Genetic Factors Associated With Adverse Pregnancy Outcomes in Chronic Pancreatitis

INTRODUCTION

The effects of genetic factors on pregnancy outcomes in chronic pancreatitis (CP) patients remain unclear. We evaluated the impacts of clinical features and mutations in main CP-susceptibility genes ( SPINK1 , PRSS1 , CTRC , and CFTR ) on pregnancy outcomes in Chinese CP patients.

METHODS

This was a prospective cohort study with 14-year follow-up. The sample comprised female CP patients with documented pregnancy and known genetic backgrounds. Adverse pregnancy outcomes were compared between patients with and without gene mutations. Univariate and multivariate analyses were performed to determine the impact factors for adverse pregnancy outcomes.

RESULTS

Totally, 160 female CP patients with a pregnancy history were enrolled; 59.4% of patients carried pathogenic mutations in CP-susceptibility genes. Adverse pregnancy outcomes occurred in 38 patients (23.8%); the prevalence of adverse outcomes was significantly higher in those harboring gene mutations than those without (30.5% vs 13.8%, P = 0.015). Notably, the rates of preterm delivery (12.6% vs 3.1%, P = 0.036) and abortion (17.9% vs 4.6%, P = 0.013) were remarkably higher in patients with gene mutations (especially SPINK1 mutations) than those without. In multivariate analyses, both CP-susceptibility gene mutations (odds ratio, 2.52; P = 0.033) and SPINK1 mutations (odds ratio, 2.60; P = 0.037) significantly increased the risk of adverse pregnancy outcomes. Acute pain attack during pregnancy was another risk factor for adverse pregnancy outcomes.

DISCUSSION

Pathogenic mutations in CP-susceptibility genes, especially SPINK1 , were independently related to adverse pregnancy outcomes in CP patients. Significant attention should be paid to pregnant females harboring CP-susceptibility gene mutations (ClinicalTrials.gov: NCT06055595).

Pancreatitis affects gut microbiota via metabolites and inflammatory cytokines: an exploratory two-step Mendelian randomisation study

Previous studies have observed relationships between pancreatitis and gut microbiota; however, specific changes in gut microbiota abundance and underlying mechanisms in pancreatitis remain unknown. Metabolites are important for gut microbiota to fulfil their biological functions, and changes in the metabolic and immune environments are closely linked to changes in microbiota abundance. We aimed to clarify the mechanisms of gut-pancreas interactions and explore the possible role of metabolites and the immune system. To this end, we conducted two-sample Mendelian randomisation (MR) analysis to evaluate the casual links between four different types of pancreatitis and gut microbiota, metabolites, and inflammatory cytokines. A two-step MR analysis was conducted to further evaluate the probable mediating pathways involving metabolites and inflammatory cytokines in the causal relationship between pancreatitis and gut microbiota. In total, six potential mediators were identified in the causal relationship between pancreatitis and gut microbiota. Nineteen species of gut microbiota and seven inflammatory cytokines were genetically associated with the four types of pancreatitis. Metabolites involved in glucose and amino acid metabolisms were genetically associated with chronic pancreatitis, and those involved in lipid metabolism were genetically associated with acute pancreatitis. Our study identified alterations in the gut microbiota, metabolites, and inflammatory cytokines in pancreatitis at the genetic level and found six potential mediators of the pancreas-gut axis, which may provide insights into the precise diagnosis of pancreatitis and treatment interventions for gut microbiota to prevent the exacerbation of pancreatitis. Future studies could elucidate the mechanism underlying the association between pancreatitis and the gut microbiota.

Diagnostic accuracy of magnetically guided capsule endoscopy with a detachable string for detecting oesophagogastric varices in adults with cirrhosis: prospective multicentre study

OBJECTIVE

To evaluate the diagnostic accuracy and safety of using magnetically guided capsule endoscopy with a detachable string (ds-MCE) for detecting and grading oesophagogastric varices in adults with cirrhosis.

DESIGN

Prospective multicentre diagnostic accuracy study.

SETTING

14 medical centres in China.

PARTICIPANTS

607 adults (>18 years) with cirrhosis recruited between 7 January 2021 and 25 August 2022. Participants underwent ds-MCE (index test), followed by oesophagogastroduodenoscopy (OGD, reference test) within 48 hours. The participants were divided into development and validation cohorts in a ratio of 2:1.

MAIN OUTCOME MEASURES

The primary outcomes were the sensitivity and specificity of ds-MCE in detecting oesophagogastric varices compared with OGD. Secondary outcomes included the sensitivity and specificity of ds-MCE for detecting high risk oesophageal varices and the diagnostic accuracy of ds-MCE for detecting high risk oesophagogastric varices, oesophageal varices, and gastric varices.

RESULTS

ds-MCE and OGD examinations were completed in 582 (95.9%) of the 607 participants. Using OGD as the reference standard, ds-MCE had a sensitivity of 97.5% (95% confidence interval 95.5% to 98.7%) and specificity of 97.8% (94.4% to 99.1%) for detecting oesophagogastric varices (both P<0.001 compared with a prespecified 85% threshold). When using the optimal 18% threshold for luminal circumference of the oesophagus derived from the development cohort (n=393), the sensitivity and specificity of ds-MCE for detecting high risk oesophageal varices in the validation cohort (n=189) were 95.8% (89.7% to 98.4%) and 94.7% (88.2% to 97.7%), respectively. The diagnostic accuracy of ds-MCE for detecting high risk oesophagogastric varices, oesophageal varices, and gastric varices was 96.3% (92.6% to 98.2%), 96.9% (95.2% to 98.0%), and 96.7% (95.0% to 97.9%), respectively. Two serious adverse events occurred with OGD but none with ds-MCE.

CONCLUSION

The findings of this study suggest that ds-MCE is a highly accurate and safe diagnostic tool for detecting and grading oesophagogastric varices and is a promising alternative to OGD for screening and surveillance of oesophagogastric varices in patients with cirrhosis.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03748563.

Combining full-length gene assay and SpliceAI to interpret the splicing impact of all possible SPINK1 coding variants

BACKGROUND

Single-nucleotide variants (SNVs) within gene coding sequences can significantly impact pre-mRNA splicing, bearing profound implications for pathogenic mechanisms and precision medicine. In this study, we aim to harness the well-established full-length gene splicing assay (FLGSA) in conjunction with SpliceAI to prospectively interpret the splicing effects of all potential coding SNVs within the four-exon SPINK1 gene, a gene associated with chronic pancreatitis.

RESULTS

Our study began with a retrospective analysis of 27 SPINK1 coding SNVs previously assessed using FLGSA, proceeded with a prospective analysis of 35 new FLGSA-tested SPINK1 coding SNVs, followed by data extrapolation, and ended with further validation. In total, we analyzed 67 SPINK1 coding SNVs, which account for 9.3% of the 720 possible coding SNVs. Among these 67 FLGSA-analyzed SNVs, 12 were found to impact splicing. Through detailed comparison of FLGSA results and SpliceAI predictions, we inferred that the remaining 653 untested coding SNVs in the SPINK1 gene are unlikely to significantly affect splicing. Of the 12 splice-altering events, nine produced both normally spliced and aberrantly spliced transcripts, while the remaining three only generated aberrantly spliced transcripts. These splice-impacting SNVs were found solely in exons 1 and 2, notably at the first and/or last coding nucleotides of these exons. Among the 12 splice-altering events, 11 were missense variants (2.17% of 506 potential missense variants), and one was synonymous (0.61% of 164 potential synonymous variants). Notably, adjusting the SpliceAI cut-off to 0.30 instead of the conventional 0.20 would improve specificity without reducing sensitivity.

CONCLUSIONS

By integrating FLGSA with SpliceAI, we have determined that less than 2% (1.67%) of all possible coding SNVs in SPINK1 significantly influence splicing outcomes. Our findings emphasize the critical importance of conducting splicing analysis within the broader genomic sequence context of the study gene and highlight the inherent uncertainties associated with intermediate SpliceAI scores (0.20 to 0.80). This study contributes to the field by being the first to prospectively interpret all potential coding SNVs in a disease-associated gene with a high degree of accuracy, representing a meaningful attempt at shifting from retrospective to prospective variant analysis in the era of exome and genome sequencing.

A machine-learning model based on dynamic contrast-enhanced MRI for preoperative differentiation between hepatocellular carcinoma and combined hepatocellular-cholangiocarcinoma

AIM

To establish a machine-learning model based on dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) to differentiate combined hepatocellular-cholangiocarcinoma (cHCC-CC) from hepatocellular carcinoma (HCC) before surgery.

MATERIALS AND METHODS

Clinical and MRI data of 194 patients with histopathologically diagnosed cHCC-CC (n=52) or HCC (n=142) were analysed retrospectively. ITK-SNAP software was used to delineate three-dimensional (3D) lesions and extract high-throughput features. Feature selection was carried out based on Pearson's correlation coefficient and least absolute shrinkage and selection operator (LASSO) regression analysis. A radiomics model (radiomics features), a clinical model (i.e., clinical-image features), and a fusion model (i.e., radiomics features + clinical-image features) were established using six machine-learning classifiers. The performance of each model in distinguishing between cHCC-CC and HCC was evaluated with the receiver operating characteristic (ROC) curve, the area under the ROC curve (AUC), sensitivity, and specificity.

RESULTS

Significant differences in liver cirrhosis, tumour number, shape, edge, peritumoural enhancement in the arterial phase, and lipid were identified between cHCC-CC and HCC patients (p<0.05). The AUC of the fusion model based on logistic regression was 0.878 (95% CI: 0.766-0.949) in the arterial phase in the test set, and the sensitivity/specificity was 0.844/0.714; however, the AUC of the clinical and radiomics models was 0.759 (95% CI: 0.663-0.861) and 0.838 (95% CI: 0.719-0.921) in the test set, respectively.

CONCLUSION

The fusion model based on DCE-MRI in the arterial phase can significantly improve the diagnostic rate of cHCC-CC and HCC as compared with conventional approaches.

The use of magnet-controlled capsule endoscopy as the initial diagnostic tool in patients with acute upper gastrointestinal bleeding

BACKGROUND

The latest magnet-controlled capsule endoscopy (MCCE) system can examine the water-distended stomach, duodenum, and the small bowel. We assessed the use of MCCE as the first diagnostic tool in patients with acute upper gastrointestinal bleeding (AUGIB).

METHODS

This was a prospective cohort study that enrolled patients admitted with AUGIB from two teaching hospitals. Patients underwent MCCE as the initial diagnostic modality. Our primary endpoint was the diagnostic yield of MCCE. The subsequent care of these patients was guided by MCCE findings.

RESULTS

Of 100 enrolled patients, 99 (mean age 54 years, 70.7% men) with a median Glasgow-Blatchford score of 6 (IQR 3-9) underwent MCCE. In three patients, MCCE found active bleeding (two duodenal ulcers and Dieulafoy's lesion). The overall diagnostic yield of MCCE was 95.8% (92 lesions in 96 patients); five in the esophagus (Mallory Weiss tears 2, varices 1, and esophagitis 2), 51 in the stomach (gastric erosions 26, gastric ulcers 14, cancer 3, GIST 3, gastric polyps 3, antral vascular ectasia 1,angiodysplasia 1), 32 in the duodenum (ulcers 28, erosions 3, polyp 1), and four in the small bowel (ulcers 2, an erosion with a nonbleeding vessel 1, Meckel's diverticulum 1). Fifty-two (52.5%) patients were discharged without endoscopy. Forty-five (45.5%) patients underwent inpatient esophagogastroduodenoscopy (EGD), which found an antral ulcer and six duodenal ulcers in addition.

CONCLUSIONS

In stable patients with AUGIB, MCCE can be used as a diagnostic tool. EGD should follow in patients with an inadequate view of the duodenum.

Progression of Gastrointestinal Injury During Antiplatelet Therapy After Percutaneous Coronary Intervention: A Secondary Analysis of the OPT-PEACE Randomized Clinical Trial

Importance

Gastrointestinal injury progression induced by antiplatelet therapy in patients after percutaneous coronary intervention (PCI) has not been well studied.

Objective

To assess the association of aspirin, clopidogrel, and their combination with gastrointestinal injury progression among patients without high bleeding risk after PCI.

Design, Setting, and Participants

This secondary analysis assessed data from the Optimal Antiplatelet Therapy for Prevention of Gastrointestinal Injury Evaluated by ANKON Magnetically Controlled Capsule Endoscopy (OPT-PEACE) double-masked, placebo-controlled, multicenter randomized clinical trial. The OPT-PEACE trial was conducted at 28 centers in China, and recruitment took place from July 13, 2017, to July 13, 2019. The trial included patients with stable coronary artery disease or acute coronary syndromes without ST-segment elevation after PCI. Statistical analysis was conducted from September 13, 2022, to January 23, 2023.

Interventions

Patients underwent magnetically controlled capsule endoscopy (MCE) at baseline and after 6 months of dual antiplatelet therapy (DAPT) with aspirin (100 mg/d) plus clopidogrel (75 mg/d). Those with no evidence of gastrointestinal ulcers or bleeding (ie, the intention-to-treat [ITT] cohort) were randomized (1:1:1) to aspirin (100 mg/d) plus matching placebo (aspirin alone), clopidogrel (75 mg/d) plus matching placebo (clopidogrel alone), or DAPT for an additional 6 months. A third MCE was performed 12 months after PCI.

Main Outcomes and Measures

The primary outcome was the rate of gastric injury progression as assessed with the results of the 3 MCEs (at baseline, 6 months, and 12 months) in the modified intention-to-treat (mITT) population. The key secondary outcome was the rate of small-intestinal injury progression. Gastric or small-intestinal injury progression was defined as a quantitative increase in erosions or ulcers between the second and third MCEs (at 6 and 12 months, respectively).

Results

This study included the 394 patients in the mITT cohort. Their mean (SD) age was 56.9 (8.7) years, and most were men (296 [75.1%]). A total of 132 patients were randomized to aspirin alone, 132 to clopidogrel alone, and 130 to DAPT. Gastric injury progression occurred in 49 aspirin users (37.1%), 64 clopidogrel users (48.5%), and 69 DAPT users (53.1%) (P = .02), reflecting a lower rate of gastric injury progression among aspirin users vs DAPT users (risk ratio [RR], 0.70 [95% CI, 0.49-0.99]; P = .009). No significant difference was observed between clopidogrel alone and DAPT (48.5% vs 53.1%; P = .46) or between aspirin alone and clopidogrel alone (37.1% vs 48.5%; P = .06). A total of 51 aspirin users (38.6%), 65 clopidogrel users (49.2%), and 71 DAPT users (54.6%) (P = .03) developed progressive small-intestinal injury, reflecting a lower rate of small-intestinal injury among aspirin users vs DAPT users (RR, 0.71 [95% CI, 0.50-0.99]; P = .01). No difference was observed between patients treated with clopidogrel vs DAPT (49.2% vs 54.6%; P = .38) or with aspirin vs clopidogrel (38.6% vs 49.2%; P = .08).

Conclusions and Relevance

In this secondary analysis of a randomized clinical trial, ongoing use of aspirin, clopidogrel, or their combination between 6 and 12 months after PCI was associated with progressive gastric and small-intestinal injury in a substantial proportion of patients, more so with DAPT than with monotherapy. Clopidogrel was at least as likely as aspirin to induce gastrointestinal injury progression. Future research is warranted to determine what impact the findings from MCEs would have on decision-making of antiplatelet therapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT03198741.

Pneumonitis After Concurrent Chemoradiation and Immune Checkpoint Inhibition in Patients with Locally Advanced Non-small Cell Lung Cancer

AIMS

Pneumonitis is a common and potentially deadly complication of combined chemoradiation and immune checkpoint inhibition (CRT-ICI) in patients with locally advanced non-small cell lung cancer (LA-NSCLC). In this study we sought to identify the risk factors for pneumonitis with CRT-ICI therapy in LA-NSCLC cases and determine its impact on survival.

MATERIALS AND METHODS

We conducted a retrospective chart review of 140 patients with LA-NSCLC who underwent curative-intent CRT-ICI with durvalumab between 2018 and 2021. Pneumonitis was diagnosed by a multidisciplinary team of clinical experts. We used multivariable cause-specific hazard models to identify risk factors associated with grade ≥2 pneumonitis. We constructed multivariable Cox proportional hazard models to investigate the impact of pneumonitis on all-cause mortality.

RESULTS

The median age of the cohort was 67 years; most patients were current or former smokers (86%). The cumulative incidence of grade ≥2 pneumonitis was 23%. Among survivors, 25/28 patients had persistent parenchymal scarring. In multivariable analyses, the mean lung dose (hazard ratio 1.14 per Gy, 95% confidence interval 1.03-1.25) and interstitial lung disease (hazard ratio 3.8, 95% confidence interval 1.3-11.0) increased the risk for pneumonitis. In adjusted models, grade ≥2 pneumonitis (hazard ratio 2.5, 95% confidence interval 1.0-6.2, P = 0.049) and high-grade (≥3) pneumonitis (hazard ratio 8.3, 95% confidence interval 3.0-23.0, P < 0.001) were associated with higher all-cause mortality.

CONCLUSIONS

Risk factors for pneumonitis in LA-NSCLC patients undergoing CRT-ICI include the mean radiation dose to the lung and pre-treatment interstitial lung disease. Although most cases are not fatal, pneumonitis in this setting is associated with markedly increased mortality.

Protocol in a Day: An Educational Institutional Workshop for Protocol Development

PURPOSE/OBJECTIVE(S)

The Protocol-in-a-Day (PIAD) workshop was developed to support junior faculty and residents with clinical trial protocol design, with the main goal of providing initial feedback during development to reduce time for review and approval from institutional oversight committees. Our objectives are to mentor and educate participants and to evaluate the time to institutional approval by oversight committees.

MATERIALS/METHODS

PIAD provided concurrent educational feedback on 6 key elements of trial design. These included: (1) regulatory aspects; (2) institutional scientific review committee (SRC) and institutional review board (IRB); (3) clinical research and data coordination (including nursing); (4) statistics; (5) correlatives including imaging, biospecimens, and health services research/patient-reported outcomes; and (6) operations. The average number of days from submission to IRB approval or study activation for PIAD protocols was compared to other protocols submitted between January 2018 - January 2022 within the Division of Radiation Oncology. Participants were also given a 15-question survey to assess their perspective of the impact of the workshop.

RESULTS

A total of 25 protocols went through the PIAD workshop between January 2018-January 2022. Of the 25 protocols, 7 (28%) were excluded from this study due to not being submitted possibly after participants benefited from education on the limitations of their design. Eighteen protocols were included in our final analyses. These protocols included phase II (n = 11), phase 1 (n = 5), and phase III (n = 2). At the time of this report, all protocols (n = 18) have received IRB approval and have been activated. Protocol elements that could impact study activation included protocols requiring investigational new drug (IND) approval (n = 8) and multicenter studies (n = 1). Analyzing the time of submission to request for activation showed a decrease in time for protocols that went through PIAD vs those that did not [PIAD protocols, 254 days vs All other protocols, 262 days]. Likewise, those who attended PIAD had a lower average time from submission to IRB Approval [ PIAD protocols, 40 days vs All other protocols, 59 days]. All participants (100%) of the PIAD workshop responded that the educational program "improved the overall quality of the study design." The most commonly cited changes were protocol language (n = 17), statistics (n = 15), consent language (n = 8), and study design (n = 8). Aspects participants identified as the most educational included mentorship from regulatory, clinical research finance, and IRB review.

CONCLUSION

PIAD from participant surveys provided high educational value in the areas of improving trial quality, language and statistical design. When analyzing the average time, from 'submission to IRB initial approval' and 'submission to activation', PIAD protocols had a shorter time for approval, and thus suggests PIAD is effective in improving the overall design of protocols.

Definitive Radiotherapy for Oligometastatic and Oligoprogressive Thyroid Cancer

PURPOSE/OBJECTIVE(S)

Local consolidative radiotherapy (LCT) for oligometastatic disease is a promising paradigm improving outcomes for various malignancies but has been underexplored for metastatic thyroid cancer. We hypothesize that LCT to distant sites with definitive RT doses can yield favorable outcomes and defer systemic therapy escalation for these patients.

MATERIALS/METHODS

We reviewed 96 thyroid cancer patients who received 175 LCT courses from 2010-2022 to 228 metastatic sites, including: thorax (45%), bone (40%), brain (6%), head/neck (5%), and abdomen (3%). Common prescriptions were 50-55Gy/4-5fxs or 56-70Gy/8-10fxs for lung; 52.5-60Gy/15fxs for mediastinum; and 18-24Gy/1fx or 27-30Gy/3fxs for bone. RECIST v1.1 and CTCAE v5.0 were used to define progression and toxicities, respectively. Outcomes were evaluated via Kaplan-Meier and associations examined via Cox proportional hazards modeling.

RESULTS

Median age was 63 years (range: 26-92), with 62 oligometastatic cases (total 1-5 sites) and 34 oligoprogressive (with 1-5 growing sites). Primary disease was controlled in all patients, with 39% receiving post-op RT and 66% prior RAI. Histologies included papillary (40%), anaplastic (25%), follicular (12%), medullary (9%), Hurthle (7%), and poorly-differentiated (7%). Median time from initial diagnosis to LCT was 3 yrs (IQR 1-8), and median follow-up from 1st LCT was 21 mos (IQR 9-51). Patients received an average 2 LCT courses (range 1-8) treating 1-4 sites. Median survival (OS) from 1st LCT was 9 yrs (95% CI = 5-14). On multivariable analysis (MVA), worse OS was associated with anaplastic histology (HR 4.6, p<.01), but longer OS was associated with prior RAI (HR 0.33, p = .02) and oligometastatic disease (HR 0.3, p = .01). For anaplastic histology, median OS was 1.2 years vs. 9.3 years for non-anaplastic; 3-yr OS was 36% vs. 88% (log-rank, p<.01). Five-year OS for oligometastatic cases was 75% vs 53% for oligoprogressive (log-rank, p = .04). Median progression free survival (PFS) from 1st LCT was 15.5 mos (95% C I = 11-20). On MVA for all LCT courses, time to any progression (TTP) was negatively associated with anaplastic histology (HR 1.7, p = .02) and 2nd or higher LCT course (HR 1.45, p = .05), but favorably associated with thoracic site (HR 0.49, p<.01). Following later LCT courses, median TTP was 11 mos vs 17 mos for initial LCT course (log-rank, p = .03). After LCT to lung/chest, TTP was 18.6 mos vs 9.5 mos for non-thoracic sites (log-rank, p<.01). Only 6% of failures occurred at previously treated lesions. Most LCT courses (67%) were without ongoing chemotherapy, while 25% entailed continuing the same regimen and 9% had planned treatment post-RT. There were 2 Grade 3 toxicities (pneumonitis and esophagitis) and no Grade 4-5 events.

CONCLUSION

With high local control rates and minimal toxicity, LCT can be a feasible strategy to defer systemic therapy escalation for oligometastatic and oligoprogressive thyroid cancer.

Long-Term Outcomes and Toxicity in Esophageal Cancer Patients after Neoadjuvant or Definitive Concurrent Chemotherapy with Proton Beam Therapy

PURPOSE/OBJECTIVE(S)

Proton-beam therapy (PT) is increasingly utilized over three dimensional-conformal radiation therapy (3D-CRT) and intensity modulated radiation therapy (IMRT) photon irradiation for the treatment of various malignancies due to better toxicity reduction. We investigated the long-term outcomes and toxicity in esophageal cancer (EC) patients treated with PT as part of their neoadjuvant concurrent chemoradiation followed by surgery (nCRT) or definitive concurrent chemoradiation (dCRT) treatment regimen.

MATERIALS/METHODS

All consecutively treated, American Joint Committee on Cancer 7th edition clinical stage I-IV EC patients from 2006 to 2022 were retrospectively analyzed. Standard RT dose for most patients was 50.4 Gy/28 fractions. nCRT patients had surgery within 4 months post-RT. Kaplan-Meier method was used to determine overall survival (OS), locoregional recurrence-free survival (LRRFS) and distant metastatic-free survival (DMFS). Acute and chronic RT-related toxicities were graded with Common Terminology Criteria for Adverse Events version 4.0.

RESULTS

There were 510 EC PT patients: 204 (40%) had nCRT and 306 (60%) had dCRT. Most lesions were located in the lower esophagus, of adenocarcinoma histology and treated with passive scatter PT. Overall median follow-up was 72 months. Median, 3- and 5-year OS for all patients were 43 months, 54.1% and 44.9%, respectively. Median LRRFS and DMFS were not reached. Esophagitis was the most common grade ≥3 (G3+) toxicity (59 patients; 28.9%, including a G4 and a G5 toxicity), followed by nausea (29 patients; 14.2%) and esophageal stricture (26 patients, 12.7%). With nCRT, median, 3- and 5-year OS were 80 months, 64.7% and 56.1%, respectively, while the median LRRFS and DMFS were not reached again. Their most common G3+ toxicity was esophagitis in 14 patients (6.9%) followed by nausea (8 patients; 3.9%). An nCRT patient developed G4 RT pneumonitis. Pathological complete response (pCR) was observed in 58 patients (28.4%). Surgery-related pulmonary, cardiac and gastrointestinal complications were reported in 38 (18.6%), 40 (19.6%) and 43 (21.1%) patients, respectively. dCRT patients had a median follow-up of 65 months, and median, 3- and 5-year OS of 32 months, 46.7% and 37.0%, respectively. Although the median LRRFS was not reached, the median DMFS was 74 months. The most observed dCRT G3+ toxicity was esophagitis (45 patients, 22.1%: including both G4 and G5 patients) and then esophageal stricture (23 patients, 11.3%). A dCRT patient developed G4 fistula.

CONCLUSION

To our knowledge, this is the largest single-institutional study on EC long-term outcomes and toxicity using PT. Our cohort reveals good outcomes and mostly mild CRT-related toxicities. Trimodality nCRT with protons demonstrates excellent outcomes relative to the CROSS trial (49.4 months) with identical pCR rate (29% in CROSS) and similar toxicity profile. nCRT with protons should be studied rigorously in the current randomized phase III trial NRG GI006.

Comorbidities and Their Impact on Treatment Tolerance and Outcome in Elderly NSCLC Patients Treated with Concurrent Chemoradiation Using Proton or Photon Followed by Immunotherapy

PURPOSE/OBJECTIVE(S)

To investigate comorbidities and their impact on treatment tolerance and survival for elderly NSCLC patients treated with concurrent chemoradiation using proton beam therapy (PBT) or intensity modulated radiation therapy (IMRT) followed by immunotherapy (IO).

MATERIALS/METHODS

This is a retrospective study in senior patients (≥ 65 years) with inoperable locally advanced- NSCLC (LA-NSCLC) who received concurrent chemoradiation (CRT) therapy followed by adjuvant IO. Comorbidities are listed in table 1 and scored according to hazard ratios (HRs) of death. Treatment tolerance and comorbidities were compared between modalities using Fisher's exact test. Association between comorbidities and treatment tolerance was analyzed using logistic regression; association between comorbidities and survival was analyzed by Cox proportional hazards regression.

RESULTS

Total 218 patients were included with median age of 72 (range 65-86) years. Fifty-three (24.3%) were PBT and 165 (75.7%) were IMRT. Majority patients were white ethnics, had stage III adenocarcinoma disease and good performance score, and received RT dose 60-66 Gy. The median follow-up time for the whole group was 23 months. A 97% of patients had ≥1, and 62% had ≥4 comorbidities. The combined comorbidity scores ranged from 0 to 25. No significant difference in comorbidities between modalities except IMRT had more patients with COPD (36% vs. 51%, p = 0.047). Rates of hospitalization and ER visit during CRT+IO were 28% and 5%, respectively. Rates of IO discontinuation and interruption were 55% and 8%, respectively. Patients received >6 months IO had significantly lower risk of death (HR: 0.25, p<0.001). No significant difference in treatment tolerance between modalities. In multivariable analysis, atrial fibrillation, pulmonary disease, and depression were the comorbidities associated with hospitalization during CRT+IO (p<0.05); dementia was the comorbidity associated with IO interruption (p = 0.042); heart failure, COPD, asthma, osteoporosis and HIV were the comorbidities associated with poor OS (p<0.05). Combined comorbidity score was associated with OS with HR of 1.13 (p<0.001) with adjustment of race, GTV and induction chemotherapy.

CONCLUSION

Comorbidities were associated with hospitalization and IO interruption during the whole course of CRT and IO therapy, with increased IO discontinuation which negatively impacted survival. Evaluating and scoring comorbidities at diagnosis could be a useful method to predict risk of death before treatment start.

Comparing 90-Day Post-Operative Mortality after Neoadjuvant Proton-Based vs. Photon-Based Chemoradiotherapy for Esophageal Cancer

PURPOSE/OBJECTIVE(S)

Standard of treatment for locally advanced esophageal cancer consists of chemoradiotherapy (CRT) followed by surgery. Evidence suggests that proton beam therapy (PBT) results in lower toxicity and fewer post-operative complications compared to photon-based radiotherapy (RT). Mortality in the first 90 days after surgery is a rare event occurring in 2-8% of patients, with higher reported rates (of up to 17%) in older patients. This 90-day mortality (90DM) rate is an important measure of post-operative (non-oncologic) mortality as a proxy of quality of care. We hypothesize that PBT could reduce the incidence of 90DM compared to photon-based RT.

MATERIALS/METHODS

From a single-center retrospectively acquired database patients with esophageal cancer treated with neoadjuvant CRT and esophagectomy in 1998-2022 were selected. Univariable logistic regression analyses were used to study the associations of RT modality and other patient- and treatment-related characteristics with 90DM. Subsequently, 3 separate methods were applied to adjust for confounding bias. These included multivariable logistic regression, 1:1 nearest-neighbor propensity score matching (PSM), and inverse probability of treatment weighting (IPTW). Finally, stratified analyses for patient groups aged ≥67 vs. <67 years were performed.

RESULTS

A total of 894 eligible patients were included (PBT, n = 202; photon-based RT, n = 692). PBT patients had a significantly higher age, better performance score, and a higher number of comorbidities. The 90DM rate was 5 (2.5%) in the PBT group and 29 (4.2%) in the photon-based RT group (p = 0.262). Significant univariable predictors of 90DM included higher age and tumor location. After multivariable adjustment, PBT vs. photon therapy was not significantly associated with 90DM (OR 0.49, 95% CI 0.18-1.31). The 90DM rates in the PSM cohort (n = 181 vs. n = 181) were 2.8% for PBT and 3.3% for photon-based RT (p = 0.379). The 90DM rates in the IPTW cohort were 2.8% for PBT and 4.1% for photon-based RT (p = 0.427). In the full cohort, stratified analysis for age groups revealed that in patients aged ≥67 years, PBT was associated with a decreased risk of 90DM compared to photon-based RT (1.3% vs. 8.8%; p = 0.046), which was not the case in patients aged <67 years. In the PSM cohort, a comparable (but non-significant) difference was observed in favor of PBT in patients aged ≥67 years (i.e., 1.5% vs. 7.5%; p = 0.099). Within-group analyses in the original cohort demonstrated that a higher age significantly increased the risk of 90DM within the photon-based RT group (8.8% vs. 2.7% for age ≥67 vs. <67 years; p = 0.001), but not within the PBT group (1.3% vs. 3.2%; p = 0.398).

CONCLUSION

Post-operative 90DM after esophagectomy for cancer was not significantly different between PBT and photon-based neoadjuvant CRT. However, among older patients we observed a signal that PBT may reduce the risk of 90DM. Higher age increased the risk of 90DM in patients who underwent photon-based RT, but not in patients who underwent PBT.

New US capsule endoscopy for superficial and submucosal imaging of the esophagus: the first-in-human study

BACKGROUND AND AIMS

EUS is essential in diagnosing and staging of esophageal subepithelial lesions and tumors. However, EUS is invasive, relies on highly trained endoscopists, and typically requires sedation. The newly developed US capsule endoscopy (USCE), which incorporates both white-light and US imaging modalities into a tethered capsule, is a minimally invasive method for obtaining superficial and submucosal information of the esophagus. This study aimed to assess the feasibility and safety of this USCE system.

METHODS

Twenty participants were enrolled: 10 healthy volunteers and 10 patients with esophageal lesions indicated for EUS. Participants first underwent USCE and subsequently EUS within 48 hours. The primary outcome was the technical success rate of USCE. Secondary outcomes were safety, visualization of the esophagus, and comfort assessment.

RESULTS

The technical success rate of USCE was 95% because 1 patient failed to swallow the capsule. No adverse events were observed. The esophagus was well visualized, and all lesions were detected under USCE optical mode in 19 participants. For healthy volunteers, the US images of normal esophageal walls were all characterized by differentiated 7-layer architecture under both USCE and EUS. For 9 patients, the features of esophageal lesions were recognized clearly under USCE, and presumptive diagnoses derived from USCE were all consistent with those from EUS. Most participants preferred USCE to EUS.

CONCLUSIONS

The novel USCE is feasible and safe to observe the esophageal mucosa and acquire submucosal information, which has the potential to be widely used in the clinic. (Clinical trial registration number: NCT05054933.).

Prospective Trial of Using Imaging to Predict Pathologic Response and Clinical Outcomes in Locally Advanced Esophageal Cancer

PURPOSE/OBJECTIVE(S)

Trimodality therapy with chemoradiation (CRT) followed by esophagectomy is the standard of care for locally advanced esophageal cancer. An unresolved question is whether pathologic complete response (pCR) can be assessed non-invasively for patients post-CRT. In this study, we assessed whether diffusion-weighted imaging (DWI) with MRI or PET can be used as predictors of pCR and other clinical outcomes after CRT.

MATERIALS/METHODS

Patients were enrolled on a single-arm institutional trial (PA13-0380) assessing the role of imaging in predicting outcomes in potentially resectable esophageal patients undergoing trimodality therapy. All patients received neoadjuvant CRT, and 29 patients had subsequent surgery. DWI MRI and PET scans were obtained at baseline, 2 weeks after the start of CRT (interim) and 4 to 6 weeks after completion of CRT (follow up). Apparent diffusion coefficients (ADCs) were calculated based on DWI images. Circulating tumor DNA was obtained for 27 patients post-radiation using CAPP-Seq. Mann-Whitney tests compared imaging changes associated with pCR. Discrimination of pCR by imaging changes was quantified by received operating characteristics. Youden's index was applied to select optimal thresholds. Kaplan-Meier analysis was performed to assess differences in overall survival (OS) and progression-free survival (PFS) by changes in DWI, PET, and ctDNA parameters.

RESULTS

Our cohort of 60 patients had a median follow up of 42.7 months, age of 65.4 yrs, and ECOG of 1 at completion of CRT. 90% were male, 58% had a history of smoking, and 85% were white. 83% had adenocarcinoma with the rest squamous cell carcinoma. Stages of the patients ranged from IIA to IIIB. All had moderately (47%) or poorly (53%) differentiated disease. All received 41.4-50.4 Gy in 1.8 Gy fractions with the majority receiving 50.4 Gy (95%). 29 patients underwent surgery after CRT of which 8 (27.6%) had pCR. Mean ΔADC from baseline to mid-treatment was most associated with pCR (AUC = 0.98, p<0.001) for patients undergoing surgery. Max ΔADC from baseline to first follow-up was most associated with OS (p = 0.002) and PFS (p<0.001) for the whole cohort. 27 patients had ctDNA analyzed after RT with the presence of ctDNA significantly associated with worse OS (HR = 0.12, p = 0.05) and PFS (HR = 0.10, p = 0.002). Combining ctDNA and max ΔADC generated a model that was more predictive of OS and PFS than either alone. We found that neither the PET parameters of TLG or SUV max at baseline or changes in these parameters from baseline to mid-treatment or first follow-up were as predictive as DWI.

CONCLUSION

We show that changes in DWI is associated with pCR, OS, and PFS in resectable esophageal cancer patients undergoing CRT. DWI was more predictive than PET and a model combining DWI and ctDNA was the most predictive of clinical outcomes. This study shows the significant promise of using DWI in potentially guiding treatment decisions in esophageal cancer patients and will require validation in a larger cohort.

Classification of PRSS1 variants responsible for chronic pancreatitis: An expert perspective from the Franco-Chinese GREPAN study group

BACKGROUND

PRSS1 was the first reported chronic pancreatitis (CP) gene. The existence of both gain-of-function (GoF) and gain-of-proteotoxicity (GoP) pathological PRSS1 variants, together with the fact that PRSS1 variants have been identified in CP subtypes spanning the range from monogenic to multifactorial, has made the classification of PRSS1 variants very challenging.

METHODS

All currently reported PRSS1 variants (derived primarily from two databases) were manually reviewed with respect to their clinical genetics, functional analysis and population allele frequency. They were classified by variant type and pathological mechanism within the framework of our recently proposed ACMG/AMP guidelines-based seven-category system.

RESULTS

The total number of distinct germline PRSS1 variants included for analysis was 100, comprising 3 copy number variants (CNVs), 12 5' and 3' variants, 19 intronic variants, 5 nonsense variants, 1 frameshift deletion variant, 6 synonymous variants, 1 in-frame duplication, 3 gene conversions and 50 missense variants. Based upon a combination of clinical genetic and functional analysis, population data and in silico analysis, we classified 26 variants (all 3 CNVs, the in-frame duplication, all 3 gene conversions and 19 missense) as "pathogenic", 3 variants (missense) as "likely pathogenic", 5 variants (four missense and one promoter) as "predisposing", 13 variants (all missense) as "unknown significance", 2 variants (missense) as "likely benign", and all remaining 51 variants as "benign".

CONCLUSIONS

We describe an expert classification of the 100 PRSS1 variants reported to date. The results have immediate implications for reclassifying many ClinVar-registered PRSS1 variants as well as providing optimal guidelines/standards for reporting PRSS1 variants.

Status quo of the public's knowledge of probiotics based on video-sharing platforms

BACKGROUND

Probiotics have been deemed multipotent and unprecedentedly applied in the health field recently. However, there are challenges in promoting credible and reliable resources while avoiding misinformation regarding probiotics for the public.

METHODS

This study analysed 400 eligible probiotic-related videos selected from YouTube, and the three most popular video-sharing platforms (Bilibili, Weibo and TikTok) in China. Video retrieval was performed on September 5^th, 2022. GQS and tailored DISCERN tool assess each video's quality, usage, and reliability. A comparative analysis of videos from different sources was carried out.

RESULTS

The identity distribution of probiotic video-producers was predominantly experts (n = 202, 50.50%), followed by amateurs (n = 161, 40.25%) and health-related institutions (n = 37, 9.25%). The videos' content category mainly discussed the function of probiotics (n = 120, 30%), the way to choose suitable products (n = 81, 20.25%), and the methods for taking probiotics (n = 71, 17.75%).The overall quality of videos was moderate (3/5 point) assessed by GQS, while the usage (1/6 point) and reliability (2/5 point) detailing probiotics assessed by tailored DISCERN tool were poor. The attitude of probiotic video-producers was primarily positive (n = 323, 80.75%), followed by neutral (n = 52, 13.00%) and negative (n = 25, 6.25%) (P < 0.001).

CONCLUSIONS

The current study showed that videos on social media platforms publicise important information including the concepts, usage, and precautions of probiotics to the public. But the overall quality of uploaded videos about probiotics was unsatisfactory. More efforts are needed to improve the higher-quality content of probiotic-related online videos and better propagate probiotic knowledge to the public in the future.

A novel capsule endoscopy for upper and mid-GI tract: the UMGI capsule

BACKGROUNDS AND AIMS

Complete and consecutive observation of the gastrointestinal (GI) tract continues to present challenges for current endoscopy systems. We developed a novel upper and mid gastrointestinal (UMGI) capsule endoscopy using the modified detachable string magnetically controlled capsule endoscopy (DS-MCE) and inspection method and aimed to assess the clinical application.

METHODS

Patients were recruited to undergo UMGI capsule endoscopy followed by esophagogastroduodenoscopy. All capsule procedures in the upper gastrointestinal (UGI) tract were conducted under the control of magnet and string. The main outcome was technical success, and the secondary outcomes included visualization of the UMGI tract, examination time, diagnostic yield, compliance, and safety evaluation.

RESULTS

Thirty patients were enrolled and all UMGI capsule procedures realized repeated observation of the esophagus and duodenum with detection rates of 100.0%, 80.0%, and 86.7% of Z-line, duodenal papilla, and reverse side of pylorus, respectively. String detachment was succeeded in 29 patients (96.7%) and the complete examination rate of UMGI tract was 95.45% (21/22). All UMGI capsule procedures were well tolerated with low discomfort score, and had a good diagnostic yield with per-lesion sensitivity of 96.2% in UGI diseases. No adverse events occurred.

CONCLUSIONS

This new capsule endoscopy system provides an alternative screening modality for the UMGI tract, and might be indicated in cases of suspected upper and small bowel GI bleeding. Trial registration DS-MCE-UGI and SB, NCT04329468. Registered 27 March 2020, https://clinicaltrials.gov/ct2/results?cond=&term=NCT04329468 .

Causal associations between modifiable risk factors and pancreatitis: A comprehensive Mendelian randomization study

Background

The pathogenesis of pancreatitis involves diverse environmental risk factors, some of which have not yet been clearly elucidated. This study systematically investigated the causal effects of genetically predicted modifiable risk factors on pancreatitis using the Mendelian randomization (MR) approach.

Methods

Genetic variants associated with 30 exposure factors were obtained from genome-wide association studies. Summary-level statistical data for acute pancreatitis (AP), chronic pancreatitis (CP), alcohol-induced AP (AAP) and alcohol-induced CP (ACP) were obtained from FinnGen consortia. Univariable and multivariable MR analyses were performed to identify causal risk factors for pancreatitis.

Results

Genetic predisposition to smoking (OR = 1.314, P = 0.021), cholelithiasis (OR = 1.365, P = 1.307E-19) and inflammatory bowel disease (IBD) (OR = 1.063, P = 0.008) as well as higher triglycerides (OR = 1.189, P = 0.016), body mass index (BMI) (OR = 1.335, P = 3.077E-04), whole body fat mass (OR = 1.291, P = 0.004) and waist circumference (OR = 1.466, P = 0.011) were associated with increased risk of AP. The effect of obesity traits on AP was attenuated after correcting for cholelithiasis. Genetically-driven smoking (OR = 1.595, P = 0.005), alcohol consumption (OR = 3.142, P = 0.020), cholelithiasis (OR = 1.180, P = 0.001), autoimmune diseases (OR = 1.123, P = 0.008), IBD (OR = 1.066, P = 0.042), type 2 diabetes (OR = 1.121, P = 0.029), and higher serum calcium (OR = 1.933, P = 0.018), triglycerides (OR = 1.222, P = 0.021) and waist-to-hip ratio (OR = 1.632, P = 0.023) increased the risk of CP. Cholelithiasis, triglycerides and the waist-to-hip ratio remained significant predictors in the multivariable MR. Genetically predicted alcohol drinking was associated with increased risk of AAP (OR = 15.045, P = 0.001) and ACP (OR = 6.042, P = 0.014). After adjustment of alcohol drinking, genetic liability to IBD had a similar significant causal effect on AAP (OR = 1.137, P = 0.049), while testosterone (OR = 0.270, P = 0.002) a triglyceride (OR = 1.610, P = 0.001) and hip circumference (OR = 0.648, P = 0.040) were significantly associated with ACP. Genetically predicted higher education and household income levels could lower the risk of pancreatitis.

Conclusions

This MR study provides evidence of complex causal associations between modifiable risk factors and pancreatitis. These findings provide new insights into potential therapeutic and prevention strategies.

Association between Dietary Habits and Pancreatitis among Individuals of European Ancestry: A Two-Sample Mendelian Randomization Study

Dietary factors are believed to potentially influence the risk of pancreatitis. Here, we systematically investigated the causal relationships between dietary habits and pancreatitis by using two-sample Mendelian randomization (MR). Large-scale genome-wide association study (GWAS) summary statistics for dietary habits were obtained from the UK Biobank. GWAS data for acute pancreatitis (AP), chronic pancreatitis (CP), alcohol-induced AP (AAP) and alcohol-induced CP (ACP) were from the FinnGen consortium. We performed univariable and multivariable MR analyses to evaluate the causal association between dietary habits and pancreatitis. Genetically driven alcohol drinking was associated with increased odds of AP, CP, AAP and ACP (all with p < 0.05). Genetic predisposition to higher dried fruit intake was associated with reduced risk of AP (OR = 0.280, p = 1.909 × 10^-5) and CP (OR = 0.361, p = 0.009), while genetic predisposition to fresh fruit intake was associated with reduced risk of AP (OR = 0.448, p = 0.034) and ACP (OR = 0.262, p = 0.045). Genetically predicted higher consumption of pork (OR = 5.618, p = 0.022) or processed meat (OR = 2.771, p = 0.007) had a significant causal association with AP, and genetically predicted higher processed meat intake increased the risk of CP (OR = 2.463, p = 0.043). Our MR study showed that fruit intake may be protective against pancreatitis, whereas dietary intake of processed meat has potential adverse impacts. These findings may inform prevention strategies and interventions directed toward dietary habits and pancreatitis.

Cross-sectional evaluation of gut microbial-host cometabolites in patients with chronic pancreatitis

OBJECTIVES

Gut bacteria facilitate nutrient metabolism and generate small molecules that form part of the broader "metabolome". It is unclear whether these metabolites are disturbed in chronic pancreatitis (CP). This study aimed to evaluate the gut microbial-host cometabolites and their relationship in patients with CP.

METHODS

Fecal samples were collected from 40 patients with CP and 38 healthy family members. Each sample was examined with 16S rRNA gene profiling and gas chromatography time-of-flight mass spectrometry to estimate the relative abundances of specific bacterial taxa between the two groups and to profile any changes in the metabolome, respectively. Correlation analysis was used to evaluate the differences in metabolites and gut microbiota between the two groups.

RESULTS

The abundance of Actinobacteria was lower at the phylum level, and that of Bifidobacterium was lower at the genus level in the CP group. Eighteen metabolites had significantly different abundances and the concentrations of 13 metabolites were significantly different between the two groups. Oxoadipic acid and citric acid levels were positively correlated with Bifidobacterium abundance (r = 0.306 and 0.330, respectively, both P < 0.05), while the 3-methylindole concentration was negatively correlated with Bifidobacterium abundance (r = -0.252, P = 0.026) in CP.

CONCLUSIONS

Gut microbiome and host microbiome metabolic products might be altered in patients with CP. Evaluating gastrointestinal metabolite levels may further enhance our understanding of the pathogenesis and/or progression of CP.

Clinical guideline on magnetically controlled capsule gastroscopy (2021 edition)

With the development and generalization of endoscopic technology and screening, clinical application of magnetically controlled capsule gastroscopy (MCCG) has been increasing. In recent years, various types of MCCG are used globally. Therefore, establishing relevant guidelines on MCCG is of great significance. The current guidelines containing 23 statements were established based on clinical evidence and expert opinions, mainly focus on aspects including definition and diagnostic accuracy, application population, technical optimization, inspection process, and quality control of MCCG. The level of evidence and strength of recommendations were evaluated. The guidelines are expected to guide the standardized application and scientific innovation of MCCG for the reference of clinicians.

Identification of novel factors that affect the onset of idiopathic chronic pancreatitis: The role for microRNA-323b-5p

BACKGROUND

The c.194+2 T>C variant of serine protease inhibitor Kazal type 1 (SPINK1) is a known genetic risk factor found in Chinese patients with idiopathic chronic pancreatitis (ICP), but the early-onset mechanisms of ICP are still unclear.

METHODS

Complementary experimental approaches were used to pursue other potential pathologies in the present study. The serum level of SPINK1 of ICP patients in the Han population in China was detected and verified by an enzyme-linked immunosorbent assay. Next, differentially expressed proteins and microRNAs from plasma samples of early-onset and late-onset ICP patients were screened by proteomic analysis and microarray, respectively.

RESULTS

Combined with these advanced methods, the data strongly suggest that the regulatory effects of microRNAs were involved in the early-onset mechanism of the ICP by in vitro experiments. There was no significant difference in the plasma SPINK1 expression between the early-onset ICP and the late-onset patients. However, the expression of plasma glutathione peroxidase (GPx3) in early-onset ICP patients was markedly lower than that in late-onset ICP patients, although the level of hsa-miR-323b-5p was lower in late-onset patients compared to the early-onset ICP group. In vitro experiments confirmed that hsa-miR-323b-5p could increase apoptosis in caerulein-treated pancreatic acinar cells and inhibit the expression of GPx3.

CONCLUSIONS

The up-regulated hsa-miR-323b-5p might play a crucial role in the early-onset mechanisms of ICP by diminishing the antioxidant activity through the down-regulation of GPx3.

Small-sized versus standard magnetic capsule endoscopy in adults: a two-center, double-blinded randomized controlled trial

BACKGROUND : Certain patients experience difficulty swallowing a video capsule endoscopy (VCE) device owing to its relatively large size. The newly developed small-sized magnetically controlled capsule endoscopy (MCE) device is the smallest VCE device ever reported. We aimed to evaluate the performance of the small-sized MCE device in terms of ingestion and examination efficacy. METHODS : Patients in two centers were prospectively enrolled and randomized to the small-sized or standard MCE groups. Differences in capsule ingestion difficulties, visualization of the gastrointestinal tract, and capsule transit times were compared. RESULTS : 96 patients were enrolled (48 in each group). In the small-sized MCE group, the mean (SD) difficulty score and time to swallow the capsule, and success rate for swallowing the capsule at the first attempt were 0.6 (1.0), 3.4 (1.3) seconds, and 89.6 %, which was significant better compared with the standard MCE group with 3.1 (1.7), 12.0 (14.3) seconds and 60.4 %, respectively (all P < 0.001). Visualization of the esophagus, stomach, and small bowel were comparable between the two groups. The small-sized MCE group had a significantly shorter gastric transit time (49.4 minutes vs. 66.2 minutes; P = 0.04) and longer small-bowel transit time (5.8 hours vs. 5.0 hours; P = 0.045). CONCLUSIONS : The small-sized MCE device is feasible and safe for gastrointestinal examination, alleviating difficulties in capsule ingestion, improving gastric emptying under magnetic control, and prolonging the small-bowel transit time.

5G-based remote magnetically controlled capsule endoscopy for examination of the stomach and small bowel

BACKGROUND AND AIMS

Remote endoscopy can improve diagnostic efficiency of gastrointestinal (GI) diseases for patients in remote areas. A novel remote magnetically controlled capsule endoscopy (MCE) system based on a 5G network was developed for real-time remote GI examinations. We aimed to evaluate the feasibility and safety of the 5G-based remote MCE for examination of the stomach and small bowel.

METHODS

This was a prospective, nonrandomized, comparative study. Consecutive participants enrolled in the First People's Hospital of Yinchuan underwent remote MCE examinations performed by an endoscopist located in Changhai Hospital. Consecutive participants enrolled in Changhai Hospital underwent conventional MCE examinations performed by the same endoscopist. The main outcomes included the complete visualization rate of the stomach and small bowel, safety assessment and network latency time of remote MCE examinations.

RESULTS

From March 2021 to June 2021, 20 participants in each group were enrolled. The complete visualization rate of the stomach and small bowel was 100% in both groups (p > 0.999) without any adverse event. The median network latency time of remote MCE group was 19.948 ms. Gastric examination time (8.96 vs. 8.92 min, p = 0.234), maneuverability (15.00 vs. 15.00, p = 0.317), image quality (1.00 vs. 1.00, p > 0.999) and diagnostic yields in the stomach and small bowel (55% vs. 30%, 5% vs. 0%, both p > 0.05) were comparable between remote and conventional MCE groups. All participants in remote MCE group considered remote MCE acceptable and necessary.

CONCLUSIONS

5G-based remote MCE was a feasible and safe method for viewing the stomach and small bowel.

Radiation Therapy Decision Making Process and Operations for COVID-19 Positive Patients

Purpose/Objective(s)

A challenging clinical dilemma during the COVID-19 pandemic is management of cancer patients who test positive for COVID. Given the need to balance the risk of disease progression with the risk of transmission to other patients and staff, radiation therapy for these patients requires careful consideration and modification of standard workflows. It is also critical to develop processes to mitigate radiation treatment interruption, which can affect patient outcomes. The objective of this study was to report the clinical operations and outcomes for COVID positive patients receiving radiation therapy during the pandemic at a tertiary cancer center including 2 network locations.

Materials/Methods

During March 2020 to March 2022, the Radiation Oncology COVID committee (RO COVID) developed an integrated process to triage patients, provide treatment recommendations, and implement infection control procedures to safely deliver radiation therapy to COVID positive patients. Policies were created for each center with multidisciplinary input from infectious disease, radiation oncology, radiation therapy, and nursing. All COVID positive patients were presented to the RO COVID group and evaluated for clinical urgency, benefit with radiation, and life expectancy. If deemed necessary, a limited planned break or hypofractionated regimen was recommended to minimize staff exposure. We conducted a retrospective review of COVID positive patients with different primary malignancies treated through the COVID positive pathway.

Results

A total of 68 COVID positive patients were treated with the COVID positive pathway (HN 15, Breast 9, CNS 8, GU 8, GYN, 7, Thoracic 6, GI 5, HEME 5, PED 3, SARC 2). The median age was 57.1 years (IQR 45.8-63.4) and 47% were female. There were 39 patients (57%) who were asymptomatic and were tested for routine pre-radiation screening or due to concerns of COVID exposure. Twenty-three (34%) patients were treated with palliative intent and 8 (12%) were treated for an emergent indication (i.e., spinal cord compression, bleeding). Thirteen (19%) patients were receiving radiation treatment, had a treatment break (7-21 days), and then resumed their radiation course. All treatments were successfully completed without known nosocomial spread of COVID to staff or other patients. Among this heterogenous group of patients, 58 (85%) were alive with a median follow up of 2 months (IQR 0.5-7.5). COVID infection may have contributed to 3 out of 10 deaths (4% of total cohort). The remaining deaths were due to progression of disease or other non-COVID causes.

Conclusion

In this study, COVID positive patients were safely treated with radiation therapy through a comprehensive decision making and clinical operations pathway taking into account evolving COVID guidelines for three different variant surges. Although limited in follow up, patient outcomes are promising with few COVID-related deaths and low overall mortality rates, even with hypofractionated regimens.

Alterations in the Gut Microbiota and Metabolomics of Seafarers after a Six-Month Sea Voyage

Maintaining the health of seafarers is a difficult task during long-term voyages. Little is known about the corresponding changes in the gut microbiome-host interaction. This study recruited 30 seafarers undertaking a 6-month voyage and analyzed their gut microbiota using 16S rRNA gene sequencing. Fecal untargeted metabolomics analysis was performed using liquid chromatography-mass spectrometry. Significant changes in the composition of the gut microbiota and an increased ratio of Firmicutes/Bacteroidetes at the end (day 180) of the 6-month voyage, relative to the start (day 0), were observed. At the genus level, the abundances of Holdemanella and Plesiomonas were significantly increased, while the abundance of Bacteroides was decreased. Predicted microbial functional analysis revealed significant decreases in folate biosynthesis and biotin metabolism. Furthermore, 20 differential metabolites within six differentially enriched human metabolic pathways (including arginine biosynthesis, lysine degradation, phenylalanine metabolism, sphingolipid metabolism, pentose and glucuronate interconversions, and glycine, serine, and threonine metabolism) were identified by comparing the fecal metabolites at day 0 and day 180. Spearman correlation analysis revealed close relationships between the 14 differential microbiota members and the six differential fecal metabolites that might affect specific human metabolic pathways. This study adopted a multi-omics approach and provides potential targets for maintaining the health of seafarers during long-term voyages. These findings are worthy of more in-depth exploration in future studies. IMPORTANCE Maintaining the health of seafarers undertaking long-term voyages is a difficult task. Apart from the alterations in the gut microbiome and fecal metabolites after a long-term voyage, our study also revealed that 20 differential metabolites within six differentially enriched human metabolic pathways are worthy of attention. Moreover, we found close relationships between the 14 differential microbiota members and the six differential fecal metabolites that might impact specific human metabolic pathways. Accordingly, preventative measures, such as adjusting the gut microbiota by decreasing potential pathobionts or increasing potential probiotics as well as offsetting the decrease in B vitamins and beneficial metabolites (e.g., d-glucuronic acid and citrulline) via dietary adjustment or nutritional supplements, might improve the health of seafarers during long-term sea voyages. These findings provide valuable clues about gut microbiome-host interactions and propose potential targets for maintaining the health of seafarers engaged in long-term sea voyages.

Cardiovascular disease risk prediction via machine learning using mental health data

Background

Robust and accurate risk prediction models are much needed in cardiovascular disease. It is well-known that mental health is associated with the risk of developing cardiovascular disease. It is unknown whether mental health markers can enhance existing risk prediction models for cardiovascular disease.

Purpose

The main purpose of this study was to assess capability of mental health factors along with traditional risk factors to be used in cardiovascular predictive machine learning models, and to develop a combined machine learning approach using both traditional risk and psychological factors in 375,145 participants of the UK Biobank.

Methods

A comprehensive Pearson correlation analysis is carried out on UK Biobank data. Subsequently, an ensemble model containing decision tree, random forest, XGBoost, support vector machine (SVM), and deep neural network (DNN) classification approaches was built to predict cardiovascular diseases (CVD) in UK Biobank participants. The model was first trained using traditional cardiovascular risk factors, and subsequently trained using a combination of cardiovascular risk and psychological factors.

Results

The correlation analysis revealed that there is a correlation between CVD and mental health factors suggesting the potential of mental health application for machine learning models. Our ensemble machine learning model was able to predict CVD with an accuracy of 73.49% using CVD risk factors alone. However, by combining psychological factors with CVD risk factors in the training data, an improved accuracy of 95.70% was achieved. The accuracy and robustness of ensemble machine learning model outperformed any of five constituent learning algorithms alone.

Conclusions

Our results suggest that mental health assessment data along with traditional risk factors provides a powerful, safe and affordable machine learning model enrichment that can be used for state-of-the-art prediction of CVD.

Funding Acknowledgement

Type of funding sources: None.

Changhai advanced endoscopy courses for ERCP (CHANCE) training program: A short-term training model in China

BACKGROUND

There is huge shortage of ERCP practitioners (ERCPists) in China, and ERCP training is urgently needed. ChangHai Advanced eNdoscopy Courses for ERCP (CHANCE) is a 4-month program for ERCP training since 2004. This study evaluated the efficiency of this short-term training model, and reported on the ERCP careers of the trainees following completion of the CHANCE program.

METHODS

This study was a retrospective investigation included all the CHANCE trainees from Jan 2004 to Dec 2014. Questionnaires were sent to all trainees. The career competence percentage, ERCP careers and predictive factors of career competence were investigated and analyzed.

RESULTS

A total of 413 trainees participated in the CHANCE program over 11 years covered by the survey and 258 questionnaires were valid for the study. The mean (SD) age of the trainees was 35.36 (4.17), and the male to female ratio was 4.4:1. The average follow-up time was 7.77 (3.44) years. A total of 173 (67.1%) trainees had achieved career competence. In terms of ERCP careers, the mean annual ERCP volume was 120.60 (96.67), with a complication percentage of 8.2%. Hospital qualification, compliance with follow-up learning guidance, participating academic activity, and practitioner type were identified predictive factors of career competence.

CONCLUSIONS

As a short-term training program, the CHANCE achieved an acceptable career competence percentage, providing endoscopists more chances to learn ERCP and giving them appropriate training guidance for career competence. This training mode is worth promoting in developing countries with shortage of ERCPists.

Clinical characteristics of smoking-related chronic pancreatitis

Objective

The pathogenesis of chronic pancreatitis (CP) is not completely clear. With further studies, smoking is toxic to the pancreas. This study classified smoking-related CP as a new etiology of CP and defined the cutoff of smoking.

Design

Patients with CP admitted from January 2000 to December 2013 were included in the study. The characteristics were compared between smoking patients, drinking patients, and a group of patients who never smoke or drink (control group). The cumulative rates of steatorrhea, diabetes mellitus (DM), pancreatic pseudocyst (PPC), pancreatic stone, and biliary stricture after the onset of CP were calculated, respectively.

Results

A total of 1,324 patients were included. Among them, 55 were smoking patients, 80 were drinking patients, and 1,189 were controls. The characteristics of smokers are different from the other two groups, especially in age at the onset and diagnosis of CP, initial manifestation, and type of pain. The development of DM (P = 0.011) and PPC (P = 0.033) was significantly more common and earlier in the smokers than in the other two groups. Steatorrhea also developed significantly more in the smokers than in the controls (P = 0.029). Smokers tend to delay the formation of pancreatic stones and steatorrhea.

Conclusion

The clinical characteristics of smoking-related CP is different from CP of other etiologies. A new type of CP, smoking-related CP, was put forward. Smoking-related CP should be separated from idiopathic CP and defined as a new independent subtype of CP different from alcoholic CP or idiopathic CP.

Expanding ACMG variant classification guidelines into a general framework

BACKGROUND

The American College of Medical Genetics and Genomics (ACMG)-recommended five variant classification categories (pathogenic, likely pathogenic, uncertain significance, likely benign, and benign) have been widely used in medical genetics. However, these guidelines are fundamentally constrained in practice owing to their focus upon Mendelian disease genes and their dichotomous classification of variants as being either causal or not. Herein, we attempt to expand the ACMG guidelines into a general variant classification framework that takes into account not only the continuum of clinical phenotypes, but also the continuum of the variants' genetic effects, and the different pathological roles of the implicated genes.

MAIN BODY

As a disease model, we employed chronic pancreatitis (CP), which manifests clinically as a spectrum from monogenic to multifactorial. Bearing in mind that any general conceptual proposal should be based upon sound data, we focused our analysis on the four most extensively studied CP genes, PRSS1, CFTR, SPINK1 and CTRC. Based upon several cross-gene and cross-variant comparisons, we first assigned the different genes to two distinct categories in terms of disease causation: CP-causing (PRSS1 and SPINK1) and CP-predisposing (CFTR and CTRC). We then employed two new classificatory categories, "predisposing" and "likely predisposing", to replace ACMG's "pathogenic" and "likely pathogenic" categories in the context of CP-predisposing genes, thereby classifying all pathologically relevant variants in these genes as "predisposing". In the case of CP-causing genes, the two new classificatory categories served to extend the five ACMG categories whilst two thresholds (allele frequency and functional) were introduced to discriminate "pathogenic" from "predisposing" variants.

CONCLUSION

Employing CP as a disease model, we expand ACMG guidelines into a five-category classification system (predisposing, likely predisposing, uncertain significance, likely benign, and benign) and a seven-category classification system (pathogenic, likely pathogenic, predisposing, likely predisposing, uncertain significance, likely benign, and benign) in the context of disease-predisposing and disease-causing genes, respectively. Taken together, the two systems constitute a general variant classification framework that, in principle, should span the entire spectrum of variants in any disease-related gene. The maximal compliance of our five-category and seven-category classification systems with the ACMG guidelines ought to facilitate their practical application.

Global trends of ERCP research in the last 25 years: A bibliometrics study

PURPOSE

Endoscopic retrograde cholangiopancreatography (ERCP) has been used in clinical practice for over 50 years. This study aims to investigate the current state of research in the field of ERCP.

METHODS

Web of Science database was searched using the term "ERCP" for articles published between 1994 and 2018. The total number of articles from the top 20 countries with the most published articles was determined. The top 5 countries were compared in terms of output per capita, number of articles published in top journals, cumulative impact factor (IF), and average IF. All annual data were subjected to time-trend analysis. The frequently used terms in the titles and abstracts of all articles were retrieved to conduct co-occurrence analysis to determine the research focus of ERCP.

RESULTS

A total of 9960 articles on ERCP were published between 1994 and 2018, of which 8778 articles were from the top 20 producing countries. There was a significant positive correlation between the output and GDP of each country (R = 0.870, P = .001). The United States of America (USA), Japan, Germany, Italy, and China were the top 5 producing countries with 3190 (32.0%), 868 (8.7%), 658 (6.6%), 512 (5.1%) and 488 (4.9%) articles published, respectively. The USA, Japan, Italy, and China were trending upwards in the total outputs and outputs per capita, while Germany were trending downwards. For average IF, Germany had a downwards trend, while the other 4 countries remained stable. Overall, the USA had the highest output per capita (97.5/10 million) and the highest average IF (6.454). China had the lowest output per capita (3.5/10 million) and average IF (3.125). The ERCP procedures for sphincter of Oddi dysfunction, the combination of ERCP, and laparoscopic cholecystectomy have been the research focus of ERCP.

CONCLUSIONS

Except for Germany, research on ERCP will continue to increase in the top-producing countries. The outputs per capita and quality of articles from developed countries are higher than those from developing countries.

The Development and Validation of Anti-paratuberculosis-nocardia Polypeptide Antibody [Anti-pTNP] for the Diagnosis of Crohn's Disease

BACKGROUND AND AIMS

Non-invasive biomarkers in sera of patients with inflammatory bowel disease [IBD] are not currently available for rapidly and accurately diagnosing the disease. We aimed to investigate and validate the potential roles of anti-paratuberculosis-nocardia polypeptide antibodies [anti-pTNP] in the diagnosis of IBD.

METHODS

Serum samples were collected from 502 patients with diagnosed Crohn's disease [CD], 141 patients with ulcerative colitis [UC], and 109 healthy donors. The levels of anti-pTNPs and anti-Saccharomyces cerevisiae antibodies [ASCAs] were determined by enzyme-linked immunosorbent assay. The effects of each variable on the diagnosis were analysed by receiver operating characteristic [ROC] analysis. We also performed an estimate study by first developing a clinical prediction model, with external validation in CD patients from nine IBD medical centres in China.

RESULTS

The levels of anti-pTNPs in sera of CD patients were higher than those in UC patients and healthy donors. The positive rates of anti-pTNPs were significantly higher in ileal CD patients than in ileocolonic and colonic CD patients, and the levels of anti-pTNP IgG in perianal patients were significantly higher than those in non-perianal CD patients. Of note, anti-pTNPs and perianal diseases were important predictors for active stage of CD patients. Discriminative ability to predict active CD patients was 0.918 (95% confidence interval [CI]:0.886-0.949).

CONCLUSIONS

Anti-pTNP functions as a novel biological marker for diagnosing CD and can be used to assess disease severity, particularly in those with lesion locations in the terminal ileum and stricturing and perianal diseases. A validated prediction model reveals that anti-pTNPs are useful for estimating the likelihood of active CD.

Single-Cell Transcriptomic Analysis of the Mouse Pancreas: Characteristic Features of Pancreatic Ductal Cells in Chronic Pancreatitis

Chronic pancreatitis (CP) is a fibroinflammatory disorder of the pancreas. Our understanding of CP pathogenesis is partly limited by the incomplete characterization of pancreatic cell types. Here, we performed single-cell RNA sequencing on 3825 cells from the pancreas of one control mouse and mice with caerulein-induced CP. An analysis of the single-cell transcriptomes revealed 16 unique clusters and cell type-specific gene expression patterns in the mouse pancreas. Sub-clustering of the pancreatic mesenchymal cells from the control mouse revealed four clusters of cells with specific gene expression profiles (combinatorial expressions of Smoc2, Cxcl14, Tnfaip6, and Fn1). We observed that immune cells in the pancreas of the CP mice were abundant and diverse in cellular type. Compared to the control, 547 upregulated genes (including Mmp7, Ttr, Rgs5, Adh1, and Cldn2) and 257 downregulated genes were identified in ductal cells from the CP group. The elevated expression levels of MMP7 and TTR were further verified in the pancreatic ducts of CP patients. This study provides a preliminary description of the single-cell transcriptome profiles of mouse pancreata and accurately demonstrates the characteristics of pancreatic ductal cells in CP. The findings provide insight into novel disease-specific biomarkers and potential therapeutic targets of CP.

AB1043 IDENTIFICATION OF UNUSUAL TOPHI ANTERIOR TO THE THYROID CARTILAGE USING DIFFERENT IMAGING METHODS

Background

Inadequately treated gout patients could develop tophi. However, tophi could appear as atypical mass, leading to difficulty in differential diagnosis.

Objectives

The objectives of the study were to describe an unusual case with tophi anterior to the Thyroid Cartilage using different imaging methods.

Methods

Clinical information of the case was presented. Ultrasound, dual energy Computed Tomography (DECT) and CT scan were compared to describe the tophi.

Results

A 66-year-old man with a 30-year history of gout was admitted. He had received urate-lowering drugs intermittently over the past few years. Physical examination revealed multiple tophi on the hands, feet, and other auricular surfaces. Moreover, there was a subcutaneous mass above the thyroid cartilage (Figure 1A). Ultrasound revealed hyperechoic nodule anterior to the thyroid cartilage, 11*7cm in size, with uneven internal echo, no blood flow signal inside, and a close relationship between the barrier of the nodule and the thyroid cartilage (Figure 1B). DECT of the neck confirmed that the mass anterior to the thyroid cartilage were tophi (Figure 1C-D). A plain radiographic evaluation demonstrated soft-tissue swellings and para-articular erosions involving hands (Figure 1E-F). The serum creatinine and uric acid levels were elevated as follows, creatinine, 562 μmol per liter (normal range, 31.8 to 116); and uric acid, 621 μmol per liter (normal range, 90 to 420).

Figure 1.

Tophi detected by different imaging methods. A.A picture of the mass anterior to the thyroid cartilage; B. A mass anterior to the thyroid cartilage detected by ultrasound; C. The mass anterior to the thyroid cartilage detected by dual energy CT; D. The mass anterior to the thyroid cartilage detected by CT scan; E. a picture of tophi in the hands; F. a plain radiograph of tophi in the hands.

Conclusion

DECT has more advantages over ultrasound and CT for detection of atypical tophi in gout patients.

Disclosure of Interests

Yutong Jiang Grant/research support from: Scientific and Technological Planning Project of Guangzhou City [grant number 202102020150], Xinyu Wu: None declared, Zetao Liao: None declared, Jun Qi: None declared, Jieruo Gu: None declared

The Impacts of Genetic and Environmental Factors on the Progression of Chronic Pancreatitis

BACKGROUND & AIMS

Both environmental factors, such as alcohol consumption and smoking, and genetic factors are strongly associated with the risk of developing chronic pancreatitis (CP). However, comprehensive understanding of their impacts on the progression of CP remains elusive.

METHODS

A prospective cohort study was performed on a large cohort of CP patients with known genetic backgrounds. The cumulative incidence of pancreatic insufficiency after the onset of CP was analyzed using Kaplan-Meier survival curves. Multivariate Cox proportional hazards regression analysis also was performed.

RESULTS

A total of 798 patients were enrolled in the study and followed up for 10.5 years. Rare pathogenic genotypes in the SPINK1, PRSS1, CTRC, or CFTR genes were identified in 410 (51.4%) patients. The development of pancreatic insufficiency was significantly earlier in patients with a history of smoking and/or alcohol consumption in both the positive (P < .001) and negative (P = .001) gene mutation groups. However, the development of pancreatic insufficiency did not differ significantly between patients with and without gene mutations despite alcohol and/or smoking status, with P values of .064 and .115, respectively. Multivariate Cox regression analysis showed that age at onset of CP (hazard ratio, [HR], 1.02; P < .001) and alcohol consumption (HR, 1.86; P < .001) were independent risk factors for the development of diabetes, while male sex (HR, 1.84; P = .022) and smoking (HR, 1.56; P = .028) were predictors of steatorrhea.

CONCLUSIONS

Although rare pathogenic mutations in the 4 major susceptibility genes for CP were not correlated significantly with the development of pancreatic insufficiency, environmental factors (either alcohol consumption or smoking) significantly accelerated disease progression (ClinicalTrials.gov: NCT04574297).

POS0014 EFFICACY AND SAFETY OF JAK INHIBITORS IN REFRACTORY OR INITIAL TREATMENT OF ADULT ONSET STILL’S DISEASE

Background

Inappropriate activation of pro-inflammatory cytokines such as interleukin (IL)-1, IL-6 or IL-18, is a pathogenic cornerstone in adult onset Still’s disease (AOSD). Beyond therapies targeting IL-1 and IL-6, Janus kinases (JAK) inhibitors have been suggested to be efficient in refractory AOSD patients [1].

Objectives

To assess the efficacy and safety of JAK inhibitors in the treatment of AOSD patient refractory to, or with initial treatment.

Methods

This retrospective study was based on our single center of the department of rheumatology and immunology. The data was collected from the patients’ medical records using a standardized questionnaire and analyzed at different time points. The response to JAK inhibitors was categorized as complete remission (CR), partial remission (PR) or failure (F) [2].

Results

7 patients were recruited (Table 1), including 4 refractory patients and 3 initial patients. Mean age at JAK inhibitor treatment start was 27.5 years for refractory patients and 35 years for initial patients; and mean disease duration was 66.5 months and 1 month respectively. All patients had fever and polyarthritis, 5 patents had rash. In addition, pulmonary hypertension, abnormal liver function tests, abdominal pain, and heart failure were also observed in our patients. Response to corticosteroids, conventional synthetic or biological Disease Modifying Anti-Rheumatic Drugs (DMARDs) had been considered inadequate in 4 refractory patients. Tofacitinib was added in the initial treatment for 3 patients for high disease activity. In total, baricitinib was used in 2 patients and tofacitinib in 5 patients. Steroids were concurrently used in 6 patients, MTX in three, SASP and NSAIDs in one. At a mean follow up of 3.8 months, complete remission was observed in one patient (with tofacitinib), partial remission was in 5 patients (4 patients with tofacitinib and one with baricitinib), and failure in one (patients with baricitinib). At the last visit, steroids could be decreased but not stopped in those 6 patients. Tolerance of JAK inhibitors was excellent, none infectious disease or other severe side effect were observed.

Table 1.

Characteristics of the AOSD patients

No.SexAge (year)Disease Duration (Month)Main symptomsTreatments before JAKionsetJAKiSteroids at onsetConconmitant treatmentSteroids at the end of F-UF-U(month)Outcome1M2629Fever, polyarthritisPred+MTXTofacitinib0MTX04PR2M259Fever, polyarthritis, rash, pulmonary hypertensionPred+MTXBaricitinib16MTX+Pred124F3M3812Fever, polyarthritis, rashPred+MTX+CsA+NSAIDsTofacitinib24Pred123PR4M21216Fever, polyarthritisPred+MTX+SASP+NSAIDs+TNFiBaricitinib4Pred+MTX+SASP+NSAIDs43PR5F331Fever, polyarthritis, rash, abnormal liver function testsPredTofacitinib40Pred25CR6F471Fever, polyarthritis, rash, abdominal painPredTofacitinib36Pred45PR7F251Fever, polyarthritis, rash, heart failurePredTofacitinib40Pred123PR

Pred: prednisone; MTX: Methotrexate; SASP: salicylazosulfapyridine; CsA: ciclosporin A; NSAIDs: Non-Steroidal Antiinflammatory Drugs; TNFi: Tumor necrosis factor inhibitor. CR: complete remission; PR: partial remission; F: failure.

Conclusion

JAK inhibitors treatment may be helpful for some patients with refractory AOSD, or patients with severe disease activity at initial treatment. Different treatment responses were observed in these short series of cases, which might be due to the phenotype of patients. However, the scale of patients in our study was too low to draw a conclusion. Further study and additional information are needed to evaluate more precisely the risk-benefit ratio of this treatment, and a possible difference in efficacy among the different groups of patients or JAK inhibitors.

References

[1]Aosd T, Table E. Ann Rheum Dis 2020;79:842–4.

[2]Vercruysse F, Barnetche T, Lazaro E, et al. Arthritis Res Ther 2019;21:1–11. doi:10.1186/s13075-019-1838-6.

Figure 1.

Changes in laboratory test (A) WBC; (B) CRP; (C) ESR;(D) Ferritin. M0: baseline; M1: month 1; M3: month 3; M5: month 5.

Acknowledgements

None

Disclosure of Interests

None declared

AB1520 EFFECTIVE TREATMENT OF TOCILIZUMAB IN PATIENTS WITH REFRACTORY ADULT-ONSET STILL’S DISEASE

Background

Pro-inflammatory cytokines such as interleukin 6 (IL-6) are involved in the pathogenesis of adult-onset Still’s disease (AOSD). Anti-IL-6 agents such as tocilizumab have been tried to treat AOSD successfully.

Objectives

To access the efficacy of tocilizumab in the treatment of AOSD patient refractory to,or with initial treatment.

Methods

We reviewed three cases with refractory AOSD treated with tocilizumab. All patients fulfill the Cush criteria for AOSD. All patients performed blood culture, auto-antibodies test and bone marrow test to exclude infectious diseases, other rheumatic diseases and tumors. All patients received broad-spectrum antibiotics and had no response. All patients received glucocorticoid therapy and at least one kind of anti-cytokine therapies but didn’t have full response. Then the three patients received intravenous tocilizumab treatment of 8mg/kg every 2 weeks or 4 weeks.

Results

The first patient, a 21-year-old woman, performed positron emission tomography (PET-CT) and lymphoglandula pathology in addition to routine tests. She received high dose methylprednisolone (500mg per day for 3 days and followed by 80mg per day), gamma globulin injection (20g per day for 3 days) and baricitinib 4mg per day for 12 days, but had no response to the treatment. Then she received tocilizumab of 8mg/kg every 2 weeks and stopped baricitinib. And the symptoms and blood tests improved gradually, and the methylprednisolone dose reduced to 16mg per day at the last follow-up.

The second patient is a 52-year-old man, and performed bone marrow cytology and PET-CT to excluded hematological diseases. He received methylprednisolone 80mg per day, adalimumab and tofacitinib treatment. But the patients still got recurrent fever, high ESR, CRP and serum ferritin. Then he stopped adalimumab and tofacitinib, and received tocilizumab of 8mg/kg every 2 weeks and reduced to 8mg/kg every 4 weeks because of economic factors. The patient did not develop fever and the inflammatory indexes such as ESR/CRP gradually decreased to normal range. And methylprednisolone dose reduced to 32mg nowadays.

The third patient is a 30-year-old woman and has recurrent AOSD for 15 years. She had tried glucocorticoids, methotrexate, iguratimod, baritinib and entanercept successively. Yet she still had recurrent arthritis on hand and knee, and elevated ESR/CRP/serum ferritin. Additionally she suffered femoral head necrosis because of excessive doses of glucocorticoid. The patient received tocilizumab 8mg/kg every 4 weeks, then joint symptoms and inflammatory indicators improved significantly. The methylprednisolone dose was also successfully reduced to 4mg/d.

The Figure 1 showed the main course of disease evolution.

Figure 1.

Conclusion

Tocilizumab may be an effective candidate in refractory AOSD despite no response to other treatments.

Disclosure of Interests

None declared

Magnetically controlled capsule endoscopy in one-time gastro-small intestinal joint examination: a two-centre experience

Background

The lesions of certain diseases are widely distributed in both stomach and small intestine, while the step-by-step strategy of gastroscopy followed by enteroscopy can be burdensome and costly. We aimed to determine if magnetically controlled capsule endoscopy (MCE) could be used in one-time gastro-small intestine (GSI) joint examination.

Methods

In this study, data of patients in Chinese PLA General Hospital and Changhai Hospital who underwent MCE GSI examination from January 2020 to August 2021 were retrospectively analysed. The primary outcome of this study was the success rate of one-time GSI joint examination, and secondary outcomes included visualization and cleanliness of gastrointestinal tract, gastrointestinal transit times, diagnostic yield and safety of MCE examination.

Results

A total of 768 patients were included. The success rate of one-time GSI joint examination was 92.58%. There were 94.92% MCEs observed > 90% gastric mucosa in the 6 anatomic landmarks. The rate of complete small bowel examination was 97.40%. The median gastric examination time, gastric transit time and small intestine transit time were 8.18 min, 63.89 min and 4.89 h, respectively. Magnetic steering of MCE significantly decreased gastric transit time (8.92 min vs. 79.68 min, P = 0.001) and increased duodenal lesion detection rate (13.47% vs. 6.26%, P = 0.001) when compared with non-magnetic steering group. Two capsules were retained and were removed by enteroscopy or spontaneously excreted.

Conclusions

MCE is feasible to complete GSI joint examination and the detection of both gastric and small intestinal diseases can be achieved simultaneously.

Trial registration Clinical Trial Registration ClinicalTrials.gov, ID: NCT05069233.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02302-0.