Pre-Diagnosis Diet Predicts Response to Exclusive Enteral Nutrition and Correlates with Microbiome in Pediatric Crohn Disease

Exclusive enteral nutrition (EEN) is effective in inducing remission in pediatric Crohn disease (CD). EEN alters the intestinal microbiome, but precise mechanisms are unknown. We hypothesized that pre-diagnosis diet establishes a baseline gut microbiome, which then mediates response to EEN. We analyzed prospectively recorded food frequency questionnaires (FFQs) for pre-diagnosis dietary patterns. Fecal microbiota were sequenced (16SrRNA) at baseline and through an 18-month follow-up period. Dietary patterns, Mediterranean diet adherence, and stool microbiota were associated with EEN treatment outcomes, disease flare, need for anti-tumor necrosis factor (TNF)-α therapy, and long-term clinical outcomes. Ninety-eight patients were included. Baseline disease severity and microbiota were associated with diet. Four dietary patterns were identified by FFQs; a "mature diet" high in fruits, vegetables, and fish was linked to increased baseline microbial diversity, which was associated with fewer disease flares (p < 0.05) and a trend towards a delayed need for anti-TNF therapy (p = 0.086). Baseline stool microbial taxa were increased (Blautia and Faecalibacterium) or decreased (Ruminococcus gnavus group) with the mature diet compared to other diets. Surprisingly, a "pre-packaged" dietary pattern (rich in processed foods) was associated with delayed flares in males (p < 0.05). Long-term pre-diagnosis diet was associated with outcomes of EEN therapy in pediatric CD; diet-microbiota and microbiota-outcome associations may mediate this relationship.

Physical Activity in Pediatric Inflammatory Bowel Disease: A Scoping Review

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic, systemic condition affecting the gastrointestinal tract. IBD can be severe and are associated with impairment in growth, school absences, abdominal pain, and fatigue. Physical activity (PA) could have an anti-inflammatory effect in addition to other benefits. It is important to address the possible risks, physiological effects of PA, and potential barriers, and facilitators for PA participation in pediatric IBD. However, potential barriers and facilitators to PA have yet to be adequately described.

METHODS

We conducted a scoping review to map and describe the current literature on PA in pediatric IBD populations between 1980 and April 2022 using Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines for Scoping reviews.

RESULTS

Nineteen articles were identified including 10 descriptive, 6 interventional, and 3 physiological responses to PA studies. Patients and healthy controls demonstrated similar responses to exercise. Barriers to participation were low self-esteem, body image, and active IBD symptoms. Facilitators included personal interest, activity with friends, and support from family.

CONCLUSION

This review highlighted that PA participation may reduce in children with IBD-related symptoms. Short- and medium-term impacts of PA on immune modulation require further study; it is possible that regular PA does not negatively affect biomarkers of disease activity.

Inflammatory Bowel Disease Among Canadian Children: Comparison Between Children of Non-European Descent and Children of European Descent

BACKGROUND

Inflammatory bowel disease (IBD) phenotypes may differ between countries and ancestral groups. The study aim was to examine ancestry and subtype variations of children newly diagnosed with IBD.

METHODS

Children newly diagnosed with IBD enrolled into the Canadian Children Inflammatory Bowel Disease Network inception cohort study were categorized into 8 ancestral groups. Prospectively collected data at diagnosis and follow-up were compared between ancestral groups.

RESULTS

Among 1447 children (63.2% Crohn's disease, 30.7% ulcerative colitis), 67.8% were European, 9.4% were South Asian, 3.8% were West Central Asian and Middle Eastern, 2.3% were African, 2.2% were East/South East Asian, 2.0% were Caribbean/Latin/Central/South American, 9.9% were mixed, and 2.6% were other. Children of African descent with ulcerative colitis had an older age of diagnosis compared with children of European descent (median 15.6 years vs 13.3 years; P = .02). Children of European descent had a higher proportion of positive family history with IBD (19.3% vs 12.1%; P = .001) compared with children of non-European descent. Children of European descent also had a lower proportion of immigrants and children of immigrants compared with children of non-European descent (9.8% vs 35.9%; P < .0001; and 3.6% vs 27.2%; P < .0001, respectively) .

CONCLUSIONS

Important differences exist between different ancestral groups in pediatric patients with IBD with regard to age of diagnosis, family history, and immigrant status. Our study adds to the knowledge of the impact of ancestry on IBD pathogenesis.

Microbiota signatures and mucosal healing in the use of enteral nutrition therapy v. corticosteroids for the treatment of children with Crohn's disease: a systematic review and meta-analysis

Corticosteroids (CS) and exclusive and partial enteral nutrition (EEN and PEN) are effective therapies in paediatric Crohn's disease (CD). This systematic review of randomised controlled trials (RCT) and cohort studies analyses the impact of EEN/PEN v. CS on intestinal microbiota, mucosal healing as well as other clinically important outcomes, including clinical remission, relapse, adherence, adverse events and health-related quality of life (HRQL) in paediatric CD. Three RCT (n 76) and sixteen cohort studies (n 1104) compared EEN v. CS. With limited available data (one RCT), the effect on intestinal microbiome indicated a trend towards EEN regarding Shannon diversity. Based on two RCT, EEN achieved higher mucosal healing than CS (risk ratio (RR) 2·36, 95 % CI (1·22, 4·57), low certainty). Compared with CS, patients on EEN were less likely to experience adverse events based on two RCT (RR 0·32, 95 % CI (0·13, 0·80), low certainty). For HRQL, there was a trend in favour of CS based on data from two published abstracts of cohort studies. Based on thirteen cohort studies, EEN achieved higher clinical remission than CS (RR 1·18, 95 % CI (1·02, 1·38), very low certainty). Studies also reported no important differences in relapse and adherence. Compared with CS, EEN may improve mucosal healing with fewer adverse events based on RCT data. While limited data indicate the need for further trials, this is the first systematic review to comprehensively summarise the data on intestinal microbiome, mucosal healing and HRQOL when comparing enteral nutrition and CS in paediatric CD.

ADALIMUMAB VERSUS INFLIXIMAB IN LUMINAL PEDIATRIC CROHN'S DISEASE: COMPARABLE OUTCOMES IN A PROSPECTIVE MULTICENTER COHORT STUDY

BACKGROUND

This study compared real-world effectiveness between adalimumab (ADA) and infliximab (IFX) in children with Crohn's disease (CD).

METHODS

Children enrolled into the prospective Canadian Children Inflammatory Bowel Disease Network (CIDsCaNN) National Inception Cohort between 2014 and 2020 who commenced ADA or IFX as first anti-tumor necrosis factor (antiTNF) agent for luminal CD were included. Multivariate logistic regression modelled the propensity of commencing ADA; propensity score matching was used to match IFX-treated children to ADA-treated children. The primary outcome at one year was steroid-free clinical remission (SFCR). Secondary outcomes at one year were I) combined SFCR and c-reactive protein (CRP) remission; II) treatment intensification; and III) antiTNF durability. Odds ratios (aOR) and hazard ratio (aHR) adjusted for concomitant immunomodulator use with 95% confidence interval (CI) are reported.

RESULTS

In the propensity score matched cohort of 147 ADA-treated and 147 IFX-treated children, 92 (63%) ADA- and 87 (59%) IFX-treated children achieved SFCR at one year (aOR: 1.4, 95% CI 0.9-2.4); 75 of 140 (54%) ADA- and 85 of 144 (59%) IFX-treated children achieved combined SFCR and CRP remission (aOR: 1.0, 95% CI 0.6-1.6). ADA-treated children less frequently underwent treatment intensification (21 [14%]) compared to IFX-treated children (69 [47%]) (P<0.0001). Discontinuation of antiTNF occurred in 18 (12%) ADA-treated and 15 (10%) IFX-treated children (aHR: 1.2, 95% CI 0.6-2.2).

CONCLUSION

Children with Crohn's disease achieved favourable outcomes at one year with either ADA or IFX as first antiTNF agents. Those receiving IFX did not have significantly superior outcomes compared to clinically similar children receiving ADA.

Structures of strong shocks in low-density helium and neon gases

Strong shocks are essential components in many high-energy-density environments such as inertial confinement fusion implosions. However, the experimental measurements of the spatial structures of such shocks are sparse. In this paper, the soft x-ray emission of a shock front in a helium gas mixture (90% helium, 10% neon) and a pure neon gas was spatially resolved using an imaging spectrometer. We observe that the shock width in the helium mixture gas is about twice as large as in the pure neon gas. Moreover, they exhibit different precursor layers, where electron temperature greatly exceeds ion temperature, extending for more than ∼350µm with the helium gas mixture but less than 30µm in the pure neon. At the shock front, calculations show that the electrons are strongly collisional with mean-free path two orders of magnitude shorter than the characteristic length of the shock. However, the helium ions can reach a kinetic regime as a consequence of their mean-free path being comparable to the scale of the shock. A radiation-hydrodynamic simulation demonstrates the impact of thermal conduction on the formation of the precursors with charge state, Z, playing a major role in heat flow and the precursor formation in both the helium mixture and the pure neon gases. Particle-in-cell simulations are also performed to study the ion kinetic effects on the formation of the observed precursors. A group of fast-streaming ions is observed leading the shock only in the helium gas mixture. Both effects explain the longer precursor layer in the helium shock.

Inverse Bremsstrahlung Absorption

Inverse bremsstrahlung absorption was measured based on transmission through a finite-length plasma that was thoroughly characterized using spatially resolved Thomson scattering. Expected absorption was then calculated using the diagnosed plasma conditions while varying the absorption model components. To match data, it is necessary to account for (i) the Langdon effect; (ii) laser-frequency (rather than plasma-frequency) dependence in the Coulomb logarithm, as is typical of bremsstrahlung theories but not transport theories; and (iii) a correction due to ion screening. Radiation-hydrodynamic simulations of inertial confinement fusion implosions have to date used a Coulomb logarithm from the transport literature and no screening correction. We anticipate that updating the model for collisional absorption will substantially revise our understanding of laser-target coupling for such implosions.

A150 MODERATE AGREEMENT IN ENDOSCOPIC DISEASE SCORING OF PEDIATRIC EOSINOPHILIC ESOPHAGITIS AMONG PEDIATRIC GASTROENTEROLOGISTS IN CANADA

Background

Endoscopy is an important tool in assessing the severity of gastrointestinal diseases including Eosinophilic Esophagitis (EoE). Agreement regarding endoscopy outcomes is important when using tools such as the Endoscopic Reference Score for EoE (EREFS).

Purpose

Our goal was to determine interrater and intrarater agreement of EREFS among Canadian pediatric gastroenterologists.

Method

Survey-based study of interrater and intrarater reliability amongst pediatric gastroenterologists with interest in pediatric EoE. Participants were sourced from the Canadian Pediatric EoE Network. Participants were asked how many years of training they’ve had with endoscopy for pediatric EoE and their comfort in disease scoring for pediatric EoE. Pediatric EoE cases were identified from the pediatric EoE registry at the Stollery Children’s Hospital with an endoscopic video associated with each case. Participants were asked to score each video using the EREFS questionnaire for the proximal, middle and distal segments of the esophagus. 15 endoscopic videos were evaluated, with 3 cases provided each week over a period of 5 weeks. Additional data included ratings of the video quality and endoscopy quality. Of 15 cases, 12 were unique cases, distributed evenly in severity between no active disease to severe disease. 3 cases were repeated to assess intrarater reliability. The maximum grade of the proximal, middle and distal segments of the esophagus for each component endoscopic finding (edema, rings, exudates, furrows, strictures) were used for reliability calculations. Fleiss Kappa was calculated for all EREFS items and for each component endoscopic finding. Cohen’s Kappa was calculated to assess intrarater reliability.

Result(s)

Fifteen participants were recruited for the study. The participants had a median of 12 years (IQR: 7, 19) of clinical experience in endoscopy for pediatric EoE. The majority of participants were “comfortable” (i.e., 4 on 5-point scale) with EREFS scoring for pediatric EoE. Fleiss Kappa for all EREFS items was 0.481. For each component endoscopic finding (edema, rings, exudates, furrows, strictures), Fleiss Kappa was 0.365, 0.293, 0.548, 0.263, 0.445 respectively. Cohen’s Kappa had a median of 0.620 (IQR: 0.593, 0.704). The majority of raters rated video quality and endoscopy quality as “good” (i.e., 4 on 5-point scale).

Conclusion(s)

There is moderate interrater reliability in EREFS scoring for pediatric EoE. Interrater reliability was between fair to moderate for each component endoscopic finding. Intrarater reliability was good. This study shows there is room for improvement in disease scoring for pediatric EoE. This could be in the form of additional training, expert-defined conventions, or centralized reading which have reduced variability in endoscopic reporting for adult GI disease in past studies and could be used in a follow-up study to attempt to improve agreement. Additionally, incorporating EREFS into routine clinical practice may increase agreement amongst endoscopists.

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A143 PEDIATRIC EOSINOPHILIC ESOPHAGITIS IN CANADA: A MULTI-CENTER COHORT WITH FOCUS ON THE STRICTURING PHENOTYPE

Background

Eosinophilic esophagitis (EoE) is a chronic eosinophil-predominant esophageal inflammatory condition, and is now recognized as one of the most common organic causes of dysphagia in pediatrics. While fibrostenotic esophageal strictures are a common complication of adult EoE, characterization of the stricturing phenotype in pediatric EoE remains at an early stage.

Purpose

Describe the Canadian pediatric EoE experience, with focus on the stricturing phenotype.

Method

New pediatric EoE diagnoses from 2015-2018 were retrospectively identified in Vancouver (BC), Northern Alberta (AB), Hamilton (ON) and Nova Scotia (NS). Incidence rates were calculated using 2016 Federal census data. Clinical, endoscopic and histologic data were gathered for each patient’s initial clinical encounter and for any esophagogastroduodenoscopies (EGD) until the end of the follow-up period (fall 2019).

Result(s)

332 new EoE cases were identified during the study period across all 4 sites. The incidence of EoE in patients less than 15 years old was 9.1 (AB), 6.5 (NS), 3.1 (BC) and 5.4 (combined) per 100,000 person-years. Incidence was not calculated for Hamilton due to risk of ascertainment bias given their catchment area overlaps with multiple other centers. Of identified cases, 40 (12.0%) had endoscopically-identified esophageal strictures at diagnosis or during the follow-up period, with a subset of 11 (3.3%) of these patients undergoing mechanical esophageal dilation. Another 11 (3.3%) patients had more subtle signs of esophageal narrowing (ex. mucosal rents), while the majority had no evidence of esophageal narrowing (281, 84.6%). The median age at diagnosis was higher in the cohort with strictures (12.4 years, IQR 8.9-14.1) than those without (10.3 years, IQR 6.1-13.6) but with wide IQR's. A similar trend was seen for the median duration of symptoms at diagnosis (1.5 years, IQR 0.5-3 versus 1.0 years, IQR 0.6-2.8). Patient reported food bolus impaction (OR 9.8, 95% CI 3.9-19.9) and dysphagia (OR 3.3, 95% CI 1.3-7.8) were associated with stricturing disease, with other symptoms less clearly linked. Trachealization was the endoscopic finding most closely associated with esophageal strictures (OR 5.7, 95% CI 2.8-11.5). Esophageal stricture(s) were noted on 72 EGDs, including 27 endoscopic esophageal dilations, but excluding 10 esophageal dilations by interventional radiology. Of the 65 EGDs done in follow-up of a known esophageal stricture (see Table), 4 of 31 had resolution of this finding post mechanical dilation, and 19 of 39 had resolution of the stricture after initiation of new medical or dietary treatments (without dilation).

Conclusion(s)

EoE is common in Canadian children, with esophageal strictures within a few years of diagnosis in 12% of cases. Interestingly, a large portion of strictures resolved without mechanical dilation, which seems to point away from fibrosis as the primary driver of esophageal strictures in this patient population.

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Women and Children's Health Research Institute

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Absorption and Transport Effects Induced in Plasmas by the Interaction of Electrons with Laser Speckles

We show that the ponderomotive force associated with laser speckles can scatter electrons in a laser-produced plasma in a manner similar to Coulomb scattering. Analytic expressions for the effective collision rates are given. The electron-speckle collisions become important at high laser intensity or during filamentation, affecting both long- and short-pulse laser intensity regimes. As an example, we find that the effective collision rate in the laser-overlap region of hohlraums on the National Ignition Facility is expected to exceed the Coulomb collision rate by 1 order of magnitude, leading to a fundamental change to the electron transport properties. At the high intensities characteristic of short-pulse laser-plasma interactions (I≳10^{17}  W cm^{-2}), the scattering is strong enough to cause the direct absorption of laser energy, generating hot electrons with energy scaling as E≈1.44(I/10^{18}  W cm^{-2})^{1/2} MeV, close to experimentally observed results.

Survey of Patient Knowledge and Awareness of "Sick Day Rules" in Rheumatology Patients on Long Term Glucocorticoid Therapy

Aims Rheumatic disease (RMD) patients treated with long-term glucocorticoids (GC) are at risk of developing tertiary adrenal insufficiency. With this survey we aimed to assess the knowledge of RMD patients taking long-term glucocorticoid therapy regarding risk of adrenal insufficiency and understanding of the "steroid sick day rules". Methods RMD patients taking ≥2.5 mg prednisolone daily for ≥3 months were recruited from the Rheumatology outpatient department in Beaumont Hospital, Dublin. Patient knowledge and previous counselling of steroid sick day rules was determined using an 8-point questionnaire carried out face-to-face or via phone call. Results 51 RMD patients on GC therapy were recruited. 3/51 (5.9%) of patients reported that they had been counselled on the Sick Day Rules. 2/51 (3.9%) carried a steroid emergency card or MedicAlert bracelet. Few patients would increase their steroid dose appropriately in response to infection, vomiting or peri-procedure [14/51 (27.5%); 9/51 (17.7%) and 5/51 (7.2%), respectively]. Conclusion We demonstrate a significant deficit of patient knowledge around the precautions for long-term GC use in rheumatic diseases. We suspect that our results may be generalisable to many other RMD units. We are currently reviewing our procedures around healthcare professional and patient education, issuing of information leaflets, emergency cards or MedicAlert bracelets etc. to at risk patients.

Direct Measurement of the Return Current Instability in a Laser-Produced Plasma

Measurements were made of the return current instability growth rate, demonstrating its concurrence with nonlocal transport. Thomson scattering was used to measure a maximum growth rate of 5.1×10^{9}  Hz, which was 3 times less than classical Spitzer-Härm theory predicts. The measured plasma conditions indicate the heat flux was nonlocal, and Vlasov-Fokker-Planck simulations that account for nonlocality reproduce the measured growth rates. Furthermore, the threshold for the return current instability was measured (δ_{T}=0.017±0.002) to be in good agreement with previous theoretical models.

A66 THE IMPACT OF A MULTIDISCIPLINARY ADOLESCENT AND YOUNG ADULT (AYA) INFLAMMATORY BOWEL DISEASE (IBD) ON CLINIC NO SHOW RATES

Background

Transitioning from pediatric to adult health care is associated with significant psychosocial and clinical morbidity. Adolescents not only transition their medical care, but also experience vast changes in the physical, social, and psychological spheres of their lives. The medical team must help navigate these changes to provide optimal care.

IBD in adolescence is associated with increased hospitalizations and surgery. This is due to several factors, including medication non-adherence and a failure to attend medical appointments. There has been a greater focus on improving care for this unique population.

McMaster Children’s Hospital has integrated the AYA IBD clinic for patients between the ages of 16 and 22. The goal is to transition patients using a developmentally appropriate framework to facilitate self-efficacy and help identify comorbid mental health conditions while building resilience.

Aims

To explore the impact of the implementation of a dedicated transition clinic on attendance at medical visits for AYA patients with IBD.

Methods

The total numbers of patients booked in the AYA IBD Clinic was compared to an age matched subset of the patients in the adult McMaster Complex IBD (CIBD) Clinic. These visits were assessed based on whether the visit was: attended, cancelled, or no showed. Visits were then stratified between in-person and virtual visits. Unpaired t tests was performed to compare the AYA IBD clinic and the CIBD clinic. Findings were deemed significant based on p-values <0.05.

Results

The percentages of patients that attended visits (in-person or virtually) was similar between both clinics at 86% versus 79% Year 1 (Y1) and 76% versus 81% Year 2 (Y2). The number of patients seen in the AYA clinic increased from Y1 (n=92) to Y2 (n=131). The CIBD clinic saw fewer patients between Y1 (n=202) and Y2 (n=79). There were a higher number of patients who cancelled or no showed in Y2 versus Y1 for the AYA virtual visits (13 versus 8) compared to the CIBD clinic (Y2,1 versus Y1,1).

Conclusions

Our results highlight the challenges of transitioning adolescent patients with IBD. Our retrospective study was not powered to show significance. Given the increase in cancellation and no-show rates in Y2, the AYA clinic has incorporated a patient navigator to issue reminder phone calls and facilitate communication with patients between clinics. Future studies will re-assess how the presence of a patient navigator impacts attendance and cancellation rates. Future studies will also assess how the AYA clinic impacts transition readiness and self-efficacy, which is being measured through validated questionnaires in our clinic.

Funding Agencies

Grants-In-Aid

Challenges and improvement needs in the care of patients with central diabetes insipidus

Central diabetes insipidus (CDI) is a rare condition, with significant impact on patient health and well-being. It is a chronic condition which usually requires meticulous long-term care. It can affect both children and adults. There is limited literature considering the needs and challenges inherent in providing high quality care to patients with CDI, across the care pathway. This paper seeks to address this gap by providing a unique and well-rounded understanding of clinical and healthcare systems-related challenges. It draws on insights from the literature, from direct clinical experience contributed by five clinicians as co-authors (providing insights from France, Ireland, Italy, Spain and the United Kingdom), and from patient perspectives provided through interviews with patient representatives from three patient organisations. We identify clinical challenges related to the diagnosis of CDI, including differentiating between other similar conditions and determining the underlying aetiology. Treatment is challenging, given the need to tailor medication to each patient’s needs and ongoing management is required to ensure that patients continue to respond adequately to treatment. Ongoing support is required when patients switch between formulations. We also identify healthcare systems challenges related to limited awareness of CDI amongst primary care physicians and general paediatricians, and the need for highly skilled specialist care and appropriate workforce capacity. There is also a significant need for raising awareness and for the education of both healthcare professionals and patients about different aspects of CDI, with the aim of supporting improved care and effective patient engagement with healthcare professionals. We reflect on this information and highlight improvement opportunities. These relate to developing guidance to support patients, carers, primary care physicians and general paediatricians to identify clinical features earlier, and to consider CDI as a possible diagnosis when a patient presents with suggestive symptoms.

Hyponatraemia and the syndrome of inappropriate antidiuresis (SIAD) in cancer

Hyponatraemia is a common electrolyte abnormality seen in a wide range of oncological and haematological malignancies and confers poor performance status, prolonged hospital admission and reduced overall survival, in patients with cancer. Syndrome of inappropriate antidiuresis (SIAD) is the commonest cause of hyponatraemia in malignancy and is characterised by clinical euvolaemia, low plasma osmolality and concentrated urine, with normal renal, adrenal and thyroid function. Causes of SIAD include ectopic production of vasopressin (AVP) from an underlying tumour, cancer treatments, nausea and pain. Cortisol deficiency is an important differential in the assessment of hyponatraemia, as it has an identical biochemical pattern to SIAD and is easily treatable. This is particularly relevant with the increasing use of immune checkpoint inhibitors, which can cause hypophysitis and adrenalitis, leading to cortisol deficiency. Guidelines on the management of acute, symptomatic hyponatraemia recommend 100 mL bolus of 3% saline with careful monitoring of the serum sodium to prevent overcorrection. In cases of chronic hyponatraemia, fluid restriction is recommended as first-line treatment; however, this is frequently not feasible in patients with cancer and has been shown to have limited efficacy. Vasopressin-2 receptor antagonists (vaptans) may be preferable, as they effectively increase sodium levels in SIAD and do not require fluid restriction. Active management of hyponatraemia is increasingly recognised as an important component of oncological management; correction of hyponatraemia is associated with shorter hospital stay and prolonged survival. The awareness of the impact of hyponatraemia and the positive benefits of active restoration of normonatraemia remain challenging in oncology.

S-GRAS score for prognostic classification of adrenocortical carcinoma: an international, multicenter ENSAT study

OBJECTIVE

Adrenocortical carcinoma (ACC) has an aggressive but variable clinical course. Prognostic stratification based on the European Network for the Study of Adrenal Tumours stage and Ki67 index is limited. We aimed to demonstrate the prognostic role of a points-based score (S-GRAS) in a large cohort of patients with ACC.

DESIGN

This is a multicentre, retrospective study on ACC patients who underwent adrenalectomy.

METHODS

The S-GRAS score was calculated as a sum of the following points: tumour stage (1-2 = 0; 3 = 1; 4 = 2), grade (Ki67 index 0-9% = 0; 10-19% = 1; ≥20% = 2 points), resection status (R0 = 0; RX = 1; R1 = 2; R2 = 3), age (<50 years = 0; ≥50 years = 1), symptoms (no = 0; yes = 1), and categorised, generating four groups (0-1, 2-3, 4-5, and 6-9). Endpoints were progression-free survival (PFS) and disease-specific survival (DSS). The discriminative performance of S-GRAS and its components was tested by Harrell's Concordance index (C-index) and Royston-Sauerbrei's R2D statistic.

RESULTS

We included 942 ACC patients. The S-GRAS score showed superior prognostic performance for both PFS and DSS, with best discrimination obtained using the individual scores (0-9) (C-index = 0.73, R2D = 0.30, and C-index = 0.79, R2D = 0.45, respectively, all P < 0.01vs each component). The superiority of S-GRAS score remained when comparing patients treated or not with adjuvant mitotane (n = 481 vs 314). In particular, the risk of recurrence was significantly reduced as a result of adjuvant mitotane only in patients with S-GRAS 4-5.

CONCLUSION

The prognostic performance of S-GRAS is superior to tumour stage and Ki67 in operated ACC patients, independently from adjuvant mitotane. S-GRAS score provides a new important guide for personalised management of ACC (i.e. radiological surveillance and adjuvant treatment).

Pediatric Patients with a Dual Diagnosis of Inflammatory Bowel Disease and Chronic Recurrent Multifocal Osteomyelitis

ABSTRACT

There is a paucity of information about the epidemiology, pathophysiology, and treatment of patients with a dual diagnosis of inflammatory bowel disease (IBD) and chronic recurrent multifocal osteomyelitis (CRMO). A retrospective chart review was performed of patients at McMaster Children's Hospital with a diagnosis of either IBD or CRMO, to identify those with the dual diagnosis over a 10-year period. A dual diagnosis was identified in seven patients. Most patients (6/7) had a diagnosis of IBD first and were subsequently diagnosed with CRMO. At the time of CRMO diagnosis, IBD treatment regimens included one or more of, sulfasalazine (1/6), infliximab (3/6), adalimumab (1/6), or no treatment (1/6). Although the etiology of the link remains unknown, there does not seem to be an association to a specific IBD subtype, age, or treatment. Our patient population demonstrated a response to biologic agents, specifically tumor necrosis factor-α inhibitors, as treatment for both conditions.

The Phenotypic Spectrum of New-onset IBD in Canadian Children of South Asian Ethnicity: A Prospective Multi-Centre Comparative Study

BACKGROUND

Canadian-born children of South Asian [SA] ethnicity develop inflammatory bowel disease [IBD] at similar rates to those among Caucasian children. We evaluated the variation in phenotypic spectrum of IBD in SA and Caucasian children in a national paediatric inception cohort of new-onset IBD.

METHODS

Patients aged <17 years, enrolled in a Canadian nationwide inception cohort study, were included. Baseline demographic and IBD phenotypic features were compared between SA and Caucasian children. Longitudinal outcomes through 18 months of follow-up were compared matched by propensity scores.

RESULTS

Of 1156 children enrolled over 2014 to 2019, 623 were Caucasian [98% and 88% parents Canadian born] and 114 SA [79% Canadian born, 87% parents SA born]. Fewer SAs have a first-degree relative with IBD, 6% vs 19% in Caucasians, p = 0.002. SAs present at a younger age, median age 11.4 years (interquartile range [IQR] 9.2-14.3) vs 13 years [IQR 10.9-15 years], p = 0.03 and more commonly with a UC/IBD-U [ulcerative colitis/IBD-unclassified] subtype [ratio of UC/IBD-U to CD 1.2:1 vs 1:1.8 for Caucasians, p <0.001]. Additionally, a greater proportion of SA CD patients present with colonic-only disease [colonic-only CD/UC/IBD-U in SAs 67% vs 57% for Caucasians, p = 0.001], and among those with CD, colonic CD in SAs 31% vs 23% in Caucasians, p = 0.20]. Perianal fistulising disease was also numerically more common in SAs (14 [27%] vs 64 [18%], p = 0.06]. Adjusting for differences in phenotypic presentation, anti-tumour necrosis factor [TNF] exposure, and time to initiation was similar, and two-thirds of children, whether anti-TNF exposed or naïve, were in corticosteroid-free clinical remission at 18 months irrespective of ethnicity.

CONCLUSIONS

The phenotypic spectrum of new-onset IBD in SA children differs from that of Caucasian children, but treatment and clinical course are similar within phenotypic subgroups.

Measurements of Non-Maxwellian Electron Distribution Functions and Their Effect on Laser Heating

Electron velocity distribution functions driven by inverse bremsstrahlung heating are measured to be non-Maxwellian using a novel angularly resolved Thomson-scattering instrument and the corresponding reduction of electrons at slow velocities results in a ∼40% measured reduction in inverse bremsstrahlung absorption. The distribution functions are measured to be super-Gaussian in the bulk (v/v_{th}<3) and Maxwellian in the tail (v/v_{th}>3) when the laser heating rate dominates over the electron-electron thermalization rate. Simulations with the particle code quartz show the shape of the tail is dictated by the uniformity of the laser heating.

A184 INCIDENCE OF VENOUS THROMBOTIC EVENTS AND RISK FACTORS IN CHILDREN HOSPITALIZED WITH INFLAMMATORY BOWEL DISEASE: A RETROSPECTIVE, CASE-CONTROL STUDY

Background

Limited research has been published to describe the incidence of venous thromboembolism (VTE) and relevant risk factors in Canadian children with inflammatory bowel disease (IBD).

Aims

The present study aimed to investigate the incidence of VTE amongst hospitalized pediatric IBD patients over a 10-year period and identify risk factors for the development of VTE.

Methods

A retrospective, matched case-control study was performed at McMaster Children’s Hospital. Hospitalized pediatric patients with IBD (&lt;18 years old) from September 2009 to August 2020 were selected. Inpatient data was extracted from the medical record database, including baseline demographic data, thromboembolic events and potential risk factors for VTE.

Results

There were 890 hospitalizations of IBD patients during the study period. 15 (1.69%) were diagnosed with a VTE, including 4 males and 11 females (mean age 13.4±2.9 years old). 12 ulcerative colitis (UC) (80%) and 3 Crohn’s disease (CD) (20%) hospitalizations were comprised in the VTE group. There was a significant difference in VTE rate between females (2.7%) and males (0.8%) (P = 0.03). The VTE rate in the UC group (4.2%) was significantly higher than in the CD group (0.6%) (P = 0.001). The incidence of VTE amongst hospitalized IBD patients did not vary over the 10-year period (P = 0.496). Length of stay in hospital, albumin level and central venous catheter were shown to be significantly different, although they were not identified as independent risk factors (P &gt;0 .05). Of the 15 hospitalizations with VTE, 6/15 (40%) were superficial VTEs in the extremities and 9/15 (60%) had a deep vein thrombosis (DVT) including 6 in the extremities and 3 in the abdomen. VTEs were associated with a peripheral line in 7 patients and with a PICC line in 4 hospitalizations. 2 of 9 (22%) with extremity DVT developed symptomatic pulmonary embolism. An inherited thrombotic condition was identified in 2 of 15 with VTEs. 12/15 (80%) with VTEs were symptomatic and all VTE related symptoms happened in patients with extremity thrombosis and pulmonary embolism. 7 of 15 (47%) VTEs were treated with anticoagulation therapy for 1–6 months. VTE related symptoms and repeat imaging tests significantly improved, and no patient developed a bleeding complication as a result of treatment.

Conclusions

The VTE rate in pediatric IBD patients was relatively low at McMaster Children’s hospital. Children with VTE were disproportionately females with ulcerative colitis compared with children with no VTE. Central venous line insertion may be correlated with the risk for VTE in children with IBD. Most VTEs and related symptoms happened in patients with extremity thrombosis and secondary pulmonary embolus. Anticoagulation therapy in children with IBD with active disease appears to be safe.

Funding Agencies

Kids Dig Health Funding from McMaster Children’s Hospital, McMaster University

A14 WIDE VARIATION IN CLINICAL MANAGEMENT OF PAEDIATRIC EOSINOPHILIC ESOPHAGITIS: A CANADIAN EXPERIENCE

Background

Eosinophilic esophagitis (EoE) is a chronic disorder treated by food elimination diet (FED), topical steroids and/or proton-pump inhibitors (PPI). Serial endoscopies and biopsies assess response to therapy. EoE management has evolved as guidelines are updated.

Aims

To identify practice variation among Canadian paediatric gastroenterologists (PG) who care for children with EoE.

Methods

An online survey using REDCap about decision-making in children with EoE was distributed to PG in Canada in November 2020.

Results

62 PG completed the survey (response rate 69%, 62/94). The majority work in academic centres (92%). 3 centers indicated an accrual of &gt;50 new patients per year; 9/16 centres have &gt;100 patients in follow-up. An EoE Clinic is present in 5 centres.

Diagnosis: Familiarity with the 2018 AGREE and 2020 AGA EoE guidelines was found to be 57% and 67% respectively. Criteria required to diagnose EoE according to current guidelines were correctly indicated by 42% of PG. (Figure 1).

Endoscopy: The majority of PG (95%) adhere to guidelines in terms of required number and location of biopsies for the initial diagnosis. Ideal timing of repeat endoscopy after change in therapy in patients who are not in histological remission was 8–12 weeks by 67% of PG, timing in stable patients on maintenance therapy varied (33% only if patient is symptomatic). 25% used the EREFS Score in reporting endoscopic findings.

Therapy: Improvement of symptoms was the highest ranked goal (64%), followed by remission of histologic findings (30%). A treatment algorithm was in place in 4 centers. The majority routinely assess adherence to therapy (73%) and consult a dietitian for FED (77%). Most (87%) do not consult an allergist for initial management. Preferred choices of 1st-line therapy varied among PG (Figure 2). When FED was selected, 32% of PG started with 1 food, 32% started with 2 foods, most frequently excluding dairy, followed by wheat. 14 (26%) start with ≥6 FED. Prescription of budesonide slurry was consistent among PG with doses of 1 and 2 mg/day in children &lt;10 and &gt;10 years, respectively.

Conclusions

The is the first Canadian study to assess the variation in management of children with EoE by PG. Overall, PG demonstrated good adherence to the guidelines in terms of initial diagnosis, but differences in maintenance therapy choice and timing of endoscopies. The results highlight a need for standardized management algorithms to deliver uniform care to this growing group. Grounding these guidelines in evidence will warrant a significant investment in further paediatric EoE research.

Funding Agencies

None

Order-of-magnitude increase in laser-target coupling at near-relativistic intensities using compound parabolic concentrators

Achieving a high conversion efficiency into relativistic electrons is central to short-pulse laser application and fundamentally relies on creating interaction regions with intensities ≫10^{18}W/cm^{2}. Small focal length optics are typically employed to achieve this goal; however, this solution is impractical for large kJ-class systems that are constrained by facility geometry, debris concerns, and component costs. We fielded target-mounted compound parabolic concentrators to overcome these limitations and achieved nearly an order-of-magnitude increase to the conversion efficiency and more than tripled electron temperature compared to flat targets. Particle-in-cell simulations demonstrate that plasma confinement within the cone and formation of turbulent laser fields that develop from cone wall reflections are responsible for the improved laser-to-target coupling. These passive target components can be used to improve the coupling efficiency for all high-intensity short-pulse laser applications, particularly at large facilities with long focal length optics.

Production of relativistic electrons at subrelativistic laser intensities

Relativistic electron temperatures were measured from kilojoule, subrelativistic laser-plasma interactions. Experiments show an order of magnitude higher temperatures than expected from a ponderomotive scaling, where temperatures of up to 2.2 MeV were generated using an intensity of 1×10^{18}W/cm^{2}. Two-dimensional particle-in-cell simulations suggest that electrons gain superponderomotive energies by stochastic acceleration as they sample a large area of rapidly changing laser phase. We demonstrate that such high temperatures are possible from subrelativistic intensities by using lasers with long pulse durations and large spatial scales.

A173 RECOGNIZING RARE PRESENTATIONS OF POLYPOSIS SYNDROMES AND THEIR ASSOCIATED MALIGNANCIES IN PEDIATRIC PATIENTS

Background

There is a range of polyposis syndromes and presentations in pediatrics. There are also associated extra-colonic malignancies of which to be cognizant when orchestrating the initial work-up of the various polyposis syndromes.

Aims

To use case review to highlight the importance of recognizing the breadth of presentations of polyposis syndromes in pediatrics.

Methods

Two recent pediatric presentations of polyposis with extra-intestinal manifestations were identified, chart review completed, and compared with newly published ESPGHAN guidelines.

Results

Two patients with intestinal polyposis are presented, in which extra-colonic malignancies and genetic mutations were identified.

The first patient presented at age 16 with a history of fatigue and abdominal pain, and was found to have pancytopenia and splenomegaly. Initial work up included a bone marrow biopsy that was normal. The patient then underwent upper and lower endoscopic evaluation for increasing abdominal pain and persistent anemia and was found to have polymorphic polyps in the duodenum, sigmoid and rectum. On pathology, polyps were mostly inflammatory, but one was found to be hamartomatous. Additional screening revealed a thyroid nodule, found to be follicular carcinoma, requiring hemithyroidectomy. The patient was confirmed to have a PTEN mutation and was diagnosed with Cowden syndrome; following this diagnosis proceeded with a prophylactic bilateral mastectomy.

The second patient was referred at age 15 with a strong family history of APC-associated FAP. At the time of consultation she was asymptomatic and she remained so throughout her work-up. Screening endoscopy revealed 70–90 recto-sigmoid adenomatous polyps as well as scattered gastric and duodenal polyps. Her initial work-up also uncovered an early papillary thyroid carcinoma. Her treatment included a total thyroidectomy and total proctocolectomy with J-pouch and ileoanal anastomosis. Follow-up endoscopy continues for surveillance of numerous gastric adenomas which to this point have not progressed to high-grade dysplasia or malignancy.

Conclusions

These 2 cases highlight the importance of recognizing that neoplastic conditions typically diagnosed in adulthood can also present in the pediatric age group. Ideally, further guidelines in pediatrics would be beneficial to ensure a consistent approach to investigating polyposis and associated malignancies. Pertaining to our specific patients, each had identification of a thyroid malignancy before the recommended screening age of 18 as per the currently accepted guideline, and neither were symptomatic. More cases are needed to establish if this earlier recognition of disease is meaningful in postulating potential mortality associated with a later diagnosis.

Funding Agencies

None

Suppression of the Biermann Battery and Stabilization of the Thermomagnetic Instability in Laser Fusion Conditions

Magnetic field generated by the Biermann battery is thought to be one of the principal mechanisms behind the inhibition of heat flow in laser-plasma interactions, and is predicted to grow exponentially in some contexts due to the thermomagnetic instability [Tidman and Shanny, Phys. Fluids 17, 1207 (1974)PFLDAS0031-917110.1063/1.1694866]. In contrast to these predictions, however, we have conducted Vlasov-Fokker-Planck simulations of magnetic field dynamics under a range of classically unstable laser-fusion conditions, and find field generation to be strongly suppressed, preventing magnetization of the transport, and stabilizing instability. By deriving new scaling laws, we show that this stabilization is a consequence of (i) heavy suppression of the Biermann battery under nonlocal conditions; (ii) rapid convection of magnetic field by the heat flow; and (iii) comparatively short field length scales. Our results indicate that classical models substantially overestimate the importance of magnetic fields generated by the Biermann battery, and the susceptibility of laser-fusion plasmas to the thermomagnetic instability.

109 Hyponatraemia in Older Patients is Often Untreated, Despite Greater Mortality Burden; Results of A Prospective Cohort Study

Introduction

Hyponatraemia is associated with increased morbidity and mortality, and is commoner in elderly patients. The aetiology and outcomes of hyponatraemia in the elderly has not been defined in prospective studies.

Methods

A single-centre 9 month prospective observational study of hyponatraemic (HN) patients (&lt;/= 130 mmol/L) was performed. Clinical outcomes in patients ≥65 years (Elderly patients, EP) and those &lt;65 years (Young Patients, YP) were analysed, and compared with age-matched eunatremic controls, Analysis was performed using Graphpad-Prism 7.

Results

1321 consecutive admissions with hyponatraemia (67% EP, median age of EP 77 (65–98) years) and 1122 eunatremic controls (63% EP, median age of EP 77 (65–99) years) were analysed.

Median nadir plasma sodium was similar in both groups with HN, 128 (107–130) mmol/L EP vs 128(110–130) mmol/L YP (p = 0.62). EP hyponatraemic patients were more likely to have hypovolaemic hyponatraemia (34%) compared with YP with hyponatraemia (28%, p = 0.03). Diuretic-induced hyponatraemia was twice as common in EP (8%) compared with YP (4%, p = 0.01). Malignancy-induced SIAD occurred with similar frequency in both groups (7% in EP SIAD vs 8% in YP SIAD, p = 0.65). Respiratory disease was causative in 10% cases of EP SIAD, compared with 4% in YP SIAD, p = 0.0004.

Hyponatraemia was corrected in 53% of EP, compared with 64% of YP, p = 0.0001. Length of stay and re-admissions rates were similar across hyponatraemia age groups. EP with HN were 2.4 times more likely to die in hospital, compared with eunatremic age-matched controls, (OR 2.4, 95% CI 1.6–3.7, p &lt; 0.0001).

Conclusions

The causation of hyponatraemia is different in elderly patients. Hyponatraemia in EP is often uncorrected, despite increased mortality compared with eunatremic age-matched controls.

Evolution of the Electron Distribution Function in the Presence of Inverse Bremsstrahlung Heating and Collisional Ionization

The picosecond evolution of non-Maxwellian electron distribution functions was measured in a laser-produced plasma using collective electron plasma wave Thomson scattering. During the laser heating, the distribution was measured to be approximately super-Gaussian due to inverse bremsstrahlung heating. After the heating laser turned off, collisional ionization caused further modification to the distribution function while increasing electron density and decreasing temperature. Electron distribution functions were determined using Vlasov-Fokker-Planck simulations including atomic kinetics.

Self-Generated Magnetic and Electric Fields at a Mach-6 Shock Front in a Low Density Helium Gas by Dual-Angle Proton Radiography

Shocks are abundant both in astrophysical and laboratory systems. While the electric fields generated at shock fronts have recently attracted great attention, the associated self-generated magnetic field is rarely studied, despite its ability to significantly affect the shock profile in the nonideal geometry where density and temperature gradients are not parallel. We report here the observation of a magnetic field at the front of a Mach ∼6 shock propagating in a low-density helium gas system. Proton radiography from different projection angles not only confirms the magnetic field's existence, but also provides a quantitative measurement of the field strength in the range ∼5 to 7 T. X-ray spectrometry allowed inference of the density and temperature at the shock front, constraining the plasma conditions under which the magnetic and electric fields are generated. Simulations with the particle-in-cell code lsp attribute the self-generation of the magnetic field to the Biermann battery effect (∇n_{e}×∇T_{e}).

Canadian Association of Gastroenterology Clinical Practice Guideline for the Medical Management of Pediatric Luminal Crohn's Disease

BACKGROUND & AIMS

We aim to provide guidance for medical treatment of luminal Crohn's disease in children.

METHODS

We performed a systematic search of publication databases to identify studies of medical management of pediatric Crohn's disease. Quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach. We developed statements through an iterative online platform and then finalized and voted on them.

RESULTS

The consensus includes 25 statements focused on medical treatment options. Consensus was not reached, and no recommendations were made, for 14 additional statements, largely due to lack of evidence. The group suggested corticosteroid therapies (including budesonide for mild to moderate disease). The group suggested exclusive enteral nutrition for induction therapy and biologic tumor necrosis factor antagonists for induction and maintenance therapy at diagnosis or at early stages of severe disease, and for patients failed by steroid and immunosuppressant induction therapies. The group recommended against the use of oral 5-aminosalicylate for induction or maintenance therapy in patients with moderate disease, and recommended against thiopurines for induction therapy, corticosteroids for maintenance therapy, and cannabis in any role. The group was unable to clearly define the role of concomitant immunosuppressants during initiation therapy with a biologic agent, although thiopurine combinations are not recommended for male patients. No consensus was reached on the role of aminosalicylates in treatment of patients with mild disease, antibiotics or vedolizumab for induction or maintenance therapy, or methotrexate for induction therapy. Patients in clinical remission who are receiving immunomodulators should be assessed for mucosal healing within 1 year of treatment initiation.

CONCLUSIONS

Evidence-based medical treatment of Crohn's disease in children is recommended, with thorough ongoing assessments to define treatment success.

Canadian Association of Gastroenterology Clinical Practice Guideline for the Medical Management of Pediatric Luminal Crohn's Disease

BACKGROUND & AIMS

We aim to provide guidance for medical treatment of luminal Crohn's disease in children.

METHODS

We performed a systematic search of publication databases to identify studies of medical management of pediatric Crohn's disease. Quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach. We developed statements through an iterative online platform and then finalized and voted on them.

RESULTS

The consensus includes 25 statements focused on medical treatment options. Consensus was not reached, and no recommendations were made, for 14 additional statements, largely due to lack of evidence. The group suggested corticosteroid therapies (including budesonide for mild to moderate disease). The group suggested exclusive enteral nutrition for induction therapy and biologic tumor necrosis factor antagonists for induction and maintenance therapy at diagnosis or at early stages of severe disease, and for patients failed by steroid and immunosuppressant induction therapies. The group recommended against the use of oral 5-aminosalicylate for induction or maintenance therapy in patients with moderate disease, and recommended against thiopurines for induction therapy, corticosteroids for maintenance therapy, and cannabis in any role. The group was unable to clearly define the role of concomitant immunosuppressants during initiation therapy with a biologic agent, although thiopurine combinations are not recommended for male patients. No consensus was reached on the role of aminosalicylates in treatment of patients with mild disease, antibiotics or vedolizumab for induction or maintenance therapy, or methotrexate for induction therapy. Patients in clinical remission who are receiving immunomodulators should be assessed for mucosal healing within 1 year of treatment initiation.

CONCLUSIONS

Evidence-based medical treatment of Crohn's disease in children is recommended, with thorough ongoing assessments to define treatment success.

Measurement of selected androgens using liquid chromatography-tandem mass spectrometry in reproductive-age women with Type 1 diabetes

STUDY QUESTION

What information does androgen profiling using liquid chromatography tandem mass spectrometry (LC-MS/MS) provide in reproductive-age women with Type 1 diabetes (T1D)?

SUMMARY ANSWER

In T1D women, androstenedione proved most useful of the measured androgens in differentiating subgroups based on clinical phenotypes of hyperandrogenism (HA) and polycystic ovary syndrome (PCOS).

WHAT IS KNOWN ALREADY

The prevalence of HA and PCOS are increased in women with T1D. These observations are based on measurement of serum androgens using immunoassays, to-date no studies using LC-MS/MS have been reported in reproductive-age women with T1D.

STUDY DESIGN, SIZE, DURATION

This was a cross-sectional study with recruitment of three groups of reproductive-age women: women with T1D (n = 87), non-diabetic women with (N = 97) and without PCOS (N = 101).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Using LC-MS/MS, we aimed to characterize androgen profiles and PCOS status in women with T1D, and interpret findings in relation to cohorts of non-diabetic women with and without PCOS.

MAIN RESULTS AND THE ROLE OF CHANCE

Compared to non-diabetic women, dehydroepiandrosterone/dehydroepiandrosterone sulphate (DHEA/DHEAS) ratio was lower (P < 0.05) in women with T1D. Testosterone levels were greater in T1D women with clinical HA and anovulation compared to those without clinical HA and with regular cycles, while androstenedione levels were greater in T1D women with HA and anovulation compared to those with HA and regular cycles and also those without HA and with regular cycles (P < 0.05 for all). Compared to T1D women without PCOS, the 18% of T1D women who had PCOS were younger with lower BMI, an older age of menarche, and were more likely to have a positive family history of PCOS (P < 0.05 for all). Androgen levels did not differ between women with T1D and PCOS compared to BMI-matched non-diabetic women with PCOS, but androstenedione levels were greater in T1D women with PCOS compared to obese women with PCOS (P < 0.05).

LIMITATIONS, REASONS FOR CAUTION

Relatively small subgroups of patients were studied, reducing the power to detect small differences. Free testosterone levels were not measured using equilibrium dialysis, and were not calculated - commonly used formulae have not been validated in T1D.

WIDER IMPLICATIONS OF THE FINDINGS

Androstenedione is a sensitive biochemical marker of clinical hyperandrogenism and PCOS in T1D. T1D women with PCOS are leaner than those without PCOS but are more likely to have a family history of PCOS. Women with T1D and PCOS have a similar biochemical phenotype to lean non-diabetic women with PCOS but differ from obese women with PCOS. The mechanisms underlying PCOS in T1D and its clinical significance require further investigation.

STUDY FUNDING/COMPETING INTEREST(S)

The study was part-funded by the Meath Foundation. The authors have no competing interests.

Observation of Nonlocal Heat Flux Using Thomson Scattering

Nonlocal heat flux was measured in laser-produced coronal plasmas using a novel Thomson scattering technique. The measured heat flux was smaller than the classical values inferred from the measured plasma conditions in regions with large temperature gradients and agreed with classical values for weak gradients. Vlasov-Fokker-Planck simulations self-consistently calculated the electron distribution functions used to reproduce the measured Thomson scattering spectra and to determine the heat flux. Multigroup nonlocal simulations overestimated the measured heat flux.

Developing an Experimental Basis for Understanding Transport in NIF Hohlraum Plasmas

We report on the first multilocation electron temperature (T_{e}) and flow measurements in an ignition hohlraum at the National Ignition Facility using the novel technique of mid-Z spectroscopic tracer "dots." The measurements define a low resolution "map" of hohlraum plasma conditions and provide a basis for the first multilocation tests of particle and energy transport physics in a laser-driven x-ray cavity. The data set is consistent with classical heat flow near the capsule but reduced heat flow near the laser entrance hole. We evaluate the role of kinetic effects, self-generated magnetic fields, and instabilities in causing spatially dependent heat transport in the hohlraum.

Structuring Diabetes Mellitus Care in Long-Term Nursing Home Residents

Nursing home residents with diabetes have more complex care needs with higher levels of comorbidity, disability and cognitive impairment. We compared current practice in the 44 long-term residents in Peamount hospital with the standards recommended in the Diabetes UK "Good Clinical Practice Guidelines for Care Home Residents with Diabetes". Of 44 residents, 11 were diabetic. Residents did not have specific diabetes care plans. There were some elements of good practice with a low incidence of hypoglycaemia and in-house access to dietetics and chiropody. However, diabetes care was delivered on an ad-hoc basis without individualised care plans, documented glycaemic targets, or scheduled monitoring for complications and no formal screening for diabetes on admission. National and local policy to guide management of diabetes mellitus should be developed. There should be individualised diabetes care plans, clear policies for hypoglycaemia, hyperglycaemia and long-term diabetes complications, screening on admission and increased uptake of the national retinal screening and foot care programmes.

Endocrinopathies and renal outcomes in lithium therapy: impact of lithium toxicity

BACKGROUND

Lithium is the mainstay of treatment for bipolar disorder, mania and an augmentation therapy in patients with treatment resistant depression. It has a narrow therapeutic index, with recognized adverse multi-system and endocrine side effects.

AIM

To assess the impact of lithium therapy, in particular lithium toxicity, on the development of endocrine and renal disorders in a cohort of patients in a single tertiary referral centre in Ireland.

STUDY DESIGN

A retrospective analysis was performed of the prevalence of lithium toxicity and renal, thyroid and parathyroid dysfunction in our study population.

METHODS

We collected laboratory data from the Clinical Chemistry department of the Adelaide and Meath Hospital incorporating the National Children's Hospital (AMNCH), Dublin, Ireland. Our study population included all patients who had at least one serum lithium measurement from January 1st 2000 to December 31st 2014 inclusive.

RESULTS

A total of 580 patients were included in the study. Among our study group, 70 patients (12.1%) had 1 toxic lithium measurement (lithium level >1.2 mmol/l). 27.8% (n > 161) of patients developed stage 3 Chronic kidney Disease (CKD) or higher, which was commoner in those patients who developed toxic lithium levels (P < 0.0001) and in those who developed hypernatraemia (P > 0.0001). 16.2% of patients (n > 94) had one serum sodium >145 mmol/l during follow up. 60 patients(10.3%) had a TSH >10 mU/l, while complete suppression of TSH (<0.05 mU/l) was observed in 22 patients (3.8%) during follow-up. 4% (n > 37) of the study population had ≥1 serum corrected calcium level > 2.55 mmol/l, and 4 patients had biochemical confirmation of primary hyperparathyroidism but PTH levels were only performed in 2.8% (n > 16) of the studypopulation.

CONCLUSION

Stage 3 CKD is common in patients receiving lithium therapy. Lithium toxicity is associated with CKD and hypernatraemia. Thyroid dysfunction and hypercalcaemia are common in patients receiving lithium therapy. Patients receiving lithium therapy require surveillance of renal, thyroid and bone biochemistry.

Enhanced TH17 Responses in Patients with IL10 Receptor Deficiency and Infantile-onset IBD

BACKGROUND

IL10 receptor (IL10R) deficiency causes severe infantile-onset inflammatory bowel disease. Intact IL10R-dependent signals have been shown to be important for innate and adaptive immune cell functions in mice. We have previously reported a key role of IL10 in the generation and function of human anti-inflammatory macrophages. Independent of innate immune cell defects, the aim of the current study was to determine the role of IL10R signaling in regulating human CD4 T-cell function.

METHODS

Peripheral blood mononuclear cells and intestinal biopsies cells were collected from IL10/IL10R-deficient patients and controls. Frequencies of CD4 T-cell subsets, naive T-cell proliferation, regulatory T cell (Treg)-mediated suppression, and Treg and TH17 generation were determined by flow cytometry. Transcriptional profiling was performed by NanoString and quantitative real-time polymerase chain reaction. RNA in situ hybridization was used to determine the quantities of various transcripts in intestinal mucosa.

RESULTS

Analysis of 16 IL10- and IL10R-deficient patients demonstrated similar frequencies of peripheral blood and intestinal Tregs, compared with control subjects. In addition, in vitro Treg suppression of CD4 T-cell proliferation and generation of Treg were not dependent on IL10R signaling. However, IL10R-deficient T naive cells exhibited higher proliferative capacity, a strong TH17 signature, and an increase in polarization toward TH17 cells, compared with controls. Moreover, the frequency of TH17 cells was increased in the colon and ileum of IL10R-deficient patients. Finally, we show that stimulation of IL10R-deficient Tregs in the presence of IL1β leads to enhanced production of IL17A.

CONCLUSIONS

IL10R signaling regulates TH17 polarization and T-cell proliferation in humans but is not required for the generation and in vitro suppression of Tregs. Therapies targeting the TH17 axis might be beneficial for IL10- and IL10R-deficient patients as a bridge to allogeneic hematopoietic stem cell transplantation.

The incidence of anterior pituitary hormone deficiencies in patients with microprolactinoma and idiopathic hyperprolactinaemia

INTRODUCTION

Patients with microprolactinoma and idiopathic hyperprolactinaemia are not generally considered to be at risk of hypopituitarism and are therefore not routinely screened for this abnormality. In our clinical practice, we have observed a number of patients with nonmacroadenomatous hyperprolactinaemia to have anterior pituitary hormone deficits.

AIMS

We aimed to establish the frequency and clinical significance of anterior pituitary hormone deficiencies, comparing patients with radiologically proven microprolactinomas and patients with idiopathic hyperprolactinaemia.

STUDY DESIGN

We retrospectively examined the casenotes of 206 patients with hyperprolactinaemia from our centre. Patients who did not fit the profile of surgically naïve microprolactinoma or idiopathic hyperprolactinaemia or who had incomplete data were excluded, resulting in a study group of 56 patients.

RESULTS

A total of 35 patients with MRI evidence of microprolactinoma were identified, three (8.57%) of whom had one or more anterior pituitary hormone deficiencies. A total of 21 patients with MRI-negative idiopathic hyperprolactinaemia were identified, nine (42%) of whom had one or more anterior pituitary hormone deficiencies (P<.01). Only one patient in the MRI-positive group had deficiency that required hormone replacement, in contrast six patients in the MRI-negative group had deficiencies that were of clinical significance and which required hormone replacement.

SUMMARY

This study shows a clinically significant incidence of anterior pituitary hormone deficiency in patients with idiopathic hyperprolactinaemia. The authors recommend that dynamic pituitary assessment should be considered routinely in this patient group. A prospective study would be required to assess the underlying cause for these abnormalities, as they suggest a nontumour pan-pituitary process.

Acromegaly

Acromegaly is a rare, chronic, progressive disease characterized by an excess secretion of growth hormone (GH) and increased circulating insulin-like growth factor 1 (IGF-1) concentrations. It is caused by a pituitary adenoma in the vast majority of cases. The clinical diagnosis, based on symptoms related to GH excess, is often delayed due to the insidious nature of the disease. Consequently, patients often have established systemic complications at diagnosis with increased morbidity and premature mortality. Serum IGF-1 measurement is recommended as the initial screen for patients with suspected acromegaly. The gold standard diagnostic test remains the oral glucose tolerance test with concomitant GH measurement. Therapy for acromegaly is targeted at decreasing GH and IGF-1 levels, ameliorating patients' symptoms and decreasing any local compressive effects of the pituitary adenoma. The therapeutic options for acromegaly include surgery, medical therapies (such as dopamine agonists, somatostatin receptor agonists and the GH receptor antagonist pegvisomant) and radiotherapy. A multidisciplinary approach is recommended with often a requirement for combined treatment modalities. With disease control, associated morbidity and mortality can be reduced. The recently published evidence-based guidelines by the Endocrine society addressed important clinical issues regarding the evaluation and management of acromegaly. This review discusses advances in our understanding of the pathophysiology of acromegaly, diagnosis of various forms of the disease and focuses on current treatment modalities, and on future pharmacological therapies for patients with acromegaly.

Impact of visceral obesity and metabolic syndrome on the postoperative immune, inflammatory, and endocrine response following surgery for esophageal adenocarcinoma

Visceral obesity and metabolic syndrome (MetSyn) represent a constellation of inflammation, insulin resistance, and hyperglycemia and are established risk factors for gastrointestinal cancer. However, their impact on the immune and inflammatory response after major upper gastrointestinal oncologic surgery is unknown. In 125 consecutive patients who underwent esophagectomy, C-reactive protein (CRP) and CRP:albumin levels were recorded preoperatively and on days 1, 3, 7, and 14 postoperatively. In a subset of 30 patients, circulating levels of IL-6, IL-8, IL-10, IL-12p70, IFN-γ, TNF-α, TGF-β, and cortisol were measured. Incidences of postoperative complications were prospectively recorded. In the study cohort, 51% of patients were viscerally obese, 40.7% had MetSyn, and 33.6% were hyperglycemic. Viscerally obese and MetSyn-positive patients demonstrated greater postoperative CRP levels and CRP:albumin levels on day 7 and day 14 compared with nonobese and MetSyn-negative patients (P < 0.05). Higher postoperative circulating levels of cortisol were observed in the viscerally obese and hyperglycemic patients compared to nonobese and normoglycemic patients. No association was observed between visceral obesity, MetSyn or hyperglycemia, and postoperative cytokine profile. Viscerally obese patients had an increased overall incidence of postoperative complications compared to nonobese patients (67.2% vs. 47.5%, P = 0.031) on univariate but not multivariate analysis (P = 0.078) and visceral obesity was not associated with an increased incidence of specific complications. Visceral obesity, MetSyn, and hyperglycemia are prevalent in patients undergoing major upper gastrointestinal resection and are associated with an exaggerated acute-phase inflammatory response postoperatively. Further research is warranted to determine whether this association is directly causal.

Diabetes in Patients With Acromegaly

Acromegaly is a clinical syndrome which results from growth hormone excess. Uncontrolled acromegaly is associated with cardiovascular mortality, due to an excess of risk factors including diabetes mellitus, hypertension and cardiomegaly. Diabetes mellitus is a frequent complication of acromegaly with a prevalence of 12-37%. This review will provide an overview of a number of aspects of diabetes mellitus and glucose intolerance in acromegaly including the following: 1. Epidemiology and pathophysiology of abnormalities of glucose homeostasis 2. The impact of different management options for acromegaly on glucose homeostasis 3. The management options for diabetes mellitus in patients with acromegaly RECENT FINDINGS: Growth hormone and IGF-1 have complex effects on glucose metabolism. Insulin resistance, hyperinsulinaemia and increased gluconeogenesis combine to produce a metabolic milieu which leads to the development of diabetes in acromegaly. Treatment of acromegaly should ameliorate abnormalities of glucose metabolism, due to reversal of insulin resistance and a reduction in gluconeogenesis. Recent advances in medical therapy of acromegaly have varying impacts on glucose homeostasis. These adverse effects influence management choices in patients with acromegaly who also have diabetes mellitus or glucose intolerance. The underlying mechanisms of disorders of glucose metabolism in patients with acromegaly are complex. The aim of treatment of acromegaly is normalisation of GH/IGF-1 with reduction of co-morbidities. The choice of therapy for acromegaly should consider the impact of therapy on several factors including glucose metabolism.

Growth of a progesterone receptor-positive meningioma in a female patient with congenital adrenal hyperplasia

Meningioma growth has been previously described in patients receiving oestrogen/progestogen therapy. We describe the clinical, radiological, biochemical and pathologic findings in a 45-year-old woman with congenital adrenal hyperplasia secondary to a defect in the 21-hydroxylase enzyme who had chronic poor adherence to glucocorticoid therapy with consequent virilisation. The patient presented with a frontal headache and marked right-sided proptosis. Laboratory findings demonstrated androgen excess with a testosterone of 18.1 nmol/L (0-1.5 nmol) and 17-Hydroxyprogesterone >180 nmol/L (<6.5 nmol/L). CT abdomen was performed as the patient complained of rapid-onset increasing abdominal girth and revealed bilateral large adrenal myelolipomata. MRI brain revealed a large meningioma involving the right sphenoid wing with anterior displacement of the right eye and associated bony destruction. Surgical debulking of the meningioma was performed and histology demonstrated a meningioma, which stained positive for the progesterone receptor. Growth of meningioma has been described in postmenopausal women receiving hormone replacement therapy, in women receiving contraceptive therapy and in transsexual patients undergoing therapy with high-dose oestrogen and progestogens. Progesterone receptor positivity has been described previously in meningiomas. 17-Hydroxyprogesterone is elevated in CAH and has affinity and biological activity at the progesterone receptor. Therefore, we hypothesise that patients who have long-standing increased adrenal androgen precursor concentrations may be at risk of meningioma growth.

LEARNING POINTS

Patients with long-standing CAH (particularly if not optimally controlled) may present with other complications, which may be related to long-standing elevated androgen or decreased glucocorticoid levels.Chronic poor control of CAH is associated with adrenal myelolipoma and adrenal rest tissue tumours.Meningiomas are sensitive to endocrine stimuli including progesterone, oestrogen and androgens as they express the relevant receptors.