Effectiveness and Safety of Switching from Intravenous to Subcutaneous Vedolizumab Formulation in Inflammatory Bowel Disease Patients in Clinical Remission

BACKGROUND AND AIMS

Subcutaneous vedolizumab formulation has been shown to be as effective and safe as the intravenous one in randomized control trials. Real-life data are limited especially for patients receiving long-term intravenous therapy. This study aimed to evaluate the safety and effectiveness of switching from intravenous to subcutaneous vedolizumab in a large cohort of patients with stable clinical remission.

METHODS

In this prospective cohort study, we enrolled consecutive patients attending our center between September 2021 and April 2022. The baseline demographic characteristics, 12- and 24-weeks follow-up clinical activity, C-reactive protein levels, and adverse events were recorded. The primary endpoint was to assess combined steroid-free clinical remission plus biochemical remission 24-week after the switch.

RESULTS

93 patients (43 Crohn's disease, 50 ulcerative colitis), switched to subcutaneous vedolizumab after a median duration of intravenous treatment of 36 months [IQR 16-52]. At baseline, 80 patients (86%) had a combined remission. At 24-week, 89.2% (n=74) maintained combined steroid-free clinical remission plus biochemical remission. 25 adverse events were reported, mostly SARS-CoV-2 infections and injection site reactions, with a further four recurrence episodes. Twelve patients (12.9%) discontinued subcutaneous administration and restarted intravenous vedolizumab.

CONCLUSIONS

Switching from intravenous to subcutaneous vedolizumab can be considered effective and safe for maintaining remission in patients with inflammatory bowel disease. In addition, this might reduce healthcare costs. However, large-scale real-life studies with long-term follow-up are necessary.

Hematocolpos due to imperforate hymen: a case report and literature systematic review

INTRODUCTION AND HYPOTHESIS

Hematocolpos is a rare condition, where menstrual blood fills the vagina, instead of being expelled, due to a series of uterovaginal pathologies, the most frequent of which is the imperforate hymen. To date, few cases of hematocolpos have been reported in the literature.

METHODS

We report a case of hematometrocolpos due to imperforate hymen initially misdiagnosed as constipation and subsequently as ovarian mass; moreover, the present study undertakes a systematic review of studies on hematometrocolpos due to imperforate hymen to synthesize available knowledge on epidemiology, diagnosis, and management about this rare condition.

RESULTS

A total of 35 studies, describing 61 patients, were identified. The presence of hematocolpos should be suspected in premenarchal patients complaining of low abdominal pain, abdominal swelling, and urinary retention. Genital examination disclosing a tender, pale hymen and ultrasound represent a useful tool for diagnosis. The goal of the management is to timely perform hymenotomy to drain the hematocolpos, followed by hymenectomy to prevent recurrence. Follow-up is needed to diagnose possible recurrences.

CONCLUSIONS

In the case of an adolescent girl complaining of genital pain associated with primary amenorrhea, hematocolpos due to imperforate hymen should be suspected.

Long-Term Risk of Colectomy in Patients with Severe Ulcerative Colitis Responding to Intravenous Corticosteroids or Infliximab

Background and aims: Intravenous corticosteroids (IVCS) and rescue therapy with infliximab (IFX) are useful for managing patients with acute severe ulcerative colitis (ASUC). However, nearly one fifth of responders undergo colectomy. Predictive factors of colectomy in this subset of patients are not fully known. We retrospectively examined the long-term risk and the predictors of colectomy in ASUC patients achieving clinical remission following treatment with IVCS or IFX. Patients and methods: Clinical and demographic characteristics were evaluated in consecutive ASUC patients who were admitted to the “Tor Vergata University” hospital between 2010 and 2020 and responded to IVCS or IFX. A multivariate logistic regression model was constructed to identify independent predictors of colectomy. Results: A total of 116 ASUC patients responding to IVCS (98 patients) or IFX (18 patients) were followed up for a median of 46 months. After discharge, 29 patients (25%) underwent colectomy. Multivariate analysis showed that a serum albumin level <3 g/dL and colonic dilation >5.5 cm on admission were independent predictors of colectomy (OR: 6.9, 95% CI: 2.08−22.8, and OR 8.5, 95% CI: 1.23−58.3, respectively). Patients with both these factors had a risk of colectomy 13 times greater than those with no risk factor. Conclusions: A low serum albumin level and colonic dilation are risk factors of long-term colectomy in ASUC patients responding to IVCS or IFX.

Two years follow-up of golimumab treatment in refractory enteropathic spondyloarthritis patients with Crohn disease: A STROBE-compliant study

Golimumab is a fully human monoclonal antibody against tumor necrosis factor (TNF) approved for the treatment of ulcerative colitis and not for Crohn disease (CD). Many CD patients experience primary, secondary failure, or intolerance to other TNF inhibitors (TNFi) approved in Italy for CD (adalimumab and infliximab). Spondyloarthritis (SpA) may be associated with CD (enteropathic, ESpA) in up to 50% of patients requiring a multidisciplinary and tailored approach. However, only few data from literature and no formal trials determined the efficacy and safety of golimumab in ESpA patients. We performed a case series on 12 patients affected by active CD and active ESpA were failure or intolerant to previous TNFi approved in Italy for both SpA and CD, infliximab and adalimumab. Golimumab was administered following rheumatologic dosage (subcutaneous 50 mg monthly; 100 mg monthly for patients ≥100 kg). Gastrointestinal and rheumatologic disease activity was evaluated with a follow-up of 2 years. A total of 9 patients were followed for 2 years of golimumab treatment. CD clinical activity ameliorated as shown by the reduction of Harvey-Bradshaw index and Crohn disease activity index (CDAI) at 12 and 24 months of treatment (P = .03 and P = .04, respectively) associated with reduction of C-reactive protein at 12 and 24 months (P = .04 for both comparisons) of treatment. SpA assessment revealed a significant reduction in tender joint count at 6 (P = .03), 12 (P = .03), and 24 months (P = .007) of treatment. Swollen joint count, pain, SpA disease activity, and disability reduced in several patients during the follow-up. No adverse events were registered in the follow-up. We demonstrate good clinical efficacy and safety profile of both gastrointestinal and rheumatologic involvement. This may indicate promising therapeutic option for ESpA patients affected by CD, and non-responsive to other TNFi.

Natural History of Ulcerative Colitis with Coexistent Colonic Diverticulosis

Ulcerative colitis (UC) and colonic diverticulosis can co-exist in some patients. However, the natural history of UC associated with colonic diverticulosis is not well known. We here compared the disease characteristics and outcome of UC patients with and without concomitant colonic diverticulosis. Medical records of 347 UC patients were included in an observational, retrospective, nested-matched case-control study. Cases were 92 patients with UC and concomitant colonic diverticulosis, while controls were 255 UC patients without concomitant colonic diverticulosis. A propensity score matching (PSM) was used to homogenate cases (n = 92) and controls (n = 153) for age. UC patients with concomitant colonic diverticulosis were less likely to have an extensive disease (25/92, 27.1%) and to experience steroid dependence (8/92, 8.6%) compared to patients without concomitant colonic diverticulosis (70/153, 45.7% and 48/153, 31.3%, respectively; p < 0.001). The use of immunosuppressants (9/92, 9.7% vs. 37/153, 24.1%; p = 0.007) or biologics (3/92, 3.2% vs. 26/153, 16.9%, p < 0.001) was significantly lower in UC patients with concomitant diverticulosis compared to the control group. On multivariate analysis, steroid dependence and extensive colitis were significantly less frequent in UC patients with concomitant colonic diverticulosis compared to UC patients without diverticula. UC patients with coexisting colonic diverticulosis are less likely to have an extensive disease and to be steroid-dependent.

Low Frequency of Acute Pancreatitis in Hospitalized COVID-19 Patients

OBJECTIVE

The clinical significance of increased serum pancreatic enzymes (PEs) in coronavirus disease 2019 (COVID-19) patients has not yet been fully understood. We aimed to investigate the frequency and the impact on clinical outcome of PE elevation and acute pancreatitis in such patients.

METHODS

Clinical data, laboratory tests, and cross-sectional images were analyzed from COVID-19 patients admitted to the Tor Vergata Hospital in Rome. Variables associated with PE abnormalities, intensive care unit (ICU) admission, or death were investigated through univariate and multivariate analyses and Cox proportional hazard model.

RESULTS

Pancreatic enzymes were available in 254 of 282 COVID-19 patients. Among these, 66 patients (26%) showed mild elevation of PE, and 11 patients (4.3%) had severe elevation (>3 times of the upper limit of normal). Overall, 2 patients met the diagnostic criteria for acute pancreatitis. Hepatic and renal involvements were associated with PE elevation. Multivariate analysis showed that mild and severe PE elevations were significantly associated with ICU admission (odds ratios, 5.51 [95% confidence interval, 2.36-12.89; P < 0.0001] and 26.2 [95% confidence interval, 4.82-142.39; P < 0.0001]).

CONCLUSIONS

Increase in serum PE, but not acute pancreatitis, is frequent in hospitalized COVID-19 patients and associates with ICU admission.

AB1085 ASSESSMENT OF DIAGNOSTIC DELAY IN PATIENTS AFFECTED BY ENTEROPATHIC SPONDYLOARTHRITIS: A CROSS-SECTIONAL STUDY

Background:

Diagnostic delay of spondyloarthritis (SpA) has been established even in combination with inflammatory bowel disease and may contribute to radiographic progression and disability.

Objectives:

We aimed to evaluate diagnostic delay in enteropathic SpA (eSpA) and explore associated demographic, clinical, and radiographic characteristics.

Methods:

We analysed consecutive eSpA patients referred to the combined gastro-rheumatologic clinic of the University of Rome Tor Vergata. Diagnostic delay was defined as the time interval from the date of first symptoms to the date of diagnosis. Conventional radiography (CR) and magnetic resonance images (MRI) of sacroiliac (SI) joints and spine were performed in axial (ax)SpA patient and examined by two independent radiologists. MRI were assessed for the presence of active/chronic inflammatory lesions, disease activity by ASDAS and inflammatory markers. Statistical analyses were performed using Mann-Whitney, chi square/Fisher tests and covariance analysis (SPSS software).

Results:

190 eSpA patients (124 female, mean age 47.5±12.8 years, disease duration 72±67.4 months, 73 UC/117 CD; 118 peripheral SpA, 72 axSpA including 44 non radiographic (nr)-axSpA) were evaluated. Axial eSpA patients had a higher prevalence of men sex (p<0.0001), HLA-B27 positivity (p=0.004), uveitis (p=0.01) and pancolitis (p<0.006) compared with peripheral eSpA. AxeSpA patients displayed higher ESR, ASDAS, and VAS pain compared with peripheral ESpA (p=0.0006, p=0.001, p=0.019, respectively). A higher prevalence of csDMARDs was detected in peripheral eSpA compared with axSpA (p=0.002) while treatment with cs and bDMARDs was similar in rad-axSpA and nr-axSpA patients.

Median diagnostic delay in eSpA was 48 months (IQR 6-77) with no difference between axial and peripheral patients. Rad-ax-SpA patients displayed a higher diagnostic delay compared with nr-axSpA (median/IQR 36/17-129 vs 31/10-57 months, p=0.03). Patients with rad-axSpA were older and with longer disease duration than patients with nr-axSpA (p=0.005 and p=0.019). Low education status and high rate of employment were found in rad-axSpA compared with nr-axSpA (p=0.003 and p=0.03, respectively).

Rad-axSpA patients with sclerosis, syndesmophytes and bridge at CR had a higher diagnostic delay than those without lesions (p=0.03, p=0.043, p<0.0001, Fig. 1A-C). Men showed a higher prevalence of spine damage lesions than women as sclerosis (p=0.02), squaring (p=0.0006), syndesmophytes (p=0.0028) and bridges (p=0.007). Longer disease duration was detected in patients with radiographic damage as bridge (p<0.0001) and sacroiliitis grade 3 (p=0.04). On MRI, SI bone oedema was associated with reduced diagnostic delay (p=0.04) while bone erosions was associated with higher diagnostic delay (p=0.002) compared with that in patients without these lesions (Fig. 1D-E). Rad-axSpA women had a higher prevalence of SI damage lesions at MRI than men (p=0.001). Patients with psoriasis displayed a higher diagnostic delay compared to those without skin involvement (p=0.004).

Figure 1.

Conclusion:

Demographic and clinical factors differentiate axSpA from nr-axSpA patients. Diagnostic delay was higher in rad-axSpA compared with nr-axSpA despite the same treatment. Some lesions of spine/SI at CR and MRI, and psoriasis, were mostly associated with diagnostic delay and sex.

Disclosure of Interests:

None declared

The power output/heart rate relationship in cycling: test standardization and repeatability

PURPOSE

The purpose of this study was to update and standardize the test for determining the power output/heart rate (PO/HR) relationship in cycling.

METHODS

The current protocol was developed in the laboratory using a wind-load cycling simulator. Five hundred incremental tests were carried out by 290 male cyclists during a 2-yr period (1995-1997). The subjects' own bicycles, equipped with a standard crankset with a built-in power measuring system, were used for testing. The test protocol consisted of time-based increments in cadence that were uniform up to submaximal speeds and progressively greater in the final phase.

RESULTS

The PO/HR relationship obtained was linear at low to submaximal PO and curvilinear from submaximal to maximal PO. A method was developed for the mathematical identification of the point of transition from the linear to the curvilinear phase (deflection point or heart rate break point). In 484 of the 500 tests performed, the deflection was independent of the final acceleration (PO at deflection 318.4 +/- 42.4 W, PO at final acceleration 351.6 +/- 43.2 W, P < 0.001), whereas in 16 tests the deflection and the start of the final acceleration coincided. To evaluate test repeatability and precision, 15 subjects repeated the test twice within a few days. No significant differences were found for the heart rate at deflection, power output at deflection, or slope of the linear part of the PO/HR relationship obtained in the two tests.

CONCLUSION

It is concluded that the deflection point obtained by determining the PO/HR relationship on a wind-load simulator is not an artifact dependent on the incremental test protocol but rather a repeatable physiological phenomenon.

Two consecutive outbreaks of Stenotrophomonas maltophilia (Xanthomonas maltophilia) in an intensive-care unit defined by restriction fragment-length polymorphism typing

OBJECTIVE

To investigate and control consecutive outbreaks of Stenotrophomonas maltophilia infections in intensive-care-unit (ICU) patients.

DESIGN

Epidemiological investigation; restriction fragment-length polymorphism typing by pulsed-field gel electrophoresis (PFGE) of genomic DNA of outbreak strains; institution of infection control measures to limit spread.

SETTING

The medical-surgical ICU in an 800-bed tertiary-care center in Calgary, Alberta, Canada.

RESULTS

S. maltophilia was recovered from 14 ICU patients (12 infected, 2 colonized) between February 1993 and February 1994. Ten of the 14 patient isolates and 1 environmental isolate were available for PFGE typing. Patient isolates from 6 of the first 10 patients were identical. Isolates from the next 3 of 4 patients and an isolate recovered from a ventilator being used by a patient not infected with S. maltophilia also were identical, but different from the first 6. The ventilator isolate was temporally associated with the latter 4 patients.

CONCLUSION

Molecular typing allowed us to determine that there were two separate consecutive S maltophilia outbreaks rather than a single protracted outbreak. Recovery of S. maltophilia from patient ventilators and an in-line suction catheter suggests that the organism may have been spread by cross-contamination from contaminated equipment or from an environmental source.

Molecular epidemiology of Xanthomonas maltophilia colonization and infection in the hospital environment

Between April 1992 and December 1993, 80 Xanthomonas maltophilia isolates were collected from 63 patients in three acute-care hospitals in Calgary, Alberta, Canada. On the basis of Centers for Disease Control and Prevention definitions, 48 patients had nosocomial and 15 had community-acquired X. maltophilia. Thirty-eight of the patients were colonized and 25 were infected. Sixty-four percent of patients who acquired X. maltophilia in the intensive care unit (ICU) became infected, whereas 32% of patients in a non-ICU setting became infected. ICU patients tended to be hospitalized for a shorter period of time than non-ICU patients before the onset of X. maltophilia infection. Regardless of being colonized or infected, all patients had debilitating conditions, with respiratory disease being the most common underlying illness (35%). Forty-two patients (88%) with hospital-acquired X. maltophilia received prior antibiotic therapy which included gentamicin, tobramycin, ceftazidime, piperacillin, and imipenem. Agar dilution MICs showed that patient isolates were resistant to these antimicrobial agents that patients had received. Pulsed-field gel electrophoresis of SpeI-digested genomic DNA revealed that six epidemiologically linked patient isolates from the ICU of one acute-care hospital had identical DNA profiles. In contrast, isolates from patients from the other two hospitals had unique genotype profiles (n = 57) regardless of the presence or absence of an epidemiologic association. In these patients there was genetic evidence against the acquisition of a resident hospital clone. These results indicate that pulsed-field gel electrophoresis can resolve genotypically distinct strains of X. maltophilia and, consequently, is a useful tool for evaluating nosocomial infections caused by X. maltophilia.

Nosocomial infections on a rehabilitation unit in an acute care hospital

In a one-year retrospective review, 138 symptomatic infections were identified in 145 admissions to a rehabilitation unit. One hundred twenty-six (91%) infections were either urinary or skin and soft tissue infections. The daily incidence of infection increased with increasing numbers of infections for infected patients. Patient factors associated with infection included male sex, young age, spinal cord injury, admission for management of decubitus ulcers or urinary infection, history of urinary infection, urologic interventions or skin breakdown, and bladder and bowel incontinence. All patients with a history of chronic urinary infection or skin breakdown developed infection. In a logistic regression model, factors that were independently associated with risk of infection in the remaining patients included sex, incontinence, chronic neurologic disease, and prior urologic interventions. This review suggests rehabilitation patients are at high risk of acquiring nosocomial infection. The subgroup of patients with the highest risk of infection are identifiable by specific characteristics.

Nosocomial infections on nursing units with floors cleaned with a disinfectant compared with detergent

Nosocomial infections on eight acute care nursing units in a tertiary care hospital was compared between two 3-month periods in which floors were cleaned with either disinfectant or detergent. Personnel performing infection surveillance were unaware of the cleaning product used. Surface cultures from selected floor sites were obtained at 3 and 6 months to assess microbial contamination. The combined nosocomial infection rate for the eight wards did not differ between disinfectant (8.0/100 patient discharges) and detergent (7.1/100). For individual wards, a significant difference in nosocomial infection rate between the two periods was observed in only one ward, favouring the detergent. No differences in floor contamination were observed.

Oral lesions in borderline and reactional tuberculoid leprosy

Thirty patients, fifteen with borderline and fifteen with reactional tuberculoid leprosy, were submitted to clinical and histopathologic studies of the buccal mucosa for detection of specific lesions. Five reactional tuberculoid and eight borderline patients presented specific conditions characterized by chronic granulomatous lesions with bacilli, chronic granulomatous lesions without bacilli, and nonspecific chronic inflammatory lesions with bacilli. The infiltrate had small extension, low bacterial levels and the mucosa, with the exception of one case, did not show ulceration. These results suggest that in the reactional tuberculoid and borderline patients the buccal mucosa is not an important source of bacilli elimination.