Genotype correlates with clinical course and outcome of children with tight junction protein 2 (TJP2) deficiency-related cholestasis

BACKGROUND AND AIMS

The study aimed to describe the clinical course and outcomes, and analyze the genotype-phenotype correlation in patients with tight junction protein 2 (TJP2) deficiency.

APPROACH AND RESULTS

Data from all children with chronic cholestasis and either homozygous or compound heterozygous mutations in TJP2 were extracted and analyzed. The patients were categorized into 3 genotypes: TJP2-A (missense mutations on both alleles), TJP2-B (missense mutation on one allele and a predicted protein-truncating mutation [PPTM] on the other), and TJP2-C (PPTMs on both alleles). A total of 278 cases of genetic intrahepatic cholestasis were studied, with TJP2 deficiency accounting for 44 cases (15.8%). Of these, 29 were homozygous and 15 were compound heterozygous variants of TJP2 . TJP2-A genotype was identified in 21 (47.7%), TJP2-B in 7 cases (15.9%), and TJP2-C in 16 cases (36.4%), respectively. Patients with the TJP2-C genotype were more likely to experience early infantile cholestasis (87.5% vs. 53.5%, p =0.033), less likely to clear jaundice (12.5% vs. 52.2%, p =0.037), more likely to develop ascites, and had higher serum bile acids. Patients with the TJP2-C genotype were more likely to die or require liver transplantation (native liver survival: 12.5% vs. 78.6%, p <0.001), with a median age at death/liver transplantation of 2.5 years. Cox regression analysis revealed that TJP2-C mutations ( p =0.003) and failure to resolve jaundice ( p =0.049) were independent predictors of poor outcomes.

CONCLUSIONS

Patients with the TJP2-C genotype carrying PPTMs in both alleles had a rapidly progressive course, leading to early decompensation and death if they did not receive timely liver transplantation.

[Severe small bowel involvement and chronic intestinal pseudo-obstruction in systemic sclerosis (scleroderma): Pathophysiological, diagnostic and therapeutic basis, including parenteral nutrition]

Gastrointestinal involvement in systemic sclerosis can be severe, reaching the critical point of chronic intestinal pseudo-obstruction, secondary to major disorders of small bowel motility. It is associated with some clinical and biological characteristics, in particular the positivity of anti-fibrillarin/U3RNP antibodies. Chronic intestinal pseudo-obstruction (CIPO) is complicated by a small intestinal bacterial overgrowth that requires cyclic antibiotic therapy. CIPO leads to a reduction of the food intake, due to painful symptoms, nausea and vomiting caused by meals, and ultimately to severe malnutrition. Meal splitting is often transiently effective and patients require exogenous nutritional support, mostly parenteral. Systemic sclerosis is not an obstacle to initiation and long-term continuation of parenteral nutrition and central venous catheter implantation is not associated with an increased risk of cutaneous or infectious complications. However, continuation of long-term parenteral nutrition requires monitoring in an expert nutrition center in order to adapt nutritional volumes and intakes and to limit potentially fatal cardiac and hepatobiliary complications. In addition to nutrition, prokinetic treatments, whose side effects must be known, can be associated. Invasive procedures, whose risk-benefit ratio must be carefully assessed, can also be used to treat symptoms exclusively.

French protocol for the diagnosis and management of hematopoietic stem cell transplantation in autoimmune diseases

Hematopoietic stem cell transplantation (HSCT) for severe ADs was developed over the past 25years and is now validated by national and international medical societies for severe early systemic sclerosis (SSc) and relapsing-remitting multiple sclerosis (MS) and available as part of routine care in accredited center. HSCT is also recommended, with varying levels of evidence, as an alternative treatment for several ADs, when refractory to conventional therapy, including specific cases of connective tissue diseases or vasculitis, inflammatory neurological diseases, and more rarely severe refractory Crohn's disease. The aim of this document was to provide guidelines for the current indications, procedures and follow-up of HSCT in ADs. Patient safety considerations are central to guidance on patient selection and conditioning, always validated at the national MATHEC multidisciplinary team meeting (MDTM) based on recent (less than 3months) thorough patient evaluation. HSCT procedural aspects and follow-up are then carried out within appropriately experienced and Joint Accreditation Committee of International Society for Cellular Therapy and SFGM-TC accredited centres in close collaboration with the ADs specialist. These French recommendations were performed according to HAS/FAI2R standard operating procedures and coordinated by the Île-de-France MATHEC Reference Centre for Rare Systemic Autoimmune Diseases (CRMR MATHEC) within the Filière FAI2R and in association with the Filière MaRIH. The task force consisted of 3 patients and 64 clinical experts from various specialties and French centres. These data-derived and consensus-derived recommendations will help clinicians to propose HSCT for their severe ADs patients in an evidence-based way. These recommendations also give directions for future clinical research in this area. These recommendations will be updated according to newly emerging data. Of note, other cell therapies that have not yet been approved for clinical practice or are the subject of ongoing clinical research will not be addressed in this document.

Association of HLA DRB1 Allele Profile with Pediatric Autoimmune Liver Disease in India

Objectives

The aim of this study is to study the association of human leukocyte antigen (HLA) DRB1 alleles with treatment response in Indian children with autoimmune liver disease (AILD).

Methods

HLA DRB1 alleles of 71 Indian children with pediatric AILD (pAILD) were analyzed along with 25 genetically confirmed patients with Wilson disease as controls. After 1 year of therapy, all those who failed to normalize aspartate & alanine transferase (AST/ ALT) (below 1.5 times of upper limit of normal) and/or failed to normalize IgG levels, or who had >2 relapses (AST/ALT levels >1.5 times of upper limit of normal) while on treatment, were labeled as difficult to treat (DTT).

Results

HLA DRB1∗3 was found to be significantly associated with AIH type 1 (46.2% vs. 4% in controls; P corrected = 0.011). Majority of the patients [55 (77.5%)] had chronic liver disease at presentation, with 42 (59.2%) having portal hypertension and 17 (23.9%) having ascites. Out of the 71 with pAILD, 19 (26.8%) were DTT. HLA DRB1∗14 was found to be independently associated with DTT cases (36.8% vs. 9.6%, OR 5.87, 95% CI 1.07-32.09, P = 0.041). Other factors independently associated with DTT were presence of autoimmune sclerosing cholangitis (OR 8.57, P = 0.008) and high-risk varices (OR 7.55, P = 0.016), improving the correctness of classification of the model from 73.2% to 84.5%.

Conclusion

HLA DRB1∗14 is independently associated with treatment response in pAILD and HLA DRB1∗3 is associated with AIH type 1. HLA DRB1 alleles may thus provide supportive information for diagnosis and prognosis of AILD.

Rotational thromboelastometry-guided blood component use in cirrhotic children undergoing invasive procedures: Randomized controlled trial

BACKGROUND & AIMS

This randomized controlled trial (RCT) was conducted with the aim to evaluate the efficacy and safety of using ROTEM-based transfusion strategy in cirrhotic children undergoing invasive procedures.

METHODS

This was an open-label, RCT which included (i) children under 18 years of age with liver cirrhosis; (ii) INR between 1.5 and 2.5; and/or (iii) platelet count between 20 × 10⁹ /L and 50 × 10⁹ /L (for procedures other than liver biopsy) and between 40 × 10⁹ /L and 60 × 10⁹ /L (for liver biopsy); and (iv) listed for invasive procedures. Stratified randomization was done for children undergoing liver biopsies. Patients randomized to the ROTEM and conventional groups received blood component transfusion using predefined criteria.

RESULTS

A total of 423 invasive procedures were screened for inclusion of which 60 were randomized (30 in each group with comparable baseline parameters). The volume of total blood components, fresh frozen plasma (FFP) and platelets transfused was significantly lower in ROTEM as compared to conventional group. Only 46.7% of children in ROTEM group received a blood component compared to 100% in conventional group (p < .001). The requirement of FFP (ROTEM: 43.3%, Conventional: 83.3%, p = .001) was significantly lower in the patients receiving ROTEM-guided transfusions. There was no difference in procedure-related bleed and transfusion-related complications between the two groups. ROTEM was cost-effective (p = .002) despite the additional cost of the test.

CONCLUSION

ROTEM-based transfusion strategies result in lower blood component transfusion in cirrhotic children undergoing invasive procedures without an increase in risk of procedure-related bleed. ROTEM-guided transfusion strategy is cost-effective.

POS0069 LONGITUDINAL CHANGES ON QUANTITATIVE CHEST HIGH-RESOLUTION COMPUTED TOMOGRAPHY IN EARLY DIFFUSE SYSTEMIC SCLEROSIS-RELATED INTERSTITIAL LUNG DISEASE AFTER AUTOLOGOUS HEMATOPOIETIC STEM CELL TRANSPLANTATION

Background

Since Burt et al. first demonstrated in the ASSIST trial (1) that lung disease high-resolution computed tomography (HRCT) volumetric measurement decreased in autologous hematopoietic stem cell transplantation (aHSCT) recipients and increased in controls receiving cyclophosphamide iv one year after starting treatment, limited data have been reported concerning the evolution of Systemic Sclerosis-Interstitial Lund disease (SSc-ILD) since and its relationship with the evolution of esophageal volume is unknown.

Objectives

To evaluate High-Resolution Computed Computed Tomography (HRCT) interstitial lung disease (ILD) and esophageal involvement in early diffuse systemic sclerosis (dSSc)-patients before and after autologous Hematopoietic Stem Cell Transplantation (aHSCT).

Methods

Overall chest HRCT, lung function and skin score changes were evaluated in 33 consecutive dSSc-patients before and after aHSCT during yearly routine follow-up between January 2000 and september 2016.Two independent radiologists blindly assessed the ILD extent using semi-quantitative Goh and Wells method (2), the widest esophageal diameter (WED) and the esophageal volume (EV) on HRCT. Patients were retrospectively classified as radiological responders or non-responders at 24 months after aHSCT according to the stability or a 5% or more decrease of HRCT ILD extent. Two by two time points comparisons after versus before aHSCT were performed using linear regressions. Survival rates were assessed for all patients by Kaplan-Meier method.

Results

Twenty-four months after aHSCT, HRCT median [IQR] ILD (-2 [-10.3; 0] points, p=0.0002) and ground-grass opacities (-2.1 [-8.3; 0] points, p=0.02) extent scores had improved, with 18 patients radiological responders (probability of response 0.78, 95% CI (0.58;0.90), whereas median WED (from 24.5 [18; 29] to 28 [19; 33] mm; p= 0.005) and EV (from 19 [13; 33] to 30 [13; 58] mm3, p=0.01) increased significantly. Kaplan-Meier analyses showed a trend towards better 5 years survival rates (100% versus 60%; HR 0.23 95%CI 0.03 to 1.62, P = 0.11) among radiological responders versus non-responders at 24 months.

Conclusion

Real-world data analysis confirmed significant HRCT SSc-ILD improvement 24 months after aHSCT, although esophageal dilatation worsened requiring specific attention.

References

[1]Burt RK, Shah SJ, Dill K, Grant T, Gheorghiade M, Schroeder J, et al. Autologous non-myeloablative haemopoietic stem-cell transplantation compared with pulse cyclophosphamide once per month for systemic sclerosis (ASSIST): an open-label, randomised phase 2 trial. Lancet Lond Engl. 6 août 2011;378(9790):498‑506.

[2]Goh NSL, Desai SR, Veeraraghavan S, Hansell DM, Copley SJ, Maher TM, et al. Interstitial lung disease in systemic sclerosis: a simple staging system. Am J Respir Crit Care Med. 1 juin 2008;177(11):1248‑54.

Disclosure of Interests

None declared

OP0284 OUTCOME OF COVID-19 IN PATIENTS WITH RHEUMATIC AND INFLAMMATORY DISEASES TREATED WITH RITUXIMAB: DATA FROM DE FRENCH RMD COVID-19 COHORT

Background:

Various observations have suggested that the course of the COVID-19 infection may be less favorable in patients with inflammatory rheumatic and musculoskeletal diseases (iRMD) receiving rituximab (RTX).

Objectives:

To investigate whether treatment with RTX is associated with severe infection and death.

Methods:

We performed an observational, multicenter, French national cohort study querying the French RMD COVID-19 cohort, including highly suspected/confirmed iRMD-COVID-19 patients. The primary endpoint was to assess the severity rate of COVID-19. Severe disease was defined by hospitalization in intensive care unit or death. The secondary objectives were to analyze death rate and length of hospital stay. Two control groups were considered for comparison with RTX treated patients: a first group including all non-RTX treated iRMD patients and a second consisting on RTX untreated iRMD patients with diseases for which RTX is a recognized therapeutic option. Adjusting on potential confounding factors was performed by using inverse probability of treatment weighting (IPTW) propensity score method.

Results:

We collected a total of 1090 records. Patients were mainly females (67.3%, 734/1090) with a mean age of 55.2±16.4 years, and 51.1% (557/1090) were over the age of 55. Almost 70% of the population had at least one comorbidity (756/1090). A total of 63 patients were treated with RTX, mainly for rheumatoid arthritis (RA) (31/63, 49.2%). RTX treated patients were more likely to be males, with older age, higher prevalence of comorbidities and corticosteroid use. The control population consisted on 1027 non-RTX treated iRMD patients, and 495 RTX untreated iRMD patients with diseases for which RTX is a recognized therapeutic option.

Of the 1,090 patients, 137 developed severe disease (12.6%). After adjusting on potential confounding factors (age, sex, arterial hypertension, diabetes, smoking status, body mass index, interstitial lung disease, cardiovascular diseases, cancer, corticosteroid use, chronic renal failure and the underlying disease), severe disease was confirmed to be observed more frequently in patients receiving RTX compared to all RTX untreated iRMD patients (effect size, ES 3.26, 95% confidence interval, CI 1.66 to 6.40, p<0.001) and the subgroup of untreated RTX patients with diseases eligible for RTX therapy (ES 2.62, 95% CI 1.34 to 5.09, p=0.005). Patients who developed a severe disease had a more recent rituximab infusion compared to patients with mild or moderate disease. Indeed, the time between the last infusion of rituximab and the first symptoms of COVID-19 was significantly shorter in patients who developed a severe form of COVID-19 (Figure 1).

Figure 1.

Distribution (Tukey’s box plot) of Lag time between last infusion of Rituximab according to disease severity. P-Values for comparison between disease severity with Kruskal Wallis test are reported; P-Value<0.001 for either post-hoc comparison of severe disease group with moderate or mild disease group (calculated using Dunn’s test).

Eighty-nine patients in our cohort died, resulting in an overall death rate of 8.2%. Death rate was numerically higher in RTX treated patients (13/63, 20.6%) compared to all RTX untreated iRMDs patients (76/1027, 7.4%) and the subgroup of untreated RTX patients with diseases eligible for RTX therapy (49/495, 9.9%). After considering the previously described confounding factors, the risk of death was not significantly increased in patients treated with RTX compared to all RTX untreated iRMDs patients (ES 1.32, 95% CI 0.55 to 3.19, p=0.53) (Table 2) and the subgroup of untreated RTX patients with diseases eligible for RTX therapy (ES 1.48, 95% CI 0.68 to 3.20, p=0.32). In line with a more severe COVID-19 disease, the length of hospital stay was markedly longer in patients treated with RTX compared to both untreated RTX patient groups.

Conclusion:

RTX therapy is associated with a more severe COVID-19 infection. RTX will have to be applied with particular caution in patients with iRMDs.

Acknowledgements:

Muriel Herasse played a major role in collecting the missing data of the cohort.

We thank Julien Labreuche (biostatistician, CHU-Lille) for the help in the statistical analysis.

Disclosure of Interests:

None declared

Myocardial performance index in term appropriate and small for gestational age neonates - a cross sectional study

BACKGROUND

It is known that small for gestational age (SGA) babies may be at an increased risk of cardiovascular diseases during adulthood. There is paucity of literature regarding comparative cardiac functions of SGA and appropriate for gestational age (AGA) babies in neonatal period. The present study was conceived to compare the cardiac function of term small and appropriate for gestational age (AGA) babies through a relatively novel echocardiographic index in early neonatal period.

OBJECTIVES

To compare values of myocardial performance index (MPI) index (MPI = IVCT + IVRT/ET) at 48-72 hours of age among AGA and SGA babies.

METHODS

Morphological and anthropometric assessment of serially born term babies was done at time of birth to recruit hundred each of AGA and SGA babies. Tissue Doppler Imaging (TDI) was done between 48-72 hours for each enrolled baby to assess both right and left ventricle MPI in each group.

RESULTS

Mean±SD values for right ventricular MPI in AGA and SGA groups were 0.268 + 0.007 and 0.30 + 0.026 respectively (p < 0.001). Mean±SD values for left ventricular MPI in AGA and SGA groups were 0.25 + 0.012 and 0.30 + 0.017 respectively (p < 0.001). There was significant negative correlation between MPI values for either ventricles and the birth weight (spearmen's rho of -0.66) (p < 0.001). Mean±SD values for LVET in AGA and SGA group were 0.304 + 0.026 and 0.266 + 0.032 respectively (p < 0.001).

CONCLUSION

MPI had a higher absolute value in the SGA babies as compared to AGA babies. These observations point towards suboptimal cardiac performance among SGA babies as compared to AGA babies on the basis of myocardial performance index.

Intersecting pentagons as surrogate for identifying the use of mini mental state examination in assessment of dementia in a largely illiterate population

Background and Rationale:

The mini-mental state evaluation (MMSE) is often used to identify patients with dementia. One component of the MMSE is the intersecting pentagon copying (IPC) test, which may be difficult to be used in an illiterate population.

Materials and Methods:

A post hoc analysis on an elderly population (60 years and above) from Himachal Pradesh was carried out. The data of only 1,513 elderly individuals out of a total of 2,000 participants with a score of more than 26 (nondemented) out of a possible score of 30 on cognitive battery available were used. The scores on the IPC were evaluated and their association with some demographic variables was also assessed.

Results:

Illiterate participants, female participants, those with greater age, and the rural/tribal population groups faced the most difficulty in drawing the intersecting pentagons and even greater difficulty in drawing them correctly.

Discussion:

The IPC presents challenges for people who are illiterate and the scoring method needs to be addressed and changed particularly when the test is used in largely illiterate populations.

Antennal uridine diphosphate (UDP)-glycosyltransferases in a pest insect: diversity and putative function in odorant and xenobiotics clearance

Uridine diphosphate UDP-glycosyltransferases (UGTs) are detoxification enzymes widely distributed within living organisms. They are involved in the biotransformation of various lipophilic endogenous compounds and xenobiotics, including odorants. Several UGTs have been reported in the olfactory organs of mammals and involved in olfactory processing and detoxification within the olfactory mucosa but, in insects, this enzyme family is still poorly studied. Despite recent transcriptomic analyses, the diversity of antennal UGTs in insects has not been investigated. To date, only three UGT cDNAs have been shown to be expressed in insect olfactory organs. In the present study, we report the identification of eleven putative UGTs expressed in the antennae of the model pest insect Spodoptera littoralis. Phylogenetic analysis revealed that these UGTs belong to five different families, highlighting their structural diversity. In addition, two genes, UGT40R3 and UGT46A6, were either specifically expressed or overexpressed in the antennae, suggesting specific roles in this sensory organ. Exposure of male moths to the sex pheromone and to a plant odorant differentially downregulated the transcription levels of these two genes, revealing for the first time the regulation of insect UGTs by odorant exposure. Moreover, the specific antennal gene UGT46A6 was upregulated by insecticide topical application on antennae, suggesting its role in the protection of the olfactory organ towards xenobiotics. This work highlights the structural and functional diversity of UGTs within this highly specialized tissue.

Dental amalgam: effects of alloy/mercury mixing ratio, uses and waste management

BACKGROUND

Silver dental amalgam is one of the oldest filling materials used in dentistry. The American Dental Association (ADA) has estimated that billions of amalgam restorations have been placed in patients in the last 150 years. Due to the presence of mercury and mishandling during the filling make it more controversial. The objective of this study was to conduct a survey of the use of different brands and to assess any deviations in practice from the hand mixing manual method of elemental mercury and alloy in a pestle/mortar and encapsulated form.

METHODS

A questionnaire was sent to 250 of randomly selected dental practitioner in various localities of Karachi. Data was analysed to record the specified brands used along with their powder/liquid (P/L) ratio and the different methods for disposing off mercury in this study.

RESULTS

The most commonly used form of dispensing method was hand mixing (57%) and only 30% of the dentists followed the manufacturer instruction for hand mixing ratio.Eighty-seven percent of dental amalgam restoration was performed and 13% removed by the dentist per month and the method of disposing the amalgam wastage that 55%, 25%, and 20% dentists were used the sink, bin and other methods respectively in their dental clinics.

CONCLUSION

Amalgam restoration is still popular filling material in the posterior region of the mouth but we need to create awareness among the dentists who do not follow the ADA specifications.

The metabolism of 20-hydroxyecdysone in mice: relevance to pharmacological effects and gene switch applications of ecdysteroids

Ecdysteroids exert many pharmacological effects in mammals (including humans), most of which appear beneficial, but their mechanism of action is far from understood. Whether they act directly and/or after the formation of metabolites is still an open question. The need to investigate this question has gained extra impetus because of the recent development of ecdysteroid-based gene-therapy systems for mammals. In order to investigate the metabolic fate of ecdysteroids in mice, [1α,2α-(3)H]20-hydroxyecdysone was prepared and injected intraperitoneally to mice. Their excretory products (urine+faeces) were collected and the different tritiated metabolites were isolated and identified. The pattern of ecdysteroid metabolites is very complex, but no conjugates were found, in contrast to the classical fate of the (less polar) endogenous vertebrate steroid hormones. Primary reactions involve dehydroxylation at C-14 and side-chain cleavage between C-20 and C-22, thereby yielding 14-deoxy-20-hydroxyecdysone, poststerone and 14-deoxypoststerone. These metabolites then undergo several reactions of reduction involving, in particular, the 6-keto-group. A novel major metabolite has been identified as 2β,3β,6α,22R,25-pentahydroxy-5β-cholest-8(14)-ene. The formation of this and the other major metabolites is discussed in relation to the various effects of ecdysteroids already demonstrated on vertebrates.

Chlamydia trachomatis causing neonatal conjunctivitis in a tertiary care center

Chlamydia trachomatis is considered a major aetiological agent of conjunctivitis in newborns. The objective of the present study was to determine the aetiology of neonatal conjunctivitis and clinico-epidemiological correlates of chlamydial ophthalmia neonatorum. Fifty-eight newborns with signs and symptoms of conjunctivitis were studied. Conjunctival specimens were subjected to Gram staining, routine bacteriological culture, culture for Neisseria gonorrhoeae and direct fluorescent antibody (DFA) staining for diagnosis of C. trachomatis infection. C. trachomatis was detected in 18 (31%) neonates. Findings suggest that since C. trachomatis is the most common cause of neonatal conjunctivitis, routine screening and treatment of genital C. trachomatis infection in pregnant women and early diagnosis and treatment of neonatal Chlamydial conjunctivitis may be considered for its prevention and control.