Immune checkpoints in rheumatoid arthritis: progress and promise.

Rheumatoid arthritis (RA) is one of the most prevalent autoimmune inflammatory conditions, and while the mechanisms driving pathogenesis are yet to be completely elucidated, self-reactive T cells and immune checkpoint pathways have a clear role. In this review, we provide an overview of the importance of checkpoint pathways in the T cell response and describe the involvement of these in RA development and progression. We discuss the relationship between immune checkpoint therapy in cancer and autoimmune adverse events, draw parallels with the involvement of immune checkpoints in RA pathobiology, summarise emerging research into some of the lesser-known pathways, and the potential of targeting checkpoint-related pathways in future treatment approaches to RA management.

Transcriptomic profiling of programmed cell death 1 (PD-1) expressing T cells in early rheumatoid arthritis identifies a decreased CD4 + PD-1 + signature post-treatment.

Programmed cell death protein 1 (PD-1)-expressing T cells are expanded in individuals with established rheumatoid arthritis (RA). However, little is known about their functional role in the pathogenesis of early RA. To address this, we investigated the transcriptomic profiles of circulating CD4+ and CD8+ PD-1+ lymphocytes from patients with early RA (n = 5) using fluorescence activated cell sorting in conjunction with total RNA sequencing. Additionally, we assessed for alterations in CD4+PD-1+ gene signatures in previously published synovial tissue (ST) biopsy data (n = 19) (GSE89408, GSE97165) before and after six-months of triple disease modifying anti-rheumatic drug (tDMARD) treatment. Comparisons of gene signatures between CD4+PD-1+ vs. PD-1- cells identified significant upregulation of genes including CXCL13 and MAF, and in pathways including Th1 and Th2, cross talk between dendritic cells and NK cells, B cell development and antigen presentation. Gene signatures from early RA ST before and after six-month tDMARD treatment revealed downregulation of the CD4+PD-1+ signatures following treatment, identifying a mechanism through which tDMARDs exert their effect by influencing T cell populations. Furthermore, we identify factors associated with B cell help that are enhanced in the ST compared with PBMCs, highlighting their importance in driving synovial inflammation.

Differential expansion of T peripheral helper cells in early rheumatoid arthritis and osteoarthritis synovium.

OBJECTIVES: Programmed cell death protein 1 (PD-1)-expressing T cells are implicated in the pathogenesis of autoimmune inflammatory diseases such as rheumatoid arthritis. A subset of CXCR5- T cells, termed T peripheral helper (Tph) cells, which drive B cell differentiation, have been identified in ectopic lymphoid structures in established rheumatoid arthritis synovial tissue. Here, we aimed to characterise these in treatment-naïve, early rheumatoid arthritis to determine whether these cells accumulate prior to fully established disease. METHODS: Fresh dissociated tissue and peripheral blood mononuclear cell (PBMC) suspensions were stained with Zombie UV, followed by anti-CD45RO, PD-1, CD3, ICOS, CD8, CD4, CD20, CXCR5, TIGIT and CD38 antibodies prior to analysis. For histology, rheumatoid arthritis synovial sections were prepared for Opal multispectral immunofluorescence with anti-CD45RO, CD20, PD-1 and CXCR5 antibodies. Images were acquired on the Perkin Elmer Vectra V.3.0 imaging system and analysed using InForm Advanced Image Analysis software. RESULTS: Flow cytometry revealed T cell infiltration in the rheumatoid arthritis synovium with differential expression of PD-1, CD45RO, ICOS, TIGIT and CD38. We observed a higher frequency of PD1hiCXCR5- Tph in rheumatoid arthritis synovial tissue and PBMCs versus controls, and no significant difference in T follicular helper cell frequency. Microscopy identified a 10-fold increase of Tph cells in early rheumatoid arthritis synovial follicular and diffuse regions, and identified Tph adjacent to germinal centre B cells. CONCLUSIONS: These data demonstrate that PD-1hi Tph cells are present in early rheumatoid arthritis, but not osteoarthritis synovium, and therefore may provide a target for treatment of patients with early rheumatoid arthritis.

Impact of Bariatric Surgery on Renal Function.

Introduction Bariatric surgery offers superior benefits for weight loss, quality of life and a spectrum of metabolic diseases. Despite these benefits, studies so far have shown varying results on its effect on renal function. Aim In this study, we aim to look at bariatric surgery's effect on renal function at one, two and three year post operation (post-op). Methods This is a retrospective cross-sectional single-center study of patients who underwent bariatric surgery between 11/2008 and 06/2018. Renal function was calculated by using Cockroft-Gault equation, expressed as Creatinine Clearance (CrCl). Statistical analysis used was one-way ANOVA (Welch's) with Games-Howell Post-Hoc Test. Results From 307 patients who underwent bariatric surgery within the time period, 145 were studied. 30.3% (n=44) were male. The average age and body mass index (BMI) at referral were 48.1±8.6 years and 47.96±7.9 kgm-2 respectively, while the average age and BMI at surgery were 49.1±8.8 years and 40.62±4.2 kgm-2 respectively. Mean CrCl at surgery, year 1, year 2, and year 3 post-op were 172.35±53.29 mL/min, 179.20±57.87 mL/min, 142.35±46.05 mL/min, and 119.56±42.46 mL/min. Marginal improvement of CrCl at year one post-op (172.35±53.29mL/min to 179.20±57.87mL/min) was statistically insignificant (p=0.731). Meanwhile, there was statistically significant CrCl decline observed from year 1 to year 3 post-op (p<0.001). Conclusion Statistically insignificant marginal improvement in CrCl at year one post-op was noted. Beyond this, there was steady CrCl decline, albeit remained higher than the lower limit for respective gender. We recommend for further studies that take into account additional factors affecting renal function.

High-resolution esophageal manometry in pediatrics: Effect of esophageal length on diagnostic measures.

BACKGROUND: High-resolution esophageal manometry (HREM), derived esophageal pressure topography metrics (EPT), integrated relaxation pressure (IRP), and distal latency (DL) are influenced by age and size. Combined pressure and intraluminal impedance also allow derivation of metrics that define distension pressure and bolus flow timing. We prospectively investigated the effects of esophageal length on these metrics to determine whether adjustment strategies are required for children. METHODS: Fifty-five children (12.3 ± 4.5 years) referred for HREM, and 30 healthy adult volunteers (46.9 ± 3.8 years) were included. Studies were performed using the MMS system and a standardized protocol including 10 × 5 mL thin liquid bolus swallows (SBM kit, Trisco Foods) and analyzed via Swallow Gateway (www.swallowgateway.com). Esophageal distension pressures and swallow latencies were determined in addition to EGJ resting pressure and standard EPT metrics. Effects of esophageal length were examined using partial correlation, correcting for age. Adult-derived upper limits were adjusted for length using the slopes of the identified linear equations. KEY RESULTS: Mean esophageal length in children was 16.8 ± 2.8 cm and correlated significantly with age (r = 0.787, P = .000). Shorter length correlated with higher EGJ resting pressure and 4-s integrated relaxation pressures (IRP), distension pressures, and shorter contraction latencies. Ten patients had an IRP above the adult upper limit. Adjustment for esophageal length reduced the number of patients with elevated IRP to three. CONCLUSIONS & INFERENCES: We prospectively confirmed that certain EPT metrics, as well as potential useful adjunct pressure-impedance measures such as distension pressure, are substantially influenced by esophageal length and require adjusted diagnostic thresholds specifically for children.

Applicability, safety, and biological activity of regulatory T cell therapy in liver transplantation.

Regulatory T cells (Tregs) are a lymphocyte subset with intrinsic immunosuppressive properties that can be expanded in large numbers ex vivo and have been shown to prevent allograft rejection and promote tolerance in animal models. To investigate the safety, applicability, and biological activity of autologous Treg adoptive transfer in humans, we conducted an open-label, dose-escalation, Phase I clinical trial in liver transplantation. Patients were enrolled while awaiting liver transplantation or 6-12 months posttransplant. Circulating Tregs were isolated from blood or leukapheresis, expanded under good manufacturing practices (GMP) conditions, and administered intravenously at either 0.5-1 million Tregs/kg or 3-4.5 million Tregs/kg. The primary endpoint was the rate of dose- limiting toxicities occurring within 4 weeks of infusion. The applicability of the clinical protocol was poor unless patient recruitment was deferred until 6-12 months posttransplant. Thus, only 3 of the 17 patients who consented while awaiting liver transplantation were dosed. In contrast, all six patients who consented 6-12 months posttransplant received the cell infusion. Treg transfer was safe, transiently increased the pool of circulating Tregs and reduced anti-donor T cell responses. Our study opens the door to employing Treg immunotherapy to facilitate the reduction or complete discontinuation of immunosuppression following liver transplantation.

A Rapamycin-Based GMP-Compatible Process for the Isolation and Expansion of Regulatory T Cells for Clinical Trials.

The concept of regulatory T cell (Treg)-based immunotherapy has enormous potential for facilitating tolerance in autoimmunity and transplantation. Clinical translation of Treg cell therapy requires production processes that satisfy the rigors of Good Manufacturing Practice (GMP) standards. In this regard, we report our findings on the implementation of a robust GMP compliant process for the ex vivo expansion of clinical grade Tregs, demonstrating the feasibility of this developed process for the manufacture of a final product for clinical application. This Treg isolation procedure ensured the selection of a pure Treg population that underwent a 300-fold expansion after 36 days of culture, while maintaining a purity of more than 75% CD4+CD25+FOXP3+ cells and a suppressive function of above 80%. Furthermore, we report the successful cryopreservation of the final product, demonstrating the maintenance of phenotype and function. The process outlined in this manuscript has been implemented in the ONE study, a multicenter phase I/IIa clinical trial in which cellular therapy is investigated in renal transplantation.

Publication Rates of Abstracts Presented at the Society of General Internal Medicine Annual Meeting.

BACKGROUND: Abstracts accepted at scientific meetings are often not subsequently published. Data on publication rates are largely from subspecialty and surgical studies. OBJECTIVE: The aims of this study were to 1) determine publication rates of abstracts presented at a general internal medicine meeting; 2) describe research activity among academic general internists; 3) identify factors associated with publication and with the impact factor of the journal of publication; and 4) evaluate for publication bias. DESIGN: Retrospective cohort study. PARTICIPANTS: All scientific abstracts presented at the Society of General Internal Medicine 2009 Annual Meeting. MAIN MEASURES: Publication rates were determined by searching for full-text publications in MEDLINE. Data were abstracted regarding authors' institution, research topic category, number of study sites, sample size, study design, statistical significance (p value and confidence interval) in abstract and publication, journal of publication, publication date, and journal impact factor. KEY RESULTS: Of the 578 abstracts analyzed, 274 (47.4%) were subsequently published as a full article in a peer-reviewed journal indexed in MEDLINE. In a multivariable model adjusting for institution site, research topic, number of study sites, study design, sample size, and abstract results, publication rates for academic general internists were highest in the areas of medical education (52.5%, OR 5.05, 95% CI 1.57-17.25, reference group Veterans Affairs (VA)-based research, publication rate 36.7%), mental health/substance use (67.7%, OR 4.16, 95% CI 1.39-13.06), and aging/geriatrics/end of life (65.7%, OR 3.31, 95% CI 1.15-9.94, p = 0.01 across topics). Publication rates were higher for multicenter studies than single-institution studies (52.4% vs. 40.4%, OR 1.66, 95% CI 1.10-2.52, p = 0.04 across categories). Randomized controlled trials had higher publication rates than other study designs (66.7% vs. 45.9%, OR 2.72, 95% CI 1.30-5.94, p = 0.03 across study designs). Studies with positive results did not predict higher publication rates than negative studies (OR 0.89, 95% CI 0.6-1.31, p = 0.21). CONCLUSIONS: This study demonstrated that 47.4% of abstracts presented at a general internal medicine national conference were subsequently published in a peer-reviewed journal indexed in MEDLINE.

Pressure-Flow Analysis for the Assessment of Pediatric Oropharyngeal Dysphagia.

OBJECTIVES: To determine which objective pressure-impedance measures of pharyngeal swallowing function correlated with clinically assessed severity of oropharyngeal dysphagia (OPD) symptoms. STUDY DESIGN: Forty-five children with OPD and 34 control children without OPD were recruited and up to 5 liquid bolus swallows were recorded with a solid-state high-resolution manometry with impedance catheter. Individual measures of pharyngeal and upper esophageal sphincter (UES) function and a swallow risk index composite score were derived for each swallow, and averaged data for patients with OPD were compared with those of control children without OPD. Clinical severity of OPD symptoms and oral feeding competency was based on the validated Dysphagia Disorders Survey and Functional Oral Intake Scale. RESULTS: Those objective measures that were markers of UES relaxation, UES opening, and pharyngeal flow resistance differentiated patients with and without OPD symptoms. Patients demonstrating abnormally high pharyngeal intrabolus pressures and high UES resistance, markers of outflow obstruction, were most likely to have signs and symptoms of overt Dysphagia Disorders Survey (OR 9.24, P = .05, and 9.7, P = .016, respectively). CONCLUSION: Pharyngeal motor patterns can be recorded in children by the use of HRIM and pharyngeal function can be defined objectively with the use of pressure-impedance measures. Objective measurements suggest that pharyngeal dysfunction is common in children with clinical signs of OPD. A key finding of this study was evidence of markers of restricted UES opening.

Successful expansion of functional and stable regulatory T cells for immunotherapy in liver transplantation.

Strategies to prevent organ transplant rejection whilst minimizing long-term immunosuppression are currently under intense investigation with regulatory T cells (Tregs) nearing clinical application. The clinical trial, ThRIL, recently commenced at King's College London, proposes to use Treg cell therapy to induce tolerance in liver transplant recipients, the success of which has the potential to revolutionize the management of these patients and enable a future of drug-free transplants. This is the first report of the manufacture of clinical grade Tregs from prospective liver transplant recipients via a CliniMACS-based GMP isolation technique and expanded using anti-CD3/CD28 beads, IL-2 and rapamycin. We report the enrichment of a pure, stable population of Tregs (>95% CD4(+)CD25(+)FOXP3(+)), reaching adequate numbers for their clinical application. Our protocol proved successful in, influencing the expansion of superior functional Tregs, as compared to freshly isolated cells, whilst also preventing their conversion to Th17 cells under pro-inflammatory conditions. We conclude with the manufacture of the final Treg product in the clinical research facility (CRF), a prerequisite for the clinical application of these cells. The data presented in this manuscript together with the much-anticipated clinical results from ThRIL, will undoubtedly inform the improved management of the liver transplant recipient.

Phenotypic Complexity of the Human Regulatory T Cell Compartment Revealed by Mass Cytometry.

Regulatory T cells (Tregs) are an essential component of the cellular immune response, occupying a key role in maintaining immunological tolerance and present an attractive therapeutic target in a range of immunopathologies. Comprehensive analysis of the human Treg compartment has been restricted due to technical limitations. The advent of mass cytometry enables simultaneous assessment of vastly increased phenotypic parameters at single-cell resolution. In this study, we used mass cytometry to examine the complexity of human Tregs using an extensive panel of surface markers associated with Treg function and phenotype. We applied unsupervised clustering analysis, revealing 22 distinct subpopulations of Tregs, representing previously identified and novel subpopulations. Our data represent the most in-depth phenotypic description of the human Treg compartment at single-cell resolution and show a hitherto unrecognized degree of phenotypic complexity among cells of the regulatory lineage.

Academic Growth Trajectories and Family Relationships among African American Youth.

This study explored trajectories of African American youths' academic functioning and assessed whether changes in parent-adolescent relationships were associated with changes in youths' academic functioning. The data were drawn from a three-year longitudinal study of gender socialization and development in two-parent African American families and included 197 families. Findings revealed gender differences in achievement trajectories and indicated that boys not only had lower levels of academic achievement compared to girls, but also experienced steeper declines in school self-esteem during adolescence. Changes in parent-adolescent relationship quality were linked to changes in academic functioning: Increases in conflict were related to decreases in GPA, school bonding, and school self-esteem and increases in warmth were related to increases in school bonding and school self-esteem.

Parental monitoring, parental warmth, and minority youths' academic outcomes: exploring the integrative model of parenting.

Guided by the integrative model of parenting, the present study investigated the relationship between parental monitoring and racial/ethnic minority adolescents' school engagement and academic motivation as a function of parental warmth, and explored whether these associations varied for boys and girls. Participants (60 % female) were 208 sixth through eighth grade students (63 % African American, 19 % Latino, 18 % Multiracial) from an urban middle school in the Midwestern United States. Youth completed an in-school survey with items on parenting (parental monitoring, mothers'/fathers' warmth), cognitive engagement (school self-esteem), behavioral engagement (school trouble), and academic motivation (intrinsic motivation). As hypothesized, mothers' warmth enhanced the association between parental monitoring and youths' engagement and motivation. No gender differences in these associations emerged. Fathers' warmth strengthened the negative association between parental monitoring and school trouble, and this association was stronger for boys. Implications regarding the importance of sustaining a high level of monitoring within the context of warm parent-adolescent relationships to best support academic outcomes among minority youth are discussed.

Poly(I:C)-induced tumour cell death leads to DC maturation and Th1 activation.

Dendritic cells (DCs) have the ability to generate peptide epitopes for MHC class I molecules derived from apoptotic tumour cells for direct recognition by cytotoxic T cells. This function has lead to DCs being used in vaccine strategies. In this study, we investigate the effect of inducing apoptosis in tumour cell lines using IFN-γ and poly(I:C), the subsequent maturation of the endocytosing DC and its ability to direct the resulting T cell response. We show that uptake of poly(I:C)-induced apoptotic tumour cells leads to DC maturation and activation with a Th1 cell polarising capacity. In contrast, these effects are not seen by DCs loaded with γ-irradiated apoptotic tumour cells. We propose that the manner in which tumour cells are induced to die can have a profound effect on the endocytosing DC and the resulting T cell response.

Classroom context, school engagement, and academic achievement in early adolescence.

Classroom context and school engagement are significant predictors of academic achievement. These factors are especially important for academically at-risk students. Grounded in an ecological systems perspective, this study examined links between classroom context, school engagement, and academic achievement among early adolescents. We took a multidimensional approach to the measurement of classroom context and school engagement, incorporating both observational and self-reported assessments of various dimensions of classroom context (instruction quality, social/emotional climate, and student-teacher relationship) and school engagement (psychological and behavioral engagement). Using data from the NICHD Study of Early Child Care and Youth Development, we tested whether school engagement mediated the link between classroom context and academic achievement among 5th grade students, and whether these pathways were the same for students with previous achievement difficulties identified in 3rd grade. Participants included 1,014 children (50% female) in 5th grade (mean age = 11). The majority of the participants were white (77%) and 23% were children of color. Results indicated that psychological and behavioral engagement mediated the link between classroom context and academic achievement for students without previous achievement difficulties. However, for students with previous achievement difficulties psychological and behavioral engagement did not mediate the link between classroom context and academic achievement. These results suggest that improving classroom quality may not be sufficient to improve student engagement and achievement for students with previous achievement difficulties. Additional strategies may be needed for these students.