Predicting the future of our oceans-Evaluating genomic forecasting approaches in marine species

Climate change is restructuring biodiversity on multiple scales and there is a pressing need to understand the downstream ecological and genomic consequences of this change. Recent advancements in the field of eco-evolutionary genomics have sought to include evolutionary processes in forecasting species' responses to climate change (e.g., genomic offset), but to date, much of this work has focused on terrestrial species. Coastal and offshore species, and the fisheries they support, may be even more vulnerable to climate change than their terrestrial counterparts, warranting a critical appraisal of these approaches in marine systems. First, we synthesize knowledge about the genomic basis of adaptation in marine species, and then we discuss the few examples where genomic forecasting has been applied in marine systems. Next, we identify the key challenges in validating genomic offset estimates in marine species, and we advocate for the inclusion of historical sampling data and hindcasting in the validation phase. Lastly, we describe a workflow to guide marine managers in incorporating these predictions into the decision-making process.

Cationic LNP-formulated mRNA expressing Tie2-agonist in the lung endothelium prevents pulmonary vascular leakage

Dysfunction of endothelial cells (ECs) lining the inner surface of blood vessels are causative for a number of diseases. Hence, the ability to therapeutically modulate gene expression within ECs is of high therapeutic value in treating diseases such as those associated with lung edema. mRNAs formulated with lipid nanoparticles (LNPs) have emerged as a new drug modality to induce transient protein expression for modulating disease-relevant signal transduction pathways. In the study presented here, we tested the effect of a novel synthetic, nucleoside-modified mRNA encoding COMP-Ang1 (mRNA-76) formulated into a cationic LNP on attenuating inflammation-induced vascular leakage. After intravenous injection, the respective mRNA was found to be delivered almost exclusively to the ECs of the lung, while sparing other vascular beds and bypassing the liver. The mode of action of mRNA-76, such as its activation of the Tie2 signal transduction pathway, was tested by pharmacological studies in vitro and in vivo in respective mouse models. mRNA-76 was found to prevent lung vascular leakage/lung edema as well as neutrophil infiltration in a lipopolysaccharide-challenging model.

A qualitative study on the influence of COVID-19 on smoking behaviors through changing social and physical contexts

Globally, COVID-19 has been a major societal stressor and disrupted social and physical environments for many. Elucidating mechanisms through which societal disruptions influence smoking behavior has implications for future tobacco control efforts. Qualitative interviews were conducted among 38 adults who smoked combustible cigarettes in 2020 and 2021. The majority were women (75.7%), identified as Black (56.8%), were employed (61.3%), had a smoke-free home (66.7%) and lived in a small metro or rural (79.0%) county, primarily in rural southwest Georgia. Participants reported more time at home, increased isolation and less socializing, changed work and financial situations and altered household and family contexts. The vast majority of participants smoked more at some point during the pandemic with about half of these continuing to smoke more at the time of the interview. More time at home, multiple sources of stress and boredom were the main reasons for increased smoking. Decreases in smoking were attributed to financial strain, smoke-free home rules and nonsmoking family members, concerns about COVID-19 and less socializing with friends who smoke. Future tobacco control efforts during societal stressors such as pandemics should take into account specific psychosocial and environmental influences in attempts to minimize negative changes to smoking patterns.

POS0234 HOW CLOSELY DO GERMAN RHEUMATOLOGISTS FOLLOW THE EULAR RECOMMENDATIONS FOR THE MANAGEMENT OF RHEUMATOID ARTHRITIS WHEN MAKING THERAPEUTIC DECISIONS?

Background

EULAR developed recommendations for the management of rheumatoid arthritis (RA) suggesting treatment escalation and changes at different stages of the disease to reach at least low disease activity with latest updates in 2013(1), 2016(2), and 2019(3). The recommendation to consider adding a biologic disease-modifying anti-rheumatic drug (bDMARD) – or, since 2016, a Januskinase inhibitor (JAKi) – after the first conventional synthetic (cs) DMARD had failed and if poor prognostic factors (PPF) are present, was strengthened 2019. Since then, it is recommended that a bDMARD or a tsDMARD should be added.

Objectives

How closely are EULAR recommendations followed in daily rheumatologic practice in Germany?

Methods

Data were used from the long-term observational cohort RABBIT, which enrols patients with RA starting a bDMARD or JAKi, or a csDMARD after at least one previous csDMARD failure. According to the publication of the recommendations, periods from [I] 01/2014 – 12/2016, [II] 01/2017 – 06/2020 and [III] 07/2020 – 04/2021 were investigated. Patients who were in at least moderate disease activity (DAS28≥3.2) were selected and analysed, if they started a csDMARD, a bDMARD or a JAKi. Patients were further stratified by prior treatments and by the presence of PPF (≥4 swollen joints, positive rheumatoid factor or ACPA, erosions).

Results

Of the 15,150 patients with RA enrolled since 2007, 2,922 treatments were initiated in period [I], 4,580 in [II] and 415 in [III] (see Table 1). The proportion of patients with 1 previous csDMARD and ≥1 PPF who – in agreement with the recommendations – switched to bDMARD or JAKi, increased from 30% (only bDMARDs) in period [I] to 68% (bDMARDs + JAKi) in [III]. The proportions were even higher in patients with 2 previous csDMARDs (86% in [I], 93% in [III]). As recommended, JAKi were used more often as first line therapy (after csDMARD) in period [III].

Table 1.

Number and percentages of treatment changes at different stages of the disease.

Patients with1 previous csDMARD & no PPF1 previous csDMARD & ≥1 PPF2 previous csDMARDs1 previous bDMARD/ JAKi≥2 previous bDMARDs/ JAKiEULAR Recommendationchange/add csDMARDadd bDMARD/ JAKi**add bDMARD/ JAKichange to another bDMARD/JAKiTotal numbers of treatment changes612073222017001863Period [I]n=25n=848n=986n=543n=52001/2014 – 12/2016*N=2,922csDMARD21 (84.0%)594 (70.0%)134 (13.6%)199 (36.6%)275 (52.9%)bDMARD4 (16.0%)254 (30.0%)852 (86.4%)344 (63.4%)245 (47.1%)Period [II]n=32n=1,090n=1,136n=1,054n=1,26801/2017 – 06/2020N=4,580csDMARD16 (50.0%)469 (43.0%)96 (8.5%)261 (24.8%)274 (21.6%)bDMARD13 (40.6%)509 (46.7%)822 (72.4%)403 (38.2%)288 (22.7%)JAKi3 (9.4%)112 (10.3%)218 (19.2%)390 (37.0%)706 (55.7%)Period [III]n=4n=135n=98n=103n=7507/2020 – 04/2021N=415csDMARD043 (31.9%)7 (7.1%)15 (14.6%)9 (12.0%)bDMARD1 (25.0%)64 (47.4%)60 (61.2%)36 (35.0%)23 (30.7%)JAKi3 (75.0%)28 (20.7%)31 (31.6%)52 (50.5%)43 (57.3%)

EULAR treatment recommendations are indicated in green. *JAKi were not available. **Recommendation in period [I]: Addition of a bDMARD should be considered; in [II]: Addition of a bDMARD or a tsDMARD should be considered, current practice would be to start a bDMARD; in [III]: a bDMARD or a tsDMARD should be added. PPF, poor prognostic factor.

Conclusion

JAKi have become more established, especially in bionaive patients, but have not reached the significance of biologics in certain patient groups. The early decision for a bDMARD or JAKi has been made more frequently in recent years, yet one third of patients did not receive the recommended treatment escalation. We cannot conclude from the data, which considerations led to the decision not to escalate. Of note, German rheumatologists should rather follow the German treatment guidelines(4), which are, however, very similar to the EULAR recommendations.

References

[1]PMID: 24161836;

[2]PMID: 28264816;

[3]PMID: 31969328;

[4]PMID: 29968101

Acknowledgements

RABBIT is supported by a joint, unconditional grant from AbbVie, Amgen, BMS, Fresenius-Kabi, Galapagos, Hexal, Lilly, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi-Aventis, VIATRIS and UCB.

Disclosure of Interests

Yvette Meissner Speakers bureau: Pfizer, Doreen Huschek: None declared, Angela Zink Speakers bureau: AbbVie, Pfizer, Roche, Sanofi, Jörg Kaufmann: None declared, Martin Bohl-Buehler Speakers bureau: Speaker for several companies in unrestricted educational programs, each of them unrestricted state-of-the-art-talks., Consultant of: PreviPharma, basic research in osteology, no overlap with rheumatological diseases, Anja Strangfeld Speakers bureau: AbbVie, Amgen, BMS, Celltrion, Janssen, Lilly, Pfizer, Roche, Sanofi, UCB.

Neutral Processes Dominate Microbial Community Assembly in Atlantic Salmon, Salmo salar

In recent years, a wealth of studies has examined the relationships between a host and its microbiome across diverse taxa. Many studies characterize the host microbiome without considering the ecological processes that underpin microbiome assembly. In this study, the intestinal microbiota of Atlantic salmon, Salmo salar, sampled from farmed and wild environments was first characterized using 16S rRNA gene MiSeq sequencing analysis. We used neutral community models to determine the balance of stochastic and deterministic processes that underpin microbial community assembly and transfer across life cycle stage and between gut compartments. Across gut compartments in farmed fish, neutral models suggest that most microbes are transient with no evidence of adaptation to their environment. In wild fish, we found declining taxonomic and functional microbial community richness as fish mature through different life cycle stages. Alongside neutral community models applied to wild fish, we suggest that declining richness demonstrates an increasing role for the host in filtering microbial communities that is correlated with age. We found a limited subset of gut microflora adapted to the farmed and wild host environment among which Mycoplasma spp. are prominent. Our study reveals the ecological drivers underpinning community assembly in both farmed and wild Atlantic salmon and underlines the importance of understanding the role of stochastic processes, such as random drift and small migration rates in microbial community assembly, before considering any functional role of the gut microbes encountered.IMPORTANCE A growing number of studies have examined variation in the microbiome to determine the role in modulating host health, physiology, and ecology. However, the ecology of host microbial colonization is not fully understood and rarely tested. The continued increase in production of farmed Atlantic salmon, coupled with increased farmed-wild salmon interactions, has accentuated the need to unravel the potential adaptive function of the microbiome and to distinguish resident from transient gut microbes. Between gut compartments in a farmed system, we found a majority of operational taxonomic units (OTUs) that fit the neutral model, with Mycoplasma species among the key exceptions. In wild fish, deterministic processes account for more OTU differences across life stages than those observed across gut compartments. Unlike previous studies, our results make detailed comparisons between fish from wild and farmed environments, while also providing insight into the ecological processes underpinning microbial community assembly in this ecologically and economically important species.

Age-dependent effects of moderate differences in environmental predictability forecasted by climate change, experimental evidence from a short-lived lizard (Zootoca vivipara)

Whether and how differences in environmental predictability affect life-history traits is controversial and may depend on mean environmental conditions. Solid evidence for effects of environmental predictability are lacking and thus, the consequences of the currently observed and forecasted climate-change induced reduction of precipitation predictability are largely unknown. Here we experimentally tested whether and how changes in the predictability of precipitation affect growth, reproduction, and survival of common lizard Zootoca vivipara. Precipitation predictability affected all three age classes. While adults were able to compensate the treatment effects, yearlings and juvenile females were not able to compensate negative effects of less predictable precipitation on growth and body condition, respectively. Differences among the age-classes' response reflect differences (among age-classes) in the sensitivity to environmental predictability. Moreover, effects of environmental predictability depended on mean environmental conditions. This indicates that integrating differences in environmental sensitivity, and changes in averages and the predictability of climatic variables will be key to understand whether species are able to cope with the current climatic change.

Prognostic and Pathogenic Role of Angiopoietin-1 and -2 in Pneumonia

RATIONALE

During pneumonia, pathogen-host interaction evokes inflammation and lung barrier dysfunction. Tie2 activation by angiopoietin-1 reduces, whereas Tie2 blockade by angiopoietin-2 increases, inflammation and permeability during sepsis. The role of angiopoietin-1/-2 in pneumonia remains unidentified.

OBJECTIVES

To investigate the prognostic and pathogenic impact of angiopoietins in regulating pulmonary vascular barrier function and inflammation in bacterial pneumonia.

METHODS

Serum angiopoietin levels were quantified in pneumonia patients of two independent cohorts (n = 148, n = 395). Human postmortem lung tissue, pneumolysin- or angiopoietin-2-stimulated endothelial cells, isolated perfused and ventilated mouse lungs, and mice with pneumococcal pneumonia were investigated.

MEASUREMENTS AND MAIN RESULTS

In patients with pneumonia, decreased serum angiopoietin-1 and increased angiopoietin-2 levels were observed as compared with healthy subjects. Higher angiopoietin-2 serum levels were found in patients with community-acquired pneumonia who died within 28 days of diagnosis compared with survivors. Receiver operating characteristic analysis revealed improved prognostic accuracy of CURB-65 for 28-day survival, intensive care treatment, and length of hospital stay if combined with angiopoietin-2 serum levels. In vitro, pneumolysin enhanced endothelial angiopoietin-2 release, angiopoietin-2 increased endothelial permeability, and angiopoietin-1 reduced pneumolysin-evoked endothelial permeability. Ventilated and perfused lungs of mice with angiopoietin-2 knockdown showed reduced permeability on pneumolysin stimulation. Increased pulmonary angiopoietin-2 and reduced angiopoietin-1 mRNA expression were observed in Streptococcus pneumoniae-infected mice. Finally, angiopoietin-1 therapy reduced inflammation and permeability in murine pneumonia.

CONCLUSIONS

These data suggest a central role of angiopoietin-1/-2 in pneumonia-evoked inflammation and permeability. Increased angiopoietin-2 serum levels predicted mortality and length of hospital stay, and angiopoietin-1 may provide a therapeutic target for severe pneumonia.

Neuronal spiking in the pedunculopontine nucleus in progressive supranuclear palsy and in idiopathic Parkinson's disease

The pedunculopontine nucleus (PPN) is engaged in posture and gait control, and neuronal degeneration in the PPN has been associated with Parkinsonian disorders. Clinical outcomes of deep brain stimulation of the PPN in idiopathic Parkinson's disease (IPD) and progressive supranuclear palsy (PSP) differ, and we investigated whether the PPN is differentially affected in these conditions. We had the rare opportunity to record continuous electrophysiological data intraoperatively in 30 s blocks from single microelectrode contacts implanted in the PPN in six PSP patients and three IPD patients during rest, passive movement, and active movement. Neuronal spikes were sorted according to shape using a wavelet-based clustering approach to enable comparisons between individual neuronal firing rates in the two disease states. The action potential widths showed a bimodal distribution consistent with previous findings, suggesting spikes from noncholinergic (likely glutamatergic) and cholinergic neurons. A higher PPN spiking rate of narrow action potentials was observed in the PSP than in the IPD patients when pooled across all three conditions (Wilcoxon rank sum test: p = 0.0141). No correlation was found between firing rate and disease severity or duration. The firing rates were higher during passive movement than rest and active movement in both groups, but the differences between conditions were not significant. PSP and IPD are believed to represent distinct disease processes, and our findings that the neuronal firing rates differ according to disease state support the proposal that pathological processes directly involving the PPN may be more pronounced in PSP than IPD.

Collective Modes in Excitonic Magnets: Dynamical Mean-Field Study

We present a dynamical mean-field study of dynamical susceptibilities in the two-band Hubbard model. Varying the model parameters we analyze the two-particle excitations in the normal as well as in the ordered phase, an excitonic condensate. The two-particle dynamical mean-field theory spectra in the ordered phase reveal the gapless Goldstone modes arising from spontaneous breaking of continuous symmetries. We also observe the gapped Higgs mode, characterized by vanishing of the gap at the phase boundary. Qualitative changes observed in the spin susceptibility can be used as an experimental probe to identify the excitonic condensation.

Anatomically constrained tractography facilitates biologically plausible fiber reconstruction of the optic radiation in multiple sclerosis

Diffusion-weighted magnetic resonance imaging (dMRI) enables the microstructural characterization and reconstruction of white matter pathways in vivo non-invasively. However, dMRI only provides information on the orientation of potential fibers but not on their anatomical plausibility. To that end, recent methodological advances facilitate the effective use of anatomical priors in the process of fiber reconstruction, thus improving the accuracy of the results. Here, we investigated the potential of anatomically constrained tracking (ACT), a modular addition to the tractography software package MRtrix3, to accurately reconstruct the optic radiation, a commonly affected pathway in multiple sclerosis (MS). Diffusion MRI data were acquired from 28 MS patients and 22 age- and sex-matched healthy controls. For each participant, the optic radiation was segmented based on the fiber reconstruction obtained using ACT. When implementing ACT in MS, it proved essential to incorporate lesion maps to avoid incorrect reconstructions due to tissue-type misclassifications in lesional areas. The ACT-based results were compared with those obtained using two commonly used probabilistic fiber tracking procedures, based on FSL (FMRIB Software Library) and MRtrix3 without ACT. All three procedures enabled a reliable localization of the optic radiation in both MS patients and controls. However, for FSL and MRtrix3 without ACT it was necessary to place an additional waypoint halfway between the lateral geniculate nucleus and the primary visual cortex to filter out anatomically implausible tracks. In the case of ACT, the results with and without an additional waypoint were virtually identical, presumably because the employed anatomical constraints already prevented the occurrence of the most implausible tracks. Irrespective of the employed tractography procedure, increased diffusivity and decreased anisotropy were found in the optic radiation of the MS patients compared to the controls.

•

Anatomical constraints improve tractography of the optic radiation in MS.

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In MS, lesion mapping is essential to implement sensible anatomical constraints.

•

Patients showed increased diffusivity and decreased anisotropy in the OR.

[Concomitant fractures of the capitulum humeri and the caput radii]

This case report describes the osteosynthetic treatment and postoperative course of a fracture of the capitulum humeri and a concomitant fracture of the head of the radius with a follow-up over 3 months. Simultaneous fractures of the capitulum humeri and the head of the radius are rare injuries of the elbow. Due to the complex anatomical relationships this type of fracture poses a big challenge for treating traumatologists.

Biceps Femoris Injury a Rarity: A Case Report

Isolated biceps femoris rupture is a rare injury associated with limitation in the function of the knee. We present a 65-year-old man who sustained an isolated complete rupture of the tendon of the biceps femoris. The diagnostic was reached after clinical examination and magnetic resonance imaging of the affected knee. This case was treated with a surgical tendon reconstruction. The outcome was good and the patient was able to walk normally again without limitation, even if he did not comply with our recommendation.

[Use of cognitive aids in pediatric emergency care : Interdisciplinary consensus statement]

Preclinical pediatric emergencies are rare events and are therefore often associated with stress and uncertainty for emergency medical service personnel. To ensure adequate treatment of pediatric patients a variety of different cognitive aids exist (e.g. books, apps, rulers, weight-adapted bag systems). Especially the size specifications of the medical equipment and the dosage of emergency medication are individually very different in children and are dependent on parameters, such as body height and weight. Therefore, cognitive aids often enable length measurement whereby it is possible to draw conclusions on body weight for calculating the child's medication dosage. These aids may help to avoid the wrong medication dose or the wrong therapy of children but uncritical and untrained usage of these aids carries a potential risk of mistakes. This recommendation gives an overview of the general requirements and different problems of cognitive aids and should help improve the general framework and the rational basis for the use and further development of cognitive aids in emergency medicine.

Impact of treatment with biologic DMARDs on the risk of sepsis or mortality after serious infection in patients with rheumatoid arthritis

Objective

This observational cohort study investigated the impact of biological (b) disease-modifying antirheumatic drugs (DMARDs) on the outcomes of serious infections (SIs) in patients with rheumatoid arthritis.

Methods

We investigated outcomes of SIs observed in 947 patients enrolled in the German biologics register RABBIT(Rheumatoid arthritis: observation of biologic therapy). Outcomes were (1) recovery without complication, (2) sepsis following SI (≤30 days), and (3) death after SI without known sepsis (≤90 days). We applied a multinomial generalised estimating equation model for longitudinal data to evaluate the risks of sepsis and death simultaneously.

Results

Sepsis within 30 days after SI was reported in 135 out of 947 patients, 85 of these had a fatal outcome. Fifty-three patients died within 90 days after SI without known sepsis. The adjusted risk of developing sepsis increased with age and was higher in patients with chronic renal disease. Compared with conventional synthetic (cs)DMARDs, the risk was significantly lower when patients were exposed to bDMARDs at the time of SI (OR: 0.56, 95% CI 0.38 to 0.81). Risk factors of fatal SI were higher age, use of glucocorticoids at higher doses and heart failure. Patients treated with bDMARDs and those with better physical function had a significantly lower mortality risk.

Conclusions

These results suggest a beneficial effect of bDMARDs on the risk of sepsis after SI and the risk of a fatal outcome. Successful immunosuppression may prevent an unregulated host response to SI, that is, the escalation to sepsis. Further investigation is needed to validate these results.

Metabolic mapping reveals sex-dependent involvement of default mode and salience network in alexithymia

Alexithymia, a personality construct marked by difficulties in processing one's emotions, has been linked to the altered activity in the anterior cingulate cortex (ACC). Although longitudinal studies reported sex differences in alexithymia, what mediates them is not known. To investigate sex-specific associations of alexithymia and neuronal markers, we mapped metabolites in four brain regions involved differentially in emotion processing using a point-resolved spectroscopy MRS sequence in 3 Tesla. Both sexes showed negative correlations between alexithymia and N-acetylaspartate (NAA) in pregenual ACC (pgACC). Women showed a robust negative correlation of the joint measure of glutamate and glutamine (Glx) to NAA in posterior cingulate cortex (PCC), whereas men showed a weak positive association of Glx to NAA in dorsal ACC (dACC). Our results suggest that lowered neuronal integrity in pgACC, a region of the default mode network (DMN), might primarily account for the general difficulties in emotional processing in alexithymia. Association of alexithymia in women extends to another region in the DMN-PCC, while in men a region in the salience network (SN) was involved. These observations could be representative of sex specific regulation strategies that include diminished internal evaluation of feelings in women and cognitive emotion suppression in men.

Noradrenaline enhances angiotensin II responses via p38 MAPK activation after hypoxia/re-oxygenation in renal interlobar arteries

AIM

Hypoxia and sympathetic activation are main factors in the pathogenesis of acute kidney injury (AKI). We tested the hypothesis that noradrenaline (NE) in combination with hypoxia aggravates the vasoreactivity of renal arteries after hypoxia/re-oxygenation (H/R). We tested the role of adrenergic receptors and p38 MAPK using an in vitro H/R protocol.

METHODS

Mouse interlobar arteries (ILA) and afferent arterioles (AA) were investigated under isometric and isotonic conditions respectively. The in vitro protocol consisted of 60-min hypoxia and control condition, respectively, 10-min re-oxygenation followed by concentration-response curves for Ang II or endothelin.

RESULTS

Hypoxia reduced the response to Ang II. Hypoxia and NE (10(-9)  mol L(-1) ) together increased it in ILA and AA. In ILA, NE alone influenced neither Ang II responses under control conditions nor endothelin responses after hypoxia. Prazosin or yohimbine treatment did not significantly influence the NE+hypoxia effect. The combination of prazosin and yohimbine or propranolol alone inhibited the effect of NE+hypoxia. BRL37344 (β3 receptor agonist) mimicked the NE effect. In contrast, the incubation with β3 receptor blocker did not influence the mentioned effect. Phosphorylation of p38 MAPK and MLC(20) was increased after H/R with NE and Ang II treatment. The selective p38 MAPK inhibitor SB202190 blocked the NE+hypoxia effect on the Ang II response.

CONCLUSION

The results suggest an interaction of NE and hypoxia in enhancing vasoreactivity, which may be important for the pathogenesis of AKI. The effect of NE+hypoxia in ILA is mediated by several adrenergic receptors and requires the p38 MAPK activation.

Comparison of tocilizumab and tumour necrosis factor inhibitors in rheumatoid arthritis: a retrospective analysis of 1603 patients managed in routine clinical practice

Tocilizumab (TCZ) and tumour necrosis factor inhibitors (TNFi) are recommended for the treatment of rheumatoid arthritis (RA) in patients with inadequate response (IR) to prior disease-modifying antirheumatic drugs (DMARDs). This retrospective analysis assessed the efficacy of TCZ and TNFi, alone or in combination with DMARDs, in 1603 patients with IR to previous treatment with either DMARDs (DMARD-IR) and/or TNFi (TNFi-IR), initiating treatment with TCZ or a TNFi, managed in routine clinical practice. Patients were grouped according to treatment history and treatment initiated: DMARD-IR patients initiating treatment with TCZ + DMARD (DMARD-IR TCZ) or TNFi + DMARD (DMARD-IR TNFi), DMARD-IR and/or TNFi-IR patients initiating treatment with TCZ monotherapy (TCZ mono) or TNFi monotherapy (TNFi mono), and TNFi-IR patients initiating treatment with TCZ + DMARD (TNFi-IR TCZ) or TNFi + DMARD (TNFi-IR TNFi). Patients initiating treatment with TCZ generally had more severe disease and longer disease duration compared with the corresponding TNFi group. Significantly more patients achieved remission (DAS28 ESR <2.6) in the TCZ groups compared with corresponding TNFi groups (DMARD-IR, TCZ 44.0 % vs. TNFi 29.6 %; monotherapy, TCZ 37.2 % vs. TNFi 30.2 %; TNF-IR, TCZ 41.3 % vs. TNFi 19.2 %; p < 0.001 for all comparisons). More patients achieved moderate–good responses (EULAR criteria) in the TCZ treatment groups (79–85 %) compared with TNFi treatment groups (65–81 %). Patient-reported outcomes showed greater improvements in TCZ compared with TNFi groups. In patients with inadequate response to DMARDs and/or TNFi treated in routine clinical practice, TCZ in combination with DMARDs or as monotherapy resulted in significantly more patients achieving remission and more marked improvements in patient-reported outcomes compared with TNF inhibitors.

First-in-human phase I study of the liposomal RNA interference therapeutic Atu027 in patients with advanced solid tumors

PURPOSE

Atu027 is a novel liposomal RNA interference therapeutic that includes a short-interfering RNA (siRNA), which silences expression of protein kinase N3 in the vascular endothelium. Atu027 has previously been shown to inhibit local tumor invasion as well as lymph node and pulmonary metastasis in mouse cancer models. This first-in-human study aimed to assess the safety, tolerability, and pharmacokinetics of Atu027 while evaluating therapeutic effects on both primary tumors and metastatic lesions.

PATIENTS AND METHODS

Thirty-four patients with advanced solid tumors received 10 escalating doses of Atu027 without premedication, as one single followed by eight intravenous infusions twice per week during a 28-day cycle. Response was monitored by computed tomography/magnetic resonance imaging at baseline, at the end of treatment (EoT), and at final follow-up (EoS), and was assessed according to RECIST.

RESULTS

Atu027 was well tolerated up to dose levels of 0.336 mg/kg; most adverse events (AEs) were low-grade toxicities (grade 1 or 2). No maximum tolerated dose was reached. Plasma levels of siRNA strands and lipids were dose proportional, peaking during 4-hour infusion. Disease stabilization was achieved in 41% of patients at EoT (n = 14 of 34 treated patients); eight patients had stable disease at EoS, and some experienced complete or partial regression of metastases. sFLT1 (soluble variant of vascular endothelial growth factor receptor-1) decreased from pretreatment levels in most patients after dose levels 04 to 10.

CONCLUSION

Atu027 was safe in patients with advanced solid tumors, with 41% of patients having stable disease for at least 8 weeks. In view of these results, further clinical trials have been initiated, and sFLT1 will be investigated as a potential biomarker.

Magnetic microreactors for efficient and reliable magnetic nanoparticle surface functionalization

Microreactors have attracted wide attention in the nano- and biotechnology fields because they offer many advantages over standard liquid phase reactions. We report the development of a magnetic microreactor for reliable, fast and efficient surface functionalization of superparamagnetic iron oxide nanoparticles (SPIONs). A comprehensive study of the development process in terms of setup, loading capacity and efficiency is described. We performed experimental and computational studies in order to evaluate the trapping efficiencies, maximum loading capacity and magnetic alignment of the nanoparticles. The results showed that capacity and trapping efficiencies are directly related to the flow rate, elution time and reactor type. Based on our results and the developed magnetic microreactor, we describe a model multistep surface derivatization procedure of SPIONs.

Case report: practicability of functionally based tractography of the optic radiation during presurgical epilepsy work up

Pre-operative tractography of the optic radiation (OR) has been advised to assess the risk for postoperative visual field deficit (VFD) in certain candidates for resective epilepsy surgery. Diffusion tensor imaging (DTI) tractography relies on a precise anatomical determination of start and target regions of interest (ROIs), such as the lateral geniculate nucleus (LGN) and the primary visual cortex (V1). The post-chiasmal visual pathway and V1 show considerable inter-individual variability, and in epilepsy patients parenchymatous lesions might further complicate this matter. A functionally based tractography (FBT) seems beneficial for precise OR identification. We assessed practicability of FBT for OR identification in a patient with occipital lobe epilepsy due to a temporo-occipital maldevelopmental tumor. The MRI protocol at 3T included a T1-weighted sagittal 3D scan, a T2-weighted axial 2D scan and a DTI scan using an echo planar spin echo sequence. ROIs for fiber tracking of OR (LGN & V1) were determined with T2*-weighted fMRI-based retinotopic assessment. After DTI pre-processing and fiber tracking, paths with similar properties were combined in clusters for visual presentation and OR localization. Retinotopic phase maps allowed for the identification of V1 and LGN for a precise DTI-based reconstruction of OR, which was distant to the patient's tumor. Location and structure of ORs were comparable in each hemisphere. FBT could thus influence the human research of the extrastriate visual pathway and the risk management of post-operative VFD in epilepsy surgery.

Delivery of therapeutic siRNA to the lung endothelium via novel Lipoplex formulation DACC

Posttranscriptional gene silencing by RNA interference can be therapeutically exploited to inhibit pathophysiological gene expression. However, in contrast to the established effectiveness of RNAi in vitro, safe and effective delivery of siRNAs to specific organs and cell types in vivo remains the major hurdle. Here, we report the development and in vivo characterization of a novel siRNA delivery system (DACC lipoplex) suitable for modulating target gene expression specifically in the lung vasculature. Systemic administration of DACC in mice delivered siRNA cargo functionally to the lung pulmonary endothelium. A single dose of DACC lipoplexes administered by bolus injection or by infusion was sufficient to specifically silence genes expressed in pulmonary endothelial cells such as CD31, Tie-2, VE-cadherin, or BMP-R2. When tested in a mouse model for lung cancer, repeated treatment with DACC/siRNA(CD31) reduced formation of lung metastases and increased life span in a mouse model of experimental lung metastasis.

Evaluation of the RABBIT Risk Score for serious infections

Objective

To evaluate the Rheumatoid Arthritis Observation of Biologic Therapy (RABBIT) Risk Score for serious infections in patients with rheumatoid arthritis (RA).

Methods

The RABBIT Risk Score for serious infections was developed in 2011 on a cohort of RA patients enrolled in the German biologics register RABBIT between 2001 and 2007. To evaluate this score, we used data from patients enrolled in RABBIT after 1 January 2009. Expected numbers of serious infections and expected numbers of patients with at least one serious infection per year were calculated by means of the RABBIT Risk Score and compared with observed numbers in the evaluation sample.

Results

The evaluation of the score in an independent cohort of 1522 RA patients treated with tumour necrosis factor α (TNFα) inhibitors and 1468 patients treated with non-biological disease-modifying antirheumatic drugs (DMARDs) showed excellent agreement between observed and expected rates of serious infections. For patients exposed to TNF inhibitors, expected as well as observed numbers of serious infections were 3.0 per 100 patient-years (PY). For patients on non-biological DMARDs the expected and observed numbers were 1.5/100 PY and 1.8/100 PY, respectively. The score was highly predictive in groups of patients with low as well as with high infection risk.

Conclusions

The RABBIT Risk Score is a reliable instrument which determines the risk of serious infection in individual patients based on clinical and treatment information. It helps the rheumatologist to balance benefits and risks of treatment, to avoid high-risk treatment combinations and thus to make informed clinical decisions.

Monotherapy with tocilizumab or TNF-alpha inhibitors in patients with rheumatoid arthritis: efficacy, treatment satisfaction, and persistence in routine clinical practice

This study aims to investigate the use of biological disease-modifying antirheumatic drugs (bDMARDs) as monotherapy in patients with rheumatoid arthritis (RA) in "real world" clinical settings and to compare tumor necrosis factor (TNF) inhibitors and tocilizumab monotherapy in terms of efficacy and patient and clinician satisfaction with treatment. This study made use of a retrospective, cohort-19 based study including included data from 254 patients (TNF inhibitors n = 128; tocilizumab n = 126) managed in 30 centers throughout Germany. Efficacy of monotherapy and patient and physician overall satisfaction with treatment were assessed at baseline, 3, and 6 months of monotherapy using a range of measures including Disease Activity Score 28 joint (DAS28), swollen joint count (SJC) and tender joint count (TJC), and visual analogue scales (VAS). Between 18 and 41 % of patients treated with bDMARDs received the agent as monotherapy. Intolerance to DMARDs, contraindications for combination therapy, and comorbidities were the most common reasons for introduction of bDMARD monotherapy. Mean DAS28 (erythrocyte sedimentation rate, ESR) was significantly lower at 3 and 6 months following tocilizumab vs. TNF inhibitors (p ≤ 0.001). Joint counts improved from baseline to month 6 in both groups (SJC -5.1 vs. -3.7 and TJC -5.6 vs. -5.1, for tocilizumab and TNF inhibitors, respectively). Patient as well as physician satisfaction (VAS 100 mm scale) was significantly higher for tocilizumab vs. TNF inhibitors (75.3 vs. 66.8; p = 0.001 and 74.9 vs. 67.1, p = 0.003, respectively). Significantly more patients remained on tocilizumab monotherapy vs. TNF-inhibitor monotherapy (89.7 vs. 75.8 %; p < 0.01). Monotherapy with bDMARDs is common in routine clinical practice. Tocilizumab monotherapy appeared to be superior over TNF-inhibitor monotherapy with respect to DAS28 and drug adherence.

First-in-human phase I study of the liposomal RNAi therapeutic Atu027 in patients with advanced cancer

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Background: Atu027 is a novel vascular stabilising, anti-metastatic, RNAi therapeutic, targeting systemic endothelial cell function and the tumor vasculature. Atu027 comprises a liposomal particle, containing an siRNA, which silences expression of the PKC pathway signalling molecule PKN3. Atu027 was previously shown to restrict tumor growth, local invasion and both, lymph node as well as pulmonary metastasis in mouse xenograft models. Methods: 34 patients with advanced cancer received 10 escalating doses of Atu027 without pre-medication as single and repeated i.v. infusions (qw2x4 per 28-d cycle) with a 3-wks dose intermission. Primary end points were safety, pharmacokinetics and -dynamics (biomarker identification). Response was monitored by CT/MR imaging at baseline, after treatment and at final follow-up (EoS) and was assessed according to RECIST. Results: Atu027 was well tolerated up to 0.336 mg/kg (around twice the predicted effective siRNA plasma levels). An MTD was not achieved. Around 50% of patients experienced disease stabilization according to RECIST. 8 patients had stable disease at EoS and 2 with neuroendocrine cancer had disease stabilization for 9 or 22 months. Partial regression of pulmonary metastasis and a regression of liver metastases were observed in subjects with neuroendocrine and breast cancer, respectively. An improved ECOG performance status was observed in patients of higher dose levels. Most AEs were low grade toxicities (1 or 2), including fatigue and increased lipase. Transient complement system activation was observed for certain factors. Area exposure levels of siRNA strands were dose-proportional and peaks were reached during 4 h-infusion. Of 102 plasma proteins assessed, sFLT1 (sVEGF-R1) was the most promising as a potential biomarker, with decreases from baseline in most pts from dose level 4-10 after treatment. Conclusions: Atu027 was well tolerated and there was suggestion of a clinically meaningful antitumor activity. In view of this further clinical trials can be initiated at a dose of up to 0.336 mg/kg and sFLT1 will be investigated as a potential biomarker. Clinical trial information: NCT00938574.

Glutamate modulates resting state activity in the perigenual anterior cingulate cortex - a combined fMRI-MRS study

The perigenual anterior cingulate cortex (PACC) shows high resting state activity and is considered part of the default-mode network (DMN). However, the biochemical underpinnings of the PACC's high resting state activity remain unclear. While animal-based evidence points toward a role for the glutamatergic system, the modulation of the resting state activity level by itself as distinguished from stimulus-induced activity remains to be shown in humans. Using combined fMRI-MRS in healthy subjects, we here demonstrate that the PACC resting state concentration of glutamate is directly related to the level of resting state activity in the same region. In contrast, no such relationship could be detected during the anticipation of reward and punishment, nor in an independent control region (the left anterior insula). Taken together, our findings demonstrate for the first time the modulation of the PACC resting state activity level by the concentration of glutamate in the same regions. This contributes to a better understanding of the biochemical basis for the brain's resting state activity as well as providing some clues regarding its apparent pathological upregulation in psychiatric disorders like the major depressive disorder.