Can the General Public Be a Proxy for an "At-Risk" Group in a Patient Preference Study? A Disease Prevention Example in Rheumatoid Arthritis

BACKGROUND

When selecting samples for patient preference studies, it may be difficult or impractical to recruit participants who are eligible for a particular treatment decision. However, a general public sample may not be an appropriate proxy.

OBJECTIVE

This study compares preferences for rheumatoid arthritis (RA) preventive treatments between members of the general public and first-degree relatives (FDRs) of confirmed RA patients to assess whether a sample of the general public can be used as a proxy for FDRs.

METHODS

Participants were asked to imagine they were experiencing arthralgia and had screening tests indicating a 60% chance of developing RA within 2 yrs. Using a discrete choice experiment, participants were offered a series of choices between no treatment and 2 unlabeled hypothetical treatments to reduce the risk of RA. To assess data quality, time to complete survey sections and comprehension questions were assessed. A random parameter logit model was used to obtain attribute-level estimates, which were used to calculate relative importance, maximum acceptable risk (MAR), and market shares of hypothetical preventive treatments.

RESULTS

The FDR sample (n = 298) spent more time completing the survey and performed better on comprehension questions compared with the general public sample (n = 982). The relative importance ranking was similar between the general public and FDR participant samples; however, other relative preference measures involving weights including MARs and market share differed between groups, with FDRs having numerically higher MARs.

CONCLUSION

In the context of RA prevention, the general public (average risk) may be a reasonable proxy for a more at-risk sample (FDRs) for overall relative importance ranking but not weights. The rationale for a proxy sample should be clearly justified.

HIGHLIGHTS

Participants from the general public were compared to first-degree relatives on their preferences for rheumatoid arthritis (RA) preventive treatments using a discrete choice experiment.Preferences were similar between groups in terms of the most important and least important attributes of preventive treatments, with effectiveness being the most important attribute. However, relative weights differed.Attention to the survey and predicted market shares of hypothetical RA preventive treatments differed between the general public and first-degree relatives.The general public may be a reasonable proxy for an at-risk group for patient preferences ranks but not weights in the disease prevention context; however, care should be taken in sample selection for patient preference studies when choosing nonpatients.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Exploring preferences of at-risk individuals for preventive treatments for rheumatoid arthritis

OBJECTIVE

Some immunomodulatory drugs have been shown to delay the onset of, or lower the risk of developing, rheumatoid arthritis (RA), if given to individuals at risk. Several trials are ongoing in this area; however, little evidence is currently available about the views of those at risk of RA regarding preventive treatment.

METHOD

Three focus groups and three interviews explored factors that are relevant to first degree relatives (FDRs) of RA patients and members of the general public when considering taking preventive treatment for RA. The semi-structured qualitative interview prompts explored participant responses to hypothetical attributes of preventive RA medicines. Transcripts of focus group/interview proceedings were inductively coded and analysed using a framework approach.

RESULTS

Twenty-one individuals (five FDRs, 16 members of the general public) took part in the study. Ten broad themes were identified describing factors that participants felt would influence their decisions about whether to take preventive treatment if they were at increased risk of RA. These related either directly to features of the specific treatment or to other factors, including personal characteristics, attitude towards taking medication, and an individual's actual risk of developing RA.

CONCLUSION

This research highlights the importance of non-treatment factors in the decision-making process around preventive treatments, and will inform recruitment to clinical trials as well as information to support shared decision making by those considering preventive treatment. Studies of treatment preferences in individuals with a confirmed high risk of RA would further inform clinical trial design.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

POS0591 TREATMENTS TO PREVENT RHEUMATOID ARTHRITIS IN FIRST DEGREE RELATIVES: DEMOGRAPHIC AND PSYCHOLOGICAL PREDICTORS OF RISK TOLERANCES

Background

There is a growing research focus on the development of interventions to reduce risk of rheumatoid arthritis (RA) in at-risk groups.(1) RA patients’ first-degree relatives (FDRs) have an elevated risk of developing RA and are potential candidates for preventive interventions. Recent studies have quantified the preferences of at risk groups for preventive treatments.(2-4) Little is known about predictors of preference heterogeneity in this context.

Objectives

Assess the extent to which FDR characteristics and beliefs predict risk tolerances for preventive treatments.

Methods

Adult FDRs of patients with confirmed RA in the UK were invited to take part in a web-based survey. FDRs enrolled in a UK prospective cohort (PREVeNT-RA) were also invited. Survey development, including attribute selection and presentation, was informed by qualitative research, ranking surveys, literature review, and expert opinion including patient research partners. Respondents received information about RA, questions to check comprehension, and an introduction to the survey. Participants were asked to imagine they were experiencing arthralgia and had positive autoantibody tests indicating a 60% chance of developing RA within two years. Using a probabilistic threshold technique, participants made choices between no treatment (no benefit and no risks) or a preventive treatment option. Treatment options were defined by a fixed level of benefit (reduction in risk of RA from 60% to 20%) and varying levels of risks (Table 1). For each treatment risk, participants made a series of choices where the risk was systematically increased or decreased until they switched their choice. This procedure was repeated for each of the remaining risks. Participants also completed items assessing demographics, perceived risk of developing RA, health literacy, subjective numeracy, the Brief Illness Perception Questionnaire (IPQ) and the Beliefs about Medicines Questionnaire General (BMQ-G). The maximum acceptable risk (MAR) respondents were willing to accept for a 40% (60% to 20%) point risk reduction in developing RA was summarized across participants using descriptive statistics. Associations between MARs and participants’ characteristics and illness/medication beliefs were assessed using interval regression. Independent variables were dichotomized and effects coded.

Table 1.

Attributes and levels of treatment options

Treatment attributeLevels describing no treatment optionLevels describing treatment optionChance of developing RA60%20%Chance of mild side effects0%2%; 4%; 5%; 7% or 10%Chance of a serious infection due to treatment0%1%; 1.5%; 2%; 3% or 5%Chance of a serious side effect that is potentially irreversible0%0.001%; 0.01%; 0.02%; 0.05% or 0.1%

Results

289 FDRs (80 male) responded. The mean (SE) MAR for mild side effects, serious infection, and serious side effects was 29.08 (1.52), 9.09 (0.60) and 0.85 (0.27), respectively. Participants aged over 60 years were less tolerant of risk of serious infection than average (mean MAR - 2.06 (0.78)) and younger participants were more tolerant of risk of serious infection than average (mean MAR + 2.06 (0.78)). Risk of mild side effects was less acceptable to participants who perceived they were likely/very likely to develop RA (mean MAR - 3.34 (1.55)) than to those who did not (mean MAR + 3.34 (1.55)). Education level, health literacy, numeracy, IPQ and BMQ-G subscales were not predictors of risk tolerance.

Conclusion

Age and perceived risk of RA had a significant impact on FDRs’ tolerance for specific, but not all, included risks. Cognitive ability and beliefs about RA/medicine did not explain preference heterogeneity. This is informative for drug development and the development of tailored risk communication resources to support preventive approaches.

References

[1]Mankia et al. Ann Rheum Dis. 2021;80(10):1286-98.

[2]Simons et al. Ann Rheum Dis. 2021;80:96-7.

[3]Harrison et al. Plos One. 2009; 14(4): e0216075.

[4]Finckh et al. Curr Rheumatol Rep. 2016;18: 51.

Acknowledgements

On behalf of the PREFER project. PREFER received funding from the IMI 2 Joint Undertaking (grant No. 115966), which receives support from the EU’s Horizon 2020 research and innovation program and European Federation of Pharmaceutical Industries and Associations (EFPIA). K. Raza is supported by the NIHR Birmingham Biomedical Research Centre.

Disclosure of Interests

Gwenda Simons: None declared, Ellen Janssen Shareholder of: Johnson & Johnson, Employee of: Janssen Research and Development, Jorien Veldwijk: None declared, Rachael DiSantostefano Shareholder of: Johnson & Johnson, Employee of: Janssen Research and Development, Matthias Englbrecht Speakers bureau: Abbvie, Chugai, Eli Lilly, Novartis, Roche, Sanofi, Mundipharma, Paid instructor for: Abbvie, Chugai, Roche, Consultant of: Abbvie, Novartis, Roche, Sanofi, Grant/research support from: Roche, Chugai, Christine Radawski Shareholder of: Eli Lilly, Employee of: Eli Lilly, Larissa Valor: None declared, Jenny Humphreys: None declared, Ian N. Bruce: None declared, Brett Hauber Shareholder of: Pfizer Inc., Employee of: Pfizer Inc., Karim Raza Consultant of: Abbvie, Sanofi, Grant/research support from: Bristol Myers Squibb, Marie Falahee: None declared.

POS0597 PREDICTORS OF PERCEIVED RISK IN FIRST DEGREE RELATIVES OF RHEUMATOID ARTHRITIS PATIENTS

Background

Risk of rheumatoid arthritis (RA) is 3-5 times higher in first-degree relatives (FDRs). Efforts are increasing to develop preventive interventions for this at risk group. Risk perception is a key predictor of health behaviours, including FDRs’ interest in predictive testing1 and preventive intervention for RA. Effective risk communication is essential for RA prevention studies and clinical translation2.

Objectives

To define variables associated with perceived risk of developing RA in FDRs of RA patients.

Methods

RA patients attending outpatient clinics (West Midlands, UK) were asked to invite their FDRs to complete a cross-sectional printed survey. Patients were also invited to complete a survey. Unique survey numbers enabled linkage of FDR and proband responses. FDRs’ perceived absolute risk, comparative risk, experiential risk, and worry about risk were assessed using 5-point Likert scales. Predictor variables included demographics, the Single Item Literacy Screener, Brief Illness Perception Questionnaire, Brief Approach/Avoidance Coping Questionnaire, Life Orientation Test Revised and the Short Health Anxiety Inventory. Patient predictors of FDR perceived risk included demographics, time since RA diagnosis and Rheumatoid Arthritis Impact of Disease Score.

Outcome measure responses were grouped into ‘low’ and ‘high’ for regression analyses. Univariable analysis used independent samples T-tests, chi-square tests and Mann-Whitney U Tests. Backwards stepwise binary logistic regression examined the relationship between FDR characteristics and perceived risk of RA. Generalised Estimating Equations assessed whether patient variables predicted FDR’s perceived risk.

Results

396 FDRs returned a survey. Paired data from 213 patients were available for 292 of these FDRs.

The distributions of risk perception scores are shown in Figure 1. All measures of perceived risk were inter-correlated (p<0.001; ranging from r=0.48 to r=0.80).

65.2% of FDRs perceived themselves to be ‘Likely’ or ‘Very Likely’ to develop RA in their lifetime. FDR’s ethnic group, deprivation index, employment status, education level, smoking status, cohabitation with index patient status, coping style and dispositional optimism were not significantly different between high and low perceived risk groups. Characteristics significant in univariable analyses were used in multivariable analyses (Table 1). Children were 3.89 times more likely than siblings to perceive themselves at high risk of RA. Higher health anxiety scores were associated with increased perceived risk. Female gender, and beliefs that RA would last a long time, and cause higher concern and negative emotional impact predicted increased risk perceptions. Higher perceptions of how well treatment would control RA was associated with a reduced likelihood of perceiving oneself at high risk.

Index patient characteristics did not associate with FDRs’ risk perceptions.

Table 1.

Multivariable analysis

FDR CharacteristicPerceived Risk [Odds Ratio (95% Confidence Interval)]AbsoluteComparativeExperientialWorry about RiskGender1.98 (1.19-3.27)* Male$ FemaleRelationship to index patient2.80 (1.70-4.61)***3.43 (2.04-5.78)***3.89 (2.24-6.75)***2.26 (1.30-3.94)** Child Sibling$Health Literacy1.50 (1.00-2.25)Illness Perceptions0.89 (0.79-0.99)*1.25 (1.05-1.48)*1.17 (0.99-1.38)0.84 (0.74-0.94)** Timeline0.91 (0.81-1.01)0.87 (0.77-0.98)*1.36 (1.13-1.63)** Treatment control1.20 (1.02-1.40)* Concern EmotionHealth Anxiety1.04 (1.01-1.07)*1.05 (1.01-1.07)*1.07 (1.03-1.11)**1.06 (1.02-1.09)**

*p<0.05, **p<0.01, ***p<0.001, $ Reference

Conclusion

FDRs’ perceived risk of RA was high. Key predictors included being a child of a patient with RA, higher health anxiety and lower perceptions of RA treatment control. An understanding of these predictors will inform the development of effective risk communication and preventive strategies.

References

[1]Wells et al. Rheumatology. 2021 doi: 10.1093/rheumatology/keab890

[2]Mankia et al. Ann Rheum Dis. 2021;80(10):1286-98

Acknowledgements

S. Bunnewell and I. Wells are joint first authors.

Disclosure of Interests

None declared

OP0276 PREFERENCES FOR TREATMENTS TO PREVENT RHEUMATOID ARTHRITIS: DISCRETE CHOICE SURVEY OF RHEUMATOID ARTHRITIS PATIENTS’ FIRST-DEGREE RELATIVES IN THE UNITED KINGDOM AND GERMANY

Background

There is a growing research focus on the development of interventions to reduce risk of rheumatoid arthritis (RA) in at-risk individuals.(1) A recent survey of the general population asked to assume a 60% risk of RA established that hypothetical preventive treatments were acceptable to most participants.(2) However the preferences of individuals who actually have an elevated risk of RA, such as first-degree relatives (FDRs) of RA patients, are not well understood.

Objectives

To quantify FDRs’ preferences for preventive treatments for RA.

Methods

Adult FDRs in the UK and Germany were invited to take part in a web-based survey via patients with clinician-confirmed RA either during a rheumatology clinic visit or by mail. In addition, FDRs taking part in a UK-based prospective cohort (PREVeNT-RA) were invited via email. Participants received information about RA followed by questions to check comprehension, and an introduction to the survey including warm-up questions. They were asked to imagine they were experiencing arthralgia and had positive autoantibody tests indicating a 60% chance of developing RA in the next two years. Using a discrete choice experiment, participants were offered a series of 15 choices between no treatment and two unlabeled hypothetical treatments to reduce risk of RA. Treatments were defined by six attributes with varying levels, describing benefits, risks, and frequency/route of administration (Table 1). Attribute selection and presentation was informed by qualitative research, ranking surveys, systematic literature review, and expert opinion. Survey layout was informed by patient research partners and qualitative pre-testing. A two-class latent class analysis was used to estimate preferences and calculate relative importance of treatment attributes and predicted uptake. A panel mixed logit model was used to obtain maximum acceptable risk estimates.

Table 1.

Treatment attributes and levels

AttributeLevelsChance of developing RA reduced from 60% to10%; 20%; 30%; 40%How the treatment is takenA shallow injection under the skinA drip into the veinOne or two tabletsHow often the medication has to be takenDailyWeeklyMonthlyEvery 6 monthsChance of mild side effects2%; 5%; 10%Chance of a serious infection due to treatment0%; 1%; 5%Chance of a serious side effect that is potentially irreversible1 in 100,000 people20 in 100,000 people100 in 100,000 people

Results

356 FDRs (252 female, 289 in the UK) responded. While treatment effectiveness was the most important attribute in both classes (Figure 1), the importance of other attributes differed between classes, with method and frequency of treatment administration being more important in class 2 and risk of mild side effects only impacting treatment choice in class 1. Perceived risk of developing RA predicted class assignment; those with higher perceived risk were more likely to belong to class 1. On average, the predicted uptake of treatment profiles estimating prevention candidates: abatacept; atorvastatin; hydroxychloroquine; tolerogenic cell-based therapy; and no treatment would be 50%, 15%, 9%, 18% and 0%, respectively. Finally, the maximum acceptable risk participants were willing to accept were 81%, 25% and 3% point increases in risk of mild side effects, serious infection, and serious side effects, respectively, for medicines that would reduce their risk of developing RA in the upcoming two years from 60% to 20%.

Conclusion

Effective preventive treatments for RA were acceptable to FDRs asked to assume a 60% chance of developing RA. Mode and frequency of treatment administration had a greater impact on treatment choices for participants with a lower perceived risk of RA. These findings are informative for target product profile development, endpoint selection, benefit-risk assessment, regulatory approval, and development of informational resources for those at risk of RA.

References

[1]Mankia et al. Ann Rheum Dis. 2021;80(10):1286-98.

[2]Simons et al. Ann Rheum Dis. 2021;80:96-7.

Acknowledgements

On behalf of the PREFER project. PREFER received funding from the IMI 2 Joint Undertaking (grant No. 115966), which receives support from the EU’s Horizon 2020 research and innovation program and European Federation of Pharmaceutical Industries and Associations (EFPIA). This abstract and its contents reflect the view of the presenter and not the view of PREFER, IMI, the European Union or EFPIA. K. Raza is supported by the NIHR Birmingham Biomedical Research Centre.

Disclosure of Interests

Gwenda Simons: None declared, Jorien Veldwijk: None declared, Rachael DiSantostefano Shareholder of: Johnson & Johnson, Employee of: Janssen Research and Development, Matthias Englbrecht Speakers bureau: Abbvie, Chugai, Eli Lilly, Novartis, Roche, Sanofi, Munidpharma, Paid instructor for: Abbvie, Chugai, Roche, Consultant of: Abbvie, Novartis, Roche, Sanofi, Grant/research support from: Roche, Chugai, Christine Radawski Shareholder of: Eli Lilly & Company, Employee of: Eli Lilly & Company, Larissa Valor: None declared, Jenny Humphreys: None declared, Ian N. Bruce: None declared, Karim Raza Consultant of: Abbvie, Sanofi, Grant/research support from: Bristol Myers Squibb, Marie Falahee: None declared

POS1483-HPR A QUANTITATIVE ASSESSMENT OF THE LIKELIHOOD THAT PATIENTS WITH RHEUMATOID ARTHRITIS WILL COMMUNICATE INFORMATION ABOUT RHEUMATOID ARTHRITIS RISK TO RELATIVES

Background:

First-degree relatives (FDRs) of patients with rheumatoid arthritis (RA) are at increased risk of RA and are being recruited to studies of predictive and preventive approaches. Access to FDRs is usually via the proband with RA. Qualitative investigations have shown that communication of RA risk to FDRs is a complex and selective process. However, quantitative data are needed to develop a robust understanding of this process and its determinants to develop effective communication strategies and support for RA patients and their relatives.

Objectives:

To identify predictors of the RA patients’ reported likelihood of communicating RA risk information to their FDRs.

Methods:

Patients with RA were invited to anonymously complete a survey assessing patient characteristics including age, gender, duration of RA, information seeking and decision making preferences (Autonomy Preference Index1), interest in FDRs taking a predictive test for RA, dispositional openness, and the general functioning subscale of the McMaster Family Assessment Device2. Reported likelihood of communicating RA risk to each of the patients’ FDRs was assessed using a Likert scale ranging from extremely unlikely (0) to extremely likely (4). The median score across all FDRs was calculated for each patient. The association between patient characteristics and the median score was examined using univariate approaches.

Results:

Surveys were completed by 482 patients (median age 65 years, 72% female). Most patients reported being likely to communicate RA risk to their FDRs (median score=3). Those who reported their likelihood of communicating RA risk to both children and siblings were more likely to communicate risk to children than siblings (p<0.001). No significant difference was found for FDRs’ gender, or patients’ gender, on reported likelihood to communicate about RA risk (p=0.32 and p=0.87, respectively). Patients who were older and who had had RA for longer were less likely to communicate about RA risk with their relatives. Patients who had higher interest in their FDRs taking a predictive test for RA, information seeking preferences, openness to communicate, and family functioning were more likely to communicate about risk (Table 1).

Table 1.

Descriptive statistics and Spearman’s rank-order correlations for the association between patients’ characteristics and their median reported likelihood of communicating to their FDRs about RA risk

Patient characteristicsDescriptive statisticsAssociation with median likelihood to communicate risk to relativesTest statisticP valueAge; median (IQR)65 (55-72)-0.19<0.001*RA duration; median (IQR)10 (4-20)-0.180.001*Autonomy preferences Information seeking; median (IQR)84 (75-97)0.26<0.001* Decision making; median (IQR)54 (42-67)0.090.048Interest in children taking a test; median (IQR)3 (2-3)0.44<0.001*Interest in siblings taking a test; median (IQR)2 (2-3)0.44<0.001*Openness; median (IQR)2 (1-3)0.130.004*Family functioning; median (IQR)2 (2-3)0.23<0.001*

* p values significant at the Bonferroni adjusted value of 0.006.

Conclusion:

Respondents were willing to communicate RA risk to their FDRs, and were more likely to communicate about risk to their children than their siblings. Factors including information seeking preferences, dispositional openness, interest in FDRs taking a predictive test, and family functioning were associated with increased likelihood of communicating RA risk information to FDRs. Patients’ age and RA duration were associated with decreased likelihood. These findings increase understanding of communication about RA risk in families, and will inform the development of informational approaches to support family communication and access to FDRs.

References:

[1]Ende et al. Journal of General Internal Medicine. 1989; 4(1): 23-30.

[2]Epstein et al. Journal of Marital and Family therapy.1983; 9(2): 171-180.

Acknowledgements:

This work was supported by Versus Arthritis; Grant reference: 21560 and Riksbankens Jubileumsfond (The Swedish Foundation for Humanities and Social Sciences); Grant reference: M13-0260:1 ‘Mind the Risk’.

Disclosure of Interests:

Imogen Wells: None declared, Peter Nightingale: None declared, Gwenda Simons: None declared, Christian Mallen Grant/research support from: Keele School of Medicine have received funding to support BMS recruit to a non-pharmacological atrial fibrillation trial., Karim Raza Grant/research support from: KR reports grants from Abbvie and Pfizer, and personal fees from Abbvie, Pfizer, Sanofi, Lilly, Bristol Myers Squibb, UCB, Janssen, and Roche Chugai, all outside the submitted work., M. Falahee: None declared

OP0160-HPR PREFERENCES FOR TREATMENTS TO PREVENT RHEUMATOID ARTHRITIS: DISCRETE CHOICE SURVEY OF GENERAL POPULATIONS IN UNITED KINGDOM, GERMANY, AND ROMANIA

Background:

There is increasing research focus on intervention for rheumatoid arthritis (RA) at the earliest stages of disease development, including treatment to prevent RA in at-risk groups. Novel cellular therapies are in development, and the effectiveness of existing immunomodulatory agents to prevent RA in those at risk is under investigation. Quantitative evidence of likely uptake of preventive treatments, and preferences for benefits and risks of such treatments is limited.

Objectives:

To quantify preferences for preventive therapies for RA.

Methods:

A web-based survey (n = 2959) was administered to an age- and gender- stratified sample of adults in the general population from online survey panels in the UK, Germany, and Romania. After receiving information about RA, questions to check comprehension of background information, an introduction to the survey tasks and warm-up questions, participants were asked to imagine that they were experiencing arthralgia (without swelling) and had positive autoantibody tests indicating a 60% chance of developing RA in the next two years. Using a discrete choice experiment with a Bayesian D-efficient design, participants were offered a series of 15 choices between no treatment and two unlabeled hypothetical treatments to lower risk of RA development. Treatments were defined by six attributes with varying levels including benefits, risks, and frequency/route of administration (Table 1). One choice task with fixed levels described treatments representative of those under investigation for RA prevention (abatacept, hydroxychloroquine, atorvastatin and tolerogenic cell-based therapy). Attribute selection and presentation was informed by previous qualitative research, ranking surveys, systematic literature review, and expert opinion. Survey design was informed by patient research partners. The survey was pre-tested during qualitative interviews and revised. A pilot of the final survey with 100 respondents was conducted to obtain priors for the final experimental design. Random parameters logit (RPL) models were used to estimate relative importance of treatment attributes and likely treatment uptake rates in each country.

Table 1.

Treatment attributes and levels

AttributeLevelsChance of developing RA reduced from 60% to10%; 20%; 30%; 40%How the treatment is takenA shallow injection under the skinA drip into the veinOne or two tabletsHow often the medication has to be takenDailyWeeklyMonthlyEvery 6 monthsChance of mild side effects2%; 5%; 10%Chance of a serious infection due to treatment0%; 1%; 5%Chance of a serious side effect that is potentially irreversible1 in 100,000 people20 in 100,000 people100 in 100,000 people

Results:

Across all three countries, effectiveness was the treatment attribute that had most impact on treatment choice (Figure 1). Method of administration was second most important for respondents from the UK and Romania but less important for German respondents. Risks of serious infection and serious side effects were more important determinants of treatment choice for respondents in Romania than they were in the UK and Germany. Percentage choice of fixed profiles reflecting abatacept, atorvastatin, hydroxychloroquine, tolerogenic cell-based therapy and no treatment differed across countries (χ2=78.90; p<0.001): 28.3%, 20.6%, 22.2% 18.5% and 10.4% respectively in the UK; 31.3%, 18.8%, 11.2%, 23.4% and 15.3% in Germany; and 27.6%, 20.5%, 15.8%, 21.7% and 14.4% in Romania.

Conclusion:

This study suggests that effective preventive treatments for RA are acceptable to members of the general population told to assume up a 60% chance of developing RA. The relative importance of treatment attributes and likely uptake of fixed treatment profiles differed across countries. These findings are informative for the design of prevention trials, and the development of informational resources and efficient preventive strategies for those at risk of developing RA.

Acknowledgements:

On behalf of the PREFER project. PREFER received funding from the IMI 2 Joint Undertaking (grant No. 115966), which receives support from the EU’s Horizon 2020 research and innovation program and European Federation of Pharmaceutical Industries and Associations (EFPIA). K. Raza is supported by the NIHR Birmingham Biomedical Research Centre.

Disclosure of Interests:

Gwenda Simons: None declared, Jorien Veldwijk: None declared, Rachael Di Santostefano Shareholder of: Johnson & Johnson, Employee of: Janssen R&D (of Johnson & Johnson), Matthias Englbrecht Speakers bureau: AbbVie, Chugai, Eli Lilly, Novartis, Roche, Sanofi, Mundipharma, Paid instructor for: AbbVie, Chugai, Roche, Consultant of: AbbVie, Novartis, Roche, Sanofi, Grant/research support from: Roche, Chugai, Christine Radawski Shareholder of: Eli Lilly & Company, Employee of: Eli Lilly & Company, Larissa Valor: None declared, Karim Raza Consultant of: Personal fees from Abbvie, Pfizer, Sanofi, Lilly, Bristol Myers Squibb, UCB, Janssen, and Roche Chugai, Grant/research support from: Abbvie and Pfizer, M. Falahee: None declared

OP0264-HPR PERSPECTIVES ON APPROACHES TO PREDICT THE DEVELOPMENT OF RHEUMATOID ARTHRITIS: A QUANTITATIVE ASSESSMENT OF PATIENTS AND THEIR FIRST DEGREE RELATIVES

Background:

There is considerable interest within the medical research community in the identification of individuals at risk of developing rheumatoid arthritis (RA), to identify those who may benefit from preventive interventions. However, it is important to understand the views of those who may be candidates for such predictive tests, to inform the development of effective approaches. First degree relatives (FDRs) of patients with RA are at an increased risk of developing RA. RA patients can provide access to FDRs. Qualitative investigations have explored the views of these groups about predictive testing for RA1,2, but quantitative approaches are needed to develop a robust understanding.

Objectives:

To identify predictors of interest in predictive testing for FDRs and patients, and to assess the likelihood of patients communicating information about RA risk to their FDRs.

Methods:

Surveys were completed by 482 RA patients and 397 of their FDRs. Patients were invited to complete the survey and to provide another to their relatives. Spearman’s Rank Correlations were used to assess relationships between interest in predictive testing/ likelihood of risk communication and potential predictor variables.

Results:

FDRs had a median age of 41 years, 64% were female. 57% were definitely interested and 36% were probably interested in taking a predictive test for RA. Several predictors were found to be associated with interest (table 1).

Table 1.

Spearman’s correlations for relatives’ and patients’ interest in predictive testing. After applying a Bonferonni adjustment, p values were taken as statistically significant at p≤0.003.

FDRsPatientsPredictors of interest in predictive testingrsPrsPBrief Illness Perception Questionnaire0.110.030.090.05 Consequences0.16*0.002*0.100.03 Timeline0.090.07-0.050.28 Personal control-0.030.59-0.020.68 Treatment control-0.020.760.020.74 Identity0.090.090.120.01 Concern0.21*<0.001*0.16*<0.001* Coherence0.110.030.0070.88 Emotional0.120.020.110.02Information Seeking0.35*<0.001*0.22*<0.001*Decision making-0.050.330.070.13Health literacy0.030.520.020.62Health numeracy-0.060.23-0.020.72Brief Avoidance Coping Questionnaire0.120.02-0.010.76Optimism0.060.26-0.070.12Health anxiety0.16*0.001*--Perceived risk0.37*<0.001*--Rheumatoid Arthritis Impact of Disease--0.050.31

– not applicable

Patients had a median age of 65 years, 71% were female. 47% were definitely interested and 30% were probably interested in their children taking a predictive test. Several predictors were found to be associated with interest (table 1). On a Likert scale from extremely unlikely (0) to extremely likely (4), most patients indicated that they were likely to communicate RA risk information to their children (median score=3).

Conclusion:

Interest in predictive testing for RA was high amongst FDRs, and factors including information seeking preference, RA risk perception, concern about RA, perceived consequences of RA and health anxiety were significantly associated with interest. Patients were also willing to communicate information about RA risk to their children. These findings increase understanding of perceptual variation in those at risk of RA, and will inform the development of information to support decision making in individuals considering predictive tests and preventive interventions. We are currently extending this preliminary analysis by building multivariate models incorporating a range of attitudes about predictive testing, assessing predictors of patients’ likelihood of communicating to their FDRs about risk, and the relationship between patients’ and FDRs’ responses.

References:

[1]Stack RJ et al. BMJ open. 2016; 6(6):e010555.

[2]Falahee M et al. Arthritis care & research. 2017; 69(10):1558-65.

Acknowledgments:

This work was supported by Versus Arthritis; Grant reference: 21560.

Disclosure of Interests:

Imogen Wells: None declared, Gwenda Simons: None declared, Rebecca Stack: None declared, Christian Mallen Grant/research support from: My department has received financial grants from BMS for a cardiology trial., Peter Nightingale: None declared, Karim Raza Grant/research support from: KR has received research funding from AbbVie and Pfizer, Consultant of: KR has received honoraria and/or consultancy fees from AbbVie, Sanofi, Lilly, Bristol-Myers Squibb, UCB, Pfizer, Janssen and Roche Chugai, Speakers bureau: KR has received honoraria and/or consultancy fees from AbbVie, Sanofi, Lilly, Bristol-Myers Squibb, UCB, Pfizer, Janssen and Roche Chugai, M. Falahee: None declared

Pharmacokinetic and pharmacodynamic profile of the sodium-glucose co-transporter-2 inhibitor empagliflozin in young people with Type 2 diabetes: a randomized trial

AIMS

To assess the pharmacokinetic and pharmacodynamic profile of a single dose of empagliflozin in young people with Type 2 diabetes to identify the appropriate doses for further paediatric development.

METHODS

We conducted a single-dose, open-label, randomized, parallel-group study with empagliflozin 5 mg, 10 mg and 25 mg in young people with Type 2 diabetes aged 10-17 years.

RESULTS

Of 39 participants screened, 27 were randomized and completed the study; their mean (± sd) age was 14.1±2.0 years and body weight was 96.7±23.5 kg. Compared with similar studies in adults with Type 2 diabetes, the maximum observed plasma concentrations were slightly lower with the 10-mg and 25-mg doses, and the area under the plasma concentration-time curve was slightly lower with the 10-mg but slightly higher with the 25-mg dose. The adjusted mean increases in urinary glucose excretion were 53 g/24 h (95% CI 32,74), 73 g/24 h (95% CI 52,94) and 87 g/24 h (95% CI 68,107), and the adjusted mean decreases in fasting plasma glucose were 0.9 mmol/l (95% CI -1.6,-0.1), 0.9 mmol/l (95% CI -1.7,-0.2) and 1.1 mmol/l (95% CI -1.8,-0.5) for the 5- 10- and 25-mg doses, respectively. There were no serious adverse events and one investigator-reported drug-related event (dehydration).

CONCLUSIONS

After a single oral dose of empagliflozin, adults and young people with Type 2 diabetes had similar exposure-response relationships after adjusting for significant covariates. These data support testing 10-mg and/or 25-mg doses of empagliflozin in an upcoming paediatric phase III Type 2 diabetes trial. (ClinicalTrials.gov registration no.: NCT02121483).

LabDisk with complete reagent prestorage for sample-to-answer nucleic acid based detection of respiratory pathogens verified with influenza A H3N2 virus

Portable point-of-care devices for pathogen detection require easy, minimal and user-friendly handling steps and need to have the same diagnostic performance compared to centralized laboratories. In this work we present a fully automated sample-to-answer detection of influenza A H3N2 virus in a centrifugal LabDisk with complete prestorage of reagents. Thus, the initial supply of the sample remains the only manual handling step. The self-contained LabDisk automates by centrifugal microfluidics all necessary process chains for PCR-based pathogen detection: pathogen lysis, magnetic bead based nucleic acid extraction, aliquoting of the eluate into 8 reaction cavities, and real-time reverse transcription polymerase chain reaction (RT-PCR). Prestored reagents comprise air dried specific primers and fluorescence probes, lyophilized RT-PCR mastermix and stick-packaged liquid reagents for nucleic acid extraction. Employing two different release frequencies for the stick-packaged liquid reagents enables on-demand release of highly wetting extraction buffers, such as sequential release of lysis and binding buffer. Microfluidic process-flow was successful in 54 out of 55 tested LabDisks. We demonstrate successful detection of the respiratory pathogen influenza A H3N2 virus in a total of 18 LabDisks with sample concentrations down to 2.39 × 10(4) viral RNA copies per ml, which is in the range of clinical relevance. Furthermore, we detected RNA bacteriophage MS2 acting as internal control in 3 LabDisks with a sample concentration down to 75 plaque forming units (pfu) per ml. All experiments were applied in a 2 kg portable, laptop controlled point-of-care device. The turnaround time of the complete analysis from sample-to-answer was less than 3.5 hours.

Human papillomavirus typing by single tube multiplex amplification in real time (SMART): the PapillomaFinder® SMART 20 assay

BACKGROUND

High-risk (hr) human papillomavirus (HPV) infections play a causal role in the development of cervical cancer. The detection of hrHPV is, therefore, advocated in cervical cancer screening programs.

OBJECTIVES

The aim of this study was to determine the performance of a novel HPV typing assay, PapillomaFinder® SMART 20. This is a one-tube-per-sample method, to be performed on standard real-time PCR platforms, using melting curve analysis to distinguish targets. The assay detects all 14 hrHPV types, of which 16, 18, 31, 33, 35, 39, 45, 52, 56 and 58 individually. HrHPV types 51, 59, 66 and 68 are detected in an hrHPV pool, and low-risk (lr) HPV types 6, 11, 40, 42, 43 and 44 in an lrHPV pool.

STUDY DESIGN

The method was tested on HPV plasmid models, WHO and QCMD proficiency panels and a series of clinical cytological samples (n=45), the latter in comparison with a clinically validated real-time quantitative PCR.

RESULTS

Type-specificity of the test was 100% using plasmids, the WHO and QCMD panels. Sensitivity for hrHPV in single infections was 100% using the WHO and QCMD panels and cytological samples, with an analytical sensitivity of 10-25 copies per reaction for all HPV types tested. Of the 34 HPV types present in the 8 multiple infections in the WHO panel, 30 were detected. In all cytological samples at least one hrHPV type was found, in concordance with the clinically validated method. Only when the viral load of the dominant HPV types in multiple infections greatly exceeded that of the other types in the infection, those other types were not always detected.

CONCLUSIONS

PapillomaFinder® SMART 20 is a rapid, easy to perform, single tube HPV typing assay. The assay detects the 14 hrHPV types, and the 6 most important lrHPV types with a high sensitivity and type-specificity.

Studien zum Vorgang der Wasserstoffübertragung, 72 [1] Versuche zur enantioselektiven Homogenhydrierung von N-Acyl-α-aminozimtsäuren mit Rh(I)-Komplexen unter Verwendung neuer optisch aktiver Co-Katalysatoren/Studies on the Occurrence of Hydrogen Transfer, 72, [1] Investigation on the Enantioselective Homogeneous Hydrogenation of N-Acyl-α-aminocinnamic Acids with Rh(I)-Complexes Using New Optically Active Co-Catalysts

3 Optically active compounds of the type I and 15 optically active compounds of the type II were investigated as co-catalysts in the homogeneous hydrogenation of N-acyl-α-aminocinnamic acids using standard conditions. In the co-catalysts of the type I the phosphorus atom is the center of the asymmetry. In the representatives of type II the side chain is optically active and the three bonded phosphorus either achiral or optically active.

The results of the homogeneous hydrogenation are deposited in the Tables I-IV. In the Tables I and IV the degree of the optical induction and the configuration of the excess enantiomer are determined using Rh/P-ratios 1:1,1 and 1:2,2. The Tables II and III show the results applying a Rh/P-ratio of 1:2,2. The observed degree of optical induction is low with the co-catalysts 1-18; only the co-catalyst 19 shows an optical induction of 68%.

A change of the configuration of the excess enantiomer of N-benzoylphenylalanine formed by the homogeneous hydrogenation of N-benzoyl-α-cinnamic acid for the first time was observed by varying the Rh/P-ratio of the co-catalysts 14, 17 and 18 from 1:1,1 to 1:2,2.

Studien zum Vorgang der Wasserstoffübertragung, 70 [1] Über den Einfluß der Struktur des Co-Katalysators auf die Hydrierung von Hexen-1 mit Rh(I)-Phosphin-Komplexen. Gibt es einen „Scheibenwischer-Effekt“?/Studies on the Occurrence of Hydrogentransfer, 70 [1] On the Influence of the Structure of the Co-Catalyst upon the Hydrogenation of Hexene-1 with Rh(I)-Phosphine-Complexes. Exists a Wind-Screen-Wiper-Effect?

It is well known, that OMe and NMe2 - substituents in the ortho-position of phenyl groups linked to phosphorus as a center o f chirality induce a high optical activity to derivatives of α-acylaminoacrylic acid in the homogeneous hydrogenation with Rh(I)-Phosphine complexes. The influence of the number, position and the nature of OR-substituents in the aromatic systems of tertiary phosphines upon the rate of the hydrogentransfer to hexene-1 as olefine is investigated and discussed (Tables I to V ). For an explanation of the chemical behaviour of co-catalyst containing o-RO-phenylsubstituents a short lasting coordinative interaction between the oxigen atom of the OR-substituent and the Rh(I) as the central atom is postulated (wind-screen-wipereffect), which stabilizes the configuration of a catalytic active intermediate. Triarylarsines with o-RO-phenyl substituents have a lower catalytic activity, as the corresponding phosphines as co-catalysts (Tables VI to VIII).

High-throughput amplification fragment length polymorphism (htAFLP) analysis identifies genetic lineage markers but not complement phenotype-specific markers in Moraxella catarrhalis

Comparative high-throughput amplified fragment length polymorphism (htAFLP) analysis was performed on a set of 25 complement-resistant and 23 complement-sensitive isolates of Moraxella catarrhalis in order to determine whether there were complement phenotype-specific markers within this species. The htAFLP analysis used 21 primer-pair combinations, generating 41 364 individual fragments and 2273 fragment length polymorphisms, with an average of 862 polymorphisms per isolate. Analysis of polymorphism data clearly indicated the presence of two phylogenetic lineages and 40 (2%) lineage-specific polymorphisms. However, despite the presence of 361 (16%) statistically significant complement phenotype-associated polymorphisms, no single marker was 100% complement phenotype-specific. Furthermore, no complement phenotype-specific marker was found within different phylogenetic lineages. These findings agree with previous results indicating that the complement resistance phenotype within M. catarrhalis is probably defined by multiple genes, although not all of these genes may be present within all M. catarrhalis isolates.

Outbreak of Norwalk virus in a Caribbean island resort: application of molecular diagnostics to ascertain the vehicle of infection

In 1998, an outbreak of gastroenteritis affected at least 448 persons including 122 staff at a resort hotel in Bermuda. A survey among staff indicated that gastroenteritis was associated with eating or drinking at the hotel (OR = 60, 95% CI = 2.4-15.1). Multiple specimens of drinking water had elevated faecal coliform levels and Escherichia coli present, suggestive of faecal contamination. Stools from 18 of the 19 persons with gastroenteritis that were tested were positive for genogroup-II Norwalk-like viruses (NLVs). RT-PCR analysis of a 31 specimen of water produced a genogroup-II NLV genome with a sequence identical to that of NLVs in the stools of three ill persons. This outbreak shows the value of new molecular diagnostics to link illness with a contaminated source through the use of sequence analysis. The risk of outbreaks such as these could be reduced in tourism dependent regions like Bermuda and the Caribbean by regular evaluation of data from the inspection and monitoring of drinking water supplies and waste water systems, by ensuring the chlorination of supplemental drinking water supplies and by establishing food-safety initiatives.

Emotions and eating in everyday life

This field study assessed emotional states experienced in everyday life and examined the subjective motivation to eat associated with these emotional states. Twenty-three female subjects rated their momentary emotional state and motivation to eat on 6 consecutive days at 11:00a.m., 2:00p.m., 5:00p.m., 8:00p.m. and 11:00p.m. A cluster analysis of the resulting 634 emotion profiles revealed three types of emotional states characterized by the labels "Anger-dominance", "Tension/Fear" and "Relaxation/Joy". A fourth cluster showing generally low levels of emotions was labelled "Unemotional state". Most of the self-rated motivations to eat were increased during periods of negative emotions. During negative emotions a heightened tendency to cope with these emotions through eating and more intense bodily symptoms of hunger were also reported. No differences in motivations to eat were found between the two negative emotion clusters or between relaxation/joy and the unemotional state. Results indicate the presence of "emotionally instrumental eating" in a non-clinical population under real life conditions. Physiological correlates of negative emotional states may be involved in emotionally instrumental eating.

Expression of the Fusarium resistance gene I-2 colocalizes with the site of fungal containment

The tomato resistance gene I-2 is one of at least six members of a gene family that are expressed at low levels in the roots, stems and leaves of young tomato plants. Plants transformed with constructs containing a functional I-2 promoter fused to the beta-glucuronidase (GUS) reporter gene were used in detailed expression studies. Highest GUS activity was found in stems of young tomato plants. Histochemical analysis revealed that the I-2 promoter drives expression of the reporter gene in vascular tissue of fruits, leaves, stems and mature roots. In younger roots, expression was most abundant at the base of lateral root primordia. Microscopical analysis of young tomato plants revealed expression in tissue surrounding the xylem vessels. We show that in resistant plants, fungal growth into this region of the vascular tissue is prevented, suggesting a correlation with the I-2-mediated resistance response.

The tomato Mi-1 gene confers resistance to both root-knot nematodes and potato aphids

Mi-1, a Lycopersicon peruvianum gene conferring resistance to the agricultural pests, root-knot nematodes, and introgressed into tomato, has been cloned using a selective restriction fragment amplification based strategy. Complementation analysis of a susceptible tomato line with a 100 kb cosmid array yielded a single cosmid clone capable of conferring resistance both to the root-knot nematode Meloidogyne incognita and to an unrelated pathogen, the potato aphid Macrosiphum euphorbiae. This resistance was stable. The Mi-1 gene encodes a protein sharing structural features with the nucleotide-binding site leucine-rich repeat-containing type of plant resistance genes.

Dissection of the fusarium I2 gene cluster in tomato reveals six homologs and one active gene copy

The I2 locus in tomato confers resistance to race 2 of the soil-borne fungus Fusarium oxysporum f sp lycopersici. The selective restriction fragment amplification (AFLP) positional cloning strategy was used to identify I2 in the tomato genome. A yeast artificial chromosome (YAC) clone covering approximately 750 kb encompassing the I2 locus was isolated, and the AFLP technique was used to derive tightly linked AFLP markers from this YAC clone. Genetic complementation analysis in transgenic R1 plants using a set of overlapping cosmids covering the I2 locus revealed three cosmids giving full resistance to F. o. lycopersici race 2. These cosmids shared a 7-kb DNA fragment containing an open reading frame encoding a protein with similarity to the nucleotide binding site leucine-rich repeat family of resistance genes. At the I2 locus, we identified six additional homologs that included the recently identified I2C-1 and I2C-2 genes. However, cosmids containing the I2C-1 or I2C-2 gene could not confer resistance to plants, indicating that these members are not the functional resistance genes. Alignments between the various members of the I2 gene family revealed two significant variable regions within the leucine-rich repeat region. They consisted of deletions or duplications of one or more leucine-rich repeats. We propose that one or both of these leucine-rich repeats are involved in Fusarium wilt resistance with I2 specificity.

Dissection of the fusarium I2 gene cluster in tomato reveals six homologs and one active gene copy

The I2 locus in tomato confers resistance to race 2 of the soil-borne fungus Fusarium oxysporum f sp lycopersici. The selective restriction fragment amplification (AFLP) positional cloning strategy was used to identify I2 in the tomato genome. A yeast artificial chromosome (YAC) clone covering approximately 750 kb encompassing the I2 locus was isolated, and the AFLP technique was used to derive tightly linked AFLP markers from this YAC clone. Genetic complementation analysis in transgenic R1 plants using a set of overlapping cosmids covering the I2 locus revealed three cosmids giving full resistance to F. o. lycopersici race 2. These cosmids shared a 7-kb DNA fragment containing an open reading frame encoding a protein with similarity to the nucleotide binding site leucine-rich repeat family of resistance genes. At the I2 locus, we identified six additional homologs that included the recently identified I2C-1 and I2C-2 genes. However, cosmids containing the I2C-1 or I2C-2 gene could not confer resistance to plants, indicating that these members are not the functional resistance genes. Alignments between the various members of the I2 gene family revealed two significant variable regions within the leucine-rich repeat region. They consisted of deletions or duplications of one or more leucine-rich repeats. We propose that one or both of these leucine-rich repeats are involved in Fusarium wilt resistance with I2 specificity.

Genetic and physical localization of the root-knot nematode resistance locus mi in tomato

As part of a map-based cloning strategy designed to isolate the root-knot nematode resistance gene Mi, tomato F2 populations were analyzed in order to identify recombination points close to this economically important gene. A total of 21,089 F2 progeny plants were screened using morphological markers. An additional 1887 F2 were screened using PCR-based flanking markers. Fine-structure mapping of recombinants with newly developed AFLP markers, and RFLP markers derived from physically mapped cosmid subclones, localized Mi to a genomic region of about 550 kb. The low frequency of recombinants indicated that recombination was generally suppressed in these crosses and that crossovers were restricted to particular regions. To circumvent this problem, a population of Lycopersicon peruvianum, the species from which Mi was originally introgressed, that was segregating for resistance was developed. Screening of this population with PCR, RFLP and AFLP markers identified several plants with crossovers near Mi. Recombination frequency was approximately eight-fold higher in the Mi region of the L. peruvianum cross. However, even within the wild species cross, recombination sites were not uniformly distributed in the region. By combining data from the L. esculentum and L. peruvianum recombinant analyses, it was possible to localize Mi to a region of the genome spanning less than 65 kb.

AFLP-based fine mapping of the Mlo gene to a 30-kb DNA segment of the barley genome

Resistance of barley (Hordeum vulgare) to the powdery mildew fungus Erysiphe graminis f.sp. hordei is conferred by several dominant genes, but also by recessive alleles of the Mlo locus mapping on the long arm of chromosome 4. In addition, this single-factor-mediated resistance is active against all known physiological races of the parasite. Thus the mechanism underlying mlo-mediated resistance should differ substantially from that mediated by the dominant genes. A positional cloning strategy to isolate the Mlo gene from the barley genome, the size of which is almost double the size of the human genome, has been designed. The AFLP technique was employed to identify markers tightly linked to the Mlo locus and to produce a local high-resolution genetic map. The use of this high-volume marker technology allowed the rapid screening of approximately 250,000 loci for linkage to Mlo. A large number of Mlo-linked AFLP markers were identified, one of which cosegregated with Mlo on the basis of more than 4000 meiotic events. A four-genome-equivalent barley YAC library (average insert size 480 kb) was constructed and screened with this cosegregating marker. Four YACs containing this marker were isolated and subsequent characterization by AFLP-based physical mapping allowed the physical delimitation of the Mlo locus to a DNA segment of 30 kb.

The barley Mlo gene: a novel control element of plant pathogen resistance

Mutation-induced recessive alleles (mlo) of the barley Mlo locus confer a leaf lesion phenotype and broad spectrum resistance to the fungal pathogen, Erysiphe graminis f. sp. hordei. The gene has been isolated using a positional cloning approach. Analysis of 11 mutagen-induced mlo alleles revealed mutations leading in each case to alterations of the deduced Mlo wild-type amino acid sequence. Susceptible intragenic recombinants, isolated from mlo heteroallelic crosses, show restored Mlo wild-type sequences. The deduced 60 kDa protein is predicted to be membrane-anchored by at least six membrane-spanning helices. The findings are compatible with a dual negative control function of the Mlo protein in leaf cell death and in the onset of pathogen defense; absence of Mlo primes the responsiveness for the onset of multiple defense functions.

Cartilage canals in human thyroid cartilage characterized by immunolocalization of collagen types I, II, pro-III, IV and X

In this study the collagenous composition of cartilage canals in human thyroid cartilage, which are perichondral invaginations of blood vessels and connective tissue, and the surrounding cartilage matrix were investigated by immunolabelling with specific antibodies against type I, II, pro-III, IV and X collagen. During childhood and early adolescence no cartilage canals were detected in thyroid cartilage, and immunolabelling for type IV collagen was restricted to basal lamina components of blood vessels in the perichondrium. First immunolabelling for type IV collagen, belonging to blood vessels in cartilage canals, in both sexes was detected about the end of the second decade; it was localized in the dorsal part of the thyroid cartilage plate. At this time thyroid cartilage has already reached its final form and size. As revealed by von Kossa staining, vascularization preceded mineralization and ossification. In contrast to the male thyroid cartilage plate, no immunostaining for type IV collagen and no ossification was detected in the ventral half of female thyroid cartilage even in advanced age. The extracellular matrix of cells in cartilage canals showed positive immunostaining for collagen types I and pro-III as well as for collagen type II, indicating that the cells in the canal possess fibroblastic and chondrogenic properties. The extracellular matrix of hypertrophic chondrocytes adjacent to cartilage canals showed strong immunoreactivity for type X collagen. First mineralization was detected close to cartilage canals, suggesting that mineralization in human thyroid cartilage starts in the extracellular matrix adjacent to cartilage canals.

Single-cell analysis of T-cell receptor-gamma rearrangements in large-cell anaplastic lymphoma

Large-cell anaplastic lymphomas (LCAL) are characterized by their distinctive morphology together with expression of the CD30 antigen. In addition, a chromosomal translocation, t(2;5) (p23; q35), can be detected in most cases. A significant proportion of LCALs carry rearrangements of the T-cell receptor-gamma (TCR-gamma) locus and display a T-cell phenotype. In about a third of the cases, another type of non-Hodgkin-lymphoma precedes LCAL. Early transformations of non-Hodgkin's lymphoma into LCAL might escape clinical detection in a significant number of cases. The existence of clonally related lymphoid cells within the lymph node infiltrates must be claimed in these cases. Recently, a small-cell-predominant variant of LCAL was described in which only few large tumor cells expressing the CD30 antigen are found together with numerous small lymphocytes, which are frequently CD30-. This observation in particular prompted us to investigate the clonal relationship of the tumor cell compartment and admixed small lymphocytes in one case of common LCAL with T-cell genotype. For this purpose, we chose to amplify rearranged TCR-gamma sequences from single cells isolated from immunostained frozen sections by using a micromanipulator. A total of 119 cells were investigated. Amplification products were obtained in 17 of 79 CD3+ cells, 12 of 30 CD30+ cells, and three of 10 CD20+ cells. The nucleotide sequences were determined in 28 cells by nonradioactive sequencing. In 11 CD30+ cells, the predominant rearrangement of TCR-gamma was identified. No clonal diversity was observed. The small CD3+ lymphocytes were unrelated to the anaplastic CD30+ tumor cells. This report describes a method to analyze rearrangements of the TCR-gamma in single cells isolated from immunostained frozen sections. Application of this technique revealed an absence of clonal diversity in a case of LCAL and documented the polyclonal nature of admixed small CD3+ lymphocytes.

Hodgkin disease: Hodgkin and Reed-Sternberg cells picked from histological sections show clonal immunoglobulin gene rearrangements and appear to be derived from B cells at various stages of development

Hodgkin disease (HD) is characterized by a small number of putative malignant cells [Hodgkin and Reed-Sternberg (HRS) cells] among a background of lymphocytes and histiocytes. The lineage of HRS cells is still elusive and a clonal origin of these rare cells has not formally been demonstrated. We isolated HRS cells by micromanipulation from histological sections of three cases of Hodgkin lymphoma (each representing a distinct subtype of the disease) and analyzed individual cells for immunoglobulin variable (V) gene rearrangements by PCR. In each of the three cases a single heavy-chain V (VH) (and in one case, in addition, a kappa light-chain) gene rearrangement was amplified from the HRS cells, identifying these cells as members of a single clone. A potentially functional VH rearrangement was obtained from a case of nodular sclerosis HD. Somatic mutations and intraclonal diversity in the VH genes indicate a germinal center B-cell origin of the HRS cells in a case of lymphocyte-predominant HD, whereas in a case of mixed-cellularity HD the sequence analysis revealed only nonfunctional V gene rearrangements, suggesting a pre-B-cell origin. This indicates that HRS cells can originate from B-lineage cells at various stages of development.

Use of the Escherichia coli beta-glucuronidase (gusA) gene as a reporter gene for analyzing promoters in lactic acid bacteria

A transcriptional fusion vector, designated pNZ272, based on the promoterless beta-glucuronidase gene (gusA) of Escherichia coli as a reporter gene, has been constructed for lactic acid bacteria. The replicon of pNZ272 was derived from the Lactococcus lactis plasmid pSH71, allowing replication in a wide range of gram-positive bacteria and E. coli. The applicability of pNZ272 and the expression of the gusA gene in L. lactis was demonstrated in shotgun cloning experiments with lactococcal chromosomal and bacteriophage DNA. In addition, three defined lactococcal promoters were inserted in pNZ272: the plasmid-derived lacA promoter, the chromosomal usp45 promoter, and a promoter from bacteriophage phi SK11G. The three resulting plasmids showed beta-glucuronidase activity in a gusA-deficient E. coli strain and in four species of lactic acid bacteria belonging to the genera Lactobacillus, Lactococcus, and Leuconostoc. The copy numbers of the gusA-expressing plasmids were similar within a single species of lactic acid bacteria. However, the specific beta-glucuronidase activity and the gusA mRNA levels varied considerably both within a single species and among different species of lactic acid bacteria. The transcriptional start site of all three promoters was determined and found to be identical in the different species. The results of this comparative promoter analysis indicate that the requirements for efficient transcription initiation differ among the lactic acid bacteria studied.

Relationships among nutritional status, disease progression, and survival in HIV infection

This investigation retrospectively studied relationships between survival in human immunodeficiency virus-seropositive outpatients receiving recent therapies (n = 77) and two markers of nutritional status, serum albumin and percent of usual body weight. Subjects were observed for an average of 186 +/- 8 days; 19% died within the study period. Kaplan-Meier curves and Cox regressions showed that older subjects who had lower CD4 counts, lower albumin levels, or had lost more weight demonstrated poorer survival. Albumin levels and weight loss were related to CD4 counts. The relative risk of death for subjects with low albumin levels (< 3.5 g/dl) was 3.6 times greater (p < 0.021, with 95% confidence limits [95%CL] of 1.2-10.9) than that for subjects with normal albumin levels (> or = 3.5 g/dl), even after controlling for age and CD4 counts. Similarly, after controlling for CD4 counts and age, subjects whose baseline body weights were < 90% of their usual weight had a greater relative death risk (8.3 times greater, p < 0.002, 95% CL 2.3-34.1) than those who had lost less. Survivors and nonsurvivors who had similar CD4 counts differed significantly in albumin levels (p < 0.05). Thus, nutritional status influences survival independent of CD4 counts.

Overproduction of bovine beta-casein in Escherichia coli and engineering of its main chymosin cleavage site

A cDNA clone containing the entire coding region for bovine beta-casein A3 flanked by 53 base pairs of 5' non-coding and 358 base pairs of 3' non-coding sequences was isolated from a bovine mammary cDNA phagemid library. The coding segment for mature beta-casein was subcloned into the T7 expression system, in which the expression of recombinant beta-casein was controlled by the T7 gene 10 promoter and ribosome binding site. High level expression of Met-beta-casein to approximately 20% of the total soluble proteins was obtained in Escherichia coli within 2 h after induction of T7 RNA-polymerase synthesis. In an attempt to induce secretion the coding segment for mature beta-casein was coupled to the ompA translational initiation signal and signal peptide coding sequence but no secretion of the fusion protein and no processing of the signal peptide from the fusion protein was observed. Instead, the Met-beta-casein could be isolated in a soluble form from E.coli cells after an osmotic shock, indicative of a periplasmic location. This procedure did not lyse the cells. The protein was purified to homogeneity after a pH 4.8 isoelectric precipitation followed by reversed-phase high-performance liquid chromatography. The beta-casein cDNA was altered to change the main chymosin cleavage site in beta-casein at position 192-193 in two ways, namely from Leu-Tyr to Pro-Pro and to Leu-stop.(ABSTRACT TRUNCATED AT 250 WORDS)

Functional analysis of the Lactococcus lactis usp45 secretion signal in the secretion of a homologous proteinase and a heterologous alpha-amylase

The ups45 gene encodes the major extracellular protein from Lactococcus lactis. The deduced sequence of the 27 residue leader peptide revealed the tripartite characteristics of a signal peptide. This leader peptide directed the efficient secretion of the homologous proteinase (PrtP) in L. lactis, indicating that the putative signal peptide of PrtP can be replaced by the 27 residue Usp45 leader peptide. In addition, the 27 residue leader peptide could be used to secrete the Bacillus stearothermophilus alpha-amylase, encoded by the amyS gene. Fusion of the usp45 promoter region and various parts of the leader sequence to an amyS gene devoid of its signal sequence, showed that in Escherichia coli the first 19, 20, and 27 residues of the Usp45 leader are able to direct alpha-amylase secretion. In L. lactis the shorter signal peptides did not result in secretion of alpha-amylase, providing experimental evidence for the hypothesis that gram-positive bacteria require a longer signal peptide for secretion than gram-negative organisms.

Integration and gene replacement in the Lactococcus lactis lac operon: induction of a cryptic phospho-beta-glucosidase in LacG-deficient strains

Insertions, replacement mutations, and deletions were introduced via single or double crossover recombination into the lacE (enzyme IIlac) and lacG (phospho-beta-galactosidase) genes of the Lactococcus lactis chromosomal lacABCDFEGX operon. LacG production was abolished in strains missing the lacG gene or carrying multicopy insertions in the lacE gene that affected expression of the lacG gene. However, these LacG-deficient strains could still ferment lactose slowly and were found to contain an enzymatic activity that hydrolyzed the chromogenic substrate o-nitrophenyl-beta-D-galactopyranoside phosphate. Induction of this phospho-beta-glycohydrolase activity coincided with the appearance of a new 55-kDa protein cross-reacting with anti-LacG antibodies that had a size similar to that of LacG but a higher isoelectric point (pI 5.2) and was not found in wild-type cells during growth on lactose. Since the phospho-beta-glycohydrolase activity and this protein with a pI of 5.2 were highly induced in both mutant and wild-type cells during growth on cellobiose that is likely to be transported via a phosphoenolpyruvate-dependent phosphotransferase system, we propose that this induced activity is a phospho-beta-glucosidase that also hydrolyzes lactose-6-phosphate.

Cloning, nucleotide sequence, and regulatory analysis of the Lactococcus lactis dnaJ gene

The dnaJ gene of Lactococcus lactis was isolated from a genomic library of L. lactis NIZO R5 and cloned into pUC19. Nucleotide sequencing revealed an open reading frame of 1,137 bp in length, encoding a protein of 379 amino acids. The deduced amino acid sequence showed homology to the DnaJ proteins of Escherichia coli, Mycobacterium tuberculosis, Bacillus subtilis, and Clostridium acetobutylicum. The level of the dnaJ monocistronic mRNA increased approximately threefold after heat shock. The transcription initiation site of the dnaJ gene was determined and appeared to be preceded by a typical gram-positive vegetative promoter sequence (TTGCCA-17 bp-TAAAAT). Upstream of the promoter region, an inverted repeat is located that is identical to those detected upstream of heat shock genes of other gram-positive organisms. A transcriptional fusion between the dnaJ expression signals and a usp45-amyS secretion cassette caused a significant increase in alpha-amylase activity after heat shock induction. Deletion mutagenesis showed that the inverted repeat is involved in heat shock regulation of the dnaJ gene. The conservation of this palindromic sequence in gram-positive heat shock genes suggests a common regulatory pathway distinct from the system used in gram-negative bacteria.

Leuconostoc lactis beta-galactosidase is encoded by two overlapping genes

A 16-kb BamHI fragment of the lactose plasmid pNZ63 from Leuconostoc lactis NZ6009 was cloned in Escherichia coli MC1061 by using pACYC184 and was found to express a functional beta-galactosidase. Deletion and complementation analysis showed that the coding region for beta-galactosidase was located on a 5.8-kb SalI-BamHI fragment. Nucleotide sequence analysis demonstrated that this fragment contained two partially overlapping genes, lacL (1,878 bp) and lacM (963 bp), that could encode proteins with calculated sizes of 72,113 and 35,389 Da, respectively. The L. lactis beta-galactosidase was overproduced in E. coli by using a lambda pL expression system. Two new proteins with M(r)s of 75,000 and 36,000 appeared upon induction of PL. The N-terminal sequences of these proteins corresponded to those deduced from the lacL and lacM gene sequences. Mutation and deletion analysis showed that lacL expression is essential for LacM production and that both the lacL and lacM genes are required for the production of a functional beta-galactosidase in E. coli. The deduced amino acid sequences of the LacL and LacM proteins showed considerable identity with the sequences of the N- and C-terminal parts, respectively, of beta-galactosidases from other lactic acid bacteria or E. coli. DNA and protein sequence alignments suggest that the L. lactis lacL and lacM genes have been generated by an internal deletion in an ancestral beta-galactosidase gene.

Utilization of injectable microimplants in aesthetic facial surgery

The authors present a series of 74 patients that underwent injections of a biphasic copolymer (Bioplastique) to improve the facial contours or to fill deep creases and folds. The followup period was ten months. This preliminary report could be useful in defining the possibilities of the new product.