AB0104 CORRELATION OF PLASMA 14-3-3Η LEVELS WITH DISEASE ACTIVITY MEASURES IN METHOTREXATE-NAÏVE RA PATIENTS TREATED WITH UPADACITINIB MONOTHERAPY IN THE SELECT-EARLY PHASE 3 STUDY

Background:

Early diagnosis and treat-to-target strategies in RA improve clinical and radiographic outcomes. 14-3-3η is a soluble diagnostic biomarker that is involved in the pathogenesis of RA (1) including the potent activation of key signalling cascades such as the JAK-STAT pathway and whose initial expression coincides with a transition to synovitis. In undifferentiated arthralgia, 14-3-3η independently predicts the development of RA. In confirmed RA, 14-3-3η levels decrease with treatment response (2) and those changes are associated with clinical and radiographic outcomes, including the prediction of joint damage progression in patients who have achieved clinical remission. Upadacitinib (UPA), an oral JAK1-selective inhibitor, demonstrated significant and clinically meaningful improvements in RA vs. methotrexate (MTX) in the SELECT-EARLY phase 3 study (3).

Objectives:

To determine the impact of treatment with UPA monotherapy 15 mg QD on the levels of plasma 14-3-3η and to explore its relationship with clinical measures in early MTX-naïve RA patients.

Methods:

Patients from the SELECT-EARLY study were randomly selected (UPA n = 100; MTX n = 100) from the pool of patients with available plasma samples. 14-3-3η tests were performed at Augurex according to standard operating procedures. Concentrations (ng/mL) were log-transformed for analysis. Non-parametric correlations between biomarker data and clinical end points were derived using the Spearman method. Changes in 14-3-3η over time were compared using a Repeated Measure Mixed Linear Model. All statistical analyses were conducted in JMP 14.1 (SAS Institute).

Results:

At baseline, 79% of patients were 14-3-3η positive (≥ 0.19 ng/mL) with similar levels in both arms. Baseline levels of 14-3-3η correlated significantly with baseline disease activity measures (CDAI ρ = 0.164, p = 0.042; DASCRP ρ = 0.222, p = 0.004; and SDAI ρ = 0.177, p = 0.028) but not with baseline mTSS (ρ =-0.021, p = 0.787); of note baseline mTSS were relatively low in this subset of early RA patients (median = 2, IQR [0 – 9.5]). Over time, 14-3-3η levels tended to be lower in both the UPA and MTX groups. However, only treatment with UPA for 24 weeks resulted in a significant decrease in circulating 14-3-3η (p = 0.0002) (Figure 1). In addition, at week 24 in the UPA arm, changes in 14-3-3η levels correlated significantly with changes in concurrent disease activity measures (Δ CDAI ρ = 0.264, p = 0.030; Δ DASCRP ρ = 0.267, p = 0.021; and Δ SDAI ρ = 0.267, p = 0.028) but not with change in mTSS (ρ =-0.186, p = 0.111). In contrast to UPA, the relatively small changes in 14-3-3η induced by MTX did not correlate with any clinical measures.

Figure1

Conclusion:

This study demonstrates that treatment with UPA 15 mg QD monotherapy for 24 weeks significantly reduces the levels of circulating 14-3-3η in MTX-naïve RA patients and that these changes correlate with clinical measures of disease activity. Although we were not able to detect a clear relationship between changes in 14-3-3η and rate of structural damage progression, we would like to hypothesize that the superior clinical activity of UPA over MTX on joint damage may be related to the significant reduction in 14-3-3η induced by UPA; this hypothesis should be tested in a larger RA cohort with a larger proportion of joint damage progressors.

References:

[1]Maksymowych WP et al. Arthritis Res Ther. 2014;16(2):R99.

[2]Hirata S et al. Arthritis Res Ther. 2015;17(1):280.

[3]van Vollenhoven R et al. Arthritis Rheumatol.;2018 (Suppl 10; vol.70).

Disclosure of Interests:

Thierry Sornasse Shareholder of: AbbVie Inc, Employee of: AbbVie Inc, Simran Chahal Shareholder of: Augurex Life Science Corp, Employee of: Augurex Life Science Corp, Yuan Gui Shareholder of: Augurex Life Science Corp, Employee of: Augurex Life Science Corp, Neeraja Nagarajan Employee of: Augurex Life Science Corp, Alan Friedman Shareholder of: AbbVie Inc, Employee of: AbbVie Inc, Norma Biln Shareholder of: Augurex Life Science Corp, AbbVie Inc, Employee of: Augurex Life Science Corp

Glycomacropeptide: long-term use and impact on blood phenylalanine, growth and nutritional status in children with PKU

Abstract

In phenylketonuria, casein glycomacropeptide (CGMP) requires modification with the addition of some essential and semi essential amino acids to ensure suitability as a protein substitute. The optimal amount and ratio of additional amino acids is undefined.

Aim

A longitudinal, parallel, controlled study over 12 months evaluating a CGMP (CGMP-AA2) formulation compared with phenylalanine-free L-amino acid supplements (L-AA) on blood Phe, Tyr, Phe:Tyr ratio, biochemical nutritional status and growth in children with PKU. The CGMP-AA2 contained 36 mg Phe per 20 g protein equivalent.

Methods

Children with PKU, with a median age of 9.2 y (5-16y) were divided into 2 groups: 29 were given CGMP-AA2, 19 remained on Phe-free L-AA. The CGMP-AA2 formula gradually replaced L-AA, providing blood Phe concentrations were maintained within target range. Median blood Phe, Tyr, Phe:Tyr ratio and anthropometry, were compared within and between the two groups at baseline, 26 and 52 weeks. Nutritional biochemistry was studied at baseline and 26 weeks only.

Results

At the end of 52 weeks only 48% of subjects were able to completely use CGMP-AA2 as their single source of protein substitute. At 52 weeks CGMP-AA2 provided a median of 75% (30–100) of the total protein substitute with the remainder being given as L-AA. Within the CGMP-AA2 group, blood Phe increased significantly between baseline and 52 weeks: [baseline to 26 weeks; baseline Phe 270 μmol/L (170–430); 26 weeks, Phe 300 μmol/L (125–485) p = 0.06; baseline to 52 weeks: baseline, Phe 270 μmol/L (170–430), 52 weeks Phe 300 μmol/L (200–490), p < 0.001)]. However, there were no differences between the CGMP-AA2 and L-AA group for Phe, Tyr, Phe:Tyr ratio or anthropometry at any of the three measured time points. Within the CGMP-AA2 group only weight (p = 0.0001) and BMI z scores (p = 0.0001) increased significantly between baseline to 52 weeks. Whole blood and plasma selenium were significantly higher (whole blood selenium [p = 0.0002]; plasma selenium [p = 0.0007]) at 26 weeks in the CGMP-AA2 group compared L-AA. No differences were observed within the L-AA group for any of the nutritional markers.

Conclusions

CGMP-AA increases blood Phe concentrations and so it can only be used partly to contribute to protein substitute in some children with PKU. CGMP-AA should be carefully introduced in children with PKU and close monitoring of blood Phe control is essential.

Electronic supplementary material

The online version of this article (10.1186/s13023-019-1011-y) contains supplementary material, which is available to authorized users.

Biological and Mechanical Evaluation of Novel Prototype Dental Composites

The breakdown of the polymeric component of contemporary composite dental restorative materials compromises their longevity, while leachable compounds from these materials have cellular consequences. Thus, a new generation of composite materials needed to be designed to have a longer service life and ensure that any leachable compounds are not harmful to appropriate cell lines. To accomplish this, we have developed concurrent thiol-ene-based polymerization and allyl sulfide-based addition-fragmentation chain transfer chemistries to afford cross-linked polymeric resins that demonstrate low shrinkage and low shrinkage stress. In the past, the filler used in dental composites mainly consisted of glass, which is biologically inert. In several of our prototype composites, we introduced fluorapatite (FA) crystals, which resemble enamel crystals and are bioactive. These novel prototype composites were benchmarked against similarly filled methacrylate-based bisphenol A diglycidyl ether dimethacrylate / triethylene glycol dimethacrylate (bisGMA/TEGDMA) composite for their cytotoxicity, mechanical properties, biofilm formation, and fluoride release. The leachables at pH 7 from all the composites were nontoxic to dental pulp stem cells. There was a trend toward an increase in total toughness of the glass-only-filled prototype composites as compared with the similarly filled bisGMA/TEGDMA composite. Other mechanical properties of the glass-only-filled prototype composites were comparable to the similarly filled bisGMA/TEGDMA composite. Incorporation of the FA reduced the mechanical properties of the prototype and bisGMA/TEGDMA composite. Biofilm mass and colony-forming units per milliliter were reduced on the glass-only-filled prototype composites as compared with the glass-only-filled bisGMA/TEGDMA composite and were significantly reduced by the addition of FA to all composites. Fluoride release at pH 7 was greatest after 24 h for the bisGMA/TEGDMA glass + FA composite as compared with the similarly filled prototypes, but overall the F^- release was marginal and not at a concentration to affect bacterial metabolism.

Refining low protein modular feeds for children on low protein tube feeds with organic acidaemias

Children with inherited metabolic disorders (IMD) who are dependent on tube feeding and require a protein restriction are commonly fed by ‘modular tube feeds’ consisting of several ingredients. A longitudinal, prospective two-phase study, conducted over 18 months assessed the long-term efficacy of a pre-measured protein-free composite feed. This was specifically designed to meet the non-protein nutritional requirements of children (aged over 1 year) with organic acidaemias on low protein enteral feeds and to be used as a supplement with an enteral feeding protein source.

Methodology

All non-protein individual feed ingredients were replaced with one protein-free composite feed supplying fat, carbohydrate, and micronutrients. Thirteen subjects, median age 7.4y (3–15.5y), all nutritionally tube dependent (supplying nutritional intake: ≥ 90%, n = 12; 75%, n = 1), and diagnosed with organic acidaemias (Propionic acidaemia, n = 6; Vitamin B₁₂ non-responsive methyl malonic acidaemia, n = 4; Isovaleric acidaemia, n = 2; Glutaric aciduria type1, n = 1); were studied. Nutritional intake, biochemistry and anthropometry were monitored at week − 8, 0, 12, 26 and 79.

Results

Energy intake remained unchanged, providing 76% of estimated energy requirements. Dietary intakes of vitamins, minerals and essential fatty acids significantly increased from week 0 to week 79, but sodium, potassium, magnesium, decosahexanoic acid and fibre did not meet suggested requirements. Plasma zinc, selenium, haemoglobin and MCV significantly improved, and growth remained satisfactory. Natural protein intake met WHO/FAO/UNU 2007 recommendations.

Conclusions

A protein-free composite feed formulated to meet the non-protein nutritional requirements of children aged over 1 year improved nutritional intake, biochemical nutritional status, and simplified enteral tube feeding regimens in children with organic acidaemias.

The challenge of nutritional profiling of a protein-free feed module for children on low protein tube feeds with organic acidaemias

BACKGROUND

Enteral tube feeding for children with organic acidaemias (OA) is recommended. Protein restriction, providing minimum safe levels of protein intake, is advocated. Standard paediatric tube feeding formulae provide more than the minimum safe protein requirements and are unsuitable in OA without modification. Modified paediatric enteral feeds consist of several modular ingredients. The aim of this prospective longitudinal interventional study was to assess the efficacy of a premeasured novel protein-free module developed for children aged over 12 months compared to conventional practice.

METHODS

In total, 15 children with OA (11.6-31 kg) needing enteral feeding were recruited. The protein-free module, from either a protein-free infant feed or modular ingredients, was replaced by the study feed. To ensure metabolic stability, energy and protein intake were unchanged. Dietary intake, anthropometry and nutritional biochemistry were recorded at baseline and week 26.

RESULTS

Dietary intakes of magnesium (P = 0.02), sodium (P = 0.005), vitamin D (P = 0.04), docosahexaenoic acid (P = 0.01) and arachidonic acid (P = 0.001) significantly improved; plasma selenium (P = 0.002) and whole blood glutathione peroxidase (P = 0.02) significantly increased. Feed preparation accuracy as measured by composition analysis showed consistent errors both in pre- and study feeds.

CONCLUSIONS

A protein-free module improved nutritional intake and biochemistry, although feed preparation errors remained a common finding.

Glycomacropeptide in children with phenylketonuria: does its phenylalanine content affect blood phenylalanine control?

BACKGROUND

In phenylketonuria (PKU), there are no data available for children with respect to evaluating casein glycomacropeptide (CGMP) as an alternative to phenylalanine-free protein substitutes [Phe-free L-amino acid (AA)]. CGMP contains a residual amount of phenylalanine, which may alter blood phenylalanine control.

METHODS

In a prospective 6-month pilot study, we investigated the effect on blood phenylalanine control of CGMP-amino acid (CGMP-AA) protein substitute in 22 PKU subjects (13 boys, nine girls), median age (range) 11 years (6-16 years). Twelve received CGMP-AA and nine received Phe-free L-AA, (1 CGMP-AA withdrawal). Subjects partially or wholly replaced Phe-free L-AA with CGMP-AA. If blood phenylalanine exceeded the target range, the CGMP-AA dose was reduced and replaced with Phe-free L-amino acids. The control group remained on Phe-free L-AAs. Phenylalanine, tyrosine and Phe : Tyr ratio concentrations were compared with the results for the previous year.

RESULTS

In the CGMP-AA group, there was a significant increase in blood phenylalanine concentrations (pre-study, 275 μmol L^-1 ; CGMP-AA, 317 μmol L^-1 ; P = 0.02), a decrease in tyrosine concentrations (pre-study, 50 μmol L^-1 ; CGMP-AA, 40 μmol L^-1 ; P = 0.03) and an increase in Phe : Tyr ratios (pre-study, Phe : Tyr 4.9:1; CGMP-AA, Phe : Tyr 8:1; P = 0.02). In the control group there was a non-significant fall in phenylalanine concentrations (pre-study 325μmol/L: study 280μmol/L [p = 0.9], and no significant changes for tyrosine or phe/tyr ratios [p = 0.9]. Children taking the CGMP-AA found it more acceptable to L-AA.

CONCLUSIONS

Blood phenylalanine control declined with CGMP-AA but, by titrating the dose of CGMP-AA, blood phenylalanine control remained within target range. The additional intake of phenylalanine may have contributed to the change in blood phenylalanine concentration. CGMP-AA use requires careful monitoring in children.

The challenges of vitamin and mineral supplementation in children with inherited metabolic disorders: a prospective trial

BACKGROUND

In order to achieve metabolic stability, dietary treatment of inborn errors of metabolism may require restriction of protein, fat or carbohydrate. Manipulation of dietary intake potentially reduces micronutrient status, and provision of a comprehensive vitamin and mineral supplement becomes an essential adjunct to dietary treatment.

AIM

To review the efficacy of a new complete vitamin and mineral supplement [Fruitivits, Vitaflo Ltd] in 14 subjects in an open prospective 26-week study.

METHOD

All subjects had dietary restrictions: low protein diets (57%, n = 8), regular daytime cornstarch and overnight glucose polymer tube feeds (29%, n = 4), low fat diet (7%, n = 1) and modified Atkins diet (7%, n = 1). Plasma nutritional biochemistry, anthropometry and food frequency questionnaires were collected at week 0, 12 and 26 weeks respectively.

RESULTS

Five nutritional parameters showed a significant improvement from baseline (week 0) to study end (week 26): folate (P = 0.01), vitamin E (P = 0.04), plasma selenium (P = 0.002), whole blood selenium (P = 0.04) and total vitamin D (P = 0.008). All the other nutritional markers did not significantly change. Even with regular monitoring, 37% of the product remained unused.

CONCLUSIONS

Despite improvements in some nutritional markers, overall use of the vitamin and mineral supplement was less than prescribed. New methods are needed to guarantee delivery of micronutrients in children at risk of deficiencies as a result of an essential manipulation of diet in inborn disorders of metabolism.

Errors in emergency feeds in inherited metabolic disorders: a randomised controlled trial of three preparation methods

OBJECTIVE

Glucose polymer-based emergency feeds (EF), used during illness to prevent metabolic decompensation and encephalopathy in inherited metabolic disorders, should be produced accurately and safely.

DESIGN

In a randomised, prospective, controlled study, the aim was to investigate if when preparing age-appropriate EF, a pre-measured sachet of glucose polymer, compared with scoops and weighing (using digital scales), decreased carer errors.

SUBJECTS

47 carers (3 men, 44 women) of 52 inherited metabolic disorders patients were recruited.

SETTING AND INTERVENTION

The carers made EF using all three techniques (weighing, scoops and pre-measured sachets) under supervision in controlled and home conditions. A 100-ml aliquot of each EF was analysed for carbohydrate concentration.

RESULTS

Under controlled preparation conditions, with 1 litre EFs, the % median glucose polymer concentration closest to target amounts was (1) pre-measured sachets (105%), (2) weighing (107%) and (3) scoops (118%; p<0.001). Similarly, under home conditions, the closest method was (1) pre-measured sachets (111%), (2) weighing (112%) and (3) scoops (118%; p<0.05). Under home preparation conditions, with 200 ml EFs, the pre-measured sachets were more likely to be within 20% of target weight than weighing (p<0.05), but there was no difference with scoops. Common errors observed were inaccurate water measurements (40% controlled and home conditions), incorrect scoop measurements and difficulty using digital scales. CONCLUSIONS; Overall, using pre-measured sachets was more accurate in EF production. Pre-measured sachets are likely to decrease preparation error and, therefore, reduce the risk of feed intolerance, particularly osmotic diarrhoea and consequential metabolic decompensation and encephalopathy.

Hematological neoplasms with first presentation as spinal cord compression syndromes: a 10-year retrospective series and review of the literature

CONTEXT

The epidural space is a well-known, albeit uncommon, location for lymphomatous involvement, estimated to occur in less than 3% of all systemic lymphomas. Initial presentation of the patient with disease in this site (i.e. primary spinal epidural lymphoma) has been considered to be "rare". When it has been reported, many studies have emphasized the occurrence of aggressive lymphomas with a poor prognosis.

DESIGN

A 10-year retrospective search of our files generated 7 patients who presented initially with back pain, incontinence and/or lower extremity weakness, and by neuroimaging studies were found to have masses causing spinal cord compression syndromes necessitating neurosurgical intervention.

RESULTS

The 7 patients included 4 males and 3 females with thoracic and lumbar epidural masses. Tumor types included high-grade non-Hodgkin lymphoma, B cell type (n = 4), indolent B cell lymphoma (n = 1), nodular sclerosing Hodgkin lymphoma (n = 1) and plasmacytoma (n = 1). Advanced disease (stage 4) was subsequently identified in all 7 patients. Despite this, survival varied greatly with therapy, from 3 weeks to almost 6 years, underscoring the need for correct classification of the lymphoma in order to optimize chemotherapeutic choices. The epidural space was the site of presentation of disease in 4% of all lymphomas diagnosed at our institution.

CONCLUSIONS

Combining all reports in the literature, epidural presentation of lymphoma is not rare. Epidural lymphomas are distinct from both primary central nervous system lymphomas and from primary dural lymphomas. A broad range of systemic hematological tumor types can present as epidural masses. A full work-up for lymphoma classification may only be possible from the tissues received at the time of the neurosurgical decompression or biopsy procedure.

Fulminant ascending paralysis as a delayed sequela of diethylene glycol (Sterno) ingestion

The authors report a 57-year-old man who survived 18 days after swallowing an 8-oz. can of Sterno in a suicide attempt. Two days after ingestion, he developed confusion and acute renal failure requiring hemodialysis, followed on day 8 by a delayed but rapidly evolving ascending paralysis. Pathologic examination showed severe demyelination, with lesser axonal damage, of virtually all cranial and peripheral nerves sampled and sparing of central myelin. The diethylene glycol in the Sterno was considered responsible for this intoxication.

Species differences in peroxisome proliferation; mechanisms and relevance

Peroxisome proliferators are a class of structurally diverse chemicals, which induce liver carcinogenesis in rodents through interaction and activation of the Peroxisome Proliferator-Activated Receptor alpha (PPARalpha). PPARalpha agonists elicit a powerful pleiotropic response, which include hypolipidaemia. We have examined the response of species that are classically unresponsive to peroxisome proliferators. Whereas hamster responds to PPARalpha agonists by hepatomegaly and induction of marker genes, the guinea pig does not undergo hepatomegaly or induction of marker genes, such as CYP4A13. Both the hamster and the guinea pig have PPARalpha, and the guinea pig receptor has been characterised to be fully functional, as demonstrated in reporter gene expression assays. However, the guinea pig PPARalpha is expressed at low levels in liver, and the currently favoured hypothesis to explain species differences in hepatic peroxisome proliferation invokes the low level of PPARalpha as the principal determinant of species responsiveness. However, the demonstration that guinea pigs and humans undergo hypolipidaemia induced by PPARalpha-agonists calls into question the mode of action of PPARalpha agonists in "non-responsive" species.

Effects of prestorage white cell reduction on platelet aggregate formation and the activation state of platelets and plasma enzyme systems

BACKGROUND

The introduction of prestorage white cell (WBC) reduction in random-donor platelet concentrates in Canada has increased the occurrence of particulate material in PCs. The effects of filtration on platelet activation state and the activation of plasma enzyme systems were assessed.

STUDY DESIGN AND METHODS

Particulate material was examined by light microscopy, electron microscopy, protein electrophoresis, and biochemical analysis. Thirty PCs (10 unfiltered, 20 filtered) were examined during processing and 5-day storage for pH, platelet count and mean volume, morphology, activation marker expression, and hypotonic shock response. Complement activation, thrombin generation, and fibrinolysis were assessed by using specific enzyme immunoassays or chromogenic assays.

RESULTS

By all analyses, the particulate material appeared to be platelet aggregates. Platelets exposed to WBC-reduction filters expressed a significantly higher level of activation markers CD62 and CD63, altered morphology, and increased platelet microparticles throughout the storage period than did unfiltered platelets. Complement activation at the C3 level was significantly increased in filtered units with little evidence of coagulation or fibrinolytic system activation.

CONCLUSION

Exposure of platelets to filters during prestorage WBC reduction increased platelet activation and mildly increased complement activation over the levels during the storage period. These alterations can contribute to the formation of irreversible platelet aggregates during processing.