Genetic landscape of common epilepsies: advancing towards precision in treatment

Epilepsy, a neurological disease characterized by recurrent seizures, is highly heterogeneous in nature. Based on the prevalence, epilepsy is classified into two types: common and rare epilepsies. Common epilepsies affecting nearly 95% people with epilepsy, comprise generalized epilepsy which encompass idiopathic generalized epilepsy like childhood absence epilepsy, juvenile myoclonic epilepsy, juvenile absence epilepsy and epilepsy with generalized tonic-clonic seizure on awakening and focal epilepsy like temporal lobe epilepsy and cryptogenic focal epilepsy. In 70% of the epilepsy cases, genetic factors are responsible either as single genetic variant in rare epilepsies or multiple genetic variants acting along with different environmental factors as in common epilepsies. Genetic testing and precision treatment have been developed for a few rare epilepsies and is lacking for common epilepsies due to their complex nature of inheritance. Precision medicine for common epilepsies require a panoramic approach that incorporates polygenic background and other non-genetic factors like microbiome, diet, age at disease onset, optimal time for treatment and other lifestyle factors which influence seizure threshold. This review aims to comprehensively present a state-of-art review of all the genes and their genetic variants that are associated with all common epilepsy subtypes. It also encompasses the basis of these genes in the epileptogenesis. Here, we discussed the current status of the common epilepsy genetics and address the clinical application so far on evidence-based markers in prognosis, diagnosis, and treatment management. In addition, we assessed the diagnostic predictability of a few genetic markers used for disease risk prediction in individuals. A combination of deeper endo-phenotyping including pharmaco-response data, electro-clinical imaging, and other clinical measurements along with genetics may be used to diagnose common epilepsies and this marks a step ahead in precision medicine in common epilepsies management

Francisella tularensis Elicits IL-10 via a PGE2-Inducible Factor, to Drive Macrophage MARCH1 Expression and Class II Down-Regulation

Francisella tularensis is a bacterial pathogen that uses host-derived PGE2 to subvert the host's adaptive immune responses in multiple ways. Francisella-induced PGE2 acts directly on CD4 T cells to blunt production of IFN-γ. Francisella-induced PGE2 can also elicit production of a >10 kDa soluble host factor termed FTMØSN (F. tularensis macrophage supernatant), which acts on IFN-γ pre-activated MØ to down-regulate MHC class II expression via a ubiquitin-dependent mechanism, blocking antigen presentation to CD4 T cells. Here, we report that FTMØSN-induced down-regulation of MØ class II is the result of the induction of MARCH1, and that MØ expressing MARCH1 “resistant” class II molecules are resistant to FTMØSN-induced class II down-regulation. Since PGE2 can induce IL-10 production and IL-10 is the only reported cytokine able to induce MARCH1 expression in monocytes and dendritic cells, these findings suggested that IL-10 is the active factor in FTMØSN. However, use of IL-10 knockout MØ established that IL-10 is not the active factor in FTMØSN, but rather that Francisella-elicited PGE2 drives production of a >10 kDa host factor distinct from IL-10. This factor then drives MØ IL-10 production to induce MARCH1 expression and the resultant class II down-regulation. Since many human pathogens such as Salmonella typhi, Mycobacterium tuberculosis and Legionella pneumophila also induce production of host PGE2, these results suggest that a yet-to-be-identified PGE2-inducible host factor capable of inducing IL-10 is central to the immune evasion mechanisms of multiple important human pathogens

TLR2 Signaling Contributes to Rapid Inflammasome Activation during F. novicida Infection

Early detection of microorganisms by the innate immune system is provided by surface-expressed and endosomal pattern recognition receptors (PRRs) such as Toll-like receptors (TLRs). Detection of microbial components by TLRs initiates a signaling cascade leading to the expression of proinflammatory cytokines including IL-6 and IL-1β. Some intracellular bacteria subvert the TLR response by rapidly escaping the phagosome and entering the cytosol. However, these bacteria may be recognized by the inflammasome, a multi-protein complex comprised of a sensor protein, ASC and the cysteine protease caspase-1. Inflammasome activation leads to release of the proinflammatory cytokines IL-1β and IL-18 and death of the infected cell, an important host defense that eliminates the pathogen's replicative niche. While TLRs and inflammasomes are critical for controlling bacterial infections, it is unknown whether these distinct host pathways cooperate to activate defenses against intracellular bacteria.Using the intracellular bacterium Francisella novicida as a model, we show that TLR2(-/-) macrophages exhibited delayed inflammasome activation compared to wild-type macrophages as measured by inflammasome assembly, caspase-1 activation, cell death and IL-18 release. TLR2 also contributed to inflammasome activation in response to infection by the cytosolic bacterium Listeria monocytogenes. Components of the TLR2 signaling pathway, MyD88 and NF-κB, were required for rapid inflammasome activation. Furthermore, TLR2(-/-) mice exhibited lower levels of cell death, caspase-1 activation, and IL-18 production than wild-type mice upon F. novicida infection.These results show that TLR2 is required for rapid inflammasome activation in response to infection by cytosolic bacterial pathogens. In addition to further characterizing the role of TLR2 in host defense, these findings broaden our understanding of how the host integrates signals from spatiotemporally separated PRRs to coordinate an innate response against intracellular bacteria

RNA metabolism is the primary target of formamide in vivo

The synthesis, processing and function of coding and non-coding RNA molecules and their interacting proteins has been the focus of a great deal of research that has boosted our understanding of key molecular pathways that underlie higher order events such as cell cycle control, development, innate immune response and the occurrence of genetic diseases. In this study, we have found that formamide preferentially weakens RNA related processes in vivo. Using a non-essential Schizosaccharomyces pombe gene deletion collection, we identify deleted loci that make cells sensitive to formamide. Sensitive deletions are significantly enriched in genes involved in RNA metabolism. Accordingly, we find that previously known temperature-sensitive splicing mutants become lethal in the presence of the drug under permissive temperature. Furthermore, in a wild type background, splicing efficiency is decreased and R-loop formation is increased in the presence of formamide. In addition, we have also isolated 35 formamide-sensitive mutants, many of which display remarkable morphology and cell cycle defects potentially unveiling new players in the regulation of these processes. We conclude that formamide preferentially targets RNA related processes in vivo, probably by relaxing RNA secondary structures and/or RNA-protein interactions, and can be used as an effective tool to characterize these processes

Host-Adaptation of Francisella tularensis Alters the Bacterium's Surface-Carbohydrates to Hinder Effectors of Innate and Adaptive Immunity

The gram-negative bacterium Francisella tularensis survives in arthropods, fresh water amoeba, and mammals with both intracellular and extracellular phases and could reasonably be expected to express distinct phenotypes in these environments. The presence of a capsule on this bacterium has been controversial with some groups finding such a structure while other groups report that no capsule could be identified. Previously we reported in vitro culture conditions for this bacterium which, in contrast to typical methods, yielded a bacterial phenotype that mimics that of the bacterium's mammalian, extracellular phase.SDS-PAGE and carbohydrate analysis of differentially-cultivated F. tularensis LVS revealed that bacteria displaying the host-adapted phenotype produce both longer polymers of LPS O-antigen (OAg) and additional HMW carbohydrates/glycoproteins that are reduced/absent in non-host-adapted bacteria. Analysis of wildtype and OAg-mutant bacteria indicated that the induced changes in surface carbohydrates involved both OAg and non-OAg species. To assess the impact of these HMW carbohydrates on the access of outer membrane constituents to antibody we used differentially-cultivated bacteria in vitro to immunoprecipitate antibodies directed against outer membrane moieties. We observed that the surface-carbohydrates induced during host-adaptation shield many outer membrane antigens from binding by antibody. Similar assays with normal mouse serum indicate that the induced HMW carbohydrates also impede complement deposition. Using an in vitro macrophage infection assay, we find that the bacterial HMW carbohydrate impedes TLR2-dependent, pro-inflammatory cytokine production by macrophages. Lastly we show that upon host-adaptation, the human-virulent strain, F. tularensis SchuS4 also induces capsule production with the effect of reducing macrophage-activation and accelerating tularemia pathogenesis in mice.F. tularensis undergoes host-adaptation which includes production of multiple capsular materials. These capsules impede recognition of bacterial outer membrane constituents by antibody, complement, and Toll-Like Receptor 2. These changes in the host-pathogen interface have profound implications for pathogenesis and vaccine development

SAT0645-HPR MYTHS AND MISCONCEPTION ABOUT THE ILLNESS AND CONVENTIONAL SYNTHETIC DMARDS (CSDMARDS) IN PATIENTS WITH SYSTEMIC IMMUNO-INFLAMMATORY RHEUMATIC DISEASES (SIRDS): A STUDY BY RHEUMATOLOGY NURSE COUNSELOR

Background:Myths and misconceptions about illness and conventional disease modifying anti-rheumatic drugs directly influence adherence to the prescribed treatment. It is estimated that 30–50% of patients do not adhere to their prescribed treatment due to various reasons where the beliefs of the patients play a crucial role. At our centre we the specialist rheumatology nurse counsel the patients at every visit and try to remove their myths and negative beliefs about the disease as well as the medications.Objectives:•To explore the common myths and misconceptions of regarding their disease and regarding the csDMARDs.•To assess the efficacy of counseling in allaying their unfounded fear.Methods:A total of 450 patients with SIRDs at least 3 times attended the rheumatology out-patient clinic on csDMARDs were enrolled to complete a questionnaire that, besides demographic information, socio-economic status, and co- morbidities, had the following questions:1.Self reported adherence to medication2.Misbelieves regarding food items3.What kind of health-provider was consulted at the onset of the symptoms4.Their belief/knowledge regarding:A. The need for physiotherapy.B. Life style modification requirementC. About osteoarthritisD. Medication requirement during remissionE. Pregnancy and DMARDsF. The need of vaccinationG. Health hazards of smoking and alcohol useH. Harms of discontinuing treatment when they felt wellResults:A total of 450 patients included spondyloarthropathy 150(34%), rheumatoid arthritis 200(45.7%), psoriatic arthritis 45(10%), and others 25(5.5%).The following observations was made:1.Self-reported adherence to medication was in 250 (55%) patients; 200(45%) patient were non-adherent to treatment2.382/450 (85%) patients had misbelieves regarding different food items.3.225/450(50)% of the patients were not doing regular physiotherapy they were totally dependent on medications for symptoms relief.4.387/450 (86%) patients confused the symptoms of osteoarthritis with that of RA.5.315/450 (70 %) patients did not feel the requirement of continuing drugs during remission.6.135/450 (30%) patients believed that while on DMARDs they cannot contemplate pregnancy.7.351/450(78%) patients accept the need for vaccination when staring DMARDs8.360/450 (80%) patients aware about side effect of smoking in disease but only 40 % were able to quit.9.273/450 (60%) patients felt that more expensive medicines e.g.bDMARDs have more effects.10.360/450 (80%) patients believed that DMARDs were ‘steroids’ and they increased weight. On analysis one patient have more than two myths simultaneously.Conclusion:Increased awareness of the patient’s beliefs about medicines is needed among health care providers. We should encourage patients to express their views about medicines as well as disease in order to optimize and personalize the information process. This can stimulate concordance and adherence to medication and follow up.These myths are deeply rooted in our society, single sitting counseling is not enough, and reinforcement is needed.References:[1]Tom Greenhalgh. Facts about rheumatoid arthritis: 7 myths you may encounter. Rheumatology Advisor. March 28, 2019.Acknowledgments:noDisclosure of Interests:None declared</jats:sec

SAT0644-HPR COMPLIANCE OF BIOLOGIC DISEASES MODIFYING ANTI-RHEUMATIC DRUGS (BDMARDS) WITH SYSTEMIC IMMUNO-INFLAMMATORY RHEUMATIC DISEASES (SIRDS). AN ASSESSMENT OF PATIENTS’ ADHERENCE AND NON- ADHERENCE CONCERNS.

Background:Patients with systemic immunoinflammatory rheumatic diseases (SIRDs) are often treated with bDMARDs when the response to conventional disease-modifying antirheumatic drugs (csDMARDs) is inadequate.There are, however, concerns about non-adherence to bDMARDs among patient. The non-adherence to bDMARDs may be caused by the various factors.Objectives:1.The main objective of present study was to find out the cause of discontinuation of bDMARDs2.To find out the adherence and non-adherence rate for bDMARDs.3.To identify the factors that are modifiable.Methods:800patients with SIRDs prescribed bDMARDs were interviewed to find out the demographic information, their socioeconomic status,and the disease duration.Additional information gathered included the comorbidities, the time for starting bDMARDs, the route of administration of bDMARDs, beliefs and perceptions about treatment efficacy and side effects if any.This was followed by looking at the adherence of bDMARDs; if they had discontinued then efforts was made to find out the reasons for the same.Based on these findings the patients were classified into adherent and non-adherent categories. The data were analyzed further for1.Factors that associated with persistence of bDMARDs.2.Factors that were associated with discontinuation of bDMARDs.Results:A total of 800 patients were interviewed that included patients with ankylosing spondylitis 430(52.4%), rheumatoid arthritis 300(37.7%), psoriatic arthritis 45(5.2%), and others 25 (0.7%).On analysis 610(76%) patient were compliant but 190(24%) patient had discontinued the bDMARDs on their own. On comparison of both groupsFactors that were significantly related to self-discontinuation were:•Negative beliefs about biologics (37%)•Cost (33%)•Reading side-effect profile on Google search (25%)•Other co-morbidities (6%)Factors that were significantly related to persistence of biologic treatment were:•Good counseling by rheumatologist and rheumatology nurse (60%)•Faith in the treating rheumatologist (25%)•Fear of deformities and pain(15%)On analysis it was found that a good counseling and clarifying the doubts of the patients regarding bDMARDs before starting the treatment encourages the patient to continue the biologic treatment, especially it allays their doubts about the drug adverse effects.Conclusion:Despite negative beliefs and misconceptions about bDMARDs, patient non-adherence at our center is not alarming.A positive reinforcement counseling appears to be the most significant factor to overcome the negative belief of patients.The affordability of the biologic treatment however remains a limiting factor in our centre as in other parts of India.References:[1]Tamas Koncz,MD,Marta,Pentek,Valentin,Brodszky,Katalin Ersek,MSc,Ewaorlewska&amp;Laszlo Gulasi Volume10,2010 –Issue9 Adherence to biologic DMARD therapies in rheumatoid arthritisAcknowledgments:noDisclosure of Interests:None declared</jats:sec