A Functional Neuroimaging Investigation of Moral Foundations Theory

Moral Foundations Theory (MFT) posits that the human mind contains modules (or "foundations") that are functionally specialized to moralize unique dimensions of the social world: Authority, Loyalty, Purity, Harm, Fairness, and Liberty. Despite this strong claim about cognitive architecture, it is unclear whether neural activity during moral reasoning exhibits this modular structure. Here, we use spatiotemporal partial least squares correlation (PLSC) analyses of fMRI data collected during judgments of foundation-specific violations to investigate whether MFT's cognitive modularity claim extends to the neural level. A mean-centered PLSC analysis returned two latent variables that differentiated between social norm and moral foundation violations, functionally segregated Purity, Loyalty, Physical Harm, and Fairness from the other foundations, and suggested that Authority has a different neural basis than other binding foundations. Non-rotated PLSC analyses confirmed that neural activity distinguished social norm from moral foundation violations, and distinguished individualizing and binding moral foundations if Authority is dropped from the binding foundations. Purity violations were persistently associated with amygdala activity, whereas moral foundation violations more broadly tended to engage the default network. Our results constitute partial evidence for neural modularity and motivate further research on the novel groupings identified by the PLSC analyses.

EXTH-14. INHIBITION OF THE ANGIOTENSIN II TYPE 2 RECEPTOR AT2R IS A NOVEL THERAPEUTIC STRATEGY FOR GLIOBLASTOMA

Glioblastoma (GBM) is a primary malignant brain tumor with poor clinical outcomes. Standard of care consists of surgical debulking followed by radiation and temozolomide, but the tumor invariably recurs, and median survival is only ~18 months. Repurposing drugs used for the treatment of other diseases is a promising avenue to identify novel treatments for this highly aggressive form of cancer. One such class of compounds is angiotensin II (AngII) receptor blockers, commonly used to control blood pressure. We show that ~80% of primary human GBM express the angiotensin II type 2 receptor (AT2R). In the presence of AngII, inhibition of AT2R using either PD123319 or EMA401 significantly inhibits GBM proliferation. This effect was lost in GBM cells with CRISPR/Cas9 mediated knockdown of AT2R. EMA401 inhibited invasion, angiogenesis, reduced GBM spheroid growth and induced apoptosis through caspase 3/7 activation. Furthermore, EMA401 induced changes in a number of growth regulatory pathways including apoptosis, DNA replication and focal adhesion. The crystal structure of AT2R bound to EMA401 revealed the receptor to be in an active-like conformation with helix-VIII blocking G protein or β-arrestin recruitment. We demonstrate that the architecture and interaction of EMA401 with AT2R differs drastically from complexes of AT2R with other compounds. Conjugation of EMA401 to angiopep-2 enhanced its blood brain barrier passage and reduced tumor volume in an orthotopic xenograft model of GBM. Targeting AT2R is a novel therapeutic strategy to treat GBM that should be explored in patients.

INNV-29. MULTISPECTRAL ANALYSIS FOR INTRA-OPERATIVE CHARACTERIZATION OF BRAIN TUMOURS, MARGINS OF RESECTION, AND ELOQUENT AREAS ACTIVATION – PRELIMINARY RESULTS

BACKGROUND

The identification of intrinsic brain tumours’ boundaries and their anatomical relationship with eloquent connectomes is one of the main challenges in neurosurgery. Several new intra-operative spectroscopic technologies have been recently investigated for this purpose. Multispectral imaging (MSI) analysis is based on analysis of reflected light, divided in specific wavelengths ranges across the electromagnetic spectrum. By doing so, it can identify wavelengths invisible to the naked eye, and make them visible by applying specific filters.

METHODS

We have used MSI to acquire intraoperative images during brain tumours surgeries. The MSI camera has been adapted to be connected to the intra-operative microscope and acquire a stack of images of different spectra to be analysed on a separate time. The focus of the images acquisition includes tumour structure, its margins, and eloquent connectomes during awake surgery or neurostimulation to analyse the possibility of different perfusion signal during activation. Image segmentation using K-mean clustering has been used to detect structural information and identify tumour’s area and tumour’s margins, while oxygen maps have been created using linear least squares regression to detect areas of metabolic activity.

RESULTS

Twenty-three patients have been enrolled in the current study at the time of this submission. We have analysed the intra-operative acquisition using intra-operative microscope picture, pre- and post-operative MRI scan, and neurophysiological findings as ground truth. Our preliminary results show that MSI is a potential additional technology to visually show tumour core, margins, and different degree of perfusions on the tissues analysed during tumour surgery. Although on a very limited subgroup of patients, MSI seems to be reliable in identify eloquent areas activation during awake surgery. These results are promising and warrant more data acquisition to be confirmed.

Transverse Pedicle Angle Is Associated With Pelvic Incidence and Increased in Lumbar Isthmic Spondylolisthesis

STUDY DESIGN

Retrospective radiographic review.

OBJECTIVES

Investigate and quantify transverse pedicle angle (TPA), the medial-to-lateral pedicle angulation, and its potential association with pelvic incidence (PI) in patients with isthmic lumbar spondylolisthesis (ISLS) and compare to those with degenerative lumbar spondylolisthesis (DSLS) and controls.

METHODS

A total of 200 patients (64 ISLS, 70 DSLS, 66 control) were included. TPA was calculated at the L3-5 vertebral levels using axial computed tomography slices. PI was measured on lateral radiographs. Two independent observers completed the measurements. As a sensitivity analysis, TPA was also measured at the most cranial and caudal aspects of the L3-5 vertebral levels of a subset of participants (29 ISLS, 31 DSLS, 35 control) and the cranial to caudal change (ΔTPA) was calculated.

RESULTS

TPA values (mean ± SD) at L4 and L5 for ISLS (L4: 17.3° ± 3.7°, L5: 26.0° ± 5.2°) were significantly higher than those for the DSLS (L4: 14.3° ± 3.8°, L5: 22.2° ± 5.0°) and control (L4: 14.5° ± 3.9°, L5: 20.7° ± 3.8°) groups. TPA in the DSLS group was significantly higher than controls at L5, but not L4. High PI predicted wider TPA at L5 in both DSLS and ISLS. ΔTPA (mean ± SD) increased sequentially proceeding through the L3-5 spinal levels for the ISLS (L3: 6.8° ± 4.4°, L4: 8.7° ± 5.2°, L5: 15.6° ± 9.0°), DSLS (L3: 8.2° ± 6.0°, L4: 8.3° ± 5.9°, L5: 18.3° ± 7.2°), and control (L3: 6.8° ± 4.4°, L4: 8.2° ± 4.7°, L5: 17.7° ± 7.0°) groups.

CONCLUSIONS

TPA was significantly increased in ISLS compared with DSLS and controls. High PI significantly predicted high TPA at the L5 vertebral level in ISLS and DSLS. ΔTPA increased sequentially proceeding through the lumbar spine across groups.

The ketogenic diet alters the expression of chromatin modifying enzymes in GBM to potentiate the effects of chemotherapy and radiotherapy

Aims

Glioblastoma Multiforme (GBM) is the most aggressive form of primary brain tumour, with a median survival of 12-14 months after diagnosis. Although GBM has been extensively characterised on the molecular level during the past decades, many targeted therapies have been proved ineffective due, in part, to high heterogeneity of GBM. Thus, novel therapies targeting the altered metabolism which is exhibited by all cancer cells have gained much attention. The therapeutic ketogenic diet (KD) is a high fat, low carbohydrate and adequate protein diet. It has been recognized as a treatment for refractory paediatric epilepsy for decades. Recent studies have shown that a KD reduced tumour growth and potentiated the effects of therapy in some glioma animal models. However, the underlying mechanism(s) is still unclear. Thus, the aim of this study was to understand the mechanism of action behind the KD’s effects in inhibiting tumour growth and potentiating chemotherapy and radiotherapy.

Method

To unravel the mechanism of action, we analyzed the expression of genes encoding chromatin modifying enzymes in brain tumour samples from mice fed either a KD or standard diet (SD), using the Mouse Epigenetic Chromatin Modification Enzyme PCR Array (Qiagen, Germany). The expression of genes of interest selected from the array were validated by qRT-PCR. Human GBM cell lines and primary cells from GBMs were used to validate the results of the GBM mouse model. Beta-hydroxybutyrate, the main physiological ketone body found in the circulation of patients during KD, was used in in vitro experiments to mimic the in vivo physiological effect of a KD. The effect of protein arginine methyltransferase 8 (PRMT8) overexpression in GBM cells was studied using a lentiviral system. Cell proliferation was measured by Sulforhodamine B assay (Sigma, USA). Spheroid growth and invasion was measured in GBM spheroids cultured in Matrigel matrix (Corning, USA).

Results

Our results highlighted changes in the expression of a number of key chromatin modifying enzymes in mice fed a KD compared to those fed a SD. PRMT8, a gene highly downregulated in GBM, was upregulated in tumors from mice fed a KD, with corresponding downregulation of its target genes, dihydrofolate reductase (DHFR) and C-X-C chemokine receptor type 4 (CXCR4). Our results also showed that overexpression of PRMT8 in GBM cells reduced cell proliferation and invasiveness.

Conclusion

PRMT8, DHFR and CXCR4 have been shown to play key roles in tumour growth, invasion, migration and chemo/radio-resistance. Moreover, therapeutic strategies to downregulate these genes have been investigated in the form of methotrexate for DHFR inhibition and small molecule inhibitors of CXCR4. Thus, our results suggest that one mechanism through which the KD exerts its therapeutic effects may be through altering the expression of chromatin modifying enzymes. This provides additional support for the use of a KD as an adjuvant in combination with existing therapeutic approaches.

EXTH-41. THE microRNA miR-138 MAY BE RESPONSIBLE FOR SOME OF THE EFFECTS OF METABOLIC KETOSIS ON MALIGNANT GLIOMA

We and others have demonstrated that altering metabolism through the use of a ketogenic diet (KD) has numerous effects in mouse models of malignant glioma including slowed growth, reduced hypoxia and angiogenesis, enhanced survival and potentiation of the effects of radiation and chemotherapy. These effects are recapitulated in vitro when the ketone β-hydroxybutyrate (BHB) is added to mouse and human malignant glioma cells grown under high glucose conditions. BHB has been demonstrated to be an epigenetic modifier, providing a potential mechanism for the pluripotent effects of ketones even in the presence of high glucose. Therefore, we have analyzed alterations in microRNA (miRNA) expression in tumors and cells treated with a KD or BHB, respectively. MicroRNAs are short, single-stranded, noncoding RNAs that posttranscriptionally control gene expression. Each miRNA can affect the expression of many genes and they are implicated in all hallmarks of cancer. We found a number of miRNAs deregulated in tumor tissue from mice fed a KD, particularly mmu-miR-138 which was increased over 30-fold relative to tumors from mice fed a standard diet. MiR-138 is involved in a variety of anti-tumor effects that correlate with our data from KD treated gliomas. We have shown that ketones radiosensitize glioma cells, potentially through a reduction in DNA damage repair. MiR-138 has been shown to reduce the expression of H2AX which plays a key role in sensing and repairing DNA damage. Hypoxia inducible factor-1α (HIF-1α) is also a target of miR-138, and we have demonstrated a reduction in hypoxia, angiogenesis and the expression of HIF-1α in tumors from mice fed a KD. Furthermore, when we genetically engineered tumor cells to express miR-138 and injected them into mice, only necrotic tumor foci were found. Thus, we suggest that miR-138 is an important regulatory mechanism for the anti-tumor actions of metabolic ketosis in glioma.

β-Hydroxybutyrate Oxidation Promotes the Accumulation of Immunometabolites in Activated Microglia Cells

Metabolic regulation of immune cells has arisen as a critical set of processes required for appropriate response to immunological signals. While our knowledge in this area has rapidly expanded in leukocytes, much less is known about the metabolic regulation of brain-resident microglia. In particular, the role of alternative nutrients to glucose remains poorly understood. Here, we use stable-isotope (¹³C) tracing strategies and metabolomics to characterize the oxidative metabolism of β-hydroxybutyrate (BHB) in human (HMC3) and murine (BV2) microglia cells and the interplay with glucose in resting and LPS-activated BV2 cells. We found that BHB is imported and oxidised in the TCA cycle in both cell lines with a subsequent increase in the cytosolic NADH:NAD⁺ ratio. In BV2 cells, stimulation with LPS upregulated the glycolytic flux, increased the cytosolic NADH:NAD⁺ ratio and promoted the accumulation of the glycolytic intermediate dihydroxyacetone phosphate (DHAP). The addition of BHB enhanced LPS-induced accumulation of DHAP and promoted glucose-derived lactate export. BHB also synergistically increased LPS-induced accumulation of succinate and other key immunometabolites, such as α-ketoglutarate and fumarate generated by the TCA cycle. Finally, BHB upregulated the expression of a key pro-inflammatory (M1 polarisation) marker gene, NOS2, in BV2 cells activated with LPS. In conclusion, we identify BHB as a potentially immunomodulatory metabolic substrate for microglia that promotes metabolic reprogramming during pro-inflammatory response.

Visual Storytelling, Intergenerational Environmental Justice and Indigenous Sovereignty: Exploring Images and Stories amid a Contested Oil Pipeline Project

Visual practices of representing fossil fuel projects are entangled in diverse values and relations that often go underexplored. In Canada, visual media campaigns to aggressively push forward the fossil fuel industry not only relegate to obscurity indigenous values but mask evidence on health impacts as well as the aspirations of those most affected, including indigenous communities whose food sovereignty and stewardship relationship to the land continues to be affronted by oil pipeline expansion. The Tsleil-Waututh Nation, based at the terminal of the Trans Mountain Pipeline in Canada, has been at the forefront of struggles against the pipeline expansion. Contributing to geographical, environmental studies, and public health research grappling with the performativity of images, this article explores stories conveying health, environmental, and intergenerational justice concerns on indigenous territory. Adapting photovoice techniques, elders and youth illustrated how the environment has changed over time; impacts on sovereignty-both food sovereignty and more broadly; concepts of health, well-being and deep cultural connection with water; and visions for future relationships. We explore the importance of an intergenerational lens of connectedness to nature and sustainability, discussing visual storytelling not just as visual counter-narrative (to neocolonial extractivism) but also as an invitation into fundamentally different ways of seeing and interacting.

Ketogenic diet and metabolic regulation of brain microglia

Ketogenic diet (KD) has been proposed as a coadjuvant therapy in the treatment of brain tumours. Reduction of blood glucose and increase in ketone bodies concentration are amongst the most important changes induced by KD in patients. Preliminary data collected in our lab indicates that KD induces substantial changes in the immune system in mice bearing brain tumours. Microglia are brain-resident immune cells that account for around 30% of the tumour mass and play a major role in controlling tumour progression by adopting a protumour (M2 polarisation) or antitumour (M1 polarisation) phenotype. We are interested in understating the molecular and metabolic determinants of microglia polarisation and how these can be modulated by the metabolic microenvironment and KD. We report some initial findings that indicate microglia adapt to changes in the metabolic microenvironment and that nutrient availability can modulate microglia activation and polarisation. We believe that the study of microglia metabolism and nutritional interventions like KD can provide new knowledge about the regulation of the brain immune system and unveil novel routes for brain cancer treatment.

Real-world experience with Temozolomide & Sativex in patients with recurrent High Grade Gliomas

Background

Glioblastoma (GBM) is the most common malignant brain tumour in adults with a median survival from progression of 8 months. A recent phase 1 study of temozolomide (TMZ) and 1:1 CBD:THC (Sativex) offers evidence of efficacy in patients with recurrent GBM (NCT01812603).

Methods

All patients receiving TMZ & Sativex (75mg/m2 daily d1 – 21 q28; Sativex continuously) for relapsed GBM or grade 3 astrocytoma at our centre were identified. Patient, tumor and treatment characteristics were recorded, and response based on sequential MRI scans using modified RANO criteria assessed.

Results

13 patients were treated over 18 months. The median age was 56; 69% were male. All had received initial chemo-radiotherapy (12 patients: 60 or 59.4Gy/30–33#; 1 patient: 45Gy/15#). 6 patients underwent reresection at recurrence. 4 patients were treated at first progression, 7 at second progression, and 2 at third or later progression. The median number of cycles of TMZ and sativex was 2. The combination treatment was tolerated well by all patients treated, with no Grade 3 or 4 toxicities, the only complaints being of discomfort in mouth after spray and ‘spaced out feeling’. Patients stopped treatment due to evidence of progressive disease on sequential MRI sign or physical deterioration. Median Overall Survival (OS) from initiation was 5.9 months (177 days); Progression Free Surival (PFS) at 3 months was 50%.

Conclusion

These results highlight some discrepancies in OS in comparison to the previous trial (NCT01812603), but our patients were treated at second/ third recurrence. We agree that the combination is well tolerated.

The Collagen-Prolyl Hydroxylases promote proliferation and invasion in GBM

Glioblastoma Multiforme (GBM) is the most aggressive form of brain tumour, with a median survival time of just 14 months. Current standard therapy includes surgical excision, followed by chemotherapy and radiotherapy, however complete surgical excision is not usually possible due to the diffuse and infiltrative nature of the disease. To combat this, therapies inhibiting the invasion of leader migratory cells are an attractive area of research. The collagen prolyl-4 hydroxylases (C-P4Hs) are a family of proteins which catalyse the hydroxylation of proline residues on pre-pro-collagen, leading to the formation of the stable triple-helical structure of functional collagen. Collagen is a highly abundant protein, and important in several oncogenic cellular processes including proliferation, invasion and migration. We hypothesis that by inhibiting the C-P4Hs, the pro-tumorigenic effect of collagen will be inhibited in GBM. To explore this, we treated cells with ethyl 3,4-dihydroxybenzoate (EDHB) (a C-P4H inhibitor) and observed the resultant effect in GBM cells lines and primary cells through proliferation assays and 3D tumour spheroid invasion assays. Our results indicate that the addition of EDHB significantly reduces proliferation and invasion in both cell lines and primary GBM samples. Furthermore, we show that the C-P4Hs are upregulated in hypoxic conditions, which are commonly found in the clinical tumour microenvironment. Our study reveals that the C-P4H proteins may be an attractive therapeutic target to reduce invasion and proliferation and may be especially attractive as adjuvants with a cytotoxic agent such as temozolomide.

Factors affecting treatment strategy, completion of planned treatment and survival in older patients with glioblastoma

Introduction

For older patients with glioblastoma (GBM), age, extent of resection, and performance status are prognostic factors. However, an international survey conducted by our Unit found that >40% of neurosurgeons use age alone to discount surgery in older (65+) patients. The aim of this study was to review management in our Unit for 65+ GBM patients, to inform future approaches.

Methods

Patients 65+ with a new GBM diagnosis in our Unit, between 2014 and 2017, were identified. Demographic data, performance status (PS), comorbidity and frailty indices, together with details of surgical/oncological management and outcome were collected.

Results

78 patients were identified. 78% aged 65–74 underwent maximal safe resection, compared with 45% aged 75–84, and 10% aged 85+. Resection was undertaken in 68% PS1, 73% PS2 and 23% PS3 patients. No PS3 patient completed intended radiotherapy, compared with 79% PS1 and 74% PS2 patients. There was a significant difference in frailty scores of patients who completed scheduled oncological therapy compared with those who did not (median score 2 vs 4.5, p=0.0338).

Median survival was 10 months for patients 65–74, 4 months for aged 75 -84, and 40 days for 85+ (p<0.0167). Median survival was significantly lower for PS3 patients (44 days) compared with PS1 or 2 (9.5 months and 7 months respectively; p<0.0167).

Conclusion

There is considerable variability in performance status and frailty of 65+ GBM patients. PS3 patients at diagnosis are very unlikely to complete oncological treatment. These factors, rather than age alone, should be used to guide management decisions.

Distal Fusion Level Selection in Scheuermann's Kyphosis: A Comparison of Lordotic Disc Segment Versus the Sagittal Stable Vertebrae

STUDY DESIGN

Retrospective study.

OBJECTIVE

To compare 2 methods of selecting the lowest instrumented vertebra (LIV) on the rates of revision surgery for distal junctional kyphosis (DJK) following treatment for Scheuermann's kyphosis (SK).

METHODS

A retrospective review of patients who have undergone surgical treatment for SK was performed. Forty-four patients were divided into 2 groups based on intervention: Group 1 (n = 26) included patients who had an LIV distal to or at the sagittal stable vertebrae (SSV), and Group 2 (n = 18) included patients who had an LIV proximal to the SSV. For each group, demographic, radiographic, and revision surgery data was analyzed.

RESULTS

The average follow-up was 3.1 years. There were no differences among demographic variables between the groups. Preoperative and postoperative thoracic kyphosis, lumbar lordosis, and sagittal balance were not different between groups. Postoperatively, Group 1 demonstrated a significantly greater average lordotic disc angle below the LIV compared with Group 2 (Group 1, -6.2 ± 4.3° vs Group 2, -2.9 ± 5.8°; P = .02). In a subgroup analysis, extending fusions to the sagittal stable vertebra rather than the first lordotic disc resulted in fewer distal LIV complications necessitating revision surgery compared with fusing short of the SSV (5% vs 36.3%, P = .04).

CONCLUSION

The SSV method may reduce complications secondary to distal junctional failure, but at the expense of incorporating additional motion segments in a typically young population.

Effectiveness and Efficiency in Small Academic Peer Groups

What are the dynamics that affect a peer group, making one work more effectively and efficiently than another? What are some of the factors that influence peer group behavior to make some experiences positive and uplifting, whereas others are negative and frustrating? Using the case study method, the current research focuses on a small, academic peer group, during a particular period, in relation to group efficiency and effectiveness in achieving group goals. Issues the group encounters in the process of group work are documented and discussed by peer members and by a participant observer. The authors suggest that the contextual and affective processes associated with the study are not unique and can characterize group behavior in other peer situations. If this is the case, then the ability for such groups to monitor interactional behavior and recognize group problems before effectiveness and efficiency are greatly compromised may be a key factor for peer group success.

Evaluating the implementation of a national clinical programme for diabetes to standardise and improve services: a realist evaluation protocol

BACKGROUND

Over the last three decades in response to the growing burden of diabetes, countries worldwide have developed national and regional multifaceted programmes to improve the monitoring and management of diabetes and to enhance the coordination of care within and across settings. In Ireland in 2010, against a backdrop of limited dedicated strategic planning and engrained variation in the type and level of diabetes care, a national programme was established to standardise and improve care for people with diabetes in Ireland, known as the National Diabetes Programme (NDP). The NDP comprises a range of organisational and service delivery changes to support evidence-based practices and policies. This realist evaluation protocol sets out the approach that will be used to identify and explain which aspects of the programme are working, for whom and in what circumstances to produce the outcomes intended.

METHODS/DESIGN

This mixed method realist evaluation will develop theories about the relationship between the context, mechanisms and outcomes of the diabetes programme. In stage 1, to identify the official programme theories, documentary analysis and qualitative interviews were conducted with national stakeholders involved in the design, development and management of the programme. In stage 2, as part of a multiple case study design with one case per administrative region in the health system, qualitative interviews are being conducted with frontline staff and service users to explore their responses to, and reasoning about, the programme's resources (mechanisms). Finally, administrative data will be used to examine intermediate implementation outcomes such as service uptake, acceptability, and fidelity to models of care.

DISCUSSION

This evaluation is using the principles of realist evaluation to examine the implementation of a national programme to standardise and improve services for people with diabetes in Ireland. The concurrence of implementation and evaluation has enabled us to produce formative feedback for the NDP while also supporting the refinement and revision of initial theories about how the programme is being implemented in the dynamic and unstable context of the Irish healthcare system.