POS0965 MAGNETIC RESONANCE ENTEROGRAPHY AS A SCREENING TOOL FOR AXIAL SPONDYLOARTHRITIS IN CROHN’S DISEASE: A PROSPECTIVE SINGLE-CENTER CROSS-SECTIONAL OBSERVATIONAL STUDY USING MRE SCREENING FOLLOWED BY CLINICAL ASSESSMENT (ProSpA-CD)

Background

Patients with inflammatory bowel disease (IBD) have an excess burden of axial spondyloarthritis (axSpA) (1), but currently there are no reliable screening tools available. Magnetic resonance enterography (MRE) is an oral contrast MRI of the small bowel used to aid the diagnosis of Crohn’s disease (CD) (2). MRE also captures the sacroiliac joints (SIJs) but the radiological assessment of this is often overlooked. MRE scans therefore contain potentially valuable unreported data, which could be used to screen for axSpA in CD patients.

Objectives

To determine: (i) the validity, sensitivity, specificity and area under the receiver operating characteristic (ROC) curve (AUC) of MRE as a screening tool for axSpA in CD, using dedicated axial MRI scans with clinical assessment as the gold standard; (ii) the proportion of patients with evidence of axSpA on MRE who fulfill the 2009 Assessment of Spondyloarthritis International Society (ASAS) criteria for axSpA; (iii) whether the presence of extra-intestinal manifestations (EIMs) or CD location can predict the occurrence of axSpA in CD.

Methods

ProSpA-CD was a pair of linked prospective observational studies conducted at a large secondary care university hospital in the UK. In ProSpA-CD-Screen, patients who had undergone MRE between 2015-2019 were assessed for eligibility. The consenting participants‘ MRE images were evaluated by a rheumatologist and a radiologist, using a scoring system for evidence of axSpA. Participants with evidence of axSpA and a control group of participants without evidence of axSpA were invited to participate in ProSpA-CD-Assess, in which the performance of MRE as a screening test was assessed against a gold standard of clinical assessment, serological testing and dedicated MRI of the spine and pelvis of each participant. ROC curve and logistic regression analyses were performed.

Results

A total of 1344 MRE scans were performed between 2015-2019, of which 501 eligible patients were identified. For ProSpA-CD-Screen, 259 participants were recruited. MRE SIJ abnormalities were identified in 94/259 participants and from these, 90 cases were recruited to ProSpA-CD-Assess. For the control group, 71/165 participants with normal SIJs were recruited to ProSpA-CD-Assess (total cases + controls = 161). A clinical diagnosis of axSpA was made in 41/161 (25.47%) participants, of which 25/161 (15.53%) fulfilled ASAS criteria. We constructed a ROC curve to assess test performance using different thresholds on the MRE scoring system. The optimum threshold corresponded to a sensitivity of 0.60 (95%CI 0.39, 0.79) and specificity of 0.85 (95%CI 0.78, 0.91) for MRE as a screening tool for axSpA (ASAS criteria) with an AUC value of 0.78 (95%CI 0.65, 0.86, p<0.05). We did not find a significant association between axSpA and CD location. Multivariable logistic regression demonstrated significant associations between axSpA (ASAS criteria) and inflammatory back pain (OR 11.03; 95%CI 2.53, 48.10; p<0.05), HLA B27 (OR 9.94; 95%CI 1.84, 53.87; p<0.05), history of dactylitis (OR 51.01; 95%CI 1.07, 2423.90; p<0.05) and plantar fasciitis (OR 9.08; 95%CI 1.30, 63.55; p<0.05).

Conclusion

We have shown that MRE as a screening tool for axSpA in a cohort of CD patients has good specificity, but poor sensitivity, suggesting that its use as a screening tool is limited. There was no significant association between axSpA and CD location or CD EIMs.

References

[1]Garber A, Regueiro M. Extraintestinal Manifestations of Inflammatory Bowel Disease: Epidemiology, Etiopathogenesis, and Management. Curr Gastroenterol Rep. 2019;21(7):31.

[2]Rimola J, Ordas I, Rodriguez S, Garcia-Bosch O, Aceituno M, Llach J, et al. Magnetic resonance imaging for evaluation of Crohn’s disease: validation of parameters of severity and quantitative index of activity. Inflamm Bowel Dis. 2011;17(8):1759-68.

Figure 1.

MRE score ROC curve for participants fulfilling ASAS criteria for axial spondyloarthritis.

Acknowledgements

Acknowledgement is given to Dr Beverly Ng, Katherine Hodges and CARE for their contribution to this study.

Disclosure of Interests

Jobie Evans Grant/research support from: Clinical study (ProSpA-CD) funded by Merck, Sharpe and Dohme (MSD), Tim Raine: None declared, Scott McDonald: None declared, Ken Poole: None declared, Richard Samworth: None declared, Philippe Riede: None declared, Elliott Rees: None declared, Simona D’Amore: None declared, Miles Parkes: None declared, Deepak Jadon Grant/research support from: Clinical study (ProSpA-CD) funded by Merck, Sharpe and Dohme (MSD)

Anti-SARS-CoV-2 antibody responses are attenuated in patients with IBD treated with infliximab

OBJECTIVE

Antitumour necrosis factor (anti-TNF) drugs impair protective immunity following pneumococcal, influenza and viral hepatitis vaccination and increase the risk of serious respiratory infections. We sought to determine whether infliximab-treated patients with IBD have attenuated serological responses to SARS-CoV-2 infections.

DESIGN

Antibody responses in participants treated with infliximab were compared with a reference cohort treated with vedolizumab, a gut-selective anti-integrin α4β7 monoclonal antibody that is not associated with impaired vaccine responses or increased susceptibility to systemic infections. 6935 patients were recruited from 92 UK hospitals between 22 September and 23 December 2020.

RESULTS

Rates of symptomatic and proven SARS-CoV-2 infection were similar between groups. Seroprevalence was lower in infliximab-treated than vedolizumab-treated patients (3.4% (161/4685) vs 6.0% (134/2250), p<0.0001). Multivariable logistic regression analyses confirmed that infliximab (vs vedolizumab; OR 0.66 (95% CI 0.51 to 0.87), p=0.0027) and immunomodulator use (OR 0.70 (95% CI 0.53 to 0.92), p=0.012) were independently associated with lower seropositivity. In patients with confirmed SARS-CoV-2 infection, seroconversion was observed in fewer infliximab-treated than vedolizumab-treated patients (48% (39/81) vs 83% (30/36), p=0.00044) and the magnitude of anti-SARS-CoV-2 reactivity was lower (median 0.8 cut-off index (0.2-5.6) vs 37.0 (15.2-76.1), p<0.0001).

CONCLUSIONS

Infliximab is associated with attenuated serological responses to SARS-CoV-2 that were further blunted by immunomodulators used as concomitant therapy. Impaired serological responses to SARS-CoV-2 infection might have important implications for global public health policy and individual anti-TNF-treated patients. Serological testing and virus surveillance should be considered to detect suboptimal vaccine responses, persistent infection and viral evolution to inform public health policy.

TRIAL REGISTRATION NUMBER

ISRCTN45176516.

The Pathogenesis of Extraintestinal Manifestations: Implications for IBD Research, Diagnosis, and Therapy

This article reports on the sixth scientific workshop of the European Crohn's and Colitis Organisation [ECCO] on the pathogenesis of extraintestinal manifestations [EIMs] in inflammatory bowel disease [IBD]. This paper has been drafted by 15 ECCO members and 6 external experts [in rheumatology, dermatology, ophthalmology, and immunology] from 10 European countries and the USA. Within the workshop, contributors formed subgroups to address specific areas. Following a comprehensive literature search, the supporting text was finalized under the leadership of the heads of the working groups before being integrated by the group consensus leaders.

A multi-centre audit of excess steroid use in 1176 patients with inflammatory bowel disease

BACKGROUND

Corticosteroids are central to inducing remission in inflammatory bowel disease (IBD) but are ineffective maintenance agents.

AIM

To benchmark steroid usage in British outpatients and assess factors associated with excess exposure.

METHODS

We recorded steroid use in unselected IBD outpatients. Cases meeting criteria for steroid dependency or excess were blind peer reviewed to determine whether steroid prescriptions were avoidable. Associations between steroid use and patient/institutional factors were analysed.

RESULTS

Of 1176 patients, 30% received steroids in the prior 12 months. 14.9% had steroid dependency or excess, which was more common in moderate/severe ulcerative colitis (UC) than Crohn's disease (CD) (42.6% vs 28.1%; P = .027). Steroid dependency or excess was deemed avoidable in 49.1%. The annual incidence of inappropriate steroid excess was 7.1%. Mixed-effects logistic regression analysis revealed independent predictors of inappropriate steroid excess. The odds ratio (OR, 95%CI) for moderate/severe compared to mild/quiescent disease activity was 4.59 (1.53-20.64) for UC and 4.60 (2.21-12.00) for CD. In CD, lower rates of inappropriate steroid excess were found in centres with an IBD multi-disciplinary team (OR 0.62 [0.46-0.91]), whilst dedicated IBD clinics protected against inappropriate steroid excess in UC (OR 0.64, 95% CI 0.21-0.94). The total number of GI trainees was associated with rates of inappropriate steroid excess.

CONCLUSIONS

Steroid dependency or excess occurred in 14.9% of British IBD patients (in 7.1% potentially avoidable). We demonstrated positive effects of service configurations (IBD multi-disciplinary team, dedicated IBD clinics). Routine recording of steroid dependency or excess is feasible and should be considered a quality metric.

DNA methylation analysis in the intestinal epithelium-effect of cell separation on gene expression and methylation profile

BACKGROUND

Epigenetic signatures are highly cell type specific. Separation of distinct cell populations is therefore desirable for all epigenetic studies. However, to date little information is available on whether separation protocols might influence epigenetic and/or gene expression signatures and hence might be less beneficial. We investigated the influence of two frequently used protocols to isolate intestinal epithelium cells (IECs) from 6 healthy individuals.

MATERIALS AND METHODS

Epithelial cells were isolated from small bowel (i.e. terminal ileum) biopsies using EDTA/DTT and enzymatic release followed by magnetic bead sorting via EPCAM labeled microbeads. Effects on gene/mRNA expression were analyzed using a real time PCR based expression array. DNA methylation was assessed by pyrosequencing of bisulfite converted DNA and methylated DNA immunoprecipitation (MeDIP).

RESULTS

While cell purity was >95% using both cell separation approaches, gene expression analysis revealed significantly higher mRNA levels of several inflammatory genes in EDTA/DTT when compared to enzymatically released cells. In contrast, DNA methylation of selected genes was less variable and only revealed subtle differences. Comparison of DNA methylation of the epithelial cell marker EPCAM in unseparated whole biopsy samples with separated epithelium (i.e. EPCAM positive and negative fraction) demonstrated significant differences in DNA methylation between all three tissue fractions indicating cell type specific methylation patterns can be masked in unseparated tissue samples.

CONCLUSIONS

Taken together, our data highlight the importance of considering the potential effect of cell separation on gene expression as well as DNA methylation signatures. The decision to separate tissue samples will therefore depend on study design and specific separation protocols.

Consistent patterns of expression of HLA class I free heavy chains in healthy individuals and raised expression in spondyloarthropathy patients point to physiological and pathological roles

OBJECTIVES

Major histocompatibility complex class I (MHC-I) proteins exist at the cell surface in antigen presenting forms and as beta2m-independent free heavy chains (FHCs). FHCs have been implicated in spondyloarthritis, but little is known about their expression in healthy individuals. We studied FHC expression on various human cell types, comparing spondyloarthropathy patients with healthy and rheumatoid arthritis (RA) patient controls.

METHODS

MHC-I expression was analysed by flow cytometry. FHC levels were normalized for overall MHC-I to generate a relative expression level. Relative FHC levels were analysed for peripheral blood and trophoblast samples from healthy volunteers, RA and spondyloarthropathy patients. Macrophages and dendritic cells were cultured in vitro to analyse changes following activation. Peripheral blood leucocytes from patients with ankylosing spondylitis (AS) and RA were treated with inflammatory stimuli and subsequent alterations in their relative FHC levels were analysed.

RESULTS

We found consistent patterns of differential relative FHC expression across lymphocyte subpopulations and particularly high expression on extravillous trophoblast. FHCs were present at higher levels in a reactive arthritis (ReA) population than in healthy controls and RA patients; differences not merely due to the presence of Human Leucocyte Antigen (HLA) B27. Treatment of leucocytes from arthritic patients with bacterial lipopolysaccharide resulted in significant up-regulation of FHC compared with an HLA B27+ control population.

CONCLUSIONS

Our findings define normal levels and tissue expression of FHCs, and support the hypothesis that disregulation of heavy chain expression may play a pathogenic role in spondyloarthropathy.

Leukocyte receptor complex-encoded immunomodulatory receptors show differing specificity for alternative HLA-B27 structures

We studied recognition of the disease-associated HLA-B27 allele by immunomodulatory receptors encoded within the leukocyte receptor complex. HLA class I are ligands for members of the killer Ig receptor (KIR) and Ig-like transcript (ILT)/LIR/LILR families (the new LILR nomenclature is described at www. gene.ucl.ac.uk/nomenclature/genefamily/lilr.html). Members of these families bound HLA-B27 in both classical and beta(2) microglobulin-independent forms. Classical complexes bound ILT2, ILT4, and LIR6 transfectants but not ILT1, ILT3, or ILT5. A free H chain form of HLA-B27 bound ILT4 and LIR6. Both forms of HLA-B27 bound KIR3DL1 transfectants. HLA-B27 free H chain bound CD14(+) cells in PBL from healthy controls, consistent with ILT4 expression on monocytes. Alternative recognition of different forms of HLA-B27 by KIR or ILT could influence their immunomodulatory function and may imply a role in inflammatory disease.

Emergency contraception: advance provision in a young, high-risk clinic population

OBJECTIVE

To assess whether advance provision of emergency contraception increases its use and whether it has secondary effects on regular contraceptive use.

METHODS

We conducted a controlled trial of female clients, aged 16-24 years, who attended a publicly funded family planning clinic. Women were systematically assigned to receive an advance provision of emergency contraception and education (treatment) or education only (control). Among 263 participants enrolled (133 treatment, 130 control), follow-up was completed in 213 (111 treatment, 102 control). The main outcome measures were emergency contraception knowledge and use, frequency of unprotected sex, and pattern of contraceptive use in the past 4 months.

RESULTS

Participants were aware of emergency contraception at follow-up, but the treatment group was three times as likely to use it (P =.006). Although the treatment group did not report higher frequencies of unprotected sex than the control group, women in the treatment group (28%) were more likely than those in the control group (17%) to report using less effective contraception at follow-up compared with enrollment (P =.05). The proportion of women in both groups who reported consistent pill use increased from enrollment to follow-up (34% versus 45%); however, the control group (58%) was more likely than the treatment group (32%) to report consistent pill use at follow-up (P =.03).

CONCLUSION

Use of emergency contraception was increased by providing it in advance, but not by education alone. Changes to less effective contraceptive methods and patterns of pill use were potentially negative effects that need to be explored in relation to observed benefits.

The risk of repeating low birth weight and the role of prenatal care

OBJECTIVE

To estimate the influence of adequacy of prenatal care and other known risk factors on the risk of repeating low birth weight (LBW) (less than 2500 g).

METHODS

This was a retrospective cohort study of women having two births in Washington state during 1984-1990, as recorded using linked birth certificate records. Logistic regression was used to control for maternal age, marital status, smoking, miscarriage, inter-pregnancy interval, and prenatal care.

RESULTS

Compared to the reference group of women with normal-weight first births (at least 2500 g), women with LBW first births, either preterm or small for gestational age (SGA), were significantly more likely to have an LBW second birth. The estimated relative risk of repeating LBW in general was 7.0 (95% confidence interval 4.8-10.1). Smoking during the second pregnancy was a significant effect modifier. The risk estimates were not significantly affected by any of the other variables entered into the models, including adequate prenatal care.

CONCLUSIONS

Prior delivery of a preterm or SGA LBW infant was the strongest predictor of LBW delivery in a subsequent pregnancy. Adequate prenatal care during the second pregnancy did not provide statistically significant protection against the risk of repeat LBW. The tendency for women to have repeat LBW deliveries despite adequate prenatal care indicates a need for a better understanding of the underlying pathophysiology of preterm and SGA delivery.

Do providers adhere to ACOG standards? The case of prenatal care

OBJECTIVE

To examine the extent to which obstetric providers abide by prenatal practice guidelines published by ACOG.

METHODS

The prenatal records were abstracted for low-risk patients initiating care with randomly selected urban obstetrician-gynecologists, rural obstetrician-gynecologists, urban family physicians, rural family physicians, and urban certified nurse-midwives in Washington state between September 1, 1988 and August 30, 1989. The prenatal care recorded in their medical charts was compared with the ACOG-recommended guidelines.

RESULTS

Overall, providers of all five types adhered closely to the published standards. Certified nurse-midwives recorded a standard of practice that most closely matched that recommended by ACOG. Overall, there was less complete adherence in the recording of maternal height, fetal activity after 30 weeks' gestation, and fetal presentation at or after 36 weeks' gestation. Those laboratory tests that ACOG has recommended most recently (serum alpha-fetoprotein and diabetes screening) and those not recommended for routine use were ordered less often on average by providers.

CONCLUSIONS

The cross-sectional nature of this study cannot demonstrate definitively that ACOG's guidelines have changed provider prenatal practices. However, these findings demonstrate that providers in varying specialties and geographic locations can adhere to a detailed set of clinical guidelines if they are appropriately disseminated and implemented.

Occult duodenal perforation complicating cerebral infarction: new problems in diagnosis of Cushing's ulcer

Cushing's ulcers of the duodenum are well known complications of neurosurgery, head trauma, and other causes of increased intracranial pressure. Perforation of Cushing's ulcer of the duodenum is infrequently described. That the use of high-dose corticosteroids for cerebrovascular infarct in an aphasic patient may obscure the symptomatology and physical findings of a perforated Cushing's ulcer has not been described to our knowledge. We report a patient with a large left hemispherical infarct and resultant aphasia who developed a perforated duodenal ulcer and extensive chemical peritonitis while receiving high dose corticosteroids for increased intracranial pressure. She was unable to register any complaints and the typical physical findings of perforated duodenal ulcer with chemical peritonitis were virtually absent. A high index of suspicion must be maintained for a perforated Cushing's duodenal ulcer in the patient receiving high dose dexamethasone despite the presence of nonspecific symptomatology and abdominal findings. Elevated serum gastrin levels, as in this patient, may also indicate the patients with increased intracranial pressure who are at greater risk for developing Cushing's ulcer.

Ultrastructural aspects of cooled thermal injury

This study reports on the effects of early cooling on the morphology of partial-thickness burns. After 10% body surface dorsal scald burns at 75 degrees C for 10 seconds, guinea pigs were treated by ice-water immersion at 10 minutes postburn of only the burned surface for 30 minutes. Skin samples from treated and untreated burn wounds were examined at 2, 8, 24, and 96 hours postburn by light and electron microscopy. During the first 24 hours, cooling was associated with reduced loss of epidermis and reduced damage to the basement membrane. There was also less damage to the dermal microvasculature and less edema fluid compared to untreated burn wounds. At 96 hours, the cooled burn wounds demonstrated minimal dermal hemorrhage and polymorphonuclear leukocytic infiltration, compared to the untreated wounds. These results indicate that on a cellular level, cooling has beneficial effects on the experimental burn wound.