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Multi-ancestry genome-wide association analyses identify 124 risk loci for rheumatoid arthritis, of which 34 are novel. A polygenic risk score based on multi-ancestry data showed comparable performance between populations of European and East Asian ancestries.Rheumatoid arthritis (RA) is a highly heritable complex disease with unknown etiology. Multi-ancestry genetic research of RA promises to improve power to detect genetic signals, fine-mapping resolution and performances of polygenic risk scores (PRS). Here, we present a large-scale genome-wide association study (GWAS) of RA, which includes 276,020 samples from five ancestral groups. We conducted a multi-ancestry meta-analysis and identified 124 loci (P < 5 x 10(-8)), of which 34 are novel. Candidate genes at the novel loci suggest essential roles of the immune system (for example, TNIP2 and TNFRSF11A) and joint tissues (for example, WISP1) in RA etiology. Multi-ancestry fine-mapping identified putatively causal variants with biological insights (for example, LEF1). Moreover, PRS based on multi-ancestry GWAS outperformed PRS based on single-ancestry GWAS and had comparable performance between populations of European and East Asian ancestries. Our study provides several insights into the etiology of RA and improves the genetic predictability of RA.

The question of how the heart develops, and the genetic networks governing this process have become intense areas of research over the past several decades. This research is propelled by classical developmental studies and potential clinical applications to understand and treat congenital conditions in which cardiac development is disrupted. Discovery of the tinman gene in Drosophila, and examination of its vertebrate homolog Nkx2.5, along with other core cardiac transcription factors has revealed how cardiac progenitor differentiation and maturation drives heart development. Careful observation of cardiac morphogenesis along with lineage tracing approaches indicated that cardiac progenitors can be divided into two broad classes of cells, namely the first and second heart fields, that contribute to the heart in two distinct waves of differentiation. Ample evidence suggests that the fate of individual cardiac progenitors is restricted to distinct cardiac structures quite early in development, well before the expression of canonical cardiac progenitor markers like Nkx2.5. Here we review the initial specification of cardiac progenitors, discuss evidence for the early patterning of cardiac progenitors during gastrulation, and consider how early gene expression programs and epigenetic patterns can direct their development. A complete understanding of when and how the developmental potential of cardiac progenitors is determined, and their potential plasticity, is of great interest developmentally and also has important implications for both the study of congenital heart disease and therapeutic approaches based on cardiac stem cell programming.

Background/Aims Pain remains a common, life-changing symptom for patients with rheumatoid (RA) and psoriatic arthritis (PsA). Its current care focuses on prescribing analgesics, particularly opioids, despite minimal supportive trial evidence and potential associated harms. Intensive management with disease-modifying anti-rheumatic drugs (DMARDs) reduces disease activity and improves function in RA and PsA. Its impacts on pain are less well established. We examined the impact of varying intensities of DMARD treatment on pain in patients with RA/PsA in a secondary analysis of three trials. Methods The trials comprised MIPA in PsA (methotrexate vs. placebo), CARDERA in early RA (triple therapy vs. monotherapy), and TITRATE in established RA (monthly assessments with DMARD uptitration and psychosocial support vs. standard care). All measured 100mm pain intensity visual analogue scores. Regression models evaluated the relationship between active vs. control treatment and: (a) achieving “low” endpoint pain scores of ≤ 34, (b) changes in pain scores between baseline and endpoint, (c) achieving ≥30% reductions in pain scores between baseline and endpoint. Results We evaluated 765 patients (from 1,023 [75%]) with endpoint pain intensity scores available. In all trials more patients achieved low endpoint pain scores (≤34) with active than control treatment (MIPA 70% vs. 42%, P=0.003; CARDERA 71% vs. 56%, P=0.011; TITRATE 67% vs. 50%; P=0.008). Multivariable models showed the associations remained significant after treatment effects were adjusted for age, sex, and baseline pain: odds ratios (ORs) 2.8 (P=0.012), 1.9 (P=0.019) and 2.1 (P=0.006) in MIPA, CARDERA, and TITRATE. The trials differed in the impact of intensive treatment on changes in pain scores. In MIPA mean changes in pain intensity scores over the trial period were similar with active and control treatment. In CARDERA (P=0.019) and TITRATE (P=0.004) mean changes in pain scores were significantly greater with active than control treatment in multivariable models (estimated differences of 6.8 and 9.4 units). The trials also differed in the impact of treatment on the proportion of patients having large reductions in pain scores (≥30). In MIPA proportionally more patients achieved this with active vs. control treatment but this was not statistically significant. In CARDERA (P=0.009) and TITRATE (P=0.002) a significantly greater proportion of patients achieved large reductions in pain scores in multivariable models with active treatment (ORs 1.9 and 2.2). Conclusion In our secondary analysis all forms of intensive management provided beneficial effects on pain in active RA and PsA. More patients achieved “low” endpoint pain scores with active treatment in all trials. In the two trials employing the most intensive management strategies (CARDERA/TITRATE) significantly greater reductions in pain scores and a greater proportion achieving substantial pain improvements with active treatment were seen. Our results support the use of intensive management to improve pain in patients with active RA/PsA. Disclosure I.C. Scott: None. D.L. Scott: None. F. Ibrahim: None.

Background/Aims Analgesics are widely prescribed in patients with inflammatory arthritis (IA) despite limited evidence of efficacy and uncertainties about potential harms. The assessment of harms is complex as some drug-related adverse events (AE), including myocardial infarctions, are part of the IA comorbidity spectrum. As trials have limited follow-up periods and often exclude patients with comorbidities, safe prescribing requires an understanding of analgesic harms in “real-world” settings. We consequently undertook the first systematic review of observational studies reporting risks of adverse events with analgesics in adults with rheumatoid arthritis (RA) and spondyloarthritis (SpA). Methods A pre-specified protocol was PROSPERO-registered (CRD42019154277). Systematic searches were conducted in Web of Science/Embase/Medline without language/date restriction on the 18/1/22. Due to marked methodological and statistical heterogeneity, studies were combined in a structured narrative synthesis. Results Studies: Of 6,444 citations screened, thirty-five studies met eligibility criteria, comprising 21 cohort (200 to 143,433 patients); 12 case-control (41 to 7,102 cases); 1 self-controlled case series; 1 case-crossover. Two evaluated opioids in RA, 23 oral NSAIDs in RA, 9 oral NSAIDs in SpA, and 1 NSAIDs and opioids in RA. None evaluated paracetamol/gabapentinoids. Fourteen were rated “good”, 19 “fair” and 1 “poor” quality. Adverse Event Risks: All studies of opioids reported significantly increased risks of fractures/serious infection. For NSAIDs renal, upper gastrointestinal (UGI), and cardiovascular (CV) events were most often reported. There was consistent evidence that NSAIDs significantly increased renal (3/3 studies) and UGI (3/4 studies) AEs. Findings with CV AEs varied: 7/18 studies showed significantly increased risks; 3/18 showed significantly reduced risks, and 3/18 showed significantly increased risks with some NSAIDs and reduced risks with others. There was no evidence NSAIDs increased risks of lower/functional gastrointestinal AEs, or fractures. With regards to mortality, one study showed a significantly reduced risk of death with NSAID use in SpA; the other showed a significantly reduced risk of death with NSAID use in inflammatory polyarthritis (but not RA). Differences Between RA And SpA: More studies reported a significantly reduced risk of CV events/fractures/deaths with NSAIDs in SpA (6/10) than RA (4/24). Differences Between IA and Non-IA Populations: Two of four studies found significant differences in AE risks in RA/SpA compared to OA/controls. One reported a significantly higher risk of myocardial infarction in SpA than OA and another a significantly lower risk of composite CV events in RA than controls. Conclusion Observational study data on risks of analgesic harms in IA are limited. All studies of opioids showed increased risks of harms. Studies of NSAIDs gave variable results, reflecting heterogeneity and potential confounding. Overall, oral NSAIDs increased renal and UGI AEs, with some evidence they reduced fractures/mortality in SpA. Further high-quality observational studies are needed to better characterise analgesic harms in IA. Disclosure C.R. White: None. O. Babatunde: None. J. Higgs: None. S. Muller: None. C.D. Mallen: None. S.L. Hider: None. I.C. Scott: None.

Background/Aims Pain is a common symptom experienced by patients with inflammatory arthritis (IA). Emerging data indicate IA pain treatment focuses on prescribing analgesics despite an absence of evidence for long-term efficacy. Delivering optimal, equitable IA pain care in England requires understanding current practice. To address this, we evaluated analgesic prescribing in patients diagnosed with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and axial spondyloarthritis (SpA) contributing data to the Clinical Practice Research Datalink Aurum, a primary care electronic health record database covering 20% of England. Methods Cross-sectional analyses (2004-2020) evaluated the annual prevalence of analgesic prescriptions in patients with RA/PsA/axial SpA. These were reported stratified by age, gender, ethnicity, deprivation, and geographical region. Analgesic prescriptions were classified using Bedson et al’s hierarchical system with an additional gabapentinoid group. Joinpoint regression models evaluated time-points when a significant change in the trends of prescription annual prevalence occurred. Results Although declining over time, the annual prevalence of analgesic prescriptions remained high (84.2% [95% CI 83.9, 84.5] in 2004; 64.5% [95% CI 64.2, 64.8] in 2020). In 2004, oral NSAIDs were the commonest analgesic (prevalence 56.1% [95% CI 55.8, 56.5]). By 2020, this fell to 22.3% (95% CI 22.1, 22.6) with opioids being the commonest analgesic (prevalence 39.0% [95% CI 38.7, 39.2]). Most opioid prescriptions were “strong/very strong” and long-term. Annual prevalence of non-NSAID analgesic prescriptions was highest in RA and of NSAIDs was highest in axial SpA. The annual prevalence of all analgesic types except NSAIDs differed by age, sex, deprivation, ethnicity, and region. Annual prevalence of non-NSAID analgesic prescriptions increased with age and deprivation, were higher in females than males, and higher in Northern than Southern England. The opposite pattern was seen with age for oral NSAIDs. NSAIDs were more commonly prescribed in males than females. Very little difference was seen in NSAID prescribing by deprivation, ethnicity, and region. There was a significant change in the trend of opioid prescription annual prevalence in 2015 (year of Public Health England’s “Opioid Aware” release) when the rate of decline increased, and at 2013 and 2018 for gabapentinoids when the annual prevalence increase slowed then declined (years of NHS England’s release of information on gabapentinoid risks, and their reclassification as controlled substances). Conclusion Whilst overall national analgesic prescribing in IA has fallen over 17 years - with interventions to deliver safer opioid/gabapentinoid prescribing potentially contributing - it remains common. This is at variance with evidence of analgesic efficacy and risks. The differences in prescribing of some analgesic types by patient sociodemographic factors and regions suggest unwarranted variation. Interventions are needed to improve the delivery of effective, equitable IA pain treatment. Disclosure I.C. Scott: None. R. Whittle: None. J. Bailey: None. H. Twohig: None. S.L. Hider: None. C.D. Mallen: None. S. Muller: None. K.P. Jordan: None.

Abstract Objective To assess the longer term impact of the COVID-19 pandemic on the self-reported physical and mental health of people with inflammatory rheumatic diseases (IRDs). Methods Two thousand twenty-four patients with IRDs were randomly selected from electronic health records. Survey invitations were sent (August 2021 coinciding with relaxation of UK COVID-19 restrictions) using SMS and postal approaches. Self-reported data included demographics, shielding status and physical (MSK-HQ) and mental health (PHQ8 and GAD7). Results Six hundred thirty-nine people completed the survey (mean (SD) age 64.5 (13.1) years, 384 (60%) female). Moderate/severe impact of the pandemic on physical and mental health was reported by 250 (41%) and 241 (39%) respectively. One hundred seventy-two (29%) reported moderate/severe depression (PHQ8 ≥ 10) and 135 (22%) moderate/severe anxiety (GAD7 ≥ 10). Females reported greater impacts of the pandemic on physical health (44% vs 34%), mental health (44% vs 34%), arthritis symptoms (49% vs 36%) and lifestyle factors (weight gain and reduced exercise and physical activity) than males. The physical and mental impacts were less in people with RA compared with other IRDs. Physical health impacts did not differ between age groups, but younger patients reported greater impacts on mental health. Conclusion The COVID-19 pandemic has had a significant impact on the physical and mental health of people with IRDs. These effects were greatest in females. Recovery needs to address the negative impact of the pandemic on lifestyle factors to minimise the long-term impacts for people with IRDs. Key Points• The pandemic had a significant impact on long term physical and mental health in almost 40% of people with IRDs.• The impact of the pandemic was greater in women for physical health, mental health and arthritis symptoms.• Many people reported negative pandemic impacts on lifestyle factors including weight and physical activity.

Objective The aim was to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic and stringent social isolation measures on patients with rheumatic disease (RD) from the beginning of the pandemic (April 2020). Methods In this UK-based single-centre, prospective, observational cohort study, all RD follow-up patients at our centre were invited by SMS text message in April 2020 to participate in the study. Participants completed questionnaires at four time points between April 2020 and December 2021. We collected demographics, clinically extremely vulnerable (CEV) status, short form 12 mental (MCS) and physical health component scores (PCS) for health-related quality of life, vaccination status, COVID-19 infection rates and incidence of long COVID. Results We enrolled 1605 patients (female, 69.0%; CEV, 46.5%); 906 of 1605 (56.4%) completed linked responses to our final questionnaire. MCS improved (+0.6, P Conclusions Mental and physical health in RD patients has changed throughout the pandemic; outcomes for both metrics of health were worse in CEV patients, although there were no differences in infection rates between the groups. These data might assist the understanding and planning of future health-care policy and social restrictions in RD patients. Trial registration ClinicalTrials.gov, www.clinicaltrials.gov, NCT04542031.

GATA4/5/6 transcription factors play essential, conserved roles in heart development. To understand how GATA4/5/6 modulates the mesoderm-to-cardiac fate transition, we labeled, isolated, and performed single-cell gene expression analysis on cells that express gata5 at precardiac time points spanning zebrafish gastrulation to somitogenesis. We found that most mesendoderm-derived lineages had dynamic gata5/6 expression. In the absence of Gata5/6, the population structure of mesendoderm-derived cells was substantially altered. In addition to the expected absence of cardiac mesoderm, we confirmed a concomitant expansion of cranial-pharyngeal mesoderm. Moreover, Gata5/6 loss led to extensive changes in chromatin accessibility near cardiac and pharyngeal genes. Functional analyses in zebrafish and the tunicate Ciona , which has a single GATA4/5/6 homolog, revealed that GATA4/5/6 acts upstream of tbx1 to exert essential and cell-autonomous roles in promoting cardiac and inhibiting pharyngeal mesoderm identity. Overall, cardiac and pharyngeal mesoderm fate choices are achieved through an evolutionarily conserved GATA4/5/6 regulatory network.

Background Many patients with rheumatoid arthritis (RA) do not attain remission/low disease activity, remaining in a moderate disease activity state (MDAS) with ongoing disability and impaired quality of life (QoL). If patients in persistent MDAS with poor future outcomes could be prospectively identified, they could arguably be treated more intensively. We evaluated baseline factors predicting function (Health Assessment Questionnaire-Disability Index [HAQ-DI] scores) and QoL (3-level EuroQol-5 dimensions questionnaire [EQ-5D-3L] index scores) at 12 months in patients with RA in persistent MDAS in a real-world setting. Methods Patients with persistent MDAS (Disease Activity Score for 28-joint count based on erythrocyte sedimentation rate [DAS28-ESR] 3.2–5.1 on at least two consecutive outpatient appointments over 12 months) were identified retrospectively from Guy’s Hospital RA Centre and analysed in two groups: (1) biologic naïve at baseline or (2) receiving/ever received biologics. The baseline timepoint was the second-visit MDAS DAS28-ESR score; the endpoint was the closest visit to 12 months. Linear regression analyses evaluated relationships between baseline variables and (1) 12-month HAQ-DI scores, (2) 12-month rank-transformed EQ-5D-3L index scores, (3) 12-month changes in HAQ-DI scores, and (4) 12-month changes in EQ-5D-3L index scores. Results The analysis included 207 biologic-naïve and 188 biologic-experienced patients. All patients had moderate disability (mean HAQ-DI 1.21 and 1.46) and impaired QoL (mean EQ-5D-3L index scores 0.52 and 0.50). Many reported moderate/severe pain (93 and 96%) and showed little change in HAQ-DI and EQ-5D-3L index scores over 12 months. In both biologic-naïve and biologic-experienced groups, multivariate analysis revealed a significant association between baseline HAQ-DI scores and endpoint HAQ-DI scores (β = 0.67, P P P P P = 0.004, respectively). Baseline EQ-5D-3L index scores were significantly associated with 12-month changes in EQ-5D-3L index scores in both groups (β = − 0.73, P P = 0.003, respectively). Conclusions Patients with RA in persistent MDAS experience substantial ongoing physical disability, poor QoL, and pain. HAQ-DI is an important predictor of future disability and reduced QoL, supporting current national recommendations to measure HAQ-DI in routine care.

The sarco-endoplasmic reticulum (SR/ER) is the largest membrane-bound organelle in eukaryotic cells and plays important roles in essential cellular processes, and in development and progression of many cardiac diseases. However, many aspects of its structural organization remain largely unknown, particularly in cells with a highly differentiated SR/ER network. In a recently published study led by Lee et al. (Nat Commun 11(1):965), we reported a cardiac enriched SR/ER membrane protein REEP5 that is centrally involved in regulating SR/ER organization and cellular stress responses in cardiac myocytes. In vitro REEP5 depletion in mouse cardiac myocytes resulted in SR/ER membrane destabilization and luminal vacuolization along with decreased myocyte contractility and disrupted Ca2+ cycling. Further, in vivo CRISPR/Cas9-mediated REEP5 loss-of-function zebrafish mutants showed sensitized cardiac dysfunction to heart failure induction upon short-term verapamil treatment. Additionally, in vivo adeno-associated viral (AAV9)-induced REEP5 depletion in the mouse demonstrated cardiac dysfunction with dilated cardiac chambers, increased cardiac fibrosis, and reduced ejection fraction. These results demonstrate the critical role of REEP5 in SR/ER organization and function.

Background Guidance for choosing face-to-face vs remote consultations (RCs) encourages clinicians to consider patient preferences, however, little is known about acceptability of, and preferences for RCs, particularly amongst patients with musculoskeletal conditions. This study aimed to explore the acceptability of, and preferences for, RC among patients with osteoporosis and rheumatoid arthritis. Methods Three UK qualitative studies, exploring patient experiences of accessing and receiving healthcare, undertaken during the pandemic, with people with osteoporosis and rheumatoid arthritis. Study team members agreed a consistent approach to conduct rapid deductive analysis using the Theoretical Framework of Acceptability (TFA) on transcripts from each data set relating to RC, facilitated by group meetings to discuss interpretations. Findings from the three studies were pooled. Results Findings from 1 focus group and 64 interviews with 35 people were included in the analysis. Participants’ attitudes to RC, views on fairness (ethicality) and sense-making (intervention coherence) varied according to their needs within the consultation and views of the pandemic. Some participants valued the reduced burden associated with RC, while others highly valued non-verbal communication and physical examination associated with face-to-face consults (opportunity costs). Some participants described low confidence (self-efficacy) in being able to communicate in RCs and others perceived RCs as ineffective, in part due to suboptimal communication. Conclusions Acceptability of, and preferences for RC appear to be influenced by societal, healthcare provider and personal factors and in this study, were not condition-dependant. Remote care by default has the potential to exacerbate health inequalities and needs nuanced implementation.

Centronuclear myopathy (CNM) is a congenital neuromuscular disorder caused by pathogenic variation in genes associated with membrane trafficking and excitation-contraction coupling (ECC). Bi-allelic autosomal recessive mutations in striated muscle enriched protein kinase (SPEG) account for a subset of CNM patients. Previous research has been limited by the perinatal lethality of Speg knockout mice. Thus, the precise biological role of SPEG in skeletal muscle remains unknown. To address this issue, we generated zebrafish spega, spegb, and spega/spegb (speg-DKO) mutant lines. We demonstrate that speg-DKO zebrafish faithfully recapitulate multiple phenotypes associated with human CNM, including disruption of the ECC protein machinery, dysregulation of calcium homeostasis during ECC, and impairment of muscle performance. Taking advantage of the availability of zebrafish models of multiple CNM genetic subtypes, we compared novel and known disease markers in speg-DKO with mtm1-KO and DNM2-S619L transgenic zebrafish. We observed desmin (DES) accumulation common to all CNM subtypes, and DNM2 upregulation in muscle of both speg-DKO and mtm1-KO zebrafish. In all, we establish a new model of SPEG-related CNM, and identify abnormalities in this model suitable for defining disease pathomechanisms and evaluating potential therapies.Summary StatementWe created a novel zebrafish speg mutant model of centronuclear myopathy that recapitulates key features of the human disorder and provides insight into pathomechanisms of the disease.

Centronuclear myopathy (CNM) is a congenital neuromuscular disorder caused by pathogenic variation in genes associated with membrane trafficking and excitation–contraction coupling (ECC). Bi-allelic autosomal-recessive mutations in striated muscle enriched protein kinase (SPEG) account for a subset of CNM patients. Previous research has been limited by the perinatal lethality of constitutive Speg knockout mice. Thus, the precise biological role of SPEG in developing skeletal muscle remains unknown. To address this issue, we generated zebrafish spega, spegb and spega;spegb (speg-DKO) mutant lines. We demonstrated that speg-DKO zebrafish faithfully recapitulate multiple phenotypes associated with CNM, including disruption of the ECC machinery, dysregulation of calcium homeostasis during ECC and impairment of muscle performance. Taking advantage of zebrafish models of multiple CNM genetic subtypes, we compared novel and known disease markers in speg-DKO with mtm1-KO and DNM2-S619L transgenic zebrafish. We observed Desmin accumulation common to all CNM subtypes, and Dnm2 upregulation in muscle of both speg-DKO and mtm1-KO zebrafish. In all, we establish a new model of SPEG-related CNM, and identify abnormalities in this model suitable for defining disease pathomechanisms and evaluating potential therapies. This article has an associated First Person interview with the joint first authors of the paper.

BackgroundRespiratory viral infections are closely associated with COPD exacerbations, hospitalisations, and significant morbidity and mortality. The consequences of the persisting inflammation and differentiation status in virus associated severe disease is not fully understood. The aim of this study was to evaluate barrier function, cellular architecture, the inflammatory response in severe COPD bronchial epithelium to human rhinovirus (HRV) induced pathological changes and innate immune responses.MethodsWell-differentiated primary bronchial epithelial cells (WD-PBECs) derived from severe COPD patients and age-matched healthy controls were cultured in the air-liquid interface (ALI) model. The differentiation phenotype, epithelial barrier integrity, pathological response and cytokine secreting profile of these cultures before and after HRV infection were investigated.ResultsWD-PBECs derived from severe COPD patients showed aberrant epithelium differentiation with a decreased proportion of ciliated cells but increased numbers of club cells and goblet cells compared with healthy controls. Tight junction integrity was compromised in both cultures following HRV infection, with heightened disruptions in COPD cultures. HRV induced increased epithelial cell sloughing, apoptosis and mucus hypersecretion in COPD cultures compared with healthy controls. A Th1/Th2 imbalance and a strong interferon and pro-inflammatory cytokine response was also observed in COPD cultures, characterized by increased levels of IFNγ, IFNβ, IP-10, IL-10 and decreased TSLP and IL-13 cytokine levels prior to HRV infection. Significantly enhanced basolateral secretion of eotaxin 3, IL-6, IL-8, GM-CSF were also observed in both mock and HRV infected COPD cultures compared with corresponding healthy controls. In response to HRV infection, all cultures displayed elevated levels of IFNλ1 (IL-29), IP-10 and TNFα compared with mock infected cultures. Interestingly, HRV infection dramatically reduced IFNλ levels in COPD cultures compared with healthy subjects.ConclusionAn altered differentiation phenotype and cytokine response as seen in severe COPD WD-PBECs may contribute to increased disease susceptibility and an enhanced inflammatory response to HRV infection.

Airway epithelium plays a pivotal role in maintaining immune homeostasis and orchestrates the innate and adaptive responses of the lung against inhaled insults. However, the aetiology of pathological changes on airway epithelium during COPD pathogenesis is not completely understood, in particular factors linked to the susceptibility to severe disease. To address this, we characterized well-differentiated primary bronchial epithelial cells (WD-PBECs) derived from severe COPD patients undergoing transplantation and age-matched healthy controls employing an air-liquid interface (ALI) 3D in vitro/ex-vivo culture model. WD-PBECs derived from severe COPD patients showed an indistinguishable morphology compared with controls. However, aberrant epithelium differentiation in terms of a decrease in the number of ciliated cells and an increase in the number of Club cells and goblet cells in was evidenced in COPD cultures compared with healthy controls. Tight junction integrity was also compromised in the former. Moreover, there was enhanced basolateral secretion of IL-6, IL-8, GM-CSF, IL-1alpha, IP-10, CCL1 as well as altered secretion of Th1 and Th2 cytokines by COPD cells. Our data demonstrate that primary bronchial epithelial cells from patients with severe COPD show alterations in individual cell types during differentiation and enhanced secretion of inflammatory mediators including an alteration in Th1 and Th2 cytokines. Such changes in COPD bronchial epithelium during severe disease may represent an underlying perturbation in cellular function in these cells which may contribute to inflammation and infection in the COPD airways.

Objectives International data suggest inflammatory arthritis (IA) pain management frequently involves opioid prescribing, despite little evidence of efficacy, and potential harms. We evaluated analgesic prescribing in English National Health Service-managed patients with IA. Methods Repeated cross-sectional analyses in the Consultations in Primary Care Archive (primary care consultation and prescription data in nine general practices from 2000 to 2015) evaluated the annual prevalence of analgesic prescriptions in: (i) IA cases (RA, PsA or axial spondyloarthritis [SpA]), and (ii) up to five age-, sex- and practice-matched controls. Analgesic prescriptions were classified into basic, opioids, gabapentinoids and oral NSAIDs, and sub-classified into chronic and intermittent (≥3 and 1–2 prescriptions per calendar year, respectively). Results In 2000, there were 594 cases and 2652 controls, rising to 1080 cases and 4703 controls in 2015. In all years, most (65.3–78.5%) cases received analgesics, compared with fewer (37.5–41.1%) controls. Opioid prescribing in cases fell between 2000 and 2015 but remained common with 45.4% (95% CI: 42.4%, 48.4%) and 32.9% (95% CI: 29.8%, 36.0%) receiving at least 1 and ≥3 opioid prescriptions, respectively, in 2015. Gabapentinoid prescription prevalence in cases increased from 0% in 2000 to 9.5% (95% CI: 7.9%, 11.4%) in 2015, and oral NSAID prescription prevalence fell from 53.7% (95% CI: 49.6%, 57.8%) in 2000 to 25.0% (95% CI: 22.4%, 27.7%) in 2015. Across years, analgesic prescribing was commoner in RA than PsA/axial SpA, and 1.7–2.0 times higher in cases than controls. Conclusions Analgesic prescribing in IA is common. This is at variance with existing evidence of analgesic efficacy and risks, and guidelines. Interventions are needed to improve analgesic prescribing in this population.

Objective\ud Treat-to-target in rheumatoid arthritis (RA) recommends targeting remission, with low disease activity (LDA) being an alternative goal. When deciding to target remission or LDA, important considerations are the likelihood of attaining them, and their impacts on function and healthrelated quality of life (HRQoL). We have addressed this by studying: (a) the frequency of remission and LDA/remission; (b) DAS28-ESR trends after remission; (c) ability of remission vs. LDA to identify patients with normal function (HAQ ≤0.5) and HRQoL (EQ-5D ≥ the normal population).\ud \ud Methods\ud We studied 571 patients in two clinical trials, and 1,693 patients in a 10-year routine care cohort. We assessed the frequency and sustainability of remission and LDA/remission, variability in DAS28-ESR after remission, and sensitivity/specificity of remission and LDA/remission at identifying patients with low disability levels and normal HRQoL using Receiver Operator Characteristic (ROC) curves.\ud \ud Results\ud Point remission and remission/LDA were common (achieved by 35-58% and 49-74% of patients, respectively), but were rarely sustained (sustained remission and remission/LDA achieved by 5-9% and 9-16% of patients, respectively). Following attaining remission, DAS28-ESR levels varied substantially. Despite this, of those patients attaining point remission, the majority (53-61%) were in remission at study end-points. Whilst remission was highly specific at identifying patients with low disability (85-91%) it lacked sensitivity (51-57%); similar findings were seen for normal HRQoL (specificity 78-86%; sensitivity 52-59%). The optimal DAS28-cut-off to identify individuals with low disability and normal HRQoL was around the LDA threshold.\ud \ud Conclusions\ud Our findings support both the treat-to-target goals. Attaining remission is highly specific for attaining low disability and normal HRQoL, although many patients with more active disease also have good function and HRQoL. Attaining a DAS28-ESR ≤3.2 has a better balance of specificity and sensitivity for attaining these outcomes, with the benefit of being more readily achievable. Although sustaining these targets over time is rare, even attaining them on a oneoff basis leads to better function and HRQoL outcomes for patients.

Letter

GATA4/5/6 transcription factors play essential, conserved roles in heart development. How these factors mediate the transition from multipotent mesoderm progenitors to a committed cardiac fate is unclear. To understand how GATA4/5/6 modulate cell fate decisions we labelled, isolated, and performed single-cell gene expression analysis on cells that expressgata5at pre-cardiac time points spanning gastrulation to somitogenesis. We found that most mesendoderm-derived lineages had dynamicgata5/6expression. In the absence of Gata5/6, the population structure of mesendoderm-derived cells was dramatically altered. In addition to the expected absence of cardiac mesoderm, we observed a concomitant expansion of cranial-pharyngeal mesoderm. Functional genetic analyses in zebrafish and the invertebrate chordateCiona, which possess a single GATA4/5/6 homolog, revealed an essential and cell-autonomous role for GATA4/5/6 in promoting cardiac and inhibiting pharyngeal mesoderm identity. Overall, the maintenance and repression of GATA4/5/6 activity plays a critical, evolutionarily conserved role in early development.

Rationale: The development and function of the pacemaker cardiomyocytes of the sinoatrial node (SAN), the leading pacemaker of the heart, are tightly controlled by a conserved network of transcription factors, including TBX3 (T-box transcription factor 3), ISL1 (ISL LIM homeobox 1), and SHOX2 (short stature homeobox 2). Yet, the regulatory DNA elements (REs) controlling target gene expression in the SAN pacemaker cells have remained undefined. Objective: Identification of the regulatory landscape of human SAN-like pacemaker cells and functional assessment of SAN-specific REs potentially involved in pacemaker cell gene regulation. Methods and Results: We performed Assay for Transposase-Accessible Chromatin using sequencing on human pluripotent stem cell–derived SAN-like pacemaker cells and ventricle-like cells and identified thousands of putative REs specific for either human cell type. We validated pacemaker cell–specific elements in the SHOX2 and TBX3 loci. CRISPR-mediated homozygous deletion of the mouse ortholog of a noncoding region with candidate pacemaker-specific REs in the SHOX2 locus resulted in selective loss of Shox2 expression from the developing SAN and embryonic lethality. Putative pacemaker-specific REs were identified up to 1 Mbp upstream of TBX3 in a region close to MED13L harboring variants associated with heart rate recovery after exercise. The orthologous region was deleted in mice, which resulted in selective loss of expression of Tbx3 from the SAN and (cardiac) ganglia and in neonatal lethality. Expression of Tbx3 was maintained in other tissues including the atrioventricular conduction system, lungs, and liver. Heterozygous adult mice showed increased SAN recovery times after pacing. The human REs harboring the associated variants robustly drove expression in the SAN of transgenic mouse embryos. Conclusions: We provided a genome-wide collection of candidate human pacemaker-specific REs, including the loci of SHOX2 , TBX3 , and ISL1 , and identified a link between human genetic variants influencing heart rate recovery after exercise and a variant RE with highly conserved function, driving SAN expression of TBX3 .

Rana et al. demonstrate that white adipose tissue-resident multipotent stromal cells (WAT-MSC) support IL-33– and LFA-1/ICAM-1–mediated proliferation and type-2 cytokine expression by ILC2. Inversely, ILC2-derived IL-4 and IL-13 promote WAT-MSC eotaxin production and eosinophil recruitment, further maintaining type-2 immune homeostasis., Group-2 innate lymphoid cells (ILC2), type-2 cytokines, and eosinophils have all been implicated in sustaining adipose tissue homeostasis. However, the interplay between the stroma and adipose-resident immune cells is less well understood. We identify that white adipose tissue–resident multipotent stromal cells (WAT-MSCs) can act as a reservoir for IL-33, especially after cell stress, but also provide additional signals for sustaining ILC2. Indeed, we demonstrate that WAT-MSCs also support ICAM-1–mediated proliferation and activation of LFA-1–expressing ILC2s. Consequently, ILC2-derived IL-4 and IL-13 feed back to induce eotaxin secretion from WAT-MSCs, supporting eosinophil recruitment. Thus, MSCs provide a niche for multifaceted dialogue with ILC2 to sustain a type-2 immune environment in WAT., Graphical Abstract

Objective\ud To evaluate the responsiveness, and concurrent validity of the Musculoskeletal Health Questionnaire (MSK-HQ) in UK primary care patients with common musculoskeletal (MSK) pain presentations.\ud \ud Methods\ud A secondary analysis of a primary care pilot randomised trial (STarT MSK) was performed. In 524 people consulting with back, neck, shoulder, knee, or multi-site pain, the following were recorded at 0/6 months: MSK-HQ, EQ-5D-5L, Roland-Morris Disability Questionnaire (RMDQ; back pain), Neck Disability Index (NDI), Shoulder Pain and Disability Index (SPADI), Knee Injury and Outcome Score (KOOS), Short-Form-12 (SF-12; multisite pain). At 6-months, patients self-rated their global change in MSK condition, from -5 (“very much worse”) to +5 (“completely recovered”). Receiver operating characteristic curves evaluated abilities of 6-month changes in each patient reported outcome measure (PROM) to discriminate between patients improving/not improving on global change scores, with Minimal Clinically Important Differences (MCID) calculated.\ud \ud Results\ud The MSK-HQ had a good ability to discriminate between MSK pain patients reporting global improvement vs. no improvement (area under the curve [AUC] 0.81; 95% CI 0.78, 0.85). Its discriminative ability was higher than the EQ-5D-5L (AUC 0.68; 95% CI 0.62, 0.73) and similar to site-specific PROMs. The MCID for the 6-month change in MSK-HQ was 5.5. The MSK-HQ had strong correlations with all PROMs, except SF-12 scores.\ud \ud Conclusion\ud In primary care patients with common MSK pain presentations, the MSK-HQ was as good as existing pain-site specific PROMs at identifying people reporting global improvements in their MSK condition, and was better than the EQ-5D-5L.

Quebec Platelet Disorder (QPD) is an autosomal dominant bleeding disorder with a unique, platelet-dependent gain-of-function defect in fibrinolysis, without systemic fibrinolysis. The hallmark feature of QPD is a >100-fold overexpression of PLAU specifically in megakaryocytes. This overexpression leads to >100-fold increased platelet stores of urokinase plasminogen activator (PLAU/uPA), subsequent plasmin-mediated degradation of diverse a-granule proteins, and platelet-dependent, accelerated fibrinolysis. The causative mutation is a 78kb tandem duplication of PLAU. How this duplication causes megakaryocyte-specific PLAU overexpression is unknown. To investigate the mechanism that causes QPD, we used epigenomic profiling, comparative genomics, and chromatin conformation capture approaches to study PLAU regulation in cultured megakaryocytes from QPD participants and unaffected controls. We show that the QPD duplication leads to ectopic interactions between PLAU and a conserved megakaryocyte enhancer found within the same topologically associating domain (TAD). Our results support a unique disease mechanism whereby the reorganization of subTAD genome architecture results in a dramatic, cell-type specific blood disorder phenotype.

Background Obesity predisposes to a pro-inflammatory state. Studies have reported worse clinical outcomes in patients with inflammatory arthritis who are obese. The relationship between obesity and outcomes in patients with polymyalgia rheumatica (PMR), another common inflammatory rheumatic condition, has not been assessed. We examined this in a cohort study of primary care-recruited patients with PMR. Methods The PMR Cohort Study is an inception cohort of patients with incident PMR, recruited from 382 general practices. Self-completed questionnaires at 0, 12, and 24-months captured: (a) PMR-related pain (0-10 numeric rating scale [NRS]); (b) PMR-related stiffness (0-10 NRS); (c) anxiety (GAD7); (d) depression (PHQ8); (e) fatigue (FACIT-Fatigue); (f) function (mHAQ); (g) quality of life (EQ-5D-3L). Height was self-reported at baseline, and weight at baseline, 12 and 24 months. Patients were categorised as underweight (BMI Results 652 patients were included (62% female). At baseline, mean age was 72 years, median BMI 26.6 (IQR 24.0-30.2), 34% were normal/under-weight, 40% overweight, and 26% obese. Compared to normal/underweight patients, obese patients had the following significantly poorer outcomes (P Conclusion Obesity is associated with poorer outcomes in patients with PMR. Consideration should be given to providing weight management support to patients with PMR and obesity. Further research should examine the impacts of weight-based steroid dosing on outcomes. Disclosures I.C. Scott None. R. Bajpai None. S.L. Hider None. T. Helliwell None. S. Muller None. C.D. Mallen None.

Background The Musculoskeletal Health Questionnaire (MSK-HQ) is a recently developed generic patient-reported outcome measure (PROM), evaluating impacts of musculoskeletal (MSK) conditions on patients’ health. Its scores range 0-56; higher scores indicate better health. Its performance (a) in patients with MSK-pain in primary care, and (b) compared to MSK pain-site reference PROMs, is uncertain. We addressed these uncertainties through secondary analysis of a previous primary-care based study, enrolling 524 patients with shoulder, neck, lower back, knee, or multi-site MSK pain managed by GPs, from 8 West Midlands practices. Methods The study captured the following self-report questionnaire data at 0 and 6 months: MSK-HQ, EQ-5D-5L, Roland-Morris Disability Questionnaire (back pain), Neck Disability Index (neck pain), Shoulder Pain and Disability Index (shoulder pain), Knee Injury and Outcome Score (knee pain), Short-Form-12 (multisite pain). At 6 months, patients self-rated their global change in MSK pain, from -5 (“very much worse”) to + 5 (“completely recovered”). Receiver operating characteristic curves evaluated the ability of 6-month changes in each PROM to discriminate between patients improving/not improving on global change scores. Minimal Clinically Important Differences (MCID) were calculated (cut-off optimising discriminatory sensitivity/specificity). Results Most (60%) reported pain improvements, with mean baseline MSK-HQ scores rising from 29.4 to 37.4 over 6-months. The MSK-HQ had a moderate ability to discriminate between patients improving vs. no change/worsening in MSK pain (area under the curve [AUC] 0.81; 95% CI 0.78-0.85). Its discriminative ability was better than the EQ-5D-3L (AUC 0.68; 95% CI 0.62-0.73) and at least as good as site-specific PROMs (Table). MCID for the 6-month change in MSK-HQ was 5.5 across all patients. Minor variation ( Conclusion In patients consulting in primary care with MSK pain, the MSK-HQ appears at least as good as existing pain-site specific PROMs at identifying patients self-reporting pain improvements, and superior to the EQ-5D-5L. Our results support the use of the MSK-HQ in this setting. Disclosures I.C. Scott None. G. McCray None. G. Lancaster None. N.E. Foster None. J.C. Hill None.

Background There is little evidence analgesics improve pain in inflammatory arthritis (IA), and substantial evidence they have significant harms. Excepting NSAIDs in ankylosing spondylitis (AS), their long-term use is not recommended in guidelines. Despite this, international data suggest pain management in IA involves the substantial and sustained use of opioids (∼40% of North American patients with rheumatoid arthritis [RA] are chronic opioid users). We evaluated analgesic prescribing practice in NHS-managed patients with IA. Methods This study was undertaken in the Consultations in Primary Care Archive (CiPCA), containing primary care consultation/prescription data from 9 general practices (∼200,000 patients) in North Staffordshire (UK) from 2000-2015. Repeated cross-sectional analyses evaluated annual prevalence of analgesic prescriptions in (a) patients with IA (RA; psoriatic arthritis [PsA]; AS), and (b) five age, sex, and practice-matched controls without inflammatory rheumatic conditions. Patients without full calendar-years of data were excluded. The numerator was the number of patients receiving oral analgesic prescriptions in a calendar-year; the denominator was the number of patients contributing data within that calendar-year. Analgesic prescriptions were classified into basic, opioids, gabapentinoids, and NSAIDs. Patients were grouped into users, or non-users of analgesics. Users were sub-classified into chronic (≥3 prescriptions across a calendar year), or intermittent (1-2 prescriptions) users. Results In all years, the majority (65.1-77.8%) of patients with IA received analgesics, compared with the minority (38.1-42.0%) of controls (Table). Opioid prescribing in IA fell slightly between 2000-2015, but remained common with 45.0% receiving an opioid, and 32.5% being chronic opioid users in 2015. The proportion of patients with IA prescribed gabapentinoids increased from 0% in 2000, to 9.4% in 2015. In contrast, the proportion prescribed NSAIDs fell from 53.3% in 2000, to 24.9% in 2015. In all years, analgesic use was commoner in patients with RA, compared to PsA and AS, and 2-4 times higher in IA than controls. Conclusion Analgesic prescribing - particularly opioids - in IA is commonplace, with most prescribed long-term. This is at variance with existing evidence, and guidelines. Interventions are needed to improve analgesic prescribing in this population. Disclosures I.C. Scott None. J. Bailey None. C. White None. C.D. Mallen None. S. Muller None.

Summary Splenic red pulp macrophages (RPMs) contribute to erythrocyte homeostasis and are required for iron recycling. Heme induces the expression of SPIC transcription factor in monocyte-derived macrophages and promotes their differentiation into RPM precursors, pre-RPMs. However, the requirements for differentiation into mature RPMs remain unknown. Here, we have demonstrated that interleukin (IL)-33 associated with erythrocytes and co-cooperated with heme to promote the generation of mature RPMs through activation of the MyD88 adaptor protein and ERK1/2 kinases downstream of the IL-33 receptor, IL1RL1. IL-33- and IL1RL1-deficient mice showed defective iron recycling and increased splenic iron deposition. Gene expression and chromatin accessibility studies revealed a role for GATA transcription factors downstream of IL-33 signaling during the development of pre-RPMs that retained full potential to differentiate into RPMs. Thus, IL-33 instructs the development of RPMs as a response to physiological erythrocyte damage with important implications to iron recycling and iron homeostasis., Graphical Abstract, Highlights • IL-33 signaling promotes development of monocyte-derived red pulp macrophages (RPMs) • Il33−/− and Il1rl1−/− mice have decreased RPMs and splenic erythrophagocytosis • ERK activation is required for RPM development and is potentiated by hemin and IL-33 • GATA2 instructs RPM development and is aberrant in Il1rl1−/− RPM precursors, Splenic red pulp macrophages (RPMs) are critical for iron recycling. Here, Lu et al. implicate a role for IL-33 signaling in the regulation of GATA2, which controls the transition of monocytes to produce pre-RPMs that are competent to terminally differentiate into mature RPMs.

OBJECTIVES: In people with rheumatoid arthritis (RA), mental health problems are common, but often not recognized or treated, contributing to increased morbidity and mortality. Most studies examining the impact of mental health problems in RA have focused on depression. We aimed to determine the association between anxiety, and disease activity and quality of life (QoL) in people with RA. METHODS: A systematic review and meta-analysis were performed. A protocol was registered with PROSPERO (CRD2-17062580). Databases (Web of Science, PsycINFO, CINAHL, Embase, Medline) were searched for studies examining the association between anxiety and disease activity and QoL, in adults with RA, from inception to February 2019. Primary outcome measures were DAS28 and SF-36. Eligibility screening and data extraction were completed by two reviewers. Disagreements were resolved by discussion or a third reviewer. Quality assessment was carried out using the Newcastle-Ottawa Scale. RESULTS: From 7712 unique citations, 60 articles were assessed for eligibility. The final review included 20 studies involving 7452 people with RA (14 cross-sectional, 6 cohort). Eleven examined disease activity, 6 reported QoL outcome measures and 3 included both. Anxiety was associated with increased disease activity and worse QoL. Meta-analysis showed anxiety to be correlated with increased DAS28 scores (r = 0.23, CI 0.14, 0.31) and reduced physical (r = - 0.39, CI - 0.57, - 0.20) and mental QoL (- 0.50, CI - 0.57, - 0.43). CONCLUSIONS: Anxiety in people with RA is associated with increased disease activity and worse QoL. Improved recognition and management of comorbid anxiety may help to improve outcomes for people with RA.Key Points• This is the first systematic review and meta-analysis to examine the relationship between anxiety and disease activity and QoL in people with RA.• Anxiety was associated with higher disease activity both cross-sectionally and at up to 12-month follow-up.• Anxiety may have a more significant impact on disease activity in early RA, highlighting the importance of early recognition and management of comorbid anxiety.• People with anxiety had poorer self-reported physical and mental QoL, although there was some heterogeneity in study findings, particularly for physical QoL (I2 = 78.5%).

Interleukin (IL)-1 family cytokines are important initiators of innate immunity and host defence; however, their uncontrolled activities can cause tissue-damaging inflammation. Consequently, IL-1 family cytokines have sophisticated regulatory mechanisms to control their activities including proteolytic processing for their activation and the deployment of soluble receptors and receptor antagonists to limit their activities. IL-33 is a promoter of type 2 immunity and allergic inflammation through its alarmin activity that can rapidly initiate local immune responses by stimulating innate immune cells following exposure to environmental insults, pathogens, or sterile injury. Recent publications have provided new insights into how the range and duration of IL-33 activity is regulated by direct sensing of host-derived and exogenous proteolytic activities as well as oxidative changes during tissue damage. Here, we discuss how this impacts our understanding of the roles of IL-33 in initiating immune responses and the evidence that these sensing mechanisms might regulate the activities of other IL-1 family cytokines and their biological functions. Finally, we discuss translational challenges these discoveries pose for the accurate detection of different forms of these cytokines.

Although treat-to-target has revolutionised the outcomes of patients with rheumatoid arthritis (RA) there is emerging evidence that attaining the target of remission is insufficient to normalise patients’ quality of life, and ameliorate the extra-articular impacts of RA. RA has a broad range of effects on patient’s lives, with four key “extra-articular” impacts being pain, depression and anxiety, fatigue and rheumatoid cachexia. All of these are seen frequently; for example, studies have reported that 1 in 4 patients with RA have high-levels of fatigue. Commonly used drug treatments (including simple analgesics, non-steroidal anti-inflammatory drugs and anti-depressants) have, at most, only modest benefits and often cause adverse events. Psychological strategies and dynamic and aerobic exercise all reduce issues like pain and fatigue, although their effects are also only modest. The aetiologies of these extra-articular impacts are multifactorial, but share overlapping components. Consequently, patients are likely to benefit from management strategies that extend beyond the assessment and treatment of synovitis, and incorporate more broad-based, or “holistic”, assessments of the extra-articular impacts of RA and their management, including non-pharmacological approaches. Innovative digital technologies (including tablet and smartphone “apps” that directly interface with hospital systems) are increasingly available that can directly capture patient-reported outcomes during and between clinic visits, and include them within electronic patient records. These are likely to play an important future role in delivering such approaches.

As primary care clinicians are typically the first point of contact for patients with musculoskeletal problems, they are crucial to the early diagnosis and treatment of patients with an incident inflammatory arthritis, like rheumatoid arthritis. Current UK and international guidelines recognise this, recommending the prompt referral of patients with suspected persistent synovitis to secondary care. In England and Wales, this is advised to occur within 3 working days. However, recent audit data suggests this recommendation is infrequently met, with some patients waiting many months for referral. In this review article we will discuss the various challenges to achieving the early referral of patients with a new-onset inflammatory arthritis from primary to secondary care. We will also describe how these challenges could potentially be overcome, with the ultimate goal of ensuring that the right patients are referred to the right services, and at the right time.

Two different Janus kinase (JAK) inhibitors-baricitinib and tofacitinib-are effective and licensed in active rheumatoid arthritis (RA). There have been recent concerns about potential thromboembolic risks with these drugs. Concerns about baricitinib focus on clinical trial findings. Using all publically available data, we estimate thromboembolic risks are approximately five events per 1000 patient years with 4 mg baricitinib daily. Concerns about tofacitinib have been raised by analyses of the Federal Drug Administration Adverse Event Reporting System (FAERs). These show some evidence of increased risks of pulmonary thrombosis, though not pulmonary embolism or venous thrombosis. Observational studies suggest in the general population and non-RA controls there are one to four thromboembolic events per 1000 patient years. In RA, thromboembolic risks increase to three to seven per 1000 patient years. The impact of biologics and disease-modifying anti-rheumatic drugs (DMARDs) on disease risk appears minimal, and the number of thromboembolic events is between four and eight per 1000 patient years. In the short term, full details of thromboembolic events in trials of JAK inhibitors need to be published. As the numbers of thromboembolic events will be small and patients enrolled in trials are not representative of all RA patients who may receive JAK inhibitors, this information is unlikely to provide definitive answers. Consequently, in the longer term, large observational studies are needed to accurately quantify thromboembolic risks attributable to JAK inhibitors and other drugs used to treat RA, and differentiate these from risks attributable to RA itself and its comorbidities.

Methotrexate (MTX) monotherapy is a common first treatment for rheumatoid arthritis (RA), but many patients do not respond adequately. In order to identify genetic predictors of response, we have combined data from two consortia to carry out a genome-wide study of response to MTX in 1424 early RA patients of European ancestry. Clinical endpoints were change from baseline to 6 months after starting treatment in swollen 28-joint count, tender 28-joint count, C-reactive protein and the overall 3-component disease activity score (DAS28). No single nucleotide polymorphism (SNP) reached genome-wide statistical significance for any outcome measure. The strongest evidence for association was with rs168201 in NRG3 (p = 10−7 for change in DAS28). Some support was also seen for association with ZMIZ1, previously highlighted in a study of response to MTX in juvenile idiopathic arthritis. Follow-up in two smaller cohorts of 429 and 177 RA patients did not support these findings, although these cohorts were more heterogeneous.

Genomic sequencing has driven precision-based oncology therapy; however, the genetic drivers of many malignancies remain unknown or non-targetable, so alternative approaches to the identification of therapeutic leads are necessary. Ependymomas are chemotherapy-resistant brain tumours, which, despite genomic sequencing, lack effective molecular targets. Intracranial ependymomas are segregated on the basis of anatomical location (supratentorial region or posterior fossa) and further divided into distinct molecular subgroups that reflect differences in the age of onset, gender predominance and response to therapy1,2,3. The most common and aggressive subgroup, posterior fossa ependymoma group A (PF-EPN-A), occurs in young children and appears to lack recurrent somatic mutations2. Conversely, posterior fossa ependymoma group B (PF-EPN-B) tumours display frequent large-scale copy number gains and losses but have favourable clinical outcomes1,3. More than 70% of supratentorial ependymomas are defined by highly recurrent gene fusions in the NF-κB subunit gene RELA (ST-EPN-RELA), and a smaller number involve fusion of the gene encoding the transcriptional activator YAP1 (ST-EPN-YAP1)1,3,4. Subependymomas, a distinct histologic variant, can also be found within the supratetorial and posterior fossa compartments, and account for the majority of tumours in the molecular subgroups ST-EPN-SE and PF-EPN-SE. Here we describe mapping of active chromatin landscapes in 42 primary ependymomas in two non-overlapping primary ependymoma cohorts, with the goal of identifying essential super-enhancer-associated genes on which tumour cells depend. Enhancer regions revealed putative oncogenes, molecular targets and pathways; inhibition of these targets with small molecule inhibitors or short hairpin RNA diminished the proliferation of patient-derived neurospheres and increased survival in mouse models of ependymomas. Through profiling of transcriptional enhancers, our study provides a framework for target and drug discovery in other cancers that lack known genetic drivers and are therefore difficult to treat., This work was supported by an Alex's Lemonade Stand Young Investigator Award (S.C.M.), The CIHR Banting Fellowship (S.C.M.), The Cancer Prevention Research Institute of Texas (S.C.M., RR170023), Sibylle Assmus Award for Neurooncology (K.W.P.), the DKFZ-MOST (Ministry of Science, Technology & Space, Israel) program in cancer research (H.W.), James S. McDonnell Foundation (J.N.R.) and NIH grants: CA154130 (J.N.R.), R01 CA169117 (J.N.R.), R01 CA171652 (J.N.R.), R01 NS087913 (J.N.R.) and R01 NS089272 (J.N.R.). R.C.G. is supported by NIH grants T32GM00725 and F30CA217065. M.D.T. is supported by The Garron Family Chair in Childhood Cancer Research, and grants from the Pediatric Brain Tumour Foundation, Grand Challenge Award from CureSearch for Children’s Cancer, the National Institutes of Health (R01CA148699, R01CA159859), The Terry Fox Research Institute and Brainchild. M.D.T. is also supported by a Stand Up To Cancer St. Baldrick’s Pediatric Dream Team Translational Research Grant (SU2C-AACR-DT1113).

BACKGROUND In this study, we reveal a previously undescribed role of the HACE1 (HECT domain and Ankyrin repeat Containing E3 ubiquitin-protein ligase 1) tumor suppressor protein in normal vertebrate heart development using the zebrafish (Danio rerio) model. We examined the link between the cardiac phenotypes associated with hace1 loss of function to the expression of the Rho small family GTPase, rac1, which is a known target of HACE1 and promotes ROS production via its interaction with NADPH oxidase holoenzymes. RESULTS We demonstrate that loss of hace1 in zebrafish via morpholino knockdown results in cardiac deformities, specifically a looping defect, where the heart is either tubular or "inverted". Whole-mount in situ hybridization of cardiac markers shows distinct abnormalities in ventricular morphology and atrioventricular valve formation in the hearts of these morphants, as well as increased expression of rac1. Importantly, this phenotype appears to be directly related to Nox enzyme-dependent ROS production, as both genetic inhibition by nox1 and nox2 morpholinos or pharmacologic rescue using ROS scavenging agents restores normal cardiac structure. CONCLUSIONS Our study demonstrates that HACE1 is critical in the normal development and proper function of the vertebrate heart via a ROS-dependent mechanism. Developmental Dynamics 247:289-303, 2018. © 2017 Wiley Periodicals, Inc.