A197 ACUTE ILEITIS IN ADULT PATIENT: A RETROSPECTIVE STUDY OF PATIENT OUTCOMES

Background

Rising availability of medical imaging exams in the emergency room potentially leads to an increase of ileitis findings by imaging in a context of gastrointestinal symptoms. However, it can be difficult to determine the clinical significance of this radiological finding in an acute consultation setting and to establish the relevant investigations.

Aims

The aim of this study is to describe the current management and the long-term outcome of patients with diagnostic of acute ileitis on imaging during an emergency consultation in our center, Centre Hospitalier Universitaire de Sherbrooke(CHUS).

Methods

We performed a retrospective study of all patients diagnosed with ileitis by abdominal ultrasound or computed tomography (CT scan) during a visit in our emergency department over the years 2010 and 2017. Patients with previous diagnosis of Crohn disease were excluded. Data collected were clinical, radiological and endoscopic at diagnostic and over at least 3 years following the initial visit.

Results

A total of 118 files were reviewed. The initial imaging modality was 43% ultrasound and 57% CT scan. 36% of patients had an ileocolonoscopy within one month of the initial visit. Of these, 60% demonstrated macroscopic endoscopic abnormalities. 51% of patients had follow-up imaging within 3 months of the initial consultation. 64% of these images demonstrated persistence of pathological changes in the ileal region. Only 48% had a stool culture at diagnosis. 72% of patients met a gastroenterologist and 45% saw a general surgeon. The most common cause of ileitis was an infectious origin at 44% predominantly with Yersinia enterocolitica and Campylobacter jejuni. 13% received a diagnostic of Crohn disease. 20% of ileitis remained undetermined. Among these, there was a case of Crohn’s disease which was eventually diagnosed 2 years later. The initial factors associated with a diagnosis of Crohn’s disease were family history of inflammatory bowel disease (OR 6.17 95% CI 1.67 to 22.781 p = 0.006), extra-digestive manifestations (OR 23.31 95% CI 2.255 to 240.92 p = 0.008), discontinuous impairment at initial imaging (OR 19.8 95% CI 4.284 to 91.52 p = 0.000), presence of stenosis at initial imaging (OR 14.429 95% CI 1.227 to 169.68 p = 0.034), the presence of abscess or collection on imaging (OR 11.54 95% CI 1.76 to 75.63 p = 0.011) and wall thickness in mm (1.22 95% CI 1.06 to 1.40 p = 0.005).

Conclusions

Our study shows that the majority of acute ileitis found on imaging are of infectious origin. A portion of acute ileitis corresponded to the initial presentation of Crohn’s disease. Thus, we believe that it is preferable to offer at least clinical follow-up to patients with acute ileitis on imaging and to consider additional investigation by imaging and / or colonoscopy when symptoms persist and this particularly in presence of factors associated with Crohn’s disease.

Funding Agencies

None

Serum Analyte Profiles Associated With Crohn's Disease and Disease Location

BACKGROUND

Crohn's disease (CD) can affect any segment of the digestive tract but is most often localized in the ileal, ileocolonic, and colorectal regions of the intestines. It is believed that the chronic inflammation in CD is a result of an imbalance between the epithelial barrier, the immune system, and the intestinal microbiota. The aim of the study was to identify circulating markers associated with CD and/or disease location in CD patients.

METHODS

We tested 49 cytokines, chemokines, and growth factors in serum samples from 300 patients with CD and 300 controls. After quality control, analyte levels were tested for association with CD and disease location.

RESULTS

We identified 13 analytes that were higher in CD patients relative to healthy controls and that remained significant after conservative Bonferroni correction (P < 0.0015). In particular, CXCL9, CXCL1, and interleukin IL-6 had the greatest effect and were highly significant (P < 5 × 10-7). We also identified 9 analytes that were associated with disease location, with VEGF, IL-12p70, and IL-6 being elevated in patients with colorectal disease (P < 3 × 10-4).

CONCLUSIONS

Multiple serum analytes are elevated in CD. These implicate the involvement of multiple cell types from the immune, epithelial, and endothelial systems, suggesting that circulating analytes reflect the inflammatory processes that are ongoing within the gut. Moreover, the identification of distinct profiles according to disease location supports the existence of a biological difference between ileal and colonic CD, consistent with previous genetic and clinical observations.

A public health enhanced surveillance system for a mass gathering event

BACKGROUND

From June 7 to June 9, 2018, a G7 Summit was held in the Canadian province of Quebec. This international political mass gathering event posed a number of potential risks to public health.

OBJECTIVE

To assess three additional monitoring strategies to detect public health threats during a mass gathering event.

INTERVENTION

In addition to routine public health monitoring, a partnership was created and three monitoring strategies were put in place three days before, during and six days after the G7 event: the analysis of data on the presenting complaint and discharge diagnosis from 11 emergency departments in the area using the logical Early Aberration Reporting System; the daily polling of key health partners with an online questionnaire; and the analysis of calls to Info-Santé, a government-run telephone consultation service for the public regarding health and social issues.

RESULTS

Emergency room data produced 78 alerts from the presenting complaints and 39 alerts from the discharge diagnoses. Of these 117 alerts, two were investigated (one in the respiratory and one in the neurological-muscular categories) and no other interventions were required. With a few exceptions, all of the health partners completed the online survey each day and no signal of concern was generated. Compared with historical data, no increase or differences in calls to Info-Santé were detected during the monitoring period.

CONCLUSION

The three additional monitoring strategies developed to detect events of public health importance during the 2018 G7 Summit in Quebec were successful in gathering timely data for analysis. Close collaboration and good participation from the different partners were essential to this project. However, because no public health event occurred, it was not possible to determine whether the enhanced surveillance system had sufficient speed and sensitivity for timely detection and response.

Abstract 4670: Evidence of neoantigen-reactive T cell response in a case of relapsing, mismatch-repair gene proficient, colorectal cancer

Whether the endogenous T cell reactivity to antigens derived from cancer mutations, called neoantigens (neoAgs), can be exploited for immunotherapy in patients with mismatch-repair (MMR) gene proficient metastatic colorectal cancer (CRC) is largely unknown. Here, we investigated the frequency of neoAg-reactive T cells longitudinally in a patient with relapsing CRC. Using whole exome and RNA sequencing, we identified 96 single nucleotide variant (SNV), 8 frameshift and 29 insertion/deletion mutations in a liver metastasis. Co-culture assays between in vitro expanded tumor infiltrating T lymphocytes (TILs) and autologous CD40-activated B cells loaded with peptides derived from SNVs led to the identification of two CD8+ T cell clones specific for PAMA733E, and respectively 1, 4 and 2 CD4+ T cell clones specific for PABPC1G563S, PDE4DIPR685S and TRPM4A480V. T cell clonality was confirmed by TCR Sanger sequencing. We assessed the in vivo frequency of these neoAg-reactive T cell clones by TCRβ chain deep sequencing (Adaptive Biotechnologies). The dominant T cell clone, reactive to PAMA733E, represented 5.2% of TILs in the primary tumor resected in 2010, 2.2% of TILs in the colonic recurrence resected in 2011, and 3.2% of TILs in the liver metastasis resected in 2012. The neoAg-reactive T cells were also detected in the peritumoral liver, but not into the distant normal liver. Along the disease course, most reactive T cell clones were not detected in the tumor draining lymph nodes or in the peripheral blood, at an average detection capacity of 1/3680 and 1/185,495 T cells respectively. When compared to the RNAseq data from 60 other CRC liver metastases, the relatively high level of transcripts related to immune cells, antigen processing and presentation, IFN-γ responsive genes, T-cell inhibitory and stimulatory receptors, cytokines, and chemokines observed in our patient metastasis suggested that there was an ongoing spontaneous immune response intratumoraly, co-existing with many immune-suppressive molecules. Our results support that neoAg-reactive T cells can be found in non-highly mutated, MMR proficient CRC tumors, at a much higher frequency than in the peripheral blood or the draining lymph nodes. As an adjuvant strategy to prevent recurrence, it may be possible in some patients to boost the immune response against a relevant neoAg expressed in the primary tumor. At the metastatic stage, a broader array of neoAgs may be targetable.

Citation Format: Mélissa Mathieu, Alexandre Paradis, Sandy Pelletier, Steven Hébert, Kevin Boutin, Éric Audemard, Sylvie Mader, Claudia Kleinman, Simon Turcotte. Evidence of neoantigen-reactive T cell response in a case of relapsing, mismatch-repair gene proficient, colorectal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4670.

Preliminary report: Surgical outcomes following genitoplasty in children with moderate to severe genital atypia

INTRODUCTION

Prior studies of outcomes following genitoplasty have reported high rates of surgical complications among children with atypical genitalia. Few studies have prospectively assessed outcomes after contemporary surgical approaches.

OBJECTIVE

The current study reported the occurrence of early postoperative complications and of cosmetic outcomes (as rated by surgeons and parents) at 12 months following contemporary genitoplasty procedures in children born with atypical genitalia.

STUDY DESIGN

This 11-site, prospective study included children aged ≤2 years, with Prader 3-5 or Quigley 3-6 external genitalia, with no prior genitoplasty and non-urogenital malformations at the time of enrollment. Genital appearance was rated on a 4-point Likert scale. Paired t-tests evaluated differences in cosmesis ratings.

RESULTS

Out of 27 children, 10 were 46,XY patients with the following diagnoses: gonadal dysgenesis, PAIS or testosterone biosynthetic defect, severe hypospadias and microphallus, who were reared male. Sixteen 46,XX congenital adrenal hyperplasia patients were reared female and one child with sex chromosome mosaicism was reared male. Eleven children had masculinizing genitoplasty for penoscrotal or perineal hypospadias (one-stage, three; two-stage, eight). Among one-stage surgeries, one child had meatal stenosis (minor) and one developed both urinary retention (minor) and urethrocutaneous fistula (major) (Summary Figure). Among two-stage surgeries, three children developed a major complication: penoscrotal fistula, glans dehiscence or urethral dehiscence. Among 16 children who had feminizing genitoplasty, vaginoplasty was performed in all, clitoroplasty in nine, external genitoplasty in 13, urethroplasty in four, perineoplasty in five, and total urogenital sinus mobilization in two. Two children had minor complications: one had a UTI, and one had both a mucosal skin tag and vaginal mucosal polyp. Two additional children developed a major complication: vaginal stenosis. Cosmesis scores revealed sustained improvements from 6 months post-genitoplasty, as previously reported, with all scores reported as good or satisfied.

DISCUSSION

In these preliminary data from a multi-site, observational study, parents and surgeons were equally satisfied with the cosmetic outcomes 12 months after genitoplasty. A small number of patients had major complications in both feminizing and masculinizing surgeries; two-stage hypospadias repair had the most major complications. Long-term follow-up of patients at post-puberty will provide a better assessment of outcomes in this population.

CONCLUSION

In this cohort of children with moderate to severe atypical genitalia, preliminary data on both surgical and cosmetic outcomes were presented. Findings from this study, and from following these children in long-term studies, will help guide practitioners in their discussions with families about surgical management.

Prospective assessment of cosmesis before and after genital surgery

INTRODUCTION

Little data exist about the surgical interventions taking place for children with disorders of sex development (DSD). Most studies that have evaluated cosmetic outcomes after genitoplasty have included retrospective ratings by a physician at a single center.

OBJECTIVE

The present study aimed to: 1) describe frequency of sex assignment, and types of surgery performed in a cohort of patients with moderate-to-severe genital ambiguity; and 2) prospectively determine cosmesis ratings by parents and surgeons before and after genital surgery.

STUDY DESIGN

This prospective, observational study included children aged <2 years of age, with no prior genitoplasty at the time of enrollment, moderate-to-severe genital atypia, and being treated at one of 11 children's hospitals in the United States of America (USA). Clinical information was collected, including type of surgery performed. Parents and the local pediatric urologist rated the cosmetic appearance of the child's genitalia prior to and 6 months after genitoplasty.

RESULTS

Of the 37 children meeting eligibility criteria, 20 (54%) had a 46,XX karyotype, 15 (40%) had a 46,XY karyotype, and two (5%) had sex chromosome mosaicism. The most common diagnosis overall was congenital adrenal hyperplasia (54%). Thirty-five children had surgery; 21 received feminizing genitoplasty, and 14 had masculinizing genitoplasty. Two families decided against surgery. At baseline, 22 mothers (63%), 14 fathers (48%), and 35 surgeons (100%) stated that they were dissatisfied or very dissatisfied with the appearance of the child's genitalia. Surgeons rated the appearance of the genitalia significantly worse than mothers (P < 0.001) and fathers (P ≤ 0.001) at baseline. At the 6-month postoperative visit, cosmesis ratings improved significantly for all groups (P < 0.001 for all groups). Thirty-two mothers (94%), 26 fathers (92%), and 31 surgeons (88%) reported either a good outcome, or they were satisfied (see Summary Figure); there were no significant between-group differences in ratings.

DISCUSSION

This multicenter, observational study showed surgical interventions being performed at DSD centers in the USA. While parent and surgeon ratings were discordant pre-operatively, they were generally concordant postoperatively. Satisfaction with postoperative cosmesis does not necessarily equate with satisfaction with the functional outcome later in life.

CONCLUSION

In this cohort of children with genital atypia, the majority had surgery. Parents and surgeons all rated the appearance of the genitalia unfavorably before surgery, with surgeons giving worse ratings than parents. Cosmesis ratings improved significantly after surgery, with no between-group differences.

Optimization of an in vitro human blood-brain barrier model: Application to blood monocyte transmigration assays

The blood–brain barrier (BBB) is a selectively permeable barrier that separates the circulating blood from the extracellular fluid of the brain and is an essential component in brain homeostasis. In vitro BBB models are valuable supporting tools that can precede and complement animal and human studies of the development and progression of the central nervous system diseases. At present, mono-, co-, and tri-culture models that use porcine, murine, or human cells have been developed. We have optimized a two-dimensional model of the human BBB using primary human brain microvascular endothelial cells and normal human astrocytes. We have validated the effectiveness of our model with transmigration assays of human blood monocytes toward CCL19, a natural ligand of the chemokine receptor CCR7. This model offers the following advantages:•

It is simple, convenient, and requires small quantities of material, reagents, and primary cells.

•

It can be used to monitor cell migration through the BBB.

•

It can be used to assess brain capillary permeability in the presence of xenobiotic, pro-inflammatory, or other substances.

Herpes simplex pneumonia in a young immunocompetent man

We report the case of a 33 year old man with herpetic bronchitis and bilateral pneumonitis. He presented without mucocutaneous lesions, and his cellular and humoral immunity were not compromised. Diagnosis was established on histological and cytological findings and confirmed by serology. Acyclovir treatment led to a favourable outcome.

Herpes simplex pneumonia in a young immunocompetent man

We report the case of a 33 year old man with herpetic bronchitis and bilateral pneumonitis. He presented without mucocutaneous lesions, and his cellular and humoral immunity were not compromised. Diagnosis was established on histological and cytological findings and confirmed by serology. Acyclovir treatment led to a favourable outcome.

[Can physicians efficaciously promote the purchase of bicycle helmets?]

OBJECTIVE

To evaluate the effectiveness of physician intervention in the purchase of bicycle helmets.

DESIGN

Randomized single-blind controlled trial; randomization by clusters.

SETTING

July 11, 1992, cycling path in Beauport, Quebec.

PARTICIPANTS

Non-helmeted cyclists riding alone and groups of two to six cyclists in which at least one member was not wearing a helmet were invited to participate in the study; 274 individuals or groups of cyclists (total n = 485 cyclists) were randomized for the study.

INTERVENTION

For the study group a physician handed out and explained the Canadian Medical Association's (CMA) pamphlet on bicycle helmets. This pamphlet includes a discount coupon for the purchase of a helmet. All of the participants in both the study group and the control group completed a questionnaire, including queries about sociodemographic characteristics, name, and telephone number.

MAIN OUTCOME MEASURE

Proportion of previously non-helmeted cyclists purchasing a helmet within 2 to 3 weeks of the intervention.

RESULTS

Telephone contact was made with 340 of the 416 non-helmeted cyclists (from 224 groups of cyclists). Of the 174 cyclists who had received a CMA pamphlet, 13.8% (n = 24) had purchased a helmet, compared to 3.0% (n = 5) of the 166 control group cyclists (RR = 4.6, 95% CL = 1.8-11.7). Similar results were achieved by cluster analysis of cyclists.

CONCLUSION

Physician intervention using the CMA pamphlet could be effective in promoting the purchase of bicycle helmets.

Effects of Vasocon-A in the allergen challenge model of acute allergic conjunctivitis

The ophthalmic combination product of 0.05% naphazoline hydrochloride and 0.5% antazoline phosphate (Vasocon-A) was evaluated as an antiallergic agent in 100 subjects with a known allergic history to cat dander, ragweed, or bluegrass pollen. Three independent study sites were used. The allergen challenge model of acute allergic conjunctivitis was selected to assess the agent as it provided a standardized and precise way to measure drug effectiveness for this indication. In a double-masked randomized fashion, the subjects were assigned to one of three groups that received one drop of Vasocon-A in one eye and one drop of either 0.05% naphazoline (group 1), 0.5% antazoline (group 2), or placebo (group 3) in the contralateral eye. After 10 minutes, the dose of allergen shown to elicit a 2+ redness and itching reaction was instilled bilaterally. Signs and symptoms of allergic conjunctivitis were evaluated after 3, 5, and 10 minutes. Subjects were then rechallenged 2 hours after drug administration to assess the duration of action of the agents. Vasocon-A was found to significantly inhibit all five major signs and symptoms of allergic conjunctivitis: itching, redness, chemosis, lid swelling, and tearing, for more than 85% of the comparisons when compared over time with placebo, naphazoline alone, or antazoline alone. The results of this study indicate that the combination of naphazoline and antazoline was more effective in inhibiting redness than naphazoline and more effective in inhibiting itching than antazoline. These findings support the use of such a combination for the treatment of allergic conjunctivitis.

The effect of hyaluronidase on akinesia during cataract surgery

The ability of hyaluronidase to improve akinesis in retrobulbar anesthesia was evaluated in a double-masked study. Forty consecutive patients undergoing cataract surgery were anesthetized with 3 ml of a 1:1 mixture of 4.0% lidocaine and 0.75% bupivacaine solution. In a predetermined randomized fashion, 2 ml of hyaluronidase (300 USP units) were added to half of the syringes, and 2 ml of saline to the remaining half. The level of akinesia was graded in six different positions of gaze. Seventy percent of the hyaluronidase group exhibited complete akinesis, while only 40% of the control group did. The mean scores for four out of six positions of gaze were significantly higher in the hyaluronidase patients than in the control group. Similarly, the hyaluronidase subjects showed a significantly higher sum score for the six sectors than did the control subjects (p = .0001). These results show that hyaluronidase significantly enhances akinesia. It is therefore recommended that it be included in the anesthetic regimen for such surgeries.

Metabolic relationships between lipolysis and respiration in rat brown adipocytes. The role of long chain fatty acids as regulators of mitochondrial respiration and feedback inhibitors of lipolysis

The calorigenic action of norepinephrine in isolated brown adipocytes was selectively mimicked by theophylline, dibutyryl cyclic AMP, and the principal fatty acids known to be present in the acyl moieties of brown adipose tissue triglycerides (palmitic, oleic, and linoleic acids). The stimulatory effects of fatty acids were entirely reversible, occurred at physiological concentrations, and were critically dependent upon the molar ratio of extracellular fatty acids to albumin. The calorigenic potency of fatty acids increased with their chain length. The apparent synchrony between the switching "on and off" of lipolysis and respiration by norepinephrine and propranolol indicated that the two phenomena are functionally inter-related and that they are both mediated by beta-adrenoreceptors. Respiratory stimulation by palmitic acid was accompanied by an inhibition of glycerol release suggesting that fatty acids retroinhibit lipolysis while simultaneously activating respiration. Studies with 2-tetradecylglycidic acid, oligomycin, and uncouplers of oxidative phosphorylation support the view that fatty acids exert their calorigenic effects by increasing mitochondrial proton permeability and by simultaneously serving as substrates for beta-oxidation via carnitine-dependent pathways. Since fatty acids mimicked the calorigenic action of norepinephrine even when beta-adrenoreceptors were blocked by propranolol, it is concluded that cyclic AMP controls respiration indirectly, most probably by modulating lipolysis. It is suggested that endogenous long chain fatty acids released in consequence of cyclic AMP activation of lipolysis play a fundamental role in the control of brown adipose tissue metabolism by self-regulating lipolysis and by serving as physiological modulators of mitochondrial oxygen consumption.

Mechanism of enhanced lipolysis in adipose tissue of exercise-trained rats

The effects of exercise training and food restriction on the regulation of lipolysis were studied comparatively in adipocytes isolated from male and female rats. Exercise training inhibited cell proliferation in parametrial, but not in epididymal adipose tissue, whereas it significantly reduced adipocyte size in both fat depots. Adipocyte capacity for responding lipolytically to epinephrine (10 microns) or to ACTH (1 micron) was markedly increased by exercise training. Enhanced lipolysis was also observed when cells isolated from exercise-trained animals were stimulated by bypassing with dibutyryl cyclic AMP (5 mM) or theophylline (5 mM) the early metabolic steps associated with hormonal activation of the adenylate cyclase complex. Significantly, binding of (-)-[3H]dihydroalprenolol to cellular receptor sites was not affected by exercise training. It is therefore concluded that exercise training increases adipocyte responsiveness to lipolytic hormones at a metabolic step distal to stimulus recognition by adrenoreceptors, possibly at the level of protein kinases or lipases. Food restriction markedly reduced adipocyte size and partially mimicked the effects of exercise training on adipocyte proliferation and lipolysis.

Stereospecific stimulation of brown adipocyte respiration by catecholamines via beta 1-adrenoreceptors

Regulation of respiration by catecholamines was studied in adipocytes isolated from interscapular brown adipose tissue of warm-acclimated rats by rapid digestion of collagenase. (-)-Norepinephrine stimulated adipocyte respiration 10-12 times above basal values in less than 3 min. (Vmax = 410 +/- 29.5 nmol O2 . min-1 . 10(-6) cells-1). Stimulated respiration remained stable for at least 20 min, provided that cells were incubated in balanced salt media containing bicarbonate. The maximal capacity of total brown adipose tissue for norepinephrine-stimulated respitarion was estimated at 1.5 ml O2/min per rat. beta-Adrenergic agonists increased calorigenesis stereospecifically with an order of potency expected for respiratory stimulation via adrenoceptors of the beta 1-subtype: (-)-isoproterenol (1/2 Vmax = 2 nM) greater than (-)-norepinephrine (1/2 Vmax = 20 nM) approximately equal to (-)-epinephrine (1/2 Vmax = 40 nM) greater than corresponding (+)-stereoisomers. The alpha-adrenergic agonist phenylephrine (1/2 Vmax = 5 microM) stimulated adipocyte respiration as rapidly and as effectively as beta-agonists. Although alpha-adrenoreceptors are present in brown adipose tissue, studies with alpha- and beta-adrenergic antagonists revealed that norepinephrine elicits thermogenesis at physiological concentrations (less than or equal to 1 microM) predominantely via beta 1-adrenergic pathways.

[The temporary asylum of Toronto (1841-1850) or the temporary impossibility of the utopia of asylum.]

The article analyzes the medical discourse of the directors of the Toronto asylum during the period from 1841 to 1850. These administrators gave the asylum the double objective of returning human dignity to the insane and of curing their insanity. Thus, they elaborated policies congruent to this double objective, policies, whéch when subjected to an elaborate analysis are seen to be ambiguous. In addition, a study of the unofficial day practices, reveals the Utopian nature of the official objectives and the veritably unchanged situation of these unfortunate people.

[The emergence of the Québec asylum in the 19th century.]

This team of five philosophers analyses the 18th and 19th century Quebec discourse on the subject of insanity. The 18th century saw the insane excluded from social contact with the state recognizing only their indigence. They were relegated either to the "Loges", designed to expiate their sins since insanity was linked to an abuse of mind and body, or to prison for appropriate punishment, since madness was considered to lead to crime. But economic pressures produced by the growing number in indigents, including the mentally ill, led to the creation of the Beauport asylum in 1845. The authors then describe how the urban insane, marginal to both the French Canadian and English Canadian communities* were placed in private institutions and subjected to a system of profit maximization controlled by bourgeois physicians. This situation increased the distance between proprietors and occupants, and accounts for the lack of original discourse on the subject of insanity. In addition, the reasoning of the alienist physicians was without scientific foundation, taking root rather in the dominant industrial capitalist ideology. As for the content of the discourse, the Beauport physicians borrowed from moral treatment and restraint system notions, giving them a certain Quebec character.