OP0187 COMPARATIVE EFFICACY OF NON-BIOLOGIC IMMUNOSUPPRESSANTS IN TAKAYASU ARTERITIS

Background

The choice of immunosuppressant (IS) in patients with Takayasu arteritis (TAK) is often arbitrary due to lack of comparison studies.

Objectives

In this retrospective, we aimed to compare the efficacy of 3 non biologic IS including azathioprine (AZA), mycophenolate mofetil (MMF) and methotrexate (MTX) in inducing and maintaining sustained remission in patients with TAK.

Methods

Patients with a diagnosis of TAK, attending our clinics between Jan 2000 and May 2019 were identified. Those who satisfied either ACR or Sharma’s classification or EULAR PRINTO PRES criteria and/or had angiographic evidence of Takayasu arteritis with a minimum 2 follow up visits were included. Patients who received upfront biologics were excluded. The patients were matched for parameters statistically different among three groups using propensity score analysis. Clinical details at the index visit defined as the time of initiation of first IS and follow up visits were prospectively recorded and retrospectively noted from electronic medical records. The primary outcomes were attainment of complete remission and relapses. Disease activity was assessed by Indian Takayasu arteritis score (ITAS), C-reactive protein and angiograms. Relapse was defined as ITAS-A(CRP) >=2 and/or progression in angiograms and/or escalation of steroid dose and/or switching of IS due to active disease. The baseline variables of patients receiving AZA, MMF and MTX were compared using chi square test or Mann Whitney U test. The comparative efficacy of IS to induce complete remission was calculated using logistic regression and presented as odds ratio (95% CI). The cumulative risk of relapse was calculated using Cox-proportional hazards model with hazards ratio and 95% confidence interval (CI) after adjusting for duration of symptoms and juvenile onset disease. The patients were censored at the time of relapse or time of switching to another IS or last follow up whichever was the earliest. AZA was arbitrary chosen as the reference drug for all the analysis. The missing values (visits) were not included in analysis and the last observation was carried forwards. Data after switching of immunosuppressant of interest till the last follow up visit was analysed descriptively. All analysis were done for matched and unmatched patient groups. The results of matched and unmatched cohort were similar, hence the results of unmatched groups are presented here.

Results

Overall, 234 patients satisfying inclusion criteria including 53 (22.6%), 156 (66.7%) and 25 (10.7%) patients receiving AZA, MMF, Mtx respectively were studied. Complete remission (CR) was attained in 183 (78.2%) patients after initiating steroids and IS. 79.2%, 77.6% and 80% of patients receiving AZA, MMF or MTX respectively achieved CR yielding an odds ratio of 1.10 (0.52-2.37), p= 0.80 and 0.96 (0.29-3.12), p= 0.94 for MMF and MTX as compared with AZA. CR was sustained in 22 (52.4%), 80 (66.1%) and 11 (55%) of patients on AZA, MMF and MTX respectively. When compared with AZA, adjusted hazards ratio (AHR) of relapse was 1.51 (0.79-2.89), p=0.21 and 2.45 (1.00-5.99), p= 0.05 with MMF and MTX after adjusting for juvenile onset disease, type 1 and type 4 disease by angiography. The frequency of remission in patients who received MMF was significantly higher in patients who presented with type 4 disease (96%) as compared with the patients who had other types on angiography (74%), p= 0.017. Conversely, 63.6% of patients with type 1 disease responded to MMF which was significantly lower than 81.3% of patients with other angiographic types (p=0.037) while no such differential response was observed for AZA or MTX. Retrospective design and small number of patients in AZA and Mtx group were the major limitations of the study.

Conclusion

In our patients with TAK, all the three IS were comparable in inducing remission. Azathioprine was equal to MMF but superior to MTX in maintaining relapse free sustained response. The efficacy of MMF differed across various angiographic types of disease.

References

None

Disclosure of Interests

None declared

POS0320 EPIDEMIOLOGY AND HEALTHCARE RESOURCE UTILIZATION OF PATIENTS WITH EGPA IN THE UNITED KINGDOM

Background

Eosinophilic granulomatosis with polyangiitis (EGPA) is characterized by eosinophilic inflammation of small with or without medium arteries. EGPA is a rare disease with varying prevalence and incidence rates globally. To date, limited information is available on the prevalence, incidence and burden of disease in the United Kingdom (UK).

Objectives

The objectives were to estimate the prevalence and incidence of EGPA, and to describe the healthcare resource utilization (HCRU) among patients with EGPA in the UK.

Methods

This retrospective database study used the UK-based Clinical Practice Research Datalink (CPRD)-AURUM database linked to the Hospital Episode Statistics (HES). Prevalence was estimated from 2005 to 2019, and incidence was estimated from 2006 to 2019. HCRU was assessed in the 12-months following the first recorded diagnosis of EGPA (index date), and included hospitalizations, emergency room visits, procedures, outpatient specialist visits, primary care visits, and oral corticosteroid use.

Results

764 people were identified with EGPA in the UK. The prevalence of EGPA, reported in the database, increased from 22.7 to 45.6 per 1,000,000 persons from 2005 to 2019 (Figure 1), whereas the incidence of EGPA from 2006 to 2019 ranged from 2.28 to 4.00 per 1,000,000 person-years. 377 patients with EGPA were successfully linked to the CPRD-HES database. Patient characteristics were as follows: mean age (SD) was 57 years (14.2); 49% were male; 81% had asthma; and 11% had peripheral neuropathy prior to the index date. For patients with EGPA, 19% had an EGPA-related hospitalization and 50% had any-cause hospitalization within 1 year of the index date (Table 1). The mean length of stay was, 18 days and 16 days for EGPA-related and any-cause hospitalizations, respectively. 52% of patients with EGPA had undergone a medical procedure, 89% of patients with EGPA had an outpatient visit to a specialist. Almost all patients with EGPA visited a general practitioner within 1 year of their EGPA diagnosis (97%) and averaged 16.0 visits in 1 year. A significant proportion of the EGPA population were prescribed OCS; most EGPA patients had a prescription in the 0–3 months after the index date (64%), and patients on average had a prescription for OCS for 6 out of the 12 months after the index date.

Table 1.

HCRU among patients with EGPA

HCRUNumber of patients N (%) [total days]Number of events per patient, Mean (SD)Total EGPA cohort (N)377 EGPA-specific hospitalizations72 (19.10)1.2 (1) EGPA-specific hospitalizations  length of stay[1283]17.8 (23.3) Any-cause hospitalizations188 (49.87)1.7 (1) Any-cause hospitalizations length of stay[2992]15.9 (23.7) Any-cause A & E events19 (5.04)1.8 (2) Any-cause outpatient visits334 (88.59)9.8 (7) Any procedures undertaken196 (51.99)6.8 (6) General Practitioner visits366 (97.08)16.0 (11)

A&E, Accident and Emergency; EGPA, eosinophilic granulomatosis with polyangiitis; HCRU, healthcare resource utilization.

Figure 1.

Prevalence of EGPA in the UK from 2005 to 2019

Prevalence is expressed as cases per 1,000,000 persons. EGPA, eosinophilic granulomatosis with polyangiitis; UK, United Kingdom.

Conclusion

The prevalence of EGPA increased over the study period in the UK, and the data show significant HCRU within 1 year of the first recorded diagnosis of EGPA. Almost all of the patients with EGPA were found to frequently visit the primary care physician and seek specialist care, and almost half required hospitalization. Funding: GSK [207888]

Acknowledgements

Funding: GSK [207888]

Disclosure of Interests

Jeremiah Hwee Shareholder of: GSK, Employee of: GSK, Qinggong Fu Shareholder of: GSK, Employee of: GSK, Lorraine Harper Speakers bureau: Viopharm (2021), Roche (2017), Consultant of: GSK (2021), Viopharm (2021), Grant/research support from: Viopharm (researcher initiated project), MSD (researcher initiated project), Krishnarajah Nirantharakumar Consultant of: Boehringer Ingelheim (Consultancy on real world evidence), Grant/research support from: AstraZeneca, Vifor and Boehringer Ingelheim (Investigator led grants), Ruchika Goel: None declared, Rupert Jakes Shareholder of: GSK, Employee of: GSK

The Built Environment and Health in Low- and Middle-Income Countries: a Review on Quantitative Health Impact Assessments

PURPOSE OF REVIEW

Features and attributes of the built environment (BE) impact positively and negatively on health, especially in cities facing unprecedented urban population growth and mass motorization. A common approach to assess the health impacts of built environment is health impact assessment (HIA), but it is rarely used in low- and middle-income countries (LMICs) where urbanization rates are fastest. This article reviews selected HIA case studies from LMICs and reports the methods and tools used to support further implementation of quantitative HIAs in cities of LMICs.

RECENT FINDINGS

In total, 24 studies were reviewed across Algeria, Brazil, China, India, Iran, Kenya, Thailand, Turkey, and Mauritius. HIAs examine specific pathways through which the built environment acts: air pollution, noise, physical activity, and traffic injury. Few HIAs of BE addressed more than one exposure pathway at a time, and most studies focused on air pollution across the sectors of transport and energy. A wide number of tools were used to conduct exposure assessment, and different models were applied to assess health impacts of different exposures. Those HIAs rely on availability of local concentration data and often use models that have set exposure-response functions (ERFs). ERFs were not adapted to local populations except for HIAs conducted in China. HIAs of BE are being successfully conducted in LMICs with a variety of tools and datasets. Scaling and expanding quantitative health impact modeling in LMICs will require further study on data availability, adapted models/tools, low technical capacity, and low policy demand for evidence from modeling studies. As case studies with successful use of evidence from modeling emerge, the uptake of health impact modeling of BE is likely to increase in favor of people and planet.

Intersection of the Academic Research Consortium – high bleeding risk criteria in patients undergoing PCI for acute coronary syndromes: insights from a high-volume single centre registry

Introduction

Patients presenting for percutaneous coronary intervention (PCI) with acute coronary syndromes (ACS) often have overlapping bleeding and ischaemic risk factors that offset the long-term success of PCI and limit the post stenting therapeutic options. Aiming at improving outcomes following PCI, the Academic Research Consortium (ARC) recently published a set of major and minor criteria that identify, a priori, patients at high bleeding risk (HBR). Indeed, knowledge of these risk factors will help in optimization of pre-procedural therapy and minimization of post intervention complications. Nonetheless, the actual prevalence of these criteria among patients undergoing PCI for ACS is not well known.

Purpose

To determine the intersection and distribution of ARC-HBR major and minor criteria in a real-world ACS population presenting for PCI.

Methods

In this analysis, we included all patients who presented with ACS to a high-volume PCI centre from 2012 to 2017 and underwent PCI with 2nd generation drug-eluting stent (DES) implantation. Patients were then classified as HBR if they met ≥1 major or ≥2 minor criteria according to the ARC-HBR definition. Baseline clinical and procedural characteristics were extracted from each patient electronic health records. The most common exclusive intersections of ARC-HBR major and minor criteria were quantitatively visualized using an Upset Plot.

Results

Only 44.6% (n=2,717) of ACS patients (n=6,097) fulfilled the ARC-HBR definition. There were significant differences in baseline clinical characteristics between HBR and non-HBR groups: age (71.4±11.5 vs. 60.9±10.3 years, p<0.001), females (40.7% vs. 25.5%, p<0.001), cerebrovascular disease (19.5% vs. 3.9%, p<0.001), and diabetes (55.4% vs. 42.1%, p<0.001). The prevalence of active smoking, a major risk factor for bleeding, was higher in the non-HBR group (20.6% vs. 9.9%, p<0.001). The most frequent major and minor criteria were severe anemia (n=1,072) and age ≥75 (n=1,264), respectively. The top five criteria intersections were: severe anemia (n=215), age ≥75 and moderate chronic kidney disease (CKD) (n=145); moderate CKD and mild anemia (n=142); age ≥75 and mild anemia (n=140); age ≥75, moderate CKD, and mild anemia (n=130) (Figure 1).

Conclusion

Among patients who have undergone PCI for ACS, a significant proportion of individuals fulfilled the ARC-HBR definition. Severe anemia was the most prevalent major criteria. Different combinations of minor criteria, mainly age ≥75, moderate CKD and mild anemia, represented the most common intersections.

Figure 1

Funding Acknowledgement

Type of funding source: None

Are the minor high bleeding risk criteria of the academic research consortium truly minor? Insights from a high-volume tertiary care pci centre

Background

The Academic Research Consortium (ARC) has recently published a consensus-based definition to identify patients at high bleeding risk (HBR), reflected by a BARC 3 or 5 bleeding rate of ≥4% at 1 year after percutaneous coronary intervention (PCI). The HBR criteria included in the definition are divided into minor and major categories, with patients deemed to be at HBR if they fulfill at least one major or two minor criteria. As a result, patients who present with only one minor criterion are categorized as non-HBR.

Purpose

To compare the differences in baseline characteristics and 1-year bleeding and ischaemic outcomes between non-HBR patients undergoing PCI that present with only one minor HBR criterion versus those that do not fulfill any HBR criteria.

Methods

The study population consisted of all consecutive patients who underwent PCI with stent implantation in a single high-volume centre from January 2014 to December 2017. Patients were classified as non-HBR if they did not fulfill at least one major or two minor ARC-HBR criteria. The outcomes of interest were major bleeding (composite of peri-procedural and post-discharge bleeding), all-cause death, and myocardial infarction (MI) at 1 year. The Kaplan-Meier method was used for time-to-event analyses, with comparative risks being assessed using Cox regression.

Results

Of the 9,623 patients included in the analysis, 5,345 were classified as non-HBR. Within the non-HBR patients, 2,078 (38.9%) presented with only one minor HBR criterion and 3,267 (61.1%) presented with no HBR criteria. Non-HBR patients with one minor criterion were more often female, significantly older, with a higher burden of comorbidities such as diabetes mellitus, hypertension and hyperlipidaemia, and more likely to have multivessel disease as well as a history of prior MI and revascularisation, while non-HBR patients with no criteria were more likely to be smokers and have a higher BMI. Distribution of the minor HBR criteria within the group presenting with one minor criterion are illustrated in the figure. Non-HBR patients with only one minor criterion had a numerically higher rate of major bleeding compared to non-HBR patients with no criteria (3.6% vs. 2.9%, p=0.09). While the rate of all-cause death was significantly higher in the group with only one minor criterion (1.2% vs. 0.4%, p=0.004), there was no difference in the rate of MI between the two groups (2.1% vs. 1.9%, p=0.83). Hazard ratios comparing the two groups are presented in the figure.

Conclusions

Non-HBR patients presenting with only one minor criterion had a numerically higher rate of post-PCI bleeding and significantly higher mortality compared to those without any criteria. Nonetheless, the major bleeding rates of both groups at 1 year were less than the 4% cutoff to qualify as HBR according to the ARC definition, thereby supporting their inclusion as “minor” criteria in the recent ARC-HBR definition.

Figure 1

Funding Acknowledgement

Type of funding source: None

Impact of high-density lipoprotein levels in males and females undergoing percutaneous coronary intervention with drug eluting stents

Background/Introduction

Low levels of high-density lipoprotein (HDL) have been associated with adverse cardiovascular events in multiple epidemiological studies. Evidence regarding the role of HDL in males and females with established coronary artery disease undergoing percutaneous coronary intervention (PCI) with drug eluting stents (DES) is scarce.

Purpose

We sought to investigate the impact of low HDL levels on 1-year cardiovascular outcomes in males and females undergoing PCI with DES.

Methods

We screened all patients undergoing PCI in our center from 2012 to 2017. Exclusion criteria were: unavailable baseline HDL measurement, age <18 years, presentation with ST-segment elevation myocardial infarction (MI) or shock, coexisting neoplastic disease and treatment without a stent or with a bare metal stent. The final population was divided by gender and further stratified to the high or low HDL group according to baseline HDL levels. Cut-offs were 40mg/dL in males and 50mg/dL in females, per the most recent ACC/AHA guideline recommendations. The primary endpoint of the analysis was major adverse cardiovascular events (MACE) at 1 year, defined as death, MI or target vessel revascularization (TVR). To account for potential clinical and anatomical confounders the outcomes were also adjusted for age, Caucasian ethnicity, hypertension, diabetes mellitus (DM), body mass index, smoking, prior MI, multi-vessel disease and type B2/C lesions.

Results

Out of the 10,843 patients included, 7,718 (71.2%) were male and 3,125 (28.8%) were female. Low HDL was noted in 58.5% of males and 63.8% of females. Patients with low HDL were younger and had a higher prevalence of DM, prior MI, smoking and multi-vessel disease. When comparing low to high HDL groups in terms of 1-year MACE a borderline significant difference was shown in males (7.4% vs. 6.0%; p-value=0.08) but not in females (7.7% vs 8.1%; p-value=0.90) [Panel A]. The numerically higher incidence of MACE in males with low HDL was primarily driven by TVR (5.4% vs 3.7%; p-value=0.005) while the rates of Death (1.4% vs. 1.3%; p=0.96) and MI (2.0% vs. 1.8%; p-value=0.89) were similar between the two groups. After adjustment the male low HDL subgroup remained at a higher risk for 1-year TVR but not 1-year MACE compared to the male high HDL subgroup [Panel B]. No difference for any individual component of MACE was shown between low and high HDL subgroups in females [Panel C].

Conclusion(s)

High HDL levels were associated with a lower incidence of TVR and borderline reduction of MACE in male but not female patients undergoing PCI with DES. No difference was demonstrated in terms of death or MI between the high and low HDL subgroups at 1-year follow-up.

Impact of HDL levels according to gender

Funding Acknowledgement

Type of funding source: None

Long-term outcomes in high-bleeding risk patients undergoing PCI for acute coronary syndromes: results from a large single-center pci registry

Introduction

Current clinical guidelines recommend prolonged dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) in patients presenting with acute coronary syndromes (ACS). However, an extended DAPT duration in high-bleeding risk (HBR) patients amplifies the risk of post procedural complications. Hence, clinicians often face the dilemma of prolonging DAPT duration to prevent recurrent ischaemic events at the expense of increasing the incidence of bleeding in high-risk patients. The actual incidence of ischaemic and bleeding events in this particular population is not well elucidated.

Purpose

To evaluate one-year ischemic and bleeding outcomes following PCI for ACS in a real-world HBR population as defined by the Academic Research Consortium (ARC) consensus document.

Methods

We included all patients who presented with ACS to a high-volume single PCI centre from 2012 to 2017 and underwent PCI with 2nd generation drug-eluting stent implantation. Patients were classified as HBR if they met ≥1 major or ≥2 minor criteria according to the recent ARC-HBR consensus. The outcomes of interest were major adverse cardiovascular events (MACE), a composite of all-cause death, myocardial infarction (MI), and target lesion revascularization (TLR), and major bleeding events, including both peri-procedural and post-discharge bleeding. All outcomes were assessed at 1-year follow-up. The Kaplan-Meier method was used for time-to-event analyses.

Results

Out of 6,097 ACS patients included in this analysis, 2,717 (44.6%) fulfilled the ARC-HBR definition. Compared to non-HBR group, HBR patients were more frequently female, older, more likely to have cardiovascular risk factors (e.g., diabetes, hypertension, and hyperlipidemia) and complex coronary artery disease (e.g., multi-vessel disease, bifurcation lesions, and calcification). The 1-year incidence of MACE was significantly higher in HBR patients (16.3% vs. 8.1%, HR 2.16, 95% CI [1.81–2.59], p<0.001) (Figure 1A). This finding was driven by higher rates of all-cause death and MI (Figure 1B). The 1-year incidence of major bleeding was also significantly higher in HBR patients compared to non-HBR (11.1% vs. 3.1%, HR: 3.92, 95% CI 3.10–4.95; p<0.001).

Conclusions

HBR patients undergoing PCI for ACS are not only subject to bleeding complications but are also at an increased risk for ischemic events and all-cause mortality.

Figure 1

Funding Acknowledgement

Type of funding source: None

Radial versus femoral access for coronary angiography and interventions: a systematic review and meta-analysis of randomized trials

Background

The presence of any benefits associated with radial or femoral access among patients undergoing coronary angiography and percutaneous coronary interventions (PCI) is still debated.

Purpose

Our aim is to provide a comprehensive quantitative appraisal of the effects of access site on the risks of stroke, myocardial infarction, and major bleeding in patients undergoing coronary angiography with or without PCI.

Methods

In January 2020, we searched PubMed, Embase, and meeting abstracts for randomized trials comparing radial versus femoral access for coronary angiography with or without subsequent PCI. Odds ratios (OR) were used as metric of choice for treatment effects with random-effects models. Co-primary efficacy endpoints were stroke and myocardial infarction. Primary safety endpoint was major bleeding. Secondary endpoints were all cause mortality and vascular complications. Heterogeneity was assessed with the I-squared index. This study is registered with PROSPERO.

Results

We identified 31 trials, including 30,414 patients. Risks of stroke (OR 1.11, 95% CI 0.76–1.64, I2=0%) and myocardial infarction (OR 0.90, 95% CI 0.79–1.03, I2=0%) were comparable between radial and femoral access. Radial access was associated with a reduction for the risk of major bleeding as compared to femoral access (OR 0.53, 95% CI 0.42–0.67, I2=3.3%) with a number needed to treat of 92. Findings were consistent regardless clinical features and procedure performed, with the only exception of an increased benefit of the radial access in patients with chronic coronary syndrome (p forinteraction=0.005). The risk for all-cause mortality (OR 0.73, 95% CI 0.61–0.89, I2=0%) and vascular complication (OR 0.32, 95% CI 0.23–0.44, I2=16.7%) was significantly lower in the radial compared to femoral access group.

Conclusions

In patients undergoing coronary angiography with or without PCI, radial compared to femoral access did not reduce the risk of stroke and myocardial infarction, with no impact on the effect estimates of clinical presentation, age, gender, or subsequent PCI. Whereas, radial access is associated with a significant risk reduction of major bleeding as compared to femoral access. The benefit favoring radial access is of important clinical relevance in view of the relatively low number needed to treat to prevent a major bleeding and the significant impact on mortality.

Funding Acknowledgement

Type of funding source: None

Pulmonary arterial hypertension-associated changes in gut pathology and microbiota

Emerging evidence implicates an interplay among multiple organs such as brain, vasculature, gut and lung in the development of established pulmonary arterial hypertension (PAH). This has led us to propose that activated microglia mediated-enhanced sympathetic activation contributes to PAH pathophysiology. Since enhanced sympathetic activity is observed in human PAH and the gut is highly innervated by sympathetic nerves that regulate its physiological functions, we hypothesized that PAH would be associated with gut pathophysiology. A monocrotaline rat model of PAH was utilized to investigate the link between gut pathology and PAH. Haemodynamics, histology, immunocytochemistry and 16S RNA gene sequencing were used to assess cardiopulmonary functions, gut pathology and gut microbial communities respectively. Monocrotaline treatment caused increased right ventricular systolic pressure, haemodynamics and pathological changes associated with PAH. PAH animals also showed profound gut pathology that included increased intestinal permeability, increased muscularis layer, decreased villi length and goblet cells. These changes in gut pathology were associated with alterations in microbial communities, some unique to PAH animals. Furthermore, enhanced gut-neural communication involving the paraventricular nucleus of the hypothalamus and increased sympathetic drive were observed. In conclusion, our data show the presence of gut pathology and distinct changes in gut microbiota and increased sympathetic activity in PAH. They suggest that dysfunctional gut-brain crosstalk could be critical in PAH and considered a future therapeutic target for PAH.

AB0596 PREDICTORS, LONG TERM CLINICAL AND TREATMENT OUTCOMES IN SOUTH ASIAN PATIENTS WITH IDIOPATHIC INFLAMMATORY MYOSITIS: A SINGLE CENTER STUDY

Background:

Idiopathic inflammatory myositis (IIM) are a heterogeneous group of immune-mediated disorders with varied presentations and multiple organ involvement. Data on long term outcome among South Asian patients with IIM is sparse.

Objectives:

To study the long term clinical outcome, treatment responses and factors predicting outcome among adult patients with IIM

Methods:

Patients diagnosed as ‘Idiopathic Inflammatory Myositis’ under the department of Clinical Immunology and Rheumatology at CMC, Vellore, India were screened retrospectively. Patients aged 18 years and above, satisfying Bohan and Peter criteria, having follow up of one year or more with atleast two outpatient or inpatient visits between January 2010 and April 2019 were included in this study. Those patients with connective tissue disease associated myositis were not included. Details on muscle weakness, extramuscular involvement, muscle enzymes and treatment administered were recorded at baseline, 3, 6, 12, 18, 24 months and yearly thereafter. After assessing their cumulative response, categorization of patients into complete and partial responders was done. Complete responders were defined as patients with persistent muscle power of more than 4/5 and/or MMT 8 more than 76/80, complete resolution of skin, articular and lung involvement (if any) as well as muscle enzymes less than twice the upper limit of normal without any documented flares during the entire follow up period. Patients not satisfying the said criterias were grouped as Partial responders. Disease free survival duration was also analyzed.

Results:

Out of 310 patients of IIM identified, 187 (60.3%) patients satisfied the inclusion criteria. Women were 2.2 times more than men and mean age at symptom onset was 35.7±12.6 years. Dermatomyositis was the predominant myositis subtype seen. All patients were put on steroids with the mean dose being 45.9 ± 18.6 mg/day. At baseline, the key immunosuppressants used were methotrexate in 44.9% and mycophenolate in 37.6% patients. The median follow up duration was 48 (25-80) months. An associated malignancy was diagnosed in 3.2% after a median duration of 24.5 months. Five patients expired after a median duration of 80 months from diagnosis. Normal muscle power was attained in 76.1% patients and 88.6% were vocational by the last follow up visit. Steroids were discontinued in 56.7% patients after a median duration of 24 months (p=0.0002). Discontinuation of the immunosuppressant was feasible in 10.2% patients after a median duration of 44 months. Assessment of the cumulative responses revealed a relapsing and remitting course in 45.9%. Outcome predictors in univariate analysis were Jo-1 status, presence of arthritis, interstitial lung disease and pericardial effusion at baseline. On multivariate analysis, absence of pericardial effusion (p=0.011) and interstitial lung disease (p=0.067) at baseline were found to be predictors of complete response. Disease free survival probability estimated at 5 years and 10 years was 91.6% and 72.4% respectively. Estimating the probability gender wise, males achieved disease free status earlier than females.

Conclusion:

A favorable clinical and functional outcome was seen in a significant proportion of these patients with IIM on long term follow up. Pericardial effusion and ILD were identified as predictors of poor clinical outcome.

References:

[1]Taborda AL, Azevedo P, Isenberg DA. Retrospective analysis of the outcome of patients with idiopathic inflammatory myopathy: a long-term follow-up study. Clin Exp Rheumatol. 2014 Apr; 32(2):188–93.

Acknowledgments:

Nil

Disclosure of Interests:

None declared

THU0523 CLINICAL UTILITY OF TESTING CONVENTIONAL AND NON-CONVENTIONAL ANTI-PHOSPHOLIPID ANTIBODIES IN SUSPECTED OBSTETRIC ANTI-PHOSPHOLIPID SYNDROME

Background:

Anti-phospholipid syndrome (APS) is an important cause for recurrent pregnancy losses (RPL). Conventional APS antibodies (aPLs) like lupus anti-coagulant (LA), anti-cardiolipin(ACL) and anti-beta 2 glycoprotein I (anti-β2 GP I) are not present in significant number of obstetric APS(OAPS) patients, leading to a state described as “ sero-negative” OAPS (SNOAPS). Recent literature shows non-conventional aPLs like Anti phosphatidylserine-prothrombin complex (Anti-PSPT) and Anti-Annexin V (Anti-Ann V) can be positive in up to 50% of SNOAPS patients

Objectives:

Testing the performance of conventional and non-conventional aPLs in suspected OAPS patients (obstetric events as defined in the Sydney classification criteria for APS)

Methods:

We performed a retrospective chart review of 101 patients who underwent combined testing for non-conventional aPLs for suspected OAPS from May 2016 to November 2019 at our department. Patients were categorized into OAPS cases (n=50, median age 31 years) and controls (n=51, median age 30 years) based on their fulfillment of clinical definition of OAPS events defined by Sydney criteria. Conventional aPLs were tested by methods adapted in Sydney criteria and Anti PSPT /Anti Ann V were tested by commercial ELISA. The sample size(n=101) has 95% confidence interval with a margin of error of 10% for the objective of the study.

Results:

36 cases (72%) were ‘sero-positive’ & 14 cases (28%) were truly ‘sero-negative’ for conventional aPLs. 5 (35.7%) of the SNOAPS patients were positive for Ant-PSPT and/or Anti AnnV antibodies. Performance of the various aPLs in suspected OAPS is displayed in Table 1 & Figure 1.

Table 1

showing the performance of the various conventional and non-conventional APLs in suspected obstetric APS cases

AntibodySensitivitySpecificityLikelihood Ratio(+)Likelihood Ratio (-)Positive Predictive ValueNegative Predictive ValueAccuracyYouden’s IndexLA50%94.1 %8.50.589.3%65.7%72.3%44.1%ACL32%98%16.30.794.1%59.5 %65.3%30 %anti β2 GP I IgM38.4%91.4 %4.50.783.3%57.1 %63.5%29.8%anti β2 GP I IgG24%96.1 %6.10.885.7%56.3%60.4%20.1%Anti PSPT28%96.1 %7.10.787.5%57.6 %62.4%24.1%Anti AnnV28%98 %14.30.793.3%58.1%63.4%26%Conventional APLs72%88.2%6.10.385.7%76.3 %79.8%60.2%Non-conventional APLS38%94.1%6.40.786.4%60.7 %66.3%32.1%All APLs82%86.3%6.000.2085.4%83 %84.2%68.3%Figure 1

showing the comparative diagnostic performance of Conventional aPL testing vs Combined testing along with non-conventional aPLs in suspected obstetric APS scenario

Conclusion:

In a delicate situation like RPL, performance of non-conventional aPLs on their own, though not as sensitive as conventional aPLs, still demonstrate better specificity. Non-conventional APLs can newly identify 1/3rd of SNOAPS as APS. The real value of testing Anti PSPT & Anti Ann V in RPL, is combined testing with conventional aPLs wherein they improve the sensitivity and accuracy of diagnosis of OAPS by 10% & 4.4 % respectively, with only 1.9% drop in specificity. Non-conventional aPLs should be tested in SNOAPS.

Disclosure of Interests:

None declared

Transcriptomic signature of gut microbiome-contacting cells in colon of spontaneously hypertensive rats

Fecal matter transfer from hypertensive patients and animals into normotensive animals increases blood pressure, strengthening the evidence for gut-microbiota interactions in the control of blood pressure. However, cellular and molecular events involved in gut dysbiosis-associated hypertension remain poorly understood. Therefore, our objective in this study was to use gene expression profiling to characterize the gut epithelium layer in the colon in hypertension. We observed significant suppression of components of T cell receptor (TCR) signaling in the colonic epithelium of spontaneously hypertensive rats (SHR) when compared with Wistar Kyoto (WKY) normotensive rats. Western blot analysis confirmed lower expression of key proteins including T cell surface glycoprotein CD3 gamma chain (Cd3g) and lymphocyte cytosolic protein 2 (Lcp2). Furthermore, lower expression of cytokines and receptors responsible for lymphocyte proliferation, differentiation, and activation (e.g., Il12r, Il15ra, Il7, Il16, Tgfb1) was observed in the colonic epithelium of the SHR. Finally, Alpi and its product, intestinal alkaline phosphatase, primarily localized in the epithelial cells, were profoundly lower in the SHR. These observations demonstrate that the colonic epithelium undergoes functional changes linked to altered immune, barrier function, and dysbiosis in hypertension.

Eastern Canadian Gastrointestinal Cancer Consensus Conference 2018

The annual Eastern Canadian Gastrointestinal Cancer Consensus Conference was held in Halifax, Nova Scotia, 20-22 September 2018. Experts in radiation oncology, medical oncology, surgical oncology, and pathology who are involved in the management of patients with gastrointestinal malignancies participated in presentations and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses multiple topics in the management of pancreatic cancer, pancreatic neuroendocrine tumours, hepatocellular cancer, and rectal and colon cancer, including ■ surgical management of pancreatic adenocarcinoma,■ adjuvant and metastatic systemic therapy options in pancreatic adenocarcinoma,■ the role of radiotherapy in the management of pancreatic adenocarcinoma,■ systemic therapy in pancreatic neuroendocrine tumours,■ updates in systemic therapy for patients with advanced hepatocellular carcinoma,■ optimum duration of adjuvant systemic therapy for colorectal cancer, and■ sequence of therapy in oligometastatic colorectal cancer.

P1760Incidence and effects of stroke, MI and bleeding on mortality among patients with ACS undergoing PCI: a comparative analysis from the PROMETHEUS registry

Background

Stroke represents a potentially calamitous complication among patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) even though its rates are relatively low. Data on the distribution of stroke occurrence over time and its overlap with myocardial infarction (MI) and bleeding after PCI is scarce.

Purpose

We sought to compare the occurrence and impacts of stroke, MI and bleeding on subsequent mortality in ACS patients undergoing PCI in contemporary clinical practice.

Methods

A total of 19,914 ACS patients who underwent PCI in the PROMETHEUS multi-center observational study were analyzed. We calculated the cumulative stroke incidence at 30 days and 1 year using Kaplan Meier (KM) method. We also compared the distribution of stroke, myocardial infarction (MI) and bleeding across time and evaluated the overlap between their occurrences. Predictors of 1 year stroke occurrence were identified through multivariable Cox-regression and stroke, MI and bleeding were entered as time-updated covariates to estimate their individual effects on subsequent mortality.

Results

Of the total number of patients, 244 patients (1.5%) had a stroke within 1 year. 48 of these patients also experienced an MI while another 48 patients experienced a bleeding event. Furthermore, 14 of these overlapping patients experienced a stroke, MI and bleeding event, all within the 1-year follow-up. Patients who sustained a stroke were more likely to have a prior history of cerebrovascular disease, peripheral artery disease, MI and heart failure compared to those who did not have a stroke. Mortality risk was significantly higher among those with stroke versus those without stroke (adjusted HR 4.84, p<0.0001). However, the association attenuated over time with a much larger effect in the first 30 days of its occurrence (adjusted HR 17.7, p<0.0001) versus beyond 30 days (adjusted HR 1.22; 95% CI: 0.6–2.46, p=0.58). Although the effects of MI and bleeding on subsequent mortality within 30 days of occurrence were significantly lower than stroke (adjusted HR 6.22, p<0.0001; adjusted HR 7.30, p<0.0001, respectively), their effects were more sustained on mortality beyond 30 days (adjusted HR 2.89, p<0.0001; adjusted HR 3.05, p<0.0001, respectively).

Conclusion

When compared with MI and bleeding, stroke had a substantially stronger impact on mortality that attenuated rapidly over time among ACS patients undergoing PCI. Optimization of modifiable risk factors and medication adherence are essential parts of management of stroke following PCI for ACS.

Sustained Captopril-Induced Reduction in Blood Pressure Is Associated With Alterations in Gut-Brain Axis in the Spontaneously Hypertensive Rat

Background We have demonstrated that the antihypertensive effect of the angiotensin-converting enzyme inhibitor, captopril ( CAP ), is associated with beneficial effects on gut pathology. Coupled with the evidence that CAP exerts prolonged reduction in blood pressure ( BP ) after discontinuation of treatment, we investigate whether persistent beneficial actions of CAP are linked to alterations of gut microbiota and improvement of hypertension-induced gut pathology. Methods and Results Spontaneously hypertensive rats ( SHR ) and Wistar Kyoto rats were treated with CAP (250 mg/kg/day) for 4 weeks followed by withdrawal for 16 weeks. Gut microbiota, gut pathology, BP, and brain neuronal activity were assessed. CAP resulted in a ≈60 mm Hg decrease in systolic BP after 3 weeks of treatment in SHR , and the decrease remained significant at least 5 weeks after CAP withdrawal. In contrast, CAP caused modest decrease in systolic BP in Wistar Kyoto. 16S rRNA gene-sequencing-based gut microbial analyses in SHR showed sustained alteration of gut microbiota and increase in Allobaculum after CAP withdrawal. Phylogenetic investigation of communities by reconstruction of unobserved states analysis revealed significant increase in bacterial sporulation upon CAP treatment in SHR . These were associated with persistent improvement in gut pathology and permeability. Furthermore, manganese-enhanced magnetic resonance imaging showed significantly decreased neuronal activity in the posterior pituitary of SHR 4 weeks after withdrawal. Conclusions Decreased BP , altered gut microbiota, improved gut pathology and permeability, and dampened posterior pituitary neuronal activity were maintained after CAP withdrawal in the SHR . They suggest that CAP influences the brain-gut axis to maintain the sustained antihypertensive effect of CAP after withdrawal.

Calibrating balance perturbation using electrical stimulation of the vestibular system

BACKGROUND

Supra-threshold galvanic vestibular stimulation (GVS) can be used to challenge the balance control system by disrupting vestibular inputs. The goal of this study was to propose an objective method to assess variability across subjects in the minimum safe GVS level that causes maximum balance degradation. New method: Thirteen healthy young subjects stood on a compliant foam surface with their eyes closed and tried to maintain a stable upright stance. Variables related to the stability of the trunk and whole body were quantified to characterize the relationship between postural responses and GVS at amplitudes from 0 to 4.5 mA in 0.5 mA increments. The relationship between decrements in postural responses and GVS was linear up to a minimum GVS level (called KNEE). An increase in the stimulation level above that did not lead to any further degradation of balance performance. The KNEE was determined by iteratively performing linear fits to the performance measure at different stimulation levels.

RESULTS

There were individual differences in KNEE; it was in the range of 1-2.5 mA across subjects. GVS caused an average performance decrement of 27-99% across six variables at the KNEE level compared to a no-stimulus condition. Comparison to existing methods: We propose a method to consistently attain the maximum level of impairment across subjects using the minimum current intensity, to minimize all types of adverse effects usually observed at high intensities.

CONCLUSIONS

Individual differences in the disruption of posture control in response to GVS have important implications for testing and training paradigms.

Eastern Canadian Colorectal Cancer Consensus Conference 2017

The annual Eastern Canadian Gastrointestinal Cancer Consensus Conference 2017 was held in St. John's, Newfoundland and Labrador, 28-30 September. Experts in radiation oncology, medical oncology, surgical oncology, and cancer genetics who are involved in the management of patients with gastrointestinal malignancies participated in presentations and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses multiple topics in the management of gastric, rectal, and colon cancer, including ■ identification and management of hereditary gastric and colorectal cancer (crc);■ palliative systemic therapy for metastatic gastric cancer;■ optimum duration of preoperative radiation in rectal cancer-that is, short- compared with long-course radiation;■ management options for peritoneal carcinomatosis in crc;■ implications of tumour location for treatment and prognosis in crc; and■ new molecular markers in crc.

Gut microbiota and serum metabolite differences in African Americans and White Americans with high blood pressure

BACKGROUND

Black Americans have greater rates, severity and resistance to treatment of hypertension than White Americans. The gut microbiota and its metabolites may contribute to this. This concept was tested in a pilot study.

METHODS

Subjects with high (HBP, >140/80 mm Hg) and normal (NBP, <120/80 mm Hg) blood pressure (BP) provided stool and blood samples for whole genome sequencing (WGS) of gut microbiota and global untargeted metabolomics of serum. Patients were either black (B) with NBP (n = 10 for WGS, 5 for metabolomics) and HBP (n = 10 and 9, BHBP) or white (W) with NBP (n = 20 and 13, WNBP) and HBP (n = 12 and 8, WHBP).

RESULTS

All four subject groups had distinct gut microbiota taxonomy by partial least squares discriminant analysis (PLS-DA). More importantly, linear discriminant analysis effect size showed marked differences in function of the microbiota of BHBP and WHBP (PLS-DA) with LDA scores <1. This included pathways for synthesis and interconversion of amino acids and inflammatory antigens. Similarly, metabolites differed (PLS-DA) with BHBP having significantly higher sulfacetaldehyde, quinolinic acid, 5-aminolevulinic acid, leucine and phenylalanine and lower 4-oxoproline and l-anserine.

DISCUSSION

Combination analyses of functional gut metabolic pathways and metabolomics data in this small pilot study suggest that BHBP may have greater oxidative stress markers in plasma, greater inflammatory potential of the gut microbiome and altered metabolites with gut microbial functions implying insulin resistance. A fuller understanding of these potential differences could lead to race-based treatments for hypertension.

Imbalance of gut microbiome and intestinal epithelial barrier dysfunction in patients with high blood pressure

Recent evidence indicates a link between gut pathology and microbiome with hypertension (HTN) in animal models. However, whether this association exists in humans is unknown. Thus, our objectives in the present study were to test the hypotheses that high blood pressure (BP) patients have distinct gut microbiomes and that gut-epithelial barrier function markers and microbiome composition could predict systolic BP (SBP). Fecal samples, analyzed by shotgun metagenomics, displayed taxonomic and functional changes, including altered butyrate production between patients with high BP and reference subjects. Significant increases in plasma of intestinal fatty acid binding protein (I-FABP), lipopolysaccharide (LPS), and augmented gut-targetting proinflammatory T helper 17 (Th17) cells in high BP patients demonstrated increased intestinal inflammation and permeability. Zonulin, a gut epithelial tight junction protein regulator, was markedly elevated, further supporting gut barrier dysfunction in high BP. Zonulin strongly correlated with SBP (R2 = 0.5301, P<0.0001). Two models predicting SBP were built using stepwise linear regression analysis of microbiome data and circulating markers of gut health, and validated in a separate cohort by prediction of SBP from zonulin in plasma (R2 = 0.4608, P<0.0001). The mouse model of HTN, chronic angiotensin II (Ang II) infusion, was used to confirm the effects of butyrate and gut barrier function on the cardiovascular system and BP. These results support our conclusion that intestinal barrier dysfunction and microbiome function are linked to HTN in humans. They suggest that manipulation of gut microbiome and its barrier functions could be the new therapeutic and diagnostic avenues for HTN.

Venous thromboembolic prophylaxis after simultaneous bilateral total knee arthroplasty: aspirin versus warfarin

Aims

The aims of this study were to compare the efficacy of two agents, aspirin and warfarin, for the prevention of venous thromboembolism (VTE) after simultaneous bilateral total knee arthroplasty (SBTKA), and to elucidate the risk of VTE conferred by this procedure compared with unilateral TKA (UTKA).

Patients and Methods

A retrospective, multi-institutional study was conducted on 18 951 patients, 3685 who underwent SBTKA and 15 266 who underwent UTKA, using aspirin or warfarin as VTE prophylaxis. Each patient was assigned an individualised baseline VTE risk score based on a system using the Nationwide Inpatient Sample. Symptomatic VTE, including pulmonary embolism (PE) and deep vein thrombosis (DVT), were identified in the first 90 days post-operatively. Statistical analyses were performed with logistic regression accounting for baseline VTE risk.

Results

The adjusted incidence of PE following SBTKA was 1.0% (95% confidence interval (CI) 0.86 to 1.2) with aspirin and 2.2% (95% CI 2.0 to 2.4) with warfarin. Similarly, the adjusted incidence of VTE following SBTKA was 1.6% (95% CI 1.1 to 2.3) with aspirin and 2.5% (95% CI 1.9 to 3.3) with warfarin. The risk of PE and VTE were reduced by 66% (odds ratio (OR) 0.44, 95% CI 0.25 to 0.78) and 38% (OR 0.62, 95% CI 0.38 to 1.0), respectively, using aspirin. In addition, the risk of PE was 204% higher for patients undergoing SBTKA relative to those undergoing UTKA. For each ten-point increase in baseline VTE risk, the risk of PE increased by 25.5% for patients undergoing SBTKA compared with 10.5% for those undergoing UTKA. Patients with a history of myocardial infarction or peripheral vascular disease had the greatest increase in risk from undergoing SBTKA instead of UTKA.

Conclusion

Aspirin is more effective than warfarin for the prevention of VTE following SBTKA, and serves as the more appropriate agent for VTE prophylaxis for patients in all risk categories. Furthermore, patients undergoing SBTKA are at a substantially increased risk of VTE, even more so for those with significant underlying risk factors. Patients should be informed about the risks associated with undergoing SBTKA.

Cite this article: Bone Joint J 2018;100-B(1 Supple A):68–75.

Abstract 004: Plasma Zonulin, Along With a Unique Gut Microbiome Profile, Are Potential Predictors of Systolic Blood Pressure in Humans

Objectives: We have previously shown that gut pathophysiology and dysbiosis are closely associated with hypertension (HTN) in animal models. However, whether this association also occurs in human HTN is unknown. To address this knowledge gap, we tested two hypotheses. 1. Hypertensive patients (HTN) have gut barrier dysfunction. 2. Prediction of blood pressure will be possible from circulating markers of gut health and gut microbiome composition.

Design and Method: Plasma and fecal samples were collected from HTN (n=22, mean SBP 155.8±3.4mmHg) and reference subjects without HTN (REF) (n=18, mean SBP 121.1±1.5mmHg) (see ClinicalTrials.gov, NCT02188381 for protocol). Gut microbiomes were analyzed using shotgun metagenomic sequencing and Qiime. Plasma analytes were measured by ELISA.

Results: Plasma intestinal fatty acid binding protein (REF;1.2 ± 0.1 ng/ml, HTN;1.9 ± 0.2 ng/ml, p=0.0097) and lipopolysaccharide (REF; 39.0 ± 9.5 pg/ml, HTN; 98.0 ± 26.2 pg/ml, p=0.0423) were increased in HTN, suggesting increased intestinal inflammation and permeability. Additionally, the soluble form of zonulin (regulator of gut tight junction proteins) was markedly elevated in the plasma of HTN (REF; 28.4 ± 2.0 ng/ml, HTN; 42.6 ± 2.7 ng/ml, P=0.0002) further supporting gut barrier dysfunction. Plasma zonulin was correlated with SBP (R 2 =0.5301, p<0.0001). Two models predicting SBP were built using stepwise linear regression analysis of microbiome shotgun metagenomics data and circulating markers of gut health. The first model used plasma zonulin as a single predictor, and the second zonulin plus butyrate producing bacteria (adjusted R 2 values of 0.506 and 0.554 respectively, p<0.001 for both). Our first model was validated by prediction of SBP in a separate validation cohort (n=36) from zonulin plasma levels (R 2 =0.4608, p<0.0001).

Conclusions: Markers of increased gut permeability, particularly zonulin, and abundance of butyrate producing bacteria predicted SBP. These results support the hypothesis that gut barrier dysfunction and gut microbiome composition are directly linked with HTN in humans.

Abstract P134: Increased Gut Permeability and Dysbiosis in Patients With Pulmonary Arterial Hypertension

Introduction: Pulmonary arterial hypertension (PAH) is a fatal disease and vasodilators are the mainstay for its therapy. However, they offer restricted advancement opportunities for the control and treatment of PAH. Thus, the PAH field needs a paradigm-shifting strategy for its successful management and control.

Objective: To test the hypothesis that gut microbial dysbiosis and its increased permeability are associated with PAH.

Methods: Healthy control subjects and patients with PAH were recruited from two hospitals in the Americas to ascertain the wider applicability of our hypothesis. Fecal samples of PAH patients (n=19) and control, reference subjects (n=16) were obtained at the Hospital de Clinicas de Porto Alegre, Brazil, for microbiota analysis. Plasma/serum samples were collected from PAH patients (n=22) and control, reference subjects (n=19) at the Mayo Clinic, Jacksonville, Florida, USA, for analysis of gut leakiness and inflammatory biomarkers.

Results: In PAH patients, a significant decrease in abundance, diversity and evenness of gut microbial population was observed as measured by 16S ribosomal DNA analyses of fecal samples. Analysis of fecal bacteria populations also demonstrated significant increases in gram-positive, facultative-anaerobic genera, such as Actinomyces, Bifidobacterium Slackia, and Streptococcus in PAH patients. Further, plasma zonulin and iFABP, the biomarkers for gut leakiness increased by 40.3% (p=0.0018) and 81% (p=0.0012), respectively in PAH patients. High plasma LPS, HMGB1, and TIMP1 levels are involved in increased gut inflammation and gut mucosal injury. We also observed LPS, HMGB1, and TIMP1 levels were increased by 363% (p=0.0096), 20.5% (p=0.0027), and 213% (p<0.0001), respectively in PAH patients.

Conclusions: PAH patients demonstrate profound gut microbial dysbiosis and increased permeability and inflammation. Further characterization of PAH specific microbial species holds novel management potential with the use of pre- and probiotics, designer antibiotics, appropriate fecal/bacterial transplantation, on top of background proven therapies.

Abstract P135: Is Heart Failure With Preserved Ejection Fraction a Gut Disorder?

Background and Objective: Heart failure (HF) with preserved ejection fraction (HFpEF) accounts for ~50% of HF hospitalizations, is associated with poor quality of life and, has a mortality rate comparable with many cancers. To date, no therapies have proven effective in slowing disease progression, mainly due to limited understanding of underlying mechanisms. Mounting evidence suggests the intestine and gut microbiota play an important role in chronic inflammation in HF, and also hypertension, a history of which is present in most HFpEF patients. However, information about intestinal involvement in HFpEF is limited. Accordingly, we investigated the hypothesis that disturbed intestinal barrier function contributes to translocation of endotoxin and inflammation activation in HFpEF.

Method and Results: Left ventricular (LV) function, intestinal permeability, circulating lipopolysaccharide (LPS, an endotoxin and strong inducer of pro-inflammatory cytokines) and high-mobility group box protein (HMGB1, a nuclear protein that triggers inflammation) were examined in a mouse model of HFpEF [4w continuous infusion of subpressor dose of angiotensin II (0.2mg/kg/d)] and 4 patients with HFpEF and 4 reference subjects. Impaired LV diastolic function (increase in LVEDP and Tau, both p<0.05) occurred in the mice with 3-fold increased intestinal permeability, 1.8-fold elevated LPS levels (137±7 vs control 77±6 pg/ml, p<0.005) and 4-fold increased HMGB1 levels (238±42 vs control 56±16 ng/ml, p<0.05). Stimulating human coronary artery endothelial cells with 10μg/ml LPS for 48h resulted in 3-fold elevation of HMGB1 (29±4 vs control 12±3 ng/ml, p<0.05) that was suppressed by butyrate (17±3 ng/ml). Patients with HFpEF had a 2-fold increase in zonulin (31±3 vs 14±2 ng/ml) and 4-fold LPS elevation (152±18 vs 32±3 pg/ml), (both p<0.05 vs reference subjects), confirming gut barrier dysfunction with translocation of endotoxin.

Conclusions: HFpEF is associated with increased gut permeability that facilitates LPS translocation activating inflammation resulting in endothelial damage. Thus, the gut could be a novel target for therapeutic interventions in patients with HFpEF.

Real-life treatment of metastatic colorectal cancer with regorafenib: a single-centre review

BACKGROUND

Various tyrosine kinase signalling pathways affect the development and progression of colorectal cancer (crc). In clinical trials, regorafenib has been associated with a survival benefit in metastatic crc (mcrc). We assessed the safety and efficacy of regorafenib in real-world patients.

METHODS

In a retrospective review of patients with mcrc treated with regorafenib at our institution from 2013 to 2015, patient demographics, treatment, and survival data were collected. Progression-free survival (pfs) and overall survival (os) were estimated using the Kaplan-Meier method.

RESULTS

In total, 48 patients were offered regorafenib, and 35 (73%) started treatment. Of the patients who started regorafenib, 57% were men. Median age in the cohort was 61 years, and all patients had a performance status in the range 0-2. Time from diagnosis of mcrc to regorafenib treatment was more than 18 months in 71% of patients. Starting dose was 160 mg in 54% of the patients, 120 mg in 40%, and 80 mg in 6%. Dose reductions occurred in 34% of the patients, and interruptions, in 29%. Best response was progressive disease (60%) and stable disease (17%); response in the rest of the patients was unknown. The most common adverse events on regorafenib (any grade) were fatigue (57%), hyperbilirubinemia (43%), thrombocytopenia (37%), anorexia (31%), and hypertension (31%). The most common grade 3 or 4 adverse events were fatigue (29%), hypophosphatemia (17%), weight loss (11%), and hyperbilirubinemia (9%). Common reasons for discontinuing regorafenib included progressive disease (51%) and toxicity (26%). In patients treated with regorafenib, pfs was 2.4 months (95% confidence interval: 1.8 to 3.3 months) and os was 5.6 months (95% confidence interval: 3.7 to 8.9 months). No factors were associated with survival in univariate or multivariate analysis.

CONCLUSIONS

In a real-world setting, regorafenib is associated with survival similar to that reported in the randomized controlled trials, but at the expense of toxicity leading to discontinuation in many patients. Future studies of regorafenib should focus on identifying the patients most likely to benefit and on minimizing toxicity.

Intestinal Permeability Biomarker Zonulin is Elevated in Healthy Aging

INTRODUCTION

Increased gut permeability ("leaky gut") has been proposed as a potential contributor to age-related inflammation and gut dysbiosis. However, information on the relationship between a leaky gut and inflammation and physical frailty during aging are limited.

OBJECTIVE

To investigate the hypothesis that an aging-associated leaky gut is linked to the age-related inflammation and frailty.

METHODS

Two cohorts of healthy adults were studied: young (18-30 years old, n = 19) and older (≥70 years old, n = 18). Serum concentrations of the tumor necrosis factor (TNF)-α and interleukin (IL)-6, zonulin (a marker for leaky gut), and high-mobility group box protein (HMGB1, a nuclear protein triggering inflammation) were measured. Correlations of serum levels of zonulin and HMGB1 with strength of plantar flexor muscles and number of steps taken per day were analyzed.

RESULTS

Serum concentration of zonulin and HMGB1 were 22% (P = .005) and 16% (P = .010) higher in the older versus young adults. Serum zonulin was positively associated with concentrations of TNF-α (r = 0.357, P = .032) and IL-6 (r = 0.345, P = .043). Importantly, both zonulin and HMGB1 were negatively correlated with skeletal muscle strength (zonulin: r = -0.332, P = .048; HMGB1: r = -0.383, P = .023), and habitual physical activity (zonulin: r = -0.410, P = .016; HMGB1: r = -0.483, P = .004).

CONCLUSIONS

Serum zonulin was associated with both systemic inflammation and 2 key indices of physical frailty. These data suggest that a leaky gut may play a critical role in the development of age-related inflammation and frailty.

Study of microbial growth on silicone tubes after transcanalicular laser-assisted dacryocystorhinostomy and correlation with patency

INTRODUCTION

Intubation in primary transcanalicular laser assisted dacryocystorhinostomy (TCLADCR) is performed to increase the success rates. However, the associated inflammation and infection can have adverse effects.

OBJECTIVE

To study the microbial infection and drug susceptibility of extubated silicone tubes and final anatomical patency in patients undergoing TCLADCR.

MATERIALS AND METHODS

A non-randomised prospective interventional study was conducted in a tertiary care eye centre. The study included twenty consecutive adult patients with primary nasolacrimal duct obstruction. They underwent TCLADCR with bicanalicular silicone intubation. The stents were removed at 2 months and subjected to culture sensitivity, followed by administration of appropriate antimicrobial agents. Main outcome measures studied were the microbial spectrum on the cultured tubes, their sensitivity profile and its correlation with final anatomical patency.

RESULTS

A positive culture was obtained in 100% cases, comprising of normal commensals and pathogenic organisms. Of the total 24 isolates, 16 (66.6%) Gram positive bacteria (75% Staphylococcus aureus) and 8 (33.3%) Gram negative bacteria (commonest E.coli) were found, with 4 tubes having more than one isolate. No fungal growth was seen. Ninety percent success rate was achieved at one year following appropriate antimicrobial therapy except in 2 patients with gram negative isolates who had failed to take the prescribed antibiotics following sensitivity reports. There was no correlation between multiple infections and success rate. However, by using the Fisher exact test, a positive correlation was obtained between appropriate antibiotic treatment and the final anatomical patency (p less than 0.05).

CONCLUSION

Silicone intubation predisposes to microbial growth, which if neglected, can lead to failure of TCLADCR.

Platelet CD40L induces activation of astrocytes and microglia in hypertension

Studies have demonstrated separately that hypertension is associated with platelet activation in the periphery (resulting in accumulation and localized inflammatory response) and glial activation in the brain. We investigated the contribution of platelets in brain inflammation, particularly glial activation in vitro and in a rat model of hypertension. We found that HTN increased the expression of adhesion molecules like JAM-1, ICAM-1, and VCAM-1 on brain endothelium and resulted in the deposition of platelets in the brain. Platelet deposition in hypertensive rats was associated with augmented CD40 and CD40L and activation of astrocytes (GFAP expression) and microglia (Iba-1 expression) in the brain. Platelets isolated from hypertensive rats had significantly higher sCD40L levels and induced more prominent glial activation than platelets from normotensive rats. Activation of platelets with ADP induced sCD40L release and activation of astrocytes and microglia. Moreover, CD40L induced glial (astrocytes and microglia) activation, NFкB and MAPK inflammatory signaling, culminating in neuroinflammation and neuronal injury (increased apoptotic cells). Importantly, injection of ADP-activated platelets into normotensive rats strongly induced activation of astrocytes and microglia and increased plasma sCD40L levels compared with control platelets. On the contrary, inhibition of platelet activation by Clopidogrel or disruption of CD40 signaling prevented astrocyte and microglial activation and provided neuroprotection in both in vivo and in vitro conditions. Thus, we have identified platelet CD40L as a key inflammatory molecule for the induction of astrocyte and microglia activation, the major contributors to inflammation-mediated injury in the brain.

Eastern Canadian Gastrointestinal Cancer Consensus Conference 2016

The annual Eastern Canadian Gastrointestinal Cancer Consensus Conference 2016 was held in Montreal, Quebec, 5-7 February. Experts in radiation oncology, medical oncology, surgical oncology, and infectious diseases involved in the management of patients with gastrointestinal malignancies participated in presentations and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses multiple topics: ■ Follow-up and survivorship of patients with resected colorectal cancer■ Indications for liver metastasectomy■ Treatment of oligometastases by stereotactic body radiation therapy■ Treatment of borderline resectable and unresectable pancreatic cancer■ Transarterial chemoembolization in hepatocellular carcinoma■ Infectious complications of antineoplastic agents.

Corrigendum: Eastern Canadian Gastrointestinal Cancer Consensus Conference 2014

[This corrects the article DOI: 10.3747/co.22.2603.].

Perindopril Attenuates Lipopolysaccharide-Induced Amyloidogenesis and Memory Impairment by Suppression of Oxidative Stress and RAGE Activation

Clinical and preclinical studies account hypertension as a risk factor for dementia. We reported earlier that angiotensin-converting enzyme (ACE) inhibition attenuated the increased vulnerability to neurodegeneration in hypertension and prevented lipopolysaccharide (LPS)-induced memory impairment in normotensive wistar rats (NWRs) and spontaneously hypertensive rats (SHRs). Recently, a receptor for advanced glycation end products (RAGE) has been reported to induce amyloid beta (Aβ1-42) deposition and memory impairment in hypertensive animals. However, the involvement of ACE in RAGE activation and amyloidogenesis in the hypertensive state is still unexplored. Therefore, in this study, we investigated the role of ACE on RAGE activation and amyloidogenesis in memory-impaired NWRs and SHRs. Memory impairment was induced by repeated (on days 1, 4, 7, and 10) intracerebroventricular (ICV) injections of LPS in SHRs (25 μg) and NWRs (50 μg). Our data showed that SHRs exhibited increased oxidative stress (increased gp91-phox/NOX-2 expression and ROS generation), RAGE, and β-secretase (BACE) expression without Aβ1-42 deposition. LPS (25 μg, ICV) further amplified oxidative stress, RAGE, and BACE activation, culminating in Aβ1-42 deposition and memory impairment in SHRs. Similar changes were observed at the higher dose of LPS (50 μg, ICV) in NWRs. Further, LPS-induced oxidative stress was associated with endothelial dysfunction and reduction in cerebral blood flow (CBF), more prominently in SHRs than in NWRs. Finally, we showed that perindopril (0.1 mg/kg, 15 days) prevented memory impairment by reducing oxidative stress, RAGE activation, amyloidogenesis, and improved CBF in both SHRs and NWRs. These findings suggest that perindopril might be used as a therapeutic strategy for the early stage of dementia.

Eastern Canadian Colorectal Cancer Consensus Conference 2013: Emerging Therapies in the Treatment of Pancreatic, Rectal, and Colorectal Cancers

The annual Eastern Canadian Colorectal Cancer Consensus Conference held in Montreal, Quebec, 17–19 October 2013, marked the 10-year anniversary of this meeting that is attended by leaders in medical, radiation, and surgical oncology. The goal of the attendees is to improve the care of patients affected by gastrointestinal malignancies. Topics discussed during the conference included pancreatic cancer, rectal cancer, and metastatic colorectal cancer.

Acute kidney injury associated with ingestion of star fruit: Acute oxalate nephropathy

Starfruit (Averrhoa carambola) and its juice are popular in the Indian subcontinent as an indigenous medicine. Oxalate concentration in this fruit and it's freshly prepared juice is very high. We present a report of patients presenting with acute kidney injury due to oxalate nephropathy admitted in a single center. All patients had history of ingesting star fruit. Patients became symptomatic after 10-12 h of eating and main symptoms were pain abdomen and decrease in urine output. Three patients needed hemodialysis. All improved with complete renal recovery. Taking star fruit in large amount on an empty stomach and in a dehydrated state is a risk factor for nephrotoxicity.

Management of bilateral microspherophakia with secondary angle closure glaucoma

BACKGROUND

Microspherophakia is characterized by lenticular myopia, late development of lens dislocation, shallow anterior chamber and angle-closure glaucoma. If it is associated with angle closure glaucoma, the management can be challenging.

OBJECTIVE

To report the management of a case of bilateral secondary angle closure glaucoma with isolated microspherophakia and right subluxated lens in a middle aged lady.

CASE

A 47-year-old female presented with bilateral secondary angle closure glaucoma with isolated microspherophakia, right subluxated lens and left operated trabeculectomy. The patient`s best corrected log mar visual acuity improved from 1.0 to 0.2 and intraocular pressure (IOP) decreased from 24.9mm of Hg to lower teens following lensectomy with scleral fixation of posterior chamber intraocular lens in the right eye. The left eye IOP remained in mid teens without medication in two year follow up.

CONCLUSION

This case demonstrates that microspherophakia should be ruled out even in middle aged patients presenting as angle closure glaucoma. The possibility of thickened cornea must be kept in mind requiring an IOP correction. Lensectomy with scleral fixation of posterior chamber IOL provides a satisfactory recovery of visual acuity and IOP control. Though in this patient, the lens was held in position by posterior synechiae in the left eye, future stability of zonules needs to be monitored.

Dermatopathia Pigmentosa Reticularis with Salzmann's nodular degeneration of cornea: A rare association

BACKGROUND

Dermatopathia pigmentosa reticularis (DPR) is a very rare autosomal dominant disorder with the diagnostic triad of generalized reticulate hyperpigmentation, noncicatricial alopecia and onychodystrophy.

OBJECTIVE

To describe the occurrence of Salzmann's nodular degeneration of cornea with moderate dry eye in a patient with Dermatopathia pigmentosa reticularis.

CASE

We present an 11 year old young Indian girl with DPR who had Salzmann's nodular degeneration of cornea with moderate dry eye. She was put on symptomatic treatment and counseled regarding the course of disease, familial nature and avoidance of exposure to sun.

CONCLUSION

In a patient of Salzmann`s nodular degeneration with generalized reticulate hyperpigmentation, noncicatricial alopecia and onychodystrophy the diagnosis of DPR must be kept in mind. A multidisciplinary approach is required for the management of such cases.

Eastern Canadian Gastrointestinal Cancer Consensus Conference 2014

The annual Eastern Canadian Colorectal Cancer Consensus Conference was held in Montreal, Quebec, 23-25 October 2014. Expert radiation, medical, and surgical oncologists and pathologists involved in the management of patients with gastrointestinal malignancies participated in presentations and discussions resulting in consensus statements on such hot topics as management of neuroendocrine tumours, advanced and metastatic pancreatic cancer, and metastatic colorectal cancer.