Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Electrocatalytic Access to Azetidines via Intramolecular Allylic Hydroamination: Scrutinizing Key Oxidation Steps through Electrochemical Kinetic Analysis

Azetidines are prominent structural scaffolds in bioactive molecules, medicinal chemistry, and ligand design for transition metals. However, state-of-the-art methods cannot be applied to intramolecular hydroamination of allylic amine derivatives despite their underlying potential as one of the most prevalent synthetic precursors to azetidines. Herein, we report an electrocatalytic method for intramolecular hydroamination of allylic sulfonamides to access azetidines for the first time. The merger of cobalt catalysis and electricity enables the regioselective generation of key carbocationic intermediates, which could directly undergo intramolecular C-N bond formation. The mechanistic investigations including electrochemical kinetic analysis suggest that either the catalyst regeneration by nucleophilic cyclization or the second electrochemical oxidation to access the carbocationic intermediate is involved in the rate-determining step (RDS) of our electrochemical protocol and highlight the ability of electrochemistry in providing ideal means to mediate catalyst oxidation.

Geriatric nutritional risk index as the prognostic factor in older patients with fragility hip fractures

This study investigated the long-term survival and incidence of secondary fractures after fragility hip fractures. The 5-year survival rate was 62%, and the mortality risk was seen in patients with GNRI < 92. The 5-year incidence of secondary fracture was 22%, which was significantly higher in patients with a BMI < 20.

BACKGROUND

Malnutrition negatively influences the postoperative survival of patients with fragility hip fractures (FHFs); however, little is known about their association over the long term.

OBJECTIVE

This study evaluated the ability of the geriatric nutritional risk index (GNRI) as a risk factor for long-term mortality after FHFs.

METHODS

This study included 623 Japanese patients with FHFs over the age of 60 years. We prospectively collected data on admission and during hospitalization and assessed the patients' conditions after discharge through a questionnaire. We examined the long-term mortality and the incidence of secondary FHFs and assessed the prognostic factors.

RESULTS

The mean observation period was 4.0 years (range 0-7 years). The average age at the time of admission was 82 years (range 60-101 years). The overall survival after FHFs (1 year, 91%; 5 years, 62%) and the incidence of secondary FHFs were high (1 year, 4%; 5 years, 22%). The multivariate Cox proportional hazard analysis revealed the risk factors for mortality as older age (hazard ratio [HR] 1.04), male sex (HR 1.96), lower GNRI score (HR 0.96), comorbidities (malignancy, HR 2.51; ischemic heart disease, HR 2.24; revised Hasegawa dementia scale ≤ 20, HR 1.64), no use of active vitamin D3 on admission (HR 0.46), and a lower Barthel index (BI) (on admission, HR 1.00; at discharge, HR 0.99). The GNRI scores were divided into four risk categories: major risk (GNRI, < 82), moderate risk (82-91), low risk (92-98), and no risk (> 98). Patients at major and moderate risks of GNRI had a significantly lower overall survival rate (p < 0.001). Lower body mass index (BMI) was also identified as a prognostic factor for secondary FHFs (HR 0.88 [p = 0.004]).

CONCLUSIONS

We showed that older age, male sex, a lower GNRI score, comorbidities, and a lower BI are risk factors for mortality following FHFs. GNRI is a novel and simple predictor of long-term survival after FHFs.

Palladium-Catalyzed Electrooxidative Hydrofluorination of Aryl-Substituted Alkenes with a Nucleophilic Fluorine Source

Herein, we report an electrocatalytic hydrofluorination of aryl-substituted alkenes with a nucleophilic fluorine source. The merger of palladium catalysis with electrooxidation enables the transformation of various substrates ranging from styrenes to more challenging α,β-unsaturated carbonyl derivatives to the corresponding benzylic fluorides. This method can also be applied to the late-stage modification of pharmaceutical derivatives. Mechanistic studies suggest that the generation of a high-valent palladium intermediate via anodic oxidation is the crucial step in this electrocatalytic hydrofluorination.

Copper Hydride-Catalyzed Enantioselective Olefin Hydromethylation

The enantioselective installation of a methyl group onto a small molecule can result in the significant modification of its biological properties. While hydroalkylation of olefins represents an attractive approach to introduce alkyl substituents, asymmetric hydromethylation protocols are often hampered by the incompatibility of highly reactive methylating reagents and a lack of general applicability. Herein, we report an asymmetric olefin hydromethylation protocol enabled by CuH catalysis. This approach leverages methyl tosylate as a methyl source compatible with the reducing base-containing reaction environment, while a catalytic amount of iodide ion transforms the methyl tosylate in situ into the active reactant, methyl iodide, to promote the hydromethylation. This method tolerates a wide range of functional groups, heterocycles, and pharmaceutically relevant frameworks. Density functional theory studies suggest that after the stereoselective hydrocupration, the methylation step is stereoretentive, taking place through an SN2-type oxidative addition mechanism with methyl iodide followed by a reductive elimination.

Exogenous Ligand-Free NiH-Catalyzed Hydroacylation of Aryl Alkenes with Aroyl Fluorides

Acyl fluorides have emerged as efficient acyl group donors, but these attractive reagents have rarely been utilized in transition-metal-catalyzed hydroacylation. Herein we report a nickel hydride-catalyzed hydroacylation of aryl alkenes using aroyl fluorides. The reaction proceeds without recourse to an exogenous ligand under mild conditions. The synthetic utility of the present method is demonstrated by the glovebox-free, gram-scale reaction and the late-stage derivatization of complex molecules containing pharmaceutical frameworks.

AB0761 Are we treating-to-target in spondyloarthritis (SpA)? A cross sectional analysis from the Asia Pacific League of Associations for Rheumatology (APLAR) SpA Registry

Background

Data on the extent of treat-to-target (T2T) recommendations application in SpA patients across Asia Pacific region is lacking. APLAR SpA Registry aimed to assess the utility of T2T on long term clinical outcomes, and to improve disease management and inform health care policy.

Objectives

To provide a snapshot of the registry including demographics, disease activity and medication use.

Methods

Patients fulfill the CASPAR 2006 for psoriatic arthritis (PsA) and 2009 ASAS criteria for axial spondylitis (AxSpA) were recruited. This cross sectional analysis included the first 188 patients recruited across 7 Asia Pacific regions (Hong Kong, Singapore, Korea, Thailand, India, Qatar & Pakistan).

Results

83 patients PsA and 115 AxSpA patients were included. They had moderate inflammation (DAPSA: 19.61±14.29, ASDAS: 2.32±1.07). Majority of PsA patients received conventional synthetic disease-modifying drug (csDMARDs, 81%) with relatively low prevalence of biologic DMARDs (bDMARDs) (24%). Most AxSpA patients used NSAIDs (79%) while nearly half of them received bDMARDs (49%). Other details listed in Table 1. Prevalence of bDMARDs use in our registry was lower than that from the USA (Corrona PsA Registry, 59%), Turkey & Canada (PsArt-ID, 40%) and the Netherlands AxSpA registry (56%) (1-3). Regarding T2T, 28% and 44% of PsA patient achieved minimal disease activity (MDA) and Disease Activity in Psoriatic Arthritis low disease activity (DAPSA LDA) respectively. The proportion of patients achieving target in other cohorts were 46% for MDA (PsArt-ID) and 46% for DAPSA LDA (Corrona) (1, 2). 37% and 47% of AxSpA patient achieved Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)<4 and Ankylosing Spondylitis Disease Activity Score (ASDAS) LDA. Proportion of patients achieving ASDAS LDA were similar to the Netherlands registry for patients with ASDAS LDA or BASDAI<4 (Figure 1A)(3). Patient on bDMARD were more likely to achieve treatment target (Figure 1B). There were no significant difference between socio-economic status and disease features between bDMARD user and non-user.

Table 1.

Demographics, clinical features and disease activity of patients

PsA (n=83)AxSpA (n=115)Age50.012.836.512.4Male n, %4251%8583%Asian n, %83100%10196%Disease duration, years7.17.35.27.6Any sacroiliitis n, %10299%HLA B27, positive n, %9189%Duration of early morning stiffness, min30392529Tender joint count7901Swollen joint count3400No. of dactylitis digit1100PASI4.05.0SPRACC1201BASDAI2.82.0ESR, mm/h31262016CRP, mg/L10151127HAQ-DI0.610.610.390.51DAPSA19.6114.29ASDAS CRP2.321.07

Data given in mean SD unless stated

. No. of case from Hong Kong 40; Singapore 46; Korea 24; Thailand 20, India 15; Qatar 10; Pakistan 33; HLA - human leucucyte antigen; PASI - psoriasis area and severity index; SPRACC - Spondyloarthritis Research Consortium of Canada Enthesitis Index; BASDAI - Bath Ankylosing Spondylitis Disease Activity Index; ESR - erythrocyte sedimentation rate; CRP - C-reactive protein; HAQ-DI - Health assessment questionnaire disability index; DAPSA - Disease activity in Psoriatic Arthritis; ASDAS - Ankylosing Spondylitis Disease Activity Score

Figure 1.

(A) Achievement of LDA in APLAR SpA registry and other registry and (B) use of bDMARDs among patients in APLAR SpA registry with or without achieving LDA

Conclusion

Patient using bDMARDs were more likely to achieve treatment target. We expect that when T2T is widely applied, better outcomes will be reported in future.

References

[1]Bakirci, S., et al. (2019). “What are the main barriers to achieve minimal disease activity in psoriatic arthritis in real life?” Clin Exp Rheumatol37(5): 808-812.

[2]Beckers, E., et al. (2021). “Treat-to-target in axial spondyloarthritis: an observational study in daily practice.” Rheumatology (Oxford).

[3]Ogdie, A., et al. (2021). “Effect of Multidomain Disease Presentations on Patients With Psoriatic Arthritis in the Corrona Psoriatic Arthritis/Spondyloarthritis Registry.” J Rheumatol48(5): 698-706.

Disclosure of Interests

Isaac T. Cheng: None declared, Ho SO: None declared, Ying Ying Leung Speakers bureau: received honorarium/ speaker fee from AbbVie, DKSH, Janssen, Novartis and Pfizer., Praveena Chiowchanwisawakit: None declared, Stanley Angkodjojo Speakers bureau: Boehringer Ingelheim Singapore in Nov 2021, Consultant of: Abbvie (Singapore), DKSH (Singapore) in 2021, Muhammad Ahmed Saeed: None declared, Kichul Shin: None declared, Mohit Goyal: None declared, Muhammad Haroon: None declared, Mohammed Hammoudeh Speakers bureau: Have you been paid as a speaker for (pharmaceutical) companies, Grant/research support from: participated in drug companies sponsored trials, Nallasivan Subramanian: None declared, Ho Yin Chung: None declared, James Cheng-Chung Wei: None declared, Mitsumasa Kishimoto Consultant of: MK received consulting fees and/or speaker fees from AbbVie, Amgen, Asahi-Kasei Pharma, Astellas, Ayumi Pharma, BMS, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Janssen, Kyowa Kirin, Novartis, Ono Pharma, Pfizer, Tanabe-Mitsubishi, and UCB Pharma., Lai-Shan Tam Consultant of: has acted as a consultant for Janssen, Pfizer, Sanofi, AbbVie, Boehringer Ingelheim, and Lilly, Grant/research support from: has received grant/research support from Amgen, Boehringer Ingelheim, Janssen, GSK, Novartis, and Pfizer

OP0062 EFFICACY AND SAFETY OF ADALIMUMAB WITH LOW AND HIGH DOSE-METHOTREXATE IN PATIENTS WITH RHEUMATOID ARTHRITIS WITH INADEQUATE RESPONSE TO METHOTREXATE: THE RANDOMISED CONTROLLED MIRACLE STUDY

Background

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that causes not only joint pain but also bone destruction resulting in impairment of quality of life. Tumor necrosis factor inhibitors have improved prognosis of patients with rheumatoid arthritis dramatically, especially in combination with methotrexate, however, the optimal dose of the concomitant methotrexate is unclear.

Objectives

To evaluate the efficacy and safety of adalimumab in combination with reduced dose of methotrexate in patients with early RA with inadequate response to methotrexate.

Methods

The MIRACLE study was a multinational, randomized, open-label study in patients with RA with inadequate response to methotrexate conducted in Asia. It compared low dose and high dose methotrexate upon starting adalimumab. Methotrexate-naive patients with RA with a disease duration of less than two years started methotrexate at 6 to 8 mg/week and increased it to the maximum tolerable dose by week 12. Patients who have not achieved remission according to simplified disease activity index (SDAI) despite methotrexate ≥ 10 mg/week at week 24 were randomised to the maximum tolerable dose of methotrexate group (10 to 25 mg/week) or the reduced dose group (6 to 8 mg/week) and started to receive subcutaneous adalimumab 40 mg every other week. The primary endpoint was non-inferiority in the achievement of SDAI remission at week 48 in the reduced dose group compared with the maximum tolerable dose group with a non-inferiority margin of -15% based on two-sided 90% confidence interval. (NCT03505008)

Results

A total of 300 patients were enrolled in the study. Among them, 291 started methotrexate and were included in the analysis. The mean age was 57.7±15.2 years, female was 74.6%, and the mean disease duration from the diagnosis of RA was 21.1±56.2 days. Anti-CCP antibody was positive in 211 (73.0%) and the mean SDAI at study enrollment was 26.5±12.4. At week 24, with the mean dose of methotrexate of 12.6±2.9 mg/week, 108 patients (37.1%) achieved remission according to SDAI and continued MTX monotherapy. 134 patients (46.0%) were randomised and started adalimumab with 68 patients in the maximum tolerable dose group and 66 patients in the reduced dose group. At week 48, the remission achievement rates were 38.4 % and 44.8 %, respectively, with the adjusted risk difference of the reduced dose group to the maximum tolerable dose group of 6.4% (-7.0% to 19.8%, 90% CI), which met the criterion for noninferiority. No significant difference was found in health assessment questionnaire disability index ≤0.5 (59.1% vs 62.0%, respectively, p=0.72) and in radiological remission rates (Δmodified total Sharp score ≤0.5, 66.3% vs 62.0 %, respectively, p=0.59). Adverse drug reactions tended to be more frequent in the maximum tolerable dose group than in the reduced dose group (22.1% vs 9.1%, respectively, p=0.06).

Conclusion

The MIRACLE randomised study demonstrated that, in patients with inadequate response to methotrexate, the efficacy of adalimumab with reduced dose of concomitant methotrexate was not inferior to that with maximum tolerable dose of methotrexate with better safety profile.

Disclosure of Interests

Hiroya Tamai Speakers bureau: Eisai, Grant/research support from: Eisai, Kei Ikeda Speakers bureau: AbbVie, Eisai, Eli Lilly, Novartis, Gilead, Asahi-Kasei, Grant/research support from: Mitsubishi-Tanabe, Toshiaki Miyamoto: None declared, Hiroaki Taguchi: None declared, Chang-Fu Kuo: None declared, Kichul Shin: None declared, Shintaro Hirata Speakers bureau: AbbVie, Asahi-Kasei, Astellas, Ayumi, Bristol Myers Squibb, Celgene, Chugai, Eisai, Eli Lilly, Gilead, Glaxo SmithKline, Janssen, Kyorin, Novartis, Pfizer, Sanofi, Tanabe-Mitsubishi, UCB, Paid instructor for: AbbVie, Mitsubishi-Tanabe, Consultant of: AbbVie, Astellas, Bristol Myers Squibb, Eisai, Gilead, Ily Lilly, Grant/research support from: AbbVie, Asahi-Kasei, Eisai, Otsuka, Sanofi, Shionogi, Chugai, Pfizer, Tanabe-Mitsubishi, Eli Lilly, UCB, yutaka okano: None declared, Shinji Sato Speakers bureau: AbbVie, Eisai, Grant/research support from: AbbVie, Eisai, Hidekata Yasuoka Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Daiichi-Sankyo, Eisai, Kissei, Takeda, Mitsubishi-Tanabe, Chugai, Novartis, Eli Lilly, Pfizer, Janssen, Sanofi, Teijin, Boehringer-Ingelheim, Bayer, Glaxo Smith Kline, Paid instructor for: AbbVie, Consultant of: AbbVie, Asahi Kasei, Grant/research support from: Mitsubishi-Tanabe, Takeda, Daiichi-Sankyo, Chugai, Bristol-Myers, MSD, Astellas, In Ah Choi Speakers bureau: Abbvie, Eisai, Sung-Hwan Park: None declared, Meng-Yu Weng Paid instructor for: Novartis, Eli Lilly, ChuGai, Abbvie, Consultant of: Abbvie, Masataka Kuwana Speakers bureau: Astellas, Asahi Kasei Pharma, Boehringer-Ingelheim, Chugai, Eisai, Janssen, Mochida, Nippon Shinyaku, Ono Pharmaceuticals, Pfizer, Mitsubishi-Tanabe, Consultant of: Boehringer-Ingelheim, Kissei, Mochida, Grant/research support from: AbbVie, Asahi Kasei Pharma, Boehringer-Ingelheim, Chugai, Eisai, MBL, Nippon Shinyaku, Ono Pharmaceuticals, Mitsubishi-Tanabe, Yun Jong Lee Grant/research support from: Yuhan, Tomonori Ishii Speakers bureau: Chugai, Mitsubishi-Tanabe, Glaxo Smith Kline, Pfizer, Eli Lilly, Janssen, AbbVie, Eisai, Astellas, Jinhyun Kim: None declared, Hideto Kameda Speakers bureau: AbbVie, Pfizer, Consultant of: AbbVie, Grant/research support from: AbbVie, Eisai, Toshihisa Kojima Speakers bureau: AbbVie, Pfizer, Eisai, Grant/research support from: AbbVie, Han Joo Baek: None declared, Ping-Ning Hsu: None declared, Chun-Ming Huang Paid instructor for: Abbvie, Pfizer, Tien-Tsai Cheng Paid instructor for: Abbvie, Grant/research support from: Abbvie, Wan-Yu Sung: None declared, Takehiro Taninaga Shareholder of: Eisai.co.,Ltd., Employee of: Eisai.co.,Ltd., Masahiko Mori Shareholder of: Eisai.co.,Ltd., Employee of: Eisai.co.,Ltd., Hideaki Miyagishi Shareholder of: Eisai.co.,Ltd., Employee of: Eisai.co.,Ltd., Yasunori Sato Speakers bureau: Eisai Co., Ltd. Kowa Company, Ltd., Consultant of: MOCHIDA PHARMACEUTICAL CO., LTD, Tsutomu Takeuchi Speakers bureau: Astellas, AbbVie, Ayumi, Bristol Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Glaxo Smith Kline, Janssen, Mitsubishi-Tanabe, Nippon-kayaku, Novartis, Pfizer, Sanofi, UCB, Grant/research support from: Asahi Kasei, AbbVie, Ayumi, Boehringer-Ingelheim, Chugai, Eisai, Eli Lilly, Mitsubishi-Tanabe, Sanofi, UCB, Yuko Kaneko Speakers bureau: Asahi Kasei, Astellas, Ayumi, Bristol Myers Squibb, Chugai, Eisai, Elli Lilly, Mitsubishi-Tanabe, Novartis, UCB, Grant/research support from: AbbVie, Chugai, Eisai, Mitsubishi-Tanabe, UCB.

POS0942 DEVELOPMENT OF PREDICTION MODEL FOR FLARE AFTER TAPERING OF TNF INHIBITORS IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background

Tumor necrosis factor inhibitors (TNFi) have become a mainstay of management for axial spondyloarthritis (axSpA). However, it remains unclear whether patients with axSpA should continue the standard-dose TNFi after achieving stable disease activity. Although complete discontinuation of TNFi is followed by early relapse in most cases, several studies documented that reduced doses of TNFi in patients with prolonged low disease activity showed similar effects on disease control and drug survival compared to standard dose of TNFi. One of the main problem in the dose-tapering strategies for TNFi is a selection of the appropriate patient. However, there has been a lack of robust evidence regarding clinical factors predicting the flare after tapering of TNFi in patients with axSpA.

Objectives

This study aims to develop and validate the prediction model to select the patients in whom tapering of TNFi does not lead to flare.

Methods

We used the data from Korean College of Rheumatology Biologics registry, which included a total of 1,730 patients receiving biologic DMARD from 2017 to 2019 in South Korea. In this study, a total of 526 patients who were initially treated with the standard-dose TNFi and tapered the dose after at least 1 year of the treatment were analyzed. Dose quotient (DQ, 0-1) was applied to quantified TNFi used during interval. The main outcome was an occurrence of flare defined as ASDAS-CRP score of ≥2.1 after 1 year of tapering TNFi. To develop the prediction model, clinical factors having relevant association (p < 0.1) with the outcome were first selected as candidate predictors. Logistic regression using a stepwise approach through backward elimination was used for the final model.

Results

Patients’ mean (SD) age was 37.5 (11.9) years, 418 (79.5%) were men, and 474 (90.1%) were HLA-B27 positive. Mean disease duration was 5.0 (6.1) years and 433 (82.3%) were TNF naïve. The mean BASFI and ASDAS-CRP at baseline were 3.4 (2.6) and 3.7 (1.0), respectively. Approximately two-thirds of the patients (65.8%) were initiated TNFi tapering at the first 1 or 2 years from baseline. At the time of TNFi tapering, the mean DQ was 0.67 (0.15) and 381 (72.4%) were prescribed concurrently with NSAIDs, and the mean BASFI and ASDAS-CRP were 1.3 (1.8) and 1.6 (0.9), respectively. During 12 months of follow up starting from the TNFi tapering, 127 (24.1%) experienced the flare. The multivariable analysis revealed that HLA-B27 positivity (OR 0.337; 95% CI 0.161-0.705; p=0.004), inflammatory back pain (OR 2.920; 95% CI 1.283-6.648; p=0.011), ASDAS-CRP at tapering (OR 2.798; 95% CI 2.030-3.856; p<0.001), and BASFI at tapering (OR 1.214; 95% CI 1.051-1.402; p=0.008) were significantly associated with flare. Based on the results of the logistic regression analysis, the predicted probability was calculated by the following formula: P=1/[1+ exp{-(1.088 x HLA-B27 negativity + 1.072 x inflammatory back pain + 1.567 x psoriasis + 0.623 x family history of axSpA + 1.092 x diabetes mellitus + 0.435 x DQ at TNFi tapering + 1.029 x ASDAS-CRP at TNFi tapering + 0.194 x BASFI at TNFi tapering)}]. The best cut-off value of the model to define the flare was 0.2416 (95% CI 0.176, 0.301) with sensitivity 74.0% and with specificity 81.0%. AUC was 0.828 (95% CI 0.786-0.869) indicating a good predication (Figure 1). The internal validation with bootstrapping showed minimal overfitting (estimated AUC 0.794) and good calibration between observed and predicted values (calibration slope 1.110, 95% CI 0.903, 1.317; intercept 0.026, 95% CI -0.091, 0.039).

Figure 1.

Apparent performance of developed model for prediction of flare after 12 months of tumor necrosis factor inhibitors tapering.

Conclusion

We developed the prediction model for the flare after 12 months of TNFi tapering in patients with axSpA. It might be applicable in real world setting, although external validation will be required in the future investigation.

References

[1]Zavada J, et al. Ann Rheum Dis. 2016;75(1):96-102.

Acknowledgements

We greatly thank to the the Clinical Research Committee of the Korean College of Rheumatology and all participating hospitals.

Disclosure of Interests

None declared

A repeating fast radio burst source in a globular cluster

Fast radio bursts (FRBs) are flashes of unknown physical origin¹. The majority of FRBs have been seen only once, although some are known to generate multiple flashes^2,3. Many models invoke magnetically powered neutron stars (magnetars) as the source of the emission^4,5. Recently, the discovery⁶ of another repeater (FRB 20200120E) was announced, in the direction of the nearby galaxy M81, with four potential counterparts at other wavelengths⁶. Here we report observations that localized the FRB to a globular cluster associated with M81, where it is 2 parsecs away from the optical centre of the cluster. Globular clusters host old stellar populations, challenging FRB models that invoke young magnetars formed in a core-collapse supernova. We propose instead that FRB 20200120E originates from a highly magnetized neutron star formed either through the accretion-induced collapse of a white dwarf, or the merger of compact stars in a binary system⁷. Compact binaries are efficiently formed inside globular clusters, so a model invoking them could also be responsible for the observed bursts.

AB0253 COMPARISON OF PHARMACODYNAMICS OF METHOTREXATE AS METHOTREXATE-POLYGLUTAMATES CONCENTRATIONS IN RHEUMATOID ARTHRITIS; INTERIM DATA EVALUATION OF MIRACLE STUDY CONDUCTED IN JAPAN, KOREA AND TAIWAN

Background:

Methotrexate (MTX) is the first-line therapy for rheumatoid arthritis (RA). The concentrations of MTX-polyglutamates (PG) in erythrocytes, an active form of MTX, are useful markers for the optimal usage of MTX in patients with RA. The concentrations of MTX-PG have been reported to be different between Japanese and Caucasians. However, the difference among Asian ethnicity remains unclear.

Objectives:

To examine MTX-PG concentrations in association with MTX dose during the first 24 weeks after the initiation of MTX for newly diagnosed RA patients in Japan, Korea and Taiwan.

Methods:

MIRACLE study is a multicenter, open-label, randomized, 48 weeks interventional study conducted in Japan, Korea and Taiwan to evaluate non-inferiority of low dose to high dose of MTX as an add-on therapy to adalimumab in 300 patients with RA who do not achieve remission after 24 weeks MTX monotherapy in stipulated dosage. In the first 24 weeks, MTX was started at 6 to 8 mg/week for newly diagnosed RA patients, and promptly escalated to the maximum tolerable dose in 12 weeks in principle. This interim data evaluation was intended to investigate the differences among countries in the relationship between MTX dose, safety and MTX-PG concentrations in erythrocytes during the first 24 weeks. The efficacy of the treatment is not included at this point.

Results:

A total of 166 patients (106 in Japan, 35 in Korea, 25 in Taiwan) were included in this interim data. The age at treatment initiation was 57.2 years old on average and female was 79.5%. The time course changes in total and individual MTX-PG levels differed in the three countries. At 24 weeks, whereas the mean total MTX-PG concentrations were comparable (112.9 nmol/L in Japan, 104.4 nmol/L in Korea, and 115.7 nmol/L in Taiwan) with a dose of MTX of 12.3 mg/week, 14.1 mg/week, and 12.2 mg/week, respectively, the individual MTX-PG concentrations were different. The MTX-PG1 and MTX-PG2 concentrations were lower in Korea than Japan and Taiwan whereas MTX-PG3, MTX-PG4 and MTX-PG5 concentrations were the highest in Korea.

Conclusion:

The distribution of short-chain and long-chain MTX-PG concentrations were various among Asian countries despite similar dose of MTX administration: NCT03505008.

Disclosure of Interests:

Hiroya Tamai: None declared, Yuko Kaneko Speakers bureau: AbbVie, Astellas, Ayumi, Bristol–Myers Squibb, Chugai, Eisai, Eli Lilly, Hisamitsu, Jansen, Kissei, Kirin, Pfizer, Sanofi, Takeda, Tanabe-Mitsubishi, and UCB., Grant/research support from: Sanofi, Hideto Kameda Speakers bureau: AbbVie, Pfizer, Consultant of: AbbVie, Grant/research support from: AbbVie, Eisai, Masataka Kuwana Speakers bureau: Astellas, Asahi Kasei Pharma, Boehringer- Ingelheim, Chugai, Eisai, Janssen, Mochida, Nippon Shinyaku, Ono Pharmaceuticals, Pfizer, Mitsubishi-Tanabe, Consultant of: Corbus, Grant/research support from: AbbVie, Asahi Kasei Pharma, Boehringer- Ingelheim, Chugai, Eisai, MBL, Nippon Shinyaku, Ono Pharmaceuticals, Mitsubishi-Tanabe, Yutaka Okano: None declared, Tomonori Ishii Speakers bureau: Chugai, Mitsubishi- Tanabe, Glaxo Smith Kline, Pfizer, Eli Lilly, Janssen, AbbVie, Eisai, Astellas, Kei Ikeda Speakers bureau: AbbVie, Eli Lilly, Novartis, Mitsubishi-Tanabe, Eisai, BMS, Grant/research support from: Mitsubishi-Tanabe, Hiroaki Taguchi: None declared, Shinji Sato: None declared, Toshiaki Miyamoto: None declared, Shintaro Hirata Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Ayumi, Bristol Myers Squibb, Chugai, Eisai, Eli Lilly, Janssen, Glaxo Smith Kline, Kissei, Pfizer, Sanofi, Mitsubishi- Tanabe, UCB, Paid instructor for: AbbVie, Mitsubishi- Tanabe, Consultant of: AbbVie, Eisai, Gilead, Grant/research support from: AbbVie, Chugai, Mitsubishi-Tanabe, UCB, Hidekata Yasuoka Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Daiichi- Sankyo, Eisai, Kissei, Takeda, Mitsubishi- Tanabe, Chugai, Novartis, Eli Lilly, Pfizer, Janssen, Sanofi, Teijin, Boehringer- Ingelheim, Bayer, Glaxo Smith Kline, Paid instructor for: AbbVie, Consultant of: AbbVie, Asahi Kasei, Grant/research support from: Mitsubishi-Tanabe, Takeda, Daiichi-Sankyo, Chugai, Bristol-Myers, MSD, Astellas, Toshihisa Kojima Speakers bureau: AbbVie, Pfizer, Eisai, Grant/research support from: AbbVie, Sung-Hwan Park: None declared, Kichul Shin: None declared, Han Joo Baek: None declared, Yun Jong Lee Grant/research support from: research fund, In Ah Choi Speakers bureau: Abbvie, Eizai, Grant/research support from: Abbvie, Eizai, Jinhyun Kim: None declared, Ping-Ning Hsu: None declared, Chang-Fu Kuo: None declared, Chun-Ming Huang Paid instructor for: AbbVie, Pfizer, Meng-Yu Weng Consultant of: AbbVie, Wan-Yu Sung: None declared, Wen-Chan Tsai: None declared, Tien-Tsai Cheng Paid instructor for: AbbVie, Grant/research support from: AbbVie, Takehiro Taninaga Shareholder of: Eisai Co., Ltd., Employee of: Eisai Co., Ltd., Masahiko Mori Shareholder of: Eisai Co., Ltd., Employee of: Eisai Co., Ltd., Hideaki Miyagishi Employee of: Eisai Co., Ltd., Yasunori Sato: None declared, Tsutomu Takeuchi Speakers bureau: Astellas, Abbvie, Daiichi Sankyo, Ayumi, Eisai, GlaxoSmithKline, Mitsubishi Tanabe, Chugai, Novartis, Eli Lilly, Pfizer, Bristol Myers Squibb, Janssen, UCB, TaishoToyama, Sanofi–Aventis, Nipponkayaku, Taiho, Gilead, Boehringer Ingelheim, Grant/research support from: Asahikasei, Astellas, Abbvie, Daiichi Sankyo, Ayumi, Eisai, Takeda, Mitsubishi Tanabe, Chugai, Eli Lilly, UCB, Sanofi–Aventis, Nipponkayaku, Boehringer Ingelheim

POS0628 FAILURE TO SUSTAIN TREATMENT TARGET AFTER TAPERING TOCILIZUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS: 4-YEAR LONGITUDINAL DATA FROM A NATIONWIDE COHORT

Background:

Tapering biologic therapy after achieving clinical remission or low disease activity (LDA) has become a viable option in daily clinical practice of treating patients with rheumatoid arthritis (RA). There are yet few studies investigating its effectiveness and safety compared with those of standard biologic treatment, especially with non-tumor necrosis factor inhibitors.

Objectives:

To investigate the effectiveness and safety of tapering tocilizumab (TCZ) in patients with RA who attained LDA after TCZ therapy.

Methods:

Data were collected from a nationwide cohort of patients with RA receiving biologic therapy in South Korea (KOBIO-RA). This study included 350 patients who were treated with TCZ and achieved Clinical Disease Activity Index (CDAI)-LDA or remission (CDAI ≤ 10) after one year of treatment. We performed a longitudinal analysis utilizing clinical data measured in all 1-year intervals using generalized estimating equations (GEE). A total of 575 one-year intervals were divided into two groups according to the dose quotient (DQ, 0-100%) of TCZ within the interval (tapering group vs. standard treatment group). The main outcome of this study was loss of CDAI-LDA in the following 1-year interval.

Results:

Tapering TCZ was conducted in 282 (49.0%) intervals with a mean (SD) DQ of 66.0 (15.5). Loss of CDAI-LDA occurred in 91 (15.1%) intervals. Multivariable GEE showed significantly increased loss of CDAI-LDA (adjusted OR (95% CI): 1.76 [1.01 to 3.07]) in the tapering group after adjusting for previous biologics use, route of TCZ administration, concomitant glucocorticoid use, and CDAI measured in the previous follow-up. In addition, the likelihood to achieve DAS28-deep remission (DAS28-ESR < 1.98) was also significantly lower in the tapering group (adjusted OR 0.68 [0.46 to 0.99]). In contrast, there was no significant difference in the proportion of fulfilling other remission criteria between the two groups (Table 1). Development any adverse drug event or event of special interest was comparable in both groups except for hypercholesterolemia, which was lower in the tapering group.

Table 1.

Demographic characteristics and csDMARDs before first bDMARD

Loss of CDAI-LDADAS28-remissionDAS28-deep remissionCDAI-remissionSDAI-remissionACR/EULAR remissionUnadjusted OR (95% CI)(vs. standard-dose group)1.02 (0.67 to 1.55)1.03 (0.71 to 1.49)0.76 (0.54 to 1.06)1.23 (0.75 to 2.00)0.92 (0.59 to 1.44)0.98 (0.65 to 1.48)Adjusted OR(95% CI)(vs. standard-dose group)1.76 (1.01 to 3.07)0.87 (0.54 to 1.38)0.68 (0.46 to 0.99)0.94 (0.57 to 1.55)0.87 (0.54 to 1.38)0.76 (0.50 to 1.18)

CDAI, clinical disease activity index; CI, confidence interval; DAS, disease activity score; LDA, low disease activity; OR, odds ratio; SDAI, simplified disease activity index.

Conclusion:

Tapering TCZ after achieving LDA in patients with RA increases the risk of losing the benefit of LDA without a significant merit in safety.

References:

[1]Smolen JS et al. Maintenance, reduction or withdrawal of etanercept after treatment with etanercept and methotrexate in patients with moderate rheumatoid arthritis (PRESERVE): a randomised controlled trial. Lancet. 2013;381:918-29.

[2]Schett G et al. Tapering biologic and conventional DMARD therapy in rheumatoid arthritis: current evidence and future directions. Ann Rheum Dis. 2016;75:1428-37.

Disclosure of Interests:

None declared

Molecular insights into the development of hepatic metastases in colorectal cancer: a metastasis prediction study

OBJECTIVE

Colorectal cancer is presently the third most commonly diagnosed cancer in the United States. In this study, we identified molecular differences between hepatic and non-hepatic metastases in colorectal cancer and evaluated their prognostic significance.

MATERIALS AND METHODS

We downloaded primary data from the NCBI Gene Expression Omnibus (GSE6988, GSE62321, GSE50760, and GSE28722). To identify the molecular differences, we used the Significance Analysis of Microarray method. We selected nine prognostic genes (SYTL2, PTPLAD1, CDS1, RNF138, PIGR, WDR78, MYO7B, TSPAN3, and ATP5F1) with hepatic metastasis prediction score in colorectal cancer (hereafter referred to as LASSO Score). We confirmed the prognostic significance of the LASSO Score by using Kaplan-Meier survival analysis, multivariate analysis, the time-dependent area under the curve (AUC) of Uno's C-index, and the AUC of the receiver operating characteristic curve at 1-5 years.

RESULTS

Survival analysis revealed that a high LASSO Score is associated with a poor prognosis in colorectal cancer patients with hepatic metastases (p = 0). Analysis of C-indices and AUC values from the receiver operating characteristic curve further supported this prediction by the LASSO Score. Multivariate analysis confirmed the prognostic significance of the LASSO Score (p = 1.13e-06).

CONCLUSIONS

This study reveals the biological mechanisms underlying hepatic metastases in colorectal cancer and will help in developing targeted therapies for colorectal cancer.

OP0023 PREDICTION OF REMISSION FOR EACH BIOLOGICS BASED ON PATIENT’S CLINICAL INFORMATION BEFORE STARTING BIOLOGICS USING EXPLAINABLE ARTIFICIAL INTELLIGENCE: DATA FROM THE KOREAN COLLEGE OF RHEUMATOLOGY BIOLOGICS REGISTRY

Background:

Many studies have identified predictive factors of response to biologics in patients wirh rheumatoid arthritis (RA). However, there is still a lack in using them in daily clinical practice. Therefore, it is necessary to develop a method that can assist the physician in selecting effective biologics.

Objectives:

The purpose of this study is to establish machine learning model that predicts remission in patients treated with biologics using data of RA patients from the Korean College of Rheumatology Biologics (KOBIO) registry, and to identify the important features that have the most influence on the response to biologics using explainable artificial intelligence (AI).

Methods:

A total of 1,527 patients who started with biologics such as etanercept, adalimumab, golimumab, infliximab, abatacept, and tocilizumab from December 2012 to June 2019 were enrolled. Remission was predicted using 46 variables corresponding to baseline profiles at the starting of each biologics. We used five machine learning methods such as lasso, ridge, SVM, random forest, and XGBoost. For explainability of those models, we used Shapley plot to interpret the feature importance for each biologics.

Results:

In all machine learning methods, the accuracy and the area under the receiver operating characteristic (AUROC) were 57.2%~74.5%, 0.547~0.747, respectively (Table 1). The accuracy and AUROC of each biologics were similar between machine learning methods. Figure 2 showed interpretation of feature importance with the Shapley plot for remission. The most important feature was age in adalimumab (younger were closer to remission), daily corticosteroid dose in etanercept, golimumab, and all TNF inhibitors (using fewer doses daily were closer to remission), baseline erythrocyte sedimentation rate in infliximab (lower ESR were closer to remission), disease duration in abatacept (longer disease durations showed difficulty determining remission), baseline c-reactive protein in tocilizumab (higher CRP were closer to remission).

Table.

Predicting remission for all biologics in various machine learning method.

MeasureLassoRidgeSVMRandom ForestXGBoostNo info rateSampleAbataceptAccuracy74.1%74.1%70.6%71.8%68.8%70.6%216AUROC0.7250.7420.7070.6770.6470.500AdalimumabAccuracy73.6%72.0%70.4%72.0%70.4%68.8%315AUROC0.7100.7290.7000.6750.6630.500EtanerceptAccuracy72.0%72.0%70.0%71.5%70.0%68.0%250AUROC0.7410.7470.7260.7190.7040.500GolimumabAccuracy71.3%68.5%66.7%68.5%68.5%68.5%138AUROC0.7460.7270.7010.6900.6550.500InfliximabAccuracy72.8%73.5%67.6%73.5%69.1%72.5%172AUROC0.6630.6830.6160.5970.5270.500TNF inhibitorsAccuracy73.9%74.5%73.9%74.2%73.6%70.3%875AUROC0.7390.7410.7260.7470.7240.500TocilizumabAccuracy62.4%63.6%62.4%59.5%57.2%59.5%436AUROC0.6330.6400.6330.6150.5470.500Figure 2.

Shapley plots and SHAP values for the feature importance from clinical information in patients with RA.

Conclusion:

We developed machine learning models for predicting remission as a response to each biologics in active RA patients based on their clinical profiles, and found important clinical features using explainable AI. This approach may support clinical decisions to improve treatment outcomes in patients with RA.

Disclosure of Interests:

None declared

Comparison of dermoscopic features between congenital and acquired acral melanocytic nevi in Korean patients

BACKGROUND

The dermoscopic patterns of acral melanocytic nevi (AMNs) are crucial in differentiating them from acral melanoma. Several studies have reported the dermoscopic patterns of acquired acral melanocytic nevi (AAMNs). However, few have investigated the dermoscopic patterns of congenital acral melanocytic nevi (CAMNs).

OBJECTIVE

To compare the clinical and dermoscopic features of CAMNs and AAMNs.

METHODS

The present study included 43 patients with CAMNs and 40 with AAMNs. We reviewed their medical records as well as their clinical and dermoscopic findings.

RESULTS

Congenital acral melanocytic nevis were more asymmetrical than AAMNs (P = 0.002) and presented more frequently as comma-shaped (P = 0.005). Regarding dermoscopic findings, globular pattern (55.8%) was the most common feature of CAMNs, while parallel furrow pattern (37.5%) was the most common feature of AAMNs. The presence of fibrillar, globular, and parallel ridge patterns, and diffuse multi-component pigmentation differed significantly between the groups (P < 0.05). Furthermore, CAMNs showed melanoma-specific dermoscopic patterns, such as parallel ridge (18.6%) and diffuse multi-component pigmentation (25.6%).

CONCLUSION

The dermoscopic patterns of CAMNs and AAMNs differed markedly. In terms of dermoscopic patterns, CAMNs resembled acral melanoma more often than AAMNs did.

Engaging Aldehydes in CuH-Catalyzed Reductive Coupling Reactions: Stereoselective Allylation with Unactivated 1,3-Diene Pronucleophiles

Recently, CuH-catalyzed reductive coupling processes involving carbonyl compounds and imines have become attractive alternatives to traditional methods for stereoselective addition because of their ability to use readily accessible and stable olefins as surrogates for organometallic nucleophiles. However, the inability to use aldehydes, which usually reduce too rapidly in the presence of copper hydride complexes to be viable substrates, has been a major limitation. Shown here is that by exploiting relative concentration effects through kinetic control, this intrinsic reactivity can be inverted and the reductive coupling of 1,3-dienes with aldehydes achieved. Using this method, both aromatic and aliphatic aldehydes can be transformed into synthetically valuable homoallylic alcohols with high levels of diastereo- and enantioselectivities, and in the presence of many useful functional groups. Furthermore, using a combination of theoretical (DFT) and experimental methods, important mechanistic features of this reaction related to stereo- and chemoselectivities were uncovered.

Antiviral activity of hypothiocyanite produced by lactoperoxidase against influenza A and B viruses and mode of its antiviral action

Hypothiocyanite (OSCN-) is a natural component of human saliva and is produced by the lactoperoxidase (LPO)/thiocyanate/hydrogen peroxide (H2O2) system. OSCN- has been previously shown to exhibit antiviral activity against influenza viruses (IFV) A/H1N1/2009 and A/H1N2/2009 in vitro as well as antimicrobial and antifungal activities. We elucidated the antiviral activity of OSCN- against both IFV types A and B and the mode of its antiviral action. OSCN- was produced constantly at 900 ± 200 μmol/l in Na3PO4 buffer solution containing NaSCN and LPO in the presence of H2O2 as an original OSCN- solution. In a plaque reduction assay, IFV A/PR/8/34 (H1N1), A/Fukushima/13/43 (H3N2), B/Singapore/222/97, and B/Fukushima/15/93 were exposed to various concentrations of OSCN- for 0 to 30 min before adsorption to MDCK cells, and plaque formation was examined. OSCN- exhibited significant similar antiviral activities against all four viruses without cytotoxicity, and the EC50 values for them were from 57 ± 16 to 148 ± 27 μmol/l regardless of the exposure times. The exposure of MDCK cells to OSCN- before viral adsorption did not affect its anti-IFV activity (EC50: more than 450 μmol/l), but the exposure after viral adsorption affected it moderately (EC50: 380 ± 40 μmol/l). Moreover, the exposure of virus particles to OSCN- at 450 μmol/l did not affect the hemagglutinin activity of IFV in hemagglutination inhibition assay. These results suggest that the attachment of OSCN- to the viral envelope critically contributes to the mode of antiviral action of OSCN- without interfering with viral adsorption. Keywords: hypothiocyanite; influenza virus type A; influenza virus type B; lactoperoxidase; antiviral activity.

Interleukin-17A negatively regulates lymphangiogenesis in T helper 17 cell-mediated inflammation

During inflammation lymphatic vessels (LVs) are enlarged and their density is increased to facilitate the migration of activated immune cells and antigens. However, after antigen clearance, the expanded LVs shrink to maintain homeostasis. Here we show that interleukin (IL)-17A, secreted from T helper type 17 (T_H17) cells, is a negative regulator of lymphangiogenesis during the resolution phase of T_H17-mediated immune responses. Moreover, IL-17A suppresses the expression of major lymphatic markers in lymphatic endothelial cells and decreases in vitro LV formation. To investigate the role of IL-17A in vivo, we utilized a cholera toxin-mediated inflammation model and identified inflammation and resolution phases based on the numbers of recruited immune cells. IL-17A, markedly produced by T_H17 cells even after the peak of inflammation, was found to participate in the negative regulation of LV formation. Moreover, blockade of IL-17A resulted in not only increased density of LVs in tissues but also their enhanced function. Taken together, these findings improve the current understanding of the relationship between LVs and inflammatory cytokines in pathologic conditions.

Environmental and health effects of the herbicide glyphosate

The herbicide glyphosate, N-(phosphonomethyl) glycine, has been used extensively in the past 40years, under the assumption that side effects were minimal. However, in recent years, concerns have increased worldwide about the potential wide ranging direct and indirect health effects of the large scale use of glyphosate. In 2015, the World Health Organization reclassified glyphosate as probably carcinogenic to humans. A detailed overview is given of the scientific literature on the movement and residues of glyphosate and its breakdown product aminomethyl phosphonic acid (AMPA) in soil and water, their toxicity to macro- and microorganisms, their effects on microbial compositions and potential indirect effects on plant, animal and human health. Although the acute toxic effects of glyphosate and AMPA on mammals are low, there are animal data raising the possibility of health effects associated with chronic, ultra-low doses related to accumulation of these compounds in the environment. Intensive glyphosate use has led to the selection of glyphosate-resistant weeds and microorganisms. Shifts in microbial compositions due to selective pressure by glyphosate may have contributed to the proliferation of plant and animal pathogens. Research on a link between glyphosate and antibiotic resistance is still scarce but we hypothesize that the selection pressure for glyphosate-resistance in bacteria could lead to shifts in microbiome composition and increases in antibiotic resistance to clinically important antimicrobial agents. We recommend interdisciplinary research on the associations between low level chronic glyphosate exposure, distortions in microbial communities, expansion of antibiotic resistance and the emergence of animal, human and plant diseases. Independent research is needed to revisit the tolerance thresholds for glyphosate residues in water, food and animal feed taking all possible health risks into account.

A multi-throughput multi-organ-on-a-chip system on a plate formatted pneumatic pressure-driven medium circulation platform

This paper reports a multi-throughput multi-organ-on-a-chip system formed on a pneumatic pressure-driven medium circulation platform with a microplate-sized format as a novel type of microphysiological system. The pneumatic pressure-driven platform enabled parallelized multi-organ experiments (i.e. simultaneous operation of multiple multi-organ culture units) and pipette-friendly liquid handling for various conventional cell culture experiments, including cell seeding, medium change, live/dead staining, cell growth analysis, gene expression analysis of collected cells, and liquid chromatography-mass spectrometry analysis of chemical compounds in the culture medium. An eight-throughput two-organ system and a four-throughput four-organ system were constructed on a common platform, with different microfluidic plates. The two-organ system, composed of liver and cancer models, was used to demonstrate the effect of an anticancer prodrug, capecitabine (CAP), whose metabolite 5-fluorouracil (5-FU) after metabolism by HepaRG hepatic cells inhibited the proliferation of HCT-116 cancer cells. The four-organ system, composed of intestine, liver, cancer, and connective tissue models, was used to demonstrate evaluation of the effects of 5-FU and two prodrugs of 5-FU (CAP and tegafur) on multiple organ models, including cancer and connective tissue.

The importance of dermoscopy for the diagnosis of acquired bilateral telangiectatic macules: the angioid streak pattern reveals underlying chronic liver disease

BACKGROUND

Acquired bilateral telangiectatic macules (ABTM) are a newly recognized disease entity, which manifest as multiple telangiectatic pigmented macules confined mostly to the upper arms.

OBJECTIVES

To evaluate clinical and dermoscopic features in a group of 50 patients with ABTM and to determine the diagnostic usefulness of dermoscopy in ABTM.

METHODS

Patients were selected from two tertiary teaching hospitals in Korea [Pusan National University Hospitals (Busan and Yangsan)]. Fifty patients (41 males and 9 females; mean age 48.1 years; range 26-78 years) with ABTM were included in the study. The dermoscopic findings were graded using a 4-point scale: none (0), mild (1), moderate (2) and severe (3). In addition, the results of 23 patients with and 27 patients without chronic liver disease (CLD) were compared to determine whether the presence of CLD affects dermoscopic findings.

RESULTS

Three distinct dermoscopic patterns were observed; brown pigmentations, telangiectasia (linear-irregular vessels) and an angioid streak pattern. Brown pigmentation in the group without CLD had higher severity score than those in CLD group (mean score: 2.00 vs. 1.48, P = 0.033). However, mean telangiectasia severity score was higher in the CLD group (2.14 vs. 1.39, P < 0.001). The angioid streak pattern was more severe and more common in patients with CLD than in those without [1.37 vs. 0.35 (P < 0.001) and 63.0% vs. 26.1%, respectively].

CONCLUSIONS

Detailed observations with dermoscopy can provide first clues of the presence of ABTM and underlying chronic liver disease.

Enhanced Th2 cell differentiation and function in the absence of Nox2

BACKGROUND

Patients with chronic granulomatous disease (CGD), whom inherit abnormal function of NADPH oxidase 2 (Nox2), suffer from hyperinflammatory responses in lung as well as bacterial and fungal infection. There have been studies to reveal the function of Nox2 in hyperinflammatory diseases, especially in asthma, but the exact role of Nox2 in asthma is still unclear and controversial. Therefore, we attempted to clarify the exact role of Nox2 in asthma, using various experimental asthma models.

METHODS

Asthma phenotypes were analyzed in response to various allergen-induced experimental asthma using Nox2-deficient mice and recombinase gene-activating-1-deficient mice. To understand the underlying mechanisms of exaggerated Th2 effector functions, we investigated the degree of T-cell activation, levels of activation-induced cell death (AICD), and regulatory T (Treg)-cell differentiation in Nox2-deficient T cells.

RESULTS

Asthma phenotypes were increased through enhanced Th2 differentiation and function in Nox2-null mice regardless of dose and route of various allergens. Nox2-deficient T cells also showed hyperactivation, reduced AICD, and diminished Treg-cell differentiation through increased AKT phosphorylation (T308/S473) and enhanced mitochondrial ROS production.

CONCLUSION

Our findings indicate that Nox2 deficiency results in exaggerated experimental asthma, which is caused by enhanced Th2 effector function in a T-cell-intrinsic manner.