Valproic acid as adjuvant treatment for convulsive status epilepticus: a randomised clinical trial

BACKGROUND

Generalised convulsive status epilepticus (GCSE) is a medical emergency. Guidelines recommend a stepwise strategy of benzodiazepines followed by a second-line anti-seizure medicine (ASM). However, GCSE is uncontrolled in 20-40% patients and is associated with protracted hospitalisation, disability, and mortality. The objective was to determine whether valproic acid (VPA) as complementary treatment to the stepwise strategy improves the outcomes of patients with de novo established GCSE.

METHODS

This was a multicentre, double-blind, randomised controlled trial in 244 adults admitted to intensive care units for GCSE in 16 French hospitals between 2013 and 2018. Patients received standard care of benzodiazepine and a second-line ASM (except VPA). Intervention patients received a 30 mg/kg VPA loading dose, then a 1 mg/kg/h 12 h infusion, whilst the placebo group received an identical intravenous administration of 0.9% saline as a bolus and continuous infusion. Primary outcome was proportion of patients discharged from hospital by day 15. The secondary outcomes were seizure control, adverse events, and cognition at day 90.

RESULTS

A total of 126 (52%) and 118 (48%) patients were included in the VPA and placebo groups. 224 (93%) and 227 (93%) received a first-line and a second-line ASM before VPA or placebo infusion. There was no between-group difference for patients hospital-discharged at day 15 [VPA, 77 (61%) versus placebo, 72 (61%), adjusted relative risk 1.04; 95% confidence interval (0.89-1.19); p = 0.58]. There were no between-group differences for secondary outcomes.

CONCLUSIONS

VPA added to the recommended strategy for adult GCSE is well tolerated but did not increase the proportion of patients hospital-discharged by day 15.

TRIAL REGISTRATION NO

NCT01791868 (ClinicalTrials.gov registry), registered: 15 February 2012.

A152 NATURAL HISTORY OF SMALL BOWEL STRICTURES IN CROHN’S DISEASE

Background

Crohn’s disease (CD) is a progressive inflammatory disease that often results in intestinal complications such as small bowel (SB) strictures. SB strictures are frequently associated with substantial morbidity and may require surgery. The natural history of SB strictures in the era of biologic treatments has not been well characterized.

Aims

To determine the proportion of patients with SB strictures who develop complicated stricturing disease and to identify clinical factors associated with this outcome.

Methods

We performed a retrospective observational study between January 1, 2009, and May 31, 2019. Adults (>17 years) with CD who underwent an abdominal CT scan or MRI were identified from our institutional data warehouse using the ICD-10 code K50* and local imaging codes. Reports were reviewed to determine the imaging protocol and the presence of SB strictures. We included CT or MR enterography studies that reported SB strictures and excluded encounters with incomplete records, diverting ostomies, ileal J-pouches, and patients evaluated for pre-surgical planning. Each imaging study was included as a separate encounter in our analysis. Our primary endpoint was the development of complicated stricturing disease defined as stricture-related hospitalization or surgery. Time to event was estimated using Kaplan–Meier analysis and associated factors were assessed by multivariable Cox proportional hazard models adjusted for age, sex, exposure to biologics and corticosteroids.

Results

A total of 6583 unique imaging studies were identified: 926 (14%) studies reported SB strictures without penetrating complications, and 568 (9%) studies reported penetrating complications. A total of 503 (8%) studies, performed on 330 patients, met our inclusion criteria: mean age 42 (SD, 15.1) years and 166 (50%) males. Overall, 144 (44%) patients developed complicated stricturing disease: 106 (32%) patients required surgery and 132 (40%) patients were hospitalized for stricture related complications. Of the patients who underwent surgery, the mean time to surgery was 13 months (SD, 18.3) and among patients who required hospitalization, mean time to hospitalization was 15 months (SD, 17.8) (Figure 1). On multivariable analysis, exposure to corticosteroids (aHR 2.11; 95% CI, 1.54–2.90; p<0.001) but not biologics (aHR 1.1; 95% CI, 0.84–1.43; p<0.48) at the time of the imaging study was independently associated with the development of complicated stricturing disease.

Conclusions

In our single center study, complicated stricturing disease occurred in 44% of patients with CD who had a SB stricture and was associated with corticosteroids but not biologics.These findings, along with additional clinical and radiologic factors may help in the development of clinical support tools to identify patients at highest risk of developing complicated stricturing disease.

Funding Agencies

None

A145 ENDOSCOPICALLY NON-VISIBLE INTERVAL COLONIC ADENOCARCINOMA DESPITE HIGH-QUALITY SURVEILLANCE

Background

Colonoscopy remains the gold-standard for screening and surveillance of colorectal cancer (CRC). Regular colonoscopy with polypectomy has been associated with reduced CRC incidence and mortality. However, interval CRC, defined as cancer diagnosed between initial screening and subsequent surveillance colonoscopies, occurs at rates of 2–14%. Identified risk factors for interval cancers include patient-related factors (older age, diverticular disease, proximal CRC), endoscopy-related factors (colonoscopy by non-gastroenterologists or in an outpatient setting; endoscopists with low rates of completion, adenoma detection or polypectomy) and biologic factors (microsatellite instability (MSI), CpG island methylation). We report a patient with interval metastatic ileo-cecal adenocarcinoma despite multiple, high-quality surveillance colonoscopies, not endoscopically visible as no visible intra-luminal mucosal component was present.

Aims

To describe a case of an interval CRC without an endoscopically visible intra-luminal component.

Methods

Case description and literature review.

Results

A 69-year-old male, with a history of multiple advanced colonic polyps requiring multiple surveillance colonoscopies and polypectomies, presented with symptoms of bowel obstruction. An abdominal CT scan revealed findings of terminal ileitis and upstream small bowel obstruction. Colonoscopy was performed, revealing obstruction of the ileo-cecal valve with a firm cecal submucosal lesion without abnormal overlying mucosal abnormalities. Exploratory laparoscopy revealed a mass at the ileo-cecal valve with associated peritoneal deposits. A right hemicolectomy was performed, and pathological examination demonstrated metastatic invasive adenocarcinoma involving the cecum, the terminal ileum and ileo-cecal valve without extension into the lumen or formation of an overt polypoid mass. The tumour extended into the wall of the distal ileum in a circumferential fashion, involving the immediate deep serosa, but with only minimal, focal mucosal ileal involvement and no overt polypoid mass. An independent review of the case and resection specimen by a second pathologist confirmed absence of significant ileal or colonic mucosal involvement and no obstructing intraluminal component.

Conclusions

This case illustrates a rare presentation of an interval CRC that was not identified despite several high-quality surveillance colonoscopies, as only minimal mucosal involvement was present. As endoscopy remains the gold-standard for early detection and removal of pre-malignant lesions and early malignancy, the patient’s presentation with interval malignant bowel obstruction and metastatic disease, despite adequate quality surveillance, demonstrates an inherent limitation of colonoscopy. To our knowledge, this is only the third documented case of endoscopically non-visible interval CRC.

Funding Agencies

NoneNone