A Case Report of Pneumoretroperitoneum from Blunt Trauma in a Patient with Chronic Obstructive Pulmonary Disease

Introduction

Pneumomediastinum is a rare complication of blunt traumatic injury and is thought to be due to the Macklin effect, a pathophysiologic process comprised of three steps: alveolar rupture secondary to blunt injury; air dissecting along bronchovascular sheaths; and spread of pulmonary interstitial edema into the mediastinal space. Pneumomediastinum is rarely associated with pneumoretroperitoneum.

Case Report

We present a case of a patient who suffered a cardiac arrest after a fall during a chronic obstructive pulmonary disease exacerbation, leading to pneumoretroperitoneum.

Conclusion

This case highlights the complications that can arise from blunt trauma and how underlying lung pathology can worsen these complications.

Secukinumab versus guselkumab in the complete resolution of ustekinumab-resistant psoriatic plaques: The ARROW study

Interleukin (IL)-23-independent IL-17A production has been suggested to be involved in persistent manifestations of psoriatic disease, including anti-IL-12/23-refractory psoriatic plaques; this study aimed to test this hypothesis by investigating the clinical and molecular effects of direct IL-17A (with secukinumab) versus selective IL-23 inhibition (with guselkumab) in patients with anti-IL-12/23 (ustekinumab)-refractory psoriatic plaques. A 16-week, randomized, open-label, parallel-group, Phase IIa study (ARROW, NCT03553823) was conducted in patients with ≥1 active psoriatic plaque (total clinical score [TCS] ≥6) at screening despite treatment with ustekinumab, and a Psoriasis Area and Severity Index (PASI) score 1-10. Patients were randomized 1:1 to receive secukinumab 300 mg (n = 20) or guselkumab 100 mg (n = 20). Biopsies from one refractory ('target plaque') were obtained at baseline and Week 16. The primary endpoint was the proportion of patients whose ustekinumab-refractory target plaque achieved clear/almost clear status (TCS 0-2) at Week 16. Transcriptomic and histological analyses were conducted on target plaques to determine the molecular effects of direct IL-17A versus selective IL-23 inhibition. At Week 16, target plaque clear/almost clear status was achieved in 60.0% of patients treated with secukinumab versus 40.0% of patients treated with guselkumab (p = 0.1715). Molecular analyses identified that secukinumab modulated a greater proportion of psoriasis disease transcriptome genes (72.1% vs. 48.0%) and resulted in more histological responders (72.2% vs. 53.3%) compared with guselkumab. Secukinumab demonstrated a greater clinical and molecular effect on ustekinumab-refractory psoriatic plaques versus guselkumab. These results are consistent with the hypothesis that IL-23-independent IL-17 mechanisms may be relevant to the inflammation driving refractory manifestations of psoriasis.

Transcriptomic Analysis of the Major Orphan Ichthyosis Subtypes Reveals Shared Immune and Barrier Signatures

Preliminary work suggested upregulation of inflammatory pathways in patients with common forms of ichthyosis. However, a comprehensive characterization of skin from various ichthyosis subtypes is unavailable, precluding the development of targeted treatments. Thus, we sought to characterize the immune and barrier profiles of common and subtype-specific skin transcriptomes in a large group of patients with ichthyosis. We performed a global RNA-sequencing analysis in 54 patients with ichthyosis (7 with Netherton syndrome, 13 with epidermolytic ichthyosis, 16 with lamellar ichthyosis, and 18 with congenital ichthyosiform erythroderma) and 40 healthy controls. Differentially expressed genes were defined on the basis of fold changes > 2 and false discovery rate < 0.05 criteria. We found robust and significant T helper (Th) 22/Th17 skewing in all subtypes (e.g., IL-17A/C/F, S100A7/8/9/12; P < 0.001) with modest changes in Th2 pathway, primarily in Netherton syndrome, and Th1 skewing in congenital ichthyosiform erythroderma. Across all subtypes (less evident in epidermolytic ichthyosis), lipid metabolism and barrier junction markers were downregulated (e.g., FA2H, CDH10/11/12/2; P < 0.05), whereas epidermal cornification and proliferation measures were upregulated (e.g., SPRR1A/1B/2C/2G, EREG; P < 0.05). Our findings suggest that the common ichthyosis variants share aberrations in Th17/Th22 and barrier function, with minimal Th2 modulation. This may help to elucidate the pathogeneses of these subtypes and inform the development of subtype-specific treatments.

Paraphilic Disorder and Gender Dysphoria in a Case with High-Functioning Autism Spectrum Disorder

Introduction

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized with difficulties in social interaction/communication, restricted interests, and repetitive behaviors. Sexual issues such as paraphilic behaviors in ASD have gained attention in recent years, however there is still a great paucity of research regarding this issue.

Objectives

The aim of this presentation is to draw attention to a crucial dimension through a case of ASD with paraphilic disorder (pedophilic tendencies) and gender dysphoria.

Methods

One case from an inpatient unit of a psychiatric clinic in Lower Saxony, Germany will be reported.

Results

Case: An 18-year-old male was referred to our acute psychiatric ward due to suicidal thoughts and other depressive symptoms. In further examination, he stated that he had pedophilic phantasies which he was trying to satisfy by using child pornography in the darknet. He had never been involved in any sexual relationship with a child and described this behavior as an addiction that he wanted to get rid of. Detailed psychiatric examination and developmental history yielded the diagnosis of high-functioning ASD. The compulsory paraphilic engagement is classified as a restrictive-repetitive interest in terms of ASD. In addition, the patient presented gender incongruence with moderate gender dysphoria, dressed in a skirt and wanted to be perceived and named rather gender-neutral, which was supported through the whole course.

Conclusions

Through systemic understanding of the high-functioning ASD structure and complex symptomatology, socio- and psychotherapeutic approaches were implemented which yielded an apparent stabilization. The detailed therapeutic process in the light of the present literature will be discussed.

Disclosure

No significant relationships.

0127 Brain bacterial peptidoglycan is region-specific and changes after ischemic stroke

Introduction

Sleep disorders and ischemic stroke (IS) are large health burdens. Almost half the USA population reports disturbed sleep and 795,000 Americans suffer a stroke annually. Despite dysregulated sleep being a stroke risk factor that can exacerbate injury and prolong recovery, sleep deprivation immediately preceding experimental stroke is neuroprotective. Bacteria and microbial products associate with (patho-)physiologies, including sleep phenotypes and IS. Peptidoglycans (PGs) are bacterial cell wall components found in diseased and healthy adults, and in developing and sleep-deprived brains. Although they influence atherosclerosis, an IS risk factor, PGs have not been characterized in post-stroke brain.

Methods

Aged (63 weeks) male wildtype mice (n=5) underwent permanent left middle cerebral artery occlusion, a model that mimics atherosclerotic IS, the most common type in humans. Surgeries began at Zeitgeber time (ZT) 12, lasted 30-40 minutes, and were followed by a 2-2.5-hour recovery period before sacrifice at ZT15. Brain stem (BS), somatosensory and prefrontal cortices (Sctx, PFC) were dissected, homogenized in phosphate buffered saline, and centrifuged. A standardized murine peptidoglycan ELISA (MyBioSource) was used for PG/MP quantification in resultant supernates. Brain areas in the left (L) IS, and right (R) control, hemispheres were compared by two-way ANOVA and Tukey’s HSD tests.

Results

Mean PG values are expressed as ng/mg tissue wet weight ± SEM. Post-IS PG in the injured L Sctx (4.28±0.48) was lower (F(2,21)=49.29, p&lt;0.05) than the uninjured R Sctx (5.66±0.29; p=0.048). There were no hemispheric PG differences in either BS or PFC. L hemispheric PG was greater in BS (7.59±0.40) versus Sctx (p=0.0008) and PFC (3.82±0.21, p=0.0002). R hemispheric PG was also greater in BS (8.26±0.53) versus Sctx (p=0.005) and PFC (3.56±0.56, p=0.0006) and in Sctx versus PFC (p=0.02).

Conclusion

This study confirms our parallel study, presented in a separate abstract herein (English et al), that PG regulation is unique within brain areas. Additionally, PG values in uninjured Sctx and in BS were similar between studies. Finally, current results suggest that reduced cerebral blood flow induced by IS reduces PG in the affected brain area. Further, PG may have a role in sleep deprivation-related IS injury and recovery.

Support (If Any)

W.M. Keck Foundation and NIH (NS025378)

0129 Region-Specific Changes in Brain Peptidoglycan Following Sleep Deprivation

Introduction

Bacterial cell wall peptidoglycan (PG) and muramyl peptides (MPs), isolated from mammalian brains and urine following sleep deprivation (SD), promote non-rapid eye movement sleep. These PG/MPs likely originate from the host microbiome and have been quantified in neonatal murine brain. PG/MP amounts and dynamics in healthy, adult murine brain remain unknown.

Methods

Wildtype mice acclimated to standard lab conditions were sacrificed at Zeitgeber time (ZT) 3 or ZT15 with (treatment, N=8), or without (control, N=8) 3h of SD prior to time points. Hypothalamic (HT), somatosensory cortex (Sctx) and brain stem (BS) areas were dissected, homogenized in phosphate buffered saline and centrifuged. PG/MP contents in resultant supernatants were determined using an ELISA (MyBioSource), interpolating sample PG from the standard curve, and expressed as ng peptidoglycan per mg tissue wet weight (ng/mg).

Results

At ZT3 and ZT15, BS PG values were significantly higher than HT or Sctx values, while HT and Sctx values did not differ from each other. At ZT3, mean PG values from control mice were: 3.6 in HT, 3.7 in Sctx, and 8.6 ng/mg in BS. After SD, corresponding values were: 3.0, 4.8 (statistically significant increase, p&lt;0.05), and 7.5 ng/mg. Further, within all 8 individual mice after SD prior to ZT3, PG levels in Sctx were higher than corresponding values in HT (p&lt;0.001).At ZT15, PG control values were: 4.6 in HT, 4.6 in Sctx, and 8.9 ng/mg in BS. After SD, PG level at ZT15 was not significantly changed in any brain area assayed. However, PG values after SD at ZT15 compared to ZT3 SD values were significantly higher for HT and BS (p&lt;0.0005 and p&lt;0.005, respectively). In an independent experiment (see Dykstra-Aiello et. al. this volume) we confirmed PG values at ZT15 in BS were significantly higher than Sctx values.

Conclusion

Results indicate unique PG regulation by brain area, sleep loss, and time-of-day suggesting physiological roles for brain PG guiding host behaviors such as sleep. Thus, mammalian sleep-wake regulation and its various associated cognitive states, are the product of millions of years of co-evolutionary symbioses between microbes and their hosts.

Support (If Any)

Supported by the W.M. Keck Foundation and NIH (NS025378).

Abstract 485: Platelet Aggregation Is Increased In Psoriasis And Associated With Biomarkers Of Vascular Health

Background: Psoriasis is associated with vascular inflammation and increased cardiovascular (CV) risk. Platelet hyperactivity is implicated in impaired vascular health and CV disease (CVD). The association between platelet activity, psoriasis, and vascular health has not been fully explored.

Objective: To measure platelet aggregation in patients with psoriasis and controls and explore the association with biomarkers of inflammation and vascular stiffness.

Methods: Participants with psoriasis (n=33, age 51 ± 16 years, 61% male), affecting 7% ± 14 of their body surface area (BSA), were compared to healthy controls (n=15) (Table 1A). Platelet aggregation in response to adenosine diphosphate (ADP) agonists, epinephrine (Epi), and arachidonic acid (AA) was measured via light transmission aggregometry (LTA). Vascular stiffness was assessed by pulse wave velocity (PWV), a metrics of arterial stiffness and biomarker of CV risk. High-sensitivity C-reactive protein (hs-CRP) was measured in a clinical laboratory.

Results: Enrolled psoriasis participants were older, were more frequently white, and had higher body mass index and elevated hs-CRP and PWV compared to controls (Table 1A). Platelet aggregation was higher in psoriasis patients after stimulation with ADP (p=0.01), Epi (p=0.05), and AA with ex vivo aspirin co-incubation (p=0.04) when compared with controls in multivariable models. Platelet aggregation to ADP trended to positive association with PWV (r=0.25, p=0.08), and hs-CRP (r=0.29, p=0.06) after adjustment for age and sex (Figure 1C).

Conclusion: Platelet aggregation was increased in participants with psoriasis and trended towards positive association with biomarkers of vascular stiffness and inflammation. These findings have important implications for future clinical trials of targeting platelet activity to reduce CV risk in psoriasis.

Abstract P135: Platelet Activation Is Present In Psoriasis And Associated With Psoriasis Severity And Endothelial Dysfunction

Background: Psoriasis is associated with impaired endothelial function and increased CV risk. P-selectin, a platelet transmembrane protein involved in binding leukocytes and endothelial cells, is implicated in CVD.

Objective: To explore platelet P-selectin expression in psoriasis and its association with biomarkers of inflammation and endothelial dysfunction.

Methods: Patients with psoriasis (n=15, age 51 ± 18 years, 73% male), percent body surface area (BSA) psoriasis 9 ± 20, were compared to controls (Table 1A). The vascular endothelium was assessed via brachial artery flow-mediated dilatation (FMD), a metric of endothelial health and biomarker of CV risk. Platelet P-selectin expression was measured on freshly isolated platelets via flow cytometry in resting and stimulated (thrombin, ADP, arachidonic acid and epinephrine) conditions. High-sensitivity C-reactive protein (hs-CRP) was measured in a clinical laboratory.

Results: Psoriasis patients were matched for traditional CV risk factors (Table 1A) aside from diabetes, which trended higher in psoriasis. No difference in hs-CRP was noted, however BSA positively correlated with hs-CRP ( r =0.65, p=0.02), while FMD trended higher in psoriasis vs. controls (5.7% vs. 2.7%, p=0.07) even after accounting for diabetes status (β=-3.0, p=0.08). Platelet analysis revealed higher basal and stimulated P-selectin expression in psoriasis vs. controls (Table 1B). Positive correlations were noted between platelet activation, BSA and hs-CRP, while a negative association was noted between FMD and platelet activation (Table 1C).

Conclusion: We describe platelet P-selectin in resting and stimulated conditions as elevated in psoriasis, positively correlated with biomarkers of psoriatic activity, and negatively associated with endothelial health. These findings have important implications for future clinical trials of targeting platelet activity to reduce CV risk in psoriasis.

The Rockefeller Team Science Leadership training program: Curriculum, standardized assessment of competencies, and impact of returning assessments

The ability to effectively lead an interdisciplinary translational team is a crucial component of team science success. Most KL2 Clinical Scholars have been members of scientific teams, but few have been team science leaders. There is a dearth of literature and outcome measures of effective Team Science Leadership in clinical and translational research. We focused our curriculum to emphasize Team Science Leadership, developed a list of Team Science Leadership competencies for translational investigators using a modified Delphi method, and incorporated the competencies into a quantitative evaluation survey. The survey is completed on entry and annually thereafter by the Scholar; the Scholar's primary mentor and senior staff who educate and interact with the Scholar rate the Scholar at the end of each year. The program leaders and mentor review the results with each Scholar. The survey scales had high internal consistency and good factor structure. Overall ratings by mentors and senior staff were generally high, but ratings by Scholars tended to be lower, offering opportunities for discussion and career planning. Scholars rated the process favorably. A Team Science Leadership curriculum and periodic survey of attained competencies can inform individual career development and guide team science curriculum development.

Safety, tolerability, efficacy, pharmacokinetics, and pharmacodynamics of the oral TYK2 inhibitor PF-06826647 in participants with plaque psoriasis: a phase 1, randomised, double-blind, placebo-controlled, parallel-group study

BACKGROUND

Blockade of tyrosine kinase 2 (TYK2) signalling has previously shown therapeutic potential in the treatment of psoriasis. The primary objective of this study was to assess the safety and tolerability of the TYK2 inhibitor PF-06826647.

METHODS

This phase 1, randomised, double-blind, placebo-controlled, parallel-group study assessed once daily oral dosing of PF-06826647 in participants with plaque psoriasis, at a single clinical research site in the USA. Eligible participants (aged 18-65 years) had plaque psoriasis covering at least 15% of total body surface area and a psoriasis area and severity index (PASI) score of at least 12 at baseline. Participants received PF-06826647 (100 mg or 400 mg), or placebo once daily for 28 days. Using a computer-generated randomisation schedule with a block size of 3, participants were sequentially randomly assigned into two cohorts by the investigator; in the first cohort, participants were randomly assigned in a 2:1 ratio to receive either oral PF-06826647 400 mg or placebo once daily, whereas participants in the second cohort were randomly assigned in a 2:1 ratio to receive either oral PF-06826647 100 mg or placebo once daily. Site, investigator, Pfizer personnel, and participants, were masked to treatment. The primary endpoint was the safety of multiple-dose PF-06826647 in participants with plaque psoriasis. Secondary endpoints were the characterisation of the pharmacokinetics of multiple-dose PF-06826647 in plasma and the change in PASI score at day 28. Safety analysis was done in all participants who received at least one dose of study drug. Efficacy analysis was done in all participants who received at least one dose of randomised study drug, and had a baseline and at least one post-baseline measurement. This study is registered as a randomised, controlled trial with ClinicalTrials.gov, NCT03210961 and is completed.

FINDINGS

The trial was done between July 14, 2017, and Jan 25, 2019. Overall from 91 participants assessed, 40 participants with moderate-to-severe psoriasis were randomly assigned to treatment (placebo 14 [35%] of 40; PF-06826647 100 mg, 11 [28%] of 40; PF-06826647 400 mg, 15 [38%] of 40). Treatment-emergent adverse events (TEAEs) were reported in 12 (80%) of 15 participants in the PF-06826647 400 mg group, seven (50%) of 14 in the placebo group and five (45%) of 11 in the 100 mg group. All TEAEs were mild in severity, except one moderate TEAE of vomiting reported in the placebo group. There were no deaths, serious TEAEs, severe TEAEs, dose reductions, or temporary discontinuations. Compared with placebo, the change from baseline in PASI score at day 28 showed a significant reduction in least squares mean difference for the PF-06826647 400 mg group (-13·05; 90% CI -18·76 to -7·35; p=0·00077) but not for the PF-06826647 100 mg group (-3·49; -9·48 to 2·50; p=0·33). Both the area under the concentration-time curve over the dosing interval and the maximum concentration increased in a less than dose proportional manner with increasing dose from 100 mg to 400 mg PF-06826647.

INTERPRETATION

PF-06826647 showed significant improvement in disease activity within 4 weeks of dosing with an acceptable safety profile. PF-06826647 holds promise over conventional oral treatments for psoriasis that have shown limited efficacy or unfavourable safety profiles.

FUNDING

Pfizer.

CCL20 in psoriasis: A potential biomarker of disease severity, inflammation, and impaired vascular health

BACKGROUND

Psoriasis is associated with increased cardiovascular risk that is not captured by traditional proinflammatory biomarkers.

OBJECTIVE

To investigate the relationship between Psoriasis Area and Severity Index, circulating proinflammatory biomarkers, and vascular health in psoriasis.

METHODS

In patients with psoriasis and in age and sex-matched controls, 273 proteins were analyzed with the Proseek Multiplex Cardiovascular disease reagents kit and Inflammatory reagents kit (Olink Bioscience), whereas vascular endothelial inflammation and health were measured via direct transcriptomic analysis of brachial vein endothelial cells.

RESULTS

In psoriasis, chemokine ligand 20 (CCL20), interleukin (IL) 6, and IL-17A were the top 3 circulating proinflammatory cytokines. Vascular endothelial inflammation correlated with CCL20 (r = 0.55; P < .001) and less so with IL-6 (r = 0.36; P = .04) and IL-17A (r = 0.29; P = .12). After adjustment for potential confounders, the association between CCL20 and vascular endothelial inflammation remained significant (β = 1.71; P = .02). In nested models, CCL20 added value (χ² = 79.22; P < .001) to a model already incorporating the Psoriasis Area and Severity Index, Framingham risk, high-sensitivity C-reactive protein, Il-17A, and IL-6 (χ² = 48.18; P < .001) in predicting vascular endothelial inflammation.

LIMITATIONS

Our study was observational and did not allow for causal inference in the relationship between CCL20 and cardiovascular risk.

CONCLUSION

We demonstrate that CCL20 expression has a strong association with vascular endothelial inflammation, reflects systemic inflammation, and may serve as a potential biomarker of impaired vascular health in psoriasis.

International observational atopic dermatitis cohort to follow natural history and treatment course: TARGET-DERM AD study design and rationale

INTRODUCTION

As new topical and systemic treatments become available for atopic dermatitis (AD), there is a need to understand how treatments are being used in routine clinical practice, their comparative effectiveness and their long-term safety in diverse clinical settings.

METHODS AND ANALYSIS

The TARGET-DERM AD cohort is a longitudinal, observational study of patients with AD of all ages, designed to provide practical information on long-term effectiveness and safety unobtainable in traditional registration trials. Patients with physician-diagnosed AD receiving prescription treatment (topical or systemic) will be enrolled at academic and community clinical centres. Up to 3 years of retrospective medical records, 5 years of prospective medical records, and optional biological samples and patient-reported outcomes will be collected. The primary aims include characterisation of AD treatment regimens, evaluation of response to therapy, and description of adverse events.

ETHICS AND DISSEMINATION

TARGET-DERM has been approved by a central IRB (Copernicus Group IRB, 5000 Centregreen Way Suite 200, Cary, North Carolina 27513) as well as local and institutional IRBs. No additional Ethics Committee reviews. Results will be reviewed by a publications committee and submitted to peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03661866, pre-results.

Comparing the Effectiveness of a Virtual Toxicology Escape Room at Two Emergency Medicine Residencies

Introduction Physical distancing guidelines during the coronavirus disease 2019 (COVID-19) pandemic forced medical residency programs to move a large portion of required didactics to virtual settings. Toxicology, a core component of emergency medicine (EM) education, was forced to adapt to similar constraints. An in-person escape room style puzzle was modified to a virtual format for educational purposes, and shared with and evaluated by two different residency programs. Materials and methods A virtual escape room, "Escape the Toxin: Online!" was created to test knowledge of toxicologic ingestion and antidote utilizing Google Forms and delivered using Zoom teleconference software to two EM residency programs in the Philadelphia region. After small groups completed the gamified activity, their scores were calculated and they completed an anonymous evaluation. Results Residents at the program where a Medical Toxicology fellowship is located found the virtual escape room to be more effective and enjoyable compared to the second program. Despite some differences in perceived effectiveness, the majority of participants were able to correctly solve the puzzle and get to the antidote. Conclusion The majority of learners who participated from both residencies agreed that they would recommend this virtual program to other EM residents.

Obesity and ethnicity alter gene expression in skin

Obesity is accompanied by dysfunction of many organs, but effects on the skin have received little attention. We studied differences in epithelial thickness by histology and gene expression by Affymetrix gene arrays and PCR in the skin of 10 obese (BMI 35-50) and 10 normal weight (BMI 18.5-26.9) postmenopausal women paired by age and ethnicity. Epidermal thickness did not differ with obesity but the expression of genes encoding proteins associated with skin blood supply and wound healing were altered. In the obese, many gene expression pathways were broadly downregulated and subdermal fat showed pronounced inflammation. There were no changes in skin microbiota or metabolites. African American subjects differed from European Americans with a trend to increased epidermal thickening. In obese African Americans, compared to obese European Americans, we observed altered gene expression that may explain known differences in water content and stress response. African Americans showed markedly lower expression of the gene encoding the cystic fibrosis transmembrane regulator characteristic of the disease cystic fibrosis. The results from this preliminary study may explain the functional changes found in the skin of obese subjects and African Americans.

Characterization of PCSK9 in the Blood and Skin of Psoriasis

Mechanisms explaining the link between psoriasis, a proinflammatory condition, and cardiovascular disease are not fully known. PCSK9 is predominantly expressed in hepatocytes as a critical regulator of lipid metabolism, and clinical trials targeting PCSK9 reduce cardiovascular disease. Independent of its role in lipid metabolism, PCSK9 levels associate with endothelial dysfunction and predict cardiovascular events. We used two separate human psoriasis cohorts and the K14-Rac1V12^-/+ murine model of psoriasis to investigate PCSK9 and cardiovascular risk in psoriasis. In both psoriasis cohorts (n = 88 and n = 20), PCSK9 levels were 20% and 13% higher than in age-, sex-, and cholesterol-matched controls, respectively (P < 0.05 for each comparison) and correlated with PASI (r = 0.43, P < 0.05). Despite no difference in hepatocyte expression, K14-Rac1V12^-/+ mice demonstrated skin-specific PCSK9 staining, which was confirmed in human psoriatic lesional skin. In patients with psoriasis, PCSK9 levels correlated with impaired endothelial vascular health (e.g., early atherosclerosis, β = 4.5, P < 0.01) and log converted coronary artery calcium score (β = 0.30, P = 0.01), which remained significant after adjustment for Framingham risk, body mass index, and active biologic use. Taken together, these findings suggest, independent of cholesterol, an association between circulating PCSK9 and early as well as advanced stages of atherosclerosis in psoriasis.

1261Geographical variations in the incidence of CIED infection and infection prevention strategies: Update from the global WRAP-IT study

Funding Acknowledgements

Medtronic, Inc.

Introduction

Cardiac Implantable Electronic Device (CIED) infections lead to significant morbidity, mortality, and use of health care resources. There is variation in infection prevention strategies among centers, and it is not clear whether there is also variation in infection rates across different geographies. Recently, WRAP-IT, the largest global randomized trial to evaluate an infection reduction strategy, randomized 6,983 patients to receive an antibacterial envelope (treatment) vs. no envelope (control). The results demonstrated a significant reduction in major CIED infection with the TYRX antibiotic envelope (12-mo infection rate for envelope vs. control 0.7% and 1.2%, respectively; HR, 0.60; 95% [CI], 0.36 to 0.98; P = 0.04).  The purpose of this analysis is to assess geographical variations in patient characteristics, procedural routines, and infection rates.

Methods

The WRAP-IT study enrolled patients undergoing a CIED pocket revision, generator replacement, or system upgrade or an initial implantation of a cardiac resynchronization therapy defibrillator and randomized them to receive the envelope or not, in addition to mandated pre-procedure intravenous antibiotic prophylaxis. To assess geographical variations in infection rates, the control group (per protocol) baseline demographics and procedural characteristics were identified. Major infection was defined as CIED infections resulting in system extraction or revision, long-term antibiotic therapy with infection recurrence, or death.

Results

A total of 3429 control patients were evaluated and followed for a mean of 20.9 ± 8.3 months; 2530 patients from 123 centers in North America, 777 patients from 46 centers in Europe, and 122 patients from 11 centers in Asia/South America. The 24-month Kaplan-Meier major infection rates were 1.2% in North America (30 pts), 2.5% in Europe (16 pts), and 4.3% Asia/South America (5 pts) (see Figure). These geographical variations in the incidence of major CIED infections were significant (overall P = 0.008, univariate). There were differences in baseline patient characteristics, including age, sex, medication use, NYHA Class, and number of previous devices across geographies. Differences also included procedural characteristics, such as device type, use of pocket wash, skin preparation, pre-operative antibiotic drug use, and procedure time.

Conclusion

Major CIED infection rates vary significantly across geographies. The effect of patient demographics and procedural characteristics on these findings will be assessed and presented at EHRA. Insights into geographical variability of CIED infections is important to mitigate infection risk, reduce morbidity and cost.

Abstract Figure. Major CIED Infection Rate by Geography

Chimeric antigen receptor T cell therapy comes to clinical practice

Adoptive cellular therapy with chimeric antigen receptor T cells (car-ts) has recently received approval from Health Canada and the U.S. Food and Drug Administration after remarkable and durable remissions were seen in children with recurrent or refractory leukemia and adults with non-Hodgkin lymphoma-responses that were so impressive that a shift in the paradigm of care has now occurred for children with acute lymphoblastic leukemia. The concept behind car-t immunotherapy is that modification of a patient's own T cells to facilitate their localization to the cancer cell, with subsequent activation of the T cell effector mechanism and proliferation, will result in targeted killing of cancer cells. The car-ts are a novel drug in that the starting material for the manufacture of the car-t product comes from the patient, whose viable T cells are then genetically modified. Thus, collaboration is needed between the pharmaceutical companies, which must meet good manufacturing standards for each patient's unique product, and the treating sites. For regulators and health authorities, this new class of drugs requires new paradigms for assessment and approval. Treatments with car-ts require that institutions address unique logistics requirements and management of novel toxicities. The Hospital for Sick Children has had early experience with both the licensing of clinical trials and the introduction of the first commercial product. Here, we provide an overview of basic concepts and treatment, with caveats drawn from what we have learned thus far in bringing this new therapy to the clinical front line.

Impact of Zostavax Vaccination on T-Cell Accumulation and Cutaneous Gene Expression in the Skin of Older Humans After Varicella Zoster Virus Antigen-Specific Challenge

Background

The live attenuated vaccine Zostavax was developed to prevent varicella zoster virus (VZV) reactivation that causes herpes zoster (shingles) in older humans. However, the impact of vaccination on the cutaneous response to VZV is not known.

Methods

We investigated the response to intradermal VZV antigen challenge before and after Zostavax vaccination in participants >70 years of age by immunohistological and transcriptomic analyses of skin biopsy specimens collected from the challenge site.

Results

Vaccination increased the proportion of VZV-specific CD4⁺ T cells in the blood and promoted the accumulation of both CD4⁺ and CD8⁺ T cells in the skin after VZV antigen challenge. However, Zostavax did not alter the proportion of resident memory T cells (CD4⁺ and CD8⁺) or CD4⁺Foxp3⁺ regulatory T cells in unchallenged skin. After vaccination, there was increased cutaneous T-cell proliferation at the challenge site and also increased recruitment of T cells from the blood, as indicated by an elevated T-cell migratory gene signature. CD8⁺ T-cell–associated functional genes were also highly induced in the skin after vaccination.

Conclusion

Zostavax vaccination does not alter the abundance of cutaneous resident memory T cells but instead increases the recruitment of VZV-specific T cells from the blood and enhances T-cell activation, particularly cells of the CD8⁺ subset, in the skin after VZV antigen challenge.

IL-4Rα Blockade by Dupilumab Decreases Staphylococcus aureus Colonization and Increases Microbial Diversity in Atopic Dermatitis

Dupilumab is a fully human antibody to interleukin-4 receptor α that improves the signs and symptoms of moderate to severe atopic dermatitis (AD). To determine the effects of dupilumab on Staphylococcus aureus colonization and microbial diversity on the skin, bacterial DNA was analyzed from swabs collected from lesional and nonlesional skin in a double-blind, placebo-controlled study of 54 patients with moderate to severe AD randomized (1:1) and treated with either dupilumab (200 mg weekly) or placebo for 16 weeks. Microbial diversity and relative abundance of Staphylococcus were assessed by DNA sequencing of 16S ribosomal RNA, and absolute S. aureus abundance was measured by quantitative PCR. Before treatment, lesional skin had lower microbial diversity and higher overall abundance of S. aureus than nonlesional skin. During dupilumab treatment, microbial diversity increased and the abundance of S. aureus decreased. Pronounced changes were seen in nonlesional and lesional skin. Decreased S. aureus abundance during dupilumab treatment correlated with clinical improvement of AD and biomarkers of type 2 immunity. We conclude that clinical improvement of AD that is mediated by interleukin-4 receptor α inhibition and the subsequent suppression of type 2 inflammation is correlated with increased microbial diversity and reduced abundance of S. aureus.

Abstract 256: The Direct Characterization of Endothelial Inflammation in Patients with Psoriasis

Objective: Psoriasis, an inflammatory autoimmune disease, increases the risk of cardiovascular disease (CVD). Active psoriatic disease is linked to systemic vascular inflammation, yet how this contributes to CVD is unknown. Using in vivo and ex-vivo measures of the vascular endothelium our study investigates the vascular health of psoriasis patients to better understand the mechanism(s) that predispose psoriatics to CVD.

Methods: Ten patients with active psoriasis (average age 46 years, 50% male (5 of 10), 6% [3.5% – 90%] body surface area involvement) were compared to age- and sex- matched controls. In vivo vascular endothelial function was assessed by brachial artery reactivity testing (BART, %) with high resolution ultrasonography. Venous endothelial cells were collected from the brachial vein using guidewires inserted through an angiocatheter and isolated with magnetic beads directed against CD146. Following collection, endothelial RNA was isolated, converted to cDNA and inflammatory gene profiling performed by RT-qPCR with Taqman probes and primers.

Results: Transcriptomic profiling of venous endothelial cells revealed upregulation of genes associated with inflammatory cytokines and chemokines ( lymphotoxin beta [2.5 - fold], CCL3 [3.5 - fold], and IL-1 β [2.8 - fold], P < 0.05 for all) and genes related to intracellular adhesion and inflammation ( ICAM1 [2.3 – fold] and COX-2 [1.4 – fold], P < 0.05 for both) in psoriatics vs. controls. Unexpectedly, endothelial nitric oxide synthase (eNOS) and phosphorylated eNOS (higher levels indicate healthy endothelial NO production) were upregulated (2 - 3 fold) in psoriatics vs. controls (p = 0.24, p = 0.14 respectively). BART was also higher in psoriatics when compared to controls (7.1 ± 1% vs. 3.9 ± 2.7%, P = 0.03).

Conclusion: This cross-sectional study is the first to directly examine the vascular endothelium of psoriatic patients. Compared to controls, active psoriatic disease was associated with upregulation of cytokines, chemokines and genes regulating intracellular adhesion as well as increased expression of eNOS, and increased BART. These findings suggest potential mechanisms to explain the increased prevalence of atherosclerosis and CVD risk seen in those with psoriasis.

Selective oral ROCK2 inhibitor reduces clinical scores in patients with Psoriasis Vulgaris and normalizes skin pathology via concurrent regulation of IL-17 and IL-10 levels

Targeted inhibition of Rho-associated kinase 2 (ROCK2) down-regulates pro-inflammatory T-cell response, while increasing the regulatory arm of immune response in animals models of autoimmunity and T helper 17 (Th17)-skewing human cell culture in vitro. We conducted a Phase 2, open-label, dose-finding study to evaluate the safety, tolerability, and activity of selective ROCK2 inhibitor, KD025, in subjects with Psoriasis Vulgaris who failed first-line therapy (NCT02317627 at ClinicalTrials.gov). Here, we report that oral administration of KD025 reduces Psoriasis Area and Severity Index (PASI) scores in 85% of patients completing the study, with minimal side effects. In the 400 mg QD and 200 mg BID cohorts 42% and 71% of patients respectively achieved at least a 50% decrease in PASI score (PASI 50) after three month of treatment. KD025 treatment reduced levels of both IL-17 and IL-23, but no IL-6 and TNF-a in the peripheral blood of clinical responders, whereas IL-10 levels were increased at the end of the study. The clinical improvement and changes in cytokine levels were associated with decreased epidermal thickness, T-cell infiltration and down-regulation of key molecules implicated in the regulation of the Th17 pathway, such as ROCK2, pSTAT3, RORgt and IRF4 in the skin. Collectively, these data demonstrate that orally available selective ROCK2 inhibitor down-regulates Th17-driven autoimmune response and improved clinical symptoms in psoriatic patients via defined molecular mechanism that involves concurrent modulation of cytokines without deleterious impact on the rest of the immune system.

Estimates of Social Consensus by Majorities and Minorities: The Case for Social Projection

Meta-analyses of research on consensus estimation have identified an asymmetry in the error patterns between majorities and minorities (Gross & Miller, 1997; Mullen & Hu, 1988). Members of the majority slightly underestimate the size of their own group, whereas members of the minority strongly overestimate the size of theirs. The present analysis shows that a single psychological assumption about projection is sufficient to explain this asymmetry. Most people, regardless of whether they are actually members of the majority or members of the minority, believe themselves to be in the majority. It is not necessary to attribute different psychological mechanisms, such as ego protection or cognitive availability, to majority and minority members. A simple quantitative model and empirical data illustrate this point.

Myeloid-derived cells reside in subcutaneous adipose tissue but are not found in circulation: a DC-expressing BDCA-1 CD206 and hematopoetic progenitor cells (HUM4P.273)

Obesity is an insulin resistance-associated metabolic disorder which is a hallmark of and risk factor for type 2 diabetes and the metabolic syndrome. It is also often linked to cardiovascular disease, certain cancers and inflammatory diseases. Different immune cells have been identified in visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) which are indicators of inflammation associated with insulin resistance and systemic endothelial dysfunction in the peripheral vasculature. However, detailed studies of infiltrating leukocytes and associated cytokines are largely absent in human adipose tissue. One hypothesis that may link obesity with inflammatory immune response is that Th17 T-cells may be involved with pathological processes. Since past studies have shown increased production of CCL20 by adipocytes in obese humans , this chemokine would be expected to chemoattract DCs and Th17 T-cells into adipose tissue; associated Th17 activation could be the nidus for inflammatory diseases. In this study, we have found that obese SAT samples have a higher percentage of DCs than in the lean SAT samples of a DC which is BDCA-1 positive. Half of these BDCA-1 cells express CD206, this population is not found in blood. We also found a population unique to SAT, a hematopoietic progenitor cell. We additionally found an increase of Th17 cells in blood of obese subjects in comparison to lean subjects.

The effects of dexamethasone on sleep in young children with acute lymphoblastic leukemia

PURPOSE

Corticosteroids, which are a mainstay in the treatment of acute lymphoblastic leukemia (ALL), have a well-documented adverse effect on sleep. We sought to characterize the effects of dexamethasone on sleep over an entire 28-day treatment cycle using actigraphy, an objective measure of sleep.

METHODS

The sleep of 25 children aged 2-9 years (mean 4.5 years) with ALL treated with dexamethasone were evaluated during maintenance chemotherapy using a within-subject experimental design, actigraphy, and standardized questionnaires to assess sleep, sleep problems, and fatigue.

RESULTS

During the five days of dexamethasone treatment, sleep time increased during the night (535 vs. 498 min; p = 0.004) and daytime napping increased the following day (14 vs. 0 min; p = 0.002), and the number of wake episodes during the night was lower (14 vs. 20; p =  ≤ 0.001). However, when assessed individually, sleep-onset time, efficiency, and wake after sleep onset during the night were unchanged during dexamethasone treatment; when the cumulative effect of all of these factors was assessed, there was a statistically and clinically significant increase in nighttime sleep duration during dexamethasone treatment.

CONCLUSIONS

During the five days of treatment with dexamethasone, an increase in nighttime sleep as well as daytime napping was observed in young children with ALL. The increases in sleep duration return to baseline one day after the discontinuation of dexamethasone.

Major ABO incompatible BMT in children: determining what residual volume of donor red cells can safely be infused following red cell depletion

Major ABO incompatible BM transplantation carries a risk of acute haemolysis. Red cell depletion reduces this risk but not all incompatible RBC (iRBCs) are removed and in children the residual volume can be significant relative to body weight. We sought to determine the volume of iRBCs that can be safely given to children. All patients receiving fresh BM from a donor with a major ABO blood group mismatch between January 2000 and July 2013 at the Hospital for Sick Children, Toronto, were included. Seventy-eight patients were identified. The median volume of iRBCs transfused was 1.6 mL/kg (range 0.1-10.6 mL/kg). Thirty-five patients had minor haemolytic events and five patients had clinically significant adverse events. Two patients, who received 3.66 and 3.9 mL iRBCs/kg, developed renal impairment and in one case hypoxia and hyperbilirubinaemia. One patient had mild hypotension that resolved with i.v. fluid. Two patients developed hypotension secondary to sepsis and unrelated to BM infusion. Although signs of haemolysis occur, with appropriate hydration and monitoring of renal function, clinically significant adverse events related to the infusion of ABO incompatible BM are rare, and, in this study, were only seen in patients receiving >3 mL/kg of iRBCs per kg.