Morphological spectrum of immune check-point inhibitor therapy-associated gastritis

AIMS

Immune check-point inhibitors are frequently used in the treatment of a variety of solid tumours. The mechanism of action of these drugs involves up-regulation of cytotoxic T cells, which can lead to a lack of self-tolerance and immune-related adverse events, including those involving the gastrointestinal tract. This study was performed to characterise the histological features of immune check-point inhibitor therapy-associated gastritis.

METHODS AND RESULTS

Gastric biopsies from patients on immune check-point inhibitor therapy with clinical suspicion of drug-associated gastrointestinal injury were identified. The predominant histological pattern of injury, distribution of injury, degree of tissue eosinophilia and prominence of apoptosis were recorded. Presenting symptoms, treatment and follow-up data were obtained by medical chart review. The 12 patients included in the study group were treated with ipilimumab, nivolumab or pembrolizumab for a variety of tumours. Symptoms at presentation included nausea, vomiting and diarrhoea. Chronic active gastritis with intra-epithelial lymphocytosis and prominent apoptosis was seen in eight of 12 patients, and was the most useful combination for the diagnosis of drug-induced gastritis in these patients. Four patients showed focal enhancing gastritis with a lymphohistiocytic cuff around inflamed glands reminiscent of Crohn's disease. One of those four patients was homozygous for the ATG16L1 Crohn's disease-associated gene variant, but had no history of inflammatory bowel disease. Ten patients responded to medication withdrawal and steroid therapy, while two required treatment with infliximab.

CONCLUSIONS

Awareness of the morphological spectrum of immune check-point inhibitor therapy-associated gastritis is important for the accurate diagnosis and prompt management of these patients.

Respiratory health status is associated with treatment outcomes in pulmonary tuberculosis

<sec id="st1"> <title>BACKGROUND</title> The association between respiratory impairment and tuberculosis (TB) treatment outcomes is not clear. </sec> <sec id="st2"> <title>METHODS</title> We prospectively evaluated respiratory health status, measured using the Saint George's Respiratory Questionnaire (SGRQ), in a cohort of new adult pulmonary TB cases during and up to 18 months following treatment in India. Associations between total SGRQ scores and poor treatment outcomes of failure, recurrence and all-cause death were measured using multivariable Poisson regression. </sec> <sec id="st3"> <title>RESULTS</title> We enrolled 455 participants contributing 619 person-years at risk; 39 failed treatment, 23 had recurrence and 16 died. The median age was 38 years (interquartile range 26-49); 147 (32%) ever smoked. SGRQ scores at treatment initiation were predictive of death during treatment (14% higher risk per 4-point increase in baseline SGRQ scores, 95%CI 2-28, P = 0.01). Improvement in SGRQ scores during treatment was associated with a lower risk of failure (1% lower risk for every per cent improvement during treatment, 95%CI 1-2, P = 0.05). Clinically relevant worsening in SGRQ scores following successful treatment was associated with a higher risk of recurrence (15% higher risk per 4-point increase scores, 95%CI 4-27, P = 0.004). </sec> <sec id="st4"> <title>CONCLUSION</title> Impaired respiratory health status was associated with poor TB treatment outcomes. The SGRQ may be used to monitor treatment response and predict the risk of death in pulmonary TB. </sec>.

Type 3 Inositol 1,4,5-Trisphosphate Receptor Is Increased and Enhances Malignant Properties in Cholangiocarcinoma

Cholangiocarcinoma (CCA) is the second most common malignancy arising in the liver. It carries a poor prognosis, in part because its pathogenesis is not well understood. The type 3 inositol 1,4,5-trisphosphate receptor (ITPR3) is the principal intracellular calcium ion (Ca2+ ) release channel in cholangiocytes, and its increased expression has been related to the pathogenesis of malignancies in other types of tissues, so we investigated its role in CCA. ITPR3 expression was increased in both hilar and intrahepatic CCA samples as well as in CCA cell lines. Deletion of ITPR3 from CCA cells impaired proliferation and cell migration. A bioinformatic analysis suggested that overexpression of ITPR3 in CCA would have a mitochondrial phenotype, so this was also examined. ITPR3 normally is concentrated in a subapical region of endoplasmic reticulum (ER) in cholangiocytes, but both immunogold electron microscopy and super-resolution microscopy showed that ITPR3 in CCA cells was also in regions of ER in close association with mitochondria. Deletion of ITPR3 from these cells impaired mitochondrial Ca2+ signaling and led to cell death. Conclusion: ITPR3 expression in cholangiocytes becomes enhanced in CCA. This contributes to malignant features, including cell proliferation and migration and enhanced mitochondrial Ca2+ signaling.

Etiology of cirrhosis in the young

The etiology and incidence of cirrhosis in adults has been well studied, however there is scant data in younger patients. The aim of this study was to determine causes of cirrhosis in patients ≤40 years old. In this multi-institutional retrospective study, pathology databases were searched for patients ≤40-year-old with a diagnosis of cirrhosis from 1995 to 2018. Clinical charts and pathology reports were reviewed to identify etiologies of cirrhosis in each case. The patients were divided into 4 age groups (<1, 1- < 5, 5- < 18, and 18-40 years old) for further analysis. We identified 594 patients (264 female, 330 male). Among <18-year-old patients, congenital cholestatic diseases and developmental disorders were the most common causes of cirrhosis (50.2%, 172/342). Metabolic and genetic diseases were also seen more commonly in this age group (16.6%, 57/342). In contrast, viral hepatitides were the most common cause of cirrhosis in 18-40-year-old patients (39.6%, 100/252) followed by autoimmune and fatty liver disease (22.2%, 56/252 and 15.07%, 38/252, respectively). Cryptogenic cirrhosis (overall 7.2%, 42/594) was seen in 3% (4/133), 1.4% (1/69), 10.7% (15/140) and 8.7% (22/252) of patients aged <1, 1- < 5, 5- < 18, and 18-40 years, respectively. Developmental and metabolic disorders are the most common causes of cirrhosis in children (<18), while viral hepatitides are leading causes in adolescents and young adults (18-40) similar to adults. The incidence of cryptogenic cirrhosis also varies depending on the age, being lowest in 1- < 5 year and highest in 5- < 18 year age group children.

Standardising the interpretation of liver biopsies in non-alcoholic fatty liver disease clinical trials

BACKGROUND

There is substantial variation in how histologic definitions and scoring systems of non-alcoholic fatty liver disease (NAFLD) are operationalised.

AIM

To develop a consensus-based framework for standardising histologic assessment of liver biopsies in clinical trials of NAFLD.

METHODS

An expert panel of 14 liver pathologists and three hepatologists was assembled. Using modified RAND/University of California Los Angeles appropriateness methodology, 130 items derived from literature review and expert opinion were rated by each panel member on a 1-9 scale. Disagreement was defined as ≥5 ratings in the lowest (1-3) and highest (7-9) categories. Items were classified as inappropriate (median 1-3.5 without disagreement), uncertain (median 3.5-6.5 or any median with disagreement) or appropriate (median 6.5-9 without disagreement). Survey results were discussed as a group before voting.

RESULTS

Current measures of disease activity and fibrosis may not fully capture important features of non-alcoholic steatohepatitis (NASH). Alternative methods to evaluate ballooning degeneration are needed. Panellists were uncertain whether portal inflammation, degree of steatosis and Mallory-Denk bodies are important measures of disease activity. Furthermore, it was felt that current staging systems do not capture the full spectrum of fibrosis in NASH. A consensus definition and sub-stages for bridging fibrosis are needed. The severity of perisinusoidal fibrosis should be captured at all stages. Lastly, a method to evaluate features of fibrosis regression should be developed.

CONCLUSION

The operating properties of the modifications proposed should be evaluated prospectively to determine reliability and responsiveness.

Limitations of Multicultural Supervision in Clinical Neuropsychology

Method

The authors reviewed the literature regarding general aspects of multicultural supervision in clinical psychology, supervision in clinical neuropsychology, and additionally highlighted the gaps related to supervision in multicultural neuropsychology. Finally, they introduced ideas to address some of the needs in the arena of supervision in multicultural neuropsychology.

Discussion

Available resources that explore, delineate, or evaluate competent multicultural supervision in clinical neuropsychology are absent. Partially, the limited understanding of - and research that focuses on - the influence of diversity in neuropsychological assessment and interventions might explain the lack of resources allotted to competent multicultural supervision in clinical neuropsychology. It is proposed that in clinical, neuropsychology supervisory process (as in therapy supervision) should include a culturally competent supervisor who can assist in the development of self-awareness, knowledge, and skills in order to provide interventions that understand, honor, and respect the clients’ multiple diversity dimensions.

Neuropsychological Considerations of the Cultural and Linguistic Challenges of Working with a Bilingual/Bicultural Patient with Multiple System Atrophy (MSA): A Case Report

Objective

This case highlights the importance of understanding bilingualism, English as a second language (ESL), immigration as an older adult, and acculturation, in light of neuropsychological test results of an individual with MSA.

Case Description

Mrs. X is a right-handed, 73-year-old, South African woman. Her first language is Afrikaans while her second language is English. She has a history of MSA (2015). She reported a significant decline in her previously mastered English fluency. Challenges with language (i.e., reading comprehension, conversation), focus, balance, and activities of daily living, bilateral arm jerks, and difficulties with ambulation, Pisa Syndrome (left), loss of appetite, incontinence, fluctuating temperature, depression, personality changes, and suspected auditory hallucinations were also expressed.

Diagnostic Impressions and Outcomes

The neurocognitive findings indicated global impairment. Aside from an average score in her reading recognition, and low-average in a test of mental flexibility, Mrs. X had impairment in attention, learning, immediate and delayed memory, executive functioning, receptive and expressive language, confrontation naming, and visuospatial abilities. Mrs. X’s motoric difficulties and parkinsonism made it difficult for her to participate in testing comfortably. Language barriers were prominent: Mrs. X occasionally required English-Afrikaans translation and multiple repetitions of prompts. Summary and impressions of test results acknowledged the cultural and linguistic limitations of the evaluation. She was diagnosed with Major Neurocognitive Disorder secondary to MSA.

Discussion

In patients with diffuse impairment, it is essential to understand the role of dual language processes, ESL, and cultural limitations of assessments in order to accurately differentiate between neurodegenerative processes (i.e., Alzheimer’s Disease vs. other disorders), as well as to determine the impact of MSA on the linguistic abilities of bilingual individuals.

Late onset systemic sclerosis with seronegativity: a rare presentation of an uncommon disease

Systemic sclerosis (SSc) is an uncommon connective tissue disorder characterized by multisystem involvement with fibrosis of skin and internal organs. Antibody formation is one of the hallmarks of SSc. Antinuclear antibodies (ANA) are positive in 97% of patients with SSc. We report a rare case where the patient was negative for ANA, Anti-topoisomerase I, Anti-centromere and Anti-RNA polymerase III antibodies.

Diagnosing Social Communication Disorder (SCD) in Multicultural Individuals: A Case Study

Objective

Explore the impact of culture, developmental stage, and cognitive functioning in a possible diagnosis of SCD.

Case Description

A 12-year-old South Asian, bilingual/bicultural adolescent male (X) presented with concerns regarding his executive and social functioning skills. His medical history was notable for craniosynostosis - successfully treated with craniofacial surgery at age 1 - and a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD), combined presentation.

Diagnostic Impressions and Outcomes

X demonstrated superior intellectual performance with some inefficiencies in cognitive processing. Challenges with social interaction were not observed over the course of testing but his mother reported difficulties understanding pragmatic aspects of communication (sexual innuendos in double entendres) and recognizing when conversation had moved to a different topic. He kept a small social circle and preferred the company of older children.

Discussion

In conceptualizing X’s difficulties with social pragmatics, we must keep in mind the socio-cultural context in which he is growing up. He is the son of immigrant parents with South Asian roots. He is at an adolescent developmental stage where he is beginning to explore his individual identity while navigating the differing mores between his South Asian home culture and his American host culture. Therefore, responding to sexual innuendos may be a decision that is fraught with cultural angst over what is appropriate in one context but not the other. His gifted abilities and ADHD may make it difficult for him to remain engaged in the classroom or with similar-aged peers who don’t challenge his intellectual proclivities. His ADHD may also explain his difficulty in recognizing when the topic of conversation has changed. In deciding whether to assign a diagnosis of SCD, it is important to remember these cultural and developmental factors which could explain his difficulties in a normalizing way. These factors should also inform potential therapeutic recommendations.

P4994Severe hypoglycemia: a marker for worse cardiovascular outcomes? A meta-analysis of randomised controlled trials

Background

Observational data have suggested that severe hypoglycemic events increase the risk of subsequent cardiovascular morbidity and mortality but the evidence from randomised studies has been inconsistent.

Purpose

This meta-analysis evaluates the relationship between severe hypoglycemic events (SHEs) and the subsequent risk of mortality and major adverse cardiovascular events (MACE).

Methods

PubMed, Embase, and Cochrane Central databases were searched for randomised controlled trials (RCTs) that reported cardiovascular outcomes in patients with diabetes with a history of SHE. Treatment effects and relative standard errors were calculated from the available data. These values were imputed in software R to perform meta-analysis via generic inverse variance method.

Results

Data from 9 RCTs and 3,462 randomised patients were available. Patients, who suffered a SHE, were found to have a significantly increased risk of subsequent all-cause mortality (HR 2.24; 95% CI 1.70, 2.95; p-value <0.01), cardiovascular mortality (HR 2.32; 95% CI 1.67, 3.22; p-value <0.01), and MACE (HR 1.66; 95% CI 1.35, 2.06; p-value <0.01) compared to the patients without a SHE. An increased risk of subsequent stroke and arrhythmic death (p-value<0.05) were also found. There was no significant association between SHE and the risk of subsequent myocardial infarction and hospitalisation for unstable angina or heart failure.

Predictors of severe hypoglycemia Older age, Lower weight, Insulin-treated, CKD, Neuropathy, previous CVD Older age, Females, Lower weight, Insulin-treated, Longer duration of diabetes, CKD, Previous CVD Older age, Females, Lower weight, Insulin-treated, Longer duration of diabetes, CKD, Previous CVD Older age, Females, Insulin-treated, Longer duration of diabetes, CKD Older age, Females, Lower weight, Insulin-treated, CKD Older age, Lower weight, Longer duration of diabetes, CKD, Poor cognition, Previous CVD CKD = Chronic kidney disease; CVD = Cardiovascular disease.

Conclusion

In patients with diabetes, the occurrence of a SHE was associated with a significantly increased risk of subsequent cardiovascular morbidity and mortality. Further studies are required to explore and circumvent the predictors of SHEs in these patients.

Acknowledgement/Funding

None

Immunohistochemical and molecular features of cholangiolocellular carcinoma are similar to well-differentiated intrahepatic cholangiocarcinoma

Cholangiolocellular carcinoma is characterized by low grade cytologic atypia, and anastomosing cords and glands resembling cholangioles or canals of Hering. Cholangiolocellular carcinoma has been variously regarded as a subtype of intrahepatic cholangiocarcinoma (World Health Organization 2000), combined hepatocellular-cholangiocarcinoma of stem cell subtype (World Health Organization 2010) and a distinct type of primary liver carcinoma. Capture-based next generation sequencing targeting the coding regions of 479 cancer genes and select introns was performed on 17 cases (5 cholangiolocellular carcinomas, 7 intrahepatic cholangiocarcinomas, 5 mixed cholangiolocellular-intrahepatic cholangiocarcinomas) along with immunohistochemistry for CK19, SALL4, CD56, CD117, and EMA. For 5 mixed cholangiolocellular-intrahepatic cholangiocarcinoma, the individual areas were micro-dissected prior to sequencing. CK19 and EMA were positive in all cases; both luminal and cytoplasmic EMA was seen in 3/5 cholangiolocellular carcinoma and 3/6 intrahepatic cholangiocarcinomas. CD117 and SALL4 were negative in all cases. CD56 was positive in 2/5 cholangiolocellular carcinoma, 4/6 intrahepatic cholangiocarcinoma and 2/5 mixed cases. Mutations typical of intrahepatic cholangiocarcinoma (IDH1/2, PBRM1, FGFR2) were present in 90% of cases with cholangiolocellular carcinoma component. The genomic profile (IDH1/2 mutations, FGFR2 fusions, chromatin-remodeling gene mutations such as ARID1A, PBRM1) and copy number alterations were similar in cholangiolocellular carcinoma, intrahepatic cholangiocarcinoma and mixed cholangiolocellular-intrahepatic cholangiocarcinoma. In all mixed cases, the immunohistochemistry results, mutational profile and copy number alterations in both components were similar. Cholangiolocellular carcinoma should be categorized as a histologic subtype of well-differentiated intrahepatic cholangiocarcinoma, and should not be considered a distinct entity, or combined hepatocellular-cholangiocarcinoma unless a distinct hepatocellular component is also present.

P2484SGLT2 inhibitors in diabetes with CKD

Background

DM mellitus (DM) and chronic kidney disease (CKD) significantly increase the risk of cardiovascular morbidity and mortality. Current guideline recommendations do not support the use of SGLT2 inhibitors in patients with CKD stage III or higher. We performed a comprehensive meta-analysis to evaluate their cardiovascular effects in patients with type 2 DM and CKD stage III or higher.

Methods

A comprehensive search was performed in PubMed, Cochrane central and Embase for randomized controlled trials (RCTs) evaluating the cardiovascular outcomes of SGLT-2 inhibitors in patients with type 2 DM and CKD defined as glomerular filtration rate of <60ml/min. There were no data available on patients with end-stage renal disease. We calculated treatment effects and associated standard errors from the corresponding odds ratio and confidence interval. These values were imputed in software R to perform meta-analysis via generic inverse variance method. Additionally, we conducted a network meta-analysis to compare the relative efficacy and safety of each agent.

Results

Data from 7 RCTs and 6,527 participants was available. In patients with type 2 DM and CKD, SGLT-2 inhibitor use resulted in a significant reduction of myocardial infarction (22%), heart failure hospitalization (39%), and major adverse cardiac events (20%) (all p-value<0.05). There was also a trend towards a reduction in stroke and cardiovascular mortality. In a network meta-analysis, canagliflozin was the most effective in reduction of MI, stroke and heart failure hospitalization. Empagliflozin performed better for the outcome of cardiovascular mortality, but the results failed to reach significance.

Conclusion

SGLT-2 inhibitors significantly improve cardiovascular outcomes in patients with type 2 DM and CKD stage III or higher. This meta-analysis confirms that renal dysfunction should not be a deterrent to the widespread utilization of SGLT-2 inhibitors. Further studies are needed to identify the mechanisms behind these improved cardiovascular outcomes

Acknowledgement/Funding

None

Barriers to screening and isoniazid preventive therapy for child contacts of tuberculosis patients

BACKGROUND

India's guidelines recommend tuberculosis (TB) screening of household contacts aged <6 years and isoniazid preventive therapy (IPT) for children without active disease. We evaluated the current status and barriers to screening and IPT provision among the child contacts of TB patients.

METHODS

Questionnaire and health record data were collected from index cases and health care providers (HCPs) at Sassoon General Hospital, Pune, India.

RESULTS

Of 80 adult TB cases, 24 (30%) reported that an HCP recommended TB screening of their child contacts; 49/178 (28%) child contacts were screened. Sixteen (33%) children had active TB, and 28 (85%) of those who screened negative were prescribed IPT. Nineteen (76%) HCPs reported recommending child contact screening. Only 8 (32%) reported ever prescribing IPT. Lack of TB screening and IPT provision for child contacts was associated with inadequate HCP counseling (aOR 19.5, P < 0.001), a non-parent index case (aOR 3.72, P = 0.008) and lack of postgraduate HCP qualification (aOR 19.12, P = 0.04).

CONCLUSIONS

TB screening and IPT provision for child contacts of adults with TB were infrequent. Many screened children had active TB. Universal, timely TB screening and IPT for exposed children are urgently needed to reduce pediatric TB in India.

Prototheca zopfii Colitis in Inherited CARD9 Deficiency

Human protothecosis is a rare microalgae infection, and its dissemination typically occurs in immunocompromised individuals, but no specific immune defect has been reported. Here, we describe an 8-year-old daughter of a consanguineous union with abdominal pain and bloody diarrhea for 3 months who was found to have pancolitis with numerous microalgae identified as Prototheca zopfii. In the absence of a known immunodeficiency, exome sequencing was performed, which uncovered a novel recessive frameshift mutation in CARD9 (p.V261fs). This report highlights that CARD9 deficiency should be investigated in patients with unexplained systemic/visceral protothecosis and suggests a new mechanistic insight into anti-Prototheca immunity.

Pancreatic Intraductal Papillary Mucinous Neoplasm With Elevated Pre-Operative Cystic Carcinoembryonic Antigen Level: A Histopathologic Correlation

Background

To study the relationship between carcinoembryonic antigen (CEA) level, intraductal papillary mucinous neoplasm (IPMN) subtype, and the presence of invasive carcinoma.

Methods

Cystic CEA level and the following pathologic variables: subtypes of IPMN, size of cystic lesion, presence of dysplasia or carcinoma, and main or branch duct involvement from 45 IPMN cases were analyzed.

Results

There was a significant correlation between pre-operative cystic fluid CEA level and the intensity of luminal CEA staining. However, there was no correlation between CEA level and cystic mucinous secretions or mucinous epithelial cytoplasm CEA staining, mucin glycoprotein expression, size of lesion, grade of dysplasia or presence of invasive carcinoma. CEA level was neither sensitive nor specific for the presence of invasive carcinoma.

Conclusions

Cystic CEA level may not be a reliable determinant of the presence or absence of invasive carcinoma in IPMNs, and its use to assess risk of malignancy may be limited.

Cryptogenic cirrhosis: Old and new perspectives in the era of molecular and genomic medicine

Cryptogenic cirrhosis (CC) is defined as cirrhosis of unknown etiology despite extensive clinical, laboratory and pathologic work-up, and constitutes approximately 5-10% of all cirrhosis cases. Histologic examination can provide important clues and help identify the potential etiology of CC. Most CC cases can still be classified into four histologic patterns: hepatitic, steatotic, biliary, and patternless (bland). The use of genetic testing has significantly improved diagnostic ability and treatment, especially in pediatric patients with acute and chronic liver diseases. More recently, whole exome sequencing has been used for identifying genetic alterations that lead to a diagnosis in adults with liver disease of unknown etiology. Recent advances in genomic analysis has allowed the unraveling of the underlying etiology in a subset of CC cases, and also helped identify new disorders. Providing a diagnosis for these patients has several important implications for treatment, possible genetic counseling, and transplant eligibility. However, detailed clinical and histologic characterization of the patients still remains an important part of the CC work-up, since clinicopathologic and genomic correlation is crucial in making a diagnosis, or in some cases, discovery of a new entity. This article summarizes the main histologic findings that can be observed in CC cases, potential causes of CC, and recent advances in the field.

Glucose Metabolic Reprogramming and Cell Proliferation Arrest in Colorectal Micropapillary Carcinoma

Background

Micropapillary carcinoma (MPC) has been reported as an aggressive variant of colorectal carcinoma (CRC) associated with frequent lymphovascular invasion and poor outcome. Altered glycogen metabolism by metabolic reprogramming plays a critical role for cancer cell growth and survival. We aimed to investigate glucose metabolic reprogramming in colorectal MPC.

Methods

Immmunostains for Ki-67 and glucose transporter 1 (GLUT1) were performed on 10 colorectal MPCs. Real-time PCR analysis of expressions of GLUT1 and glycogen metabolizing enzymes: glycogen synthase (GYS1) and glycogen phosphorylase (PYGL) was performed on cultured monolayer and three-dimensional (3D) spheroid HCT116 colon cancer cells.

Results

GLUT1 was strongly expressed in MPC as compared to adjacent conventional glandular component, and was also significantly increased expression in 3D spheroids. Upregulation of GYS1 and PYGL was markedly increased in 3D spheroids. The proliferation rate (Ki-67) of MPC was significantly lower compared to conventional glandular component. The 3D spheroids showed increased cell cycle arrest. Our results demonstrate altered glycogen metabolism in colorectal MPC.

Conclusion

The reprogramming of glycogen metabolism in MPC provides a source of energy contributing to tumor cell survival in a low proliferation state. Targeting glucose-regulated metabolism may warrant consideration as possible MPC therapies.