portal venous inflow and resistance. We studied over 20 minutes the effect of 10 mg isosorbide dinitrate sublingual on intrasplenic pulp pressure, mean arterial pressure and heart rate, in 13 patients with cirrhotic or non-cirrhotic portal hypertension. The pulp pressure fell progressively over 20 minutes, from mean 43.6 +/- 2.4 (SEM) to 35.6 +/- 1.8 cm H2O (p less than 0.001). This was accompanied initially by a significant fall in mean arterial pressure (85.8 +/- 1.9 to 80.4 +/- 2.7 mmHg at 4 minutes; p less than 0.01) and rise in heart rate (92.5 +/- 5.0 to 102.6 +/- 5.9 per minute at 6 minutes; p less than 0.02), following which these parameters remained stable. One patient developed giddiness due to hypotension at 15 minutes. We conclude that sublingual isosorbide dinitrate decreases pulp pressure in cirrhotic and non-cirrhotic portal hypertensives, but this is initially accompanied by significant hemodynamic changes.

Psychiatric factors in ulcerative colitis

Controlled study on 20 patients of ulcerative colitis was conducted at Gastroenterology Department of Civil Hospital, Ahmedabad. It has been observed that in three fourth of the cases, age of onset is before 40 years; & male, female ratio 4:1. No significant trend emerged in marital status, type of family, birth order, dietary habit and parental profile. The disease is common in lower socio-economic status. Ulcerative colitis patients are particularly exposed to stressful life situations and more prone to develop illness.

Emotional factors in bronchial asthma

Controlled study on 30 patients of bronchial asthma was conducted at General Medicine Dept. of Civil Hospital, Ahmedabad. It has been observed that parental loss or deprivation in childhood per se is a significantly important factor in asthmatics. Asthmatics are found to be reserved, detached, affected by feelings, emotionally less stable, mild, accommodating, shy, timid, tender-minded, dependent, tense and frustrated in comparison to the control cases.

Prevalence of psychiatric disorders in ahmedabad (an epidemiological study)

A psychiatric survey was carried out in an urban area of Ahmedabad which consisted mainly of middle class population. 461 families were surveyed which consisted of a total number of 2712 persons.The data was collected in a predetermined form. The index cases were individually evaluated in detail with the help of a structured Psychiatric proforma, case work and psychiatric examination by a consultant for psychiatric diagnosis. Out of the total of 2712 persons surveyed, 128 were found to be suffering from psychiatric disorders, the prevalance rate being 4.7% (47.2 per thousand).