332 THE PATIENT EXPERIENCE OF THE OLDER PERSONS REHAB AT HOME (OPRAH) SERVICE

Background

The Older Persons Rehab at Home (OPRAH) team is a novel service developed to provide patients with intensive domiciliary based therapy to regain function, mobility and social care goals. This provides rehabilitation in the patients’ own home and accelerates discharge from the acute care sector. In this study patient and carer experiences of the service were explored.

Methods

Patients were sent a postal questionnaire after discharge from the service to collect information on the patient experience of the OPRAH service. The following measures were collected: satisfaction with the service, experience of interacting with therapy staff, involvement in shared goal setting and achievement of rehabilitation goals. Data from participants who responded to feedback questionnaires from the first 12 months of the service were analysed using descriptive statistics.

Results

Ninety-five participants were sent feedback questionnaires with 31 responses received (33%). 96% of participants reported that they were satisfied with the service, with the same proportion expressing that they both felt they were treated with respect and dignity and that they had confidence and trust in the staff. All respondents felt that they could understand the answers to any questions they had while receiving rehabilitation and 92% of participants understood their rehabilitation goals, with 88% of participants feeling they achieved their rehabilitation goals. 88% of participants felt they were adequately involved in their care planning with 83% of participants feeling their family members had ample opportunity to ask questions during their rehabilitation experience. Results did not different by age group of patient or by time with the service.

Conclusion

In this structured evaluation of the OPRAH team participants highly rated the service. Our results highlight that this integrated approach to care allowed patients to be involved in shared goal setting with the majority of patients satisfied that they achieved their goals.

311 FROM ONE FRONT DOOR TO ANOTHER: OUTCOMES OF PATIENTS DIRECTLY DISCHARGED FROM THE FRAILTY AT THE FRONT DOOR SERVICE

Background

The Frailty at the Front Door service is a novel service that provides comprehensive geriatric assessment in the emergency department for older adults who have an unplanned emergency presentation to hospital. It is important to monitor outcomes of patients discharged by the service to ensure appropriate patient selection.

Methods

Patients over the age of 75 with a Manchester Triage Score of between three and five and a possible frailty syndrome are eligible for review by the service. After initial review patients are either discharged directly or recommended for admission. We reviewed the outcomes of patients who were discharged directly after Emergency Department (ED) assessment by the service.

Results

Discharge disposition was available for review in 413 (95%) of patients since initiation of the service in October 2021. 30% (n= 122) of patients were discharged directly after initial ED review. Elevated 4AT score (p = 0.002) but not frailty (p = 0.80) was associated with decreased chances of direct discharge. Of patients discharged directly from ED 13% were reviewed post discharge by the community integrated care team (GICOP), with 43% of these reviews taking place within 30 days. Overall, 16% of patients discharged directly represented to ED within 30 days. There was a trend towards lower rates of representation to ED among patients who were seen by GICOP after discharge from ED (p = 0.12).

Conclusion

There was a high rate of direct discharge after review by the service, with low rates of representation to hospital. While limited by low numbers there was a trend towards lower representation rates in patients reviewed post-discharge by the integrated care team. Future quality improvement initiatives will aim to improve the integration between the services and highlighting patients who would benefit from more timely reviews.

225 OLDER PERSONS REHAB AT HOME (OPRAH) INDICATES AN EFFECTIVE ALTERNATIVE PATHWAY TO INPATIENT REHABILITATION

Background

Older adults have longer hospital stays, higher incidence of nosocomial complications and higher readmissions rates. Older persons rehabilitation at home (OPRaH) is a novel service developed to provide patients with intensive domiciliary based therapy to regain function, mobility and social care goals. OPRaH offers a comprehensive geriatric and interdisciplinary approach. The model enables a safe and accelerated discharge from acute care to home.

Methods

Patients are identified and screened by a team coordinator. On Discharge to OPRaH the following measures were collected; basic demographics, referral source, clinical frailty score and Functional Independence Measures (FIM). Outcomes evaluated are the FIM change, readmission rates, length of inpatient stay savings and time on the service. Data from the first year of operation was analysed using descriptive statistics.

Results

109 patients have undergone rehabilitation with the service with a median age of 82 years (63-103 range). Over two thirds (68%) were classified as frail, with 44% living alone. An injurious fall was the most common reason for index hospitalisation (50%). Referral source was inpatient acute medical team in 50% of cases, with 21% from acute geriatrics , 13 % ortho geriatrics, 13% surgical. Average functional independence measure scores improved from 89 to 102 (p = 0.007). There was no difference in the magnitude of improvement by frailty status (13 vs 14, p = 0.85). The average length of stay saving was 7 days per case, with a total of 757 days saved in one year. Readmission rate within 30 days was 9.3 %. Participants highly rated the service through structured evaluation.

Conclusion

This novel service provides a valuable intervention to a wide case-mix of older adults with evidence of improvements in formal markers of functional impairment after intervention. Referral was based on definable rehabilitation goals and not just on frailty status, age, or gender.

342 THE DISCRIMINATORY VALUE OF ANP-LED CGA ON PATIENT REPORTED SYMPTOMS AND IMPACT ON CARERS: A CROSS-SECTIONAL STUDY

Background

Comprehensive Geriatric Assessment (CGA) is a cornerstone in geriatric care. Objective findings from CGA may differ to patient and carer reported symptoms. This study compared patient reported symptoms with objective metrics collected during CGA and explored the relationship with carer burnout.

Methods

Cross-sectional study of patients attending an Advanced Nurse Practitioner (ANP)-led integrated care clinic. Patient-reported geriatric syndromes included low mood, memory concerns, incontinence, falls or dizziness. CGA metrics collected included Barthel Index, Lawton IADLs, MOCA scores, Geriatric depression scale scores, Rockwood Clinical Frailty Scale (CFS) scores and presence or absence of carer burnout. Descriptive statistics were used to compare the relationship between these variables and logistic regression explored the magnitude of association with carer burnout.

Results

We reviewed 99 CGAs over three months. Median age was 81 (IQR 75–86) with 62% female. Cognitive impairment was present in 96% of patients. Self-reported memory trouble was associated with lower MOCA scores (9 vs 23, p < 0.001) and the presence of dizziness was associated with an increased prevalence of falls (89% vs 24%, < 0.001). The presence of incontinence and functional dependency on IADL were both associated with carer strain and a larger magnitude of association with carer strain was seen with increasing frailty (OR 13.7, 95% CI 3.8-58.8 for moderate to severe frailty) than moderate to severe cognitive impairment (OR 8, 95% CI 3.0–24.1)

Conclusion

Older people reported a wide range of symptoms often subtle, some of which are unmasked during CGA. The resultant frailty syndromes often represent increasing degrees of functional impairment impacting on patient and carer quality of life. Striking the balance between patient reported symptoms and objective measurement is important to allow individualised care pathways to be developed as well as highlighting patients at risk of functional and cognitive decline.

355 PREDICTORS OF HOME SUPPORT SERVICES AND THE CONSEQUENCES OF MISMATCH BETWEEN ALLOCATED AND RECEIVED SERVICES IN COGNITIVELY-IMPAIRED OLDER ADULTS

Background

Home support services aim to support older people to remain at home. Despite substantial investment in home support hours (€600 million), this has not translated into increased carers on the ground for older people. We aimed to report patterns of home support service utilisation in older patients with memory problems, and identify any mis-matches between allocated and received hours, and the impact on patients and caregivers.

Methods

Retrospective analysis of consecutive patients referred to community geriatric clinic from January 2021 to May 2022. 95/104 patients who were identified were suitable for inclusion.

Results

Participants had a median age of 82 (IQR 78-86) of whom 57% were female (n=54). 80% (n=76) were frail (CFS ≥4), with 82% dependent for IADLs (Lawton-Brody IADL Scale ≤6). Median MOCA score was 18, with 44% having moderate to severe cognitive impairment (MOCA ≤17). 40% of patients lived with alone (n=38). 52% (n=49) received formal home supports while 80% (n=76) had an informal carer. 37% (n=18) had a mismatch between hours allocated and hours received. There was a significant difference between median hours of care allocated (7) and median hours of care received (5), p <0.001. Increasing age and frailty, worsening cognitive and functional impairment and living status (living alone) predicted allocation of home supports. Patients who lived with family members were 3 times more likely not to receive allocated hours (OR 3.84 (95% CI 1.2–13.7))

Conclusion

In this vulnerable population with cognitive and functional decline, just over half received formal home support hours. A large proportion experienced significant mismatch between allocated and received hours. Family and informal caregivers often have to fill gaps, adding to existing carer strain. Future models of home support should prioritise early intervention for people with IADL loss to remain independent at home and broaden of the scope of practice of carers to facilitate this.

310 A COMPARATIVE ANALYSIS OF THE IRISH POST-GRADUATE GERIATRIC TRAINING SCHEME WITH THE EUROPEAN POST-GRADUATE CURRICULUM IN GERIATRIC MEDICINE

Background

Minimum training recommendations to become a specialist geriatrician in the EU have been published. In this study we sought to evaluate the curriculum of the higher specialist training scheme in Geriatric Medicine in Ireland and examine how it compares with the knowledge recommendations from the European post-graduate curriculum in Geriatric medicine, which is endorsed by both the European Geriatric Medicine Society (EuGMS) and the European Academy of Medicine of Ageing (EAMA).

Methods

In this study we examined the content of didactic study-day lectures given over a five-year rolling period which is the minimum duration of the higher specialist training programme in Geriatric medicine in Ireland. We also examined the published Irish curriculum and compared how both the Irish curriculum and content of the study-days matches up with the 36 items that are identified as the core knowledge content in the European post-graduate curriculum.

Results

There were 24 study days delivered over a five-year time period. The Irish geriatric medicine curriculum formally outlined that 30 of the 36 knowledge areas proposed in the European curriculum should be formally covered during post-graduate geriatric training in Ireland. The European curriculum recommended formal teaching in sarcopenia, sleep disorders, tissue viability, iatrogenic care delivered disorders, sexuality in older adults and geron-technology/e-health, none of which were referred to in the Irish curriculum. However, despite this discrepancy, formal teaching was delivered on 92% (n = 33) of proposed areas. Pain assessment, sleep disorders and tissue viability were areas not covered in Irish didactic study-days. 24 of 36 topics were covered at least twice.

Conclusion

There was high concordance between the content of the Irish and European post-graduate curriculum in Geriatric medicine. Benchmarking against European training standards is an opportunity to ensure that parity of education and training is achieved across the EU.

OP0068 DISTINCT STROMAL AND IMMUNE CELL INTERACTIONS SHAPE THE PATHOGENESIS OF RHEUMATOID AND PSORIATIC ARTHRITIS

Background

Rheumatoid (RA) and psoriatic arthritis (PsA) are common autoimmune and autoinflammatory diseases of unknown aetiology characterised by complex synovial pathology with a detrimental effect on the patient’s quality of life. Significant differences in pathophysiology may explain distinct clinical manifestations and account for differential responses to specific therapeutics. Recent implementation of single cell transcriptomic analysis of sorted synovial cells has revealed the diverse cellular landscape of the RA synovial stromal and immune cell compartments, however, a complete analysis of immune and stromal cells in tandem, for RA and PsA patient synovial tissue has not been performed.

Objectives

To combine novel scRNA transcriptomic approaches and ex vivo assays in order to: identify differences in the cellular landscape of RA and PsA synovial tissue inflammation and immune – stromal cell interactions that drive pathology in RA and PsA.

Methods

Single cell transcriptomic profiling of 178,000 synovial tissue cells from 5 PsA and 4 RA patients, importantly, without prior sorting of immune and stromal cells. This approach enabled the generation of a unique cell atlas of intact synovial tissue identifying immune and stromal cell interactions. State of the art data integration and annotation techniques identified and characterised 18 stromal and 14 immune cell clusters. Bioinformatic examination of cell-cell communication via construction of receptor-ligand interaction networks with further in vitro validation of stromal and immune cell crosstalk through flow cytometric analysis, multiplex ELISA and mitochondrial and single cell metabolic profiling by multiphoton and florescent lifetime imaging microscopy, seahorse.

Results

Following quality control and data integration the PsA and RA cellular landscape was generated and nine mega clusters indicative of fibroblasts, endothelial cells, pericytes, macrophages, dendritic cells (DC), B cells, plasma cells, T cells and NKT consisting of several sub clusters were identified. Distinct points of transcriptomic deviation and convergence between RA and PsA were identified for each of the major cell types of the joint. Specifically, cell cycle and trajectory analysis revealed that only a fraction of synovial T cells are actively proliferating. Additionally, the differential usage of immunoglobulin light chains by memory and plasma cells indicates that plasma cells are potentially not derived from the local memory B cell pool of the synovial tissue. Importantly, we report distinct fibroblast and endothelial cell transcriptomes indicating differentially abundant subpopulations in RA and PsA characterised by distinct transcription factor usage and signalling pathway enrichment. Specifically transcriptomic imputation analysis revealed abundance of invasive FAPα+THY1+ regulated by transcription factor TEAD1 in RA compared to PsA synovial tissue. In order to identify potential cell-cell communication driving inflammation in RA and PsA, novel receptor–ligand interaction networks were generated and downstream of the receptor, target characterisation was performed. Herein we identify RA-specific synovial T cell-derived TGF-β and macrophage IL-1β synergy in driving the transcriptional profile of FAPα+THY1+ invasive synovial-fibroblasts, expanded in RA compared to PsA synovial tissue biopsies (Figure 1). Ex vivo treatment of RA patient synovial fibroblasts identified TGF-b and IL-1b synergy are a major driver of IL-6 production, fibroblast activation and adhesion molecule expression. Interestingly, the aforementioned proinflammatory changes of RA patient synovial fibroblasts were coupled with significant alterations in mitochondrial eccentricity and size and a marked metabolic adaptation towards a strongly glycolytic profile (Figure 1).

Figure 1.

Conclusion

Disrupting specific immune and stromal cell interactions offers novel opportunities for targeted therapeutic intervention in RA and PsA.

Disclosure of Interests

Achilleas Floudas: None declared, Conor Smith: None declared, Orla Tynan: None declared, Nuno Neto: None declared, Vinod Krishna Employee of: Janssen Pharmaceuticals, Sarah Wade: None declared, Megan Hanlon: None declared, Clare Cunningham: None declared, Viviana Marzaioli: None declared, Mary Canavan: None declared, Jean Fletcher: None declared, Suzanne Cole Employee of: Janssen Pharmaceuticals, Ling-Yang Hao Employee of: Janssen Pharmaceuticals, Sunil Nagpal Employee of: Janssen Pharmaceuticals, GSK, Michael Monaghan: None declared, Douglas Veale Consultant of: Janssen, Eli Lilly, Pfizer, Ursula Fearon Consultant of: Janssen, Eli Lilly, Pfizer.

POS0495 CYTOKINE SYNERGY ENHANCES SYNOVIAL FIBROBLAST ACTIVATION IN CHILDREN WITH DOWN’S SYNDROME-ASSOCIATED ARTHRITIS

Background

We have previously shown that children with Down’s syndrome-associated arthritis (DA) display a more aggressive form of inflammatory arthritis compared to that of Juvenile Idiopathic Arthritis (Shih et al., 2019). DA is associated with an increase in polyfunctional T-cells coexpressing TNF-α DA is associated with an increase in polyfunctional T-cells coexpressing TNF-fibroblasts (FLS) (Foley et al., 2019).

Objectives

In this study we examine the effect of cytokine synergy on primary DA FLS function.

Methods

Primary DA FLS were cultured and stimulated with TNF-α (0.1 and 1ng/ml), IL-17A (20 and 50ng/ml), IFN-ɣ (10 and 50ng/ml) and GM-CSF (20 and 100ng/ml) or a combination of these cytokines and the following functional experiments performed. Chemokine and adhesion molecule cell surface expression were quantified by flow cytometry, in addition to quantification of leukocyte-DA-FLS adhesion assays. Gene and protein expression of proinflammatory and metabolic mediators were quantified by ELISA and RT-PCR. Furthermore, real-time metabolic activity in response to cytokine stimulation was assessed by measuring the two major energy pathways: glycolysis (ECAR) and oxidative phosphorylation (OCR), by the Seahorse XFe96 Analyser.

Results

We examined the effects of T cell derived cytokines, TNF-α, IL-17A, IFN-γ and GM-CSF, alone and in combination on DA FLS function. TNF-α, IL-17A and IFN-γ induced IL-6, RANTES and MCP-1 production, with no effect observed for GM-CSF. Furthermore, TNF-α, IFN-ɣ and IL-17A increased leukocyte adhesion to DA FLS. TNF-α and IFN-ɣ induced cell surface expression of CXCR3, CXCR4, ICAM-1 and VCAM-1 on DA FLS. Next, we investigated the potential synergistic relationship that these cytokines could have on proinflammatory mediators. IL-17A and IFN-ɣ potentiated the effects TNF-α on IL-6 and MCP-1 secretion compared to stimulation alone. Furthermore, cytokine synergy significantly induced IL-6, IL-8, RANTES and LDHA mRNA expression compared to basal. IL-17A and IFN-αL-17A and IFN- eeased ts TNF-α on IL-6 and MCP-1 secretion compared to stimulation alone. Additionally, IFN the ECAR:OCR ratio demonstrating a shift in the metabolic profile of DA FLS to glycolysis. Overall DA FLS are transformed from a quiescent metabolic state to an energetic phenotype.

Conclusion

TNF-αNF-lusion:OCR ratio demonstrating a shift in the metabolhe aggressive phenotype of DA FLS through increased cytokine, adhesion molecule and chemokine expression, which is pathways for the treatment of DA.

References

[1]Foley, C. et al. (2019) ‘Increased T cell plasticity with dysregulation of T follicular helper, T peripheral helper and T regulatory cell responses in children with JIA and Down syndrome-associated arthritis’, Arthritis & Rheumatology, pp. 0–1. doi: 10.1002/art.41150.

[2]Shih, Y. J. et al. (2019) ‘Enthesitis-related arthritis is the most common category of juvenile idiopathic arthritis in Taiwan and presents persistent active disease’, Pediatric Rheumatology. Pediatric Rheumatology. doi: 10.1186/s12969-019-0363-0.

Disclosure of Interests

None declared.

AB0074 RAPAMYCIN INHIBITS IL-1β INDUCED RA SYNOVIAL FIBROBLAST ACTIVATION, AN EFFECT ASSOCIATED WITH ALTERATION IN THEIR METABOLIC PROFILE

Background

Rheumatoid Arthritis (RA) is a common autoimmune disease characterized by systemic polyarthritis affecting the joints, most notably of the hands and feet. A fundamental feature of RA is inflammation within the synovial joint due to neo-angiogenesis which facilitates an influx of immune cells and release of pro-inflammatory mediators.

Objectives

In this study we investigate the effect of metabolic reprogramming on IL-1β regulation of stromal cell activation and invasiveness in RA.

Methods

Primary RA synovial fibroblasts (RAFLS) and human umbilical vein endothelial cells (HUVEC) were cultured with IL-1 β (2 ng/mL) alone or in combination with the metabolic inhibitor rapamycin (100nM). Pro-inflammatory cytokines IL-6, MCP-1 and Rantes were quantified by real-time PCR and ELISA. Cellular adhesion and network formation were quantified by adhesion binding assays and Matrigel invasion assays. pS6 (a surrogate marker of the mTOR pathway) was quantified by flow cytometry. Cellular bioenergetics was assessed using the Seahorse-XFe-technology and key glycolytic genes (HK2, PKM2, G6DP) were quantified by real-time PCR. YAP was measured by Western-Blot.

Results

IL-1β significantly induced secretion of IL-6 (p<0.05), MCP-1 (p<0.01) and Rantes (p<0.01) from RAFLS. IL-1β induced leukocyte adhesion to RAFLS (p=0.062) and HUVEC (p=0.051), in addition to an increase RAFLS and HUVEC network formation. This was accompanied by a change in the cellular bioenergetic profile of cells, where IL-1β increased the ECAR/OCR ratio in favour of glycolysis for RAFLS (p<0.05) and HUVEC, and induced the % frequency in the cell surface expression of pS6 on RAFLS. Rapamycin inhibited IL-1β -induced leukocyte adhesion and network formation in RAFLS (p<0.05; p<0.05 respectively) and HUVEC (p<0.05). Rapamycin inhibited IL-1β -induced Rantes secretion (p<0.05), no effect observed for IL-6 and MCP-1. Rapamycin also inhibited IL-1b-induce YAP protein expression which is involved in FLS invasive capacity through cytoskeletal rearrangement. This was accompanied by a shift in the metabolic profile from a glycolytic/energetic state back towards a more quiescent state.

Conclusion

Rapamycin inhibits IL-1β -induced pro-inflammatory mechanisms in key stromal cells involved in the pathogenesis of RA. Targeting metabolism may lead to new potential therapeutic or adjuvant strategies, particularly for those patients who have sub-optimal responses to current treatments.

References

[1]Kim EK, Min HK, Lee SY, Kim DS, Ryu JG, Na HS, Jung KA, Choi JW, Park SH, Cho ML. Metformin rescues rapamycin-induced mitochondrial dysfunction and attenuates rheumatoid arthritis with metabolic syndrome. Arthritis Res Ther. 2020 Apr 10;22(1):77. doi: 10.1186/s13075-020-02174-3. PMID: 32276645; PMCID: PMC7149912.

Disclosure of Interests

None declared

POS0419 DIFFERENTIAL miRNA EXPRESSION AND ENDOTHELIAL CELL FUNCTION IN RHEUMATOID ARTHRITIS AND PSORIATIC ARTHRITIS

Background

Rheumatoid arthritis (RA) and Psoriatic arthritis (PsA) constitute forms of inflammatory arthritis (IA) characterised by enhanced angiogenesis, immune cell infiltration, and generation of a hypoxic microenvironment leading to an invasive synovial pannus that results in bone and cartilage destruction. However, significant differences in circulating biomarkers in addition to disease pathogenesis at the clinical, immunological, cellular, and molecular levels have been identified that differentiate the two pathotypes.

Objectives

The aim of this study was to examine circulatory miRNA as cellular biomarkers that can distinguish RA form PsA and to evaluate the potential implication for disease pathogenesis. Furthermore, this study aimed to examine the differential effect of the joint microenvironment on endothelial cell (EC) function in both RA and PsA.

Methods

RA, PsA and healthy controls (HC) were recruited from St. Vincent’s University Hospital, and serum was collected. Multiplex analysis of 68 serum miRNAs was performed using the FirePlex miRNA Immunology-V2 panel (FirePlex Bioworks Inc). Receiver operator characteristic (ROC) curves were generated to determine sensitivity and specificity of specific miRNAs whilst DNA intelligent analysis (DIANA)-mirPath and STRING software were used to analyse pathways targeted by the dysregulated miRNAs. Additionally, human umbilical vein endothelial cells (HUVEC) were cultured with RA and PsA synovial fluid (SF). Angiogenesis, invasion, and cellular adhesion were quantified by Matrigel tube formation assays, wound healing assays, and adhesion assays. Real-time cellular bioenergetics was analysed in HUVEC in response to RA and PsA SF using the Seahorse XFe96 Analyser.

Results

7 miRNAs; miR-126-3p, miR-29b-3p, miR-22-3p, miR-223-3p, miR-320a, let-7g-5e, and let-7g-5p (all**p≤0.01), were significantly elevated in RA serum compared to both PsA patients and HC, with ROC curve analysis demonstrating the predictive accuracy with which each miRNA differentiated between RA and PsA (all <0.05). Biplot analysis further identified that three miRNA, miR-29b-3p, miR-22-3p, and miR-223-3p demonstrated the greatest separation between RA and PsA (all p<0.05). DIANA and STRING analysis identified the P13K-Akt pathway as being the primary target of these 3 miRNAs with specific gene targets involved in this pathway including factors all importantly associated with endothelial cell migration, proliferation, invasion, and angiogenesis. Next, we examined the effect of the joint microenvironment on endothelial cell function and demonstrated that PsA SF significantly enhanced EC tube formation (p<0.05) and EC leukocyte adhesion (p<0.05), with RASF only significantly inducing EC leukocyte adhesion. Finally, metabolic analysis of endothelial cells demonstrated that PsA SF significantly induced baseline glycolysis (p<0.05), baseline OCR (p<0.05), maximal respiratory capacity (p<0.05) and spare respiratory capacity (p<0.05), with no effect observed for RA SF.

Conclusion

Circulating miRNAs may be valuable as diagnostic biomarkers that can distinguish RA from PsA. Additionally, the joint microenvironment induces EC function and metabolic capacity, with these effects more pronounced in response to PsA SF compared to RA SF.

References

[1]Cunningham, C. C., S. Wade, A. Floudas, C. Orr, T. McGarry, S. Wade, S. Cregan, U. Fearon, and D. J. Veale. 2021. Serum miRNA Signature in Rheumatoid Arthritis and “At-Risk Individuals”. Front Immunol 12.

[2]Wade, S. M., T. McGarry, S. C. Wade, U. Fearon, and D. J. Veale. 2020. Serum MicroRNA Signature as a Diagnostic and Therapeutic Marker in Patients with Psoriatic Arthritis. J Rheumatol 47: 1760-1767

[3]Fromm, S., C. C. Cunningham, M. R. Dunne, D. J. Veale, U. Fearon, and S. M. Wade. 2019. Enhanced angiogenic function in response to fibroblasts from psoriatic arthritis synovium compared to rheumatoid arthritis. Arthritis Res Ther 21: 297.

Disclosure of Interests

None declared.

OP0013 LOSS OF SYNOVIAL TISSUE MACROPHAGE HOMEOSTASIS PRECEDES RHEUMATOID ARTHRITIS CLINICAL ONSET

Background

Synovial tissue macrophages significantly contribute to Rheumatoid Arthritis, yet the precise nature/function of macrophage subsets within the inflamed joint remains unexplored.

Objectives

To fully explore the spectrum of distinct macrophage activation states residing within the synovium of RA, at risk and healthy individuals.

Methods

Single-cell synovial tissue suspensions from RA (n=44), IAR (n=5), HC (n=11), PsA (n=11) and OA (n=4) were obtained, and synovial macrophage subsets examined by advanced multiparameter flow cytometric analysis, bulk RNA-sequencing, metabolic and functional assays.

Results

Multidimensional analysis identifies enrichment of CD206+CD163+ synovial-tissue macrophages co-expressing CD40 in the RA joint compared to healthy synovial-tissue, with frequency of CD206+CD163+CD40+ macrophages associated with increased disease activity and treatment response. In contrast, CX3CR1-expressing macrophages which form a protective barrier in healthy synovium are significantly depleted in RA. Importantly this signature of enriched CD40 expression coupled with depleted CX3CR1 expression is an early phenomenon, occurring prior to clinical manifestation of disease in individuals ‘at-risk’ of RA (IAR). RNAseq and metabolic profiling of sorted RA synovial-macrophages identified that this population is transcriptionally distinct, displaying unique inflammatory, phagocytic and tissue-resident gene signatures, paralleled by a bioenergetically stable profile as indicated by NAD(P)H emission. Functionally CD206+CD163+ RA macrophages are potent producers of pro-inflammatory mediators (reversed by CD40-signalling inhibition) and induce an invasive phenotype in healthy synovial-fibroblasts. These findings identify a distinct pathogenic population of synovial-tissue macrophage involved in shaping the immune response in RA. Crucially, this signature is present pre-disease representing a unique opportunity for early diagnosis and therapeutic intervention.

Conclusion

We have identified a novel population of tissue-resident macrophages in the RA synovium which are transcriptionally/metabolically distinct and capable of contributing to disease pathology. Uncovering the molecular patterns and cues that transform this immunoregulatory macrophage population into a dysfunctional inflammatory activation state may provide opportunities to reinstate joint homeostasis in RA patients.

Disclosure of Interests

Megan Hanlon: None declared, Mary Canavan: None declared, Nuno Neto: None declared, Qingxuan Song Employee of: Employee of Janssen Pharmaceuticals, Phil Gallagher: None declared, Ronan Mullan: None declared, Conor Hurson: None declared, Barry Moran: None declared, Michael Monaghan: None declared, Sunil Nagpal Employee of: Employee of Janssen Pharmaceuticals, Douglas Veale Consultant of: Janssen, Eli Lilly, Pfizer, Ursula Fearon Consultant of: Janssen, Eli Lilly, Pfizer

90 IMPACT OF AN INTEGRATED CARE MODEL FOR OLDER PERSONS: EVALUATING A PILOT PROGRAMME

Background

In September 2019 Sláintecare helped establish an Integrated Care team for Older People. The aim of this service was to provide a Comprehensive Geriatric Assessment (CGA) to older people within a community network. Service user experience/feedback are critically important for development of a team and a service. To give service users a platform to evaluate the service a patient experience survey was conducted.

Methods

The survey was designed by the multidisciplinary team, consisting of 13 closed/3 open questions. A Likert scale was utilised for closed questions and thematic analysis for open questions. A question on impact of COVID-19 was also included.

150 of the 950 service users who received a CGA from June 2020 to June 2021 were selected randomly and invited to participate in the postal survey. All participants received a covering letter, questionnaire and a stamped address envelope to return their completed surveys.

Results

47% response rate (71/150). 77% were aged ≥75. 52% completed the survey themselves, 48% required assistance. 61% attended more than twice and most would prefer to attend a local spoke clinic. 96% agreed/strongly agreed that they were satisfied with the service. 99% felt they were treated with dignity/respect and had confidence in the service. 93% agreed that they were involved in care decisions. 82% reported their carers had the opportunity to discuss concerns. Themes emerging included importance of care close to home, avoiding acute hospital, difficulty parking at tertiary centres. 42% highlighted isolation and loneliness due to COVID-19 as a major issue.

Conclusion

Service users had an overwhelmingly positive experience especially when care was delivered in clinics close to their homes. Development of the hub and spoke model is acceptable and feasible to older people and their carers’ in this region and will be the focus for expansion of this service.

33 ARE CLINICAL TRIALS RANDOMISING HOUSEHOLDS TO LIFESTYLE INTERVENTIONS FOR THE PREVENTION OF COGNITIVE DECLINE FEASIBLE?

Background

Dementia is increasing in prevalence worldwide. Several lifestyle factors have been identified as targets for dementia prevention, which may be more effective if targeted at households instead of an individual. To date there have been no clinical trials randomising households to lifestyle interventions of sleep, diet and/or physical activity to prevent cognitive decline. To inform future studies, qualitative approaches can give valuable in-depth insights into the values and beliefs of all household members towards behavioural change.

Methods

Semi structured interviews were carried out among eight households affected by cognitive impairment. Interview content was analysed, and important themes identified.

Results

Eighteen participants were interviewed within household pods. Among those, eight had cognitive impairment and the remainder were spouses or first-degree relatives living in the same home. Several themes of interest emerged including household members without dementia were more likely to report poor sleep habits; sleep was perceived the hardest behaviour to change; although most participants had healthy diets, most were interested in making a change and felt there was a strong link with nutrition and cognition; physical activity is challenging to adapt due to lack of motivation and focus when individuals are cognitively impaired and motivation to pursue physical activity in households centred on relaxation and social interaction.

Conclusion

This study identified beliefs and preferences of households towards lifestyle intervention trials. Barriers to study participation including risk of harm, complexity of intervention and deviation from routine emerged during discussions. Findings from this study should be used to inform future clinical trial protocols and future qualitative studies should explore acceptability and feasibility of digital intervention applications.

112 INTEGRATED CARE PROGRAMME FOR OLDER PEOPLE (ICPOP) IN A RURAL SETTING—ROLE OF ADVANCED NURSE PRACTITIONER (ANP)

Background

Sláintecare advocates for right care, in the right place at the right time. ANPs for Older Persons in the community are uniquely placed to deliver care as close as possible to the older person’s home and to lead a holistic, flexible model of care minimising admission to acute care and maximising existing local resources. A pilot programme aimed at providing ANP led comprehensive geriatric assessment (CGA) (with Geriatrician support) to older people in a defined area commenced in June 2019. This pilot was part of a larger Hub and Spoke model funded by Sláintecare which gave additional MDT support.

Methods

A referral template was designed. Criteria for referral included; age &gt; 75 years, Rockwood Frailty Scale 4–6 (focusing on Falls, Cognitive Impairment and Complex Frailty). Older people on the cusp of requiring long term care (LTC) were also prioritised. A prospective database of patients was maintained by the ANP to evaluate the service.

Results

From June 2019 to August 2021, 156 patients received an ANP led CGA, mostly conducted in the home. 247 reviews were conducted at the local spoke clinic and 46 joint ANP/Geriatrician home visits. Majority of referrals were from GP (n = 69), hospital (n = 30), LTC reviews (n = 22) and Community Nursing Units (CNUs) (n = 19). 449 outpatient appointments have been removed from the tertiary referral centre. Independent case load management from the ANP includes further appointments, telephone follow up/advice and she is a point of contact where crises arise before referral to acute services. 99% of patients surveyed reported satisfaction with the service especially the ease of local access and home visits.

Conclusion

Older Persons’ ANP can provide longitudinal care pathways for older adults in the community in conjunction with ICPOP and local CNUs, intervening before crises emerge and providing continuity of care and an alternative to acute care.

102 PROMOTING BRAIN HEALTH IN AN INTEGRATED CARE OUTREACH PROGRAMME

Background

Lifestyle modifications, in older at risk populations, may prevent or slow the rate of cognitive decline. Promotion of brain health has been recommended by the WHO and other governing bodies. Supporting patients in making these lifestyle changes, however, can be complex. Generic guidance may not apply to all in a heterogenous and frail patient cohort, when physical mobility may be limited and weight loss/nutrition a concern. We sought to review current practices and barriers to brain health guidance in a regional integrated care outreach programme (ICOP).

Methods

From March–June’21 the comprehensive geriatric assessment (CGA) of consecutive patients were reviewed. Those presenting with cognitive complaints, for their first assessment, were included. Demographic data and data on screening for hearing impairment and sleep disturbance were collected, in addition to information on physical activity and nutritional risk. Whether information and guidance on aspects of brain health was given was also assessed.

Results

30 patients met the inclusion criteria. The mean age was 80.3 and the mean clinical frailty scale (CFS) was 4.4. Hearing impairment was present in 20% (n = 6), with no information available in 10% (n = 3). All patients were screened for sleep disturbance, with 13% (n = 4) not fully satisfied with their sleep. Mobility aids, assistance or supervision were required in 40% (n = 12), and 23% (n = 7) were at medium or high malnutrition risk. Only 30% (n = 9) cooked their own meals. Generic brain health advice, or advice about sleep was documented in 30 (n = 9), without hearing impairment advice documented in any patient.

Conclusion

There are several barriers to brain health advice in the ICOP setting, with only 30% of patients having brain health advice documented. We are currently developing patient information leaflets on brain health, that will take potential barriers into account. Dedicated and specific information on local hearing services is also in development, as part of an ongoing quality improvement project.

AB0018 ACCUMULATION OF FUNCTIONALLY MATURE CD1C+ DENDRITIC CELLS CONTRIBUTES TO SYNOVIAL INFLAMMATION IN INFLAMMATORY ARTHRITIS

Background:

Myeloid Dendritic Cells (DC) are potent antigen presenting cells that can be subdivided into CD141 and CD1c+ DC. We have previously reported an unacknowledged role for CD141+DC in the IA synovium. However, the identification and function of CD1c+ DC in the IA synovium has yet to be fully elucidated.

Objectives:

To investigate if CD1c+DC reside in the IA synovium and ascertain if they represent a unique population, distinct from peripheral CD1c+DC and if they contribute to synovial inflammation.

Methods:

Synovial tissue (ST) biopsies and synovial fluid mononuclear cells (SFMC) were obtained via arthroscopy and healthy control (HC) ST was obtained during ACL surgery. Synovial tissue single cells suspensions were generated following enzymatic and mechanical digestion. Single cell analysis of synovial tissue cell suspensions, along with PBMC and SFMC was performed by multicolour flow cytometry. CD1c+DC were sorted from IA synovial fluid and peripheral blood and bulk RNA sequencing was performed. CD1c+DC functionality and maturation was assessed using OVA DQ phagocytosis assays, multiplex ELISA and DC: T cell cocultures.

Results:

Within the circulation the frequency of CD1c+DC are significantly decreased in IA peripheral blood compared to HC (p<0.01) in addition to expressing significantly higher levels of the maturation markers CD80 (p<0.01) and CD40 (p=0.08). IA peripheral blood DC also express significantly higher levels of CXCR3 (p<0.01) and CCR7 (p<0.05) compared to HC - suggestive of DC migration from the periphery to the synovium. Following RNA-seq analysis, IPA and differentially expressed gene (DEG) analysis revealed an enrichment in genes involved in DC maturation, TLR signalling and chemokine signalling in IA peripheral blood compared to HC. In support of the hypothesis that DC migrate and accumulate in the IA synovium, CD1c+ DC were identified in IA ST and were significantly enriched compared to IA peripheral blood (p<0.01). IA ST CD1c+DC express significantly higher levels of the activation marker CD80 compared to IA peripheral blood (p<0.05) or HC ST (p<0.05). Upon examination of IA synovial fluid, we report similar findings to ST, whereby CD1c+DC are enriched in synovial fluid compared to PB (p<0.001). Moreover, RNA sequencing and PCA analysis of synovial versus blood CD1c+DC revealed distinct transcriptional variation between both sites. Functionally, synovial CD1c+DC express higher levels of the maturation markers CD80, CD83, CD40, PD-L1 and BTLA (all p<0.05) and have distinct coexpression of these maturation markers which is unique to the synovium. Synovial CD1c+DC are less phagocytic compared to peripheral blood DC, have decreased production of MMP1 and MMP9 and importantly are still capable of additional activation in-vitro. Finally, synovial CD1c+DC induce the proinflammatory cytokines TNFα, GMCSF, IL-17a and IFNγ from CD4+ T-cells in allogeneic DC: T cells cocultures.

Conclusion:

Mature circulatory CD1c+DC migrate and accumulate in the IA synovium. Synovial DC are present in the IA synovium in a mature state, have distinct tissue specific characteristics and can induce proinflammatory CD4+T cell responses.

Acknowledgements:

We would like to thank all the patients who contributed to this study

Disclosure of Interests:

Mary Canavan: None declared, Viviana Marzaioli: None declared, Vipul Bhargava Employee of: Janssen Research and Development, Sunil Nagpal Employee of: Janssen Research and Development, Phil Gallagher: None declared, Conor Hurson: None declared, Ronan Mullan: None declared, Douglas Veale Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, MSD, UCB, Consultant of: Abbvie, Janssen, Novartis, Pfizer, MSD, UCB, Grant/research support from: Pfizer, Janssen, AbbVie, UCB, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Pfizer, Janssen, Abbvie, UCB

OP0028 CD206+CD163+ PATHOGENIC MACROPHAGES ENRICHED IN RHEUMATOID ARTHRITIS SYNOVIAL TISSUE WITH DISTINCT TRANSCRIPTIONAL SIGNATURES

Background:

Synovial tissue macrophages are an exquisitely plastic pool of innate cells that play a key role in RA disease progression. However, the precise nature, diversity, and function of macrophage subsets within the inflamed joint remains unexplored.

Objectives:

Therefore, the aims of this study are to phenotypically, transcriptionally and functionally characterise synovial tissue macrophages residing within the inflamed joint.

Methods:

Rheumatoid Arthritis, Psoriatic Arthritis, Osteoarthritis and healthy control synovial-tissue biopsies and synovial-fluid mononuclear cells were analysed using the following panel (CD40,-CD45,-CD64,-CD68,-CD163,-CD206,-CD253,-CCR4,-CCR7,-CXCR1,-CXCR3). CD206+CD163+ and CD206-CD163- macrophages were sorted from RA synovial-tissue by FACSAria sorter; RNAseq and FLIM analysis, autologous T-cell co-culture and heathy fibroblast experiments performed. Cytokine expression was measured by MSD immunoassay.

Results:

RA synovial tissue and fluid macrophages display markers typical of both M1 (CD40+CD253+) and M2 (CD206+CD163+) macrophages with a spectrum of macrophage activation states identified. Within this spectrum, significant enrichment of dominant CD206+CD163+ macrophage-subtype is present in synovial tissue versus fluid (p<0.05). CD206+CD163+ synovial tissue macrophages express significantly more CD40 than synovial fluid (p<0.0003), positively correlate with disease activity (r=0.6, p<0.01), with baseline levels predicting response to therapy (p<0.05). Moreover, CD206+CD163+CD40+ macrophages are enriched in RA synovial tissue compared to PsA and OA pathotypes (p<0.05). While the CD206+CD163+ subset is present in healthy synovial tissue, expression of CD40 is completely absent in healthy synovium (p<0.05) with dramatically decreased expression of CX3CR1 on RA macrophages. RNA-seq analysis indicates that CD206+CD163+ population is transcriptionally distinct from synovial tissue CD206-CD163-, synovial fluid CD206+CD163+, and RA monocyte-derived M1/M2 macrophages, with unique tissue-resident gene signatures. Moreover, differing metabolic demands between CD206+CD163+ and CD206-CD163- subsets was demonstrated by RNAseq and FLIM analysis. CD206+CD163+ macrophages enhance autologous T-cell responses, spontaneously secrete high levels of pro-inflammatory cytokines and activate healthy fibroblasts towards pro-inflammatory mechanisms thus further contributing to the local inflammatory response. Finally, inhibition of CD40 activity abrogates the expression of pro-inflammatory mediators (TNFa, IL-1B, IL-6, IFNy) and induces IL-10 expression in sorted CD206+CD163+ synovial tissue-macrophages suggesting a key role for CD40 in driving this pathogenic phenotype.

Conclusion:

This data identifies for the first-time enrichment of a previously undescribed dysfunctional dominant and transcriptionally distinct macrophage subtype in RA synovial tissue. Taken together, this data provides a greater understanding of the critical role tissue-resident macrophages play in perpetuating inflammation in RA. Further investigation of the molecular patterns and cues that shape specific synovial macrophage subsets may provide opportunities to reinstate RA joint homeostasis.

Disclosure of Interests:

Megan Hanlon: None declared, Mary Canavan: None declared, Qingxuan Song Employee of: Janssen Research & Development, Nuno Neto: None declared, Phil Gallagher: None declared, Ronan Mullan: None declared, Conor Hurson: None declared, Michael Monaghan: None declared, Sunil Nagpal Employee of: Janssen Research & Development, Douglas Veale Speakers bureau: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Consultant of: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB

AB0916-PARE KNOWLEDGE OF DISEASE, DIAGNOSIS, ADHERENCE AND IMPACT OF RESEARCH IN PATIENTS WITH INFLAMMATORY ARTHRITIS

Background:

The diagnosis and treatment of inflammatory arthritis has been transformed largely by the development of drugs that target specific molecules of the immune system. However, these changes have increased the complexity of the mechanisms of disease, its treatment and patients understanding. Patient education is needed in this area to facilitate decision making and to facilitate strong patient-partnerships in research.

Objectives:

The aim of this study was to examine the level of understanding of inflammatory arthritis patients and the need for strong patient-partnership in research.

Methods:

An online anonymous survey addressed questions about diagnosis, routine tests, medications and how they work, medication adherence, disease flare, heredity, pregnancy, and patient involvement in research.

Results:

There were 1,873 respondents, 1416 of which had inflammatory arthritis (IA)-RA (65.8%) and PsA (34.2%). They were predominantly female (RA 86%, PsA 85 %), aged 55±13 and 50±12. Less than 35% of patients had an understanding of diagnostic tests, what was measured and the implication for disease, with 75.5% also concerned about heredity. There was a high level of understanding of how specific medications treat inflammatory arthritis (72.9%). Adherence was also very high (>87%), with the main reasons for stopping medication without the advice of their clinician, ‘feeling better’ and ‘side effects’ however a significant proportion of patients (69.9%) reported a disease-flare following cessation of medication. Patients of childbearing age (69%) were also concerned that inflammatory arthritis reduced their chances of getting pregnant, with only 8% believing arthritis medications were safe to take during pregnancy. Finally, only 9% of patients had ever been asked to participate in a research study.

Conclusion:

This study demonstrates a need for the development of stronger patient-partnerships with clinicians and researchers in relation to patient education and engagement with research, to create a platform where patients can have meaningful input and involvement in future research studies.

Acknowledgements:

We wish to thank all the patients who contributed to this study

Disclosure of Interests:

Mary Canavan: None declared, Viviana Marzaioli: None declared, Alex Donnelly: None declared, Siobhan Wade: None declared, Alexander Fraser: None declared, Tim O’Sullivan: None declared, Sinead Harney: None declared, Arthritis Ireland: None declared, Douglas Veale Speakers bureau: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Consultant of: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB

OP0025 CD209+/CD14+ DENDRITIC CELLS ARE ENRICHED AND ACTIVATED AT THE SITE OF INFLAMMATION AND ARE MODULATED BY JAK/STAT SIGNALLING

Background:

Dendritic cells (DCs) are a heterogeneous population of professional antigen-presenting cells which are at the interface between innate and adaptive immunity. A specific subset of DCs is known to derive from monocyte and has a key role in inflammation and infection.

Objectives:

This study aimed to characterize the phenotype and function of a distinct CD209+/CD14+ DC subset in the periphery and at the site of inflammation in patients with rheumatoid (RA) and psoriatic arthritic (PsA), in addition to examining the effect Tofacitinib and TNF inhibitor on their development.

Methods:

Peripheral blood and synovial fluid mononuclear cells (PBMC and SFMC) were isolated by Ficoll density gradient from healthy subject (HC), and patients with RA and PsA. Single cell synovial tissue suspension (ST) from RA and PsA patients were also established using enzymatic/mechanical digestion. PBMC, SFMC and ST were analysed by flow cytometry to identify the CD209+/CD14+ DC subset, its frequency and the cell surface expression of chemokines receptors (CCR6, CCR7, CXCR3, CXCR4 and CXCR5) and activation markers (CD40 and CD80). In addition, PBMC were stimulated with different TLR (LPS, CPG, R848, Poly I:C) and intracellular staining for IL12, TNFα, IL1β and IL6 was performed by flow cytometry. Lineage negative cells (CD3/CD19/CD56-) were stimulate with GMCSF/IL4 in the presence or absence of the JAK/STAT inhibitor Tofacitinib or the TNF inhibitor Humira, and the CD209+/CD14+ DC development was evaluated by flow cytometry.

Results:

We identified, for the first time, a distinct CD209+/CD14+ DC population in PBMC of patients with RA and PsA, with similar frequency across the groups. However, when PBMC were stimulated with TLRs, an increase of IL12 and TNFα was observed in RA and PsA PBMC when compared to HC. Interestingly, this distinct DC population was significantly enriched at the site of inflammation, in both SFMC and ST, displaying a more mature phenotype, evident by the observed significant increase in CD40 and CD80 expression. SPICE analysis further identified differential expression and co-expression of chemokine receptors at the periphery of RA and PsA patients, when compared to the HC. Furthermore synovial tissue single cell analysis from RA/PsA demonstrated a unique chemokines receptors profile demonstrating increased single expression and co-expression of CXCR3 and CXCR5 compared to periphery. Finally, we have previously observed that JAK/STAT is involved in monocyte-derived dendritic cells population development (1,2), therefore we performed CD3, CD19 and CD56 depletion of RA/PsA PBMC followed by stimulation with GMCSF/IL4, to spike the Mo-DC population, in the presence of Tofacitinib or Humira. Interestingly, we observed that JAK/STAT inhibition, but not TNF inhibitor, reduced the generation and development of CD209+/CD14+ DC.

Conclusion:

We identify for the first time a distinct monocyte-derived DC population characterized as CD209+/CD14+ in the periphery of RA and PsA patients. This population was enriched at the site of inflammation and displayed a unique chemokine receptor profile and activation markers, suggesting that these cells are already activated in the periphery of IA patients, and are recruited and further activated in the inflamed joint. In addition, we showed that the CD209+/CD14+ DC development is regulated by JAK/STAT signalling, but not TNF inhibition.

References:

[1]Marzaioli V, Canavan M, Floudas A, et al. Monocyte-Derived Dendritic Cell Differentiation in Inflammatory Arthritis Is Regulated by the JAK/STAT Axis via NADPH Oxidase Regulation. Front. Immunol. 2020;11:1406.

[2]Marzaioli V, Hurtado-Nedelec M, Pintard C, et al. NOX5 and p22phox are 2 novel regulators of human monocytic differentiation into dendritic cells. Blood. 2017;130(15):1734–1745.

Acknowledgements:

The authors also wish to thank all the patients who volunteered to participate into this study and the funding

Disclosure of Interests:

Viviana Marzaioli: None declared, Achilleas Floudas: None declared, Mary Canavan: None declared, Siobhan Wade: None declared, Kieran Murray: None declared, Ronan Mullan: None declared, Douglas Veale Speakers bureau: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Consultant of: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB

POS0387 ACPA STATUS CORRELATES WITH DIFFERENTIAL IMMUNE PROFILE OF RHEUMATOID ARTHRITIS PATIENTS

Background:

Rheumatoid arthritis (RA) is a progressive erosive autoimmune disease that affects 1% of the world population. Anti-citrullinated protein autoantibodies (ACPA) are routinely used for the diagnosis of RA, however 20-30% of patients are ACPA negative. ACPA status is a delineator of RA disease endotypes with similar clinical manifestation but potentially different pathophysiology. Elucidating the underlying mechanisms of disease pathogenesis could inform a treat to target approach for both ACPA-positive and ACPA-negative RA patients.

Objectives:

To identify peripheral blood and synovial tissue immune population differences that associate with RA disease endotype.

To identify unique RA patient synovial tissue gene signatures and enriched pathways that correlate with ACPA status.

Methods:

Detailed high dimensionality flow cytometric analysis with supervised and unsupervised algorithm analysis of ACPApos and ACPAneg RA patient peripheral blood and synovial tissue single cell suspensions. Ex vivo peripheral blood and synovial tissue T cell stimulation and cytokine production characterisation. RNAseq analysis with specific pathway enrichment analysis of APCApos and ACPAneg RA patient synovial tissue biopsies.

Results:

Detailed profiling based on high dimensionality flow cytometric analysis of key peripheral blood and synovial tissue immune populations including B cells, T follicular helper (Tfh) cells, T peripheral helper cells (Tph) and CD4 T cell proinflammatory cytokine responses with supervised and unsupervised algorithm analysis revealed unique RA patient peripheral blood B cell and Tfh cell profiles. ACPApos RA patients were characterised by significantly (*P=0.03) increased frequency of Tfh (CXCR5+CD4+) cells and distinct clustering influenced by increased switched (IgD-CD27+) and DN (IgD-CD27-) memory B cells compared to APCAneg RA patients. Surprisingly synovial tissue B cell subpopulation distribution was similar between ACPAneg and ACPApos RA patients, with significant accumulation of switched and double negative memory B cells, highlighting a key role for specific B cell subsets in both disease endotypes. Interestingly, synovial tissue CD4 T cell proinflammatory cytokine (TNF-α, IFN-γ, IL-2, GM-CSF, IL-17A, IL-22, IL-4) production was markedly different between ACPAneg and APCApos RA patients with hierarchical clustering and PCA analysis revealing endotype specific cytokine profiles with ACPAneg RA patient synovial T cells showing increased TNF-α (P=0.01) expression. RNAseq analysis of RA patient synovial tissue revealed significant disease endotype specific gene signatures with specific enrichment for B cell receptor signalling and T cell specific pathways in ACPApos compared to ACPAneg RA patients. Additionally, significantly different chemokine receptor expression based on RA patient ACPA status was observed with increased CXCR3 (P<0.001), CCR7 (P=0.002), and CCR2 (P=0.004) but decreased CXCR7 (P=0.007) expression in APCApos compared to ACPAneg RA patient synovial biopsies.

Conclusion:

ACPA status associates with unique synovial tissue immune cell and gene profile signatures highlighting differences in the underlying immunological mechanisms involved, therefore reinforcing the need for a treat to target approach for both endotypes of RA.

Figure 1.

RNAseq analysis of synovial tissue biopsies revealed specific T cell related pathway enrichment in ACPA positive compared to ACPA negative RA patients (n=50, analysis performed with the DESq2 and pathfindeR pipelines in R).

Disclosure of Interests:

Achilleas Floudas: None declared, Mary Canavan: None declared, Trudy McGarry Employee of: Novartis, Vinod Krishna Employee of: Janssen, Sunil Nagpal Employee of: Janssen, GSK, Douglas Veale Speakers bureau: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Consultant of: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB

POS0007 LOSS OF BALANCE BETWEEN PROTECTIVE AND PRO-INFLAMMATORY SYNOVIAL TISSUE T CELL POLYFUNCTIONALITY PREDATES CLINICAL ONSET OF RHEUMATOID ARTHRITIS

Background:

Effective treatment of Rheumatoid arthritis (RA) patients is achievable within a short window of opportunity following diagnosis. T-cells are early drivers of synovial inflammation of RA, therefore, identification of pathogenic T-cell subsets at the synovial tissue of pre-RA, arthralgia subjects, would greatly improve our understanding of disease pathogenesis. Comparative analysis of healthy control, arthralgia subject and RA-patient derived synovial tissue T-cell responses will lead to the identification of pathogenic as well as protective cytokine milieu, thus enabling the identification of early therapeutic targets to help steer the immune response towards resolution.

Objectives:

Characterization of T-cell polyfunctionality in the periphery and synovial tissue of ’at-risk; subjects (Arthralgia) RA-patients and healthy controls (HC).

Identification of specific, pathogenic, synovial tissue T-cell subsets.

Methods:

Synovial biopsies from RA, AR and HC were obtained by arthroscopic surgery followed by RNAseq analysis (Guo et al., PLoS One, 2018). Single cell synovial tissue cell suspensions from RA, AR and HC and paired PBMC were stimulated in vitro and polyfunctional synovial T-cell subsets examined by flow cytometric analysis, SPICE visualization and FlowSom clustering. Flow-Imaging, was utilised to confirm specific T-cell cluster identification. Fluorescent Lifetime Imaging Microscopy (FLIM) was used to visualise metabolic status of specific T-cell populations.

Results:

T-cell associated pro-inflammatory gene pathways were increased in RNAseq analysis of RA-patient and arthralgia subject compared to HC synovial tissue biopsies. Flow cytometric analysis of pro-inflammatory cytokine (TNF-α, IFN-γ, IL-2, GM-CSF, IL-17A, IL-22) production and SPICE analysis of ex vivo stimulated T-cells revealed marked polyfunctionality of arthralgia subject synovial T-cells, thus providing evidence for a dysregulated synovial T-cell response that pre-dates clinical onset of disease. Importantly, HC synovial tissue harbours a small, albeit surprisingly polyfunctional, CD4 T-cell population characterised by significantly increased IL-4 and GM-CSF cytokine production compared to arthralgia subject (P<0.001 and P=0.01) and RA-patient (P<0.001 and P=0.004) synovial tissue. However, not all polyfunctional T-cells are equal in their pathogenic potential. Therefore, in order to identify highly pathogenic synovial T-cells, cluster analysis of flow cytometric data using the unsupervised algorithm FlowSom was performed and led to the identification of specific T-cell clusters with unique polyfunctionality characteristics. Specifically a cluster of CD4+CD8+ double positive (DP) T-cells with high polyfunctionality scores was identified. Hybrid flow cytometry and imaging technique confirmed the co-expression of CD4 and CD8 by a synovial T-cell population. DP T-cells are enriched in RA-patient synovial fluid and synovial tissue and arthralgia subject synovial tissue, but are absent from HC synovial tissue. Importantly, DP T-cell synovial accumulation strongly (P=0.002) correlates with DAS28(CRP) of RA-patients. Initial studies utilising the novel, non-invasive FLIM technique for visualisation of cellular NAD, revealed that DP T-cells have a metabolic profile indicative of activated memory T-cells.

Conclusion:

These data highlight a key early loss of balance between protective and pathogenic synovial T-cell polyfunctionality and the emergence of specific, highly polyfunctional and pathogenic T-cell clusters in RA.

Figure 1.

Identification of highly polyfunctional and pro-inflammatory synovial DP T-cells. A. Cluster analysis of RA-patient synovial tissue T-cells (asterisks indicate DP T-cell clusters). B. Flow imaging of CD4+, CD8+ and DP synovial T-cells. C. SPICE flow cytometric data visualization of DP arthralgia subject and RA-patient synovial T-cells. D. Correlation between the frequency of RA-patient synovial DP T-cells and disease severity.

Disclosure of Interests:

Achilleas Floudas: None declared, Nuno Neto: None declared, Mary Canavan: None declared, Trudy McGarry Employee of: Novartis, Vinod Krishna Employee of: Janssen, Sunil Nagpal Employee of: Janssen, GSK, Michael Monaghan: None declared, Douglas Veale Speakers bureau: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Consultant of: Abbvie, Janssen, Novartis, MSD, Pfizer, UCB, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB.

Rheumatoid arthritis synovial microenvironment induces metabolic and functional adaptations in dendritic cells

Rheumatoid arthritis (RA) is a chronic autoimmune disease which causes degradation of cartilage and bone. It is well appreciated that the pathogenic hallmark of RA is the mass influx of inflammatory cells into the joint. However, the role that dendritic cells (DC) may play in this inflammatory milieu is still relatively unexplored. Moreover, the contribution this unique synovial microenvironment has on DC maturation is still unknown. Using monocyte-derived DC (MoDC), we established an in-vitro model to recapitulate the synovial microenvironment to explore DC maturation. MoDC treated with conditioned media from ex-vivo synovial tissue biopsy cultures [explant-conditioned media (ECM)] have increased expression of proinflammatory cytokines, chemokines and adhesion molecules. ECM DC have increased expression of CD83 and CC-chemokine receptor (CCR)7 and decreased expression of CCR5 and phagocytic capacity, suggestive of heightened DC maturation. ECM-induced maturation is concomitant with altered cellular bioenergetics, whereby increased expression of glycolytic genes and increased glucose uptake are observed in ECM DC. Collectively, this results in a metabolic shift in DC metabolism in favour of glycolysis. These adaptations are in-part mediated via signal transducer and activator of transcription-3 (STAT-3), as demonstrated by decreased expression of proinflammatory cytokines and glycolytic genes in ECM DC in response to STAT-3 inhibition. Finally, to translate these data to a more in-vivo clinically relevant setting, RNA-seq was performed on RA synovial fluid and peripheral blood. We identified enhanced expression of a number of glycolytic genes in synovial CD1c+ DC compared to CD1c+ DC in circulation. Collectively, our data suggest that the synovial microenvironment in RA contributes to DC maturation and metabolic reprogramming.

Mass and the Dangers of Syncope

Introduction Syncope is defined as a transient, self-limited loss of consciousness with an inability to maintain postural tone that is followed by spontaneous recovery. We revisit situational syncope focusing on one situation, Mass. Methods We interrogated our electronic syncope database for key terms associated with situational syncope. From the most commonly encountered situation, Mass, we interrogated the results of tilt testing performed to identify evidence of orthostatic hypotension. Results There were 110 cases of situational syncope identified with 56.3% (n=62) taking place at mass. All had tilt table testing performed and 15.4% (n=17) had evidence of orthostatic hypotension. Conclusion The multiple sudden changes in position during mass from sitting to kneeling to standing can precipitate an episode of orthostatic hypotension. Consideration should be given as to whether it is safe for older mass goers to be subjected to such significant orthostatic stress.

Key Service Improvements After the Introduction of an Integrated Orthogeriatric Service

Introduction:

Models of orthogeriatric care have been shown to improve functional outcomes for patients after hip fractures and can improve compliance with best practice guidelines for hip fracture care.

Methods:

We evaluated improvements to key performance indicators in hip fracture care after implementation of a formal orthogeriatric service. Compliance with Irish Hip Fracture standards of care was reviewed, and additional outcomes such as length of stay, access to rehabilitation, and discharge destination were evaluated.

Results:

Improvements were observed in all of the hip fracture standards of care. Mean length of stay decreased from 19 to 15.5 days (mean difference 3.5 days; P < .05). A higher proportion of patients were admitted to rehabilitation (16.7% vs 7.9%, P < .05), and this happened in a timelier fashion (17.8 vs 24.8 days, P < .05). We found that less patients required convalescence post-hip fracture.

Discussion:

A standardized approach to integrated post-hip fracture care with orthogeriatrics has improved standards of care for patients.

Conclusion:

Introduction of orthogeriatric services has resulted in meaningful improvements in clinical outcomes for older people with hip fractures.

A review of vitamin D insufficiency and its management: a lack of evidence and consensus persists

Vitamin D deficiency is the most common nutritional deficiency worldwide, however uncertainty persists regarding the benefits of vitamin D supplementation. Vitamin D is essential for calcium homeostasis, and has been linked to falls and fractures in older people. There are numerous risk factors for vitamin D deficiency, chief among them old age. Studies of vitamin D supplementation have given mixed signals, but over all there is evidence of benefit for those with risk factors for deficiency. International guidelines recommend vitamin D target levels of >25 to >80 nmol/l, best achieved by a daily dose of 800-1000 IU. Large bolus doses should be avoided. There are still unanswered questions regarding vitamin D supplementation and target levels. There is need for well designed and powered trials to achieve consensus.

The pathogenic role of dendritic cells in non-infectious anterior uveitis

BACKGROUND

Anterior uveitis (AU) is characterised by infiltration of immune cells into the anterior chamber of the eye. Dendritic cells (DC) are professional antigen presenting cells that initiate and promote inflammation. This study aims to characterise DC in AU and to examine the effects of aqueous humor (AqH) on DC maturation and function.

METHODS

The frequency and phenotype of AU and healthy control (HC) circulating DC was examined. AU and HC AqH was immunostained and assessed by flow cytometry. The effect of AU and HC AqH on DC activation and maturation was examined and subsequent effects on CD4⁺ T cell proliferation assessed.

RESULTS

AU peripheral blood demonstrated decreased circulating myeloid and plasmacytoid DC. Within AU AqH, three populations of CD45⁺ cells were significantly enriched compared to HC; DCs (CD11c⁺ HLA-DR⁺), neutrophils (CD15⁺ CD11c⁺) and T cells (CD4⁺ and CD8⁺). A significant increase in IFNγ, IL8 and IL6 was observed in the AU AqH, which was also significantly higher than that of paired serum. AU AqH induced expression of CD40 and CD80 on DC, which resulted in increased T cell proliferation and the production of GM-CSF, IFNγ and TNFα.

CONCLUSION

DC are enriched at the site of inflammation in AU. Our data demonstrate an increase in inflammatory mediators in the AU inflamed microenvironment. AU AqH can activate DC, leading to subsequent proliferation and activation of effector T cells. Thus, the AU microenvironment contributes to immune cell responses and intraocular inflammation.

Global Survey of the Frequency of Atrial Fibrillation–Associated Stroke

Background and Purpose—

Atrial fibrillation (AF) is increasingly recognized as the single most important cause of disabling ischemic stroke in the elderly. We undertook an international survey to characterize the frequency of AF-associated stroke, methods of AF detection, and patient features.

Methods—

Consecutive patients hospitalized for ischemic stroke in 2013 to 2014 were surveyed from 19 stroke research centers in 19 different countries. Data were analyzed by global regions and World Bank income levels.

Results—

Of 2144 patients with ischemic stroke, 590 (28%; 95% confidence interval, 25.6–29.5) had AF-associated stroke, with highest frequencies in North America (35%) and Europe (33%) and lowest in Latin America (17%). Most had a history of AF before stroke (15%) or newly detected AF on electrocardiography (10%); only 2% of patients with ischemic stroke had unsuspected AF detected by poststroke cardiac rhythm monitoring. The mean age and 30-day mortality rate of patients with AF-associated stroke (75 years; SD, 11.5 years; 10%; 95% confidence interval, 7.6–12.6, respectively) were substantially higher than those of patients without AF (64 years; SD, 15.58 years; 4%; 95% confidence interval, 3.3–5.4; P <0.001 for both comparisons). There was a strong positive correlation between the mean age and the frequency of AF ( r =0.76; P =0.0002).

Conclusions—

This cross-sectional global sample of patients with recent ischemic stroke shows a substantial frequency of AF-associated stroke throughout the world in proportion to the mean age of the stroke population. Most AF is identified by history or electrocardiography; the yield of conventional short-duration cardiac rhythm monitoring is relatively low. Patients with AF-associated stroke were typically elderly (>75 years old) and more often women.

Attitudes to outcomes measured in clinical trials of cardiovascular prevention

BACKGROUND

Selecting outcome measures in cardiovascular prevention trials should be informed by their importance to selected populations. Major vascular event outcomes are usually prioritized in these trials with considerably less attention paid to cognitive and functional outcomes.

AIM

To examine views on importance of outcome measures used in clinical trials.

DESIGN

Cross-sectional survey.

METHODS

Of 367 individuals approached, 280 (76%) participated: outpatients attending cardiovascular prevention clinics (n = 97), active retirement groups members (n = 75), medical students (n = 108). Participants were asked to rank, in order of importance, outcome measures, which may be included in cardiovascular prevention trials. Results were compared between two groups: <65s (n = 157) and ≥65s (n = 104).

RESULTS

When asked what outcomes were most important to measure in cardiovascular prevention trials, respondents reported: death (31.6%) stroke (28.5%), dementia (26.9%), myocardial infarction (MI) (7.9%) and requiring nursing home (NH) care (5.1%). When asked the most relevant outcomes regarding successful ageing respondents reported; maintaining independence (32.4%), avoiding major illness (24.3%), good family life (23.6%), living as long as possible (15.8%), avoiding NH care (3.1%) and contributing to society (0.8%) as most important. When asked what outcome concerned them most about the future, respondents reported: dementia (32.6%), dependence (30.4%), death (12.8%), stroke (12.5%), cancer (6.2%) requiring NH care (4.8%) and MI (0.7%). Maintaining independence was considered most important in younger and older cohorts.

CONCLUSION

Cognitive and functional outcomes are important patient-relevant outcomes, sometimes more important than major vascular events. Incorporating these outcomes into trials may encourage patient participation and adherence to preventative regimens.

Dysregulated bioenergetics: a key regulator of joint inflammation

Objectives

This study examines the relationship between synovial hypoxia and cellular bioenergetics with synovial inflammation.

Methods

Primary rheumatoid arthritis synovial fibroblasts (RASF) were cultured with hypoxia, dimethyloxalylglycine (DMOG) or metabolic intermediates. Mitochondrial respiration, mitochondrial DNA mutations, cell invasion, cytokines, glucose and lactate were quantified using specific functional assays. RASF metabolism was assessed by the XF24-Flux Analyzer. Mitochondrial structural morphology was assessed by transmission electron microscopy (TEM). In vivo synovial tissue oxygen (tpO₂ mmHg) was measured in patients with inflammatory arthritis (n=42) at arthroscopy, and markers of glycolysis/oxidative phosphorylation (glyceraldehyde 3-phosphate dehydrogenase (GAPDH), PKM2, GLUT1, ATP) were quantified by immunohistology. A subgroup of patients underwent contiguous MRI and positron emission tomography (PET)/CT imaging. RASF and human dermal microvascular endothelial cells (HMVEC) migration/angiogenesis, transcriptional activation (HIF1α, pSTAT3, Notch1-IC) and cytokines were examined in the presence of glycolytic inhibitor 3-(3-Pyridinyl)-1-(4-pyridinyl)-2-propen-1-one (3PO).

Results

DMOG significantly increased mtDNA mutations, mitochondrial membrane potential, mitochondrial mass, reactive oxygen species and glycolytic RASF activity with concomitant attenuation of mitochondrial respiration and ATP activity (all p<0.01). This was coupled with altered mitochondrial morphology. Hypoxia-induced lactate levels (p<0.01), which in turn induced basic fibroblast growth factor (bFGF) secretion and RASF invasiveness (all p<0.05). In vivo glycolytic markers were inversely associated with synovial tpO₂ levels <20 mm Hg, in contrast ATP was significantly reduced (all p<0.05). Decrease in GAPDH and GLUT1 was paralleled by an increase in in vivo tpO₂ in tumour necrosis factor alpha inhibitor (TNFi) responders. Novel PET/MRI hybrid imaging demonstrated close association between metabolic activity and inflammation. 3PO significantly inhibited RASF invasion/migration, angiogenic tube formation, secretion of proinflammatory mediators (all p<0.05), and activation of HIF1α, pSTAT3 and Notch-1IC under normoxic and hypoxic conditions.

Conclusions

Hypoxia alters cellular bioenergetics by inducing mitochondrial dysfunction and promoting a switch to glycolysis, supporting abnormal angiogenesis, cellular invasion and pannus formation.