COVID-19 infection in patients with intestinal failure: UK experience

BACKGROUND

The direct effect of the coronavirus disease 2019 (COVID-19) pandemic on patients with intestinal failure (IF) has not been described.

METHODS

We conducted a nationwide study of UK IF centers to evaluate the infection rates, presentations, and outcomes in patients with types 2 and 3 IF.

RESULTS

A total of 45 patients with IF contracted COVID-19 between March and August 2020; this included 26 of 2191 (1.2%) home parenteral nutrition (HPN)-dependent adults and 19 of 298 (6.4%) adults hospitalized with type 2 IF. The proportion of patients receiving nursing care for HPN administration was higher in those with community-acquired COVID-19 (66.7%) than the proportion in the entire HPN cohort (26.1%; P < .01). Two HPN-dependent and 1 hospitalized patient with type 2 IF died as a direct consequence of the virus (6.7% of 45 patients with types 2 or 3 infected).

CONCLUSION

This is the first study to describe the outcomes of COVID-19 in a large cohort of patients requiring long-term PN. Methods to reduce hospital and community nosocomial spread would likely be beneficial.

Epstein-Barr Virus-Positive Mucocutaneous Ulcers Complicate Colitis Caused by Immune Checkpoint Regulator Therapy and Associate With Colon Perforation

BACKGROUND & AIMS

Cancer therapy with immune checkpoint inhibitors can cause colitis and colon perforation. We investigated whether infection with Epstein Barr virus (EBV) associates with development and severity of colitis in patients receiving immune checkpoint inhibitor therapies.

METHODS

We performed a retrospective analysis of fixed colon tissues from 16 patients (12 men, 4 women, median age, 69.5 y) with colitis after immune checkpoint inhibitor therapy (9 patients treated with anti-CTLA4, 3 patients treated with anti-PD1, and 4 patients received a combination). Ten tissue samples were biopsies and 6 were collected during resection (4 surgeries for colon perforation). Patients were treated between 2010 and 2018 in the United Kingdom. The tissues were analyzed by pathology, in situ hybridization (to detect EBV-encoded small RNAs [EBERs]), and immunohistochemistry. Clinical data were also collected.

RESULTS

Colon tissues from 4 of the 13 patients who received anti-CTLA4 (alone or in combination, 4 with colon perforation) had EBV-positive lymphoproliferations that manifested as florid ulcers associated with polymorphous infiltrates containing EBV-positive blasts (CD30+ or CD30-negative, CD20+, CD3-negative, and EBER+), plasma cells (CD138+, CD20-negative, and EBER+ or EBER-negative), and small B cells (CD20+, CD3-negative, and EBER+ or EBER-negative), consistent with EBV-positive mucocutaneous ulcers (EBVMCUs). In analyses of biopsies collected from 2 patients with EBVMCUs over multiple time points, we found that earlier biopsies had no or only a few EBV-positive cells, whereas 1 later biopsy had EBVMCU and co-infection with cytomegalovirus. EBVMCUs were associated with steroid-refractory colitis (100% of EBV-positive patients vs 12.5% of EBV-negative patients; P = .008) and colon perforation (100% of EBV-positive patients vs no EBV-negative patients; P = .001).

CONCLUSIONS

We found that colon tissues from 4/13 patients with colitis after anti-CTLA4 therapy (4/6 patients who underwent resection and 4/4 patients with colon perforation) contained EBVMCUs. EBVMCUs seem to arise secondarily in areas of inflamed colon due to immunosuppressive treatment for colitis. EBVMCUs are associated with steroid-refractory colitis and colon perforation.

Sugar sensor genes in the murine gastrointestinal tract display a cephalocaudal axis of expression and a diurnal rhythm

Distributed along the length of the gastrointestinal (GI) tract are nutrient sensing cells that release numerous signaling peptides influencing GI function, nutrient homeostasis and energy balance. Recent studies have shown a diurnal rhythm in GI nutrient sensing, but the mechanisms responsible for rhythmicity are poorly understood. In this report we studied murine GI sugar sensor gene and protein expression levels in the morning (7 AM) and evening (7 PM). Sweet taste receptor ( tas1r2/tas1r3/gnat3/gnat1) sugar transporter ( slc5a1, slc2a2, slc2a5) and putative sugar sensor ( slc5a4a and slc5a4b) gene expression levels were highest in tongue and proximal and distal small intestine, respectively. Clock gene ( cry2/arntl) activity was detected in all regions studied. Slc5a4a and slc5a4b gene expression showed clear diurnal rhythmicity in the small intestine and stomach, respectively, although no rhythmicity was detected in SGLT3 protein expression. Tas1r2, tas1r3, gnat1, and gcg displayed a limited rhythm in gene expression in proximal small intestine. Microarray analysis revealed a diurnal rhythm in gut peptide gene expression in tongue (7 AM vs. 7 PM) and in silico promoter analysis indicated intestinal sugar sensors and transporters possessed the canonical E box elements necessary for clock gene control over gene transcription. In this report we present evidence of a diurnal rhythm in genes that are responsible for intestinal nutrient sensing that is most likely controlled by clock gene activity. Disturbances in clock gene/nutrient sensing interactions may be important in the development of diet-related diseases, such as obesity and diabetes.

Effects of eosinophilic oesophagitis on quality of life in an adult UK population: a case control study

Eosinophilic oesophagitis (EoE) is a chronic immune-mediated esophageal disease, characterized by symptoms related to esophageal dysfunction and histologically by eosinophil predominant inflammation. Current evidence for an adverse impact on quality of life (QoL) is conflicting and there are no data from a UK population regarding QoL. We conducted a prospective cross-sectional observational study using the Short Form-36 Health Survey, Hospital Dysphagia/Odynophagia Questionnaire, and the EoE Adult Quality of Life Questionnaire to assess QoL and severity of dysphagia in EoE patients, compared to age and gender matched healthy control subjects. Data were also collected on comorbidity and medication use. Eighty-eight subjects were recruited (44 patients). Patients had higher rates of antihistamine and topical (swallowed) corticosteroid use. Physical QoL did not differ between patients and controls, although patients did report a statistically significant lower mental QoL, with small absolute magnitude of difference. Patients reported higher dysphagia scores and these were negatively correlated with both physical and mental QoL. Higher rates of dysphagia and medication use in patients may among other things account for lower mental QoL. However, a higher rate of dysphagia in patients is not associated with a reduced physical QoL. Our findings are of clinical value, particularly when a new diagnosis of EoE is made, as clinicians can reassure patients that their general physical health should not be greatly affected by the diagnosis. Moreover, it may also be useful for patients to be aware that EoE may have an impact on their mental health, but this effect is likely to be small. We therefore advocate education and reassurance in this respect for all patients at diagnosis.

Eosinophilic oesophagitis

Eosinophilic oesophagitis is a chronic immune-mediated inflammatory disorder of the oesophagus, characterized by symptoms of dysphagia or food bolus obstruction. Diagnosis is supported by typical histological findings. This article covers pertinent aspects of the disease, pathogenic explanations and treatment options.

Differences in intestinal metaplasia in Barrett's esophagus patients in an ethnically diverse south London population

Barrett's esophagus (BE) is the replacement of any portion of the normal distal squamous epithelial mucosa by metaplastic columnar epithelium and is the only known precursor for esophageal adenocarcinoma. We undertook a study to identify ethnic differences for the presence of intestinal metaplasia (IM) in BE in patients in an ethnically diverse south London population. Retrospective analysis was done using the endoscopy database of St George's Hospital NHS Trust, which serves a large ethnically diverse London population. Gastroscopy records between 2009 and 2012 were retrieved, and patients with an endoscopic diagnosis of BE were identified. Patients of Indian subcontinent Asian origin (ISCA) were further identified. The presence of IM was retrieved from hospital pathology databases and was the primary outcome measured. Multivariate logistic regression analysis was performed to determine the odds of having IM by ethnic origin. ISCAs were 70% less likely to have IM compared to non-ISCAs (OR 0.32, 95% CI: 0.16-0.61, p = 0.001). This is the first study to identify differences in histological findings in ISCAs with BE living in the UK. Our findings may be useful for the future risk stratification of BE patients. Identification of environmental factors responsible for this difference would be of great therapeutic value.

New Barrett's oesophagus surveillance guidelines: significant cost savings over the next 10 years on implementation

OBJECTIVE

We aimed to estimate the cost saving (over the next 10 years) by our trust implementing the new British Society of Gastroenterology (BSG) surveillance guidelines for Barrett's oesophagus (BO).

DESIGN

Retrospective endoscopy database analysis.

SETTING

Two endoscopy units of St George's Hospital NHS Trust, London.

PATIENTS

Gastroscopy records between 2009 and 2012 were retrieved and patients with an endoscopic diagnosis of BO were identified. BO segment length was recorded and the presence (or absence) of intestinal metaplasia in the oesophageal biopsy samples was reviewed from pathology databases. Patients were then stratified into risk groups in accordance with the new BSG guidelines.

INTERVENTIONS

Nil.

MAIN OUTCOME MEASURES

The projected surveillance costs using the new and the old guidelines were calculated over the next 10 years and the cost saving by the implementation of the new guidelines thus determined.

RESULTS

The 10 year projected cost saving for our trust by implementing the new BO surveillance guidelines was £720 330 (or £72 033 per annum). Projected across the NHS, implementation of the new guidance may save £100 million over the next 10 years.

CONCLUSIONS

All trusts should review their Barrett's surveillance population and implement these new recommendations expeditiously.

Documentation of cerebrospinal fluid opening pressure and other important aspects of lumbar puncture in acute headache

BACKGROUND

Measuring cerebrospinal fluid (CSF) opening pressure by lumbar puncture (LP) is an essential tool in the investigation of patients with acute headache.

AIM

To assess documentation of opening CSF pressure in those with acute headache undergoing LP. General documentation of the procedure and CSF investigations was also assessed.

METHODS

Retrospective review of medical records of patients admitted to a teaching hospital Acute Medical Admissions Unit over a three-month period with a presenting complaint of headache.

RESULTS

A total of 106 patients presented with headache of whom 48 patients had at least one LP attempted. Only 41 patients (85%, 95% CI 72-94) had their LP documented. Of 47 patients that had a successful LP, 22 (47%) had a recorded opening pressure. Eighteen (32%) of all patients had their position recorded, with seven (15%) patients having had position and opening pressure documented. Twenty patients (43%) had the appropriate results documented. Twelve patients (31%) had paired serum glucose measured.

CONCLUSIONS

Documentation of a LP for headache in the acute setting was generally poor. CSF opening pressure measurement was frequently omitted and no appropriate action taken if high. Paired serum glucose was rarely measured. Acute physicians may benefit from a proposed protocol and documentation sticker.

Induction and persistence of B-cell tolerance to the thymus-dependent component of the alpha(1 leads to 6) glucosyl determinant of dextran. Recovery induced by treatment with dextranase in vivo

A direct comparison was made between thymus-dependent (TD) and thymus-independent (TI) responses in mice tolerized for (1 leads to 6) glycosyl determinants by the injection of dextran B512. Long-lasting B-cell tolerance by dextran was reversed when mice were treated with dextranase in vivo. Complete or partial reversion of tolerance with the enzyme was invariably obtained for the TI response but the TD component proved to be more resistant and dependent on the immunogen used to test the reversion. The uniformity of the spectrotype in BALB/c mice, even under conditions of partial tolerance, permitted the analysis by isoelectric focussing of serum from tolerant mice treated with dextranase and immunized with TD dextran-ovalbumin. Results showed that, with one single exception, mice thus treated produced spectrotypes no different from the pattern normally found in immune animals. The results presented suggest that at least some alpha(1 leads to 6) specific B cells, both TD and TI, persist in tolerized mice for at least 2 weeks after tolerance induction and they do not support the concept of clonal elimination for either TI or TD responses in adult mice.

Characteristics of the T-dependent alpha(1 leads to 6) glucosyl (dextran) antibody response induced in mice with isomaltohexaose coupled to chicken gamma-globulin

Isomaltohexaose flavazole coupled to chicken gamma-globulin (IM6-CGG) induced T cell-dependent anti-alpha(1 leads to 6) dextran-specific IgM and IgG responses in CBA, BALB/c and A strain mice. The IgG responses were of restricted heterogeneity as judged by isoelectric focusing, and belonged mostly to the IgG1 subclass with a minor IgG3 component in the case of BALB/c and CBA mice. All four subclasses of IgG were produced in A strain mice. In contrast, native dextran B 512 induces exclusively T cell-independent IgM responses of the same specificity for all 3 strains. All BALB/c mice immunized with different doses of IM6-CGG either in Freund's adjuvant or with Al(OH)3 plus Bordetella pertussis showed the same spectrotypes by isoelectric focusing. Sera obtained at different times after immunization of BALB/c mice failed to show spectrotype variations. Late, but not early, bleedings from CBA mice showed a tendency towards more uniform isoelectric focusing patterns.

The use of hapten-polysaccharide conjugates for the induction of B-cell tolerance involving IgE responses. I. Preparation, characterization and specific tolerogenic activity of penicilloy l-substituted levans affecting IgE responses in normal and sensitized mice

Benzyl penicillin was coupled directly to the hydroxylic groups of dextrans and levans, and indirectly to the amino groups of diaminopropyl-carboxymethyl-levans. Derivatives of both types were tested for their capacity to react with anti-penicilloyl antibodies, either in vitro (immunoprecipitation and its inhibition) or in vivo (inhibition of PCA reaction). Only derivatives coupled to diaminopropyl-carboxymethyl-levans were active by both criteria. High molecular weight penicilloyl-diaminopropyl-carboxymethyl-levans were tested for their immunogenicity (IgM response) and capacity to induce tolerance in the IgE component of anti-penicilloyl responses in DBA/2 and CBAT6T6 mice. The IgM response to the levan carrier was very much depressed by penicilloyl substitution of the levan, whilst that to the penicilloyl determinants was also very poor. These derivatives induced a state of IgE antibody tolerance when given before or after the induction of an allergic response with penicilloyl-ovalbumin. A higher degree of substitution was required for the induction of tolerance after immunization.

The tolerance induced was specific, since it did not affect IgE responses against ovalbumin and persisted for at least 3 months. Further challenges with penicilloyl-ovalbumin did not break the tolerant status.