Prevalence and risk factors of bowel symptoms in Korean patients with ulcerative colitis in endoscopic remission: a retrospective study

BACKGROUND

Many patients with ulcerative colitis (UC) in clinical remission frequently complain of bowel symptoms such as increased stool frequency (SF) and rectal bleeding (RB). However, studies on these patient-reported outcomes in patients with inactive UC are limited, especially in Korea. Therefore, we investigated the prevalence and risk factors of bowel symptoms in Korean patients with inactive UC.

METHODS

We investigated the prevalence of bowel symptoms in patients with endoscopically quiescent UC between June 1989 and December 2016 using a well-characterized referral center-based cohort. The Mayo clinic score (MCS) was used to evaluate bowel symptoms at the most recent visit near the date of endoscopy. Clinical characteristics of the patients were compared based on the presence or absence of bowel symptoms.

RESULTS

Overall, 741 patients with endoscopically quiescent UC were identified, of whom 222 (30%) and 48 (6.5%) had an SF and RB subscore of ≥ 1, respectively. Patients with bowel symptoms (SF + RB ≥ 1; n = 244 [32.9%]) had higher rates of left-sided colitis (E2) or extensive colitis (E3) than patients without bowel symptoms (SF + RB = 0; n = 497 [67.1%]; P = 0.002). Multivariate analysis revealed that female sex (odds ratio [OR]: 1.568; 95% confidence interval [CI]: 1.023-2.402; P = 0.039) and E2 or E3 (OR 1.411; 95% CI 1.020-1.951; P = 0.038) were the significant risk factors for increased SF.

CONCLUSIONS

This study revealed that one-third of patients with endoscopically quiescent UC reported increased SF. Female sex and disease extent may be associated with bowel symptoms.

Frequency of Positive Conversion of Interferon-Gamma Release Assay Results Among Patients With Inflammatory Bowel Disease Treated With Non-tumor Necrosis Factor Inhibitors

Considering the risk of reactivation of latent tuberculosis infection (LTBI), not only before starting tumor necrosis factor inhibitors but also before non-TNF inhibitor therapy, LTBI screening is routinely recommended for patients with inflammatory bowel disease (IBD). However, data on the positive conversion of LTBI test results during non-TNF inhibitor therapy are scarce. Among IBD patients treated with vedolizumab and/or ustekinumab, a total of 91 patients who had negative baseline interferon-gamma release assay (IGRA) results, assessed by QuantiFERON^®-TB Gold In-tube or QuantiFERON^®-TB Gold Plus, were enrolled. Serial LTBI test results after starting non-TNF inhibitor therapy were collected, and patients' clinical characteristics were analyzed. Positive IGRA conversion was observed in six of 91 patients (6.6%). The cumulative IGRA conversion-free survival rates after starting therapy were 97.7% after 1 year and 86.7% after 2 years. Ulcerative colitis was more common among converters compared with non-converters (66.7 vs. 23.5%, P = 0.040). Among six converters, four had been treated with vedolizumab, one with ustekinumab, and the other with vedolizumab followed by ustekinumab. All six patients had been previously exposed to TNF inhibitors before non-TNF inhibitor therapy: five to infliximab and one to both infliximab and adalimumab. After positive IGRA conversion, none of the six converters developed active tuberculosis while maintaining non-TNF inhibitor therapy (median 6.8 months, range 0.4-32.1 months). Positive IGRA conversion among IBD patients treated with vedolizumab and/or ustekinumab appears to occur somewhat frequently, but its clinical implications remain to be elucidated.

A randomized phase III trial comparing adjuvant single-agent S1, S-1 with oxaliplatin, and postoperative chemoradiation with S-1 and oxaliplatin in patients with node-positive gastric cancer after D2 resection: the ARTIST 2 trial☆

BACKGROUND

Adjuvant chemotherapy and chemoradiotherapy are some of the standards of care for gastric cancer (GC). The Adjuvant chemoRadioTherapy In Stomach Tumors (ARTIST) 2 trial compares two adjuvant chemotherapy regimens and chemoradiotherapy in patients with D2-resected, stage II or III, node-positive GC.

PATIENTS AND METHODS

The ARTIST 2 compared, in a 1:1:1 ratio, three adjuvant regimens: oral S-1 (40-60 mg twice daily 4 weeks on/2 weeks off) for 1 year, S-1 (2 weeks on/1 week off) plus oxaliplatin 130 mg/m² every 3 weeks (SOX) for 6 months, and SOX plus chemoradiotherapy 45 Gy (SOXRT). Randomization was stratified according to surgery type (total or subtotal gastrectomy), pathologic stage (II or III), and Lauren histologic classification (diffuse or intestinal/mixed). The primary endpoint was disease-free survival (DFS) at 3 years; a reduction of 33% in the hazard ratio (HR) for DFS with SOX or SOXRT, when compared with S-1, was considered clinically meaningful. The trial is registered at clinicaltrials.gov (NCT0176146).

RESULTS

A total of 546 patients were recruited between February 2013 and January 2018 with 182, 181, and 183 patients in the S-1, SOX, and SOXRT arms, respectively. Median follow-up period was 47 months, with 178 DFS events observed. Estimated 3-year DFS rates were 64.8%, 74.3%, and 72.8% in the S-1, SOX, and SOXRT arms, respectively. HR for DFS in the control arm (S-1) was shorter than that in the SOX and SOXRT arms: S-1 versus SOX, 0.692 (P = 0.042) and S-1 versus SOXRT, 0.724 (P = 0.074). No difference in DFS was found between SOX and SOXRT (HR 0.971; P = 0.879). Adverse events were as anticipated in each arm, and were generally well-tolerated and manageable.

CONCLUSIONS

In patients with curatively D2-resected, stage II/III, node-positive GC, adjuvant SOX or SOXRT was effective in prolonging DFS, when compared with S-1 monotherapy. The addition of radiotherapy to SOX did not significantly reduce the rate of recurrence after D2 gastrectomy.

Safety and Optimal Timing of BCG Vaccination in Infants Born to Mothers Receiving Anti-TNF Therapy for Inflammatory Bowel Disease

BACKGROUNDS AND AIMS

We aimed to evaluate the safety of Bacille Calmette-Guérin [BCG] vaccination in infants born to mothers receiving anti-tumour necrosis factor [anti-TNF] therapy for inflammatory bowel disease.

METHODS

Adverse events of BCG vaccination were evaluated in 90 infants who were last exposed to anti-TNF agents at a median of gestational week 30.

RESULTS

After receiving BCG vaccination at a median age of 6 months [range, 0.25-11 months], three infants [3.3%] showed injection site swelling, two of whom also showed axillar lymphadenopathy. The rates of adverse events were similar between infants who were last exposed to anti-TNF agents before the third trimester [n = 35] and those who were last exposed in the third trimester [n = 55] [2.9% vs 3.6%; p = 1.00]. All adverse events were spontaneously resolved and there were no serious adverse events such as active tuberculosis infection or death.

CONCLUSIONS

BCG vaccination after 6 months of age is of low risk in infants exposed to anti-TNF agents in utero.

Long-term clinical outcomes of endoscopic submucosal dissection for colorectal neoplasia with or without the hybrid technique

AIM

The main aim of this study was to compare the long-term outcome of a conventional colorectal endoscopic submucosal dissection (ESD) in which submucosal dissection was continued throughout until the completion of resection (ESD-T) to hybrid endoscopic submucosal dissection (ESD-H) in the colorectum.

METHOD

Medical records of 836 colorectal neoplasia patients treated by ESD-T or ESD-H were reviewed. ESD-H was defined as colorectal ESD with additional snaring in the final stage of the procedure. Primary outcomes were the overall and metastatic recurrence rates. Secondary outcomes were short-term outcomes such as the en bloc resection rate, procedure time and adverse events.

RESULTS

The overall recurrence rate was higher in the ESD-H than in the ESD-T group (5.7% vs 0.7%, P = 0.001). The metastatic recurrence rate showed no significant difference between these groups (1.4% vs 1.4%, P = 1.000). Multivariate analysis revealed that a failed en bloc resection (hazard ratio 24.097; 95% CI 5.446-106.237; P < 0.001) and larger tumour size (hazard ratio 1.042; 95% CI 1.014-1.070; P = 0.003) were independently associated with overall recurrence. The ESD-H group showed a lower en bloc resection rate (56.8% vs 96.5%, P < 0.001), shorter procedure time (45.6 vs 54.3 min, P < 0.001) and higher perforation rate (10.3% vs 6.0%, P = 0.029).

CONCLUSION

Although long-term outcomes in terms of overall recurrence are inferior following ESD-H, a failed en bloc resection and large tumour size are the only independent risk factors for recurrence. Further investigations are warranted to improve the long-term outcomes of ESD-H.

Low-dose CT angiography of the lower extremities: a comparison study of image quality and radiation dose

AIM

To investigate the image quality and radiation dose of ultralow-dose (ULD) and low-dose (LD) lower-extremity computed tomography (CT) angiography (LE-CTA) using the advanced modelled iterative reconstruction (ADMIRE) algorithm to detect peripheral arterial disease (PAD) in comparison with standard-dose (SD) CT.

MATERIALS AND METHODS

One hundred and seven consecutive patients were examined using LE-CTA at 70 kVp and a dual-source scanner to achieve three image sets using 30% (ULD), 70% (LD), and 100% (SD) tube loads. Qualitative analysis was conducted by examining the three image sets for overall quality. The image quality of arterial segments was analysed by two independent readers. In addition, the CT dose index (CTDI_vol) was measured in the three image sets.

RESULTS

The mean overall quality scores were 3.4±0.6 for ULD CT, 3.9±0.3 for LD CT, and 3.9±0.2 for SD CT. Both readers scored the arterial segments as 2-4 (adequate-excellent) in the three image sets. In addition, 89.4% (93/104) and 54.8% (57/104) segments of PAD with calcified plaques were scored 4 between SD and LD CT and between SD and ULD CT, respectively, and 45.2% (47/104) segments had a lower score by one point in ULD CT compared with SD CT. The mean CTDI_vol was 4.1±1.1 mGy for SD CT, 2.9±0.8 mGy for LD CT, and 1.2±0.3 mGy for ULD CT.

CONCLUSIONS

LD/ULD CT at 70 kVp using ADMIRE reconstruction enables a reduction in the radiation dose while enabling adequate evaluation or follow-up of PAD based on LE-CTA.

A laboratory study to detect simulated pulpal blood flow in extracted human teeth using ultrasound Doppler flowmetry

AIM

To develop a laboratory-based tooth model of simulated blood flow in teeth and evaluate it using ultrasound Doppler flowmetry (UDF).

METHODOLOGY

A laboratory-based tooth model for UDF was created based on a microfluidic experimental model proposed by Kim & Park (2016 a,b). Twenty-one maxillary or mandibular anterior human teeth within 1 month of extraction were used. Four holes were made in each tooth to fit 1.6-mm diameter polytetrafluoroethylene (PTFE) tubes: at the apical foramen, palatal surface in the centre of the crown, palatal surface apical to the cementoenamel junction (CEJ) and the root centre. Fluid mimicking pulsating blood was pumped (pressure range: 0-200 mbar, flow rate range: 0-80 μL min^-1 ) into the apical foramen via the PTFE tubes, which exited the tooth through the palatal surface in the centre of the crown (control group), palatal surface below the CEJ (group 1) and the palatal surface at the mid-root level (group 2). An UDF transducer of 20 MHz was placed at a 60° angle to the labial surface of tooth and was used to measure the fluid flow velocity (Vs, Vas, Vm, Vam, Vd, Vad and Vakd). The flow velocity of the different groups was compared using the Wilcoxon signed-rank test, with a 95% confidence level.

RESULTS

UDF facilitated the detection of the simulated pulpal blood flow in the control group and group 1, but not in group 2. The mean and standard deviations of Vas, Vam and Vakd were 0.921 ± 0.394, 0.479 ± 0.208 and 0.396 ± 0.220 cm s^-1 , respectively, in the control group, and 0.865 ± 0.368, 0.424 ± 0.215 and 0.487 ± 0.279 cm s^-1 , respectively, in group 1. The pulpal blood flow values of the control group and group 1 were not significantly different (p > 0.05).

CONCLUSIONS

This laboratory study revealed that ultrasound Doppler flowmetry enabled the detection of simulated blood flow below the level of the CEJ but not at the mid-root level.

Association of Faecal Calprotectin Level and Combined Endoscopic and Radiological Healing in Patients With Crohn's Disease Receiving Anti-tumour Necrosis Factor Therapy

BACKGROUND AND AIMS

Combined endoscopic and radiological healing, or deep healing, is associated with favourable outcomes in patients with Crohn's disease; thus, a non-invasive biomarker for predicting deep healing would be invaluable. We evaluated the usefulness of faecal calprotectin for predicting deep healing in patients with Crohn's disease receiving anti-tumour necrosis factor [TNF] therapy.

METHODS

We analysed the records of patients with Crohn's disease who received anti-tumour necrosis factor therapy and underwent endoscopic evaluation, radiological evaluation, and faecal calprotectin measurement within a period of 3 months between August 2017 and November 2018. Results of endoscopic and radiological studies were independently reviewed by two gastrointestinal endoscopists and a gastrointestinal radiologist, respectively. Serum C-reactive protein and albumin were also measured.

RESULTS

Out of 268 patients analysed, 77 [28.7%] had deep healing, 36 [13.4%] had endoscopic healing only, 36 [13.4%] had radiological healing only, and 119 [44.4%] had neither. The median duration of anti-TNF treatment was 40.0 months. The deep healing group had the lowest median faecal calprotectin level [56.5 mg/kg] among the four groups [p <0.001]. The faecal calprotectin cutoff level of 81.1 mg/kg showed a sensitivity of 0.623 and a specificity of 0.817 in predicting deep healing (area under the receiver operating characteristic curve [AUROC], 0.767; 95% confidence interval, 0.702-0.832). Adding serum C-reactive protein and serum albumin to faecal calprotectin further increased the AUROC to 0.805 [95% confidence interval, 0.752-0.858].

CONCLUSIONS

Faecal calprotectin, when combined with serum C-reactive protein and albumin, showed acceptable performance in predicting deep healing in patients with Crohn's disease.

Induction of cell cycle arrest and apoptosis by tomentosin in hepatocellular carcinoma HepG2 and Huh7 cells

Tomentosin, a sesquiterpene lactone, is known to possess various biological activities. However, its anticarcinogenic activity against human hepatocellular carcinoma (HCC) cells has not been investigated in detail. Thus, this study aimed to elucidate the cytotoxic mechanism of tomentosin in human HCC cell lines HepG2 and Huh7. WST-1, cell counting, and colony formation assay results showed that treatment with tomentosin decreased the viability and suppressed the proliferation rate of HepG2 and Huh7 cells in a dose- and time-dependent manner. Cell cycle analysis revealed increased population of cells at the SubG1 and G2/M stage, and decreased population of cells at the G0/1 stage in HepG2 and Huh7 cells treated with tomentosin. Annexin V/propidium iodide double staining and TUNEL assay results showed increased apoptotic cell population and DNA fragmentation in HepG2 and Huh7 cells treated with tomentosin. Western blotting analysis results showed that tomentosin treatment significantly increased the expression level of Bax, Bim (short form), cleaved PARP1, FOXO3, p53, pSer15p53, pSer20p53, pSer46p53, p21, and p27, but decreased the expression of Bcl2, caspase3, caspase7, caspase9, cyclin-dependent kinase 2 (CDK2), CDK4, CDK6, cyclinB1, cyclinD1, cyclinD2, cyclinD3, and cyclinE in a dose-dependent manner. Taken together, this study revealed that tomentosin, which acted through cell cycle arrest and apoptosis, may be a useful therapeutic option against HCC.

Long-term prognosis of ulcerative colitis and its temporal changes between 1986 and 2015 in a population-based cohort in the Songpa-Kangdong district of Seoul, Korea

OBJECTIVE

No population-based study has evaluated the natural course of UC over three decades in non-Caucasians. We aimed to assess the long-term natural course of Korean patients with UC in a population-based cohort.

DESIGN

This Korean population-based, Songpa-Kangdong IBD cohort included all patients (n=1013) newly diagnosed with UC during 1986-2015. Disease outcomes and their predictors were evaluated.

RESULTS

During the median follow-up of 105 months, the overall use of systemic corticosteroids, thiopurines and antitumour necrosis factor (anti-TNF) agents was 40.8%, 13.9% and 6.5%, respectively. Over time, the cumulative risk of commencing corticosteroids decreased, whereas that of commencing thiopurines and anti-TNF agents increased. During follow-up, 28.7% of 778 patients with proctitis or left-sided colitis at diagnosis experienced proximal disease extension. A total of 28 patients (2.8%) underwent colectomy, demonstrating cumulative risks of colectomy at 1, 5, 10, 20 and 30 years after diagnosis of 1.0%, 1.9%, 2.2%, 5.1% and 6.4%, respectively. Multivariate Cox regression analysis revealed that extensive colitis at diagnosis (HR 8.249, 95% CI 2.394 to 28.430), ever use of corticosteroids (HR 6.437, 95% CI 1.440 to 28.773) and diagnosis in the anti-TNF era (HR 0.224, 95% CI 0.057 to 0.886) were independent predictors of colectomy. The standardised mortality ratio in patients with UC was 0.725 (95% CI 0.508 to 1.004).

CONCLUSION

Korean patients with UC may have a better clinical course than Western patients, as indicated by a lower colectomy rate. The overall colectomy rate has continued to decrease over the past three decades.

Tip-in versus conventional endoscopic mucosal resection for flat colorectal neoplasia 10 mm or larger in size

PURPOSE

A modified endoscopic mucosal resection (EMR) technique, Tip-in EMR, was recently introduced to enhance the complete resection of colorectal neoplasia (CRN). We aimed to evaluate the feasibility of Tip-in EMR for flat CRNs.

METHODS

From January to September 2018, conventional or Tip-in EMR was consecutively performed for 112 flat CRNs ≥ 10 mm in diameter. Tip-in EMR was performed when en bloc snaring was impossible with conventional EMR or when a lesion was inadequately lifted owing to a previous forceps biopsy. We retrospectively collected the clinical, procedural, and histologic data of the conventional and Tip-in EMR groups and compared the en bloc resection rate, complete resection rate, and complications between the two groups.

RESULTS

Among 112 flat CRNs of 80 patients, conventional EMR and Tip-in EMR were performed for 74 and 38 lesions, respectively. The median lesion size was 12 (10-27) mm. Tip-in EMR was superior to conventional EMR in terms of en bloc resection (94.7% vs. 77.0%, p = 0.018) and histologic complete resection (76.3% vs. 54.1%, p = 0.022). There was no difference in postprocedural bleeding between the two groups; however, overall adverse events, including bleeding and postpolypectomy electrocoagulation syndrome, were more frequent in the Tip-in EMR group.

CONCLUSIONS

Tip-in EMR is a feasible technique for flat colorectal lesions ≥ 10 mm and is superior to conventional EMR with respect to en bloc and complete resection rates. The safety profiles of Tip-in EMR and conventional EMR should be compared via large-scale prospective studies.

Concordance regarding disease type and phenotypic characteristics among patients with familial inflammatory bowel disease

BACKGROUND AND AIMS

The phenotypic concordance among familial cases of inflammatory bowel disease (IBD) has been rarely reported. Thus, the present study aimed to evaluate the concordance regarding disease type and phenotypic features in a large cohort of Korean patients with IBD.

METHODS

A total of 6647 patients with IBD who visited the Asan Medical Center between June 1989 and September 2016 were enrolled in the study. When at least two familial cases existed in our cohort, they were included in the concordance analysis (κ index). The concordance between younger and older members for IBD type [Crohn's disease (CD) and ulcerative colitis (UC)] and phenotypic characteristics such as disease extent and location, disease behavior, the use of medication, and need for surgery were evaluated.

RESULTS

A positive family history of IBD was noted in 216 patients with CD (7.0%) and in 238 patients with UC (6.7%). Of all patients, 167 consanguineous pairs in 146 families were identified. The crude concordance rate for IBD type was 82.6% with a κ index of 0.656 [95% confidence interval (CI): 0.545-0.768, good concordance]. There was mild concordance for disease location in CD (κ = 0.256; 95% CI: 0.007-0.505) and for the use of antitumor necrosis factor agents in UC (κ = 0.354; 95% CI: -0.049-0.757). The concordance for IBD type and several phenotypes in first-degree relative pairs was better than that in the entire pairs.

CONCLUSIONS

Disease type and phenotypic characteristics of patients with familial IBD may be anticipated.

Robotic-assisted latissimus dorsi muscle flap for autologous chest reconstruction in poland syndrome

BACKGROUND

As chest reconstructions in Poland syndrome are performed for patients at young ages, patients are generally concerned about conspicuous scars. Meanwhile, a robotic-assisted latissimus dorsi (LD) muscle harvest with inconspicuous scars has been performed for autologous breast reconstruction. As our experience with robotic-assisted LD flap harvest has increased over the years, we have made improvements in surgical techniques to optimize results. The purpose of this study was to introduce and identify the role of the refined robotic-assisted LD muscle flap harvest technique in autologous chest reconstruction in patients with Poland syndrome.

METHODS

Autologous chest reconstruction using a robotic-assisted LD muscle flap harvest was performed for 21 patients with Poland syndrome. Subjective assessments were performed to evaluate improvement in chest deformity, patient satisfaction with overall outcomes, chest symmetry, and scars. Assessments by the operator and two independent evaluating investigators were carried out with patients' photographs. The complication rates and the time for robotic surgery were also evaluated.

RESULTS

At the last visit, the average patient grades for improvement in chest deformity, satisfaction with overall outcomes, chest symmetry, and scars were 4.80, 4.72, 4.18, and 4.87, respectively. Assessments by the operator and two independent evaluating investigators demonstrated that improvement in chest deformity was achieved in all patients. No serious complications such as flap loss were recorded for any patient. The time for robotic surgery markedly decreased as experience accumulated.

CONCLUSIONS

Surgical refinements for robotic-assisted LD flap harvest might be effective and reduce operative times for patients with Poland syndrome.

Long-term Outcomes of Adalimumab Therapy in Korean Patients with Ulcerative Colitis: A Hospital-Based Cohort Study

BACKGROUND/AIMS

Studies on long-term outcomes of adalimumab therapy in non-Caucasian patients with ulcerative colitis (UC) are lacking.

METHODS

We analyzed long-term outcomes of Korean UC patients treated with adalimumab at the Asan Medical Center, Seoul, Korea.

RESULTS

Between July 2013 and October 2018, adalimumab therapy was started in a total of 100 patients with UC (65 males [65.0%]; median age, 39.5 years [interquartile range, 23.3 to 49.8 years]; and median disease duration, 3.0 years [interquartile range, 1.0 to 7.0 years]). The median duration of adalimumab therapy was 13.5 months (interquartile range, 4.0 to 32.0 months). Eight of 100 patients (8.0%) received induction therapy only, four (4.0%) of whom ultimately underwent colectomy. Of 92 patients who received adalimumab maintenance therapy, 30 (30.0%) stopped adalimumab therapy due to loss of response, and one patient (1.0%) was lost to follow-up. Among the 92 patients who received adalimumab maintenance therapy, the cumulative proportions of patients remaining on adalimumab maintenance therapy were 70.0% at 1 year and 48.9% at 5 years. High partial Mayo score after 8 weeks of adalimumab therapy (hazard ratio [HR], 1.217; 95% confidence interval [CI], 1.040 to 1.425; p=0.014) and a history of exposure to two biologic agents before adalimumab therapy (HR, 4.722; CI, 1.033 to 21.586; p=0.045) were predictors of adalimumab discontinuation.

CONCLUSIONS

Long-term outcomes of adalimumab therapy in Korean UC patients appear to be comparable to those in previously published Western studies. Furthermore, previous exposure to multiple biologic agents before adalimumab therapy and disease activity after 8 weeks of adalimumab therapy were predictors of adalimumab discontinuation.

Expression Quantitative Trait Loci (eQTL) Mapping in Korean Patients With Crohn's Disease and Identification of Potential Causal Genes Through Integration With Disease Associations

Background

Expression quantitative trait loci (eQTL) datasets have extensively been used to help interpret genome-wide association study signals. Most eQTL analyses have been conducted with populations of European ancestry.

Objective

To determine the most functionally relevant genes at the Crohn’s disease (CD) loci identified in genome-wide association studies (GWAS) involving Asian populations and to find novel disease-associated genes, we conducted an eQTL analysis.

Methods

eQTL analysis was performed using whole-blood RNA-sequencing of 101 Korean patients with CD. FastQTL was used for a pair-wise genome analysis of ∼ 6.5 M SNPs and ∼ 22 K transcripts.

Results

We identified 135,164 cis-eQTL and 3,816 eGenes with a false discovery rate less than 0.05. A significant proportion of the genes identified in our study overlapped with those identified in previous studies. The significantly enriched pathways of these 3,816 eGenes included neutrophil degranulation and small molecule biosynthetic process. Integrated analysis of CD GWAS with Korean eQTL revealed two putative target genes, TNFSF15 and GPR35, at two previously reported loci, whereas TNFSF15 only with the whole blood data from the Genotype-Tissue Expression (GTEx) project, highlighting the utility of building a population-specific data set, even of modest size. The risk alleles of these genes were found to be associated with lower expression levels of TNFSF15 and GPR35, respectively. Our eQTL browser can be accessed at “http://asan.crohneqtl.com/”.

Conclusion

This resource would be useful for studies that need to employ genome-wide association analyses involving Asian populations.

Changes in prevalence and perception of complementary and alternative medicine use in Korean inflammatory bowel disease patients: results of an 8-year follow-up survey

BACKGROUND/AIMS

The use of complementary and alternative medicine (CAM) is a global phenomenon, including inflammatory bowel disease (IBD) patients. We aimed to assess the change in prevalence and patterns of CAM use, and attitudes towards CAM over an 8-year time interval (2006 vs. 2014) among IBD patients in Korea.

METHODS

A total of 221 IBD patients (CD=142, UC=79) were asked to complete a questionnaire regarding CAM at two time points: at enrollment (2006) and 8 years later (2014/2015).

RESULTS

The proportion of patients ever using CAM increased significantly from 60.2% in 2006 to 79.6% in 2014 (P<0.001), while the proportion of current CAM users increased slightly (35.7% to 38.0%, P=0.635); 21.7% used CAM consistently at both time points. The proportion of patients who felt CAM was less effective (P<0.001) and more expensive (P=0.04) than conventional treatments increased over time. Also, the proportion among ever CAM users who perceived a positive effect from CAM significantly decreased in 2014 compared to 2006 (P=0.004). Higher education (adjusted odds ratio [aOR], 2.10), prior side effects to conventional therapies (aOR, 2.23), and prior use of corticosteroids (aOR, 2.51) were associated with CAM use. Interestingly, use of CAM before IBD diagnosis (aOR, 2.73) was significantly associated with consistent CAM use.

CONCLUSIONS

Although the attitudes toward CAM have become less favorable, the majority of IBD patients have experienced CAM with an overall increase of current CAM users over time. Moreover, more than half of current CAM users used CAM consistently over time.

Cost of Endoscopic Submucosal Dissection Versus Endoscopic Piecemeal Mucosal Resection in the Colorectum

BACKGROUND

Few studies have compared the costs of colorectal endoscopic submucosal dissection (ESD) and endoscopic piecemeal mucosal resection (EPMR).

AIMS

Here, we aimed to investigate the cost-effectiveness of these approaches by analyzing clinical outcomes and costs.

METHODS

Data from patients undergoing colorectal ESD and EPMR were retrospectively reviewed. Clinical outcomes (procedure time, complete resection, and recurrence) were compared, and total direct costs (procedural and follow-up) were assessed.

RESULTS

Data from 429 ESD and 115 EPMR patients were included in the analysis. The complete resection rate was significantly higher (83.9% vs. 32.2%, p < 0.001), recurrence rate was lower (0.5% vs. 7.1%, p < 0.001), procedure time was longer (55.4 ± 47.0 vs. 25.6 ± 32.7 min, p < 0.001), and total direct procedural costs at the initial resection were higher (1480.0 ± 728.0 vs. 729.8 ± 299.7 USD, p < 0.001) in the ESD group than in the EPMR group. The total number of surveillance endoscopies was higher in the EPMR group (1.7 ± 1.5 vs. 1.3 ± 1.1, p = 0.003). The cumulative total costs of ESD and EPMR were comparable at 3 and 2 years' follow-up in the adenoma and mucosal/superficial submucosal cancer subgroups, respectively.

CONCLUSIONS

Colorectal ESD was associated with higher complete resection and lower recurrence rates. EPMR showed shorter procedure times and similar cumulative total direct costs. ESD or EPMR should be chosen based on both clinical outcomes and cost-effectiveness.

Clinical Characteristics and Postoperative Outcomes of Patients Presenting With Upper Gastrointestinal Tract Crohn Disease

PURPOSE

Upper gastrointestinal (GI) tract involvement in Crohn disease (CD) is rare and effectiveness of surgical treatment is limited. The aim of this study was to evaluate characteristics and surgical outcomes of upper GI CD.

METHODS

Medical records of 811 patients who underwent intestinal surgery for CD between January 2006 and December 2015 at a single institution were reviewed. Upper GI CD was defined by involvement of the stomach to the fourth portion of duodenum, with or without concomitant small/large bowel CD involvement according to a modification of the Montreal classification.

RESULTS

We identified 24 patients (21 males, 3 females) who underwent surgery for upper GI CD. The mean age at diagnosis was 27 ± 12 years, the mean age at surgery was 33 ± 11 years, and the mean duration of CD was 73.6 ± 56.6 months. Fifteen patients (62.5%) had history of previous perianal surgery. Ten patients (41.7%) had duodenal or gastric stricture and 14 patients (58.3%) had penetrating fistula; patients with fistula were significantly more likely to develop complications (57.1% vs. 20.0%, P = 0.035). One patient with stricture had surgical recurrence. In seven patients with fistula, fistula was related to previous anastomosis. Patients with fistula had significantly longer hospital stays than those with stricture (16 days vs. 11 days, P = 0.01).

CONCLUSION

Upper GI CD is rare among CD types (2.96%). In patients with upper GI CD, penetrating fistula was associated with longer hospital stay and more complications.

Intrinsically p-type cuprous iodide semiconductor for hybrid light-emitting diodes

Cuprous halides, characterized by a direct wide band-gap and a good lattice matching with Si, is an intrinsic p-type I-VII compound semiconductor. It shows remarkable optoelectronic properties, including a large exciton binding energy at room temperature and a very small piezoelectric coefficient. The major obstacle to its application is the difficulty in growing a single-crystal epitaxial film of cuprous halides. We first demonstrate the single crystal epitaxy of high quality cuprous iodide (CuI) film grown on Si and sapphire substrates by molecular beam epitaxy. Enhanced photoluminescence on the order of magnitude larger than that of GaN and continuous-wave optically pumped lasing were found in MBE grown CuI film. The intrinsic p-type characteristics of CuI were confirmed using an n-AlGaN/p-CuI junction that emits blue light. The discovery will provide an alternative way towards highly efficient optoelectronic devices compatible with both Si and III-nitride technologies.

Incidence and risk factors of Pneumocystis jirovecii pneumonia in Korean patients with inflammatory bowel disease

BACKGROUND AND AIM

Little is known whether routine prophylaxis against Pneumocystis jirovecii pneumonia (PJP) is needed in patients with inflammatory bowel disease (IBD) on immunosuppression, especially in Asian populations. We, therefore, sought to investigate the incidence and risk factors of PJP in patients with IBD in Korea.

METHODS

We investigated the incidence of PJP in patients with IBD and compared the characteristics of IBD patients with PJP episodes (IBD-PJP group) with those of matched controls (IBD-only group) using a large, well-characterized referral center-based cohort.

RESULTS

Among the 6803 IBD patients (3171 with Crohn's disease and 3632 with ulcerative colitis) enrolled in the Asan IBD Registry between June 1989 and December 2016, six patients (0.09%) were diagnosed with PJP. During the 57 776.0 patient-years of follow-up (median 7.2 years per patient), the incidence of PJP was 10.4 cases per 100 000 person-years, and none of these patients had received PJP prophylaxis. In case-control analysis, the IBD-PJP group (n = 6) showed significantly higher C-reactive protein level at diagnosis of IBD (P = 0.006), as well as higher exposure to corticosteroids (P = 0.017), than did controls (n = 24). In addition, the IBD-PJP group showed higher rates of double (50% vs 12.5%) or triple (33.3% vs 4.2%) immunosuppression than did controls, although these are not statistically significant.

CONCLUSIONS

Although the incidence of PJP in Korean patients with IBD is low, careful monitoring is necessary for the early detection of PJP. In addition to the patients receiving double or triple immunosuppression, PJP prophylaxis should be considered especially in patients with severe disease activities requiring corticosteroids.

Clinical outcomes of submucosal colorectal cancer diagnosed after endoscopic resection: a focus on the need for surgery

Background/Aims

We aimed to investigate the proportion of and risk factors for residual cancer and/or lymph node metastasis after surgery was performed because of high-risk pathological features in endoscopic resection specimen of suspected superficial submucosal colorectal cancer (SSMC).

Methods

We reviewed medical records of 497 patients (58.8 ± 9.8 years, 331 males) undergoing endoscopic resection of suspected SSMC. High-risk pathological features included: deep submucosal cancer invasion ≥ 1,000 μm; positive lymphovascular and/or perineural invasion; poorly differentiated adenocarcinoma; and positive resection margin. We investigated the occurrence of additional surgery and residual cancer and/or lymph node involvement in the surgical specimen.

Results

En bloc resection was performed in 447 patients (89.9%). High-risk pathological features were detected in 372 patients (74.8%). Additional surgery was performed in 336 of 372 patients with high-risk pathological features. Of these, 47 surgical specimens (14.0%) showed residual cancer and/or lymph node metastasis. Piecemeal resection was more common in those with residual cancer and/or lymph node involvement than those without (9/47 [19.1%] vs. 24/289 [8.3%], P= 0.032). Positive resection margin was also significantly associated with positive residual cancer and/or lymph node involvement. As the number of high-risk pathological features increased, the risk of regional lymph node metastasis increased proportionally (P= 0.002).

Conclusions

High-risk pathological features were frequently detected after endoscopic resection of suspected SSMC while residual cancer and/or lymph node metastasis were not commonly present in the additional surgical specimen. Further optimized strategy for proper endoscopic management of suspected SSMC is necessary.

Endoscopic diagnosis and treatment planning for colorectal polyps using a deep-learning model

We aimed to develop a computer-aided diagnostic system (CAD) for predicting colorectal polyp histology using deep-learning technology and to validate its performance. Near-focus narrow-band imaging (NBI) pictures of colorectal polyps were retrieved from the database of our institution. Of these, 12480 image patches of 624 polyps were used as a training set to develop the CAD. The CAD performance was validated with two test datasets of 545 polyps. Polyps were classified into three histological groups: serrated polyp (SP), benign adenoma (BA)/mucosal or superficial submucosal cancer (MSMC), and deep submucosal cancer (DSMC). The overall kappa value measuring the agreement between the true polyp histology and the expected histology by the CAD was 0.614-0.642, which was higher than that of trainees (n = 6, endoscopists with experience of 100 NBI colonoscopies in <6 months; 0.368-0.401) and almost comparable with that of the experts (n = 3, endoscopists with experience of 2,500 NBI colonoscopies in ≥5 years) (0.649-0.735). The areas under the receiver operating curves for CAD were 0.93-0.95, 0.86-0.89, and 0.89-0.91 for SP, BA/MSMC, and DSMC, respectively. The overall diagnostic accuracy of the CAD was 81.3-82.4%, which was significantly higher than that of the trainees (63.8-71.8%, P < 0.01) and comparable with that of experts (82.4-87.3%). The kappa value and diagnostic accuracies of the trainees improved with CAD assistance: that is, the kappa value increased from 0.368 to 0.655, and the overall diagnostic accuracy increased from 63.8-71.8% to 82.7-84.2%. CAD using a deep-learning model can accurately assess polyp histology and may facilitate the diagnosis of colorectal polyps by endoscopists.

Biosimilars: concept, current status, and future perspectives in inflammatory bowel diseases

The inflammatory bowel diseases (IBD), which consist of Crohn's disease and ulcerative colitis, are chronic, incurable immunemediated inflammatory disorders of the intestine. As IBD incidence continues to increase globally and its mortality is low, prevalent cases of IBD are rapidly increasing, thereby leading to a substantial increase in health care costs. Although the introduction of biologic agents for IBD management has revolutionized the armamentarium of IBD therapy, the high cost of this therapy is concerning. With the expirations of patents for existing biologic agents (originals), biosimilars with cheaper costs have been highlighted in the field of IBD. Despite concerns regarding their short- and long-term efficacy, safety, immunogenicity, and interchangeability, increasing evidence via prospective observations and phase III or IV clinical trials, which aim to prove the "biosimilarity" of biosimilars to originals, has partly confirmed their efficacy, safety, and interchangeability. Additionally, although patients and physicians are reluctant to use biosimilars, a positive budget impact has been reported owing to their use in different countries. In the near future, multiple biosimilars with lower costs, and efficacy and safety profile similar to originals, could be used to treat IBD; thus, further consideration and knowledge dissemination are warranted in this new era of biosimilars.

Association of FUT2 and ABO with Crohn's disease in Koreans

BACKGROUND AND AIM

Fucosyltransferase 2 (FUT2) at 19q13 is a well-established susceptibility locus for Crohn's disease (CD) in Caucasians. FUT2 encodes α-1,2-fucosyltransferase that regulates the secretion of the α-1-2-N-acetylgalactosaminyltransferase and α-1-3-galactosyltransferase (ABO) antigens in both the gastrointestinal mucosa and secretory glands. Given that CD is thought to arise from dysregulated mucosal immune responses to the gut flora and both the ABO blood group and the FUT2 secretor status affect the composition of the gut microbiota, the goal of this study was to evaluate the associations of variants of FUT2 and ABO with CD in Koreans.

METHODS

Three single-nucleotide polymorphisms from the FUT2 and ABO genes were genotyped in 1735 patients with CD and 8074 healthy controls.

RESULTS

The FUT2 non-secretor allele showed genome-wide significant association with CD in Koreans (rs1047781, odds ratio [OR] = 1.30, Pcombined  = 3.52 × 10-12 ). The ABO locus showed genome-wide significant association with CD in Asians (Pmeta  = 2.35 × 10-8 ). A moderate association was observed with the A and B groups (OR = 1.40, P = 2.26 × 10-6 ; and OR = 1.32, P = 1.92 × 10-4 , respectively) compared with the O group. Following stratification on the basis of FUT2 genotype, carriers of the secretor O blood group were significantly protective against CD than were those of the secretor non-O blood group (OR = 0.63, 95% confidence interval = 0.54-0.73, P = 2.86 × 10-9 ).

CONCLUSIONS

These are the first results indicating that the O blood group and FUT2 secretor status are protective factors against CD in Asians.

P643 A case of Fabry cardiomyopathy refractory to enzyme replacement therapy; the importance of early diagnosis and treatment in Fabry cardiomyopathy

A 56-year-old male was referred in order to identify Fabry disease after his older brother was confirmed as Fabry disease of cardiac variant type. He had been treated with hypertrophic cardiomyopathy (HCMP) five years ago. He didn’t have a history of hypertension. Blood pressure was 118/65 mmHg and pulse rate was 75 beats per minute. Serum creatinine was 1.07 mg/dl and estimated glomerular filtration rate was 75.2 ml/min. Cardiac enzymes including CK-MB and troponin-T were normal. There was no proteinuria on urinalysis. A 12-leads electrocardiogram revealed normal sinus rhythm with severe left ventricular hypertrophy (LVH) and strain pattern. Transthoracic echocardiogram (TTE) showed diffuse severe concentric hypertrophy of the left ventricle (LV) of an average ventricular wall thickness of 17 mm with normal systolic function (left ventricular ejection fraction (LVEF), 56%). TTE also revealed left ventricular outflow tract obstruction with systolic anterior motion of mitral valve. Right ventricle (RV) was also hypertrophied (RV free wall thickness, 7mm). Also, echocardiography revealed findings of diastolic dysfunction; left atrial enlargement, mitral inflow of a pseudo-normal pattern on pulsed wave Doppler image and an increased left ventricular filling pressure on tissue Doppler image (E/e’=20). Cardiac magnetic resonance imaging (MRI) revealed diffuse LV and RV hypertrophy and preserved LV systolic function with hypokinesia of mid-septal LV wall. Delayed hyper-enhancement (DHE) was not found within entire myocardium. A coronary CT angiography was performed because of regional wall motion abnormality but did not show any significant stenoses. He was confirmed as Fabry disease with the same genetic mutation as his brother. He did not present symptoms and signs of any other organs besides only myocardial hypertrophy. He received enzyme replacement therapy (ERT) with intravenous agalsidase-beta every other week via outpatient department for 3 years. Recently, TTE was performed and showed diffuse severe concentric LVH of an average ventricular wall thickness increased to 19 mm despite regularly ERT. Focal intramural and subepicardial DHE was newly developed at LV basal lateral and septal wall on cardiac MRI. Neutralizing antibody against agalsidase -beta was not found in serum.

Fabry disease of cardiac variant type can be delayed in diagnostic aspect because of absence of typical symptoms and signs. Despite the absence of neutralizing antibody, ERT did not prevent both further myocardial hypertrophy and myocardial fibrosis in patient with advanced myocardial hypertrophy caused by delayed diagnosis of Fabry disease. Suspicion of Fabry disease through detailed history taking including family history in patients with diffuse ventricular hypertrophy on an echocardiography can lead to early diagnosis and treatment and can result in improvement in a clinical outcome.

430 Relation of blood pressure to coronary artery calcium and mortality

Background

Diastolic blood pressure has a J-curve relation with coronary heart disease and death, but it is debating whether a J-curve association exists in general population. We aimed to assess the relation of blood pressure to mortality, and whether their association is interacted with presence of high coronary artery calcium (CAC).

Methods

The KOICA registry is a retrospective, multicenter observational study designed to investigate the effectiveness and prognostic value of CAC score for primary prevention of cardiovascular disease in asymptomatic Korean adults. The association between CAC score and blood pressure was assessed. Patients were divided into 2 groups according to the baseline CACS (&gt; 300 and ≤ 300), and all-cause mortality was assessed.

Results

The study population composed 48903 subjects with a mean age of 54 ± 9. There were 425 (0.9%) deaths during follow-up. At baseline, SBP (systolic blood pressure) more than 110 mmHg and DBP (diastolic blood pressure) more than 80 mmHg was associated with increased risk for CACS &gt; 300. In patients with baseline CACS ≤ 300, all-cause mortality was increased in patients with SBP of 110-119 mmHg (HR 1.47, p = 0.023), 130-139 mmHg (HR 1.72, p = 0.002) and ≥ 140 mmHg (HR 1.47, p = 0.042) compared to SBP of 120-129 mmHg, whereas DBP did not predict all-cause mortality. In contrast, SBP was not associated to all-cause mortality in patients with CACS &gt; 300, whereas DBP &lt; 60 mmHg (HR 3.53, p =0.018) and 70-79 mmHg (HR 2.21, p = 0.042) was associated with increased risk for all-cause mortality compared to DBP of 80-89 mmHg.

Conclusion

Low DBP was associated with increased risk for all-cause mortality in subjects with high CAC score, suggesting high-risk for coronary artery disease. However, this J-curve relation was not shown in the population with low CAC score.

Clinical Implications of the CMV-Specific T-Cell Response and Local or Systemic CMV Viral Replication in Patients With Moderate to Severe Ulcerative Colitis

BACKGROUND

The precise role of cytomegalovirus (CMV) in ulcerative colitis (UC) remains disputed. We evaluated the association of CMV-specific host immune responses and systemic or local viral replication with responses to systemic steroids in patients with moderate to severe UC.

METHODS

Patients who were hospitalized for moderate to severe UC between April 2015 and June 2016 were enrolled. At baseline, all enrolled patients underwent CMV-specific enzyme-linked immunospot assays, quantitative polymerase chain reaction (qPCR) analysis of blood and colonic tissue for CMV viral load, histopathological testing for CMV in colonic tissue by hematoxylin and eosin staining, and immunohistochemical (IHC) analysis. Clinical responses to steroid therapy based on the Oxford index were assessed on day 3.

RESULTS

Of the 80 patients evaluated, 28 (35.0%) had poor responses to steroid therapy on day 3 of intensive treatment. The presence of inclusion bodies (32.1%) and high-grade (≥3) positivity on IHC (50.0%), as well as colonic (mean 1440.4 copies/mg) and blood (mean, 3692.6 copies/mL) CMV viral load, were higher in steroid-refractory UC patients than the control group (13.5%, 1.9%, mean 429.2 copies/mg, and mean 231.2 copies/mL, respectively; P = .046, .009, .017, and .002, respectively). However, CMV-specific T-cell responses were not associated with steroid-refractory UC. Multivariate analysis revealed that a higher Mayo score (odds ratio [OR], 2.00; P = .002) and higher blood CMV viral load via qPCR analysis (OR, 3.58; P = .044) were independent risk factors for steroid-refractory UC.

CONCLUSIONS

In patients with moderate to severe UC, higher Mayo score and blood CMV expression determined by qPCR are independently associated with steroid refractoriness.

CLINICALTRIALSGOV REGISTRATION NUMBER

NCT02439372.

Prognostic Predictions for Patients with Glioblastoma after Standard Treatment: Application of Contrast Leakage Information from DSC-MRI within Nonenhancing FLAIR High-Signal-Intensity Lesions

BACKGROUND AND PURPOSE

Attempts have been made to quantify the microvascular leakiness of glioblastomas and use it as an imaging biomarker to predict the prognosis of the tumor. The purpose of our study was to evaluate whether the extraction fraction value from DSC-MR imaging within nonenhancing FLAIR hyperintense lesions was a better prognostic imaging biomarker than dynamic contrast-enhanced MR imaging parameters for patients with glioblastoma.

MATERIALS AND METHODS

A total of 102 patients with glioblastoma who received a preoperative dynamic contrast-enhanced MR imaging and DSC-MR imaging were included in this retrospective study. Patients were classified into the progression (n = 87) or nonprogression (n = 15) groups at 24 months after surgery. We extracted the means and 95th percentile values for the contrast leakage information parameters from both modalities within the nonenhancing FLAIR high-signal-intensity lesions.

RESULTS

The extraction fraction 95th percentile value was higher in the progression-free survival group of >24 months than at ≤24 months. The median progression-free survival of the group with an extraction fraction 95th percentile value of >13.32 was 17 months, whereas that of the group of ≤13.32 was 12 months. In addition, it was an independent predictor variable for progression-free survival in the patients regardless of their ages and genetic information.

CONCLUSIONS

The extraction fraction 95th percentile value was the only independent parameter for prognostic prediction in patients with glioblastoma among the contrast leakage information, which has no statistically significant correlations with the DCE-MR imaging parameters.

Association of TRAP1 with infliximab-induced mucosal healing in Crohn's disease

BACKGROUND AND AIM

Anti-tumor necrosis factor (TNF) agents, such as infliximab (IFX), have been increasingly used to induce and maintain disease remission in patients with Crohn's disease (CD). Despite a considerable non-response rate, little is known about the genetic predictors of response to anti-TNF therapy in CD. Our aim in this study was to investigate the genetic factors associated with response to anti-TNF therapy in patients with CD.

METHODS

We performed a two-stage genome-wide association study (GWAS) to identify loci influencing the response to IFX among Korean patients with CD, comprising 42 good responders with mucosal healing and 70 non-responders. The achievement of mucosal healing was assessed by endoscopy and imaging. The functional significance of TRAP1 (TNF receptor associated protein 1) was examined using dextran sodium sulfate-induced colitis model in TRAP1 transgenic mice.

RESULTS

The GWAS identified rs2158962, an intronic single nucleotide polymorphism (SNP) of TRAP1, significantly associated with mucosal healing (odds ratio = 4.94; P_combined  = 1.35 × 10^-7 ). In the dextran sodium sulfate-induced acute colitis, TRAP1 transgenic mice showed a better response to IFX than the wild-type mice.

CONCLUSIONS

The TRAP1 gene is associated with mucosal healing in CD patients following IFX therapy. Identifying the genetic predictors of mucosal healing to anti-TNF therapy can prevent patients from exposure to ineffective therapies.

Distinct Cutoff Values of Adalimumab Trough Levels Are Associated With Different Therapeutic Outcomes in Patients With Inflammatory Bowel Disease

Background and Aims

We aimed to evaluate the relationship of serum adalimumab trough levels (ATL) with disease activity of inflammatory bowel disease (IBD) patients in a large, well-characterized referral center-based cohort.

Methods

We compared serum ATL between those with clinical, biochemical, or endoscopic/radiologic disease activity and those without.

Results

A total of 236 patients with IBD were included. Higher cutoff levels were associated with endoscopic and/or radiologic responses (cutoff value: 5.3 mcg/mL, P = 0.003) compared with improvement in C-reactive protein (cutoff value: 4.3 mcg/mL, P = 0.031).

Conclusions

Higher cutoff ATL was associated with endoscopic and/or radiologic response.

Impact of genomic alterations on lapatinib treatment outcome and cell-free genomic landscape during HER2 therapy in HER2+ gastric cancer patients

Background

To identify predictive markers for responders in lapatinib-treated patients and to demonstrate molecular changes during lapatinib treatment via cell-free genomics.

Patients and methods

We prospectively evaluated the efficacy of combining lapatinib with capecitabine and oxaliplatin as first line neoadjuvant therapy in patients with previously untreated, HER2-overexpressing advanced gastric cancer. A parallel biomarker study was conducted by simultaneously performing immunohistochemistry and next-generation sequencing (NGS) with tumor and blood samples.

Results

Complete response was confirmed in 7/32 patients (21.8%), 2 of whom received radical surgery with pathologic-confirmed complete response. Fifteen partial responses (46.8%) were observed, resulting in a 68.6% overall response rate. NGS of the 16 tumor specimens demonstrated that the most common co-occurring copy number alteration was CCNE1 amplification, which was present in 40% of HER2+ tumors. The relationship between CCNE1 amplification and lack of response to HER2-targeted therapy trended toward statistical significance (66.7% of non-responders versus 22.2% of responders harbored CCNE1 amplification; P = 0.08). Patients with high level ERBB2 amplification by NGS were more likely to respond to therapy, compared with patients with low level ERBB2 amplification (P = 0.02). Analysis of cfDNA showed that detectable ERBB2 copy number amplification in plasma was predictive to the response (100%, response rate) and changes in plasma-detected genomic alterations were associated with lapatinib sensitivity and/or resistance. The follow-up cfDNA genomics at disease progression demonstrated that there are emergences of other genomic aberrations such as MYC, EGFR, FGFR2 and MET amplifications.

Conclusions

The present study showed that HER2+ GC patients respond differently according to concomitant genomic aberrations beyond ERBB2, high ERBB2 amplification by NGS or cfDNA can be a positive predictor for patient selection, and tumor genomic alterations change significantly during targeted agent therapy.

Phase III, randomised trial of avelumab versus physician's choice of chemotherapy as third-line treatment of patients with advanced gastric or gastro-oesophageal junction cancer: primary analysis of JAVELIN Gastric 300

Background

There currently are no internationally recognised treatment guidelines for patients with advanced gastric cancer/gastro-oesophageal junction cancer (GC/GEJC) in whom two prior lines of therapy have failed. The randomised, phase III JAVELIN Gastric 300 trial compared avelumab versus physician’s choice of chemotherapy as third-line therapy in patients with advanced GC/GEJC.

Patients and methods

Patients with unresectable, recurrent, locally advanced, or metastatic GC/GEJC were recruited at 147 sites globally. All patients were randomised to receive either avelumab 10 mg/kg by intravenous infusion every 2 weeks or physician’s choice of chemotherapy (paclitaxel 80 mg/m² on days 1, 8, and 15 or irinotecan 150 mg/m² on days 1 and 15, each of a 4-week treatment cycle); patients ineligible for chemotherapy received best supportive care. The primary end point was overall survival (OS). Secondary end points included progression-free survival (PFS), objective response rate (ORR), and safety.

Results

A total of 371 patients were randomised. The trial did not meet its primary end point of improving OS {median, 4.6 versus 5.0 months; hazard ratio (HR)=1.1 [95% confidence interval (CI) 0.9–1.4]; P = 0.81} or the secondary end points of PFS [median, 1.4 versus 2.7 months; HR=1.73 (95% CI 1.4–2.2); P > 0.99] or ORR (2.2% versus 4.3%) in the avelumab versus chemotherapy arms, respectively. Treatment-related adverse events (TRAEs) of any grade occurred in 90 patients (48.9%) and 131 patients (74.0%) in the avelumab and chemotherapy arms, respectively. Grade ≥3 TRAEs occurred in 17 patients (9.2%) in the avelumab arm and in 56 patients (31.6%) in the chemotherapy arm.

Conclusions

Treatment of patients with GC/GEJC with single-agent avelumab in the third-line setting did not result in an improvement in OS or PFS compared with chemotherapy. Avelumab showed a more manageable safety profile than chemotherapy.

Trial registration

ClinicalTrials.gov: NCT02625623.

A 30-year Trend Analysis in the Epidemiology of Inflammatory Bowel Disease in the Songpa-Kangdong District of Seoul, Korea in 1986-2015

BACKGROUND AND AIMS

Although the incidence of inflammatory bowel disease [IBD] is increasing in Asia, data on long-term epidemiological trends are limited. We performed a 30-year longitudinal study to investigate temporal trends in the epidemiology of Crohn's disease [CD] and ulcerative colitis [UC] in Seoul, Korea.

METHODS

This population-based study included 1431 IBD patients [418 CD, 1013 UC] diagnosed between 1986 and 2015 in the Songpa-Kangdong district of Seoul, Korea. Temporal trends in incidence, prevalence, and disease phenotype at diagnosis were analysed.

RESULTS

The adjusted mean annual incidence rates of CD and UC per 100 000 inhabitants increased from 0.06 (95% confidence interval [CI], 0.05-0.07) and 0.29 [95% CI, 0.27-0.31], respectively, in 1986-1990 to 2.44 [95% CI, 2.38-2.50] and 5.82 [95% CI, 5.73-5.92], respectively, in 2011-2015. Average annual percentage change in IBD incidence was 12.3% in 1986-1995, 12.3% in 1996-2005, and 3.3% in 2006-2015. The male-to-female ratio of the adjusted incidence rate was 3.3:1 for CD and 1.2:1 for UC. Perianal fistula/abscess was present in 43.3% of patients before or at CD diagnosis. At diagnosis, 54.3% of UC patients presented only with proctitis. The adjusted prevalence rate in 2015 was 31.59/100 000 [95% CI, 31.10-32.07] for CD and 76.66/100 000 [95% CI, 75.91-77.42] for UC.

CONCLUSIONS

The incidence and prevalence of IBD in Korea have continued to increase over the past three decades. Korean patients have distinct demographic and phenotypic characteristics, including a male predominance and high frequency of perianal fistula/abscess in CD and high proportion of proctitis in UC.

Efficacy and safety findings from DREAM: a phase III study of DHP107 (oral paclitaxel) versus i.v. paclitaxel in patients with advanced gastric cancer after failure of first-line chemotherapy

Background

Paclitaxel is currently only available as an intravenous (i.v.) formulation. DHP107 is a novel oral formulation of lipid ingredients and paclitaxel. DHP107 demonstrated comparable efficacy, safety, and pharmacokinetics to i.v. paclitaxel as a second-line therapy in patients with advanced gastric cancer (AGC). DREAM is a multicenter, open-label, prospective, randomized phase III study of patients with histologically/cytologically confirmed, unresectable/recurrent AGC after first-line therapy failure.

Methods and materials

Patients were randomized 1 : 1 to DHP107 (200 mg/m2 orally twice daily days 1, 8, 15 every 4 weeks) or i.v. paclitaxel (175 mg/m2 day 1 every 3 weeks). Patients were stratified by Eastern Cooperative Oncology Group performance status, disease status, and prior treatment; response was assessed (Response Evaluation Criteria in Solid Tumors) every 6 weeks. Primary end point: non-inferiority of progression-free survival (PFS); secondary end points: overall response rate (ORR), overall survival (OS), and safety. For the efficacy analysis, sequential tests for non-inferiority were carried out, first with a non-inferiority margin of 1.48, then with a margin of 1.25.

Results

Baseline characteristics were balanced in the 236 randomized patients (n = 118 per arm). Median PFS (per-protocol) was 3.0 (95% CI 1.7-4.0) months for DHP107 and 2.6 (95% CI 1.8-2.8) months for paclitaxel (hazard ratio [HR] = 0.85; 95% CI 0.64-1.13). A sensitivity analysis on PFS using independent central review showed similar results (HR = 0.93; 95% CI 0.70-1.24). Median OS (full analysis set) was 9.7 (95% CI 7.1 - 11.5) months for DHP107 versus 8.9 (95% CI 7.1-12.2) months for paclitaxel (HR = 1.04; 95% CI 0.76-1.41). ORR was 17.8% for DHP107 (CR 4.2%; PR 13.6%) versus 25.4% for paclitaxel (CR 3.4%; PR 22.0%). Nausea, vomiting, diarrhea, and mucositis were more common with DHP107; peripheral neuropathy was more common with paclitaxel. There were only few Grade≥3 adverse events, most commonly neutropenia (42% versus 53%); febrile neutropenia was reported infrequently (5.9% versus 2.5%). No hypersensitivity reactions occurred with DHP107 (paclitaxel 2.5%).

Conclusions

DHP107 as a second-line treatment of AGC was non-inferior to paclitaxel for PFS; other efficacy and safety parameters were comparable. DHP107 is the first oral paclitaxel with proven efficacy/safety for the treatment of AGC.

ClinicalTrials.gov

NCT01839773.

Interstitial lung disease and risk of mortality: 11-year nationwide population-based study

BACKGROUND

Patients with interstitial lung disease (ILD) constitute a substantial disease burden. Although ILD outcomes have been investigated, the risk of death due to ILD has not been studied in the light of confounders and comorbidities. In this nationwide, 11-year longitudinal, population-based study, we aimed to discover if ILD is an independent risk factor for mortality.

DESIGN

Data on 1 031 392 (2.2%) randomly selected subjects from 47 279 373 Korean residents were collected from the 2002 Korean National Health Insurance database. The ILD group comprised patients with an initial diagnosis of ILD between January 2003 and December 2007. Each patient was followed until 2013. We used Cox proportional hazard regression analyses to calculate the risk of death adjusted for comorbidities and confounders.

RESULTS

ILD developed in 783 of the 303 385 subjects during the 5-year period (51 per 100 000 person-years). Death occurred in 157 (23.2%) cases and 272 controls (10.4%). ILD was significantly associated with the risk of death (hazard ratio 2.1, 95% confidence interval [CI] 1.6-2.7) and for those aged 40-59, 60-69 and 70 years. A high proportion of patients with ILD died due to respiratory causes.

CONCLUSION

ILD patients had a significantly higher risk of death than matched controls, after adjustment for potential confounders and comorbidities.

Risk factors of traditional serrated adenoma and clinicopathologic characteristics of synchronous conventional adenoma

BACKGROUND AND AIMS

Traditional serrated adenoma (TSA) is rare and known to have a malignant potential. We aimed to investigate the prevalence and risk factors of TSA and compare the characteristics of synchronous conventional adenoma (AD) in patients with TSA with those of AD in patients with AD only.

METHODS

We reviewed medical records of 31,932 healthy subjects who underwent screening colonoscopy at a single hospital between 2012 and 2017.

RESULTS

TSA was observed in 116 patients (.4%). Among them, 47 patients (40.5%) had TSA only and 69 patients (59.5%) had synchronous AD. Multivariable analysis showed independent risk factors for TSA to include age ≥50 years (odds ratio [OR], 3.34; 95% confidence interval [CI], 1.72-6.49; P < .001), hypertension (OR, 2.07; 95% CI, 1.09-3.92; P = .026), and current smoking (OR, 2.58; 95% CI, 1.28-5.23; P = .008). There were significantly more ADs (2.5 ± 2.0 vs 1.8 ± 1.6, P = .009) and ADs were of larger size (6.7 ± 5.0 vs 5.3 ± 3.6 mm, P = .027) in TSA patients than in AD-only patients. Furthermore, advanced adenoma and high-risk adenoma were more frequently observed in TSA patients than in AD-only patients (24.2% vs 11.2%, P = .002; 43.5% vs 23.6%, P < .001).

CONCLUSIONS

The prevalence of TSA in healthy adults was .4%. Age ≥50 years, hypertension, and current smoking may be risk factors of TSA. Synchronous AD is often observed with TSA and may show more advanced features than those in AD-only patients.

Effects of smoking on the association of human leukocyte antigen with ulcerative colitis

BACKGROUND AND AIM

Tobacco smoking is a risk factor for gastrointestinal disorders, causing mucosal damage and impairing immune responses. However, smoking has been found to be protective against ulcerative colitis (UC). Human leukocyte antigen (HLA) is a major susceptibility locus for UC, and HLA-DRB1*15:02 has the strongest effect in Asians. This study investigated the effects of smoking on the association between HLA and UC.

METHODS

The study enrolled 882 patients with UC, including 526 never, 151 current, and 205 former smokers, and 3091 healthy controls, including 2124 never, 502 current, and 465 former smokers. Smoking-stratified analyses of HLA data were performed using a case-control approach.

RESULTS

In a case-control approach, HLA-DRB1*15:02 was associated with UC in never smokers (OR_{never smokers}  = 3.20, P_{never smokers}  = 7.88 × 10^-23 ) but not in current or former smokers (P_{current smokers}  = 0.72 and P_{former smokers}  = 0.33, respectively). In current smokers, HLA-DQB1*06 was associated with UC (OR_{current smokers}  = 2.59, P_{current smokers}  = 6.39 × 10^-12 ). No variants reached genome-wide significance in former smokers.

CONCLUSIONS

An association between UC and HLA-DRB1*15:02 was limited to never smokers. Our findings highlight that tobacco smoking modifies the effects of HLA on the risk of UC.

P6278Ageing is associated with increased endothelial sodium-glucose cotransporter 1 expression at arterial sites at risk promoting enhanced anthocyanin accumulation and improved vascular oxidative stress

Introduction

Ageing is characterized by endothelial dysfunction and vascular oxidative stress affecting initially arterial sites at risk. Anthocyanin-rich products are potent stimulators of the endothelial formation of nitric oxide. Sodium-glucose co-transporter 1 (SGLT1) expression has been shown to be increased by oxidative stress and mediate anthocyanin uptake in endothelial cells.

Purpose

The study determined whether ageing is associated with an upregulation of SGLT1 in arterio-susceptible (aortic arch) and resistant (aorta) sites, and evaluated the vascular SGLT1-mediated anthocyanin uptake. In addition, the impact of a 2-week ingestion of an anthocyanin-rich blackcurrant concentrate (ARBC) by old rats on vascular anthocyanin uptake and oxidative stress, and systolic blood pressure (SBP) was assessed.

Methods

Male Wistar rats (22-month old) were either untreated or treated with ARBC (60 and 120 mg/kg/day) in the drinking water for 2 weeks. SGLT1 expression was assessed by immunofluorescence, anthocyanin accumulation by Neu A reagent using a purified extract (BCE) prepared from ARBC, oxidative stress by dihydroethidium using confocal microscopy, and SBP by tail-cuff sphingomanometry.

Results

SGLT1 immunofluorescence was observed predominantly in the endothelium and was higher in the aortic arch than the aorta in old rats whereas only low levels were observed in young rats (12-week old). Exposure of vascular sections to BCE resulted in anthocyanin uptake exclusively in the endothelium, which was higher in the aortic arch than the aorta, and more pronounced in old than young rats. Anthocyanin uptake induced by BCE in the aorta was markedly reduced by LX4211 (a SGLT1/2 inhibitor) both in old and young rats. A high level of oxidative stress was observed throughout the aortic wall of old compared to young rats, which was inhibited by LX4211. Ingestion of ARBC by old rats resulted in a dose-dependent accumulation of anthocyanins throughout the aorta wall and the aortic arch. The tissue accumulation of anthocyanins was associated with a reduced level of oxidative stress. Ageing was associated with increased SBP by about 8 mmHg, which was reduced by ARBC 60 and 120 mg/kg/day treatment by about 5 and 7 mmHg, respectively.

Conclusion

The present findings indicate that ageing is associated with an upregulation of SGLT1 predominantly in the endothelium and that this effect is more pronounced at the aortic arch than the aorta. The increased endothelial expression level of SGLT1 promoted a greater accumulation of anthocyanins sensitive to LX4211. In addition, a 2-week ingestion of ARBC by old rats resulted in the accumulation of anthocyanins throughout the arterial wall of the aortic arch and aorta, and resulted in a reduced level of oxidative stress and systolic blood pressure. Thus, SGLT1 may be an attractive target to restore vascular protection at arterial sites at risk by promoting endothelial and vascular uptake of anthocyanins.

Prone positioning before extracorporeal membrane oxygenation for severe acute respiratory distress syndrome: A retrospective multicenter study

OBJECTIVE

To evaluate the clinical outcomes of patients with severe acute respiratory distress syndrome (ARDS) subjected to prone positioning before extracorporeal membrane oxygenation (ECMO).

DESIGN

A retrospective analysis of a multicenter cohort was carried out.

SETTING

Patients admitted to the Intensive Care Units of 11 hospitals in Korea.

PATIENTS

Patients were divided into those who underwent prone positioning before ECMO (n=28) and those who did not (n=34).

INTERVENTIONS

None.

VARIABLES OF INTEREST

Thirty-day mortality, ECMO weaning failure rate, mechanical ventilation weaning success rate, mechanical ventilation-free days at day 60.

RESULTS

The prone group had lower median peak inspiratory pressure and lower median dynamic driving pressure before ECMO. Thirty-day mortality was 21% in the prone group and 41% in the non-prone group (p=0.098). The prone group also showed a lower ECMO weaning failure rate, and a higher mechanical ventilation weaning success rate and more mechanical ventilation-free days at day 60. In the non-prone group, median dynamic compliance marginally decreased shortly after ECMO, but no significant change was observed in the prone group.

CONCLUSIONS

Prone positioning before ECMO was not associated to increased mortality and tended to exert a protective effect.

Prevalence of and factors related to latent tuberculous infection among all employees in a referral hospital

SETTING

Referral hospital, South Korea.

OBJECTIVE

To investigate the prevalence of and factors related to latent tuberculous infection (LTBI) among all hospital employees.

DESIGN

A cross-sectional study of 479 health care workers (HCWs) undergoing LTBI screening.

RESULTS

Overall prevalence of LTBI was 15.7%, 43.1% of whom initiated and completed LTBI treatment. Compared with HCWs without LTBI, those with LTBI were more likely to be older (P < 0.001), male (P = 0.003), work in low-risk departments (P = 0.013) and have more years of employment (P < 0.001). LTBI prevalence was highest in physicians (27.8%), followed by HCWs without patient contact (23.4%), nurses (8.3%) and other HCWs in contact with patients (6.9%). In multivariate analysis, compared with HCWs aged <20 years, those aged 40 years were 4.08 times more likely to have LTBI (P = 0.007). In addition, compared with HCWs working for <1 year, those working for 1-5 years or for 5 years were respectively 7.55 (P = 0.014) and 13.69 (P = 0.001) times more likely to have LTBI.

CONCLUSIONS

Our results suggest that modified LTBI screening strategies, including HCWs with no patient contact and encouraging LTBI treatment participation, might be helpful in improving LTBI control in HCWs.

Outcomes of ulcerative colitis-associated dysplasia patients referred for potential endoscopic submucosal dissection

BACKGROUND AND AIM

The feasibility of endoscopic submucosal dissection (ESD) as a treatment option for dysplasia in ulcerative colitis (UC) has been reported, but the associated therapeutic decision-making and clinical outcomes have not been extensively investigated.

METHODS

We retrospectively reviewed 25 UC patients who were referred for potential ESD of non-polypoid or sessile dysplasia. We analyzed the treatment decisions and the ESD and colectomy outcomes for this patient group.

RESULTS

All lesions were located at the colitic segments. The median UC duration was 13.4 years. A colectomy was recommended for 10 patients because of ulceration with indistinct borders (one patient), non-ulceration with indistinct borders (two patients), and non-lifting signs (seven patients). The remaining 15 patients underwent ESD. The en bloc and R0 resection rates were 93.3% and 80%, respectively. The median hospitalization periods were 1 (range, 1-2) day after ESD and 7 (range, 5-30) days after colectomy. No procedure-related complications occurred after ESD, but early and late postoperative complications occurred in two (22.2%) and six (66.7%) of the colectomized patients, respectively. Fourteen ESD cases were followed endoscopically for a median period of 24.7 (range, 5.2-64.8) months. Local recurrence occurred in 2 (14.3%) patients, and metachronous recurrence was identified in two separate patients (14.3%).

CONCLUSIONS

Endoscopic submucosal dissection is a feasible endoscopic treatment option for UC-associated dysplasia showing noninvasive pit or vascular patterns, no surface ulceration, distinct borders, and appropriate lifting after submucosal injection. Meticulous endoscopic surveillance is essential to monitor for local or metachronous recurrence of dysplasia after ESD.

The Influence of Preoperative Medications on Postoperative Complications in Patients After Intestinal Surgery for Crohn's Disease

BACKGROUND

Many patients with Crohn's disease (CD) are treated with medications, including steroids, immunomodulators, and anti-tumor necrosis factor alpha (anti-TNF-α) agents, at the time of surgery. This study evaluated the effects of these medications on postoperative complications in CD patients.

METHODS

This retrospective study analyzed patients who underwent bowel resection for CD between January 2006 and December 2015. Postoperative complications were defined as a Clavien-Dindo classification of grade 2A or higher within the first 30 days after surgery.

RESULTS

Of the 817 patients enrolled, 687 patients received bowel resection and anastomosis without stoma formation. Of 687 patients, 381 (55.5%) were being treated with preoperative medications at the time of surgery (medication group) and 306 (44.5%) were not (nonmedication group). The overall rate of postoperative complications was not different between the medication and nonmedication groups (23.4% vs 21.9%, P = 0.36). Preoperative treatments with immunomodulators plus anti-TNF-α agents (relative risk [RR], 2.314; 95% confidence interval [CI], 1.126-4.753; P = 0.022) and treatment with immunomodulators plus steroids (RR, 2.536; 95% CI, 1.124-5.725; P = 0.025) were risk factors for infectious complications. Preoperative treatments with immunomodulators plus anti-TNF-α agents (RR, 2.731; 95% CI, 1.102-6.769; P = 0.03) and treatment with immunomodulators plus steroids (RR, 3.118; 95% CI, 1.169-8.320; P = 0.023) were significantly associated with increased risk of intra-abdominal sepsis.

CONCLUSIONS

Preoperative treatments with immunomodulators plus anti-TNF-α agents or steroids were risk factors for infectious complications, especially intra-abdominal sepsis in patients who underwent bowel resection and anastomosis.

A Novel Blood-Based Colorectal Cancer Diagnostic Technology Using Electrical Detection of Colon Cancer Secreted Protein-2

Colorectal cancer (CRC) is the second-leading cause of cancer-related mortality worldwide, which may be effectively reduced by early screening. Colon cancer secreted protein-2 (CCSP-2) is a promising blood marker for CRC. An electric-field effect colorectal sensor (E-FECS), an ion-sensitive field-effect transistor under dual gate operation with nanostructure is developed, to quantify CCSP-2 directly from patient blood samples. The sensing performance of the E-FECS is verified in 7 controls and 7 CRC samples, and it is clinically validated on 30 controls, 30 advanced adenomas, and 81 CRC cases. The concentration of CCSP-2 is significantly higher in plasma samples from CRC and advanced adenoma compared with controls (both P < 0.001). Sensitivity and specificity for CRC versus controls are 44.4% and 86.7%, respectively (AUC of 0.67), and 43.3% and 86.7%, respectively, for advanced adenomas (AUC of 0.67). CCSP-2 detects a greater number of CRC cases than carcinoembryonic antigen does (45.6% vs 24.1%), and the combination of the two markers detects an even greater number of cases (53.2%). The E-FECS system successfully detects CCSP-2 in a wide range of samples including early stage cancers and advanced adenoma. CCSP-2 has potential for use as a blood-based biomarker for CRC.

Update on the Natural Course of Fistulizing Perianal Crohn's Disease in a Population-Based Cohort

BACKGROUND

This study sought to re-estimate the cumulative incidence of perianal or rectovaginal fistulas and the associated proctectomy rate in the prebiologic era vs the biologic era using a population-based cohort of Crohn's disease (CD) patients.

METHODS

The medical records of 414 residents of Olmsted County, Minnesota, who were diagnosed with CD between 1970 and 2010 were reviewed. The cumulative incidence of perianal or rectovaginal fistulas from time of CD diagnosis and the cumulative rate of proctectomy from date of first perianal or rectovaginal fistula diagnosis were estimated using the Kaplan-Meier method.

RESULTS

Eighty-five patients (20.5%) diagnosed with CD between 1970 and 2010 had at least 1 perianal or rectovaginal fistula episode between January 1, 1970, and June 30, 2016. The cumulative incidence of perianal or rectovaginal fistulas was 18% after 10 years, 23% after 20 years, and 24% after 30-40 years from CD diagnosis. The cumulative incidence of perianal or rectovaginal fistulas was significantly lower in patients diagnosed in 1998 or after than in patients diagnosed before 1998 (P = 0.03, log-rank). Among 85 patients developing perianal or rectovaginal fistulas, 16 patients (18.8%) underwent proctectomy for the treatment of perianal or rectovaginal fistulas during follow-up.

CONCLUSIONS

In a population-based inception cohort of CD, one-fifth of patients were diagnosed with at least 1 perianal or rectovaginal fistula. The cumulative probability of perianal or rectovaginal fistulizing disease has decreased over time.

Incidence and clinical impact of perianal disease in patients with ulcerative colitis: A nationwide population-based study

BACKGROUND AND AIM

The risk and clinical impact of perianal disease (PAD) in ulcerative colitis (UC) patients have not been fully evaluated. We investigated the incidence of PAD in UC patients and compared clinical characteristics and outcomes of UC according to the presence of PAD.

METHODS

We performed a nationwide population-based cohort study and a hospital-based cohort study. Using the 2010-2014 data from the Korean National Health Insurance claims database, we calculated incidence rates and standardized incidence ratios of PAD in UC patients compared with the general population. We evaluated the clinical characteristics and outcomes of UC patients with PAD in both population-based and hospital-based cohorts. To reduce clinically meaningful confounding factors, we also conducted matched analyses.

RESULTS

In the population-based cohort, the incidence rate and standardized incidence ratio of PAD in UC patients were 3.74/1000 person-years (95% confidence interval, 3.25-4.31) and 2.88 (95% confidence interval, 2.50-3.32), respectively. In the hospital-based cohort, the cumulative probabilities of PAD at 1, 5, 10, and 20 years after diagnosis were 1.0%, 2.3%, 4.0%, and 6.3%, respectively. In both population-based and hospital-based cohorts, UC patients with PAD showed higher proportions of corticosteroid use and extensive colitis at diagnosis. The requirements for anti-tumor necrosis factor agents and colectomy were significantly higher in UC patients with PAD before and after matched analysis.

CONCLUSIONS

The risk of PAD is higher in UC patients than in the general population. UC patients with PAD have distinct clinical features and poor outcomes, as indicated by the greater need for UC-related medications and colectomy.

Amino acid position 37 of HLA-DRβ1 affects susceptibility to Crohn's disease in Asians

Crohn's disease (CD) and ulcerative colitis (UC) are the major types of chronic inflammatory bowel disease (IBD) characterized by recurring episodes of inflammation of the gastrointestinal tract. Although it is well established that human leukocyte antigen (HLA) is a major risk factor for IBD, it is yet to be determined which HLA alleles or amino acids drive the risks of CD and UC in Asians. To define the roles of HLA for IBD in Asians, we fine-mapped HLA in 12 568 individuals from Korea and Japan (3294 patients with CD, 1522 patients with UC and 7752 controls). We identified that the amino acid position 37 of HLA-DRβ1 plays a key role in the susceptibility to CD (presence of serine being protective, P = 3.6 × 10-67, OR = 0.48 [0.45-0.52]). For UC, we confirmed the known association of the haplotype spanning HLA-C*12:02, HLA-B*52:01 and HLA-DRB1*1502 (P = 1.2 × 10-28, OR = 4.01 [3.14-5.12]).

Immunoprofiling of Colitis-associated and Sporadic Colorectal Cancer and its Clinical Significance

Immunoprofiling is useful for predicting prognosis in various malignancies and provides targets for immunotherapy. Quantitative multispectral imaging system, which allows simultaneous detection of multiple immune markers, is a novel method for examining the tumor immune environment. We compared the expression levels of various surface markers in immune cells between colitis-associated cancer (CAC) and sporadic colorectal cancer (CRC) and evaluated the clinical usefulness of immunoprofiling in CRC. Tumor specimens from 24 CAC patients and 48 sporadic CRC patients, matched by age, sex, and tumor location to CAC, were included in the analysis. The expression levels of CD3, CD8, Foxp3, and programmed death-ligand 1 (PD-L1) in immune cells at the invasive margins of tumor tissues were evaluated by quantitative multispectral imaging. The CAC group had significantly less levels of cells expressing CD3, CD8, Foxp3, or PD-L1 (all, p < 0.01). In the CAC group, patients whose immune cells had high expression of CD3⁺ and CD8⁺ had better overall survival. The immune profiling patterns of CAC patients were significantly distinct from those of sporadic CRC patients, suggesting that CAC and sporadic CRC have distinct disease phenotypes. Immunoprofiling can be helpful for evaluation of clinical prognosis in CAC.

Factors influencing obesity among preschoolers: multilevel approach

BACKGROUND

Childhood obesity is a complex and multifaceted problem involving interactions among child, family and community environment.

AIM

The purpose of this study was to examine the contributing factors to early childhood obesity within a multilevel context, including child and family, childcare setting and community.

METHODS

A cross-sectional, quantitative research design was employed. A total of 129 preschoolers and their parents in northwest Florida participated in this study. Child height and weight were measured, and body mass index (BMI) was calculated. Parents and directors of preschools completed survey questionnaires to assess child/family, childcare setting and community factors, respectively. Hierarchical multiple regression was used to evaluate the association of each level of factors with child BMI z-score.

RESULTS

Twenty-one per cent of children were overweight or obese (≥85th BMI percentile). In hierarchical multiple regression, household income, parent beliefs, attitudes and practices for child feeding, family obesogenic environment, child routines (screen time on weekends, sleep hours, bedtime) and physical activity environment were significantly related to child BMI z-score.

CONCLUSIONS

The findings of this study provide a broader understanding of factors that influence child BMI z-score. Shaping a non-obesogenic environment by establishing healthy routines for children in the home, childcare setting and community is essential in childhood obesity prevention.

IMPLICATIONS FOR NURSING PRACTICE AND HEALTH POLICY

Paediatric nurses should routinely assess accurate parental perception of child weight, feeding style and child routines in well-child care visits. Healthcare professionals and health policymakers should enact policies that build a healthy environment for preschoolers in their childcare setting and community.

Vedolizumab Drug Level Correlation With Clinical Remission, Biomarker Normalization, and Mucosal Healing in Inflammatory Bowel Disease

BACKGROUND/AIMS

The clinical utility of vedolizumab (VDZ) trough levels (VTLs) in inflammatory bowel disease (IBD) is not well defined. The aims of this study are to determine the median VTLs and frequency of detected antibodies, the correlation of VTLs with C-reactive protein (CRP) and mucosal healing (MH), and the change in clinical management based on VTLs.

METHODS

A cross-sectional study of IBD patients treated with VDZ with VTLs checked between July 1, 2016, and March 1, 2017, was conducted. Mucosal healing was defined as absence of mucosal ulcers in Crohn's disease (CD) and Mayo endoscopic score ≤1 for ulcerative colitis (UC). Normal CRP was defined as ≤8 mg/L.

RESULTS

A total of 171 patients (62% CD, 31% UC, 7% indeterminate colitis) were included. Median VTLs was 15.3 ug/mL (range, 0-60), and 1 patient had detectable antibodies to VDZ. Patients with a normal CRP had a median VTLs of 17.3 ug/mL vs 10.7 ug/mL in high CRP patients (P = 0.046). This was noted in CD (20.3 vs 10.4 ug/mL; P = 0.005) but not in UC patients (14.4 vs 20.8; P = 0.72). Mucosal healing was achieved in 35% of patients (37 of 105); among these, median VTLs was 13.7 ug/mL vs 16.1 ug/mL in patients who did not achieve MH (P = 0.64). Vedolizumab trough levels resulted in a change in clinical management in 73%.

CONCLUSIONS

Our cohort showed a low rate of immunogenicity to VDZ and an association between VTLs and CRP in CD but not in UC patients. No relationship between VTLs and MH was detected. Vedolizumab trough level measurements altered management in approximately three fourths of patients.