The Methylation of Clock Genes in Perinatal Depression: Which Role for Oxytocin?

Background: Perinatal Depression (PD) is a widespread disabling condition that is hypothesized to be associated with abnormalities in circadian rhythms and neuropeptide release including oxytocin (OXT). Methods: Fourty-four pregnant women (28 with PD, and 16 controls) were evaluated through the Edinburgh Postnatal Depression Scale (EPDS), the State/Trait Anxiety Inventory Form Y (STAI-Y), and the Prenatal Attachment Inventory (PAI). A blood sample was collected from all participants, and OXT plasma levels, DNA methylation of clock genes, as well as of FOXp3 and HERV-W were measured. Linear regression analyses were performed to assess the effect of oxytocin on the methylation of selected genes. Continuous ordinal regression models was further applied to see if the score of rating scales was associated to gene methylation, adjusting for oxytocin-methylation interaction. Results: OXT plasma levels were positively associated with CRY1 methylation. Women with higher OXT plasma levels showed an association between higher degree of CRY2 methylation (thus, reduced expression) and lower EPDS (OR = 0.21; P = 0.043) and STAI-S scores (OR = 6.96; P = 0.019). Finally, with high OXT levels, hypermethylation of CRY1 was associated to higher scores on the PAI (OR = 2.74; P = 0.029) while higher methylation of HERV-W related to lower PAI scores (OR = 0.273; P = 0.019). Conclusion: Our results suggest a possible protective role played by oxytocin in the development of PD by promoting a favorable methylation profile characterized by reduced expression of CRY1 and CRY2. Moreover, oxytocin strengthens the association between maternal prenatal attachment with a favorable pattern of methylation of clock genes and HERV-W, which is essential for pregnancy outcomes.

6128Losartan vs Nebivolol vs the association of both on the progression of aortic root dilation in genotyped Marfan Syndrome: 48 months open label randomized controlled phase III trial

Background

Marfan Syndrome (MFS) is a rare multisystemic genetic disease caused by mutations in the Fibrillin 1 (FBN1) gene. Aortic root aneurysm, potentially evolving to dissection and rupture, is the most important clinical complication. Beta blockers (BB) and Angiotensin II receptor blockers (ARB), these latter exerting an anti-TGFbeta1 effect, are current cornerstones of medical therapy in patients diagnosed with MFS and presenting aortic root aneurysm. The study aimed at comparing the effect of single drug (nebivolol and losartan) vs. the combination of both (losartan + nebivolol) in limiting the progression of the growth of the aortic root diameter (ARD) in FBN1 genotyped patients with aortic root aneurysm (z-score>2), who had not undergone prior aortic surgery.

Methods

We designed a controlled, open-label, single-blinded, 1:1:1 randomized, phase III single-centre study [NCT00683124]. Calculated sample size was 291 (power 90%, type I error 5%, 20% attrition, expected dropout 20%). ARD data collection was performed with annual 2D-transthoracic echocardiograms for four years. ARDs were measured with 2D-transthoracic echocardiogram as absolute values, aortic root ratio (ARR), and z-score. The primary endpoint was the modification of ARD z-score at 48 months. The analysis of the primary endpoint aimed at showing differences of ARD z-score comparing:

– The combined treatment arm (group A).

– The group aggregating both single treatment arms (group B).

– The nebivolol arm (group C).

– The losartan arm (group D).

Results

We enrolled 262 patients (126 adults, aged 17–55, and 136 children, aged 1–16); 236/262 (22 dropout; 4 lost at follow-up) completed the planned follow-up: 81 in the group A, 79 in the BB in the group C and 76 in the group D. No patient developed acute aortic dissection. Both drugs administered either individually or in combination were well tolerated without evidence of side effects. At 48 months, the ARD Z-score decreased from baseline to end-follow-up in all treatment arms. The decrease was significantly higher in the combined treatment arm (A) than in the single treatment aggregated arm (group B) with a difference in ARD z-score change of 0.17 (p=0.009) in the combined arm (A). Similarly, the decrease of z-score was inferior in the nebivolol arm and in the losartan arm than in the combined arm (by 0.16, p=0.032, and by 0.18, p=0.019, respectively). After Bonferroni correction for these post-hoc comparisons only the decrease of z-score in the losartan arm remained significantly inferior (p<0.025).

Conclusions

This study shows that the current cornerstones of medical therapy in MFS (ARB and BB) are effective in limiting the progression of the growth of the aortic root diameter: their combination exploits a synergistic effect. The combined administration of BB and ARB in patients with aortic root aneurysm is a sustainable, well tolerated treatment that effectively limits the rate of progression of aortic root dilation.

Acknowledgement/Funding

The financial support of Telethon, Italy (Grant no. GGP08238) is gratefully acknowledged.The drugs are a gift of Menarini and MSD

P5723IEVA: Integration and Extraction of Variant Attributes in NGS analysis

Purpose

This project aimed at reducing NGS errors through the introduction of a bioinformatic solution in the bioinformatic analytic step of the genetic testing process. iEVA is a tool that enhances NGS-derived informative features to use them in a filtering process based on a Machine Learning algorithm (ML). It considers sequencing features (e.g. technical errors, duplicates of PCR) together with nucleotide sequence characteristics.

Methods

To demonstrate the effectiveness of iEVA in eliminating FP and FN errors from the NGS bioinformatic pipeline, we developed two ML-based filtering algorithms. The training dataset consisted of 7968 single nucleotide variants (SNV) and 306 Insertions and Deletions (InDels) validated by Sanger sequencing performed by expert molecular biologists. Variants derived from 800 sequences obtained with the Illumina Trusight Cardio panel containing 174 genes related to cardiovascular diseases. Two Random Forest classifiers were trained with the task of discriminating between sequencing error and real variant. The first one was trained using attributes derived from the most common variant caller (GATK v3.8), and the second one using iEVA results. To evaluate ML models, we used a 3-Fold cross-Validation and validated the results using an independent validation dataset consisting of 3415 SNV and 132 InDels.

Results

Using iEVA attributes, we obtained 1 FP (excluded by Sanger) and 3 FN (confirmed by Sanger) less than using common variant caller attributes. In the independent validation dataset, the iEVA-trained classification model identified 1 Sanger-confirmed variant that was missed by variant caller-trained model.

Conclusions

Variant filtering is crucial to exclude sequencing errors and to recognize true variants. Even a single filtering error may negatively impact on the patient when a genetic diagnosis is missed. To obtain a certain genetic diagnosis, a 0% error probability is needed. The introduction of iEVA in the pipeline is an easy, time- and cost-saving tool to reduce errors and to improve the precision of the genetic data.

Acknowledgement/Funding

Italian Ministry of Health Research Funding to the IRCCS Foundation University Hospital Policlinico San Matteo of Pavia

P5539Genetic heterogeneity of spontaneous coronary artery dissection (SCAD)

Introduction

SCAD is a rare coronary event that may cause acute coronary syndromes (ACS). SCAD predominantly occurs in apparently healthy, young to middle aged women (up to 95% of cases). The known causes include: heritable connective tissue diseases, fibromuscular dysplasia, arteritis, contraceptives, cocaine abuse and chest trauma. A variable proportion of patients manifests progression to longer segments of the same vessel or recurrence of dissection in other coronary arteries. SCAD can be the first manifestation of a previously unrecognised systemic disease.

Methods

In 2010 we started collecting consecutive SCAD, as first clinical manifestation, in patients addressed to our attention for investigation of genetic or non genetic causes, after successful management of the acute phase and exclusion of systemic inflammatory and autoimmune diseases. All patients underwent genetic visit and counselling, collection of clinical reports and imaging records, clinical cardiologic evaluation with pan-angio CT scan, biochemical testing including coagulation-related tests, and and genetic testing of genes causing connective tissue diseases. Parallel clinical family screening and genetic testing were systematically performed.

Results

The series is constituted of 35 patients (28F and 7M) (age at onset, mean ± SD, 44±7.6 years) with ACS-SCAD (20 STEMI and 15 NSTEMI) and 9 second dissections in a different coronary artery. Two sisters had ACS-SCAD caused by dissection of the same coronary artery.

We identified pathologic mutations (n=19/35, 54%) in COL3A1 (n=3), FBN1 (n=1), FBN1+TGFBR1 (n=1), TGFBR1 (n=2), TGFBR2 (n=1), MYLK (n=1), SMAD3 (n=1), COL5A1 (n=1 homozygous), COL5A2 (n=1), MYH11 (n=1), TGFB2 (n=1), ABCC6 (1 homozygous), ELN (2 homozygous sisters and 1 heterozygous unrelated patient), NOTCH1 (n=1). In 8 (23%) patients we identified VUS classified as C3 because previously unreported and predicted as uncertain on the basis of in silico analyses. In the remaining 8 patients we only identified C2 variants. A second SCAD (14 days to 78 months after the first event) occurred in 9 patients (9/35, 25%) (COL3A1 (n=2), FBN1 (n=1), FBN1+TGFBR1 (n=1), MYLK (n=1), COL5A2 (n=1), NOTCH1 (n=1) COL5A2 (n=1) and 1 with a C2 variant in COL3A1. Two patients with thrombocytosis were carriers of the somatic JAK2 V617F mutation. Extra-coronary arterial dilations/aneurysms occurred in 13 families; in the follow-up 2 patients demonstrate dissection in non-coronary arteries.

Conclusions

Our series, with the potential bias of a referral centre for inherited cardiovascular disease, demonstrated that SCAD is the possible first manifestation of a genetic disorder and that neither disease gene or mutation predicts the risk of a second coronary event. SCAD is a potentially fatal coronary event associated with ACS, warning for familial disease and unpredictable risk of recurrence.

Metabolic control and complications in Italian people with diabetes treated with continuous subcutaneous insulin infusion

BACKGROUND AND AIM

The objective of this cross-sectional study was to evaluate the degree of glycaemic control and the frequency of diabetic complications in Italian people with diabetes who were treated with continuous subcutaneous insulin infusion (CSII).

METHODS AND RESULTS

Questionnaires investigating the organisation of diabetes care centres, individuals' clinical and metabolic features and pump technology and its management were sent to adult and paediatric diabetes centres that use CSII for treatment in Italy. Information on standard clinical variables, demographic data and acute and chronic diabetic complications was derived from local clinical management systems. The sample consisted of 6623 people with diabetes, which was obtained from 93 centres. Of them, 98.8% had type 1 diabetes mellitus, 57.2% were female, 64% used a conventional insulin pump and 36% used a sensor-augmented insulin pump. The median glycated haemoglobin (HbA_1c) level was 60 mmol/mol (7.6%). The HbA_1c target (i.e. <58 mmol/mol for age <18 years and <53 mmol/mol for age >18 years) was achieved in 43.4% of paediatric and 23% of adult participants. Factors such as advanced pump functions, higher rate of sensor use, pregnancy in the year before the study and longer duration of diabetes were associated with lower HbA_1c levels. The most common chronic complications occurring in diabetes were retinopathy, microalbuminuria and hypertension. In the year before the study, 5% of participants reported ≥1 episode of severe hypoglycaemic (SH) episodes (SH) and 2.6% reported ≥1 episode of ketoacidosis.

CONCLUSIONS

Advanced personal skills and use of sensor-based pump are associated with better metabolic control outcomes in Italian people with diabetes who were treated with CSII. The reduction in SH episodes confirms the positive effect of CSII on hypoglycaemia.

CLINICAL TRIAL REGISTRATION NUMBER

NCT 02620917 (ClinicalTrials.gov).

Supporting Translational Research on Inherited Cardiomyopathies through Information Technology

Objectives: The INHERITANCE project, funded by the European Commission, is aimed at studying genetic or inherited Dilated cardiomyopathies (DCM) and at understanding the impact and management of the disease within families that suffer from heart conditions that are caused by DCMs. The biomedical informatics research activity of the project aims at implementing information technology solutions to support the project team in the different phases of their research, in particular in genes screening prioritization and new gene-disease association discovery.

Methods: In order to manage the huge quantity of scientific, clinical and patient data generated by the project several advanced biomedical informatics tools have been developed. The paper describes a layer of software instruments to support translation of the results of the project in clinical practice as well as to support the scientific discovery process. This layer includes data warehousing, intelligent querying of the phenotype data, integrated search of biological data and knowledge repositories, text mining of the relevant literature, and case based reasoning.

Results: At the moment, a set of 1,394 patients and 9,784 observations has been stored into the INHERITANCE data warehouse. The literature database contains more than 1,100,000 articles retrieved from the Pubmed and generically related to cardiac diseases, already analyzed for extracting medical concepts and genes.

Conclusions: After two years of project the data warehouse has been completely set up and the text mining tools for automatic literature analysis have been implemented and tested. A first prototype of the decision support tool for knowledge discovery and gene prioritization is available, but a more complete release is still under development.