A37 FECAL CALPROTECTIN IN A PEDIATRIC, POPULATION-BASED STUDY: UTILITY IN DIAGNOSIS AND INFLAMMATORY BOWEL DISEASE MONITORING

Background

Fecal calprotectin (FC) is a sensitive marker of intestinal inflammation, and is used to both discriminate inflammatory bowel disease (IBD) from non-IBD patients and to monitor patients with IBD. It is unclear whether normal values established in adult patients are applicable in pediatrics.

Purpose

To evaluate FC’s ability to differentiate IBD from non-IBD pediatric patients, and to understand factors influencing FC in pediatric IBD(pIBD).

Method

Stool FC samples collected on all patients<19 years of age in British Columbia(BC) from May 2020 to August 2022 were run using a Buhlmann ELISA at BC Children’s Hospital(BCCH). The BCCH GI database identified patients with IBD. FC’s ordered by adult IBD providers and patients awaiting endoscopy were excluded. The remaining samples were analysed as non-IBD. The sensitivity(Sn), negative predictive value(NPV) and false positive(FP) of FC were evaluated; comparisons were made using the Wilcoxon rank-sum test and chi-squared.

Result(s)

3506 FC samples met inclusion criteria: 1853 IBD and 1653 non-IBD. 221 IBD samples were from prior to diagnosis, with median (IQR) FC 2615ug/g(1090-4183); median FC for non-IBD patients was 54ug/g(24-122). Using the Buhlmann "normal" cutoff of 80ug/g, the Sn was 0.991 (NPV 0.998) with a FP rate of 37%. Young patients were more likely to have FP's: <6yo's (n=305) had a FP rate of 42% vs 36% in those >6yo (n=1348)(p=0.035). With a FC cutoff of 160ug/g, Sn was 0.973 (NPV 0.996), with a FP rate of 20% (24% <6yo vs 19% >6yo, p=0.025). At a threshold of 250ug/g, Sn was 0.959 (NPV 0.994) with a FP rate of 13% (18% <6yo vs 12% >6yo, p=0.01). For patients <2yo, all 4 new IBD diagnosis had FC>1900ug/g. In the non-IBD population (n=69 samples <2yo), the FP rate was 52%, 30%, and 22% using a threshold of 80, 160, and 250ug/g, respectively.

Evaluating FC as a disease-monitoring tool in IBD (667 patients, 1632 samples) found that at 6, 12, 18, and 24+ months post diagnosis, FC decreased from 750(159-1883), 505(110-1566), 351(87-1379), to 308ug/g(85-1129), respectively. Similarly, the proportion of FC’s <250ug/g increased from 4.1% at diagnosis to 30%, 39.7%, 41.5%, 47% during the follow up period.

Patients with UC/IBD-U had higher FC’s, and were less likely to achieve FC<250ug/g. By 12 months post diagnosis, median FC of CD patients was 347ug/g(96-1150) and UC/IBD-U was 745ug/g(191-2017)(p=0.036), and at 18 months, CD 273ug/g(61-902) vs UC/IBD-U 932ug/g(144-2229)(p<0.001). At 2+yrs, median FC for CD patients was 259ug/g(76-1038) vs 387ug/g(108-1577) for UC/IC (p=0.017).

Patients cared for by an IBD specialist had better FC outcomes vs those managed by non-IBD GIs: median FC at 12 months was 246ug/g(n=79) vs 677ug/g(n=153)(p=0.002), with 51% vs 34% achieving FC<250(p=0.014). Similarly, at 2+yrs post diagnosis, median FC was 243ug/g(n=437) vs 356ug/g(n=407)(p=0.02).

Conclusion(s)

Higher FC thresholds are likely required in younger populations compared to established adult cutoffs. In this pIBD cohort, <50% achieve FC levels <250ug/g.

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None

Disclosure of Interest

None Declared

A45 INFLIXIMAB IN COMBINATION WITH AN IMMUNOMODULATOR IS ASSOCIATED WITH AN ATTENUATED ANTIBODY RESPONSE TO BNT162B2 SARS-COV-2 VACCINE IN PEDIATRIC INFLAMMATORY BOWEL DISEASE PATIENTS

Background

Adult data have shown that Infliximab (IFX) impairs the antibody response to a single dose of the mRNA-BNT162b2 SARS-CoV-2 vaccine in patients with inflammatory bowel disease (IBD). The true impact of IFX on SARS-CoV-2 vaccine efficacy in pediatric IBD (PIBD) patients is unknown.

Aims

To evaluate the humoral immune response to the BNT162b2 SARS-CoV-2 in PIBD patients treated with anti-tumor necrosis factor (TNF) therapy.

Methods

PIBD patients treated with anti-TNF therapy either alone or in combination with an immunomodulator, who received at least one dose of the BNT162b2 SARS-CoV-2 vaccine, were prospectively enrolled from 1st June 2021 at BC Children’s Hospital. Serum antibody levels for [spike (S) protein and receptor-binding domain (RBD)] were determined at baseline and 28 days after their first and second vaccine doses. Antibody responses were assessed using multiplex serology IgG assay against four SARS-CoV-2 antigens: S-protein, RBD, N-terminal domain (NTD) and N-protein using the SARS-CoV-2 Panel 2 (Meso Scale Diagnostics).

Results

Forty-two PIBD patients received a single dose of BNT162b2 (median age 14.5yrs (IQR 14–16); 43% female; 79% crohn’s disease, 21%, ulcerative colitis). Of those on IFX monotherapy (43%), both S-protein and RBD antibody concentrations 28 days post BNT162b2 were comparable to healthy adult controls (n=20, median age: 36yrs (IQR 29–40); 65% female) who had received one dose of BNT162b2 (p = 0.07) [Figure 1]. In PIBD patients on IFX in combination with either azathioprine or methotrexate (57%) both S-protein and RBD antibody concentrations were significantly lower than controls after 1 dose of BNT162b2 (p = 0.0003) [Figure 1].

In the PIBD cohort (n=27) who received 2 doses of BNT162b2 vaccine (median age 14yrs (IQR 14–16);41% female;63% crohn’s disease, 37% ulcerative colitis; median interval between doses 56 days (IQR 22–105)), there was no difference in antibody response after 2 doses compared to healthy adult controls (n=14, median age: 44 years (IQR 36–51); 29% female) whether they were on IFX monotherapy (41%) or in combination with an immunomodulator (59%) [Figure 1].

Conclusions

We provide evidence of an attenuated antibody response in PIBD patients on IFX in combination with an immunomodulator after a single dose of BNT162b2. However, our data show a robust antibody response in PIBD patients, despite their infliximab treatment, after two doses of BNT162b2 vaccine. Our results are consistent with adult IBD data and highlight the importance of administering the second vaccine dose to achieve protection in this vulnerable patient population. Long-term follow-up to assess longevity of vaccine protection is warranted.

Funding Agencies

None

The Phenotypic Spectrum of New-onset IBD in Canadian Children of South Asian Ethnicity: A Prospective Multi-Centre Comparative Study

BACKGROUND

Canadian-born children of South Asian [SA] ethnicity develop inflammatory bowel disease [IBD] at similar rates to those among Caucasian children. We evaluated the variation in phenotypic spectrum of IBD in SA and Caucasian children in a national paediatric inception cohort of new-onset IBD.

METHODS

Patients aged <17 years, enrolled in a Canadian nationwide inception cohort study, were included. Baseline demographic and IBD phenotypic features were compared between SA and Caucasian children. Longitudinal outcomes through 18 months of follow-up were compared matched by propensity scores.

RESULTS

Of 1156 children enrolled over 2014 to 2019, 623 were Caucasian [98% and 88% parents Canadian born] and 114 SA [79% Canadian born, 87% parents SA born]. Fewer SAs have a first-degree relative with IBD, 6% vs 19% in Caucasians, p = 0.002. SAs present at a younger age, median age 11.4 years (interquartile range [IQR] 9.2-14.3) vs 13 years [IQR 10.9-15 years], p = 0.03 and more commonly with a UC/IBD-U [ulcerative colitis/IBD-unclassified] subtype [ratio of UC/IBD-U to CD 1.2:1 vs 1:1.8 for Caucasians, p <0.001]. Additionally, a greater proportion of SA CD patients present with colonic-only disease [colonic-only CD/UC/IBD-U in SAs 67% vs 57% for Caucasians, p = 0.001], and among those with CD, colonic CD in SAs 31% vs 23% in Caucasians, p = 0.20]. Perianal fistulising disease was also numerically more common in SAs (14 [27%] vs 64 [18%], p = 0.06]. Adjusting for differences in phenotypic presentation, anti-tumour necrosis factor [TNF] exposure, and time to initiation was similar, and two-thirds of children, whether anti-TNF exposed or naïve, were in corticosteroid-free clinical remission at 18 months irrespective of ethnicity.

CONCLUSIONS

The phenotypic spectrum of new-onset IBD in SA children differs from that of Caucasian children, but treatment and clinical course are similar within phenotypic subgroups.

O-101 Neospermatogenesis benefits from a three-dimensional culture system

Study question

Does a three-dimensional (3D) culture system increase the efficiency of male germline differentiation of mouse embryonic stem cells (mESC) over a bidimensional method?

Summary answer

Our 3D culture system based on direct spherification proves superior to the standard bidimensional plating in promoting neogametogenesis of mESC into post-meiotic male germ cells.

What is known already

Two-dimensional monolayer cell cultures are common in stem cell research. However, this method does not replicate a physiological 3D spatial relationship and may provide an inaccurate replication of in vivo environments. A 3D spherical structure allows us to mimic the seminiferous tubule, the site of in vivo spermatogenesis. By using spheroids as a scaffold to replicate cell culture systems, we can study spermatogenesis in a controlled setting. Direct spherification, a technique commonly used in molecular gastronomy, provides an opportunity to create spheroids that mimic in vivo events that materialize in the lab

Study design, size, duration

mESCs were initially cultured on a 6-well plate coated with fibroblasts and inserted into sodium alginate spheres. To coax differentiation, spheres (3 to 6 mm in diameter) were plunged directly into differentiation medium (DM) while the control mESC in 6-well dishes were layered with it. Cells obtained from both culture systems were tested by biomarkers for different germ cell stages

Participants/materials, setting, methods

Bidimensional mESC at 80% confluence were differentiated either on a plate or spherified for a 3D culture. Both systems underwent the same timeline of exposure to EpiLC medium with Activin A, bFGF and KSR for 3 days and PGCLC medium with BMP4, LIF, SCF and EGF for 7 days. Differentiated cells were retrieved from each method at day 3 and day 10 to assess for germ line differentiation markers, DAZL, VASA and BOULE

Main results and the role of chance

Under optic visualization through the sphere wall, cellular aggregation was seen on day 2 of culturing in EpiLC medium while this phenomenon was not observed on bidimensional plating. In the conventional method, cells expressed 7% DAZL (spermatogonium cell stage) and 1% VASA (pre-spermatid cell stage) whereas in direct spherification, cells expressed 20% DAZL (P &lt; 0.001) and 15% VASA positivity (P &lt; 0.0001).

To further compare the different methods in later stages of germ-line differentiation, the remaining spheres were cultured in PGCLC medium for 7 days. At day 10, isolated cells were assessed for VASA and DAZL again. In the conventional method, 23% of cells expressed positivity for VASA and 29% DAZL whereas direct spherification achieved a positivity rate of 43% for VASA (P &lt; 0.005) and 45% for DAZL (P &lt; 0.005). This increased expression in both VASA and DAZL signify the increased number of cells undergoing germline differentiation.

Additionally, BOULE was assessed for the presence of meiotic cells such as the spermatocyte. The conventional method yielded &lt; 1% BOULE positivity whereas in direct spherification, there was 10% positivity (P &lt; 0.005).

Direct spherifcation result shows that differentiation almost doubled in comparison to the conventional method, yielding more post-meiotic cells in the same amount of time

Limitations, reasons for caution

Despite a higher differentiation rate in direct spherification, these cells would still need to be tested for their fertilization potential. The ability to achieve fertilization, blastocysts and live pups would provide final proof and reliability of this method of neogametogenesis

Wider implications of the findings

Differentiating ESCs through direct spherification provides an alternative to studying intercellular relationships. This provides an opportunity to study spermatogenesis in more detail by replicating the microenvironment of the seminiferous tubule. Once embryo developmental competence of the de novo gamete is confirmed, this may open a new chapter in human reproduction

Trial registration number

N/A

A56 CLINICAL AND BIOCHEMICAL EFFICACY ARE NOT AFFECTED BY SWITCH FROM INFLIXIMAB ORIGINATOR TO RENFLEXIS IN PEDIATRIC INFLAMMATORY BOWEL DISEASE PATIENTS

Background

Increased infliximab (IFX) utilization has generated higher drug expenditures and cost burden to the healthcare system. The expiration of the IFX originator Remicade patent led to the addition of biosimilar agents to the drug market that may reduce drug expenditures. In British Columbia, Pharmacare’s 2019 biosimilar initiative mandated all pediatric inflammatory bowel disease (IBD) patients on Remicade to switch to the biosimilar Renflexis. To date, there is limited pediatric IBD data demonstrating that switching from IFX originator to IFX biosimilar CT-P13 is safe and effective, and no data on switching to Renflexis.

Aims

To determine the proportion of patients remaining on Renflexis 6 months after switch from originator IFX. The secondary aims are to determine the proportion of patients remaining in clinical and biochemical remission after switch.

Methods

In this prospective, longitudinal observation single-center study, all children with Crohn’s disease and ulcerative colitis receiving maintenance IFX originator therapy were switched to Renflexis by May 15th 2020. Baseline demographics, concomitant therapy, clinical disease indices (wPCDAI, PUCAI), growth data, blood work, fecal calprotectin and IFX drug levels were collected at baseline and prospectively from 6 months after the switch. All data are presented as median and interquartile range.

Results

A total of 139 children (110 CD, 25 UC and 4 IBDU; Median age 16.2 (3.7) years) with a median IFX originator duration of 42.7 (35.1) months before switching to Renflexis were included. 137/139 (99%) of patients remained on Renflexis at study end. The proportion of children in clinical remission from baseline to 6 months post switch was unchanged (133/139 (95.7%) vs. 130/132 (98.5%), p=0.17). There was no significant change pre and post switch in median CRP (&lt;5 (0) mg/L vs &lt;5 (0) mg/L, p=0.26) or fecal calprotectin (72.5 (144.2) ug/g vs. 65.5 (140.0) ug/g, p=0.87). There was no significant change pre and post switch in the proportion of patients with normal CRP (&lt;5 mg/L) (89/103 (86.4%) vs 89/98 (90.8%), p=0.33) or normal fecal calprotectin (&lt;250 ug/g)(91/112 (81.2%) vs 51/63 (80.9%), p=0.60). There was no significant change pre and post switch in IFX trough level (15.5 (12.3) ug/mL vs 17.5 (12.9) ug/mL, p=0.42). 2 patients had antibodies to IFX after switching. Safety profile is improved with adverse events in 38/139 (27.3%) children on IFX originator vs. 11/139 (7.91%) children on Renflexis for 6 months.

Conclusions

Pediatric IBD patients can be successfully switched from IFX originator to biosimilar Renflexis during maintenance without affecting efficacy, immunogenicity or safety in the short term.

Funding Agencies

None

A191 TEN YEARS FOLLOW UP OF EARLY ONSET INFLAMMATORY BOWEL DISEASE PATIENTS- A SINGLE CENTER RETROSPECTIVE COHORT STUDY

Background

Early onset inflammatory bowel disease (EOIBD) and Very early onset inflammatory bowel disease (VEOIBD) prevalence has been increasing over the last decades. These young patients have been known to have special disease characteristics and disease location. Although it is known that only a low percentage of these patients require biologic treatment after diagnosis, there is only scarce evidence about their long- term outcome and biologic requirements.

Aims

To assess the ten year outcome of early onset and very early onset IBD patients.

Methods

We retrospectively reviewed IBD patients diagnosed under 10 years of age, between January 2005 and December 2009, from the British Columbia (BC) Pediatric IBD database. Disease characteristics and symptoms at diagnosis were documented. The disease location and severity at diagnosis were documented according to the Paris classification. Data collected retrospectively included a ten year treatment follow up period, number of hospitalizations, corticosteroid courses and surgeries. These parameters were documented at three time points: after the first year, after five years and ten years.

Results

68 patients under the age of 10 were diagnosed with IBD during the study period. 2 patients failed to meet inclusion criteria and were excluded. Median age at diagnosis was 6.06 (IQR 4.5–8.6). 47.7% of patients had Crohn’s disease and 71.2% were males. 63 patients completed the 5 year follow up, and 52 the 10-year period due to lack of follow up or transfer to adult care. After the first year of follow up 0% patients in the VEOIBD group and 5% patients in the EOIBD group were treated with biologic treatment, whereas after the 10-year period 42.3% and 29.6% of patients were treated with biologic therapy respectively (p=0.282). Overall, 4 patients underwent colectomy and 2 a small bowel resection.

Conclusions

Although the percentage of VEIBD and EOIBD patients receiving biologic treatment after ten years is higher than after the first year, it is still lower than what is reported in the literature in older pediatric IBD patients and adults.

Funding Agencies

None

The kids are not alright: Lessons from the advocacy pursuit of restrictions on food marketing

Issue

Poor nutrition is a leading contributor to ill health worldwide. WHO recommends restrictions on the marketing of unhealthy food to children to reduce intakes of energy-dense, nutrient-poor foods. In Canada, the government made this a mandate commitment. This provides an opportunity for other countries pursuing public health nutrition policy to better understand and overcome commercial interests when trying to advance public health.

Background

Heart & Stroke Foundation (H&S) advocated for over a decade (2008-2019) to secure government policies to restrict food marketing to youth in Canada. The inclusion of such policy in the government's 2015 mandate was promising and the associated bill was one of the strongest in the world - well received by public health advocates worldwide, positioning Canada as global leader. However, the commercial interests of various stakeholders including food and marketing industries created concerns among policy makers. Public health advocates underestimated the influence, power and opposition of industry.

Results

In order to counter industry opposition, the public health community worked in coalitions and employed a range of innovative tactics to mitigate policy concerns. This included public engagement on social media, evidence generation, celebrity endorsement, as well as calling out industry practices and political blockers. Despite the innovative and collaborative approach of public health, the policy failed to be adopted.

Lessons

Food industry will use a range of concerns including economic, environmental, and health issues to generate skepticism among policy makers. Public health advocates working in nutrition need to be proactive and prepared with insightful counter arguments and evidence to dispel myths and re-frame the issue.

Key messages

Public health progress on nutrition policy is at an early stage and we need to learn lessons from successes and failures. There is a strong amount of food industry opposition to public health nutrition policy.

When universal health care isn’t truly universal: Beyond filling gaps in access to medicines

Issue

The Canadian healthcare system is defined by universality, but unfortunately that does not extend to drugs outside of hospitals. Access to medication remains an area of inequity, fragmentation and system failure, with millions struggling with cost related non-adherence. This has created major implications for public health, limiting the health status of populations. Canada's inequitable system and the recent pursuit to fix it, provides an opportunity to examine ways of balancing public health goals and health systems reform in a country with established public and private care services.

Background

The government mandated the creation of a plan to improve access to medications. Stakeholder consultations ran from June -September 2018 and the Heart & Stroke Foundation (H&S) aimed to create policy recommendations that would improve population health outcomes and inequities. Research review and analysis determined the scope of the problem and viable solutions. Questions arose around whether a solution could improve equity and lower health care costs without dismantling the existing private system.

Results

Visionary principles led to the recommendation of a universal pharmacare program, designed to improve access to cost-effective medicines for all people in Canada regardless of geography, age, or ability to pay. A hybrid -program would include a robust common formulary for which the public payer is the first payer creating cost efficiencies. Top-up private insurance would result in less strain on the public system and maintain the presence of the existing private industry.

Lessons

Health charities have a unique role to play in creating innovative policy solutions that also serve patient interests. In order to advance public health, health charities need to maintain focus on equity and avoid policy development that is biased with conflict of interest.

Key messages

Canada is primed to implement a unique universal pharmacare program that addresses healthy inequities. Varied stakeholder interests can block public health goals.

Raising the bar: Sex and Gender-Based Analysis and Reporting (SGBAR) in health research

Issue

For decades, research has been male dominated: research led by men with male participants. Two-thirds of heart disease and stroke clinical research is based on men. When research is led by women, sex and gender are more likely to be incorporated into the research itself, and the levels of sex reporting also increases. Unfortunately, the low involvement of women in research around the world - as both researchers and participants - has led to findings that are not always applicable to women, resulting in gaps in treatment, care and recovery. The results are worse health outcomes for women in most countries.

Background

Applying sex and gender methods and analysis in research leads to higher quality results. A review of the literature and research landscape showed that sex and gender analysis was more common in public health, but not in clinical, biomedical or health systems research.

Results

The Heart and Stroke Foundation (Heart & Stroke), as both a funder of research and advocate for systems change recognized the research system perpetuated the inequities in women's health. The solution was to restructure the organization's research funding enterprise and also push for change among the health community. H&S put SGBAR requirements into its research funding program. To build on the change, H&S is now working across all levels of government and research institutions to secure SGBAR as a standard of practice. To date, this advocacy pursuit has created substantial systems change.

Lessons

Due to the complex research landscape, making SGBAR a priority across all research institutions is a massive undertaking. There is a need for both top down and bottom up approaches to ensure wide scale change.

Key messages

Incorporating sex and gender-based analysis and reporting in health research will improve health equity. Health research Funding agencies have an opportunity to raise the bar and shift the research environment.

Phenotypic Variation in Paediatric Inflammatory Bowel Disease by Age: A Multicentre Prospective Inception Cohort Study of the Canadian Children IBD Network

BACKGROUND AND AIMS

Incidence of paediatric inflammatory bowel disease [IBD] in Canada is among the highest worldwide, and age of onset may be decreasing. In a multicentre nationwide inception cohort study, we examined variation in phenotype of IBD throughout the paediatric age spectrum.

METHODS

Children aged ≥2 years [y] and <17y [A1 age at diagnosis], with new onset IBD, were systematically evaluated at sites of the Canadian Children IBD Network. Prospectively recorded phenotypic data were compared between age groups.

RESULTS

Among 1092 children (70% Caucasian; 64% Crohn's disease [CD], 36% ulcerative colitis/inflammatory bowel disease unclassified [UC/IBD-U]; median age 13 y, interquartile range [IQR] 11-15 y), 210 [19%] were diagnosed before the age of age 10 y [Paris A1a] and 43 [4%] before age 6 y (very-early-onset [VEO-IBD]). CD was less common in younger children [42%, 56%, 66%, respectively, of VEO-IBD, A1a; A1b]. Colon-only IBD [UC/IBDU or CD-colon] was present in 81% of VEO-IBD and 65% of A1a; ileal disease increased progressively, reaching plateau at age 10 y. CD location was ileocolonic [L3] in 53% overall. Ileitis [L1] increased with age [6% of VEO-IBD; 13% of A1a; 21% of A1b], as did stricturing/penetrating CD [4% of A1a; 11% of A1b]. At all ages UC was extensive [E3/E4] in >85%, and disease activity moderate to severe according to Physician's Global Assessment [PGA] and weighted Paediatric Crohn's Disease Activity Index/Paediatric Ulcerative Colitis Activity Index [wPCDAI/PUCAI] in >70%. Heights were modestly reduced in CD [mean height z score -0.30 ± 1.23], but normal in UC/IBD-U.

CONCLUSIONS

Paris classification of age at diagnosis is supported by age-related increases in ileal disease until age 10 years. Other phenotypic features, including severity, are similar across all ages. Linear growth is less impaired in CD than in historical cohorts, reflecting earlier diagnosis.

A104 A STUDY OF POST-INDUCTION INFLIXIMAB TROUGH LEVELS DEMONSTRATES MOST PEDIATRIC IBD PATIENTS ARE BEING UNDERDOSED

Background

Infliximab (IFX) is widely used for induction and maintenance of remission in pediatric inflammatory bowel disease (PIBD). Post induction IFX trough levels are a predictor of clinical and biochemical remission at week 52.

Aims

- evaluate the effectiveness of infliximab (IFX) induction regimens in attaining therapeutic post induction IFX trough levels in 2 PIBD cohorts.

- investigate baseline laboratory values and patient factors as predictors of post-induction levels.

Methods

78 patients from Vancouver, Canada [Cohort 1 (C1) originator IFX; variable dose induction regimen] and 62 patients from Glasgow, Scotland [Cohort 2 (C2) replication cohort - biosimilar IFX; standard induction of 5mg/kg at 0, 2 and 6 weeks, with 8 weekly maintenance] were included in the study. Baseline characteristics and laboratory values from time of IFX initiation were recorded. Mann-Whitney U Testing was utilized to analyse the relationship between IFX trough levels and lab parameters.

Results

The median pre-dose 4 trough in C1 & C2 was 4.25mg/L (IQR 7.8) and 1.85mg/L (IQR 3.38) respectively. In C1 patients who had a trough level &lt;3mg/L pre-dose 4, 62% (20/32) had already had a dose adjustment documented. The IFX dose of 50% (39/78) of C1 patients and 65% (40/62) of C2 patients was escalated following the pre-dose 4 IFX level.

TABLE 1

Baseline median albumin (Alb) was significantly lower and replicated in both cohorts in those with low pre-dose 4 IFX levels:

IFX trough &lt;0.8mg/L

C1: Alb 30g/L vs 37.5g/L in IFX ≥0.8mg/L, p=0.002

C2: Alb 34.5g/L vs 37g/L in IFX ≥0.8mg/L, p=0.02

IFX trough &lt;3.0mg/L

C1:Alb 34.5g/L vs 38g/L in IFX ≥3.0mg/L, p= 0.05

C2:Alb 35g/L vs 37g/L in IFX ≥3.0mg/L, p=0.04

IFX trough &lt;5.0mg/L

C1:Alb 35g/L vs 39g/L in IFX ≥5.0mg/L, p=0.006

C2:Alb 35g/L vs 37g/L in IFX ≥5.0mg/L, p=0.45

In the combined cohort (C1 + 2), patients with baseline albumin ≤30g/L had significantly lower IFX levels pre-dose 4 than those with albumin &gt;30g/L (1.4mg/L vs 3.55mg/L, p=0.0003). In patients with an albumin ≤30g/L, 23% (6/26) achieved a dose 4 trough level of ≥3.0mg/L, however only 1/6 patients received a standard induction regime meaning only 4% (1/26) of patients had a trough ≥3.0mg/L on standard treatment.

Conclusions

Standard IFX induction regimen is ineffective in achieving relevant post-induction trough levels (&gt;5 mg/L) in the majority of PIBD patients regardless of IFX type. We suggest that optimization of initial IFX prescribing based on baseline albumin (i.e. a higher dose given to patients with albumin &lt; 30g/L) and subsequent levels will improve post-induction trough levels and consequently clinical outcomes for a greater proportion of patients.

Funding Agencies

None

A171 MAGNETIC RESONANCE IMAGING IN CHILDREN WITH EARLY ONSET INFLAMMATORY BOWEL DISEASE- A RETROSPECTIVE COHORT STUDY

Background

Magnetic Resonance (MR) Imaging is the preferred imaging method in Inflammatory Bowel Disease (IBD) patients to investigate for small bowel disease. There are challenges in performing MR imaging in Early Onset IBD (EO-IBD) patients, and in particular in children with Very Early Onset IBD (VEO-IBD). These children often need a general anaesthetic which exposes them to adverse effects and preclude conventional luminal distention influencing the quality of the test. Therefore, the utility of MR imaging in this age group is questionable.

Aims

To assess the quality of MRI studies in VEO-IBD and EO-IBD patients and to compare the utility of this test between the two groups.

Methods

We retrospectively identified and reviewed IBD patients diagnosed under 10 years of age, between January 1999 and December 2011, from the British Columbia Children’s Hospital (BCCH) GI Division IBD database. Patients’ first diagnostic MRI results were recorded. Disease location and severity were documented according to the Paris classification.

Results

124 patients were included in the cohort, 54 VEO-IBD and 70 EO-IBD patients (See Table 1). Median age at diagnosis was 6.46 (IQR 3.94–8.71), 65.32% males and 43.54% were diagnosed with Crohn’s disease. Overall, 52 patients underwent MRI, 17 (31.48%) in the VEO-IBD group and 35 (50%) in the EO-IBD group; median time from diagnosis to MRI was 3.02 years (IQR 1.08–5.83) for VEO-IBD and 0.44 years (IQR 0.07–1.58) for EO-IBD (p&lt;0.001). In the EO-IBD group there was a significantly higher percentage of patients with MRI findings than in the VEO-IBD group, 23 (67.31%) and 5 (29.41%) respectively (p=0.014). Only one patient in the VEO-IBD group had a disease characteristic identified by MR imaging that could not be diagnosed by endoscopy (small bowel disease).

Conclusions

The diagnostic yield of MRI in children with VEO-IBD appears to be quite limited but requires further study.

Funding Agencies

None

Oral manifestations of thrombocytopaenia

The appearance in the mouth of haemorrhagic petechiae, ecchymoses or blood blisters with spontaneous bleeding is suggestive of a haemorrhagic disorder that may be caused either by functional impairment of platelets or of blood vessel walls, by an abnormal decrease in the number of circulating platelets (thrombocytopaenia), or by defects in the blood clotting mechanism. Thrombocytopaenia from decreased production or increased destruction of platelets may be caused by multiple factors including immune mediated mechanisms, drugs or infections.

A diagnosis of thrombocytopaenic purpura can be made when any other disease entity that might be causing the purpura is excluded on the basis of the medical history, the physical examination, a complete blood count and a peripheral blood smear.

In this paper, we outline the clinical features of oral thrombocytopaenic purpura and briefly discuss some aspects of its aetiopathogenesis and treatment.

Electroselective α-bromination of acetophenone using in situ bromonium ions from ammonium bromide

A greener and expeditious method for the side chain bromination of acetophenone using in situ generated bromonium ions from NH₄Br in a H₂O:CH₃CN medium at ambient temperature has been developed in an undivided cell equipped with a Pt/Pt electrode.

Diabetes UK Position Statement. Competency frameworks in diabetes

The quality, skills and attitudes of staff working in the healthcare system are central to multidisciplinary learning and working, and to the delivery of the quality of care patients expect. Patients want to know that the staff supporting them have the right knowledge and attitudes to work in partnership, particularly for conditions such as diabetes where 95% of all care is delivered by the person with diabetes themselves. With the current changes in the NHS structures in England, and the potential for greater variation in the types of 'qualified provider', along with the recent scandal at Mid-Staffordshire Hospital, staff need to be shown to be competent and named/accredited or recognized as such. This will help to restore faith in an increasingly devolved delivery structure. The education and validation of competency needs to be consistently delivered and assured to ensure standards are maintained for different roles and disciplines across each UK nation. Diabetes UK recommends that all NHS organizations prioritize healthcare professional education, training and competency through the implementation of a National Diabetes Competency Framework and the phased approach to delivery to address this need.

The novel use of commonly captured data to assess a district's diabetes service that encompasses both primary and secondary care

AIM

To identify commonly captured data in the UK to look at the performance of a district's diabetes care that encompasses both primary and secondary care.

METHODS

Primary care quality outcomes framework (QOF) measures for diabetes, referral rates for first appointment for specialist secondary care and emergency admission rates for diabetes (Dr Foster/HES) were used to produce a performance index scoring system. Illustrative measures from QOF were total diabetes points, DM23 attainment of HbA1c <7% (53 mmol/mol) and its exemption rate (number of patients excluded from analysis). The performance index was used to study the effectiveness of the Medway district diabetes service and this was compared to another district (Guildford) within the same Strategic Health Authority and nationally.

RESULTS

Medway has the highest prevalence of Diabetes (6.1%) of the 8 Primary Care Trusts examined, the lowest achievement of diabetes QOF points (96.1%) and the lowest achievement of an HbA1c level <7% (53 mmol/mol) (54.3%). Exemption reporting was the 3rd highest. SAR for first diabetes out-patient appointment to the hospital was low at 281 (predicted 576) 48% of expected. The emergency admission rate was high at 225 (predicted 168) 133% of expected. Thus primary care diabetes needs to raise performance and implement a lower threshold for OPD referral to prevent emergency admissions.

CONCLUSION

It is possible to produce an assessment of diabetes care that transcends primary/secondary care that gives a true reflection of a district's performance which will be useful to plan future health service provision.

Face recognition: a convolutional neural-network approach

We present a hybrid neural-network for human face recognition which compares favourably with other methods. The system combines local image sampling, a self-organizing map (SOM) neural network, and a convolutional neural network. The SOM provides a quantization of the image samples into a topological space where inputs that are nearby in the original space are also nearby in the output space, thereby providing dimensionality reduction and invariance to minor changes in the image sample, and the convolutional neural network provides partial invariance to translation, rotation, scale, and deformation. The convolutional network extracts successively larger features in a hierarchical set of layers. We present results using the Karhunen-Loeve transform in place of the SOM, and a multilayer perceptron (MLP) in place of the convolutional network for comparison. We use a database of 400 images of 40 individuals which contains quite a high degree of variability in expression, pose, and facial details. We analyze the computational complexity and discuss how new classes could be added to the trained recognizer.

Antigen-specific T cell responses to BK polyomavirus antigens identify functional anti-viral immunity and may help to guide immunosuppression following renal transplantation

Infection with the polyoma virus BK (BKV) is a major cause of morbidity following renal transplantation. Limited understanding of the anti-viral immune response has prevented the design of a strategy that balances treatment with the preservation of graft function. The proven utility of interferon-gamma enzyme-linked immunospot (ELISPOT) assays to measure T cell responses in immunocompetent hosts was the basis for trying to develop a rational approach to the management of BKV following renal transplantation. In a sample of transplant recipients and healthy controls, comparisons were made between T cell responses to the complete panel of BKV antigens, the Epstein-Barr virus (EBV) antigens, BZLF1 and EBNA1, and the mitogen phytohaemagglutinin (PHA). Correlations between responses to individual antigens and immunosuppressive regimens were also analysed. Antigen-specific T cell responses were a specific indicator of recent or ongoing recovery from BKV infection (P < 0·05), with responses to different BKV antigens being highly heterogeneous. Significant BKV immunity was undetectable in transplant patients with persistent viral replication or no history of BKV reactivation. Responses to EBV antigens and mitogen were reduced in patients with BKV reactivation, but these differences were not statistically significant. The T cell response to BKV antigens is a useful and specific guide to recovery from BKV reactivation in renal transplant recipients, provided that the full range of antigenic responses is measured.

The psychological impact caused by genital warts: has the Department of Health's choice of vaccination missed the opportunity to prevent such morbidity?

This study evaluated the psychological impact caused by genital warts and whether this altered over time. Eighty-four patients with genital warts and a group of 28 appropriately matched volunteers from the local general population were recruited. The patients were divided into three groups of 28 according to the Health Protection Agency classification codes for genital warts. A comprehensive health questionnaire was completed by all participants. Patients with first attack genital warts experienced significantly more distress, anxiety and depression and were less satisfied with their lives than all the other groups. They also reported less satisfaction with the practical support they received. The recurrent episode genital warts group experienced significantly high levels of emotional distress and the re-registered group reported significantly less emotional and practical support according to their needs. While the first attack genital warts group experienced the most psychological effects, it is clear that those effects did not disappear as an individual came to terms with their diagnosis. The choice of vaccine to prevent cervical cancer will not prevent clinical warts occurring and therefore will not help prevent the psychological morbidity associated with this condition.

121. EXTRACELLULAR ROLES FOR PROREGIONS OF MOUSE BMP15 AND GDF9 IN VIVO

Bone morphogenetic protein 15 (BMP15) and growth differentiation factor 9 (GDF9) are essential for normal follicular development and ovulation in mammalian species. As TGF-beta family proteins, BMP15 and GDF9 are expressed as pre-pro-mature proteins, with a signal region prompting extracellular secretion, a proregion that is post-translationally cleaved, and a mature protein that is known to be biologically active as a non-covalently interacting dimer. Until recently, the proregion was thought primarily to facilitate correct folding and dimerization of the mature proteins within the oocyte prior to processing and cleavage. However, our in vitro work with recombinant mouse BMP15 and GDF9 has shown that each of the proregion, mature protein and the non-processed promature protein are secreted from transfected 293H cells. We showed non-covalent interactions existing between the proregion and mature protein of each of BMP15 and GDF9, and between the BMP15 proregion and GDF9 mature protein. Importantly, a mouse BMP15 proregion antibody was able to abolish cooperative BMP15 and GDF9 bioactivity measured using a granulosa cell thymidine incorporation bioassay, providing strong evidence for an extracellular role for the mouse BMP15 proregion. Currently, to find out whether BMP15 and GDF9 proregions have extracellular roles in vivo, our investigation has utilised knock-down of BMP15 and GDF9 proregion proteins by mouse immunisation. Ovaries of mice immunised with the GDF9 proregion had significantly increased numbers of corpora lutea (p<0.005), while ovaries from mice immunised with BMP15 proregion peptides had significantly fewer corpora lutea (p<0.005). These findings provide the first evidence that the proregions of mouse GDF9 and BMP15 have different physiological roles outside the oocyte. Our future aim is to elucidate the function of these proregions, how these may differ between BMP15 and GDF9, and whether these aspects differ between species with different ovulation quota.