Initial Management of Intra-abdominal Abscesses and Preventive Strategies for Abscess Recurrence in Penetrating Crohn's Disease: A National, Multicentre Study Based on ENEIDA Registry

INTRODUCTION

Intra-abdominal abscesses complicating Crohn's disease [CD] are a challenging situation. Their management, during hospitalisation and after resolution, is still unclear.

METHODS

Adult patients with CD complicated with intra-abdominal abscess. who required hospitalisation, were included from the prospectively maintained ENEIDA registry from GETECCU. Initial strategy effectiveness and safety to resolve abscess was assessed. Survival analysis was performed to evaluate recurrence risk. Predictive factors associated with resolution were evaluated by multivariate regression and predictive factors associated with recurrence were assessed by Cox regression.

RESULTS

In all, 520 patients from 37 Spanish hospitals were included; 322 [63%] were initially treated with antibiotics alone, 128 [26%] with percutaneous drainage, and 54 [17%] with surgical drainage. The size of the abscess was critical to the effectiveness of each treatment. In abscesses < 30 mm, the antibiotic was as effective as percutaneous or surgical drainage. However, in larger abscesses, percutaneous or surgical drainage was superior. In abscesses > 50 mm, surgery was superior to percutaneous drainage, although it was associated with a higher complication rate. After abscess resolution, luminal resection was associated with a lower 1-year abscess recurrence risk [HR 0.43, 95% CI 0.24-0.76]. However, those patients who initiated anti-TNF therapy had a similar recurrence risk whether luminal resection had been performed.

CONCLUSIONS

Small abscesses [<30mm] can be managed with antibiotics alone; larger ones require drainage. Percutaneous drainage will be effective and safer than surgery in many cases. After discharge, anti-TNF therapy reduces abscess recurrence risk in a similar way to bowel resection.

The Natural History of Patients With Pre-Existing and De Novo Inflammatory Bowel Disease After Solid Organ Transplantation: EITOS Study of GETECCU

BACKGROUND

Limited data are available on the outcome of inflammatory bowel disease (IBD) in patients with solid organ transplantation (SOT). We describe the natural history of pre-existing IBD and de novo IBD after SOT.

METHODS

This was a retrospective, multicenter study that included patients with pre-existing IBD at the time of SOT and patients with de novo IBD after SOT. The primary outcome was IBD progression, defined by escalation of medical treatment, surgical therapy, or hospitalization due to refractory IBD. Risk factors were identified using multivariate Cox proportional hazard analysis.

RESULTS

A total of 177 patients (106 pre-existing IBD and 71 de novo IBD) were included. Most patients with pre-existing IBD (92.5%) were in remission before SOT. During follow-up, 32% of patients with pre-existing IBD had disease progression, with a median time between SOT and IBD progression of 2.2 (interquartile range, 1.3-4.6) years. In the de novo cohort, 55% of patients had disease progression with a median time to flare of 1.9 (interquartile range, 0.8-3.9) years after diagnosis. In the pre-existing IBD cohort, active IBD at the time of SOT (hazard ratio, 1.80; 95% confidence interval, 1.14-2.84; P = .012) and the presence of extraintestinal manifestations (hazard ratio, 3.10; 95% confidence interval, 1.47-6.54; P = .003) were predictive factors for IBD progression.

CONCLUSIONS

One-third of patients with pre-existing IBD and about half of patients with de novo IBD have disease progression after SOT. Active IBD at the time of SOT and the presence of extraintestinal manifestations were identified as risk factors for IBD progression.

Increased prevalence of migraine in women with inflammatory bowel disease: A cross-sectional study

BACKGROUND

Some studies have suggested an association between migraine and inflammatory bowel disease. We determined migraine prevalence in a cohort of patients with inflammatory bowel disease.

METHODS

Patients with inflammatory bowel disease aged 18-65 years were interviewed using an ad hoc headache questionnaire. Those who admitted a history of headache in the last year answered the three questions of the ID-Migraine questionnaire. Those who answered "yes" to the three of them were classified as "definite" and those who answered "yes" to two were classified as "probable" migraine.

RESULTS

We interviewed 283 patients with inflammatory bowel disease. Of these, 176 (62.2%) had headache. Fifty-nine (20.8%; 95% CI 16.3-26.0%) met migraine criteria either definite (n = 33; 11.7%; 95% CI 8.2-16.0%) or probable (n = 26; 9.2%; 95% CI 6.1-13.2). When divided by gender, 12 men (9.6%; 95% CI 5.1-16.2%) and 47 women (29.8%; 95% CI 22.8-37.5%) met migraine criteria. The prevalence of migraine was increased in inflammatory bowel disease patients from the current cohort (20.8%) versus that reported for our general population for the same age group (12.6%; p < 0.0001). These differences remained significant in female inflammatory bowel disease patients (29.8% versus 17.2% in our general population; p < 0.0001), but not in males (9.6% in inflammatory bowel disease vs 8.0%; p = 0.30). Seventeen patients with inflammatory bowel disease (6.0%; 95% CI 3.54-9.44%) fulfilled chronic migraine criteria. There were no differences in migraine prevalence by inflammatory bowel disease subtypes.

CONCLUSION

Migraine prevalence, including chronic migraine, seems to be increased in patients with inflammatory bowel disease. The fact that this association was stronger for women suggests an influence of sex-related factors.

Low-dose lipopolysaccharide exposure during oocyte maturation disrupts early bovine embryonic development

Gram-negative bacteria release of lipopolysaccharide (LPS) endotoxin elicits robust immune responses capable of disrupting normal ovarian function contributing to female infertility. However, effects of subclinical or non-detectable infections on oocyte competence and subsequent embryo development remain to be fully elucidated. The aim of this study was to investigate the effects of exposing bovine oocytes to low LPS doses on oocyte and embryo competence. Bovine oocytes were collected from slaughterhouse-derived ovaries and matured with vehicle-control or increasing doses of LPS (0.01, 0.1, and 1 μg/mL) for 21 h. Oocytes (n = 252) were evaluated for nuclear maturation. A set of embryos from LPS-matured oocytes (n = 300) were cultured for 8 d to evaluate day 3 cleavage rates and day 8 blastocyst rates along with blastocyst cell counts. A subset of oocytes (n = 153) was fertilized and cultured for time-lapse image capture and analysis of embryo development. Results demonstrate no significant treatment differences among treatment groups in percent of oocytes at germinal vesicle (GV; P = 0.90), germinal vesicle breakdown (GVBD; P = 0.13), meiosis I (MI; P = 0.26), or metaphase II (MII; P = 0.44). Likewise, treatment differences were not observed in cleavage rates (P = 0.97), or blastocyst rates (P = 0.88) evaluated via traditional microscopy. Treatment with LPS did not affect total blastocyst cell count (P = 0.68), as indicated by trophectoderm (P = 0.83), and inner cell mass (P = 0.21) cell counts. Time-lapse embryo evaluation demonstrated no differences among control or LPS matured oocytes in number of zygotes that did not cleave after fertilization (P = 0.84), or those that cleaved but arrested at the 2-cell stage (P = 0.50), 4-cell (P = 0.76), prior to morula (P = 0.76). However, embryos derived from oocytes challenged with 0.1 μg/mL LPS tended to have reduced development to the morula stage compared with vehicle-treated controls (P = 0.06). Additionally, the percentage of blastocysts derived from oocytes matured in 0.01 μg/mL LPS tended to decrease compared to vehicle-treated controls (11.38 and 25.45 %, respectively; P = 0.09). Similarly, the proportion of oocytes that developed to the blastocyst stage was greater in vehicle-treated controls (25.45 %) compared with embryos derived from oocytes matured in 0.1 and 1 μg/mL (5.92 and 6.55 %, respectively; P = 0.03) LPS. These data suggest LPS-matured oocytes that subsequently underwent in vitro fertilization, experienced decreased competence to develop to the blastocyst stage.

Should Inflammatory Bowel Disease Clinicians Provide Their Patients with e-Health Resources? Patients' and Professionals' Perspectives

Introduction: The internet is emerging as a source of information for patients with inflammatory bowel disease (IBD). However, it is not always reliable and may cause anxiety. We aim to assess patients' information habits and patients' and professionals' perceptions of a national website integrated as an educational resource for the IBD unit. Methods: Patients aged 18-65 years, comfortable with the internet, and attending follow-ups at participating IBD units (March-June 2019) and their professionals were invited to evaluate a recommended website through an online survey. Results: Three hundred eighty-nine patients and 95 professionals completed the survey. The internet (n = 109; 27.4%) was the second preferred source of information after the health care team (n = 229; 57.5%). Eighty percent of patients searched the internet for information on their disease and 28.6% did so at least once a week (n = 114), especially newly diagnosed ones (<2 years). Patients valued a website recommended by their professional (n = 379; 95.2%) and endorsed by the National Working Group (n = 377; 94.7%). They would attend online educational initiatives on the website (n = 279; 70.1%) and complete periodical surveys to improve its usefulness (n = 338; 84.9%). According to IBD professionals, this type of website is the best patient source of supplementary information (n = 76; 80%) and they "prescribe" it to most patients (67.0 ± 25.2%), especially the newly diagnosed patients (52.7 ± 26.5%). It effectively integrates routine face-to-face education (n = 95; 100%). Conclusions: Patients of IBD units, especially newly diagnosed ones, appreciate a trusted e-Health resource to back up professional information. The favorable opinion of patients and professionals will allow its use in training interventions.

Benefits of Paediatric to Adult Transition Programme in Inflammatory Bowel Disease: The BUTTERFLY Study of GETECCU and SEGHNP

(1) Background: Transition is a planned movement of paediatric patients to adult healthcare systems, and its implementation is not yet established in all inflammatory bowel disease (IBD) units. The aim of the study was to evaluate the impact of transition on IBD outcomes. (2) Methods: Multicentre, retrospective and observational study of IBD paediatric patients transferred to an adult IBD unit between 2017-2020. Two groups were compared: transition (≥1 joint visit involving the gastroenterologist, the paediatrician, a programme coordinator, the parents and the patient) and no-transition. Outcomes within one year after transfer were analysed. The main variable was poor clinical outcome (IBD flare, hospitalisation, surgery or any change in the treatment because of a flare). Predictive factors of poor clinical outcome were identified with multivariable analysis. (3) Results: A total of 278 patients from 34 Spanish hospitals were included. One hundred eighty-five patients (67%) from twenty-two hospitals (65%) performed a structured transition. Eighty-nine patients had poor clinical outcome at one year after transfer: 27% in the transition and 43% in the no-transition group (p = 0.005). One year after transfer, no-transition patients were more likely to have a flare (36% vs. 22%; p = 0.018) and reported more hospitalisations (10% vs. 3%; p = 0.025). The lack of transition, as well as parameters at transfer, including IBD activity, body mass index < 18.5 and corticosteroid treatment, were associated with poor clinical outcome. One patient in the transition group (0.4%) was lost to follow-up. (4) Conclusion: Transition care programmes improve patients' outcomes after the transfer from paediatric to adult IBD units. Active IBD at transfer impairs outcomes.

Real-world outcomes of switching from adalimumab originator to adalimumab biosimilar in patients with inflammatory bowel disease: The ADA-SWITCH study

BACKGROUND AND AIMS

Data on the outcomes after switching from adalimumab (ADA) originator to ADA biosimilar are limited. The aim was to compare the treatment persistence, clinical efficacy, and safety outcomes in inflammatory bowel disease patients who maintained ADA originator vs. those who switched to ADA biosimilar.

METHODS

Patients receiving ADA originator who were in clinical remission at standard dose of ADA originator were included. Patients who maintained ADA originator formed the non-switch cohort (NSC), and those who switched to different ADA biosimilars constituted the switch cohort (SC). Clinical remission was defined as a Harvey-Bradshaw index ≤4 in Crohn's disease and a partial Mayo score ≤2 in ulcerative colitis. To control possible confounding effects on treatment discontinuation, an inverse probability treatment weighted proportional hazard Cox regression was performed.

RESULTS

Five hundred and twenty-four patients were included: 211 in the SC and 313 in the NSC. The median follow-up was 13 months in the SC and 24 months in the NSC (p < 0.001). The incidence rate of ADA discontinuation was 8% and 7% per patient-year in the SC and in the NSC, respectively (p > 0.05). In the multivariate analysis, switching from ADA originator to ADA biosimilar was not associated with therapy discontinuation. The incidence rate of relapse was 8% per patient-year in the SC and 6% per patient-year in the NSC (p > 0.05). Six percent of the patients had adverse events in the SC vs. 5% in the NSC (p > 0.05).

CONCLUSION

Switching to ADA biosimilar did not impair patients' outcomes in comparison with maintaining on the originator.

Increased risk of MAFLD and Liver Fibrosis in Inflammatory Bowel Disease Independent of Classic Metabolic Risk Factors

BACKGROUND & AIMS

There is conflicting evidence regarding the prevalence of and risk factors for metabolic-associated fatty liver disease (MAFLD) in patients with inflammatory bowel disease (IBD). We aimed to determine MAFLD prevalence and risk factors in IBD patients.

METHODS

Cross-sectional, case-control study included all consecutive IBD patients treated at 2 different university hospitals. Controls were subjects randomly selected from the general population and matched by age, sex, type 2 diabetes status, and body mass index in a 1:2 ratio. MAFLD was confirmed by controlled attenuation parameter. Liver biopsies were collected when MAFLD with significant liver fibrosis was suspected. In addition, age- and fibrosis stage-paired non-IBD patients with biopsy-proven MAFLD served as a secondary control group.

RESULTS

Eight hundred thirty-one IBD patients and 1718 controls were included. The prevalence of MAFLD and advanced liver fibrosis (transient elastography ≥9.7 kPa) was 42.00% and 9.50%, respectively, in IBD patients and 32.77% and 2.31%, respectively, in the general population (P < .001). A diagnosis of IBD was an independent predictor of MAFLD (adjusted odds ratio, 1.99; P < .001) and an independent risk factor for advanced liver fibrosis (adjusted odds ratio, 5.55; P < .001). Liver biopsies were obtained from 40 IBD patients; MAFLD was confirmed in all cases, and fibrosis of any degree was confirmed in 25 of 40 cases (62.5%). Body mass index and type 2 diabetes prevalence were significantly lower in IBD-MAFLD patients than in severity-paired patients with biopsy-proven MAFLD.

CONCLUSIONS

MAFLD and liver fibrosis are particularly prevalent in IBD patients, regardless of the influence of classic metabolic risk factors.

Surgery due to Inflammatory Bowel Disease During Pregnancy: Mothers and Offspring Outcomes From an ECCO Confer Multicentre Case Series [Scar Study]

AIMS

i] To evaluate the evolution of pregnancies and offspring after inflammatory bowel disease [IBD] surgery during pregnancy; and ii] to describe the indications, the surgical techniques, and the frequency of caesarean section concomitant with surgery.

METHODS

Patients operated on due to IBD during pregnancy after 1998 were included. Participating clinicians were asked to review their databases to identify cases. Data on patients' demographics, IBD characteristics, medical treatments, IBD activity, pregnancy outcomes, surgery, delivery, and foetal and maternal outcomes, were recorded.

RESULTS

In all, 44 IBD patients were included, of whom 75% had Crohn's disease; 18% of the surgeries were performed in the first trimester, 55% in the second, and 27% in the third trimester. One patient had complications during surgery, and 27% had postsurgical complications. No patient died. Of deliveries, 70% were carried out by caesarean section. There were 40 newborns alive. There were four miscarriages/stillbirths [one in the first, two in the second, and one in the third trimester]; two occurred during surgery, and another two occurred 2 weeks after surgery; 14% of the surgeries during the second trimester and 64% of those in the third trimester ended up with a simultaneous caesarean section or vaginal delivery. Of the 40 newborns, 61% were premature and 47% had low birth weight; 42% of newborns needed hospitalisation [25% in the intensive care unit].

CONCLUSIONS

IBD surgery during pregnancy remains an extremely serious situation. Therefore, surgical management should be performed in a multidisciplinary team, involving gastroenterologists, colorectal surgeons, obstetricians, and neonatal specialists.

Impact of chronic exposure of rats to bisphenol A from perinatal period to adulthood on intraprostatic levels of 5α-reductase isozymes, aromatase, and genes implicated in prostate cancer development

The synergetic effect of estrogens and androgens is known to play a crucial role in the physiopathology of the prostate gland. Bisphenol A (BPA) is an endocrine disrupting compound that can interfere with endocrine hormone functioning and thereby influence prostate development. The objective of this study was to examine the impact on prostate expression of aromatase, 5α-R isozymes, and prostate cancer-related genes of exposure to low doses of BPA from perinatal period to adulthood. Vehicle or BPA (2.5 μg/kg b.w./day) was administered to gestating Wistar rats from gestational day 12 (GD12) to parturition and then to their male pups from postnatal day 1 (PND1) until euthanization on PND90. Their prostate glands were examined by qRT-PCR, Western blot, PCR array, and morphological study. mRNA and protein levels of 5α-R2 were significantly reduced and mRNA and protein levels of aromatase were significantly increased in BPA-treated animals, which also showed modifications of 8 out of the 84 key genes implicated in the development of prostate cancer. Because BPA interferes with genes involved in intraprostatic androgen and estrogen production and others implicated in prostate cancer, research is warranted into the prostate disease risk associated with chronic low-dose BPA exposure throughout life.

Prevalence of antinuclear antibodies in inflammatory bowel disease and seroconversion after biological therapy

BACKGROUND

Estimates of detectable antinuclear antibodies (ANA) prevalence vary widely, from 6% in healthy populations to 50-80% in patients with autoimmune disease. However, there is a lack of evidence about the overall prevalence in inflammatory bowel disease (IBD) and ANA seroconversion after the beginning of biological therapy.

OBJECTIVES

The aim of the study was to investigate the overall prevalence of ANA in IBD patients, their relationship with different treatments, clinical outcomes and the seroconversion rate of ANA in patients treated with biological therapy.

METHODS

Ambispective observational study including all consecutive IBD patients was carried out. Information about the presence of ANA, disease phenotype, duration, activity, complications, and past and current treatments were transversally collected. Retrospectively, in patients with detectable ANA, data regarding previous ANA detection and the diagnosis of lupus-like syndrome (LLS) was gathered.

RESULTS

A total of 879 IBD patients were included. We observed a detectable ANA prevalence of 13.6%. The presence of ANA was frequently associated with biological therapy (36/118) and decreased when immunomodulators were combined to this therapy (7/32). Of 78 patients with ANA prior to the beginning of biological therapy, a seroconversion rate of 28.8% was observed after a mean of 3.14 years. Only 1 patient suffered LLS.

CONCLUSION

Our study showed a prevalence of detectable ANA higher than the expected in healthy population. The presence of ANA was lower when immunomodulator therapy is associated. The ANA seroconversion rate is relevant after the initiation of biological treatment nevertheless, the risk of LLS appeared to be marginal.

Serum TSH as a predictor of malignancy in indeterminate thyroid nodules

INTRODUCTION

Thyroid nodules are lesions that are radiologically distinct from the thyroid parenchyma. Cervical ultrasound diagnoses 19-67% of nodules and is crucial in identifying those that lack cytological characterisation. Approximately 25% of biopsies reveal an indeterminate cytological result (Bethesda III), in which the risk of malignancy is variable (5-15%). The clinical importance of the diagnostic strategy used for thyroid nodules results from the need to exclude malignancy. The aim of this study was to evaluate the usefulness of serum thyroid-stimulating hormone (TSH) levels as a predictor of malignancy in cytologically indeterminate thyroid nodules.

METHODS

Our retrospective study included 40 patients with cytologically indeterminate thyroid nodules seen in our hospital between January 2013 and December 2017. Clinical parameters were reviewed, including age, gender, serum TSH levels, family history of thyroid carcinoma, radiation exposure and some sonographic features of the nodules. Statistical analysis was performed using SPSS. Statistical significance was defined as p<0.05.

RESULTS

Female gender was predominant (85%) and the mean (SD) age was 53.3 (15) years. Thyroid carcinoma was confirmed in 28% of patients. Median TSH levels were higher in patients with malignant (2.73µIU/ml) compared with benign (1.56µIU/ml) nodules (p<0.05). We demonstrated an increased risk of malignancy in patients with TSH levels of 2.68µIU/ml or above (p<0.05).

CONCLUSION

Higher serum TSH levels are associated with an increased risk of thyroid carcinoma in cytologically indeterminate nodules. TSH can become a fundamental diagnostic tool in stratifying the risk of malignancy and assist in diagnostic and therapeutic approaches to these nodules.

POS1376 UVEITIS IN 1449 PATIENTS WITH INFLAMMATORY BOWEL DISEASE. STUDY FROM A SINGLE UNIVERSITY CENTER

Background:

Inflammatory bowel disease (IBD), which includes Crohn’s disease (CD), and Ulcerative colitis (UC) are related to Spondyloarthritis (SpA). Ocular manifestations (OM) are well-stablished in axial SpA but not in IBD. It has been classically reported that whereas uveitis with axial SpA is predominantly anterior, unilateral, acute, and non-recurrent; in IBD it is bilateral, posterior, insidious, and chronic (1).

Objectives:

In a large unselected series of IBD, our aim was to assess a) epidemiology and clinical features of uveitis associated to IBD, b) to compare patients who developed uveitis and those who did not, and c) its relationship with biological treatment used in IBD.

Methods:

Study of all consecutive patients from a single University Hospital during the last 40 years with: a) IBD (CD and UC), and b) uveitis according to Standarization Uveitis Nomenclature (SUN) Working Group. Demographic features, clinical findings, occurrence of other extraintestinal manifestations and treatment were recorded.

Results:

We studied 1449 (714 women/735 men) patients with IBD, mean age of 55.2±15.9 years.

Uveitis was present in 23 (1.6 %) (38 eyes) of 1448 IBD patients. The most common pattern of uveitis was typically anterior (n=18; 78.3%), unilateral (n=19; 82.6%), acute (n=19; 82.6%), and non-recurrent (n=12; 52.2%).

The comparative study between patients with and without uveitis showed a significant predominance of women (Table 1) in patients with uveitis, as well as erythema nodosum, hidradenitis suppurativa and joint involvement.

Regarding IBD severity, in terms of surgical interventions, and conventional and biological immunosuppressive treatments, there were no significant differences.

Conclusion:

Although uveitis is more infrequent in IBD than in axial SpA, it is also anterior, unilateral, acute, and non-recurrent in contrast with published data from selected series. Patients with uveitis do not seem to represent more severe phenotype of IBD.

References:

[1]Lyons & Rosenbaum JT. Arch Ophthalmol 1997; 115:61-4.

Table 1.

General features of 1448 patients with IBD with and without uveitis.

Overall(n=1449)Uveitis(n=23)Non uveitis(n=1426)pMain general featuresAge, years, mean±SD55.2±15.949.1±14.655.2±15.90.8Sex, women/men, n, (% of women)714 / 735 (49.3)17 / 6 (73.9)697 / 729 (48.9)0.02*IBD duration, years, mean±SD13.2 ± 9.717.4 ± 10.213.1 ± 8.90.08IBD SeveritySurgical Interventions, n (%)289 (19.9)2 (8.7)284 (19.9)0.7Conventional Immunosuppressive drugs, n (%)878 (60.6)14 (60.9)863 (60.5)0.5Biological Therapy, n (%)384 (26.5)7 (30.4)378 (26.5))0.9TNFi monoclonal antibodies384 (26.5)7 (30.4)378 (26.5)0.9Ustekinumab27 (1.9)1 (4.3)27 (1.9)0.5Other23 (1.6)1 (4.3)22 (1.6)0.3Extraintestinal manifestationsCutaneous manifestations, n (%) (TOTAL)125 (8.6)9 (39.1)121 (8.7)0.1Erythema nodosum, n (%)26 (1.8)6 (26.1)24 (1.7)0.009*Pyoderma gangrenosum, n (%)13 (0.9)1 (4.3)13 (0.9)0.7Hidradenitis suppurativa, n (%)2 (0.1)1 (4.3)1 (0.1)0.0001*Joint involvement, n (%) (TOTAL)131 (9)10 (43.5)121 (8.5)0.0001*Axial pattern, n (%)65 (4.5)4 (17.4)58 (4.1)0.0001*Peripheral pattern, n (%)64 (4.4)4 (17.4)63 (4.4)0.9

Disclosure of Interests:

Lara Sanchez-Bilbao: None declared, María José García-García: None declared, David Martínez-López: None declared, Montserrat Rivero-Tirado: None declared, Beatriz Castro: None declared, Iñigo González-Mazón: None declared, Javier Crespo: None declared, Miguel A González-Gay Speakers bureau: AbbVie, Pfizer, Roche, Sanofi, Celgene and MSD., Grant/research support from: AbbVie, MSD, Jansen and Roche,, Ricardo Blanco Speakers bureau: AbbVie, Pfizer, Roche, Bristol-Myers, Janssen, Lilly and MSD., Grant/research support from: AbbVie, MSD and Roche

Effectiveness and Safety of Ustekinumab in Ulcerative Colitis: Real-world Evidence from the ENEIDA Registry

BACKGROUND AND AIMS

The development programm UNIFI has shown promising results of ustekinumab in ulcerative colitis [UC] treatment which should be confirmed in clinical practice. We aimed to evaluate the durability, effectiveness, and safety of ustekinumab in UC in real life.

METHODS

Patients included in the prospectively maintained ENEIDA registry, who received at least one intravenous dose of ustekinumab due to active UC [Partial Mayo Score [PMS]>2], were included. Clinical activity and effectiveness were defined based on PMS. Short-term response was assessed at Week 16.

RESULTS

A total of 95 patients were included. At Week 16, 53% of patients had response [including 35% of patients in remission]. In the multivariate analysis, elevated serum C-reactive protein was the only variable significantly associated with lower likelihood of achieving remission. Remission was achieved in 39% and 33% of patients at Weeks 24 and 52, respectively; 36% of patients discontinued the treatment with ustekinumab during a median follow-up of 31 weeks. The probability of maintaining ustekinumab treatment was 87% at Week 16, 63% at Week 56, and 59% at Week 72; primary failure was the main reason for ustekinumab discontinuation. No variable was associated with risk of discontinuation. Three patients reported adverse events; one of them had a fatal severe SARS-CoV-2 infection.

CONCLUSIONS

Ustekinumab is effective in both the short and the long term in real life, even in a highly refractory cohort. Higher inflammatory burden at baseline correlated with lower probability of achieving remission. Safety was consistent with the known profile of ustekinumab.

Evaluation of Saliva Stability for NMR Metabolomics: Collection and Handling Protocols

Maintaining a salivary metabolic profile upon sample collection and preparation is determinant in metabolomics. Nuclear magnetic resonance (NMR) spectroscopy was used to identify metabolite changes during short-term storage, at room temperature (RT)/4 °C/-20 °C, and after sample preparation, at RT/4 °C (mimicking typical clinical/laboratory settings). Interestingly, significant metabolic inter-individual and inter-day variability were noted, probably determining sample stability to some extent. After collection, no changes were noted at -20 °C (at least for 4 weeks). RT storage induced decreases in methylated macromolecules (6 h); lactate (8 h); alanine (12 h); galactose, hypoxanthine, pyruvate (24 h); sarcosine, betaine, choline, N-acetyl-glycoproteins (48 h), while acetate increased (48 h). Less, but different, changes were observed at 4 °C, suggesting different oral and microbial status at different temperatures (with a possible contribution from inter-individual and inter-day variability), and identifying galactose, hypoxanthine, and possibly, choline esters, as potential general stability indicators. After preparation, addition of NaN3 did not impact significantly on saliva stabilization, neither at RT nor at 4 °C, although its absence was accompanied by slight increases in fucose (6.5 h) and proline (8 h) at RT, and in xylose (24 h) at 4 °C. The putative metabolic origins of the above variations are discussed, with basis on the salivary microbiome. In summary, after collection, saliva can be stored at RT/4 °C for up to 6 h and at -20 °C for at least 4 weeks. Upon preparation for NMR analysis, samples are highly stable at 25 °C up to 8 h and at 4 °C up to 48 h, with NaN3 addition preventing possible early changes in fucose, proline (6-8 h), and xylose (24 h) levels.

Review of Philippine Health Laws and its Implication to HTA Institutionalization

Objective

To identify the implications of health legislations on the direction of health technology assessment (HTA) institutionalization in the Philippines.

Methods

We reviewed 15 health laws and extracted information using a preset data extraction tool. The collected data was then subjected to the KJ (Kawakita Jiro) method to group similar provisions, taking into account their respective implications to the HTA direction. Once grouped, a core concept was identified that captured the underlying provisions within the group. After which, the core concepts were tabulated and matched with the core components of HTA institutionalization to identify specific policy implication to HTA.

Results

Three major paradigms emerged that are considered important in the institutionalization of HTA. First, common among the health laws are the need for the provision or expansion of benefit packages through the Philippine Health Insurance Corporation. Aside from the benefit packages, the reviewed laws also require delivery of new health services that entail the use of specific health technologies. Lastly, as a consequence of the need for new health services, equity concerns became evident in relation to the identified health services specifically in terms of socioeconomic divide, geographical location and disease status.

Discussion and Conclusions

The three paradigms identified from the review of health laws indicate synergism and antagonism to the HTA-related policy content of the Philippines' UHC Law. Some identify the need for HTA before being funded by the government while others do not explicitly state this. Despite the health laws requiring expansion or creation of benefit packages and delivery of new health services, there is still a need to undergo HTA in order to ensure efficient use of resources. The presence of these laws should not be tantamount to exception of undergoing HTA process but rather should be taken as a guide for priority-setting of topics for assessment.

Key messages

In the process of institutionalizing HTA, existing legislations on health can help map out areas of priority for assessment. Many health policies preceded the signing of the Universal Health Care Law, thus it is important to review them to determine provisions that are synergistic or antagonistic to the content of UHC Law.

Impact of immune-mediated diseases in inflammatory bowel disease and implications in therapeutic approach

Inflammatory bowel diseases (IBD) belong to the group of immune-mediated diseases (IMIDs). The effect of associated IMIDs in the prognosis in IBD is nowadays unknown. To describe IMIDs associated to IBD patients and evaluate differences linked to the presence or absence of IMIDs. A unicentric retrospective descriptive study was designed. A cohort of 1,448 patients were categorized according to the presence of IMIDs. Clinical characteristics were obtained from IBD database. Univariate and multivariate analysis were performed. 385 patients were diagnosed with associated IMIDs while 1,063 had no associated IMIDs. A prevalence of 26.6% IMIDs associated to IBD was observed. Asthma, skin psoriasis and rheumatoid diseases were most commonly found. Factors associated to the presence of IMIDs were women (OR 1.48; 95 CI 1.17–1.87) and Crohn’s disease (OR 1.35; 95 CI 1.07–1.70). Patients with associated IMIDs required more immunomodulator (OR 1.61; 95 CI 1.27–2.43) and biological treatment (OR 1.81; 95 CI 1.47–2.43). More surgical risk was observed in multivariate analysis in those patients diagnosed with IMIDs prior to the onset of IBD (OR 3.71; 95% CI 2.1–6.56). We considered the presence of IMIDs a poor prognostic factor and suggest a closer monitoring of these patients.

Intraparotid mucous retention cyst in an infant: a rare case report

Mucocoeles can be defined as benign lesions that have resulted from extravasation or retention of saliva in the extraglandular spaces, and commonly affect the minor salivary glands. This case details a mucous retention cyst within the parotid gland of an infant, and its management.

AB0721 OCULAR INVOLVEMENT IN INFLAMMATORY BOWEL DISEASE. STUDY OF 1442 PATIENTS FROM A SINGLE UNIVERSITARY CENTER

Background:

Inflammatory bowel disease (IBD), which includes Crohn’s disease (CD), and Ulcerative colitis (UC) are related to Spondyloarthritis (SpA). Ocular manifestations (OM) are well-stablished in SpA but not in IBD. It has been classically reported that whereas uveitis with SpA is predominantly anterior, unilateral, sudden, and limited; in IBD it is bilateral, posterior, insidious, and chronic(Lyons & Rosenbaum JT. Arch Ophthalmol 1997; 115:61-4).

Objectives:

In a large unselected series of IBD, we study the OM and assess;a) epidemiological, clinical features,b) the relationship with extraintestinal manifestations.

Methods:

Study of all consecutive patients from a single University Hospital during the last 40 years with: a) IBD (CD and UC), andb) OM: uveitis and scleral pathology diagnosed by clinical features and slit-lamp.

Results:

OM were present in 42 (2.9%) (25 women/17 men) (84 eyes) of 1442 IBD patients; OM included the uveitis group (UG) (n=23; 1.6%) and the scleral pathology group (SG) (n=19, 1.32%) (TABLE).

The most common pattern in SG was episcleritis (n=16; 84.21%) and scleritis (n=3). In UG, uveitis was typically anterior (n=18; 78.3%), unilateral (n=19; 82.6%), sudden (n=19; 82.6%), and limited (n=12; 52.2%).

The comparative study between SG vs UG showed in UG a significant predominance of women and UC. Also, a non-significative higher frequency in Pyoderma gangrenosum, erythema nodosum and joint involvement was observed in UG.

After a mean follow-up of 15.2±9.97 years, extraintestinal manifestations were observed in 100% of patients, being articular forms (n=16; 38.10%) the most common type. In addition, joint/axial flare is more related to the presence of uveitis (p=0.038).

Conclusion:

Both uveitis and episcleritis are equally frequent OM in IBD. Although uveitis is more infrequent in IBD than in SpA, it is also anterior, unilateral, sudden and limited in contrast with published data from selected series.

References:

[1]Lyons & Rosenbaum JT. Arch Ophthalmol 1997; 115:61-4

TABLE.Uveitis(n= 23)Epi/scleritis(n=19)pDEMOGRAPHIC PARAMETERSSex, n (%)6 ♂ / 17 ♀11 ♂ / 8 ♀p= 0.04*Age at diagnosis (years) mean ± SD49.13±14.6447.63±12.48p= 0.415INTESTINAL AFFECTIONCD, n (%)12 (52.17)16 (84.21)p= 0.02*UC, n (%)11 (47,83)3 (15,74)p= 0.16EXTRAINTESTINAL AFFECTIONCutaneous manifestations•Erythema nodosum, n (%)6 (26.09)2 (10.53)p= 0.30•Pyoderma gangrenosum, n (%)1 (4.35)0 (0)p= 0.92•Psoriasis, n (%)1 (4.35)4 (21.01)p= 0.23Joint involvement10 (43.50)6 (31.60)p= 0.36•Psoriathic arthritis, n (%)1 (4.35)3 (15.80)p= 0.47•Enteropathic Spondyloarthritis, n (%)6 (26.09)3 (15.80)p= 0.66•Ankylosing Spondylitis, n (%)3 (13.04)0 (0)p= 0.28Digestive manifestations•NASH, n(%)4 (17.39)6 (31.58)p= 0.28

*p value < 0.05. SD:standard deviation;CD:Crohn’s disease; UC:ulcerative colitis; NASH:non-alcoholic steatohepatitis.

Disclosure of Interests:

Lara Sanchez-Bilbao Grant/research support from: Pfizer, David Martinez-Lopez: None declared, Iñigo González-Mazón: None declared, María José García-García: None declared, Montserrat Rivero-Tirado: None declared, Beatriz Castro: None declared, Javier Crespo: None declared, Miguel A González-Gay Grant/research support from: Pfizer, Abbvie, MSD, Speakers bureau: Pfizer, Abbvie, MSD, Ricardo Blanco Grant/research support from: AbbVie, MSD, and Roche, Speakers bureau: AbbVie, Pfizer, Roche, Bristol-Myers, Janssen, and MSD

Clinical Performance of Flash Glucose Monitoring System in Patients with Liver Cirrhosis and Diabetes Mellitus

Flash glucose monitoring system (FGMS) is an improved subset of continuous glucose monitoring with a recognized effectiveness on glycemic control, though validation in patients with Liver Cirrhosis (LC) is lacking. To evaluate the accuracy of FGMS in patients with Type 2 Diabetes Mellitus (DM) and LC, a prospective, case-control study was performed in 61 ambulatory patients with LC and DM (LC group, n = 31) or DM (Control group, n = 30). During 14 days, patients performed 4 assessments per day of self-monitoring of blood glucose (SMBG, reference value) followed by FGMS scanning. There were 2567 paired SMBG and FGMS values used in the accuracy analysis, with an overall mean absolute relative difference (MARD) of 12.68% in the LC group and 10.55% in the control group (p < 0,001). In patients with LC, the percentage of readings within Consensus Consensus Error Grid analysis Zone A and A + B were 80.36% and 99,26%, respectively. Sensor clinical accuracy was not affected by factors such as body mass index, age, gender, Child-Pugh score or edematoascitic decompensation. This is the first study to approach FGMS clinical accuracy in LC, revealing a potential usability of this system to monitor glycemic control in this population.

Role of VEGFs in metabolic disorders

Obesity and metabolic disorders are important public health problems. In this review, the role of vasculature network and VEGF in the adipose tissue maintenance and supplementation is discussed. Angiogenesis is a key process implicated in regulation of tissues homeostasis. Dysregulation of new blood vessels formation may be crucial and contribute to the onset of several pathological conditions, including metabolic syndrome-associated disorders. Adipose tissue homeostasis is fine regulated by vascular network. Vessels support adipose structure. Vasculature modulates the balance between positive and negative regulator factors. In white adipose tissue, vascular endothelial growth factor (VEGF) controls the metabolic activities of adipocytes promoting the trans-differentiation from white to beige phenotype. Trans-differentiation results in an increase of energy consumption. VEGF exerts an opposite effect on brown adipose tissue, where VEGF increases oxygen supply and improves energy expenditure inducing the whitening of adipocytes.

Prevalence and Factors Associated With Fatigue in Patients With Inflammatory Bowel Disease: A Multicentre Study

BACKGROUND AND AIMS

The aims of this study were to determine the prevalence of fatigue in patients with inflammatory bowel disease [IBD], to identify the factors associated with fatigue and its severity, to assess the impact of fatigue on quality of life [QoL], and to evaluate the relationship between fatigue and sleep disorders.

METHODS

This was a prospective multicentre study conducted at 22 Spanish centres. Consecutive patients followed at IBD Units were included. Fatigue was evaluated with the Fatigue Severity Scale [FSS] and the Fatigue Impact Scale [FIS]. Quality of life and sleep quality were assessed using the IBD Questionnaire-Short Form [IBDQ-9] and the Pittsburgh Sleep Quality Index [PSQI], respectively.

RESULTS

A total of 544 consecutive adult IBD patients were included [50% women, mean age 44 years, 61% Crohn's disease]. The prevalence of fatigue was 41% (95% confidence interval [CI] = 37-45%). The variables associated with an increased risk of fatigue were: anxiety [OR = 2.5, 95% CI = 1.6-3.7], depression [OR = 2.4, 95% CI = 1.4-3.8], presence of extraintestinal manifestations [EIMs] [OR = 1.7, 95% CI = 1.1-2.6], and treatment with systemic steroids [OR = 2.8, 95% CI = 1.4-5.7]. The presence of EIMs [regression coefficient, RC = 8.2, 95% CI = 2.3-14.2], anxiety [RC = 25.8, 95% CI = 20.0-31.5], depression [RC = 30.6, 95% CI = 24.3-37.0], and sleep disturbances [RC = 15.0, 95% CI = 9.3-20.8] were associated with severity of fatigue. Patients with fatigue had a significantly decreased IBDQ-9 score [p < 0.001].

CONCLUSIONS

The prevalence of fatigue in IBD patients is remarkably high and has a negative impact on QoL. Therapy with systemic steroids is associated with an increased risk of fatigue. The severity of fatigue is associated with anxiety, depression, sleep disorders, and the presence of EIMs. Fatigue was not associated with anaemia, disease activity or anti-TNF therapy.

Role of age and comorbidities in mortality of patients with infective endocarditis

PURPOSE

The aim of this study was to analyse the characteristics of patients with IE in three groups of age and to assess the ability of age and the Charlson Comorbidity Index (CCI) to predict mortality.

METHODS

Prospective cohort study of all patients with IE included in the GAMES Spanish database between 2008 and 2015.Patients were stratified into three age groups:<65 years,65 to 80 years,and ≥ 80 years.The area under the receiver-operating characteristic (AUROC) curve was calculated to quantify the diagnostic accuracy of the CCI to predict mortality risk.

RESULTS

A total of 3120 patients with IE (1327 < 65 years;1291 65-80 years;502 ≥ 80 years) were enrolled.Fever and heart failure were the most common presentations of IE, with no differences among age groups.Patients ≥80 years who underwent surgery were significantly lower compared with other age groups (14.3%,65 years; 20.5%,65-79 years; 31.3%,≥80 years). In-hospital mortality was lower in the <65-year group (20.3%,<65 years;30.1%,65-79 years;34.7%,≥80 years;p < 0.001) as well as 1-year mortality (3.2%, <65 years; 5.5%, 65-80 years;7.6%,≥80 years; p = 0.003).Independent predictors of mortality were age ≥ 80 years (hazard ratio [HR]:2.78;95% confidence interval [CI]:2.32-3.34), CCI ≥ 3 (HR:1.62; 95% CI:1.39-1.88),and non-performed surgery (HR:1.64;95% CI:11.16-1.58).When the three age groups were compared,the AUROC curve for CCI was significantly larger for patients aged <65 years(p < 0.001) for both in-hospital and 1-year mortality.

CONCLUSION

There were no differences in the clinical presentation of IE between the groups. Age ≥ 80 years, high comorbidity (measured by CCI),and non-performance of surgery were independent predictors of mortality in patients with IE.CCI could help to identify those patients with IE and surgical indication who present a lower risk of in-hospital and 1-year mortality after surgery, especially in the <65-year group.

Increased Antimicrobial Resistance of MRSA Strains Isolated from Pigs in Spain between 2009 and 2018

The problem of emerging resistant microorganisms such as Methicillin-Resistant Staphylococcus aureus (MRSA) associated to livestock is closely linked to improper use of antimicrobial agents. The aim of this study is to find out the prevalence and characteristics of these strains, as well as their evolution in healthy pigs on the Island of Tenerife, Spain. Between October 2009 and December 2010, 300 pigs from 15 wean-to-finishing farms were screened. Between 1 September 2017 and 31 March 2018, a new sampling was performed collecting 125 nasal swabs from pigs belonging to the same farms and under the same conditions as the previous study. MRSA antibiotic resistant patterns were studied. Results: Prevalence of MRSA isolates was 89.6%. All isolates belonged to Sequence Type 398 (ST398), a livestock related strain. All strains studied were resistant to beta-lactamic non-carbapenemic antibiotics and sensitive to teicoplanin, linezolid, vancomycin, rifampicin, quinupristin-dalfospristin, and mupirocine. Between 2009/2010-2017/2018 a significant increase in resistance to gentamicin, tobramycin, trimethoprim-sulfomethoxazole, clindamycin, Fosfomycin, and tigecycline antibiotics was observed in isolated MRSA strains compared to the previous period. We consider a major control and surveillance program of antibiotic use in veterinary care is needed in order to reduce the presence of MRSA strains in livestock and control this significant multi-resistance increase.

The Harvey-Bradshaw Index Adapted to a Mobile Application Compared with In-Clinic Assessment: The MediCrohn Study

Objectives: Mobile apps are useful tools in e-health and self-management strategies in disease monitoring. We evaluated the Harvey–Bradshaw index (HBI) mobile app self-administered by the patient to see if its results agreed with HBI in-clinic assessed by a physician.

Methods: Patients were enrolled in a 4-month prospective study with clinical assessments at months 1 and 4. Patients completed mobile app HBI and within 48 h, HBI was performed by a physician (gold standard). HBI scores characterized Crohn's disease (CD) as remission <5 or active ≥5. We determined agreement per item and total HBI score and intraclass correlation coefficients (ICCs). Bland–Altman plot was performed. HBI changes in disease activity from month 1 to month 4 were determined.

Results: A total of 219 patients were enrolled. All scheduled assessments (385 pairs of the HBI questionnaire) showed a high percentage of agreement for remission/activity (92.4%, κ = 0.796), positive predictive value (PPV) for remission of 98.2%, and negative predictive value of 76.7%. High agreement was also found at month 1 (93.15%, κ = 0.82) and month 4 (91.5%, κ = 0.75). Bland–Altman plot was more uniform when the HBI mean values were <5 (remission). ICC values were 0.82, 0.897, and 0.879 in all scheduled assessments, 1 and 4 months, respectively.

Conclusions: We found a high percentage of agreement between patients' self-administered mobile app HBI and in-clinic physician assessment to detect CD activity with a remarkably high PPV for remission. The mobile app HBI might allow a strict control of inflammation by remote monitoring and flexible follow-up of CD patients. Reduction of sanitary costs could be possible.

Wearable and Implantable Epidermal Paper-Based Electronics

Traditional manufacturing methods and materials used to fabricate epidermal electronics for physiological monitoring, transdermal stimulation, and therapeutics are complex and expensive, preventing their adoption as single-use medical devices. This work describes the fabrication of epidermal, paper-based electronic devices (EPEDs) for wearable and implantable applications by combining the spray-based deposition of silanizing agents, highly conductive nanoparticles, and encapsulating polymers with laser micromachining. EPEDs are inexpensive, stretchable, easy to apply, and disposable by burning. The omniphobic character and fibrous structure of EPEDs make them breathable, mechanically stable upon stretching, and facilitate their use as electrophysiological sensors to record electrocardiograms, electromyograms, and electrooculograms, even under water. EPEDs can also be used to provide thermotherapeutic treatments to joints, map temperature spatially, and as wirelessly powered implantable devices for stimulation and therapeutics. This work makes epidermal electronic devices accessible to high-throughput manufacturing technologies and will enable the fabrication of a variety of wearable medical devices at a low cost.

Effects of perinatal exposure to bisphenol A on the intraprostatic levels of aromatase and 5α-reductase isozymes in juvenile rats

The impact of bisphenol A (BPA) on the prostate gland has taken center stage, with a special focus placed on understanding how BPA affects prostate physiopathology. In this study, we evaluated the ability of lower doses of BPA to induce alterations in 5α-R isozymes and aromatase, in the prostate of juvenile rats exposed during developmental stage. Gestating Wistar rats were treated s.c with either vehicle or BPA (2.4 and 10 μg/kg b.w./day) from gestational day 12 to parturition. Then, male pups were s.c treated from postnatal day 1 through day 21, when they were euthanized and qRT-PCR, western blot and hormone levels determination were performed. We found that BPA at dose of 2.4 and 10 μg/kg b.w./day significantly decreased the mRNA and protein levels of 5α-R2. However, neither 5α-R1 nor 5α-R3 was affected by this exposure. BPA at dose of 10 μg/kg b.w./day significantly increased the mRNA and protein levels of aromatase. BPA also decreased plasma levels of both testosterone and dihydrotestosterone and increased estradiol. These data lend support that low-dose BPA during fetal and neonatal prostate development interfere with in situ estrogen and androgen production in the prostate gland of juvenile rats through the enzymes aromatase and 5α-Reductase.

Portable and power-free serodiagnosis of Chagas disease using magnetic levitating microbeads

Magnetic levitating microbeads enable the point-of-care detection of Chagas antibodies in blood solutions using a portable magnetic stage requiring no electricity.

Outbreak of vancomycin-resistant enterococcus on a haematology ward: management and control

Vancomycin-resistant enterococci (VRE) infections and outbreaks are still infrequent in Spain. A six-month outbreak, which took place in a haematology ward, its control and management are described in this study. A total of 22 patients were colonised and two bloodstream infections occurred during this period. Even though there were two waves of new colonised patients, a multidisciplinary approach, quick interventions and enhanced infection control policies were required in order to control this outbreak.

Evaluation of Muscle Performance in Mice by Treadmill Exhaustion Test and Whole-limb Grip Strength Assay

In vivo muscle function testing has become of great interest as primary phenotypic analysis of muscle performance. This protocol provides detailed procedures to perform the treadmill exhaustion test and the whole-limb grip strength assay, two methods commonly used in the neuromuscular research field.

Phenotypic Resistance to Disinfectants and Antibiotics in Methicillin-Resistant Staphylococcus aureus Strains Isolated from Pigs

The aim of this research was to study the phenotypic resistances to disinfectants and antibiotics in strains of methicillin-resistant Staphylococcus aureus (MRSA) obtained from Canary black pigs. Analyses were performed on 54 strains of MRSA, isolated in Canary black pigs from the province of Tenerife (Spain); all of them carried the mecA gene. The strains were isolated by means of nasal swab samples of healthy pigs, collected under veterinarian supervision. Bactericidal activity of antiseptics and disinfectants was tested by means of the dilution-neutralization method. Susceptibility to the disinfectants glutaraldehyde, peracetic acid and silver nitrate was assessed, as well as to the antiseptics chlorhexidine, benzalkonium chloride and povidone iodine. Susceptibility to a wide array of antibiotics representing the main groups was determined by means of the disc diffusion method. All the strains demonstrated susceptibility to the disinfectants tested at the recommended concentration, and even to dilutions equal to or lesser than 1/16. The most effective antiseptic and disinfectant were, respectively, chlorhexidine and silver nitrate. With regard to the antibiotics, the strains proved to be multiresistant. All presented phenotypic resistance to the β-lactam antibiotics ampicillin, penicillin and cefoxitin, as well as to numerous aminoglycosides, tetracycline and trimethoprim-sulfamethoxazole. It was also observed that 61.1% of the strains were carriers of plasmids. Our results underline that in the strains such as MRSA, which show multiple resistances to antibiotics, the antiseptics and disinfectants show great efficacy. Moreover, as other authors also suggest, for the treatment and prevention of infections caused by MRSA, the use of β-lactam and aminoglycoside antibiotics may be less effective.

Tuberculosis in Anti-Tumour Necrosis Factor-treated Inflammatory Bowel Disease Patients After the Implementation of Preventive Measures: Compliance With Recommendations and Safety of Retreatment

BACKGROUND AND AIMS

Despite having adopted preventive measures, tuberculosis (TB) may still occur in patients with inflammatory bowel disease (IBD) treated with anti-tumour necrosis factor (anti-TNF). Data on the causes and characteristics of TB cases in this scenario are lacking. Our aim was to describe the characteristics of TB in anti-TNF-treated IBD patients after the publication of the Spanish TB prevention guidelines in IBD patients and to evaluate the safety of restarting anti-TNF after a TB diagnosis.

METHODS

In this multicentre, retrospective, descriptive study, TB cases from Spanish hospitals were collected. Continuous variables were reported as mean and standard deviation or median and interquartile range. Categorical variables were described as absolute and relative frequencies and their confidence intervals when necessary.

RESULTS

We collected 50 TB cases in anti-TNF-treated IBD patients, 60% male, median age 37.3 years (interquartile range [IQR] 30.4-47). Median latency between anti-TNF initiation and first TB symptoms was 155.5 days (IQR 88-301); 34% of TB cases were disseminated and 26% extrapulmonary. In 30 patients (60%), TB cases developed despite compliance with recommended preventive measures; *not performing 2-step TST (tuberculin skin test) was the main failure in compliance with recommendations. In 17 patients (34%) anti-TNF was restarted after a median of 13 months (IQR 7.1-17.3) and there were no cases of TB reactivation.

CONCLUSIONS

Tuberculosis could still occur in anti-TNF-treated IBD patients despite compliance with recommended preventive measures. A significant number of cases developed when these recommendations were not followed. Restarting anti-TNF treatment in these patients seems to be safe.

Notch activation drives adipocyte dedifferentiation and tumorigenic transformation in mice

Adipocyte-specific activation of Notch signaling suppresses lipid metabolism pathways that provide ligands to Pparγ, leading to adipocyte dedifferentiation and development of liposarcomas (LPSs) resembling human dedifferentiated LPSs with complete penetrance. Pparγ ligand supplementation prevents liposarcoma development.

Liposarcomas (LPSs) are the most common soft-tissue cancer. Because of the lack of animal models, the cellular origin and molecular regulation of LPS remain unclear. Here, we report that mice with adipocyte-specific activation of Notch signaling (Ad/N1ICD) develop LPS with complete penetrance. Lineage tracing confirms the adipocyte origin of Ad/N1ICD LPS. The Ad/N1ICD LPS resembles human dedifferentiated LPS in histological appearance, anatomical localization, and gene expression signature. Before transformation, Ad/N1ICD adipocytes undergo dedifferentiation that leads to lipodystrophy and metabolic dysfunction. Although concomitant Pten deletion normalizes the glucose metabolism of Ad/N1ICD mice, it dramatically accelerates the LPS prognosis and malignancy. Transcriptomes and lipidomics analyses indicate that Notch activation suppresses lipid metabolism pathways that supply ligands to Pparγ, the master regulator of adipocyte homeostasis. Accordingly, synthetic Pparγ ligand supplementation induces redifferentiation of Ad/N1ICD adipocytes and tumor cells, and prevents LPS development in Ad/N1ICD mice. Importantly, the Notch target HES1 is abundantly expressed in human LPS, and Notch inhibition suppresses the growth of human dedifferentiated LPS xenografts. Collectively, ectopic Notch activation is sufficient to induce dedifferentiation and tumorigenic transformation of mature adipocytes in mouse.