AB1220 DO ANTIBODIES HAVE DIFFERENTIAL EFFECT ON RADIOGRAPHIC PROGRESSION IN RA?

Background:

The presence of bony erosions in patients with RA is a marker of disease severity and once present they are largely irreversible. Previous studies have shown that those who are RF positive have more erosions than those who are RF negative. Likewise, ACPA is associated with increased bone loss and rapid erosive changes.

Objectives:

The aim of our study was to determine which of these two antibodies is more strongly associated with erosive disease and whether being double +ve confers higher risk than single positive antibody status.

Methods:

A retrospective study of 774 patients diagnosed with RA at a large university teaching hospital during the period of January 1981 and December 2018. Clinical records were reviewed to determine antibody status, date of diagnosis, duration of symptoms, DAS-28, age, ethnicity and whether the 1987 Rheumatoid Arthritis criteria was met. The presence of radiographic erosions at diagnosis were determined from reports of plain film radiographs of hands and feet of all patients. Chi square model was utilised to ascertain if there was a significant relationship among the four groups. Mann Whitney two-tailed U test was employed to determine the significance of relationship between the double negative group and other arms for all variables including disease duration and delta change in DAS28. Significance level was predefined at 0.05.

Results:

All patients fulfilled the 2010 ACR/EULAR criteria. 240 (31%) patients were male and 534 (69%) were female with an age range of 17 to 90 years for the cohort. The duration of symptoms ranged for the patient cohort from 0.5 to 250 months with a median of 6 months while the duration of disease ranged from 4 to 455 months with a median of 49 months. DAS 28 ranged from 1.19 to 8.4 with a median of 4.4. 367 (47%) were positive for both RF and ACPAs, 87 (11%) were positive for RF alone, 66 (9%) were positive for ACPA alone and 254 (33%) were antibody negative.

There were a total of 127 patients with erosions at the time of diagnosis. Patients in the double positive group had a significantly higher (p=0.003) erosion burden compared to the double negative group i.e. 21.5% in RF+/ACPA+ versus 11.0% in RF-/ACPA- group. The erosion burdens in RF+/ACPA- and RF-/ACPA+ groups were 13.7% and 12.1% respectively.

Conclusion:

This is the first real world study to demonstrate the radiographic erosive burden in the RA cohort with respect to RF/ACPA status. Our results show that patients RF+/ACPA+ have nearly two-fold higher incidence of radiographic erosions than patients who are RF-/ACPA-. Patients with single antibody positivity have a trend towards higher erosive burden compared to the double antibody negative group however it’s the combination of two antibodies which is strongly associated with erosive disease.

Disclosure of Interests:

Amal Minocha: None declared, Sebi Kukran: None declared, Philip Yee: None declared, Muhammad Khurram Nisar Grant/research support from: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB

, Consultant of: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB

, Speakers bureau: Muhammad Nisar undertakes clinical trials and received support (including attendance at conferences, speaker fees and honoraria) from Roche, Chugai, MSD, Abbvie, Pfizer, BMS, Celgene, Novartis and UCB

Despite high satisfaction, majority of gastro-oesophageal reflux disease patients continue to use proton pump inhibitors after antireflux surgery

BACKGROUND

While antireflux surgery is effective in controlling symptoms of gastro-oesophageal reflux, its role in eliminating the use of antireflux medicines after surgery and as such its long-term cost-effectiveness remains controversial.

AIM

To assess the patient satisfaction and the continued medication use following laparoscopic Nissen fundoplication at a tertiary level community hospital.

METHODS

Adult patients who underwent laparoscopic Nissen fundoplication at our institution over a period of over 3 years were asked to complete a questionnaire recording their demographic information, date and reason for the surgery, preprocedure and postprocedure symptoms, smoking and alcohol use, and medication use preoperatively and post-operatively. Patients were also asked about their satisfaction with surgery.

RESULTS

One hundred patients participated in the study. Overall, 90% patients experienced satisfaction with their surgery. Eighty percentage patients were willing to undergo surgery again, if needed. Over two-thirds (67%) patients had decrease in the severity of their symptoms. None of the patients had worsening of symptoms post-operatively. However, 80% patients were still taking antireflux medications including proton pump inhibitors (53%).

CONCLUSIONS

Most patients continue to use antireflux medications including after laparoscopic Nissen fundoplication despite high satisfaction with surgery.

Postinfectious gastroparesis related to autonomic failure: a case report

BACKGROUND AND AIM

Severe dysautonomia may be secondary to viral infections, resulting in impaired autoimmune, cardiovascular, urinary and digestive dysfunction. Herein, we present a case of a 31-year-old white female patient who had severe gastroparesis related to autonomic failure following an episode of acute gastroenteritis. This seems to be the first report providing thorough assessment of the enteric and autonomic nervous system by analysis of full-thickness small intestinal biopsies, cardiovagal testing and autopsy.

HOSPITAL COURSE

This patient affected by a severe gastroparesis was treated with antiemetics, prokinetics, analgesics and gastric electrical stimulation to control symptoms. Nutritional support was made using jejunal feeding tube and, in the final stage of disease, with total parenteral nutrition. Autonomic studies revealed minimal heart rate variability and a disordered Valsalva manoeuvre although the enteric nervous system and the smooth muscle layer showed a normal appearance. Hospital courses were complicated by episodes of bacteraemia and fungemia. Serum antiphospholipid antibodies were noted but despite anticoagulation, she developed a pulmonary embolism and shortly thereafter the patient died. Autopsy revealed acute haemorrhagic Candida pneumonia with left main pulmonary artery thrombus. Sympathetic chain analysis revealed decreased myelinated axons with vacuolar degeneration and patchy inflammation consistent with Guillain-Barre syndrome. The evaluation of the enteric nervous system in the stomach and small bowel revealed no evidence of enteric neuropathy or myopathy.

CONCLUSION

A Guillain-Barre-like disease with gastroparesis following acute gastroenteritis is supported by physiological and autonomic studies with histological findings.

Lactose intolerance: diagnosis and management

Lactose intolerance affects hundreds of millions of people worldwide. Although the presentation is frequently atypical, it should be part of the differential diagnosis when evaluating nonspecific gastrointestinal symptoms. We review the terminology, types of lactase deficiencies, diagnostic procedures, and management.

Effectiveness of single dilation with Maloney dilator versus endoscopic rupture of Schatzki's ring using biopsy forceps

Current recommendations for treatment of patients with symptomatic Schatzki's ring are based on anecdotal experience or uncontrolled studies. Maloney dilation is the gold standard. We performed a randomized controlled trial to compare the use of a single 52-Fr Maloney dilation versus four quadrant biopsy of Schatzki's ring for relief of dysphagia. The subjects answered standardized dysphagia-related questions on a scale of 0-5 (0 = no dysphagia; 5 = cannot handle secretions). To account for modifications in diet and eating habits, subjects answered 11 question to arrive at a eating/diet score. Patients with Schatzki's ring were randomized into one of the two protocols. Group 1 underwent endoscopic biopsies of the ring, one biopsy in each quadrant. In group 2, the endoscope was taken out, and a single 52-Fr Maloney dilation was performed. Twenty-six patients participated in the study and were followed for up to 15 months. There was no significant difference in age, sex, race, smoking, alcohol abuse, or medication intake between the two groups. Dysphagia score improved by 91% in both groups at three months and 84% and 85% at 12 months in groups 1 and 2, respectively. The eating/diet habit score improved by 78% in both groups. There was one failure in each group, and one recurrence at six months in the dilation group. Fifty-five percent of dilation group and 100% of biopsy group described the procedure as easy. There was no difference in the amount of sedatives used during the procedure or the acid blockers after the procedure. In patients undergoing endoscopy, the superior cost/safety profile of endoscopic biopsy makes it a preferred choice for treatment of Schatzki's ring over bougienage.

Prevalence of previous appendectomy among patients needing gastrointestinal endoscopy

BACKGROUND

The appendix may be an immune modulator of the gut, and its absence may lead to an increase in gastrointestinal illnesses. If this is true, we may expect patients needing endoscopy to have a higher prevalence of previous appendectomy.

METHODS

We did a case-control study at the University of Oklahoma Hospital for 13 months. Subjects having endoscopic evaluation at the University of Oklahoma Hospital formed the study group. Patients seen at the general medicine clinic of the University of Oklahoma served as controls. We recorded the patient's name, age, sex, race, history of smoking, and history of appendectomy or tonsillectomy.

RESULTS

The endoscopy group had 524 patients; 469 patients were in the control group. There were no differences based on race or history of smoking. There was greater prevalence of previous appendectomy in the endoscopy group (33.46% vs. 20.55%). The prevalence of tonsillectomy was 29.28% in the study group vs. 21.61% among the controls. Multiple regression revealed that history of appendectomy and not tonsillectomy was related to the performance of endoscopy.

CONCLUSION

History of appendectomy is associated with greater performance of endoscopy.

When to suspect lactose intolerance. Symptomatic, ethnic, and laboratory clues

Lactose intolerance is widespread, with adult-type hypolactasia being the predominant cause of lactose malabsorption. Daily ingestion of less than 240 mL of milk is well tolerated by most lactose-intolerant adults. Some persons with normal lactase activity may become symptomatic on consumption of products containing lactose. Lactose maldigestion may coexist in adults with irritable bowel syndrome and in children with recurrent abdominal pain. Management consists primarily of dietary changes. People who avoid dairy products should receive calcium supplementation and should be advised to read ingredient labels carefully. Several lactase replacement products are available, but their efficacy varies.

Is a history of tonsillectomy associated with a decreased risk of Helicobacter pylori infection?

To determine the relation between a history of tonsillectomy and the prevalence of colonization by Helicobacter pylori (HP), we conducted an observational, cohort study at the University of Oklahoma Hospital over a 13-month period. Subjects under-going upper endoscopic evaluation and antral biopsies for HP at the University of Oklahoma Hospital formed the database. The indication of the endoscopy and biopsies was determined by the endoscopist. The antral biopsy specimens were tested for HP using a rapid urease test. We recorded the patient's name, age, gender, race, history of smoking, and history of appendectomy or tonsillectomy. One hundred nine subjects constituted our database. There was no difference in age, gender, or smoking between the HP+ (n = 37) and HP- (n = 72) groups. The ability to pay for healthcare through a third-payor party also was similar. The prevalence of prior tonsillectomy was 30.6% in HP- group versus 5.4% in HP+ group (p < 0.01). In contrast, the prevalence of prior appendectomy was 21.6% in HP+ group versus 23.6% in HP- group (p = not significant). Multiple regression was carried out to account for confounding variables. The model showed that only white race and tonsillectomy were significantly related to the presence of HP colonization. Both appendectomy and health insurance, which were the surrogate markers for access to healthcare and socioeconomic status, were insignificant. We conclude that a history of tonsillectomy is associated with decreased prevalence of HP colonization.

Role of appendectomy and tonsillectomy in pathogenesis of ulcerative colitis

We wished to determine the effect of appendectomy and tonsillectomy on the subsequent risk for development of ulcerative colitis (UC). We conducted a case-control study at the University of Oklahoma Hospital and VA Medical Center gastroenterology clinics, as well as at the offices of private physicians. Subjects being followed for UC formed the study group. Patients being followed at Internal Medicine Associates of the University of Oklahoma clinics formed the controls. We recorded the patient's name, age, sex, race, history of smoking, and history of appendectomy or tonsillectomy. The study group consisted of 193 patients, and there were 394 controls. The prevalence of appendectomy was lower (17.8% vs 5.2%) among patients with UC (P < 0.01). The prevalence of tonsillectomy was similar in the two groups (20.6% vs 18.1%; P = NS). We conclude that appendectomy is associated with a decreased risk for subsequent development of ulcerative colitis.

Bullous esophagitis due to chronic graft-versus-host disease

Vesiculobullous lesions of esophagus in patients post bone marrow transplantation may occur due to infectious agents or acute graft-versus-host disease (GVHD). We report the case of a patient who developed a large bulla in the esophagus as a result of chronic GVHD. Potential etiologies, diagnosis and management of bullous esophagitis are reviewed.

Reliability and reproducibility of breath hydrogen and methane in male diabetic subjects

We studied the variability and reliability of breath hydrogen and methane as well as the alterations in intestinal gas profile in response to lactulose ingestion in 13 asymptomatic male patients with diabetes mellitus (DM). Seventeen healthy subjects served as controls. The prevalence of methane producers was 33% in DM and 45% among control subjects (P = NS). The prevalence of nonhydrogen producers was 7.7% and 5.9%, respectively. The coefficient for interday variation of H2 was 72.6 +/- 9.8% in DM and 49.7 +/- 9.8% in controls (P < 0.05). Similarly, the coefficient for interday variation of CH4 was 94.3 +/- 18.8 and 69.4 +/- 16.8% respectively (P = NS). The reproducibility of basal H2 and CH4 among diabetics as assessed by r1 (measure of reliability) was poorer among diabetics when breath analysis was performed on different days (P < 0.001). There was no significant difference between diabetics and controls with respect to basal or peak or area under the curve for H2 and CH4 in response to lactulose. We conclude that there is poor reproducibility of fasting breath gas levels among asymptomatic male subjects with diabetes. In addition, DM is not associated with alterations in hydrogen- or methane-producing potential.

Does concurrent acute ethanol ingestion during omeprazole therapy affect pituitary gonadal axis in male subjects?

OBJECTIVE

Literature suggests that both ethanol and omeprazole may affect the endocrine system. We studied the effect of concurrent use of ethanol and omeprazole on the pituitary gonadal axis in healthy males.

METHODS

Serum testosterone, luteinizing hormone, and follicle stimulating hormone levels were assessed in a fasting state before and after ingestion of 0.5 g/kg bodyweight of ethanol. Subjects then received omeprazole therapy (20 mg 2x/d for one week) followed by assessment of hormone levels before and after ethanol ingestion as done previously.

RESULTS

Total testosterone levels before and after ethanol at baseline declined an average of 46.6 ng/dL (n = 8; p = NS). The testosterone levels before and after ethanol following omeprazole therapy rose an average of 55.4 ng/dL (n = 8; p = NS). There was no significant difference in the change of ethanol induced testosterone concentrations as a result of omeprazole therapy. Similarly the free testosterone, follicle stimulating hormone, and luteinizing hormone were also not affected by ethanol or omeprazole alone or in combination.

CONCLUSIONS

We conclude that omeprazole and/or acute ingestion of ethanol do not affect the pituitary gonadal axis in healthy male subjects.

Noncardiac chest pain: where does it start?

The pathogenesis of recurrent noncardiac chest pain remains an enigma. The literature suggests that it may be caused by a heightened state of visceral nociperception. Coronary atherosclerosis must first be excluded with a reasonable degree of certainty. The physician can then focus on reassuring the patient and continuing management, bearing in mind the caveat, first do no harm. Polypharmacy and hazardous procedures should be avoided. Aggressive acid suppression is helpful in patients with gastroesophageal reflux disease, and antidepressants have shown promise in otherwise unexplained cases of chest pain. Despite significant morbidity in patients with the disorder, the long-term prognosis is excellent.

Massive chylothorax complicating cirrhosis of the liver

Chylothorax is an unusual complication of cirrhosis of the liver. This condition is probably underdiagnosed because appropriate tests are not usually done. We describe the case of a 54-year-old man with cirrhosis of the liver and massive chylothorax. Despite chest tube drainage and intensive supportive therapy, there was a fatal outcome. Our case highlights the difficulties in the management of this complication and draws attention to the possible dangers of certain therapeutic procedures.

Massive gastrointestinal bleeding associated with hookworm infestation in a child: case report

We report a rare case of massive haematochezia due to hookworm infestation that required two laparotomies before the cause of bleeding could be diagnosed. The need to consider this parasite as a possible cause of gut bleeding in endemic countries is stressed, as early recognition may avoid unnecessary investigations and surgical interventions.

Does fluoroscopic guidance for Maloney esophageal dilation impact on the clinical endpoint of therapy: relief of dysphagia and achievement of luminal patency

BACKGROUND

Use of fluoroscopy for Maloney esophageal dilation is controversial. We designed this prospective, randomized, single-blinded study to determine whether fluoroscopic guidance has an impact on relief of dysphagia and achievement of luminal patency.

METHODS

Patients with benign esophageal strictures were randomized to undergo Maloney dilation with or without fluoroscopic guidance. Strictures were dilated to size 48F. Dysphagia scores were obtained before and 1 week after dilation.

RESULTS

Eighty-three patients underwent 100 dilation sessions with fluoroscopic guidance being used for 50 sessions (156 dilations) and blinded technique for 50 (161 dilations). A 12.5 mm barium pill passed after dilation following 62.0% of the fluoroscopic dilation sessions and 42.0% of the blinded dilations (p = 0.045). Dysphagia was improved in 93.0% of patients receiving fluoroscopic dilations and 69.0% of patients receiving blinded dilations (p = 0.006). The mean improvement in dysphagia score was -2.10 points for the fluoroscopic group versus -1.50 points for the blinded group (p = 0.057). Differences in these parameters between techniques were even greater in 12 patients re-randomized to both techniques at different sessions.

CONCLUSIONS

The use of fluoroscopic guidance impacts favorably on the efficacy of Maloney dilation, resulting in greater relief of dysphagia and increased luminal patency compared to the blinded technique. Based on these results, use of fluoroscopy is recommended when Maloney esophageal dilation is performed.

Erythromycin shortens orocaecal transit time in diabetic male subjects: a double-blind placebo-controlled study

BACKGROUND

The effects of erythromycin on small bowel motility are controversial. Orocaecal transit time (OCTT) is considered to be a valid measure of small bowel motility.

METHODS

We studied the effect of erythromycin on OCTT in diabetic male subjects in a double-blind placebo-controlled crossover fashion. After an overnight fast, subjects received erythromycin 500 mg, 250 mg or placebo, on 3 different days. A standard solid meal containing 20 g lactulose was administered 30 min after the erythromycin ingestion. Exhaled breath was collected and hydrogen concentration was assessed over 5 h. Breath hydrogen concentrations for each session were analysed over time by a generalized logistic function generating a sigmoidal curve. Front transit time was recorded as the time point when a sustained rise in breath hydrogen concentration of at least 5 p.p.m. was first observed.

RESULTS

The mean +/- S.E.M. time taken for the front of the meal to reach the caecum was 92.5 +/- 9.5, 86.1 +/- 16.5 and 62.3 +/- 12.1 min for placebo, erythromycin 250 mg and erythromycin 500 mg, respectively. The OCTT was significantly decreased with erythromycin 500 mg compared to placebo (P < 0.05).

CONCLUSION

Oral administration of 500 mg erythromycin has prokinetic effect on orocaecal transit in male patients with diabetes mellitus.

Omeprazole therapy does not affect pharmacokinetics of orally administered ethanol in healthy male subjects

The purpose of this study was to study the effect of high-dose omeprazole therapy (20 mg twice daily) on kinetics of moderate amounts of orally administered ethanol. Eight healthy men participated in the study. After an overnight fast, they drank 0.5 g/kg body weight ethanol over 20 min. Blood samples were drawn before and then every 20 min after ethanol ingestion for the next 3 h. Subjects then ingested omeprazole 20 mg twice daily for 6 days. On the seventh day, the same dose of oral ethanol was administered as before and blood samples drawn. Blood ethanol concentrations were determined. We fit a one-compartment model with first-order absorption and zero order elimination to the blood ethanol data with PCNONLIN (SCI Software, Lexington, KY, U.S.A.) separately for each subject before as well as after omeprazole therapy. Area under the curve was calculated using the trapezoidal rule. There were no differences in the peak concentration, time to peak concentration, area under the curve, or elimination rate constant for ethanol before and after omeprazole treatment. Omeprazole treatment (20 mg twice daily) does not affect the pharmacokinetics of orally ingested ethanol in healthy male subjects. Our results do not rule out a possible effect on psychomotor function as a result of a pharmacodynamic interaction.

Lack of crucial role of mast cells in pathogenesis of experimental colitis in mice

Mast cell alterations have been implicated in the pathogenesis of chronic ulcerative colitis (UC). We studied the effect of mast cell deficiency of the severity of inflammation in a murine model of colitis. Colitis was induced in mice using dextran sodium sulfate (DSS). Mast-cell-deficient mice (WBB6F1/J-W/WV; N = 17) and normal littermates (WBB6F1/J-+/+; N = 17) were administered DSS 4% w/v for seven days, then water alone for one week, followed by 5% DSS for six days. Animals were sacrificed at the end of the protocol. Segments of proximal, mid-, and distal colon of each animal were processed for histopathological examination. Mortality and morbidity (diarrhea and weight loss) for each group were assessed. There was no significant difference between the two groups in either their clinical parameters (mortality and morbidity) or the severity of colitis as graded histopathologically. Our findings suggest that mast cells are not crucial for the development of DSS-induced colitis.