Postere Ibd

Contents
Abstracts from the 2012 Advances in Inflammatory Bowel Diseases

Crohns & Colitis Foundations National Clinical & Research Conference
December 1315, 2012
Hollywood, Florida
S1 Oral AbstractsClinical
S3 Oral AbstractsPediatrics
S6 Oral AbstractsNursing
S7 Oral AbstractsBasic Science
S14 Poster PresentationsClinical
S68 Poster PresentationsPediatrics
S81 Poster PresentationsNursing
S83 Poster PresentationsBasic Science
S117 Author Index
Volume 18
Number S1
December 2012
CCFA and Wiley have published this supplement without financial support
Volume 18, Issue S1 was mailed the week of November 26, 2012.
Clinical Oral Presentations
O-1a
Sustained Therapeutic Benefit of Vedolizumab Throughout 1 Year in Ulcerative
Colitis in GEMINI I, a Randomized, Placebo-Controlled, Double-Blind,
Multicenter Trial
William Sandborn
1
, Bruce Sands
2
, Paul Rutgeerts
3
, Serap Sankoh
4
,
Maria Rosario
4
, Catherine Milch
4
, Irving Fox
4
1
University of California San Diego, La Jolla, CA, USA,
2
Mount Sinai School of
Medicine, New York, NY, USA,
3
University Hospital Gasthuisberg, Leuven, Belgium,
4
Millennium Pharmaceuticals, Inc., Cambridge, MA, USA
BACKGROUND: We assessed the effect of vedolizumab (VDZ), an investigational,
gut-selective monoclonal antibody targeting a4b7 integrin, over 52 wks of ther-
apy in patients with moderately to severely active ulcerative colitis in whom at
least 1 prior therapy had failed.
METHODS: Eligible adult patients had a Mayo score _6 and endoscopic subscore
_2 despite corticosteroids (CSs), purine antimetabolites, and/or TNFa antagonists.
After 2 induction doses of VDZ (wk 0, wk 2), patients with clinical response
(reduction in Mayo score of _3 points and _30% from baseline, plus decrease in
rectal bleeding subscore of _1 point or absolute rectal bleeding subscore _1
point) to VDZ at wk 6 were randomized 1:1:1 to VDZ 300 mg IV q4wks, VDZ 300
mg IV q8wks, or placebo (PBO) for 46 wks. Clinical remission was dened as com-
plete Mayo score (CMS) or partial Mayo score (PMS) _2 and no individual sub-
score >1; clinical response was based on PMS, as a reduction _2 points and
_25% from baseline; durable mucosal healing, as Mayo endoscopic subscore _1
at both wks 6 and 52. Because the dened study endpoints used both CMS and
PMS, analyses were conducted to evaluate agreement; moderate to substantial
agreement was found between clinical response and remission endpoints as
dened by CMS and PMS at wks 6 and 52.
RESULTS: Among patients with a clinical response to VDZ at wk 6 (intention-to-
treat [ITT] population, N = 373), decreases in PMS occurred as early as wk 2 (Fig
1). After successful induction, PMS remained substantially lower than baseline in
both VDZ groups through wk 52, whereas an increase in PMS was noted starting
at wk 22 in the PBO group. Mean vedolizumab trough concentrations in the pla-
cebo group declined over time and were below quantitation limits at wk 22. In
the ITT population, remission rates by PMS in the VDZ groups remained stable,
whereas PBO remission rates decreased, over the course of the maintenance
phase (Fig 2). Durable mucosal healing was achieved by 42.6%, 43.2%, and 17.5%
of patients in the VDZ q8wks, VDZ q4wks, and PBO groups, respectively
(P < 0.0001 for both comparisons of VDZ vs PBO). Median CS dose declined over
the maintenance phase in both VDZ groups, compared with rising CS use after
wk 26 in the PBO group (Fig 3). In patients blinded to treatment who did not
achieve a clinical response by wk 6 (n = 174), 25.0% of VDZ vs 14.6% of PBO
patients achieved clinical response, and 8.7% vs 4.9% clinical remission, as deter-
mined by PMS by wk 10.
CONCLUSION(S): In patients who responded to VDZ by wk 6, treatment effect
was observed as early as wk 2; sustained reductions in PMS were observed in
VDZ-treated patients over a 1-year period. Clinical remission rates in VDZ patients
remained stable during the maintenance phase. Durable mucosal healing was
achieved in more than twice as many VDZ patients as PBO patients. Continued
dosing with VDZ induced response and remission among patients who did not
achieve response at wk 6.
O-1b
Efficacy of Vedolizumab in Ulcerative Colitis by Prior Treatment Failure in
GEMINI I, a Randomized, Placebo-Controlled, Double-Blind, Multicenter Trial
Brian Feagan
1
, Bruce Sands
2
, Serap Sankoh
3
, Catherine Milch
3
, Irving Fox
3
1
London Health Science Center, University Hospital, London, Ontario, Canada,
2
Mount Sinai School of Medicine, New York, NY, USA,
3
Millennium Pharmaceuti-
cals, Inc., Cambridge, MA, USA
BACKGROUND: Vedolizumab (VDZ), a selective antagonist of the a4b7 integrin,
has been studied in the treatment of moderately to severely active ulcerative coli-
tis in patients in whom conventional treatment has failed (NCT00783718). In an
exploratory analysis, we evaluated the efcacy of VDZ in a subgroups of patients
with failure of specic classes of drug therapy.
_2 despite treatment with corticosteroids (CSs), purine antimetabolites, and/or
anti-TNFa. After 2 induction doses of VDZ (wk 0, wk 2), patients with clinical
response (reduction in Mayo score of _3 points and _30% from baseline, plus
decrease in rectal bleeding subscore of _1 point or absolute rectal bleeding sub-
score _1 point) at wk 6 were randomized 1:1:1 to VDZ 300 mg IV q4wks, VDZ 300
mg IV q8wks, or placebo (PBO) for 46 wks. The primary outcome of the induction
phase was clinical response at 6 wks. Secondary outcomes were clinical remission
(complete Mayo score of _2 points and no individual subscore >1 point) and mu-
cosal healing (Mayo endoscopic subscore of _1 point) at 6 wks. The primary out-
come of the maintenance phase was remission at wk 52. Secondary outcomes
were durability of clinical response and remission (endpoint met at both wks 6 and
52), mucosal healing (Mayo endoscopic subscore _1), and CS-free remission at 52
wks. Patients were categorized on the basis of failure of prior treatment with: an
anti-TNFa; an immunomodulator but not an anti-TNFa; or CSs only.
Figure 1.
Figure 2.
Figure 3.
Copyright VC
2012 Crohns & Colitis Foundation of America, Inc.
DOI 10.1002/ibd.23058
RESULTS: Overall, patients receiving VDZ had improved clinical response and
remission, mucosal healing, durable clinical response and remission, and CS-free
remission, compared with placebo recipients (Tables 1 and 2, and data not
shown). Although condence intervals (CIs) included 0 for treatment differences
from placebo, VDZ efcacy was generally similar across prior treatment failure
subgroups and consistent with the overall study results in the induction (Table 1)
and maintenance (Table 2) phases. Patients with prior anti-TNFa failure generally
had higher rates of adverse events than did anti-TNFa na ve patients.
CONCLUSION(S): The point estimates for the efcacy of VDZ in inducing clinical
response, clinical remission, and mucosal healing in patients with prior anti-TNFa,
immunosuppressive, or CS failure, were consistently superior to PBO at wk 6. In
patients with a clinical response at wk 6, VDZ was superior to PBO in maintaining
clinical response, clinical remission, and mucosal healing at wk 52, regardless of
the type of prior treatment failure.
O-2
Pediatric and Adult Patients Had a Similar Pouch Survival Rate after
Restorative Proctocolectomy
Xianrui Wu, Saurabh Mukewar, Ravi Kiran, Feza Remzi, Bo Shen
Cleveland Clinic, Cleveland, OH, USA
BACKGROUND: There were limited data in the literature on the long-term pouch
outcomes in children who underwent restorative proctocolectomy with ileal
pouch-anal anastomosis (IPAA). The aim of this study was to compare long-term
pouch outcomes in pediatric and adult patients. Figure 1.
2012 IBD Abstracts S2
METHODS: Consecutive inammatory bowel disease (IBD) patients with ileal
pouches seen in our Pouchitis Clinic from 2002-2012 were studied. The pouch
outcome in pediatric patients was evaluated in comparison with adults by both
univariate and multivariate analyses.
RESULTS: All eligible patients were included into the study (N = 1,289), of whom
108 (8.4%) were pediatric patients (<18 years). Male accounted for 50.9% of pedi-
atric patients and 55.5% of adults. Pediatric patients had a younger age at the
time of IBD diagnosis and pouch construction and a shorter duration from IBD di-
agnosis to colectomy. Fewer pediatric patients had a history of smoking (9.3% vs.
20.7%, P = 0.004), concomitant extra-intestinal manifestations (21.5% vs. 39.1%,
P<0.001), and dysplasia as the indication for colectomy (0.9% vs. 13.6%, P<0.001)
than the adults. On the other hand, pediatric patients had higher rates of pouch
surgery-associated complications (21.3% vs. 13.9%, P = 0.036), postoperative
pouch-associated hospitalization (25.9% vs. 13.4%, P<0.001) and postoperative
use of anti-TNF biologics (16.7% vs. 7.9%, P = 0.002) than the adults. Pouch failed
in 100 patients (7.8%) after a mean follow-up of 10.666.8 years, including 13
(12.0%) in the pediatric group and 87 (7.4%) in the adult group (P = 0.082). Risk
factors for pouch failure in the multivariate analysis included preoperative use of
anti-TNF biologics, postoperative use of anti-TNF biologics, Crohns disease of
pouch, pouch surgery-related complications and postoperative pouch-associated
hospitalization. However, pediatric patients were not found to be signicantly
associated with pouch failure in neither the univariate nor multivariate analyses,
with a hazard ratio of 0.67 (95% condence interval: 0.36-1.24, P = 0.2) from the
multivariate analysis.
CONCLUSION(S): Pediatric patients suffered from a higher incidence of postopera-
tive pouch complications than adults; however the long-term pouch retention
rates were comparable.
O-3
Single Incision Laparoscopic Ileocecectomy for Pediatric Crohn Disease
Constantine Saites, Sigrid Bairdain, Chueh Lien, Victor Johnson,
David Zurakowski, Bradley Linden
Boston Childrens Hospital, Boston, MA, USA
BACKGROUND: The single-incision laparoscopic technique has become an increas-
ingly popular alternative for conventional pediatric laparoscopic surgery. Ileoce-
cectomy is a mainstay surgical therapy for pediatric Crohn disease. However,
there are few descriptions on the technique and experience of single-incision lap-
aroscopic ileocecectomy (SIL-I) in the pediatric population. We describe our tech-
nique and initial experience with SIL-I for the surgical management of pediatric
patients with Crohn disease.
METHODS: Records of all patients with Crohn disease who underwent SIL-I
between 2010-2012 were retrospectively reviewed. Variables including patient
demographics, operative information, length of stay, and postoperative complica-
tions were collected. The operation is generally performed by placing an Olym-
pus Triport 15
VR
, rst releasing adhesions and separating the terminal ileum from
associated abscess, when one was present. The right colon is then mobilized dis-
tally around the hepatic exure to the level of the duodenum. This gives
adequate mobilization to allow a safe extracorporeal anastomosis. The proximal
extent of disease is identied, and the mesentery is divided with the ligature to
the level of the ileocecal valve. The small intestine is divided with a laparoscopic
stapler. The port is removed, and the incision is extended to approximately 3.5cm
through the base of the umbilicus. The specimen is externalized, remaining mes-
entery to the cecum is taken, and the right colon is divided using a surgical sta-
pler. The anastomosis is performed by creating a 12 cm, side-by-side, functional
end-to-end stapled anastomosis.
RESULTS: Thirty-one SIL-I cases (mean patient age 17 6 4 years) were reviewed. The
average time from diagnosis of Crohn disease to surgery was 4.8 6 4.5 years. Seven
patients (23%) were below the 5th percentile for weight preoperatively. The major
indication for surgery was obstruction/stricture (n = 23) followed by refractory
inammatory disease (n = 18). Three patients had undergone prior abdominal
operation. Twenty patients underwent epidural placement and four patients under-
went ureteral stent placement under the same anesthetic prior to SIL-I. There were
no operations where an additional laparoscopic port was placed; however, one
operation required conversion to a midline laparotomy in the setting of extensive
interloop abscesses, dense adhesions and interloop stulae. All anastomoses were
stapled extracorporeally. The mean operative time was 3.8 6 1.1 hours. There were
no intraoperative complications. Five postoperative complications were docu-
mented, including one supercial wound infection, 2 intraabdominal abscesses (1
within 30 days of operation, 1 more than 3 months post-procedure), 1 PICC-associ-
ated bacteroides bacteremia, and 1 small bowel obstruction. Average postoperative
length of stay was 7.1 62.9 days, and median length of follow up was 5.27 months.
CONCLUSION(S): This is the largest reported series of SIL-I in the pediatric surgery
population. Our presented technique is safe, effective, and may be adopted by
any pediatric surgeon with laparoscopic experience. Further studies are necessary
to demonstrate both cost-effectiveness and long-term outcomes of SIL-I versus
conventional laparoscopic techniques.
O-4
Intestinal Transplantation for End Stage Crohns Disease: Therapeutic Efficacy
and Disease Recurrence
Darlene Koritsky, Guilherme Costa, Geoffrey Bond, Bonnie Schuster, Mary Rob-
erts, Barbara Hoffman, William Stein, Kyle Soltys, Hiroshi Sogawa, Erin Rubin,
Miguel Regueiro, Kareem Abu-Elmagd
University of Pittsburgh Medical Center, Pittsburgh, PA, USA
BACKGROUND: Intestinal transplantation has recently evolved and more fre-
quently utilized to rescue patients with irreversible intestinal failure who no lon-
ger can be maintained on TPN therapy. End stage Crohns disease has been the
second leading indication for transplantation in the adult population. This is the
rst study to address the procedures therapeutic efcacy and the impact of dis-
ease recurrence on long-term outcome.
METHODS: Between May 2, 1990 and June 30, 2012, a total of 309 consecutive
adult patients received 342 intestinal and multivisceral transplantations. Of these,
57 (18%) suffered recalcitrant Crohns disease with irreversible intestinal failure for
a mean duration of 55 years. All patients failed TPN therapy with multiple line
infections (94%), limited venous access (83%), and signicant liver damage (80%).
The male to female ratio was 1:1.7 with a mean age of 43 10 years. All patients
underwent multiple abdominal surgeries with proctocolectomy in 36 (63%). Si-
multaneous hepatic replacement was required in 12 (21%) patients due to end
stage liver failure with a mean serum bilirubin of 9 11 mg/dL. The remaining
45 (79%) patients received liver-free visceral allografts with intestine alone in 43
and modied multivisceral graft including the stomach, duodenum, pancreas,
and intestine in 2. Positive lymphocytotoxic crossmatch was documented in 14
(25%) recipients. All donors were cadaveric, ABO identical with random HLA
crossmatch. Rejection prophylaxis was tacrolimus based in all patients with utili-
zation of induction (cyclophosphamide/daclizumab) therapy in 8 (14%) and recip-
ient pretreatment with rATG/alemtuzumab in 37 (65%) recipients.
RESULTS: With a mean follow-up of 54 48 months, 33 (58%) of the Crohns dis-
ease patients are currently alive with a retransplantation rate of 7%. Acute and
chronic rejection was the leading cause of graft loss with an overall incidence of
56%. The actuarial patient survival rate was 90% at 1 year, 74% at 3 years, 56% at
5 years, and 43% at 10 years with respective graft survival of 86%, 65%, 53%, and
42%. Inclusion of the donor liver was associated with better long-term survival
outcome with a 10-year survival rate of 57% for both patient and graft. Recipient
pretreatment signicantly improved patient survival with 1, 3, 5, and 10 year sur-
vival rates of 92%, 79%, 61% and 61%, respectively. All survivors achieved full
nutritional autonomy enjoying unrestricted oral diet. Disease recurrence was his-
tologically documented in 4 (7%) allografts at 3, 15, 18, and 19 months from the
time of transplantation with no impact on graft function. With similar distribution
of type of transplanted organs and immunosuppression, there was no signicant
(P = 0.6) difference in survival between the Crohns and non-Crohns patients.
However, the cumulative risk of graft loss due to acute and chronic rejection was
modestly higher in the Crohns disease compared to the non-Crohns disease
patients.
CONCLUSION(S): Intestinal and multivisceral transplantation is a life-saving and an
effective therapy for patients with end stage Crohns disease. Disease recurrence
is very low and at best histologic with no signicant impact on survival outcome
and graft functions.
Pediatric Oral Presentations
O-5a
Inflammation and Steroid Therapy Is Associated With White Matter
Microstructure Integrity in Pediatric Crohns Disease
Christine Mrakotsky
1
, Christopher Watson
2
, Deborah Waber
1
, Richard Grand
3
,
Michael Rivkin
2
1
Department of Psychiatry, Boston Childrens Hospital, Harvard Medical School,
Boston, MA, USA,
2
Department of Neurology, Boston Childrens Hospital, Boston,
MA, USA,
3
Division of Gastroenterology, Boston Childrens Hospital, Harvard Medi-
cal School, Boston, MA, USA
BACKGROUND: Pediatric Crohns disease (CD) is marked by intestinal and systemic
inammation with high circulating concentrations of pro-inammatory proteins
(IL-6, TNF-a, CRP) during active disease. While anti-inammatory treatments such
as corticosteroids have for long been considered to affect cognitive and brain de-
velopment, inammation itself has the potential to disrupt the central nervous
system, particularly the white matter. White matter abnormalities have been
found at higher incidence in adults with CD as compared to healthy controls;
however, no such data is available for pediatric CD. Loss of white matter integrity
has been associated with functional impairment, particularly processing speed,
memory, and emotion regulation. We previously found inammation to be inver-
sely correlated with cognition and mood in pediatric CD. We here provide a rst
report of the effects of inammation vs. steroids on white matter microstructure
integrity in pediatric CD.
METHODS: Structural and diffusion magnetic resonance imaging (MRI, DTI) was
carried out in 30 children age 9-14 years (CD patients: n = 11, age-matched
healthy controls: n = 19). Participants were scanned on a 3 Tesla Siemens Trio
MRI system, with a 32-channel head coil. Diffusion-weighted imaging data were
acquired using a single shot spin-echo echo planar imaging sequence. A total of
30 diffusion sensitization directions were acquired. Voxel sizes were 1.7 1.7
1.7 mm
3
. Average fractional anisotropy (FA), a measure reecting white matter
ber density and myelination was computed for several ber tracts across the
brain. All CD patients were scanned during steroid treatment for an acute are
(prednisone dose: M = 30.7, SD = 9.6 mg/day). Serum markers of inammation
included hsCRP, IL-6, and TNFR2. Demographics, SES and general cognitive ability
were comparable between groups. Inammation was higher in CD patients than
healthy controls.
RESULTS: CD patients had lower FA than controls in several limbic (temporal) and
subcortical ber tracts including the left and right cingulum angular bundle, the
right uncinate and temporal part of the superior longitudinal fasciculus (P < .05
to < .10). Regression models including all subjects accounting for inammation
levels and steroid dose revealed higher inammation (hsCRP, IL6, TNFR2) but not
steroid dose to be a signicant predictor (P < .01 to < .05) for lower FA in the
cingulum, particularly on the left. Conversely, higher steroid dose but not inam-
mation predicted lower FA in the right uncinate and temporal part of the supe-
rior longitudinal fasciculus (p < .05). Correlations between inammation and FA
adjusted for steroid yielded similar ndings for the overall sample and for CD
patients only (see table).
CONCLUSION(S): Results of this rst association between pediatric CD and brain
development suggest differential impact of steroids and inammatory markers on
white matter microstructure. The inverse correlation between left cingulum integ-
rity and circulating inammation is of clinical interest as the cingulum is integral
part of the limbic system, connecting prefrontal with medial temporal cortex and
thus has been linked to emotion processing, memory and executive functions, -
all previously associated with inammation. Further neuroimaging and behavioral
studies including CD patients off steroids are warranted to elucidate these initial
ndings.
O-5b
Chronic Inflammation and Its Association With Neurobehavioral Functions in
Pediatric Crohns Disease
Christine Mrakotsky
1
, Kristin Maletsky
1
, Jonathan Girard
2
, Deborah Waber
1
,
Athos Bousvaros
2
, Richard Grand
3
1
Boston, MA, USA,
2
Center for Inflammatory Bowel Disease, Boston Childrens Hos-
pital, Harvard Medical School, Boston, MA, USA,
3
Division of Gastroenterology,
Boston Childrens Hospital, Harvard Medical School, Boston, MA, USA
BACKGROUND: Pediatric Crohns disease (CD) is associated with high circulating
concentrations of pro-inammatory cytokines (IL-6, TNF-a) and acute phase pro-
teins (CRP). These proteins can cross the blood-brain-barrier. For example, IL-6 is
expressed in the hippocampus, hypothalamus and cortex, TNF-a in microglia.
Thus, excess cytokines have the potential to disrupt brain systems critical for
memory, executive functions and mood. Children with CD therefore may be at
particular risk for cognitive and emotional problems based on not only short and
long-term medication regimens, but their underlying disease itself. Our earlier
reports of behavioral impact of inammation have been confounded by the fact
that patients were concurrently treated with corticosteroids, which can cause sim-
ilar behavioral and CNS side-effects. We here investigate the effects of inamma-
tion on memory and executive functions independent of steroids.
METHODS: Behavioral and cytokine data from an ongoing NIH study were avail-
able on 61 children with CD age 8-16 years who have completed the study
thus far. Patients were assessed at one time-point of a longitudinal design,
when all were off steroids for at least 4-6 months. Standardized measures of
memory, executive functions, IQ, mood, sleep, and pain severity were adminis-
tered. Questionnaires included the Behavior Rating of Executive Functions
(BRIEF), Child Behavior Checklist (CBCL), Youth Self Report (YSR), and Childrens
Depression Inventory (CDI). Serum markers of inammation included high-sensi-
tivity C-reactive protein (hsCRP) and pro-inammatory cytokines/receptors (IL-6,
TNFR2).
RESULTS: Higher levels of inammation in patients with CD were variably associ-
ated with poorer neurobehavioral outcome, as indicated by parent and self-
report of cognitive and mood problems in daily life. TNFR2 emerged as the most
robust predictor for executive problems, which were primarily of cognitive nature
(see table). Effects remained after adjusting for pain, sleep, IQ, and prior steroid
therapy. Correlations were modest but consistent with the literature. There was
no sizable effect on laboratory cognitive measures.
CONCLUSION(S): Results replicate earlier ndings of the impact of inammation
on cognition and mood in children with CD. Higher levels of inammation were
associated with more reported problems in executive functions, including difcul-
ties in controlling ones behavior, getting started on or completing tasks, working
efciently, as well as in attention and working memory. These functions are pre-
sumably mediated by prefrontal cortex, limbic system and potentially intercon-
necting white matter. While few effects were found on laboratory cognitive tests,
patients and parents reported more cognitive problems in daily life associated
with higher inammatory markers. This discrepancy between test and question-
naire results in populations without frank neurological impairment is a known
phenomenon in neuropsychological research, and one that is likely best
addressed with the use of more sensitive neural measures such as neuroimaging.
Clinically, these ndings carry important implications for patient education, that
underlying chronic inammation, especially when untreated, can have far reach-
ing developmental impact.
O-6
Serologic Protection to and Completion of Vaccinations in Children With
Inflammatory Bowel Disease
Jennifer deBruyn
1
, Ing Shian Soon
1
, Sharon Feng
1
, Kevin Fonseca
2
, Susan Kuhn
1
,
Otto Vanderkooi
1
, Iwona Wrobel
1
1
University of Calgary, Calgary, Alberta, Canada,
2
Provincial Laboratory of Public
Health, Calgary, Alberta, Canada
BACKGROUND: In children with inammatory bowel disease [IBD], data on sero-
logic protection to vaccines along with adherence to vaccination schedules is lim-
ited. The study objectives were to determine the proportion of children with IBD
with serologic protection to vaccines and evaluate adherence to vaccination
schedules.
METHODS: In this single-center cross-sectional study, children with IBD followed
at the Alberta Childrens Hospital were enrolled (September 2011-August 2012).
Demographic data, IBD medication, infection risk factors, and vaccination records
were collected. Serum was collected and analyzed by the Provincial Laboratory of
Public Health. Serologic protection for rubella and hepatitis B virus (HBV) were
dened by titers of IgG _15 IU/mL and antibody to HBV surface antigen _10 IU/
L, respectively. Serologic protection for hepatitis A virus (HAV) was dened by
positive detection of HAV IgG. Serology results for varicella, measles, mumps, tet-
anus, and diphtheria are pending. From vaccination records, the proportion with
complete series for each vaccine according to the Alberta schedule was
evaluated.
RESULTS: In total, 156 children (93 Crohns disease, 47 ulcerative colitis, 16 IBD-
unclassied) completed the study and underwent serum collection; vaccine
records were available for 152. At enrolment, 93 subjects (60%) were using immu-
nosuppressive medications (20 systemic corticosteroids, 70 immunomodulators,
48 biologics); an additional 32 subjects had previously used immunosuppressive
medications. For HBV (administered at 10 years of age), though 115 subjects
completed the series, 33 (29%) lacked serologic protection. Twenty-ve (16%)
subjects received no (n = 14) or incomplete (n = 11) vaccine not accounted for
by young age. In total, 57 (37%) subjects lacked serologic protection to HBV;
potential risk factors in this naive subgroup included history of travel outside of
Canada (n = 49), blood transfusion (n = 8), and body piercing (n = 15). There
was no association between HBV serologic protection or completion of vaccine
series and any current or past immunosuppressive medication use. For measles-
mumps-rubella, though 140 subjects completed the series, 26 (18.6%) lacked se-
rologic protection to rubella, including 15 subjects currently using immunosup-
pressive medications. Ten subjects received no or incomplete vaccine series not
accounted for by young age. There was no association between rubella serologic
protection and any current or past use of immunosuppressive medications. For
varicella zoster virus (VZV), 60 subjects received _1 VZV vaccine dose and 83
non-vaccinated subjects had previously been infected with chickenpox. However
10 (6.5%) subjects had neither been infected nor vaccinated, including 7 subjects
currently using immunosuppressive medications. For diphtheria-pertussis-tetanus-
polio-haemophilus inuenza b, though 131 subjects were up to date for age, 23
subjects received no or incomplete series not accounted for by young age. For
HAV, 9 subjects received complete HAV series and all mounted serologic protec-
tion. Though 137 subjects had no prior history of HAV vaccination, 22 of these
subjects mounted serologic protection. In total, 32 (20.5%) subjects had serologic
protection to HAV.
CONCLUSION(S): Children with IBD are at risk for vaccine-preventable illnesses
due to lack of receiving or completing vaccine series and inadequate serologic
protection despite vaccination. Therefore, clinicians caring for patients with IBD
should be conscientious about vaccination schedule adherence, serology mea-
surement, and booster vaccinations where appropriate.
O-7
Early Infliximab Trough Levels Predict Remission at one Year in Pediatric IBD
Patients
Casey Rosenthal, Gil Melmed, Bhavna Tripuraneni, Jennifer Gebbia, Silvia Callejas,
Sharmayne Farrior, Shervin Rabizadeh, Marla Dubinsky
Cedars Sinai Medical Center, Los Angeles, CA, USA
BACKGROUND: Among patients with IBD, detectable trough concentrations of
iniximab (IFX) during maintenance dosing are associated with response to ther-
apy. Moreover the presence of anti-iniximab antibodies (ATI) increases drug
clearance and loss of response. It is unknown whether IFX and ATI levels at the
completion of induction dosing predicts long term efcacy of maintenance ther-
apy. We determined whether week 14 trough IFX levels (IFX14) and ATI levels
(ATI14) were associated with week 54 outcomes in pediatric IBD patients.
METHODS: A prospective cohort of pediatric IBD patients receiving IFX were
tested for IFX and ATI levels at both weeks 14 and 54 or at early termination. Pri-
mary non-responders (NR) were patients who stopped drug before week 14 and
early terminators were patients who stopped drug between weeks 14-54. Primary
outcome was week 54 clinical remission (CR) : PCDAI <10 for Crohns disease or
partial Mayo <2 points and no sub-score >1 for ulcerative colitis and the ab-
sence of a dose or frequency intensication beyond 5 mg/kg q 8 weeks prior to
week 54. Secondary outcomes were deep remission (DR): clinical remission with
normal CRP, sustained durable remission (SDR): CR at every maintenance infusion
(week 14-54) and week 54 IFX (IFX54) and ATI (ATI54) levels. Univariate analyses
were used to determine associations between IFX14 and ATI14 and week 54 out-
comes, as appropriate. Regression tree analysis was used to determine the opti-
mal IFX14 cutoff level associated with remission. IFX and ATI ELISA testing were
performed at Prometheus labs (San Diego, CA).
RESULTS: 38 patients (median age: 12.6 yrs.) were enrolled of whom 4 were pri-
mary NR. 2/4 primary NR had detectable ATI levels and 3/4 had undetectable IFX
levels before week 14. Of the 34 who entered maintenance at week 14, 3
patients discontinued IFX prior to week 54. Of the remaining 31 patients, 20 met
criteria for both clinical and deep remission and 14 for SDR. ATI were detected in
3/34 (8%) at week 14 and 7/34 (20%) at week 54 or at early termination. 4/7
patients developed ATI after week 14. Week 14 IFX trough level was associated
with CR (P = 0.009), DR (P = 0.009) and SDR (p = 0.04). The optimal cut point
for IFX trough level at week 14 to predict DR was 5.5 u g/m l(p = 0.01). IFX14
was associated with IFX54 (P = 0.02) and inversely associated with ATI54 (P =
0.003). ATI14 was associated with ATI54 (P = 0.004) and inversely associated with
IFX54 (P = 0.06) but was not associated with any of the remission outcomes.
CONCLUSION(S): Iniximab levels at week 14 are associated with clinical, deep
and sustained durable remission at week 54, with a minimum trough level of 5.5
lg/mL being strongly predictive of deep remission. Moreover, week 14 IFX trough
levels correlate with both week 54 IFX and ATI levels. The presence of ATI at
week 14 did not predict remission outcomes but did correlate with IFX and ATI
levels at week 54. Assessment of iniximab levels at an early time point may be
warranted to optimize dosing to maximize long term therapeutic benet.
O-8
YI
Trends in Hospitalization Rates and Disease Behavior in Pediatric Inflammatory
Bowel Disease in the United States from 2000 to 2009
Chaitanya Pant
1
, Jessica Philpott
2
, Michael Anderson
1
, John Grunow
1
,
Judith OConnor
1
, Thomas Sferra
3
1
University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA,
2
Cleve-
land Clinic, Cleveland, OH, USA,
3
Rainbow Babies & Childrens Hospital, Case West-
ern Reserve University School of Medicine, Cleveland, OH, USA
BACKGROUND: Recent studies suggest an increasing incidence of inammatory
bowel disease (IBD) in children. However, the impact of this increase on the secu-
lar trends of inpatient care and disease burden in hospitalized children with IBD
is unknown. Therefore, the aims of this study were to evaluate the rate of hospi-
talization and disease behavior in hospitalized children with IBD in the United
States from 2000 to 2009.
METHODS: We used the U.S. Healthcare Cost and Utilization Project Kids Inpa-
tient Database. Data were weighted to generate national-level estimates.
RESULTS: We identied 61,779 cases of pediatric IBD during four triennial periods
from 2000 to 2009. During the period of study, the rate of hospitalization of chil-
dren with any diagnosis of IBD increased from 43.6 to 72.0 (cases per 10,000 total
hospitalizations entered into the database per year; 2000 vs. 2009; P < 0.001).
Specically, for Crohns disease (CD) the rate increased from 28.3 to 45.7 (P <
0.001) and for ulcerative colitis (UC) 15.2 to 26.1 (P < 0.001). There was an
increasing trend in the rate of hospitalization in pediatric cases of IBD overall,
and CD and UC individually (evaluation of entire time period, Cochran-Armitage
test for trend, P < 0.001 for each disease). The age distribution of hospitalized
children with IBD did not change over the decade of study. Mortality (1 per 1,000
cases of IBD) and length of hospital stay (LOS; median, 4 days) remained con-
stant. Hospitalization charges (adjusted for ination) increased (median, $11,614
to $20,724, P < 0.001). Signicant increasing trends were found for comorbid dis-
ease burden and systemic complications (including electrolyte disturbances and
anemia), and the need for blood transfusion and parenteral nutrition (P < 0.001
for each). There, also, was an increase in the number of cases with stulae,
obstruction, and perianal disease (P <0.001 for each). In comparison of IBD and
non-IBD cases, those with IBD had lower mortality, longer LOS, and higher
charges (P < 0.001 for each). Case-control matching demonstrated a lower risk of
death (adjusted odds ratio, aOR 0.25, 95% CI, 0.20-0.31), longer LOS (aOR 2.48,
95% CI, 2.40-2.50), and higher charges (aOR 1.92, 95% CI, 1.88-1.96) in those with
IBD.
CONCLUSION(S): These results demonstrate an increasing trend in the number of
pediatric cases with IBD admitted to the hospital from 2000 to 2009. Moreover,
we found an increasing trend in disease-specic and systemic complications in
these children along with an increasing cost of the hospital stay. These ndings
are consistent with earlier studies demonstrating that the epidemiology of pedi-
atric IBD is changing as demonstrated by an increase in hospitalized cases. Also,
these data suggest there has been an increase in the severity and frequency of
complicated disease.
O-9
YI
Long-term Outcomes With Infliximab Treatment in Children With Crohns
Disease at a Single Centre
Peter Church, Jack Guan, Liad Salz, Karen Frost, Aleixo Muise, Thomas Walters,
Anne Griffiths
Hospital for Sick Children, Toronto, Ontario, Canada
BACKGROUND: Iniximab is highly effective in inducing clinical response and
remission in luminal Crohns disease (CD) in children (Hyams, 2007), but pediatric
data concerning long-term durability of response are limited. We reviewed the
efcacy of iniximab induction and regularly scheduled maintenance treatment
in achieving short- and long-term clinical remission, normal linear growth and in-
testinal healing in a single-center cohort.
METHODS: From 2000 to 2011 at SickKids Hospital, Toronto, 195 children (63%
male; median age 14.0 yrs, IQR 12.3-15.6) with intestinal inammatory CD (20%
L1; 17% L2; 63% L3) received iniximab 3-dose induction (5 mg/kg/dose at weeks
0, 2, 6). Median duration of diagnosed CD at initiation was 19.9 mos (range 0.3-
136.8). Responders continued on regularly scheduled maintenance treatment /-
immunomodulator (IM). Patient health records were retrospectively reviewed to
extract at 6 mos and annually thereafter: physician global assessment (PGA) of
continued response/remission versus loss of response, PCDAI, linear growth, re-
evaluation colonoscopic data and serum levels of iniximab and antibodies. Dura-
bility of response was calculated using a Kaplan-Meier Survival Curve. Pearsons
chi-square was used to assess the inuence of maintenance regimen (monother-
apy versus combination) on likelihood of secondary loss of response (LoR).
RESULTS: Among the 195 patients treated, rates of clinical response (judged by
PGA) and remission (judged by PGA and PCDAI / = 1 dose escalation. In subjects
with LoR, antibodies to Iniximab (ATI) were positive in 85%, absent but with
undetectable drug levels in 10%, and inconclusive in 5%. Concurrent IM use (104/
180 responders) did not signicantly alter LoR, ATI or need for dose escalation.
Linear growth data were available for 95% of the cohort. Overall the median
height z-score fell from 0.57 at diagnosis to 0.8 at the initiation of Iniximab.
Long-term data for patients with growth potential (Tanner 1 or 2 at initiation of
iniximab) and at least 3 years of follow-up are shown in Table.
CONCLUSION(S): These long-term data support the effectiveness of Iniximab in
achieving response and improved growth parameters in patients with luminal
Crohns disease. Most secondary LoR was associated with ATI formation. Concur-
rent IM use did not alter LoR.
O-10
Improving Oral Medication Adherence in Pediatric IBD by Teaching Problem
Solving Skills: Year 2 Results of the PHONE Trial
Rachel Greenley
1
, Eve Nguyen
1
, Jennifer Kunz
2
, Amitha Gumidyala
1
, Molly Tho-
mason
1
, Jennifer Walter
1
, Michael Stephens
3
, Vincent Biank
4
, Ellen Blank
3
, Praveen
Goday
3
, Ranjana Gokhale
5
, Barbara Kirschner
5
, Alfonso Martinez
3
, Adrian Mir-
anda
3
, Joshua Noe
3
, Neelesh Tipnis
6
, Narajanan Venkatsubramani
7
, Steven Werlin
3
,
Stacy Kahn
5
1
Rosalind Franklin University of Medicine & Science, North Chicago, IL, USA,
2
Ros-
alind Franklin University, North Chicago, IL, USA,
3
Medical College of Wisconsin,
Milwaukee, WI, USA,
4
NorthShore Medical Group, Evanston, IL, USA,
5
University of
Chicago, Chicago, IL, USA,
6
UC San Diego, San Diego, CA, USA,
7
Duke University
School of Medicine, Durham, NC, USA
BACKGROUND: Despite the prevalence of oral medication nonadherence among
youth with inammatory bowel disease (IBD), few evidence-based tools exist to
address this issue. Development of brief interventions that can be implemented
in regular clinical practice is needed. Problem solving skills training (PSST), which
involves teaching families a structured approach to identifying and solving adher-
ence barriers, is a promising intervention that has been used to successfully
address nonadherence in other pediatric chronic diseases. We report on the Year
2 outcomes of a randomized clinical trial of a phone-delivered PSST intervention
to reduce adherence barriers and improve adherence in youth with IBD. Recruit-
ment for this study is ongoing.
METHODS: English speaking youth ages 11-18 followed in one of two Pediatric
IBD clinics in the Midwest, with a conrmed diagnosis of IBD, who had a parent/
guardian willing to participate, and who were prescribed an oral IBD maintenance
medication were eligible to participate. Families completed a baseline assessment
of adherence barriers (A1), and follow-up assessments at approximately 3 months
(A2) and 5 months post recruitment (A3). The primary outcome was improvement
in adherence to an oral maintenance medication, which was assessed via electronic
monitoring. Following A1, families were randomized to either immediate treatment
(i.e., 2 phone PSST sessions) or a wait list comparison group. Following A2, those in
the immediate treatment group were re-randomized to either a maintenance con-
dition or to receive two additional phone PSST intervention sessions, while those
in the wait list group were automatically given treatment (i.e., 2 phone PSST inter-
vention sessions). See Figure 1 for a diagram of the study procedure.
RESULTS: To date, 76 participants (parent-child dyads or triads) have been con-
sented and 38 have complete data available for the current analyses. Participating
youth were predominately male (56%) and Caucasian (88%). Most participants had
Crohns disease (71%). Eighteen of 38 youth (47%) had perfect adherence
(i.e.,100%) during the baseline-monitoring interval and thus, had no improvement
in adherence following the two intervention sessions. The remaining twenty youth
had a mean pre-intervention adherence rate of 62% (SD = 28%), which improved
to 75% (SD = 28%) following two phone intervention sessions. This nding was
consistent with a medium effect size (d = 0.59). Little additional benet on adher-
ence was seen among those receiving an additional 2 (4 total) PSST intervention
sessions; however, this subsample was small (n = 8). In addition, families reported
high satisfaction with key intervention components. On an Intervention Satisfac-
tion Scale ranging from 1 to 5, with higher scores reecting higher satisfaction,
mean youth satisfaction ratings ranged from 3.9 to 4.4. Mean mother satisfaction
ratings ranged from 3.5 to 4.5. See Table 1 for satisfaction ratings by item.
CONCLUSION(S): Results to date support phone-delivered PSST as a useful inter-
vention for families of youth with IBD who have adherence problems. Additional
analyses will explore differences in intervention efcacy as a function of youth
age, SES, and disease severity. Analyses will also explore cost-savings of delivering
the intervention via phone versus in person.
Nursing Oral Presentations
O-11
Creating and Implementing a Pre-visit Planning (PVP) Tool for IBD Visits
Emmala Shonce
Levine Childrens Hospital, Charlotte, North Carolina, USA
BACKGROUND: ImproveCareNow (ICN) is an established network of gastroenterol-
ogy care centers and professionals that has raised the standard of care in pediatric
IBD by creating Model IBD Care: Guidelines for Consistent Reliable Care following
the carefully analyzed results of thousands of doctorpatient visits as well as the
latest studies and treatments worldwide. The success of the program lies in devel-
oping and using specic tools which lead to further improvement in the delivery
of care at each involved site. One such tool addresses the concept of pre-visit plan-
ning (PVP). PVP tools are used to identify possible patient needs or areas to
address prior to the time of the actual visit, in the hopes lining up appropriate
resources and avoiding delays or missed opportunities during the ofce visit itself.
METHODS: 4 PVP tools provided by well-established teams in ICN where reviewed,
and used to create our rst PVP tool draft. The tool addressed information regarding
initial diagnosis, most recent screening tests, current weight and medication dos-
ages, and status of immunizations. The clinic schedules were reviewed on Friday
afternoons, which is an administrative time for our clinic. Any identied IBD patient
for the upcoming week got a PVP tool completed that date. Any outstanding needs
were highlighted, and the form was given to the corresponding provider for noti-
cation. After the completion of the visit, the providers where asked to return the
PVP form with either written or verbal notications pertaining to their response to
recommendations. Using a PDSA (plan, study, do, act) the tool was revised and re-
trialed several times based on comments and feedback from our providers.
RESULTS: After multiple cycles and revisions, we were able to create a tool that
was comprehensive but quick, taking only about 3 minutes to complete per
patient. We were able to identify and complete the tool on >90% of routine
scheduled IBD visits. We received qualitative feedback from the providers that
they felt that the tool was useful, and helped them ensure needed items were Figure 1.
brought to their attention quickly, saving them time during the actual visits. Inci-
dentally, after our interventions we noted an increase in remission rates for this
patient population from a dismal 40% to well above 60%.
CONCLUSION(S): Participating in a quality collaborative such as ICN, where tools
such as our PVP form are considered routine, can be time consuming but cer-
tainly worthwhile to increase standardization of care delivery, and to ultimately
improve patient outcomes. Using a PDSA format which allows measurement of
both objective and subjective data, was benecial in this setting to create an
effective, well received tool.
O-12
Innovative Teaching for Humira (adalimumab) Injections to Children with
Teresa Wachs
Seattle Childrens, Seattle, WA, USA
BACKGROUND: Humira (adalimumab) is a fully human anti-TNF- alpha monoclonal
antibody used to treat Inammatory Bowel Disease in Adults and Children. It is
available in both prelled syringes and prelled pens. The injections are widely
reported to cause varying degrees of discomfort. The pH of Humira is 5.2, which
may contribute to the pain. Children are especially reluctant to receive any treat-
ments that involve needles. The goal of teaching is to encourage any child over the
age of 7 to be involved with their injections and over time gain independence. The
degree of involvement will progress with their comfort and acceptance of therapy.
Methods of coping with the injection site discomfort and the progressive involve-
ment were developed to promote self injection and tolerance of side effects.
METHODS: Children are given the option to be taught to self inject when therapy
begins or participating while a parent or caregiver administers the medication.
Most children prefer the Humira pen so they do not see the needle or have to
watch it penetrate the skin. Depending on the childs developmental level, a multi-
step process in introduced. If a child is hesitant to self administer, they are asked to
clean the skin and/ or gently squeeze the skin while the infection is given. This
actively engages the child in the treatment. When they are more comfortable, the
next step is to have the child press the activator button. The last step before inde-
pendence is having the child do the injection while the parent holds the syringe to
prevent them from inadvertently lifting it before the medication is fully infused.
Dealing with the pain of the injection is a signicant skill for a child to acquire. We
developed several strategies to distract and calm the child during the administra-
tion. These include the use of specic music via earphones that allows the child to
focus and prepare to depress the activator at a certain point the song and know
when the music comes to a another point the pain will be gone. Ice applied to the
site for 20 minutes prior to injections is helpful to some children as is a warm pack
after the injection. Giving the injection after soaking for 5-10 minutes in the bath-
tub to relax and then immediately immersing the limb after the injection is effec-
tive. Lastly allow the child to choose a piece of very sour candy and place in their
mouth just prior to injection. Count to 3 and then bite into the candy while you
depress the activator in the pen. This gives them 2 powerful sensations and they
are distracted. This method is met with enthusiasm.
RESULTS: Children were able to progress to independence and develop skills to
assist them in coping with a difcult treatment. These skills can be transferred to
other treatment settings and give the child a sense of control and self efcacy.
CONCLUSION(S): Children need creative methods to cope with painful procedures
and can become independent with a program that encourages a gradual pro-
gression in their involvement.
Basic Science Oral Presentations
O-13
Epithelial Cell Autophagy in Antibacterial Defense of the Small Intestine
Jamaal Benjamin, Lora Hooper
UT Southwestern Medical Center, Dallas, TX, USA
BACKGROUND: The intestines of all mammals are colonized with a diverse micro-
biota that provide metabolic benets to their hosts. However, this symbiotic rela-
tionship can break down when resident bacteria opportunistically invade the in-
testinal barrier, leading to pathologies such as inammatory bowel disease (IBD)
and bacteremia. As a result, epithelial cell innate immune responses play an
essential role in preventing bacterial invasion of host tissues and maintaining a
symbiotic host-bacterial relationship. Autophagy is emerging as an important
component of innate immunity. Mounting evidence suggests that dysregulation
of autophagy can lead to inammatory bowel disease. Additionally, increased
bacterial invasion of epithelial cells is a hallmark of IBD. Little is known, however,
about the role of autophagy in controlling interactions between intestinal bacte-
ria and the intestinal epithelium in vivo.
METHODS: The present study was conducted to evaluate the role of autophagy
in the epithelial cells of the small intestine. We utilized a known intestinal patho-
gen, Salmonella typhimurium, and monitored enterocyte autophagy activation in
gnotobiotic (germ-free) and conventionally (CV) raised wild-type mice following
intragastric bacterial challenge. Autophagy activation was analyzed via immuno-
uorescence, Western blot analysis and electron microscopy. We next investigated
the role of Toll-like receptors (TLRs) on autophagy activation by utilizing mice de-
cient in myeloid differentiation protein (MyD88), an adaptor molecule essential
for TLR signaling. Finally, we demonstrated a critical role for epithelial cell autoph-
agy by generating mice lacking Atg5, a critical autophagy protein, specically in
the epithelial cells of the small intestine, and monitoring the ability of Salmonella
to translocate to extraintestinal sites including the liver and spleen.
RESULTS: In this study, we demonstrate that small intestinal epithelial cell autoph-
agy is essential for protection against tissue invasion by intestinal pathogens and
opportunistically invasive commensals. We show that small intestinal autophagy
is an early innate immune response that functions in an epithelial cell-intrinsic
MyD88 dependent, NOD2-independent manner. Utilizing mice decient in small
intestinal epithelial cell autophagy (Atg5
DIEC)
, we have determined that epithelial
cell autophagy is required to limit pathogen dissemination to extraintestinal sites,
including the liver and spleen.
CONCLUSION(S): This study represents the rst comprehensive and mechanistic in
vivo dissection of the microbiota capable of activating epithelial cell autophagy, the
pattern recognition receptors (PRRs) required for this activation, as well as the criti-
cal antibacterial role of epithelial cell autophagy in the intestine. A deeper under-
standing of how small intestine epithelial cell autophagy functions will be crucial in
understanding how autophagy mutations predispose for IBD development and
thus improve treatment modalities for both Crohns Disease and Ulcerative Colitis
O-14
YI
A Variant in ATG16L1 Associated With Crohns Disease Reduces Invasion of
Human Cells by Salmonella
Stephen Murphy, Jeannette Messer, David Boone
The University of Chicago, Chicago, IL, USA
BACKGROUND: Genome wide association studies (GWAS) have identied a number
of CD-associated polymorphisms in genes that regulate autophagy. Autophagy or
macroautophagy is a fundamental cellular process that coordinates homeostasis
through a variety of mechanisms including derivation of nutrients from endoge-
nous proteins and organelles during times of environmental stress to destruction
of intracellular pathogens. One CD-associated variant is found in ATG16L1, a key
regulator of autophagy involved in membrane architecture remodelling and auto-
phagosome formation. This variant results in a form of ATG16L1 that is defective in
clearing intracellular microbes. However, little is known about the effects of this
variant on bacterial invasion into cells. We therefore investigated the effect of
ATG16L1 mutations on bacterial infection into human cells.
METHODS: Human cells with a deletion of the ATG16L1 gene or cells with the
ATG16L1 CD-associated T300A variant were generated by homologous recombi-
nation in HCT116 cells (IEC). These gene targeted knockout and T300A knockin
cells were exposed to Salmonella enterica serovar typhimurium and assessed for
infection by live cell imaging, ow cytometric high resolution microscopy and an-
tibiotic protection assays. Analyses of alterations of actin nucleation events were
performed by immunoprecipitation and immunoblotting.
RESULTS: Cells lacking ATG16L1 displayed decreased rates of infection compared
to WT IEC. Normal rates of infection were restored by complementation of
ATG16L1 decient cells with ATG16L1, but not by complementation with the
ATG16L1 T300A variant. Similarly, gene-targeted cells with the ATG16L1 T300A
knockin were resistant to infection by Salmonella. Thus, ATG16L1 facilitates Sal-
monella infection of IEC and the CD-associated variant in ATG16L1 protects cells
from Salmonella infection. Actin nucleation events that mediate Salmonella were
altered in cells decient for or expressing the T300A variant of ATG16L1.
CONCLUSION(S): These ndings suggest that the CD-associated variant in
ATG16L1 has a protective, benecial effect against bacterial infection. This effect
was mediated at least in part by distortion of the actin nucleation machinery in
these cells. The high prevalence of the T300A variant in the European population
may reect positive selection for this benecial role against bacterial infection.
O-15
YI
MicroRNA-regulated Pathways in Pediatric IBD
Adam Zahm
1
, Daphne Tsoucas
2
, Robert Baldassano
3
, Joshua Friedman
2
1
Department of Pediatrics, Perelman School of Medicine at the University of
Pennsylvania, Division of Gastroenterology and Nutrition, The Childrens Hospital
of Philadelphia, Philadelphia, PA, USA,
2
Department of Pediatrics, Perelman School
of Medicine at the University of Pennsylvania, Division of Gastroenterology and
Nutrition, The Childrens Hospital of Philadelphia, Philadelphia, PA, USA,
3
The
Childrens Hospital of Philadelphia, Philadelphia, PA, USA
BACKGROUND: The discovery of microRNA (miRNA) has produced a range of
insights in mammalian development and human disease. However, there are
few reports of the molecular function of miRNA in IBD, particularly in
children.
METHODS: Large-scale analysis of miRNA expression was performed in rectal tis-
sues obtained from children with Crohn disease (CD), ulcerative colitis (UC), and
normal controls. The Nanostring platform was used to avoid artifacts due to
nucleic acid amplication or afnity hybridization. Bioinformatic tools were used
to identify candidate miRNA:mRNA target relationships, and these were tested by
reporter assays in cultured intestinal epithelial cells.
RESULTS: We have found a unique signature of tissue- and disease-specic
miRNA expression in children with IBD. Based on these results, we have identi-
ed several candidate miRNA:mRNA relationships of potential pathologic signi-
cance, including regulation of the CD-associated gene NOD2/CARD15. The
results have been validated by reporter assays in cultured intestinal epithelial
cells.
CONCLUSION(S): IBD in children is associated with widespread changes in
miRNA expression. Some of these changes are linked to altered expression of
genes of known signicance in IBD. Because miRNAs are particularly amenable
to pharmacologic inhibition, these ndings may lead to novel therapeutic strat-
egies in IBD.
O-16
YI
Commensal Bacteria Play an Important Role in Ulcerative Colitis via Bacterial
Sphingolipids-Mediated Regulation of Host Invariant Natural Killer T Cells
Dingding An, Sungwhan Oh, Dennis Kasper
Harvard Medical School, Boston, MA, USA
BACKGROUND: Our group has shown previously that microbiota can impact ul-
cerative colitis disease phenotypes by modulating invariant natural killer T (iNKT)
cell functions. We further found that chemokine CXCL16 is responsible for this
modulation, with germ-free (GF) mice having high CXCL16 level, large iNKT cell
numbers and severe experimental ulcerative colitis outcome. In this study, we
hypothesized that in addition to CXCL16 regulated functions, intestinal micro-
biota can directly impact iNKT cells by providing bacterial antigen, such as
glycosphingolipids.
METHODS: We generated a Bacteroides fragilis mutant (del SPT) that no longer
produces any sphingolipids. We then mono-colonized GF mice using wild-type or
del SPT mutant. Theses mice were further challenged with an experimental ulcer-
ative colitis modeloxazolone colitis model and the disease phenotypes were
evaluated.
RESULTS: We found that the wild-type B. fragilis mono-colonized mice have signif-
icantly lower colonic iNKT cell numbers than the mutant mono-colonized mice,
which are similar to the GF mice. CXCL16 levels in both of the mono-colonized
mice are as low as that of the conventional mice, indicating the existence of a
new pathway for colonic iNKT cell regulation. When challenged in the oxazolone
colitis model, the mutant-colonized mice were much more susceptible than the
wild-typecolonized mice. These phenotypes were diminished when the mice
were treated with CD1d antibody, indicating iNKT cell-specic functions were
involved.
CONCLUSION(S): Our study demonstrated that microbiota regulate colonic iNKT
cells via a new and unknown pathway. This pathway uses components in bacte-
rial sphingolipid biosynthesis and it points to a new direction for therapeutic
intervention of ulcerative colitis.
O-17
YI
Clostridium Difficile Toxin A-associated DNA Augments the Host Inflammatory
Response
Xiaotong Yang
1
, Dan Li
2
, Hua Xu
2
, Ciaran Kelly
3
, Xinhua Chen
3
1
Institute of Microbiology and Immunology, Shanghai Normal University, Shang-
hai, Shanghai, China,
2
Beth Israel Deaconess Medical Center, Boston, MA, USA,
3
Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
BACKGROUND: Clostridium difcile infection (CDI) is the leading recognized cause
of nosocomial infectious diarrhea in the developed world. The importance of CDI
amongst patients with inammatory bowel disease (IBD) is increasingly being rec-
ognized. Recent studies on CDI in IBD patients have demonstrated a concerning
trend towards increased rates of infection, morbidity, mortality and healthcare
costs. Guidelines now promote testing for C. difcile in IBD patients experiencing
a relapse of colitis. The major virulent factors of C. difcile are two large protein
exotoxins - A and B, which initiate a marked intestinal inammatory response. In
this study we discovered that toxins secreted by Clostridium difcile contain sig-
nicant amounts of bacterial DNA, which was further conrmed (by sequencing)
to be of C. difcile origin. It is known that toll-like receptor 9 (TLR-9) recognizes
bacterial DNA containing CpG dinucleotides and triggers an inammatory
response. In this study, we aim to examine the role of toxins-associated DNA in
the inammatory response in CDI.
METHODS: HT-29 cells, THP-1 cells, wild type (WT) and TLR9 knock-out (TLR9KO)
mouse macrophage lines were stimulated with C. difcile toxins A or its deriva-
tives treated with DNAse I digestion or by heat inactivation. ODN TTAGGG was
used to antagonize TLR9 receptor. Toxin cytotoxicity was measured by standar-
dized cell rounding assay. IL-8 or KC(IL-8 homologue) release was measured by
ELISA.
RESULTS: Both C. difcile toxin A and B contain DNA from C. difcile as deter-
mined by gene sequencing. In vitro pull-down assays demonstrated that both
toxin A and B have strong afnity for DNA. HT-29 intestinal epithelial cells,
THP-1 monocytes and macrophages each secreted high levels of IL-8 or KC in
response to toxin A (10nM) stimulation. IL-8 production was attenuated when
cells were treated with the TLR9 antagonist ODN TTAGGG. Heat inactivation of
toxin A demolished its cytotoxicity (i.e. no cell rounding in HT-29 cells), but
IL-8 production was still induced although at lower levels than by untreated
toxins. Digesting toxin A with DNAse I also reduced IL-8 production in all
tested cell lines. Furthermore, compared to wild type control, TLR9 knock-out
macrophages produced signicantly lower amount of KC in response to toxin
A.
CONCLUSION(S): We have made the novel observation that C. difcile toxins con-
tain genomic DNA that is bound with high afnity. C. difcile toxin A- associated
DNA augments toxin-induced inammation by activating TLR9 signaling path-
ways. Antagonizing or knocking out the TLR9 receptor results in reduced toxin A
induced inammatory cytokine production. Our data suggest that C. difcile DNA
bound to exotoxins A and/or B and signaling via TLR 9 may be a signicant con-
tributing virulence factor in C. difcile infection.
O-18
YI
Impaired Mucosal Immunity to Commensal Fungi Influence Colitis
Iliyan Iliev, Vincent Funari, Christopher Reyes, Courtney Becker, David Underhill
Cedars-Sinai Medical Center, Los Angeles, CA, USA
BACKGROUND: Interactions between commensal microbiota and the immune
system are critical for establishing a proper balance between immune host
defense mechanisms and tissue health. Changes in the composition of gut bac-
terial communities have been associated with intestinal inammation and obe-
sity. Recent studies have begun to note that a fraction of mucosa-associated
microorganisms are not bacterial. Mucosal fungal infections are relatively com-
mon in Crohns Disease patients, and antibodies against fungal antigens (ASCA)
are a widely accepted clinical marker for disease severity. What fungi populate
the intestine and how immunity to them might play a role in inammatory dis-
ease is currently unknown. Fungi are sensed by number of innate immune
receptors among which Dectin-1 has emerged as the main innate immune re-
ceptor for recognition, phagocytosis, and killing of fungi by myeloid
phagocytes.
METHODS: Commensal fungi were visualized and quantied by staining with Dec-
tin-1 probe followed by microscopy and FACS analysis, and additionally detected
in fecal samples by qPCR for fungal 18S rDNA. To dene the mouse intestinal fun-
gal microbiome (the mycobiome), we isolated DNA from murine feces, amplied
the internal transcribed spacer region (ITS1-2) of fungal rDNA, and performed
high-throughput sequencing. To induce colitis wild type and Dectin-1-/-
mice were treated with DSS. In some cases mice were supplemented with
C. tropicalis - a common commensal fungus we found in murine gut and sub-
jected to DSS. To determine whether the altered fungal burden during colitis
contributes to disease severity, we suppressed fungal growth with uconazole, a
specic antifungal drug.
RESULTS: We found that mice lacking Dectin-1, recognizing fungal cell wall b-glu-
can, are more susceptible to experimental colitis characterized by increased inl-
tration of Th17 and Th1 cells in the colon. Interestingly this pathology was driven
by intestinal fungus, and antifungal therapy ameliorated colitis severity in knock-
out mice. Deep sequencing analysis of the fungal mycobiome revealed fungal
species that are overrepresented in the gut during experimental colitis. When
Dectin-1-/- mice were supplemented with Candida tropicalis, a specic commen-
sal fungus found in the intestine during colitis, they experienced more severe in-
testinal inammation and augmented Th17 mucosal responses in absence of Dec-
tin-1. Consistently, intestinal dendritic cells (DCs) from Dectin-1-/- mice, but not
WT DCs, showed reduced ability to kill fungi. Therefore the data suggest that an
inability of Dectin-1-/- mice to mount effective immune responses to specic in-
testinal fungi creates conditions that promote inammation. Since the mouse
model suggested that Dectin-1 is involved in contributing to the severity of colo-
nic disease, we focused on the severity of ulcerative colitis (UC), the form of IBD
that always affects the colon. In particular we focused on severe UC, termed
medically refractory UC (MRUC), consisting of patients requiring colectomy as a
result of lack of response to medication. We found that a specic variant of the
gene for Dectin-1 is strongly associated with a severe form of ulcerative colitis
requiring colectomy.
CONCLUSION(S): Together our ndings reveal a novel eukaryotic fungal commu-
nity in the gut and show that altered interactions between the fungal microora
and the host intestinal phagocytes can profoundly inuence intestinal pathology.
O-19
YI
Transmigrating Neutrophils Shape the Mucosal Microenvironment
During Colitis
Eric Campbell
1
, Walter Bruyninckx
2
, Louise Glover
1
, Caleb Kelly
1
,
Douglas Kominsky
1
, Brittelle Bowers
1
, Amanda Bayless
1
, Eoin McNamee
1
,
Paul Jedlicka
1
, Cormac Taylor
3
, Sean Colgan
1
1
University of Colorado, Aurora, CO, USA,
2
Hanover College, Hanover, IN, USA,
3
University College Dublin, Dublin, Ireland
BACKGROUND: Neutrophil (PMN) accumulation in crypt abscesses is a pathologi-
cal hallmark of ulcerative colitis. PMN transepithelial migration is orchestrated
through a complex series of cell-cell interactions involving bi-directional signaling
molecules. Thus we hypothesized that migrating PMN inuence the transcrip-
tional prole of epithelia as they transmigrate, priming them for either resolution
or chronic inammation a concept we term transcriptional imprinting . Employ-
ing a novel approach to a PMN-transepithelial migration model, we attempted to
ascertain the inuence of transmigration on epithelial gene expression by micro-
array analysis.
METHODS: DNA Microarray was used to identify transcriptional changes in intesti-
nal epithelial cells post-PMN transmigration. Real-time oxygen sensing was per-
formed with an SDR-OxoDish (PreSens). Wild-type C57/B6 mice, ODD-Luciferase
(HIF reporter) mice and gp
91phox
-null (NADPH oxidase decient) mice were sub-
jected to chemically-induced colitis (TNBS).
RESULTS: Microarray studies revealed a cohort of hypoxia-responsive genes
regulated by PMN-epithelial crosstalk. Real-time oxygen measurements effec-
tively demonstrated that activated PMN rapidly depleted microenvironmental
oxygen. Subsequent studies indicated that activated PMNs are sufcient to
induce hypoxia-inducible factor (HIF) stabilization and activity in epithelial cells.
Intestinal epithelial hypoxia induced by activated PMNs during transmigration
was found to be dependent on the PMN respiratory burst. HIF is known to
inuence the expression of barrier-protective genes in the epithelium, initiate
glycolytic metabolism and attenuates the clinical course/disease parameters in
murine colitis. To ascertain the clinical relevance of transmigrating PMN and
the induction of epithelial hypoxia, we stained biopsies from UC patients for
evidence of Glut1 expression. PMN transmigration increased crypt epithelial
Glut1 expression (see Figure). We investigated the relative contribution of PMN
to inammatory hypoxia in vivo, utilizing a colitis model. Antibody-mediated
depletion of PMNs worsened the course of colitis, exhibited reduced tissue hy-
poxia visualized with Hypoxyprobe-1 staining and attenuated the induction of
hypoxia-dependent genes. Patients with chronic granulomatous disease (CGD)
lack functional NADPH oxidase and develop IBD-like symptoms. We demon-
strated that murine gp91
phox-/-
mice mirror human CGD, develop a severe coli-
tis, with exaggerated PMN inltration. However, these inltrating PMN are inca-
pable of inducing a hypoxic microenvironment. Finally, pharmacological
intervention with a HIF-stabilizing compound (PHD inhibitor), resulted in reca-
pitulation of mucosal HIF-signaling concomitant with abrogation of colitis-se-
verity in the gp91
phox-/-
mice.
CONCLUSION(S): In conclusion, transcriptional imprinting of host tissue by
inltrating neutrophils signicantly modulates the host response to
inammation. Moreover, the respiratory burst contributes fundamentally to
localized oxygen depletion and resultant microenvironmental hypoxia. We
propose that this microenvironment established by inltrating PMN is
protective during colitis.
O-20
Regulation of Epithelial Innate Immunity through Hypoxia-mediated
Autophagy
Louise Glover, Brittelle Bowers, Caleb Kelly, Eric Campbell, Douglas Kominsky,
Sean Colgan
University of Colorado, Aurora, CO, USA
BACKGROUND: The gastrointestinal epithelium comprises the primary barrier
between omnipresent luminal antigens and the underlying immune cell reper-
toire, and is subject to profound metabolic uctuations, particularly in inamma-
tory bowel disease (IBD). A role for the hypoxia-inducible transcription factors
(HIFs) in orchestrating transcriptional changes to promote barrier function has
been well dened. Given the importance of HIF signaling to epithelial homeosta-
sis, we hypothesized that HIF-mediated transcriptional changes contribute to epi-
thelial innate immunity. Promoter microarray screens of HIF-enriched genomic
DNA, derived from chromatin immunoprecipitation (ChIP-on-chip), highlighted
autophagy as a novel pathway coordinately regulated by HIF-1. A fundamental
role for autophagy in IBD pathogenesis has recently been elucidated, dened
largely by abrogated bacterial killing (xenophagy). However, little is known about
transcriptional regulation of coordinated autophagy gene responses, and how
these modulate intestinal epithelial cells (IEC) xenophagy.
METHODS: Cell Culture: Human intestinal epithelial Caco-2 and T84 cells were
used. Hypoxia was dened as pO
2
20 torr and pCO
2
35 torr. ChIP-on-chip: ChIP
was performed with a polyclonal HIF-1a antibody using sheared chromatin from
hypoxic Caco-2 cells. ChIP-enriched and input DNA were Cy-labeled and hybri-
dized to a promoter microarray (Switchgear Genomics). The log2 ratio (input-Cy3/
HIF-ChIP-Cy5) was analyzed to identify sequences specic for HIF-1a binding.
ChIP-qPCR: ChIP-qPCR was used to quantify HIF binding to candidate loci using
primer sets anking putative HRE sites. Salmonella Typhimurium Invasion and O2
Consumption: Caco-2 cells were infected with late-log cultures of S. Typhimurium
14028 at an multiplicity of infection (MOI) of 100. The SDR OxoDish system (Pre-
sens) was used to measure the effect of Salmonella invasion on epithelial O
2
con-
sumption in real-time. Gentamicin kill assays: Caco-2 cells were infected with S.
Typhimurium and incubated in antibiotic-free medium for 30 min, followed by
media supplemented with 50 lg/mL gentamicin (Sigma) for 1h. Viable intracellu-
lar bacteria were quantied by colony counts following epithelial lysis in 1% Tri-
ton-X-PBS.
RESULTS: A cohort of promoters for autophagy genes were specically enriched
for HIF binding by ChIP-chip. Transcript levels of candidate genes were induced
by 6hrs under hypoxia or prolyl hydroxylase inhibition in Caco-2 and T84 cells,
corroborating association between HIF binding and gene expression. Hypoxic
Caco-2 cells displayed 3.5-fold higher LC3/p62positive puncta by IF than nor-
moxic cells. By immunoblot analysis, LC3-II and p62 protein levels were
increased and decreased respectively in hypoxic lysates, indicating hypoxia-
induced autophagic turnover. Hypoxia stimulation of autophagy increased Sal-
monella killing, conrming hypoxic induction of xenophagy. Moreover, invasive
Salmonella induced a time- and MOI-dependent depletion of O
2
with
Figure 1.
stabilization of HIF protein. To analyze baseline epithelial autophagy in the ab-
sence of HIF signaling in vivo, we measured IEC levels of LC3 and p62 protein
in HIF-1b
-/-
mice. Consistent with a role for HIF, the ratio of LC3-I to LC3-II and
total levels of p62 were increased in vil-Cre
/HIF-1b
/
mice relative to vil-Cre
-
/
HIF-1b
/
controls.
CONCLUSION(S): Modulation of HIF-mediated autophagy by inammatory hypoxia
and/or bacterial pathogens themselves denes a conserved innate response for
host protection, and may represent a novel target for development of therapeutic
strategies to modify epithelial autophagic targeting of bacteria.
O-21
YI
Intestinal Epithelial-Cell (IEC) Control of Intestinal Inflammation: Essential Role
of Tumor Necrosis Factor Alpha-Induced Protein 3 (TNFAIP3)
Stephen Murphy, Lesley Rhee, Thomas Nero, David Boone
BACKGROUND: Intestinal epithelial cells (IEC) contribute to intestinal immune ho-
meostasis by providing a dynamically permeable barrier, generating anti-microbial
peptides (AMPs) and producing immuno-modulatory cytokines. IECspecic dis-
ruption of the activity of transcription factor nuclear factor kappaB (NF-kB) leads
to a loss of intestinal immune homeostasis and susceptibility to inammatory
bowel disease (IBD). This is due to both the induction of immuno-modulatory
cytokines and production of anti-apoptotic factors by NF-kB in IEC. TNFAIP3
blocks NF-kB activation and inhibits apoptosis and we have previously shown
that IEC-specic expression of TNFAIP3 protects against chemically induced colitis,
through modulation pro-inammatory signals and maintenance of the epithelial
cell barrier. Here we present novel ndings of the role of TNFAIP3 in exacerbating
colitis in the IL10-decient (IL-10KO) model of IBD. These ndings highlight, not
only the specic function of TNFAIP3 in IBD, but also the role of the epithelium
in restraining onset of colitis in a genetically susceptible host.
METHODS: Villin-TNFAIP3 transgenic mice were bred to IL-10KO mice and the sus-
ceptibility and severity of colitis assessed. Analysis of the extent of inammation
in these mice was performed by ELISA, ow cytometry and immunoblotting. To
further delineate pathological mechanism we performed, IF-IHC for the mucus
layers of affected mice, FISH, bacterial staining and TFRLP analyses to characterize
the microbiotic dysbiosis associated with this model of IBD.
RESULTS: Villin-TNFAIP3 transgenic x IL-10KO mice exhibited a more severe colitis
than IL-10KO mice. By ages 3-4 weeks, the villin-TNFAIP3 transgenic x IL-10KO
mice were signicantly runted, smaller by weight, and showed evidence of accel-
erated colitis with rectal prolapse, rectal bleeding and diarrhea compared to lit-
termate IL-10KO mice. Gross analysis of organs demonstrated severely thickened
colons and histology revealed severe inammation at a younger age compared
to IL-10KO mice. Analysis of peripheral and mesenteric lymphocytes showed an
increase in activated CD4 cells that are likely involved in the process of acceler-
ated inammation in the colon. ELISA for a variety of cytokines revealed a Th1-
type inammation with no evidence of altered Th2 or Th17 responses. Disease in
these mice was revealed to be a result, at least in part, of alteration in the quality
of the inner sterile mucus layer and AMPs associated with this. FISH staining
revealed an increase in bacterial: epithelial cell interaction upon constitutive
expression of TNFAIP3 in IEC driven by decreases in specic AMPs.
CONCLUSION(S): These ndings demonstrate that signaling events within IEC that
are controlled by TNFAIP3 are critical in regulating intestinal homeostasis. In the
chemically induced injury model of DSS, TNFAIP3 protects against IBD by pre-
venting IEC apoptosis. However, in the IL-10KO model, TNFAIP3 expression in IEC
distorts the cell signals that usually prevent the onset and severity of IBD. More
signicantly, we highlight a fundamental role for IEC in both mediating develop-
ment of adaptive immunity and controlling the extent of innate responses to res-
ident intestinal microbes and how these contribute to IBD development.
O-22
YI
Interaction of Formyl Peptide Receptor 1 (FPR1) and Enteric Commensal
Bacteria in Intestinal Homeostasis and Wound Healing
Ashfaqul Alam, Giovanna Leoni, Jaclyn Kwal, Huixia Wu, Asma Nusrat,
Andrew Neish
Emory University, Atlanta, GA, USA
BACKGROUND: The microbiota of the intestinal lumen is essential for normal gut
tissue development, renewal and restitution. Understanding how enteric com-
mensal bacteria interact with intestinal epithelia via pattern recognition receptors
(PRRs) is a crucial step in the delineation of mechanisms for intestinal homeosta-
sis and reparative processes that can be harnessed for the design of novel thera-
peutics for inammatory bowel disease (IBD). Pattern recognition receptors
expressed in the epithelial mucosa maintain homeostatic balance with the micro-
biota and ensure clearance of pathogenic bacteria. N-formyl peptide receptors
(FPRs) represent a family of mammalian pattern recognition receptors that can
specically bind an array of peptides and small molecules derived from bacteria
and host. FPRs are seven membrane-pass G protein coupled surface receptors,
which modulate multiple phagocyte immune functions. Intestinal epithelial cells
also express FPRs that can stimulate migration of cultured intestinal epithelial
cells in response to exogenous bacterial formylated peptides or endogenous
ligands in a redox dependent manner. However, it is incompletely understood
how gut symbionts function as a pro-healing and -homeostatic regulator in the
intestine.
METHODS: To study restitution of epithelial wounds, dened mechanical mucosal
wounds were inicted in mouse distal colon by using endoscope and forceps.
Wound restitution in chemically induced murine colitis model was also studied
by using dextran sodium sulfate (DSS).
RESULTS: Here we report that gut microbiota stimulate ROS generation in wound
associated colonic epithelial cells through FPR1 in vivo causing rapid phosphoryl-
ation of FAK and ERK in a NADPH oxidase1 (Nox1)-dependent manner. In
addition, enteric microbiota require FPR1 and Nox1 to augment proliferation and
migration of wound associated epithelial cells, and therefore, to enhance repara-
tive processes of colonic epithelial wounds inicted either by biopsy forcep or by
DSS.
CONCLUSION(S): Taken together, these ndings demonstrate a novel role for
FPR1 in perceiving enteric microbiota to regulate homeostasis and restitution of
the intestinal mucosa.
O-23
IFN-c-mediated Induction of an Apical IL-10 Receptor on Polarized Intestinal
Epithelia
Douglas Kominsky, Eric Campbell, Caleb Kelly, Louise Glover, Brittelle Bowers,
Amanda Bayless, Stefan Ehrentraut, Sean Colgan
BACKGROUND: Tissues of the mucosa are lined by an epithelium that pro-
vides barrier and transport functions. It is now appreciated that cytokines
secreted at sites of inammation have important implications in the onset
and progression of chronic inammation. Here we investigated potential anti-
inammatory mechanisms of IFN-c in models of IBD both in vitro and in
vivo.
METHODS: Guided by initial microarray analysis, we utilized qPCR, western blot,
and confocal microscopy to characterize receptor expression in vitro. We next
examined the functional consequences of receptor expression. Finally, we utilized
endpoints established in the in vitro models to examine receptor expression in a
murine IBD model and in human IBD patient samples.
RESULTS: In vitro studies revealed that IFN-c selectively induced the expression of
IL-10R1 on intestinal epithelia. Further analysis revealed that IL-10R1 was
expressed predominantly on the apical membrane of polarized T84 cells. Recep-
tor activation functionally induced canonical IL-10 target gene expression in epi-
thelia, concomitant with enhanced barrier restitution. Colonic tissue isolated from
murine colitis revealed that levels of IL-10R1 and SOCS3 were increased in the ep-
ithelium and coincided with increased tissue IFN-c and IL-10 cytokines. In parallel,
immunouorescent staining revealed apical expression of the IL-10R in colitic
mouse tissue and subsequent studies showed that treatment of mice with rIFN-c
was sufcient to drive expression of IL-10R1 to the apical surface of colonic epi-
thelium. Finally, we examined IL-10R1 in human IBD patient specimens. Diseased
tissue demonstrated increased IL-10R1 transcript with apical epithelial protein
localization.
CONCLUSION(S): Together, these results provide novel insight into an anti-inam-
matory role for IFN-c in intestinal inammation through the induction of a polar-
ized IL-10 receptor complex and suggest that rational IL-10 based therapies
should incorporate tissue polarity.
Figure 1.
O-24
YI
Microbial Regulation of CD141 Human Intestinal DCs Support ILC Production
of IL-22 in IBD
Randy Longman
1
, Gretchen Diehl
2
, Arun Swaminath
1
, Ellen Scherl
3
, Dan Littman
2
1
Columbia University Medical Center, New York, NY, USA,
2
Skirball Institute of Bio-
molecular Medicine, Department of Pathology, NYU School of Medicine, New
York, NY, USA,
3
Jill Roberts IBD Center, Weill-Cornell, New York, NY, USA
BACKGROUND: Interleukin (IL)-22 is an IL-10 family member that acts on epithelial
cells to promote healing. Although initially characterized as a cytokine made by T
cells (predominantly Th17 cells), more recent data has revealed the contribution
of non-T cells, including lymphoid tissue inducer cells and innate lymphoid cells
(ILCs), in IL-22 production. This emerging subset of ILCs plays an important role
in mouse models of colitis, but their role in human IBD and regulation by intesti-
nal microbiota remain less clear.
METHODS: Lamina propria mononuclear cells (LPMCs) were isolated from both
endoscopic biopsies and surgically resected intestinal tissue. Cytokine production
was analyzed by ow cytometry. Dendritic cells (DCs) and ILCs were sorted by
FACS. Dextran sodium sulfate (DSS) and Citrobacter rodentium were used to eval-
uate ILC function in chemical and infectious mouse models of colitis, respectively.
RESULTS: By analysis of Th17 cytokine production in lamina propria mononuclear
cells (LPMCs) from IBD patients and non-IBD controls, we show an increased pro-
duction of IL22 in intestinal ILCs. Interestingly, IL22 production correlates with ex-
posure to the fecal stream in patients with surgical diversion. Mouse models of
both chemical and infectious colitis revealed the sufciency for human microbiota
to induce ILC production of IL-22 and the importance of MyD88 signaling in
CD11c-expressing cells to promote protection by inducing IL-22 production by
ILCs. Surprisingly, TLR-induced signaling in CD14, but not CD103, intestinal
DCs support ILC production of IL22 via IL23 and IL1b.
CONCLUSION(S): These results characterize an important class of ILCs producing
IL-22 in mild to moderate IBD and suggest the importance of CD14 intestinal
DCs in integrating the microbial signals that regulate ILC function. The produc-
tion and regulation of IL-22 by intestinal ILCs may have important implications
for diagnostic and therapeutic developments in the clinical management of IBD.
O-25
Loss of Reciprocal Regulation of Innate and Adaptive Immunity Causes Colitis
in Alpha(V) Integrin-Deficient Mice
Subhankar Mukhopadhyay
1
, Mridu Acharya
2
, Helena Paidassi
2
, Manjae Kwon
2
,
Marianela Feliu
2
, Adam Lacy-Hulbert
3
1
Oxford University, Oxford, Oxfordshire, UK,
2
Massachusetts General Hospital, Bos-
ton, MA, USA,
3
Massachusetts General Hospital/ Harvard Medical School, Boston,
MA, USA
BACKGROUND: The maintenance of intestinal immune homeostasis involves a
complex interplay between the luminal microbiota, barrier epithelial cells and the
immune system. Inammatory bowel disease (IBD) is thought to arise from the
breakdown of this mutual relationship and dysregulation of immune responses to
commensal bacteria. Although many studies have now established critical roles
for both the adaptive and innate immune systems in this process, how these two
arms of the immune system work together remains poorly understood. We have
previously described the critical role of activation of TGF-beta by Dendritic cells
(DCs), mediated by the alpha(v)beta8 integrin, in regulation of T cell responses.
We showed that deletion of alpha(v) in myeloid cells resulted in the failure to
generate intestinal adaptive regulatory T cells (Tregs), leading to development of
colitis. In this study, we have investigated the role of alpha(v)-mediated TGF-beta
activation in regulation of mucosal innate immune cells and initiation of intestinal
inammation in response to microbial stimulation.
METHODS: To address this question, we have used complementary in vivo and in
vitro approaches. Lymphocyte decient alpha(v) conditional knockout mice
(Itgav-SCID mice) were generated, and T cell adoptive transfer used to dene the
roles of the myeloid lineage and T lymphocytes in development of colitis in this
model system. In parallel, control and alpha(v) decient myeloid cells were stimu-
lated in vitro with microbial components, and the inuence of sub- populations
of intestinal T cells on responses determined. Finally, gene expression analysis
was used to identify candidate innate immune genes contributing to the devel-
opment of colitis in mouse models.
RESULTS: We have found that innate immune cells from alpha(v) decient mice
mount increased inammatory responses to microbial stimulation. Surprisingly,
we nd that this is not due primarily to loss of direct effects of alpha(v) or TGF-
beta activation on myeloid cells. Instead, we have found that increased innate
immune responses are caused by the imbalance in effector and regulatory T cells
in this model. Specically we nd that cytokines derived from effector T cells
from mice with colitis activate macrophages, increasing their production of pro-
inammatory cytokines in response to microbial stimulation. Tregs, through pro-
duction of IL10, suppress this activation, promoting innate immune homeostasis
in the intestine. Hence, we show that intestinal inammation in the alpha-v
knockout model requires the presence of adaptive immune T cells, as well as in-
testinal microbiota. Building on these studies, through microarray and directed
QRT-PCR analysis, we have identied genes expressed by innate immune cells
that may contribute to the development of colitis.
CONCLUSION(S): Together these ndings identify TGF-beta-dependent reciprocal
signaling circuits that occur between the innate and adaptive arms of the
immune system. Innate immune cells instruct regulatory T cells through local
activation of TGF-beta; these Tregs in turn regulate innate immune responses to
microbes. We propose that failure of this regulatory relationship leads to the
emergence of inammatory myeloid cells that initiate intestinal inammation.
O-26
YI
Mechanisms of Protection of Alpha4-Deficient T Cells in a Model of Chronic
Experimental Colitis
Dmitry Ostanin, Elvira Kurmaeva, Songlin Zhang, Richard Bao, Berney Seth
Louisiana State University Health Sciences Center, Shreveport, LA, USA
BACKGROUND: Gastrointestinal (GI) tract represents an important interphase
between the body and the outside world. Under steady-state conditions, T-cell-
associated a4 integrins (a4b7, a4b1) play an important role in T-cell recruitment
to the gut-associated lymphoid tissue (GALT: Peyers Patches, lymphoid follicles),
mesenteric lymph nodes (MLNs) and small intestine. Moreover, these molecules
are important contributors to the pathogenesis of experimental and human
Crohns disease (CD). Although the effectiveness of anti-adhesion therapy target-
ing a4 integrins is thought to be primarily due to blocking effector T cell recruit-
ment into intestinal tissues, there is little direct evidence to conrm this, since a4
integrins can be also found on natural killer cells, monocytes, and granulocytes.
Therefore, the objective of the current study was to ascertain the importance of
T cell-associated a4 integrins in the induction of chronic gut inammation.
METHODS: We utilized cre/loxP technology to generate conditional mutant mice
with T cells lacking a4 integrins (a4-/-). Using adoptive T cell transfer model of
CD, we reconstituted recombination activating gene-decient (RAG-1-/-) mice
with a4-/- or control a4/ CD4CD45RB
high
T cells and monitored development
of disease. Blinded histopathological colon scores, inltrating leukocyte numbers
and phenotype, and cytokine production by colon lamina propria (LP) cells were
determined. To determine the effect of a4 integrin deletion on T cell trafcking,
we conducted competitive homing experiments.
RESULTS: While a4/ T cells elicited moderate to severe colitis, colitis in the
a4-/-RAG-1-/- mice was remarkably attenuated. This correlated with a signi-
cant reduction in T cells, granulocytes, and monocytes in colons of these mice
compared to the a4/RAG-1-/- group. Analysis of cytokines produced by
mononuclear cells isolated from colon LP in the a4-/-RAG-1-/- mice showed
reduced levels of IL-1b, IL-2, IL-17, and TNF-a but not IFN-c or IL-12p70 compared
to control. Single-cell analysis of CD4 T cells by intracellular staining revealed
comparable production of IFN-c and IL-17 by a4-/- and a4/, suggesting that
a4-/- T cells are not defective in their ability to become activated and secrete
pro-inammatory cytokines. Trafcking of a4-/- and control T cells to MLN was
comparable to WT, while homing of a4-/- T cells to small intestine and colon was
severely compromised. Finally, analysis of surface integrins in reconstituted mice
revealed that following transmigration into colon LP, T cells downregulate a4b7
but maintain high levels of b1 integrin expression.
CONCLUSION(S): Alpha4 integrins are important for intravascular recruitment of T
cells to the intestine and induction of colitis. At the same time, our data sug-
gested that b1 integrins may be important for their localization within the intesti-
nal tissue. Further work will need to determine relative importance of these
integrins in the ability of T cells to induce experimental colitis.
O-27
TLR4 Signaling Alters Intestinal Epithelial Cell Differentiation and the
Stem Cell Niche
Julie Davies, Rebeca Santaolalla, Maria Abreu
University of Miami, Miami, FL, USA
BACKGROUND: In patients with colitis and colitis-associated cancers we have
demonstrated increased expression of TLR4 in intestinal epithelial cells. We have
developed a mouse model with transgenic expression of TLR4 under the control
of the intestinal epithelial cell specic villin promoter (V-TLR4). These mice have
increased inammation and sensitivity to tumor induction. Tumors can be
induced in the V-TLR4 mice by azoxymethane (AOM) alone, which is only poorly
tumorigenic in WT mice.
METHODS: V-TLR4 mice were crossed to Lgr5-EGFP mice wherein cells which
express the stem cell marker Lgr5 also express EGFP. Expression of Lgr5 was
visualized in proximal and distal colon sections by IF. The differentiation of secre-
tory lineage epithelial cells was determined in the terminal ileum by H&E
staining for Paneth cells and Periodic acid Schiff staining for Goblet cells. Gene
expression in normal colonic tissue was compared between the strains by
microarray.
RESULTS: Colonic expression of EGFP in the V-TLR4xLgr5-EGFP was increased
and differentially localized compared to control Lgr5-EGFP mice. In V-TLR4xLgr5-
EGFP mice the expression of Lgr5 was found in the crypts similar to controls,
but was also found sporadically throughout the length of the crypt. The num-
ber of Lgr5 positive cells in the colon was increased proximally compared to
distal expression. The ileum in V-TLR4 mice had increased numbers of goblet
cells by Periodic acid Schiff staining and immunouorescence (IF) for Muc2. As
well, the ileum had decreased numbers of Paneth cells by H&E staining and
decreased numbers of lysozyme positive cells by IF. The gene expression array
revealed 223 genes that were up-regulated in the normal surrounding tissue in
V-TLR4 compared to WT, and 334 genes that were down-regulated (fold differ-
ences, P<0.05 compared to WT). The gene expression of defensins in the colo-
nic normal tissue was decreased in the V-TLR4 compared to WT which corre-
lates with the decreased number of Paneth cells in the ileum and may suggest
a reduction in Paneth-like function in the colon. In addition, expression levels
of several inammatory chemokines were reduced in the colonic tissue of V-
TLR4 mice.
CONCLUSION(S): Over-expression of TLR4 in the epithelium alters the differentia-
tion of secretory lineage cells and expands the stem cell population. Reduced
chemokine signaling in the V-TLR4 mice may impact the recruitment of immune
cell populations to the colon altering the epithelial microenvironment. These data
suggest that innate immune receptors and bacterial ligands may inuence epi-
thelial cell differentiation and function under homeostatic and inammatory pre-
malignant conditions.
O-28
Critical Role of Plasmacytoid Dendritic Cells in Commensal Microbial Polysac-
charideMediated Immunoregulation
Suryasarathi Dasgupta, Deniz Erturk-Hasdemir, Dennis Kasper
BACKGROUND: The microbiota is important in shaping the mammalian hosts
immune system and is useful in identifying mechanisms of immune maturation.
In the limited number of associations between commensal microbes and the
immune system that are known to indicate a profound immunomodulatory rela-
tionship, the microbes involved have been identied at the genus (or sometimes
the species) level; in contrast, little relevant information has been obtained at the
microbial molecular level. A notable exception is the relationship between capsu-
lar polysaccharide A (PSA) of the gut commensal Bacteroides fragilis and the
induction of regulatory T cells (Tregs) that can limit pathologic inammation
both in the gut and in more distant tissues. The ability of PSA to induce secretion
of the potent anti-inammatory cytokine interleukin 10 (IL-10) is vital to the con-
trol of inammation. Restoration of tissue homeostasis by a functional class of
dendritic cells (DCs), designated tolerogenic DCs, has been described and is due,
at least in part, to generation or enhancement of the function of Tregs. Although
PSA affects DCs, it has not been shown whether DCs play a role in the immunor-
egulatory activities of PSA.
METHODS: We treated specic-pathogen-free animals with B fragilis expressing
PSA and followed T regs and associated DCs in mesenteric lymph nodes and
other tissues in absence of additional inammatory stimulus. We puried PSA
from B fragilis and utilized in vitro in DC-CD4T cell co-culture assay and in
vivo in TNBS-induced colitis and Myelin-PLP induced multiple sclerosis mod-
els. Genetically decient mice, antibody mediated in vivo inhibition and
depletion along with adoptive transfer of PSA treated DC subsets were
employed.
RESULTS: We show that a subset of DCs known as plasmacytoid DCs (PDCs) when
exposed to PSA are potent inducers of IL-10 production by CD4 T cells in vitro.
In the murine model of colonic inammation, PDCs characteristically phenotype
PSA mediated protection in a Toll-like receptor 2 (TLR2) dependent way. Interest-
ingly, PDCs are essential for the immunoprotective activities of PSA in this colitis
model as observed by antibody mediated PDC depletion and adoptive transfer
experiments. TLR2, an immunosensitive receptor of PSA, is induced in PDCs by
PSA and, along with ICOSL and CD86, mediates PSAs immunoregulatory function
in vitro and in vivo. Finally, in a murine model of multiple sclerosis wherein PSA
was found to be protective, we observed near complete mortality in mice treated
with PDC depleting antibody irrespective of PSA treatment, while the isotype
control treated mice survived and were protected signicantly by PSA treatment
in terms of clinical scores.
CONCLUSION(S): Our results demonstrate how a prototypical molecule from the
commensal microbiota enables a subset of DCs to modify pathologic outcome in
the gut and a distant tissue. Understanding functional polarization of PDCs or
other DCs by molecules derived from the commensal microbiota and elucidating
how these molecules shape immune development may help identify new thera-
peutic approaches to inammatory diseases.
O-29
Mucosal Delivery of IL-27 Attenuates Murine Enterocolitis via T Cell-Derived
IL-10
Scott Durum
1
, Julie Hixon
1
, Wenqing Li
1
, Barbara Felber
1
, Miriam Anver
1
,
Charles Stewart
1
, Wei Shen
1
, Mairi McLean
1
, Pieter Rottiers
2
, Lothar Steidler
2
,
Miranda Hanson
1
1
NCI NIH, Frederick, MD, USA,
2
ActoGeniX, Zwijnaarde, Belgium
BACKGROUND: Treatment of inammatory bowel disease (IBD) would benet by
local delivery of therapeutics, avoiding systemic effects. Lactococcus lactis is a
food grade bacterium that has been engineered to deliver experimental protein
therapeutics to the bowel following oral administration. It has been shown to be
safe in clinical trials. IL-27 is a cytokine that has been shown to inhibit develop-
ment of pro-inammatory Th17 cells and induce development of suppressor Tr1
cells that act by producing immunosuppressive IL-10.
METHODS: Murine IL-27 was engineered into Lactococcus lactis (LL-IL-27) to treat
murine IBD by oral gavage. Several IBD models were evaluated. T cell transfer IBD
was treated with LL-IL-27 at the time symptoms developed 7.5wk after transfer, and
treatment was performed daily for two weeks. Acute colitis was induced by DSS in
drinking water for 5 days followed by 5 daily treatments with LL-IL-27. Acute colitis
was also induced by TNBS installation, the next day LL-IL-27 treatments began for 3
days. Mice were monitored for survival, disease activity index (DAI:weight loss, stool
consistency and occult blood in stool) and gut pathology at sacrice.
RESULTS: Engineered bacteria produced approximately 300ng/mL of IL-27 in cul-
ture, which was biologically active in inducing Stat3 phosphorylation and IL-10
expression in murine T cells. LL-IL-27 showed a substantial therapeutic benet in
T cell transfer induced enterocolitis, improving survival, decreasing DAI, reducing
inammatory cytokine levels and eliminating pathology in the colon and small
intestine (Fig. 1). LL-IL-27 treatment decreased CD4 and IL-17 T cells in gut tis-
sue. The therapeutic benet required induction of IL-10 in the transferred T cell
population which was primarily expressed by intraepithelial CD4CD8a T cells
(Fig. 2). LL-IL-27 was much more effective in reducing DAI and colon pathology
than either LL-IL-10 (Fig. 3) or systemic administration of recombinant mouse IL-
27. LL-IL-27 was also very effective in acute colitis induced by DSS in drinking
water or TNBS installation as determined by DAI and pathology.
CONCLUSION(S): LL-IL-27 was highly effective in three different murine IBD mod-
els that differ substantially in mechanism. These results suggest that intestinal
application of LL-IL-27 offers promise as a more effective and safer management
of IBD in humans. Figure Legends. Figure 1: LL-IL-27 improves survival in T cell
transfer induced enterocolitis. At the onset of disease (7.5 wk), mice were gav-
aged for 14 days (hatched bar). (A) Percent survival. (B) DAI.(C) H&E sections of
distal colons (top). Histopathological scores for distal colon (bottom). (D) H&E sec-
tions of small intestines (SI) Figure 2: LL-IL-27 decreases inammatory cytokines,
increases IL-10 in vivo. (A) Cytokine and transcription factor gene expression in
distal colons (B) Colitic mice were treated for 14 days, colons were harvested 7
Figure 1.
days following the last gavage or at death. (C) Healthy mice were gavaged with
LL-IL-27, colons were harvested the next day. (D) LL-IL-27 increases IL-10 reporter
expression in CD4CD8a (DP) and CD8 cells. Figure 3: IL-10 is required for LL-
IL-27s therapeutic effect but LL-IL-10 is less effective than LL-IL-27. (A) Percent
survival. (B) H&E sections of distal colons (left). Histopathological scores (right).
O-30
TLR4 Activates the B-Catenin Pathway to Cause Intestinal Neoplasia
Rebeca Santaolalla
1
, Jose Ruiz
1
, Julie Davies
1
, Daniel Sussman
1
,
Cristhine Pastorini
1
, Cecilia Espana
1
, Oname Burlingame
1
, Pablo Bejarano
1
,
Negar Rassaei
1
, Jeffrey Ko
2
, Ramanarao Dirisina
2
, Terrence Barrett
2
, Limin Shang
3
,
Sergio Lira
4
, Masayuki Fukata
1
, Maria Abreu
1
1
University of Miami, Miami, FL, USA,
2
Northwestern University, Chicago, IL, USA,
3
Novimmune, Plan-Les-Ouates, Geneva, Switzerland,
4
Mount Sinai School of Medi-
cine, New York, NY, USA
BACKGROUND: Colonic bacteria have been implicated in the development of co-
lon cancer. We have previously demonstrated that toll-like receptor 4 (TLR4), the
receptor for bacterial lipopolysaccharide, is over-expressed in humans with ulcera-
tive colitis-associated cancer. We aimed to determine whether TLR4 plays a role
as a tumor promoter in the absence of inammation.
METHODS: In vivo studies were performed using villin-TLR4 mice, which we
generated to over-express TLR4 in the intestinal epithelium, and C57BL/6J
wild type mice as controls. Colonic tumorigenesis was induced using the
genotoxic agent azoxymethane (AOM). Cell proliferation was assessed by
BrdU labeling, and b-catenin was stained by immunohistochemistry. Colon
specimens at baseline and after AOM were scored for histological inamma-
tion by three pathologists blinded to the mouse strain and treatment. In
vitro experiments were performed using SW480 and IEC-6 intestinal epithe-
lial cell lines.
RESULTS: We found that at baseline villin-TLR4 mice had increased epithelial
proliferation as well as longer crypts, compared to wild type mice. In addition,
villin-TLR4 mice developed spontaneous duodenal adenomas. In wild-type mice,
AOM treatment rarely resulted in tumors. By contrast, AOM induced robust co-
lonic tumorigenesis in villin-TLR4 mice. Furthermore, villin-TLR4 mice were more
likely to develop larger quantities of tumors than wild-type mice. Histologically,
these tumors ranged from low-grade to high-grade dysplasia and carcinoma in
situ similar to adenomatous polyps in humans. Moreover, histological scoring of
villin-TLR4 and wild-type mice before and after AOM did not reveal any acute
inammation. Tumors arising in villin-TLR4 mice are characterized by intense nu-
clear b-catenin staining. In addition, villin-TLR4 mice showed an increase in b-
catenin nuclear translocation as well as a greater cell proliferation in non-dys-
plastic colon compared to wild-type mice. Biochemical studies in colonic epithe-
lial cells lines revealed that TLR4 activates b-catenin in a PI3K-dependent
manner.
CONCLUSION(S): Over-expression of TLR4 increases the risk of colon neoplasia
even in the absence of inammation. Our studies highlight a previously unex-
plored link between innate immune signaling and activation of oncogenic path-
ways, which may be targeted to prevent or treat colorectal cancer.
O-31
YI
TAMing Colitis and Colitis-Associated Colon Cancer
Lidia Bosurgi
1
, Diana Uribe
2
, Jochem Bernink
1
, Victor Delgado Cuevas
1
, Eugenio
Antonio Carrera Silva
1
, Nicola Gagliani
1
, Jonathan Leighton
3
, Sourav Ghosh
2
, Carla
Rothlin
1
1
Yale University, New Haven, CT, USA,
2
University of Arizona, Tucson, AZ, USA,
3
Mayo Clinic, Scottsdale, AZ, USA
BACKGROUND: Inammatory Bowel Diseases (IBD) are chronic, relapsing, inam-
matory disorders characterized by a robust cytokine-driven inammation of the
gut. This chronic inammation leads to signicant morbidity and mortality,
including an increased risk for colorectal cancer.
METHODS: Using a combination of mouse models and analyses of human sam-
ples, we show that the receptor tyrosine kinases (RTK) Axl and Mer, members of
the TAM subfamily, and their ligand Protein S (Pros1) mediate an anti-inamma-
tory response that is fundamental for preventing colitis. Furthermore, in marked
contrast to the reported oncogenic function of Axl and Mer in tumors, genetic
ablation of Axl and Mer in mouse models promotes colitis-associated colon
cancer.
RESULTS: Axl
-/-
Mer
-/-
mice develop an exacerbated inammatory response to Dex-
tran Sulfate Sodium (DSS)-induced colitis, as determined by colonoscopy score,
histopathological analysis and inammatory prole of lamina propria leukocytes.
Axl
-/-
Mer
-/-
mice develop an increase number and larger polyps than wild type
(WT) mice upon azoxymethane (AOM)-DSS treatment. Axl and Mer are expressed
in intestinal macrophages upon inammation and Axl
-/-
Mer
-/-
macrophages pro-
duce higher levels of pro-inammatory cytokines in response to intestinal injury
than WT controls. Furthermore, the TAM agonist Pros1 is essential for limiting the
pathological activation of macrophages and induced colitis. Pros1 is expressed in
activated T cells and functions to dampen the inammatory response in macro-
phages through Axl and Mer. Transfer of Pros1
-/-
na ve T cells into Rag1
-/-
mice
leads to acceleration of colitis in comparison to WT na ve T cells. Remarkably, IBD
also shows a signicant association with PROS1 deciency. Patients with active
IBD more frequently showed lower levels of plasma PROS1 in comparison to
healthy controls.
CONCLUSION(S): Therefore, our results identify the TAM RTKs and their ligand
Pros1 as a hitherto unknown mechanism for the prevention of pathological
inammation in the intestine. While TAM inhibitors have been identied as
prospective candidates for molecular anti-cancer therapeutics, the benecial
anti-inammatory effects of the TAM pathway present a paradox at least in the
Figure 2.
Figure 3.
context of colitis-associated colon cancer. Future efforts in TAM-based therapeu-
tics would benet from comprehensive understanding of TAM function both in
cancer cells and in the tumor microenvironment.
Clinical Poster Presentations
P-1
YI
Reactivation of Latent Tuberculosis After Treatment With Biologic Therapy
Ian Grimes, Anurag Soni, Freddy Caldera
University of Wisconsin Hospital and Clinics, Madison, WI, USA
Anti-tumor necrosis factor (TNF) therapy is associated with increased infectious
risk including reactivation of latent tuberculosis infection (LTBI). It is recom-
mended that patients with risk factors for tuberculosis (TB) be evaluated for LTBI
prior to initiation of anti-TNF therapy. Patients with evidence of LTBI undergo
treatment before initiation of biologic therapy. The risk of disseminated TB after
treatment and initiation of biologic therapy is not well characterized in patients
with inammatory bowel disease. We present a patient who developed dissemi-
nated TB as a complication of anti-TNF therapy after completing appropriate
treatment for LTBI
Case Report: A 52 yo Sri Lankan male with clinical and pathologic evidence of
Crohn colitis is found to have asymptomatic LTBI. Treatment with isoniazid (INH)
was initiated. After 6 weeks of therapy he was started on iniximab. The patient
had a good initial response to therapy but required intermittent prednisone for
control of his symptoms. After a viral URI, iniximab was discontinued and not
restarted. He completed a 9-month course of INH and was feeling well on no
anti-TB treatment. The patients Crohn disease ared and he was initiated on ada-
limumab after a colonoscopy conrmed active disease. Three months after adali-
mumab initiation and 4 months after completion of INH for LTBI he had a febrile
illness, diarrhea and weight loss. A CT abdomen/pelvis was obtained and showed
multiple lesions throughout the spleen and liver. The adalimumab was stopped
and he was admitted to hospital for further work-up. After an extensive work-up
including evaluation for fungal etiologies and a spleen biopsy he was initiated on
empiric anti-TB treatment. After several weeks the AFB smear from both sputum
and spleen were positive for pan-susceptible TB. While undergoing treatment for
active TB he has been maintained on mesalamine based therapy with marginal
control of his Crohn disease.
Discussion: Prior to initiation of anti-TNF treatment patients with IBD should be
evaluated for active and latent TB1. The risk of disseminated TB after treatment for
LTBI and initiation of biologic therapy is unknown. If evidence of LTBI is found, treat-
ment is recommended prior to starting biologic therapy2,3. Recommendations
from the ATS and BTS vary from 1-9 months of treatment prior to starting anti-TNF
therapy, even though chemoprophylaxis is only effective 70% of the time after 9
months. 4,5 We present the case of a patient with Crohn disease, found to have LTBI
and initiated on therapy. After completion of LTBI treatment anti-TNF therapy was
instituted. He became ill and was admitted to hospital where he was found to have
disseminated TB. Though this patients TB presented after completion of therapy for
LTBI most cases of disseminated TB are discovered early in the treatment course of
anti-TNF therapy. Close monitoring for reactivation is warranted even if patients
have undergone treatment, since treatment is not always effective.
We present a case report of a patient with Crohn disease and treated LTBI who
developed disseminated disease after completion of treatment and initiation of a
biologic agent.
P-2
YI
Infliximab Induced Anterior Uveitis in a Patient With Ulcerative Colitis
Manish Singla
1
, Philip Lindholm
2
, Daniel Hodge
3
, Fouad Moawad
1
, Ganesh
Veerappan
1
1
Walter Reed National Military Medical Center, Bethesda, MD, USA,
2
Walter Reed
National Military Medical Center, Bethesda, MD, USA
3
Tumor necrosis factor alpha (TNF-a) antagonists are increasingly used to treat
Crohns disease (CD), ulcerative colitis (UC), and rheumatologic conditions includ-
ing psoriatic arthritis, rheumatoid arthritis, and ankylosing spondylitis. Sepsis,
reactivation tuberculosis, lymphoma, and drug-induced lupus are serious but
uncommon adverse events associated with use of Iniximab. However, less fre-
quent reactions are emerging as Iniximab use has increased. In this case, we
present a 49 year-old male with left-sided UC who developed anterior uveitis fol-
lowing escalation of Iniximab therapy.
Since his diagnosis of UC in 1992, the patient had been poorly controlled on vari-
ous forms of mesalamine (5-ASA) therapy and often required intermittent courses
of steroids for acute ares. In 2011, the patient was placed on steroids for a UC
are and associated polyarthralgias, but transitioned to 6-mercaptopurine (6-MP)
for maintenance therapy. The patient was in clinical remission, but 6-MP was dis-
continued secondary to hepatotoxicity and pancytopenia. A decision was made
to initiate Iniximab therapy at 5 mg/kg every eight weeks, which maintained the
patient in clinical remission for eight months. He then developed arthralgias, fa-
tigue and elevation in inammatory markers in between Iniximab infusions. In
response to these breakthrough symptoms, his dose was increased to 10 mg/kg
every eight weeks.
Upon initial administration of Iniximab at 10 mg/kg, he developed acute onset
of bilateral conjunctival hyperemia and chemosis. He experienced bilateral eye
pain, photophobia, and blurry vision consistent with uveitis that persisted for
two weeks and resolved without treatment. Prior to his second escalated dose of
iniximab, he was pretreated with 100 mg intravenous hydrocortisone in addition
to acetaminophen and diphenhydramine. During his iniximab infusion, he expe-
rienced unilateral chemosis and hyperemia without acute eye pain, changes in
vision, or photophobia. Ophthalmologic consultation conrmed a diagnosis of
uveitis, but pretreatment with hydrocortisone may have decreased the severity of
uveitis causing a milder version of the previous attack. The patient was started
on ocular steroids with plans to pre-treat him with prednisone three days prior
to his next iniximab dose.
Our patients ares of uveitis occurred upon increasing his Iniximab dose, and
then recurred upon receiving that same elevated dose. This strongly suggests
that his uveitis was caused by the higher dose of Iniximab. TNF-a blockade is
typically used to treat uveitis ares associated with inammatory bowel disease.
Paradoxical reactions have been reported describing anterior uveitis following
therapy with Etanercept, but less commonly with therapy with Iniximab. The
proposed mechanism is that peripheral TNF-a blockade may increase T-cell reac-
tivity leading to inammation in the eye, or may participate in demyelination of
the optic nerve causing neuritis. These infrequent adverse reactions are described
sporadically in rheumatologic conditions but are not described in association
with inammatory bowel disease. With increasing use of TNF-a blockade for the
treatment of UC and CD, it is important to consider and recognize anterior uveitis
as a possible reaction following induction and escalation of TNF-a blockade ther-
apy. Potential treatment options include reduction in infusion rate, dose-adjust-
ment, pretreatment with steroids, or treatment with an alternate TNF-a
antagonist.
P-3
YI
Successful Use of Infliximab in the Treatment of Corticosteroid Dependent Col-
lagenous Colitis
Suresh Pola, William Sandborn, Elisabeth Evans, Marianne Fahmy
University of California San Diego, La Jolla, CA, USA
A 58-year-old woman status-post Roux-en-Y gastric bypass for obesity experi-
enced two months of diarrhea with up to 12-15 watery bowel movements daily
along with night time symptoms and fecal incontinence. After stool cultures, ova
and parasite examination, and C. difcile toxin PCR were unrevealing for infection,
the patient underwent colonoscopy and was diagnosed with collagenous colitis
based on an endoscopically normal appearing colon and classic histology on ran-
dom biopsies. The patient had been taking ibuprofen and a dexlansoprazole and
both were discontinued. The patient was initially treated with budesonide 9 mg
daily. The patient had no response and was given adjunctive therapies including
diphenoxylate/atropine, loperamide, and bismuth with no response. She was
given mesalamine but this was held due to nausea and vomiting. The patient
also failed a trial of cholestyramine for one month. The patient had then had 6
months of diarrhea and experienced a 10-lb weight loss and was then hospital-
ized for dehydration and given IV Solu-Medrol. Stool culture grew Aeromonas
hydrophilia caviae and this was treated to eradication with trimethoprim-sulfame-
thoxazole. The patient had persistent symptoms and was discharged on 6-mer-
captopurine 50 mg daily, octreotide 50 mcg subcutaneous injection twice daily,
and prednisone. Four weeks later, the patient was hospitalized for acute pancrea-
titis thought to be due to the 6-mercaptopurine; this was discontinued. Other
unsuccessful treatment attempts included alosetron 1 mg twice daily, tincture of
Figure 1.
opium, and Boswellia serrata extract. She then came to our medical center where
she underwent esophagogastrojejunoscopy with jejunal biopsies were negative
for celiac disease. A neuroendocrine tumor work up was negative including calci-
tonin, VIP, and 24 hour HIAA. Magnetic resonance enterography was normal.
Colonoscopy was repeated, again conrming the diagnosis of collagenous colitis.
After 18 months of symptoms the patient was considered for colectomy with re-
versal of her Roux-en-Y gastric bypass, but salvage therapy was attempted with
iniximab with induction dosing (5 mg/kg intravenously at weeks 0, 2, and 6)
with oral methotrexate 12.5 mg/week. A mild transaminase elevation was suc-
cessfully managed with a dose reduction to 7.5 mg of weekly oral methotrexate.
The patient began to notice some improvement in her symptoms and was able
to begin tapering her prednisone at week 4 of iniximab treatment. Repeat colon
biopsies at week 5 of iniximab therapy revealed persistent collagenous colitis.
The patient was off prednisone and without diarrhea at 8 weeks and gradually
returned to her baseline weight. At approximately 6 months following iniximab
initiation, the patient remained asymptomatic and off corticosteroids. Repeat co-
lon biopsies revealed a normal appearing colon with no evidence of collagenous
colitis. Relapse and steroid dependence is not uncommon in microscopic colitis.
Anti TNF use has been reported as successful in 5/7 patients with refractory mi-
croscopic colitis. We demonstrate the successful use of iniximab in a patient
with severe refractory collagenous colitis resulting in symptomatic and histologic
remission.
Anti-TNF therapies should be considered in patients with refractory or corticoste-
roid dependent collagenous colitis.
P-4
YI
Carcinoid Tumors and Inflammatory Bowel Disease: A Possible Association
Helen Fasanya-Uptagraft, Jane Onken, Julie Thacker, Fletcher Srygley
Duke University Medical Center, Durham, NC, USA
It is well established that longstanding inammatory bowel disease (IBD) is asso-
ciated with an increased risk of small bowel and colorectal adenocarcinoma. The
association of neuroendocrine tumors and IBD is less well understood. We report
2 cases of neuroendocrine tumor diagnosed in IBD patients admitted to our insti-
tution within days of each other and a third case of a patient with a previous di-
agnosis of neuroendocrine tumor referred to our institution for consultation.
Case 1 involves a 44 year-old Caucasian male with a 20-year history of Crohns.
After 8 years of abdominal pain, he developed a small bowel perforation and
underwent emergency laparotomy with ileocecal resection. Surgical pathology
revealed a well-differentiated T2N1M0 carcinoid tumor measuring 12 mm within
the distal ileum without associated inammation. The remaining excised small
bowel had extensive involvement with Crohns disease with a stula tract extend-
ing into the appendix associated with an abscess. Post-operatively, his course was
complicated by recurrent stula formation and resultant malabsorption. Eight
years after the initial resection, he had a positive Octreotide scan but no further
radiographic evidence of carcinoid recurrence. He was treated with IM Octreotide
but continued to have high-output stulae and, 2 years later, underwent resec-
tion of several stulae. Small bowel pathology showed evidence of now meta-
static, well differentiated neuroendocrine tumor.
Case 2 involves a 49 year-old Caucasian female with a 35-year history of
untreated ulcerative colitis, admitted with bloody stools and abdominal pain.
Biopsies obtained during diagnostic exible sigmoidoscopy showed severe colitis
and an incidental, well-differentiated neuroendocrine tumor measuring 4 mm.
Further radiographic investigation including octreotide scan and repeat colono-
scopy failed to reveal a primary carcinoid.
Case 3 involves a 62 year-old Caucasian female who was referred to our institu-
tion for the management of ileocolonic Crohns disease diagnosed 35 years
ago. She experienced symptoms of rectal bleeding and abdominal pain for 4
years prior to diagnosis and by the time she sought medical attention, she
required an emergency laparoscopy with ileocecectomy for massive hemor-
rhage. The pathology specimen showed an early carcinoid tumor within the ter-
minal ileum. She was followed for 10 years afterwards without any evidence of
tumor recurrence.
Discussion: Gastrointestinal carcinoid tumors are rare, and the concomitant di-
agnosis of carcinoid and IBD is even rarer. It has been debated whether the
incidence of carcinoid tumors is actually increased in patients with IBD or if
there are simply more incidental carcinoids diagnosed in IBD patients who are
more likely to require surgery for a complication of the intestinal inammation.
All three cases presented had concurrent active inammation when the carci-
noid tumor was discovered. They differ in the location of the carcinoid Case
1 had evidence of carcinoid in an area without inammation, while Case 2 had
carcinoid tumor identied amongst severe inammation in the rectum and
Case 3 had carcinoid tumor in an inamed terminal ileum. These cases support
the hypothesis that there may be an association between carcinoid and IBD,
but Case 1 suggests that carcinoids can also arise in areas without chronic mu-
cosal inammation.
P-5
YI
Infliximab Induced Systemic Lupus Erythematosus: A Case Report
George Elias, Maen Masadeh, Bashar Hmoud, Gurinder Luthra
University of Texas Medical Branch, Galveston, TX, USA
A 41-year-old Hispanic female was diagnosed with Crohns disease in 1998, and
was treated with Mesalamine and 6 Mercaptopurine. She also required the use of
prednisone for 6-8 weeks at least once a year. Her disease was complicated by
perianal stulae and recurrent perianal abscesses. In 2001, she was started on
Iniximab (5 mg/kg) every 8 weeks. However, it was stopped in 2003 for nancial
reasons. She continued to use 5 ASA and 6-mercaptopurine. In addition, predni-
sone and Flagyl were used for treatment of acute are-ups. Iniximab was
restarted in January 2009 due to frequent are-up and inability to control peria-
nal disease. In April 2009, the patient presented to the clinic complaining of right
toe pain and swelling, and this was preceded with multiple episodes of large and
small joint pain and swelling, with lower extremity tingling. She denied skin
rashes, oral ulcers, or photosensitivity. The physical exam was remarkable for right
toe swelling and tenderness with normal range of motion. Serology was positive
for ANA (1:320), mildly elevated anti DsDNA (1:20), increased anti-B2 lipoprotein
antibodies (29.4), low C4 and mildly decreased C3. Anti-Smith, anti SSA, anti SSB,
anti RNP and anti-histone antibodies were negative. Rheumatoid factor and uri-
nalysis were normal. Correlation of the history, examination, and laboratory nd-
ings in the context of patients exposure to iniximab, the diagnosis of TNF-alpha
antagonist induced Lupus syndrome (TAILS) was made. Treatment included stop-
ping iniximab. Patient was started on hydroxychloroquine (200 mg twice daily).
Arthralgia resolved 6 months after stopping iniximab. Her symptoms of lower
extremity tingling also partially resolved with gabapentin in 12 months. Serology
and complement levels were found to be normal. Discussion: The occurrence of
TAILS is estimated to be 0.5-1% with iniximab, and etanercept being the most
common agents. Onset of symptoms ranges from 10 days to 54 months after ex-
posure. In our patient, symptoms started 3 months after restarting iniximab. Pre-
senting symptoms can widely vary involving musculoskeletal system, neuropathy,
and neuropsychiatric disorders. Arthritis is the most common presenting disorder.
Peripheral neuropathy was found in 5 out of 32 patients receiving iniximab, and
neuropsychiatric symptoms developed in 3% of patients receiving either inixi-
mab or etanercept. Our patient presented with arthralgia, arthritis and peripheral
neuropathy. Anti-neutrophil antibodies were found to be positive in the majority
of patients and in our patient as well. In a prospective controlled study, only 20%
of patients receiving iniximab were positive for anti-double stranded DNA, and
it was mildly elevated in our patient. Anti-histone antibodies are positive in 95%
of patients with drug induced lupus, and only in 17-57% of patients with TAILS.
Anti-histone antibodies were negative in our patient. Resolution of symptoms
was found in most of the patients after stopping the drug in 3 weeks to 6
months. Our patients arthritis resolved after 6 months, and it required the addi-
tion of hydroxychloroquine. Peripheral neuropathy required more time to resolve
(12 months).
P-6
YI
Autoimmune Enteropathy, A Rare Cause of Intractable Diarrhea Presenting in
an 80-Year-Old Man
Veena Nannegari, Susan Samson, Jesse Green, Catherine Bartholomew,
Richard MacDermott
Albany Medical Center, Albany, New York, USA
An 80-year-old-male presented with a four month history of 8 to 10 watery, non-
bloody bowel movements a day. As a result he developed severe hypokalemia
and a 60 pound weight loss. Serum gastrin, calcitonin, thyroid function panel, ce-
liac studies, metanephrines, catecholamines, and urine 5-HIAA were normal. Stool
studies for infectious etiology were negative. The patient underwent an upper
endoscopy, enteroscopy, and colonoscopy. Duodenal biopsies revealed chronic
active inammation with villous atrophy. Jejunal biopsies were consistent with a
diagnosis of autoimmune enteropathy (AIE). The patient was started on 40 mg of
prednisone and 150 mg of azathioprine a day in the setting of a normal enzyme
activity level. His symptoms improved to one bowel movement a day with an
increase in his weight. However, as the steroids were tapered, the diarrhea
returned. Thereafter, therapy with intravenous iniximab at a dose of 5 mg / kg
was initiated. Patient is currently receiving azathioprine and iniximab while re-
attempting to taper steroid therapy in an effort to control symptoms. AIE is a
rare disease characterized by intractable diarrhea, malabsorption and anorexia
leading to severe weight loss. This condition more often affects infants within the
rst 6 months of life and is described only in case reports in adults. The average
age at diagnosis is 55 in adults and patients usually require immunosuppressive
therapy. Extraintestinal manifestations include hypothyroidism, nephritic and ne-
phrotic syndrome, autoimmune hemolytic anemia, rheumatoid arthritis, dermati-
tis/atopic eczema, autoimmune hepatitis, and chronic pancreatitis. The diagnostic
criteria for AIE includes chronic diarrhea of more than 6 weeks that does not
improve with dietary modication, malabsorption, partial or complete blunting of
the small bowel villi, deep crypt lymphocytosis, increased crypt apoptotic bodies,
minimal intraepithelial lymphocytosis, and exclusion of other causes of villous at-
rophy. The presence of anti-enterocyte or anti-goblet cell antibodies is supportive
of the diagnosis, although not conrmatory. The differential diagnosis of AIE
includes celiac disease and common variable immune deciency (CVID). The pres-
ence of intraepithelial cell lymphocytosis is found in celiac disease, while immu-
noglobulin deciency and a normal albumin suggest CVID. Unlike in celiac dis-
ease, dietary modications are generally ineffective in AIE and patients may
require total parenteral nutrition. Management of AIE is clinically challenging
because of its uncommon nature and paucity of evidence based clinical guide-
lines. Corticosteroids including budesonide and prednisone are rst line therapies
in the treatment of AIE. In patients refractory to steroids, treatment and mainte-
nance of remission with azathioprine, 6-mercaptopurine, cyclosporine, tacrolimus,
mycophenolate mofetil, sirolimus, iniximab, and rituximab has been described.
We present a case of AIE, a rare entity, diagnosed in an 80-year-old male whose
symptoms became steroid refractory and required the use of an immunomodula-
tor and a biologic agent to control malabsorption, diarrhea, and weight loss.
P-7
YI
Immunosuppression and Prophylactic Antiviral Therapy in a Patient with
Crohns Disease Flare and Hepatitis B Infection
Benjamin Levy, Elizabeth Bollinger, Catherine Hudson, Stephen Landreneau
Louisiana State University New Orleans, New Orleans, LA, USA
Crohns disease patients with co-morbid Hepatitis B infection present a challeng-
ing therapeutic dilemma during IBD exacerbations because immunosuppressive
therapies such as prednisone and biologics may cause a are of their hepatitis.
Several studies have previously shown that using antiviral prophylaxis with drugs
such as tenofovir, entecavir, or adefovir in patients with Crohns and Hepatitis B is
frequently efcacious in preventing Hepatitis B viral load escalations during
immunosuppression periods. Resistance patterns have suggested that tenofovir
and entecavir may serve as superior antiviral prophylaxis medications. Studies
have also shown that prophylaxis with antiviral medications should be started
early (either at the start of immunosuppression or prior to immunosuppression)
rather than waiting for hepatitis B reactivation to occur.
A 40-year-old African American female with a past medical history of Crohns dis-
ease presented to our gastroenterology clinic after being lost to follow-up for
many years. She was rst diagnosed with Crohns disease in 1991; the extent of
her disease was unknown at this time but she had been taking mesalamine 800
mg three times daily for years. Upon presentation, she complained of diffuse ab-
dominal pain and 5-6 watery bowel movements per day for the past several
weeks. She was afebrile with a normal heart rate and blood pressure. Her abdo-
men was diffusely tender to palpation throughout, with voluntary guarding and
no rebound tenderness. She was transferred to the emergency department and
admitted to the internal medicine service. Labs were signicant for an elevated
C-reactive protein of 14.39 mg/dL (normal range <0.9 mg/dL), normal white
blood cell count and hemoglobin of 11.7 mg/dL. A Hepatitis panel revealed posi-
tive Hepatitis B surface antigen, negative Hepatitis B E antigen, plus a HBV DNA
qualitative PCR 2542 IU/mL (log 3.4). A exible sigmoidoscopy revealed diffuse
inammation, pseudopolyps and a narrowed stricture at 20 cm that was able to
be traversed (see images). Biopsies were consistent with Crohns disease. The
patient was started on both intravenous steroids as well as tenofovir for her Hep-
atitis B infection.
The patient is currently being treated on a steroid taper without hepatitis viral
load are, liver enzyme elevations, or abdominal symptoms. The surgery team
was consulted early on to discuss possible need for surgical intervention and the
potential role of biologics to prevent future structuring disease. The patient has
achieved dramatic symptomatic improvement on tenofovir and prednisone with
resolution of her loose bowel movements and debilitating abdominal pain.
Through the use of tenofovir prophylaxis, we were able to prevent worsening of
her Hepatitis B infection and alleviate her family and primary internal medicine
teams concern that steroid immunosuppression therapy may fuel a Hepatitis B
re storm in her liver leading to hepatic complications.
This case report supports the limited literature that prophylactic antiviral therapy
can control Hepatitis B viral ares in patients being treated with steroids for a
Crohns Disease are. Our plan based on the literature review is to continue teno-
fovir therapy with any future biologic or immunosuppressive treatment regimens.
P-8
Coexistence of Crohns Disease and Carcinoid Tumor
Veronica Baptista, David Cave
U Mass Memorial Medical Center, Worcester, MA, USA
The coexistence of carcinoid tumor and Crohns disease (CD) is rare. To date,
there have been about 50 reported cases. Carcinoid is a slow growing tumor.
When arising in the small bowel, it can mimic CD with symptoms of abdominal
pain, weight loss, diarrhea, and small bowel obstruction. They have some similar
gross pathologic appearance of brosis and thickening of the bowel wall. Histol-
ogy provides the denitive diagnosis. However, a small focus of carcinoid can be
easily missed in a resected specimen of small bowel with CD. Therefore, the true
incidence of carcinoid in CD may be underestimated.
Review of patient medical record and literature search on CD and carcinoid
tumor.
Figure 1.
A 68-year-old woman was referred for evaluation of chronic abdominal symp-
toms. She brought in a long list of non-specic complaints. Most notably, her
constipation alternating with diarrhea had become more diarrheal-predominant,
associated with right lower abdominal pain and a twelve pound weight loss over
the last year. Her last screening colonoscopy was normal to the cecum three
years ago. Her other medical history includes anxiety, and sigmoid colectomy for
recurrent diverticulitis in 1998. She denied use of non-steroidal anti-inammatory
medications. She has a son with ulcerative colitis. Colonoscopy to the terminal il-
eum showed prior end-end sigmoid anastomosis, an 8 mm polyp 10 cm from the
ileocecal valve, and multiple 1-3 mm ulcers in the terminal ileum up to 20 cm
from the ileocecal valve. Biopsy showed active ileitis with ulceration, no granulo-
mas or dysplasia. Biopsy of the 8 mm polyp showed well differentiated neuroen-
docrine neoplasm suggestive of carcinoid tumor. CT enterography revealed no
masses or liver lesions. Video capsule endoscopy showed few 1 mm jejunal
ulcers, and many 2 mm ulcers throughout the ileum, consistent with small bowel
CD. Subsequent ileocectomy conrmed pathologic diagnoses of Crohns ileitis
and carcinoid tumor (stage IIIB, Ki67 <1%).
Coexistence of CD and carcinoid tumor was once thought to be rare. A recent
study noted that carcinoid tumors are 15 times more common in patients with
CD. The pathogenesis of the two disease association is unclear, but inammation,
pro-inammatory cytokines, or hyperplasia may play a role in the development of
carcinoid tumors, which can even be found in areas with no Crohns involvement.
Given the similarity in clinical presentation, it is important to be aware of their
association, so that carcinoid tumor could be detected and resected prior to me-
tastasis. Optimal management of CD after a diagnosis of malignancy such as car-
cinoid tumor can also be a challenge. Given the rare coexistence of the two con-
ditions, there are currently no reports to our knowledge on the risk of recurrence
with immunomodulators or anti-TNF use in CD after carcinoid tumor resection.
Future research on the use of these agents in Crohns management after a recent
diagnosis of malignancy would be of interest.
P-9
Henoch-Sch onlein Purpura Occurring 5 Years After Initiation of Adalimumab
Nisha Varadarajan, Pia Prakash, Jason Reich, Matthew Chandler, Marie Borum
George Washington University, Washington, DC, USA
Biologic therapy has become increasingly important in the management of
inammatory bowel disease. Increased use of these agents can be associated
with rare adverse effects. Vasculitis has been reported to rarely occur with tumor
necrosis factor-a (TNF-a) inhibitors. There are only two reported cases of Henoch-
Sch onlein purpura (HSP) associated with TNF-a inhibitors. We report a rare case
of HSP occurring 5 years after initiation of adalimumab therapy.
Case Report: A 36 year old man with a history of ulcerative colitis, well controlled
with Asacol and 6-MP for 4 years, developed bloody diarrhea refractory to oral
steroids. Persistent symptoms resulted in hospitalization with intravenous steroid
administration without sustained improvement of his symptoms. Adalimumab
was prescribed with initial control of symptoms. However, worsening symptoms
and clinical status prompted the performance of a total proctocolectomy with
ileoanal pouch anastomosis. Subsequent histologic review of the surgical speci-
men and serologic testing (ASCA positive) was consistent with Crohns disease.
Recurrent symptoms prompted restarting of adalimumab with clinical improve-
ment. Five years following the reinitiation of adalimumab, he developed non-
blanching, punctuate lesions on bilateral feet and ankles. Punch biopsies revealed
leukocytoclastic vasculitis and heavy granular IgA deposition in small vessels con-
sistent with Henoch-Sch onlein purpura. Humira was discontinued with resolution
of the rash. He is presently maintained on 6-MP
Vasculitis is an unusual complication of TNF-a inhibitors, with Henoch-Sch onlein
purpura rarely occurring. While previous reports described HSP associated with
adalimumab, our case is unique in that HSP occurred 5 years following the initia-
tion of adalimumab, which is signicantly longer than previous reported occur-
rences. It is critical that physicians are aware of the rare association of vasculitis
with TNF-a inhibitors. Additionally, physicians and patients should be aware that
vasculitis can occur many years after the initiation of adalimumab use.
P-10
A Case of Olmesartan Induced Enteropathy
Arushi deFonseka, Anne Tuskey, Christopher Moskaluk
University of Virginia, Charlottesville, VA, USA
Clinical Scenario: A 60 year old African American gentleman with a history of
high blood pressure on olmesartan for the past 7 years presents with a 6 month
history of diarrhea consisting of 3-4 loose, non-bloody bowel movements a day,
associated with a ten pound weight loss over that time period. He has no known
personal or family history of inammatory bowel disease, Celiac disease, or colon
cancer. Physical exam was normal. On laboratory evaluation, with the exception
of an albumin of 3.3 and Hgb 12.6 (MCV 89), CBC, CMP, ESR, CRP, and TSH were
within normal limits. Testing for Celiac disease was negative or normal including
TTG, anti-endomysial antibody, total IgA, DQ2 and DQ8. MRI of the abdomen
with contrast showed diffuse enhancement and bowel wall thickening of the
proximal jejunum with associated prominent mesenteric lymph nodes. Duodenal
biopsies from EGD had near total villous blunting with increased intraepithelial
lymphocytes, but no clonality (see gures 12). Colonoscopy with biopsies dem-
onstrated increased intraepithelial lymphocytes of the colon and terminal ileum,
which also had marked villous blunting. Patient was empirically placed on a glu-
ten free diet prior to completion of the above work up, which did not improve
his symptoms. He was then started on a trial of budesonide, which caused his
stools to become more formed, but did not change the frequency. Stool studies
that had not been sent initially were obtained and were positive for Clostridium
difcile infection, which was treated with a 2 week course of Flagyl, but not
thought to explain the ndings on imaging and endoscopic evaluation. Patients
antihypertensive medication was switched from olmesartan to amlodipine, result-
ing in complete resolution of symptoms.
Discussion: Olmesartan is associated with a spruelike enteropathy consisting of
chronic diarrhea, weight loss, negative Celiac testing, and lack of response to a
gluten free diet. Symptoms characteristically resolve with histologic improvement
after withdrawal of olmesartan. A recently published retrospective study of 22
patients with olmesartan associated enteropathy reported a median age at diag-
nosis of 69.5. Most patients were taking 40 mg/day, with a mean duration of ex-
posure of 3.1 years (range 0.5-7). In addition to diarrhea and weight loss, present-
ing symptoms included nausea and vomiting (68%), abdominal pain (50%),
bloating (41%), and fatigue (68%). Histologic examination of the small bowel
demonstrated villous atrophy, with a thick band of subepithelial collagen deposi-
tion (collagenous sprue) in 7. Out of 13 patients who underwent colonoscopy, 5
had evidence of microscopic colitis. Of the 14 patients in whom gastric biopsies
were obtained, 5 had lymphocytic gastritis and 2 had collagenous gastritis. All
patients responded clinically to withdrawal of olmesartan, with histologic recov-
ery documented by duodenal biopsies in 17 out of 18 patients. Though the
mechanism of olmesartan induced enteropathy is unknown, inhibition of TGF-B
(involved in gut immune homeostasis) is thought to play a role. More studies will
need to be done to determine if other angiotensin receptor blockers in addition
to olmesartan are also associated with spruelike enteropathy.
Figure 1.
Figure 2.
P-11
Sarcoidosis During Therapy With Adalimumab in a Crohns Disease Patient:
Consequence of the Therapy or Association With the Disease Itself?
Paulo Kotze, Ivan de Barcelos, Vinicius Abou-Rejaile, Lorete Kotze
Catholic University of Parana, Curitiba, Parana, Brazil
Biological therapy represented an advance in the management of granulomatous
and rheumatologic conditions. Adalimumab (ADA) is approved for the manage-
ment of Crohns disease (CD) since 2007, and the experience with its safety prole
and possible adverse events is expanding over the last years. Induced sarcoidosis
due to anti-TNF therapy is described in some patients with rheumatologic and
skin conditions. There are only two reported CD patients who developed sarcoid-
osis after anti-TNF initiation, one with Iniximab and another one with Natalizu-
mab. The aim of this report is to present one of the rst described CD patients
with the diagnosis of sarcoidosis during ADA therapy, with emphasis on the dif-
ferential diagnosis with hepatosplenic T-cell lymphoma and on the obscure rela-
tion between CD and this condition.
Short report with detailed clinical description of a young CD patient who devel-
oped sarcoidosis during therapy with ADA.
This is the case of a 25 year-old female with diagnosis of ileocolic CD for 18
months (Montreal classication A2L3B3). She rst came to our unit after 8 months
of medical therapy with ADA, Azathioprine (AZA) and steroids, and presented
with an abdominal abscess secondary to stulizing abdominal CD. She was sub-
mitted to laparotomy, ileocolic resection and retroperitoneal abscess drainage,
without further complications. Prevention of postoperative recurrence with ADA
and AZA was maintained, and a colonoscopy 6 months after surgery revealed en-
doscopic recurrence. Ten months after surgery, she presented with subacute
cough and respiratory symptoms. Further investigation with CT-scan revealed
bilateral nodules on the mediastinum with perihilar inltrate, as well as multiple
nodules on the spleen. A hypothesis of hepatosplenic T-cell lymphoma was
made. A mediastinoscopy with biopsy of the nodes was performed, and histology
demonstrated clear pattern of sarcoidosis, with no lymphoproliferative character-
istics. After discussion with the pneumology department, AZA therapy was inter-
rupted and biological treatment with ADA was maintained under strict supervi-
sion. Oral prednisolone was initiated and the patient improved. She is still in
monotherapy with ADA as steroids were withdrawn after 3 months, and persisted
asymptomatic.
The correct mechanism that explains the occurrence of sarcoidosis in CD patients
is not clear. It can be related to anti-TNF therapy or even to an association
between these two conditions that can be explained due to immunological basis
(paradoxical effect). The resolution of the signs and symptoms of sarcoidosis after
anti-TNF interruption could elucidate the causative factor of the drug. In the pres-
ent report, the decision regarding the maintenance of ADA was difcult, and sup-
ported by the literature in some reported cases with other conditions. The risk of
severe recurrence and further need for surgery in a young patient with worse
prognostic features led to this treatment issues. Multidisciplinary and individual-
ized decisions are advised in complex cases as this.
P-12
Non-Multiple Sclerosis Neurological Symptoms Associated With Anti-Tumor Ne-
crosis Factor Therapy in a Crohns Patient
Mazer Ally, Hanna Zembrzuska, Ganesh Veerappan
Walter Reed National Military Medical Center, Bethesda, MD, USA
The development of anti-tumor necrosis factor (TNF) therapy has transformed the
management of Crohns disease (CD). Side effects include hypersensitivity reac-
tions and increased risk of infections. Neurological side effects associated with
anti-TNF therapy are rare, and are primarily associated with demyelination and
include sensory disturbances, optic neuritis, hemiparesis, transverse myelitis, Guil-
lain-Barre syndrome (GBS) or aggravation of known multiple sclerosis (MS). We
describe an unusual presentation of recurrent paresthesias with ataxic gait in a
non-MS patient with CD exposed to two different anti-TNF therapies.
A 63-year-old woman diagnosed in 2011 with ileocolonic inammatory CD was
started on prednisone and mesalamine with good clinical response. As she
tapered steroids, patients intestinal symptoms recurred and she additionally
developed perianal stulas. Patient started 6-mercaptopurine (6MP) and antibiot-
ics (ciprooxacin/metronidazole) in addition to mesalamine therapy. She had a
partial response to treatment, and was started on adalimumab which induced
clinical remission within the rst few doses. However, shortly after her loading
dose of adalimumab, the patient developed bilateral paresthesias in her hands
and feet. At the time, the reaction was attributed to her antibiotics and she
stopped 6MP, antibiotics and mesalamine. However, one month after weaning off
these drugs, her paresthesias progressively worsened with difculty standing or
walking. She had no previous history of neurological symptoms or family history
of MS. An evaluation by neurology included a normal serum B 12 level, MRI of
the brain and cervical spine, and electromyography. Although the patients CD
was in clinical remission, the adalimumab was discontinued given her severe neu-
rological symptoms. Within three weeks, her neurological symptoms completely
resolved; however, her Crohns symptoms recurred. We discussed the possibility
of this reaction being specic to adalimumab, and offered the patient iniximab
because of her great response to adalimumab. However after one week of her
rst infusion of iniximab, the patient developed recurrent neurological symp-
toms with paresthesias to the bilateral upper and lower extremities and gait
ataxia. With concern for a class effect drug reaction, iniximab was discontinued
and she was started on methotrexate, which resulted in clinical and endoscopic
remission of Crohns without any subsequent neurological symptoms.
Neurological symptoms are rare but serious complications of anti-TNF therapy.
Anti-TNF drugs have been associated with increased MS exacerbations and other
complications associated with demyelination. This case illustrates an unusual case
of ataxia and paresthesias secondary to anti-TNF therapy, unrelated to known
anti-TNF neurologic complications (MS, GBS, optic neuritis, etc.). Based on our
work up the etiology for her neurological symptoms are unclear, but a presumed
peripheral demyelination may be a potential cause. Presumed demyelination has
been suggested in other similar cases of peripheral neuropathies associated with
anti-TNF therapy in non-IBD patients. Symptoms generally resolve with discontin-
uation of the drug. It is important to recognize neurologic symptoms as an
adverse effect of anti-TNF therapy and it is likely due to central or peripheral
demyelination.
P-13
Clinical Efficacy of Infliximab in Moderate to Severe Ulcerative
Fabian Juliao
1
, Juan Marquez
2
, Natalia Aristizabal
1
, Yepes Carlos
1
, Zuleta Julio
1
,
J Perez Gisbert
3
1
Pablo Tob on Uribe Hospital, Medell n, Antioquia, Colombia,
2
Cl nica Las Americas,
Medellin, Antiqoquia, Colombia,
3
La Princesa Hospital and CIBEREHD, Madrid,
Madrid, Spain
Previous studies have shown that iniximab (IFX) is effective in the management
of moderate to severe active ulcerative colitis (UC). Latin American studies are
lacking and we therefore sought to evaluate the response to short and long term
IFX therapy in patients with moderate to severe UC. We assessed clinical variables
including furthermore determination of IFX optimization, corticosteroids discon-
tinuation, mucosal healing, colectomy rate and hospitalization
A retrospective and descriptive study was performed in two centers in the city of
Medell n-Colombia (Pablo Tobon Uribe Hospital and Las Americas Clinic) in 253
patients with UC. We included 28 patients who received at least one infusion of
IFX for the treatment of moderate to severe UC that was refractory to conven-
tional treatment or that was steroid-dependent
From October 2005 to July 2011, 28 patients with moderate to severe UC were
infused with IFX; the median of the follow-up was 27.4 months (range: 1-69
months). 24 patients (86%) had short-term primary response, while 19 (68%)
achieved initial clinical remission. After one year, 17 (71%) out of the 24 patients
who had an initial response also showed sustained response, and 10 (59%)
remained in clinical remission. 9 (39%) out of 23 patients receiving steroids at the
beginning of the study, had steroid-free remission after a follow-up period of 1
year. At 6 months, complete healing was observed in 29% and endoscopic
improvement in 57%. Only 3 (11%) patients required colectomy during the fol-
low-up.
This is the rst study evaluating the use of IFX in patients with moderate to
severe active UC in a Latin American population. We found that IFX therapy is
effective for inducing clinical remission, and that most patients who had initial
response showed long-term sustained response.
P-14
Retained Rectum in a Patient Status Post Total Proctocolectomy for Ileocolonic
Crohns Disease
Angelo Paredes, James Duncan, Michael McNally, Neil Gambil, Ganesh
Veerappan
A 28-year-old female with a twenty-year history of penetrating ileocolonic Crohns
disease status post total proctocolectomy (TPC) presented to the inammatory
bowel disease clinic with 4 months of a draining perianal abscess. The discharge
was serosanguineous mixed with mucoid tissue soiling 5 feminine pads daily.
Three years prior to presentation she had an emergent subtotal colectomy with
ileostomy for a colonic perforation while on adalimumab. Subsequent to her sur-
gery, adalimumab was discontinued and she was maintained in clinical remission
on mesalamine and azathioprine. One year later, a necrotic rectal stump pre-
cluded an attempt to restore continuity and underwent completion proctectomy
through a perineal approach and maintained her permanent ileostomy. She
remained on mesalamine and azathioprine with stable ostomy output and with-
out any gastrointestinal symptoms until her current presentation.
Her exam was signicant for a 3 cm midline draining open wound at the level of
her prior anus with surrounding erythema but no uctuance. The site was exqui-
sitely tender to palpation and blood mixed with pus was easily expressed. CT and
magnetic resonance imaging of the pelvis revealed a perianal stula communicat-
ing with a hyperintense lesion within the presacral fat and posterior to the uterus
measuring 16 x 19 x 26 mm suggestive of a remnant rectal pouch. Additionally,
there was evidence of a stulous track from the rectal remnant to the perineum
and a rectovaginal stula. Initial therapy with oral metronidazole improved her
perineal pain and drainage. She underwent a redo abdominoperineal resection
where the remnant rectum was identied and completely resected. A rectovagi-
nal stula was identied in the posterior vaginal wall and excised. The histopa-
thology of the specimen was signicant for colonic tissue with chronic active coli-
tis and transmural inammation. After surgical excision of the active diseased
colonic remnant tissue her stulas healed and her perineal pain ceased.
This is an unusual case of an unintentionally retained rectum in a patient status
post proctocolectomy presenting as active perianal Crohns disease. Approxi-
mately 75% of all CD patients will require surgery during their lifetime, which can
include a total colectomy in medically refractory Crohns colitis. Patients with rec-
tal and perianal involvement of Crohns undergo TPC and end ileostomy given
the high rates of complications in the excluded rectal stump. In patients with
acute complications from Crohns colitis requiring urgent colonic resections, TPC
is typically done in a two-step fashion, as was the intent with this patient. Rou-
tinely, due to the length of remaining distal rectum within the pelvic oor, an
open abdominal approach is required to assure all colonic tissue is excised. The
surgical perineal approach to removing the distal segment in this patient under-
estimated the length of the remaining colon within the pelvis leading to the
retained rectum. Having completely removed the anal canal with adjacent rectal
tissue and the proximal colon in the initial surgery, the patient was left with a
oating segment of rectum within the pelvic oor, which maintained active CD.
This case illustrates an unusual surgical complication of a completion proctec-
tomy in Crohns.
P-15
Pulmonary Necrobiotic Nodules in a Patient With UC and Primary Sclerosing
Cholangitis: a Rare Extraintestinal Manifestation of IBD: Case Report
Moni Barbosa
1
, Flora Gondim
1
, Fabio Vosqui
1
, Camila Ribeiro
2
, Valdiana Surlo
1
,
Bruno Silva
1
, Joao Coelho Filho
3
, Anto nio Lemos
1
, Genoile Santana
1
1
University Hospital Professor Edgard Santos, Salvador, Bahia, Brazil,
2
Bahiana
School of Medicine and Public Health, Salvador, Bahia, Brazil,
3
Brazilian Institute
for Tuberculosis Research, Salvador, Bahia, Brazil
The extraintestinal manifestations of inammatory bowel disease have been
described in association with almost every organ system. IBD can be associated
with several respiratory disorders. Histologically, the nodules usually show sterile
aggregates of neutrophils containing areas of necrosis. We found published
reports of 15 cases of pulmonary nodules associated with IBD, as of august 2011,
predominantly as a manifestation of Crohns disease (CD)
A 17- year-old male patient was diagnosed with ulcerative colitis (UC), with
extensive colitis, and primary sclerosing cholangitis (PSC) 2 years ago. He had
been treated with topical combined with oral mesalazine and ursodeoxycholic
acid since the diagnosis of the disease. The patient started on azathioprine 3
months ago. He was current in remission, but increased ESR and CRP still
remained. He presented with symptoms of cough, pleuritic chest pain and mild
dyspnea. He described no fevers. He was treated with ceftriaxone and azithromy-
cin, azathioprine was stopped, but it appeared to be ineffective. CT of the thorax
revealed pleural effusion and multiple small pulmonary nodules in both lungs.
Open lung biopsy showed a granuloma with central coagulative and lytic necro-
sis, neutrophils in the periphery and foamy histiocytes, consistent with necrobi-
otic nodules, interstitial pneumonia, organizing pneumonia and focal bronchiolitis
obliterans. His respiratory symptoms improved with a course of prednisone (1
mg/kg/day). A follow-up CT scan showed resolution of the pleural effusion and a
>75% reduction in pulmonary nodules size.
Respiratory manifestations can be observed in patients with IBD, but they remain
uncommon. The incidence of respiratory involvement is greater in UC than in CD,
although the necrobiotic nodules have been reported most frequently in CD. We
report a case of UC associated with PSC presenting lung involvement with pre-
dominance of necrobiotic nodules and serositis. Unlike other cases, this patient
presents at younger age than usual. Of 15 reported patients with the association
of IBD and necrobiotic nodules, CD was present in 10 patients and UC in ve
(aged 20 to 75 years). The respiratory disease can develop at any point during
the course of IBD. Most patients have respiratory and constitutional symptoms,
but quiescent bowel disease, as occurred in this case. Most cases responded well
to steroids, but the exclusion of an infectious cause is mandatory. In most
reported cases steroid therapy was prescribed alone, however in some patients
there was an association with other drugs such as immunosuppressive drugs and
iniximab. Clinical and radiologic spontaneous resolution, although controversial,
has been reported, which may raise questions about the optimal therapeutic
management for this condition.Pulmonary necrobiotic nodules are a rare manifes-
tation of IBD. Although steroid therapy provides favorable clinical and radiological
response, further studies are needed to dene the best approach.
P-16
Fulminant Colitis Following Rituximab Therapy for Disseminated B Cell
Marginal Lymphoma
Seth Lipka
1
, Seymour Katz
2
, Rabbi Zia
3
, James Crawford
2
, Joseph Ramek
2
1
Nassau University Medical Center, East Meadow, NY, USA,
2
North Shore University
Hospital-Long Island Jewish Health System, Manhasset, New York,
3
Long Island
Clinical Research Associates, Great Neck, NY, USA
Rituximab (RTX) is a murine IgG1 monoclonal anti-CD20 antibody used in the
treatment of CD20 positive hematological malignancies and a variety of autoim-
mune disorders. Rarely fulminant colitis has been reported with the use of RTX.
We report a patient who developed two episodes of fulminant colitis on two
occasions after infusion with RTX requiring surgery. A 62 year-old female pre-
sented in October 2002 with a lower abdominal wall mass. A peripheral blood
smear showed atypical lymphocytes. Histological and ow cytometry revealed
marginal zone B-cell lymphoma. Cytogenetic studies demonstrated a deletion of
the long arm of chromosome 6. A PET scan showed hypermetabolic activity in
the right thigh as well as areas of hypermetabolic activity in the anks bilaterally.
The patient was offered treatment with CHOP together with RTX or RTX alone.
The patient decided to undergo therapy with RTX alone. After receiving several
cycles of RTX therapy from 2002 to 2005, the patient reported severe diarrhea,
abdominal pain, distention, nausea and vomiting. A CT scan of the abdomen Figure 1.
Figure 2.
with contrast revealed pneumatosis with diffuse wall thickening and distention of
the entire colon. A laparotomy and subtotal colectomy with ileostomy was per-
formed for toxic megacolon. Three months later the ileostomy was closed. After
recurrence of the lymphoma in September 2010 a second course of 4 cycles of
RTX therapy was started. Weight loss, diarrhea, diffuse abdominal pain, and rectal
pain recurred. Physical exam revealed diffuse abdominal tenderness with hepato-
megaly. A sigmoidoscopy revealed diffuse rectal ulceration. Random biopsies
demonstrated severely inamed tissue with neutrophils invading into the lamina
propria. With stool cultures, ova and parasites, and C. diff toxins A/B were all neg-
ative. Rituximab induced colitis was established and the patient underwent a
proctectomy. RTX induced colitis may stem from the disruption in the protective
role B cells play in the immune equilibrium as demonstrated from a case of UC
exacerbated with RTX use. This protective effect was also shown in a mouse
model where B Cell depleted TCRaldouble-knock out mice developed severe co-
litis. B cells in gut associated lymphoid tissue were shown to protect against
autoimmune disease through the promotion TGF-b and IL-4 in mice. In another
model by Mizoguchi et al a protective quality of regulatory B-Cells was shown in
TCRa-/- mice. B cells regulation of CD4 T-cell activity or B cells effect on mucosal
clearance of apoptotic cells have been shown as a key component in the devel-
opment of inammatory bowel disease in murine models. As shown in an animal
model B cell depletion may lead to T-regulatory cell dysfunction with stimulation
of autoreactive T Cells. This disequilibrium of the GI tract innate immune system
may lead to activation of cytotoxic T cells and colitis seen in susceptible RTX
patients. In conclusion B cells may have both an inammatory and anti-inamma-
tory function with disruption of this equilibrium with RTX. Susceptible individuals
may develop severe colitis. Clinicians must be aware of this side effect so with-
drawal of RTX can prevent the loss of a viable colon or death.
P-17
Higher Methotrexate Polyglutamate Levels Are Found With Subcutaneous Com-
pared With Oral Methotrexate Preparations in IBD Patients
Bincy Abraham, Charles Hotte
Baylor College of Medicine, Houston, Texas, USA
Methotrexate (MTX) is a useful and often underutilized medication in the treat-
ment of inammatory bowel disease (IBD). However, there are no standard guide-
lines on MTX dosing in IBD patients. With azathioprine/6-mercaptopurine use, 6-
thioguanine metabolites have been used to determine adequate dose and moni-
tor compliance. MTX is an antifolate entering cells through the reduced folate
carrier and activated to methotrexate polyglutamates (MTX PGs) by folylpolyglu-
tamate synthase. The addition of these glutamic acid residues enhances intracel-
lular retention of MTX and promotes the sustained inhibition of aminoimidazole
carboxamide ribonucleotide (AICAR) transformylase and thymidylate synthase.
These nal steps in the de novo purine and pyrimidine biosynthesis results in the
drugs antiproliferative and anti-inammatory effects. Studies have demonstrated
that individual pharmacogenetics and route of administration may play a signi-
cant role in MTX PGs and response to MTX in rheumatoid arthritis patients. MTX-
PG levels of >60 nmol/L (compared to <60) were 5 fold more likely to have a
good response and levels <20 nmol/L were 3 fold more likely to have a poor
response compared in rheumatoid arthritis patients. The absorption of MTX is
generally rapid, however variability in its absorption has been detected in sub-
jects receiving oral treatment due to drug-induced epithelial denudation, motility
changes and alterations in intestinal ora. Patients with IBD will often have muco-
sal changes, alterations in gut ora, and motility abnormalities that can affect
drug absorption. No prior studies have evaluated the use of MTX-PG levels in IBD
patients.
To assess bioavailability of MTX in IBD patients from our center, we measured
MTX-PG levels on those who received weekly MTX for greater than 3 months.
Ten patients (9 Crohns disease and 1 Ulcerative Colitis) were evaluated. Eight
patients were on SQ dosing (10 to 25 mg) and 3 were on PO dosing (25 mg).
One patient had levels drawn on oral and after switching to SQ.
The average MTX-PG was 25.8 nmoles/L in the PO group (n = 3) and 54.5 nmols/
L in the SQ group (n = 8) (P = 0.002). Four patients (all in SQ group) had levels
>60 nmoles/L and none had levels <20. The remainder of the patients were in
the intermediate range (3 in PO, 4 in SQ) One patient whose oral MTX-PG levels
were low (31.3) was switched from 25 mg PO to SQ which lead to higher MTX-
PG levels(79.4). One patient with renal insufciency intentionally on a lower SQ
MTX dose of 10 mg/wk showed higher metabolite levels (69 nmols/L) due to
lower renal excretion.
Oral absorption of MTX may be poor in patients with inammatory bowel dis-
ease. SQ MTX can lead to higher MTX metabolite levels, which may lead to
improved therapeutic efcacy.
P-18
Mesenchymal Stromal Cells Did Not Increase The Risk of Infectious Complica-
tions in Patients With Inflammatory Bowel Disease
Oleg Knyazev
1
, Irina Ruchkina
1
, Svetlana Mikhailova
1
, Anatoliy Konoplyannikov
2
1
Central Research Institute of Gastroenterology, Moscow, Moscow, Russia,
2
Medi-
cal Radiological Research Center, Obninsk, Kaluga Region, Russia
BACKGROUND: In any immunosuppressive therapy, the question always arises -
whether this therapy increases the risk of infectious complications? The most seri-
ous problem in modern medicine have severe infectious complications of anticy-
tokine therapy in patients with inammatory bowel disease (IBD), having
acquired immune deciency. Accumulated to date show that in spite of the pro-
nounced effect on immunosuppression, alloreactivity and mitogen-provoked reac-
tions, mesenchymal stromal cells (MSC) did not inhibit the activity of immune
cells directed against infectious agents.
METHODS: Objective: To compare the risk of infectious complications in patients
treated with anticytokine therapy with iniximab (IFX) and cell therapy using cul-
ture MSC. Materials and Methods. 60 patients with ulcerative colitis (UC) and
Crohns disease (CD) at the age of 19 to 58 years (M-29), who received a compre-
hensive anti-inammatory therapy with culture MSCs, which were introduced
under the scheme 0-1-26. 59 patients with UC and CD in age from 20 to 62 years
(M-38) received induction IFX therapy 0-2-6 and maintenance therapy after 8
weeks for 12 months. The observation time for both groups of patients was 64
weeks.
RESULTS: Frequency of severe infection (SI) among patients treated with MSCs
was 1.6% (1 case of pneumonia). Frequency of severe SI among patients receiv-
ing IFX was 15.6% (6 cases). For individual forms that look as follows: pneumonia
3 cases (5.7%), throat abscess 1 case (1.9%), lung abscess 1 case (1.9%),
pleural effusion - a case of (1.9%). The frequency of exacerbations of chronic
inammatory disease and mild SI was 10.0% and 33.9% respectively (P < 0.05).
The risk of developing tuberculosis, and activation of latent tuberculosis infection
was higher in patients who received IFX, than in patients receiving cell therapy
0.03 (95% CI 0.17-0.72), (P = 0.0007, x2-13.4). The relative risk of developing
opportunistic infections and infectious complications in patients with IBD receiv-
ing biological therapy MSCs compared with anticytokine therapy was 0.3 (95% CI
0.13-0.68), OR-0.22 (95% CI 0.07-0.64), (P = 0.003, x2-8.6).
CONCLUSION(S): The frequency of infectious complications, acute exacerbations
of chronic inammatory diseases, the risks of opportunistic infection and activa-
tion of latent tuberculosis infection was higher in patients who received IFX, than
in patients receiving biological therapy MSC.
P-19
Long-Term Efficacy of Adalimumab for Treatment of Moderately to Severely
Active Ulcerative Colitis
Jean-Frederic Colombel
1
, William Sandborn
2
, Doug Wolf
3
, Remo Panaccione
4
,
Andreas Lazar
5
, Martina Kron
5
, Anne Robinson
6
, Roopal Thakkar
6
1
Hopital Huriez, CHRU, Lille, Nord, France,
2
University of California San Diego, La
Jolla, CA, USA,
3
Atlanta Gastroenterology Associates, Atlanta, GA, USA,
4
University
of Calgary, Calgary, AB, Canada,
5
Abbott GmbH & Co. KG, Ludwigshafen, Germany,
6
Abbott Laboratories, Abbott Park, IL, USA
BACKGROUND: To evaluate long-term efcacy of adalimumab (ADA) for patients
with moderately to severely active ulcerative colitis (UC).
METHODS: The ADA UC development program consists of two trials (ULTRA 1
and ULTRA 2)
1, 2
followed by an ongoing multicenter open-label (OL) extension. Figure 1.
Patients entering the extension on OL weekly ADA dosing continued on same.
Patients entering the extension study from any blinded cohort (ADA or placebo
[PBO]) or an OL cohort receiving ADA 40 mg every other week (eow) received OL
ADA 40 mg eow. For patients entering from a blinded cohort, increase to 40 mg
weekly for are or non-response was allowed at or after week 12. For patients
entering from an OL cohort, increase to 40 mg weekly for are or non-response
was allowed at or after week 12 for patients in clinical response at entry, or week
2 for patients with inadequate response at entry. Adjustments to concomitant
medications including corticosteroids were allowed per protocol specications.
Partial Mayo score (PMS, Mayo score without endoscopy subscore) was collected
at every study visit during the lead-in trials and the OL extension. Mean PMS
over time through 2 years (112 weeks) from rst dose of ADA was assessed using
observed case method in the any ADA population (patients who received at
least one dose of ADA in the lead-in or extension trials,) using a data cut off of
31 July 2011. The proportion of patients in clinical remission per PMS (PMS _2
with no subscore >1) at week 60 of the OL extension was assessed in the intent-
to-treat (ITT) population (patients enrolled in the extension, excluding patients
from sites non-compliant with good clinical practices), using the last observation
carried forward (LOCF) method to handle missing data.
RESULTS: The observed mean PMS at day of rst dose of ADA was 5.9 (n = 992),
and decreased over time through 112 weeks of treatment to 1.8 (N = 444, Table).
Of the 588 ITT patients from the lead-in studies who enrolled into the OL exten-
sion, 351 (59.7%, LOCF) achieved clinical remission per PMS at week 60 of the OL
extension. No new safety signals were observed.
CONCLUSION(S): The results of the ongoing extension trial support clinically
meaningful efcacy of adalimumab for the treatment of moderately to severely
active UC, sustained for up to 2 years. 1. Reinisch. Gut. 2011; 60:780. 2. Sandborn.
Gastroenterology. 2012; 142:257.
P-20
Mucosal Healing in Ulcerative Colitis Patients With Week 8 Response to Adali-
mumab: Subanalysis of ULTRA 2
Geert DHaens
1
, Gert Van Assche
2
, Doug Wolf
3
, William Sandborn
4
, Jean-Frederic
Colombel
5
, Andreas Lazar
6
, Martina Kron
6
, Anne Robinson
7
, Roopal Thakkar
7
1
Academic Medical Center and Imelda GI Clinical Research Center, Amsterdam,
Netherlands,
2
Mount Sinai Hospital, Toronto, ON, Canada,
3
Atlanta Gastroenterol-
ogy Associates, Atlanta, GA, USA,
4
University of California San Diego, La Jolla, CA,
USA,
5
6
Abbott GmbH & Co. KG, Ludwig-
shafen, Germany,
7
BACKGROUND: To investigate mucosal healing in adult patients with moderately
to severely active ulcerative colitis (UC) failing conventional therapy who
responded to induction with the anti-tumour necrosis factor (TNF) agent adali-
mumab (ADA) in the 52-week (wk), double-blind, randomized, placebo-controlled
ULTRA 2 trial.
1
METHODS: Patients were stratied by prior anti-TNF use and randomized 1:1 to
receive induction dosing with ADA 160/80 mg or placebo (PBO) at wks 0/2, then
ADA 40 mg every other week or PBO from wk 4. Concomitant medications were
maintained at stable doses, except corticosteroids, which could be tapered begin-
ning at wk 8. Response to ADA induction was assessed at wk 8 in ADA-treated
patients by full Mayo score (FMS; response = Mayo score decrease of _3 points
and _30% from baseline and decrease in rectal bleeding score [RBS] of _1 or
absolute RBS of 0 or 1) and partial Mayo score (PMS, Mayo score without endos-
copy subscore; response = PMS decrease _2 points and _30% from baseline,
and RBS criteria as above). At wk 52, the proportion of patients with mucosal
healing (dened as a Mayo endoscopy subscore of 0 or 1) was assessed for ADA-
treated patients who responded at wk 8 by FMS or PMS, compared with all PBO-
treated patients, using non-responder imputation to handle missing data or for
patients who moved to open-label dosing at any time (including patients who
escalated to weekly dosing) for inadequate response. Subgroup analyses by prior
anti-TNF use were also performed. The treatment groups were compared overall
(Cochran-Mantel-Haenszel) and by subgroups (chi-square).
RESULTS: At wk 8 of ULTRA 2, 50.4% (125/248) of ADA-treated patients responded
per FMS, and 49.6% (123/248) responded per PMS. Signicantly more patients
treated with ADA vs PBO achieved mucosal healing at wk 52, for both FMS and
PMS responders (Table). Similar treatment effects at wk52 were observed for anti-
TNF-na ve and anti-TNF-exposed patients.
CONCLUSION(S): In patients with moderately to severely active UC in ULTRA 2,
clinically meaningful long-term mucosal healing efcacy with ADA was seen at
wk 52 in pts with wk 8 full or partial Mayo score response. 1. Sandborn. Gastro-
enterology. 2012; 142:257.
P-21
Reduced Steroid Usage in Ulcerative Colitis Patients With Week 8 Response to
Adalimumab: Subanalysis of ULTRA 2
Gert Van Assche
1
, Doug Wolf
2
, Geert DHaens
3
, William Sandborn
4
, Jean-Frederic
Colombel
5
, Andreas Lazar
6
, Martina Kron
6
, Anne Robinson
7
, Roopal Thakkar
7
1
2
Atlanta Gastroenterology Associates,
Atlanta, GA, USA,
3
Academic Medical Center and Imelda GI Clinical Research Cen-
ter, Amsterdam, Netherlands,
4
University of California San Diego, La Jolla, CA,
USA,
5
6
Abbott GmbH & Co. KG, Ludwig-
shafen, Germany,
7
BACKGROUND: To investigate corticosteroid (CS)-free remission and reduction in
CS use in adult patients (pts) with moderately to severely active ulcerative colitis
(UC) failing conventional therapy who responded to induction with the anti-TNF
agent adalimumab (ADA) in the 52-week (wk), double-blind (DB), placebo (PBO)-
controlled ULTRA 2 trial.
1
METHODS: Pts were stratied by prior anti-TNF use and randomized 1:1 to receive
ADA induction (160/80 mg) or PBO at wks 0/2, then ADA 40 mg every other
week or PBO from wk4. Pts using CS at baseline (BL) were included; CS tapering
was allowed (not required) from wk8. Response to induction was assessed at wk8
in ADA-treated pts using full Mayo score (FMS; response = Mayo score decrease
of _3 points and _30% from BL and decrease in rectal bleeding score [RBS] _1
or absolute RBS _1) and partial Mayo score (PMS, Mayo score without endoscopy
subscore; response = PMS decrease _2 points and _30% from BL, and RBS crite-
ria as above). At wk52, the proportion achieving CS-free remission (Mayo score
_2, no subscore >1) and the proportion free of CS were compared for ADA-
treated pts who responded at wk8 (FMS or PMS) vs. PBO-treated pts, overall
(Cochran-Mantel-Haenszel) and by prior anti-TNF use (chi-square). Mean percent
changes in CS dose from BL to end of DB treatment were compared (ANOVA).
RESULTS: Of 150 ADA-treated pts using CS at BL, 90 (60%) responded per FMS,
and 90 (60%) responded per PMS at wk8. Compared with all PBO-treated pts
using CS at BL (n = 140), signicantly more ADA wk8 responders (by FMS or
PMS) achieved CS-free remission or were CS-free at wk52 (Table). Similar wk52
results were observed for anti-TNF-na ve and -exposed pts. For ADA-treated wk8
responders, mean percent changes in CS dose from BL to end of DB treatment
were 64.4% (FMS) and 68.3% (PMS), vs. 17.5% for PBO-treated pts (P<0.003).
CONCLUSION(S): In pts with moderately to severely active UC who used CS at BL
in ULTRA 2, clinically meaningful long-term CS-free remission and CS-sparing ef-
cacy with ADA was seen at wk52 in pts with wk8 response by full or partial
Mayo score. ADA treatment resulted in clinically meaningful reductions in CS
doses. 1. Sandborn. Gastroenterology. 2012; 142:257.
P-22
Rate of and Response to Dose Escalation in Patients Treated With Adalimumab
for Moderately-to-Severely Active Ulcerative Colitis: ULTRA 2 Subanalysis
Doug Wolf
1
, Geert DHaens
2
, William Sandborn
3
, Jean-Frederic Colombel
4
, Gert
Van Assche
5
, Andreas Lazar
6
, Qian Zhou
7
, Anne Robinson
7
, Jingdong Chao
7
, Roo-
pal Thakkar
7
1
Atlanta Gastroenterology Associates, Atlanta, GA, USA,
2
Academic Medical Center
and Imelda GI Clinical Research Center, Amsterdam, Netherlands,
3
University of
California San Diego, La Jolla, CA, USA,
4
5
6
Abbott GmbH & Co. KG, Ludwigsha-
fen, Germany,
7
Abbott, Abbott Park, IL, USA
BACKGROUND: To investigate the incidence of and outcomes following dose
escalation in adult patients with moderately to severely active ulcerative colitis
(UC) failing conventional therapy by response to induction with the anti-tumor
necrosis factor (TNF) agent adalimumab (ADA) in the 52-week (wk), double-blind,
randomized, placebo-controlled ULTRA 2 trial.
1
METHODS: In ULTRA 2, patients were randomized 1:1 to receive induction dosing
with ADA 160/80 mg or placebo (PBO) at wks 0/2, then ADA 40 mg every other
week (eow) or PBO from wk4. Concomitant UC-related medications were main-
tained at stable doses, except corticosteroids, which could be tapered beginning
at wk8. We evaluated dose escalation in the patients randomized to ADA by
response status at wk8, assessed using the partial Mayo score (PMS, Mayo score
without endoscopy subscore; response = PMS decrease _2 points and _30%
from baseline, and decrease in rectal bleeding score [RBS] of _1 or absolute RBS
of 0 or 1). Per protocol, patients with inadequate response at 2 consecutive visits
at least 2 wks apart could rst move to open-label ADA dosing (40 mg eow) at
or after wk12, then to open-label weekly dosing for continued inadequate
response. The proportions of patients with remission (full Mayo score _2 with no
subscore >1), response (decrease in full Mayo score _3 points and _30%, with
RBS criteria as above), and mucosal healing (endoscopy subscore = 0 or 1) at
wk52 were assessed for ADA-treated patients who moved to weekly dosing dur-
ing the study by wk8 response status per PMS (yes/no), using observed analysis
(reporting the outcomes for patients still in the study at wk52), and NRI (nonres-
ponder imputation; reporting all patients who dose-escalated, with those not in
the study at wk52 considered not to have efcacy).
RESULTS: 123 of 248 ADA-treated patients (49.6%) responded to ADA at wk8 per
PMS. Of the wk8 responders, 20 (16.3%) moved to weekly dosing during the
study; 6/20 (30.0%) had previous anti-TNF exposure. Of the 125 wk8 non-res-
ponders, 48 (38.4%) moved to weekly dosing; 26/48 (54.2%) had previous anti-
TNF exposure. The proportions of patients with remission, response, and mucosal
healing at wk52 for patients who moved to weekly ADA are shown (Table).
CONCLUSION(S): In ULTRA 2, 16.3% of wk8 responders to ADA received weekly
dosing; these patients had clinically meaningful rates of remission, response, and
mucosal healing at wk52. Additionally, some wk8 non-responders to ADA
achieved response and mucosal healing at wk52 following escalation to weekly
dosing, suggesting that weekly dosing may be a benecial strategy among cer-
tain wk8 non-responders as well as wk8 responders. 1. Sandborn WJ, et al. Gas-
troenterology. 2012; 142:257.
P-23
Concomitant Use of Adalimumab and Immunomodulators Compared With Ada-
limumab Alone: Pooled Malignancy Safety Analysis
James Lewis
1
, William Sandborn
2
3
, Mark Osterman
1
,
Anne Robinson
4
, Winnie Lau
4
, Bidan Huang
4
, Paul Pollack
4
, Roopal Thakkar
4
1
University of Pennsylvania, Philadelphia, PA, USA,
2
University of California San
Diego, La Jolla, CA, USA,
3
4
Abbott Labo-
ratories, Abbott Park, IL, USA
BACKGROUND: An elevated risk of skin cancer and lymphomas has been reported
in patients receiving thiopurines.
1,2
We assessed the incidence of malignancies in
patients with Crohns disease (CD) using adalimumab (ADA) alone or in combina-
tion with immunomodulators (IMM).
METHODS: The proportion of patients with treatment-emergent malignancies was
determined from the cumulative adverse event data in lead-in and long-term
studies of ADA in CD (CLASSIC I and II, CHARM, GAIN, ADHERE, and EXTEND)
among patients who received at least 1 dose of ADA. Two categories (non-mela-
noma skin cancer [NMSC] or all other types of malignancies) were assessed
according to receipt of ADAno IMM (ADA monotherapy without any IMM),
ADAany IMM (dened as azathioprine, mercaptopurine, or methotrexate), or
ADAthiopurine only at lead-in study baseline. IMM alone was not analyzed
because of short duration of exposure due to open label crossover to ADA in
most patients during long-term follow-up. Odds ratios (OR) with 95% condence
intervals (CIs) were calculated using logistic regression; events per 100 patient
years (PY) were compared using Poisson regression. Both analyses were run rst
without adjustment for covariates and then rerun adjusting for the following vari-
ables: previous anti-TNF use, baseline steroid use, baseline CDAI, age, race, sex,
weight, disease duration, and smoking status. Standardized incidence ratios (SIRs,
ratio of observed to expected number of cancers) and 95% CIs were calculated,
using expected cancer rates based on age- and sex-specic cancer incidence data
from the Surveillance Epidemiology and End Results (SEER) registry. In situ malig-
nancies and certain other diagnoses not included in SEER were excluded from
the SIR calculations. SIRs indicate whether the observed number of malignancies
is less than (SIR <1.0) or greater than (SIR >1.0) that expected in an age- and
sex-adjusted population.
RESULTS: 1594 patients (representing 3050 patient-years of exposure) were
included in the pooled analysis. Proportions of patients with malignancies, ORs
with CIs, event rates, and P-values are shown in Table 1. SIRs (with CIs) are shown
in Table 2. For the non-skin cancer category, a variety of solid tumors in different
organs were observed. There were 2 lymphomas, both in the ADAIMM group, 1
of which occurred in the ADAthiopurine group, and 1 acute myeloid leukemia
(in the ADAthiopurine group).
CONCLUSION(S): The incidence of malignancy with adalimumab monotherapy
was not elevated compared to expected rates, whereas incidence of malignancy
with combination therapy was higher than expected in the general population
and higher than with adalimumab monotherapy. 1. Beaugerie. Lancet.
2009;374:1617. 2. Peyrin-Biroulet. Gastroenterology. 2011;141:1621.
P-24
The Relationship Between Plasma Concentrations of Certolizumab Pegol and
Clinical Efficacy: Results From the PRECiSE 2 Trial
William Sandborn
1
, Brian Feagan
2
, Gerry Parker
3
, Bosny Pierre-Louis
3
, Scott Lee
4
1
2
London Health Science
Center, University Hospital, London, Ontario, Canada,
3
UCB, Slough, Berkshire,
United Kingdom,
4
University of Washington, Seattle, WA, USA
BACKGROUND: We retrospectively evaluated the relationship of certolizumab
pegol plasma concentrations following induction therapy and clinical efcacy
using data from the PRECiSE 2 trial.
METHODS: Patients aged _18 years with moderate to severe Crohns disease who
enrolled in PRECiSE 2 were given open-label (OL) induction of subcutaneous cer-
tolizumab pegol 400 mg at Weeks 0, 2, and 4. Clinical remission, dened as a
Crohns disease Activity Index (CDAI) score of _150 points, was evaluated at
Week 6. Plasma certolizumab pegol concentration was measured at Week 6 (2
weeks after the last induction dose) and was assessed by quartile. This post hoc
analysis evaluated potential associations between certolizumab pegol plasma
concentration and remission rates at 6 weeks. A multivariable linear regression
analysis was performed to determine if certolizumab pegol plasma concentration
at Week 6 is inuenced by baseline factors, including C-reactive protein (CRP),
body weight, immunosuppressant use, CDAI, and sex.
RESULTS: 572 patients had certolizumab pegol plasma concentrations available at
Week 6 (n = 143 per quartile) following OL certolizumab pegol induction.
Patients with certolizumab pegol plasma concentration in quartiles 1 and 2 had
clinical remission rates of 41% and 44%, respectively, while those with a certolizu-
mab pegol concentration in quartiles 3 and 4 had clinical remission rates of 57%
and 55%, respectively (Table 1). A signicant statistical correlation between
plasma quartile and clinical remission was observed (P = 0.0036). CRP level and
body weight were inversely associated with certolizumab pegol quartile. A multi-
variable analysis showed that baseline CRP level and body weight were signi-
cant predictors of plasma certolizumab pegol concentration at Week 6 (Table 2).
CONCLUSION(S): Baseline CRP level and body weight are signicantly correlated
with certolizumab pegol plasma concentration. Certolizumab pegol plasma con-
centration in the top 2 quartiles may predict a greater likelihood of achieving
clinical remission following standard induction therapy. Further research to better
understand these relationships for induction therapy as well as maintenance ther-
apy with certolizumab pegol is warranted.
P-25
Baseline Corticosteroid Use and Corticosteroid-Free Clinical Remission in
Crohns Disease Patients Treated With Certolizumab Pegol in the PRECiSE 2
Trial
William Sandborn
1
, Brian Feagan
2
, Scott Lee
3
, Stephen Hanauer
4
1
2
3
University of Washington,
Seattle, WA, USA,
4
University of Chicago Hospital Center, Chicago, IL, USA
BACKGROUND: The efcacy of certolizumab pegol as a corticosteroid-sparing
agent has not been thoroughly evaluated. A post hoc analysis evaluated this
question in a 26-week randomized, double-blind, placebo-controlled trial per-
formed in adults with moderate to severe Crohns disease who were stratied by
corticosteroid use at baseline (PRECiSE 2 trial, NCT00152425).
1
METHODS: Adult patients (N = 668) with active Crohns disease (Crohns Disease
Activity Index [CDAI] 220450) were enrolled and received open-label induction
therapy with certolizumab pegol (400 mg administered subcutaneously at Weeks
0, 2, and 4). Patients who responded at Week 6 to certolizumab pegol induction
therapy (the intent-to-treat [ITT] population) were randomized to continuous
therapy with 400 mg certolizumab pegol or placebo every 4 weeks through
Week 24, with follow-up at Week 26. While corticosteroid tapering was not man-
datory, the number of patients eligible to taper corticosteroids was evaluated,
along with the number of patients that initiated corticosteroid tapering between
Weeks 8 and 12. Patients who, in the investigators opinion, showed a clinical
response 8-12 weeks from their rst injection of certolizumab pegol were eligible
to taper corticosteroids. The decision to initiate corticosteroid tapering was at
the discretion of the investigator. Corticosteroid-free clinical remission (dened as
a CDAI score of _150 and discontinuation of all oral steroids) was evaluated in
the certolizumab pegol arm at Week 26 using a last observation carried forward
imputation.
RESULTS: Among 215 patients with a response to certolizumab pegol induction
therapy at Week 6 (the ITT population in the certolizumab pegol arm), 34% (74/
215) were treated with corticosteroids at baseline. 70% (52/74) of the patients in
the certolizumab pegol arm on corticosteroids at baseline were eligible to taper
corticosteroid treatment. Of these eligible patients, 87% (45/52) initiated a taper
of their corticosteroid treatment. 31% (14/45) of the population on corticoste-
roids at baseline that initiated a taper were in a corticosteroid-free clinical remis-
sion at Week 26. Additionally, 38% (82/215) of the ITT population and 49% (68/
140) of the population not on corticosteroids at baseline were in corticosteroid-
free clinical remission at Week 26.
CONCLUSION(S): Approximately one third of patients on corticosteroids at base-
line were able to achieve clinical remission and successfully taper corticosteroids
with certolizumab pegol in the PRECiSE 2 trial. Further investigation is warranted
regarding the signicant proportion of patients who were able to taper off of
corticosteroids while on maintenance therapy with certolizumab pegol, as well as
the reasons that some patients did not initiate a corticosteroid taper when they
were eligible.
P-26
Vedolizumab Induction Therapy for Patients With Crohns Disease and Prior
Anti-TNF Antagonist Failure: A Randomized, Placebo-controlled, Double-blind,
Multicenter Trial
Bruce Sands
1
, Brian Feagan
2
, Paul Rutgeerts
3
4
, William
Sandborn
5
, Richmond Sy
6
, Geert DHaens
7
, Shomron Ben-Horin
8
, Jing Xu
9
, Irving
Fox
9
, Asit Parikh
10
, Catherine Milch
9
, Stephen Hanauer
11
1
2
3
University Hospital Gas-
thuisberg, Leuven, Belgium,
4
5
University
of California San Diego, La Jolla, CA, USA,
6
The Ottawa Hospital - Riverside Cam-
pus, Ottawa, Ontario, Canada,
7
University of Amsterdam, Amsterdam, The Nether-
lands,
8
Chaim Sheba Medical Center, Tel-Aviv University, Ramat Gan, Israel,
9
Millennium Pharmaceuticals, Inc., Cambridge, MA, USA,
10
Takeda Pharmaceuticals,
Deerfield, IL, USA,
11
University of Chicago Medical Center, Chicago, IL, USA
BACKGROUND: Vedolizumab (VDZ) is an investigational gut-selective monoclonal
antibody targeting the a4b7 integrin. We assessed the efcacy and safety of VDZ
as induction therapy in patients with Crohns disease (CD), with the primary anal-
ysis in patients with prior TNFa antagonist failure.
METHODS: In a 10-wk, phase 3 study, adult patients with moderately to severely
active CD (CD Activity Index [CDAI] of 220-400) and with either a CRP >2.87 mg/
L, or colonoscopy photo of active CD within 4 months prior to randomization, or
a fecal calprotectin >250 lg/g stool at screening plus imaging or endoscopic evi-
dence of CD within 4 months prior to screening, despite treatment with purine
antimetabolites, TNFa antagonists, and/or, for patients outside the US, corticoste-
roids, were randomized 1:1 to receive VDZ 300 mg IV or placebo (PBO) at wks 0,
2, and 6. The primary endpoint was clinical remission (CDAI _150) at wk 6 in
patients who had prior TNFa antagonist failure. Secondary endpoints were clinical
remission at wk 6 in the overall population (TNFa antagonist na ve and TNFa an-
tagonist failure), clinical remission at wk 10 in the TNFa antagonist failure and
overall populations, sustained clinical remission (CDAI _150 at wk 6 and wk 10)
in the TNFa antagonist failure and overall populations, and CDAI 100 response
(_100-point decrease from baseline in CDAI) in the TNFa antagonist failure popu-
lation. All endpoints were tested sequentially; Hochberg method was used to
control alpha for endpoints in the 2 populations.
RESULTS: Of 416 patients randomized, 315 (76%) had prior TNFa antagonist fail-
ure. Patient demographics were similar between treatment groups, except the
baseline CDAI was slightly higher in the VDZ than the PBO group (313.9 vs 301.3;
P = 0.015). In the TNFa antagonist failure subpopulation, the difference in the
proportion of patients in the VDZ and PBO groups with clinical remission at wk 6
was not statistically signicant (Table). Because the primary endpoint was not
met, analyses of key secondary endpoints are considered exploratory. In the anti-
TNFa failure subpopulation, greater proportions of VDZ-treated patients had
achieved CDAI 100 response by wk 6 and were in clinical remission by wk 10
compared to PBO. In the overall population, more patients in the VDZ group
than the PBO group were in clinical remission at wk 6 and wk 10, and at both
time points (ie, sustained clinical remission). Treatment-emergent AEs were
reported in 56% of the VDZ patients vs 60% of PBO patients; serious AEs were
reported in 6% vs 8%, respectively. No deaths occurred.
CONCLUSION(S): Although VDZ therapy was not more effective than PBO for
inducing clinical remission at wk 6 in the anti-TNFa failure population, clinical
remission rates at wk 10 were higher with VDZ than PBO, indicating that patients
with previous anti-TNFa failure may require an additional dose for induction.
Notably, VDZ therapy resulted in higher rates, compared with PBO, of achieving
Figure 1.
CDAI 100 response at wk 6, in both anti-TNFa failure and overall populations, and
in clinical remission at wk 6 and at wk 10 in the overall population.
P-27
Sustained Therapeutic Benefit of Vedolizumab Throughout 1 Year in Ulcerative
Colitis in GEMINI I, a Randomized, Placebo-Controlled, Double-Blind, Multicen-
ter Trial
William Sandborn
1
, Bruce Sands
2
, Paul Rutgeerts
3
, Serap Sankoh
4
,
Maria Rosario
4
, Catherine Milch
4
, Irving Fox
4
1
2
Mount Sinai School of
Medicine, New York, NY, USA,
3
University Hospital Gasthuisberg, Leuven, Belgium,
4
Millennium Pharmaceuticals, Inc., Cambridge, MA, USA
BACKGROUND: We assessed the effect of vedolizumab (VDZ), an investigational,
gut-selective monoclonal antibody targeting a4b7 integrin, over 52 wks of ther-
apy in patients with moderately to severely active ulcerative colitis in whom at
least 1 prior therapy had failed.
point) to VDZ at wk 6 were randomized 1:1:1 to VDZ 300 mg IV q4wks, VDZ 300
mg IV q8wks, or placebo (PBO) for 46 wks. Clinical remission was dened as com-
plete Mayo score (CMS) or partial Mayo score (PMS) _2 and no individual sub-
score >1; clinical response was based on PMS, as a reduction _2 points and
_25% from baseline; durable mucosal healing, as Mayo endoscopic subscore _1
at both wks 6 and 52. Because the dened study endpoints used both CMS and
PMS, analyses were conducted to evaluate agreement; moderate to substantial
agreement was found between clinical response and remission endpoints as
dened by CMS and PMS at wks 6 and 52.
RESULTS: Among patients with a clinical response to VDZ at wk 6 (intention-to-
treat [ITT] population, N = 373), decreases in PMS occurred as early as wk 2 (Fig
1). After successful induction, PMS remained substantially lower than baseline in
both VDZ groups through wk 52, whereas an increase in PMS was noted starting
at wk 22 in the PBO group. Mean vedolizumab trough concentrations in the pla-
cebo group declined over time and were below quantitation limits at wk 22. In
the ITT population, remission rates by PMS in the VDZ groups remained stable,
whereas PBO remission rates decreased, over the course of the maintenance
phase (Fig 2). Durable mucosal healing was achieved by 42.6%, 43.2%, and 17.5%
of patients in the VDZ q8wks, VDZ q4wks, and PBO groups, respectively
(P<0.0001 for both comparisons of VDZ vs PBO). Median CS dose declined over
the maintenance phase in both VDZ groups, compared with rising CS use after
wk 26 in the PBO group (Fig 3). In patients blinded to treatment who did not
achieve a clinical response by wk 6 (n = 174), 25.0% of VDZ vs 14.6% of PBO
patients achieved clinical response, and 8.7% vs 4.9% clinical remission, as deter-
mined by PMS by wk 10.
CONCLUSION(S): In patients who responded to VDZ by wk 6, treatment effect
was observed as early as wk 2; sustained reductions in PMS were observed in
VDZ-treated patients over a 1-year period. Clinical remission rates in VDZ patients
remained stable during the maintenance phase. Durable mucosal healing was
achieved in more than twice as many VDZ patients as PBO patients. Continued
dosing with VDZ induced response and remission among patients who did not
achieve response at wk 6.
P-28
Efficacy of Vedolizumab in Ulcerative Colitis by Prior Treatment Failure in GEM-
INI I, a Randomized, Placebo-Controlled, Double-Blind, Multicenter Trial
Brian Feagan
1
, Bruce Sands
2
, Serap Sankoh
3
, Catherine Milch
3
, Irving Fox
3
1
2
3
Millennium Pharmaceuti-
cals, Inc., Cambridge, MA, USA
BACKGROUND: Vedolizumab (VDZ), a selective antagonist of the a4b7 integrin,
has been studied in the treatment of moderately to severely active ulcerative coli-
tis in patients in whom conventional treatment has failed (NCT00783718). In an
exploratory analysis, we evaluated the efcacy of VDZ in a subgroups of patients
with failure of specic classes of drug therapy.
_2 despite treatment with corticosteroids (CSs), purine antimetabolites, and/or
anti-TNFa. After 2 induction doses of VDZ (wk 0, wk 2), patients with clinical
response (reduction in Mayo score of _3 points and _30% from baseline, plus
decrease in rectal bleeding subscore of _1 point or absolute rectal bleeding sub-
score _1 point) at wk 6 were randomized 1:1:1 to VDZ 300 mg IV q4wks, VDZ
300 mg IV q8wks, or placebo (PBO) for 46 wks. The primary outcome of the
induction phase was clinical response at 6 wks. Secondary outcomes were clinical
remission (complete Mayo score of _2 points and no individual subscore >1
point) and mucosal healing (Mayo endoscopic subscore of _1 point) at 6 wks.
The primary outcome of the maintenance phase was remission at wk 52. Second-
ary outcomes were durability of clinical response and remission (endpoint met at
both wks 6 and 52), mucosal healing (Mayo endoscopic subscore _1), and CS-
free remission at 52 wks. Patients were categorized on the basis of failure of prior
treatment with: an anti-TNFa; an immunomodulator but not an anti-TNFa; or CSs
only.
remission, compared with placebo recipients (Tables 1 and 2, and data not
shown). Although condence intervals (CIs) included 0 for treatment differences
from placebo, VDZ efcacy was generally similar across prior treatment failure
subgroups and consistent with the overall study results in the induction (Table 1)
and maintenance (Table 2) phases. Patients with prior anti-TNFa failure generally
had higher rates of adverse events than did anti-TNFa na ve patients.
Figure 1.
Figure 2.
Figure 3.
CONCLUSION(S): The point estimates for the efcacy of VDZ in inducing clinical
response, clinical remission, and mucosal healing in patients with prior anti-TNFa,
immunosuppressive, or CS failure, were consistently superior to PBO at wk 6. In
patients with a clinical response at wk 6, VDZ was superior to PBO in maintaining
clinical response, clinical remission, and mucosal healing at wk 52, regardless of
the type of prior treatment failure.
P-29
Efficacy of Vedolizumab in Ulcerative Colitis by Prior Treatment Failure in GEM-
INI I, a Randomized, Placebo-Controlled, Double-Blind, Multicenter Trial
Asit Parikh
Takeda Pharmaceuticals, Deerfield, IL, USA
BACKGROUND: Vedolizumab (VDZ) has demonstrated efcacy in the treatment of
moderately to severely active ulcerative colitis in patients in whom conventional
treatment has failed (NCT00783718). In this prespecied exploratory analysis, ef-
cacy was assessed in subgroups based on prior failure of specic classes of
agents.
point) at wk 6 were randomized 1:1:1 to VDZ 300 mg IV q4wks, VDZ 300 mg IV
q8wks, or placebo (PBO) for 46 wks. The primary outcome of the induction phase
was clinical response (reduction in complete Mayo score of _3 points and _30%
from baseline and a decrease in rectal bleeding subscore of _1 point or an abso-
lute rectal bleeding subscore of _1 point) at 6 weeks. Secondary outcomes were
clinical remission (complete Mayo score of _2 points and no individual subscore
>1 point) and mucosal healing (Mayo endoscopic subscore of _1 point) at 6
weeks. The primary outcome in maintenance was remission at wk 52. Secondary
outcomes were durability of clinical response and remission (endpoint met at
both wks 6 and 52), mucosal healing (Mayo endoscopic subscore _1), and CS-
free remission at 52 wks. Patients were categorized based on failure of prior
treatment with one or more TNFa antagonists, an immunomodulator but not a
TNFa antagonist, or corticosteroids only.
remission, compared with placebo recipients (Tables 1 and 2 and data not
shown). VDZ efcacy was similar across prior treatment failure subgroups and
consistent with the overall study results in the induction (Table 1) and mainte-
nance (Table 2) phases. In the maintenance phase, there was a greater incidence
of AEs in patients with prior anti-TNFa failure vs other pooled subgroups for all
treatment groups (VDZ q8, 98% vs 73%; VDZ q4, 85% vs 79%; PBO, 89% vs 82%).
Overall TNF failure pts had higher rates of AEs than TNF na ve.
CONCLUSION(S): VDZ was numerically superior to PBO in inducing clinical
response, clinical remission, and mucosal healing by wk 6 in all prior treatment
failure categories. In patients with a clinical response at week 6, VDZ was superior
to PBO in maintaining clinical response, clinical remission, and mucosal healing at
wk 52, regardless of the type of prior treatment failure.
P-30
Clinical Response Is a Meaningful Endpoint in Ulcerative Colitis Clinical Studies
William Sandborn
1
, Brian Feagan
2
, Colleen Marano
3
, Richard Strauss
3
, Jewel
Johanns
3
, Hongyan Zhang
3
, Cynthia Guzzo
3
4
, Walter
Reinisch
5
, Peter Gibson
6
, Judith Collins
7
, Gunnar Jarnerot
8
, Paul Rutgeerts
9
1
2
3
Janssen Research and De-
velopment, LLC, Spring House, PA, USA,
4
6
Universitatsklinik fu r Innere Medizin IV, Wien, N/A, Austria,
7
Alfred Hospital, Mel-
bourne, VIC, Australia,
8
Oregon Health Sciences University, Portland, Oregon,
USA,
9
Orebro University Hospital, Orebro, N/A, Sweden,
10
University Hospital Gas-
thuisberg, Leuven, Belgium
BACKGROUND: Both clinical response and clinical remission have been utilized to
assess the efcacy of biologic agents in the treatment of ulcerative colitis (UC).
Previous studies demonstrated that clinical response and clinical remission are
associated with similar improvements in the quality of life of patients with UC. To
further evaluate the meaningfulness of clinical response as a measure of efcacy,
Mayo score and IBDQ data were summarized for patients not in clinical response,
in clinical response, and in clinical remission from the PURSUIT SC induction study
of golimumab (GLM) in UC.
METHODS: This post hoc analysis includes patients from the phase III portion of
PURSUIT SC-induction study (n = 774). The study enrolled patients with baseline
Mayo scores of 6-12 inclusive, including an endoscopic subscore >2. Data from
the Mayo and IBDQ scores were summarized for patients not in clinical response,
patients in clinical response and patients in clinical remission; each response cate-
gory includes both GLM and placebo-treated patients. The category of clinical
response includes patients in clinical remission as these patients also met the cri-
teria for clinical response. Data are summarized for the partial Mayo score and
the stool frequency and rectal bleeding subscores, as well as the IBDQ and its
associated bowel symptom score as patient-reported outcomes. Clinical response
was dened as a decrease from baseline in Mayo score by _30% and _3 points,
with a decrease in rectal bleeding subscore of _1 or rectal bleeding subscore of
0 or 1. Clinical remission was dened as a Mayo score _2 points, with no individ-
ual subscore >1.
RESULTS: The mean baseline partial Mayo and IBDQ scores were similar among the
3 categories for patients not in clinical response, in clinical response or in clinical
remission, respectively (Table 1). The mean change from baseline partial Mayo
score at week 6 for patients in clinical response and clinical remission were similar
and both were substantially larger than for those patients not in clinical response.
In addition, the majority of patients in clinical response and in clinical remission
showed improvement in the stool frequency and rectal bleeding subscores of the
Mayo score, compared with fewer patients not in clinical response. Similar results
were observed with the mean change in IBDQ score, mean change in IBDQ bowel
symptom subscore, the proportion of patients with >20 point improvement in
IBDQ scores, and the proportion of patients with IBDQ scores _170.
CONCLUSION(S): Symptomatic improvement (as measured by partial Mayo score,
stool frequency, rectal bleeding, and IBDQ) in patients who achieved clinical
response approached that of patients in clinical remission. Patients not in clinical
response showed little change in UC symptoms. Overall, the results support clini-
cal response as a meaningful measure of efcacy in UC clinical studies.
P-31
Low Bone Mineral Density in IBD Patients Was Not Associated With Calcium
Intake or Intestinal Absorption, but With Disease Activity
Graziela Zanetti, Luanda Gomes, Cyrla Zaltman, Laura Mendonca,
MariaLucia Farias
1
Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
BACKGROUND: Reduced bone density has been described in patients with inam-
matory bowel disease (IBD) probably with a multifactorial etiology. Low dietary cal-
cium intake, impaired intestinal calcium absorption eventually aggravated by vita-
min D deciency and the presence of chronic inammation were postulated as
possible causes. The aim of this study is to verify the prevalence of impaired bone
density and the associated factors in IBD patients living in a tropical region of Brazil.
METHODS: Seventy-eight IBD patients (47 CD, 31 UC) and a control group (n =
56) of both genders, aged 20 yr to 50 yr were enrolled. They were submitted to
a medical interview, physical examination, and also an assessment of dietary cal-
cium intake, serum levels of 25-HO vitamin D and parathyroid hormone (PTH).)
An inadequate dietary calcium intake was identied when it was less than 1000
mg/day. Vitamin D insufciency was dened as 25(OH) vitamin D levels <30 ng/
mL. Intestinal calcium absorption was estimated by measuring the response to
oral 1 g of elemental calcium overload. Bone mineral density (BMD) was eval-
uated by DXA. For postmenopausal women and men older than 50 yr, T-scores
identied osteopenia (<1.0 and >2.5) and osteoporosis (<2.5). For all
patients, a Z-score of 2.0 or less identied BMD less than the expected range
for age
RESULTS: Prevalence of low BMD in IBD group (23.07%) was signicantly higher
than controls (7.14%) (P = 0.014), mainly in CD patients (27.65%).Inadequate die-
tary calcium intake was detected in all groups (37.5% controls vs 38.3% IBD). Vita-
min D insufciency was common with no differences between the studied
groups (33% IBD vs 44.6% controls). The baseline PTH was equally increased (sec-
ondary hyperparathyroidism) in IBD and controls (14% vs12.5%). The increase of
urinary calcium/creatinine ratio and reduction of serum PTH levels two hours af-
ter oral calcium challenge in comparison to baseline values were similar in all
groups, suggesting a normal intestinal calcium absorption in IBD group. No sig-
nicant correlation was observed between serum 25(OH)D levels, intestinal cal-
cium absorption or Z- score. In the entire cohort, PTH levels were inversely corre-
lated with serum 25(OH)D levels (r = 0.169, P = 0.004) and higher in IBD
patients with low Z-score. Binomial logistic regression analysis revealed that PTH
levels and clinical disease activity were the main factors associated with low BMD
(P = 0.012 and P = 0.004, respectively).
CONCLUSION(S): A BMD less than the expected range for age occurs more fre-
quently in young adults IBD patients being related to disease activity and sec-
ondary hyperparathyroidism. Vitamin D insufciency and intestinal calcium
absorption could not be associated to the higher prevalence of impaired BMD in
IBD patients.
P-32
Vitamin A Deficiency in Crohns Disease is Not Related to Diet Intake, Reduced
Intestinal Absorption or Hepatic Storage
Tianny Silva, Cyrla Zaltman, Marco Antonio Pinto, Luanda Gomes, Laura Men-
donca, MariaLucia Farias, Andrea Ramalho, Marcia Soares-Mota
Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
Figure 1.
BACKGROUND: Crohns Disease (CD) is a chronic inammatory bowel disorder sus-
ceptible to nutritional decits, such as malnutrition and vitamins deciencies. The
aim of this study was to evaluate the status of retinol at serum levels and liver stor-
age and assess daily intake of vitamin A and body composition in CD patients.
METHODS: Thirty-eight CD outpatients from a tertiary Brazilian Center (HUCFF)
were enrolled. The nutritional status of vitamin A was assessed by serum retinol
and relative-dose-response test, for evaluation of hepatic reserve. The cutoff points
used to inadequacy were <1.05 mmol/L and _20%, respectively. Body composition
was measured by Dual Energy X-ray Absorptiometry and the daily intake of dietary
retinol was analyzed by questionnaire of frequency of consumption.
RESULTS: Forty percent CD patients were overweight and 56% had high fat body
mass. Patients with previous surgical resection had a lower weight (P = 0.020)
and lean mass (P = 0.03). The intake of vitamin A was adequate in 70% of CD
patients, being similar between patients with and without retinol deciency (P =
0.55). The retinol deciency was detected in 29% of CD group who had lower
BMI (P = 0.029) and body fat mass (kg) (P = 0.032). Disease duration (P = 0.255),
intestinal surgeries (P = 0.386) and ileum involvement (P = 0.160), were not asso-
ciated with retinol deciency. The RDR test was positive in 37% of the sample,
showing that the hepatic storage of vitamin A was decient in these patients.
CONCLUSION(S): The results suggest that vitamin A decit in CD is not related to
Vitamin A intake, reduced retinol intestinal absorption or mobilization of hepatic
storage. This nding could be secondary to an increased oxidative stress that
occurs in Crohns disease.
P-33
A Randomized Trial of Electronic (E-mail) Educational Prevention Messages
within the CCFA Partners Cohort
Millie Long, Michael Kappelman, Christopher Martin, Wenli Chen, Kristen Anton,
Robert Sandler
University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
BACKGROUND: Recommended preventive care in patients with inammatory bowel
disease (IBD) includes annual inuenza vaccination. Vaccination is particularly im-
portant among patients treated with immunosuppression. Electronic (e-mail) edu-
cational interventions may be one avenue to improve preventive care in IBD.
METHODS: Crohns and Colitis Foundation of America (CCFA) Partners is an
ongoing internet cohort study of patients with IBD. In September 2011, coincid-
ing with the inuenza vaccination season, individuals within the cohort were
randomized to receive e-mail notications on the importance of inuenza vaccine
(active arm) or general education regarding bone health (placebo arm). These
messages included information on indications for vaccination or bone health
screening, complications of these disorders within IBD patients, rates of vaccina-
tion or bone health preventive activities within the IBD population, and referen-
ces for further reading. After 6 months, receipt of inuenza vaccine was meas-
ured. Data were stratied by age, disease type, immunosuppression status and
by whether the patient had a primary care provider. Pearsons chi squared test
statistic was used to compare vaccine receipt in those randomized to the vaccine
message as compared to those randomized to the bone health message.
RESULTS: A total of 4186 individuals were 1) enrolled in the partners cohort in
the fall of 2011, 2) received an e-mail educational intervention, and 3) completed
a follow-up survey 6 months later. Of these individuals, 2064 received the vaccine
educational message, and 2122 received a bone health message. The study popu-
lation was 62.9% Crohns disease (CD) and 37.1% ulcerative colitis (UC). The me-
dian age was 45 years old (IQR 32-57) and 53.5% were on a form of immunosup-
pression during the study period. A total of 65.7% of the cohort received an
inuenza vaccine (66.5% for CD and 61.4% for UC, P = 0.31). There was signi-
cantly higher vaccine receipt among those on immunosuppression, older individ-
uals (_median age of 45) and among those with a primary care physician
(P<0.001 for each). The vaccination rate among those receiving the e-mail vac-
cine intervention was no different than that of the placebo arm (65.9% versus
65.5%, P = 0.94). There was no difference in vaccine receipt by educational inter-
vention within strata of age, immunosuppression, disease type or primary care
physician.
CONCLUSION(S): Widespread electronic (e-mail) educational messages on the
benets of inuenza vaccine were not effective in improving inuenza vaccina-
tion utilization in this large cohort of individuals with IBD. Multi-component pre-
ventive interventions, beyond patient education, are needed in the future.
P-34
YI
New Quality of Life Index for Patients With Inflammatory Bowel Disease
Laith Alrubaiy, Wai-yee Cheung, John Williams, Ian Russell
Swansea University, Swansea, UK
BACKGROUND: Health-related quality of life (HR-QoL) is now a standard measure
of the quality of care and is an important outcome measure in clinical trials.
There are several specic HRQoL measurement tools for patients with inamma-
tory bowel disease. However, all of them has been designed for outpatient and
stable patients and not ideal for acutely ill patients and those who have stoma.
Our aim is to develop a short quality of life questionnaire (Colitis Crohns Ques-
tionnaire) for acute inpatient setting and patients with stoma.
METHODS: Based on the UK Inammatory Disease Questionnaire 1 which has
been developed and validated in 2000, we derived the Colitis Crohns question-
naire which has 32 questions and supplementary 10 questions for stoma to
reect the wider range and frequency of symptoms in patients with inamma-
tory bowel disease. To ensure that the resulting questionnaire is clear to
patients, we asked a small sample of patients to complete the questionnaires.
We have analysed baseline questionnaires completed by the 124 participants in
the COnStRUCT trial cohort group. A short form of the Colitis Crohns Question-
naire was derived by regressing the total Colitis Crohns questionnaire on the
32 individual items. Internal consistency was assessed by item-total correlation
and Cronbach alpha. Construct Validity was assessed by comparing it with SF12
and EQ5D.
RESULTS: We found that 12 items together accounted for 95% of the variation in
total scores between patients: sleeping, appetite, energy level, rushing to toilet,
being bloated, incomplete emptying of bowels, blood in stool, generally unwell,
faecal incontinence, nocturnal diarrhoea, passing winds and effect on leisure
activities. Reassuringly, none of these items had item-total correlations greater
than 0.8, showing that all items added extra information and none had a single
response chosen by more than 80% of patients i.e. all items give good discrimi-
nation. However two of the top 12 faecal incontinence and passing winds have
item-total correlations less than 0.2, suggesting that they may not be measuring
severity. So these items are candidates for removal from the short form. Indeed,
since the top 8 items together accounted for 92% of the variation in total scores,
they have the potential to form the denitive short form. We have also checked
construct validity against the SF12 and EQ5D. Correlations of the short form with
SF12 PCS (-0.421), SF12 MCS (-0.400) and EQ5D (-0.398) were around 0.4 dem-
onstrating good evidence of construct validity as recommended by Streiner and
Norman2. Test-retest reliability and responsiveness have yet to be checked. How-
ever, it is clear that the short CCQ performs well in this population and is very
likely to yield a valid and efcient short form.
CONCLUSION(S): We have developed a short HRQoL measurement tool for
patients with inammatory bowel disease managed in community, hospital as
well as patients with stoma. This tool has a great potential use in clinical trials
and in IBD UK registry.
P-35
YI
Further Validation of Swansea Inflammatory Bowel Disease Clinical Severity
Index (SICSI)
Laith Alrubaiy, John Williams, Hayley Hutchings
BACKGROUND: To assess IBD activity, many severity scales have been developed.
Yet, most of them were not properly validated and did not go through robust
methodology. Using different scoring systems makes it difcult to compare differ-
ent trials especially when the end points are different. Because new therapies for
IBD are rapidly emerging, there is a need to optimize and standardize methodol-
ogy for assessing of disease activity in clinical trials. With the nationwide initiative
to establish an IBD registry, a valid and easy to use activity measurement tool is
needed. We believe that having a single disease activity index that is suitable for
all types and presentations of IBD will make it very useful to monitor patients
and assess their response to treatment.
METHODS: Literature search was conducted using MEDLINE and Google scholar
database from January 1947 to 2011 to identify the clinical severity indices com-
monly used in clinical trials. Seventeen indices were identied for both ulcerative
colitis and Crohns disease. We followed a clini-metric approach to develop the
simple IBD clinical severity index. Common items between Ulcerative colitis and
Crohns disease were chosen. Few items were added to cover disease specic
domains. The new index was examined by gastroenterologists and methodolo-
gists in Swansea University to ensure good face and content validity. The index
was tested on 50 patients with different presentations of inammatory bowel dis-
ease. Harvey Bradshaw index and Simple clinical colitis index were used for con-
struct validity. Responsiveness was checked by repeating the test within 2-week
period.
RESULTS: The new index, simple IBD clinical severity index, showed good face
and content validity. It covers all presentations of IBD including Crohns disease,
ulcerative colitis and perianal disease. It has good reliability and construct validity.
It is easy to use in daily practice
CONCLUSION(S): Simple IBD clinical severity index is a new tool to assess the
clinical activity of IBD. It is valid, reliable, user friendly and non-invasive index.
Further studies are required to check how it performs on a wider range of
patients.
P-36
YI
How to Check the Validity of Clinical Severity Indices in Inflammatory Bowel
Disease
Laith Alrubaiy, John Williams, Hayley Hutchings
BACKGROUND: Although a host of clinical severity indices has been developed
for inammatory bowel disease, none has been appropriately validated. This vari-
ation made it difcult to compare the outcomes of different clinical trials. There
is no single gold standard clinical severity index and each investigator chooses
or develops his own index. Therefore, there is a need to develop a single clinical
severity index in inammatory bowel disease that is valid and reliable. The aim of
this study is to identify the required standards for a valid and reliable severity
index in inammatory bowel disease and apply them to evaluate the commonly
used clinical severity indices in inammatory bowel disease.
METHODS: Literature search was conducted using MEDLINE and Google scholar
database from January 1947 to 2011 to identify the required standards for clinical
severity indices in inammatory bowel disease. We also reviewed the commonly
used clinical severity indices in inammatory bowel disease and their validation
studies. Personal communications, websites, and major textbooks were critically
reviewed to identify potentially relevant materials. One hundred article was crit-
ically evaluated.
RESULTS: A new 10-point scoring checklist was developed and applied to assess
the disease severity indices in inammatory bowel disease. The scoring system
covers items selection, validity, reliability and responsiveness of the indices. Below
is the scoring table. A score is given if the standard is met. 1. Face validity for the
items was checked 2.Content validity was assessed by experts. 3.Items with
endorsement rate of 80% were identied and removed. 4.Items with discrimina-
tion power 5.Items with item-total correlation 6.Internal consistency is acceptable
(eg, Cronbach a >0.7). 7.Inter-observer reliability >0.75 8.Test-retest reliability
>0.75 9.Construct validity >0.4 10. Responsiveness factor (sensitivity to change)
>0.5 The higher the score of the index, the more valid and reliable it is. However,
we recommend that 7 is the minimum acceptable score for clinical practice as
non-empirical validity are judgmental and it is difcult to assess them properly.
Item discrimination power can be substituted by Item total correlation to remove
redundant items. Inter-observer reliability is closely related to test-retest reliability
and one of them should be enough to assess the reliability of the index.
CONCLUSION(S): This study dened the required standards for developing disease
severity indices in inammatory bowel disease and developed a 10-point check-
list to systematically evaluate current and future indices. Using this checklist will
ensure that any new index is valid and reliable
P-37
YI
Demographics and Phenotypic Behavior of Inflammatory Bowel Disease in
South Asians Living in the United States
Hashim Khandwalla, Bincy Abraham, Jason Hou, Joseph Sellin
BACKGROUND: The incidence and prevalence rates of inammatory bowel disease
(IBD) have increased in South Asian populations. There are no data on the IBD
phenotype and behavior in South Asian patients living in the U.S. Our objective
was to determine the demographics, disease type, behavior and phenotypic vari-
ation of South Asian patients with IBD.
METHODS: Adult South Asian patients with IBD were identied from a patient
care database between January 2008 and June 2012 in the IBD Center at Baylor
College of Medicine, a tertiary care center. Clinical and demographic data were
abstracted from systematic review of electronic medical records using a standar-
dized abstraction form. Additional data were obtained via telephone interview
pertaining to patient birth place, parents place of birth, rst generation immigra-
tion status, time spent in the U.S., family history of IBD, and dietary pattern.
RESULTS: We identied 47 South Asian patients with IBD; 26 (55%) with ulcerative
colitis (UC) and 21 (45%) with Crohns disease (CD). The male/female ratio was 1.2
for UC and 1.1 for CD. The median age at diagnosis of both UC and CD was 28
years (range 11-66). The mean duration of disease was 7 years (range 1-18) for
UC and 6.5 years (range 1-16) for CD. Six patients (23%) with UC and 3 patients
(14%) with CD had a positive family history of IBD. One patient (4%) with UC,
and 3 patients (14%) with CD, had a prior or current history of smoking. Thirty
four patients; 18 (69%) with UC and 16 (76%) with CD were born outside the US
(1st generation). The mean time spent in the US prior to disease manifestation or
diagnosis was 18 6 9.3 years for UC and 16.7 6 8.9 years for CD. Approximately
25% of IBD patients were vegetarians with an equal percentage in both UC and
CD. Fourteen patients (54%) with UC had pancolitis, 11 (42%) had left sided dis-
ease and 1 (4%) had proctitis. Three patients (12%) required a colectomy. Twelve
patients (57%) with CD had ileocolonic involvement (57%), 6 (29%) had ileal dis-
ease and 3 (14%) had colonic disease. Ten (48%) patients with CD had stricturing
and/or penetrating disease of which, 4 (40%) required bowel resection. Eleven
(23%) patients (23%) had extra-intestinal manifestations, primarily joint involve-
ment. No patient was diagnosed with colorectal cancer. Eleven patients (42%)
with UC and 14 patients (67%) with CD were maintained on immunomodulator
or biologic therapy.
CONCLUSION(S): South Asian patients were more likely to have UC than CD.
There was a slight male predominance for both UC and CD. The median age at
diagnosis for CD was similar to that reported previously in Caucasian populations,
but higher for UC. There was a high positive family history of IBD as well as pres-
ence of extra-intestinal manifestations. Disease extent and location was predomi-
nantly pancolitis in UC and ileocolonic in CD.
P-38
YI
Ursodeoxycholic Acid and Risk of Colorectal Neoplasia in Patients With Primary
Sclerosing Cholangitis and Inflammatory Bowel Disease: A Meta-Analysis
Siddharth Singh, Sahil Khanna, Darrell Pardi, Edward Loftus, Jayant Talwalkar
Mayo Clinic, Rochester, MN, USA
BACKGROUND: Primary Sclerosing Cholangitis associated with inammatory
bowel disease (PSC-IBD) is associated with signicantly increased risk of colorectal
cancer (CRC). Several preclinical and observational studies have shown that urso-
deoxycholic acid (UDCA) may modify the risk of inammatory bowel disease
(IBD)-associated colorectal cancer (CRC). We performed a systematic review and
meta-analysis of studies evaluating the effect of UDCA on the risk of IBD-associ-
ated colorectal neoplasia (dened as CRC and/or dysplasia) in patients with PSC-
IBD.
METHODS: We conducted a systematic search of Medline, Embase and Web of
Science (from inception up to July 2012), and manually reviewed the bibliogra-
phies of relevant articles. Studies were included if they: (1) evaluated and clearly
dened exposure to UDCA in patients with PSC-IBD, (2) reported IBD-associated
colorectal neoplasia (CRC and/or dysplasia) as outcome, and (3) reported relative
risks or odds ratios (OR) or provided data for their calculation. The primary out-
come was risk of any colorectal neoplasia and advanced neoplasia (CRC and
high-grade dysplasia). Summary OR estimates with 95% condence intervals (CIs)
were calculated using the random-effects model. Statistical heterogeneity was
calculated using the Cochrans Q statistic and I2 value.
RESULTS: Seven studies (4 observational, 3 randomized controlled trials) reporting
165 cases of colorectal neoplasia in 713 patients with PSC-IBD were included in
the analysis. Overall, meta-analysis showed no signicant protective association
between UDCA use and colorectal neoplasia (OR, 0.83; 95% CI, 0.38-1.81). There
was considerable heterogeneity among studies (I
2
, 66%; P = 0.008), attributable
partly to differences of dose of UDCA used in the included studies. Six studies
reported 41 cases of advanced colorectal neoplasia (CRC and/or HGD) in 546
patients with PSC-IBD. In this group, the use of UDCA was associated with a 63%
risk reduction of advanced colorectal neoplasia that was statistically signicant
(adjusted OR, 0.38; 95% CI, 0.16-0.92). This result was consistent across all
included studies (I2,17%; P = 0.30). In a subgroup analysis, low-dose UDCA use
(8-15 mg/kg/day) was associated with signicant risk reduction of colorectal neo-
plasia (OR, 0.19; 95% CI, 0.08-0.49), whereas high-dose UDCA (16-30 mg/kg/day)
did not signicantly modify the risk of colorectal neoplasia (OR, 2.03; 95% CI,
0.52-7.73). The number of patients with PSC-IBD needed to treat with UDCA to
prevent 1 case of advanced colorectal neoplasia was 12, based on our analysis.
CONCLUSION(S): Meta-analysis of existing studies supports a protective associa-
tion between UDCA use, particularly at low doses, and advanced colorectal neo-
plasia in patients with PSC-IBD.
P-39
YI
Reduction in Need for Surgical Interventions Among Crohns Patients During
the Anti-Tumor Necrosis Factor Era: A United States Perspective
Douglas Nguyen, Johnathan Zhang, M. Mazen Jamal
University of California-Irvine, Orange, CA, USA
BACKGROUND: Prior to the introduction of the rst anti-tumor necrosis (anti-TNF)
factor in late 1998, patients with moderate to severe and stulizing Crohns dis-
ease had few non-surgical options. In clinical trials, anti-TNF therapy has been
shown to be effective for inducting and maintaining remission in patients with
moderately active disease. However, the long-term clinical efcacy and extent to
which anti-TNF therapy have altered the natural history of Crohns disease
remains largely unknown.
METHODS: The Nationwide Inpatient Sample database was utilized for inpatient
data analysis from 1988 to 2006. Patients with primary Crohns disease ICD-9-CM
discharge diagnose were included. Age-adjusted rates for surgery and surgery-
related morality were calculated. Procedural rates for small bowel resection, colec-
tomy procedures, abdominal stula surgery, and anal surgery were also analyzed.
Analysis of variance was used to evaluate trends and Pearson correlation coef-
cient was used to control for important co-variates.
RESULTS: Of the 373,429 hospitalized Crohns patients during 1988-2006 in our
sample, the mean age was 47.1 6 19.21 years, 40.5% were male, and 61.2% were
Caucasians. During 1999-2006 (anti-TNF era), there was signicant reduction in
need for colectomy (OR 0.72, 95% CI 0.70-0.75), small bowel resection (OR 0.66,
95% CI 0.64-0.68), stula surgery (OR 0.74, 95% CI 0.69-0.80), and anal surgery
(OR 0.59, 95% CI 0.53- 0.64) compared to the time period of 1988-1998. Overall,
there was a 16.8% relative risk reduction in need for any type of surgery related
to Crohns disease during the anti-TNF era compared to the pre-anti-TNF era
(P<0.01). There was no difference in surgery-related mortality during the pre-
anti-TNF era compared to the anti-TNF era.
CONCLUSION(S): The use of anti-TNF appears to be changing the natural history
of Crohns disease. Since the approval of Iniximab for Crohns disease in late
1998, there is a trend towards decreased need for surgeries related to Crohns
disease.
P-40
YI
Validation and Comparison of Algorithms to Identify Adult-Onset Inflammatory
Bowel Disease Patients From Within Health Administrative Data
Eric Benchimol
1
, Astrid Guttmann
2
, David Mack
1
, Geoffrey Nguyen
2
, Alan For-
ster
1
, James Gregor
3
, John Marshall
4
, Douglas Manuel
1
1
University of Ottawa, Ottawa, ON, Canada,
2
University of Toronto, Toronto, ON,
Canada,
3
University of Western Ontario, London, ON, Canada,
4
McMaster Univer-
sity Health Sciences, Hamilton, ON, Canada
BACKGROUND: Health administrative databases can be used to track disease inci-
dence, outcomes and care quality. Case validation is necessary to ensure accurate
disease ascertainment using these databases. Disease-specic codes and algo-
rithms (combinations of disease-specic health services codes) have been vali-
dated in various regions to identify adult-onset IBD. We previously validated an
algorithm to identify pediatric-onset IBD and create the Ontario Crohns and Coli-
tis Cohort (OCCC), a population-based surveillance cohort. In this study, we aimed
to validate adult-onset IBD identication algorithms to expand the OCCC to
adults.
METHODS: Two cohorts of patients were used to validate algorithms: 1) Ottawa
Hospital Algorithm Development Cohort: An electronic database (Ottawa Hospital
Data Warehouse) of outpatient visits, hospitalizations, pathology and radiology
reports was searched. The charts of patients with either a diagnostic ICD code for
Crohns or UC, or a referral to IBD, Crohns or UC in a keyword search of either a
histology or radiology report were extracted (n = 5847). Patients >18 years seen
at the Ottawa Hospital from scal years (FY) 2002-2005 were classied as incident
IBD (n = 554), prevalent IBD (n = 1193) or non-IBD (n = 3330). 2) Ontario Algo-
rithm Validation Cohort: The charts from 5 community practices (family medicine
and gastroenterology) and 3 tertiary care centers across Ontario, comprising the
practices of >30 physicians, were extracted to classify IBD patients diagnosed
FY2001-2005 (n = 464) and non-IBD patients (n = 1051). We linked to health
administrative databases from FY1991-2010 and compared the accuracy of vari-
ous algorithms with various lengths of time to qualify. In addition, their latest di-
agnosis (Crohns or UC) was determined from charts to validate an algorithm to
distinguish patients with Crohns from those with UC.
RESULTS: Over 5000 algorithms were tested. Table 1 details the diagnostic accura-
cies of published algorithms. One health care contact was not adequate to iden-
tify patients with IBD. The Manitoba algorithm attained the lowest false-positive
rate, while maintaining sensitivity. The algorithms functioned variably by age,
with diagnostic accuracy lower in patients with onset >65 years (e.g. Ottawa Hos-
pital Algorithm Development Cohort for the Manitoba algorithm: Sens 59.3%,
Spec 98.2%, PPV 58.2%, NPV 98.3%). Having 5 of the last 9 physician billing codes
for Crohns or UC accurately distinguished IBD subtypes (accuracy 91.1%), while
having 4 of the last 7 codes (accuracy 90.7%) and 5 of the last 8 codes (accuracy
90.2%) also functioned adequately.
CONCLUSION(S): Patients with adult-onset IBD can be accurately identied from
within health administrative data. The previously validated algorithms from Mani-
toba were the most accurate. Further work will explore other algorithms, particu-
larly in patient subgroups such as the elderly. The OCCC will be expanded to
include adult patients, creating a large, population-based surveillance cohort of
all patients with IBD in Ontario, Canada.
P-41
YI
A Population-Based Study: Do Women With Ulcerative Colitis Breastfeed?
Mette Julsgaard, Mette Nrgaard, Christian Hvas, Anne Grosen, Sara Hasseriis,
Lisbet Christensen
Aarhus University Hospital, Aarhus C, Jutland, Denmark
BACKGROUND: Medical treatment of ulcerative colitis (UC) is important for induc-
tion and maintenance of remission. Limited population-based data on UC regard-
ing medical treatment and breastfeeding behaviour during the postpartum pe-
riod exist. In an American population 75% of women with UC breastfed
regardless of medical treatment.
1
We aimed to assess how medical treatment of
women with UC in the postpartum period was associated with breastfeeding
behaviour. Furthermore an association between breastfeeding and risk of relapse
was investigated.
METHODS: Women with UC in North Western Denmark, who had given birth
between 2000-2005 among a population of 1.6 million. Diagnoses and birth out-
come were conrmed by population-based medical databases. Breastfeeding
behaviour, relapse, medical treatment and counselling regarding medical treat-
ment were investigated by questionnaires. Medical treatment was additionally
conrmed through regional prescription databases.
RESULTS: Of 115 women, 93 (81%) fullled the questionnaire. Overall 62 (67%)
received medical treatment in the postpartum period, of whom 58 (94%) (95% CI
84.3-98.2) breastfed their infants on an average period of 8 months. In the 31
women (33%) who did not receive medical treatment 27 (87%) (95% CI 70.2-96.4)
breastfed their infants on an average period of 6 months. Twenty-three (37%) of
the medical treated women had received counseling on medical treatment and
breastfeeding, most often by a gastroenterologist. Among the women in medical
treatment 18 of the 58 women (31%) (95% CI 19.5-44.5) who breastfed their
infants experienced a relapse compared with 2 of the 4 women (50%) (95% CI
6.8-93.2) who did not breastfeed their infants.
CONCLUSION(S): The vast majority of women with UC breastfed their infants and
breastfeeding behaviour did not differ by medical treatment status. Breastfeeding
did not increase the risk of relapse during the postpartum period. REF:
1
Kane S,
Lemieux N. The role of breastfeeding in postpartum disease activity in women
with inammatory bowel disease. Am J Gastroenterol 2005;100:102-105.
P-42
YI
Timing of Anti-TNF Therapy Influences Short-Term Outcomes in IBD Patients
Jason Harper, Timothy Zisman
University of Washington, Seattle, WA, USA
BACKGROUND: The optimal time to initiate anti-TNF therapy in patients with IBD
is uncertain. There is emerging evidence that early use of these agents in patients
with moderate-to-severe disease may alter the natural history of IBD. We set out
determine whether the earlier use of anti-TNF therapy was associated with better
short-term outcomes in a biologic-na ve cohort.
METHODS: A retrospective cohort of patients with biopsy-proven UC or CD, na ve
to biologic therapy, who started therapy with iniximab (IFX), adalimumab (ADA)
or certolizumab (CTZ) between 2000-2011, was selected. Subjects with a prior his-
tory of IBD-related surgery were excluded. Primary non-responders to biologic
therapy, individuals who were on corticosteroids beyond the biologic induction
period, and subjects with less than six months of continuous follow-up were also
excluded. Subjects were followed for a maximum of three years or until lost to
follow up. The primary outcome of interest was the occurrence of any IBD-related
hospitalization, surgery or corticosteroid use (after biologic induction) during fol-
low-up. Subjects were stratied according to whether they started a biologic
early (within 1 year of IBD diagnosis) or late (>1 year since diagnosis). Multivari-
able logistic regression was performed with the composite outcome as the de-
pendent variable of interest. A survival analysis was also performed comparing
early versus late initiators and their time to the composite outcome with subjects
censored at three years or when lost to follow up.
RESULTS: Early initiators (N = 34) were younger (mean age D 5.4 years) than late
initiators (N = 78) (P = 0.02), and had a higher frequency of ADA/CTZ use than
the late initiators (38.2% versus 15.4%, P = 0.03). They were also more likely to
be on corticosteroids at the time of biologic initiation (64.7% versus 42.3%, P =
0.03) and less likely to be on aminosalicylates (8.8% versus 28.2%, P = 0.02). The
groups did not differ by sex distribution, mean body weight, immunomodulator
use, presence of extra-intestinal disease, tobacco use or IBD subtype (including
clinical phenotype among CD patients or extent of colitis among UC patients)
(P>0.10). The mean follow-up time between groups did not differ (719 days [SE
57.9] in the early group versus 774 days [SE 41.1] in the late group, P = 0.45). Af-
ter multivariable adjustment, there was a higher likelihood of the composite out-
come in late initiators of biologic therapy (adjusted OR 6.6, SE 5.5, P = 0.02).
When initiation was considered as a continuous function, it remained signicantly
associated with the composite outcome (adjusted OR 1.1 per year since diagno-
sis, SE 0.06, P = 0.05). When modeled as a survival function, the adjusted hazard
ratio for the composite outcome was 4.9 in the late initiators (SE 3.8, P = 0.04).
CONCLUSION(S): Early initiation of anti-TNF therapy in patients with IBD who al-
ready have indications for its use may be associated with better outcomes. These
ndings support a possible role for top-down therapy in IBD treatment. This is in
line with other emerging data that the early use of anti-TNF agents may alter the
natural history of IBD.
P-43
YI
The Colectomy and Mortality Rates in Inflammatory Bowel Disease Patients
with Clostridium Difficile Associated Disease: A Nationwide Analysis from 2000-
2008.
Nilay Kumar, Gagan Kumar, Nanda Venu
Medical College of Wisconsin, Milwaukee, Wisconsin, USA
BACKGROUND: Incidence of Clostridium difcile associated disease (CDAD) is con-
tinuing to increase nationwide. It is now the most common nosocomial infection.
Despite advances in medical management the mortality rate continues to be very
high in hospitalized patients with CDAD. CDAD increases the morbidity and mor-
tality in patients with inammatory bowel disease (IBD).
METHODS: Using the National Inpatient Sample database from 2000-2008,
patients aged 18 or more with discharge diagnosis of CDAD and UC or Crohns
Disease (CD) were identied through appropriately validated ICD-9-CM diagnosis
codes. Patients undergoing colectomy were also identied by appropriately vali-
dated ICD-9-CM procedure codes. The colectomy and mortality trends in CDAD
were evaluated in patients admitted with UC or CD and was compared with non-
CD/UC hospitalized patients. Multivariate logistic regression was performed using
survey commands in STATA to analyze the outcomes of CDAD in patients with
UC and CD. The analysis was adjusted for age, sex, race and other relevant co-
morbid conditions.
RESULTS: A total of 699,151 patients with UC were evaluated over a 9 year period;
30,569 of them also had concomitant CDAD. The number of UC related hospital-
izations has increased from 61,195 in 2000 to 105,468 in 2008. Similarly CD
related hospital admissions have increased from 102,148 in 2000 to 181,507 on
Figure 2.
Figure 3.
Figure 1.
Figure 2.
2008. The all cause in-hospital mortality and colectomy for non-CD/UC hospital-
ized patients with CDAD was 9.8% and 1.8% respectively. This has not changed
signicantly from 2000 to 2008. The rate of colectomy in hospitalized patients
with UC has shown a steady decline from 8.3% to 6.1% from 2000 to 2008 (p <
0.001). Similarly, in Crohns disease, the colectomy rates have declined from 7.9%
in 2000 to 5.9% to 2008 (p < 0.001). However, in patients with UC with CDAD,
the colectomy rates have increased from 10% to 15% during this same time pe-
riod (P = 0.04). This increase was not observed in CD patients with CDAD. All
cause in-hospital mortality in UC patients has increased from 1.6% to 2.0%. A
concomitant infection with CDAD resulted in increased mortality (7.9% in 2000 to
14.9%, P < 0.001). In CD, the in-hospital mortality did not change signicantly
over the 9 years (1.1% to 1.1%). Similarly, the CDAD in CD had higher mortality
(2.7% in 2000 and 4.5% in 2008). Increasing age (OR 1.06; 95% Condence Inter-
val (95%CI) 1.05-1.06), Charlsons comorbidity index (1.39; 95% CI 1.36-1.43) and
CDAD (OR 5.9; 95% CI 5.4-6.5) are associated with higher odds of mortality.
Trends of colectomy and associated mortality in patients with CDAD and UC/CD
are depicted in graph below.
CONCLUSION(S): Our study indicates that in a nationally representative patient
population, there is an overall decrease in rate of colectomy in patients hospital-
ized with UC and CD from 2000-2008. However in UC patients with CDAD the
rate of colectomy and mortality continues to increase in the time period 2000-
2008. In CD patients with CDAD the increasing trend in mortality was seen but
there was no increase in colectomy rates in the same time period.
P-44
YI
Fatigue in IBD Is Related to Poor Quality of Life And Sleep, Not Inflammation
Jana Hashash
1
, David Benhayon
2
, Eva Szigethy
2
, Claudia Rivers
1
, David Binion
1
,
Kyle Duff
1
, Miguel Regueiro
1
1
University of Pittsburgh, Pittsburgh, PA, USA,
2
Childrens Hospital of Pittsburgh,
Pittsburgh, PA, USA
BACKGROUND: Fatigue is common in patients with Inammatory Bowel Disease
(IBD), and the etiology is likely multifactorial. The aim of our study was to identify
factors associated with fatigue.
METHODS: We conducted a retrospective chart review of consecutive adult
patients enrolled in the IBD registry between 7/2010 and 5/2011 in a tertiary care
clinic. Crohns disease (CD) and ulcerative colitis (UC) disease severity was meas-
ured with either Harvey-Bradshaw Index (HBI) or the UC Activity Index (UCAI),
respectively. Labs were obtained to measure anemia, vitamin deciencies, and
inammatory markers. Fatigue was dened by Item-1 of the Short IBD Question-
naire (SIBDQ), a quality of life (QOL) measure, which is scored on a 7-point Likert
scale. Threshold for fatigue was dened as some of the time. The selection of fa-
tigue threshold on SIBDQ was validated using the Patient Reported Outcomes
Measurement Information System (PROMIS) fatigue scale on a subset of patients
(n = 40; r = 0.67; P < 0.001). Sleep quality was assessed using the Pittsburgh
Sleep Quality Index (PSQI). Patients with and without fatigue were assessed for
differences in baseline characteristics using t-tests (continuous variables) and chi-
square tests (categorical variables). Use of psychotropic medications and narcotics
were assessed between patients as proxy measures of psychopathology and pain.
RESULTS: There were 781 patients enrolled in the registry; 37.4% UC and 62.6%
CD. Of these, 695 (258 UC, 437 CD) completed the SIBDQ at the ofce visit. Many
(58%) patients had fatigue at time of evaluation: 401 reported fatigue all the
time, most of the time, good bit of the time, or some of the time, whereas 294
recorded fatigue a little of the time, hardly any of the time, or none of the
time on Item-1. Fatigue correlated signicantly with sleep disturbance (PSQI),
QOL (total SIBDQ), and HBI/UCAI scores for the entire population and also when
stratied into UC and CD cohorts. These ndings were also clinically signicant;
sleep and QOL scores were clinically impaired in patients with fatigue. More
females than males reported fatigue and a higher percentage had CD. There was
no difference in C-reactive protein (CRP), erythrocyte sedimentation rate (ESR),
hemoglobin, vitamin B12, and albumin levels between patients with fatigue and
those without, however this may be due to our smaller sample size assessing
those variables.
CONCLUSION(S): Patients with fatigue had decreased QOL (lower total SIBDQ
score) and also had greater sleep disturbance (higher PSQI scores). While disease
severity did have an association with fatigue, it appeared more related to symp-
tom burden rather than elevated inammatory markers. Patients with fatigue
were more likely to be taking psychotropic medications and/or narcotics, sug-
gesting that psychopathology and pain may play a role in etiology of fatigue.
Interestingly, the impact of inammation or anemia on fatigue was less than
the impact of sleep disturbance. These ndings suggest that better understand-
ing of pathways to fatigue can inform comprehensive treatment of IBD patients.
Future studies will need to assess the predictive relationships between sleep,
psychopathology and disease activity and also the impact of IBD-related
medications.
P-45
YI
Inflammatory Bowel Disease-Associated With Colorectal Cancers in Korea: A
Single-Center Experience
Jae Yeon Lee, Byong Duk Ye, Suk-Kyun Yang, Jong Wook Kim, Sang Hyoung
Park, Soo-Kyung Park, Dong-Hoon Yang, Kee Wook Jung, Kyung-Jo Kim, Jeong-Sik
Byeon, Seung-Jae Myung, Jin-Ho Kim
University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
BACKGROUND: Although a colorectal cancer (CRC) is a well-known complication
of inammatory bowel disease (IBD), the epidemiology and characteristics of CRC
associated with IBD in Asians are still unclear.
METHODS: We retrospectively reviewed the medical records of IBD patients who
were registered at the Asan Medical Center from July 1989 to August 2012.
Patients who were diagnosed with CRC at the time of or after diagnosis of IBD
were identied.
RESULTS: A total of 3575 patients with denite IBD (1877 with ulcerative colitis
[UC] and 1698 with Crohns disease [CD]), were enrolled and 25 patients diag-
nosed with IBD-associated colorectal adenocarcinoma (15 with UC and 10 with
CD) were identied. There were 14 females (56%) and the median age at diagno-
sis of CRC was 43.1 years (interquartile range [IQR], 32.0-52.1 years). Two UC
patients had combined primary sclerosing cholangitis. The median interval from
IBD diagnosis to cancer diagnosis was 11 years (IQR, 5.1-16.8 years). Five patients
(20%) were diagnosed with cancer at the time of IBD diagnosis. Three patients
(12%) had synchronous lesions. The histologies of CRCs were as follows; moder-
ately differentiated adenocarcinoma in 11 (44%), mucinous adenocarcinoma in 6
(24%), poorly differentiated adenocarcinoma in 4 (16%), well differentiated adeno-
carcinoma in 3 (12%), and signet ring cell carcinoma in 1 (4%). The stage distribu-
tion of cancer was as follows; I in 3 (12%), II in 8 (32%), III in 5 (20%) and IV in 9
(36%). The cumulative risk of CRC in IBD, UC and CD patients were 0.6%, 0.7%
and 0.5%, respectively after 10 years and 5.8%, 5.1% and 7.2% respectively after
20 years.
CONCLUSION(S): The IBD-associated CRC tends to show an advanced stage at di-
agnosis. The risk of CRC in Korean IBD patients appears to be comparable to that
of Western IBD patients.
P-46
YI
Clinical Features and Natural History of Patients Diagnosed With Asymptomatic
Ulcerative Colitis
Soo-Kyung Park, Byong Duk Ye, Suk-Kyun Yang, Jong Wook Kim, Sang Hyoung
Park, Dong-Hoon Yang, Kee Wook Jung, Kyung-Jo Kim, Jeong-Sik Byeon, Seung-
Jae Myung, Jin-Ho Kim
University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
BACKGROUND: A few ulcerative colitis (UC) patients are diagnosed when they do
not have any symptoms related with UC. However, the prevalence of asymptom-
atic UC patients together with their clinical features and prognosis are not clear
yet.
METHODS: We retrospectively analyzed the data of UC patients from the IBD
database of Asan Medical Center and identied UC patients who were asymp-
tomatic at diagnosis. The prevalence of asymptomatic UC cases and the clinical
features and prognosis of them compared with matched (1:4) symptomatic UC
cases were investigated,
RESULTS: A total of 2045 UC patients, who were diagnosed with UC between July
1977 and August 2011 and followed for more than one year were reviewed. Nine-
teen patients (0.9%) without symptoms were incidentally diagnosed with UC dur-
ing screening colonoscopy. The proportion of male patients was 78.9% (n = 15),
and their median age at diagnosis was 47 years (range, 34-71 years). At diagnosis,
proctitis was noted in 10 patients (52.6%), left-sided colitis in 5 patients (26.3%),
extensive colitis in 3 patients (15.8%), and atypical distribution in 1 patient (5.3%).
The Mayo score at diagnosis was 1 in 13 patients (68.4%) and 2 in 6 patients
(31.6%). The 5- year cumulative probability of developing symptoms was 66.5%
(95% condence interval [CI] 40.8%-93.1%). During follow-up (median 3.7 years vs.
3.7 years, P = 0.96), the proportion of using corticosteroids (31.6% vs. 56.6%, P =
0.07), azathioprine (0% vs. 28.9%), and iniximab (0% vs. 5.3%) together with colec-
tomy rate (0% vs. 7.9%) were comparable between 19 asymptomatic patients and
76 matched symptomatic patients. The cumulative probability of using corticoste-
roids showed a lower tendency (hazard ratio 0.43; 95% CI 0.18-1.04; P = 0.06) in
asymptomatic patients compared with symptomatic patients.
CONCLUSION(S): The prevalence of asymptomatic UC patients was 0.9% in our
hospital-based study. These asymptomatic UC patients appear to show a better
prognosis compared with symptomatic UC patients.
P-47
YI
Quantitative Analysis of Fusobacterium Nucleatum and Expression of its Adhe-
sin Fada in the Normal and Diseased Pouch
Xiaowei Wang
1
, Bo Shen
2
, Yiping Han
1
1
Case Western Reserve University, Cleveland, OH, USA,
2
Cleveland Clinic, Cleve-
land, OH, USA.
BACKGROUND: Fusobacterium nucleatum (Fn) is a heterogeneous gram-negative
common oral anaerobe, with ve different subspecies. It can invade mucosal epi-
thelial cells through a unique adhesin, FadA, and cause inammation. Fn has
recently been linked to inammatory bowel disease (IBD) and colorectal cancer.
In this study, we examined the presence of Fn and expression of FadA in the
pouch of IBD patients following colectomy.
METHODS: We collected a total of 46 pouch aspirates from the following groups: 1)
normal pouch (n = 19); 2) pouchitis (n = 19); and 3) Crohns disease (CD) of pouch
(n = 8). 16S rRNA genes copies of total bacteria, Fn and its subspecies animalis
were measured by real-time quantitative PCR (qPCR). FadA gene copy numbers and
expression of FadA were also evaluated by qPCR. The results obtained from different
groups were compared by analysis of variance (ANOVA) or paired t-test.
RESULTS: We observed an increase of mean total bacteria per microgram of DNA
by 9.5 fold in pouchitis (group 2) and 12.0 fold in CD of pouch (group 3), respec-
tively, compared to the normal pouches (group 1) (P < 0.001). Fn increased by
27.5 fold per microgram DNA in pouchitis (P < 0.001), 66.1 fold in CD of pouch
(P < 0.001), when compared to the controls. The proportion of Fn in the ora
increased from 0.6% in the normal pouches to 1.7% in pouchitis (P < 0.001) and
3.1% in CD of pouch (P < 0.001). In the normal pouches, only one quarter of the
Fn population belonged to the subspecies animalis, however, in the diseased
pouches, approximately half of all Fn were animalis (P < 0.001). FadA gene copy
numbers increased >1 log in pouchitis, and >2 logs in CD of pouch (P < 0.001).
The FadA expression level in Fn also increased nearly 100% in the diseased
pouches compared to the controls (P < 0.01).
CONCLUSION(S): To the best of our knowledge, this is the rst study quantifying
Fn and its virulence component in pouch. Compared to the normal controls, we
observed a signicant increase of Fn, in both absolute quantity and proportion,
in diseased pouches. Fn subspecies animalis is the predominant subspecies asso-
ciated with disease. FadA gene copies and expression increased signicantly in
disease compared to health, indicating its virulent role in pathogenesis. Fn (and
its subspecies animalis) are likely key etiologic agents in pouch disorders, and
FadA is a potential target for disease diagnosis and therapy.
P-48
YI
The Incidence and Risk Factors for Free Bowel Perforation in Patients With
Crohns disease
Jong Wook Kim, Byong Duk Ye, Suk-Kyun Yang, Sang Hyoung Park, Soo-Kyung
Park, Dong-Hoon Yang, Kee Wook Jung, Kyung-Jo Kim, Jeong-Sik Byeon, Seung-
Jae Myung, Jin-Ho Kim
University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
BACKGROUND: Free bowel perforation (FP) in Crohns disease (CD) can be life-
threatening especially among previously stable patients in clinical remission. The
aim of this study was to investigate the incidence and risk factors of FP in CD
patients.
METHODS: We analyzed the medical records of CD patients registered at the
Asan Medical Center from March 1991 to May 2012. The incidence of FP, dened
as a sudden spontaneous penetration of the bowel resulting in intestinal con-
tents owing into the peritoneal cavity, was investigated. Clinical characteristics
were compared between patients who developed FP and those who did not,
using the Cox proportional hazards analysis.
RESULTS: Among 2385 patients registered, we included 1601 patients who had
no previous history of intestinal perforation. There were 1136 (71.0%) males, and
the mean age at diagnosis of CD was 24.8 years (standard deviation, 8.7 years).
Over a median follow-up time of 5.5 years (interquartile range [IQR], 2.49.0),
seventy three patients (4.6%) developed FP, with the incidence of 6.96 per 1000
person-years (95% condence interval [CI], 5.50-8.81). Among FP cases, there
were 55 males (75.3%), and the median age at FP was 21 years (IQR, 1731
years). The disease locations were ileum in 23 (31.5%), ileocolon in 48 (65.8%)
and colon in 2 (2.7%). The disease behaviors before FP were non-stricturing and
non-penetrating in 8 (11.0%), structuring in 22 (30.1%), and penetrating in 43
(58.9%). On multivariable analysis, stricturing behavior (vs. non-stricturing and
non-penetrating; hazard ratio [HR], 4.8; 95% CI, 2.011.5) and previous azathio-
prine use (HR, 0.2; 95% CI, 0.10.3) were independently associated with FP.
CONCLUSION(S): The incidence of FP in a large cohort of Korean patients with CD
was 4.6%. Patients with stricturing behavior seem to be at higher risk for future
development of FP. Azathioprine use could possibly decrease the risk of FP.
P-49
YI
Low Ultraviolet Exposure Is Associated With Increased Risk of Hospitalization
in Inflammatory Bowel Disease
Berkeley Limketkai, Theodore Bayless, Steven Brant, Susan Hutfless
Johns Hopkins University School of Medicine, Baltimore, MD, USA
BACKGROUND: Vitamin D possesses immunomodulatory properties and a de-
ciency may contribute to inammatory bowel disease (IBD) pathogenesis. Simi-
larly, greater latitudes have higher incidences of Crohns Disease. In this study, we
examine whether ultraviolet (UV) exposure is associated with the risk of hospitali-
zation among patients with Crohns Disease (CD) and ulcerative colitis (UC) from
a large administrative database of annual United States hospitalizations.
METHODS: The Nationwide Inpatient Sample was analyzed for all hospitalizations
between 1998 through 2009. ICD-9 codes in all diagnosis code positions were used
to identify hospitalizations for CD (555.x) or UC (556.x). UV exposure was assigned
as the mean erythemal dose (mW/m
2
) for a particular month, year, and hospital
location, using surface UV data from the National Oceanic and Atmospheric Admin-
istration. UV exposure was then stratied into low (0-49 mW/m
2
), moderate (50-149
mW/m
2
), and high (_150 mW/m
2
) index groups. Logistic regression was used to
estimate the population-level odds ratio (OR) of CD or UC hospitalization according
to UV index. Multivariable models were adjusted for age, sex, race, and year.
RESULTS: There were 1,236,167 CD and 732,008 UC hospitalizations among
388,050,685 total hospitalizations. Of CD patients, 59.6% were female and 84.3%
were white with a mean age of 47.8 years at hospitalization; 54.0% of UC patients
were female and 81.5% were white with a mean age of 53.0 years at hospitaliza-
tion. The number of overall hospitalizations was lowest for the low UV index
group at 86.6 million, while the moderate and high UV index groups had 176.7
and 124.8 million hospitalizations, respectively. On the other hand, for CD
patients, the adjusted odds of hospitalization were greater for the low UV (OR
1.15; 95% CI 1.14-1.15) and moderate UV (OR 1.04; 95% CI 1.04-1.05) groups
when compared with the high UV index group (trend P < 0.0001). This trend
was also seen for UC patients: the low UV (OR 1.09; 95% CI 1.09-1.10) and moder-
ate UV (OR 1.03; 95% CI 1.02-1.03) groups had greater odds of hospitalization
than the high UV index group (trend P < 0.0001).
CONCLUSION(S): Lower UV indices were associated with greater odds of hospitali-
zation with CD and UC patients, while this trend was not seen in the total num-
ber of hospitalizations.
P-50
CCFA GI Buddy Provides Patient Reported Outcomes and IBD Symptoms
Evaluation
Orna Ehrlich
1
, Ashish Atreja
2
, Sheri Markus-Kennell
1
, Kimberly Frederick
1
1
Crohns & Colitis Foundation of America, New York, NY, USA,
2
Mount Sinai School
of Medicine, New York, NY, USA
BACKGROUND: Crohns disease and ulcerative colitis, collectively known as inam-
matory bowel diseases (IBD), are chronic, relapsing inammatory diseases of the
gastrointestinal tract that signicantly affect many patients both physically and
psychosocially. Given the unpredictable nature of IBD, the disease often requires
patient self-management and self-reporting of health status to providers. As a
result, patient-provider communication regarding symptoms and other factors
affecting disease management is of utmost importance to ensure that all aspects
of care, including treatment decisions, are being managed appropriately for opti-
mal outcomes. Few tools, however, exist to date to promote self-management
and optimize patient-provider communication across all aspects of disease man-
agement. To address this unmet need, the Crohns & Colitis Foundation of Amer-
ica developed GI Buddy, a unique interactive disease management tracker speci-
cally designed for patients with IBD to self-report multiple aspects of their day-
to-day disease experiences.
Figure 1.
METHODS: GI Buddy can be accessed from an internet desktop portal or by mo-
bile application (iPhone) in order to conveniently input variables in real time.
Patients must be 13 years or older to utilize GI Buddy. The tool provides: 1) Lon-
gitudinal capture of patient reported outcomes, including symptoms, emotional
factors, missed medications, and diet log (see gure 1a); 2) Support tools, such as
medication reminders and log of questions or notes for next provider interaction;
and 3) Entry of medication history, procedure history, and healthcare team con-
tact information for personal health record.
RESULTS: Over time, patients can view their past history of all inputs in several
manners and are encouraged to share their reports with their provider to discuss
health status and ultimately improve communication and disease management
decisions. Reports include: 1) Summary reports with several designated time
frames (week, month, quarter, year) to review past history at a glance and assess
potential relationships between symptoms, missed medications, food log or
skipped meals, and overall IBD impact (see gure 1b); and 2) Detailed reports of
all tracker inputs entered over a patient-dened custom time frame.
CONCLUSION(S): GI Buddy has the potential for greatly improving the collection of
patient history and patient reported outcomes in order to improve patient-provider
communication regarding true health status and, ultimately, patient outcomes. Our
next goal is to systematically measure the adoption of this tool and determine its
impact on improving outcomes. This will provide us with a better understanding
of patient reported outcomes regarding daily management of IBD on a population
level, including symptoms, medication adherence, diet, and psychosocial health.
P-51
Short- and Long-Term Outcomes of Infliximab Treatment for Refractory
Ulcerative Colitis and Related Prognostic Factors: A Japanese Single-Center
Study
Hiroki Tanaka, Masaki Yamashita, Manabu Ishii, Satoshi Motoya,
Akimichi Imamura
IBD Center, Sapporo Kosei General Hospital, Sapporo, Hokkaido, Japan
BACKGROUND: In Japan, iniximab (IFX) has been established as a useful treatment
option for patients diagnosed with refractory ulcerative colitis (UC). However, the
details of IFX treatment in Japanese patients with refractory UC remain unclear. We
analyzed the short- and long-term outcomes of IFX treatment in Japanese patients
with refractory UC and related prognostic factors.
METHODS: Retrospective data regarding 75 patients with refractory UC who received
IFX treatment at the IBD Center, Sapporo Kosei General Hospital from July 2005 to
November 2011 were collected. The Lichtiger clinical activity index (CAI) score of
these subjects was >5. Short-term outcomes of the IFX treatment were evaluated
on the basis of a decrease in the CAI scores. Remission was dened as a CAI score
of _4. These scores were calculated at baseline as well as at 2 and 6 weeks follow-
ing IFX administration. The cumulative colectomy rate following IFX administration
was considered as the long-term treatment outcome and was estimated using the
KaplanMeier method. The background factors that inuenced the remission rate
and the cumulative colectomy rate were evaluated using a multivariate logistic
regression analysis and a multivariate Cox regression analysis, respectively.
RESULTS: Of the 75 subjects (mean age, 36.2 years), 34 were female. The mean dura-
tion of disease was 5.3 years, the mean C-reactive protein level was 1.2 mg/dl, and
the mean CAI score at baseline was 9.5. Of these 75 subjects, 43 had total colitis, 30
had left-sided colitis, and 2 had proctitis-type colitis. Concomitant treatment with aza-
thioprine and 5-aminosalicylic acid was administered in 79% and 88% subjects,
respectively. Previous treatment included granulocytemonocyte adsorptive aphere-
sis in 66 subjects and calcineurin inhibitor (cyclosporin or tacrolimus) treatment in 27.
Steroid resistance was observed in 43 subjects, whereas 32 demonstrated steroid de-
pendence. Prednisolone was administered in 37 subjects at baseline at an average
dose of 8.5 mg. Remission rates at 2 and 6 weeks were 45% and 55%, respectively.
Previous treatment with calcineurin inhibitors was a signicant poor prognostic fac-
tor for remission after 2 (OR 0.200, 95% CI 0.062-0.645, P = 0.007) and 6 weeks (OR
0.241, 95% CI 0.077-0.755, P = 0.015) according to the multivariate logistic regression
analysis, whereas it was the background factor that signicantly decreased the cumu-
lative nonoperation rate according to the multivariate Cox regression analysis (HR
8.292, 95% CI 2.637-26.079, P < 0.001). The 1-, 3-, and 5-year cumulative noncolec-
tomy rates were 75%, 70%, and 65%, respectively.
CONCLUSION(S): This retrospective study revealed good short- and long-term out-
comes of IFX treatment in Japanese patients with refractory UC. Previous treatment
with calcineurin inhibitors may be a poor prognostic factor of IFX treatment in such
patients.
P-52
Dairy Food Consumption by Patients With Inflammatory Bowel Disease
Mirella Lopes, Raquel Rocha, Vanessa Oliveira, Fernanda Coqueiro, Camilla
Menezes, Naiade Silveira, Patr cia Nunes, Neog elia Almeida, Genoile Santana
Federal University of Bahia, Salvador, Bahia, Brazil
BACKGROUND: Osteoporosis is one of the extra-intestinal complications more
common in patients with inammatory bowel disease (IBD). A risk factor is cal-
cium deciency, resulting mainly from the use of steroids. Furthermore, various
dietary restrictions, including milk products are reported by these patients. The
aim of this study is to assess the dietary intake of dairy products and dietary cal-
cium in patients with ulcerative colitis (UC) and Crohns disease (CD).
METHODS: Descriptive and cross-sectional study involving IBD patients from the
Gastroenterology Outpatient Unit of the University Hospital Professor Edgard
Santos. We performed a questionnaire with demographic, socioeconomic, clini-
cal, dietary and one quantitative food frequency questionnaire (FFQ), between
September 2011 and March 2012. The FFQ was applied to assess the average
daily intake of dairy and calcium, comparing them with the standard baseline
established. The consumption of dairy products has been transformed into serv-
ings for statistical analysis and considered adequate when there was intake of
at least three portions a day. The calcium intake was considered adequate
when there was equivalent to 1000 mg a day for individuals of 19-50 years in
both sexes, 1000 mg individuals of 51-70 years for males and 1,200 mg for
women from 5170 years.
RESULTS: We included 65 IBD patients (UC = 67.7%). The average daily consump-
tion of dairy products was 1.2 6 1.2 servings. The calcium intake was 560.1 6 350.3
mg for women older than 51 years-old and 567.4 6 352.4 mg for other patients. All
of them was lower than the value recommended by the literature (P = 0.00). Most
patients (64.7%) reported the dairy food restriction. Among these, patients with UC
presented a statistically signicant lower calcium (P = 0.01) and dairy (P = 0.00)
intake than those who denied restriction. However, in CD patients there was not a
statistically signicant difference between the two groups. The main reasons
reported for the restriction of dairy products was related to worse in gastrointesti-
nal symptoms and dietary counseling conducted by health professionals.
CONCLUSION(S): It was observed an inadequate intake of dietary calcium and
dairy products among patients with IBD, especially among individuals who
reported restriction of dairy products. These results are relevant, considering that
patients with IBD are at high risk for developing osteoporosis. This observation
reinforces the important role of health professionals in developing measures to
prevent and treat early nutritional deciencies in patients with IBD in order to
prevent osteoporosis.
P-53
Prevalence of Different Immune-Mediated Inflammatory Diseases in Patients
With Inflammatory Bowel Disease. AQUILES study
S Tabernero
1
, I Mar n-Jimenez
2
, F G omez
3
, J Perez Gisbert
4
, JL Perez-Calle
5
, M
Lujan
6
, J Gordillo
7
, I Moral
1
, M Andreu
8
, L Cea-Calvo
9
, R Garc a de Vicu~ na
4
, F
Vanaclocha
10
1
Pr ncipe de Asturias Hospital, Alcala de Henares, Madrid, Spain,
2
Gregorio
Mara~ n on Hospital, Madrid, Spain,
3
Reina Sofia Hospital, C ordoba, C ordoba, Spain,
4
La Princesa Hospital and CIBEREHD, Madrid, Spain,
5
Alcorc on Foundation Hospi-
tal, Alcorc on, Madrid, Spain,
6
Valencia General Hospital Consortium, Valencia,
Spain,
7
Santa Creu i Sant Pau Hospital, Barcelona, Spain,
8
del Mar, Hospital, Barce-
lona, Spain,
9
Merck Sharp & Dohme de Espa~ na, Madrid, Madrid, Spain,
10
12 de
Octubre Hospital, Madrid, Spain.
BACKGROUND: Background: Patients with inammatory bowel disease (IBD) fre-
quently show other immune mediated inammatory diseases (IMID)
METHODS: Aims and Methods: We describe the baseline prevalence of other
IMID in patients with IBD recruited for the AQUILES study, a two year observatio-
nal study that will evaluate the incidence of new diagnosis of IMID in patients
with IBD, psoriasis or spondyloarthritis (SpA) recruited from IBD, Rheumatology,
or Dermatology ofces. For IBD patients, inclusion criteria were age _18 years-
old and previous or new diagnosis of IBD
RESULTS: Results: 478 patients with IBD were recruited (40.9 years-old [SD:
14.2]; 52.7% females; mean disease duration 3 years [IQR: 0-9]; history of familiar
IBD: 12.6% and newly diagnosed IBD: 32.6%). The diagnoses were CD (58.2%),
UC (40.4%) and indeterminate colitis (1.5%). The proportion of IBD patients with
SpA at baseline was 9.8% (ankylosing spondylitis: 3.1%, enteropathic arthritis:
4.2%, undifferentiated SpA: 2.3%). The proportion with psoriasis was 2.5%, pyo-
derma gangrenosum was present in 2.1% and uveitis in 0.6%. There were no
differences between men and women. SpA was more frequent in those with
previous vs. de novo IBD (11.8% vs. 5.8%, p = 0.038) and, non-signicantly, in
those with familiar disease (17.2% vs. 9.4%, P = 0.070). IMIDs were more fre-
quent in CD (table). In multivariate analysis including age, sex, IBD diagnosis,
duration of disease, extra-intestinal ndings and other IMID, SpA was associated
to CD (OR: 2.0 [95% CI: 1.0-4.1] vs. UC) and disease duration _8 years (OR: 3.0
[1.5-6.3]) or 4-7 years (OR: 2.4 [1.0-5.7]), and psoriasis to CD (OR: 3.6 [0.8-16.4]
vs. UC)
CONCLUSION(S): Conclusion: In patients with IBD recruited for the AQUILES study
in Spain, the proportion of other IMIDs was higher than the known prevalence in
general population of Spain. Psoriasis and SpA were more frequent in CD
P-54
Factors Associated to the Presence of Spondyloarthritis in Patients With Inflam-
matory Bowel Disease, AQUILES Study
S Tabernero
1
, I Mar n-Jimenez
2
, F G omez
3
, M Chaparro
4
, P L opez
5
, M Lujan
6
, J
Gordillo
7
, PM Lastra
2
, M Andreu
8
, L Cea-Calvo
9
, R Garc a de Vicu~ na
4
, F
Vanaclocha
10
1
Pr ncipe de Asturias Hospital, Alcala de Henares, Madrid, Spain,
2
Gregorio
Mara~ n on Hospital, Madrid, Spain,
3
Reina Sofia Hospital, C ordoba, C ordoba, Spain,
4
La Princesa Hospital and CIBEREHD, Madrid, Spain,
5
Alcorc on Foundation Hospi-
tal, Alcorc on, Madrid, Spain,
6
Valencia General Hospital Consortium, Valencia,
Spain,
7
Santa Creu i Sant Pau Hospital, Barcelona, Spain,
8
del Mar, Hospital, Barce-
lona, Barcelona, Spain,
9
Merck Sharp & Dohme de Espa~ na, Madrid, Madrid, Spain,
10
12 de Octubre Hospital, Madrid, Madrid, Spain
BACKGROUND: Patients with inammatory bowel disease (IBD) show frequent
extra-intestinal manifestations and other immune diseases
METHODS: We describe the prevalence of spondyloarthritis (SpA) and the associ-
ated variables in a large sample of patients with IBD. Patients aged _18 years-old
with known or newly diagnosed IBD were included. Clinical data were collected
through direct interview and from patients clinical record. Multivariate models
including age, sex, durations of disease, presence of other extraintestinal manifesta-
tions, psoriasis, age at diagnosis, location of disease and classication, were devel-
oped to assess the independent factors related to the presence of SpA at baseline.
RESULTS: 478 patients were recruited (mean age: 40.9 years-old [14.2]; 52.7%
females; mean disease duration 3 years [IQR: 0-9]; 278 [58.2%] CD, 193 [40.4%] UC
and 7 [1.5%] indeterminate colitis). In CD patients, the prevalence of SpA was
12.9%. In the multivariate model variables with the highest adjusted effect on the
prevalence of SpA were duration of disease _8 years (OR: 2.2 [95% CI: 0.7-6.9]) or 4-
7 years (OR: 2.5 [0.8-8.1]), psoriasis (OR: 2.0 [0.4-10.2]) and extra-intestinal manifesta-
tions (OR: 2.1 [0.9-4.9]), but only extra-intestinal manifestations (OR: 2.2 [1.0-4.6])
remained as independent. The prevalence of SpA in UC patients was 5.7%. In the
multivariable model the highest adjusted effect was for duration of disease (OR
1.06 [1.00-1.13] per year of duration), psoriasis (OR 29.3 [1.6-544.1]), and extension
(E2 left colitis-: OR 5.6 [1.2-26.9] compared to E1 ulcerative proctitis-), and they
remained as independent in the model. The results are limited by the low preva-
lence of some variables, like psoriasis, leading to wide condence intervals.
CONCLUSION(S): In patients with CD recruited for the AQUILES study in Spain, the
presence of SpA was associated to other extra-intestinal manifestations while in
patients with UC it was associated to duration of disease, psoriasis and extension of
disease
P-55
Dose Escalation in Patients With Crohns Disease Who Are Newly Initiated to
Therapy With an Anti-TNF
Sunanda Kane
1
, Sara Horst
2
, Dawn Beaulieu
2
, David Schwartz
2
1
Mayo Clinic, Rochester, Minnesota, USA,
2
Vanderbilt University Medical Center,
Nashville, TN, USA
BACKGROUND: Anti-TNF agents are indicated for the treatment of moderate to
severe Crohns disease. Loss of clinical response is an important consideration
with anti-TNF treatment since up to 40% of patients may lose response to their
rst anti-TNF in the rst year of treatment. Options for patients that lose response
include transition to a different medication or increasing existing medication
dose to regain response. This loss of response has important clinical as well as
cost and resource utilization implications. The aim of this analysis is to evaluate
anti-TNF dosing over time in a US patient claims database.
METHODS: An independent analysis was conducted using OptumInsights Clinfor-
matics DataMart, a database of administrative health claims from a large national
health insurer, for patients with a diagnosis of Crohns disease who received a pre-
scription for a rst anti-TNF during April 2008January 2012. Patients were eligible
for inclusion in the analysis if they were aged _18 years, had not received an anti-
TNF in the 6 months prior to rst anti-TNF, and had 24-months pharmacy and medi-
cal continuous enrollment in the database. The number of patients with a dose
increase above the approved and initially prescribed maintenance dose of adalimu-
mab, certolizumab pegol, or iniximab as a rst treatment change at any point dur-
ing the 24-month analysis period was evaluated. To identify a dose increase, data
were converted to weekly milligrams or vials. A dose increase for certolizumab
pegol was dened as an increase above 400 mg every 4 weeks. Split dosing of cer-
tolizumab pegol to 200 mg every 2 weeks was not considered a dose increase. A
dose increase for adalimumab was dened as an increase above 40 mg every 2
weeks and for iniximab as any increase in the number of vials per week.
RESULTS: There were 393, 137, and 326 patients with CD who met the eligibility
requirements and initiated treatment on adalimumab, certolizumab pegol, or inixi-
mab, respectively. Of these patients, 55 (14%), 4 (3%), and 107 (33%), respectively,
received an increase from their initial maintenance dose as the rst treatment change
during the 24-month analysis period. The median times to dose escalation were 106,
162, and 154 days for adalimumab, certolizumab pegol, and iniximab, respectively.
CONCLUSION(S): This analysis of patient level claims data demonstrates that fewer
patients prescribed certolizumab pegol as a rst anti-TNF had a dose increase as
a rst treatment change within the 24-month period, as compared with adalimu-
mab or iniximab. In addition, the median length of time to this rst treatment
change was the longest for certolizumab pegol. Further studies are needed to
explore prescribing habits with anti-TNFs, such as choice for rst anti-TNF, change
of dose, as well as discontinuation and switch of agents, and the impact of these
changes from both a clinical and economic perspective.
P-56
Hispanic Ethnicity and Inflammatory Bowel Disease in the Central Valley of
California
Amita Kalra, Jagrati Mathur, Andrew Yue, Paul Mills, David Limsui
University of California San Francisco, Fresno, CA, USA
BACKGROUND: Inammatory bowel disease (IBD) has not been extensively stud-
ied in minority populations, especially Hispanics. We developed a community-
based IBD registry for Community Regional Medical Center in Fresno, CA, the
regions safety net health system for a unique population with 50.9% of county
residents identifying themselves as Hispanic. We examined potential differences
in gender, IBD subtype, disease location, disease behavior, IBD related surgery,
and age of diagnosis for this ethnically and socio-demographically diverse
population.
METHODS: A total of 1,216 possible IBD patients between years 2000 and 2010
were identied by ICD-9 codes from our medical records database. The medical
records of all these patients were retrospectively reviewed to conrm diagnosis
of IBD and collect epidemiologic and disease specic data. A conrmed IBD case
was dened by presence of endoscopic, histologic, or radiographic evidence of
IBD and treatment with an IBD-related medication or surgery. This data was ana-
lyzed to determine whether there were signicant associations between race/eth-
nicity (Hispanics, Non-Hispanic Whites, Others) and gender, IBD subtype, disease
location, disease behavior, IBD related surgery, or age of diagnosis. Chi square
analysis was performed for categorical data and all p-values are two-sided.
RESULTS: In this period from 2000-2010, there were 614 conrmed IBD cases: 388
ulcerative colitis (UC), 226 Crohns disease (CD). Hispanics comprised 39% of UC
patients and 16% of CD patients. Among patients with UC, the median age of di-
agnosis in Hispanics was 32 years, which was signicantly younger than in Non-
Hispanic Whites with a median age of diagnosis of 38 years. In Crohns Disease,
however, there was no signicant difference in median age of diagnosis which
was 31 years in Hispanics and 32 years in Non-Hispanic Whites. In Hispanics 68%
of UC patients were male, whereas in Non-Hispanic Whites 47% of UC patients
were male which was a signicant difference (P = 0.0001) (table 1). In contrast,
for CD there were no signicant associations between race/ethnicity and gender
(P = 0.33) (table 2). In addition, among the UC patients, there was no signicant
association between race/ethnicity and disease location (P = 0.30), or colectomy
(P = 0.17). Among the CD patients, there were no signicant associations
between race/ethnicity and disease location (P = 0.52), disease behavior (P =
0.27) or CD related surgery (P = 0.73).
CONCLUSION(S): In Hispanics, ulcerative colitis is more predominant in males and
diagnosed at a younger age than in Non-Hispanic Whites. There are racial/ethnic
differences in inammatory bowel disease and further studies in minority popula-
tions are needed.
P-57
A Health Survey of Gastroenterologist Prescribing Practices with Adalimumab
for Crohns Disease
Samantha Zullow, Deborah Greenberg, Kathleen Tracy, Ankur Rustgi, Raymond
Cross, Mark Flasar
University of Maryland, Baltimore, MD, USA
BACKGROUND: To assess prescribing practices of gastroenterologists (GIs) treating
Crohns Disease (CD) with adalimumab (ADA), and identify variables associated
with FDA-approved ADA dosing.
METHODS: A survey was developed and tested for content validity by expert
review and sent to 13,031 GIs with valid email addresses who are members of
the American Gastroenterology Association (AGA) in three email blasts over 6
weeks. Multivariate regression analyses examined relationships between clinical
variables and FDA-approved dosing of ADA for CD.
RESULTS: 398 (3%) of GIs completed the survey, reporting a mean of 11/-SD
years of GI practice. An academic practice setting was reported by 43%, while
72% prescribe ADA >a few times yearly and 15% follow >200 CD patients.
Ninety percent of GIs believe ADA has a moderate-signicantly positive impact
on patient care. The FDA-approved ADA induction and maintenance strategy for
CD was correctly identied by 82%. Respondents were more likely to prescribe
ADA correctly if they followed >200 CD patients (P = .045) and prescribed ADA
>a few times per year (P = .037). Years in practice, practice setting, gender and
region did not have a signicant impact on prescribing practices. ADA prescribing
and dosing practices based on different clinical scenarios (extremes of body
weight and prior exposure to iniximab) were assessed. For body weight scenar-
ios, correct ADA dosing was associated with higher frequency of prescribing (P =
.014) and CD patient volumes (P = .025). Despite variability in appropriate ADA
loading in patients with prior iniximab exposure, no association with ADA pre-
scribing or CD patient volumes was seen on adjusted analyses. Frequency of ADA
prescribing and CD patient volumes were predictive of the total number of cor-
rect survey answers (P =.014 and P =.017, respectively). Only 50% of GIs always
administered loading doses when switching to ADA from another anti-TNF. Of
these GIs, 43.5% reported unclear efcacy of loading doses and 24.3% were wor-
ried about risk of infection secondary to excess anti-TNF as a reason not to load
ADA. Eighteen percent of respondents reported pharmacies had reduced their
prescribed ADA doses in the past.
CONCLUSION(S): Eighteen percent of GIs were not able to correctly identify the
FDA approved ADA induction and maintenance strategy. For overall responses
and for questions with varied patient weights, GIs who reported using the
approved strategy tend to prescribe ADA more frequently and follow more
patients with CD in practice. Half of GIs do not load ADA when transitioning
from another anti-TNF Further research is needed to conrm our ndings and
identify barriers to optimal ADA use by GIs for CD.
P-58
Adalimumab Sustains Deep Remission for 3 Years: Data From CHARM and
ADHERE
William Sandborn
1
2
, Edouard Louis
3
, Remo Panaccione
4
,
Mei Yang
5
, Jingdong Chao
5
, Roopal Thakkar
5
, Anne Robinson
5
, Paul Pollack
5
, Par-
vez Mulani
5
1
University of California, San Diego, La Jolla, CA, USA,
2
Hopital Huriez, CHRU, Lille,
Nord, France,
3
University of Lie`ge, Lie` ge, na, Belgium,
4
University of Calgary, Cal-
gary, AB, Canada,
5
BACKGROUND: Deep remission (DR), dened as clinical remission and mucosal
healing (MH), has been associated with improved patient outcomes.
1
Evidence of
DR beyond 1 year has not been characterized. We aimed to evaluate the impact
of adalimumab (ADA) on DR over a 3-year period.
METHODS: We analyzed the intention-to-treat (ITT) population from CHARM
(56 weeks, randomized at Week 4 to placebo [PBO], ADA 40 mg every other
week [eow], and ADA 40 mg weekly) and its 2-year open label extension
ADHERE (all patients given open-label ADA 40 mg eow or weekly). Due to the
absence of endoscopic measurements in CHARM and ADHERE, a practical index
obtained from a Least Absolute Shrinkage and Selection Operator (LASSO) pro-
cedure was used to predict MH (dened as a CD Endoscopic Index of Severity
[CDEIS] score _4.24). DR was dened as a Crohns Disease Activity Index (CDAI)
score <150 plus predicted MH. Patients who discontinued, had missing data,
or switched to open-label therapy during CHARM were classied as DR non-
responders at subsequent time points. Rates of DR (assessed at Weeks 26 and
56) were compared between the ADA and PBO arms using chi-square tests.
The rates of DR are also assessed in the open-label extension ADHERE (up to
Week 164).
RESULTS: Of 517 patients randomized to ADA in CHARM, 318 (62%) entered
ADHERE. DR rates at Weeks 26 and 56 were signicantly higher for the ADA eow
and ADA weekly arms compared with PBO. Rates of DR on open-label ADA were
maintained up to Week 164 during ADHERE (gure).
CONCLUSION(S): DR was achieved by a substantial proportion of patients in
CHARM. Rates of DR achievement were sustained over 3 years. Reference.
1
Oral
presentation OP317. UEGW 2010, Barcelona, Spain, October 23-27.
P-59
Development of Three Practical Indices for Mucosal Healing Among Patients
With Moderate to Severe Crohns Disease
William Sandborn
1
, Remo Panaccione
2
3
, Edouard Louis
4
,
Mei Yang
5
, Roopal Thakkar
5
, Jingdong Chao
6
, Parvez Mulani
5
1
2
University of Calgary, Calgary,
AB, Canada,
3
4
University of Lie`ge, Lie`ge, na,
Belgium,
5
Abbott Laboratories, Abbott Park, IL, USA,
6
BACKGROUND: Healing of the intestinal mucosa is considered a valid and impor-
tant metric of improvement in Crohns disease (CD). However, a patient must
undergo an endoscopy to verify the presence of mucosal ulceration. Regular
monitoring using endoscopy is challenging owing to its expensive and intrusive
nature. There are currently no easily accessible proxy measures for identifying
patients who are likely to have achieved mucosal healing (MH) in CD.
METHODS: The practical MH indices were developed using intent-to-treat (ITT)
patient-level data from the EXTend the Safety and Efcacy of Adalimumab Through
ENDoscopic Healing (EXTEND) trial (160 mg adalimumab at Week 0, 80 mg at Week
2, and randomized to 40 mg every other week or placebo at Week 4). Each index
corresponds to 1 of 3 mucosal healing measures: Simple Endoscopic Score for CD
(SES-CD) <5, CD Endoscopic Index of Severity (CDEIS) score _4.24, and observed
MH based on a review committee opinion. For each measure, a logistic regression
model was developed to predict MH at Week 12 using demographic, laboratory,
and CD severity characteristics. Important predictors were selected using the Least
Absolute Shrinkage and Selection Operator (LASSO) procedure, which identies a
parsimonious model while retaining predictive accuracy. These 3 indices, named as
SES-CD Based Index, CDEIS Based Index, and Observed MH Based Index, were
evaluated using the accuracy (c-statistic), sensitivity, and specicity measures.
Figure 1.
RESULTS: Important factors associated with MH were similar across the 3 indices
(Table). The performance of each index was also evaluated and listed in the table.
CONCLUSION(S): Platelet count, CRP, and CDAI (number of liquid or very soft
stools) are the common factors associated with MH across all 3 indices. The accu-
racy rates suggest the practical indices may be a clinically useful guide for identi-
fying patients who are likely or unlikely to have achieved MH.
P-60
Adalimumab Therapy Reduces Hospitalization Rates in Patients With Ulcerative
Colitis Among Initial Responders
William Sandborn
1
, Brian Feagan
2
, Mei Yang
3
, Martha Skup
3
, Roopal Thakkar
3
,
Andreas Lazar
4
, Parvez Mulani
3
, Jingdong Chao
5
1
2
3
Abbott Laboratories,
Abbott Park, IL, USA,
4
Abbott GmbH & Co. KG, Ludwigshafen, Germany,
5
Abbott,
Abbott Park, IL, USA
BACKGROUND: Two double-blind, placebo-controlled trials (ULTRA 1 and 2)
revealed that adalimumab (ADA) therapy signicantly reduces hospitalization and
non-signicantly decreases colectomy rates in patients with moderate to severe
ulcerative colitis (UC).
1
We assessed the effect of an ADA 160/80/40 mg treatment
regimen on rate reduction of all-cause and UC-related hospitalization and colec-
tomy in these 2 trials among initial ADA responders.
METHODS: The pooled dataset included 963 patients (480 ADA, 483 placebo
[PBO]). Hospitalization and colectomy events were based on safety reports
reviewed by 2 gastroenterologists who were blinded to treatment. Conservatively,
hospitalizations from initial ADA non-responders (per Mayo score at Week 8)
through Week 8 were counted, but were censored after Week 8 to reect the
clinical practice pattern of continuing treatment in initial ADA-responders. Rate
and number of hospitalizations were compared between groups using person-
year (PY)based incidence rates (IRs) and Poisson regression, respectively; Z-tests
were used to assess statistical differences.
2
RESULTS: 32% and 34% reductions in the number of patients hospitalized and
number of hospitalizations for any reason, respectively, were observed with ADA
therapy vs. PBO (Table, P < 0.05 for both comparisons). When UC-related hospi-
talizations were compared, reductions for rate (50%) and number (54%) of hospi-
talizations were both statistically signicant.
CONCLUSION(S): Initial ADA responders had a signicantly lower rate of UC-
related and all-cause hospitalization compared with PBO. Reduction of all-cause
hospitalization is unique for ADA compared to any other antitumor necrosis fac-
tor agent. A lower, but non-signicant colectomy rate was observed in patients
receiving ADA vs. placebo. References:
1
Oral presentation OP209. UEGW 2011,
Stockholm, Sweden, October 2226, 2011.
2
Miettinen O. Am J Epidemiol.
1976;103:22635.
P-61
Adalimumab Induction Dose Reduces Hospitalization Risk in Patients With Ul-
cerative Colitis During the First 8 Weeks of Therapy
William Sandborn
1
, Brian Feagan
2
, Andreas Lazar
3
, Roopal Thakkar
4
, Martha
Skup
4
, Mei Yang
4
, Jingdong Chao
5
, Parvez Mulani
4
1
2
3
Abbott GmbH & Co. KG,
Ludwigshafen, Germany,
4
Abbott Laboratories, Abbott Park, IL, USA,
5
Abbott,
Abbott Park, IL, USA
BACKGROUND: Analysis of data from 2 double-blind, placebo controlled trials
(ULTRA 1 and 2) revealed that adalimumab (ADA) maintenance therapy reduces
hospitalization in patients with moderate to severe ulcerative colitis (UC) through
Week 52.
1
The impact of ADA induction dosing on hospitalization and colectomy
has not yet been reported.
METHODS: We assessed the effect of a 160/80/40 mg ADA induction regimen
(160 mg at Week 0 and 80 mg at Week 2 followed by adalimumab 40 mg every
other week [eow] at Week 4 and Week 6) on the risk of hospitalizations (all-cause,
UC-related, and UC- or drug-related) and colectomy during the rst 8 weeks of
these 2 trials. The pooled dataset included 963 patients (480 ADA, 483 placebo
[PBO]). Hospitalization and colectomy events were based on safety reports
reviewed by 2 gastroenterologists who were blinded to treatment. Because the
exposure was similar between treatment groups, the risk of hospitalizations and
colectomies between the groups was compared using Chi-square tests.
RESULTS: Signicant reductions in the risk of all-cause (40%), UC-related (50%),
and UC- or drug-related (47%) hospitalizations were observed in the ADA group
compared with PBO (table, P < .05 for all). Although not statistically signicant,
the relative risk for colectomy was lower in the ADA group compared with PBO
(relative risk: 0.8, P <.770).
CONCLUSION(S): Patients who received 160/80/40 mg ADA induction dosing had
a signicantly lower risk of all-cause, UC-related, and UC- and drug-related hospi-
talizations compared with PBO during the rst 8 weeks of therapy. The incidence
of colectomy was non-signicantly lower in patients receiving ADA induction
therapy vs. PBO. These data further support a favorable benet/risk prole of
ADA in UC. References:
1
Oral presentation OP209. UEGW 2011, Stockholm, Swe-
den, October 2226, 2011.
P-62
Direct and Indirect Utilization and Costs Associated With Ulcerative Colitis
Russell Cohen
1
, Joanne Rizzo
2
, Min Yang
3
, Melissa Diener
4
, Mei Yang
2
, Martha
Skup
2
, Parvez Mulani
2
, Jingdong Chao
5
1
University of Chicago, Chicago, IL, USA,
2
Abbott Laboratories, Abbott Park, IL,
USA,
3
Analysis Group, Inc., Boston, MA, USA,
4
Analysis Group, Inc, New York, NY,
USA,
5
BACKGROUND: To assess direct (medical services and prescription drugs) and indi-
rect (work-loss) utilization and costs of privately insured US employees with ulcer-
ative colitis (UC) and compare these outcomes with demographically matched
controls without UC.
METHODS: Employees 1864 years old with _2 UC diagnosis (dx) (ICD-9: 556.xx)
were selected from Ingenix Employer Solutions databases from 1/1/2000 to 3/31/
2010. Employees with Crohns Disease (CD, ICD-9: 555.xx) were excluded. UC patients
were matched to controls (employees without UC or CD) 1:1 on sex, age, region,
and dx date (date of UC dx or other disease for controls). All patients had continu-
ous eligibility for _1 year before (baseline period) and 1 year after (study period) the
dx date. Direct costs (costs associated with hospitalization, emergency room visits,
outpatient visits, and medication treatment) and indirect costs (lost wages from time
away from work due to disability and medically-related absenteeism) were adjusted
to 2010 US dollars (USD). Descriptive analyses compared baseline demographics,
comorbidities, and direct/indirect utilizations/costs during the study period. A multi-
variate analysis compared costs adjusting for baseline comorbidities. These analyses
were also performed for a subgroup of patients with moderate to severe UC (UC
hospitalization or use of systemic corticosteroids, immunosuppressants, or biologics).
RESULTS: 5157 employees with UC and 5157 matched controls (mean age, 48
years; 63.7% men) met the inclusion criteria. Employees with UC had signicantly
more baseline comorbidities including hypertension (21.1% vs. 17.3%, P<.0001),
and higher Charlson comorbidity index scores (0.45 vs. 0.26, P < .0001) than did
controls. Patients with moderate to severe UC (N = 1754) experienced signicantly
higher medical care usage (higher rates per year of hospitalization, emergency
department, and prescription medication use and a greater number of hospitaliza-
tion, disability, medically-related absenteeism, and outpatient visit days per year),
and incurred higher total annual healthcare costs versus controls (Table). A whole-
group analysis revealed that, regardless of disease severity, UC patients experienced
signicantly higher medical care costs and utilization than controls (Table).
CONCLUSION(S): Employed patients with UC had a higher use of medical resour-
ces and direct/indirect costs, especially those with moderate to severely active
UC. Interventions targeting these sicker patients may have the greatest impact
upon overall utilization and costs.
P-63
TOUCH
VR
Patient Reported Outcomes Study: The Impact of Natalizumab on
Crohns Disease Severity
James Lewis
1
, Arpita Nag
2
, Lori Taylor
3
, Gary Hogge
4
5
,
Sunanda Kane
6
, Remo Panaccione
7
, David Rubin
8
1
2
Elan Pharmaceuticals, South
San Francisco, CA, USA,
3
Elan Pharmaceuticals, Inc., South San Francisco, CA, USA,
4
GSH Biomedical Consulting, San Francisco, CA, USA,
5
Hopital Huriez, CHRU, Lille,
Nord, France,
6
7
University of Calgary, Cal-
gary, AB, Canada,
8
University of Chicago Medicine, Chicago, IL, USA
BACKGROUND: Natalizumab (NAT) is an integrin receptor antagonist indicated for
inducing and maintaining clinical response and remission in adult patients with
moderately to severely active Crohns disease with evidence of inammation who
have had an inadequate response to, or are unable to tolerate, conventional CD
therapies and inhibitors of TNF-a.
METHODS: The study sample was comprised of patients enrolled in the TYSABRI
Outreach: Unied Commitment to Health (TOUCH
VR
) prescribing program that
were apprised of the project and agreed to study participation. Patients com-
pleted online or phone surveys regarding demographic characteristics, CD history
and CD severity as dened by ACG Practice Guidelines (Lichtenstein GR, Hanauer
SB, Sandborn WJ. Management of Crohns disease in adults: ACG practice guide-
lines. Am J Gastroenterol. 2009;104:465483) and measured by patient self-
reports based on disease status descriptors and the patient reported components
of the Harvey-Bradshaw index (HBI). Data were collected prior to the initiation of
NAT therapy and at month 3 of treatment.
RESULTS: At the end of the study, 61 patients have provided baseline data.
Females comprised 61% of the sample, with a mean age of 42 years and mean
time from diagnosis of 13 years. CD complications had been experienced by a
high percentage of the patients (66% stula, 54% bowel obstruction, 52% ab-
scess) and 25% reported having had an ostomy. Seventy-percent of patients who
were administered the hospital anxiety and depression scale were diagnosed
with depression and anxiety. Of the 24 patients that have completed the 3-
month follow-up, 83.3% identied their disease severity as moderate to severe at
baseline. At the month 3 measure, 41.7% rated their disease status as moderate
to severe (P = 0.001). Signicant reductions in disease severity were also seen
across the 2 patient reported components of the HBI (mean well-being 2.0 vs.
1.0, P = 0.01; mean abdominal pain 2.0 vs. 1.0, P = 0.001; and mean number of
liquid stools 14.9 vs. 13.7). The patients reported experiencing a mean of 6.8 CD
relapses in the 3 months prior to treatment initiation vs. 4.0 in the 3 months after
(P = 0.004).
CONCLUSION(S): The demographics of the sample appear to be consistent with
product labeling pointing to patients who have moderate to severe CD despite
attempts at control through the use of conventional and anti-TNF therapies.
The disease history of patients entering into therapy with NAT in this naturalis-
tic study indicates a high percentage of patients with CD complications and
concomitant psychiatric disturbances. Among patients who completed a fol-
low-up interview, there was signicant improvement in disease activity. How-
ever, it is not possible to know the true response rate as patients who did not
complete the follow-up survey may have been more likely to be non-
responders.
P-64
TOUCH
VR
Patient Reported Outcomes Study: The Impact of Natalizumab on
Common Measures of Quality of Life in CD patients
Sunanda Kane
1
, Arpita Nag
2
, Lori Taylor
3
, Gary Hogge
4
5
,
James Lewis
6
, David Rubin
7
, Remo Panaccione
8
1
2
Elan Pharmaceuticals, South San Fran-
cisco, CA, USA,
3
4
GSH
Biomedical Consulting, San Francisco, CA, USA,
5
Hopital Huriez, CHRU, Lille, Nord,
France,
6
7
University of Chicago
Medicine, Chicago, IL, USA,
8
University of Calgary, Calgary, AB, Canada
VR
agreed to study participation. Patients completed online or phone surveys con-
taining two validated measures of health-related quality of life (QOL), the Short-
Inammatory Bowel Disease Questionnaire (SIBDQ) and SF-12. The scales compris-
ing the SIBDQ and their clinically meaningful differences (CMD) are bowel (5) and
systemic (2.5) symptoms and social (2.5) and emotional function (6). The SF-12 is
comprised of 8 scales; 2 summary scales (Physical Component Summary [PCS]
and Mental Component Summary [MCS]) can be computed. The CMD of each SF-
12 scale is 5 pts. The scales of the SIBDQ and SF-12 are converted to their more
familiar IBDQ and SF-36 scores. Patients also completed global assessments of
QOL and of the impact of CD on QOL. Data were collected at baseline and at
month 3 of treatment.
RESULTS: Sixty-one patients have provided baseline data (females = 61%, mean
age = 42 years, mean time from diagnosis = 13 years). At baseline, the mean
total IBDQ was 112; the SF-36 PCS was 29 and the MCS was 37 (US general popu-
lation mean = 50). A signicant change of 32 points on the total IBDQ scale
(p_0.001) was noted among the 24 patients who completed the 3-month follow-
up. Signicant improvements in each of the four component scales were also
seen (p_0.01). Improvements on each of the IBDQ scales were clinically meaning-
ful. Signicant improvement was noted on the SF-36 PCS scale (mean change 7.0,
P = 0.001) and 5 of the 8 individual scales of the SF-36 (P < 0.05). The mean
change on each scale of the SF-36, including those not reaching statistical signi-
cance, was clinically meaningful. The patient global assessment of QOL over the
last 2 weeks was signicantly higher at follow-up (3.4 vs. 2.4, P < 0.006) and simi-
lar results were observed regarding their assessment of the impact of CD on QOL
(6.2 vs.4.3, P < 0.001).
CONCLUSION(S): Some of these patients experienced large and meaningful
improvement in QOL after 3 months of therapy.
P-65
TOUCH
VR
PRO Study: The Impact of Natalizumab on Utilization of Healthcare
Resources by the Patients and Their Associated Treatment Satisfaction
David Rubin
1
, Arpita Nag
2
, Lori Taylor
3
, Gary Hogge
4
, Sunanda Kane
5
, James
Lewis
6
, Remo Panaccione
7
8
1
University of Chicago Medicine, Chicago, IL, USA,
2
Elan Pharmaceuticals, South
San Francisco, CA, USA,
3
4
GSH Biomedical Consulting, San Francisco, CA, USA,
5
Mayo Clinic, Rochester, Min-
nesota, USA,
6
7
University of Cal-
gary, Calgary, AB, Canada,
8
Hopital Huriez, CHRU, Lille, Nord, France
VR
were apprised of the project and agreed to study participation. CD patients com-
pleted online or phone surveys regarding their prior biologic history, steroid use,
complications over the past 3 months and healthcare utilization. Patients also
completed the Treatment Satisfaction Questionnaire for Medicines (TSQM) which
measures their satisfaction with treatment effectiveness, side-effects and conven-
ience, and global treatment satisfaction. Data were collected prior to the initia-
tion of NAT therapy and at month 3 of treatment.
RESULTS: To date, 61 patients have provided baseline data. Females comprised
61% of the sample, with a mean age of 42 years and mean time from diagnosis
of 13 years. Ninety-two percent of the patients reported prior biologic use, 87%
had used iniximab; 66% had used adalimumab and 21% had used certolizumab.
Overall, 23% of patients had used one anti-TNF, while 56% had used 2 anti-TNFs
and 13% had used all 3 anti-TNFs. Sixty-ve percent of patients reported steroid
use in the past 3 months prior to baseline, and during this same time, the mean
number of hospital admissions was 0.8, mean days in hospital was 6.4, the mean
number of emergency room (ER) visits due to CD was 1.3, and mean days of total
parenteral nutrition was 6.3. Among the 24 patients providing month 3 data,
there was a signicant decrease in the number of CD-related ER visits (1.3 vs. 0.7,
P = 0.032) and the percent of patients with CD-related complications (abscess,
stula, ostomy, obstruction (50% vs. 41%)). Signicant improvements were
observed in each of the four scales of the TSQM at follow-up (Effectiveness Scale
28.6 vs. 63.0, P < 0.001; Side-effects Scale 61.6 vs. 82.2, P = 0.01, Convenience
Scale 63.8 vs. 70.8, P = 0.05; Global Satisfaction Scale 41.3 vs. 67.0, P < 0.001).
CONCLUSION(S): CD patients who have failed conventional therapy and at least
one anti-TNF therapy report substantial resource utilization in a three month pe-
riod of time. Although there are limitations due to patient drop-out, the follow-
up from many of these patients demonstrates signicant improvement, suggest-
ing the ability of NAT to reduce resource utilization. Further study of patient sub-
types most likely to benet in this manner is warranted.
P-66
Anthropometric Assessment of Crohns Disease Patients According to Drug
Therapy
Fernanda Coqueiro
1
, Raquel Rocha
1
, Naiade Silveira
1
, Patr cia Nunes
1
, Neog elia
Almeida
2
, Genoile Santana
2
1
School of Nutrition, Federal University of Bahia, Salvador, Bahia, Brazil,
2
University
Hospital Professor Edgard Santos, Federal University of Bahia, Salvador, Bahia,
Brazil
BACKGROUND: Various medications are available to patients with Crohns disease
(CD), however, data regarding the inuence of some of these therapies on nutri-
tional status are scarce. The objective of this study was to evaluate the anthropo-
metric nutritional status of patients with CD according to drug therapy
METHODS: The study was conducted in patients with CD, aged over 18 years. We
excluded patients who have altered the drug or its dose, less than 3 months prior
to study initiation. For anthropometric data were used weight, height, body mass
index (BMI), corrected arm muscle area (AMA) and triceps plus subscapular skin-
fold thickness (TSTSST). Assessments occurred at two times: T0 - initial assess-
ment; T1 - 3 months after the rst evaluation. Patients were also asked about the
change in appetite. Changes in nutritional status such as weight, BMI, AMA, and
(TSTSST) were evaluated by Wilcoxon t test. To evaluate the association
between medication and anthropometry was used Fishers exact test.
RESULTS: We evaluated 46 patients with a mean age of 39.9 6 10.6 years, and 27
(58.7%) females. Thirty patients (65.2%) were in remission. The most widely used
drug in the sample was the immunosuppressant azathioprine (78.2%), followed
by iniximab (19.5%), aminosalicylics (17.4%) and corticosteroids (10.9%). In the
rst evaluation, we found that 43.5% of patients were overweight (BMI _25 kg/
m2), with greater frequency among those using iniximab (66.7%). Among these,
55.6% (5/9) were obese (BMI _30 kg/m2). Loss of muscle mass was observed in
45.7% of patients, especially among those who used steroids 4 (80.0%) and aza-
thioprine 18 (50.0%). Approximately 89% had adequate reserve of adipose tissue,
and this excess was seen more frequently in those treated with iniximab
(33.3%). No association was found between the use of azathioprine and anthro-
pometric indicators. At T0, most of the patients reported no increase in appetite
presented in the different drug therapies, despite the high frequency of over-
weight. Already in T1 increased appetite was reported by the majority of those
who used iniximab, increasing from 33.3% to 66.7% between T0 and T1. Was
only possible to observe a statistically signicant weight gain among patients tak-
ing azathioprine, 69.0 6 19.5 kg and 70.2 6 19.4 kg at T0 and T1, respectively (P
= 0.03). However, by excluding patients with concomitant use of other drugs, sta-
tistical signicance was not maintained. In evaluating the reserves of adipose tis-
sue and muscle mass, there was no change at T0 and T1 (P > 0.05).
CONCLUSION(S): Thus, the use of medications may be followed by weight gain, even
without a change in appetite, suggesting monitoring of weight gain of patients in-
dependent of drug therapy. We emphasize that the BMI value indicate adequacy of
weight in relation to height is not necessarily correlated with good nutritional status,
because we observed depletion of muscle mass in overweight patients.
P-67
Low Rate of Clostridium Difficile Infection Testing in Patients With Newly Diag-
nosed Inflammatory Bowel Disease and Diarrhea
Anita Krishnarao
1
, Lauren de Leon
2
, Renee Bright
2
, Neal Leleiko
3
, Bruce Sands
4
,
Marjorie Merrick
5
, Nicole Flowers
6
, Samir Shah
2
1
Alpert Medical School of Brown University, Providence, RI, USA,
2
Rhode Island
Hospital, Providence, RI, USA,
3
Rhode Island Hospital/Alpert Medical School of
Brown University, Providence, RI, USA,
4
Mount Sinai School of Medicine, New
York, NY, USA,
5
Crohns & Colitis Foundation of America, New York, NY, USA,
6
Cen-
ters for Disease Control and Prevention, Atlanta, GA, USA
BACKGROUND: Clostridium difcile infection (CDI) has been reported in patients
with inammatory bowel disease (IBD) in the community and during hospitaliza-
tion, and may occur in IBD without exposure to antibiotics. The rate of CDI in
patients with and without IBD has increased over the last decade. CDI is associ-
ated with various adverse outcomes in IBD, including disease relapse, colectomy
(in ulcerative colitis), hospitalization and mortality. Thus, testing for CDI in
patients with diarrhea and IBD is considered standard of care. There is a lack of
data regarding the prevalence of CDI in newly diagnosed IBD, and its effect on
disease course. As a basis for future studies to determine the impact of CDI on
the course of IBD, we sought to determine rate of CDI and CDI testing at diagno-
sis of IBD.
METHODS: Rhode Island patients diagnosed with IBD after January 2008 and
within one year of diagnosis were eligible to enroll in the Ocean State Crohns
and Colitis Area Registry (OSCCAR), a prospective cohort started January 2008.
Medically trained personnel conrmed diagnosis of IBD by chart review using
standard criteria. All patients completed a questionnaire regarding symptoms at
diagnosis. This included self-report of diarrhea (loose or watery bowel move-
ments and/or increased frequency of stool) within 4 weeks before diagnosis of
IBD. Trained data abstractors recorded occurrence of CDI toxin or PCR assay test-
ing and results from medical records of the gastroenterologist and/or surgeon
who reported a new diagnosis, or inpatient records if diagnosed during
hospitalization.
RESULTS: Among 338 patients enrolled from January 2008 to June 2011, 260
(76.9%) reported diarrhea. Of the 260 patients, results of CDI testing were
recorded in diagnosing physicians records for 120 patients (46.2%). CDI testing
was not recorded or possibly not performed for the remaining 140 patients
who presented with diarrhea. An additional 21 patients were tested for CDI but
did not report having diarrhea or did not have a symptom inventory on record.
Of the 141 patients tested for CDI, 74 were female; 65 were diagnosed with ul-
cerative colitis, 65 with Crohns disease, and 11 patients had IBD undetermined.
Seven (4.9%) of the 141 patients tested were positive for CDI (2.1% of all
patients).
CONCLUSION(S): Testing for CDI is lower than expected at diagnosis of IBD espe-
cially among patients who presented with diarrhea. Although the prevalence of CDI
among tested patients is only 5%, low rate of testing and possible delayed diagno-
sis of CDI in newly diagnosed IBD may be a signicant quality issue. A limitation of
the study is that we are unable to determine whether CDI testing was done prior
to specialty referral and thus we may underestimate the rate of CDI testing.
P-68
Exploring the Humanistic and Economic Burden of Crohns Disease: Considera-
tions for Novel Compounds
Helen Kitchen
1
, Louise Heron
1
, Adam Gater
1
, Catherine Pollard
1
, Brian Hansen
2
,
Martin Strandberg-Larsen
3
1
Adelphi Values Ltd, Bollington, Cheshire, UK,
2
Novo Nordisk A/S, Soborg, Den-
mark,
3
Novo Nordisk A/S, Soborg, Denmark
BACKGROUND: Crohns disease (CD), an inammatory bowel disease (IBD),
affects approximately 1.4 million people in the United States (US). With the
increasing focus on patient-centred outcomes, novel CD treatments must dem-
onstrate efcacy and tolerability with added value for patients, carers, health-
care systems and society. Therefore, it is important to focus on patient-reported
outcomes (PRO) such as health-related quality of life (HRQoL) along with the
economic costs when evaluating novel CD treatments. We reviewed the
patient-reported and economic burden of CD and documented, for the rst
time, CD symptoms and impact of symptoms in an all-encompassing conceptual
model. PRO measures currently used to assess these concepts were identied
and critically reviewed.
METHODS: Articles were identied in MEDLINE, EMBASE, EconLit, HEED, CRD data-
bases and PSYCINFO using pre-dened search terms/limits. The literature search
revealed 561 abstracts of which 31 articles met full review criteria. Concepts were
extracted to form a conceptual model and identify patient-relevant concepts that
may be valuable to measure when assessing new treatments. PRO measures
were identied via the PRO and Quality of Life Database (PROQOLID) and were
reviewed according to the US FDA PRO Guidance for industry. Data on direct and
indirect costs of CD were also extracted.
RESULTS: CD symptoms manifest primarily as gastrointestinal disturbances includ-
ing abdominal pain/cramping and diarrhoea. Fever, fatigue and weight loss are
also prominent symptoms. These symptoms impact patients physical functioning,
daily activities, emotional well-being, and ability to work. CD is also associated
with substantial direct costs (e.g. hospitalisations), estimated at $18-$19,000 per-
patient per-year in the US, and indirect costs (e.g. work absenteeism), estimated
at $7,260 per-patient per-year. Costs are especially high in specic sub-groups
(e.g. presence of stulas). Seven disease-specic and generic PRO instruments
and one composite measure were reviewed in-depth; measures of HRQoL (IBDQ,
SF-36 and IBDQOL), occupational functioning (CPWDQ and WPAI-CD) and disease
activity/symptoms (CDAI, CDAI-short and GSRS). The CDAI is the current standard
measure of CD severity and serves as a key indicator of treatment efcacy. While
there is evidence as to the quantitative measurement properties for the CDAI
there are limitations regarding symptom coverage and validity in certain sub-
populations. Instruments to assess HRQoL and occupational functioning used
concurrently with the CDAI may demonstrate the wider inuence of treatment
on other symptoms and patients lives.
CONCLUSION(S): The disease course of CD is characterised by remissions and
relapses, thus the lifetime human and economic burden of CD is substantial. PRO
measures can be important complementary measures to demonstrate the ef-
cacy, tolerability and value of a treatment in clinical trials and clinical practice.
This review highlights the need for disease-specic PRO measures that provide
comprehensive assessment of relevant domains of disease activity/symptoms,
HRQoL and occupational functioning. Qualitative research to identify the salient
symptoms for patients and their effect on HRQoL would be useful to ensure com-
prehensive measurement of patient burden in future clinical trials. Further patient
and cost-of-illness research into the drivers of direct and indirect costs of CD is
necessary in light of increasing requirements for cost-effectiveness data to sup-
port reimbursement.
P-69
Impact of Golimumab SC on Disease Specific and Generic HRQoL in Patients
With Moderately to Severely Active UC: PURSUIT-SC Induction
Brian Feagan
1
, Peter Gibson
2
, Colleen Marano
3
, Richard Strauss
4
, Chenglong Han
5
,
Jewel Johanns
3
, Hongyan Zhang
3
, Cynthia Guzzo
3
6
, Walter
Reinisch
7
, Judith Collins
8
, Gunnar Jarnerot
9
, Paul Rutgeerts
10
, William Sandborn
11
1
2
Alfred Hospital, Melbourne, VIC, Australia,
3
Janssen Research and Development,
LLC, Spring House, PA, USA,
4
Janssen Research and Development. LLC, Spring
House, PA, USA,
5
Janssen Global Services LLC, Malvern, PA, USA,
6
Hopital Huriez,
CHRU, Lille, Nord, France,
7
Universitatsklinik fu r Innere Medizin IV, Wien, N/A, Aus-
tria,
8
Oregon Health Sciences University, Portland, Oregon, USA,
9
Orebro Univer-
sity Hospital, Orebro, N/A, Sweden,
10
University Hospital Gasthuisberg, Leuven,
Belgium,
11
University of California San Diego, La Jolla, CA, USA
BACKGROUND: PURSUITSC was a Phase 2/3 multicenter, randomized, double-
blind, placebo-controlled study to evaluate the safety and efcacy of subcutane-
ous golimumab (GLM) in adults with moderately to severely active ulcerative coli-
tis (UC). To assess the effect of SC administered GLM induction therapy to
improve health related quality of life (HRQOL) in patients with active UC.
METHODS: Patients with moderately to severely active UC dened by a Mayo
score of 6-12 including an endoscopy subscore of _2 with inadequate response
or intolerance to conventional UC therapies but na ve to treatment with TNF
inhibitors were randomized in the Phase 3 portion of PURSUIT SC to receive pla-
cebo or golimumab (GLM) 200 mg, 100 mg or 400 mg, 200 mg at weeks 0 and 2.
Disease specic HRQOL was measured using the Inammatory Bowel Disease
Questionnaire (IBDQ) and generic HRQOL was measured using the 36 item short
form health survey (SF-36) at weeks 0 and 6. IBDQ has 32 items summarized by
one total IBDQ score (32-224) and 4 domain scores with higher score indicating
better HRQOL; SF-36 is summarized by physical and mental component summary
scores (PCS and MCS) and 8 sub-scales (0-100) with higher score indicating better
HRQOL. Clinically meaningful improvements were dened as a change of>20
points in IBDQ score and _5 points in SF-36 PCS and MCS. Correlation of IBDQ
remission (_170) with clinical remission dened as a Mayo score _2 points, with
no individual subscore >1 was analyzed.
RESULTS: At baseline, mean SF-36 PCS and MCS scores were approximately 40,
signicantly below the US norm of 50. Compared to the PBO group, signicantly
greater improvement were observed in the GLM-treated group in IBDQ (27.2 vs.
14.6, P < 0.001), SF-36 PCS (4.14 vs. 2.46, P < 0.01) and MCS (4.89 vs. 1.60, P <
0.001) at week 6. Mean improvements in IBDQ (27.4 and 27.0), PCS (4.51 and
3.78) and MCS score (4.69 and 5.10) were comparable for GLM 200/100 mg and
400/200 mg groups. In cumulative percentage curve, compared to PBO, greater
proportions of patients in each GLM group achieved any improvement to clini-
cally meaningful improvement in IBDQ (51.1% vs. 35.2%, P < 0.001), PCS (41.0%
vs. 31.6%, P = 0.01) and MCS (42.7% vs. 28.5%, P < 0.001) at week 6. The distri-
butions of IBDQ score shifted from a mean of 129.4 6 33.9 at baseline to
156.5639.8 at week 6 in GLM treated patients with 45.2% of patients achieving
IBDQ remission, compared to a mean of 144.2 6 37.1 in PBO group with 28.1%
achieving IBDQ remission (P < 0.001 vs. GLM group). Additionally, greater propor-
tions of patients in each GLM group achieved clinically meaningful improvement
in each of IBDQ dimension scores compared to PBO. IBDQ remission was signi-
cantly associated with clinical remission by Mayo score with an Odds Ratio (95%
CI) of 12.5 (7.2-21.8; P < 0.0001) vs. those without remission in IBDQ.
CONCLUSION(S): SC induction treatment with GLM signicantly improved disease-
specic and generic HRQOL in patients with moderately to severely active UC.
P-70
Sexual Interest and Satisfaction in an Internet Cohort of Patients with Inflam-
matory Bowel Diseases
Michael Kappelman
1
, Christopher Martin
1
, Kevin Weinfurt
2
, Kathryn Flynn
2
, Wenli
Chen
1
, Kristen Anton
1
, Raymond Cross
3
, Millie Long
4
, Robert Sandler
4
1
University of North Carolina, Chapel Hill, NC, USA,
2
Duke University, Durham, NC,
USA,
3
University of Maryland, Baltimore, MD, USA,
4
University of North Carolina at
Chapel Hill, Chapel Hill, NC, USA
BACKGROUND: Although GI and other somatic symptoms, concerns about body
image, medication side effects, and surgical treatments and ostomies may impair
sexual functioning in patients with inammatory bowel diseases (IBD), few stud-
ies have examined this. We sought to evaluate sexual interest and satisfaction in
a large cohort of adult patients with IBD and identify clinical and demographic
factors associated with these patient-reported outcomes.
METHODS: CCFA Partners is an ongoing internet cohort study of over 12,000
patients with IBD. We invited a randomly selected subset of the cohort to com-
plete a six question supplemental survey regarding sexual interest and satisfac-
tion, and whether IBD symptoms or ostomy (if applicable) affected sexual satis-
faction. Measures were developed and validated as part of the NIH Patient
Reported Outcome Measurement Information System (PROMIS) initiative. Demo-
graphic information, self-reported disease indices [Short Crohns Disease Activity
Index (SCDAI), Simple Clinical Colitis Activity Index (SCCAI), and Manitoba Index],
the Short IBD questionnaire (SIBDQ) quality of life index, and additional PROMIS
outcomes were also measured. We used descriptive statistics and bivariate com-
parisons to assess relationships between sexual interest and satisfaction and the
other measures.
RESULTS: A total of 2581 individuals completed the supplemental survey (32%
opted out). Mean age was 42(SD = 14); 71% female. Of 2151 patients who
reported active IBD symptoms, 80% indicated that their symptoms affected their
sexual satisfaction and 33% indicated their symptoms affected their sexual satis-
faction quite a bit or very much . Of 110 patients with an ostomy, equal numbers
reported that their ostomy affected their satisfaction not at all or a little bit ver-
sus quite a bit or very much . On average, males had higher sexual interest and
satisfaction than females (p < 0.001), while there was no difference in sexual in-
terest or satisfaction among those with CD versus UC. Among CD patients, active
perirectal disease was associated with lower levels of sexual interest and satisfac-
tion. Sexual interest and satisfaction were both negatively associated with
increasing disease activity as measured by SCDAI, SCCAI, and Manitoba Index and
positively associated with higher levels of health-related quality of life as meas-
ured by SIBDQ (P < 0.001 for all comparisons). Sexual interest and satisfaction
were both negatively associated with increasing levels of fatigue, anxiety, and
depression.
CONCLUSION(S): IBD patients are willing to respond to questions regarding their
sexual interest and satisfaction, as indicated by the high response rate. IBD, par-
ticularly active disease, is associated with impaired sexual functioning. Only about
half of patients with ostomies indicated that their ostomies affected sexual satis-
faction. Providers should be aware that disease activity can affect sexual function
and satisfaction, and counsel or screen appropriate patients.
P-71
An Update on the CCFA Partners Internet Cohort Study
Michael Kappelman
1
, Robert Sandler
2
, Christopher Martin
1
, Wenli Chen
1
, Kristen
Anton
1
, James Lewis
3
, Millie Long
2
1
2
University of North Carolina
at Chapel Hill, Chapel Hill, NC, USA,
3
University of Pennsylvania, Philadelphia, PA,
USA
BACKGROUND: Most observational studies of inammatory bowel disease (IBD)
rely on administrative data and/or medical records of subjects followed at tertiary
care centers. Yet, many research questions require data captured directly from
the patient such as diet, adherence, quality of life, and other patient-reported
outcomes (PROs). To address this gap, in June 2011 we developed an internet-
based cohort of patients with IBD in collaboration with the Crohns and Colitis
Foundation of America (CCFA). In this abstract, we present the current status of
this project.
METHODS: We established the CCFA Partners cohort of adults with IBD by recruit-
ing through the CCFA email roster and various promotional activities developed
with the assistance of the CCFA marketing department including the foundation
website, social media outlets, newsletters, chapter events, and paid advertising.
Respondents complete a baseline survey that includes questions about disease
history, medication use, disease activity, quality of life and other PROs, and health
behaviors including adherence and prevention. Participants are invited to com-
plete follow-up surveys every 6 months. Quarterly emails are used to inform par-
ticipants about the status of the cohort, and deliver educational messages. Col-
laboration with the IBD scientic community was actively sought through the
development of an open and transparent ancillary studies process.
RESULTS: As of August 26, 2012, 11743 individuals with self-reported IBD have
joined CCFA Partners. The median age was 43 years (IQR 18-91), 8282 (71%) were
female. A total of 7345 (63%) had CD, 4101 (35%) had UC, and 297 (3%) had
indeterminate colitis (IC) / IBD unspecied. Of those with CD, 2769 (38%) were
currently on biologics, 1796 (24%) on thiopurines, and 2559 (35%) on 5-ASA. Of
patients with CD, 92% have used biologic, immunomodulator or corticosteroid
therapy at some point in their illness and 51% have had one or more CD-related
operations. For UC, 661 (16%) were currently on biologics, 808 (20%) on thiopur-
ines, and 2580 (63%) on 5-ASA. Of patients with UC, 88% have used a biologic,
immunomodulator or corticosteroid at some point for their illness, and 16% have
had surgery. A total of 4385 subjects have completed _1 follow-up survey (48%
of eligible participants), 1889 have completed _2 follow-up surveys, and 4385
participants (34%) remain active in the cohort (have completed a follow-up sur-
vey in the last 6 months). We have received a total of 12 ancillary study applica-
tions; 9 have been approved and are underway. Topics include the effects of
sleep, depression, and menstruation on disease activity, an evaluation of health
literacy, and the use of the CCFA Partners cohort to screen and recruit subjects
for independent studies. Two validation studies are ongoing, and a pilot study to
collect DNA from selected members is planned.
CONCLUSION(S): CCFA Partners is a novel, ongoing internet-based prospective
cohort study. As enrollment and long-term follow-up continue to accrue, this
cohort will be a valuable resource for clinical and translational research. Contin-
ued validation studies and efforts to collect and bank biospecimens will add
additional value to this cohort.
P-72
Adherence to Vaccination Program in Inflammatory Bowel Disease
Laura Sempere, Ana Gutierrez, Isabel Almenta, Julio Barrenengoa, Nuria Acame,
Enrique de Madaria, Jose Sanchez-Paya
Hospital General Universitario de Alicante, Alicante, Spain
BACKGROUND: Due to the increase of infections in patients with inammatory
bowel disease (IBD), recently the administration of vaccines has been recom-
mended from various medical societies. Multiple vaccines have been indicated in
these patients. The implementation of vaccination programs involves many medi-
cal visits. There are no studies evaluating the adherence to vaccination programs
in IBD.
METHODS: In our center we have a vaccination program for patients on anti-
TNFa therapy. We conducted an observational retrospective study with prospec-
tive follow up to evaluate the adherence to vaccination program of these
patients. The patients were vaccinated against inuenza, tetanus, diphtheria, hep-
atitis A, hepatitis B, Streptococcus pneumoniae, Neisseria meningitidis serogroup
C and Haemophilus inuenzae type B. The adherence was assessed by two pa-
rameters: the inclusion and the fulllment of the vaccination program. In addi-
tion we evaluated multiple clinical and demographic variables as predictive fac-
tors of non-adherence: sex, age, type of IBD, Montreal classication for IBD, time
evolution of IBD, perianal disease, clinical activity of IBD, previous bowel resec-
tion, extraintestinal manifestations, comorbidity, concomitant treatment, gastroen-
terologist, preventive medicine physician, civil status, offspring, employment sta-
tus and studies.
RESULTS: In the period of the study 115 IBD patients were valid for vaccine pro-
gram. Only 84 (73%) patients attended the rst visit of Preventive Medicine Serv-
ice. Non-inclusion causes reported by patients were: 16 (52%) patients related
that were not referred to Preventive Medicine Service, 5 (16%) inconvenience, 5
(16%) lack of belief in the effect of vaccines, 2 (7%) oversight and 3 (9%) other
causes. By univariate analysis the only predictive factor associated with non-inclu-
sion was the medical follow-up by gastroenterologist non-specialist in IBD care
(40.9% /18.3% p = 0.008). Of the total 84 patients included in vaccination pro-
gram only 65 (77.4%) patients completed de vaccination program. Non-fulllment
causes reported by patients were: 6 (32%) patients related inconvenience, 4
(21%) lack of belief in the effect of vaccines, 4 (21%) oversight, 3 (16%) IBD activ-
ity and 2 (10%) other causes. The univariate analysis did not show predictive fac-
tors associated with non-fulllment. The global adherence to vaccination program
was 56.5%.
CONCLUSION(S): The establishing of vaccination program in our hospital for
patients with IBD on anti-TNFa therapy has had a suboptimal adherence. The gas-
troenterologist attitude was essential for the inclusion but not for the fulllment
of the program.
P-73
Clinical Features Associated With the Use of Immunosuppressive Drugs in
Patients with Ulcerative Colitis in Two Referrals Centers in Salvador-Bahia/
Brazil
Camila Ribeiro
1
, Bruno Silva
2
, Sonyara Lisboa
1
, Mariana Souza
1
, Renata Portela
1
,
Neogelia Almeida
2
, Carla Lima
3
, Genoile Santana
2
1
Bahiana School of Medicine and Public Health, Salvador, Bahia, Brazil,
2
University
Hospital Professor Edgard Santos, Federal University of Bahia, Salvador, Bahia, Bra-
zil,
3
General Hospital Roberto Santos, Salvador, Bahia, Brazil
BACKGROUND: Immunosuppressive drugs are effective on Ulcerative Colitiss (UC)
treatment. Some clinical features are more frequently in patients with indication
for treatment using these medications. We aim to evaluate the association
between the use of Immunosuppressive drugs and clinical features in patients
with UC from the city of Salvador-Bahia/Brazil.
METHODS: Cross-sectional study on two referral center for adult patients diag-
nosed with UC. Interviews were conducted with patients and chart review. Statis-
tical analyses were performed using SPSS 17.0 (Chicago, IL). We used Students t-
test to compare the difference between two means and the chi-square test to
assess the signicance of association and trends between categorical variables.
RESULTS: Among the 197 patients enrolled, 136 (69%) were women. The average
age at diagnosis (6SD) was 39 6 12.9 years (range 11-74). The mean disease du-
ration from diagnosis was 7.5 6 6.3 years (range 0.1 to 34). Immunosuppressive
agent (azathioprine) was used for 38 (19.3%) patients. Mean age, in years, of the
users of azathioprine (32.9 6 11.5) was lower than those who did not use (40.4
6 12.8) this drug during treatment (p < 0.001). There was no statistically signi-
cant difference between illness duration and the use of immunosuppressive drug.
The extent of UC was described in 186 patients, with predominance of left colitis
(45.7%), followed by extensive colitis (36.6%) and proctitis (17.7%). In the group
of subjects using azathioprine, 55.6% had extensive colitis, while left colitis and
proctitis were described, respectively, in 33.3% and 11.1% of patients in this
group (p < 0.05). In relation to the signs and symptoms present at diagnosis of
UC, we found that 18 (9.2%) patients reported weight loss at diagnosis; those,
eight (21.1%) started using azathioprine over time. In turn, the group that did
not complain weight loss (178 patients), only 6.3% needed to use immunosup-
pressive agent (p < 0.05). We found that 84 patients (42.6%) required hospitali-
zation to control UC activity. Of the 38 patients who received azathioprine, the
majority (65.8%) needed to be hospitalized at least once, contrasting with the
lower proportion of subjects who required hospitalization (37.1%) in the other
group that had never made use of immunosuppressive therapy (p < 0.001).
There was also statistically signicant association between use of steroids and
immunosuppressive therapy. Of the 38 patients who underwent treatment with
azathioprine, only 1 (2.6%) started the use of this drug without prior exposure
to steroids (p < 0.001). The proportion of individuals who used steroids and
also requiring the use of immunosuppressive therapy was directly proportional
to the number of times that underwent steroids, since the majority (57%) users
of azathioprine used steroids for at least three different times along UC course,
compared to 43% who required those in no more than two distinct moments
(p < 0.001).
CONCLUSION(S): The younger age, extensive colitis, presence of weight loss, need
of hospitalization to control the disease and use of steroids more than twice are
probably clinical features associated to a more severe UC in this population. In
this group of patient we need to take special attention to optimize the UC
therapy.
P-74
Inward and Outward: The Role of Patient Self-Monitoring and Patient Com-
munities in IBD
Elana Silver, Sylvan Wallenstein, Aaron Levy
Laurelton Research, Oakland, CA, USA
BACKGROUND: IBD is a difcult disease for patients and their doctors, in part
because of its variable manifestations and idiosyncratic response to treatment.
The importance of patients ability to describe their disease state, treatment
response, and life habits is indisputable, but these things can be difcult to
dene and describe to doctors, perhaps in part due to time constraints during
ofce visits. We hypothesize that participating in patient communities and self-
monitoring may help clarify these issues in patients own minds and may thereby
be of some therapeutic value.
METHODS: We distributed an online survey to approximately 430 IBD patients via
an overlapping network of patient communities contacted through Facebook and
group email, beginning with attendees of two CCFA support groups in San Fran-
cisco. We also conducted key informant interviews with six attendees of these
groups. To increase participation, several key informants also distributed the sur-
vey, along with a personal request to participate, to their own network of con-
tacts with IBD. The survey asked about formal tracking (recording symptoms,
diet, or other aspects of IBD using paper-and-pen or an electronic app), mindful
tracking (careful awareness without any writing or keystrokes), attending support
groups, and journaling of feelings.
RESULTS: Interviews with IBD patients who attend a support group indicate that
tracking is perceived as most valuable when directed both inward and outward.
In other words, tracking is seen as a way for patients to embrace an awareness
of their health state and engage with their doctors and the patient community.
76 people responded to the survey, giving a response rate of -18%. This
response rate is not unusual for internet based surveys (1), and may in part
reect that many people never noticed the survey invitation on Facebook or
amid other group email. 68% of participants were female, and ages ranged from
18 to 75. 37% were currently experiencing an IBD are. 51% ever attended a
CCFA support group, and 12% attend these groups regularly. Top reasons for
attending support group meetings are shown in Table 1. 87% of participants had
ever tried formal tracking, and 38% do so regularly. Among those who had ever
tracked, 36% used an app, 26% paper-and-pen, and 20% both. 60% had tracked
for between one month and one year, while 17% had tracked for over a year,
and 21% for less than one month. The areas most commonly tracked were bowel
movement characteristics, medications, and pain (Table 2). Compared to mindful
tracking and journaling of feelings, formal tracking was seen as most useful for
communicating with doctors, but formal and mindful tracking were seen as simi-
larly useful for improving general physical and mental health (Table 3). 70% of
respondents reported feeling that they have all the resources they need (eg.
technical knowledge, emotional support, and/or medical attention) to handle
their IBD.
CONCLUSION(S): The results of this survey and key informant interviews demon-
strate that many patients nd value in formal tracking, mindfulness, and partici-
pating in patient communities. A doctors recommendation to try these methods
may be helpful for patients and doctors.
P-75
Where Have All the IBD Patients Gone? - Attributes/Reasons for Loss of Follow-
up
Birju Shah, Asif Ali, Sowjanya Kanna, Kiran Anna, Kevin Mullen
MetroHealth Medical Center - Case Western Reserve University, Cleveland, OH,
USA
BACKGROUND: An estimated 1.4 million Americans suffer from inammatory
bowel disease (IBD) per the CDC. Not only does this disease affect patients
acutely during a are, but it also has long term implications including a higher
prevalence of colorectal cancer, metabolic and psychological disturbances, and
an impaired quality of life. It is important that these patients follow up regu-
larly with their gastroenterologist to screen for and prevent these long term
complications. Observation at our center has shown that patients have pro-
longed periods where they have not had a clinic visit since the initial diagnosis.
The aim of this study is to determine the reasons for loss of follow-up in this
population.
METHODS: A retrospective chart review was performed of all patients with a di-
agnosis of IBD (Crohns disease and ulcerative colitis) between 1/2000 and 6/2011
at our hospital. Patients were considered lost to follow-up if they had not had a
clinic visit with a gastroenterologist in the past calendar year. Those patients who
met criteria were contacted by phone to assess the reasons for not following up.
RESULTS: 589 patients in our department carried a diagnosis of IBD. Excluding 53
patients who were either deceased or had transferred care to a different provider,
91% (536) of the patients remained and were included in the study. 41% (220
patients) met the criteria for being lost to follow up. Of these, 22% (49) of these
patients were able to be contacted. Table 1 lists the demographics of patients
that were lost to follow-up, and Figure 1 displays the percentage of patients lost
to follow-up within each demographic group. Miscommunication between the
physician and patient was stated as the primary reason that 65% of these
patients had not followed up (table 2).
CONCLUSION(S): This is one of the rst studies to identify the factors that affect
follow-up of IBD patients in a community based inner city hospital, and it high-
lights demographics of patients for which to focus resources to encourage fol-
low-up. Our study indicates that younger patients and Caucasians were least
likely to be lost to follow-up. The overwhelming reason given by the vast major-
ity of patients for not following up was miscommunication. This implies the need
for better interaction between the clinician and patient. A dedicated community
outreach team may help in forming a bridge between the physician and patient
in order to promote a closer relationship, effective communication, and ultimately
better patient care.
P-76
Pediatric and Adult Patients Had a Similar Pouch Survival Rate After Restorative
Proctocolectomy
Xianrui Wu, Saurabh Mukewar, Ravi Kiran, Feza Remzi, Bo Shen
Cleveland Clinic, Cleveland, OH, USA
BACKGROUND: There were limited data in the literature on the long-term pouch
outcomes in children who underwent restorative proctocolectomy with ileal
pouch-anal anastomosis (IPAA). The aim of this study was to compare long-term
pouch outcomes in pediatric and adult patients.
METHODS: Consecutive inammatory bowel disease (IBD) patients with ileal
pouches seen in our Pouchitis Clinic from 2002-2012 were studied. The pouch
outcome in pediatric patients was evaluated in comparison with adults by both
univariate and multivariate analyses.
RESULTS: All eligible patients were included into the study (N = 1,289), of whom
108 (8.4%) were pediatric patients (<18 years). Male accounted for 50.9% of pedi-
atric patients and 55.5% of adults. Pediatric patients had a younger age at the
time of IBD diagnosis and pouch construction and a shorter duration from IBD di-
agnosis to colectomy. Fewer pediatric patients had a history of smoking (9.3% vs.
20.7%, P = 0.004), concomitant extra-intestinal manifestations (21.5% vs. 39.1%, P
< 0.001), and dysplasia as the indication for colectomy (0.9% vs. 13.6%, P <
0.001) than the adults. On the other hand, pediatric patients had higher rates of
pouch surgery-associated complications (21.3% vs. 13.9%, P = 0.036),
Figure 1.
postoperative pouch-associated hospitalization (25.9% vs. 13.4%, P < 0.001) and
postoperative use of anti-TNF biologics (16.7% vs. 7.9%, P = 0.002) than the
adults. Pouch failed in 100 patients (7.8%) after a mean follow-up of 10.666.8
years, including 13(12.0%) in the pediatric group and 87 (7.4%) in the adult group
(P = 0.082). Risk factors for pouch failure in the multivariate analysis included pre-
operative use of anti-TNF biologics, postoperative use of anti-TNF biologics,
Crohns disease of pouch, pouch surgery-related complications and postoperative
pouch-associated hospitalization. However, pediatric patients were not found to
be signicantly associated with pouch failure in neither the univariate nor multi-
variate analyses, with a hazard ratio of 0.67 (95% condence interval: 0.36-1.24, P
= 0.2) from the multivariate analysis.
CONCLUSION(S): Pediatric patients suffered from a higher incidence of postopera-
tive pouch complications than adults; however the long-term pouch retention
rates were comparable.
P-77
Family History of Inflammatory Bowel Disease Among Patients with Ulcerative
Colitis: A Systematic Review and Meta-Analysis
Ryan Childers
1
, Swathi Eluri
2
, Rayna Matsuno
3
, Theodore Bayless
4
, Susan
Hutfless
4
1
Johns Hopkins Bayview Medical Center, Baltimore, MD, USA,
2
Johns Hopkins Hos-
pital, Baltimore, MD, USA,
3
Johns Hopkins School of Public Health, Baltimore, MD,
USA,
4
Johns Hopkins University School of Medicine, Baltimore, MD, USA
BACKGROUND: Ulcerative colitis (UC) is the most prevalent form of inammatory
bowel disease (IBD). Though the inuence of family history on disease course
among patients with Crohns disease (CD) is well-documented, less is known about
the role of family history on UC presentation and progression. We aimed to under-
stand the prevalence of family history in UC and its effects on age of disease pre-
sentation, concordance, need for surgery, disease location, and presence of extrain-
testinal manifestations by conducting a systematic review and meta-analysis.
METHODS: MEDLINE was searched for studies that reported the prevalence of
family history of IBD among UC patients. Data on degree of family history (rst
degree, second degree, or distant relative), study type (cohort, case-control, and
cross-sectional), and secondary outcomes (age at diagnosis, concordance of dis-
ease type [UC, CD, or indeterminate colitis], concordance of disease site [proctitis,
left-sided or pancolitis], need for surgery, and extra-intestinal manifestations were
abstracted. Pooled prevalence estimates were calculated by tting random effects
Figure 1.
models for overall prevalence of family history, type of family history, age at diag-
nosis, need for surgery, and presence of extraintestinal manifestations. When an
insufcient number of studies reported on an outcome, we described the nd-
ings qualitatively.
RESULTS: 72 studies representing 95,607 patients met the inclusion criteria and
were included in the qualitative and quantitative analyses. The overall prevalence
of a family history of IBD in UC patients was 12% (95% condence interval [CI] 11
to 13%). Family history of UC (9%) was more prevalent than CD (2%). UC patients
who were younger (age 18 or less) at time of diagnosis were more likely to have
a family history of IBD (prevalence 15%, 95% CI: 11-20%) than older patients
(prevalence 11%; 95% CI: 9-13%). There was insufcient data to perform meta-
analyses or identify trends in the other secondary outcomes, including concord-
ance of degree of family history, need for surgery, disease location, extraintestinal
manifestations.
CONCLUSION(S): 12% of UC patients have a family history of IBD. Family history is
greater among pediatric-onset patients. Family history among pediatric UC is
15%. UC patients are more likely to have a family history of UC compared with
CD. Further research examining the relationship between family history and dis-
ease course may help clarify pathophysiologic mechanisms of IBD.
P-78
Prevalence and Risk Factors of Vitamin D Deficiency in Patients with Inflamma-
tory Bowel Disease
Ankit Patel, Diane Kamen, Lawrence Comerford
Medical University of South Carolina, Charleston, South Carolina, USA
BACKGROUND: Vitamin D deciency is a common occurrence in patients suffering
from inammatory bowel disease (IBD). Although vitamin D has long been known
to be essential for bone health and mineralization, recent studies have proposed
that vitamin D plays an anti-inammatory role and may play a part in the pathoge-
nesis of Crohns disease and ulcerative colitis. The aim of our study was to look at
the prevalence of vitamin D deciency in patients with IBD at our Center and deter-
mine if there are any predictors that strongly correlate with vitamin deciency.
METHODS: Using the Enterprise Data Warehouse at MUSC, de-identied data on
490 patients 18 years or older, since 2006, who had a diagnosis code of either re-
gional enteritis (Crohns) or ulcerative colitis unspecied AND a total 25-hydroxy-
vitamin D (25D) lab value were studied. The season (summer, winter, spring, fall)
that the initial 25D lab was drawn was used, in addition to age, sex, and race.
Because all information was de-identied, IRB approval was not needed. Stata v11
was used to perform t-tests comparing mean 25D levels and logistic regression
models comparing decient to sufcient patients, with p-values of <0.05 consid-
ered signicant.
RESULTS: Of the 490 patients, 19.8% were African American and 78.0% Caucasian.
67.0% had a diagnosis code of Crohns, 19.8% with ulcerative colitis, plus 13.2%
who had both codes listed. 25D was signicantly lower in African Americans (n =
97, mean = 20.4 /- 12.9 ng/mL) than Caucasians (n = 382, mean = 32.0 /-
12.8 ng/mL, P < 0.01). Those with a diagnostic code of Crohns also had signi-
cantly lower 25D levels (n = 330, mean = 28.3 /- 13.8 ng/mL) than ulcerative
colitis (n = 97, mean = 31.9 /- 13.7 ng/mL, P = 0.02). Those with 25D levels in
the summer had a mean value of 30.5 /- 13.7 ng/mL & winter 27.4 /- 12.1.
Using a cutoff value of 30 ng/mL for 25D, logistical regression analysis showed
that race, diagnostic code of Crohns, and season are all signicant predictors for
25D deciency. Furthermore, with a lower cutoff of 20 ng/mL, analysis shows that
race and diagnostic code are signicant predictors.
CONCLUSION(S): Vitamin D deciency is highly prevalent among IBD patients.
Race, season and type of IBD are signicant predictors of vitamin D insufciency
(25D <30 ng/mL), with African Americans with Crohns being at the highest risk.
This exploratory analysis utilizing the MUSC Clinical Data Warehouse provides
support for pursuing a prospective study investigating the role of vitamin D de-
ciency in IBD.
P-79
YI
A Retrospective Comparative Study of Tacrolimus and Infliximab in Steroid-Re-
fractory Ulcerative Colitis
Shinta Mizuno, Katsuyoshi Matsuoka, Nagamu Inoue, Makoto Naganuma, Tada-
kazu Hisamatsu, Tomoharu Yajima, Takanori Kanai, Haruhiko Ogata, Yasushi Iwao,
Toshifumi Hibi
Keio University School of Medicine, Shinjuku, Tokyo, Japan
BACKGROUND: Iniximab (IFX) and tacrolimus (Tac) were recently approved for
use in refractory ulcerative colitis (UC) in Japan. There was, however, no consen-
sus on which drug to use for steroid-refractory UC. To clarify the positioning of
each drug in the treatment of steroid-refractory UC, we retrospectively compared
the therapeutic effect of IFX and Tac and also evaluated the therapeutic effect of
switching between IFX and Tac.
METHODS: A total of 76 UC patients treated with either IFX or Tac between July,
2009 and November, 2011 in our institute were retrospectively analyzed. We
assessed disease activity at 3 months after starting treatment using Lichtiger
index. A score of Lichtiger index less than or equal to 4 was dened as clinical
remission. Colonoscopy was conducted at 3-6 months after starting treatment.
Mucosal healing was dened as Mayo endoscopic score 0 or 1.
RESULTS: IFX and Tac were administered as a rst-line therapy to 33 and 43 ste-
roid-refractory patients, respectively. The average Lichtiger index of 43 patients
who received Tac was 11.8, and that of 33 patients who received IFX was 8.8,
showing that Tac was used for more severe cases than IFX in our institute.
Twenty-two cases (51.2%) out of the 43 Tac treated cases achieved clinical remis-
sion at 3 months, while 15 cases (45.5%) out of 33 IFX treated cases achieved
clinical remission. The rates of mucosal healing were 41.9% and 33.3% in Tac and
IFX treated patients, respectively. Thus, there was no signicant difference on the
clinical efcacy of Tac and IFX as a rst-line treatment. We next analyzed clinical
efcacy stratied by disease severity. In patients with severe disease who had a
score of Lichtiger index of 11 or more, the clinical remission rates were 48.0%
and 33.3% in Tac and IFX groups, respectively, suggesting that Tac tends to have
a superior efcacy in severe cases compared with IFX, although the difference
was not statistically signicant. There is no signicant difference between two
groups in 1 year event-free survival. We next analyzed 6 cases who received Tac
after failed IFX (IFX-Tac) and 15 cases who received IFX after failed Tac (Tac-IFX).
Only 1 case (16.7%) out of the 6 cases in the IFX-Tac group achieved clinical
remission. Six cases (40.0%) out of the 15 cases in the IFX-Tac group achieved
clinical remission. These ndings suggest that the clinical efcacy of IFX and Tac
is inferior when used as salvage therapy compared with these drugs used as a
rst-line treatment.
CONCLUSION(S): IFX and Tac are effective therapy in treating steroid-refrac-
tory UC. We could not identify difference on the clinical efcacy between the
two agents, although Tac tends to be more effective than IFX in severe
cases. Cases who did not respond to a rst-line therapy responded less to a
second-line treatment. Switching therapy must be considered carefully,
because it does not have a satisfactory efcacy and may cause serious
adverse effects.
P-80
YI
Effect of Antineutrophil Cytoplasmic Antibodies on the Risk of Acute and
Chronic Pouchitis: A Systematic Review and Meta-Analysis
Siddharth Singh
1
, Piyush Sharma
2
, Edward Loftus
1
, Darrell Pardi
1
1
Mayo Clinic, Rochester, MN, USA,
2
All India Institute of Medical Sciences, New
Delhi, New Delhi, India
BACKGROUND: Acute and chronic pouchitis are frequent complications after ileal
pouch-anal anastomosis (IPAA) surgery for ulcerative colitis (UC). Serological
markers such as antineutrophil cytoplasmic antibodies (ANCA) and anti-Saccharo-
myces cerevisiae antibodies (ASCA) have been associated with risk of developing
pouchitis after IPAA, although results have been variable. We performed a system-
atic review and meta-analysis of studies evaluating the association between
ANCA or ASCA and subsequent risk of development of acute and chronic pouchi-
tis after IPAA for adult patients with UC.
METHODS: We conducted a systematic search of Medline, Embase and Web of
Science (from inception up to July 2012), and manually reviewed the bibliogra-
phies of relevant articles. Studies were included if they (1) evaluated and clearly
dened ANCA and/or ASCA status, (2) reported acute and chronic pouchitis inci-
dence after IPAA in adult patients with UC, and (3) reported relative risks (RR) or
odds ratio (OR) or provided data for their estimation. Acute pouchitis was dened
as single or intermittent episodes of antibiotic-responsive pouchitis, and chronic
pouchitis was dened based on antibiotic-dependent or antibiotic-refractory pou-
chitis. Summary OR estimates with 95% condence intervals (CIs) were calculated
using the random-effects model. Statistical heterogeneity was calculated using
the Cochrans Q statistic and I
2
value.
RESULTS: Results: Eight studies reporting 184 cases of acute pouchitis in 669
adults and 6 studies reporting 151 cases of chronic pouchitis in 891 adults who
underwent IPAA for UC were included in the analysis. Neither ANCA positivity (n
= 8 studies; OR, 1.54; 95% CI 0.79-3.02; P = 0.21), nor ASCA positivity (n = 2
studies; OR, 1.28; 95% CI, 0.25-6.54; P = 0.77) were associated with increased risk of
acute pouchitis after IPAA, and there was some heterogeneity across studies
(Cochrans Q P = 0.02, I
2
= 60; Cochrans Q P = 0.08, I
2
= 68, respectively). On the
other hand, ANCA-positive patients were more likely than ANCA-negative patients
with UC to develop chronic antibiotic-dependent or antibiotic-refractory pouchitis
after IPAA (n = 6 studies; OR, 1.76; 95% CI, 1.19-2.61; P = 0.005). The results were
consistent across all studies (Cochrans Q P = 0.43, I
2
= 0). This association was
stronger at high ANCA titers (n = 3 studies; OR, 3.60; 95% CI 1.47-8.82; P = 0.005)
as compared to low ANCA titers (n = 3 studies; OR, 2.54; 95% CI, 1.02-6.37; P =
0.046). There was no relation between ASCA positivity and risk of chronic pouchitis
(n = 3; OR, 0.89; 95% CI 0.49-1.59; P = 0.68). There was no evidence of publication
bias.
CONCLUSION(S): ANCA-positive adults are more likely than ANCA-negative
patients to develop chronic, antibiotic-dependent or antibiotic-refractory pouchi-
tis after IPAA for UC, especially with higher titers. ASCA status was not associated
with the risk of chronic pouchitis. The risk of developing acute antibiotic-respon-
sive pouchitis is not associated with ANCA or ASCA status. This information may
be used to counsel UC patients regarding their risk of pouchitis after IPAA.
P-81
YI
The Utility of a Thiopurine Monitoring Program to Detect Adverse Reactions in
Inflammatory Bowel Disease Patients
Steven Armbruster, Helen Copsey, Corinne Maydonovitch, Ganesh Veerappan
BACKGROUND: Thiopurines, Azathioprine (AZA) and 6-mercaptopurine (6MP), are
common therapies for inammatory bowel disease (IBD) patients. These drugs,
with complex metabolic pathways, have signicant adverse reactions including
leukopenia, hepatitis and infectious complications. Due to these reactions, it is
recommended that routine labs be obtained during induction and maintenance
thiopurine treatment. Unfortunately, poor adherence to these lab draw require-
ments may lead to a delay in identifying complications. Our IBD clinic imple-
mented a thiopurine monitoring program (TMP) on July 1st 2011 in an attempt
to increase lab compliance. The aim of this study was to compare lab draw com-
pliance and complication rates in patients enrolled in thiopurine monitoring pro-
gram (TMP) vs. patients not enrolled (TMP-).
METHODS: All patients who received thiopurines from our pharmacy from July
1st 2011 to July 1st 2012 were identied (N = 192). All pediatric and non-IBD
patients were excluded (N = 62). From the list of adult IBD patients on thiopur-
ines, we constructed and compared two cohorts of patients (TMP, TMP-). As
part of the program, TMP patients were contacted by medical staff at time of
recommended lab draws. Dedicated IBD staff interpreted labs and intervened
upon abnormal results. Induction compliance was dened as at least 4 out of 5
expected lab draws (at 2, 4, 6, 8, 12 weeks) in the rst 3 months of therapy. Main-
tenance compliance was dened as at least 3 out of 4 expected lab draws (every
3 months per year). Complications were dened as leukopenia, hepatitis, pancrea-
titis, GI intolerance, infection/fever, rash, and arthralgias. Patient demographics
and clinical data were extracted using our centers electronic medical record.
RESULTS: 130 patients were identied for analysis (63 patients TMP and 67
patients TMP-). There was no signicant difference in demographics, type of IBD
(UC, CD) or phenotype of IBD (Montreal classication) between the 2 groups. A sig-
nicantly greater percentage of TMP patients were compliant with lab draws
compared to the TMP- patients (79% vs. 49%, P = 0.000). Specically, TMP
patients were more compliant than TMP- patients with lab draws during induction
(74% vs. 30%, P = 0.001) compared to maintenance monitoring (88% vs. 65%, P =
0.074). However, there was no difference in overall rates of adverse reactions
between TMP and TMP- patients (43% vs. 33%, P = 0.197). Specically, TMP and
TMP- patients had similar rates of leukopenia (19% vs. 13%, P = 0.477) and hepati-
tis (19% vs. 21%, P = 0.829), but more non-laboratory related adverse reactions
were noted in TMP patients compared to TMP- patients (11% vs. 2%, P = 0.029).
CONCLUSION(S): Our study suggests that while a thiopurine monitoring program
increased lab draw compliance, it did not signicantly impact complication rates. This
nding suggests either the recommended lab intervals are unnecessarily rigorous, or
more likely that our study is underpowered to show a true difference between the
groups. Interestingly, this program increased the detection of non-laboratory related
adverse reactions, which may be attributed to increased contact with routine outreach
to these patients. We hope to continue this program and hypothesize that with more
patients enrolled, the true impact of this program will be seen.
P-82
Investigation Into Depression and Anxiety With Relative Risk Facts in Patients
With Inflammatory Bowel Disease
Chen Li, Jianxin Wu, Wensong Ge, Yingwei Chen, Huiping Xia, Jiangao Fan
Shanghai Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of
Medicine, Shanghai, Yangpu
BACKGROUND: Inammatory bowel disease (IBD) is a lifelong illness and has
great negative impact on quality of life and physical and mental health of the
patient. Although studies have investigated Health-related Quality of Life (HRQOL)
in IBD, rarely have reports on psychic and psychological status of patients with
IBD been published in English or Chinese. We investigated the status of depres-
sion and anxiety in IBD patients for better clinical care.
METHODS: Fifty-two patients with IBD precisely diagnosed with repeated endoscopy,
pathology and consultation were recruited according to the current consensuses
and criteria. Questionnaires comprising survey index of Zung Self-rating Depression
Scale (SDS) and Hamilton Anxiety Scale (HAMA) were distributed for cohort study fo-
cusing on depression and anxiety-related mental state with paired control group.
Data were collected, analyzed and evaluated with software SPSS 19.0, and binomial
logistic regression was employed for analysis of predisposing factors.
RESULTS: Scores of SDS and HAMA in IBD group were signicantly higher than
those in control group (P < 0.01) but no signicant difference was demonstrated
between CD and UC group. Binomial logistic regression showed that gender, age,
marital status, annual family income, disease course and activity (active or remis-
sion) had no statistically signicant correlation with SDS or HAMA while scores of
SDS were apt to increase among those female or elder cases with longer disease
course and higher disease activity index in comparison with their partners. How-
ever, patients with higher annual family income demonstrated trends towards
lower scores of SDS. And higher scores of HAMA were found in similar trends in
those with the same factors excluding elder age as that of SDS in younger cases
together with lower income.
CONCLUSION(S): Both the depression and anxiety scores were signicantly higher
in IBD patients than in control group. Psychic and psychological care after assess-
ment must be emphasized on clinical management in spite that scores of SDS or
HAMA may still below the range of the diagnostic criteria in those with symp-
toms of anxiety or depression.
P-83
The Use of a Montelukast Prophylaxis Protocol for Patients Experiencing
Infliximab Reactions
Robert Dracker
Infusacare Medical Services, Liverpool, New York, USA
BACKGROUND: The use of iniximab in patients with inammatory bowel disease
has been an important therapeutic modality which has reduced the inherent
morbidity and mortality of those aficted. The development of an immediate
Remicade reaction which is characteristic of this therapy in some patients has
Figure 1.
Figure 2.
resulted in the use of a variety of preventative medications such as antihist-
amines and glucocorticoids, an interruption or cessation of therapy and a delay
or change in its use. The routine use of prophylactic therapy is common at many
sites despite the fact that these reactions occur in less than 20 percent of
patients. However the typical immediate reaction, characterized by facial and
chest ushing/anxiety/ shortness of breath, chest tightness, bronchospasm/pruri-
tus and low grade fever is unpredictable in occurrence and may be severe. The
routine use of sedating antihistamines and large doses of glucocorticoids to
avoid this reaction is associated with inherent side effects such as signicant
sedation, chronic exposure to steroid therapy, related costs, extension of infusion
time and additional costs. These concerns are signicant particularly when the
use of these medications may be ineffective in many instances. The signs and
symptoms of the immediate-type Remicade reaction are unique to this medica-
tion and is suggestive of leukotriene pathway activation.
METHODS: In consideration of the possible role of leukotrienes as biologic media-
tors, a protocol was developed utilizing montelukast, a selective leukotriene recep-
tor (CysLT1) antagonist, for those patients who have demonstrated typical Remi-
cade reactions. Thirty seven patients received montelukast, 10 mg on a daily basis
for 7 days prior to each infusion and also received a dose immediately prior to the
start of the infusion. Prior to montelukast use, fteen of these patients had previ-
ously been pre-treated with diphenhydramine and methylprednisolone as
requested by their referring physician and still developed a typical reaction.
RESULTS: To date, none of these treated patients have developed a subsequent
reaction utilizing this montelukast protocol. These patients have required no other
reaction-specic therapy either for prophylaxis or treatment during their infusion
CONCLUSION(S): This therapeutic approach had resulted in a signicant reduced
cost, avoidance of alternative therapy side effects, the maintenance of scheduled
patient infusion periods and the ability to maintain the continued effective use of
iniximab. Currently, the role of specic leukotriene molecules and activation cas-
cade is being evaluated.
P-84
High Definition Technology can Enhance Adenoma Detection in Inflammatory
Bowel Disease Patients
Jason Reich, Nisha Varadarajan, Pia Prakash, Marie Borum
BACKGROUND: Patients with inammatory bowel disease (IBD) have increased
risk for the development of colorectal carcinoma. In previous studies, 3.6% of
patients were reported to have adenomas detected on surveillance colonoscop-
ies. It has also been reported that high denition (HD) colonoscopes have
improved targeted detection of dysplastic lesions in IBD. This study evaluated the
detection of colitis-associated dysplasia and adenomas using HD colonoscopes.
METHODS: Medical records of consecutive patients seen in an IBD program at a
university gastroenterology practice were evaluated. Patient age, gender, race,
disease type (UC, CD), date of diagnostic colonoscopy and subsequent surveil-
lance colonoscopies were obtained. Colitis-associated dysplasia and adenomas
detected prior to and following the initiation of HD technology were docu-
mented. Patients were excluded if they were lost to follow-up, underwent total
colectomy with ileostomy and those transferring care to the practice without pre-
vious medical records. A database, maintaining patient condentiality, was cre-
ated using Microsoft Excel. Statistical analysis was performed using Fisher Exact
test and t-test with signicance set at P < 0.05.
RESULTS: Medical records of 303 patients (179 females, 124 males) with IBD (130
UC, 173 CD) were evaluated. There were 170 white, 80 African-American and 53 of
other or undocumented ethnicity. The mean age was 40 years. 31 patients (10%)
had adenomas (23 UC, 8 CD). There was a signicant difference (P = 0.004) in the
rate of which adenomas were detected in patients with UC compared to CD. Addi-
tionally, there was a signicant difference (P = 0.0001) in the rate at which adeno-
mas were detected prior to HD technology (5.2%) and following HD technology
(15.2%). There was no signicant difference in the prevalence of adenomas based
upon gender (P = 0.18), race (P = 0.84), or age (P = 0.29). Five (1.6%) patients had
colitis-associated dysplasia (2UC, 3CD). 0 patients had dysplasia detected prior to
HD technology and 5 patients were identied to have dysplasia detected following
the introduction of HD technology (P = 0.06). There was no signicant difference
in prevalence of colitis-associated dysplasia based upon gender (P = 0.164), race
(P = 0.39), age (P = 0.78) or disease type (P = 1.000)
CONCLUSION(S): High denition colonoscopes have been reported to increase
detection of dysplastic lesions in patients with IBD. While the sample size was
too small to analyze the impact of HD on colitis-associated dysplasia, the
detection of dysplasia following introduction of HD colonoscopes approached
signicance. However, this investigation revealed that there was a signicant
increase in the detection of adenomas in IBD patients using HD technology.
While other potential factors, (i.e. pre-procedure cleansing, disease severity and
skill of the endoscopist) can inuence adenoma detection, recognition of the
potential impact of HD technology is important. Physicians should utilize HD
technology as much as possible when evaluating IBD patients to ensure opti-
mum care.
P-85
Individuals With Ulcerative Colitis May Have More Adenomas Than Individuals
With Crohns Colitis
BACKGROUND: Individuals with Ulcerative Colitis (UC) and Crohns disease (CD)
have an increased risk for the development of colorectal cancer after 8 years of
disease duration. Additionally, there is an increased incidence of adenomatous
polyps in individuals after the age of 50 years. In patients with inammatory
bowel disease, it is important to distinguish colitis-associated dysplasia from ade-
nomatous polyps occurring with quiescent colitis. It has been previously esti-
mated that 9.5% of individuals with UC have adenomas. This study evaluated the
detection of adenomas during surveillance colonoscopies in patients with ulcera-
tive colitis and Crohns disease.
METHODS: Medical records of consecutive patients seen in an IBD program at a uni-
versity gastroenterology practice were evaluated. Patient age, gender, race, disease
type (Ulcerative Colitis, Crohns disease), date of diagnostic colonoscopy and subse-
quent surveillance colonoscopy were obtained. Patients were excluded if they were
lost to follow-up or underwent total colectomy with ileostomy. A database, main-
taining patient condentiality was created using Microsoft Excel. Statistical analysis
was performed using Fisher Exact test and t-test with signicance set at P < 0.05.
RESULTS: Medical records of 303 patients (179 females, 124 males) with IBD (130
UC, 173 CD) were evaluated. There were 170 white, 80 African-American and 53
of other or undocumented ethnicity. The mean age was 40 years. Twenty-three
(18.3%) of UC patients and 7 (4.2%) of Crohns patients had adenomas. There was
a statistically signicant difference (P = 0.004) in the rate at which adenomas were
detected in patients with UC and Crohns disease. There was no signicant differ-
ence in the rate of adenoma detection in UC females and males (P = 1.000). There
was a signicant difference (P = 0.0015) in the rate of adenoma detection in Crohns
disease females (7 of 7) and males (0 of 7). There was no signicant difference in the
rate of adenoma detection based upon age (P = 0.88) or ethnicity P = (0.83).
CONCLUSION(S): Inammatory bowel disease patients are at increased risk for the
development of colorectal cancer based upon colitis-associated dysplasia, as well
as, adenomas developing in quiescent colitis. It has previously been documented
that patients with ulcerative colitis have a similar rate of adenoma development as
individuals without inammatory bowel disease. In this study, UC patients had sig-
nicantly more adenomas than Crohns patients. In addition, UC patients had sig-
nicantly more (P = 0.022) adenomas detected than in the reported prevalence in
the general population. While this study is limited due to sample size and retro-
spective design, the greater than expected prevalence of adenomas in individuals
with ulcerative colitis is of interest. Further investigation is necessary to gain a
broader understanding of adenoma development in inammatory bowel disease.
P-86
Gastroenterologists Inconsistently Assess for and Advise Against Tobacco use
in Patients With Inflammatory Bowel Disease
Pia Prakash, Nisha Varadarajan, Jason Reich, Marie Borum
BACKGROUND: Tobacco use can inuence the expression of inammatory bowel
disease (IBD). It has been reported that smoking decreases ulcerative colitis exac-
erbations and increases symptoms in individuals with Crohns disease. While
improvement in ulcerative colitis expression can occur with tobacco use, the
overall negative health effects of tobacco warrant smoking cessation counseling.
This study evaluated the rate at which gastroenterologists assessed tobacco use
and counseled against smoking in IBD patients.
METHODS: Medical records of consecutive patients seen in an IBD program at a
university gastroenterology practice were evaluated. Patient age, gender, race,
disease type (ulcerative colitis, Crohns disease), tobacco use and smoking cessa-
tion counseling were obtained. A database, maintaining patient condentiality,
was created using Microsoft Excel. Statistical analysis was performed using Fisher
Exact test and t-test, with signicance set at P < 0.05.
RESULTS: Medical records of 343 IBD patients were evaluated. 22 (6.4%) were
smokers, 20 (5.8%) were former smokers and 272 (79%) were non-smokers. 29
(8.4%) had no documented smoking status. Of the 22 smokers, 15 patients had
Crohns disease and 7 had ulcerative colitis. 12 of the 22 (54%) smokers were
counseled against smoking while 10 (46%) had no documented smoking cessa-
tion counseling. Two ulcerative colitis patients were counseled to continue smok-
ing to control their symptoms and 1 former smoker was counseled to consider
resuming tobacco use if his symptoms were not controlled with aminosalicylates.
CONCLUSION(S): While smoking has been reported to be associated with
decreased symptoms in ulcerative colitis patients, tobacco use has signicant del-
eterious health effects. All IBD patients should be assessed for tobacco use and
counseled against smoking. However, this study revealed that gastroenterologists
inconsistently evaluated IBD patients for smoking. Additionally, in the patients
who smoked, only half were counseled to stop. Notably, 10% of the ulcerative
colitis patients who smoked or previously smoked were advised to consider con-
tinuing tobacco use to control their symptoms. While this study is limited due to
sample size and retrospective design with reliance on documentation, it provides
a foundation for further research into the complexities of tobacco use and IBD. It
is important that a tobacco history be obtained from all patients, that patients
are advised of the hazards of smoking, and that tobacco not be considered a
therapeutic option in IBD management.
P-87
Gastroenterologists May Not Consistently Perform Surveillance Colonoscopies
at Recommended Intervals in Individuals With Crohns Colitis
Nisha Varadarajan, Jason Reich, Pia Prakash, Marie Borum
BACKGROUND: Individuals with ulcerative colitis (UC) and Crohns colitis are at an
increased risk for the development of colorectal cancer. It is recommended that
screening colonoscopies begin 8 years following diagnosis and every 1-2 years
thereafter. It has been speculated that individuals with Crohns colitis may not be
as consistently evaluated by colonoscopy with biopsies as individuals with ulcera-
tive colitis. This study evaluated the frequency at which individuals diagnosed
with Crohns colitis undergo surveillance colonoscopies compared to those with
ulcerative colitis.
METHODS: Medical records of patients seen at an Inammatory Bowel Disease
(IBD) program at a university medical center were evaluated. All IBD patients
were included. Patients were excluded if their diagnosis was less than 8 years
prior or had a total colectomy with ileostomy. Patient age, gender, ethnicity, dis-
ease type (Crohns colitis or ulcerative colitis), date of diagnosis, and timing of
subsequent surveillance colonoscopies were recorded. A database maintaining
patient condentiality was created using Microsoft Excel. Statistical analysis was
performed using an unpaired t-test with signicance set at p < 0.05.
RESULTS: 56 individuals (27 women, 29 men) with IBD (32 Crohns colitis, 24 UC)
were evaluated in this study with an average age of 42.5 years. There were 34
white, 18 African American, and 4 of other or undocumented ethnicity. The aver-
age time interval between surveillance colonoscopies was 3.14 years. 37 (66.1%)
IBD patients had surveillance colonoscopies with a frequency greater than 2
years. There was a signicant difference (P = 0.0108) in the frequency of surveil-
lance colonoscopies in Crohns colitis patients (3.66 years) compared to those
with ulcerative colitis (2.46 years). There was no signicant difference between
the frequency of surveillance colonoscopies based upon gender (P = 0.6465), age
(P = 0.2671), and ethnicity (P = 0.5886).
CONCLUSION(S): There is an increased risk of colorectal cancer development in
individuals with ulcerative colitis and Crohns colitis. While guidelines for the fre-
quency of surveillance have been published, inconsistency in surveillance colonos-
copies may occur. This study revealed that the time interval between surveillance
was longer than recommended in patients with Crohns colitis. It is important that
gastroenterologists encourage all individuals with IBD to undergo surveillance
colonoscopies at recommended intervals to optimize clinical outcome.
P-88
Are Inflammatory Bowel Disease Patients Undergoing Surveillance Colonoscop-
ies at the Recommended Time?
Nisha Varadarajan, Jason Reich, Pia Prakash, Marie Borum
BACKGROUND: Individuals with inammatory bowel disease (IBD), both ulcerative
colitis (UC) and Crohns colitis, are at an increased risk for colorectal cancer (CRC).
Since the risk of CRC increases with the duration of disease, it is recommended
that surveillance colonoscopies begin 8 years following diagnosis. Multiple factors
may prevent patients from receiving a surveillance colonoscopy within the rec-
ommended time frame. This study investigated the impact of patient demo-
graphics, insurance type, frequency of care, and transfer of care into the practice
upon the timing of surveillance colonoscopy.
METHODS: All medical records of patients seen in an IBD program at a university
medical center were reviewed. Patient age, gender, ethnicity, disease type (UC or
Crohns colitis), date of diagnosis, and timing of surveillance colonoscopies were
obtained. Furthermore, type of insurance, frequency of follow-up, and whether
the patient had transferred care into the practice were recorded. Exclusion criteria
included patients diagnosed within 8 years, those lost to follow-up, patients who
underwent total colectomy with ileostomy, and those transferring care without
previous medical records. A database maintaining patient condentiality was cre-
ated using Microsoft Excel. Statistical analysis, using a Fisher Exact test and t-test
with signicance set at p < 0.05, was performed.
RESULTS: The medical records of 224 patients (131 female, 93 male) with IBD (99
UC, 124 Crohns colitis, 1 indeterminate) were evaluated. There were 125 white,
61 African American, and 38 of other or undocumented ethnicity. The mean age
was 40.6 years. 153 (68.3%) underwent a surveillance colonoscopy within 8 years
of diagnosis, while 71 (31.7%) underwent initial surveillance 9 or more years after
diagnosis. The average time interval to surveillance colonoscopy in the latter
group was 11.3 years. There was no signicant difference in the performance of
surveillance colonoscopy based upon age (P = 0.8072), gender (P = 0.4703), eth-
nicity (P = 0.8696), or disease type (P = 1.000). Additionally, there was no signi-
cant difference in timing of surveillance colonoscopy based upon insurance car-
riers (7 different insurance types identied), or frequency of follow-up
appointments (P = 0.1362). Notably, there was a signicant difference (P =
0.0106) in the timing of surveillance colonoscopies based upon whether the
patient had transferred care into the practice.
CONCLUSION(S): This study demonstrated that a substantial number of patients
did not undergo surveillance colonoscopy at the recommended time following
diagnosis. While patient demographics, insurance type, and frequency of follow-
up did not impact timing of surveillance, transfer of care signicantly inuenced
the time at which the surveillance colonoscopy was performed. When there is
transfer of care into a new practice, physicians may rely on the patients recollec-
tion of previous colonoscopies rather than available medical record documenta-
tion. Additionally, patients may need time to establish a relationship with the
physician before adhering to surveillance recommendations. It is critical that
physicians are aware of the possible impact of transfer of care upon the timing
of surveillance colonoscopy in IBD patients, especially since there is more fre-
quent change of managing physicians due to patient relocation and changes in
insurance coverage. Further research should be done to investigate these issues
to ensure optimal clinical outcome.
P-89
Gastroenterologists Rarely Assess for Accutane Use in Patients with Inflamma-
tory Bowel Disease
Nisha Varadarajan, Pia Prakash, Jason Reich, Marie Borum
BACKGROUND: Accutane, a synthetic vitamin A analog, is the treatment of choice
for severe recalcitrant nodulocystic acne. It is known to be associated with a
number of adverse effects, including hepatotoxicity, idiopathic intracranial hyper-
tension, and teratogenicity. An association between Accutane use and the subse-
quent development of inammatory bowel disease (IBD) has also been sug-
gested. This study evaluated the frequency at which gastroenterologists assessed
Accutane use in individuals with inammatory bowel disease.
METHODS: Medical records of patients managed at an IBD program at a univer-
sity medical center were evaluated. Patient age, gender, ethnicity, disease type
(ulcerative colitis or Crohns disease), date of diagnosis, and Accutane use (past
and present) were obtained. A database, maintaining patient condentiality, was
created using Microsoft Excel. Statistical analysis was performed using a Fisher
Exact test and t-test, with signicance set at p < 0.05.
RESULTS: The medical records of 344 (211 female, 133 male) patients with IBD
were evaluated. 192 (55.8%) had Crohns disease, 151 (43.9%) had ulcerative coli-
tis, and 1 (0.2%) had indeterminate disease. The mean age was 41.2 years. Four
(3 female, 1 male) of the 344 IBD patients were asked about Accutane use, with
one having reported use prior to the onset of IBD. The mean age of patients
asked about Accutane use was 34.3 years. Patient gender (P = 1.000) and ethnic-
ity (P = 0.6336) did not inuence the rate of inquiry about Accutane.
CONCLUSION(S): It has been suggested that Accutane use may be associated
with the onset of inammatory bowel disease. Awareness of the potential inu-
ence of Accutane upon IBD development is important. This study revealed that
physicians rarely asked about the use of Accutane in patients with IBD. It is possi-
ble that physicians doubt the causal relationship between Accutane and IBD, and
therefore did not inquire about previous or present use. Additionally, it is possible
that the inquiry about Accutane was made, but not documented in the medical
records. Notably, the patients in whom physicians asked about Accutane use
were considerably younger than the patients who were not asked. It is important
that physicians are aware of all medications that have the potential to inuence
IBD onset or exacerbations. Physician awareness and inquiry can heighten
patients concern about medications, result in avoidance of potentially hazardous
medications, and possibly improve clinical outcomes.
P-90
Natalizumab Use in Large Community-Based Gastroenterology Practice: Results
of 18 Difficult to Treat Crohns Patients
Betty White, William Holderman, MD
Digestive Health Specialists, Tacoma, WA, USA
BACKGROUND: Natalizumab has been shown to be effective in the treatment of
moderate to severe Crohns disease which is refractory to other forms of medical
therapy. (ENACT-2) (1). Despite proven efcacy, its utilization in community-based
practices is low. This has been primarily secondary to safety concerns and lack of
familiarity. The introduction of JC virus antibody testing now allows for identica-
tion of identify those patients who are at a higher risk of complications(2). We
perform approximately 1200 infusions per year and have found the addition of
natalizumab and the integration of the TOUCH program to be a straightforward
addition to our current biologic infusion practice. In our experience, natalizumab
is well tolerated and is an effective treatment option.
METHODS: A total of 204 infusions (range 3-22) as of January, 2012 were given to
18 patients. All had seen and failed previous biologics and immunosuppressant
therapy. Length of disease averaged 11.2 years (range 3-28).
RESULTS: Only one patient had to discontinue treatment secondary to an adverse
reaction - severe recurrent headaches. (Patient had clinical response.) Extensive
neurologist guided evaluation was negative. One patient had temporary cessation
of treatment after an incidental colon cancer was found within a resected chronic
brotic stricture. Natalizumab was resumed postoperatively without sequelae af-
ter oncologist approval. Four patients had no response, two eventually went to
surgery. Currently 14 patients are on chronic maintenance therapy. All patients
have been tested for the JC virus, 2 of 18 were positive. Of the JC positive
patients, one discontinued therapy secondary to lack of response. The other has
elected to continue treatment (12 months) secondary to previously unobtainable
steroid-free response. All patients remain enrolled in the TOUCH program and
have been counseled on the risk of PML and death.Of those that continued on
treatment the clinical response has ranged from mild (5) to moderate improve-
ment(3), to deep sustained remission(4), along with closure of persistent draining
stulae(2). The time to full response and remission ranged from 3 to 9 months.
The most rapid response occurred in a 15 year-old male with refractory Crohns
colitis, who after three infusions, had accelerated return of normal growth curve,
15lb weight gain and normalization of all biochemical parameters. Corticosteroids
were weaned in all patients except one.
CONCLUSION(S): In our community practice we have found that natalizumab to
be an effective and well tolerated treatment option for patients with Crohns dis-
ease who have failed anti-TNF agents. Serious side effects were minimal and eas-
ily managed. The delivery of the medication and integration of the TOUCH pro-
gram into our busy infusion practice was straightforward. The addition of JC virus
antibody testing has allowed the identication of patients who can safely receive
natalizumab. Our experience demonstrated that natalizumab can be safely and
effectively delivered in a community-based practice and can enhance the out-
come in our most difcult to treat Crohns disease patients.
P-91
Intra-abdominal and Pelvic Abscess in Crohns Disease: A Single Center
Experience
Francisca Dias de Castro, Joana Magalhaes, Bruno Rosa, Maria Joao Moreira,
Jose Cotter
Gastroenterology Department, Alto Ave Hospital Center, Guimaraes, Braga,
Portugal
BACKGROUND: Intra-abdominal and pelvic abscesses occur in 10-30% of patients
with Crohns disease (CD) at some time in the course of the illness. We aimed to
characterize patients with abdominal or pelvic abscesses complicating CD.
METHODS: Retrospective single center study, including 21 patients admitted in
our Hospital between January 2007 and December 2011 with abdominal or pelvic
abscess complicating CD. Statistics were performed with SPSS v.17.0
RESULTS: Twenty one patients included, 52% male, with median age 2968,4
years. The average hospital stay was 30615 days. 24% of our patients were
treated only with antibiotics, in 14% surgical and/or percutaneous drainage was
performed and 62% were submitted to surgical bowel resection. The abscess size
or location failed to anticipate the need for bowel resection. However all patients
who had stula or a history of abdominal surgery related to CD, underwent surgi-
cal drainage or bowel resection. Of those submitted to surgical intervention, one
began biological therapy after discharge compared with 5 patients treated con-
servatively (antibiotics with or without drainage), this difference being statistically
signicant. The median follow-up after hospital discharge was 32 months, with
recurrence of abscess in 2 patients, one treated conservatively and other with
bowel resection.
CONCLUSION(S): In patients with abdominal or pelvic abscess complicating CD,
the need for surgical intervention is related to the presence of stula and previ-
ous abdominal surgery related to CD. Treatment with antibiotics alone did not
show to increase the rate of recurrence. Patients treated conservatively were later
more often treated with biological therapy compared with those treated surgi-
cally, and this difference was statistically signicant. The biological therapy has
proved to be safe in penetrating CD, with low recurrence rate.
P-92
Rates of Pharmacologic VTE Prophylaxis in Hospitalized Patients with Severe
Ulcerative Colitis
Andrew Tinsley
1
, Steven Naymagon
2
, Laura Enomoto
1
, Christopher Hollenbeak
3
,
Thomas Ullman
2
1
Penn State Hershey Medical Center, Hershey, Pennsylvania, USA,
2
Mount Sinai
Medical Center, New York, New York, USA,
3
Penn State College of Medicine, Her-
shey, PA, USA
BACKGROUND: Inammatory bowel disease (IBD) patients are at increased risk for
venous thromboembolism (VTE) compared to the general population. This risk
appears greatest in hospitalized patients. As a result, several practice guidelines
now recommend pharmacologic prophylaxis for IBD inpatients. Despite the dem-
onstrated support for the use of prophylactic anticoagulation, it is unclear
whether this tactic is being used consistently in clinical practice. Our aim was to
determine the rates of pharmacologic VTE prophylaxis in ulcerative colitis (UC)
inpatients at a tertiary referral center. We also examined several demographic
and clinical variables to see whether any of them were associated with receiving
pharmacologic VTE prophylaxis.
METHODS: We conducted a retrospective cohort study of 264 patients, with a
rst admission for severe UC, to a tertiary referral center between January 1st,
2007 and December 31st, 2012. The medical record of each patient was exam-
ined to determine whether pharmacologic VTE prophylaxis was ordered and
administered during the hospitalization. Several demographic and clinical varia-
bles were analyzed using logistic regression to evaluate potential factors associ-
ated with the receipt of VTE pharmacologic prophylaxis.
RESULTS: The overall percentage of patients that had VTE pharmacologic prophy-
laxis ordered was 54.9%. The rate of VTE pharmacologic prophylaxis in patients
admitted to the medical service was 46.2% compared to 90.4% in those admitted
to surgery. In medical patients who received pharmacologic VTE prophylaxis,
36.4% of ordered doses were not given compared to 15.8% of doses in surgical
patients (P < 0.001). In the multiple logistic regression analysis, having an addi-
tional VTE risk factor (OR 1.86, 95% CI 1.023.40), private insurance (OR 5, 95% CI
2.1211.11) or being admitted to a surgical service (OR 6.9, 95% CI 2.2321.26)
was associated with receiving VTE pharmacologic prophylaxis.
CONCLUSION(S): The majority of medical patients admitted with severe UC were
not ordered for VTE pharmacologic prophylaxis despite current recommendations
and practice guidelines. Even in patients who were ordered for pharmacologic
VTE prophylaxis, over one third of doses were not given. Low rates of pharmaco-
logic VTE prophylaxis in hospitalized IBD patients may lead to unnecessary mor-
bidity and mortality.
P-93
Human Papillomavirus Vaccine Compliance in Inflammatory Bowel Disease
Patients in Clinical Practice
Farra Wilson, Richard Bloomfeld
Wake Forest Baptist Health, Winston Salem, North Carolina, USA
BACKGROUND: Immunomodulators and biologics are commonly used to treat
patients with Inammatory Bowel Disease (IBD) and immunosuppression may
lead to an increased risk of infection, including vaccine-preventable infections.
Despite this, IBD patients are often under-vaccinated, as compared to the general
population. The are many reasons, including inadequate knowledge regarding
which immunizations can be administered to immunosuppressed IBD patients
and ambiguity as to whether the primary care physician or the gastroenterologist
should be administering vaccinations. One of the recommended vaccinations for
female IBD patients between the ages of 9 and 26 is the Human Papillomavirus
(HPV) vaccine, Gardasil
VR
. This vaccine is particularly important given the evidence
showing increased risk of cervical dysplasia, and possibly cervical cancer, among
female IBD patients. The aim of this study was to assess how many female
patients in the IBD Clinic at Wake Forest Baptist Health have a primary care physi-
cian and have been compliant with HPV vaccination.
METHODS: Consecutive female IBD patients, between the ages of 18-27, who
were seen at the Wake Forest Baptist Health IBD Clinic, were prospectively en-
rolled in a quality improvement project beginning January 2012. Charts were
reviewed to assess whether or not the subjects have a primary care physician,
whether they have been offered the HPV vaccine, and if they have received the
HPV vaccine.
RESULTS: Twenty women were enrolled. Of these, 95% (19 out of 20) reported
having a primary care physician, 80% (16 out of 20) reported being offered the
HPV vaccine, and 65% (13 out of 20) reported receiving the HPV vaccine.
CONCLUSION(S): In the Wake Forest Baptist Health IBD Clinic, 95% of young women
have primary care doctors, 80% have been offered the HPV vaccine, and 65% report
that they have received the HPV vaccine. This is higher compliance with the HPV
vaccine than reported in a national sample or in other IBD clinics. The difference in
compliance may be explained by socioeconomic factors, insurance status, and avail-
ability of primary care physicians. Further research is warranted to understand the
barriers to vaccination in IBD patients in different populations.
P-94
6-Mercaptopurine Side Effect Profile in the Elderly Inflammatory Bowel Disease
Patient
Seth Lipka
1
, Anthony Vacchio
2
, Seymour Katz
3
1
Nassau University Medical Center, East Meadow, NY, USA,
2
Long Island Clinical
Research Associates, Great Neck, NY, USA,
3
Albert Einstein College of Medicine,
Bronx, New York
BACKGROUND: A total of 77 million baby boomers will join the category of el-
derly over the next 19 years, at a rate of 4 million per year. The elderly inamma-
tory bowel disease patient is under represented in clinical trials and often clini-
cians make decisions using data from such trials involving a much younger
patient populations. We set out to investigate the safety of 6-Mercaptopurine in
our elderly patient population.
METHODS: Using an electronic search database we identied 41 patients with
Inammatory Bowel disease on 6-Mercaptopurine/Azathioprine with either Ulcer-
ative colitis (UC) or Crohns disease (CD). A comparison of the dosage, side effect
prole, and duration of therapy was examined.
RESULTS: Of 41 patients with inammatory bowel disease, 26 were female and 25
were male. The mean age of the patient population was 70.4 years old. Twenty-
ve patients were diagnosed with CD and 16 with UC. The dosage of 6-MP
ranged from 25 mg to 150 mg. The average duration of therapy was 48.5
months. Thirty patients experienced a single side effect, whereas 8 had multiple
occurrences. Four patients had to discontinue therapy (1 rash, 1 hepatitis & rash,
1 pancytopenia, 1 infection) secondary to a severe side effect. The other 26
patients continued their therapy at the current dose, or tolerated therapy after
lowering dosage. Two patients developed malignancies while on 6-MP(1 Basal
Cell Carcinoma& Squamous Cell Skin Cancer, 1 Bladder Cancer & Prostate Cancer).
CONCLUSION(S): Our experience demonstrates of 41 patients with inammatory
bowel disease 37/41 (90.2%) were able to tolerate the medication without having
to discontinue treatment. Of those with side effects 26/30 (86.7%) were able to
continue 6-MP /Azathioprine In our elderly IBD patient population taking immu-
nomodulators that with periodic measurement of CBC, creatinine, and hepatic
prole long-term therapy remained benecial.
P-95
Individuals With Inflammatory Bowel Disease May Have Limited Knowledge of
the Restroom Access Act
BACKGROUND: Altered bowel habits in individuals with inammatory bowel dis-
ease (IBD) can result in a decreased quality of life. Avoidance of social situations
can occur due the fear of not having restroom access. Legislation, initially drafted
in Illinois, stated that anyone with a medical emergency must be allowed private
restroom access in establishments with three or more employees. While addi-
tional states have passed the Restroom Access Act, it is uncertain if individuals
with IBD are aware of this legislation. This study assessed whether individuals
presenting with an IBD exacerbation were aware of the legislation which allows
for restroom access during a medical emergency.
METHODS: Consecutive patients presenting with an exacerbation of their ulcera-
tive colitis or Crohns disease and managed in a university IBD program during a
1 month period were surveyed about their knowledge of the Restroom Access
Act. No patient was excluded. Patient age, gender and disease type were
obtained. A database was created using Microsoft Excel.
RESULTS: Twenty-four consecutive patients (21 women, 3 men; mean age 48.6
years) presenting with an IBD exacerbation were surveyed. There were 13 with ul-
cerative colitis and 11 with Crohns disease. 12 patients were African-American
and 12 were non-African American. All patients reported previous episodes of
increased bowel frequency, urgency and an emergent need for a restroom. None
of the patients reported denial of restroom access. None of the patients were
aware of the Restroom Access Act.
CONCLUSION(S): The Restroom Access Act, also referred to as Allys Law, is legisla-
tion that allows for individuals with a medical emergency to have access to a pri-
vate restroom in establishments that have three or more employees. It has been
passed in 12 states and enables individuals with inammatory bowel disease to
utilize restrooms in emergency circumstances. This study revealed that none of
the IBD patients presenting with an exacerbation were aware Allys Law. All of
the patients reported previous circumstances in which they had an emergent
need for a restroom. This study is biased because all of the patients resided in a
jurisdiction that did not pass specic legislation allowing for bathroom access in
a medical emergency. Additionally, this study is limited due size and single insti-
tution design. Nevertheless, this survey illustrates a potential need for increased
awareness of legislation that enables restroom availability and continuing advo-
cacy for the medical needs of IBD patients.
P-96
Increased Awareness of the Cervical Cancer Risk and Need for Pap Smears in
Women with Inflammatory Bowel Disease Is Necessary
Shelton McMullan, Shivangi Pandya, Samir Vermani, Pia Prakash, Marie Borum
BACKGROUND: Women with inammatory bowel disease (IBD) are at increased
risk for the development of cervical cancer. It has been suggested that women
at increased risk, including IBD women, undergo annual Pap smears. However,
there is no consensus regarding the frequency at which IBD women should
undergo cervical cancer screening. This study evaluated the rate at which Pap
smears were performed in women treated at a university inammatory bowel
disease center.
METHODS: Medical records of women with ulcerative colitis and Crohns disease
cared for at a university inammatory bowel disease center during a three year
period were evaluated. Patient age, disease type, and frequency of Pap smears
were obtained. Patients were excluded if they had a hysterectomy, were not age-
eligible for a Pap smear or their gynecologist or primary care providers were out-
side of the university and their medical records were not available. A database
was created using Microsoft Excel. Statistical analysis was performed using Fish-
ers Exact test with signicance set at P < 0.05.
RESULTS: 130 medical records of IBD women were reviewed. There were 49 African-
American and 81 non-African American women (mean age 41.95 years). 57 women
had UC and 73 had Crohns disease. 68 women with IBD were eligible to undergo
Pap smears. 45 women (66.18%; 26 of 43 with UC, 19 of 25 with Crohns disease)
had a Pap smear performed. 23 had a Pap smear within the past 3 years and 22
(32.35%) women had their Pap smear within the past 1 year. Women with UC
patients were signicantly more likely (P = 0.0198) to have Pap smears compared to
women with Crohns disease. There was no signicant difference in the rate at which
women underwent cervical cancer screening based upon race (P = 0.2102). There
was no signicant difference (P = 1.0) in whether women with IBD had Pap smears
were performed at 3 years or 1 year (P = 1.0). Women with UC compared to Crohns
disease more frequently had a Pap smear at 1 year (approaching signicance at P =
0.0639) and were statistically more likely to undergo Pap smears at 3 years (P =
0.0198). There was no signicant difference in the performance of Pap smears at 3
years (P = 0.2102) and at 1 year (P = 0.1563) based upon race.
CONCLUSION(S): Woman at increased risk for the development of cervical cancer
should undergo annual Pap smears. It has been suggested that since IBD
women are at increased risk for cervical cancer, Pap smears should be per-
formed more frequently than performed in the general population. This study
revealed that IBD women inconsistently undergo Pap smears, with only two-
thirds of eligible patients undergoing cervical cancer screening. In addition,
only half of the IBD women who had Pap smears had one performed within the
past year. While this study limited due to size and retrospective design, it sug-
gests that there should be heightened awareness among physicians and
patients of the importance of cervical cancer in IBD women. There is also a
need for a consensus on the appropriate frequency of Pap smear screening in
patients with IBD.
P-97
YI
Usefulness of Fecal Calprotectin in Clinical Practice in a District General
Hospital
Laith Alrubaiy
1
, Ahsan Malik
2
, Ian Rees
2
, Dafydd Bowen
2
1
Swansea University, UK, Swansea, UK,
2
Prince Philip Hospital, Llanelli, UK
BACKGROUND: Calprotectin is a calcium and zinc binding protein, mainly con-
tained in neutrophils. If present in stools it is a marker of bowel inammation.
We evaluated the diagnostic value of fecal calprotectin (FC) as a non-invasive
marker of bowel inammation in routine out-patient gastroenterology clinic.
METHODS: A retrospective study of patients who had FC testing presenting with
a multitude of gastrointestinal symptoms in a district general hospital over a 12
month period. The clinical, FC results and the endoscopic ndings were recorded.
FC level more than 50 lg/gm was considered positive.
RESULTS: FC was requested for 72 patients. 44 were female (mean age 44 years)
and 28 were male (mean age 47 years). FC was requested for various symptoms
including chronic diarrhoea, abdominal pain, abdominal distension and per rectal
bleeding. Patients were divided into 3 groups based on clinical practice of gastro-
enterologist. In the rst group only FC was requested initially as a screening test
to assess bowel inammation. 31 patients fell in this group, 21 of 31 had nega-
tive FC and no further investigations were done, while 10 of 31 had positive FC
(mean 150.3 lg/gm). Out of these 5 had no further investigations as symptoms
settled on subsequent clinic visit and 5 went on to have further investigations
(Colonoscopy /- Capsule endoscopy) which were all normal. In the second
group patients had both FC and colonoscopy requested on initial out-patient
review. There were 23 patients in this group. 13 of 23 had normal FC and colono-
scopy and no further investigations were done. 2 of 23 had abnormal FC (mean
271.5 lg/gm) and colonoscopy. Both were diagnosed with IBD. 8 of 23 had raised
FC (mean 171.25 lg/gm) but a normal colonoscopy. 5 of 8 had no further investi-
gations done while 3 had small bowel investigations which were normal. 1
patient of these 3 was treated for presumed small bowel Crohns due to raised
FC despite normal capsule endoscopy with good effect. In the third group colo-
noscopy was the initial investigation of choice and was found to be normal but
FC was done later in view of persistent symptoms to look for small bowel inam-
mation. 18 patients fell in this group. 12 of 18 had normal FC and had no further
investigations. 6 of 18 had raised FC (mean 114.33 lg/gm). 3 patients with raised
FC had small bowel investigation done and all were normal.
CONCLUSION(S): In conclusion FC was benecial when negative. It provided reas-
surance to the clinicians and helped avoid invasive investigations. However when
FC was positive clinical judgment and patient symptoms dictated the need for fur-
ther investigations. None of the patients diagnosed with IBD had a negative FC.
P-98
YI
The Precise Treatment Strategy for Adalimumab According to Endoscopic Eval-
uation in Patients With Crohns Disease
Noriko Kamata, Kenji Watanabe
Osaka City University Graduate School of Medicine, Osaka, Japan
BACKGROUND: The aim of the present study is to evaluate the clinical and endo-
scopic efcacy of adalimumab(ADA) in patients with Crohns disease (CD) who
had been treated with or without Iniximab(IFX) prospectively. And we investi-
gated the clinical strategy for ADA based on the endoscopic efcacy.
METHODS: Suitable endoscopic examination (ileocolonoscopy or balloon entero-
scopy) was performed to assess the most inamed lesion before and after 28
weeks for ADA treatment. We evaluated the clinical and endoscopic efcacy
according to Harvey-Bradshaw Index (HBI: remission <4) or CRP, endoscopic ef-
cacy according to simple endoscopic score for Crohns disease (SES-CD). The en-
doscopic efcacy was dened by the decreasing SES-CD score. The primary end-
point is endoscopic efcacy at 28 weeks.
RESULTS: 80 CD patients (mean age: 35.0 year, Male:62/ Female:18, L1/L2/L3 = 23/
8/49) were enrolled. Most patients (97.5%: 78/80) could perform self-injection of
ADA. Anti-TNFa agent na ve patients (N group) was 35 cases (43.8%), and switched
cases from Iniximab (IFX) to ADA (S group) was 45 cases (56.2%). Loss of response
for IFX (L group) in S group was 29 cases (shortened injection interval less than 7
weeks was 23 cases: 11 cases were clinical active and 12 cases were endoscopic
active), and intolerant for IFX (R group) in S group was 14 cases. Clinical remission
induction was signicant higher in N group (100%) (P = 0.039) than R group
(71.4%) and L group (70.0%) at 28 weeks, and CRP (mg/dl) was also signicantly
lower in N group (0.08) (P = 0.003) than R group (0.34) and L group (0.78) at 28
weeks. Endoscopic efcacy according to SES-CD was 60.9% (25/41, P = 0.057) (N
group: 12, L group: 22, R group; 7), especially signicant improvement was shown
in N group (P = 0.003) and R group (P = 0.042). Furthermore, L group was classi-
ed into 11 clinical remission cases and 11 clinical active cases, all of them were
treated with shortened IFX infusion of interval less than 7 weeks as treatment for
Loss of response. The former were signicantly effective for ADA switched from IFX
(P = 0.002). On the other side, the latter needed more strong or additional therapy
(e.g. IFX re-induction and dose escalation, or add azathioprine). The recurrence rate
after 28 weeks of endoscopic effective group (20.0%, 5/25) was signicantly lower
endoscopic ineffective group (75.0%, 12/16) (P = 0.002).
CONCLUSION(S): ADA is effective not only anti-TNFa agent na ve patients as the
1st line therapy but intolerant patients for IFX. Precise endoscopic evaluation
should achieve the suitable timing for switch to ADA from IFX. Endoscopic ef-
cacy bring better prognosis than just clinical efcacy.
P-99
YI
Colonoscopic Perforation in IBD and non-IBD Patients Bears Similar Severe
Adverse Outcomes
Saurabh Mukewar, Xianrui Wu, Megan Costidio, Aaron Brzezinski, Ravi Kiran,
Rocio Lopez, Bo Shen
Cleveland Clinic, Cleveland, Ohio, USA
BACKGROUND: Endoscopic perforation is a dreaded complication with signicant
morbidity and even mortality in some cases. Whether perforation in IBD patients
has better or worse outcomes than non-IBD patients is not known. Aim: To assess
prevalence of perforations in patients undergoing lower GI endoscopy and to
compare characteristics and outcomes of endoscopy associated perforation in
IBD patients with those without IBD.
METHODS: We conducted an IRB approved case-control study and identied
patients with lower GI endoscopy-associated perforations at the Cleveland Clinic
from January 2002 to June 2011. Patients with non-endoscopy associated perfora-
tions and partial tears were excluded from analysis. Thirty-ve different variables
were recorded. Severe adverse sequelae after perforation were complications
leading to signicant morbidity and in some cases mortality, such as wound
infection or supercial dehiscence, adult respiratory distress syndrome, fascial
dehiscence, cardiac arrhythmia, septic shock, pulmonary embolism, aspiration
pneumonitis, pancreatitis, acalculous cholecystitis, myocardial infarction, incarcer-
ated incisional hernia, parastomal hernia, bleeding ileostomy, pelvic abscess, ana-
phylactic reaction, renal failure, anemia requiring blood transfusion, pneumome-
diastinum, deep vein thrombosis, pleural effusions, prolonged Ileus, urinary tract
infection.
RESULTS: Rates of perforation are described in table 1. Younger age, prior abdom-
inal surgeries, no polypectomy, biopsy, stricture dilation, absence of diverticulosis,
lower Charlsons combined condition and age-related score and higher 10-year
survival probability were found to be signicantly associated with IBD. On multi-
variate analysis, presence of IBD was NOT associated with greater risk of severe
adverse sequelae in patients with endoscopic perforation.
CONCLUSION(S): IBD-patients undergoing colonoscopy, sigmoidoscopy and pou-
choscopy are at a greater risk and those undergoing ileoscopy via stoma are at a
lower risk of perforation than non-IBD patients. On multivariate analysis, presence
of IBD was NOT associated with greater risk of severe adverse sequelae in
patients with endoscopic perforation.
P-100
Capsule Endoscopy Scoring Systems and CRP: Evaluation of Small Bowel Dis-
ease Activity in Crohns Disease
Francisca Dias de Castro, Bruno Rosa, Joana Magalhaes, Maria Joao Moreira,
Jose Cotter
Gastroenterology Department, Alto Ave Hospital Center, Guimaraes, Braga,
Portugal
BACKGROUND: Capsule endoscopy (CE) is an established technology for the eval-
uation of small bowel diseases, including Crohns disease (CD). New scores, as
Lewis Score (LS) and CD activity index (CECDAI) have been developed to stand-
ardize the reporting small bowel inammation. Mucosal healing is being increas-
ingly recognized as a cornerstone on management of CD. C reactive-protein
(CRP) is an acute phase reactant, and has been used as a biomarker of luminal
inammation and a predictor of the course of CD. Our aim was to assess the cor-
relation between the two CE inammation scoring systems and their association
with CRP.
METHODS: Retrospective single-center study, including 42 patients with isolated
small-bowel CD, submitted to CE. CPR levels were assessed at the time of CE. LS
and CECDAI were calculated by a single reviewer and correlation between these
two scores and CRP was calculated using Spearman test. Linear regression analy-
sis was used to identify threshold levels for CECDAI.
RESULTS: Forty two patients included, 69% female with mean age 34 6 12 years.
The mean small bowel transit time was 353 6 126 min. In the majority (57%) of
patients, CE diagnosed proximal small bowel involvement, revealing CD related
lesions, out of the reach of the standard endoscope. At the time of CE measure-
ment of CRP was 12,8 6 26,5 mg/dl. The mean LS was 1387 6 1693,8, range
112-6150 and the mean CECDAI was 7,1 6 5.7, range 1-22. In our cohort, CECDAI
demonstrated a good correlation with CRP levels (rs = 0.467, P < 0.002), better
than LS (rs = 0.357, P < 0.022). Strong correlation between LS and CECDAI was
demonstrated (rs = 0.683, P < 0.01). Linear regression analysis demonstrated that
LS thresholds of 135 and 790 correspond with CECDAI levels of 5 and 7, respec-
tively. The presence of high levels of CRP was signicantly related to CECDAI _7
(P < 0.05), but no association was demonstrated to LS_790.
CONCLUSION(S): We demonstrate a strong correlation between these two scores
and calculate the CECDAI levels corresponding to LS threshold of 135 and 790. In
our cohort, we demonstrate a signicant association between CRP and CECDAI,
better than LS. Prospective studies may in the future support the use of both of
the scores in follow-up of patients with isolated small-bowel CD to assess
response to medical therapy, such as others endoscopic scores used for ileoco-
lonic CD.
P-101
Does Wireless Capsule Endoscopy Affect Outcomes After Ileal Pouch-Anal Anas-
tomosis in IBD Patients Treated With Anti-TNF Agents?
Brian Teng, Gil Melmed, Zuri Murrell, Phillip Fleshner
BACKGROUND: The extent of known preoperative small-bowel mucosal inamma-
tion may be impacted by the use of anti-TNF drugs in medically refractory ulcera-
tive colitis (UC) patients evaluated while on therapy just prior to surgery. This
masking effect may hide small bowel disease during wireless capsule endoscopy
(WCE) that might only be revealed when patients are taken off therapy after sur-
gery. We have previously published that WCE does not predict outcomes in a
cohort of patients with UC or inammatory bowel disease-unspecied (IBDU)
undergoing ileal pouch-anal anastomosis (IPAA). This is an expanded study exam-
ining whether preoperative wireless capsule endoscopy (WCE) could help predict
outcome of IPAA in UC and IBDU patients treated with anti-TNF agents.
METHODS: UC or IBDU patients undergoing WCE before IPAA were identied in a
prospectively maintained surgical database. Patients were grouped into three cat-
egories: medically-refractory disease on anti-TNF agents at time of WCE, medi-
cally-refractory disease not on anti-TNF agents at time of WCE, and patients hav-
ing dysplasia/cancer. Patients with a normal WCE study were classied as WCE-
negative (WCE-). Patients were classied as being positive (WCE) if either more
than 3 mucosal ulcerations or mucosal erosions were found. Only patients having
a complete WCE examination were included in the study cohort. Outcome was
assessed prospectively and included no pouchitis (NP), acute pouchitis (AP),
chronic pouchitis (CP), or de novo Crohns disease (CD). Analysis was performed
on SPSS v19 using the chi-squared test.
RESULTS: The 137 study patients (81 UC, 56 IBDU) had a median age of 39 years and
included 68 (50%) males. WCE was positive (WCE) in 28 patients (20%) and nega-
tive (WCE-) in 109 patients (80%). The incidence of WCE in UC was 16% compared
to 44% in IBDU (P = 0.02). There was no signicant difference in WCE between the
109 patients treated with anti-TNF (18%) vs the 28 patients without anti-TNF treat-
ment (29%). Median follow-up time after ileostomy closure was 30 months (3-113
months). Pouch inammation developed in 49 patients (35%), and included 19 (14%)
patients with AP, 7 (5%) patients with CP, and 23 (17%) patients with de novo CD. The
overall incidence of AP, CP, CD in the WCE-positive patient group was 4%, 11%, 25%
compared with 17%, 4%, 15% in the WCE-negative patient group (P = 0.10). Associa-
tions between anti-TNF therapy, WCE ndings and outcome are shown in Table 1.
There was no signicant difference in outcome between patients with medically-re-
fractory disease on anti-TNF agents at time of WCE, medically-refractory disease not
on anti-TNF agents at time of WCE, and patients having dysplasia/cancer.
CONCLUSION(S): WCE ndings are not inuenced by the preoperative use of anti-
TNF agents. WCE ndings do not affect outcome after IPAA regardless of surgical
indication or preoperative anti-TNF use. The value of WCE in the preoperative
evaluation of these patients is questionable.
P-102
Chromoendoscopy in Community GI: A Single Physician Experience
Niren Jasutkar
1
, Samir Shah
2
, Steven Reinert
3
, Murray Resnick
1
1
Brown University/Rhode Island Hospital, Providence, RI, USA,
2
Rhode Island Hos-
pital, Providence, RI, USA,
3
Lifespan Information Services, Providence, RI, USA
BACKGROUND: Early detection of dysplastic tissue during colonoscopy allows
early intervention and may decrease colon cancer and improve survival. Previous
work from academic centers has demonstrated chromoendoscopy increases diag-
nostic yield for intraepithelial neoplasia in inammatory bowel disease compared
with white-light colonoscopy. However, the feasibility of this technique has not
yet been adequately studied in the community setting. We evaluated a single
physicians experience with chromoendoscopy in patients with IBD.
METHODS: We performed a retrospective review of surveillance colonoscopies
(with & without chromoendoscopy) in patients with IBD between January 2005 &
August 2012. Pathology and procedure reports were reviewed. We collected de-
mographic data (age, gender), diagnosis (Crohns, UC, IBDU), smoking and family
history, history of polyps, length of colonoscopy, complications from procedure,
location & number of biopsies, and nal diagnosis from pathology.
RESULTS: A total of 184 colonoscopies were evaluated, of these 64 were per-
formed using chromoendoscopy with indigo carmine dye. Cases comprised of
118 individual patients, 64 males & 54 females, with a mean age of 51.6 years.
There were no adverse events associated with colonoscopy in our study popula-
tion. The average length of procedure was 38.8 [34.1, 43.4] minutes for chromoen-
doscopy, and 20.5 [18.1, 22.9] minutes without (P < 0.001). Chromoendoscopy
yielded an average of 42.0 [38.0, 46.0] biopsies in 13.1 [12.4, 13.86] jars per case,
while white-light averaged 34.9 [32.4, 37.3] biopsies in 10.0 [9.68, 10.44] jars (P <
0.001) per case. In the cases we reviewed, white light colonoscopy found 87 polyps
and chromoendoscopy found 157 polyps. An average of 2.4 [1.9, 3.0] polyps were
resected per case during chromoendoscopy while white-light yielded 0.7 [0.5, 1.0]
polyps per case on average (P < 0.001). Chromoendoscopy led to discovery of 25
dysplastic lesions at a rate of 0.39 [0.23, 0.55] per case compared to 8 dysplastic
lesions at a rate of 0.07 [0.02, 0.11] per case with regular colonoscopy (P < 0.001).
Of all polyps discovered via chromoendoscopy, 31.25% were dysplastic lesions.
With white light 6.67% (P < 0.001) of all polyps resected were dysplastic. In our
study, there was only one case which found low grade dysplasia on a random bi-
opsy; otherwise all remaining dysplastic lesions were found from resected polyps.
CONCLUSION(S): Chromoendoscopy yields increased recognition of dysplastic pol-
yps in patients with IBD. In our analysis colonoscopy time was prolonged by an
average of 18 minutes per procedure with chromoendoscopy; however, the tech-
nique allowed for a ve-fold higher rate of detection of dysplastic lesions com-
pared to white light colonoscopy, similar to published data from academic cen-
ters. Random biopsy yielded low grade dysplasia in only one case, suggesting
that the utility & cost effectiveness of random biopsies may be exceedingly low.
Chromoendoscopy is an effective tool and should be utilized more frequently in
patients with IBD undergoing surveillance colonoscopy. Our experience shows it
can be done successfully and safely in the community practice setting.
P-103
Capsule Endoscopy for Assessing Small Bowel Residual Lesions at Resection
and Postsurgical Recurrence in Crohns Disease
Tomoaki Kono, Nobuyuki Hida, Koji Nogami, Masaki Iimuro, Yoshio Ohda, Yoko
Yokoyama, Koji Kamikozuru, Katsuyuki Tozawa, Ken Fukunaga, Shiro Nakamura,
Takayuki Matsumoto
Department of Lower Gastroenterology, Hyogo College of Medicine, Hyogo, Ja-
pan, Nishinomiya
BACKGROUND: Despite signicant advances in treatment of Crohns disease (CD),
surgery represents an almost unavoidable step. However, surgical resection of
intestine is not a cure and most patients will develop recurrence. The efcacy of
postsurgical small bowel capsule endoscopy (CE) in detecting recurrence in
patients with CD remains controversial. The aim of our study was to prospectively
evaluate the usefulness of CE for assessing small bowel residual lesions at resec-
tion and postsurgical recurrence in patients with CD.
METHODS: Nineteen patients with CD who underwent ileocolonic or partial ileal
resection of all macroscopically diseased tissue were prospectively enrolled into a
trial. At 2-3 weeks after surgery, small bowel residual lesions at resection were
assessed by CE. To evaluate endoscopic recurrence, small bowel lesions were
reexamined by CE at 6-8 months after surgery, and were compared with ndings
at very early postoperative period. For the evaluation of small bowel mucosal
inammatory change, the Lewis score (LS) was used.
RESULTS: At very early postoperative period, one CE was excluded because the
distal segment of ileum could not be inspected. Seventy-two% (13/18) of patients
had villous edema, and 67% of them showed ulcers, and one showed stenosis of
small bowel. Mean total LS at very early postoperative period was 428.3 (range:
8-4264). Based on total LS, 78% (14/18) of patients corresponded to mild to
severe active disease (LS>135). These lesions were evenly distributed in all seg-
ments of the remaining small intestine. Mean LS of proximal, mid and distal ter-
tile was 286.6 6 994.5, 83.0 6 133.2 and 146.7 6 170.3, respectively. Ulcers on
ileo-colonic and ileo-ileal anastomosis were observed in 83% of them. At 6-8
months after surgery, 13 patients underwent follow-up CE. All 13 patients were in
clinical remission at follow-up period. Sixty-nine% of patients was on scheduled
iniximab within one month of surgery. Endoscopic progressive recurrence which
dened as an increase of total LS more than 100 points in comparison to pervi-
ous nding was observed in 38% of patients. No patients showed complications
related to CE.
CONCLUSION(S): Many residual small bowel inammatory lesions were observed
by CE at very early postoperative period in patients with CD after radical or cura-
tive resection. Repeated CE may be useful technique for postoperative assess-
ment of endoscopic recurrence at regularly follow-up in CD.
P-104
Immune-related Serum miRNAs Are Differentially Expressed in IBD Patients
Compared to Healthy Controls
Grant Gallagher
1
, AnneMarie Kinder
1
, Rachael Siegel
1
, Jane Friehling
2
, Nicholas
Megjugorac
1
, Grant Gallagher
1
1
Humigen, LLC, Hamilton, NJ, USA,
2
South Jersey Gastroenterology, Marlton, NJ,
USA
BACKGROUND: The lack of a reliable, non-invasive test for IBD represents a critical
gap in the diagnosis and care of patients with Crohns disease or ulcerative colitis.
In this study, the utility of serum-based microRNAs (miRNAs) as diagnostic indica-
tors of IBD is examined.
METHODS: Whole blood and serum were collected from 20 people with ulcera-
tive colitis and 18 people with Crohns disease in this prospective study; 14
healthy subjects served as controls. miRNAs of interest were selected for their pu-
tative ability to modulate immunologically-relevant genes, using online, open
source tools. Serum miRNA levels were quantied using qRT-PCR.
RESULTS: Six individual microRNAs were shown to be present at statistically dis-
tinct levels in the serum of IBD patients compared to normal controls (P < 0.01;
Mann-Whitney U test). Presented below as: miRNA: sensitivity(%)/specicity (%)
miR-326: 62.2% sens/85.7% spec miR-543: 88.9% sens/92.9% spec miR-223: 78.4%
sens/100% spec miR-590-3p: 62.5% sens/100% spec miR-30d: 92.9% sens/92.9%
spec miR-200a: 82.1% sens/100% spec miR-141 was shown to be differentially
expressed in the sera of donors with ulcerative colitis patients as compared to
those with Crohns disease (sensitivity 80%, specicity 100%).
CONCLUSION(S): Six miRNAs have the potential to be used as a panel of bio-
markers to distinguish serum samples from subjects with IBD from healthy con-
trols. One miRNA (miR-141) may serve to further differentiate between ulcerative
colitis and Crohns disease.
P-105
GA-map
TM
IBD Test Potential New Tool for IBD Prediction and Management
Morten Isaksen
1
, Heidi Veb
1
, Monika Sekelja
1
, Knut Rudi
2
, Morten Vatn
3
1
Genetic Analysis AS, Oslo, Norway,
2
Norwegian University of Life Sciences, Aas,
Norway,
3
Oslo University Hospital, Oslo, Norway
BACKGROUND: In addition to genetic factors, several recent discoveries have
shown that the gut microbiota seems to play an important role in the etiology of
IBD (1). As a high through-put, low cost alternative to 454 pyro-sequencing, the
GA-map
TM
technology platform has been develop to prole the composition of
the gut microbiota (2). We have used this technology to develop a specic IBD
test that offers promise of being an effective additional diagnostic tool in IBD dis-
ease prediction and management. A rst version of the assay has been tested on
treatment na ve IBD patients and symptomatic non-IBD patients and a healthy
population.
METHODS: A population of 187 treatment na ve patients symptomatic of IBD iden-
tied by primary care physicians and referred to colonoscopy were used in this
study. In addition, a reference population of 84 healthy individuals who did not
undergo colonoscopy where also included. IBD were determined in all sympto-
matic patients by colonoscopy. Fecal samples were collected (before colonoscopy
in symptomatic IBD patients), and DNA extracted after a mechanical lysis. The GA-
map
TM
IBD test was performed essentially as described in (2), but with specic IBD
related DNA probes (48 121 different probes) and using Luminex MagPix system
for detection and quantication of labeled DNA probes (indicative of presence of
different bacteria). The signals from each DNA probe in each sample was subject
to PCA analysis and model was developed based on leave-on-out cross-validation.
RESULTS: When comparing the healthy population to patients diagnosed with IBD
through colonoscopy, the GA-map
TM
IBD test was able to correctly predict IBD
with a 94% sensitivity and 86% specicity, and 90% accuracy. When comparing
non-IBD (patients symptomatic for IBD, but conrmed non-IBD by colonoscopy)
the numbers were 78%, 70% and 74%, respectively. The prediction capability of
the GA-map
TM
test seems to be inuenced by age and type of disease, as UC
patients in the age-group 15 35 years showed the best prediction of disease with
88% sensitivity and 63% specicity when compared to symptomatic non-IBD.
CONCLUSION(S): These results show that the GA-map
TM
IBD test can be used to
distinguish healthy individuals from IBD patients with high accuracy. In addition,
the test can be used to specify which symptomatic patients have IBD with 78%
certainty. This shows potential to use the test to rule out symptomatic patients
that do not need to undergo colonoscopy, thereby saving both payers and
patients of costs, recourses and discomfort. The relatively poor specicity of the
test could be an indication that symptomatic patients where IBD was not seen
by colonoscopy, could be an early sign of developing gut related complications.
This prospect will be followed up in a new study.
P-106
YI
More is Less: Extended Enoxaparin After Surgery for Inflammatory Bowel Dis-
ease - A Cost-based Decision-Analysis
Parambir Dulai, Breanne Piazik, Samuel Finlayson, Stefan Holubar
Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
BACKGROUND: Inammatory Bowel Disease (IBD) patients undergoing colorectal
surgery are at an increased risk of Venous Thromboembolism (VTE), particularly
beyond 10 days post-op. Optimal VTE prophylaxis, however, is not well dened in
this population. In cancer patients undergoing abdominopelvic surgery, several
randomized trials suggested that extended therapy with enoxaparin was a more
effective treatment strategy, while several decision analyses suggested subcutane-
ous heparin may result in more cost minimization. These previous studies were
performed prior to the availability of generic enoxaparin and failed to incorporate
rates of patient compliance. Thus we aimed to construct a cost minimization de-
cision analysis which included these important factors in a population known to
be at high-risk for VTE.
METHODS: We constructed a cost minimization decision model to evaluate four
strategies for management of postoperative VTE risk after surgery for IBD: (1)
inpatient subcutaneous heparin (SQH) 5000 units TID 10 days; (2) inpatient
enoxaparin 40 mg daily 10 days; (3) SQH 5000 units TID 30 total days (10
inpatient, 20 outpatient days); (4) enoxaparin 40 mg daily 30 total days (10
inpatient, 20 outpatient days). Our model made the following assumptions: (1) no
prior history of VTE; (2) only major bleeding required intervention; (3) 90% of
major bleeds were treated medically with transfusion of 2 units PRBC and 10%
required reoperation; (4) heparin-induced thrombocytopenia (HIT) occurred
within the rst 10 days of exposure. Rates of inpatient and outpatient VTE, adher-
ence to outpatient treatment, and strategy specic complications including HIT
and major bleeding for each strategy, were obtained from published literature
and modeled. Costs (in US dollars), including costs of strategy specic complica-
tions, were based on published literature, institutional charges and average
wholesale pricing. Sensitivity analyses were performed to account for uncertainty
in estimates.
RESULTS: In this model, extended duration prophylaxis with enoxaparin was asso-
ciated with the greatest cost minimization with an estimated cost of $2,585,
Figure 1.
compared to extended SQH which cost $2,768. Inpatient-only prophylaxis with
enoxaparin and SQH cost $2,944 and $3,267, respectively. Our model was sensi-
tive to rates of VTE (Figure 1), rates of HIT, and drug costs (Figure 2). Sensitivity
analysis revealed that the extended SQH strategy was associated with the most
cost minimization when VTE rates with enoxaparin were >6.5% (vs. 5.7% in the
base case) and costs of outpatient enoxaparin were >$712 (vs. $528 in the base
case). SQH was also associated with the most cost minimization if patient adher-
ence rates were >85% (vs. 65% in the base case).
CONCLUSION(S): Our model, in contrast to previously published cancer surgery
literature, suggests that in IBD patients extended duration prophylaxis with enox-
aparin for a total of 30 days post-operatively would result in the greatest cost-
minimization. This may be in part due to the availability of generic enoxaparin,
reduced risk of HIT, and increased adherence with outpatient enoxaparin result-
ing in greater VTE prevention relative to SQH.
P-107
YI
African-American Crohns Patients Are More Likely to Return to the Operating
Room After Initial Surgery When Compared to Caucasians
Nicole Griglione, Shadi Sadeghi, Jahnavi Srinivasan, Jill Woodard, Tom Ahearn,
Tanvi Dhere
BACKGROUND: Whether race affects the natural history of Crohns disease is a
matter of debate. While some studies have suggested African-American patients
have worse outcomes, others have failed to show any racial disparity. The aim of
the current study was to evaluate for differences in surgical outcomes between
African-American and Caucasian Crohns patients undergoing surgery at a tertiary
care referral center.
METHODS: With IRB approval, the medical records of our institution were queried
to identify consecutive African-American and Caucasian patients who underwent
surgery for Crohns disease from December 1, 2009 and December 15, 2011. A
retrospective chart review was performed using our electronic medical records.
Using Fishers exact test, we evaluated for differences in peri-operative factors
and postoperative complications.
RESULTS: A total of 79 Crohns patients were included in the study including 32
African-Americans (41%) and 47 Caucasians (59%). No signicant differences were
seen with age, sex, type of insurance (uninsured versus Medicare/Medicaid versus
private insurance), pre-operative exposure to immunosuppressives, body mass
index (BMI), or smoking history (P > 0.05) between the two populations.
Although there was a trend toward lower albumin levels and higher percentage
of patients requiring total parenteral nutrition in African-Americans, the results
did not reach statistical signicance (2.90 vs 3.19, P = 0.09; 72% vs 48%, P =
0.06). More African-American patients underwent open surgery compared to Cau-
casians (72% vs. 55%), but the difference did not reach statistical signicance (p
= 0.16). No signicant differences were seen in location of disease (i.e. small
bowel, large bowel, or both) and indication for operation (i.e. perforation, refrac-
tory disease, or stulas). African-Americans were more likely to receive a blood
transfusion peri-operatively (59% vs 24%, P = 0.004). In addition, more African-
Americans required a repeat operation during the same hospitalization (28% vs
3%, P = 0.01) or within 90 days of the original surgery (68% vs 15%, P = 0.01).
CONCLUSION(S): Despite the lack of signicant differences in several pre-operative
factors that could potentially affect post-operative outcomes such as smoking his-
tory and BMI, African-Americans were more likely to require repeat surgery com-
pared to Caucasians. In addition, African-Americans were more likely to require a
blood transfusion peri-operatively. The disparities cannot solely be attributed to
healthcare access or utilization since there were no differences in types of insur-
ance or preoperative medical treatments between the two groups. Further large
scale studies are required to identify potential reasons for these outcomes.
P-108
Cost-Effectiveness of Infliximab versus Colectomy for Severe Ulcerative Colitis:
A Markov Analysis
Stefan Holubar, Breanne Piazik, Kathleen Xu, Parambir Dulai, Anne Tosteson,
Corey Siegel, Samuel Finlayson
Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
BACKGROUND: Chronic ulcerative colitis (CUC) is a chronic disease that affects
approximately 750,000 persons in North America, up to 30% of whom will require
surgery for refractory disease. When patients are on standard medications, a
common question is whether to initiate biologic therapy with iniximab (IFX) or
proceed directly to colectomy. Iniximab has an annual cost of >$20,000, with
rare but life-threatening complications. Alternatively, immediate colectomy has a
one-time cost of >$40,000 and its own short- and long-term risks. A recent deci-
sion-analysis suggested surgery was the more cost-effective strategy, but did not
include complications specic to iniximab or colectomy. Thus we aimed to con-
struct a Markov decision model to determine the most cost-effective manage-
ment strategy for CUC taking into account both benets and risks of therapeutic
options.
METHODS: A Markov analysis was constructed which assessed the cost-effective-
ness of iniximab or colectomy for CUC refractory to non-biologic therapy. Our
base case was a 30 year old male ulcerative colitis patient, refractory to Asacol, 6-
MP/AZA, and high-dose corticosteroids. The model included 5 major health states
(remission on IFX, ileostomy with rectal stump, ileal pouch-anal anastomosis, per-
manent ileostomy, and death). The model included strategy specic risks for IFX
including disease progression (resulting in colectomy), lymphoma, colorectal can-
cer, and life-threatening infection. Surgery specic risks included perioperative
death, operative stoma complications, and pouch complications including pou-
chitis and pouch excision. Relevant probabilities, costs, and utilities were
obtained from the medical literature. Standard discount rate of 3% was applied
to both costs and post-colectomy quality of life. In our primary analysis our
model was run for 70 years using TreeAge Pro 2012 (Williamstown, MA). Results
are reported in US dollars and quality-adjusted life years (QALYs) based on Euro-
QoL 5D.
RESULTS: Overall, the surgery strategy was found to be the more cost-effective
strategy resulting in fewer dollars spent and more QALYs gained (total costs of
the surgery strategy = $270,477.74 with 18.34 QALYs gained vs. total costs of IFX
strategy = $305,705.34 with 16.59 QALYs gained). Our model was sensitive to an-
nual IFX costs (Figure 1), the post-colectomy utility discount rate (Figure 2), and
the model length (Table 1). Surgery was no longer the less costly strategy if the
annual cost of IFX was <$7,243 (vs. $22,400 in the base case), and surgery did
Figure 2.
Figure 1.
not result in improved quality of life if discounting of the post-colectomy state
was >12% (vs. 3% in the base case). When the model length was decreased to 1-
or 2-years, the IFX strategy dominated, but at all other model lengths, surgery
dominated.
CONCLUSION(S): Our model, which included complications of both surgery and
IFX, suggested that for patients who are failing maximal non-biologic medical
therapy for chronic ulcerative colitis, IFX therapy is a cost-effective short-term
strategy, while surgery is the cost-effective long-term strategy. Given the sensitiv-
ity of our model to discounting of future health states, patient perceptions of
treatments for ulcerative colitis are a vital part of the decision-making process in
this population.
P-109
Intestinal Transplantation for End Stage Crohns Disease: Therapeutic Efficacy
and Disease Recurrence
Darlene Koritsky, Guilherme Costa, Geoffrey Bond, Bonnie Schuster, Mary Rob-
erts, Barbara Hoffman, William Stein, Kyle Soltys, Hiroshi Sogawa, Erin Rubin,
Miguel Regueiro, Kareem Abu-Elmagd
University of Pittsburgh Medical Center, Pittsburgh, PA, USA
BACKGROUND: Background: Intestinal transplantation has recently evolved and
more frequently utilized to rescue patients with irreversible intestinal failure who
no longer can be maintained on TPN therapy. End stage Crohns disease has
been the second leading indication for transplantation in the adult population.
This is the rst study to address the procedures therapeutic efcacy and the
impact of disease recurrence on long-term outcome.
METHODS: Methods: Between May 2, 1990 and June 30, 2012, a total of 309 con-
secutive adult patients received 342 intestinal and multivisceral transplantations.
Of these, 57 (18%) suffered recalcitrant Crohns disease with irreversible intestinal
failure for a mean duration of 55 years. All patients failed TPN therapy with
multiple line infections (94%), limited venous access (83%), and signicant liver
damage (80%). The male to female ratio was 1:1.7 with a mean age of 43 10
years. All patients underwent multiple abdominal surgeries with proctocolectomy
in 36 (63%). Simultaneous hepatic replacement was required in 12 (21%) patients
due to end stage liver failure with a mean serum bilirubin of 9 11 mg/dl. The
remaining 45 (79%) patients received liver-free visceral allografts with intestine
alone in 43 and modied multivisceral graft including the stomach, duodenum,
pancreas, and intestine in 2. Positive lymphocytotoxic crossmatch was docu-
mented in 14 (25%) recipients. All donors were cadaveric, ABO identical with ran-
dom HLA crossmatch. Rejection prophylaxis was tacrolimus based in all patients
with utilization of induction (cyclophosphamide/daclizumab) therapy in 8 (14%)
and recipient pretreatment with rATG/alemtuzumab in 37 (65%) recipients.
RESULTS: Results: With a mean follow-up of 54 48 months, 33 (58%) of the
Crohns disease patients are currently alive with a retransplantation rate of 7%.
Acute and chronic rejection was the leading cause of graft loss with an overall
incidence of 56%. The actuarial patient survival rate was 90% at 1 year, 74% at 3
years, 56% at 5 years, and 43% at 10 years with respective graft survival of 86%,
65%, 53%, and 42%. Inclusion of the donor liver was associated with better long-
term survival outcome with a 10-year survival rate of 57% for both patient and
graft. Recipient pretreatment signicantly improved patient survival with 1, 3, 5,
and 10 year survival rates of 92%, 79%, 61% and 61%, respectively. All survivors
achieved full nutritional autonomy enjoying unrestricted oral diet. Disease recur-
rence was histologically documented in 4 (7%) allografts at 3, 15, 18, and 19
months from the time of transplantation with no impact on graft function. With
similar distribution of type of transplanted organs and immunosuppression, there
was no signicant (P = 0.6) difference in survival between the Crohns and non-
Crohns patients. However, the cumulative risk of graft loss due to acute and
chronic rejection was modestly higher in the Crohns disease compared to the
non-Crohns disease patients.
CONCLUSION(S): Conclusion: Intestinal and multivisceral transplantation is a life-
saving and an effective therapy for patients with end stage Crohns disease. Dis-
ease recurrence is very low and at best histologic with no signicant impact on
survival outcome and graft functions.
P-110
Complication Rates After Bowel Resections for Crohns Disease: A Brazilian
Single-Center Comparison Between Laparoscopic And Conventional Surgery
Paulo Kotze, Vinicius Abou-Rejaile, Ivan de Barcelos, Eron Miranda,
Juliana Martins, Juliana Rocha, Lorete Kotze
Cajuru University Hospital - Catholic University of Parana, Curitiba, Parana, Brazil
BACKGROUND: Signicant advances in medical therapy for Crohns disease (CD)
occurred in the last 12 years, mainly due to the introduction of anti-TNF therapy.
Laparoscopic colorectal surgery represented the most important advance on sur-
gical treatment in the management of CD, as it also had developed in the treat-
ment of other conditions. The advantages of the laparoscopic procedures, such
as shorter hospital stay, lower bleeding and better cosmesis were also noticed in
resections for CD. There is a tendency for lower complication rates after laparo-
scopic bowel resections as compared to open surgery. The aim of this study was
to analyze and compare the complication rates after bowel resections for CD
between the two approaches in a Brazilian case series.
METHODS: This is a retrospective longitudinal study, including CD patients submitted
to bowel resections from a single Brazilian Inammatory Bowel Diseases (IBD) referral
center, treated between January 2008 and June 2012, with laparoscopic surgery (LS)
or conventional surgery (CS). A review of electronic charts was performed, with a spe-
cic protocol. Variables analyzed: age at surgery, gender, Montreal classication,
smoking, concomitant medication, type of surgery, surgical approach, presence and
type of complication up to 30 days after the procedures. Complications were dened
as medical (urinary tract infection, pneumonia, ileus, pancreatitis and central venous
catheter infection) or surgical (abdominal abscess, stula, anastomotic leakage and
wound infection). Readmission and reoperation rates, as well as mortality, were also
analyzed. Patients were allocated in two groups regarding the type of procedure (LS
or CS), and complication rates and characteristics were compared. Statistical analysis
was performed with Mann Whitney test (quantitative variables) and chi-square test
(qualitative variables), with P < 0.05 considered signicant.
RESULTS: A total of 46 patients (25 men) were included (16 submitted to laparo-
scopic surgery), with mean age of 38.1 (612,7) years. The groups were considered
homogeneous according to age, gender, CD location, perianal disease and concom-
itant medications. There were more patients with stulizing CD on the CS group (P
= 0.029). The most common procedure performed was ileocolic resection on both
groups (56.7% of the CS and 75% of the LS patients - P = 0.566). Overall, total com-
plications (surgical and medical, including minor and major issues) occurred in 60%
(18/30) of the CS group and 12,5% (2/16) of the LS group (P = 0.002). Wound infec-
tion was the most frequent complication (10/30 on CS and 1/16 on the LS groups).
There were 3 deaths in the CS group. Specic analysis of each complication did not
demonstrate any difference between the groups regarding abdominal sepsis, uri-
nary tract infections, pneumonia, readmission, reoperations and deaths (P = 0.074).
CONCLUSION(S): There was a higher complication rate in patients operated with
CS as compared to LS. This was probably due to patient selection for the
Figure 2.
laparoscopic approach, with severe cases, mostly due to stulizing abdominal CD,
being operated mainly by open surgery. Randomized controlled trials can lead to
better conclusions regarding this topic. However, LS tends to be the recom-
mended approach in most cases of non-complicated CD.
P-111
Combined Therapy With Surgery and Anti-TNF Therapy for Perianal Crohns
Disease: Seton Withdrawal Timing Data From a Brazilian Case Series
Paulo Kotze
1
, Idblan Albuquerque
2
, Andre Moreira
3
, Claudio Coy
4
, Ana Pugas de
Carvalho
3
, Galdino Formiga
2
, Raquel Leal
4
, Maria de Lourdes Ayrizono
4
, Wanessa
Tonini
1
, Marcia Olandoski
1
1
Cajuru University Hospital - Catholic University of Parana, Curitiba, PR, Brazil,
2
Heliopolis Hospital - Sao Paulo, Brazil,
3
Rio de Janeiro State University (UERJ), Rio
de Janeiro, Brazil,
4
Unicamp, Campinas, Sao Paulo, Brazil
BACKGROUND: Perianal stulizing Crohns disease (CD) is one of the most severe
phenotypes of inammatory bowel diseases (IBD). Combined therapy with exami-
nation under anesthesia, seton placement and anti-TNF therapy is the most com-
mon strategy for the management of this condition. There is still lack of data
regarding the proper timing of seton withdrawal after induction therapy with
anti-TNF agents, and the criteria for its determination is undened. The aim of
this study was to analyze the timing of seton withdrawal in a Brazilian case series
of perianal stulizing CD patients.
METHODS: This was a retrospective observational study that included Brazilian
patients with perianal stulizing CD submitted to combined therapy with exami-
nation under anesthesia and seton placement followed by anti-TNF therapy, from
4 IBD referral centres, from January 2009 to June 2012. Electronic chart review
was performed and data were inputted in a specic protocol. We analyzed
patients demographic characteristics, Montreal classication, concomitant medi-
cation, type of biological agent, classication of the stulae, occurrence of peria-
nal complete remission, number of setons placed and timing of seton withdrawal.
Complete perianal remission was dened as absence of drainage from the stula
tracks without after seton removal.
RESULTS: A total of 78 patients were included, 44 females (55.8%) with a mean age
of 33.8 (615) years. Medium time of CD diagnosis was 88.9 (676.8) months. Mon-
treal Classication: age at diagnosis (A1 = 21.8%, A2 = 50% e A3 = 28.2%); disease
location (L1 = 0%, L2 = 7.7%, L3 = 78.2% e L4 = 14.1%); disease phenotype (B3 in
100% of the cases). Azathioprine was used in combination with the anti-TNF agents
in 76.6% of the cases, 66.2% of the patients were treated with Iniximab (IFX) and
33.8% with Adalimumab (ADA). Complex stulae were found in 52/78 patients
(66.7%). Medium follow-up period was 48.2 months, and 52,6% of the patients had
complete perianal remission. The average number of setons placed was 2 (61.4)
per patient, ranging from 1 to 7. Seton withdrawal occurred in 51 patients (65.3%),
performed in an average period of 7.3 (66,4; 1 to 36) months.
CONCLUSION(S): After combined surgery with seton placement and anti-TNF ther-
apy, approximately 2/3 of the patients had their setons removed in this study,
and the average period for the withdrawal was 7.3 months. There is still unclear
criteria for the denition of the proper timing for seton withdrawal with the aim
of perianal complete remission, and an individualized approach is recommended.
P-112
Single Incision Laparoscopic Ileocecectomy for Pediatric Crohn Disease
Constantine Saites, Sigrid Bairdain, Chueh Lien, Victor Johnson, David Zurakow-
ski, Bradley Linden
Boston Childrens Hospital, Boston, MA, USA
BACKGROUND: The single-incision laparoscopic technique has become an increas-
ingly popular alternative for conventional pediatric laparoscopic surgery. Ileoce-
cectomy is a mainstay surgical therapy for pediatric Crohn disease. However,
there are few descriptions on the technique and experience of single-incision lap-
aroscopic ileocecectomy (SIL-I) in the pediatric population. We describe our tech-
nique and initial experience with SIL-I for the surgical management of pediatric
patients with Crohn disease.
METHODS: Records of all patients with Crohn disease who underwent SIL-I
between 2010-2012 were retrospectively reviewed. Variables including patient
demographics, operative information, length of stay, and postoperative complica-
tions were collected. The operation is generally performed by placing an Olym-
pus Triport 15
VR
, rst releasing adhesions and separating the terminal ileum from
associated abscess, when one was present. The right colon is then mobilized dis-
tally around the hepatic exure to the level of the duodenum. This gives
adequate mobilization to allow a safe extracorporeal anastomosis. The proximal
extent of disease is identied, and the mesentery is divided with the ligature to
the level of the ileocecal valve. The small intestine is divided with a laparoscopic
stapler. The port is removed, and the incision is extended to approximately 3.5
cm through the base of the umbilicus. The specimen is externalized, remaining
mesentery to the cecum is taken, and the right colon is divided using a surgical
stapler. The anastomosis is performed by creating a 12 cm, side-by-side, func-
tional end-to-end stapled anastomosis.
RESULTS: Thirty-one SIL-I cases (mean patient age 17 6 4 years) were reviewed.
The average time from diagnosis of Crohn disease to surgery was 4.8 6 4.5 years.
Seven patients (23%) were below the 5th percentile for weight preoperatively.
The major indication for surgery was obstruction/stricture (n = 23) followed by
refractory inammatory disease (n = 18). Three patients had undergone prior ab-
dominal operation. Twenty patients underwent epidural placement and four
patients underwent ureteral stent placement under the same anesthetic prior to
SIL-I. There were no operations where an additional laparoscopic port was placed;
however, one operation required conversion to a midline laparotomy in the set-
ting of extensive interloop abscesses, dense adhesions and interloop stulae. All
anastomoses were stapled extracorporeally. The mean operative time was 3.8 6
1.1 hours. There were no intraoperative complications. Five postoperative compli-
cations were documented, including one supercial wound infection, 2 intraabdo-
minal abscesses (1 within 30 days of operation, 1 more than 3 months post-pro-
cedure), 1 PICC-associated bacteroides bacteremia, and 1 small bowel
obstruction. Average postoperative length of stay was 7.1 6 2.9 days, and me-
dian length of follow up was 5.27 months.
CONCLUSION(S): This is the largest reported series of SIL-I in the pediatric surgery
population. Our presented technique is safe, effective, and may be adopted by
any pediatric surgeon with laparoscopic experience. Further studies are necessary
to demonstrate both cost-effectiveness and long-term outcomes of SIL-I versus
conventional laparoscopic techniques.
P-113
Serum Infliximab Trough Levels Above 1.0 Mg/mL Are Required to Obtain Clini-
cal Efficacy in Patients With Crohns Disease
Hirotsugu Imaeda, Akira Andoh, Kenichiro Takahashi, Takehide Fujimoto, Hiro-
mitsu Ban, Shigeki Bamba, Yoshihide Fujiyama
Shiga University of Medical Science, Otsu, Shiga, Japan
BACKGROUND: Iniximab created new perspectives for the treatment of moder-
ate to severe Crohns disease (CD) who have an incomplete response to conven-
tional therapies. However, effective serum concentrations of iniximab remain
unclear. In this study, we analyzed and compared clinical markers and serum ATI
(anti-iniximab antibodies) levels in two groups of CD patients (one group exhib-
ited positive trough iniximab levels and another group was negative).
METHODS: Fifty CD patients under iniximab maintenance therapy were enrolled.
Serum iniximab trough levels, clinical markers (ESR, CRP, serum albumin, and
fecal calprotectin) were analyzed. Serum ATI levels and trough levels of iniximab
were determined by the new method of enzyme-linked immunosorbent assay
(ELISA). This method doesnt depend on serum free iniximab, so true ATI levels
can be detected directly. (Figure 1) The cutoff value of ATIs were 10.2 lg/mL-c.
Concentrations of trough iniximab levels of above 1.0 lg/mL were dened as
positive.
RESULTS: CRP levels, ESR, ATI levels and fecal calprotectin levels were signicantly
lower in the patients positive for iniximab trough levels (above 1.0 lg/mL) than
the patients negative for iniximab trough levels (CRP; P = 0.004, ESR; P = 0.011,
ATIs; P = 0.011 and fecal calprotectin; P = 0.043). (Figure 2) Serum albumin levels
were signicantly higher in the patients positive iniximab trough levels than the
patients negative for iniximab trough levels (P = 0.0001). Dose-escalation of inix-
imab from 5 mg/kg to 10 mg/kg induced a signicant increase in iniximab trough
Figure 1.
levels and a signicant decrease in CRP levels in 8 patients who revealed mild ele-
vation of ATIs (all were ATI levels under _35 lg/mL-c), but was not effective for 2
patients who had a high levels of ATIs (ATI levels _52 lg/mL-c). (Figure 3)
CONCLUSION(S): These observations suggest that serum iniximab trough levels
above _1.0 lg/mL might be required for positive clinical responses to iniximab.
High ATI levels suggest a negative response to dose-escalation of iniximab.
P-114
Intensified Anti-TNF-Alpha Therapy and Bacterial-DNA Translocation in Patients
With Mutated NOD2/ATG16L1-Combined Genotypes
Ana Guti errez
1
, Michael Scharl
2
, Laura Sempere
1
, Ernst Holler
3
, Pedro Zapater
1
,
Isabel Almenta
1
, Jose Gonzalez-Navajas
1
, Jose Such
1
, Reiner Wiest
4
,
Gerhard Rogler
2
, Ruben Frances
1
1
Hospital General Universitario de Alicante, Alicante, Spain,
2
University Hospital
Zurich, Zurich, Switzerland,
3
Regensburg University, Regensburg, Germany,
4
Uni-
versity Clinic for Visceral Medicine, Bern, Switzerland
BACKGROUND: Bacterial-DNA translocation is a frequent event in patients with
Crohns disease (CD), which etiology has been related with NOD2 and ATG16L1
gene mutations. We evaluated whether the presence of bacterial-DNA transloca-
tion and of these genotypes had an impact on anti-TNF-alpha therapy schedules.
METHODS: CD patients on anti-TNF-alpha therapy admitted or followed at our
hospital were included. NOD2 and ATG16L1 genotypes, bacterial-DNA presence,
TNF-alpha and free anti-TNF-alpha levels in blood were determined.
RESULTS: Fifty-two patients were included, 30 on Iniximab and 22 on Adalimu-
mab. The proportion of patients being on an intensied therapy was signicantly
higher in the groups with either a varNOD2/wtATG16L1 or a varNOD2/varATG16L1
genotype. No statistically signicant differences were observed in the percentage
of smokers, the time from diagnosis or the time from initiation of anti-TNF therapy
between intensied and non-intensied patients, all of which could affect the need
for intensication. Twenty percent of patients on anti-TNF therapy showed bacte-
rial-DNA in blood. Of those, 50% were on an intensied drug schedule vs 33% of
patients without bacterial-DNA (P = ns). No differences were observed for the dis-
tribution of each anti-TNF-alpha between patients, either grouped by genotype or
by the presence of bacterial-DNA. Signicantly decreased levels of serum free anti-
TNF-alpha were observed in the varNOD2/varATG16L1 genotype, despite a signi-
cant number of patients being on an intensied schedule. The presence of bacte-
rial-DNA further decreased free serum anti-TNF-alpha levels. Since interactions
between biologics and azathioprine or methotrexate have been described, we
repeated the analysis excluding patients under combined therapies (n = 26). The
results were comparable, although we also detected a statistically signicant differ-
ence in the group of varNOD2/wtATG16L1 patients. Further, variability in the group
of patients with a wild-type NOD2/ATG16L1 genotype was signicantly lower. We
designed an in vitro experiment on neutrophils obtained immediately before anti-
TNF-alpha infusion (trough levels) of 12-patient genotype-stratied subgroups with-
out bacterial-DNA. Levels of TNF-alpha were signicantly increased after 24-hour E.
coli bacterial-DNA stimulation in the subgroups bearing a variant vs wild-type
NOD2 genotype. No differences in apoptotic activity of neutrophils at this time-
point were observed between groups. Forty-eight hours after anti-TNF-alpha addi-
tion, levels of TNF-alpha were signicantly decreased in all subgroups with wild-
type NOD2. This reduction was not observed in supernatants with variant NOD2.
On the other hand, a signicant reduction in free anti-TNF-alpha levels was found
in the supernatants of the subgroups carrying a variant NOD2 genotype, either
alone or combined, compared with wild-type NOD2. No differences in apoptotic
activity of neutrophils between groups were observed at this time-point either.
CONCLUSION(S): Results identify a genotype-based subgroup of patients who
might require more aggressive therapeutic programs to control inammation and
bacterial-DNA translocation episodes.
P-115
DNA Methylation and Microbiota Separation of Ulcerative Colitis in Treatment
Naive Children
Richard Kellermayer
1
, Dorottya Nagy-Szakal
1
, Ronald Harris
1
, Stephen Cox
2
,
Scot Dowd
3
, Harland Winter
4
, Sabina Mir
1
1
Baylor College of Medicine, Houston, TX, USA,
2
Research and Testing Laboratory,
Lubbock, TX, USA,
3
MR DNA (Molecular Research), Shallowater, TX, USA,
4
Massa-
chusetts General Hospital, Boston, MA, USA
BACKGROUND: Inammatory bowel diseases (IBD, including Crohn disease [CD]
and ulcerative colitis [UC]) are emerging globally supporting the hypothesis that
Figure 2.
Figure 3.
environmental factors may play a role in their pathogenesis. Commensal microbes
and epigenetic characteristics, such as DNA methylation can respond to environ-
mental changes and have been implicated in triggering these diseases. Therefore,
we evaluated the relationship between colonic mucosal microbiota and DNA
methylation in untreated pediatric IBD
METHODS: The mucosal microbiota was studied by 454 pyrosequencing of the
bacterial 16S rRNA gene and the fungal small subunit (SSU) ribosomal region in
transverse colonic biopsy specimens from 26 controls, 16 untreated pediatric CD
(15 treatment na ve), and 6 UC cases (5 treatment na ve). Genome-wide DNA
methylation was examined by Innium HumanMethylation450 BeadChip Kits in a
subset of treatment na ve samples (10 controls, 10 CD, and 4 UC). Validation of
the DNA methylation results was performed on an independent cohort (12 con-
trols, 5 CD, 5 UC) and by bisulte-pyrosequencing of select loci.
RESULTS: There was no consistent DNA methylation association with CD. How-
ever, UC had a large number of signicant DNA methylation associations (4302
shared CpG sites between discovery and validation cohort; false discovery rate:
FDR<0.01). The UC-linked methylation changes associated with genes involved in
cell adhesion and communication, defense and immune responses. UC microbiota
separated from controls and CD (P = 0.048). The genus Faecal bacterium was
increased in UC (U test P = 0.013, FDR = 0.24). UC associated DNA methylation
changes correlated with bacterial taxa abundance at reads with incomplete or
uncertain genus assignment belonging to the families Eubacteriaceae and
Lachnospiraceae.
CONCLUSION(S): UC associated DNA methylation and microbiota changes overlap
at select loci and taxa. These ndings may have etiologic, diagnostic and thera-
peutic relevance for IBD.
P-116
A Traditional Chinese Herbal Formulation - FAHF-2 for the Treatment of
Crohns Disease
David Dunkin, Ying Song, Stephanie Dahan, Clare Ceballos, Keith Benkov,
Xiu-Min Li, Lloyd Mayer
Mount Sinai School of Medicine, New York, NY, USA
BACKGROUND: The prevalence of Crohns disease (CD) is increasing. Current
therapies can have serious side effects. We developed an herbal formula, FAHF-2,
which is based on a traditional Chinese herbal formula that has long been used
in China to treat colitis. We sought to investigate the anti-inammatory effects of
FAHF-2 on murine models of colitis, RAW264.7 macrophages, and peripheral
blood mononuclear cells (PBMCs) from children with CD.
METHODS: A CD45RBhi transfer model of colitis was utilized to assess the effective-
ness of FAHF-2. Outcome was assessed by weight loss, histology and cytokine pro-
duction from splenocytes and MLN cells. The effects of FAHF-2 on TNF-a produc-
tion were assessed in vitro and activation of NF-jB in LPS-stimulated RAW264.7
cells was determined by Western blot. PBMCs isolated from 26 CD children and 17
non-IBD children were cultured for 24 hours with or without FAHF-2 in the pres-
ence or absence of LPS. Cytokine and chemokine production in the culture super-
natants were measured by multiplex bead immunoassay. The effect of FAHF-2 on
TNF-a producing monocytes and T cells was determined by ow cytometry.
RESULTS: FAHF-2 treatment in a murine model of colitis signicantly decreased
weight loss (11.3% vs. 19.2%, P < 0.05) and caused less inammatory inltrates (P
< 0.05) than untreated controls. FAHF-2 treatment signicantly decreased TNF-a,
IFN-c and IL-17 production by splenocytes and MLN cells stimulated with anti-
CD3/CD28. (P < 0.05) Pre-incubation of RAW267.4 cells with FAHF-2 decreased
TNF-a production in a dose dependent manner and caused decreased IjB-a
phosphorylation (P < 0.001), IjB-a degradation (P < 0.001) and AKT phosphoryla-
tion (P < 0.01) following LPS stimulation without inducing toxicity. A signicant
increase in TNF-a was detected in PBMC cultures stimulated with LPS from CD
subjects as compared with PBMC cultures from non-IBD children. FAHF-2 treat-
ment in vitro signicantly reduced LPS-induced TNF-a, IL-12, IFN-c, IL-2, IP-10,
MIG, and MIP-1b production, and increased GM-CSF production by PBMCs from
CD subjects (n = 14). FAHF-2 also signicantly reduced the percent of TNF-
aCD14 monocytes in LPS-stimulated PBMCs from CD and the percent of TNF-
aCD3 T cells in anti-CD3/28 mAb-stimulated PBMCs from CD (n = 4).
CONCLUSION(S): FAHF-2 was effective in reducing weight loss, colitis and proin-
ammatory cytokines in a murine model. It inhibited pro-inammatory cytokine
production and the number of TNF-a CD14 LPS stimulated monocytes and
TNF-aCD3 CD3/CD28 stimulated T cells in PBMCs from CD children. FAHF-2 in-
hibition of LPS-stimulated TNF-a production may be due, at least partially, to
blocking the NF-jB pathway. Further clinical investigation of FAHF-2 for the treat-
ment of CD is warranted.
P-117
The Subgingival Oral Microbiome in Pediatric Patients With Crohns Disease
Judith Kelsen
1
, Leah Posivak
1
, Aubrey Bailey
2
, Stephanie Grunberg
2
,
Robert Baldassano
1
, James Lewis
2
, Fredric Bushman
2
, Gary Wu
2
1
The Childrens Hospital of Philadelphia, Philadelphia, PA, USA,
2
The University of
Pennsylvania, Philadelphia, PA, USA
BACKGROUND: IBD is associated with a dysbiotic gut ora. As oral manifestations
are commonly found in Crohn disease (CD), we hypothesized that the oral micro-
biome may also be dysbiotic in patients with IBD. We characterized the subgingi-
val oral microbiota in a longitudinal cohort of pediatric patients with CD and
healthy controls to determine association with disease activity.
METHODS: Subgingival plaque samples were obtained longitudinally from
patients with CD and healthy controls at 2 time points. Samples were obtained
from patients with CD prior to iniximab and at week 8 of therapy. Samples were
analyzed by 16S rDNA 454 sequencing. Clinical records and diet inventories were
obtained. Disease activity was measured by Pediatric Crohn Disease Activity Index
(PCDAI) and fecal calprotectin (FCP).
RESULTS: 13 patients with CD and 13 controls were included. 85% of patients
with CD demonstrated a decrease in PCDAI from severe disease, mean 37.5, to
mild or quiescent disease at week 8, mean 13. There was a 77% decrease in the
FCP from a mean 819, to a mean 401 at week 8. We used unweighted UniFrac to
monitor changes in community membership, and found that the CD community
showed greater dispersion than controls (P < 0.0001), suggestive of dysbiosis in
the oral bacterial community. These alterations were observed in the absence of
clinical gingivitis.
CONCLUSION(S): This is the rst study to demonstrate signicant alterations in
the subgingival oral microbiome in the absence of clinical gingivitis. Increased
dispersion of the cohorts with CD suggests loss of regulation of the normal com-
munity. Additional analyses are underway to identify the taxa responsible for this
nding. Newly diagnosed patients are being recruited to determine disease effect
on the oral and gut microbiome.
P-118
A Novel Mechanistic Biomarker Panel Predicts Response to Infliximab in
Patients with Crohns Disease
Michael Macoritto, Vy Hoang, Ty Thomson, Daphna Laifenfeld, David Drubin
Selventa, Cambridge, MA, USA
BACKGROUND: Anti-TNF therapies are an important treatment for many patients
with moderate to severe Crohns, yet not all patients respond to these drugs, sug-
gesting variable underlying molecular mechanisms in clinically similar patients. Anti-
TNF therapy has risks, such that treatment of a patient unlikely to respond delays
effective therapy and incurs adverse events. Identication of the different mecha-
nisms driving the disease in clinically similar but molecularly distinct patients will
enable determination of patients driven by TNF as well as those driven by alterna-
tive mechanisms. This in turn can result in prediction of response to anti-TNF thera-
pies, as well as have implications for the development and application of alternative
targeted therapies for Crohns. The overall objective of this research was to develop
and test a gene expression-based mechanistic biomarker panel that can predict
response to iniximab in Crohns Disease patients based on TNF signaling levels.
METHODS: A molecular footprint (MF) for TNF, reecting the downstream signaling
of TNF, was developed from a collection of peer-reviewed literature reporting the
results of TNF modulation on gene expression. The MF included 1853 genes culled
from 691 unique peer reviewed publications. Following the development of the MF,
a transcriptomic data set, GSE9686, originating from a study of 11 patients with pedi-
atric onset Crohns who were treatment-na ve to anti-TNF therapy (Carrey et al.,
2008), was analyzed. Baseline colon biopsies were used to generate gene expression
fold changes by comparison to disease centroid. Individual patients were then strati-
ed for TNF signaling strength by a semi-quantitative scoring algorithm applied to
the genes within the TNF MF. The original 1853 gene MF was narrowed down to a
10 gene biomarker panel resulting in a similar stratication (r = 0.98, P<0.0001), and
was then applied to a second published data set, GSE16879 (Arijs et al, 2009), which
contains baseline data from 19 biologic treatment-na ve Crohns colitis patients prior
to iniximab treatment. Response to iniximab was dened as complete mucosal
healing with a drop of at least 3 points on the histologic score.
RESULTS: Stratifying patients for TNF signaling strength with the rened bio-
marker panel in the pre-iniximab treatment state accurately predicted respond-
ers and non-responders to iniximab in the independent data set (AUROC AUC =
0.92, p < 0.001).
CONCLUSION(S): This preliminary study demonstrates that identication of anti-
TNF responders is possible in patients with Crohns colitis prior to treatment,
based on identication of TNF signaling strength via a 10 gene biomarker panel.
Additional efforts to conrm these initial observations as well as segregate other
molecular subtypes are ongoing.
P-119
Dissecting the IBD Transcriptome
Atle Granlund
1
, Arnar Flatberg
2
, Ann stvik
2
, Ignat Drozdov
3
, Bjrn Gustafsson
2
,
Mark Kidd
4
, Vidar Beisvag
2
, Sverre Torp
2
, Helge Waldum
2
, Tom Christian Martin-
sen
2
, Jan Damas
2
, Terje Espevik
2
, Arne Sandvik
2
1
University of Trondheim, Trondheim, Sr-Trndelag, Norway,
2
Norwegian Univer-
sity of Science and Technology, Trondheim, Norway, Trondheim, Sr-Trndelag,
Norway,
3
Bering Limited, London, United Kingdom,
4
Yale University School of
Medicine, New Haven, CT, USA
BACKGROUND: Since the appearance of whole genome gene expression (WGGE)
analysis, it has been used to analyse mucosal IBD samples. As ulcerative colitis
(UC) and Crohns disease (CD) are clinically distinct, many efforts have been made
to differentiate these at a transcriptional level. Even though several studies have
shown promise in discerning UC and CD, gene expression ngerprinting has not
yet reached the clinic. However, using publicly available data sets from these pre-
vious analyses enable instant cross-platform, cross-laboratory validation of local
analysis. This opens for powerful analysis comparing the two diseases on both a
global and focused gene expression level. We present the to date largest WGGE
analysis of colonic mucosal IBD samples including samples from inamed and un-
inamed tissue from both UC and CD, as well as normal controls. Focusing on
subsets of genes representing areas of particular interest in IBD, T helper (Th) cell
differentiation and antimicrobial peptide (AMP)-related expression, eases the
interpretation of results. A meta-analysis including all available, comparable data
was used to validate and strengthen observations.
METHODS: Colon pinch biopsies drawn from a cohort of IBD patients and healthy
controls were analysed using Illumina whole genome gene expression analysis.
Differential expression (DE) was identied using LIMMA linear model in the R sta-
tistical computing environment. Pearson correlation coefcients were calculated
for DE genes, and networks were enriched for gene ontology (GO) categories.
Sets of genes encoding AMPs and proteins important in Th cell differentiation
were dened and used in the interpretation of the results. All available data sets
were analysed using the same methods, and results were compared on a global
and focused level as T scores.
RESULTS: Gene expression in inamed colon mucosa from UC and CD are remark-
ably similar. The patterns of antimicrobial protein (AMP) and for T helper (Th)
Figure 1.
Figure 2.
Figure 3.
cell-related gene expression were also very similar, except for IL23A which was
consistently higher expressed in UC than in CD. AMPs are generally highly
expressed across all studies, with the notable exception of previously identied
down regulation of DEFB1 and LEAP2. DEFB1 expression is strongly correlated
with down regulation of PPARG (rho: 0.73), a protein known to be related to
DEFB1 expression. Un-inamed tissue from patients demonstrated minimal differ-
ences from healthy control.
CONCLUSION(S): There is little evidence of reproducible differences between
WGGE analysis of UC and CD. This suggests that once the inammation is estab-
lished, the two diseases follow a similar path with regard to mucosal gene
expression. There is no observable difference in the Th subgroup involvement
between UC and CD based on expression in colon mucosa. Th1/Th17 related
expression, with little Th2 differentiation, dominated both diseases. The different
IL23A expression between UC and CD suggests an IBD subtype specic role.
AMPs are strongly overexpressed in IBD. This IBD WGGE study for the rst time
integrates external data sets, providing a sound background for further research
on IBD pathobiology. This strategy proves powerful, and facilitates result interpre-
tation and validation.
P-120
Tumor Suppressor Mir-193a-3p Is Down-Regulated in UC-Associated Neoplasia
Joel Pekow, Katherine Meckel, Ursula Dougherty, Marc Bissonnette
University of Chicago, Chicago, IL, USA
BACKGROUND: Mechanisms of cancer development in patients with chronic ulcer-
ative colitis (UC) remain poorly understood. Changes in miRNAs have been impli-
cated in the pathogenesis of many cancer types, although there is limited data
describing miRNAs in IBD-associated cancer. We sought to determine the expres-
sion of miRNAs in UC-associated neoplastic tissue in order to provide insight into
mechanisms of tumorigenesis and develop markers for neoplasia in this high-risk
population.
METHODS: We extracted total RNA from formalin xed parafn embedded colonic
tissues (FFPET) from 10 normal controls (N), 9 UC patients without dysplasia (UC),
9 UC dysplastic lesions (UCD: 3 HGD and 6 CRC), and 10 adjacent non-dysplastic
tissues in UC patients harboring a dysplastic lesion (UCrD). Following extraction
of total RNA, the miRNA prole was quantied using the Nanostring Technologies
nCounter analysis system in 31 patients. Real time PCR of miR-193a-3p was per-
formed in all patients and values were normalized to RNU48 as reference gene.
Total RNA was also extracted from the rectosigmoid colon of 22 patients with
quiescent UC without dysplasia and 20 patients harboring neoplasia proximal to
the rectum. Gene expression in these samples were analyzed using the Illumina
HumanHT-12 v4 expression beadchip.
RESULTS: We identied thirteen miRNAs which were dysregulated in both UCD
and UCrD compared to UC without dysplasia, representing a eld effect of
miRNA changes present in non-dysplastic tissue in UC patients harboring remote
dysplasia. Of these miRNA, miR-193a-3p showed the greatest down-regulation
and we further examined its expression by real time PCR in a larger cohort of
patients. Compared to normal controls, expression of miR-193a-3p was down-
regulated 2.9-fold in UC (P = 0.04), 5.3-fold in UCD (P = 0.003), and 3.3-fold in
UCrD (P = 0.03). Compared to UC without dysplasia, miR-193a-3p was down
regulated 1.9-fold in UCD (P = 0.05) and 1.2-fold in UCrD (P = 0.7). Supporting
its role as a tumor suppressor, several miR-193a-3p targets predicted in silico
were up-regulated on gene expression array in UC patients harboring remote ne-
oplasia compared to those without neoplasia. These included genes involved in
IL-17, TGF-beta, and IGF-1 signaling pathways.
CONCLUSION(S): miRNA changes, including down-regulation of miR-193a-3p,
occur in both neoplastic and adjacent non-neoplastic tissue in patients with UC.
Although changes in miR-193a-3p have not been described in colon cancer, this
miRNA is down-regulated in other cancers and may be epigenetically regulated
through hypermethylation. As several predicted targets of miR-193a-3p involved
in tumorigenesis are up-regulated in the mucosa of patients harboring neoplasia,
we postulate that down-regulation of miR-193a-3p is important in neoplastic
transformation in UC and is a candidate biomarker for neoplasia in this high-risk
population.
P-121
Disease Activity Is Associated With Increased Bacterial Diversity in
Michael Docktor
1
, Yaoyu Wang
2
, Shelly Abramowicz
3
, Sarah Weber
4
,
Heike Boisvert
5
, Margaret Duncan
5
, Athos Bousvaros
1
, Bruce Paster
5
1
Center for Inflammatory Bowel Disease, Boston Childrens Hospital, Harvard Medi-
cal School, Boston, MA, USA,
2
Center for Cancer Computational Biology, Boston,
MA, USA,
3
Department of Oral and Maxillofacial Surgery Harvard School of Dental
Medicine, Dept of Plastic and Oral Surgery Boston Childrens Hospital, Boston, MA,
USA,
4
Center for Inflammatory Bowel Disease, Boston Childrens Hospital, Boston,
MA, USA,
5
Department of Microbiology, Forsyth Institute, Cambridge, MA, USA
BACKGROUND: Our prior work has demonstrated the oral microbiome to be less
diverse in children with Inammatory Bowel Disease (IBD) as compared to
healthy, non-IBD controls. As in our previous studies, we used the Human Oral
Microbe Identication Microarray (HOMIM) to further elucidate the alterations
within the oral microora in IBD (Docktor et al, IBD Journal 2011). In this investi-
gation, we chose to evaluate the impact of disease activity on the oral bacterial
community.
METHODS: We obtained 65 oral samples (32 tongue, 29 buccal mucosa brushings
and 4 saliva samples) from 34 unique individuals with IBD. Ages ranged from 7-
23 years (median 15 years) in CD, 4-21 years (median 15 years) in UC and 16
years in the single IBD-indeterminate patient. The 34 pediatric subjects included
21 Crohns disease (CD), 12 Ulcerative colitis (UC) and 1 IBD-indeterminate. All IBD
patients had their disease activity assessed at the time of sample collection using
standard indices (Pediatric Ulcerative Colitis Activity Index [PUCAI] and the Pediat-
ric Crohns Disease Activity Index [PCDAI]). 23 subjects had inactive disease and
11 subjects were deemed active (either mild, moderate or severe). Bacterial DNA
was isolated using standard techniques and PCR amplied with universal 16S
rDNA primers. PCR products were labeled in a nested PCR with a Cy3 uorescent
dye and hybridized to the HOMIM microarray. This technology allows for the si-
multaneous detection of nearly 300 of the most predominant oral bacterial spe-
cies. Principal Component Analysis (PCA), linear model, and Shannon Diversity
Index (SDI) were employed to determine species and phylum-level differences
among groups.
RESULTS: Using SDI, we identied an overall increase in diversity in patients with
active IBD vs. quiescent disease. Linear model analysis demonstrated a marked
loss among species from Firmicutes and Proteobacteria and an increase in Bacter-
oidetes in active disease. Clustering of samples based on disease activity was
noted given similar population structure observed by PCA (Figure 1- Red circles
= Active IBD, Blue triangles = Inactive IBD).
CONCLUSION(S): Our ndings suggest that patients with active IBD have a sys-
temic alteration in their bacterial communities as evidenced by an altered oral
microbiome. Specically, patients with active disease exhibited a loss of commen-
sal microora within the Firmicutes (particularly Streptococcus genus), and an
expansion of Bacteroidetes. Further studies are underway to assess confounding
factors (i.e., age, immunosuppression) and to quantitatively determine species-
level differences between IBD and healthy controls.
P-122
YI
Clinical Characteristics and Imaging Features of Small Bowel Adenocarcinomas
in Crohns Disease
Nicholas Weber, Joel Fletcher, Jeff Fidler, John Barlow, Shiv Pruthi, Edward Loftus,
Darrell Pardi, Thomas Smyrk, Brenda Becker, David Bruining
Mayo Clinic, Rochester, MN, USA
Figure 1.
BACKGROUND: Small bowel adenocarcinoma occurs uncommonly in patients
with Crohns disease. It has a poor prognosis, possibly related to difculties in
early diagnosis. There is a paucity of data on clinical characteristics and radiologic
features. We sought to update our institutional experience with Crohns disease
and small bowel adenocarcinoma.
METHODS: Medical records were abstracted to identify all Crohns disease patients
with small bowel adenocarcinoma evaluated at Mayo Clinic, Rochester, MN
between 1976 and 2011. Clinical, demographic, and outcomes data were
obtained for each patient. Pre-operative CT scans were re-evaluated by a gastro-
intestinal radiologist.
RESULTS: Twenty-ve cases (16 males) were identied. Median ages at Crohns
and cancer diagnoses were 22 (range, 15-69) and 54 years (range, 31-73), respec-
tively. Median interval between Crohns diagnosis and cancer detection was 21
years (range, 1-50). Seventeen patients (68%) had a history of small bowel stric-
ture prior to cancer diagnosis. Previous Crohns therapy included corticosteroids
(96%), aminosalicylates (67%), immunomodulators (52%), and anti-TNF agents
(32%). At diagnosis, 14 patients (58%) were receiving corticosteroids, 4 (17%) an
aminosalicylate, 4 (17%) an immunomodulator, 6 (25%) an anti-TNF agent, 2 (8%)
an immunomodulator and anti-TNF agent, and 3 (13%) were on no Crohns ther-
apy. All patients were symptomatic at presentation with abdominal pain (96%),
nausea/vomiting (92%), and weight loss (73%). Bowel perforation was detected in
22% of cases at the time of imaging. Malignancies were identied in the jejunum
(19%) and the ileum (81%). Tumors were typically classied as grade 3 or 4 (91%).
Lymph node involvement or distant metastases were present at diagnosis in
72%. All patients underwent surgical resection, and 9 (38%) received adjuvant
chemotherapy with 5-FU and leucovorin or FOLFOX. Median time from adenocar-
cinoma diagnosis to last visit or death was 0.9 years (range, 0-19.5). Eighteen
(75%) patients had persistent or recurrent adenocarcinoma at last follow-up. Of
patients with recurrent cancer, 5 (50%) had received steroids, 4 (40%) had
received an aminosalicylate, 1 (10%) had received an immunomodulator, 1 (10%)
had received anti-TNF therapy, and 3 (30%) had received no Crohns therapy after
resection. One- and two-year mortality rates were 29% and 50%, respectively.
Twelve patients (48%) had an abdominal CT performed a median of 6 days
(range, 0-24) prior to surgical resection, and six (50%) were CT enterography stud-
ies. On radiologic re-review, the adenocarcinoma was identied in 6 patients
(50%) of which four (66%) were on CT enterography. Lesions were located in the
ileum (66%) or jejunum (33%). CT features included stricture with bowel dilata-
tion (91%), stricture due to a mass lesion (60%), active inammation (36%), and
lymphadenopathy (50%).
CONCLUSION(S): Small bowel adenocarcinoma is an uncommon complication of
Crohns disease but results in signicant two-year mortality. Cross-sectional imag-
ing ndings suggesting the diagnosis include a mass lesion associated with stric-
ture and proximal bowel dilatation, but these ndings often are not present even
in symptomatic patients. While advanced imaging may assist with the pre-opera-
tive diagnosis, the malignancy is often diagnosed at laparotomy and often at an
advanced stage.
P-123
YI
Efficacy of Infliximab as Rescue Therapy for Ulcerative Colitis Refractory to
Tacrolimus
Noritaka Takatsu, Motochika Yasaka, Yutaka Yano, Fumihito Hirai, Toshiyuki
Matsui
Fukuoka University Chikushi Hospital, Chikushino, Fukuoka, Japan
Figure 1.
Figure 2.
BACKGROUND: Little is known about the efcacy of iniximab for ulcerative colitis
refractory to tacrolimus. The aim of this study is to evaluate the efcacy and
safety of iniximab for ulcerative colitis refractory to tacrolimus
METHODS: We report a retrospective, observational, single center case series of
10 consecutively enrolled patients with ulcerative colitis refractory to tacrolimus
that received iniximab. All patients received iniximab (5 mg per kilogram of
body weight) intravenously at weeks 0, 2, and 6 and then every eight weeks. Me-
dian follow-up duration was 14.7 months (range, 5.4-24.4 months). The clinical
response was evaluated based on a disease activity index (DAI) score.
RESULTS: Iniximab produced a clinical response in 7 patients (70%), and remis-
sion was achieved in 3 of these 7 (42.9%) within 8 week. Overall cumulative col-
ectomy-free survival was estimated to be 88.9% at 24 months. Five patients expe-
rienced infectious complications under iniximab (herpes zoster and
cytomegalovirus reactivation). No mortality occurred.
CONCLUSION(S): Iniximab may offer a therapeutic option as rescue therapy for
patients with UC after failing to respond to tacrolimus.
P-124
Incidence and Management of Infusion Reactions to Infliximab in a Prospective
Real-Life Community Registry
Bernie Sattin
1
, Denis Choquette
2
, Francois Nantel
1
1
Janssen, Toronto, ON, Canada,
2
Institut de Rhumatologie de Montreal, Montreal,
QC, Canada
BACKGROUND: Iniximab (IFX) is a therapeutic monoclonal antibody targeting
TNFa indicated in the treatment of a number of chronic inammatory diseases.
IFX is administered by intravenous infusion and may be associated with infusion
reactions (IR).
METHODS: RemiTRAC Infusion is a prospective Canadian observational registry in
which IFX infusions are followed to document the incidence and management of
IR, pre-medication use and adverse events (AE). An IR was dened as any AE
occurring during the infusion or within 1 hour post infusion. Since its inception
in 2005, 1398 patients have been enrolled and 18,121 infusions were recorded.
There were 253 Crohns disease patients (16%) and 80 UC patients (6%). The ma-
jority of remaining patients (64%) were treated for rheumatologic conditions.
RESULTS: A total of 181/1398 patients reported at least one IR (13%). Only 292/
18,121 infusions resulted in an IR (1.6%) and most IRs were mild to moderate in
severity (94%). The most common infusion AE was pruritus which occurred in
14.2% of IR. Flushing (9.9%), urticaria (9.2%), nausea (6.3%) dyspnoea (6.0%) and
chest discomfort (5.0%) were the only other infusion AEs occurring in _5% of IR.
Pre-medication, which included anti-histamines, intravenous steroids and/or acet-
aminophen, was used in 42% of infusions and 1.8% of them were associated
with an IR. Interestingly, infusions without any pre-medication were associated
with a 1.4% incidence of IR. Infusions pre-medicated with anti-histamines, either
alone or in combination with steroids, were associated with a signicantly higher
incidence of IR, up to 3.3% in the presence of anti-histamines (P < 0.0001) and
up to 5.3% in the presence of anti-histamines and steroids (P < 0.0001). In con-
trast, only acetaminophen pre-medication was associated with a reduced inci-
dence of IR (0.8%, P < 0.0001). We noted that infusions immediately following an
IR were associated with a 31% incidence of a subsequent IR (44/140) despite the
prevalent use of prophylactic pre-medication. This likely explains the higher inci-
dence of IR in the presence of anti-histamines and/or steroids.
CONCLUSION(S): This registry shows that, in community-based infusion clinics,
infusion reactions to IFX are rare in incidence and largely mild to moderate in na-
ture. Only the use of acetaminophen pre-medication was associated with a lower
incidence of IR.
P-125
Effect of Mesenchymal Stromal Cells of Bone Marrow at the Level of Adhesion
Molecules in Patients With Inflammatory Bowel Disease
Oleg Knyazev
1
, Oxana Boldyreva
1
, Irina Ruchkina
1
, Anatoliy Konoplyannikov
2
,
Venera Sagynbaeva
1
1
Central Research Institute of Gastroenterology, Moscow, Moscow, Russia,
2
Medi-
cal Radiological Research Center, Obninsk, Kaluga Region, Russia
BACKGROUND: Intercellular adhesion molecule provide the mechanical interaction
of cells with each other. Increased adhesiveness is important in the pathogenesis
of endothelial dysfunction during inammation, atherosclerosis, septic shock and
other pathologic processes. Aim. Study the effect of mesenchymal stromal cells
(MSCs) of bone marrow to the level of adhesion molecules in patients with
inammatory bowel disease (IBD).
METHODS: Examined 14 patients IBD receiving culture MSCs, including 9 patients
with ulcerative colitis (UC) and Crohns disease in 5 patients (BC). The age of
patients 20 to 58 years, mean age 35,6 6 3,0 (M 6 r). The diagnosis of UC
and BC veried the data of clinical, laboratory, histological and instrumental
methods. Before and after the transplantation of MSCs to determine the level of
adhesion molecules of vascular endothelium of type 1 sVCAM-1, sE-selectin, sL-
selectin, sP-selectin in serum by ELISA with the use of test kits Bender
MedSystems (Austria).
RESULTS: The level of sVCAM-1 before treatment MSCs in serum of patients with
IBD was 13,964,4 ng/mL, sE-selectin - 10.163.3 ng/mL, sL-selectin - 9.0560.5 ng/
mL, sP-selectin - 12.261.8 ng/mL. The level of sE-selectin and sP-selectin after
transplantation of MSCs signicantly decreased to 5.761.3 ng/mL and 6.661,1
ng/mL, respectively (P < 0.001). The concentration of sVCAM-1 after administra-
tion of MSCs in serum was 12.262.2 ng/mL (P = 0.2), sL-selectin - 8.960.5 ng/mL
(P = 0.6).
CONCLUSION(S): Mesenchymal stromal cells in the bone marrow signicantly
reduced the levels of sE-selectin and sP-selectin, but do not affect the concentra-
tion of sVCAM-1 and sL-selectin in patients with inammatory bowel disease.
P-126
Factors Affecting Postoperative Recurrence in Japanese Patients With Crohns
Disease in The Era of Biologic Therapy: Retrospective Single Center Study
Motohiro Esaki, Takayuki Matsumoto, Junji Umeno, Kouichi Asano, Tomohiko
Moriyama, Shotaro Nakamura, Takanari Kitazono
Department of Medicine and Clinical Science, Graduate School of Medical Scien-
ces, Kyushu University, Fukuoka, Fukuoka, Japan
BACKGROUND: Because of the excellent short-term prophylactic effect of inixi-
mab, anti-TNFa monoclonal antibody has been increasingly applied to postopera-
tive patients with Crohns disease (CD) in Japan. However, such application of bio-
logics should be based on further clinical evidence. We thus investigated factors
affecting postoperative recurrence of CD to ascertain longer prophylactic effect
of anti-TNFa monoclonal antibody.
METHODS: Postoperative clinical course and endoscopic/radiographic ndings of
44 patients with CD, who underwent curative ileal or ileocolonic resection, were
retrospectively analyzed. Postoperative recurrence was determined based on en-
doscopic/radiographic ndings, irrespective of clinical symptoms or laboratory
data. Recurrence at the anastomotic site was dened by an endoscopic score >i2
of Rutgeerts score or depiction of small barium ecks indicating erosion or ulcer-
ation, thickened mucosal folds, or intestinal narrowing under radiography. Recur-
rence was also regarded to be positive when active inammatory lesions were
detected outside the anastomotic site. Age, disease duration, history of intestinal
resection, disease type, extent of disease, perianal disease, smoking habit, and
postoperative treatments were also reviewed, and possible contribution of clinical
factors to postoperative recurrence was analyzed.
RESULTS: During the mean follow-up period of 29.6 6 19.2 months, postoperative
recurrence was dened to be positive in 23 of 44 patients. Active inammatory
lesions were detected in the anastomotic site in 13 patients, outside the anasto-
motic site in 6 patients, and both in 4 patients. Postoperatively, 23 patients were
treated by scheduled iniximab (5 mg/kg, every 8 weeks) and 2 patients were
treated by adalimumab (40 mg, every other week). Univariate analysis using Log-
rank test revealed that history of intestinal resection (P = 0.017) and current
smoking habit (P = 0.007) were more frequent in patients with recurrence than
in those without. In addition, recurrence was less frequent in patients with anti-
TNFa monoclonal antibody than in those without (P = 0.006). Multivariate analy-
sis using Cox proportional hazards model demonstrated that patients treated
with anti-TNFa monoclonal antibody were less likely to recur (RR = 0.09. 95%CI;
0.02-0.34), while patients with history of intestinal resection had an increased risk
of recurrence (RR = 8.54, 95%CI; 1.79-60.36).
CONCLUSION(S): Anti-TNFa monoclonal antibody treatment after intestinal resec-
tion obviously improves postoperative clinical course in patients with CD. Postop-
erative prophylaxis by biologic therapy might be appropriate for patients requir-
ing repeated surgery in consideration of their higher recurrence rate.
P-127
Loss of Efficacy to Anti-TNF Therapy in the Management of Crohns Disease: A
Brazilian Multicenter Observational Study
Paulo Kotze
1
, Juliano Ludvig
2
, Fabio Teixeira
3
, Harry Kleinubing Jr
4
, Everson
Malutta
5
, Eron Miranda
1
, Marcelo Hardt
6
, Marcia Olandoski
7
1
Colorectal Surgery Unit Cajuru University Hospital - Catholic University of Par-
ana, Curitiba, PR, Brazil,
2
ESADI - Blumenau SC, Blumenau, SC, Brazil,
3
Gastro-
saude Marilia SP, Marilia, SP, Brazil,
4
Univille Joinville SC, Joinville, SC,
Brazil,
5
UNIVALI, Itajai, SC, Brazil,
6
Catholic University of Parana Curitiba PR
Brazil, Curitiba, PR, Brazil,
7
Statistics department Catholic University of Parana
Curitiba PR, Curitiba, PR, Brazil
BACKGROUND: Besides the great benet of anti-TNF agents in the management
of Crohns disease (CD), it is known that efcacy of both Iniximab (IFX) and Ada-
limumab (ADA) can be reduced over time. Loss of response to these agents can
be explained by immunological issues, such as antibody formation or even lower
trough levels of the drugs. There is lack of real life data in Latin American CD
patients regarding the issue of loss of efcacy (LOE) to anti-TNF therapy. The pri-
mary objective of this study was to analyze the incidence of LOE to both IFX and
ADA in a cohort of Brazilian CD patients. The secondary objectives were to dene
the timing of LOE to the drugs and to identify possible risk factors for its
appearance.
METHODS: This was a retrospective, observational cohort study, with CD
patients treated with anti-TNF therapy from 5 referral IBD centres from Brazil.
Inclusion criteria: CD patients, responders to the rst biological agent (anti-TNF
naive) with completed induction regimen. Exclusion criteria: undetermined IBD,
primary non-responders and patients previously exposed to anti-TNF agents.
Patients were allocated in two groups, regarding the drug administered (IFX or
ADA). Electronic chart review was performed and a specic protocol was ful-
lled. Variables analyzed: demographic data, Montreal classication, concomi-
tant medications, smoking, perianal CD, time of follow-up, presence of LOE, tim-
ing and the reasons for its occurrence. LOE was dened as one of the following
characteristics: need for steroids, occurrence of abdominal surgery during treat-
ment, dose increase, interval shortening or switching of the anti-TNF agent. Sta-
tistical analysis was performed with students t test, Mann Whitney, Fischer or
chi-square tests to demonstrate comparability of the groups. Log-rank test
(Kaplan Meier) was performed to analyze the timing of loss of efcacy. Cox
regression multivariate analysis was also performed to dene risk factors, with P
< 0.05 considered signicant.
RESULTS: A total of 175 patients were included in the study (117 in the IFX and
58 in the ADA group). The groups were considered homogeneous regarding de-
mographic data, Montreal classication, smoking status and perianal CD. There
were more patients exposed to steroids and azathioprine in the IFX group. Me-
dium follow-up period was 17.3 (612.4) months on the IFX and 13.1 (611.3)
months on the ADA group. Overall, LOE occurred in 47/117 (40.2%) of the IFX
and in 9/58 (15.5%) ADA patients (P = 0.001). Medium timing for LOE was 11.8
(68.1) months on IFX and 13.3 (612.3) months on ADA patients (P = 0.073),
without signicant difference on the reasons for its occurrence (P = 0.125). On
multivariate analysis, younger patients (Montreal A1) were at risk for LOE (P =
0.032). On COX regression analysis, a higher risk for LOE was noticed when IFX
was administered (OR = 3.33; P = 0.006) and in patients with perianal CD (OR =
2.23; P = 0.026).
CONCLUSION(S): Loss of efcacy (LOE) was observed in 40.2% of the IFX and in
15.5% of the ADA patients, without any signicant difference in timing and rea-
sons for its occurrence. These data were similar to the literature of other coun-
tries. The risk for the development of LOE was higher in younger patients, on IFX
therapy and with perianal CD.
P-128
Fecal Microbial Transplantation Shows Efficacy in Children With Refractory Ul-
cerative Colitis Early Results of Phase I Clinical Trial
Sachin Kunde
1
, Deborah Cloney
2
, Harold Conrad
2
, Subra Kugathasan
3
1
Helen DeVosc Childrens Hospital / Michigan State University, Grand Rapids, MI,
USA,
2
Helen DeVosc Childrens Hospital, Grand Rapids, MI, USA,
3
Emory University,
Atlanta, GA, USA
BACKGROUND: Fecal microbial transplantation (FMT) is being investigated as a
promising alternative treatment option for ulcerative colitis (UC). The interest and
enthusiasm is very high among patients with IBD despite lack of prospective
data. Interest in FMT has largely been driven by new research into the gut micro-
biota, which is being appreciated as a microbial human organ with important
roles in immunity and energy metabolism. We hypothesize that FMT may restore
abnormal microbiota to normal in UC thus induce remission in refractory UC.
We have initiated the rst phase I clinical trial for use of FMT in UC with goals of
assessing 1) the safety and tolerability, and 2) evaluate clinical response to FMT.
METHODS: Study was approved by Spectrum Health institutional review board.
We obtained investigational new drug (IND) approval from the U.S. FDA for use
of human stool as a biologic. We plan to enroll ten children (age 7-21 yrs) with
mild to moderate, treatment resistant UC. After extensive donor screening guided
by FDA and American Blood Bank Association, every subject received freshly pre-
pared 8 oz fecal enemas for 5 days over 1 week period. Pediatric ulcerative colitis
activity index (PUCAI) was collected at baseline and weekly for a month after
FMT. Safety data was collected using common terminology criteria for adverse
events v3.0
/
and using FDA guidance for industry from toxicity grading scale for
healthy adult and adolescent volunteers enrolled in preventive vaccine clinical tri-
als, 2007
/
. Clinical response was dened as a decrease in PUCAI by 15 points at
one month after FMT.
Figure 1.
RESULTS: We plan to enroll 10 subjects. Eight subjects have been enrolled to date
and complete data is available on 3 subjects who have completed the study.
Their baseline PUCAI scores were 30, 35 and 50, which improved to 15, 0 and 40
respectively, at one month after FMT. All the subjects tolerated fecal enemas
without leakage. One subject received only 6 oz enemas due to feeling of full-
ness. No serious adverse events were noted. Symptoms associated with FMT
were mild (cramping, fullness, atulence, bloating, diarrhea and nausea, which
did not need treatment) to moderate (fever in one, which responded to anti-
pyretic and anti-histaminic medications). These symptoms were self-limiting and
lasted only for the duration of FMT treatment days.
CONCLUSION(S): Fecal microbial transplantation as an enema is feasible, well tol-
erated and can be performed easily in children with UC with minimal training
and support. Two of three subjects achieved clinical response by reduction in
PUCAI of 15 points or more. One of them had complete resolution of disease ac-
tivity. More data is anticipated for the Advances in IBD meeting in December.
Larger prospective and controlled studies are needed to study clinical efcacy,
endoscopic healing and the mechanism of action of FMT.
P-129
Natalizumab Use in Patients With Crohns Disease (CD) and Relapsing Multiple
Sclerosis (MS): Updated Utilization and Safety Results
Fred Kerwood
1
, Lynda Cristiano
2
, Gary Bloomgren
2
, Carmen Bozic
2
, Yu-Jiang Liu
3
,
Grainne Quinn
4
1
2
Biogen Idec, Weston,
MA, USA,
3
Biogen Idec Ltd, Maidenhead, Berkshire, UK,
4
Elan Corporation, PLC,
Dublin 2, N/A, Ireland
BACKGROUND: Natalizumab was approved by the FDA in 2008 for adult patients
with moderately to severely active CD with evidence of inammation who have
had an inadequate response to, or are unable to tolerate, conventional CD thera-
pies and inhibitors of TNF-a. The TYSABRI Outreach: Unied Commitment to
Health (TOUCH
VR
) Prescribing Program, Crohns Disease: Investigating Natalizumab
through Further Observational Research & Monitoring (CD INFORM), TYSABRI
Global Observation Program In Safety (TYGRIS), and TYSABRIVR
Pregnancy Expo-
sure Registry (TPER) are ongoing risk management activities designed to further
evaluate the safety of natalizumab. This report summarizes recent data on natali-
zumab utilization and safety in patients with Crohns disease (CD) and relapsing
multiple sclerosis (MS).
METHODS: TOUCH
VR
is a mandatory prescribing program for all patients, prescrib-
ers, pharmacies and infusion centers in the US using natalizumab. TOUCHVR
is
designed to inform about the risk of progressive multifocal leukoencephalopathy
(PML); warn against concurrent use with antineoplastic, immunosuppressant, or
immunomodulating agents, and in patients who are immunocompromised; and
promote early diagnosis of PML and timely discontinuation of natalizumab in the
event of suspected PML. CD INFORM, a post-marketing commitment, collects
patient history, efcacy as assessed by the Harvey Bradshaw Index (HBI), Health
Related Quality of Life outcomes, and serious adverse events (SAE) in CD patients
on natalizumab therapy. TYGRIS, also a post-marketing commitment, is evaluating
the long-term safety of natalizumab in MS. Post-marketing surveillance data are
also collected. TPER evaluates the outcomes of pregnancy in women with CD
and MS exposed to natalizumab.
RESULTS: As of 30 June 2012, -104,300 patients have been exposed to natalizu-
mab in the post-marketing setting (103,259 MS; 1,041 CD),. As of 01 August 2012,
271 cases of PML have been conrmed (270 MS, 1 CD). Of the 271 natalizumab-
treated patients who developed PML, 212 (78%) had survived, exhibiting varying
levels of disability and there were 59 (22%) deaths. Presence of anti-JCV antibod-
ies, prior treatment with immunosuppressants and longer treatment duration
with natalizumab, especially beyond 2 years, are identied risk factors for poten-
tial development of PML. As of 07 August 2012, 163 patients were enrolled in CD
INFORM with the number of natalizumab infusions ranging from 1-56, with a
mean and median of 14.6 and 10, respectively. The average HBI at time of entry
for these patients was 8.2 (range 0 to 28). Of the 99 CD patients with an HBI
assessment after receiving 6 months of natalizumab therapy, the average total
score was 4.8, a mean decrease of 2.8 points from baseline. Cumulatively, as of
07 August 2012, there were 93 SAEs occurring in 51 patients reported in CD
INFORM, 4 patients experienced 8 SAEs that were considered treatment related.
As of 23 May 2012, 375 women (7 with CD) were prospectively enrolled in the
TPER with372 outcomes reported, including 8 twin pregnancies resulting in 2
outcomes for each pregnancy. Current exposure and safety data from patients
receiving natalizumab in both indications will be presented.
CONCLUSION(S): Cumulative data from both indications suggest a safety prole
consistent with natalizumab product labeling.
P-130
Factors Predicting Disease Flare in Inactive Ulcerative Colitis
Garth Swanson, Sharon Jedel, Li Hong, Robin Voigt, Maliha Shaikh,
Ali Keshavarzian
Rush University Medical Center, Chicago, IL, USA
BACKGROUND: Ulcerative Colitis (UC) tends toward a chronic relapsing pattern in
most patients. Predicting severity of disease course in Ulcerative Colitis is important
to achieve optimal relapse prevention, limit hospitalizations, and prevent surgery.
The aim of the current study was to examine which factors might be associated
with a disease relapse in a high risk group of patients with inactive UC.
METHODS: 49 patients with inactive UC were recruited into the study. UC subjects
had a documented moderate to severe are in the last 6 months (Mayo Score >6),
but were inactive at the time of enrollment (Mayo Score <2). All subjects were on
a stable course of medications (5ASA, immunomodulators, biologics, and off pred-
nisone) for at least 3 months before enrollment. All subjects underwent a gastroen-
terologist visit with a clinical assessment, blood draw, stool collection, an
unprepped exible sigmoidoscopy with biopsies at the time of enrollment. In addi-
tion all subjects completed a series of validated psychosocial questionnaires includ-
ing: IBD Quality of Life Questionnaire (IBDQ), Perceived Health Competence Scale
(PHCS), Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), Per-
ceived Stress Questionnaire (PSQ), and Mindful Attention Awareness Scale (MAAS).
Patients were then followed up in the study at 8 weeks, 6 months, and 12 months
with all the same measures at enrollment. If patients developed symptoms of a
are during the trial they were seen by the study gastroenterologist. Of the sub-
jects that ared, those that ared in the rst 90 days were dened as early are.
The remainder of patients who ared were then dened as late are. Baseline fac-
tors were then examined to determine which were associated with a disease are.
Statistical calculations were performed by Cox proportional model analysis.
RESULTS: Over the course of the 12 month study 28/49 subjects had a disease
relapse (57%). 11 patients had an early are, and 17 had a late are. In our study
baseline factors that were associated with an early are included elevated IL-6,
Mayo Score, and lack of normal vascularity or mild granularity on rst endoscopy
(P < 0.05). Baseline factors not signicantly associated with an early disease are
included pathology, cytokines (TNF, IL-8, and IL-10), stool calprotectin, urinary cor-
tisol, validated psychological questionnaires, or quality of life.
CONCLUSION(S): Patients with UC are at signicant risk of disease relapse. Factors
such as a mild increase in clinical disease activity (Mayo Score 1 or 2), elevated IL-
6, or loss of normal vascular pattern or mild granularity on endoscopy were asso-
ciated with a relapse of disease. Findings on pathology, stool calprotectin, and
symptoms of stress, depression, or decreased quality of life were not able to
accurately predict a disease are. Further studies are needed to conrm these
ndings, but adding IL-6, a noninvasive marker of disease activity, or noting
subtle changes in endoscopic ndings may be important in clinical decision mak-
ing to limit disease relapse.
P-131
Evaluation of Mucosal Healing in Small Bowel Crohns Disease Treated with
Certolizumab Pegol Assessed by Wireless Capsule Endoscopy
Ira Shafran, Patricia Burgunder, Renee DePanicis, Kara Fitch
Shafran Gastroenterology Center, Winter Park, FL, USA
Figure 1.
BACKGROUND: Certolizumab pegol (CZP), a pegylated anti-TNF agent has been
approved for the induction and maintenance of response and remission in adult
patients with moderate to severe Crohns disease. Biologic agents have demon-
strated efcacy in the healing of gut mucosa leading to better long-term out-
comes by sustaining steroid free remission, decreasing the need for major surgery
and hospitalizations, and by improving patients overall quality of life. The MUSIC
trial revealed CZP-induced endoscopic response and remission at 10 and 54
weeks. Our primary objective is to evaluate mucosal healing assessed by wireless
capsule endoscopy (WCE) using the Lewis scoring system (LS) in patients with
moderate-to-severe Crohns disease treated with CZP.
METHODS: We performed a prospective, open-label trial in 10 patients with docu-
mented moderate-to-severe Crohns disease for a period of six months. All
patients were given standard induction dose therapy with CZP at 0, 2, and 4
weeks, then standard maintenance dose therapy with CZP every 4 weeks through
the end of the study period. WCE was performed at baseline, 16 weeks, and 26
weeks. Blood work including CMP, HEMGPD, and CRP were obtained, as well as
Crohns disease activity index (CDAI) and Short Inammatory Bowel Disease Ques-
tionnaire (SIBDQ) at baseline and every 4 weeks throughout the study.
RESULTS: Ten patients were enrolled in this trial. Of the 10 patients, 6 were male
and 4 were female, with an average age of 33.4 and a mean disease duration of
13.1 years. Seven patients had no prior Crohns surgery, 3 had previous small
bowel resection. Eight of the ten patients were secondary non-responders (SNR)
to biologics; 3 lost response to both iniximab (IFX) and adalimumab, 5 lost
response to either IFX or adalimumab, 1 was biologically na ve and the last had
an early allergic reaction to IFX. Eight of the ten patients who completed this trial
demonstrated an overall clinical improvement in mucosal healing, CDAI and
SIBDQ. Of those who responded to CZP, the mean LS at baseline fell from 1861
to 226 at 26 weeks and the mean CDAI decreased from 265 at baseline to 117 at
26 weeks. The mean SIBDQ increased in responders from 39 at baseline to 50 by
the end of study.
CONCLUSION(S): This study demonstrates clear evidence of mucosal healing using
CZP in patients with moderate-to-severe Crohns disease. All patients who
responded to CZP had prior exposure to anti-TNF therapy. This study establishes
a proof of concept that WCE used in conjunction with the LS is a valuable diag-
nostic test to assess mucosal healing in patients with small bowel Crohns disease
treated with CZP. CZP was well-tolerated in this population with no safety issues.
Larger, placebo controlled trials are warranted to assess small bowel mucosal
healing in patients treated with CZP.
P-132
The Use of Wireless Capsule Endoscopy in Community Practice: An 11 Year
Experience
Ira Shafran, Patricia Burgunder, Michael Kwa
Shafran Gastroenterology Center, Winter Park, FL, USA
BACKGROUND: The role of wireless capsule endoscopy (WCE) in small bowel
Crohns disease (SBCD) has been studied in many clinical trials and has been
shown to be superior to other modalities (eg, barium radiography, colonoscopy
with ileoscopy, computed tomography enterography, push enteroscopy) for diag-
nosing and evaluating non-stricturing SBCD. There have been concerns about the
risk of capsule retention in SBCD because of small bowel strictures, with reported
capsule retention rates in patients with known SBCD as high as 13% (range 4-13).
Our purpose is to demonstrate the safety of WCE in patients with known or sus-
pected SBCD in our community based, private practice that specializes in inam-
matory bowel disease (IBD).
METHODS: We performed a retrospective chart review of patients with conrmed
SBCD who had undergone WCE between 2001 and 2012. Patients with docu-
mented bowel obstruction; radiographic or endoscopic evidence of strictures <1
cm in diameter; history of bowel obstruction, stenotic surgical hookups, or intesti-
nal scarring were excluded from undergoing WCE per facility protocol. All
patients had either a computed tomographic enterography, magnetic resonance
enterography or small bowel follow-through in addition to careful pre-screening
history and physical exam to evaluate for WCE exclusion criteria prior to any cap-
sule swallow.
RESULTS: Ninety four patients with conrmed SBCD underwent WCE and were
included in the study; 44% (n = 43) males, 56% (n = 51) females with a mean
age of 46, and mean disease duration of 7.54 years (range <1-46). Forty seven
patients (50%) had CD for <1 year in duration at the time of WCE, and the major-
ity had mild-to-moderate CD. Of the 94 patients, 23 patients had serial capsule
studies for reassessment during the 11 year study period, with a total of 42 WCE
studies done on this population. Of the 94 patients, and 136 separate studies
only 1 capsule was retained (0.7%) in this 11 year period. This retained capsule
was easily removed by endoscopy from a duodenal stricture.
CONCLUSION(S): WCE can be safely performed in SBCD patients, as evidenced by
our single center, community IBD practice performing 136 WCE procedures on 94
patients revealing only one single retention event. We believe that careful selec-
tion of appropriate patients allows for the safe use of WCE technology in patients
with SBCD. By having a single expert physician in inammatory bowel disease
evaluate and prescreen each patient with a carefully taken medical history, physi-
cal exam, and use of radiography prior to WCE, the risk of capsule retention in
this population is minimized.
P-133
Effect of Time Of Meal Consumption on Pharmacokinetics and the Clinical Effi-
cacy of Oral Tacrolimus in Refractory Ulcerative Colitis
Nobuyuki Hida, Koji Nogami, Masaki Iimuro, Tomoaki Kono, Yoshio Ohda, Yoko
Yokoyama, Koji Kamikozuru, Katsuyuki Tozawa, Ken Fukunaga, Shiro Nakamura,
Takayuki Matsumoto
Department of Lower Gastroenterology, Hyogo College of Medicine, Hyogo, Ja-
pan, Nishinomiya-city, Hyogo, Japan
BACKGROUND: Tacrolimus is effective treatment for induction of remission in re-
fractory ulcerative colitis (UC). Previous studies demonstrated that oral tacrolimus
ingestion in a fed condition reduced bioavailability and slowed absorption in
healthy volunteers and instable liver transplant recipients. This study investigated
the inuence of time of meal consumption on pharmacokinetics and the clinical
efcacy of oral tacrolimus in refractory ulcerative colitis.
METHODS: This was a randomized, open-label study in 20 patients with refractory,
moderately active UC (Disease activity index: 6-10). Oral tacrolimus initial dose of
0.1 mg/kg per day was given (A) 1 hour before meal (fasting condition; n = 10),
or (B) immediately after meal (fed condition; n = 10). Venous blood samples
were collected at 1, 2, 4, 6, 12 hours following oral tacrolimus on the rst day.
The blood trough level was adjusted to 10-15 ng/mL for rst 2 weeks and then
adjusted to 5-10 ng/mL for 10 weeks in both groups. Clinical response was eval-
uated at week 2 and 12.
RESULTS: Mean maximum tacrolimus blood concentration (Cmax) and time of
Cmax (Tmax) values of group A and B were 16.9 6 5.7 ng/mL, 1.3 6 0.5 hours
versus 5.7 6 2.5 ng/mL, 3.8 6 1.1 hours, respectively (P < 0.01). The tacrolimus
12-hour trough level of day 1 was similar between group A and B; 2.6 6 1.2 ng/
mL and 2.0 6 0.8, respectively. The time required for achieving target trough
level was 7.2 6 0.4 days in group A and 8.5 6 2.9 days in group B (P > 0.05).
Clinical improvement was observed in 60% of patient in group A and 80% in
group B at week 12. During treatment, adverse events were occurred 30% in
group A and 20% in group B.
CONCLUSION(S): Results suggest that fed condition had a signicant effect in
slowing absorption of tacrolimus, but did not affect trough levels and clinical
response of treatment in patients with refractory UC.
Pediatric Poster Presentations
P-134
YI
Ulcerative Colitis in a Child With Partial Trisomy 16
Janet DiFalco, Rebecca Abell, Jeffrey Morganstern
Stony Brook Long Island Childrens Hospital, Stony Brook, NY, USA
Full trisomy 16 is incompatible with life and will always result in spontaneous
abortion. In fact, it is one of the most common causes of miscarriage.
1
Patients
with partial, or mosaic trisomy 16, however, can survive and live for many years.
The reported cases of partial trisomy 16 in the literature have been associated
with a variety of abnormalities including intrauterine growth retardation, hypoto-
nia, facial abnormalities, failure to thrive, psychomotor delay, cardiac defects, am-
biguous genitalia, and anomalies of the gut and ano-rectum.
2,3
To our knowl-
edge, there are no reported cases of inammatory bowel disease in a patient
with partial trisomy 16.
We present a 10 year old female with partial trisomy 16 and developmental delay
with a 5 week history of acute onset diarrhea. Initial exam was unremarkable
except for dysmorphic facial features and underweight relative to height. Lab
results were signicant for mild anemia, thrombocytosis, and signicantly ele-
vated perinuclear anti-nuclear cytoplasmic antibody (pANCA) level of 120.2 EU/
mL. Markers for Crohns disease were negative. An upper endoscopy and colono-
scopy revealed moderately erythematous mucosa and exudate throughout the
colon. Esophagus, stomach, duodenum and terminal ileum appeared normal.
Biopsies conrmed pancolitis. The patient was given a diagnosis of ulcerative coli-
tis and treated initially with sulfasalazine, and subsequently 6-mercaptopurine.
She is currently in clinical remission.
The genetic basis of inammatory bowel disease is a growing area of research.
Over 100 susceptibility loci for inammatory bowel disease have been discovered,
the most well-known being NOD2 (also known as CARD15 or IBD1) which lies on
chromosome 16.
4
Many of these loci have been associated with both Crohns
disease and ulcerative colitis.
4
NOD2 has been most strongly associated with
Crohns disease, but also with ulcerative colitis.
5
Although it is reasonable to
assume that trisomy 16 could result in altered expression of the NOD2 gene and
contribute to the development of IBD, there are no reported cases of trisomy 16-
associated IBD in the literature. As more children with potentially fatal genetic
conditions are living longer and IBD is becoming more prevalent, we can expect
to see more cases of IBD in this group of patients. Whether there is a true associ-
ation between IBD and trisomy 16 remains to be seen.
1. Current diagnosis & treatments : Obstetrics & gynecology (10th ed. ed.). New
York: McGraw-Hill. 2007. 2. Benn P. Trisomy 16 and trisomy 16 Mosaicism: a
review. Am J Med Genet. 1998 Sep 1;79(2):121-33. 3. Langlois S, Yong PJ, Yong
SL, Barrett I, Kalousek DK, Miny P, Exeler R, Morris K, Robinson WP. Postnatal fol-
low-up of prenatally diagnosed trisomy 16 mosaicism. Prenat Diagn. 2006
Jun;26(6):548-58. 4. Cho JH, Brant SR. Recent insights into the genetics of inam-
matory bowel disease. Gastroenterology. 2011 May;140(6):1704-12. 5. Mirza MM,
Lee J, Teare D, Hugot JP, Laurent-Puig P, Colombel JF, Hodgson SV, Thomas G,
Easton DF, Lennard-Jones JE, Mathew CG. Evidence of linkage of the inammatory
bowel disease susceptibility locus on chromosome 16 (IBD1) to ulcerative colitis. J
Med Genet. 1998 Mar;35(3):218-21.
P-135
YI
Simultaneous Presentation of Celiac Disease and Ulcerative Colitis, Was
Wrongly Considered Crohns Disease in a Child
Imad Absah
Mayo Clinic College of Medicine, Rochester, MN, Olmsted
Occurrence of IBD and CD disease simultaneously in children is uncommon. Few
reports about the frequency and management of similar cases are available in
the literature.
Case presentation: 17 Yo female presented with bloody diarrhea, abdominal pain
and weight loss. Endoscopic evaluation showed normal TI, pan colitis, nonspecic
gastritis and duodenitis with villous atrophy. Diagnosis of Crohns was made and
patient started 6MP and steroids. She didnt tolerate 6MP and symptoms per-
sisted. Second opinion was obtained, review of the biopsies suggested features
of UC and duodenal changes consistent with CD. Patient started sulfasalazine
that resulted in some clinical improvement, but the weight and hair loss per-
sisted. Repeated scopes showed improved colonic inammation with persistent
duodenal changes. Finally CD serum markers were checked and they were posi-
tive (tTg IgA 123), patient started gluten free diet that resulted in clinical remis-
sion and weight gain.
Discussion: Finding of upper GI involvement in IBD patient is common and not
enough to make Crohns diagnosis. It was not clear if the SB involvement in our
patient was part of her UC or true coincidence of CD. Reports of false positive
CD titers in IBD patients, especially Crohns disease, are available. Persistent of SB
changes despite proper UC treatment and the improvement after starting gluten
free diet suggested true coincidence of UC and CD.
Conclusion: This case suggests an association between UC and CD. Also shows
the importance of screening for CD with serum titers in IBD patients with SB
involvement, when there is persistence of symptoms, histologic changes and fre-
quent relapses.
P-136
YI
Fecal Bacteriotherapy in a 6 Year Old Patient With Ulcerative Colitis and
Clostridium Difficile
Namita Singh, David Suskind, Ghassan Wahbeh
Seattle Childrens Hospital, Seattle, WA, USA
Inammatory bowel disease (IBD) is thought to be a disorder of the innate and
reactive immune system, and its interaction with the gastrointestinal microbiome.
A growing body of literature supports the use of fecal bacteriotherapy in eradi-
cating Clostridium difcile (C. diff ) infections. Its use in IBD has been reported
but not established. 20-25% of IBD patients present in childhood. Current avail-
able IBD therapies pose signicant challenges, especially in young children with
IBD, due to their side effects and route of administration. We discuss our experi-
ence with fecal bacteriotherapy in a 6 year old child with relapsing Ulcerative Co-
litis (UC) and recurrent C. diff infection.
A 6 year old female was diagnosed with UC after presenting with bloody
stools, abdominal pain, anemia and elevated ESR. Initial colonoscopy showed
pancolitis and a normal terminal ileum. Due to lack of response to oral mesal-
amine and steroid dependence, azathioprine was started with rectal mesal-
amine and rectal steroids. Allopurinol was added after breakthrough symptoms
and severe anemia. She continued to have intermittent moderate symptoms
(blood, diarrhea) at 1 year out from diagnosis. C. diff antigen and toxin were
present, and persisted despite treatment with metronidazole and vancomycin.
The family was interested in pursuing fecal bacteriotherapy prior to initiating
further antibiotic courses and iniximab. Approval was obtained from bioethics
committee. Her mother was the stool donor and was screened for stool infec-
tions, viral hepatitis and HIV. At baseline, a sigmoidoscopy showed no pseudo-
membranes, but microscopic moderate chronic active colitis. A nasogastric
(NG) tube was placed. Fresh donor stool was mixed with saline then superl-
trated to 30 cc suspension. The suspension was instilled via NG tube unevent-
fully post procedure, after which it was removed and the patient discharged
home. Symptoms and stool inammatory markers were followed from baseline
to 16 weeks post procedure. No treatments aside from azathioprine and allo-
purinol were used.
Stool calprotectin decreased from 504 at baseline to 76 by week 12. C.diff anti-
gen and toxin were cleared by 3 weeks. Microbiome analysis of the donor stool
and the patients stool before and at 3 periods after bacteriotherapy are pending
and will be nalized shortly.
We describe a case of successful fecal bacteriotherapy for a child with recalcitrant
UC and C diff. The implication of the improved calprotectin will be further
explored with reducing her current medications. The relative ease, tolerability and
success of the procedure should encourage further study.
P-137
YI
Evolution of IBD Serologies Over Time in 3 Pediatric Patients
Rebecca Abell, Jeffrey Morganstern
Stony Brook Long Island Childrens Hospital, Stony Brook, New York, USA
Inammatory bowel disease (IBD) serologic testing, including perinuclear antineu-
trophil cytoplasmic antibody (pANCA) and anti-Saccharomyces cerevisiae antibody
(ASCA) is known to be helpful in diagnosing IBD and differentiating Crohns disease
from Ulcerative Colitis. In addition, it can be predictive of more severe disease that
may require surgical intervention. Thus far, there have been few studies examining
the use of serial IBD serologies to evaluate disease status or progression, especially
in the pediatric population. We present 3 patients who had a signicant change in
IBD serologic markers over time.
Case 1: The rst case is a 7 year old male who was diagnosed with ulcerative colitis
and had a refractory disease course, ultimately resulting in total colectomy. At time
of diagnosis, he had a pANCA level of 23.4 EU/mL and absent immunouorescence
(IFA) perinuclear pattern. All other markers were negative. Repeat testing 9 years
later demonstrated a pANCA of 33.1 EU/mL and was still IFA negative. A third set
was repeated 7 months later and revealed a pANCA of 32.4 EU/mL, and an IFA
perinuclear pattern detected. Case 2: A 9 year old male was diagnosed with ulcera-
tive colitis. He initially presented with hematochezia and was treated successfully
with 5-aminosalycilates. Initial serologic testing three years after diagnosis revealed
a pANCA of 32.8 EU/mL with absent IFA pattern and DNAse sensitivity not
detected. All other markers were negative. Three years later the testing was
repeated and pANCA increased signicantly to 55.7 EU/mL, IFA perinuclear pattern
was now detected and was found to be DNAse sensitive. Case 3: A 14 year old
female was diagnosed with Crohns disease after presenting with abdominal pain.
She was treated with mesalamine and subsequently 6-mercaptopurine with good
response. Initial IBD serology at time of diagnosis showed ASCA IgA of 48.3 EU/mL.
All other markers were negative. Repeat labs 9 years later demonstrated a mark-
edly decreased ASCA IgA of 4.6 EU/mL with all other markers negative.
These cases provide evidence that IBD serologic testing may not be constant
over time. This suggests the possibility that repeating the tests may be clinically
useful. It is well established that serial measurements of ANCA are useful for fol-
low-up of disease activity and prediction of relapses in adult patients with sys-
temic vasculitides. However, the data is less clear in IBD, particularly in pediatric
patients. In the adult literature, IBD serologic testing has been shown in some
studies to change with surgery and medical therapy, while other studies have
shown no change. A pediatric study by Canini et al of over 100 patients showed
that ASCA levels decreased signicantly after medical and surgical intervention.
The authors proposed that ASCA values be used as a follow-up in children with
Crohns disease.
At this time there is inconsistent data, particularly in the pediatric population, as to
whether IBD serologic markers change over time or with therapy. The current stand-
ard of practice is to check the serologic markers only once at the time of diagnosis,
however serial IBD serologies may aid in optimizing patient care over time.
P-138
The Development of Diffuse Large B-Cell Lymphoma in Early Onset Pediatric
IBD
Jason Dranove
1
, Jennifer Pope
1
, Victor Pineiro
1
, Sandra Kim
2
1
Levine Childrens Hospital / Carolinas Medical Center, Charlotte, NC, USA,
2
Univer-
sity of North Carolina School of Medicine, Chapel Hill, NC, USA
Lymphoma risk, particularly hepatosplenic T-cell lymphoma, in inammatory
bowel diseases (IBD) patients treated with immunomodulators and/or anti-TNF
alpha therapy is a major concern for both physicians and patients; the majority
of cases are in young males and patients treated with combination therapy
(immunomodulator and anti-TNF alpha agents). Less is known about the demo-
graphic pattern and clinical course of IBD patients who develop non-Hodgkins
Lymphoma.
We describe the case of an 8-year-old Asian-American female child with very early
onset Crohns disease (diagnosed at 19 months of age) who subsequently devel-
oped diffuse large B-cell lymphoma at 8 yrs of age. Since her initial Crohns dis-
ease diagnosis, she has undergone treatment with various combinations of
immunomodulators, corticosteroids, and anti-TNF alpha agents.
The patient underwent extensive diagnostic evaluation by pediatric gastroenterol-
ogists and immunologists at 19 months and was diagnosed with upper and
lower GI tract Crohns disease. Original presenting symptoms included chronic di-
arrhea and failure to thrive since infancy. She initially was treated with corticoste-
roids and methotrexate. At age 4 yrs, she underwent colonoscopy to restage dis-
ease; she had a colonic stricture at the splenic exure with perforation, requiring
resection and primary anastomosis. Post-operatively, her physicians initiated com-
bination therapy (iniximab and methotrexate). However, she continued to have
poor growth, recurrent rectal strictures requiring dilatation, and painful oral, vagi-
nal, and nasal ulcers. At age 6 yrs, therapy was changed to adalimumab mono-
therapy, but she did not have a signicant clinical response. Adalimumab was
subsequently discontinued, and azathioprine monotherapy was initiated between
6-8 yrs. We assumed clinical care at age 8 yrs. We performed an EGD; she had a
large jejunal ulcer (Figure 1). Azathioprine was discontinued, corticosteroids were
weaned, and adalimumab and methotrexate dual therapy was initiated. Despite
this, she developed progressively worsening left-sided abdominal pain and dis-
tention. CT enterography showed a dilated transverse colon and thickened jejunal
loops with no obvious mass. Repeat EGD showed a necrotic-appearing area in
the jejunum at the site of the previously seen ulcer (Figure 2). An exploratory lap-
arotomy revealed a large jejunal mass matted to the colon, creating a partial co-
lonic obstruction (Figure 3). The mass was resected, and primary anastomosis
was performed; histopathology of the mass was consistent with diffuse large B-
cell lymphoma. All immunosuppressant medications were discontinued. Initial
immunologic evaluation revealed a signicant decrease in NK cell function. De-
spite excellent response to chemotherapy, the patient continues to have diarrhea,
poor growth, and recurrent oral ulcerations.
Because of the striking lack of response to traditional Crohns therapy, the very
young age of presentation, and the lack of NK cell function, this patient most
likely has signicant immune dysfunction. This increases concerns for future
malignancies, particularly lymphoproliferative disorders. In light of the medically
refractory nature of her IBD in this clinical setting, we are considering bone mar-
row transplantation. An extensive evaluation is in progress by an expert immu-
nologist. Findings could help delineate potential immunologic mechanisms for
pediatric IBD patients with very early onset disease.
P-139
Transient Mimickers of Crohns Disease
Kathleen Usmani, Anupama Chawla, Jeffrey Morganstern
Stony Brook Long Islands Childrens Hospital, Stony Brook, New York, USA
We present 3 cases with initial clinical and pathological ndings consistent with
Crohns disease who are currently clinically well despite no medical therapy,
prompting the question, "Are there transient mimickers of Crohns disease?"
Case 1: A 14 year old female presented with right sided abdominal pain, a
painful hemorrhoid and intermittent blood in the stool. Physical examination
revealed a perianal skin tag. Lab evaluation revealed mildly elevated ESR of 26
mm/h and equivocal anti-Saccharomyces cerevisiae IgG. Esophagogastroduode-
noscopy (EGD) and colonoscopy revealed gastritis and terminal ileal disease.
She was treated with metronidazole, budesonide, mesalamine and a proton
pump inhibitor. Parents made dietary changes, removing all additives and
preservatives from the diet. After 6 months, unconvinced this was Crohns,
they discontinued all medications. One year off treatment she remained clini-
cally well. Repeat colonoscopy was grossly and histologically normal. Case 2: A
12 year old male presented with a 3 week history of abdominal pain, fatigue
and weight loss. Lab evaluation revealed anemia, thrombocytosis and hypoal-
buminemia, ESR 32 mm/h, CRP 20 g/dL, amylase and lipase 833/1850 Unit/L
respectively. EGD and colonoscopy revealed histological evidence of Crohns
disease in the esophagus, stomach and small intestine. Imaging studies failed
to demonstrate any anatomic cause for pancreatitis. The patient was treated
with mesalamine and subsequently azathioprine. After 10 months, iniximab
therapy was recommended due to persistently elevated inammatory markers
and pancreatic enzymes as well as hypoalbuminemia despite treatment.
Parents declined, discontinued all medications and placed him on oral
Figure 3.
Figure 2.
Figure 1.
supplements including sh oil and Intestinew . At two years all labs normalized
and the patient remained clinically well. Colonoscopy was never repeated.
Case 3: A 16 year old female status post total colectomy with Duhamel proce-
dure for Hirschprungs disease in infancy presented at age 8 with diarrhea, ab-
dominal pain, hypoalbuminemia, and elevated ESR. On enteroscopy ulcerations
were found in the terminal ileum. Histology revealed chronic inammation
consistent with Crohns disease. Her response to corticosteroids and immuno-
modulators was poor. She developed severe borborygmi. After discussion with
the surgical team, it was felt that her Duhamel was dysfunctional. A diverting
ileostomy was performed with resolution of symptoms. Repeat ileoscopy
revealed no ileal ulcerations. ESR and albumin normalized. Most likely ulcera-
tions were secondary to chronic partial obstruction and severe bacterial
overgrowth.
Twenty ve percent of Inammatory bowel disease (IBD) is diagnosed in the pe-
diatric age group. Following clinical, radiological and histological evaluation, a di-
agnosis of IBD is rendered. It is a lifelong disease with no cure. Our cases illus-
trate that there may be other diseases that mimic Crohns disease at the initial
onset but do not follow the typical natural history of Crohns disease. These cases
serve as a reminder that Crohns disease can be a challenge to diagnose even for
the most astute clinician. Advances in serologic and genetic testing, as well as
imaging increase the likelihood of making a correct diagnosis. Nonetheless, as
the above cases illustrate, 100% certainty is not always possible.
P-140
Anti-TNF Alpha Therapy and Orofacial Crohns Disease in Pediatrics
Laurence Chapuy, Colette Deslandres
Sainte-Justine University Hospital Center. Division of Gastroenterology, Hepato-
logy and Nutrition, Montreal, QC, Canada
Orofacial granulomatosis (OFG) is a very rare and disabling manifestation of
Crohns disease (CD). Remission of orofacial Crohns disease (OCD) is difcult to
obtain. The aim of the study was to evaluate the efcacy of iniximab and adali-
mumab in pediatric patients suffering from OCD.
4 patients (3 boys) with OCD were treated with anti-TNF-a therapy between 2000
and 2012. Clinical data were retrospectively extracted from the medical charts to
determine outcome and adverse effects of therapy.
Case 1: a 16 year old boy was diagnosed with OFG at the age of 11. Subse-
quently, he presented with colitis and perianal CD. He responded very well to
corticosteroids but failed therapy to 6 mercaptopurine (6MP) and methotrexate.
Iniximab (IFX) induced a good clinical response but he developed a serum sick-
ness (polyarthritis) and was switched to adalimumab (ADA) with excellent
response. Case 2: a fteen year old boy presented with severe perianal CD at 12
years of age and was started on IFX at diagnosis. He developed OFG on IFX,
which responded very well to corticosteroids. Transient improvement of both
OFG and perianal disease was noted by decreasing the interval of administration
of IFX. Because of loss of response to IFX and positive ATI (antibody to IFX), he
was switched to ADA with an excellent clinical response. Case 3: a 14 year old
boy was diagnosed with severe Crohns colitis and failure to thrive at 10 years of
age. On 6MP he developed severe perineal abscess and was switched to IFX. He
responded well to IFX but had an allergic reaction, thus was switched to ADA.
On ADA, he developed OFG although his digestive symptoms were well con-
trolled. Subsequent local corticosteroid injection in his lips successfully controlled
the OFG. Case 4: a 19 year old girl was diagnosed with CD at 3 years of age. She
presented with severe OFG, perianal and genital involvement. She received epi-
sodic infusions of IFX with only transient improvement and unfortunately her
response to ADA was not sustained thus she underwent left sided colectomy
with proctectomy then right colectomy with ileostomy, after which her OFG
appeared improved on ADA.
All 4 patients with OCD had a severe perianal disease and variable colonic
involvement. Two patients presented with OFG whereas the other two developed
OFG during the course of their disease on biologics. The three boys presented
adverse effects to IFX (serum sickness, allergic reaction, loss of response with pos-
itive ATI): both OFG and perianal disease responded very well to ADA in 2
patients, including the patient in whom OFG occurred on IFX; in the third patient,
perianal disease and colitis were quiescent on ADA but OFG only responded to
local corticosteroid injection. Case #4 had the worst clinical course. She improved
after completion of her colectomy and her OFG is now well controlled on ADA.
P-141
Lymphocytic Colitis in a Two Year Old Presenting with Chronic Diarrhea
Jordan Weitzner
1
, Daniel Kleven
2
, Kim-Doan Nguyen
3
1
Georgia Health Sciences University Dept of Pediatrics, Augusta, GA, USA,
2
Geor-
gia Health Sciences University Dept of Pathology, Augusta, GA, USA,
3
Georgia
Health Sciences University Section of Pediatric Gastroenterology, Augusta, GA,
USA
Lymphocytic colitis (LC) is a subtype of microscopic colitis characterized by
chronic, non-bloody, watery diarrhea, normal colonoscopy, and abnormal histo-
pathological ndings dened by >20 intraepithelial lymphocytes per 100 entero-
cytes. Dened in 1976, it has traditionally been a disease of adulthood with the
mean age of diagnosis of >50 years. Over the past decade, numerous reports
have suggested that LC may present at any age with increasing incidence in chil-
dren. We describe a 2-year-old girl with LC who presented with chronic diarrhea.
To our knowledge, she is the youngest described patient with LC.
A 2-year-6-month-old girl presented with episodic crampy abdominal pain, non-
bloody, nonmucoid, watery diarrhea and decreased growth velocity. These cycles
occurred every 1-2 months since 18 months of age. Stool cultures, C difcile, ova
and parasites were negative. Celiac screen, RAST for food allergies, and standard
blood tests were all within normal limits. CT abdomen was normal. EGD and colo-
noscopy appeared normal. Histopathology of esophagus, stomach, duodenum,
and terminal ileum were normal. However, biopsies of all sections of colon and
rectum showed marked intraepithelial lymphocytosis within the lamina propria
that was consistent with LC. She was started on sulfasalazine (25 mg/kg/day)
with initial success marked by decreased stooling and decrease in abdominal
pain. The mother discontinued the medication and symptoms returned almost
immediately. Three weeks after discontinuation of sulfasalazine, patient returned
to clinic due to increased symptoms. She was restarted on sulfasalazine (40 mg/
kg/day) with near complete resolution of abdominal pain, having 1-2 formed
stools daily, and two-month interval weight gain of 1.5 kg.
The cause of LC is unknown although bacteria, viruses, non-steroidal anti-inam-
matory drugs, or autoimmunity have been implicated as inciting factors. Treat-
ment is aimed at decreasing diarrhea symptoms and inammation. Bulking
agents improve diarrhea and anti-inammatory agents such as sulfasalazine and
corticosteroids have been used with success. While LC is a rare disease in chil-
dren, it should be considered in pediatric patients with chronic non-bloody
diarrhea.
P-142
Crohns Disease in HIV-infected Children: A Report of 2 Cases
Shatha Yousef
1
, Aida Chaparro
1
, Ana Puga
2
, Ana Hernandez
2
, Tracie Miller
1
1
University of Miami/Miller School of Medicine, Miami, FL, USA,
2
Broward Health,
Fort Lauderdale, FL, USA
Inammatory bowel disease is infrequently reported among HIV-infected adults
and rarely in children. The course of IBD may be less severe in HIV-infected
patients because of underlying immunosuppression from the virus.
One perinatally HIV-infected adolescent and one HIV-infected young adult were
diagnosed with Crohns disease at the University of Miami Pediatric Gastroenterol-
ogy Program. A retrospective review of medical records including history, physical
examination, laboratory, radiographic and pathology results was performed.
Case 1: A 20 year-old African American male acquired HIV early in infancy, pre-
sumed secondary to pre mastication of food. A life-long history of noncompliance
with antiretroviral medications improved recently with increased CD4 count by
over 300% (42 to 144 cell/mm3) and viral load from 1,452 to 838 copies/mL one
month prior to presentation. He presented with abdominal pain, intermittent
bloody diarrhea, nausea, and weight loss over 6 months. He had history of aph-
thous oral ulcers and right knee pain. Skin tags were noted on rectal exam. EGD
revealed nodularity in the stomach. Colonoscopy showed aphthous ulcers scat-
tered throughout the colon with friable intervening mucosa. Histopathologic ex-
amination of biopsies showed Helicobacter pylori-associated chronic active gastri-
tis and villous blunting of the duodenum with chronic inammation of lamina
propria. Colonic biopsies revealed acute inammation of lamina propria with
occasional eosinophils and intervening normal tissue. Special tests for infectious
pathogens were negative. IBD antibody panel revealed positive C-ANCA. UGI/
SBFT was normal. H. pylori was managed with triple therapy. High dose steroids
and mesalamine were started. Case 2: A 13 year-old African American boy with
vertically-acquired HIV was chronically under control with CD4 counts >35% and
viral loads <200 copies/mL. History of chronic failure to thrive led to gastrostomy
tube placement for nutritional supplementation in infancy. He developed acute
pancreatitis at the age of 10 years, endoscopy revealed focal acute duodenitis.
Abdominal CT revealed bowel wall thickening of several loops. He was lost to GI
follow-up for 3 years after which time he presented with early satiety, nausea,
poor weight gain, and oral ulcers. There was diffuse abdominal tenderness. Labo-
ratory work up revealed a positive ASCA IgA (117.5 u, normal _ 20 u). MR-enter-
ography was normal. Repeat EGD revealed focal chronic esophagitis and focally
eroded fundic mucosa. Colonic biopsies revealed patchy active colitis with crypti-
tis, supporting the diagnosis of Crohns disease. High-dose corticosteroids were
initiated with improvement in appetite and oral ulcers. Thiopurines and mesal-
amine were started with a corticosteroid taper. Two months later, remarkable
weight gain with improved appetite and tolerance to gastrostomy supplementa-
tion was noted.
We describe 2 cases of HIV diagnosed in infancy presenting with Crohns disease
at the time of improved immunocompetence secondary to immunoreconstitution
in one, and as a lifelong HIV non-progressor in the second. Our pediatric cases
suggest that intact immunity plays a role in the expression of IBD in this popula-
tion. As HIV-infected children have an increased life expectancy due to effective
therapies, early suspicion for IBD in individuals with suggestive symptoms is war-
ranted. Close monitoring for opportunistic infections and emergence of malig-
nancies with treatment is essential.
P-143
YI
Outcome Following Infliximab Therapy for Pediatric Patients Hospitalized With
Severe Colitis
Tolulope Falaiye, Keisha Mitchell, Zengqi Lu, Benjamin Saville, Sara Horst, Dawn
Beaulieu, Dedrick Moulton, David Schwartz, Keith Wilson, Michael Rosen
Vanderbilt University School of Medicine, Nashville, TN, USA
BACKGROUND: Children with Crohns disease frequently present with a colitis-pre-
dominant phenotype, which can have substantial overlap with ulcerative colitis
(UC). While randomized trials have demonstrated the efcacy of iniximab for pe-
diatric Crohns disease and UC, few patients in these studies exhibited colitis
requiring hospitalization. The aims of this study were to 1) determine the rate of
subsequent iniximab failure and dose escalation in pediatric patients initiated
on iniximab during hospitalization for colitis-predominant inammatory bowel
disease (IBD), and 2) to identify potential laboratory predictors of these
endpoints.
METHODS: We conducted a retrospective cohort study of children admitted to
Vanderbilt Childrens Hospital from 2005 to 2010 with colitis-predominant Crohns
disease (Crohns colitis), UC, or IBD-unspecied (IBD-U) initiated on iniximab ther-
apy during admission.
RESULTS: From 188 inpatients selected by ICD-9 code and pharmacy record
searches, we identied 29 patients meeting inclusion criteria of hospitalized coli-
tis-predominant IBD treated with iniximab (12 Crohns colitis, 15 UC, and 2 IBD-
U). Median age at rst iniximab infusion was 14 years (range 5-17). Median fol-
low-up was 923 days (range 133-1952). Steroid-free clinical remission was dened
as a physicians global assessment (PGA) of inactive to mild disease activity and
remaining off systemic steroids. 12 patients (41%) were in steroid-free clinical
remission at both 26 and 52 weeks after initiating iniximab. Dose escalation of
iniximab was dened as an increase from the initial 5 mg/kg dosing or decrease
in the interval of infusions from the standard induction and every 8 weeks main-
tenance regimen. 16 patients (55%) required dose escalation with a median time
to dose escalation of 144 days (range 7-881) (Figure 1). Iniximab failure occurred
in 19 patients (66%) with a median time to iniximab failure of 365 days (range
24-965) (Figure 2). Iniximab failure was due to ineffectiveness in 13 patients
(68%) and adverse reaction in 6 patients (32%). 12 of 29 patients (41%)
underwent colectomy with median time to colectomy of 1387 days (range
28-1864). The rates of 26 and 52 week steroid-free clinical remission, inixi-
mab failure, dose escalation, and colectomy did not differ signicantly
amongst IBD phenotypes. Of 9 patients (31%) on concomitant immunomodu-
lators (thiopurines or methotrexate) only 2 (22%) required dose escalation,
versus 16 of 20 (80%) started on iniximab monotherapy (P = 0.010). Base-
line serum albumin was signicantly lower, and baseline ESR was signicantly
higher in patients subsequently requiring iniximab dose escalation. Median
serum albumin was 3.0 g/dL (interquartile range [IQR] 2.6-3.1) in those requir-
ing dose escalation versus 3.3 g/dL (IQR 3.0-3.6) in those not requiring dose
escalation (P = 0.034). Median ESR was 53 mm/hr (IQR 37-74) in those
requiring dose escalation versus 23 mm/hr (IQR 21-34) in those not requiring
dose escalation (P = 0.002).
CONCLUSION(S): The majority of hospitalized pediatric patients with colitis treated
with iniximab require early dose escalation and exhibit response failure in the
long-term. This study suggests that low serum albumin and high serum inam-
matory markers may identify hospitalized children with colitis who would benet
from a higher iniximab starting dose, and that prospective studies in this area
are warranted.
P-144
YI
Long-term Outcomes With Infliximab Treatment in Children With Crohns Dis-
ease at a Single Centre
Peter Church, Jack Guan, Liad Salz, Karen Frost, Aleixo Muise, Thomas Walters,
Anne Griffiths
Hospital for Sick Children, Toronto, Ontario, Canada
BACKGROUND: Iniximab is highly effective in inducing clinical response and
remission in luminal Crohns disease (CD) in children (Hyams, 2007), but pediatric
data concerning long-term durability of response are limited. We reviewed the ef-
cacy of iniximab induction and regularly scheduled maintenance treatment in
achieving short- and long-term clinical remission, normal linear growth and intes-
tinal healing in a single-center cohort.
METHODS: From 2000 to 2011 at SickKids Hospital, Toronto, 195 children (63%
male; median age 14.0 yrs, IQR 12.3-15.6) with intestinal inammatory CD (20%
L1; 17% L2; 63% L3) received iniximab 3-dose induction (5 mg/kg/dose at
weeks 0, 2, 6). Median duration of diagnosed CD at initiation was 19.9 mos
(range 0.3-136.8). Responders continued on regularly scheduled maintenance
treatment /- immunomodulator (IM). Patient health records were retrospectively
reviewed to extract at 6 mos and annually thereafter: physician global assess-
ment (PGA) of continued response/remission versus loss of response, PCDAI, lin-
ear growth, re-evaluation colonoscopic data and serum levels of iniximab and
antibodies. Durability of response was calculated using a Kaplan-Meier Survival
Curve. Pearsons chi-square was used to assess the inuence of maintenance regi-
men (monotherapy versus combination) on likelihood of secondary loss of
response (LoR).
RESULTS: Among the 195 patients treated, rates of clinical response (judged by
PGA) and remission (judged by PGA and PCDAI / = 1 dose escalation. In sub-
jects with LoR, antibodies to Iniximab (ATI) were positive in 85%, absent but
with undetectable drug levels in 10%, and inconclusive in 5%. Concurrent IM
use (104/180 responders) did not signicantly alter LoR, ATI or need for dose
escalation. Linear growth data were available for 95% of the cohort. Overall
the median height z-score fell from 0.57 at diagnosis to 0.8 at the initia-
tion of Iniximab. Long-term data for patients with growth potential (Tanner 1
or 2 at initiation of iniximab) and at least 3 years of follow-up are shown in
Table.
Figure 1.
Figure 2.
CONCLUSION(S): These long-term data support the effectiveness of Iniximab in
achieving response and improved growth parameters in patients with luminal
Crohns disease. Most secondary LoR was associated with ATI formation. Concur-
rent IM use did not alter LoR.
P-145
YI
Trends in Hospitalization Rates and Disease Behavior in Pediatric Inflammatory
Bowel Disease in the United States From 2000 to 2009
Chaitanya Pant
1
, Jessica Philpott
2
, Michael Anderson
1
, John Grunow
1
, Judith
OConnor
1
, Thomas Sferra
3
1
University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA,
2
Cleve-
land Clinic, Cleveland, OH, USA,
3
Rainbow Babies & Childrens Hospital, Case West-
ern Reserve University School of Medicine, Cleveland, OH, USA
BACKGROUND: Recent studies suggest an increasing incidence of inammatory
bowel disease (IBD) in children. However, the impact of this increase on the secu-
lar trends of inpatient care and disease burden in hospitalized children with IBD
is unknown. Therefore, the aims of this study were to evaluate the rate of hospi-
talization and disease behavior in hospitalized children with IBD in the United
States from 2000 to 2009.
METHODS: We used the U.S. Healthcare Cost and Utilization Project Kids Inpa-
tient Database. Data were weighted to generate national-level estimates.
RESULTS: We identied 61,779 cases of pediatric IBD during four triennial periods
from 2000 to 2009. During the period of study, the rate of hospitalization of chil-
dren with any diagnosis of IBD increased from 43.6 to 72.0 (cases per 10,000 total
hospitalizations entered into the database per year; 2000 vs. 2009; P <0.001).
Specically, for Crohns disease (CD) the rate increased from 28.3 to 45.7 (P
<0.001) and for ulcerative colitis (UC) 15.2 to 26.1 (P <0.001). There was an
increasing trend in the rate of hospitalization in pediatric cases of IBD overall,
and CD and UC individually (evaluation of entire time period, Cochran-Armitage
test for trend, P <0.001 for each disease). The age distribution of hospitalized
children with IBD did not change over the decade of study. Mortality (1 per 1,000
cases of IBD) and length of hospital stay (LOS; median, 4 days) remained con-
stant. Hospitalization charges (adjusted for ination) increased (median, $11,614
to $20,724, P <0.001). Signicant increasing trends were found for comorbid dis-
ease burden and systemic complications (including electrolyte disturbances and
anemia), and the need for blood transfusion and parenteral nutrition (P <0.001
for each). There, also, was an increase in the number of cases with stulae,
obstruction, and perianal disease (P <0.001 for each). In comparison of IBD and
non-IBD cases, those with IBD had lower mortality, longer LOS, and higher
charges (P <0.001 for each). Case-control matching demonstrated a lower risk of
death (adjusted odds ratio, aOR 0.25, 95% CI, 0.20-0.31), longer LOS (aOR 2.48,
95% CI, 2.40-2.50), and higher charges (aOR 1.92, 95% CI, 1.88-1.96) in those with
IBD.
CONCLUSION(S): These results demonstrate an increasing trend in the number of
pediatric cases with IBD admitted to the hospital from 2000 to 2009. Moreover,
we found an increasing trend in disease-specic and systemic complications in
these children along with an increasing cost of the hospital stay. These ndings
are consistent with earlier studies demonstrating that the epidemiology of pedi-
atric IBD is changing as demonstrated by an increase in hospitalized cases. Also,
these data suggest there has been an increase in the severity and frequency of
complicated disease.
P-146
Steroid Use Increases the Risk of Overweight and Obesity in Children With
Alexis Pankow, John Thompson, Gitit Tomer
Childrens Hospital at Montefiore, Bronx, NY, USA
BACKGROUND: CDC data show that the prevalence of obesity (BMI>95% for age)
in the US is 18-20% in children and adolescents. Similarly, in New York City 17%
of school children are obese. Intriguingly, even in children with IBD the rates of
overweight / obesity were reported to be as high as 10-30%. Our goal was to
examine the change in overweight / obesity rates among our diverse population
of inner-city IBD patients after 1 year of therapy, and to evaluate the role of ste-
roid therapy in accelerating obesity rates in IBD patients.
METHODS: A retrospective study of IBD children followed at Monteore Childrens
Hospital. Patient demographics, clinical information, and anthropometrics were
recorded. We analyzed for correlations between BMI increase after one year of
therapy and steroid use and demographics.
RESULTS: We analyzed the charts of 82 IBD patients followed at Childrens Hospi-
tal at Monteore; 35 were excluded for incomplete data. Of 47 patients studied
77% had Crohns Disease (CD), 21% had Ulcerative Colitis (UC), and one had inde-
terminate colitis. Patient demographics: 72% males, 32% African American, 34%
multiracial, 8.5% white, 6% Asian, 17% declined to report; mean age of diagnosis
13.3 years. There was a trend for increased rates of overweight/obesity after 1
year of therapy. The prevalence of obesity (BMI >95%) increased from 4% at di-
agnosis to 8.5% at 1 year (P = 0.2), while the prevalence of overweight / obesity
(BMI>85%) increased from 13% at diagnosis to 21% at 1 year (P = 0.1). The prev-
alence of BMI >90% increased from 4 (8.5%) at diagnosis to 7 (15%) after one
year (P = 0.17). Most of the increased frequency of overweight/obesity was due
to steroid use. Among 22 steroid treated patients none (0%) had BMI >90% at di-
agnosis, while 3 (14%) had BMI >90% after one year of therapy (P = 0.036). How-
ever, among 25 patients not treated with steroids there was no increase in the
number of patients with BMI >90% (4 patients [16%] at diagnosis and after 1
year). Across all BMI categories the percentile BMI for age increased from 46% to
61% (P = 0.0004) in our cohort. Most of the increase was due to steroid use.
Among patients on steroids the average percentile BMI increased from 33% to
58% (P = 0.00035) whereas among patients not on steroids the percentile BMI
increased from 57% to 64% (P = 0.1). Interestingly, the percentile BMI increased
signicantly more in males than in females after 1 year of therapy. In females the
average increase in percentile BMI was 5% points (P = 0.2), whereas in males the
average increase was 18% points (P = 0.0004).
CONCLUSION(S): 1) In our diverse inner city pediatric IBD patients prevalence of
overweight / obesity nearly doubled in the rst year after diagnosis and average
percentile BMI increased signicantly. 2) Patients treated with steroids had a sig-
nicant increase in BMI at 1 year, and were more likely to become overweight/
obese. 3) Risk of obesity and its complications should be taken into account
when initiating steroid use in children with IBD.
P-147
Physical Activity and Health Outcomes in Pediatric Inflammatory Bowel Disease
Sarah Hagin
1
, Debra Lobato
2
, Jason Shapiro
2
, Jack Nassau
2
, Elizabeth McQuaid
2
,
Ronald Seifer
2
, Sheryl Kopel
2
, Julie Boergers
2
, Kristina Suorsa
1
, Barbara Bancroft
1
,
Neal Leleiko
2
1
Rhode Island Hospital, Providence, RI, USA,
2
Rhode Island Hospital/Alpert Medi-
cal School of Brown University, Providence, RI, USA
BACKGROUND: Health behaviors, such as physical activity (PA), are important to
the development and health outcomes of children, including those with chronic
illnesses. Due to concerns related to growth and bone health, PA may be espe-
cially important in Pediatric Inammatory Bowel Disease (Pedi IBD). Previous
research examining PA and related factors (i.e., muscle mass) has demonstrated
the potential for PA to have a positive impact on IBD health outcomes. However,
studies have been limited and results have been inconsistent. It is important to
examine PA and other health behaviors in Pedi IBD in order to maximize health
promotion and IBD health outcomes. Objective: To examine PA rates and the
relationship between PA and health outcomes in Pedi IBD.
METHODS: Children diagnosed with IBD (8.0 to 17.5 years old) were recruited as
part of a larger study examining biomedical, behavioral, and adherence factors
associated with Pedi IBD health outcomes. All participants were also enrolled in
the Pediatric IBD Collaborative Research Group Registry and biomedical data
were derived from the registry data. Participants who had completed physical ac-
tivity questionnaires (N = 51) were included in the analyses. PA questionnaire
items were adapted from the Youth Risk Behavior Survey (YRBS) from the Center
for Disease Control and Prevention and the International Physical Activity Ques-
tionnaire-short form (IPAQ-SF). Overall PA rates were calculated into days per
week. Health outcomes were measured by physician global assessment (PGA),
height z-scores, and erythrocyte sedimentation rate (ESR). Chi-square goodness-
of-t tests were conducted to examine PA rates compared to state-based propor-
tions from the YRBS. Correlations were conducted to evaluate the relationship
between PA and biomedical factors.
RESULTS: Average age was 15 years old and 63% were male. Sixty-nine% had
Crohns disease. Average PA rate was 3 days/week. Reported PA rates were not
signicantly different than state-based YRBS proportions (Table 1). Anthropomet-
ric and disease activity characteristics are presented in Table 2. A signicant posi-
tive correlation was found between PGA and PA days/week (r(47) = .35, P = .02).
Participation in organized sports was associated with lower ESR (r(30) = -.36, P =
.04), even after accounting for PGA (partial r(28) = -.40, P = .03). Greater time
engaged in sedentary behaviors (i.e., >3 hours of computer/video game time per
day) was associated with higher ESR (r(39) = .32, P = .04). A signicant positive
association was found between height z-scores and number of PA days/week
(r(35) = .38, P =.02).
CONCLUSION(S): Rates of PA in Pedi IBD appear to be comparable to those with-
out IBD. Results from the present study suggest that PA is associated with health
outcomes in Pedi IBD, with greater PA rates associated with better health out-
comes. Study limitations include cross-sectional design and correlational analyses
which limit interpretation of directionality, as well as, moderate sample size, and
reliance on self-reported activity rates. Given the potential impact PA may have
on IBD health outcomes, including growth and development, it is important for
future research to 1) continue to examine the relationship between PA and IBD
health outcomes, including long-term trends and outcomes; 2) examine factors
that promote healthy PA behaviors in Pedi IBD to develop interventions to maxi-
mize health outcomes.
P-148
Serologic Protection to and Completion Of Vaccinations In Children With
Jennifer deBruyn
1
, Ing Shian Soon
1
, Sharon Feng
1
, Kevin Fonseca
2
, Susan Kuhn
1
,
Otto Vanderkooi
1
, Iwona Wrobel
1
1
University of Calgary, Calgary, Alberta, Canada,
2
Provincial Laboratory of Public
Health, Calgary, Alberta, Canada
BACKGROUND: In children with inammatory bowel disease [IBD], data on sero-
logic protection to vaccines along with adherence to vaccination schedules is lim-
ited. The study objectives were to determine the proportion of children with IBD
with serologic protection to vaccines and evaluate adherence to vaccination
schedules.
METHODS: In this single-center cross-sectional study, children with IBD followed
at the Alberta Childrens Hospital were enrolled (September 2011-August 2012).
Demographic data, IBD medication, infection risk factors, and vaccination records
were collected. Serum was collected and analyzed by the Provincial Laboratory of
Public Health. Serologic protection for rubella and hepatitis B virus (HBV) were
dened by titers of IgG _15 IU/mL and antibody to HBV surface antigen _10 IU/
L, respectively. Serologic protection for hepatitis A virus (HAV) was dened by
positive detection of HAV IgG. Serology results for varicella, measles, mumps, tet-
anus, and diphtheria are pending. From vaccination records, the proportion with
complete series for each vaccine according to the Alberta schedule was
evaluated.
RESULTS: In total, 156 children (93 Crohns disease, 47 ulcerative colitis, 16 IBD-
unclassied) completed the study and underwent serum collection; vaccine
records were available for 152. At enrolment, 93 subjects (60%) were using immu-
nosuppressive medications (20 systemic corticosteroids, 70 immunomodulators,
48 biologics); an additional 32 subjects had previously used immunosuppressive
medications. For HBV (administered at 10 years of age), though 115 subjects
completed the series, 33 (29%) lacked serologic protection. Twenty-ve (16%)
subjects received no (n = 14) or incomplete (n = 11) vaccine not accounted for
by young age. In total, 57 (37%) subjects lacked serologic protection to HBV;
potential risk factors in this naive subgroup included history of travel outside of
Canada (n = 49), blood transfusion (n = 8), and body piercing (n = 15). There
was no association between HBV serologic protection or completion of vaccine
series and any current or past immunosuppressive medication use. For measles-
mumps-rubella, though 140 subjects completed the series, 26 (18.6%) lacked se-
rologic protection to rubella, including 15 subjects currently using immunosup-
pressive medications. Ten subjects received no or incomplete vaccine series not
accounted for by young age. There was no association between rubella serologic
protection and any current or past use of immunosuppressive medications. For
varicella zoster virus (VZV), 60 subjects received _1 VZV vaccine dose and 83
non-vaccinated subjects had previously been infected with chickenpox. However
10 (6.5%) subjects had neither been infected nor vaccinated, including 7 subjects
currently using immunosuppressive medications. For diphtheria-pertussis-tetanus-
polio-haemophilus inuenza b, though 131 subjects were up to date for age, 23
subjects received no or incomplete series not accounted for by young age. For
HAV, 9 subjects received complete HAV series and all mounted serologic protec-
tion. Though 137 subjects had no prior history of HAV vaccination, 22 of these
subjects mounted serologic protection. In total, 32 (20.5%) subjects had serologic
protection to HAV.
CONCLUSION(S): Children with IBD are at risk for vaccine-preventable illnesses
due to lack of receiving or completing vaccine series and inadequate serologic
protection despite vaccination. Therefore, clinicians caring for patients with IBD
should be conscientious about vaccination schedule adherence, serology mea-
surement, and booster vaccinations where appropriate.
P-149
Inflammation and Steroid Therapy Is Associated With White Matter Microstruc-
ture Integrity in Pediatric Crohns Disease
Christine Mrakotsky
1
, Christopher Watson
2
, Deborah Waber
1
, Richard Grand
3
, Mi-
chael Rivkin
4
1
Boston, MA, USA,
2
Department of Neurology, Boston Childrens Hospital, Boston,
MA, USA,
3
Division of Gastroenterology, Boston Childrens Hospital, Harvard Medi-
4
Department of Neurology, Boston Childrens Hospi-
tal, Harvard Medical School, Boston, MA, USA
BACKGROUND: Pediatric Crohns disease (CD) is marked by intestinal and systemic
inammation with high circulating concentrations of pro-inammatory proteins
(IL-6, TNF-a, CRP) during active disease. While anti-inammatory treatments such
as corticosteroids have for long been considered to affect cognitive and brain de-
velopment, inammation itself has the potential to disrupt the central nervous
system, particularly the white matter. White matter abnormalities have been
found at higher incidence in adults with CD as compared to healthy controls;
however, no such data is available for pediatric CD. Loss of white matter integrity
has been associated with functional impairment, particularly processing speed,
memory, and emotion regulation. We previously found inammation to be inver-
sely correlated with cognition and mood in pediatric CD. We here provide a rst
report of the effects of inammation vs. steroids on white matter microstructure
integrity in pediatric CD.
METHODS: Structural and diffusion magnetic resonance imaging (MRI, DTI) was
carried out in 30 children age 9-14 years (CD patients: n = 11, age-matched
healthy controls: n = 19). Participants were scanned on a 3 Tesla Siemens Trio
MRI system, with a 32-channel head coil. Diffusion-weighted imaging data were
acquired using a single shot spin-echo echo planar imaging sequence. A total of
30 diffusion sensitization directions were acquired. Voxel sizes were 1.7 1.7
1.7 mm
3
. Average fractional anisotropy (FA), a measure reecting white matter
ber density and myelination was computed for several ber tracts across the
brain. All CD patients were scanned during steroid treatment for an acute are
(prednisone dose: M = 30.7, SD = 9.6 mg/day). Serum markers of inammation
included hsCRP, IL-6, and TNFR2. Demographics, SES and general cognitive ability
were comparable between groups. Inammation was higher in CD patients than
healthy controls.
RESULTS: CD patients had lower FA than controls in several limbic (temporal) and
subcortical ber tracts including the left and right cingulum angular bundle, the
right uncinate and temporal part of the superior longitudinal fasciculus (P<.05 to
<.10). Regression models including all subjects accounting for inammation levels
and steroid dose revealed higher inammation (hsCRP, IL6, TNFR2) but not steroid
dose to be a signicant predictor (P <.01 to <.05) for lower FA in the cingulum,
particularly on the left. Conversely, higher steroid dose but not inammation pre-
dicted lower FA in the right uncinate and temporal part of the superior longitudi-
nal fasciculus (p <.05). Correlations between inammation and FA adjusted for
steroid yielded similar ndings for the overall sample and for CD patients only
(see table).
CONCLUSION(S): Results of this rst association between pediatric CD and brain
development suggest differential impact of steroids and inammatory markers on
white matter microstructure. The inverse correlation between left cingulum integ-
rity and circulating inammation is of clinical interest as the cingulum is integral
part of the limbic system, connecting prefrontal with medial temporal cortex and
thus has been linked to emotion processing, memory and executive functions, -
all previously associated with inammation. Further neuroimaging and behavioral
studies including CD patients off steroids are warranted to elucidate these initial
ndings.
P-150
Chronic Inflammation and Its Association With Neurobehavioral Functions in
Pediatric Crohns Disease
Christine Mrakotsky
1
, Kristin Maletsky
2
, Jonathan Girard
2
, Deborah Waber
1
,
Athos Bousvaros
3
, Richard Grand
4
1
Boston, MA, USA,
2
Department of Psychiatry, Boston Childrens Hospital, Boston,
MA, USA,
3
Center for Inflammatory Bowel Disease, Boston Childrens Hospital,
Harvard Medical School, Boston, MA, USA,
4
Division of Gastroenterology, Boston
Childrens Hospital, Harvard Medical School, Boston, MA, USA
BACKGROUND: Pediatric Crohns disease (CD) is associated with high circulating
concentrations of pro-inammatory cytokines (IL-6, TNF-a) and acute phase
proteins (CRP). These proteins can cross the blood-brain-barrier. For example,
IL-6 is expressed in the hippocampus, hypothalamus and cortex, TNF-a in
microglia. Thus, excess cytokines have the potential to disrupt brain systems
critical for memory, executive functions and mood. Children with CD therefore
may be at particular risk for cognitive and emotional problems based on not
only short and long-term medication regimens, but their underlying disease
itself. Our earlier reports of behavioral impact of inammation have been con-
founded by the fact that patients were concurrently treated with corticoste-
roids, which can cause similar behavioral and CNS side-effects. We here investi-
gate the effects of inammation on memory and executive functions
independent of steroids.
METHODS: Behavioral and cytokine data from an ongoing NIH study were avail-
able on 61 children with CD age 8-16 years who have completed the study
thus far. Patients were assessed at one time-point of a longitudinal design,
when all were off steroids for at least 4-6 months. Standardized measures of
memory, executive functions, IQ, mood, sleep, and pain severity were adminis-
tered. Questionnaires included the Behavior Rating of Executive Functions
(BRIEF), Child Behavior Checklist (CBCL), Youth Self Report (YSR), and Childrens
Depression Inventory (CDI). Serum markers of inammation included high-sensi-
tivity C-reactive protein (hsCRP) and pro-inammatory cytokines/receptors (IL-6,
TNFR2).
RESULTS: Higher levels of inammation in patients with CD were variably associ-
ated with poorer neurobehavioral outcome, as indicated by parent and self-
report of cognitive and mood problems in daily life. TNFR2 emerged as the most
robust predictor for executive problems, which were primarily of cognitive nature
(see table). Effects remained after adjusting for pain, sleep, IQ, and prior steroid
therapy. Correlations were modest but consistent with the literature. There was
no sizable effect on laboratory cognitive measures.
CONCLUSION(S): Results replicate earlier ndings of the impact of inammation
on cognition and mood in children with CD. Higher levels of inammation were
associated with more reported problems in executive functions, including difcul-
ties in controlling ones behavior, getting started on or completing tasks, working
efciently, as well as in attention and working memory. These functions are pre-
sumably mediated by prefrontal cortex, limbic system and potentially intercon-
necting white matter. While few effects were found on laboratory cognitive tests,
patients and parents reported more cognitive problems in daily life associated
with higher inammatory markers. This discrepancy between test and question-
naire results in populations without frank neurological impairment is a known
phenomenon in neuropsychological research, and one that is likely best
addressed with the use of more sensitive neural measures such as neuroimaging.
Clinically, these ndings carry important implications for patient education, that
underlying chronic inammation, especially when untreated, can have far reach-
ing developmental impact.
P-151
YI
Evaluation of TMPT in a Racially Diverse Pediatric IBD Population
Dyer Heintz, Ashish Patel
UT-Southwestern, Dallas, TX, USA
BACKGROUND: Inammatory bowel disease (IBD) is a chronic autoimmune condi-
tion affecting the gastrointestinal tract with nearly 30% presenting by age 18
1
.
Thiopurines are popular treatment option for patients, but they have signicant
side effects, including myelosuppression, hepatotoxicity and increased risk of can-
cer
2,3
. Thiopurine methyltransferase (TPMT) genetics or enzyme activity (EA) are
measured in attempts to predict side effects
4
, most notably myelosuppression,
but they may vary based on age, sex and race
5-7
. This study aims to identify any
differences in TPMT measurement in a racially diverse pediatric population with
IBD based on age, sex, race or diagnosis.
METHODS: We reviewed our established pediatric IBD database, composed of 384
patients diagnosed with Crohns disease, ulcerative colitis, or IBD-indeterminate
between Jan 2003 and Dec 2010, for the usage of thiopurines. Patients were
screened for TPMT genetics and/or EA. We considered EA >23.6 EU/mL normal,
6.7-23.6 EU/mL intermediate and <6.7 EU/mL low. Basic demographic data,
including sex, race, diagnosis and age at time of EA level were collected. Data
was then evaluated for differences in TPMT EA based on age, sex, race and diag-
nosis. Data was also evaluated for differences in both TPMT genetics and/or EA
with focus on variability between white, black and Hispanic/Latino populations.
Other races were included for descriptive purposes.
RESULTS: Of the 384 patients in the database, 287 (74.7%) patients had TPMT
measured by genetics and/or EA; however, only 244 (63.5%) took thiopurines.
Overall, 218 (89.3%) of 244 patients on thiopurines had TPMT measured. Table 1
illustrates TPMT enzyme activity by age. Table 2 illustrates TPMT measurement by
genetics and/or EA by race. There was no correlation between EA and age or
specic age groups. Males had a signicantly higher EA compared to females,
31.2 vs. 27.4 EU/mL (P = 0.015). Black patients had a lower EA compared to white
and Hispanic/Latino groups (P < 0.5), see Chart 1. Patients with UC had a
signicantly higher average EA compared to those with Crohns, 31.9 vs. 27.8 EU/
mL (P = 0.01).
CONCLUSION(S): TPMT measurements were performed in the majority of patients
taking thiopurines. Nineteen of 26 patients took thiopurines without TPMT evalu-
ation prior to ofcial recommendations for TPMT testing in 2006
4
. Age did not
signicantly affect EA as a prior study suggested
7
, although the 0-5 year group
was small. Males had small but signicantly higher EA, which be related to the
racial diversity or sampling. Mutations in white patients (all 3A) and black patients
(all 3C) are consistent with prior genetic studies
8,9
. Enzyme activity was lower in
black patients with a higher rates of mutations compared to other groups, sug-
gesting black children with IBD may be at risk for drug induced myelosuppres-
sion and require lower thiopurine dosing. Closer monitoring may be indicated.
TPMT measurements have a trimodal distribution consistent with historical con-
trols
11
, although there is a group with normal and intermediate levels who need
more investigation. Interestingly, there was a small, but signicant difference in
EA between patients with UC and Crohns disease. This nding is notable could
relate to inammation, disease activity or concurrent medications.
P-152
YI
The Role of Thiopurine Metabolites in Thiopurine Related Toxicities in Pediatric
Patients With IBD
Dyer Heintz, Ashish Patel
UT-Southwestern, Dallas, TX, USA
BACKGROUND: Inammatory bowel disease (IBD) is a chronic autoimmune condi-
tion affecting the gastrointestinal tract with 30% of diagnoses presenting by age
18
1
. Thiopurines, 6-mercaptopurine and azathioprine, are popular treatment
option for patients, but they have signicant side effects, including myelosup-
pression and hepatotoxicity
2,3
. Monitoring of thiopurine metabolites, thioguanine
nucleotide (6-TGN) and methyl mercaptopurine nucleotide (6-MMPN), can aid in
dosing and identifying potential side effects
4
. The aim of this study is to identify
the relationship between thiopurine metabolites, myelosuppression and hepato-
toxicity in a racially diverse pediatric population with IBD.
METHODS: We reviewed our established pediatric IBD database, composed of 384
patients diagnosed with Crohns disease, ulcerative colitis, or IBD-indeterminate
between Jan 2003 and Dec 2010, for usage of 6-mercaptopurine and/or azathio-
prine. Laboratory data were evaluated for thiopurine metabolites, evidence of
leucopenia (WBC < 3,000/mm
3
), thrombocytopenia (platelet < 100,000/mm
3
)
and transaminitis (ALT > 100 unit/L). We performed a retrospective chart review
for patients with evidence of myelosuppression or hepatotoxicity to collect dura-
tion on thiopurines, dosing, thiopurine methyltransferase (TPMT) genetics and/or
enzyme activity, other medical conditions, and demographic data.
RESULTS: Of the 384 total patients, 244 (63.5%) took thiopurines. Thiopurine
metabolites were obtained in 194 (79.5%) of these patients. Elevated TGN (>400
pmol/8 X10
8
RBC) was seen in 21 patients with 3 having evidence of myelosup-
pression. Twenty-three (9.4%) patients had evidence of myelosuppression while
on thiopurines (Table 1), 18 of which had metabolites drawn at the time of mye-
losuppression. When other medical conditions likely to account for the myelosup-
pression were factored in, including 2 with lymphoma, 2 EBV infections, and 1 vi-
ral infection, there were only 18 patients (7.4%). Myelosuppression was transient
(<1 month) in 16 patients. Dosing was decreased by 1/4 to 1/2 in 6 patients and
stopped in 2 patients (1 due to poor response). Elevated 6-MMPN (>5700 pmole/
8 X10
8
RBC) was seen in 23 patients with 2 having transaminitis. Eighteen
patients (7.4%) overall had evidence of hepatotoxicity while on thiopurines (Table
1), 15 of which had metabolites drawn. When other medical conditions likely to
account for transaminitis were evaluated, including 5 with primary sclerosing
cholangitis, 2 EBV infections and 1 lymphoma, there were only 10 patients (4.1%).
Increased levels were transient (<1 month) in 12 patients. Dosing was decreased
by 1/4 to 1/3 in 3 patients and stopped in 1 (due to poor response).
CONCLUSION(S): Thiopurine metabolites were obtained in most patients. Eleva-
tions were rare overall and unlikely to result in toxicity. Myelosuppression and
hepatotoxicity were usually transient, responded to decreased dosing, and
Figure 1.
resulted in cessation of therapy in only 1 patient. Both myelosuppression and
hepatotoxicity were seen after 1 year of medication usage in preteen patients,
and were unrelated to excessive dosing, sex or race. Crohns disease was more
prominent in both categories, although its implication is unclear. Patients with in-
termediate TMPT enzyme activity may be at increased risk for myelosuppression
independent of dosing and metabolite levels. Monitoring for side effects of thio-
purines in children with IBD should not rely only on metabolites.
P-153
YI
Non-Adherence and Disease Severity in Pediatric Inflammatory Bowel Disease
George Zacur, Shehzad Saeed, Katherine Loreaux, Kevin Hommel
Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio, USA.
BACKGROUND: The treatment of Inammatory Bowel Disease (IBD) involves com-
plex medical and nutritional therapies that pose signicant challenges to effective
disease management (i.e., adherence to treatment regimens) for children and
their families. Research on adherence rates in pediatric IBD has been largely de-
scriptive, neglecting the relationship between adherence and disease symptoms
and severity. The purpose of this study is to examine the relationship between
medication non-adherence (i.e., aminosalicylates and thiopurine immunomodula-
tors) and disease severity and symptoms in pediatric patients with IBD.
METHODS: This study is part of a larger, ongoing, retrospective longitudinal
observational cohort study of pediatric patients with a conrmed diagnosis of
Crohns disease, ulcerative colitis, or indeterminate colitis who were prescribed
aminosalicylates and/or thiopurine immunomodulators and received a Physician
Global Assessment (PGA) during regular clinic visits over a contiguous 2-year pe-
riod. Fifty-three (53) pharmacy rell records with a prescription duration range of
364-803 days were obtained. Medication adherence rates were calculated based
on the validated medication possession ratio formula. Physicians provided an
assessment of IBD patients disease severity using the PGA as part of standard
clinic procedure for IBD patients. Chi-square analysis was performed to assess the
association between adherence and disease severity.
RESULTS: Thirty-one (31) patients were on an aminosalicylate, and 22 were on a
thiopurine immunomodulator. Forty-three percent (43%) of all records obtained
were identied as non-adherent, using an 80% cut point for medication rells.
The rate of adherence for both medications was 78%. The prevalence of non-ad-
herence to aminosalicylates and thiopurine immunomodulators was 50% and
30%, respectively. Patients taking aminosalicylates who were adherent were more
likely to have quiescent disease severity than non-adherent patients (P = 0.0126).
Similarly, adherent patients on thiopurine immunomodulators were also more
likely to be quiescent (P = 0.0035). When the denition of non-adherence was
dened as relling less than 85% of prescribed medication, a stricter criterion,
both groups showed quiescent disease severity with improved adherence (amino-
salicylates P = 0.012; thiopurines P = 0.0113).
CONCLUSION(S): These results suggest that disease severity is signicantly related
to poor medication adherence. This study should assist clinicians caring for pedi-
atric patients with IBD by better understanding the impact of non-adherence on
disease severity and ultimately inform the timing of early interventions aimed at
improving adherence and quality of care in this population. This may also have
implications for cost of delivered care as more adherent patients may require
fewer hospitalizations and acute care visits, decreased surgical interventions, and
perhaps a reduced need for step up therapy to more expensive medications (e.g.,
biologics).
P-154
YI
Patients With Inflammatory Bowel Disease Prior to Transition of Care: Compari-
son of Patient and Parent Perspectives
Yamini Natarajan, Bincy Abraham
BACKGROUND: Approximately 25% of patients with IBD are diagnosed younger
than age 18. As these young patients become adults, their care will transition
from pediatric to adult gastroenterologists. In this critical time period, patients
may be at risk having relapse related to loss of follow up, suboptimal understand-
ing and low adherence to treatment. Patients in the pediatric setting are usually
accompanied by their parents, who often play a large role in the transition pro-
cess. Our study aimed to evaluate the views of pre-transitional patients and their
parents regarding four domains integral to the transition process: knowledge of
disease, attitude towards transition process, perception of disability, and self-
efcacy.
METHODS: IBD patients ages 13 to 22 who were followed by a pediatric gastroen-
terologist were identied. We distributed paper questionnaires that enquire about
similar issues related to disease knowledge, attitude towards the transition process,
perception of disability, and self-efcacy to these patients and their parents during
their clinic visit. The surveys were completed by each party separately and col-
lected on the same day. We compared the proportions of patients and parents
with each answer and calculated the concordance between the answers of patients
and parents to similar questions (using unweighted Kappa test).
RESULTS: 40 patient and parent pairs were enrolled in the study, of which 32
patient-parent pairs completed all questionnaires (1 pair excluded because neither
parent was present at clinic visit and 7 were excluded due to incomplete surveys).
As expected, patients and parents showed high degree of concordance regarding
type of IBD, age of diagnosis, and duration of disease (Kappa 0.84-1, P < 0.0001).
There was moderate concordance regarding the internet as a source of information
on IBD, (Kappa 0.41, P = 0.02), and ability to keep insurance information with the
patient (Kappa 0.65, P = 0.0002). As far as perception of disability, parent and
patient views had only fair concordance on food choices (kappa 0.37, P = 0.02)
and further education (kappa 0.29, P = 0.02): 67% patients reported that their dis-
ease affected their food choices, while 84% parents reported that their childs dis-
ease affected their food choices; 97% patients reported that their education was
not affected, while 83% parents reported so. Low concordance was observed for
parents and patients views on importance of learning about transition process and
concern about switching to an adult gastroenterologist (kappa 0.35-0.39, P = 0.02-
0.04): 69% of patients thought it was important to nd out early about the switch-
ing process, while 83% of patients thought the same; 19% of patients reported
they were concerned about switching to an adult gastroenterologist, while 28% of
parents reported the same. A stronger concordance, but a lower concern of going
to a new clinic location (kappa 0.52, P = 0.008) was reported in only 15% of
patients, but 34% of parents.
CONCLUSION(S): While patients and their parents have similar views of knowl-
edge, sources of information and perception of disability, there was a discrepancy
in perceiving the importance and concern for the transition process with parents
expressing greater concern than patients.
P-155
Post-Operative Complications in Pediatric Inflammatory Bowel Disease: a Popu-
lation-Based Study
Eugenie Penninck
1
, Mathurin Fumery
1
, Julia Salleron
2
, Guillaume Savoye
3
, Domini-
que Turck
4
, Jean-Louis Dupas
5
, Eric Lerebours
1
, Laurent Peyrin-Biroulet
1
, Jean-
Frederic Colombel
6
, Corinne Gower-Rousseau
7
1
Gastroenterology Unit, Lille, Nord, France,
2
Biostatistics Unit EA 2694, Lille, Nord,
Lille,
3
Rouen University and Hospital, Rouen, Seine Maritime, France,
4
Pediatric
Unit, Lille, Nord, France,
5
Amiens University and Hospital, Amiens, Somme, France,
6
7
Epidemiology Unit, Lille, Nord, France
BACKGROUND: We sought to describe in a pediatric population-based cohort the
incidence of and factors associated with post-operative complications in inam-
matory bowel disease (IBD).
METHODS: Using the population-based EPIMAD Registry (Northern France), we
identied all children who underwent at least one major abdominal surgery for
IBD among 692 incident cases with Crohns disease (CD) (n = 532) or ulcerative
colitis (UC) (n = 160) diagnosed between 1988 and 2004. Median age at rst
major abdominal surgery was 16 years [Q1 = 14-Q3 = 16]. Medical records were
reviewed for early (within 30 days of surgery) and late (_30 days) complications
which were graded according to Dindos criteria (1). Factors associated with com-
plication were assessed using multivariate Cox models and expressed as hazard
ratios (HR) with 95% condence intervals (CI)
RESULTS: Among 153 IBD patients (22%) who underwent at least one major ab-
dominal surgery until December 2009, 76 (49.7%) experienced at least one post-
operative complication with a total of 113 complications; 51 patients had one com-
plication and 25 more than one. The frequency of severe post-operative complica-
tions (grade>2) was similar in CD and UC (28% vs 27%; P = 0.95). A total of 64
early complications was observed in 47 patients (31%), with 32 infectious and 32
non-infectious. A total of 49 late complications was observed in 37 patients (24%),
with 5 infectious and 44 non-infectious. The cumulative probability of any post-op-
erative complication was 31% (95% CI, 24-39) at 6 months and 45% (38-54) at 1
year. No death occurred. Multivariate analysis found that the type of IBD was the
only factor associated with any post-operative complication (HR relative to UC vs.
CD, 2.2; 95% CI, 1.3-3.9). Age, gender, systemic steroid, immunosuppressive therapy
during the 3 months before abdominal surgery were not risk factors.
CONCLUSION(S): About one half of pediatric patients with IBD experienced at least
one post-operative complication that occurred either early (31%) or late (24%).
Only UC relative to CD was signicantly associated with an increased risk of post-
operative complications. (1) Dindo et al. Annals of Surgery 2004;240:205-13
P-156
Information Needs for Pediatric IBD Patients and Their Parents
Dawn Ebach
University of Iowa, Iowa City, IA, USA
BACKGROUND: It is important for patients to understand their disease and treat-
ment options in order to fully participate in decision making and to improve
adherence to recommendations.1 To better anticipate patient needs investigating
how patients learn about their disease and whether the sources of information
are accurate is needed. In addition, there can often be a disconnect between
what a physician feels is important information and what the patient wants to
know. A 2011 study in adults revealed that 24% of patients were dissatised in
the information they received and that there was information that they wanted
and were not provided such as about prognosis or self-management.2 1. Siegel,
CA. Shared decision making in inammatory bowel disease: helping patients
understand the tradeoffs between treatment and options. Gut 2012;61:459-465. 2.
Bernstein KI, Promislow S, Carr R, et al. Information needs and preferences of
recently diagnosed patients with inammatory bowel disease. Inamm Bowel Dis
2011:17:590-598.
METHODS: A questionnaire obtained from an ongoing IRB approved study of
shared decision making aids was analyzed. Pediatric IBD patients between 8-20
and their parents were invited to participate if they were newly diagnosed or
were having a change in therapy.
RESULTS: A total of 13 subjects (6 mothers, 2 fathers, and 5 patients) completed
the questionnaire. Five of the patients were newly diagnosed and 1 had been
diagnosed <3 years. The internet was the most common source of previous
knowledge of IBD (7 patients) and a close family member was second (5). Sub-
jects ranked IBD topics that they preferred to learn more about and this is shown
in Table 1. The subjects prefer to obtain this information from their health care
provider (12/13). Other sources of information preferred include from a book (8/
12) and a website (7/12). Learning from friends or family member (4/12), com-
puter applications (3/12) or videos (3/12) were least preferred.
CONCLUSION(S): Patients prefer to obtain information about their disease from
their physician and they want to know about IBD complications, signs and symp-
toms of a are, and daily life with IBD.
P-157
Intra-abdominal Abscesses in Pediatric Crohns Disease: Management and
Outcomes
Jason Shapiro
1
, Carolina Cerezo
2
, Jared Silverstein
2
, Linda Shalon
2
, Neal Leleiko
1
1
Rhode Island Hospital/Alpert Medical School of Brown University, Providence, RI,
USA,
2
Rhode Island Hospital/Hasbro Childrens Hospital, Providence, Rhode Island,
USA
BACKGROUND: Crohns disease (CD) is a chronic inammatory condition of the
gastrointestinal tract. Intra-abdominal abscess is one of the serious complications
of penetrating disease. While medical management of aggressive disease is criti-
cal to reduce the inammatory response, use of immunosuppressive or biologic
agents may be problematic in the setting of an abscess. Conventional medical
management of CD-related abscesses has included a combination of bowel rest,
parenteral nutrition, and antibiotics. Percutaneous drainage may augment medi-
cal management by avoiding or delaying the need for surgical intervention. There
is little available data to guide the management decisions of intra-abdominal
abscesses in the pediatric population. Objective: To evaluate the management
and outcomes for Crohns related intra-abdominal abscesses in the pediatric
population.
METHODS: We conducted a retrospective review of medical records of all pediat-
ric patients (6-21 years) diagnosed with Crohns disease related intra-abdominal
abscess at Hasbro Childrens Hospital in Providence, Rhode Island over a 10-year
period (2002-2012). Patients with perianal and peri-rectal abscesses in the ab-
sence of an intra-abdominal abscess were excluded from our study.
RESULTS: 17 out of 271 patients were identied. The patient characteristics are
summarized in Table 1. Imaging modalities to diagnose abscess included CT, MR
enterography and ultrasound (Table 2) The number of CT scans per patient from
IBD diagnosis ranged from 0-7 (average 2.7). Initial management and outcome
measures are summarized in Table 3. 94% of patients were initially managed
medically with IV antibiotics and bowel rest, 5 of which underwent percutaneous
drainage. About half of the patients required TPN for an average duration of 3
weeks. At medical stabilization, 3 patients were escalated to an anti-TNF agent.
After initiation of anti-TNF therapy, there were no abscess recurrences, infections
or adverse effects reported in the follow-up period (average clinical follow-up of
10 months).
CONCLUSION(S): This pilot study at our institution shows considerable variability
in the diagnosis and treatment of intra-abdominal abscesses in pediatric patients
with CD. These patients were seen over a 10-year period. During this period, the
impact of increasing use of immunomodulators and biologic agents is unknown.
It is still unclear if medical management (with or without percutaneous drainage)
followed by escalation of medical therapy to an anti-TNF is safe or equivalent to
surgical management. Future prospective studies will be needed to clarify the
true incidence and optimal management of this severe complication of CD.
P-158
Retrospective Review of Infliximab Use in Patients Less Than Six Years of Age
Kathy Christenson, Julie Bass, William San Pablo, Ellen Carpenter, Christy Sirridge
Childrens Mercy Hospitals and Clinics, Kansas City, Missouri, USA
BACKGROUND: The REACH study helped determine the efcacy and safety of
iniximab in patients 6-17 years of age. The dosing, including induction, was
found to be similar to adult dosing. This study also demonstrated an incidence of
serious infections at 5.7%. The most prevalent adverse events were respiratory
infections. In 2012, deBie et al. reviewed the literature on the use of anti-TNF
medications in pediatric IBD and found adjustments in dosing between 27-49%
of the time. The median time to dose adjustment was 6-9 months. After initiation
of iniximab, intestinal surgery was performed in 25-35% of patients with Crohns
disease. There are no reports on the use of iniximab in patients less than 6 years
of age.
METHODS: This was a descriptive, retrospective chart review of patients with IBD
receiving iniximab as standard care for treatment of IBD from June 2002- July
2012.
RESULTS: Since 2002, our institution has diagnosed 790 patients with IBD; 50
patients (6%) were under 6 years of age at the time of diagnosis. 13 (26%) of
these patients with IBD received iniximab when they were less than 6 years of
age; 8 diagnosed with Crohns disease, 3 with UC, and 2 with indeterminant coli-
tis. The age at diagnosis ranged from 11 months to 66 months with a mean of
37 months. 12 patients presented with bloody diarrhea. The age iniximab was
initiated ranged from 15 months to 69 months with a mean of 46 months. 7
patients received monotherapy. Prior to 2008, iniximab was given in combina-
tion with mercaptopurine in one patient and azathioprine in 3 patients. Since
2008, methotrexate was given in combination with iniximab in two patients.
The number of doses of iniximab given ranged from 2 to 38 with dosage ranges
of 4.7 mg/kg to 13 mg/kg. The doses were adjusted in 6 patients, 4 with success.
Two patients still on iniximab have not had dose adjustments due to high initial
doses (9.3 mg/kg and 12.5 mg/kg). Seven patients had colectomies; two diag-
nosed with UC, two indeterminant colitis, two diagnosed with Crohns after an
initial diagnosis of UC, and one patient with severe perianal Crohns disease. Six
of the patients requiring colectomy were prior to 2008; only one out of 7
patients in the past 4 years required a colectomy. Two patients developed hives
after 6-7 doses and one had an acute infusion reaction with facial swelling and
desaturation. Other potential complications were limited to one patient with
mycoplasma pneumonia, one with recurrent UTIs, and one with recurrent Clos-
tridium difcile. The patient with severe perianal disease has since been diag-
nosed with IL10RA.
CONCLUSION(S): Iniximab was used successfully in 6 out of 7 patients with IBD
in the past 4 years. All six patients who received iniximab prior to 2008 went on
to colectomy.
P-159
6-TGN Levels in Pediatric IBD Patients: Adherence Is More Important Than
Dose
Neal Leleiko
1
, Debra Lobato
1
, Sarah Hagin
2
, Chris Hayes
3
, Elizabeth McQuaid
1
,
Ronald Seifer
1
, Sheryl Kopel
1
, Julie Boergers
1
, Jack Nassau
1
, Jason Shapiro
1
, Kris-
tina Suorsa
2
, Barbara Bancroft
2
1
Rhode Island Hospital/Alpert Medical School of Brown University, Providence, RI,
USA,
2
Rhode Island Hospital, Providence, RI, USA,
3
Hasbro Childrens Hospital,
Providence, RI, USA
BACKGROUND: Thiopurine immunosuppressants such as 6Mercaptopurine are
widely used to induce and maintain remission in children with both Crohns Dis-
ease and Ulcerative colitis. Therapeutic efcacy is associated with higher RBC lev-
els of the thiopurine metabolite 6-TGN. Studies in both children and adults have
inexplicably failed to demonstrate a signicant correlation between prescribed
dose and level of 6-TGN. We aimed to determine whether 6-TGN levels were
related to adherence and whether adherence varied among individuals over a
sustained 6-month period
METHODS: We used electronic monitoring devices to assess adherence in a sam-
ple of children with IBD who were taking 6-Mercaptopurine.
RESULTS: During 3,423 days of monitoring in 21 subjects, adherence to 6 MP was
only 70.4%. Adherence varied signicantly for each individual from month to
month. As a result of the variable and generally low adherence to the prescribed
dose of 6-MP, the 6-TGN level was not correlated with the prescribed dose. The
6-TGN level was signicantly correlated to the actual dose as calculated from the
measured adherence to the prescribed dose. It was also signicantly correlated
to adherence alone.
CONCLUSION(S): Lack of efcacy to thiopurines (and probably other oral medica-
tions) may be attributed in part to poor adherence. Novel ways of assessing and
improving adherence are necessary. Past clinical trials that do not assess adher-
ence must be viewed with concern, and future trials should assess adherence in
study subjects.
P-160
Improving Oral Medication Adherence in Pediatric IBD by Teaching Problem
Solving Skills: Year 2 Results of the PHONE Trial
Rachel Greenley
1
, Eve Nguyen
1
, Jennifer Kunz
1
, Amitha Gumidyala
1
, Molly Tho-
mason
1
, Jennifer Walter
1
, Michael Stephens
2
, Vincent Biank
3
, Ellen Blank
2
, Praveen
Goday
2
, Ranjana Gokhale
4
, Barbara Kirschner
4
, Alfonso Martinez
2
, Adrian Mir-
anda
2
, Joshua Noe
2
, Neelesh Tipnis
5
, Narajanan Venkatsubramani
6
, Steven Werlin
2
,
Stacy Kahn
4
1
Rosalind Franklin University of Medicine & Science, North Chicago, IL, USA,
2
Med-
ical College of Wisconsin, Milwaukee, WI, USA,
3
NorthShore Medical Group, Evan-
ston, IL, USA,
4
University of Chicago, Chicago, IL, USA,
5
UC San Diego, San Diego,
CA, USA,
6
Duke University School of Medicine, Durham, NC, USA
BACKGROUND: Despite the prevalence of oral medication nonadherence among
youth with inammatory bowel disease (IBD), few evidence-based tools exist to
address this issue. Development of brief interventions that can be implemented
in regular clinical practice is needed. Problem solving skills training (PSST), which
involves teaching families a structured approach to identifying and solving adher-
ence barriers, is a promising intervention that has been used to successfully
address nonadherence in other pediatric chronic diseases. We report on the Year
2 outcomes of a randomized clinical trial of a phone-delivered PSST intervention Figure 1.
Figure 2.
Figure 3.
to reduce adherence barriers and improve adherence in youth with IBD. Recruit-
ment for this study is ongoing.
METHODS: English speaking youth ages 11-18 followed in one of two Pediatric
IBD clinics in the Midwest, with a conrmed diagnosis of IBD, who had a parent/
guardian willing to participate, and who were prescribed an oral IBD maintenance
medication were eligible to participate. Families completed a baseline assessment
of adherence barriers (A1), and follow-up assessments at approximately 3 months
(A2) and 5 months post recruitment (A3). The primary outcome was improve-
ment in adherence to an oral maintenance medication, which was assessed via
electronic monitoring. Following A1, families were randomized to either immedi-
ate treatment (i.e., 2 phone PSST sessions) or a wait list comparison group. Fol-
lowing A2, those in the immediate treatment group were re-randomized to either
a maintenance condition or to receive two additional phone PSST intervention
sessions, while those in the wait list group were automatically given treatment
(i.e., 2 phone PSST intervention sessions). See Figure 1 for a diagram of the study
procedure.
RESULTS: To date, 76 participants (parent-child dyads or triads) have been con-
sented and 38 have complete data available for the current analyses. Participating
youth were predominately male (56%) and Caucasian (88%). Most participants
had Crohns disease (71%). Eighteen of 38 youth (47%) had perfect adherence
(i.e.,100%) during the baseline-monitoring interval and thus, had no improvement
in adherence following the two intervention sessions. The remaining twenty
youth had a mean pre-intervention adherence rate of 62% (SD = 28%), which
improved to 75% (SD = 28%) following two phone intervention sessions. This
nding was consistent with a medium effect size (d = 0.59). Little additional ben-
et on adherence was seen among those receiving an additional 2 (4 total) PSST
intervention sessions; however, this subsample was small (n = 8). In addition,
families reported high satisfaction with key intervention components. On an
Intervention Satisfaction Scale ranging from 1 to 5, with higher scores reecting
higher satisfaction, mean youth satisfaction ratings ranged from 3.9 to 4.4. Mean
mother satisfaction ratings ranged from 3.5 to 4.5. See Table 1 for satisfaction rat-
ings by item.
CONCLUSION(S): Results to date support phone-delivered PSST as a useful inter-
vention for families of youth with IBD who have adherence problems. Additional
analyses will explore differences in intervention efcacy as a function of youth
age, SES, and disease severity. Analyses will also explore cost-savings of delivering
the intervention via phone versus in person.
P-161
Thrombosis in Pediatric Patients With Inflammatory Bowel Disease; a Case for
Risk Stratification, and Prophylactic Anticoagulation
Naamah Zitomersky
1
, Anne Levine
2
, Benjamin Atkinson
2
, Menno Verhave
3
, Jeni-
fer Lightdale
3
, Cameron Trenor, III
4
1
Gastroenterology Division, Boston Childrens Hospital, Harvard Medical School,
Boston, MA, USA,
2
Division of Gastroenterology, Boston Childrens Hospital, Bos-
ton, MA, USA,
3
Division of Gastroenterology, Boston Childrens Hospital, Harvard
Medical School, Boston, MA, USA,
4
Division of Hematology/Oncology, Boston
BACKGROUND: Inammatory Bowel Disease (IBD) increases the risk of throm-
boembolism. The safety of anticoagulation in active IBD is established and adult
guidelines recommend prophylactic anticoagulation for IBD inpatients, yet pediat-
ric inpatients are rarely considered for thromboprophylaxis. The aim of our study
was to systematically evaluate the incidence of thrombotic events in a pediatric
inpatient IBD population.
METHODS: We retrospectively reviewed an inpatient billing database for all IBD
colitis admissions and an anticoagulation database for thrombotic complications
from 2006 to 2011.
RESULTS: Of 532 patients admitted with IBD-related colitis, ten (1.9%) had throm-
boembolic events (nine venous, one arterial), two with recurrent thrombosis.
Line-associated thrombosis occurred in four of 104 (3.8%) IBD inpatients with in-
dwelling lines. Established risk factors in IBD inpatients with thrombotic complica-
tions included: indwelling catheter (4/10), rst-degree family member with VTE
(2/10), hereditary thrombophilia (3/10), smoking (1/10), oral contraceptive (1/5
females) and thalidomide (1/10). Additionally eight of ten patients had acquired
thrombophilias, mostly elevation of factor VIII and anticardiolipin antibodies.
Patients with IBD and VTE received therapeutic anticoagulation without signi-
cantly increased bleeding. Thrombus resolution was documented in seven cases,
persistence in two cases and recurrence in two cases.
CONCLUSION(S): IBD inpatients have an increased risk of VTE, including complica-
tions of embolism, recurrence, persistence, and indenite anticoagulation. Thera-
peutic anticoagulation in pediatric IBD patients with active colitis appears safe.
We identied both inherited thrombophilias and acquired risk factors in patients
with IBD and VTE. We propose an algorithm for pediatric inpatients with IBD coli-
tis to identify high-risk patients for prophylactic anticoagulation.
P-162
Role of Pelvic Magnetic Resonance Imaging for Evaluation of Disease Activity
in Pediatric Patients With Perianal Crohns Disease
Sakil Kulkarni, Timothy Yates, Chantal Lucia-Casadonte, Roberto Gomara,
Jesse Reeves-Garcia, Ricardo Restrepo
Miami Childrens Hospital, Miami, Florida, USA
BACKGROUND: Approximately one-third of the patients with Crohns Disease have
perianal involvement. Cessation of drainage from the orices of the stula is still
been used widely as an indicator for cure in the pediatric population. However,
recent literature has shown us that cessation of drainage is not equivalent to
healing of a stula. Contrast-enhanced pelvic Magnetic Resonance Imaging has
been used to diagnose and monitor perianal Crohns Disease. Adult studies have
used various radiologic parameters (T2 hyperintensity, rectal wall thickening,
bowel stratication, Percentage Increase in T2 hyperintensity etc.) and scores
(Van Assche Score) to monitor perianal Crohns Disease. However, similar studies
are lacking in pediatric population.
METHODS: We performed a retrospective chart review of children under the age
of 18 years at initial diagnosis who underwent contrast-enhanced pelvic MRI for
perianal Crohns disease. We analyzed a total of 44 pelvic MRI images. Of those,
29 were baseline images, performed at the time of diagnosis and 15 were follow
up images (while on treatment). We also noted down clinical (stula drainage)
and laboratory (hemoglobin, hematocrit, albumin, ESR and CRP). We compared
various radiological parameters and scores amongst the two groups. We also
compared the correlation of the radiological parameters to laboratory values at
the time of MRI.
RESULTS: We found that amongst individual parameters, the PI (percentage
increase in intensity on contrast enhancement compared to fat) [2], was signi-
cantly higher in the baseline group compared to treatment group {318.97 6
116.81 vs. 246.15 6 74.89 P = 0.021}. There was no signicant difference
amongst the other individual parameters (T2 hyperintensity, rectal wall thicken-
ing, Parks classication, St James classication, presence of abscesses). However,
the MRI based scores suggested by Van Assche et al [1] (15.28 6 3.82 vs10.47 6
4.62, P = 0.002) and Horsthius et al [1] (21.34 6 4.74 vs 14.87 6 6.02, P = 0.001)
were signicantly higher in the baseline group compared to treatment group.
Also, MRI scores by Horstheus et al showed signicant positive correlation to ESR
(Pearson co-efcient = 0.398, P = 0.012) and negative correlation to serum albu-
min (Pearson co-efcient = -0.558, P = 0.00), hemoglobin (Pearson co-efcient =
0.317, P = 0.016) and hematocrit. (Pearson co-efcient = -0.383, P = 0.016).
Similar results were seen with the Van Assche score.
CONCLUSION(S): Authors suggest that the use of radiological parameters and
scores described above will help the pediatric gastroenterologist to better moni-
tor treatment of perianal Crohns disease. To the best of authors knowledge; this
is the rst study in pediatric population which demonstrates the value of using
the above radiological parameters and scores to monitor perianal Crohns disease.
References 1) Horsthuis K, de Ridder L, Smets AM, van Leeuwen MS, Benninga
MA, Houwen RH, et al. Magnetic resonance enterography for suspected
Figure 1.
inammatory bowel disease in a pediatric population. J Pediatr Gastroenterol
Nutr. Nov; 51(5):603-9. 2) Villa C, Pompili G, Franceschelli G, Munari A, Radaelli G,
Maconi G, et al. Role of magnetic resonance imaging in evaluation of the activity
of perianal Crohns disease. Eur J Radiol. Apr; 81(4):616-22.
P-163
Compound Heterozygous IL10RA Mutations in Brothers with Very Early Onset
Julia Bracken, Darrel Dinwiddie, Kathy Christenson, Charles Roberts, Carol Saun-
ders, Sarah Soden, Neil Miller, Stephen Kingsmore
Childrens Mercy Hospital and Clinics, Kansas City, MO, USA
BACKGROUND: Background: Interleukin 10 receptor (IL10R) mutations have been
reported to cause aggressive inammatory bowel disease (IBD) in children (1).
Very Early Onset IBD (VEO-IBD) is known to be associated with severe disease,
poor response to therapy and increased morbidity and mortality. CMH00165 and
CMH00166 are brothers who both presented with early in life Crohns Disease
(CD), thus far refractory to medical management. CMH00165 is a 4 year old male
who presented at 12 months of age with perirectal abscess, failure to thrive,
hematochezia and skin rash. CMH00166 is a 1 year old male who presented at 4
months of age with oral lesions, anemia, failure to thrive and skin rash. Immunol-
ogy evaluation for the pair was unremarkable. Skin biopsy revealed neutrophilic
dermatitis and GI mucosal biopsies conrmed diagnosis of Crohns disease. Medi-
cal therapy including azathioprine, iniximab, methotrexate, adalimumab, and,
nally tacrolimus has failed to adequately control disease. Poor therapeutic
response resulted in corticosteroid dependence, two bowel resections in the
older child, failure to thrive, nutritional insufciency requiring intermittent paren-
teral nutrition and repeated hospitalizations.
METHODS: Methods: Given the severe and early onset phenotype of disease in a
sibling pair, the family consented to exome sequencing at the Center for Pediatric
Genomic Medicine (CPGM) at Childrens Mercy Hospital. DNA isolation was per-
formed on blood specimens from the children and both unaffected parents.
Exome enrichment was conducted with the Illumina TruSeq Exome v1 (62.2 meg-
abase) kit and sequenced on an Illumina HiSeq 2000 to a depth of >8 gigabases
per sample. Base calls(1 x 100 nucleotides) were generated with Illumina RTA
1.12.4.2 & CASAVA-1.8.2, aligned to the human genome reference NCBI 37 using
Genomic Short-read Nucleotide Alignment Program (GSNAP), and variants were
detected using the Genome Analysis Tool Kit (GATK)3. Variants were characterized
with the CPGMs Rapid Understanding of Nucleotide variant Effect Software
(RUNES v1.0)3.
RESULTS: Results: Both affected children were found to have compound heterozy-
gous mutations in the Interleukin 10 Receptor A. Each parent was found to be a
carrier of a single gene mutation. Variant 1: IL10RA, c.784C>T, p.Arg262Cys has
been previously reported in VEO-IBD. Variant 2: IL10RA, c.349C>T, p.Arg117Cys is
a novel variant affecting a conserved amino acid, and is predicted to be
deleterious.
CONCLUSION(S): Conclusions: We present a novel IL10RA variant and a case of
compound heterozygosity in the IL10 receptor leading to early and aggressive
IBD. This is the second family in which exome sequencing of an affected child or
children and healthy parents was useful for molecular diagnosis of VEO-IBD4.
Given previously reported success with allogeneic bone marrow transplantation
in children with IL10R mutations2, this family will be presented with additional
therapeutic options.
P-164
Early Infliximab Trough Levels Predict Remission at One Year in Pediatric IBD
Patients
Casey Rosenthal, Gil Melmed, Bhavna Tripuraneni, Jennifer Gebbia, Silvia Callejas,
Sharmayne Farrior, Shervin Rabizadeh, Marla Dubinsky
BACKGROUND: Among patients with IBD, detectable trough concentrations of
iniximab (IFX) during maintenance dosing are associated with response to ther-
apy. Moreover the presence of anti-iniximab antibodies (ATI) increases drug
clearance and loss of response. It is unknown whether IFX and ATI levels at the
completion of induction dosing predicts long term efcacy of maintenance ther-
apy. We determined whether week 14 trough IFX levels (IFX14) and ATI levels
(ATI14) were associated with week 54 outcomes in pediatric IBD patients.
METHODS: A prospective cohort of pediatric IBD patients receiving IFX were
tested for IFX and ATI levels at both weeks 14 and 54 or at early termination. Pri-
mary non-responders (NR) were patients who stopped drug before week 14 and
early terminators were patients who stopped drug between weeks 14-54. Primary
outcome was week 54 clinical remission (CR) : PCDAI <10 for Crohns disease or
partial Mayo <2 points and no sub-score >1 for ulcerative colitis and the ab-
sence of a dose or frequency intensication beyond 5 mg/kg q 8 weeks prior to
week 54. Secondary outcomes were deep remission (DR): clinical remission with
normal CRP, sustained durable remission (SDR): CR at every maintenance infusion
(week 14-54) and week 54 IFX (IFX54) and ATI (ATI54) levels. Univariate analyses
were used to determine associations between IFX14 and ATI14 and week 54 out-
comes, as appropriate. Regression tree analysis was used to determine the opti-
mal IFX14 cutoff level associated with remission. IFX and ATI ELISA testing were
performed at Prometheus labs (San Diego, CA).
RESULTS: A total of 38 patients (median age: 12.6 yrs.) were enrolled of whom 4
were primary NR. 2/4 primary NR had detectable ATI levels and 3/4 had undetect-
able IFX levels before week 14. Of the 34 who entered maintenance at week 14, 3
patients discontinued IFX prior to week 54. Of the remaining 31 patients, 20 met
criteria for both clinical and deep remission and 14 for SDR. ATI were detected in 3/
34 (8%) at week 14 and 7/34 (20%) at week 54 or at early termination. 4/7 patients
developed ATI after week 14. Week 14 IFX trough level was associated with CR (P
= 0.009), DR (P = 0.009) and SDR (p = 0.04). The optimal cut point for IFX trough
level at week 14 to predict DR was 5.5 lmL (p = 0.01). IFX14 was associated with
IFX54 (P = 0.02) and inversely associated with ATI54 (P = 0.003). ATI14 was associ-
ated with ATI54 (P = 0.004) and inversely associated with IFX54 (P = 0.06) but was
not associated with any of the remission outcomes.
CONCLUSION(S): Iniximab levels at week 14 are associated with clinical, deep
and sustained durable remission at week 54, with a minimum trough level of 5.5
lg/mL strongly predictive of deep remission. Moreover, week 14 IFX trough levels
correlate with both week 54 IFX and ATI levels. The presence of ATI at week 14
did not predict remission outcomes but did correlate with IFX and ATI levels at
week 54. Assessment of iniximab levels at an early time point may be warranted
to optimize dosing to maximize long term therapeutic benet.
Nursing Poster Presentations
P-165
Learning from Transitional Care: Experiences and Recommendations of Young
Adults
Maureen Kelly, Ali Annaim, Paul Mihas, Michael Kappelman
UNC-Chapel Hill, Chapel Hill, NC, USA
BACKGROUND: There are few studies addressing the experience of transitional
care in young adults with inammatory bowel diseases (IBD). Most of the studies
include patients with other chronic health problems, and are descriptive studies
related to patient satisfaction regarding the experience, rather than studies based
on clinical outcomes. Study Aim: To evaluate the experience of adolescents with
IBD who have transitioned to adult care.
METHODS: Former patients in the pediatric gastroenterology clinic at a tertiary
care center were interviewed using a two-part telephone questionnaire. Twenty
young adults completed a ten question scaled survey using a ve point Likert
scale. The responses were ranked from 1 to 5 (5 as the most positive response),
and consisted of questions related to level of preparedness from the pediatric
provider, independent research on the adult provider, level of preparedness
before rst appointment with the adult provider, communication, condence in
ability to manage disease independently, understanding of disease and plan
before transition, satisfaction with experience, as well as preferred method of
education. Eighteen of the participants also agreed to complete an open-ended
questionnaire. This portion of the interview included questions related to the
patients knowledge of their disease, medication, adherence, nutrition, self-man-
agement skills, knowledge of reproductive health, attending college or starting a
job, health insurance, ongoing adult support, and nding a new heath care
provider.
RESULTS: The young adults described an overall positive transition experience
with a mean of 4 (very satised) on the Likert scale. The results of the open-
ended questions revealed six overarching themes and better reected the com-
plexity of the transition process. These themes included: 1) reaction to transition
spanning a wide range of experiences from hand holding to guided discovery to
complete independence; 2) relationship with healthcare providers, including the
ability to listen and discuss sensitive topics; 3) knowledge including information
about the treatment plan and the transition process itself; 4) emotions ranging
from anxiety about their diet to helplessness when hospitalized; 5) communica-
tion including what occurs between the young adult and the pediatric provider,
as well as between the pediatric and adult provider; and 6) recommendations
which included the need to do research on their own during the transition pro-
cess, not only on their medical condition, and resources available to them, but
also on the background of their adult provider.
CONCLUSION(S): Obtaining only quantitative data on the adolescent transitioning
process is not sufcient to capture the experience. Many of the participants in
this study remember what they consider a smooth transition, but even those
individuals made recommendations to improve the process. Open-ended
questions allow for patients to discuss what worked and did not work for them
during the transition experience. Implications for Research to Nursing: Address-
ing the needs of the adolescent with IBD who is transitioning from pediatric to
adult care includes careful attention to their medical, psychosocial, and educa-
tional needs. Communication is essential for this transition to occur smoothly.
Nurses and nurse practitioners have a key role in this process.
P-166
Innovative Teaching for Humira (adalimumab) Injections to Children with
Teresa Wachs
Seattle Childrens, Seattle, WA, USA
BACKGROUND: Humira (adalimumab) is a fully human anti-TNF- alpha monoclonal
antibody used to treat Inammatory Bowel Disease in Adults and Children. It is
available in both prelled syringes and prelled pens. The injections are widely
reported to cause varying degrees of discomfort. The pH of Humira is 5.2, which
may contribute to the pain. Children are especially reluctant to receive any treat-
ments that involve needles. The goal of teaching is to encourage any child over
the age of 7 to be involved with their injections and over time gain independ-
ence. The degree of involvement will progress with their comfort and acceptance
of therapy. Methods of coping with the injection site discomfort and the progres-
sive involvement were developed to promote self injection and tolerance of side
effects.
METHODS: Children are given the option to be taught to self inject when therapy
begins or participating while a parent or caregiver administers the medication.
Most children prefer the Humira pen so they do not see the needle or have to
watch it penetrate the skin. Depending on the childs developmental level, a mul-
tistep process in introduced. If a child is hesitant to self-administer, they are
asked to clean the skin and/ or gently squeeze the skin while the infection is
given. This actively engages the child in the treatment. When they are more com-
fortable, the next step is to have the child press the activator button. The last
step before independence is having the child do the injection while the parent
holds the syringe to prevent them from inadvertently lifting it before the medica-
tion is fully infused. Dealing with the pain of the injection is a signicant skill for
a child to acquire. We developed several strategies to distract and calm the child
during the administration. These include the use of specic music via earphones
that allows the child to focus and prepare to depress the activator at a certain
point the song and know when the music comes to a another point the pain will
be gone. Ice applied to the site for 20 minutes prior to injections is helpful to
some children as is a warm pack after the injection. Giving the injection after
soaking for 5-10 minutes in the bathtub to relax and then immediately immers-
ing the limb after the injection is effective. Lastly allow the child to choose a pi-
ece of very sour candy and place in their mouth just prior to injection. Count to
3 and then bite into the candy while you depress the activator in the pen. This
gives them 2 powerful sensations and they are distracted. This method is met
with enthusiasm.
RESULTS: Children were able to progress to independence and develop skills to
assist them in coping with a difcult treatment. These skills can be transferred to
other treatment settings and give the child a sense of control and self efcacy.
CONCLUSION(S): Children need creative methods to cope with painful procedures
and can become independent with a program that encourages a gradual pro-
gression in their involvement.
P-167
Creating and Implementing a Pre-visit planning (PVP) Tool for IBD Visits
Emmala Shonce
Levine Childrens Hospital, Charlotte, North Carolina, USA
BACKGROUND: ImproveCareNow (ICN) is an established network of gastroenterol-
ogy care centers and professionals that has raised the standard of care in pediat-
ric IBD by creating Model IBD Care: Guidelines for Consistent Reliable Care follow-
ing the carefully analyzed results of thousands of doctorpatient visits as well as
the latest studies and treatments worldwide. The success of the program lies in
developing and using specic tools which lead to further improvement in the
delivery of care at each involved site. One such tool addresses the concept of
pre-visit planning (PVP). PVP tools are used to identify possible patient needs or
areas to address prior to the time of the actual visit, in the hopes lining up
appropriate resources and avoiding delays or missed opportunities during the
ofce visit itself.
METHODS: 4 PVP tools provided by well-established teams in ICN where
reviewed, and used to create our rst PVP tool draft. The tool addressed informa-
tion regarding initial diagnosis, most recent screening tests, current weight and
medication dosages, and status of immunizations. The clinic schedules were
reviewed on Friday afternoons, which is an administrative time for our clinic. Any
identied IBD patient for the upcoming week got a PVP tool completed that
date. Any outstanding needs were highlighted, and the form was given to the
corresponding provider for notication. After the completion of the visit, the pro-
viders where asked to return the PVP form with either written or verbal notica-
tions pertaining to their response to recommendations. Using a PDSA (plan,
study, do, act) the tool was revised and re-trialed several times based on com-
ments and feedback from our providers.
RESULTS: After multiple cycles and revisions, we were able to create a tool that
was comprehensive but quick, taking only about 3 minutes to complete per
patient. We were able to identify and complete the tool on >90% of routine
scheduled IBD visits. We received qualitative feedback from the providers that
they felt that the tool was useful, and helped them ensure needed items were
brought to their attention quickly, saving them time during the actual visits. Inci-
dentally, after our interventions we noted an increase in remission rates for this
patient population from a dismal 40% to well above 60%.
CONCLUSION(S): Participating in a quality collaborative such as ICN, where tools
such as our PVP form are considered routine, can be time consuming but cer-
tainly worthwhile to increase standardization of care delivery, and to ultimately
improve patient outcomes. Using a PDSA format which allows measurement of
both objective and subjective data, was benecial in this setting to create an
effective, well received tool.
P-168
Infliximab Adverse Reaction Quality Study
Kate Milbury
Portland Gastroenterology Center, Portland, Maine, USA
BACKGROUND: This was an evaluation of rate and severity of infusion reactions.
We retrospectively observed who was reacting adversely and why, hoping to
determine that our site was in a reasonable average of previously documented
adverse reactions to Iniximab. Another goal was to determine why pts left the
drug and/or this particular infusion site. This was designed as a Quality Study for
use within the scope of a large GI practice. Our hope was to evaluate and
observe the very best patient outcomes within our setting.
METHODS: Chart review of 880 infusions over a period of 40 mo. Gender, age,
dx., intra infusion reactions and delayed (up to 14 days) were all considered. Our
success rate with re-infusing known reactors was evaluated and pre-infusion
meds for both known and non-reactors. RN specic re-constitution practices were
considered as well as any similarities in problematic drug lot #. Length of time of
infusion was reviewed along with what point in the infusion did the adverse
event occur? Would any patterns emerge within prescribing physicians?
RESULTS: 30 adverse reactions observed in a total of 124 pts. (880 infusions) v All
age 55 or younger v 16 female 6 male. Second time reactors (8) were mixed. v
16 dx. of CD, 4 UC, 2 dual dx. v No pattern of errors in re-constitution practice
(84% of all infusions by single RN) v More intense reaction sx. observed with
delayed reactions. One pt. w/ severe systemic sx. requiring respiratory support. (9
yr. drug holiday not prev. disclosed no steroids given pre-inf ) v Successful in re-
treating known reactors ongoing in only 2 cases. Both receiving IV/PO steroids In
conjunction w/ IV antihistamine pre inf. v No patterns within pre-scribing physi-
cians v Adverse reactions occurred during rate increases in the 80-150 mL. range
v Most severe delayed reaction found in pt. infused over 1hr.55 min. (non-dis-
closed drug holiday) Average length of infusion for all reactors was 2hrs.15 min
CONCLUSION(S): Conclusions: We should consider a more standardized approach
to pre-infusion meds. Seeing clearly that pre-medicating w/ a combo of steroids
and anti-histamines (along w/ standard Acetaminophen) was associated w/ lower
prevalence of infusion reactions in both non and second time known reactors.
We were within the standard 3% expectation of adverse reaction for Iniximab. In
124 patients observed, 7 were found to fail Iniximab as a direct result of their
adverse reaction. All went onto alternative biologics. Other evidence for losing
pts. to our particular infusion site incl. poor compliance, insurance changes or
loss, scheduling unavailability, and pt. re-location. AN ADDENDUM TO THIS STUDY
REVIEWS ADDING IV HYDROCORTISONE PRE-INFUSION. COMPLETION BY 10/1/12
P-169
Does Measuring Infliximab and Human Anti-Chimeric Antibody Concentrations
in Patients With Inflammatory Bowel Disease Impact Clinical Management? A
Canadian Experience.
Usha Chauhan
1
, Usha Dutta
2
, David Armstrong
2
, Eric Greenwald
2
, John Marshall
3
,
Frances Tse
2
, Ted Xenodemetropoulos
2
, Halder Smita
2
1
Hamilton Health Sciences-McMaster University Medical Centre, Hamilton, Ontario,
Canada,
2
McMaster University, Hamilton, Ontario, Canada,
3
McMaster University
Health Sciences, Hamilton, ON, Canada
BACKGROUND: Background: Iniximab (IFX) is a chimeric (mouse/human) anti-tu-
mor necrosis factor alpha (anti-TNFa) therapy used for treatment of inammatory
bowel disease (IBD). The main phenotypes of IBD are Crohns disease (CD) and Ul-
cerative colitis (UC). On biological therapy, patients may become unresponsive to
therapy or develop side effects. The reasons for which may be sub-therapeutic
drug levels or development of Human Anti-Chimeric Antibodies (HACA). Objec-
tive assessment of these two parameters would help guide therapy in some com-
plex patients with IBD. An HACA serum assay is commercially available through
Prometheus Laboratories, Inc., San Diego, CA. In Canada, the Ministry of Health
and Long Term Care in Ontario (MOHLT) has granted approval for this test, in
selected IBD patients, 12 months ago.
METHODS: Methods: We conducted a retrospective chart review of adult patients
with IBD in whom HACA and Iniximab trough levels were estimated, to deter-
mine whether these results impacted clinical management. The indications for
these tests were recorded for each patient. Approval was sought from MOHLT for
performing the test. Serum was collected 24 to 48 hours prior to the next inixi-
mab infusion.
RESULTS: Results: Thirty-six patients with IBD (29 CD, 7 UC) had HACA and Inixi-
mab levels estimated. The mean age (SD) was 32.5 (13) years and 56% were
females. The mean disease duration (SD) was 10(6) years and mean duration on
iniximab therapy (SD) was 4(3) years. Indication for testing were diminished
response to therapy in 80%, development of side effects in 14% and primary
non-response in 6%. HACA was positive in 7 patients and iniximab levels were
undetectable in 9 patients. Iniximab levels were undetectable in all patients
who were HACA positive except one. Based on these results, treatment was
altered in 78% of the patients. Among the 7 HACA positive patients, 3 were
switched biological therapy, 2 were switched to immunomodulators (endoscopy
showed inactive disease), 2 were continued on iniximab with increased fre-
quency. Among 29 patients who were HACA negative, 9 patients had undetect-
able drug concentration. In them, frequency of infusion was increased in 6, dose
was increased in 2 (10 mg/kg every 4 weeks), and one patient was switched to
another biological agent. After modications in therapy, the drug levels were
retested in 4 patients. It was detectable in 3 and undetectable in one who was
then referred for surgery. Among the remaining 20 patients with detectable drug
levels (>6.25 lg/mL), only limited modications were required. Of these, 8 were
continued on the same treatment, 6 were switched to another biological agent,
the iniximab dose was increased in 3, started immunomodulator therapy in 2
and in one patient the dose of iniximab was decreased.
CONCLUSION(S): Conclusion: Measurement of HACA and iniximab concentration
impacts clinical management of patients with IBD. The use of these tests helps
tailor therapy and optimizes patient management.
Basic Science Poster Presentations
P-170
YI
TGF-b as a Key Factor for Generation of IL-17-Producing Regulatory T Cells in
Inflamed Gut Mucosa
Zaruhi Hovhannisyan, Sara Farsio, Lloyd Mayer
Mount Sinai School of Medicine, New York, New York, USA
BACKGROUND: IL-17-producing CD4 helper T(Th17) cells are involved in inam-
matory bowel disease (IBD) and mucosal immunity. While a great degree of plas-
ticity in Th17 and regulatory T(Treg) cell differentiation programs is recognized,
the interplay between these two developmentally related T cell subsets under
chronic inammatory conditions remains obscure. We have recently shown that
the unique inammatory environment in Crohns disease (CD) contributes to the
generation of distinct FoxP3IL-17-producing Tregs in inamed CD gut mucosa.
Our study aims to further elucidate the factors that control the fate of Treg and
Th17 cells in a specic CD inammatory microenvironment, which will provide a
better understanding of immune responses in intestine.
METHODS: Surgical specimens from patients undergoing bowel resection for IBD
or colorectal cancer were used as the source of lamina propria lymphocytes(LPL).
Mucosal tissues from IBD patients and normal controls were cultured for 24h in
serum-free medium. Supernatants were collected and stored at 20oC. Bacterial
antigens(BAgs) were prepared from fresh human stool aspirates collected from
IBD patients and healthy controls during regular colonoscopy.
RESULTS: The supernatants from CD, but not UC or normal-derived mucosal cul-
tures, were able to potently induce FoxP3IL-17 population in UC, but not nor-
mal CD4 LPLs. The induction of these cells was abolished by an addition of neu-
tralizing aTGF-b antibody to the cultures. Analysis of cytokine prole revealed a
signicant increase in IL-6, IL-8 and IL17-A in CD mucosal tissue cultures when
compared to those derived from UC or normal controls. Notably, we found that the
levels of bioactive TGF-b were signicantly increased in CD-derived mucosal tissue
cultures when compared to normal controls or explants derived from UC and,
remarkably, non-inamed CD mucosal tissue cultures. Thus, the inamed CD mu-
cosa is an environment rich in bioactive TGF-b with the potential to promote the
generation of FoxP3IL-17 cells. To assess whether the bacterial microbiota can
inuence the conversion of Treg to Th17 cells in vitro, UC CD4 LPLs were cultured
with BAgs derived from IBD patients and normal controls. Interestingly, BAgs
derived from either source potently induced a FoxP3IL-17 population in UC
CD4 LPLs in a dose-dependent manner. The cognate T cell/BAg/MHC recognition
was found to be essential for the differentiation of these cells. In contrast, no
induction of IL-17Tregs was observed in response to BAgs in UC PB-derived
CD4 T cells, while BAgs derived from any source were able to induce IFN-c pro-
duction in both LP- and PB-derived CD4 T cells. Analysis of the TCR repertoire
revealed the predominant usage of Vb5.1, Vb2 and Vb9 by FoxP3IL-17 cells
induced by CD BAg, whereas FoxP3IL-17 cells induced by UC and NL BAgs
shared Vb2 usage.
CONCLUSION(S): Given signicantly elevated levels of bioactive TGF-b in CD
mucosal tissues as the ability of TGF-b to potently induce IL-17Tregs in UC LPLs
in vitro, our data suggest that TGF-b may be responsible, at least in part, for
IL-17Treg cell development in CD. Our results also indicate a potential role of
bacterial microbiota in modulation of IL-17 expression by LP CD4 Tregs.
P-171
YI
Mechanisms of Protection of Alpha4-Deficient T Cells in a Model of Chronic Ex-
perimental Colitis
Dmitry Ostanin, Elvira Kurmaeva, Songlin Zhang, Richard Bao, Berney Seth
Louisiana State University Health Sciences Center, Shreveport, LA, USA
BACKGROUND: Gastrointestinal (GI) tract represents an important interphase
between the body and the outside world. Under steady-state conditions, T-cell-
associated a4 integrins (a4b7, a4b1) play an important role in T-cell recruitment
to the gut-associated lymphoid tissue (GALT: Peyers Patches, lymphoid follicles),
mesenteric lymph nodes (MLNs) and small intestine. Moreover, these molecules
are important contributors to the pathogenesis of experimental and human
Crohns disease (CD). Although the effectiveness of anti-adhesion therapy target-
ing a4 integrins is thought to be primarily due to blocking effector T cell recruit-
ment into intestinal tissues, there is little direct evidence to conrm this, since a4
integrins can be also found on natural killer cells, monocytes, and granulocytes.
Therefore, the objective of the current study was to ascertain the importance of
T cell-associated a4 integrins in the induction of chronic gut inammation.
METHODS: We utilized cre/loxP technology to generate conditional mutant mice
with T cells lacking a4 integrins (a4-/-). Using adoptive T cell transfer model of
CD, we reconstituted recombination activating gene-decient (RAG-1-/-) mice
with a4-/- or control a4/ CD4CD45RB
high
T cells and monitored development
of disease. Blinded histopathological colon scores, inltrating leukocyte numbers
and phenotype, and cytokine production by colon lamina propria (LP) cells were
determined. To determine the effect of a4 integrin deletion on T cell trafcking,
we conducted competitive homing experiments.
RESULTS: While a4/ T cells elicited moderate to severe colitis, colitis in the
a4-/-RAG-1-/- mice was remarkably attenuated. This correlated with a signi-
cant reduction in T cells, granulocytes, and monocytes in colons of these mice
compared to the a4/RAG-1-/- group. Analysis of cytokines produced by
mononuclear cells isolated from colon LP in the a4-/-RAG-1-/- mice showed
reduced levels of IL-1b, IL-2, IL-17, and TNF-a but not IFN-c or IL-12p70 compared
to control. Single-cell analysis of CD4 T cells by intracellular staining revealed
comparable production of IFN-c and IL-17 by a4-/- and a4/, suggesting that
a4-/- T cells are not defective in their ability to become activated and secrete
pro-inammatory cytokines. Trafcking of a4-/- and control T cells to MLN was
comparable to WT, while homing of a4-/- T cells to small intestine and colon was
severely compromised. Finally, analysis of surface integrins in reconstituted mice
revealed that following transmigration into colon LP, T cells downregulate a4b7
but maintain high levels of b1 integrin expression.
CONCLUSION(S): Alpha4 integrins are important for intravascular recruitment of T
cells to the intestine and induction of colitis. At the same time, our data sug-
gested that b1 integrins may be important for their localization within the intesti-
nal tissue. Further work will need to determine relative importance of these
integrins in the ability of T cells to induce experimental colitis.
P-172
YI
Mutual Expression of Runx3 and ThPOK Regulates Intestinal CD4 T Cell
Immunity
Bernardo Reis, Aneta Rogoz, Frederico Costa-Pinto, Daniel Mucida
The Rockefeller University, New York, NY, USA
BACKGROUND: Environmental cues are part of differentiation processes of all cell
types- and T cells are no different. Peripheral mature CD4 and CD8 T cells express
ThPOK and Runx3, respectively, in a mutually exclusive fashion. In the intestine,
where a large amount of diverse antigens can be constantly perceived as stimuli,
the immune system developed particular pathways to deal with this rich luminal
content without generating progressive inammation. While Treg and other
regulatory cells can be found in the intestinal tissue, not much is known about
cell-intrinsic mechanisms that regulate CD4 T helper function at this environmen-
tal intersection.
METHODS: To address the stability and function of the CD4 T cell lineage in the
intestine, we analyzed ThPOK and Runx3 expression using GFP or YFP-knockin re-
porter strains, respectively. We performed loss-of-function experiments in both
ThPOK and Runx3 using naive CD4 T-cell transfer model of colitis and C. roden-
tium infectious model to evaluate the contribution of these transcription factors
in CD4 T cells immunity in the intestine.
RESULTS: We observed that a population of ThPOK
low
CD4 T cells expresses high levels
of the CD8-lineage transcription factor Runx3. Upregulation of Runx3 by intraepithelial
CD4 T cell populations was associated with changes toward the CD8 lineage and
reduced Th17 differentiation. ThPOK loss-of-function experiments suggested that
ThPOK is directly involved in repression of CD8 cytotoxic (CTL)-conversion and in the
inammatory potential of CD4 T cells, although it does not directly regulate Th17 dif-
ferentiation. On the contrary, Runx3 loss-of-function resulted in increased levels of in-
testinal ThPOK expression by CD4 T cells and enhanced Th17 differentiation. Periph-
eral modulation of ThPOK and Runx3 in CD4 T cells was dependent on TGF-b and
retinoic acid (RA) signaling, indicated in vitro, using exogenous cytokines during CD4-
T cell differentiation, and in vivo, using mice decient in TGF-b or RA signaling.
CONCLUSION(S): Our results provide functional relevance and mechanistic evidence
for a continuous role of T-cell development transcription factors in the periphery, com-
posing a tightly regulated process that drastically changes CD4 T cell activity in a site-
specic manner. The functional studies with induced changes in ThPOK and Runx3
expression levels raise the possibility that disruption of this pathway may result in
uncontrolled CD4 T cell responses. Reinforcement of this pathway lead to attenuated
intestinal inammation and increased susceptibility to extracellular bacterial infection.
It is also possible however, that excessive triggering of the CTL-function on CD4 T cells
results in breakdown of the epithelial layer as observed in celiac disease, but paradoxi-
cally could also increase resistance to viral infections that shut down the MHC-I pre-
sentation pathway. Factors that inuence this pathway in one way or another are a
potential target for therapeutic interventions in inammatory disorders.
P-173
YI
Hypoxia Inducible Factor (HIF)-Dependent Regulation of TH1 CD41 T Cells in
Eoin McNamee, Eric Clambey, Carol Aherne, Holger Eltzschig
University of Colorado Denver, Aurora, CO, USA
BACKGROUND: Hypoxia and inammation share an interdependent relationship.
During inammatory bowel disease (IBD) the inamed intestinal mucosa becomes
hypoxic due to increased metabolic demand and a paucity of available oxygen. Sta-
bilization of hypoxia-inducible factors (HIF) occur within the cellular milieu of the
inamed intestine and directly affects the leukocyte transcriptome. While effector
T
H
1 CD4
T cells inltrating the intestinal lamina propria have been implicated in

driving induction and perpetuation of the inammatory processes in Crohns Dis-
ease (CD), the effect of hypoxia signaling on effector T
H
1 T cells remains unknown.
METHODS: To address this, we examined the role of hypoxia signaling on the regu-
lation of T
H
1 CD4
T cells by differentiating murine T

H
1 T cells ex vivo and exposed
them to ambient hypoxia in vitro (1% P0
2
). The effect of hypoxia on transcriptional
machinery and cytokine production was assessed by QPCR, ow cytometry, west-
ern immunoblotting and ELISA. Using the CD45Rb
high
murine model of ileocolitis
we assessed the localization of T cells inltrating hypoxic lesions within the
inamed mucosa and the stabilization of T cell-HIF. Lastly, using targeted pharma-
cological treatment or T cells with and intrinsic genetic deletion of HIF, we further
assessed the impact of HIF stabilization or deletion on CD45Rb
high
ileocolitis.
RESULTS: Using the CD45Rb
high
murine model of ileocolitis, we show that lamina
propria-inltrating CD4
T cells are exposed to regions of fulminant hypoxia and

express stabilized hypoxia-inducible factor compared to colonic CD4
T cells
from uninamed mice. Building on these preliminary studies we differentiated
murine T
H
1 CD4
T cells ex vivo and exposed them to ambient hypoxia in vitro

(1% P0
2
). Experimental hypoxia induced a marked repression of the transcription
factor Tbet (Tbx21; the master regulator of T
H
1 T cells) at both the mRNA and
protein levels. This was paralleled with a functional effect as hypoxia further sup-
pressed IFNc secretion (the predominant Tbet-responsive T
H
1 effector cytokine).
These ndings were also mirrored with pharmacological stabilization of HIF using
the prolyl-hydroxylase inhibitor, DMOG. In an effort to dene the molecular
mechanism employed by hypoxia to repress Tbet, both lentiviral knock-down and
genetic deletion of T cell-intrinsic HIF, revealed a redundant role HIF-1a whereas
hypoxic-repression of Tbet and IFNc was attenuated in HIF-2a decient T cells.
Lastly, in a proof of principal in vivo experiment, pharmacological stabilization of
HIF attenuated all indices of CD45Rb
high
colitis while conversely, selective T cell-
HIF-2a deletion exacerbated disease compared to WT counterparts.
CONCLUSION(S): Based on these preliminary studies, we hypothesize that HIF-2a
critically regulates mucosal T
H
1 CD4
T cell function and may highlight a novel

targeted therapeutic option for the treatment of inammatory bowel disease.
P-174
YI
Commensal Bacteria Play an Important Role in Ulcerative Colitis via Bacterial
Sphingolipids-Mediated Regulation of Host Invariant Natural Killer T Cells
Dingding An, Sungwhan Oh, Dennis Kasper
BACKGROUND: Our group has shown previously that microbiota can impact ulcera-
tive colitis disease phenotypes by modulating invariant natural killer T (iNKT) cell
functions. We further found that chemokine CXCL16 is responsible for this modula-
tion, with germ-free (GF) mice having high CXCL16 level, large iNKT cell numbers and
severe experimental ulcerative colitis outcome. In this study, we hypothesized that in
addition to CXCL16 regulated functions, intestinal microbiota can directly impact
iNKT cells by providing bacterial antigen, such as glycosphingolipids.
METHODS: We generated a Bacteroides fragilis mutant (del SPT) that no longer pro-
duces any sphingolipids. We then mono-colonized GF mice using wild-type or del SPT
mutant. Theses mice were further challenged with an experimental ulcerative colitis
modeloxazolone colitis model and the disease phenotypes were evaluated.
RESULTS: Results: We found that the wild-type B. fragilis mono-colonized mice have
signicantly lower colonic iNKT cell numbers than the mutant mono-colonized mice,
which are similar to the GF mice. CXCL16 levels in both of the mono-colonized mice
are as low as that of the conventional mice, indicating the existence of a new pathway
for colonic iNKT cell regulation. When challenged in the oxazolone colitis model, the
mutant-colonized mice were much more susceptible than the wild-typecolonized
mice. These phenotypes were diminished when the mice were treated with CD1d
antibody, indicating iNKT cell-specic functions were involved.
CONCLUSION(S): Our study demonstrated that microbiota regulate colonic iNKT cells
via a new and unknown pathway. This pathway uses components in bacterial sphin-
golipid biosynthesis and it points to a new direction for therapeutic intervention of ul-
cerative colitis.
P-175
Activation of Heat Shock Factor 1 Attenuates Murine Intestinal Inflammation
via Enhanced Treg Function
Colm Collins, Derek Strassheim, Pamela Puthoor, Alyson Yeckes, Kayla Pound,
Edwin de Zoeten
University of Colorado, Denver, Aurora, Colorado, USA
BACKGROUND: Inammatory Bowel Disease (IBD) is a chronic inammatory condi-
tion thought to reect a failure of the enteral immune system to adequately reg-
ulate itself, resulting in unrestrained inammation. Regulatory T cells (Tregs)
mediate suppression of this overactive immune response; therefore, better under-
standing of their role in the pathogenesis of IBD will undoubtedly inform the de-
velopment of novel therapies. Previous data demonstrates that inhibition of heat
shock protein 90 (HSP90) activity enhances Treg function via a mechanism involv-
ing disruption of a complex containing HSP90 and heat-shock factor 1 (HSF1).
Genetic deciency in HSF1 has been shown previously to result in more severe
chemically-induced colitis, yet efforts to enhance HSF1 activation in mouse mod-
els of IBD have not been attempted to date. Heat-shock proteins are up-regu-
lated in response to cellular stress including inammation to prevent protein mis-
folding and aggregation as well as to act as molecular chaperone proteins to
drive de novo transcription. HSF1 has been shown previously to translocate to
the nucleus and drive expression of a number of anti-inammatory genes such as
IL-10 and HSP70. We hypothesized, therefore, that enhanced HSF1 function might
enhance Treg function and thereby attenuate murine colitis.
METHODS: Heat shock (42
o
C, 30 min) of na ve CD4
T cells resulted in a signi-

cant increase in Treg induction upon anti-CD3 activation when coupled with
TGFb. Conversion from na ve cell to Treg coincided with shuttling of HSF1 from
the cytoplasm into the nucleus within 1 hr of stimulation with anti-CD3 as well
as a signicant increase in nuclear expression of HSF1 from bona de Tregs rela-
tive to na ve CD4
CD25
neg
T cells. In contrast, genetic deletion of HSF1 resulted
in a decrease in intestinal Foxp3
Treg frequency along with impaired Treg sup-

pressive function in vitro. This phenomenon is characteristic of human IBD.
RESULTS: Administration of Celastrol, an HSF1 activator, enhanced Treg suppres-
sive function and drove translocation of HSF1 from the cytoplasm into the nu-
cleus in WT cells relative to vehicle controls. HSF1 translocation in turn resulted
in upregulation of IL-10 mRNA transcripts in isolated Tregs in vitro. Activation of
HSF1 with Celastrol attenuated established inammation in the T-cell driven
CD45RB
High
colitis model. Two week continuous treatment with an osmotic pump
attenuated histological evidence of inammation and increased the frequency of
Foxp3
IL-10 producing Tregs in the colonic lamina propria.

CONCLUSION(S): Targeting HSF1 for therapeutic benet represents an exciting
strategy, as HSF1 is preferentially upregulated at sites of specic inammation.
Furthermore, as we increase our understanding of the anti-inammatory mecha-
nisms of HSF1 activation in murine models of IBD, this data will provide proof of
principle for the expansion of current clinical trials using HSF1 activators for can-
cer chemotherapy to include indications in IBD. Funding from K08DK080189
(EDZ) & CCFA-2652 (CBC) and UL1 RR025780 (EDZ & CBC).
P-176
Mucosal Delivery of IL-27 Attenuates Murine Enterocolitis via T Cell-Derived IL-10
Scott Durum
1
, Julie Hixon
1
, Wenqing Li
1
, Barbara Felber
1
, Miriam Anver
1
, Charles
Stewart
1
, Wei Shen
1
, Mairi McLean
1
, Pieter Rottiers
2
, Lothar Steidler
2
, Miranda Hanson
1
1
NCI NIH, Frederick, MD, USA,
2
ActoGeniX, Zwijnaared, NA, Belgium
BACKGROUND: Treatment of inammatory bowel disease (IBD) would benet by
local delivery of therapeutics, avoiding systemic effects. Lactococcus lactis is a
food grade bacterium that has been engineered to deliver experimental protein
therapeutics to the bowel following oral administration. It has been shown to be
safe in clinical trials. IL-27 is a cytokine that has been shown to inhibit develop-
ment of pro-inammatory Th17 cells and induce development of suppressor Tr1
cells that act by producing immunosuppressive IL-10.
Figure 1.
Figure 2.
METHODS: Murine IL-27 was engineered into Lactococcus lactis (LL-IL-27) to treat
murine IBD by oral gavage. Several IBD models were evaluated. T cell transfer IBD
was treated with LL-IL-27 at the time symptoms developed 7.5 wk after transfer,
and treatment was performed daily for two weeks. Acute colitis was induced by
DSS in drinking water for 5 days followed by 5 daily treatments with LL-IL-27.
Acute colitis was also induced by TNBS installation, the next day LL-IL-27 treat-
ments began for 3 days. Mice were monitored for survival, disease activity index
(DAI:weight loss, stool consistency and occult blood in stool) and gut pathology
at sacrice.
RESULTS: Engineered bacteria produced approximately 300 ng/mL of IL-27 in cul-
ture, which was biologically active in inducing Stat3 phosphorylation and IL-10
expression in murine T cells. LL-IL-27 showed a substantial therapeutic benet in
T cell transfer induced enterocolitis, improving survival, decreasing DAI, reducing
inammatory cytokine levels and eliminating pathology in the colon and small
intestine (Fig. 1). LL-IL-27 treatment decreased CD4 and IL-17 T cells in gut tis-
sue. The therapeutic benet required induction of IL-10 in the transferred T cell
population which was primarily expressed by intraepithelial CD4CD8a T cells
(Fig. 2). LL-IL-27 was much more effective in reducing DAI and colon pathology
than either LL-IL-10 (Fig. 3) or systemic administration of recombinant mouse IL-
27. LL-IL-27 was also very effective in acute colitis induced by DSS in drinking
water or TNBS installation as determined by DAI and pathology.
CONCLUSION(S): LL-IL-27 was highly effective in three different murine IBD mod-
els that differ substantially in mechanism. These results suggest that intestinal
application of LL-IL-27 offers promise as a more effective and safer management
of IBD in humans. Figure Legends. Figure 1: LL-IL-27 improves survival in T cell
transfer induced enterocolitis. At the onset of disease (7.5 wk), mice were gav-
aged for 14 days (hatched bar). (A) Percent survival. (B) DAI.(C) H&E sections of
distal colons (top). Histopathological scores for distal colon (bottom). (D) H&E
sections of small intestines (SI) Figure 2: LL-IL-27 decreases inammatory cyto-
kines, increases IL-10 in vivo. (A) Cytokine and transcription factor gene expres-
sion in distal colons (B) Colitic mice were treated for 14 days, colons were har-
vested 7 days following the last gavage or at death. (C) Healthy mice were
gavaged with LL-IL-27, colons were harvested the next day. (D) LL-IL-27
increases IL-10 reporter expression in CD4CD8a (DP) and CD8 cells. Figure 3:
IL-10 is required for LL-IL-27s therapeutic effect but LL-IL-10 is less effective
than LL-IL-27. (A) Percent survival. (B) H&E sections of distal colons (left). Histo-
pathological scores (right).
P-177
Vedolizumab Does Not Affect the Suppressive Activity of Gut-homing T Regula-
tory Cells
Eric Fedyk, Li-Li Yang, Tim Wyant, Vivek Kadambi
Millennium: The Takeda Oncology Company, Cambridge, MA, USA
BACKGROUND: The a4b7 integrin is a phenotypic marker of memory T lympho-
cytes that preferentially migrate through the gut (ie, gut-homing memory T cells).
Phenotypically discrete subsets of human gut-homing memory T cells have been
identied, including pro-inammatory TH17 and anti-inammatory T regulatory
(Treg) cells. The activity of these subsets may inuence human gastrointestinal
homeostasis and disease. Vedolizumab is an investigational humanized monoclo-
nal antibody which binds to the a4b7 integrin and is being developed for ulcera-
tive colitis (UC) and Crohns disease (CD). We therefore investigated if vedolizu-
mab modulated the activity of human Treg cells.
METHODS: Total (CD4
CD25
CD127
low
FoxP3
) and gut-homing
(a4b7
high
CD4
CD25
CD127
low
FoxP3
) populations of Treg cells were identied

by ow cytometry in whole blood samples from healthy human volunteers (n =
8). Both populations were subsequently isolated to >95% purity from whole
blood by immunomagnetic separation and uorescence-activated cell sorting.
Puried human Treg cells were activated by stimulation with anti-CD2, CD3 and
CD28 beads, and functional activity was assessed by co-culturing with re-
sponder T cells, activated by prior stimulation with phytohemagglutinin or anti-
CD3/CD28 beads. Proliferation of responder cells was measured by ow cytome-
try. Potential effects of vedolizumab were assessed by co-culture of Treg and re-
sponder cells with saturating concentrations of vedolizumab.
RESULTS: We identied a subset of gut-homing Treg cells which comprise -5% of
the total gut-homing memory T cell population found in peripheral blood. We
isolated these cells and demonstrated that they exhibit suppressive activity that
is typical of Treg cells in vitro. Specically, co-culture of activated responder T
cells with the total Treg population, or the gut-homing Treg subset, inhibited
proliferation of responder T cells (ie, suppression of pro-inammatory activity by
Treg). This suppressive activity was not affected by exposure to vedolizumab.
Incubation of the total Treg population, or the gut-homing Treg subset, with sat-
urating exposures of vedolizumab did not affect the suppression of responder T
cells, as compared to vehicle control or an isotype control antibody.
Figure 3.
CONCLUSION(S): There was no effect of vedolizumab on the suppressive activity of
the total Treg population or the gut-homing subset of this population found in periph-
eral blood of healthy volunteers. These data indicate that vedolizumab does not affect
potential anti-inammatory activity of human Treg cells residing in the submucosa.
P-178
Critical Role of Plasmacytoid Dendritic Cells in Commensal Microbial Polysac-
charideMediated Immunoregulation
Suryasarathi Dasgupta, Deniz Erturk-Hasdemir, Dennis Kasper
BACKGROUND: The microbiota is important in shaping the mammalian hosts
immune system and is useful in identifying mechanisms of immune maturation.
In the limited number of associations between commensal microbes and the
immune system that are known to indicate a profound immunomodulatory rela-
tionship, the microbes involved have been identied at the genus (or sometimes
the species) level; in contrast, little relevant information has been obtained at the
microbial molecular level. A notable exception is the relationship between capsu-
lar polysaccharide A (PSA) of the gut commensal Bacteroides fragilis and the
induction of regulatory T cells (Tregs) that can limit pathologic inammation
both in the gut and in more distant tissues. The ability of PSA to induce secretion
of the potent anti-inammatory cytokine interleukin 10 (IL-10) is vital to the con-
trol of inammation. Restoration of tissue homeostasis by a functional class of
dendritic cells (DCs), designated tolerogenic DCs, has been described and is due,
at least in part, to generation or enhancement of the function of Tregs. Although
PSA affects DCs, it has not been shown whether DCs play a role in the immunor-
egulatory activities of PSA.
METHODS: We treated specic-pathogen-free animals with B fragilis express-
ing PSA and followed T regs and associated DCs in mesenteric lymph nodes
and other tissues in absence of additional inammatory stimulus. We puried
PSA from B fragilis and utilized in vitro in DC-CD4T cell co-culture assay and
in vivo in TNBS-induced colitis and Myelin-PLP induced multiple sclerosis
models. Genetically decient mice, antibody mediated in vivo inhibition and
depletion along with adoptive transfer of PSA treated DC subsets were
employed.
RESULTS: We show that a subset of DCs known as plasmacytoid DCs (PDCs) when
exposed to PSA are potent inducers of IL-10 production by CD4 T cells in vitro.
In the murine model of colonic inammation, PDCs characteristically phenotype
PSA mediated protection in a Toll-like receptor 2 (TLR2) dependent way. Interest-
ingly, PDCs are essential for the immunoprotective activities of PSA in this colitis
model as observed by antibody mediated PDC depletion and adoptive transfer
experiments. TLR2, an immunosensitive receptor of PSA, is induced in PDCs by
PSA and, along with ICOSL and CD86, mediates PSAs immunoregulatory function
in vitro and in vivo. Finally, in a murine model of multiple sclerosis wherein PSA
was found to be protective, we observed near complete mortality in mice treated
with PDC depleting antibody irrespective of PSA treatment, while the isotype
control treated mice survived and were protected signicantly by PSA treatment
in terms of clinical scores.
CONCLUSION(S): Our results demonstrate how a prototypical molecule from the
commensal microbiota enables a subset of DCs to modify pathologic outcome in
the gut and a distant tissue. Understanding functional polarization of PDCs or
other DCs by molecules derived from the commensal microbiota and elucidating
how these molecules shape immune development may help identify new thera-
peutic approaches to inammatory diseases.
P-179
Frequency of E. coli and Mycobacteria Reactive CD4 T-cells in Intestinal Biop-
sies of Crohns Disease Patients
Ingrid Olsen, Knut Lundin, Ludvig Sollid
Centre for Immune Regulation, Oslo, Norway
BACKGROUND: Crohns disease is thought to be a dysregulated immune response
to the commensal ora in genetically predisposed individuals. However, there are
data supporting that opportunistic pathogens like invasive E. coli and Mycobacte-
rium avium paratuberculosis (MAP) may be involved. Although genes associated
with Crohns disease are generally involved in autophagy and the innate immune
response, the resulting lesions are characterized by inltration of T cells. By study-
ing the specicity of these T cells it is possible to get some answers about the
relevance of various commensal and opportunistic bacteria in the development
of lesions. We have previously demonstrated the presence of MAP and E. coli re-
active T cells in Crohns disease patients. In the present study, we wanted to look
at the frequency of mycobacteria and E. coli reactive CD4 T-cell clones in intesti-
nal biopsies from patients with active disease.
METHODS: The biopsies were obtained by colonoscopy from adult patients with
Crohns disease (n = 5) and ulcerative colitis (n = 4). CD4 T cells were isolated and
expanded in wells containing 0.1100 T-cell clones/well. Specic antigen was not
added at any time. The cells were propagated with mitogens and cytokines. The
cells were screened for proliferative responses to MAP and E. coli crude antigens.
RESULTS: A frequency of MAP reactive T cells ranging from 0.491.88% was found
in Crohns disease patients while the frequency of E. coli reactive T cells was
0.070.19%. In comparison no or low numbers of MAP reactive clones were
detected in three out of four ulcerative colitis patients, while the fourth patient
had a frequency similar to that of Crohns patients. Both the MAP reactive and E.
coli reactive T cells had an inammatory phenotype with secretion of IL-17 and/
or IFN-c.
CONCLUSION(S): Despite the low numbers of mycobacteria in the gut, these bac-
teria seem to be very potent in inducing an inammatory response. This is
maybe not so surprising considering the well-described inammatory properties
of mycobacteria. Whether these responses are caused mainly by MAP or by envi-
ronmental mycobacteria remains to be answered. The results support a role of
Mycobacteria specic T cells as important players in the pathogenesis of Crohns
disease.
P-180
M2 Macrophages Drive the Production of Induced Regulatory T Cells in the
Gut
Dipica Haribhai, Jennifer Ziegelbauer, Kyle Upchurch, Erica Schmitt, Calvin
Williams
Medical College of Wisconsin, Milwaukee, WI, USA
BACKGROUND: Induced regulatory T (iTreg) cells develop in peripheral tissues
and are essential for the control of inammation that affects mucosal surfaces.
iTreg cells can be derived in vitro, which suggests the possibility of using iTreg
cells as immunotherapy for the treatment of inammatory bowel disease. How-
ever, the factors that generate and stabilize iTreg cells in vivo are not well
established.
METHODS: We used a mouse model of inammatory bowel disease to investigate
the role of macrophages and macrophage-produced TGF-b in the iTreg cell induc-
tion pathway. Bone marrow derived macrophages were differentiated into M1
and M2 macrophage subsets in vitro or kept undifferentiated. We then pretreated
C57BL/6 Rag1-decient mice with the different types of macrophages and
induced colitis by adoptive transfer of na ve CD4
T cells lacking Treg cells.

Weight loss, ow cytometry of mesenteric lymph nodes and gut inltrates, and
colitis scores were used to assess the impact of macrophage pretreatment on dis-
ease progression and iTreg cell induction.
RESULTS: In the absence of macrophage pretreatment, we found markedly
reduced iTreg cell induction in Rag1
/
C57BL/6 mice relative to similar experi-
ments in BALB/c control mice. Pretreatment of Rag1
/
C57BL/6 mice with M2
macrophages but not M1 macrophages increased the frequency of iTreg cells by
15 fold and slowed disease progression. iTreg cell induction in vivo depended
upon the Smad3 component of TGF-b signaling. When Rag1
/
C57BL/6 mice
were treated with M2 macrophages followed by immunotherapy with nTreg cells
the mice survived, gained weight and resolved their gut inammation.
CONCLUSION(S): These data demonstrate that M2 macrophages establish and
maintain the iTreg cell niche in the gastrointestinal tract, possibly through a TGF-
b-dependent process. M2 macrophages can also serve as a tolerogenic adjuvant
in cell-based immunotherapy to increase iTreg cell production.
P-181
Negative Regulation of IL-10 Expression in CD4 T Cells by Growth Factor Inde-
pendent-1
Craig Maynard, Carson Moseley, Stacey Harbour, Henrietta Turner, Robin Hatton,
Casey Weaver
University of Alabama at Birmingham, Birmingham, AL, USA
BACKGROUND: Interleukin-10 (IL-10) is an immunoregulatory cytokine that can be
expressed by multiple immune cell types including regulatory and pro-inamma-
tory subsets CD4 T cells. As a major product of intestinal T regulatory (Treg) cells,
IL-10 is especially essential for the induction and maintenance of tolerance to the
intestinal microbiota. However, Il10 is also induced during T effector cell develop-
ment seemingly as a mechanism for auto-regulation of pro-inammatory T cell
responses. This suggests that opposite those mechanism that promote expression
of Il10 must exist some means of negative regulation in order for benecial
immune responses to ensue. We previously observed elevated expression of the
transcriptional repressor growth factor independent 1 (G1) in CD4 T cells in
which Il10 expression was either absent or actively suppressed. We therefore
examined the possible role of G1 in modulating expression of IL-10 and the pos-
sible implications for development of intestinal inammation.
METHODS: We utilized a combination of in vitro T cell polarizations, retroviral
transductions, with real-time PCR and ow cytometric analyses to examine the
effect of G1 on expression of IL-10 in CD4 T cells. Chromatin immunoprecipita-
tion (ChIP) was used to assess G1 binding to the Il10 locus. Finally, we employed
WT and G1-decient CD4 T cells to probe the impact of the G1-IL-10 axis on
disease development in the T cell transfer model of colitis.
RESULTS: We found that, in vitro, G1-decient effector T cells express elevated
levels of IL-10 mRNA and protein relative to G1-sufcient cells and ectopic
expression of G1 results in signicantly diminished expression of IL-10. We also
demonstrated that Gf1 binds the Il10 promoter in effector CD4 T cells that were
differentiated in vitro or isolated from mice with ongoing colitis. Notably, in the T
cell transfer model of colitis, deciency of G1 in CD4 T cells resulted in delayed
or diminished disease development, which could be at least partially restored by
co-deletion of Il10.
CONCLUSION(S): Collectively, our data identify G1 as a central node in the nega-
tive regulation of Il10 expression in CD4 T cells and suggest the possibility of uti-
lizing Gf1-dependent pathways for therapeutic manipulation of IL-10 expression.
P-182
YI
Effects of Adiponectin on DSS-induced Acute Ulcerative Colitis in Mice
Kamaljeet Kaur, Arpit Saxena, Shweta Hedge, Raja Fayad
University of South Carolina, Columbia, SC, USA
BACKGROUND: Inammatory Bowel Disease (IBD) comprising of Ulcerative colitis
(UC) and Crohns disease (CD) is marked by chronic and repetitive inammation
and immune response. Acute UC has been characterized by severe inammation
of colonic epithelia and the underlying layers. As the epithelial tissue lining of
the gut gets abraded, an anatomical feature of gut inammation, the colonic epi-
thelial crypts start losing their normal structure. Consequently, cellular compo-
nents of the immune system begin to inltrate the mucosal layers of the colon.
Acute inammation also affects the numbers and function of epithelial and gob-
let cells residing inside the crypts, resulting in altered ratios between them and
an abnormal mucus production from the goblet cells. Adiponectin (APN), an adi-
pocytokine, secreted by adipocytes, has been shown to possess both pro- as well
as anti-inammatory effects on the gut. In case of acute inammation, it has
been shown to act as a pro-inammatory molecule such that, its absence has a
protective role against inammation. In the present study we have tried to show
the protective role of APN absence against acute ulcerative colitis in a murine
model.
METHODS: WT (C57Bl/6) and APNKO mice (n = 5) were housed in the animal fa-
cility at University of South Carolina. The mice were given 2.5% DSS ad libitum in
drinking water for 5 days, followed by normal drinking water for next 5 days to
induce acute inammation. Mice were injected with 1.5 mg/kg of recombinant
Adiponectin intraperitoneally every alternative day for a period of 10 days and
sacriced by cervical dislocation on day 11. The clinical score parameters includ-
ing weight loss, diarrhea and blood in stools were measured on a scale of 12.
Food and water consumption was also recorded. Histological staining procedures
including Hematoxylin and Eosin, BrdU, Alcian blue and TUNEL assay were used
to study the relative numbers of epithelial and goblet cells, and the extent of
proliferation and immune cell inltration and cell death. Expression levels of pro-
and anti-inammatory proteins and cytokines were also studied using several
genomic and proteomic techniques.
RESULTS: The intraperitoneal injections of APN worsened the symptoms of acute
ulcerative colitis in the experimental mice. The proteomic and genomic studies
showed an increase in the expression of pro-inammatory proteins. A higher
expression of pro-inammatory cytokines such as IL-6 and TNF-a was observed.
The external administration of APN to DSS-treated APNKO mice exhibited the
highest clinical score and lowest goblet cell numbers, indicating the reduced
secretion of mucus in the colon tissue, which indicate a reduce protection from
DSS induced insult of the colon tissue. There was no signicant difference
between DSS-treated WT mice and the DSS-treated APNKO mice which were
administered APN externally. However WT mice treated with DSS showed highest
degree of inammation and immune cell inltration.
CONCLUSION(S): It can be concluded that the absence of APN serves a protective
role against DSS-induced acute ulcerative colitis by increasing the density of the
goblet cells and epithelial cell proliferation.
P-183
YI
Humanized Mouse Models to Study Mechanisms of Intestinal Inflammation
Jeremy Goettel, Willem Lexmond, Edda Fiebiger, Scott Snapper
Boston Childrens Hospital and Harvard Medical School, Boston, MA, USA
BACKGROUND: IBD can result from hyperactivation of T effector cells, and/or reg-
ulatory T cells (Tregs) dysfunction. Studies in mice show that Treg function is crit-
ical to maintain mucosal immune homeostasis, yet, a critical barrier to under-
standing human Treg function in the intestinal mucosa is the lack of a robust in
vivo model and limitations on experimenting with human subjects. Development
of immunodecient mouse strains such has NOD.SCID.IL-2Rc-/- (NSG) has enabled
Figure 1.
Figure 2.
engraftment of human leukocytes into a murine host, permitting the study of
human immune cells in vivo in a xenobiotic setting. Using this approach, we
have developed two novel mouse models of intestinal inammation that are de-
pendent on human T cells.
METHODS: For anti-CD3 enteritis, 8-10 week old NSG mice were injected with
2x10
6
human CD4 (hCD4) T cells, and12 days later, mice received either a sin-
gle i.p. injection of OKT3 or control IgG. Serum was collected at 0,1,6, and 24
hours and analyzed for human cytokines by luminex. Intestinal inammation was
assessed after 24 hours based on clinical and histological scores. T cell activation
was quantied by ow cytometry for spleen and small intestine lamina propria.
qPCR was performed on RNA isolated from splenic T cells and small intestine
RNA. For TNBS-induced colitis, two days following transfer of 2 x10
6
hCD4 T
cells, mice were sensitized with 1% TNBS solution applied to 1 cm2 patch of skin
at the base of the neck. One week post-sensitization, mice were administered a
single intrarectal dose of 0.125 mg TNBS in 50% ethanol. Weight loss was moni-
tored daily and mice were sacriced three days following the TNBS enema. Colo-
nic inammation was assessed by H&E stained colon sections.
RESULTS: OKT administration resulted in diarrhea and severe small intestine villous
atrophy within 24 hours, only in hCD4 reconstituted NSG mice. In addition,
OKT3 promoted T cell recruitment into the SI lamina propria, reduced cell surface
CD3 expression and concomitant increase in CD25, a marker of activation. NSG
mice receiving OKT3 in the absence of hCD4 T cells were free of clinical or his-
tological signs of inammation, indicating that hCD4 T cells are necessary for
OKT3-induced enteritis. hCD4 reconstituted NSG mice, following sensitization
and exposure to TNBS, exhibited clinical and histological features of colitis in con-
trast to control NSG mice lacking hCD4 T cells.
CONCLUSION(S): Human CD4 T cells adoptively transferred into NSG mice can
induce small bowel and colonic inammation in mice following exposure to
OKT3 and TNBS respectively. These models will facilitate preclinical assessment of
therapeutic applications targeting T cells and aid in mechanistic studies evaluat-
ing pathways controlling mucosal homeostasis.
P-184
YI
Leukocyte Recruitment Alters Pathological Angiogenesis Gene Expression Dur-
ing DSS Colitis
Kai Fang, Shuai Yuan, John Glawe, Songlin Zhang, Christopher Kevil
Louisiana State University Health Sciences Center, Shreveport, Shreveport, LA,
USA
BACKGROUND: CD18 is one of the major leukocyte adhesion molecules control-
ling leukocyte recruitment. We have previously reported that CD18 gene de-
ciency protects mice from DSS and T cell mediated colitis and alters pathological
angiogenesis during colitis. In this study, we examined how CD18 deciency
alters angiogenic gene expression associated with experimental colitis.
METHODS: CD18-/- and wide type mice were administered 3% dextran sulfate so-
dium (DSS) in drinking water and colon tissue collected at days 0, 2, 4 and 6 (n
= 5). Colon tissue between the cecum and anus was longitudinally cut in half
and used for histopathological analysis and RNA isolation. Tissue histology sec-
tions were scored in a blinded fashion and qRT-PCR was performed for angio-
genic genes previously identied during experimental colitis. Statistical analysis
was performed by one-way ANOVA with day 0 as control.
RESULTS: Colitis was signicantly inhibited in CD18-/- mice during throughout the
DSS treatment time course compared with wild type mice. mRNA levels of Ecscr
(endothelial cell-specic chemotaxis regulator), a membrane protein regulating
endothelial chemotaxis and tube formation, was signicantly inhibited compared
to wild type mice during DSS induction of colitis. Similarly, the expression of tryp-
tophanyl-tRNA synthetase (Wars), matrix metallopeptidase 3 (Mmp3), C-C chemo-
kine receptor type 5 (Ccr5), and complement component 3 (C3) were also inhib-
ited in DSS treated CD18-/- mice.
CONCLUSION(S): Together, these results indicate that CD18 deciency and blunt-
ing of leukocyte recruitment during DSS induced colitis signicantly inhibits tis-
sue inammation coincident with decreased pathological angiogenesis gene
expression.
P-185
YI
Application of Comparative Functional Genomics to Identify New Pathways of
Pediatric IBD Pathogenesis
Kai Fang
1
, Matthew Grisham
2
, Christopher Kevil
1
1
Department of Pathology, Louisiana State University Health Sciences Center,
Shreveport, Shreveport, LA, USA,
2
Department of Immunology and Molecular Mi-
crobiology, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
BACKGROUND: Experimental models of colitis in mice have been extensively used
to study molecular events that occur during inammatory bowel disease (IBD) de-
velopment. However, direct and comprehensive comparison of mouse and
human inamed colon tissue at the genome level remains largely unknown and
to what extent such differences reect changes associated with human IBD. Here
we report comparative functional genomic analysis between experimental colitis
models and pediatric IBD.
METHODS: Two sets of pediatric IBD microarray data (GEO accession number
GSE9686 and GSE10616) and experimental colitis microarray data (DSS colitis
model GEO number GSE22307 and T-cell transfer colitis model GEO number 27302)
were used for comparative functional genome expression pattern analysis. All
microarray data were obtained using Affymetrix GeneChip arrays providing the
most comprehensive coverage of transcribed genomes of human or mouse. Micro-
array data were input into Genesifter software and normalized for comparison
using the Robust Multichip Averaging (RMA) method. Threshold value for signi-
cant differences in gene expression was set at 2 fold and the Benjamini-Hochberg
test used to diminish false discovery rates. Identied genes were uploaded into In-
genuity software for network analysis, and cREMaG (cis-Regulatory Elements in the
Mammalian Genome) software for transcription factor/promoter analysis.
RESULTS: Microarray analysis revealed that chitinase 3-like 1(cartilage glycopro-
tein-39, CHI3L1), Cysteine-rich, angiogenic inducer 61 (CYR61, or CCN1), and Che-
mokine (C-C motif ) ligand 2 (CCL2) were up regulated in both pediatric CD and
UC. Ingenuity network analysis of differentially expressed genes from pediatric
CD was clustered into 8 networks and pediatric UC into 25 networks. By compari-
son of pediatric IBD and experimental colitis microarray data, we found the fol-
lowing common features: 1) CXCL9 and S100A8 were abundantly up regulated; 2)
cytokine-cytokine receptor networks were dysregulated; and 3) IRF-1 transcription
binding sites were over represented in the promoter region of up regulated
genes, while HNF1A and Lhx3 binding sites were over represented in the pro-
moter region of the down regulated genes.
CONCLUSION(S): Together, our study provides a comprehensive comparative view
of genome expression and transcription factor prole changes between pediatric
IBD and experimental colitis models revealing common pathways that may be
useful for future therapeutics.
P-186
YI
Opposing Roles for EGFR in Colitis-Associated Cancer: The Presence of Active
Inflammation Determines a Protective Versus Tumorigenic Role for EGFR
Philip Dub e, D Polk
Childrens Hospital Los Angeles, Los Angeles, CA, USA
BACKGROUND: Colitis-associated cancer (CAC) is a serious complication in chronic
IBD. Epidermal growth factor (EGF) and its receptor (EGFR) are promising thera-
peutic targets for IBD; however, since EGFR is also associated with tumor growth,
this suggests that EGFR activation in IBD might promote cancer. We have shown
that genetic EGFR inactivation increases tumor progression in the IL10 knockout
and azoxymethane/dextran sulfate sodium (AOM/DSS) mouse models of CAC. An
important question is whether this protective role of EGFR is indirect, by optimiz-
ing epithelial regeneration and limiting injury during inammation, or whether
EGFR directly regulates the growth of preexisting tumors. We hypothesize that
EGFR differentially regulates tumorigenesis in CAC, with a protective role to pro-
mote healing during inammation and to indirectly reduce subsequent tumor
growth, and a tumorigenic role to directly promote the growth of preexisting
tumors. We used a pharmacological approach to inhibit EGFR either during
inammation or tumor growth in the AOM/DSS model.
METHODS: To induce colitis-associated tumors, wildtype mice were given the car-
cinogen AOM (12 mg/kg, i.p.), followed by 6 d of DSS (3% w/v in drinking water)
one week later. Mice were euthanized either immediately following DSS adminis-
tration (n = 7-8), or 65 d (n = 5) or 95 d (n = 9-10) following DSS withdrawal. To
inhibit EGFR, mice were given getinib (200 mg/kg/d, by gavage), an EGFR kinase
inhibitor, or vehicle, either during DSS administration (inammatory phase), or for
one month 65 d following DSS withdrawal (tumor growth phase). We have
shown that this dose of getinib inhibits mouse EGFR in vivo.
RESULTS: Getinib worsened colitis when co-administered with DSS, with increased
body weight loss (2462% weight loss vs. 1161% in vehicle-treated mice, P < 0.001),
and increased colon weights (9.760.8 mg/g body weight vs. 7.460.5 mg/g, P <
0.05). Getinib treatment alone did not cause weight loss. To determine the effect of
EGFR inhibition during the inammatory phase on subsequent tumor growth, mice
were given getinib only during DSS administration and euthanized 65 d later. Geti-
nib during this phase did not affect the number of colon polyps (1061 vs. 1161, P =
0.45), but increased polyp size (4.460.4 mm in diameter vs. 1.760.1 mm, P < 0.0001).
To determine how EGFR inhibition would affect the growth of preexisting tumors,
mice were given getinib only during the tumor growth phase, 2 months following
DSS withdrawal. In this phase, getinib did not affect polyp number (861 vs. 1061, P
= 0.19), but decreased polyp size (2.160.2 mm vs. 2.860.2 mm, P = 0.03).
CONCLUSION(S): EGFR inhibition worsened DSS-induced colitis, and subsequently
increased tumor growth in AOM/DSS. In contrast, EGFR inhibition after tumor for-
mation decreased tumor growth. This suggests that EGFR produces opposing
effects on tumor growth in CAC, in which EGFR is protective during inammation
and deleterious following tumor formation. An important issue is to determine
which EGFR-induced pathways/functions produce such disparate outcomes in
order to develop safe and efcacious therapies for IBD. Thus, targeted EGFR
therapies have the potential to ameliorate inammatory damage and reduce sub-
sequent tumor growth in IBD; however, caution must be exercised as such thera-
pies may also exacerbate the growth of preexisting tumors.
P-187
YI
5-Hydroxytryptophan Alleviates Inflammation-Associated Mood Disturbance in
Two Mouse Models of Colitis
Heba Iskandar, Jeffrey Marhinshaw, Emily Vivio, Suprada Rao, Matthew Ciorba
Washington University in St. Louis, Saint Louis, MO, USA
BACKGROUND: Anxiety and depression states are common in patients with
inammatory bowel disease (IBD) and correlate with disease activity suggesting a
biologic link to inammation. Experimentally lowered serum levels of tryptophan,
the amino acid precursor of serotonin, can induce mood disturbance. We previ-
ously reported that in patients with active Crohns disease serum tryptophan lev-
els can be severely depressed while kynurenine levels are elevated. This elevated
kynurenine/tryptophan ratio reects increased expression of the immunomodula-
tory enzyme indoleamine 2,3 dioxygenase (IDO) present in active IBD and colitis
models. In the current study we aimed to determine if enteral delivery of 5-
hydroxytryptophan (5-HTP), the tryptophan-based serotonin precursor, improved
mood disturbance or affected colitis severity in two mouse models.
METHODS: Dextran sodium sulfate (DSS) colitis was induced in Bl6 mice with 3%
DSS given over 3 5-day courses, with 10-day recovery periods. 2,4,6 trinitroben-
zene sulfonic acid (TNBS) colitis was induced in BALB/c mice using 4 escalating
doses of TNBS (0.35 mg to 1.2 mg). In each experiment there were 3 groups of
7-10 mice: 1) control group (PBS gavage), 2) colitis control group (PBS gavage),
and 3) colitis group with 5-HTP (0.5 mg gavage before testing). Behavior was
lmed and scored at three time points: pre-colitis, after acute colitis, and after
chronic colitis. Anxiety-like behavior was tested using the light-dark preference
test (LDT). Depressive behavior was tested using the tail suspension test (TST).
Locomotor activity (LMA) was tested at each time-point to rule out potential
physical impairment prior to behavioral testing. Colitis activity was followed clini-
cally (diarrhea, hematochezia, and weight loss) and assessed by histology and
myeloperoxidase (MPO) activity.
RESULTS: No differences in clinical or histology parameters were identied
between colitis groups. Similarly, MPO activity did not differ with or without 5-
HTP supplementation in both DSS and TNBS colitis. Locomotor abilities were simi-
lar in all 3 groups. No differences in mouse behavior were present at baseline or
after acute colitis. Mice with chronic colitis from DSS spent signicantly less time
in light than controls, indicating anxiety-like behavior. This anxiety behavior was
normalized by 5-HTP supplementation. Depressive behavior as measured by TST
immobility time was longer in chronic DSS colitis; however, a therapeutic effect
of 5-HTP was not observed. In TNBS colitis, mice had fewer entries to the light
compared to controls in the LDT. This anxiety-like behavior was normalized by 5-
HTP supplementation. There was no effect of TNBS colitis or 5-HTP on immobility
as measured by the TST. Table 1 summarizes these ndings.
CONCLUSION(S): Anxiety- and depressive-like behavior is heightened in 2 models
of chronic colitis. While anxiety behavior patterns vary by mouse strain, they are
normalized by administration of the tryptophan-derived serotonin precursor 5-
HTP. Importantly, colitis is not worsened by enteral supplementation with physio-
logic doses of 5-HTP (i.e. proportional to human dosing). With translational valida-
tion, 5-HTP may be considered an intervention for colitis-associated anxiety in
IBD patients.
P-188
YI
Identification of Lactic Acid From Probiotic Yeast as an Anti-Cancer and
Anti-Inflammatory Component
Guoxun Yang
1
, Hua Xu
2
, Jeffrey Goldsmith
2
, Ciaran Kelly
3
, Xinhua Chen
3
1
Fudan University, School of Pharmacy, Shanghai, Shanghai, China,
2
Beth Israel
Deaconess Medical Center, Boston, MA, USA,
3
Beth Israel Deaconess Medical Cen-
ter, Harvard Medical School, Boston, MA, USA
BACKGROUND: Saccharomyces cerevisiae (Sc; aka bakers yeast or brewers yeast)
has been used for centuries for the production of fermented foods and bever-
ages. We previously reported that Saccharomyces boulardii, a strain of Saccharo-
myces cerevisiae, possesses both anti-inammatory and anti-cancer properties.
The aim of this study is to purify and chemically characterize the anti-inamma-
tory/anti-cancer constituents from the Sc and examine its protective mechanism.
METHODS: Chemical Purication: Sc was cultured in sterile water for 48h at 37
C.
The culture supernatant was passed through a 0.22 mm lter and a 15KD lter.
The ltrate was applied on an anion exchange column (AG 1-X8 resin). The 0.1M
NH4Ac eluate was collected, freeze-dried and then passed through a Sephadex
LH-20 column. Acetone:H
2
O = 1:1 was used as eluant. The resultant fractions
were combined based on thin layer chromatography (TLC) analysis. On the basis
of EGFR dephosphorylation activity, the active fraction was further separated by
Sephadex LH-20. The resulting active fraction was pure and retained activity. This
was then analyzed by NMR spectra based on the 1H, 13C. Western blot analysis:
HT29 cells grown in complete media with serum were exposed to increasing con-
centrations of lactic acid. Cell extracts were prepared and Western blotting was
performed using EGFR antibodies. DSS model: DSS (4% for 5 days) was adminis-
tered to 8-week-old female C57BL6 mice with or without Lactic acid (3 mg/mL)
treatment. Apc/Min mice: C57BL/6J Min/ (ApcMin) mice were fed with or with-
out 3 mg/mL lactic acid in drinking water starting from age of 16 weeks. DSS-
ApcMin model: 6-week old female ApcMin mice (n = 17) by 7 days of treatment
with 2% DSS dissolved in their drinking water and gavaged with yeast every
other day. Mice were evaluated for colonic tumor development at 11 weeks of
age.
RESULTS: 1) Through a bioassay-guided separation process with EGFR dephospho-
rylation as readout, we isolated an active compound from S. cerevisiae culture
using a combination of ion exchange and sizing chromatography. 1D and 2D
NMR spectral analysis indicated the active compound is lactic acid. 2) In vitro
assay indicates that lactic acid induces rapid dephosphorylation of EGFR in HT29
colon cancer cells. 3) Whole yeast administration protected DSS-induced colonic
tumor formation in DSS-Apc/min mice colon cancer model (P < 0.006). 4) Lactic
acid oral treatment (3 mg/mL) attenuated DSS-induced colitis according to dis-
ease activity index and histology score. 5) Oral administration of lactic acid (3
mg/mL) in ApcMin mice with advanced stage cancer signicantly enhanced sur-
vival in comparison to control (P < 0.01).
CONCLUSION(S): Although lactic acid-producing bacteria have long been sug-
gested as benecial probiotics including reports on potential anticancer function
a direct link between lactic acid and anti-cancer property has not been reported.
Our nding of EGFR inactivation by lactic acid and its production by yeast may
represent a common mechanism shared by both prokaryotic and eukaryotic pro-
biotics. In addition, the in vivo protective effects of lactic acid in DSS colitis
model and mice with terminal intestinal cancer suggest lactic acid might be an
affordable and novel anti-cancer agent in humans. These unexpected effects of
lactic acid warrant further investigation.
P-189
YI
Components of Enteric Dysbiosis Are Present at the Onset of
Immune-mediated, Spontaneous Colitis
Christopher Packey
1
, Nitsan Maharshak
1
, Sayeed Manick
1
, Paul Hudson
1
,
Melissa Ellerman
1
, Scott Plevy
2
, Ryan Sartor
1
, Ian Carroll
1
1
2
University of North Carolina
School of Medicine, Chapel Hill, NC, USA
BACKGROUND: Patients with inammatory bowel diseases (IBD) frequently dem-
onstrate intestinal dysbioses, but it is unknown if shifts in the microbiota drive
disease or if they are a by-product of inammation. We utilized multiple culture-
independent techniques to investigate whether enteric dysbiosis ensues prior to
or subsequent to the development of inammation in the interleukin-10 knock-
out (IL-10 KO) mouse model of immune-mediated, spontaneous colitis.
METHODS: 8-10 week old germ-free (GF) wild-type (WT) (n = 4) and IL-10 KO (n
= 9) 129Sv/Ev mice were colonized with identical specic pathogen-free (SPF)
feces, and fecal samples were subsequently taken weekly for 4 weeks. Mice were
necropsied at 2 and 4 weeks and colonic tissues were harvested. Fecal DNA was
isolated and 454 pyrosequencing and qPCR of 16S rRNA genes were performed.
QIIME pipeline was utilized for 454 analyses. IL-12p40 secretion from colonic tis-
sue explants was measured by ELISA and Kruskal-Wallis one-way analysis of var-
iance performed.
RESULTS: Colonic inammation in IL-10 KO mice as measured by pro-inamma-
tory IL-12p40 secretion was seen at 2 weeks after colonization (P<0.02 between
groups), whereas WT mice did not develop colitis. QIIME pyrosequencing analyses
revealed that microbiota a-diversity (species richness) and b-diversity (species di-
versity) increased from week 1 to week 2 in WT and IL-10 KO mice, then dramati-
cally decreased at weeks 3 and 4 in IL-10 KO mice (P<0.05) despite increases in
total fecal bacterial numbers (P<0.0007). Levels of abundant fecal Bacteroidetes
remained unchanged in IL-10 KO mice at week 2, then decreased at weeks 3 and
4. qPCR showed that IL-10 KO mouse fecal Lactobacillus spp. levels were lesser
than WT mouse levels at weeks 1 and 2, then signicantly increased to exceed
WT levels at weeks 3 and 4 (P<0.002). However, at 2 weeks after colonization,
some obvious microbial shifts had already commenced in IL-10 KO mice. These
included decreases in Firmicutes, (including several members of the Lachnospira-
ceae family), Verrucomicrobia, (including the abundant human intestinal colonizer
Akkermansia muciniphila, which are decreased in IBD patients), and Actinobacte-
ria. There were also dramatic increases in fecal levels of the Proteobacteria phy-
lum in IL-10 KO mice at 2 weeks. E. coli levels, which were lower in IL-10 KO mice
than WT mice at week 1, increased to approximate WT levels at 2 and 3 weeks,
and then continued to increase until they exceeded WT levels at week 4
(P<0.0001).
CONCLUSION(S): GF IL-10 KO mice housed in our gnotobiotic facility develop spon-
taneous colitis by 2 weeks after colonization with SPF microbiota. While some alter-
ations in the enteric microbiota composition do not occur until after this time
point, other changes are already observed by 2 weeks after conventionalization.
Though expansion of this line of research is needed, these results suggest that it is
possible that some components of intestinal dysbioses precede and drive the de-
velopment of immune-mediated, spontaneous colitis in the IL-10 KO mouse, and
perhaps in humans. If proven, a primary focus in preventing and/or managing IBD
would involve avoidance and/or reversal of dysbioses with prebiotics, probiotics,
antibiotics, fecal transplant, or anti-microbial peptide induction.
P-190
YI
Intestinal Persistence of Crohns Disease-associated Adherent-Invasive Esche-
richia Coli Enhances Spontaneous Visceral Hypersensitivity
Frederic Carvalho, Agathe Gelot, Nicolas Barnich, Arlette Darfeuille-Michaud,
Alain Eschalier, Denis Ardid
Universite dAuvergne, Clermont-Ferrand, Auvergne, France
BACKGROUND: Crohns disease (CD) results from breakdown of homeostasis
between intestinal microbiota and the mucosal immune system, with both
genetic and environmental inuencing factors. Various studies in CD patients
have reported abnormal gut colonization by pathogenic Escherichia coli referred
to as adherent invasive E. coli (AIEC) linked to overexpression of the bacterial col-
onizing receptor CEACAM6. Among characteristics of CD are the presence of co-
lonic hypersensitivity and abdominal pain. The aim of our study was to investi-
gate whether, intestinal AIEC colonization could be at the origin of spontaneous
development of visceral hypersensitivity and whether this latter may persist even
after bacterial clearance and intestinal inammation alleviation.
METHODS: Transgenic mice overexpressing the human CEACAM6 glycoprotein
and their wild-type littermates were orally infected by CD-associated AIEC bacte-
ria (reference strain LF82) or by a non-pathogenic E. coli (MG1655). At 3, 9 and 21
days after infection, visceral hypersensitivity was assessed using a technique
based on measuring electromyographic abdominal contractions induced by colo-
rectal distension. Briey, by progressive ination of a balloon inserted into the co-
lon, stomach cramps whose amplitude is proportional to the colon sensitivity
were induced. Inammation was monitored using anatomical indicators of colitis
such as spleen and colon weight, and assessed by determination of the colonic
myeloperoxidase (MPO) activity and expression of systemic pro-inammatory
cytokines.
RESULTS: Human CEACAM6 expression in transgenic mice induced a signicant
decrease in the visceral hypersensitivity in comparison to their housekeeping WT
mice. Otherwise, infection with CD-associated AIEC LF82, but not with non-patho-
genic E. coli MG1655, highly increased levels of visceral hypersensitivity at day 3
post-infection in comparison to their housekeeping WT. Of interest, such visceral
hypersensitivity persisted in transgenic mice after bacterial clearance and did not
match with intestinal inammation.
CONCLUSION(S): In the present study, we show a direct involvement of CD-associ-
ated AIEC LF82 colonization in colonic hypersensitivity. This was observed only in
transgenic mice expressing CEACAM6, indicating that increased AIEC intestinal
persistence may impact on colonic sensitivity, which persists after bacterial clear-
ance. Thus hypersensitivity and abdominal pain in CD patients could be linked to
bacterial infection.
P-191
Loss of TLR2 Worsens Spontaneous Colitis in MDR1A Deficiency Through
Commensal-Induced Pyroptosis
Birgit Ey
1
, Annette Eyking
1
, Nita Salzman
2
, Guido Gerken
1
, Daniel Podolsky
3
,
Elke Cario
1
1
Div. of Gastroenterology and Hepatology, University Hospital of Essen, Medical
School, University of Duisburg-Essen, Germany, Essen, NRW, Germany,
2
Depart-
ment of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA,
3
Dept. of
Internal Medicine, UT Southwestern Medical Center, Dallas, U.S.A, Dallas, TX, USA
BACKGROUND: Variants of the multidrug resistance gene (MDR1/ABCB1) have
been associated with increased susceptibility to severe Ulcerative Colitis (UC).
However, the innate immune mechanisms modulating colonic inammation in
MDR1A deciency have not been established yet. The aim of this study was to
investigate the role of TLR/IL-1R signaling pathways including the common adap-
tor MyD88 in the pathogenesis of chronic colitis in mice lacking MDR1A.
METHODS: Mice (SPF) double or triple knockout in TLR2, MD-2, MyD88 and
MDR1A were generated (F7; FVB/N). Male mice (n>6) were examined at 5 or 10
weeks of age. Colitis activity was assessed by standard clinical parameters and
histopathology. Real-time qRT-PCR and protein arrays were employed to deter-
mine cyto-/chemokine proles in colonic tissues and 16S rRNA analysis to cover
the dominant bacterial populations. CD11b- myeloid cells were cultured in the
presence of non-pathogenic E.coli-eGFP and cell death was examined by TUNEL
(-/ caspase-1 inhibitor) and caspase-1 activity assays.
RESULTS: Genetic deletion of TLR2 in MDR1A deciency resulted in fulminant pan-
colitis with early expansion of CD11b/Ly6C-myeloid cells producing IL-1 in
the lamina propria. Blockade of IL-1 activity by treatment with IL-1 receptor an-
tagonist inhibited colitis acceleration in TLR2/MDR1A deciency. Colitis exacerba-
tion via IL-1 in TLR2/MDR1A double-knockout mice required the commensal
microbiota and depended on the lipopolysaccharide (LPS) co-receptor MD-2 and
the adaptor protein MyD88. Of note, loss of TLR2 in the context of MDR1A de-
ciency neither affected Paneth cell gene expression nor provoked major shifts in
commensal composition. However, in contrast to TLR2-expressing WT or MDR1A,
TLR2/MDR1A double-decient CD11b-myeloid cells hyperresponded to non-
pathogenic E. coli or LPS with increased IL-1 secretion and cell death via cas-
pase-1, demonstrating balloon-shaped vesicles around the nucleus with absence
of nuclear fragmentation; these features are consistent with pyroptosis.
CONCLUSION(S): Our ndings imply pyroptosis as a maladaptive host defense
strategy for clearance of commensal gut bacteria in the context of combined
deciencies in MDR1A and TLR2, leading to spontaneous and uncontrolled colitis
progression through aberrant MD-2 and IL-1R signaling via MyD88.
P-192
Shear Wave Velocity Elastography Discriminates Acutely Inflamed from Fibrotic
Bowel in a Crohns Disease Animal Model
Ryan Stidham, Jonathan Dillman, Peter Higgins, David Moons, Laura Johnson,
Jonathan Rubin
University of Michigan, Ann Arbor, MI, USA
BACKGROUND: Crohns disease (CD) is a relapsing and remitting form of trans-
mural inammatory bowel disease that affects the gastrointestinal tract of both
children and adults. Deposition of brosis within the bowel wall as a response to
inammation occurs unpredictably in some CD patients with resultant stricture
formation and bowel obstruction. While a variety of imaging tests can identify
bowel wall hyperperfusion and active inammation in CD, including contrast-
enhanced ultrasound, no commercially available diagnostic test has been demon-
strated to conrm the presence of bowel wall brosis in a reliable, noninvasive
manner in humans to date. Discriminating bowel wall active inammation from -
brosis is important as bowel segments that are abnormally narrowed due to
active inammation generally respond to medical therapy, whereas narrowed
brotic bowel segments frequently require endoscopic dilatation or surgical man-
agement The purpose of our study was to determine if acoustic radiation force
impulse (ARFI) elastography-derived bowel wall shear wave velocity (SWV) can be
used to discriminate inamed from brotic bowel segments in an established CD
animal model. If accurate, such an imaging test would almost certainly alter cur-
rent paradigms of radiologic evaluation and medical and surgical management in
CD.
METHODS: University Committee on the Use and Care of Animals approval was
obtained. An acute inammation CD model was produced by treating Lewis rats
with a single trinitrobenzene sulfonic acid (TNBS) enema, with imaging per-
formed two days later (n = 8). Colonic brosis in Lewis rats was achieved by
administering repeated TNBS enemas over four weeks, with imaging performed
seven days later to allow acute inammation resolution (n = 8). Nine transcutane-
ous bowel wall SWV measurements (Virtual Touch IQ/Acuson S3000 ultrasound
system; Siemens Medical Solutions USA) were obtained from the colon in all rats
without and with applied strain. Mean SWVs without and with applied strain
were compared between animal cohorts, and receiver operating characteristic
curves were created to assess diagnostic performance. Three rats died prior to
imaging.
RESULTS: Mean bowel wall SWVs were signicantly higher for brotic versus acute
inammation cohort rats at 0% (3.42 6 1.12 vs. 2.30 6 0.51 m/s; P = 0.047) and
30% (6.27 6 2.20 vs. 3.61 6 0.87 m/s; P = 0.021) applied strain. Both acute
inammation and brotic cohort rats demonstrated linear increases in mean
SWVs with increasing applied strain, with signicantly different mean slopes (P =
0.016) and y-intercepts (P = 0.023). The c-statistic of SWV for differentiating histo-
pathologically-conrmed brotic from inamed bowel was 0.895.
CONCLUSION(S): Bowel wall SWV distinguishes brotic from inamed intestine in
an animal model of Crohns disease.
P-193
Vagus Nerve Stimulation Reduces Inflammation of the Small Intestinal Mucosa
in the Indomethacin-Induced Enteropathy Model
Yaakov Levine, April Caravaca, Michael Faltys, Anthony Arnold, Ralph Zitnik
SetPoint Medical Corporation, Valencia, CA, USA
BACKGROUND: The inammatory reex mediates central regulation of innate and
adaptive immunity (Olofsson P, et al. Immunological Reviews. 2012; 248:188). Acti-
vation of its efferent arm (the Cholinergic Anti-inammatory Pathway), either by
direct electrical stimulation of the vagus nerve (VNS) or pharmacologic means
reduces, and vagotomy worsens disease severity in several models of colitis. Addi-
tionally, VNS reduces inammatory inltrates in the small intestinal muscularis in
a post-surgical ileus model (De Jonge, Nat Immunol 2005; 6(8):844). However the
effect of VNS on the small intestinal mucosa has not been extensively studied.
We sought to determine whether VNS might also reduce inammatory small in-
testinal mucosal lesions, given their importance in Crohns disease. Objective: To
assess VNS effects on small intestinal mucosal lesion area, small intestinal tissue
IL-23 levels, and systemic HMGB1 levels after induction of enteropathy in rats.
METHODS: Sprague Dawley rats were pretreated with VNS (left cervical vagus, 1
mA pulse current amplitude,10Hz pulse frequency, 200 microsecond pulse width,
60 second VNS treatment duration) or sham stimulation followed with subcutane-
ous injection of 10 mg/kg indomethacin to induce intestinal lesions. 24 h there-
after, animals were injected i.v. with Evans blue to stain mucosal ulcerations, and
euthanized. The small intestine was excised, cleaned, formalin-xed, at-mounted,
photographed, and the total lesion area quantitated using digital morphometry,
performed by a blinded scorer. In some animals the distal jejunum was snap-fro-
zen and homogenized. IL-23 and HMGB1 were measured by immunoblot in snap-
frozen jejunal tissue, and in serum, respectively. IL-23 levels were normalized to
b-actin loading control.
RESULTS: The majority of the lesions were localized to the distal jejunum and proxi-
mal ileum. VNS signicantly inhibited disease severity in the small intestinal mu-
cosa as assessed by reductions in total lesion area (sham = 124614 mm2 vs. VNS:
62614 mm2, n = 17-20; P < 0.01). Intestinal IL-23, an important mediator of
inammation in IBD, was signicantly reduced by VNS (VNS = 0.436 0.15 fold-
increase vs. sham, n = 8-11; P < 0.02). Additionally, VNS treatment reduced serum
levels of HMGB1, a marker of tissue damage and mediator of local and systemic
inammation (VNS = 0.506 0.20 Fold-increase Vs. Sham, n = 9-11; P < 0.01).
CONCLUSION(S): VNS treatment reduced the severity of systemic and intestinal
inammation induced by systemic indomethacin administration. Reductions in
small mucosal intestinal lesion area, small intestinal IL-23 levels, and systemic
HMBG1 levels were observed. These preclinical results provide further rationale
supporting the study of VNS in IBD. If successful, clinical application of VNS may
offer an efcacious and cost-effective alternative treatment approach for Crohns
disease and colitis.
P-194
Colonization With Distinct Proteobacteria Provocateurs Induces Multifactorial
Gastrointestinal Inflammation That Is Regulated by CD41 T Cells
Amanda Ramer-Tait
1
, Anne-Marie Overstreet
2
, Jesse Hostetter
2
, Albert Jergens
2
,
Michael Wannemuehler
2
1
University of Nebraska-Lincoln, Lincoln, NE, USA,
2
Iowa State University, Ames,
IA, USA
BACKGROUND: An abundance of clinical, epidemiologic and animal model studies
indicates that IBD results from complex interactions between a genetically sus-
ceptible host and environmental factors that induce an aberrant immune
response against resident members of the gastrointestinal microbiota. Although
many gene polymorphisms have been associated with an increased risk of IBD,
they only explain a small percentage of the overall disease risk. Initiation of IBD
may also be explained by environmental factors, including persistent colonization
with bacterial provocateurs.
METHODS: Our laboratory has developed a novel model of multifactorial gastroin-
testinal inammation that allows us to study the role of bacterial provocation on
the onset of disease. By utilizing immunocompetent C3H/HeN:Tac mice harboring
a dened microbiota (the altered Schaedler ora or ASF), we can evaluate the
induction of immune responses to antigens derived from the resident microbiota.
RESULTS: Prior colonization of these dened microbiota (DM) mice with Helico-
bacter bilis increased host susceptibility to the onset of colitis following a subse-
quent inammatory insult with a very low dose (1.5%) of the inammatory trig-
ger, dextran sulfate sodium (DSS). This dose of DSS alone was not sufcient to
elicit colitis. In addition, prior colonization with non-pathogenic Escherichia coli
SWW33 failed to affect disease severity. Interestingly, both H. bilis- and E. coli-
colonized mice treated with DSS upregulated mucosal expression of IL-17A
mRNA; however, expression was higher in E. coli-colonized mice compared to H.
bilis-colonized mice at 3 weeks post-infection. This pattern reversed at 12 weeks
post-infection with the antigen-specic IL-17A protein production from CD4
T
cells following a similar pattern. Although the induction of IL-17A was demonstra-
ble in mice colonized with either provocateur, only mice colonized with H. bilis
were more susceptible to low-dose DSS-induced colitis. Together, these data sug-
gest that H. bilis and E. coli differentially induce pathogenic or benecial mucosal
immune responses to antigens derived from the resident microbiota. We subse-
quently hypothesized that the dichotomous immune responses induced following
colonization with these provocateurs would be reected in the differential, func-
tional capacity of the antigen-specic CD4
T cells. Following colonization with

either H. bilis or E. coli for 3 weeks, DM mice were administered either a monoclo-
nal antibody to deplete CD4
T cells or an isotype control antibody. Mice then

received an inammatory insult in the form of 1.5% DSS. Unexpectedly, depletion
of CD4
T cells in H. bilis-colonized mice prior to the DSS treatment period exa-

cerbated disease as evidenced by marked signs of clinical disease as well as
severe colonic shortening, cecal atrophy, edema and luminal blood. Severe histo-
pathological inammation was also observed in anti-CD4 treated, H. bilis-colon-
ized mice, characterized by signicant edema, vasculitis, glandular drop out, ne-
crosis of the progenitor epithelium and stromal collapse. In contrast, depletion of
CD4
T cells from E. coli-colonized mice caused only minor increases in disease

severity, including mild histopathological changes of edema, inammatory cell
inltrate and crypt hyperplasia.
CONCLUSION(S): These ndings indicate that colonization with distinct Proteobac-
teria provocateurs altered the character of the hosts adaptive immune response
directed against the resident microbiota following a multifactorial inammatory
insult.
P-195
Acute Small Bowel Infection Induces Colitis Via CD103(-) Antigen Presenting
Cells and Th1 Responses
Sara Dann
1
, Kim Nguyen
1
, Christine Le
2
, Elaine Hanson
2
, Lars Eckmann
2
1
University of Texas Medical Branch, Galveston, TX, USA,
2
University of California
San Diego, La Jolla, CA, USA
BACKGROUND: We have previously shown infection with Giardia, a parasite that
infects the small intestine but does not elicit inammation, triggers colitis in sev-
eral genetic mouse models of IBD. Our aims were to characterize the disease phe-
notypes in different models and to elucidate mechanisms contributing to disease
pathogenesis.
METHODS: TCRalpha-decient (TCRalpha
-/-
), CCR7-decient (CCR7
-/-
), and IL10-de-
cient (IL-10
-/-
) mice were infected with Giardia by oral gavage. During the 12
weeks following infection, colitis was evaluated clinically, histologically, and bio-
chemically. Leukocytes were isolated from the intestinal lamina propria and mes-
enteric lymph nodes and evaluated by ow cytometric analysis.
RESULTS: As previously demonstrated in TCRalpha
-/-
and IL-10
-/-
mice, Giardia
infection of CCR7
-/-
mice triggered colitis within 2 weeks, in contrast to unin-
fected littermate controls. Surprisingly, comparison of gene expression proles
revealed Giardia induces a predominant Th1 phenotype in all animals, regardless
of genetic background. Because T cell polarization is inuenced by cytokines
secreted by antigen presenting cells (APC), we examined macrophage and den-
dritic cells responses. Within one week following infection, but prior to inamma-
tion, the numbers of CD11c
CD11b
dendritic cells and CD11c

-
CD11b
macro-
phages were signicantly increased in the colon of IL-10
-/-
mice compared to
uninfected and wild-type controls. Furthermore, the CD103
subsets of both pop-

ulations were markedly diminished and CD103
-
subsets were signicantly
expanded.
CONCLUSION(S): Taken together, our ndings suggest Giardia-triggered colitis is
induced by the loss of regulatory APC and expansion of CD103
-
APC, which
maybe novel targets for the treatment and prevention of IBD.
P-196
YI
TNF-a Inhibitors Attenuate Neuropeptide Y (NPY) Expression in the Murine En-
teric Nervous System: Implications in Inflammation and Colonic Motility
Bindu Chandrasekharan
1
, Efi Kokkotou
2
, Malu Tansey
1
, Shanthi Srinivasan
1
1
Emory University, Atlanta, GA, USA,
2
Beth Israel Deacones Medical Centre, Har-
vard Medical School, Boston, MA, USA
BACKGROUND: Neuropeptide Y (NPY) is a small peptide neurotransmitter pro-
duced by the enteric neurons. We have demonstrated that NPY is upregulated in
the murine enteric nervous system (ENS) during experimental colitis and that
NPY knockout mice are resistant to experimental colitis. However the mechanism
of NPY up regulation in the ENS, and its downstream impact on colonic motility
are unknown. We investigated whether TNF-a inhibitor, Etanercept, can regulate
NPY expression and colonic motility.
METHODS: We utilized an enteric neuronal cell line developed in our laboratory
and dextran sodium sulfate mouse model of colitis to study NPY expression as
modulated by TNF-a. NPY expression in human colonic biopsies was assessed by
real time PCR. Colonic motility was assessed in using isometric muscle recording
in isolated circular muscle strips with intact innervation. Neuronal apoptosis was
evaluated by cleaved caspase-3 immunostaining. Neuronal nitric oxide synthase
containing neurons (nNOS) were quantied by Diaphorase staining.
RESULTS: NPY expression was upregulated in human IBD, and IBD colons dis-
played increased neuronal apoptosis and impaired motility. Etanercept attenuated
NPY expression in vitro and in vivo. Etanercept-treated mice exhibited attenuated
inammation and reduction in neuronal apoptosis. There was restoration of
nNOS neurons in DSS mice treated with Etanercept, which was evidenced by the
reduction in pellet frequency and water content (diarrhea phenotype typical of
IBD).
CONCLUSION(S): Our data establish the signicance of NPY-TNF-a interactions in
IBD. Motility disorders persist in IBD patients even after the resolution of inam-
mation; hence it is compelling to further explore the role of TNF-a inhibitors in
modulating motility issues associated with inammatory disorders.
P-197
YI
B Cells Contribute to Mucosal Homeostasis and Prevention of Colitis Through
IL-10 Production
Yoshiyuki Mishima, Ryan Sartor
BACKGROUND: The role of IL-10-producing B cells in regulating intestinal homeo-
stasis and inammatory bowel diseases (IBD) is poorly understood. Several studies
showed that B cell depletion by rituximab (anti-CD20 antibody) might contribute
to developing colitis (IBD 2007, Gut 2008). Hypothesis: Intestinal B cells con-
tribute to mucosal homeostasis and protection against IBD through IL-10
secretion.
METHODS: Wild-type (WT) or IL-10
-/-
splenic CD4
T cells were co-transferred

with puried splenic B cells from WT or IL-10
-/-
mice into Rag2
-/-
IL-10
-/-
(DKO)
mice. 6 weeks after co-transfer, these mice were evaluated for colitis severity by
histology (0: non-inamed, 12: severe inammation), colonic tissue explant cyto-
kine secretion (gut cult.), mesenteric lymph nodes (MLN) cytokine production
(MLN cult.), and Foxp3 expression in MLN CD4
T cells. To investigate suppressive

mechanisms of B cells on the bacteria-activated differentiation of na ve T cells in
vitro, B cells from WT or IL-10
-/-
mice were co-cultured with a) CD25
-
CD4
T cells
from IL-10
EGFP
reporter mice and IL-10
-/-
antigen-presenting cells (APC) or b)
CD25
-
CD4
T cells and IL-10

-/-
APC co-cultured with either WT or IL-10
-/-
CD25
CD4
and/ or B cells from WT or IL-10

-/-
mice stimulated by cecal bacterial
lysates (CBL). IL-10, IFNc and IL-17a supernatant levels were measured by ELISA
and IL-10, IFNc, IL-17a, Foxp3 and GFP expression were assessed by ow cytome-
try (FACS).
RESULTS: In vivo, histology showed WT CD4
T cell recipient DKO mice that

received co-transferred WT B cells developed less severe colitis than those receiv-
ing either IL-10
-/-
B cells or no B cells (4.3 6 1.0, 7.2 6 1.1 and 7.6 6 0.7,
p<0.02). Gut cult. and MLN cult. demonstrated that either spontaneous or bacte-
ria-induced IFNc and IL-17a secretion was signicantly lower and IL-10 levels
were higher in DKO mice that received WT B cells than those receiving IL-10
-/-
B
cells or no B cells. Foxp3 expression in MLN CD4
T cells was induced by co-

transferring either WT B cells (10.961.0%, p<0.05) or IL-10
-/-
B cells (11.660.8%,
p<0.05), compared to animals without B cells (7.461.2%). However, all DKO mice
with transferred IL-10
-/-
CD4
T cells developed severe colitis with no evidence of

suppression by WT or IL-10
-/-
B cells. In vitro, CBL-stimulated WT but not IL-10
-/-
B
cells produced abundant IL-10 and suppressed IFNc and IL-17a production by
CD25
-
CD4
WT T cells and IL-10

-/-
CD25
T cells equivalent to co-cultured WT or

IL-10
-/-
CD25
regulatory T cells. FACS data demonstrated that% of either CBL-

stimulated IL-17a
or IFNc
unfractionated CD4
T cells were signicantly lower

when co-cultured with WT but not IL-10
-/-
B cells. Interestingly, although both
WT and IL-10
-/-
B cells induced Foxp3
CD4
T cells, only WT B cells could induce

GFP
IL-10-producing regulatory T cells (Tr1 cells) (3.760.3% with WT B cells,

2.260.2% with IL-10
-/-
B cells, and 2.060.3% without B cells, p<0.01).
CONCLUSION(S): WT but not IL-10
-/-
B cells ameliorate T cell-mediated colitis de-
spite B cell induction of Foxp3
CD4
T cells being IL-10 independent. IL-10-pro-

ducing B cells may contribute to intestinal homeostasis by suppressing effector T
cells directly (by IL-10 secretion) and indirectly (by induction of IL-10-producing
Tr1 cells).
P-198
SP-333, A Guanylate Cyclase-C Agonist, Ameliorates DSS-Colitis in Mice Via a
Novel Cyclic GMP-Mediated Mechanism
Kunwar Shailubhai
1
, John Foss
1
, Graham Zhang
2
, Krishna Arjunan
2
, Rong Feng
1
,
Stephen Comiskey
1
, Gary Jacob
1
, Scott Plevy
3
1
Synergy Pharmaceuticals, Inc and PA Biotech Center, Doylestown, PA, USA,
2
Insti-
tute of Hepatitis Virus Research, PA Biotech Center, Doylestown, PA, USA,
3
Univer-
sity of North Carolina School of Medicine, Chapel Hill, NC, USA
BACKGROUND: SP-333, an analog of uroguanylin (UG), activates guanylate cy-
clase-C (GC-C) to stimulate production of cyclic GMP, which is essential for epithe-
lial cell homeostasis and for maintenance of intestinal mucosal barrier. Expression
of UG has recently been shown to be reduced in inamed tissues from patients
with inammatory bowel diseases (IBD), implying that disruption in GC-C signal-
ing might be associated with the etiology of IBD. We previously reported that UG
expression is suppressed in human colon tumors; and that oral administration of
UG in Apc
Min/
mice inhibits polyp formation via a cGMP-mediated mechanism
1
.
Subsequently, we also reported that GC-C agonists ameliorated GI inammation
in murine colitis models
2
. The precise mechanism, however, by which GC-C ago-
nists exert their anti-inammatory activities remained to be elucidated
METHODS: Colitis in mice was induced by 5% DSS mixed in drinking water start-
ing at day 0. Mice (n = 12 per group) were given once daily oral dose of either
Figure 1.
SP-333 (0.005 to 50 mg/kg) or 5-ASA as positive control (100 mg/kg) or PBS as
vehicle from day 0 to 6. Mice were sacriced on day 7 and colon tissue sections
were analyzed for colitis severity, disease activity index (DAI), Ki-67 staining and
for myeloperoxidase (MPO) activity. Levels of SP-333 in blood plasma were ana-
lyzed by LC-MS/MS method (LLOQ: 1 ng/mL). Colon explant cultures were used
to assess production of inammatory cytokines. Effects of SP-333 on activation of
NF-kappa B and on production of cytokines were also measured in T84 colon car-
cinoma cells.
RESULTS: Treatment with SP-333 (0.05 mg/kg) was as effective as 5-ASA (100 mg/
kg) in ameliorating colitis, suppressing DAI, reducing MPO activity and normaliz-
ing Ki-67 staining. The pharmacokinetics study in DSS-colitic mice indicated that
systemic absorption of orally administered SP-333 was minimal. In T84 cells, treat-
ment with SP-333 reduced levels of p-NF-kappaB-p65 in the nuclear fraction and
increased levels of cytosolic I-kappa B without affecting I-kappa kinase (IKK).
Treatment with 8-Br-cGMP, a positive control, exhibited similar inhibition in NF-
kappa B activation. SP-333 also suppressed LPS-stimulated production of IL-8, IL-
17a, IL-23 and TNF-alpha in T-84 cells.
CONCLUSION(S): Oral treatment with SP-333 ameliorated colitis in mice possibly
via activation of GC-C signaling to inhibit NF-kappa B activation and to suppress
production of pro-inammatory cytokines (Fig 1). This is the rst ever study sug-
gesting that the anti-inammatory effect of GC-C agonists might be through inhi-
bition of NF-kappa B activation and it opens a novel avenue for development of
GC-C agonists as a new class of orally delivered, mucosally active, drug candi-
dates for treatment of IBD. SP-333 is entering clinical development for the treat-
ment of mild to moderate ulcerative colitis. 1. Shailubhai K, et al., Cancer Res. 60:
5151-5157, 2000. 2. Shailubhai K, et al., Am J Gastroenterol.106(S1):S455, 2011
P-199
IL-36g Promotes Intestinal Inflammation Via Intestinal Macrophage/DC
Activation
Oscar Medina-Contreras, Duke Geem, Charkes Parkos, Timothy Denning
BACKGROUND: The two most common forms of inammatory bowel disease (IBD),
Crohns disease and ulcerative colitis, affect approximately 1.4 million people in the
United States. Uncontrolled APCs reactivity toward commensal bacteria and the con-
sequent pro-inammatory cytokine production is implicated in disease pathogene-
sis. Neutralization of TNF is currently one of the most effective biological therapies
for Crohns patients, however, there remains a pressing need for the development
of novel therapeutics targeting pro-inammatory cytokines. Several members of the
IL-1 family of cytokines, including IL-1a, IL-1b, IL-18 and IL-33 are associated with
the pathophysiology of IBD. Since we have identied a member of the IL-1 family of
cytokines, termed IL-36g, in a genetic screen for factors selectively expressed by
inammatory colonic lamina propria (cLP) macrophages, in this work we focus on
dening the pathogenic role for IL-36g during intestinal inammation.
METHODS: C57BL/6 mice were fed for 5 days with 3% DSS dissolved in drinking
water, and IL-36Ra was injected intraperitoneally on days 1, 1 and 3. Animals
were assessed daily for stool consistency, fecal blood, and weight loss. cLP cells
were isolated by magnetic positive selection or cell sorting. Cell surface staining
and intracellular cytokine detection was performed using labeled antibodies for
CD45, CD103, CD11c, MHC-II, CD11b, F4/80, Ly6C, Cx3cr1-FITC, live/dead staining,
CD4, TCRb, CD45, IL-17A, IFNg, and FoxP3. qPCR on total RNA from macrophages
was performed using SYBR Green. Treg induction was performed by co-culture of
macrophages, OT-II CD4 T cells and OVA for 3 days.
RESULTS: Our results demonstrated that IL-36g is highly induced in the inamed
colonic tissue of mice during acute and chronic intestinal inammation with one of
the major cell types expressing IL-36g in the inamed colonic mucosa being
inammatory Ly6CCX3CR1(lo) macrophages. This specic expression prompted us
to investigate the modulation of the function of resident inammatory macro-
phages, and we observed that inammatory cLP macrophages isolated from DSS-
treated mice failed to promote Foxp3 induction in responding CD4 T cells when
compared to control macrophages. The addition of IL-36g to co-cultures of T cells
and cLP macrophages isolated from healthy mouse colon conrmed this specic
inhibition of FoxP3 cell differentiation in the presence of IL-36g. Together, these
data suggest that one important biological function of IL-36g is to inhibit Foxp3
Treg cell differentiation. We next examined the role of IL-36g in vivo during DSS-
induced colitis by administration of the IL-36 receptor antagonist (IL-36Ra) on days
1, 1, and 3 of the DSS regimen, which resulted in a signicant reduction in the
overall disease when compared to mice that did not receive IL-36Ra.
CONCLUSION(S): Since IL-36Ra blocks the function of IL-36R, which can bind IL-
36a, IL-36b, and IL-36g, we conclude from these studies that at least one of these
IL-36R ligands is important in the pathogenesis of intestinal inammation. Collec-
tively, our data demonstrate an important role for the macrophage-derived
inammatory cytokine IL-36g and the IL-36g/IL-36R axis during the pathogenesis
of intestinal inammation. The present work will aid in understanding appropriate
targets for immunotherapy. This work was supported by CCFA (RFA, CDA) and
NIH (AA017870 and AI083554) awards.
P-200
Genotype, Immunophenotype, and Cytokine Signaling in Crohns Disease
James Lord, Janice Chen, Karen Cerosaletti, Jane Buckner
Benaroya Research Institute, Seattle, WA, USA
BACKGROUND: Cytokine signaling networks play a central role in shaping the dif-
ferentiation and activity of the immune system in health and disease. Genetic
association studies have implicated the genes of several cytokine signaling pro-
teins, such as Jak2 and Stat3, in Crohns disease pathogenesis. Our institution has
previously determined that a genetic polymorphism within the PTPN2 gene asso-
ciated with both Crohns and type I diabetes is also associated with decreased
Stat5 signaling through the IL-2 receptor in T cells.
METHODS: Through a CCFA pilot award, we surveyed Stat phosphorylation by a
panel of 10 cytokines in 5 major peripheral immune cell subsets in the peripheral
blood of both Crohns disease patients and healthy donors with and without
Crohns-associated polymorphisms in the Jak2, Stat3, and PTPN2 genes. At the
same time, we immunophenotyped these peripheral blood cells with multiple 12-
color panels by ow cytometry to correlate cytokine signaling strength with the
frequency and phenotype of immune cell subsets.
RESULTS: The risk allele of Jak2 was associated with increased Stat3 phosphoryla-
tion in T cells by the pro-inammatory cytokine IL-6, which is thought to play a
central role in Crohns disease pathogenesis. However, both Crohns disease and
its risk allele of Stat3 were, in contrast, paradoxically associated with decreased
IL-6 signaling through Stat3 in T cells. Furthermore, the risk allele of Stat3 para-
doxically associated with increased IL-4, IL-13, and GM-CSF signaling in mono-
cytes, despite the fact that none of these cytokines signal through Stat3, and
they would all be predicted to play a protective role in Crohns. In contrast to
prior ndings in type I diabetes, Crohns was associated with increased signaling
by IL-2 in T cells. The IL-2 signal strength correlated with CCR7 expression in
CD4- (presumed CD8) T cells lacking the gut-homing integrin alpha 4 beta 7.
CCR7 expression also correlated with IL-7 signaling in subsets of these same cells,
as well as both IL-6 and IL-27 signaling in both CD4- and CD4 T cells, particu-
larly CD4FOXP3 regulatory T cells (Tregs). A strong negative correlation was
observed between IL-27 signal strength in CD4 T cells and expression of the in-
hibitory molecules CD39 and TIGIT on Helios-negative Tregs, believed to repre-
sent peripherally-induced Tregs. Correlations between cytokine signaling and
immune cell phenotypes were not seen outside the T cell compartment.
CONCLUSION(S): This hypothesis-generating survey of cytokine signaling and
immunophenotype in the peripheral blood of patients with Crohns disease or its
genetic risk factors revealed paradoxical differences in the signal strength of a
number of cytokines implicated in Crohns disease pathogenesis. These cytokine
signal intensities were correlated with differences in the phenotype of circulating
T cell subsets. Future analyses of these data will also compare the effects of dis-
ease characteristics and genetics on immunophenotype.
P-201
Overexpression of MMP9 in Colonic Epithelium Is Associated With Defective
Permeability and Increased Levels of Pro-Inflammatory-Chemokine Kc,
in Acute Colitis
Lewins Walter
1
, Hongchun Liu
1
, Neal Patel
2
, Pallavi Garg
1
1
Georgia State University, Atlanta, GA, USA,
2
Emory University, Decatur, GA, USA
BACKGROUND: Inammatory Bowel Disease (IBD) including ulcerative colitis and
Crohns Disease, is a chronic inammatory disease that affects the entire gastroin-
testinal tract particularly the colonic mucosa and is associated with an increased
risk of colon cancer. Matrix metalloproteinases (MMPs) are the Zn2 dependent
proteinases expressed in the gut mucosa during the course of active IBD. Of the
MMPs, MMP9 is the predominant MMP highly expressed in IBD but absent in nor-
mal colonic tissues. In the present study, we used MMP9 transgenic mice (Tg-vil-
lin-MMP9) that specically overexpress MMP9 in the colonic epithelium to investi-
gate the mechanism by which it mediates inammation in acute colitis.
METHODS: Age and gender matched Tg-villin-MMP9 and their wild type litter-
mates (WT) mice were used for in vivo experiments and stably transfected
HCT116 colonic epithelium cell line overexpressing MMP-9 was used for in vitro
experiments. Barrier function was performed by 4kD FITC dextran and Swiss rolls
were used for Alcian blue (AB-PAS) staining. Organ culture ELISA was used to
measure protein levels of Kc. Dextran sodium sulfate (3% DSS) and Salmonella
typhimurium (S.T.) were used to induce colitis. Colonic tissues after induction of
acute colitis were histologically examined and extracts were analyzed by western
blotting, myeloperoxidase (MPO) assay and Q-PCR.
RESULTS: At the basal level mRNA level and the protein expression of MMP9
were signicantly higher (1260.52-fold and 5.760.06-fold respectively) in Tg-vil-
lin-MMP9 mice than in WT mice. Tg-villin-MMP9 mice showed signicant increase
(3.1660.82) in permeability compared to WT littermates (1.0760.16). AB-PAS
staining revealed a signicant decrease in goblet cell numbers in Tg-villin-MMP9
mice compared to WT mice. At the basal level, Q-PCR indicated a signicant
increase (5.761.25-fold) in the level of pro-inammatory chemokine Kc mRNAs
(human homologue is IL-8) in Tg-villin-MMP9 compared to WT mice. Organ cul-
ture ELISA showed signicantly increased expression of Kc protein levels among
Tg-villin-MMP9 mice (2.6160.18) compared to WT mice (1.2860.25). This result
was also supported by in vitro model. Stably transfected HCT116 colonic epithe-
lium cell line over-expressing MMP9 exhibited a signicant increase in IL-8 protein
levels (3.360.56) compared to vector (1.4660.14). Tg-villin-MMP9 mice exposed
to DSS- and S.T.-induced colitis exhibited a signicant loss of body weight and
higher mortality. Tg-villin-MMP9 mice exposed to DSS- induced colitis exhibited
signicantly higher clinical score (9.560.5) compared to WT littermates (6.560.6).
Tg-villin-MMP9 mice undergoing DSS- and S.T.-induced colitis showed signi-
cantly higher histological scores (7.260.5 and 7.860.6 respectively) and increased
MPO activity (1.960.7 MPO U/mg protein and 2.460.4) compared to WT animals
(3.660.8 and 3.260.5; and 0.760.2 MPO U/mg protein and 0.660.4 respectively).
Further, the level of mRNA encoding Kc was also signicantly higher (9.0610.5-
fold) in Tg-villin-MMP9 mice undergoing DSS-induced colitis, and also in mice
undergoing S.T.-induced colitis (7.869.6-fold), compared to the levels in WT
littermates.
CONCLUSION(S): Together, the data show that constitutive expression of MMP9 in
colonic epithelium causes spontaneous inammation associated with permeability
defect and an increase in the levels of pro-inammatory chemokine Kc. Results
acquired from the study may help in modifying the therapeutic strategy as the
treatment of acute colitis.
P-202
Interleukin 23 and Tumor-Elicited Inflammation in Colitis-Associated and Spon-
taneous Colon Cancer
Sergei Grivennikov
1
, Kepeng Wang
2
, Michael Karin
2
1
Fox Chase Cancer Center, Philadelphia, PA, USA,
2
University of California, San
Diego, La Jolla, CA, USA
BACKGROUND: Colitis associated cancer (CAC) is the most serious complication of
inammatory bowel diseases (IBD) and its pathogenesis is driven by inamma-
tion. Cytokines are molecular mediators of inammation. Cytokines like IL-6, IL-17
and IL-23 are upregulated not only in CAC tumors, but also in spontaneous colo-
rectal cancer (CRC), where they regulate tumor-elicited inammation.
METHODS: We use mouse models of CAC (azoxymethane DSS) and monoallelic
inactivation of APC tumor suppressor gene in the colon only as a model of CRC.
RESULTS: We found that due to the disruption of barriers during colitis or during
CRC initiation commensal microora activates expression of IL-23, which as a
master regulator of tumor elicited inammation controls the expression of other
pro-tumorigenic cytokines such as IL-6, IL-11, IL-17 and IL-22. Inactivation of IL-23
or some of its downstream cytokines reduced tumor-elicited inammation and
decreased CAC and CRC development
CONCLUSION(S): IL-23 is important for CAC and CRC tumorigenesis and regulates
tumor -elicited inammation
P-203
In Vitro Pharmacology of AVX-470, an Oral Anti-TNF Polyclonal Antibody for
the Treatment of IBD
Amy Holdorf
1
, Brenda Lemos
1
, David Keane
1
, Michael Quesenberry
1
, Shawn
Clark
2
, Kailash Bhol
1
, Barbara Fox
1
, Daniel Tracey
1
1
Avaxia Biologics, Inc., Lexington, MA, USA,
2
Xtal BioStructures, Natick, MA, USA
BACKGROUND: AVX-470 is a bovine polyclonal anti-TNF antibody that is being
developed as an oral therapeutic for the treatment of IBD. The antibody is
designed to work locally within the inamed GI tract, minimizing systemic expo-
sure and the resulting systemic immunosuppression. Oral delivery of a surrogate
antibody specic for murine TNF (AVX-470 m) has previously been shown to
effectively treat DSS- and TNBS-induced colitis in mice. The goal of this study is
to determine the in vitro pharmacological parameters of AVX-470, and to com-
pare some of these parameters to the monoclonal antibody iniximab.
METHODS: AVX-470 was generated by immunization of pregnant dairy cows with
recombinant human TNF. Colostrum was collected and the immunoglobulin frac-
tion was enriched, with a majority of the polyclonal antibody of bovine isotype
IgG1. AVX-470 binding to TNF was quantied by direct ELISA on TNF-coated
plates. Neutralization of soluble TNF by AVX-470 was determined using the cell-
based L929 assay. Sandwich ELISAs were used to determine AVX-470 cross-reac-
tivity with other cytokines. The TNF-specic component of AVX-470 was isolated
on a TNF-afnity column and the activity of the afnity-puried and parent mate-
rials were compared in both a TNF-specic binding ELISA and in the L929 TNF
neutralization assay. Afnity puried AVX-470 (AVX-470A) was used to measure
the binding afnity to human TNF by both Surface Plasmon Resonance (SPR) and
by competitive ELISA. Flow cytometric analysis was used to assess the ability of
AVX-470 to signal through transmembrane TNF and induce apoptosis in PMA and
Ionomycin activated human PBMC, as measured by annexin V and propidium
iodide uptake.
RESULTS: AVX-470 bound to human TNF in a solid phase ELISA with a high titer,
and robustly neutralized soluble human TNF in a cell-based assay. While AVX-470
bound strongly to human TNF, it bound less well to non-human primate TNF,
and bound weakly to other species (human>cynomolgus monkey/rhesus maca-
que>dog>>rodent and cow). AVX-470 demonstrated no cross reactivity to TNF-
related cytokines. By both SPR and competitive ELISA, AVX-470A showed an afn-
ity to TNF in the high picomolar range, comparable to that of iniximab. The
monoclonal antibody iniximab displayed a very sharp inhibition curve while the
polyclonal AVX-470A displayed a shallower inhibition curve, indicative of a broad
range of antibodies directed against multiple epitopes on TNF. AVX-470 induced
apoptosis by reverse signaling in activated human PBMC, similar to that of inixi-
mab, while control bovine immunoglobulin showed no effect on apoptosis.
CONCLUSION(S): AVX-470 is a potent, specic, high afnity anti-TNF antibody
which binds to TNF in a solid phase binding assay, neutralizes soluble TNF in the
L929 cell-based assay, and induces reverse signaling through membrane TNF as
measured by induction of apoptosis. In afnity measurements, TNF neutralization,
and apoptosis studies, AVX-470 was comparable to iniximab. AVX-470 has some
reactivity to non-human primate TNF, but little to no reactivity to other species
tested. This nding has enabled a toxicology study in cynomolgus monkeys.
Taken together, these in vitro data support the use of AVX-470 as a therapeutic
agent for the treatment of IBD.
P-204
Inhibition of the mTOR Pathway Alleviates Intestinal Fibrosis Via Suppression
of Myofibroblast Proliferation
Jun Yang, James Cao, Veena Nannegari, Catherine Bartholomew, Richard MacDer-
mott, Xinjun Cindy Zhu
Albany Medical Center, Albany, New York, USA
BACKGROUND: Intestinal brosis is generally considered to be an irreversible
stage which gradually evolves in response to prolonged injury or inammation.
The pathophysiology of intestinal brosis in IBD is not fully understood. Rapam-
cyin, an inhibitor of mTOR, has recently been reported to alleviate a severe form
of IBD, presumably by improving the inammatory response by down-regulating
the immune system. Recent studies suggest that the mTOR signaling pathway
may be involved in transforming growth factor b1(TGFb1)-dependent brogenic
processes in several organ systems. Low-dose oral administration of rapamycin
reduces brogenesis, improves liver function, and prolongs survival in rats with
established liver cirrhosis. We hypothesized that rapamycin ameliorates intestinal
brosis via inhibition of submucosal myobroblast proliferation.
METHODS: Mice were divided into four groups including control, TNBS alone,
rapamycin alone, and both rapamycin and TNBS. Rapamycin (5 mg/kg/day) was
administrated intraperitoneally for 6 weeks and TNBS enema weekly for 6 weeks
to induce intestinal brosis. Mouse colon samples were collected for examination
of submucosal collagen deposition by Massons trichrome blue and myobroblast
proliferation by either aSMA or HIT-5 (focal adhesion protein hydrogen peroxide
inducible clone 5). Isolated primary intestinal cells or smooth muscle cell line was
treated with TGFb1 for 72 hours either with or without rapamycin. Myobroblast
cells were identied by staining with aSMA.
RESULTS: Colon samples harvested from TNBS-treated mice displayed severe stric-
ture over the distal colon while only mild, patchy erythema and edema observed in
the rectum from rapamycin treated TNBS group. While being completely distorted
in vehicle treated TNBS group, mucosal crypt architecture was largely preserved in
rapamycin treated TNBS group. Colon thickness is an indirect measurement of intes-
tinal inammation and brosis. TNBS treatment induced overall thickening of the
colon tissue, especially in the submucosa and muscularis layers, which was markedly
prevented by rapamycin treatment. Furthermore, we observed the presence of
hyperproliferation of myobroblasts (aSMA and Hic-5 positive cells) along with sig-
nicant collagen deposition in the intestine from TNBS treated group. In contrast,
intestine from rapamycin treated group exhibited very mild proliferation of myo-
broblasts and deposition of collagen. Direct effect of rapamycin on myobroblast
proliferation was also examined in primary intestinal cells and smooth muscle cell
line. We observed that rapamycin markedly inhibited proliferation of aSMA and Hic-
5 positive cells elicited by TGF-b1in primary intestinal cell cultures.
CONCLUSION(S): Rapamycin ameliorates intestinal brosis in TNBS mouse model.
Our in vitro data suggest that rapamycin exerts anti-brotic effect in part via
direct suppression of myobroblast proliferation. These ndings may have pre-
ventive or therapeutic applications in brotic Crohn disease.
P-205
YI
Intestinal Epithelial VDR Is Sufficient to Inhibit Experimental Colitis Independ-
ent of Immune VDR Actions
Weicheng Liu, Yunzi Chen, Ursula Dougherty, Maya Golan, Yan Chun Li
BACKGROUND: Impaired mucosal barrier function is a potential contributor to
IBD pathogenesis. While epidemiological evidence demonstrates vitamin D-de-
ciency is highly prevalent in IBD and vitamin D status is inversely associated with
disease severity, the mechanistic impact(s) of vitamin D deciency remains
unclear. Vitamin D hormone activity is mediated by the vitamin D receptor (VDR).
Previous studies using IL-10(-/-)/VDR(-/-) mice concluded that VDR signaling in
immune cells inhibits colonic inammation and colitis development. In addition,
our investigations of VDR(-/-) mice suggested that the epithelial VDR attenuates
experimental colitis by protecting the mucosal epithelial barrier and that colonic
epithelial VDR levels were markedly reduced in the biopsies from patients with
IBD. Aims: To identify the anti-colitic role of the colonic epithelial vs. immune
VDR signaling in the development of experimental colitis.
METHODS: Transgenic (Tg) mice were generated in which villin promoter was
used to target Flag-tagged human (h)VDR to intestinal epithelial cells (IEC). Trans-
genic-VDR(-/-) (Tg-KO) mice were also produced through breeding in which only
the IECs were reconstituted with hVDR in the VDR(-/-) background. Tg, Tg-KO,
VDR(-/-) and wild-type (WT) mice were studied in parallel using TNBS- and DSS-
colitis models.
RESULTS: In both TNBS and DSS models, Tg mice were highly resistant to colitis
induction compared to WT mice, manifested by lower clinical and histological
scores and marked reduction in colonic epithelial damage and inammatory cyto-
kine production. Colonic epithelial permeability was well preserved in Tg mice.
VDR(-/-) mice developed the most severe colitis that led to high mortality in both
models, whereas Tg-KO mice were highly resistant to colitis with almost no mor-
tality. Mechanistically, VDR overexpression attenuated TNBS- or DSS-induced IEC
apoptosis, with marked suppression of PUMA induction and caspase 3 activation.
In vitro and in vivo data demonstrated that VDR signaling inhibited PUMA expres-
sion by blocking NF-kB activation.
CONCLUSION(S): These results demonstrate that intestinal epithelial VDR signaling
inhibits colonic inammation by protecting the integrity of the mucosal epithelial
barrier. The observation that the hVDR transgene rescues VDR-null mice from devel-
oping severe colitis despite a VDR-null immune system demonstrates that the anti-
colitic activity of the epithelial VDR is independent of the immune VDR actions.
P-206
YI
The Fucosyltransferase 3 Driven Expression of Sialyl Lewis A on the Intestinal
Epithelium Regulates PMN Clearance During Inflammation
Jennifer Brazil, Renpeng Liu, Richard Cummings, Charkes Parkos, Nancy Louis
Emory University, Atlanta, Georgia, USA
BACKGROUND: The transepithelial migration (TEM) of polymorphonuclear leukocytes
(PMN) across the epithelium, leading to intestinal crypt abscess formation, is a histo-
pathological hallmark of inammatory bowel disease (IBD), yet the mechanisms con-
trolling PMN TEM remain poorly dened. Using the novel mAb GM35, we have
demonstrated a role for the epithelial glycoprotein CD44v6 in the detachment of
migrating PMN from the apical aspect of the intestinal epithelium. Here we further
dene the specic structure of the functional GM35-binding epitope and dene rel-
evant enzymes contributing to its synthesis in human IECs, in order to identify
potential pharmacologic targets for therapeutic intervention in individuals with IBD.
METHODS: The potential for GM35 to recognize a carbohydrate epitope was
explored by immunoblotting of protein extracts of intestinal epithelial cell lines
(IECs) before and after pretreatment with either tunicamycin or benzyl 2-acet-
amido-2-deoxy-a-D-galactopyranoside to block either N- or O-glycan biosynthesis,
respectively. Specic recognition of glycans by GM35 was explored using a glycan
microarray (v5.1) available from the Consortium for Functional Glycomics, which
contains 610 glycans. Analyses of sialyl Lewis A (sLe
a
) biosynthesis exploited the
nding that distinct cultured IECs exhibit differing expression of the sLe
a
-contain-
ing glycan recognized by GM35. IECs were lysed and the N- and O-glycans
released by either enzymatic or chemical means, respectively, were structurally
characterized by tandem mass spectrometry. Expression levels of galactosyl-,
sialyl-, and fucosyl-transferase mRNA and protein were dened via real time PCR
and immunoblotting, respectively, and compared in sLe
a
high (T84) and low
(SKCO15) IECs. The roles of specic enzymes in the synthesis of sLe
a
in SKCO15
IECs were explored by transient transfection and immunoblotting.
RESULTS: Immunoblotting following treatments of cells with glycosylation inhibi-
tors demonstrated that GM35 recognizes an O-glycan epitope. Glycan microarray
studies revealed that GM35 strongly recognizes the tetrasaccharide sialyl lewis A
(sLe
a
). Surface glycan mapping of T84 IECs by tandem mass spectrometry identi-
ed multiple O-glycans candidates expressing sLe
a
, which were absent from
SKCO15 IECs. Comparison of gene and protein expression in T84 and SKCO15
IECs revealed differences in the expression of several glycosylation enzymes impli-
cated in the biosynthesis of sLe
a
, such as expression of a1-3/4 fucosyltransferase
3 (Fut3) which was markedly increased in T84 IECs. Forced overexpression of Fut3
in SKCO15 IECs resulted in the robust expression of sLe
a
.
CONCLUSION(S): The Fut3 driven expression of sLe
a
displayed on the O-glycans of
CD44v6 inuences PMN clearance during inammatory episodes through the reg-
ulation of the detachment of PMNs from the apical epithelial surface into the
lumen of the intestine. Increased understanding of the biosynthesis and expres-
sion of the inammation induced glycoepitope sLe
a
could provide future thera-
peutic targets for the treatment of IBD.
P-207
YI
The Inflammatory Cytokine IFNg Regulates Intestinal Epithelial Homeostasis by
Controlling the Spatiotemporal Localization of Akt, 14.3.3z and Beta-catenin
Porfirio Nava, Ryuta Kamekura, Oscar Medina-Contreras, Ross Hamilton, Keli
Kolegraff, Stefan Koch, Timothy Denning, Charkes Parkos, Asma Nusrat
BACKGROUND: Regulated intestinal epithelial cell proliferation and differentiation
play a pivotal role in controlling intestinal epithelial homeostasis and barrier func-
tion. Pro-inammatory cytokines such as IFNg and TNFa that are increased in the
intestinal mucosa of patients with inammatory bowel disease (IBD) inuence epi-
thelial homeostasis and compromise barrier function. These proinammatory cyto-
kines modulate intestinal epithelial (IEC) homeostasis through effects on IEC prolif-
eration that is in turn regulated by b-catenin, an adherens junction-associated
protein. Chronic exposure to IFNg results in protein kinase B (PKB/Akt)-mediated b-
catenin signaling that initially promotes, and subsequently suppresses IEC prolifera-
tion. The mechanism(s) governing the suppression of b-catenin signaling after IFNg
treatment are however poorly understood and therefore the focus of this study.
METHODS: Cell Culture. Intestinal epithelial T84, SW480 and CHO-K1 cells were
grown as previously described. Animal Experiments. C57Bl/6J mice were obtained
from The Jackson Laboratories. Animals were housed in a standard day and night
cycle, with free access to food and water. Experimental colitis was induced by
addition of 3% wt/vol dextran sulfate sodium (DSS; US Biologicals).
RESULTS: Complementary in vitro and in vivo experimental approaches were used
to demonstrated that IFNg induces activation of Akt and that in turn phosphoryl-
ates b-catenin and GSK3b at serine 552 and serine 9 respectively. These post-
translational modications in these molecules facilitate the interaction of b-cate-
nin and GSK3b with 14.3.3z thereby promoting b-catenin stabilization and trans-
activation. By western blotting and qRT-PCR we demonstrate that transactivation
of b-catenin after IFNg treatment increases Akt1 expression. Moreover, subcellular
fractionation studies were used to demonstrate that de novo synthesis of Akt1
leads to enrichment of active Akt1 in the nucleus. Interestingly, an increase in the
nuclear pool of active Akt1 promotes phosphorylation of 14.3.3z at serine 58 resi-
due that facilitates the expulsion of 14.3.3z/pb-cat552 protein complex from the
nuclear compartment. Expulsion of 14.3.3z from the nucleus results in the inhibi-
tion of b-catenin transactivation as shown by Top-ash reporter assay. The in
vitro results were conrmed in vivo by analysis of the intestinal epithelium in an
acute epithelial injury (DSS) model and by intraperitoneal administration of IFNg.
CONCLUSION(S): Here we show that the b-catenin-dependent, anti-proliferative
activity of IFNg requires synthesis, activation and sub-cellular compartmentaliza-
tion of 14.3.3z scaffold protein and the Akt isoform Akt1. 14.3.3f associates with
phosphorylated b-catenin (pb-cat552) in IECs exposed to IFNg that in turn pro-
motes b-catenin dependent-Akt1 expression. Akt1 upregulation and its accumula-
tion in the nucleus results in translocation of 14.3.3f and pb-cat552 from the nu-
cleus to the cytosol thereby suppressing b-catenin transactivation and IEC
proliferation. These results provide a novel mechanism by which IFNg decreases
active b-catenin in the nucleus to suppress IEC proliferation during inammation
in IBD. Indeed we believed that the decreased intestinal epithelial proliferation
observed during sustained inammation-induced injury is most likely a protective
response that prevents continued proliferation that could lead to neoplastic
transformation of the epithelium.
P-208
YI
Neutrophil Interactions With ICAM-1 at the Luminal Surface of the Intestinal
Epithelium Enhance Neutrophil Survival and Alter Epithelial Barrier Function
Ronen Sumagin, Charkes Parkos
BACKGROUND: Neutrophil transepithelial migration (TEM) is a hallmark of inam-
matory bowel disease (IBD), and is associated with epithelial injury and impaired
barrier function. While TEM has been extensively modeled, little is known about
neutrophil interactions with ligands expressed on the luminal surface of the intes-
tinal epithelium. ICAM-1 is a well-recognized signaling receptor and endothelial
ligand for migrating neutrophils. Its expression is also induced on the luminal
(apical) membrane of intestinal epithelial cells (IEC) exposed to interferon c (IFNc),
and in the colonic mucosa of individuals with active IBD. However, the role of
ICAM-1 in mediating functional effects of neutrophil interactions with intestinal
epithelial cells is undened.
METHODS: ICAM-1 expression in cultured IECs and mouse intestinal epithelium
was induced by exposure to IFNc (100U/mL, 24h) and IFNcTNFa (500ng each,
24h, ip) respectively, and analyzed by ow cytometry and immunouorescence.
The effects of neutrophil-IEC interactions, and specically of ICAM-1 engagement
by antibody crosslinking on the regulation of epithelial barrier function was
examined in T84 IECs by measuring changes in transepithelial resistance (TER)
and permeability to 4kDa FITC-Dextran, and by using an intestinal loop model
from anesthetized mice, measuring absorption of FITC-dextran from the intestinal
lumen into the circulation.
RESULTS: We conrmed upregulation of ICAM-1 expression in IFNc treated T84
cells, in the intestinal epithelium of patients with IBD, and further showed induc-
tion in ICAM-1 expression in-vivo in murine small intestine pre-treated with IFNc
and TNFa. In cultured IECs, expression of ICAM-1 enhanced neutrophil adhesion
to the apical epithelial membrane. The majority (-60%) of apically adhered neu-
trophil that completed TEM were found to exhibit luminal crawling behavior,
which was signicantly enhanced (>33%) when T84 cells were pre-exposed to
IFNc. Neutrophil interactions with apical epithelial membrane of IFNc pretreated
IECs also resulted in enhanced neutrophil survival as evident by decreased apo-
ptosis. The effects on neutrophil crawling and apoptosis were ICAM-1-dependent
and were reversed by treatment with an anti-ICAM-1 function-blocking antibody.
Furthermore, neutrophil interactions with the apical epithelial membrane resulted
in time-dependent decrease in TER. This decrease was prevented by inhibition of
neutrophil adhesion and crawling using an anti-CD11b/CD18 function-blocking
antibody, suggesting that neutrophil induced effects on barrier function were due
to direct engagement of ligands on epithelial surface. Experiments modeling neu-
trophil apical engagement using antibody-mediated crosslinking of cell surface
ICAM-1 in cultured IECs and in-vivo, using murine intestinal loop model conrmed
a direct role for ICAM-1 engagement in regulating epithelial barrier function. Anti-
body crosslinking of ICAM-1 resulted in time-dependent decrease in TER (up to
30%) and increased ux of FITC-dextran (-2.5-fold at 4 hours) in-vitro and
increased ux of FITC-dextran (-1.6-fold) in-vivo. ICAM-1 mediated changes in bar-
rier function were accompanied by actin rearrangement and dependent on MLCK.
CONCLUSION(S): These studies suggest that neutrophil engagement of apically
expressed ICAM-1during IBD results in signaling events that can inhibit neutrophil
clearance and alter barrier. Such interactions may contribute to further recruit-
ment of inammatory cells and impede resolution of inammation. Thus, target-
ing ICAM-1 in the intestinal epithelium may provide new/improved therapeutic
approaches for treating IBD.
P-209
YI
miR-142-3p Regulates ATG16L1 Expression and Autophagic Activity in
Intestinal Epithelial HCT116 Cells
Zili Zhai, Feng Wu, Alice Chuang, Jim Chuang, David Boone, John Kwon
BACKGROUND: Multiple genetic studies have implicated autophagy-related genes,
ATG16L1 and IRGM, in the pathogenesis of Crohns disease (CD). Functional char-
acterizations of the CD-associated genetic variations in ATG16L1 and IRGM high-
light the signicance of an intact autophagic function in the control of intestinal
inammation and CD. A polymorphism in the IRGM gene has been recently
found to result in altered miR-196 binding to and regulation of the IRGM tran-
script. MicroRNAs (miRNAs) are small, non-coding RNAs that play a critical role in
the post-transcriptional regulation of gene expression. Until now, there is a lack
of knowledge of whether ATG16L1 is regulated by miRNAs. The purpose of this
study was to assess the involvement of miRNAs in the regulation of ATG16L1
expression and autophagic activity.
METHODS: The wide type (WT) 3
/
-untranslated region (3
/
UTR) and truncated 3
/
UTR
fragments of ATG16L1 were cloned into a pMIR-GLO vector and the functional
ATG16L1 3
/
UTR was evaluated by transfection of these 3
/
UTR vectors into colonic
epithelial HCT116 cells for luciferase reporter assay. In silico analysis for putative
miRNA binding sites in the ATG16L1 3
/
UTR was performed using online search tools.
The regulatory effects of putative miRNAs on ATG16L1 expression were determined
by qRT-PCR and Western blot following transfecting HCT116 cells with individual
miRNA mimics. To validate the predicted consensus sequences for functional miR-
NAs in the ATG16L1 3
/
UTR, luciferase reporter assays were performed with the vec-
tors containing either WT miRNA or mutant miRNA binding sites. Finally, to assess
the functional consequence of miRNA regulation of ATG16L1, the effects of miRNA
mimic transfection on autophagic response to starvation were evaluated by exam-
ining autophagy marker LC3II formation using Western blot and confocal imaging.
RESULTS: Dual luciferase reporter assay following transfection of vectors with WT
3
/
UTR or truncated 3
/
UTR segments of ATG16L1 suggests that the rst half of
ATG16L1 3
/
UTR in the 5
/
end is more functional for miRNA targeting. Five poten-
tial miRNA binding sites within the region for miRs-30b*, 142-3p, 505*, 548-
3p, and 770-5p were identied by bioinformatics tools. Among these putative
miRNAs, miR-142-3p, upon overexpression in HCT116 cells, resulted in a signi-
cant decrease in both ATG16L1 mRNA and protein levels. Further observation
demonstrated that mutating the miR-142-3p binding sequence abolished the
reduced luciferase activity by ATG16L1 3
/
UTR, suggesting ATG16L1 is a gene tar-
get for miR-142-3p. Moreover, the regulation of ATG16L1 expression by miR-142-
3p blunted the starvation-induced autophagic activity as indicated by decreased
LC3II production.
CONCLUSION(S): Our study revealed miR-142-3p as a new autophagy-regulating
small molecule by targeting ATG16L1, implying a role of this miRNA in the intesti-
nal inammation and CD. Further studies are needed to conrm the miR-142-3p
regulation of ATG16L1 expression and autophagic activity in vivo. These data may
help develop miRNA-based therapy and diagnosis for CD.
P-210
YI
Interaction of Formyl Peptide Receptor 1 (FPR1) and Enteric Commensal Bacte-
ria in Intestinal Homeostasis and Wound Healing
Ashfaqul Alam, Giovanna Leoni, Jaclyn Kwal, Huixia Wu, Asma Nusrat, Andrew
Neish
BACKGROUND: The microbiota of the intestinal lumen is essential for normal gut
tissue development, renewal and restitution. Understanding how enteric com-
mensal bacteria interact with intestinal epithelia via pattern recognition receptors
(PRRs) is a crucial step in the delineation of mechanisms for intestinal homeosta-
sis and reparative processes that can be harnessed for the design of novel thera-
peutics for inammatory bowel disease (IBD). Pattern recognition receptors
expressed in the epithelial mucosa maintain homeostatic balance with the micro-
biota and ensure clearance of pathogenic bacteria. N-formyl peptide receptors
(FPRs) represent a family of mammalian pattern recognition receptors that can
specically bind an array of peptides and small molecules derived from bacteria
and host. FPRs are seven membrane-pass G protein coupled surface receptors,
which modulate multiple phagocyte immune functions. Intestinal epithelial cells
also express FPRs that can stimulate migration of cultured intestinal epithelial
cells in response to exogenous bacterial formylated peptides or endogenous
ligands in a redox dependent manner. However, it is incompletely understood
how gut symbionts function as a pro-healing and -homeostatic regulator in the
intestine.
METHODS: To study restitution of epithelial wounds, dened mechanical mucosal
wounds were inicted in mouse distal colon by using endoscope and forceps.
Wound restitution in chemically induced murine colitis model was also studied
by using dextran sodium sulfate (DSS).
RESULTS: Here we report that gut microbiota stimulate ROS generation in wound
associated colonic epithelial cells through FPR1 in vivo causing rapid phosphoryl-
ation of FAK and ERK in a NADPH oxidase1 (Nox1)-dependent manner. In addi-
tion, enteric microbiota require FPR1 and Nox1 to augment proliferation and
migration of wound associated epithelial cells, and therefore, to enhance repara-
tive processes of colonic epithelial wounds inicted either by biopsy forcep or by
DSS.
CONCLUSION(S): Taken together, these ndings demonstrate a novel role for
FPR1 in perceiving enteric microbiota to regulate homeostasis and restitution of
the intestinal mucosa.
P-211
YI
Claudin-7 in Colonic Intestinal Epithelial Cell Differentiation and IBD
Attila Farkas, Roland Hilgarth, Cristopher Capaldo, Charkes Parkos, Michael Koval,
Asma Nusrat
Emory University, Atlanta, Georgia, USA
BACKGROUND: Intestinal epithelial cells (IECs) serve as a dynamic barrier that sep-
arates luminal antigens from the underlying tissue compartments. In inamma-
tory bowel diseases (IBD) the epithelial barrier is compromised, leading to uid
and electrolyte loss and exposure to luminal antigens. The intercellular tight junc-
tions (TJs) play a pivotal role in regulating the IEC barrier function. Key regulators
of TJ permeability are the claudin family of proteins. As IECs proliferate and differ-
entiate along the crypt-luminal axis of the colon, claudin protein expression is
changed from leaky claudins at the crypt bottom to tight claudins at the lumi-
nal surface. Such differential claudin expression along the crypt-lumen axis is per-
turbed in IBD resulting in a leaky epithelial barrier. Preliminary observations on
colonic mucosal cryosections by immunouorescence labeling and confocal mi-
croscopy revealed a gradient of claudin-7 along the crypt-luminal axis with differ-
entiated surface epithelium showing the highest levels. Additionally, based on
preliminary observations and a published report claudin-7 expression is
decreased in IBD. This study was designed to investigate the mechanisms by
which claudin-7 is regulated during IEC differentiation.
METHODS: Caco-2 cell cultures were used to model IEC differentiation. Immunou-
orescent and immunohistochemical labeling of human tissue was performed using
claudin-7 and HNF4-a antibodies. mRNA and heteronuclear RNA levels of claudin-7
were assessed by RT-qPCR. Claudin-7/luciferase reporter assays were performed to
analyse claudin-7 promoter activity. TF/DNA array (Panomics, Combo array) was
used for the analysis of TF activity during IEC differentiation. PROMO 3.0 web serv-
ice was utilized for in silico promoter analysis. Chromatin immunoprecipitation with
HNF4-a antibodies was used to examine binding to claudin-7 promoter.
RESULTS: Increased claudin-7 mRNA and hnRNA levels were observed in a cul-
tured cell model of differentiating IECs, suggesting transcriptional control of
expression. We conrmed that claudin-7 promoter activity increased during IEC
differentiation, using a human CLDN7 promoter-Luciferase reporter construct.
Truncated CLDN7 reporter constructs were generated to identify the minimal pro-
moter region required for a comparable response during IEC differentiation. Tran-
scription factors (TFs) potentially responsible for claudin-7 expression during IEC
differentiation were identied using a TF/DNA array to analyze nuclear extracts
from undifferentiated and differentiated IECs. Results obtained from the array
were cross-referenced with putative TF binding motifs obtained by in silico analy-
sis of the human CLDN7 promoter. Using this approach, HNF4-a was identied as
a candidate TF that controls CLDN7 gene activity. Consistent with this, immuno-
histochemical labeling of intestinal epithelium revealed a gradient of HNF4-a
expression along the crypt-luminal axis analogous to the pattern of claudin-7
expression. Moreover, HNF4-a binding to the minimal CLDN7 promoter was con-
rmed by chromatin immunoprecipitation. Interestingly, the HNF4a gene regula-
tory region contains an IBD susceptibility locus and HNF4-a gene expression is
decreased in IBD patients compared to a healthy control group.
CONCLUSION(S): Taken together, these results highlight the importance of claudin-
7 and its regulator HNF4-a, in IEC differentiation and epithelial barrier function. Fur-
ther investigation of claudin-7 regulation in IEC differentiation under inammatory
conditions will provide important insight into the design of therapeutic agents
that promote epithelial barrier function and ameliorate mucosal inammation.
P-212
YI
A Variant in ATG16L1 Associated with Crohns Disease Reduces Invasion of
Human Cells by Salmonella
Stephen Murphy, Jeannette Messer, David Boone
BACKGROUND: Genome wide association studies (GWAS) have identied a number
of CD-associated polymorphisms in genes that regulate autophagy. Autophagy or
macroautophagy is a fundamental cellular process that coordinates homeostasis
through a variety of mechanisms including derivation of nutrients from endoge-
nous proteins and organelles during times of environmental stress to destruction
of intracellular pathogens. One CD-associated variant is found in ATG16L1, a key
regulator of autophagy involved in membrane architecture remodelling and auto-
phagosome formation. This variant results in a form of ATG16L1 that is defective in
clearing intracellular microbes. However, little is known about the effects of this
variant on bacterial invasion into cells. We therefore investigated the effect of
ATG16L1 mutations on bacterial infection into human cells.
METHODS: Human cells with a deletion of the ATG16L1 gene or cells with the
ATG16L1 CD-associated T300A variant were generated by homologous recombi-
nation in HCT116 cells (IEC). These gene targeted knockout and T300A knockin
cells were exposed to Salmonella enterica serovar typhimurium and assessed for
infection by live cell imaging, ow cytometric high resolution microscopy and an-
tibiotic protection assays. Analyses of alterations of actin nucleation events were
performed by immunoprecipitation and immunoblotting.
RESULTS: Cells lacking ATG16L1 displayed decreased rates of infection compared
to WT IEC. Normal rates of infection were restored by complementation of
ATG16L1 decient cells with ATG16L1, but not by complementation with the
ATG16L1 T300A variant. Similarly, gene-targeted cells with the ATG16L1 T300A
knockin were resistant to infection by Salmonella. Thus, ATG16L1 facilitates Sal-
monella infection of IEC and the CD-associated variant in ATG16L1 protects cells
from Salmonella infection. Actin nucleation events that mediate Salmonella were
altered in cells decient for or expressing the T300A variant of ATG16L1.
CONCLUSION(S): These ndings suggest that the CD-associated variant in
ATG16L1 has a protective, benecial effect against bacterial infection. This effect
was mediated at least in part by distortion of the actin nucleation machinery in
these cells. The high prevalence of the T300A variant in the European population
may reect positive selection for this benecial role against bacterial infection.
P-213
YI
Ischemia/reperfusion-induced Intestinal Injury Is Mediated by Epithelial-Cell
Specific Myd88 Signaling but Independent of Microbial Status
Marcus Muehlbauer, Ernesto Perez-Chanona, Christian Jobin
BACKGROUND: TLR/MyD88 signaling has been shown to mediate protective
effects in models of chemical-induced intestinal injury. However, the cell type
compartment responsible for mediating cytoprotective effects remains to be
dened. Aim: Determine the role of IEC-derived MyD88 signaling in ischemia-
reperfusion (I/R) induced intestinal injury.
METHODS: Epithelial-cell specic MyD88-/- mice (deletion of exon 3) were gener-
ated by intercrossing MyD88f/f with Vil-Cre mice (C57BL6). Successful deletion of
MyD88 (exon 3) in intestinal epithelial cells was conrmed by PCR analysis of iso-
lated RNA. Germ-free(GF), conventionalized(CVN) wild-type(WT), MyD88f/f,
MyD88-/- and MyD88IEC-/- mice (4-8/group) were subjected to ileal ischemia by
obstructing the distal branches of the superior mesenteric artery for 60 minutes
(ischemia) followed by 90 minutes of reperfusion. Sections of the ileum inside
the ischemic region (damage) and outside (healthy) were collected and xed in
10% formalin. Tissue damage was assessed using a histological necrosis scoring
system. Expression of ileal pro-inammatory mediators (Cxcl1, Il1b, Tnf ) was eval-
uated using ABIPrism sequence detection system. Neutrophil inltration was
measured by staining for myeloperoxidase (MPO) using IHC. IgA deposition and
complement activation (staining for C3d) was measured using IHC.
RESULTS: Intestinal RNA showed the expected WT MyD88 product of 405 bp
(MyD88f/f ), whereas a fragment length of 226 bp was found in MyD88IEC-/-
mice. I/R-induced ileal injury was greater in GF mice vs. CVN mice
(660.9vs2.860.8, P < 0.05). This nding suggests that bacteria play a protective
role during I/R-induced injury. To link this effect to host innate signaling, we per-
formed I/R in MyD88 decient mice. No difference in histological damage was
observed between genotypes after 60 min ischemia, but decreased deposition of
IgA and complement activation was observed in MyD88IEC-/- mice compared to
MyD88f/f mice. As a consequence I/R-induced intestinal damage was diminished
in MyD88IEC-/- compared to MyD88f/f control mice after 90 min reperfusion
(4.661.3vs1061.7, P < 0.05). In addition neutrophil inltration per crypt/villus sig-
nicantly decreased in I/R-exposed MyD88IEC-/- mice compared to MyD88f/f con-
trol mice (1.760.3 vs 460.3, P < 0.05). Cxcl1 mRNA accumulation (fold-increase
over healthy WT control) signicantly decreased in I/R-exposed MyD88IEC-/- mice
compared to MyD88f/f control mice (2056130vs13726538, P < 0.05). In contrast
Tnf mRNA expression was signicantly upregulated in I/R-exposed MyD88IEC-/-
mice compared to MyD88f/f control mice (8.3761.9-fold over WT, P < 0.05)
whereas the Il1b mRNA expression remained unchanged.
CONCLUSION(S): Our data suggests that while bacteria protect against I/R-
induced intestinal injury, this effect is independent of IEC-derived MyD88 signal-
ing. In contrast, epithelial-derived MyD88 signaling contributes to enhanced inl-
tration of neutrophils and enhanced deposition and denaturation of IgA leading
to complement activation. The combination of complement activation through
denaturized IgA and increasing numbers of inltrating neutrophils leads to wor-
sening histological damage scores in MyD88f/f mice.
P-214
YI
Crohns-associated T300A Variant in Atg16L1 Regulates Cell Growth and Mito-
chondrial Function in Human Colon Carcinoma Cells
Wesley Grimm, Jeannette Messer, Stephen Murphy, Stephen Archer, Marc Bisson-
nette, David Boone
BACKGROUND: Autophagy is a catabolic process that encapsulates long-lived pro-
teins and organelles for lysosomal digestion and turnover. Lipidation of LC3 is
essential for membrane formation and achieved by a protein complex including
Atg5, Atg12 and Atg16L1. Disease-associated variants in genes that participate in
autophagy have implicated this process in the pathogenesis of inammatory
bowel disease. A Crohns-associated threonine to alanine (T300A) substitution in
Atg16L1 does not affect basal autophagy while it alters handling of intracellular
microbes and increases production of inammatory cytokines. Mice decient in
Atg16L1 are susceptible to colitis and develop a Crohns-like pathology, but the
autophagy-dependent and independent mechanisms underlying these observa-
tions are not known. This study aims to uncover novel cellular and molecular
functions of Atg16L1 T300A relevant to the pathogenesis of Crohns disease.
METHODS: Using homologous gene targeting we generated human colon carci-
noma cell lines decient in Atg16L1 or expressing the T300A variant.
RESULTS: Both of these perturbations in Atg16L1 reduce cell growth by causing
cell cycle arrest suggesting that T300A affects growth-dependent functions of
Atg16L1 beyond LC3 lipidation. Delayed cell growth is associated with a reduced
glycolytic phenotype, which is not due to a defect in uptake of glucose. More-
over, growth changes do not appear to reect a defect in nutrient acquisition as
supplementation with methyl pyruvate or 2-oxoglutarate fail to increase prolifera-
tion rates in cells lacking Atg16L1 or carrying T300A. Mitochondrial membrane
potential and ATP production are not affected in cells decient in Atg16L1 and
elevated in cells expressing T300A. The T300A polymorphism also alters mito-
chondrial morphology and respiration, suggesting that Atg16L1 could play a gen-
eral role in mitochondrial function.
CONCLUSION(S): These studies suggest that the Crohns-associated T300A poly-
morphism in Atg16L1 regulates mitochondrial function and cellular proliferation.
P-215
Epithelial Notch-1 Signaling Associated With a Regulatory T Cell Signature: A
Role for the Epithelial Barrier
Lauren Laitman
1
, Zaruhi Hovhannisyan
1
, Douglas Mathern
1
, David Dunkin
1
, Sara
Farsio
1
, Alina Iuga
2
, Giulia Roda
1
, Stephanie Dahan
1
1
2
Columbia University Medi-
cal Center, New York, NY, USA
BACKGROUND: Gut lympho-epithelial interactions occur in the epithelial layer and
sub-epithelial space. We have recently shown that the presence of LPLs promotes
mucosal barrier function in the RAG1-/- transfer model of colitis putatively due to
the Notch-1 signaling pathway. This nding was corroborated in vitro as epithelial
barrier function correlated with the activation of the Notch-1 signaling pathway
in vitro. Moreover, the Notch-1 signaling pathway is dysregulated in Crohns dis-
ease (CD) epithelia compared to NOR or ulcerative colitis (UC) mucosa. AIM: To
determine whether the Notch pathway is mandatory for barrier function in vivo
and to elucidate its role in the development of colitis.
METHODS: Anesthetized WT mice received intra-rectal injections of complexed
Notch-1 or scrambled siRNA (5 nmol in 20 ll of solution/mouse) prior to and dur-
ing a 3% dextran sulfate sodium (DSS) regimen (administered in the drinking
water). Mice were monitored for weight loss and sacriced at different time-points.
The colonic permeability was assessed by Ussing chamber. Colonic Notch-1, Hes-1,
CDX-2 and Claudin-5 mRNA expression was assessed by Real-Time PCR. Colonic tis-
sues were formalin-xed and parafn-embedded for histology scoring and
immuno-uorescence staining. 16S analysis was performed by Real-Time PCR in co-
lonic and mesenteric lymph node tissues. Lamina propria and mesenteric lymph
node cells were isolated and subjected to FACS analysis for FoxP3 expression.
RESULTS: Notch-1, Hes-1 and CDX-2 mRNA expression was decreased in the
Notch-1 siRNA treated WT mice (P = 0.001, P = 0.03 and P = 0.008). These nd-
ings correlated with a drastic decrease in claudin-5 mRNA expression (P = 0.009)
and crypt staining (P = 0.0003). While no differences in resistance were seen
between the groups, there was a signicant decrease in ux (P = 0.03) and a sig-
nicant increase in 16S mRNA expression (P = 0.01) in mice that received the
Notch-1 siRNA. Mice treated with Notch-1 siRNA in conjunction with DSS treat-
ment lost signicantly more weight than mice treated with scrambled siRNA and
DSS (P = 0.02); they also presented a higher colitis score (P < 0.05) and a notice-
able decrease in CD4CD45FoxP3 cells.
CONCLUSION(S): Local knock down of Notch-1 impaired expression of the genes
related to Notch-1 and to barrier function affecting epithelial integrity. Unbal-
anced tight junction stoichiometry has been proposed to lead to permeability
defect. Such a breach in the epithelium increases the susceptibility to DSS treat-
ment, due to increased bacterial translocation eliciting a decrease in FoxP3
expressing cells. Abnormal intestinal barrier function has been observed in
inammatory bowel disease (IBD) patients and in some of their rst-degree rela-
tives. Genome wide association studies have shown that some barrier integrity
genes could predispose to disease development. Therapeutic restoration of bar-
rier integrity would provide protection and prevent intestinal leakiness.
P-216
Transcriptional Regulation of IL-10 Expression by Peroxisome Proliferator-Acti-
vated Receptor (Pparc) in Human Intestinal Epithelial Cells
Jinhee Hyun, Saravana Kanagavelu, Jose Ruiz, Masayuki Fukata
BACKGROUND: IL-10 is an important immunomodulatory cytokine in the regula-
tion of intestinal inammation in inammatory bowel disease (IBD). PPARc is a
nuclear receptor known to modulate transcriptional activities of many cytokines
and is highly expressed in intestinal epithelial cells (IECs). Human IECs have been
shown to express IL-10, but how its expression is regulated remains obscure
especially in the setting of inammation. We have demonstrated that intestinal
15d-PGJ2 (an endogenous PPARc ligand) is predominantly induced by inltrated
macrophages (Mus) through toll-like receptor 4 (TLR4)-mediated Cox-2 induction
during colitis. In this study, we addressed whether PPARc activation regulates
expression of IL-10 in IECs.
METHODS: Human IEC cell line SW480-APC expressing TLR4 (top) and mouse peri-
toneal Mus (bottom) were co-cultured in transwells. 15d-PGJ2 production and IL-
10 mRNA expression were measured by enzyme linked assay and real-time PCR in
the presence or absence of lipopolysaccharide (LPS). In order to examine whether
the IL-10 promoter has PPARc responsive elements, a 2,000 bp of IL-10 promoter
was cloned from SW480-APC genomic DNA into the luciferase reporter vector.
Expression and activity of PPARc were blocked by siRNA and a specic inhibitor
SR202, respectively. The IL-10 promoter activity was analyzed by luciferase reporter
assay. PPARc activity was conrmed using a reporter vector PPRE X3-TK-luc.
RESULTS: Co-culturing SW480-APC with Mus increased IL-10 expression in IECs
within 24 hours, which was signicantly enhanced by LPS stimulation in later
time point (72 hours). LPS stimulation of SW480-APC resulted in PPARc activation
peaked at 48 hours. During SW480-APC / Mu co-culture, LPS stimulation induced
15d-PGJ2 production, which is abolished when TLR4-decient Mus were used.
Knocking down the expression of PPARc suppressed IL-10 promoter activity and
mRNA expression in SW480-APC in baseline as well as after LPS stimulation.
CONCLUSION(S): These results suggest that PPARc positively regulates IL-10
expression in IECs at the transcriptional level. During inammation, mucosal Mus
induce PPARc ligand (15d-PGJ2) in a TLR4-dependent manner that contributes to
PPARc activation in IECs and thus IL-10 expression. This may be an intrinsic immu-
noregulatory program that is mediated through host-bacterial interactions, which
dampens on-going inammation during intestinal inammation and thus can be
a novel therapeutic target for IBD.
P-217
Enteropathogenic E. coli Induces Intestinal Barrier Dysfunction by Exploiting
Novel N-WASP-Mediated Cytoskeletal Junction Regulatory Activities
John Garber
1
, Emily Mallick
2
, John Leong
3
, Scott Snapper
4
1
Massachusetts General Hospital, Boston, MA, USA,
2
University of Massachusetts
Medical School, Worcester, MA, USA,
3
Tufts University School of Medicine, Boston,
MA, USA,
4
Boston Childrens Hospital and Harvard Medical School, Boston, MA, USA
BACKGROUND: Several IBD-associated polymorphisms have been associated with
genes encoding subunits of the Arp2/3 complex, which promotes the assembly
of actin laments. As the immediate upstream activator of the Arp complex, N-
WASP is poised to integrate multiple cytoskeletal regulatory pathways required
for apical junction complex (AJC) stability and plasticity, and is also the target of
bacterial effector proteins that enable important enteropathogens to disrupt in-
testinal barrier integrity. The EPEC effector protein EspF, which has been shown
to disrupt intestinal barrier, specically activates N-WASP and sorting nexin 9
(SNX9), a protein that directly interacts with N-WASP and is involved in coordinat-
ing endocytosis and endosomal sorting. To investigate the role of N-WASP in
junction regulation and response to pathogens, we generated cell lines depleted
of N-WASP and SNX9, and examined dynamic AJC function and the ability of
EPEC to induce barrier dysfunction.
METHODS: Stable N-WASP (NWKD) and SNX9 knockdown (SNX9 KD) Caco-2 cell
lines were generated using lentiviral constructs expressing shRNA. >90% deple-
tion of N-WASP and SNX9 was conrmed by Western blot. Cells expressing non-
silencing siRNA for N-WASP or SNX9 were used as controls (WT). WT and KD cells
were plated on 0.4 um Transwell lters and cultured over 21 days, with serial
measurements of transepithelial electrical resistance (TER). Assessment of TER
and immunouorescence localization of SNX9 and junction molecules (occludin,
ZO-1, E-cadherin) was performed in conuent Caco-2 monolayers at steady state
and under conditions that induce TJ disassembly (calcium depletion). Fully conu-
ent WT and NWKD cultures were infected with EPEC strain E2348/69, and TER
serially assessed during the 12 hours post-infection.
RESULTS: N-WASP knockdown led to decreased epithelial barrier integrity, reected
by lower maximal TER (14 days after plating: NWKD 153.8 Xcm
2
vs. WT 310.8 Xcm
2
,
P < 0.001). During calcium-switch, NWKD cells exhibited delayed translocation of
occludin at 12 and 20 hours after calcium repletion, and a delay in ZO-1 localization
to the AJC at 12 hours. During AJC disassembly induced by rapid removal of cal-
cium, NWKD monolayers exhibited delayed loss of TER, reecting loss of junction
plasticity. By immunouorescence, we found that SNX9 localized to tight junctions
and co-localized with junction proteins, such as occludin, during AJC disassembly.
Notably, in contrast to N-WASP knockdown, depletion of SNX9 potentiated epithelial
barrier function (7 days after plating: SNX9 KD TER 748 Xcm
2
vs. WT 347.2 Xcm
2
, P
= 0.03). We hypothesized that EspF utilizes N-WASP to disrupt the AJC, and pre-
dicted that wild type EPEC should be attenuated in its ability to induce junction dis-
ruption in NWKD. Compared to WT controls, NWKD Caco-2 cells were resistant to
EPEC-induced barrier dysfunction: four hours after infection, TER in WT cells
decreased by 61.4% vs. 28.8% in NWKD monolayers (P < 0.01 compared to WT).
CONCLUSION(S): N-WASP, the immediate upstream activator of the IBD-associated
Arp2/3 complex, regulates intestinal epithelial barrier function and response to
enteric pathogens. A complex of N-WASP and SNX9 specically regulates the dis-
assembly of intercellular junctions and may represent a future target of strategies
for mitigating intestinal barrier defects central to IBD pathogenesis.
P-218
The Mitochondrial Protein Prohibitin Is Crucial for Maintaining Intestinal Epi-
thelial Cell Homeostasis in Mice
Arwa Kathiria
1
, Mackenzie Butcher
1
, William Neumann
2
, Robert Genta
2
, Rhonda
Souza
2
, Bin He
1
, Bert OMalley
1
, Sylvie Robine
3
, Winston Thompson
4
, Arianne
Theiss
1
1
Baylor University Medical Center, Baylor Research Institute, Dallas, TX, USA,
2
Uni-
versity of Texas Southwestern Medical Center, Dallas, TX, USA,
3
Institut Curie,
Paris, Cedex 05, France,
4
Morehouse School of Medicine, Atlanta, GA, USA
BACKGROUND: Mitochondrial dysfunction is central to many chronic diseases.
Inammatory bowel disease (IBD), proposed to be an energy decient disease of
the intestinal epithelium, is associated with mitochondrial abnormalities of the
epithelium before the onset of inammation. We and others previously demon-
strated that levels of the mitochondrial protein prohibitin (PHB) are decreased in
mucosal biopsies of active and inactive IBD and in experimental models of colitis.
Prohibitin, the major component protein of the inner mitochondrial membrane,
regulates respiratory chain assembly and function. In this study, we sought to
use an intestinal epithelial cell-specic PHB conditional knockout mouse model to
examine the role of prohibitin in maintaining mucosal homeostasis.
METHODS: Transgenic mice bearing a tamoxifen-dependent Cre recombinase
expressed under the control of the villin promoter (vil-CreERT2) and PHB-oxed
(PHB/) mice were crossed to generate a mouse line with inducible intestinal
epithelial cell-specic deletion of the PHB gene (PHBDIEC). 8-week old PHBDIEC
mice were i.p. injected with the estrogen analog tamoxifen for four consecutive
days to activate deletion of PHB from the intestinal epithelium. PHB/ litter-
mates were injected with vehicle. Tamoxifen injections were repeated every 4
weeks. 12 weeks after initial tamoxifen injection mice were sacriced and
assessed for mucosal barrier function, mitochondrial function, and inammation
as measured by TNFa and IL-1b mRNA expression, Cox2 and p65 protein expres-
sion, histology, myeloperoxidase activity, and spleen weight.
RESULTS: PHBDIEC mice gained less weight starting 6 weeks after initial tamoxifen
injection which by 12 weeks was 20% below weight gained by PHB/ litter-
mates. PHBDIEC mice exhibited increased water content of stool, gut permeability
as measured by FITC-dextran translocation, spleen weight, colonic myeloperoxi-
dase activity, colonic TNFa and IL-1b mRNA expression, and Cox2 and p65 protein
expression. Transmission electron microscopy revealed that mitochondria in intes-
tinal epithelial cells of PHBDIEC mice exhibited structural abnormalities including
electron dense spherical inclusion bodies, disorganization and dissolution of cris-
tae, and dilation/swelling. Colonic expression of mitochondrial unfolded-protein
response proteins ClpP, Hsp60 and PKR were increased in PHBDIEC mice. Histo-
logical examination revealed that the epithelium of PHBDIEC mice exhibited areas
of high-grade dysplasia and lymphoid polyps.
CONCLUSION(S): Intestinal epithelial cell-specic PHB deciency causes mitochon-
drial dysfunction and intestinal inammation. PHB is crucial in maintaining normal
mucosal barrier function and epithelial cell homeostasis. Loss of PHB expression
in intestinal inammation may be an early event rather than a consequence of
disease development.
P-219
Regulation of Epithelial Innate Immunity through Hypoxia-mediated
Autophagy
Louise Glover, Brittelle Bowers, Caleb Kelly, Eric Campbell, Douglas Kominsky,
Sean Colgan
BACKGROUND: The gastrointestinal epithelium comprises the primary barrier
between omnipresent luminal antigens and the underlying immune cell reper-
toire, and is subject to profound metabolic uctuations, particularly in inamma-
tory bowel disease (IBD). A role for the hypoxia-inducible transcription factors
(HIFs) in orchestrating transcriptional changes to promote barrier function has
been well dened. Given the importance of HIF signaling to epithelial homeosta-
sis, we hypothesized that HIF-mediated transcriptional changes contribute to epi-
thelial innate immunity. Promoter microarray screens of HIF-enriched genomic
DNA, derived from chromatin immunoprecipitation (ChIP-on-chip), highlighted
autophagy as a novel pathway coordinately regulated by HIF-1. A fundamental
role for autophagy in IBD pathogenesis has recently been elucidated, dened
largely by abrogated bacterial killing (xenophagy). However, little is known about
transcriptional regulation of coordinated autophagy gene responses, and how
these modulate intestinal epithelial cells (IEC) xenophagy.
used. Hypoxia was dened as pO
2
20 torr and pCO
2
35 torr. ChIP-on-chip: ChIP
was performed with a polyclonal HIF-1a antibody using sheared chromatin from
hypoxic Caco-2 cells. ChIP-enriched and input DNA were Cy-labeled and hybri-
dized to a promoter microarray (Switchgear Genomics). The log2 ratio (input-Cy3/
HIF-ChIP-Cy5) was analyzed to identify sequences specic for HIF-1a binding.
ChIP-qPCR: ChIP-qPCR was used to quantify HIF binding to candidate loci using
primer sets anking putative HRE sites. Salmonella Typhimurium Invasion and O2
Consumption: Caco-2 cells were infected with late-log cultures of S. Typhimurium
14028 at an multiplicity of infection (MOI) of 100. The SDR OxoDish system (Pre-
sens) was used to measure the effect of Salmonella invasion on epithelial O
2
con-
sumption in real-time. Gentamicin kill assays: Caco-2 cells were infected with S.
Typhimurium and incubated in antibiotic-free medium for 30 min, followed by
media supplemented with 50 lg/mL gentamicin (Sigma) for 1h. Viable intracellu-
lar bacteria were quantied by colony counts following epithelial lysis in 1% Tri-
ton-X-PBS.
RESULTS: A cohort of promoters for autophagy genes were specically enriched
for HIF binding by ChIP-chip. Transcript levels of candidate genes were induced
by 6hrs under hypoxia or prolyl hydroxylase inhibition in Caco-2 and T84 cells,
corroborating association between HIF binding and gene expression. Hypoxic
Caco-2 cells displayed 3.5-fold higher LC3/p62positive puncta by IF than nor-
moxic cells. By immunoblot analysis, LC3-II and p62 protein levels were increased
and decreased respectively in hypoxic lysates, indicating hypoxia-induced auto-
phagic turnover. Hypoxia stimulation of autophagy increased Salmonella killing,
conrming hypoxic induction of xenophagy. Moreover, invasive Salmonella
induced a time- and MOI-dependent depletion of O
2
with stabilization of HIF pro-
tein. To analyze baseline epithelial autophagy in the absence of HIF signaling in
vivo, we measured IEC levels of LC3 and p62 protein in HIF-1b
-/-
mice. Consistent
with a role for HIF, the ratio of LC3-I to LC3-II and total levels of p62 were
increased in vil-Cre
/HIF-1b
/
mice relative to vil-Cre
-
/HIF-1b
/
controls.
CONCLUSION(S): Modulation of HIF-mediated autophagy by inammatory hypoxia
and/or bacterial pathogens themselves denes a conserved innate response for
host protection, and may represent a novel target for development of therapeutic
strategies to modify epithelial autophagic targeting of bacteria.
P-220
RNA Stability: A Novel Mechanism of Toll-Like Receptor 4 Gene Regulation by
Pregnane X Receptor
Subhajit Mukherejee, Madhukumar Venkatesh, Hao Li, Paromita Mukherjee,
Sridhar Mani
Albert Einstein College of Medicine, Bronx, NY, USA
BACKGROUND: The gut epithelium is the single most important element govern-
ing gut barrier function and innate immunity. Breach in epithelial integrity has
been linked not only to a heightened risk of inammatory bowel disease (IBD),
but also to a broad spectrum of human ailments. At the molecular level, several
defects in predisposing genes (e.g., NOD2/CARD15, TLRs) identied using ge-
nome-wide approaches play a central role in bacterial recognition and signaling
in the gut. Indeed, Toll-like Receptors (TLRs) feature prominently, in that, they rec-
ognize pathogen-associated molecular patterns and are key mediators of innate
immunity. Most molecular models predict the engagement of TLRs by bacteria to
be sufcient to explain the inammatory phenomenon in IBD; hence tight regula-
tion of their expression is extremely important to maintain gut epithelial homeo-
stasis. Since the TLRs, in particular TLR4, are the rst group of molecules that
engage gut luminal microbiota, it is important to understand the current knowl-
edge of its regulation in the gut epithelium. TLR4 is regulated both at the level
of transcription as well as post-transcription. Virtually all the transcription map-
ping has been performed in the macrophage system which suggests that TLR4
promoter contain multiple binding sites for PU.1 and other transcription factors
(e.g., Sp1, AP1). While the transcriptional regulation of TLR4 is most well charac-
terized, post-transcriptional regulation has also emerged to be an important regu-
latory mechanism of TLR4 and other inammatory gene expressions (e.g., TNF-a,
IL-6). Current literature suggests that this second level of regulation of TLR4 is
through modication of mRNA stability.
METHODS: PXR (Pxr
-/-
) and Pxr
-/-
/Tlr4
-/-
double knock-out mice gut permeability
defects were observed by performing transmission electron microscopy and FITC-
dextran assays. Gene expression and signaling was analyzed by qRT-PCR and im-
munoblot of epithelial cells isolated from mouse small gut and human IBD
patient gut tissues. Nuclear run-on, chromatin Immunoprecipitation (ChIP), actino-
mycin D chase and RNA Immunoprecipitation assays were performed in LS174T
and Caco-2 intestinal cell lines to analyze PXR effect on TLR4 expression.
Figure 1.
RESULTS: In our study we have found that Pregnane X Receptor (PXR), an adopted
orphan nuclear receptor, plays an important role in the maintenance of gut epithe-
lial homeostasis. We have shown that Pxr
-/-
mice exhibit a distinctly leaky gut bar-
rier pathology. The barrier defects in Pxr
-/-
mice resulted from an enhanced epithe-
lium-specic Tlr4 gene expression and signaling. These defects were found to be
corrected in Pxr
-/-
/Tlr4
-/-
double knock-out mice. Indeed, the role of PXR in main-
taining gut epithelial barrier was found to be directly related to its ability to inver-
sely regulate TLR4 expression. PXR is known to predominantly function as a classi-
cal ligand-dependent transcription factor. However, nuclear run-on and ChIP
studies have shown that PXR has minimal effects on TLR4 gene transcription. How-
ever, we observed that PXR activation in vitro, decreased TLR4 mRNA stability and
this effect was mediated by PXR binding to the TLR4 mRNA 3
/
untranslated region.
CONCLUSION(S): Overall, our studies implicate epithelial PXR as a central regulator
of TLR4 mediated control of gut immunity. These ndings indicate that novel
immune regulation strategies might involve PXR-RNA binding.
P-221
Creatine Kinase, a Novel HIF-2a Target, Regulates Apical Junction Complex As-
sembly in Intestinal Epithelial Cells
Louise Glover, Brittelle Bowers, Bejan Saeedi, Stefan Ehrentraut, Douglas Komin-
sky, Eric Campbell, Caleb Kelly, Sean Colgan
BACKGROUND: Intestinal epithelial cells (IEC) lining the GI tract exhibit a uniquely
adaptive oxygen prole subject to frequent, prodigious uctuations. Adaptive
responses to hypoxia are orchestrated through coordinated transcriptional
changes driven largely by hypoxia-inducible factor (HIF). Recent studies have
highlighted a protective role for HIF-1 in epithelial barrier function and homeo-
stasis. We therefore sought to dene the relative contribution of HIF-1 and HIF-2
transactivation to epithelial hypoxic responses. A ChIP-on-chip screen highlighted
creatine kinase (CK) isozymes as a novel gene family regulated by HIF-2a. Cyto-
solic CK enzymes temporally regulate cellular ATP regeneration and energy home-
ostasis through the transfer of high-energy phosphate from phosphocreatine
(PCr) to ADP, thus acting as a metabolic sensor specically at subcellular regions
of high and uctuating energy demand.
cultured under normoxic (21% O
2
) or hypoxic conditions (1% O
2
) ChIP-on-chip:
ChIP was performed with a polyclonal HIF-2a antibody. ChIP-enriched and input
DNA were Cy-labeled, hybridized to a promoter microarray, and log2 ratios (input-
Cy3/HIF-ChIP-Cy5) analyzed to identify sequences specic for HIF-2a binding. ChIP-
qPCR was used to quantify HIF-2 occupancy of candidate loci. Transfections and
Promoter-luciferase assay: 1.4kb of 5
/
anking promoter region of human CKM
and CKB were cloned into pGL3 basic backbone, and co-transfected with oxygen-
stable HIF-1a or HIF-2a expression plasmids into Caco-2 using Lipofectamine-LTX.
Luciferase activity was normalized to co-transfected Renilla reporter. Calcium
Switch and TER measurements: T84 plated on transwell inserts were incubated
for 16h in low Ca
2
medium (LCM) or 5 mins in HBSS with 2 mM EDTA before
switching to normal Ca
2
conditions [1.8 mM]. Transepithelial resistance (TER) was
measured over time using a voltameter, and expressed in ohm.cm2. TNBS Colitis
and creatine supplementation: Female C57/BL6 mice were fed 2% Cr-supple-
mented or normal chow for 3 weeks. TNBS was induced by intrarectal administra-
tion of 2.5% TNBS in 40% EtOH; controls received EtOH alone.
RESULTS: Immunolocalization studies indicated that CK enzymes CKM and CKB local-
ize to apical junctions in both model polarized epithelia and in human colonic mu-
cosa, and are transcriptionally induced in hypoxia. Promoter-reporter and ChIP-qPCR
analyses revealed that HIF-2, but not HIF-1, binds and transactivates CKM and CKB
promoters at proximal HRE sites. To investigate whether CK contributes to epithelial
junction regulation, we performed calcium switch on T84 monolayers. Pharmacologi-
cal inhibition of CK with 10uM DNFB signicantly attenuated apical junctional re-as-
sembly, as indicated by TER measurement and analysis of junctional protein localiza-
tion, implicating a prominent role for the Cr-PCr shuttle. Dietary creatine
supplementation in a murine TNBS model of acute colitis ameliorated clinical symp-
toms, including mortality, weight and crypt loss. Quantitative RT-PCR analyses further
revealed reduced expression of CK enzymes in colonic mucosa of IBD patients, sug-
gestive of an impaired CK/PCr energy circuit in chronic intestinal inammation.
CONCLUSION(S): Taken together, these results support a prominent role for HIF-
regulated creatine kinase in apical junction homeostasis, and implicate a compel-
ling link between cellular energy status and junction integrity. Moreover, modula-
tion of mucosal creatine levels through creatine supplementation may represent
a novel therapeutic strategy for IBD.
P-222
TLR4 Signaling Alters Intestinal Epithelial Cell Differentiation and the Stem Cell
Niche
Julie Davies, Rebeca Santaolalla, Maria Abreu
BACKGROUND: In patients with colitis and colitis-associated cancers we have
demonstrated increased expression of TLR4 in intestinal epithelial cells. We have
developed a mouse model with transgenic expression of TLR4 under the control
of the intestinal epithelial cell specic villin promoter (V-TLR4). These mice have
increased inammation and sensitivity to tumor induction. Tumors can be
induced in the V-TLR4 mice by azoxymethane (AOM) alone, which is only poorly
tumorigenic in WT mice.
METHODS: V-TLR4 mice were crossed to Lgr5-EGFP mice wherein cells which
express the stem cell marker Lgr5 also express EGFP. Expression of Lgr5 was
visualized in proximal and distal colon sections by IF. The differentiation of secre-
tory lineage epithelial cells was determined in the terminal ileum by H&E staining
for Paneth cells and Periodic acid Schiff staining for Goblet cells. Gene expression
in normal colonic tissue was compared between the strains by microarray.
RESULTS: Colonic expression of EGFP in the V-TLR4xLgr5-EGFP was increased and
differentially localized compared to control Lgr5-EGFP mice. In V-TLR4xLgr5-EGFP
mice the expression of Lgr5 was found in the crypts similar to controls, but was
also found sporadically throughout the length of the crypt. The number of Lgr5
positive cells in the colon was increased proximally compared to distal expres-
sion. The ileum in V-TLR4 mice had increased numbers of goblet cells by Periodic
acid Schiff staining and immunouorescence (IF) for Muc2. As well, the ileum had
decreased numbers of Paneth cells by H&E staining and decreased numbers of ly-
sozyme positive cells by IF. The gene expression array revealed 223 genes that
were up-regulated in the normal surrounding tissue in V-TLR4 compared to WT,
and 334 genes that were down-regulated (fold differences, P < 0.05 compared to
WT). The gene expression of defensins in the colonic normal tissue was
decreased in the V-TLR4 compared to WT which correlates with the decreased
number of Paneth cells in the ileum and may suggest a reduction in Paneth-like
function in the colon. In addition, expression levels of several inammatory che-
mokines were reduced in the colonic tissue of V-TLR4 mice.
CONCLUSION(S): Over-expression of TLR4 in the epithelium alters the differentiation
of secretory lineage cells and expands the stem cell population. Reduced chemokine
signaling in the V-TLR4 mice may impact the recruitment of immune cell popula-
tions to the colon altering the epithelial microenvironment. These data suggest that
innate immune receptors and bacterial ligands may inuence epithelial cell differen-
tiation and function under homeostatic and inammatory premalignant conditions.
P-223
aPKC, a Kinase Involved in the Pathogenesis of Epithelial Barrier Function, Is
Regulated by PDK1 in Intestinal Epithelia
Flavia Wald
1
, Anastasia Mashukova
2
, Radia Forteza
1
, Pedro Salas
1
1
2
Nova Southeastern University, Ft-Lauderdale-
Davie, FL, USA
BACKGROUND: Atypical protein kinase C (aPKC) is fundamental for polarization in
epithelia and is also a key element of the Par3-Par6-aPKC polarity complex. In epi-
thelial cells, aPKC controls the assembly and localization of tight junctions. Previous
work of our lab showed that proinammatory signaling downregulates aPKC in in-
testinal epithelial cells in vitro and in vivo, mimicking some of the effects of tumor
necrosis factor-stimulation. Furthermore, we found in colonoscopy samples from IBD
patients a signicant negative correlation between the expression of active aPKC
and local inammation, suggesting that aPKC is likely to participate in the pathoge-
nesis of epithelial barrier function in IBD. Therefore, the posttranslational mecha-
nisms that regulate steady-state levels of aPKC were examined. Phosphorylation of
the activation domain of aPKC is vital not only for the activation of newly synthe-
sized molecules, but also for the rephosphorylation of molecules that already phos-
phorylated their targets and became dephosphorylated. This rescue mechanism is
blocked in inammation. Although it is known that phosphoinositide-dependent
protein kinase 1 (PDK1) is the activating kinase for newly synthesized aPKC mole-
cules, the kinase responsible for the rescue of aPKC remains unrevealed.
METHODS: To identify the activating kinase during the rescue mechanism, we
inhibited protein synthesis and analyzed the stability of the remaining aPKC pool.
Also, the direct interaction between PDK1 and aPKC was demonstrated by co-
immunoprecipitation in cells without protein synthesis. The downregulation of
PDK1 by knockdown, inhibitors (BX-912) and a specic pseudosubstrate peptide
destabilized aPKC. Moreover, we showed that after immunodepletion of PDK1,
aPKC rephosphorylation and rescue was achieved by adding recombinant PDK1.
RESULTS: Altogether these results indicate that PDK1 is responsible not only for
the activation of newly synthesized aPKC molecules, but is necessary and suf-
cient to rescue dephosphorylated aPKC.
CONCLUSION(S): The status of PDK1 in mice models of inammation and colono-
scopy samples of IBD patients, is currently being investigated
P-224
Antigen Up-take by Intestinal Epithelial Cells in IBD
Francisco Rausell-Palamos, Lloyd Mayer
Mount Sinai School of Medicine, New York, NY, USA
BACKGROUND: Previous work of our group showed that inammatory bowel dis-
ease (IBD) patients could not be orally tolerized against keyhole limpet hemocya-
nin (KLH) [1]. Our aim is to test in vitro the antigen up-take ability of the same
antigen in isolated IECs from IBD patients and non-inammatory controls. 1.
Kraus TA et al. Failure to induce oral tolerance to a soluble protein in patients
with inammatory bowel disease. Gastroenterology (2004) 126: 1771-1778.
METHODS: Surgical specimens were obtained from intestinal resections per-
formed in Mount Sinai Medical Center. Five ulcerative colitis (with inamed tissue
(UC I) and four out of them also with non-inamed tissue (UC NI)), and ve
Crohns disease (CD) patients and 8 normal mucosal samples (NL) were included.
Briey, the protocol of IECs isolation consisted in intense cleaning of surgical
pieces with PBS; the mucosa was stripped from the submucosa in small pieces
(3-5 mm). The pieces were incubated in DTT (1 mM in RPMI medium) for 15 min
followed by 2 incubations of 30 min each in 25 mL of Dispase II (1.5 mg/mL in
RPMI) at 37

C. After washing and centrifugation, IECs were recovered from the
supernatant and were counted and adjusted to a nal concentration of 106 cells/
mL in RPMI (plus antibiotics and Fungizone). 105 cells/well were plated in 96
wells plates in a total volume of 200 ll/well of RPMI with or without 100 lg of
KLH. At different time points (0.5, 1, 2, 4 and 18 h) IECs were surface stained for
ow cytometry analysis with CD45 (as a marker of leukocytes) and Ep-CAM (as a
marker of IECs) antibodies, xed and permeabilized and intra-cellular stained with
an anti-KLH antibody. In 4 UC inamed, 4 CD and 7 NL samples from same
patients MHCII expression was analyzed by ow cytometry. In other set of experi-
ments, after overnight (ON) incubation with or without KLH, MHCII expression
was analyzed by ow cytometry in Ep-CAM cells from 3 NL and 3 UC inamed
samples. Comparisons between groups were statistically analyzed by Mann-Whit-
ney test for unpaired samples.
RESULTS: As showed in Table 1, the proportion of leukocytes and IECs in mucosa
reected the inammatory state of the tissue with increased proportion of leuko-
cytes and decreased levels of IECs in IBD samples. IECs from UC inamed showed
an increased earlier up-take of KLH compared to CD, however CD IECs had larger
overnight uptake of KLH than UC inamed (Fig. 1). The percentage of IECs that
are MHCII is signicantly higher in inamed UC patients compared to NL,
although KLH incubation does not have any effect on% of IECs expressing
MHCII (Fig. 2).
CONCLUSION(S): The different kinetics of KLH up-take by IECs from CD and UC
patients can affect the way through which KLH can be presented to immune
cells. Although KLH presence does not seem to be important to IECs expression
of MHCII molecules, differences in MHCII expression suggests a difference in the
ability of IECs from both types of IBD to stimulate different immune cells subsets.
P-225
IFN-c-Mediated Induction of an Apical IL-10 Receptor on Polarized Intestinal
Epithelia
Douglas Kominsky, Eric Campbell, Caleb Kelly, Louise Glover, Brittelle Bowers,
Amanda Bayless, Stefan Ehrentraut, Sean Colgan
BACKGROUND: Tissues of the mucosa are lined by an epithelium that provides
barrier and transport functions. It is now appreciated that cytokines secreted at
sites of inammation have important implications in the onset and progression
of chronic inammation. Here we investigated potential anti-inammatory mecha-
nisms of IFN-c in models of IBD both in vitro and in vivo.
METHODS: Guided by initial microarray analysis, we utilized qPCR, western blot,
and confocal microscopy to characterize receptor expression in vitro. We next
examined the functional consequences of receptor expression. Finally, we utilized
endpoints established in the in vitro models to examine receptor expression in a
murine IBD model and in human IBD patient samples.
RESULTS: In vitro studies revealed that IFN-c selectively induced the expression of
IL-10R1 on intestinal epithelia. Further analysis revealed that IL-10R1 was
expressed predominantly on the apical membrane of polarized T84 cells. Recep-
tor activation functionally induced canonical IL-10 target gene expression in epi-
thelia, concomitant with enhanced barrier restitution. Colonic tissue isolated from
murine colitis revealed that levels of IL-10R1 and SOCS3 were increased in the ep-
ithelium and coincided with increased tissue IFN-c and IL-10 cytokines. In parallel,
immunouorescent staining revealed apical expression of the IL-10R in colitic
Figure 1.
Figure 2.
mouse tissue and subsequent studies showed that treatment of mice with rIFN-c
was sufcient to drive expression of IL-10R1 to the apical surface of colonic epi-
thelium. Finally, we examined IL-10R1 in human IBD patient specimens. Diseased
tissue demonstrated increased IL-10R1 transcript with apical epithelial protein
localization.
CONCLUSION(S): Together, these results provide novel insight into an anti-inam-
matory role for IFN-c in intestinal inammation through the induction of a polar-
ized IL-10 receptor complex and suggest that rational IL-10 based therapies
should incorporate tissue polarity.
P-226
YI
MicroRNA-Regulated Pathways in Pediatric IBD
Adam Zahm
1
, Daphne Tsoucas
2
, Robert Baldassano
3
, Joshua Friedman
2
1
Department of Pediatrics, Perelman School of Medicine at the University of
Pennsylvania, Division of Gastroenterology and Nutrition, The Childrens Hospital
of Philadelphia, Philadelphia, PA, USA,
2
Department of Pediatrics, Perelman School
of Medicine at the University of Pennsylvania, Division of Gastroenterology and
Nutrition, The Childrens Hospital of Philadelphia, Philadelphia, PA, USA,
3
The
Childrens Hospital of Philadelphia, Philadelphia, PA, USA
BACKGROUND: The discovery of microRNA (miRNA) has produced a range of
insights in mammalian development and human disease. However, there are few
reports of the molecular function of miRNA in IBD, particularly in children.
METHODS: Large-scale analysis of miRNA expression was performed in rectal tis-
sues obtained from children with Crohn disease (CD), ulcerative colitis (UC), and
normal controls. The Nanostring platform was used to avoid artifacts due to
nucleic acid amplication or afnity hybridization. Bioinformatic tools were used
to identify candidate miRNA:mRNA target relationships, and these were tested by
reporter assays in cultured intestinal epithelial cells.
RESULTS: We have found a unique signature of tissue- and disease-specic miRNA
expression in children with IBD. Based on these results, we have identied several
candidate miRNA:mRNA relationships of potential pathologic signicance, includ-
ing regulation of the CD-associated gene NOD2/CARD15. The results have been
validated by reporter assays in cultured intestinal epithelial cells.
CONCLUSION(S): IBD in children is associated with widespread changes in miRNA
expression. Some of these changes are linked to altered expression of genes of
known signicance in IBD. Because miRNAs are particularly amenable to pharma-
cologic inhibition, these ndings may lead to novel therapeutic strategies in IBD.
P-227
YI
ATG16L1 T300A Dependent Differential Gene Expression Identifies Genes
Required for Anti-Bacterial Autophagy
Jakob Begun
1
, Aylwin Ng
2
, Ramnik Xavier
3
1
Massachusetts General Hospital, Boston, MA, USA,
2
Center for Computational
and Integrative Biology, Boston, MA, USA,
3
Division of Gastroenterology, Massa-
chusetts General Hospital, Boston, MA, USA
BACKGROUND: Crohns disease (CD) is an inammatory process characterized by
an inappropriate immune response to bowel ora in a genetically predisposed
host. The pathogenesis of CD remains poorly understood, but genetic studies
have identied several contributory pathways including autophagy. The process
of autophagy has emerged as a critical cellular function with implications in me-
tabolism, cell signaling, programmed cell death, cancer biology, and immunol-
ogy. Recently autophagy has been recognized as a critical pathway in control-
ling intracellular bacterial replication. The common coding sequence
polymorphism T300A in the ATG16L1 (autophagy-related protein 16-like 1) gene
is associated with an increased risk of CD. The mechanism by which the T300A
polymorphism increases the risk of CD is unclear but studies have implicated
increased production of colitogenic cytokines, impaired Paneth cell function,
and impaired anti-bacterial autophagy. To further elucidate the mechanism by
which the T300A polymorphism may lead to CD we performed perturbational
gene expression proling of peripheral blood mononuclear cells (PBMCs) from
healthy volunteers harboring the T300A polymorphism stimulated with a variety
of immune ligands.
METHODS: RNA from PBMCs from healthy volunteers homozygous for the
ATG16L1 *300A and *300T alleles was harvested at 0, 4 and 24 hrs after exposure
to MDP, Pam
3
Cys, or infection with Borrelia burgdorferi and expression proling
performed using Illumina arrays in duplicate. A differential-of-differential algo-
rithm was applied to identify genes whose differential response is dependent on
the ATG16L1 T300A polymorphism. Selected genes were tested for an effect on
anti-bacterial autophagy by treating HeLa CCL2 cells stably expressing LC3B-GFP
fusion protein with siRNA for 48 hours and then infecting with Salmonella enter-
ica serovar typhimurium. Antibacterial autophagy rates were determined using
epiuorescent microscopy and enumerating the fraction of Salmonella with sig-
nicant LC3-GFP accumulation indicating the presence of an autophagosome.
Knockdown efciency was determined by real time quantitative PCR.
RESULTS: We compared gene expression of PBMCs from healthy volunteers carry-
ing the ancestral *300T and the risk *300A alleles of ATG16L1. Baseline gene
expression was similar between WT and T300A alleles, but diverged upon treat-
ment with three different microbial ligands (the NOD2 agonist MDP, the TLR2
ligand Pam3Cys, and the spirochete Borrelia burgdorferi). Hierarchical clustering
revealed strong induction of immune-related genes by all three stimuli with
some differences. A differential-of-differential approach was used to determine
the subset of genes whose differential expression was dependent on the ATG16L1
polymorphism. A total of 22 genes differential expression is affected by the
T300A polymorphism. Conrmed knockdown of two genes identied through
this strategy, RAB24 and CLEC12A, resulted in decreased antibacterial autophagy.
RAB24, is a GTPase purported to play a role in autophagosome formation and
maturation. CLEC12A is a C-type lectin receptor and belongs to a family of trans-
membrane proteins that recognize pathogen-associated molecular patterns and
engage downstream immune signal transduction pathways. The CLEC12A ligand
is unknown but stimulation leads to enhanced antigen presentation reminiscent
of NOD2 stimulation.
CONCLUSION(S): Differential gene expression in an allele- and ligand-specic man-
ner plus an IBD-related phenotypic assay placed RAB24 and CLEC12A in the
ATG16L1 interaction network, and within the microbe-induced autophagy
pathway.
P-228
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i
t
h
d
r
a
w
n
P-229
COMMD1 is an Immune Regulatory Gene That Plays a Role In IBD Pathogenesis
Haiying Li
1
, Lillienne Chan
1
, Rinse Weersma
2
, Paulina Bartuzzi
2
, Bart van de Sluis
2
,
Shelby Melton
1
, Nathan Gluck
3
, Ezra Burstein
1
1
UT Southwestern Medical Center, Dallas, Texas, USA,
2
University Medical Centre
Groningen, Groningen, The Netherlands,
3
Tel Aviv Sourasky Medical center, Tel
Aviv, Israel
BACKGROUND: The 2p15 locus has been linked to risk for inammatory disorders
such as ankylosing spondylitis, and more recently, Crohns disease. However, the
precise gene in this region that is responsible for these associations remains
uncertain.
METHODS: A metaanalysis of GWAS data as well eQTL analysis was employed to
ascertain potential candidate genes in the 2p15 locus. The biologic relevance of
the presumed associations were then analyzed utilizing conditional gene inactiva-
tion in mice.
RESULTS: We identied a specic single nucleotide polymorphism (SNP) in the
2p15 region that was linked to higher risk for ulcerative colitis. This SNP was
located just 3
/
of the COMMD1 gene and eQTL analysis in 2 different cohorts
indicated that this SNP correlates with differential expression of COMMD1 mRNA
in normal subjects. To further examine the potential role of COMMD1 in IBD
pathogenesis, we employed murine models of conditional gene inactivation. We
show that Commd1 loss in the myeloid lineage, a central arm of the innate
immune system, leads to exaggerated inammatory responses due to decreased
termination of NF-kB initiated gene expression. Moreover, these animals demon-
strate an increased predisposition to colitis in a variety of models, including DSS-
induced colitis and IL-10 deciency. In addition to greater inammation, an
increased progression to dysplasia and frank neoplasia was also evident. Finally,
we nd that mucosal inammation in IBD patients leads to decreased COMMD1
expression. This suppression of COMMD1, which is pro-inammatory, is mediated
by IFN-gamma dependent signal transduction pathways that affect COMMD1
mRNA stability.
CONCLUSION(S): Altogether, our studies demonstrate that the COMMD1 gene
plays an anti-inammatory role and that decreased expression plays a role in the
pathogenesis of IBD.
P-230
YI
TAMing Colitis and Colitis-Associated Colon Cancer
Lidia Bosurgi
1
, Diana Uribe
2
, Jochem Bernink
1
, Victor Delgado Cuevas
1
, Eugenio
Antonio Carrera Silva
1
, Nicola Gagliani
1
, Jonathan Leighton
3
, Sourav Ghosh
2
, Carla
Rothlin
1
1
Yale University, New Haven, CT, USA,
2
University of Arizona, Tucson, AZ, USA,
3
Mayo Clinic, Scottsdale, AZ, USA
BACKGROUND: Inammatory Bowel Diseases (IBD) are chronic, relapsing, inam-
matory disorders characterized by a robust cytokine-driven inammation of the
gut. This chronic inammation leads to signicant morbidity and mortality,
including an increased risk for colorectal cancer.
METHODS: Using a combination of mouse models and analyses of human sam-
ples, we show that the receptor tyrosine kinases (RTK) Axl and Mer, members of
the TAM subfamily, and their ligand Protein S (Pros1) mediate an anti-inamma-
tory response that is fundamental for preventing colitis. Furthermore, in marked
contrast to the reported oncogenic function of Axl and Mer in tumors, genetic
ablation of Axl and Mer in mouse models promotes colitis-associated colon
cancer.
RESULTS: Axl
-/-
Mer
-/-
mice develop an exacerbated inammatory response to Dex-
tran Sulfate Sodium (DSS)-induced colitis, as determined by colonoscopy score,
histopathological analysis and inammatory prole of lamina propria leukocytes.
Axl
-/-
Mer
-/-
mice develop an increase number and larger polyps than wild type
(WT) mice upon azoxymethane (AOM)-DSS treatment. Axl and Mer are expressed
in intestinal macrophages upon inammation and Axl
-/-
Mer
-/-
macrophages pro-
duce higher levels of pro-inammatory cytokines in response to intestinal injury
than WT controls. Furthermore, the TAM agonist Pros1 is essential for limiting the
pathological activation of macrophages and induced colitis. Pros1 is expressed in
activated T cells and functions to dampen the inammatory response in macro-
phages through Axl and Mer. Transfer of Pros1
-/-
na ve T cells into Rag1
-/-
mice
leads to acceleration of colitis in comparison to WT na ve T cells. Remarkably, IBD
also shows a signicant association with PROS1 deciency. Patients with active
IBD more frequently showed lower levels of plasma PROS1 in comparison to
healthy controls.
CONCLUSION(S): Therefore, our results identify the TAM RTKs and their ligand
Pros1 as a hitherto unknown mechanism for the prevention of pathological
inammation in the intestine. While TAM inhibitors have been identied as pro-
spective candidates for molecular anti-cancer therapeutics, the benecial anti-
inammatory effects of the TAM pathway present a paradox at least in the con-
text of colitis-associated colon cancer. Future efforts in TAM-based therapeutics
would benet from comprehensive understanding of TAM function both in can-
cer cells and in the tumor microenvironment.
P-231
YI
Investigating the Role of CYLD in Intestinal Homeostasis and IBD
Diana Legarda, Adrian Ting
Mount Sinai School of Medicine, NY, NY, USA
BACKGROUND: Cylindromatosis, or CYLD, was originally identied as a deubi-
quitinating enzyme in that it removes K63-linked polyubiquitin chains as a
means of negatively regulating signal transduction events, such as the NF-kap-
paB signaling pathway. More recently, CYLD was identied as being required
for necrotic cell death. Necrosis is characterized by disruption of the cell mem-
brane, release of cellular contents, and subsequent inammation. The molecu-
lar mechanisms underlying necrosis and ensuing inammation involve the pro-
necrotic molecules RIP1 and RIP3, and attenuation of this form of cell death is
mediated by the cleavage of these molecules by the pro-survival molecule
Caspase-8. Studies performed in our lab have demonstrated that downstream
of TNFR signaling, Caspase-8 can cleave CYLD, generating a survival signal.
Loss of Caspase-8 prevented CYLD cleavage and degradation, resulting in ne-
crosis. Therefore, both a loss of function in CYLD, through enhanced NF-kap-
paB signaling, and a gain of function, through necrosis, could result in
inammation.
METHODS: These studies were performed in the context of both intestinal epithe-
lial cells and macrophages, as both cell types have been implicated in the pro-
gression of inammation associated with CD.
RESULTS: Given this, we are examining the potential role for CYLD in the mainte-
nance of intestinal homeostasis and in the pathogenesis of Crohns disease (CD),
keeping both its deubiquitinating and pro-necrotic functions in mind. Our prelim-
inary results suggest that CYLD can regulate components of the NOD2 signaling
pathway via its deubiquitinating function. Mutations in NOD2, an intracellular
PRR, have been associated with an increased risk for CD. Deregulation of this
pathway could result in the inammation observed during CD. Studies have also
revealed that necrotic cell death contributes to the intestinal inammation
observed during IBD. Our results demonstrate Caspase-8-dependent cleavage of
CYLD after TNF, LPS, and poly(I:C) stimulation. Blocking Caspase-8 activity pre-
vents cleavage of CYLD, resulting necrosis.
CONCLUSION(S): Collectively, these studies contribute to a growing body of work
delineating the role of CYLD in inammatory diseases such as CD.
P-232
YI
Transmigrating Neutrophils Shape The Mucosal Microenvironment During
Colitis
Eric Campbell
1
, Walter Bruyninckx
2
, Louise Glover
1
, Caleb Kelly
1
, Douglas Komin-
sky
1
, Brittelle Bowers
1
, Amanda Bayless
1
, Eoin McNamee
1
, Paul Jedlicka
1
, Cormac
Taylor
3
, Sean Colgan
1
1
University of Colorado, Aurora, CO, USA,
2
Hanover College, Hanover, IN, USA,
3
University College Dublin, Dublin, Ireland
BACKGROUND: Neutrophil (PMN) accumulation in crypt abscesses is a pathologi-
cal hallmark of ulcerative colitis. PMN transepithelial migration is orchestrated
through a complex series of cell-cell interactions involving bi-directional signaling
molecules. Thus we hypothesized that migrating PMN inuence the transcrip-
tional prole of epithelia as they transmigrate, priming them for either resolution
or chronic inammation a concept we term transcriptional imprinting . Employ-
ing a novel approach to a PMN-transepithelial migration model, we attempted to
ascertain the inuence of transmigration on epithelial gene expression by micro-
array analysis.
METHODS: DNA Microarray was used to identify transcriptional changes in intesti-
nal epithelial cells post-PMN transmigration. Real-time oxygen sensing was per-
formed with an SDR-OxoDish (PreSens). Wild-type C57/B6 mice, ODD-Luciferase
(HIF reporter) mice and gp
91phox
-null (NADPH oxidase decient) mice were sub-
jected to chemically-induced colitis (TNBS).
RESULTS: Microarray studies revealed a cohort of hypoxia-responsive genes regu-
lated by PMN-epithelial crosstalk. Real-time oxygen measurements effectively
demonstrated that activated PMN rapidly depleted microenvironmental oxygen.
Subsequent studies indicated that activated PMNs are sufcient to induce hy-
poxia-inducible factor (HIF) stabilization and activity in epithelial cells. Intestinal
epithelial hypoxia induced by activated PMNs during transmigration was found to
be dependent on the PMN respiratory burst. HIF is known to inuence the
expression of barrier-protective genes in the epithelium, initiate glycolytic metab-
olism and attenuates the clinical course/disease parameters in murine colitis. To
ascertain the clinical relevance of transmigrating PMN and the induction of epi-
thelial hypoxia, we stained biopsies from UC patients for evidence of Glut1
expression. PMN transmigration increased crypt epithelial Glut1 expression (see
Figure). We investigated the relative contribution of PMN to inammatory hy-
poxia in vivo, utilizing a colitis model. Antibody-mediated depletion of PMNs
worsened the course of colitis, exhibited reduced tissue hypoxia visualized with
Hypoxyprobe-1 staining and attenuated the induction of hypoxia-dependent
genes. Patients with chronic granulomatous disease (CGD) lack functional NADPH
oxidase and develop IBD-like symptoms. We demonstrated that murine
gp91
phox-/-
mice mirror human CGD, develop a severe colitis, with exaggerated
PMN inltration. However, these inltrating PMN are incapable of inducing a
hypoxic microenvironment. Finally, pharmacological intervention with a HIF-stabi-
lizing compound (PHD inhibitor), resulted in recapitulation of mucosal HIF-signal-
ing concomitant with abrogation of colitis-severity in the gp91
phox-/-
mice.
CONCLUSION(S): In conclusion, transcriptional imprinting of host tissue by inl-
trating neutrophils signicantly modulates the host response to inammation.
Moreover, the respiratory burst contributes fundamentally to localized oxygen
depletion and resultant microenvironmental hypoxia. We propose that this micro-
environment established by inltrating PMN is protective during colitis.
P-233
YI
Anti-fibrogenic Roles of Cathelicidin in Chronic Colitis Associated Colonic
Fibrosis
Hon Wai Koon
1
, Junhwan Yoo
1
, Tressia Hing
1
, David Shih
2
, Charalabos
Pothoulakis
1
1
UCLA, Los Angeles, CA, USA,
2
BACKGROUND: Cathelicidin (LL-37 in human and mCRAMP in mice) is a family of
endogenous anti-microbial peptides that protect the host from infection as part
of the innate immune response. Recent evidences suggest that cathelicidins may
modulate inammation. Here we determine whether cathelicidin can modulate
colonic brosis in animal model of colitis as well as human colonic broblasts.
METHODS: Wild-type and mCRAMP decient mice were administered with trini-
trobenzene sulphonic acid (TNBS) to induce chronic (7 weeks) colitis. Some mice
were treated intracolonically with cathelicidin and colonic histological changes
and brogenic mediator levels during colonic inammation were evaluated.
RESULTS: TNBS induced chronic colitis associated colonic brosis in mice that was
reduced by exogenous intracolonic cathelicidin (mCRAMP) administration (5 mg/
kg every 3 days). This inhibitory mCRAMP effect was associated with lower colo-
nic histological damage and reduced levels of the brotic mediator collagen
1alpha2, broblast inltration and proinammatory cytokine TNFalpha levels in
colon compared to controls. Exogenous mCRAMP treatment also prevented body
weight loss due to chronic colitis. However, endogenous cathelicidin expression
was not altered in the colons of TNBS exposed mice. There were no signicant
difference of TNBS-induced colonic brosis between wild-type mice and mCRAMP
decient mice, suggesting that endogenous cathelicidin does not play a role in
the development of colitis associated brosis. Exposure of human colonic CCD-
18Co broblasts to LL-37 (10 microM) signicantly reduced transforming growth
factor-beta1 (50 ng/mL) and insulin-like growth factor 1 (10ng/mL) induced colla-
gen COL1A2 protein and mRNA expression. LL-37 treatment did not change basal
TGF-beta1 and insulin like growth factor-1 expression in colonic CCD-18Co bro-
blasts. LL-37 (10 microM) stimulated collagenase MMP1 mRNA expression in CCD-
18Co which is capable for degrading extracellular matrix including collagen.
CONCLUSION(S): Cathelicidins modulates chronic colitis associated colonic brosis
by mechanisms involving inhibition of collagen expression and activation of colla-
genase expression in colonic broblasts. Our results also indicate that exogenous
cathelicidin administration may represent a novel approach for treatment of colo-
nic brosis in Crohns disease.
P-234
YI
High Intestinal Cathelicidin Level Predicts Good Prognosis of Ulcerative Colitis
Patients
Hon Wai Koon
1
, David Shih
2
, Charalabos Pothoulakis
1
1
UCLA, Los Angeles, CA, USA,
2
BACKGROUND: Cathelicidins (LL-37 in human and mCRAMP in mice) represent a fam-
ily of endogenous peptides with well-established anti-microbial activity. We previ-
ously reported an anti-inammatory role for endogenous cathelicidin in the dextran
sulfate (DSS) mouse model, resembling ulcerative colitis (UC) (Gastroenterology 2011
141:1852-63). Here we examined the role of endogenous and exogenous cathelicidin
in the trinitrobenzene sulphonic acid (TNBS) mouse model, resembling Crohns dis-
ease (CD), and determined the anti-inammatory mechanism of this response.
METHODS: Wild-type (WT) and mCRAMP decient (Camp-/-) mice were injected
with TNBS intracolonically (100 mg/kg, 5 mice/group). Some mice were treated
intracolonically with mCRAMP (5 mg/kg). After 7 days mouse colons were col-
lected for analysis.
RESULTS: In colonic biopsies from UC and CD patients (n = 10-13/group), high in-
testinal cathelicidin LL-37 protein level was statistically associated with good
prognosis of UC patients in term of less hospitalization, less IBD related surgery,
less abnormal white blood cell counts and less anemia (P = 0.02), suggesting
anti-inammatory effects of cathelicidin in UC. There is no correlation between
cathelicidin and prognosis status among CD patients. In mouse model of colitis,
colonic mCRAMP mRNA levels in WT mice were signicantly increased (-15 fold,
P = 0.0001) following TNBS administration, compared to ethanol-treated groups.
TNBS exposed Camp-/- mice had signicantly higher colitis histology score (by
35%, P = 0.04) and TNFalpha levels (by -25%, P = 0.03) compared to WT mice.
On the other hand, intracolonic mCRAMP ameliorated acute colitis evidenced by
signicantly reduced colonic histology score (-40%, P = 0.0006) and tissue TNFal-
pha protein level (-40%, P = 0.03). Exposure of mouse macrophages to a patho-
genic molecule lipopolysaccharide (LPS) and agellin increased TNFalpha protein
expression (by -3 fold, P = 0.0001) which was signicantly reduced in the pres-
ence of mouse cathelicidin mCRAMP (1-10 microM). Such inhibition was not
affected by pretreatment of FPRL1 and P2X7 receptor antagonist WRW4 and
KN62 (5 microM) respectively, suggesting that the anti-inammatory effects of
cathelicidin is receptor independent. Microora load of guts in wild-type and
mCRAMP decient mice were not different during TNBS colitis, suggesting that
only the anti-inammatory effects of endogenous cathelicidin modulate colitis.
However, exogenous cathelicidin signicant reduced microora load of the guts.
Therefore, exogenous cathelicidin may modulate colitis via both antibacterial
effects and anti-inammatory effects. Induction of endogenous cathelicidin by so-
dium butyrate partially ameliorated DSS colitis in mice.
CONCLUSION(S): Endogenous cathelicidin level may be useful UC diagnostic
marker as it predicts prognosis of UC patients. Cathelicidin administration amelio-
rate intestinal inammation by modulating responses to pathogenic molecules,
suggesting a novel therapy for colitis.
P-235
YI
MicroRNA-132 Modulates Cholinergic Signaling and Inflammation in Human
Nitsan Maharshak
1
, Shani Shenhar-Tsarfaty
2
, Nimrod Aroyo
3
, Naama Orpaz
3
,
Irene Guberman
2
, Jonathan Canaani
2
, Zamir Halpern
3
, Iris Dotan
3
, Shlomo Ber-
liner
3
, Hermona Soreq
2
1
University of North Carolina School of Medicine, Chapel Hill, NC, USA,
2
The He-
brew University of Jerusalem, Jerusalem, Israel,
3
Tel Aviv Sourasky Medical Center,
Tel Aviv, Israel
Figure 1.
BACKGROUND: A feedback loop, termed the anti-inammatory reex, exists
between the immune system and the nervous system. Inammation triggers an
afferent vagal response that is transmitted to the hypothalamus, where it stimu-
lates the efferent vagal nerve to release the neurotransmitter acetylcholine. Ace-
tylcholine activates its nicotinic receptor on macrophages through which it inhib-
its production of pro-inammatory cytokines. Multi-leveled evidence suggests a
role for the anti-inammatory reex in the pathogenesis of inammatory bowel
disease (IBD). Electrical stimulation of the vagus nerve attenuated DSS-induced
colitis in rats. Similarly, in vagotomized mice, DSS-induced colitis was more severe
compared to control mice and sympathectomy improved experimental colitis.
Although, the anti-inammatory reex has not been studied in human IBD, en-
teric nervous system abnormalities in IBD patients, may support its potential role
in the pathogenesis of this disease. MicroRNA-132 (miR-132) targets acetylcholin-
esterase (AChE) and potentiates the cholinergic blockade of inammatory reac-
tions in cultured cells and experimental mice, but the implications of this interac-
tion to human inammatory disease remained unexplored. This study aimed to
test whether vagal tone (assessed through AChE activity) correlates with inam-
mation and whether miR-132 is causally involved in anti-inammatory reactions
of patients with IBD and modulates vagal tone and consequently inammation in
IBD patients compared to healthy controls (HC).
METHODS: We prospectively collected clinical data and measured inammation
readouts and the cholinergic status (total capacity for hydrolyzing acetylcholine
in ones circulation), as well as AChE activity in two independent cohorts of IBD
patients and HC (Cohort 1: n = 77 IBD, n = 74 HC and cohort 2: n = 33 IBD, n =
16 HC participants). We quantied miR-132 levels systemically in peripheral blood
and locally in intestinal tissue biopsies removed at colonoscopy from inamed
and apparently quiescent tissues of tested volunteers.
RESULTS: MiR-132 levels are higher in inamed compared to apparently quiescent
intestinal biopsies from IBD patients, while systemic levels were unchanged
among groups. Correspondingly, the cholinergic status as well as AChE activity
was signicantly lower in IBD patients suffering from moderate-severe disease as
compared to HC or IBD patients presenting low disease severity. IBD patients (n
= 33) presented lower AChE activity compared to HC (n = 16) (2896 128 AU vs
3916 102AU, P = 0.001), and a negative correlation between AChE activity and
C-reactive protein (CRP) levels (r = -0.47, P = 0.01). Corroborating these observa-
tions in an additional cohort of participants, CRP and AChE activity were nega-
tively correlated in patients with moderate-severe disease (n = 16; r = -0.6, P =
0.04) and positively correlated in HC (n = 74, r = 0.24, P = 0.046).
CONCLUSION(S): We demonstrated a strong negative correlation between AChE ac-
tivity and hs-CRP that is disease severity dependent in IBD patients and maybe
locally regulated by colonic miR-132, suggesting a new insight to inammation
regulation in IBD. This may signify dual protective role for cholinergic status on
inammation where in acute inammation cholinergic status enhances the inam-
matory process to overcome triggering events such as infections, but in chronic
inammatory states the cholinergic status promotes amelioration of the inamma-
tory process to restore homeostasis. This may implicate a novel homeostatic mech-
anism involving a miR-132-mediated change of the cholinergic status in IBD.
P-236
YI
Adenosine Generation and Signaling Through the ENT2 Equilibrative Nucleo-
side Transporter Protects During Acute Colitis
Carol Aherne, Paul Jedlicka, Holger Eltzschig
University of Colorado Denver, Aurora, CO, USA
BACKGROUND: Increasing evidence supports the notion that inammatory bowel
disease (IBD), including ulcerative colitis and Crohns disease occurs in a geneti-
cally susceptible host with an inappropriate immune response promoting a path-
ogenic inammation in the intestinal mucosa characterized by epithelial barrier
dysfunction and aberrant leukocyte recruitment. Recent ndings support a role
for both a barrier protective and anti-inammatory approach as successful thera-
peutic strategies in IBD. Adenosine is an endogenous molecule that is dramati-
cally increased during inammation. Adenosine signaling through its receptors
(A2A and A2B) has been implicated as an anti-inammatory and barrier protec-
tive pathway in models of mucosal inammation, including IBD. Equilibrative
nucleoside transporters (ENT1 and ENT2) expressed on mucosal surfaces rapidly
clear adenosine from the extracellular space thereby limiting the potentially pro-
tective signaling of adenosine through its receptors. We hypothesize that increas-
ing extracellular adenosine through blockade of adenosine transporters (ENT1 or
ENT2) will enhance protective adenosine signaling pathways to attenuate muco-
sal inammation during acute colitis.
METHODS: ENT1 and 2 expression was studied in human IBD samples and during
DSS colitis. The effect of genetic deciency of ENT1 and ENT2 on acute colitis
was studied using the DSS model. Pharmacologic blockade of the ENT channels
and adenosine receptors was examined during DSS.
RESULTS: Both ENT1 and 2 are expressed in the human intestine during IBD.
ENT2 exhibits a more robust expression at the level of the epithelium in the mu-
rine intestine and can be altered during inammation. Genetic deciency of ENT1
does not affect the outcome of DSS colitis. Interestingly, loss of ENT2 expression
dramatically attenuates DSS-colitis as measured by disease activity parameters
(weight loss, colon length and histology) and cytokine expression compared to
wildtype controls. Pharmacologic blockade of ENT2 mimics the genetic deletion
of ENT2. Finally, inhibition of A2B adenosine receptor signaling reverses the pro-
tection observed in ENT2 decient mice during DSS.
CONCLUSION(S): Initial ndings indicate that blockade of the ENT2 equilibrative
nucleoside transporter protects the intestinal mucosa during acute colitis through
enhanced signaling of the A2B adenosine receptor.
P-237
YI
IL-10 Receptor Signaling in Intestinal Innate Immune Cells is Critical for Main-
taining Mucosal Homeostasis
Dror Shouval
1
, Jeremy Goettel
2
, Marc-Andre Wurbel
1
, Bruce Horwitz
3
, Scott
Snapper
2
1
Boston Childrens Hospital, Boston, MA, USA,
2
Boston Childrens Hospital and
Harvard Medical School, Boston, MA, USA,
3
Pathology Department, Brigham and
Womens Hospital, Boston, MA, USA
BACKGROUND: IL-10 receptor (IL-10R) mutations have been shown to cause
severe very early onset IBD in humans, and similarly, IL-10Rb KO mice develop
spontaneous intestinal inammation. While recent data show that IL-10R signal-
ing is important on different T cell populations to prevent IBD, there is no data
on the role of IL-10R signaling on innate immune cells in maintaining mucosal
homeostasis. We hypothesized that innate IL-10R signaling is a key regulator in
the intestine of immune responses and prevention of colitis.
METHODS: IL-10Rb KO and RAG KO mice (both on the 129/SvEv background)
were crossed to generate double KO mice (DKO), which lack an adaptive immune
response and possess an innate immune system that is IL-10R decient. For
adoptive transfer experiments, DKO and RAG KO mice were injected with 1-
2x10
6
wild-type (WT) sorted CD4
T cells. Colitis was assessed based on clinical,

endoscopic and histological scores. FACS analysis for different innate and T cell
populations was performed, as well as RT-PCR for various transcripts. In some
experiments mice were treated twice weekly with IL-10Ig, a fusion protein of IL-
10 and IgG2A. To assess whether IL-10R signaling in dendritic cells (DCs) affects T
cells proliferation and suppression in-vitro, WT CD4
CD25
-
sorted CFSE-labeled T
na ve cells were cultured with WT or IL-10Rb KO sorted CD11c
DCs, aCD3 and

different concentrations of WT Tregs, for 3-4 days. Proliferation was determined
by dilution of CFSE labeling. In-vitro Treg generation was assessed by dening
the frequency of CD4
CD25
FoxP3
T cells, following 5 days of culture of WT

CD4
CD25
-
T na ve cells with aCD3, TGF-b and IL-2, and either WT or IL-10Rb KO
DCs.
RESULTS: DKO mice were viable, occasionally developed abscesses, but impor-
tantly, did not develop spontaneous colitis. However, following adoptive transfer
of total WT CD4
T cells they developed severe intestinal inammation after 4-5

weeks, associated with Th
1
-Th
17
immune responses. IL-10Ig treatment did not
ameliorate disease, implicating that IL-10R signaling in innate immune cells is im-
portant in driving the inammation. WT CD4
CD25
-
T na ve transfer to DKO also
led to development of colitis, although to a lesser extent, but resulted in
decreased Treg generation, compared to WT T na ve transfer to RAG KO mice.
Decreased Treg generation was also documented in-vitro when WT T na ve cells
were cultured with IL-10Rb KO DCs. Moreover, IL-10Rb KO DCs increased the pro-
liferative function of WT T effector cells, and decreased the suppressive function
of WT Tregs.
CONCLUSION(S): Innate IL-10R signaling is critical for maintaining intestinal muco-
sal homeostasis and prevention of IBD. Aberrant signaling in innate immune cells
enables WT CD4
T cells to become colitogenic. Further work is needed to clarify

the mechanism of how innate IL-10R signaling modulates the crosstalk with T
cells, and whether it inuences microbial composition of the intestine.
P-238
YI
Intestinal Epithelial-Cell (IEC) Control of Intestinal Inflammation: Essential Role
of Tumor Necrosis Factor Alpha-induced Protein 3 (TNFAIP3)
Stephen Murphy, Lesley Rhee, Thomas Nero, David Boone
BACKGROUND: Intestinal epithelial cells (IEC) contribute to intestinal immune ho-
meostasis by providing a dynamically permeable barrier, generating anti-microbial
peptides (AMPs) and producing immuno-modulatory cytokines. IECspecic dis-
ruption of the activity of transcription factor nuclear factor kappaB (NF-kB) leads
to a loss of intestinal immune homeostasis and susceptibility to inammatory
bowel disease (IBD). This is due to both the induction of immuno-modulatory
cytokines and production of anti-apoptotic factors by NF-kB in IEC. TNFAIP3
blocks NFkB activation and inhibits apoptosis and we have previously shown that
IEC-specic expression of TNFAIP3 protects against chemically induced colitis,
through modulation pro-inammatory signals and maintenance of the epithelial
cell barrier. Here we present novel ndings of the role of TNFAIP3 in exacerbating
colitis in the IL10-decient (IL-10KO) model of IBD. These ndings highlight, not
only the specic function of TNFAIP3 in IBD, but also the role of the epithelium
in restraining onset of colitis in a genetically susceptible host.
METHODS: Villin-TNFAIP3 transgenic mice were bred to IL-10KO mice and the sus-
ceptibility and severity of colitis assessed. Analysis of the extent of inammation
in these mice was performed by ELISA, ow cytometry and immunoblotting. To
further delineate pathological mechanism we performed, IF-IHC for the mucus
layers of affected mice, FISH, bacterial staining and TFRLP analyses to characterize
the microbiotic dysbiosis associated with this model of IBD.
RESULTS: Villin-TNFAIP3 transgenic x IL-10KO mice exhibited a more severe colitis
than IL-10KO mice. By ages 3-4 weeks, the villin-TNFAIP3 transgenic x IL-10KO
mice were signicantly runted, smaller by weight, and showed evidence of accel-
erated colitis with rectal prolapse, rectal bleeding and diarrhea compared to lit-
termate IL-10KO mice. Gross analysis of organs demonstrated severely thickened
colons and histology revealed severe inammation at a younger age compared
to IL-10KO mice. Analysis of peripheral and mesenteric lymphocytes showed an
increase in activated CD4 cells that are likely involved in the process of acceler-
ated inammation in the colon. ELISA for a variety of cytokines revealed a Th1-
type inammation with no evidence of altered Th2 or Th17 responses. Disease in
these mice was revealed to be a result, at least in part, of alteration in the quality
of the inner sterile mucus layer and AMPs associated with this. FISH staining
revealed an increase in bacterial: epithelial cell interaction upon constitutive
expression of TNFAIP3 in IEC driven by decreases in specic AMPs.
CONCLUSION(S): These ndings demonstrate that signaling events within IEC that
are controlled by TNFAIP3 are critical in regulating intestinal homeostasis. In the
chemically induced injury model of DSS, TNFAIP3 protects against IBD by pre-
venting IEC apoptosis. However, in the IL-10KO model, TNFAIP3 expression in IEC
distorts the cell signals that usually prevent the onset and severity of IBD. More
signicantly, we highlight a fundamental role for IEC in both mediating develop-
ment of adaptive immunity and controlling the extent of innate responses to res-
ident intestinal microbes and how these contribute to IBD development.
P-239
YI
Decreased Expression of Tissue Non-Specific Alkaline Phosphatase in Pediatric
Diana Lerner
1
, Nita Salzman
1
, Vincent Biank
2
, Katherine Fredrich
1
, Michael Hay-
ward
1
, Kimberly Greguska
1
, Nicholas Peterson
1
, Michael Stephens
1
, David
Gourlay
3
1
Medical College of Wisconsin, Milwaukee, WI, USA,
2
NorthShore Medical Group,
Evanston, IL, USA,
3
Department of Surgery, Childrens Research Institute, Milwau-
kee, WI, USA
BACKGROUND: Inammatory bowel disease (IBD) is a chronic, inammatory con-
dition of the gastrointestinal tract with the highest incidence in early adolescence
and young adulthood. Abnormal activation of the innate immune system in
response to bacterial antigens is thought to be involved in the pathophysiology
of the disease. We have previously shown that children with IBD have decreased
expression of Intestinal Alkaline Phosphatase (IAP). IAP dephosphorylates Lipo-
polysaccharide (LPS) and decreases bacterial lipopolysaccharide (LPS) mediated
TLR4 activation. IAP has also been implicated in the preservation of normal gut
homeostasis and is currently under investigation for treatment of steroid-resistant
UC. TNAP is another form of Alkaline Phosphatases that is predominantly found
in liver, bone and kidney tissues. TNAP expression has been shown to increase in
animal models of colitis but has not been investigated in IBD. Hypothesis: TNAP
expression in terminal ileum (TI) samples of pediatric IBD patients will be
increased compared to controls.
METHODS: TNAP gene expression was measured by RT-PCR on ileal tissue against
a plasmid standard curve using GAPDH as an internal control. Patients were con-
sidered controls if they were diagnosed with polyps or constipation and hemato-
chezia and were otherwise healthy. Disease severity was assessed using physician
global assessment. Statistical analysis was performed using Kruskal-Wallis test.
RESULTS: Data from 62 pediatric patients were analyzed, 22 controls, 31 with CD
and 9 with UC. Among the CD patients, 2 had severe disease, 13 moderate, 13
mild, and 3 were in remission and 7 out of 31 were newly diagnosed and
untreated. Among the UC patients, 1 had severe disease, 5 moderate, 2 mild and
1 was in remission and 4 out of 9 were newly diagnosed. The Controls had a
higher median of TNAP expression, 9689 units with a range of (3924-49356) com-
pared to the Crohns group, 1848 units (136 11533) and UC group, 1061 units
(147-16818) P < 0.0001.
CONCLUSION(S): TNAP mRNA expression in the TI of pediatric patients with IBD is
signicantly decreased compared to controls. Increased immunogenicity of bacte-
rial antigens due to loss of dephosphorylating activity of both IAP and TNAP in
the intestine may contribute to the persistence of the inammatory response. A
larger sample size will allow us to investigate differences in TNAP expression in
relation to disease severity, treatment responsiveness, and symptom prole.
P-240
YI
Functional Response of Human Intestinal Macrophages to TLR Ligands in
Patients With IBD
Sebastian Strobel
1
, Maria Alejandra Quintero
2
, Maria Abreu
1
1
2
Human Institute for Genomics, Miami, FL,
USA
BACKGROUND: The human gastrointestinal tract is constantly exposed to com-
mensal bacteria and their products. To avoid constant inammatory responses,
the local macrophages show a depressed inammatory response. It is believed
that in IBD this regulation is altered resulting in a state of chronic inammation.
Aim: Evaluate the TLR response, TLR expression and cytokine secretion in lamina
propria macrophages from patients with IBD in inamed and uninamed mucosa
METHODS: We isolate lamina propria macrophages from tissue biopsies obtained
during colonoscopies in patients with Crohns disease or ulcerative colitis by
CD33 selection. Biopsies were taken from inamed and uninamed areas of the
colon. Isolated macrophages were then cultured in media and stimulated with
the TLR4 ligand LPS (1lg/mL) and TLR2 ligand PAM3 (200lg/mL). Supernatants
were analyzed for TNFa, IL-8 and TGFb concentration by ELISA.
RESULTS: On average, we were able to isolate 210,000 CD33 macrophages per
biopsy site per patient with an average of 231,590 cells from inamed areas (n =
39) versus 204,134 cells from normal mucosa (n = 58), P = 0.6405. Preliminary
results show that TNF-a is induced in response to 1 lg/mL LPS compared to 3.92
pg/1000 CD33 TNFa in the control group. LPS concentrations below 1 lg/mL
did not show any TNFa release in the collected supernatant. Costimulation with
LPS/PAM3 also did not result in enhanced TNFa secretion but showed the same
TNFa release compared to single LPS stimulation.
CONCLUSION(S): Our preliminary data show that colonic lamina propria macro-
phages from patients with Crohns disease and ulcerative colitis respond to the
TLR4 ligand LPS with secretion of TNFa and IL-8. In addition, there is an increased
number of macrophages in samples obtained from inamed mucosa versus nor-
mal mucosa. These data suggest that macrophages in the colon of patients with
IBD inappropriately respond to TLR4 ligand abundantly present in the colon per-
petuating inammation.
P-241
YI
Microbial Regulation of CD141 Human Intestinal DCs Support ILC Production
of IL-22 in IBD
Randy Longman
1
, Gretchen Diehl
2
, Arun Swaminath
1
, Ellen Scherl
3
, Dan Littman
2
1
Columbia University Medical Center, New York, NY, USA,
2
Skirball Institute of Bio-
molecular Medicine, Department of Pathology, NYU School of Medicine, New
York, NY, USA,
3
Jill Roberts IBD Center, Weill-Cornell, New York, NY, USA
BACKGROUND: Interleukin (IL)-22 is an IL-10 family member that acts on epithelial
cells to promote healing. Although initially characterized as a cytokine made by T
cells (predominantly Th17 cells), more recent data has revealed the contribution
of non-T cells, including lymphoid tissue inducer cells and innate lymphoid cells
Figure 1.
(ILCs), in IL-22 production. This emerging subset of ILCs plays an important role
in mouse models of colitis, but their role in human IBD and regulation by intesti-
nal microbiota remain less clear.
METHODS: Lamina propria mononuclear cells (LPMCs) were isolated from both
endoscopic biopsies and surgically resected intestinal tissue. Cytokine production
was analyzed by ow cytometry. Dendritic cells (DCs) and ILCs were sorted by
FACS. Dextran sodium sulfate (DSS) and Citrobacter rodentium were used to eval-
uate ILC function in chemical and infectious mouse models of colitis, respectively.
RESULTS: By analysis of Th17 cytokine production in lamina propria mononuclear
cells (LPMCs) from IBD patients and non-IBD controls, we show an increased pro-
duction of IL22 in intestinal ILCs. Interestingly, IL22 production correlates with ex-
posure to the fecal stream in patients with surgical diversion. Mouse models of
both chemical and infectious colitis revealed the sufciency for human microbiota
to induce ILC production of IL-22 and the importance of MyD88 signaling in
CD11c-expressing cells to promote protection by inducing IL-22 production by
ILCs. Surprisingly, TLR-induced signaling in CD14, but not CD103, intestinal
DCs support ILC production of IL22 via IL23 and IL1b.
CONCLUSION(S): These results characterize an important class of ILCs producing
IL-22 in mild to moderate IBD and suggest the importance of CD14 intestinal
DCs in integrating the microbial signals that regulate ILC function. The produc-
tion and regulation of IL-22 by intestinal ILCs may have important implications
for diagnostic and therapeutic developments in the clinical management of IBD.
P-242
YI
Plasmacytoid Dendritic Cells and Anti-Inflammatory Intestinal IgA Production
Katharina Lahl
1
, Emily Deal
2
, Harry Greenberg
1
, Eugene Butcher
1
1
Stanford University, Palo Alto, CA, USA,
2
The J. David Gladstone Institutes, San
Francisco, CA, USA
BACKGROUND: Immunoglobulin A (IgA) is critical to maintaining the integrity of
the gastrointestinal epithelium and is one of the most potent immune system
components for the regulation of the microbiome in the intestine. Dysbiosis is a
frequent cause as well as a crucial effector of IBD. Secretory IgA directly regulates
microbial colonization and noxious antigen (Ag) penetration across the epithelial
barrier. Additionally, mucosal IgA exerts multiple direct anti-inammatory effects:
competition with pro-inammatory IgG responses, down-regulation of pro-inam-
matory cytokines by immune cells, and inhibition of the respiratory burst of
monocytes. The lack of secretory IgA leads to more activated B cells in Peyers
Patches, impaired intestinal antitoxin protection, and elevated levels of serum IgG
that react with intestinal bacteria. Despite a clear role for IgA in regulating vari-
ous forms of inammatory bowel diseases, the basic mechanisms that instruct
specic IgA production remain largely enigmatic. Plasmacytoid dendritic cells are
the main type I interferon (IFN) producers of the body. Type I IFNs can potently
activate B cells and induce antibody class switch.
METHODS: We used murine rotavirus (RV) infection as a model to study whether
in gut-associated lymphoid tissues, plasmacytoid dendritic cells directly induce
antigen-specic IgA. We chose RV since plasmacytoid dendritic cells are especially
well equipped to sense viral infections, and RV is highly conned to the intes-
tines. We depleted pDCs using two different approaches: We either injected
depleting antibodies (anti-PDCA1) prior to RV infection, or used genetically engi-
neered mice in which diphtheria toxin injection resulted in specic ablation of
pDCs. To test for the specic role of type I IFN in our model, we injected an anti-
body targeting SiglecH (a sialic acidbinding immunoglobulin (Ig)like lectin re-
ceptor exclusively expressed by pDCs) that leads to a blockade of type I IFN pro-
duction by pDCs specically.
RESULTS: Rotavirus infection led to a higher percentage of activated B cells in gut-
associated lymphoid tissues as measured by CD69 expression. Both methods of
depletion of pDCs as well as blocking type I IFN production by pDCs however led
to a lower percentage of total activated B cells in gut-associated lymphoid tissues
early after RV infection. This resulted in severely diminished induction of fecal RV-
specic IgA in all pDC-manipulated mice when compared to untreated RV-infected
mice. pDC manipulation further resulted in slightly prolonged viral shedding.
CONCLUSION(S): We show here that plasmacytoid dendritic cells (pDCs) act as
innate antigen-presenting cells, through type I IFN production, and are directly
required for the optimal development of antigen specic IgA-biased immune
responses in the gut. We thus dene a critical role of pDCs in the induction of
mucosal IgA.
P-243
YI
Defect in TLR5 Expression Enhances Spontaneous Visceral Hypersensitivity
Frederic Carvalho
1
, Mathieu Meleine
1
, Matam Vijay-Kumar
2
, Andrew Gewirtz
2
,
Alain Eschalier
1
, Denis Ardid
1
1
Universite dAuvergne, Clermont-Ferrand, Auvergne, France,
2
Georgia State Uni-
versity, Atlanta, Georgia, USA
BACKGROUND: Irritable Bowel Syndrome (IBS), such as Crohns disease (CD), is an
intestinal disease that is associated with colonic hypersensitivity and abdominal
pain associated with other symptoms (bloating and bowel dysfunction). More-
over, alterations in innate immune function genes and activities have been
described in IBS and CD patients. Among them, Toll-Like Receptor 5 (TLR5) is a
primordial innate immune receptor, responsible for the primary defense of the or-
ganism against microbial intruders. This receptor acts as a sentinel by detecting
the presence of potentially virulent invasive bacteria expressing agellin, the mi-
crobial TLR5 ligand. Mice decient in TLR5 (T5KO) have been described to uni-
formly exhibit increased levels of inammatory markers, resulting in a sub-clinical
inammation. Consequently, we hypothesized that, depending on the level of in-
testinal inammation, T5KO mice will spontaneously develop a visceral hypersen-
sitivity and thus provide a practical means to study mechanisms underlying
inammation and visceral pain.
METHODS: Two distinct strains of T5KO mice (knockout mouse strains on the
C57BL/6 background decient in TLR5 from Drs. Akira and Flavell) were assayed
for intestinal inammation level and visceral hypersensitivity. Inammation was
monitored using clinical anatomical indicators of colitis such as spleen and colon
weight, and assessed by determination of the colonic myeloperoxidase (MPO) ac-
tivity and expression of systemic pro-inammatory cytokines. In parallel, visceral
hypersensitivity was assessed using a technique based on measuring electromyo-
graphic abdominal contractions induced by colorectal distension. This test is to
induce, by progressive ination of a balloon inserted into the colon, stomach
cramps whose amplitude is proportional to the colon sensitivity.
RESULTS: Mice decient for TLR5 uniformly exhibited increased levels of inam-
matory markers and greater visceral hypersensitivity in comparison to their
housekeeping WT mice.
CONCLUSION(S): Direct involvement of TLR5 in colonic hypersensitivity has been
demonstrated. Such impact on colonic sensitivity could be related to its role in
the modulation of the intestinal microbiota and its role on micro-colonic inam-
mations. Thus, approaches focused on TLR5-dependent pathway could be used
to initiate new pharmacological strategies based on the use of specic molecules
modulating the activity of this protein.
P-244
YI
Fecal Lipocalin 2, a Sensitive and Broadly Dynamic Non-Invasive Biomarker of
Gut Inflammation
Benoit Chassaing
1
, Gayathri Srinivasan
1
, Andrew Young
2
, Maria Delgado
2
,
Andrew Gewirtz
1
, Matam Vijay-Kumar
1
1
2
Grady Health System, Atlanta, GA,
USA
BACKGROUND: Inammation has classically been dened histopathologically,
especially by the presence of immune cell inltrates. However, more recent stud-
ies suggest a role for "low-grade" inammation in a variety of disorders ranging
from metabolic syndrome to cancer, which is dened by modest elevations in
pro-inammatory gene expression. Consequently, there is a need for cost-effec-
tive, non-invasive biomarkers that, ideally, would have the sensitivity to detect
low-grade inammation and have a dynamic range broad enough to reect clas-
sic robust intestinal inammation.
METHODS: In this study we investigated the extent to which fecal Lcn-2 can serve
as a sensitive and non-invasive biomarker of i) intestinal inammation using a
well-studied murine models of dextran sulfate sodium (DSS) induced colitis and
ii) spontaneous colitis in IL-10 and TLR5 decient mice.
RESULTS: We report that, for assessment of intestinal inammation, fecal lipocalin
2 (Lcn-2), measured by ELISA, serves this purpose. Specically, using a well-char-
acterized mouse model of DSS colitis, we observed that fecal Lcn-2 and intestinal
expression of pro-inammatory cytokines (IL-1b, CXCL1, TNFa) are modestly but
signicantly induced by very low concentrations of DSS (0.25 and 0.5%), and
become markedly elevated at higher concentrations of DSS (1.0 and 4.0%). As
expected, careful histopathologic analysis noted only modest immune inltrates
at low DSS concentration and robust colitis at higher DSS concentrations. In ac-
cordance, increased levels of the neutrophil product myeloperoxidase (MPO) was
only detected in mice given 1.0 and 4.0% DSS. In addition, fecal Lcn-2 marks the
severity of spontaneous colitis development in IL-10 and TLR5 decient mice.
CONCLUSION(S): Unlike histopathology, MPO, and q-RT-PCR, the assay of fecal
Lcn-2 requires only a stool sample, permits measurement over time, and can
detect inammation as early as 1 day following DSS administration. Thus, assay
of fecal Lcn-2 by ELISA can function as a non-invasive, sensitive, dynamic, stable,
specic and cost-effective means to monitor intestinal inammation in mice.
P-245
YI
Impaired Mucosal Immunity to Commensal Fungi Influence Colitis
Iliyan Iliev, Vincent Funari, Christopher Reyes, Courtney Becker, David Underhill
BACKGROUND: Interactions between commensal microbiota and the immune sys-
tem are critical for establishing a proper balance between immune host defense
mechanisms and tissue health. Changes in the composition of gut bacterial com-
munities have been associated with intestinal inammation and obesity. Recent
studies have begun to note that a fraction of mucosa-associated microorganisms
are not bacterial. Mucosal fungal infections are relatively common in Crohns Dis-
ease patients, and antibodies against fungal antigens (ASCA) are a widely
accepted clinical marker for disease severity. What fungi populate the intestine
and how immunity to them might play a role in inammatory disease is currently
unknown. Fungi are sensed by number of innate immune receptors among which
Dectin-1 has emerged as the main innate immune receptor for recognition, phag-
ocytosis, and killing of fungi by myeloid phagocytes.
METHODS: Commensal fungi were visualized and quantied by staining with Dec-
tin-1 probe followed by microscopy and FACS analysis, and additionally detected
in fecal samples by qPCR for fungal 18S rDNA. To dene the mouse intestinal fun-
gal microbiome (the mycobiome), we isolated DNA from murine feces, amplied
the internal transcribed spacer region (ITS1-2) of fungal rDNA, and performed
high-throughput sequencing. To induce colitis wild type and Dectin-1-/- mice
were treated with DSS. In some cases mice were supplemented with C. tropicalis
- a common commensal fungus we found in murine gut and subjected to DSS.
To determine whether the altered fungal burden during colitis contributes to dis-
ease severity, we suppressed fungal growth with uconazole, a specic antifungal
drug.
RESULTS: We found that mice lacking Dectin-1, recognizing fungal cell wall b-glu-
can, are more susceptible to experimental colitis characterized by increased inl-
tration of Th17 and Th1 cells in the colon. Interestingly this pathology was driven
by intestinal fungus, and antifungal therapy ameliorated colitis severity in knock-
out mice. Deep sequencing analysis of the fungal mycobiome revealed fungal
species that are overrepresented in the gut during experimental colitis. When
Dectin-1-/- mice were supplemented with Candida tropicalis, a specic commen-
sal fungus found in the intestine during colitis, they experienced more severe in-
testinal inammation and augmented Th17 mucosal responses in absence of Dec-
tin-1. Consistently, intestinal dendritic cells (DCs) from Dectin-1-/- mice, but not
WT DCs, showed reduced ability to kill fungi. Therefore the data suggest that an
inability of Dectin-1-/- mice to mount effective immune responses to specic in-
testinal fungi creates conditions that promote inammation. Since the mouse
model suggested that Dectin-1 is involved in contributing to the severity of colo-
nic disease, we focused on the severity of ulcerative colitis (UC), the form of IBD
that always affects the colon. In particular we focused on severe UC, termed
medically refractory UC (MRUC), consisting of patients requiring colectomy as a
result of lack of response to medication. We found that a specic variant of the
gene for Dectin-1 is strongly associated with a severe form of ulcerative colitis
requiring colectomy.
CONCLUSION(S): Together our ndings reveal a novel eukaryotic fungal commu-
nity in the gut and show that altered interactions between the fungal microora
and the host intestinal phagocytes can profoundly inuence intestinal pathology.
P-246
Autophagy is Involved in Optimal Expression of TL1A (TNFSF15) by Microbes
in Primary Human Monocytes
David Shih
1
, Libo Zheng
1
, Xiaolan Zhang
2
, Jeremy Chen
1
, Ryan Ichikawa
1
, Chara-
labos Pothoulakis
3
, Hon Wai Koon
3
, Stephan Targan
1
1
Cedars-Sinai Medical Center, Los Angeles, CA, USA,
2
The Second Hospital of
Hebei Medical University, Shijianzuang, Hebei, China,
3
UCLA, Los Angeles, CA,
USA
BACKGROUND: Inammatory bowel disease (IBD) is postulated to result from a
dysregulated mucosal immune response to host microora in genetically suscep-
tible individuals. Genetic studies identied several IBD associated genes including
autophagy genes (ATG16L1 and IRGM) and tumor necrosis factor superfamily
member 15 (TNFSF15). Autophagy describes a biological process that involves
trafcking and handling of macro-molecules including bacteria. Studies show that
autophagy plays an important role in the clearance of microbial pathogens. Alter-
ations in the autophagic machinery such as in ATG16L1 and IRGM may result in
the ineffective elimination of pathogens and the persistent activation of the
inammatory cascade in the intestine, which may contribute to the pathogenesis
of IBD. TL1A is a cytokine and its elevation is associated with more aggressive
IBD disease course. Induction of TL1A expression occurs through a variety of
innate immune pathways including activation of Fcc receptor, TLRs, and enteric
microorganisms in primary human monocytes. This study examines the role of
bacteria-host interaction, specically the interaction between autophagy, bacteria,
and TL1A expression.
METHODS: Fresh human blood monocytes were cultured with E. coli and starva-
tion media (EBSS) to induce autophagy. Monocytes were transiently transfected
with siRNAs targeting ATG16L1 or control. Knock-down of ATG16L1 expression is
conrmed by RT-PCR. Activation of autophagy was assessed by Western blot for
LC3 and P62 and immunouorescent staining for LC3. TL1A mRNA was measured
by RT-PCR and protein expression was measured by ow cytometry and ELISA.
To determine the functional relevance of monocyte TL1A induction, we co-cul-
tured bacteria stimulated monocytes with CD4
T cells with either neutralizing

TL1A antibody or isotype antibody and measured IFN-c production by ELISA.
RESULTS: Knock-down of ATG16L1 expression by 70% of baseline expression led
to 48% reduction (P = 0.04) in bacteria induced TL1A expression. Activation of
autophagy by starvation (elevated LC3-II conversion, reduced P62, and punctate
LC3 staining pattern) enhanced bacteria induction of TL1A (mRNA avg 6 fold
increase, P<0.01; membrane bound TL1A avg 5 fold increase, P<0.01; secreted
TL1A avg 3 fold increase, P<0.01). In contrast, autophagy did not enhance IC
induced TL1A expression. Functional analysis showed that autophagy enhanced
microbial dependent TL1A production in monocytes potentiated CD4
T cell
effector function by augmenting IFN-c production that was reduced up to 50%
(P = 0.03) by blocking TL1A antibody.
CONCLUSION(S): Our data suggest that activation of autophagy is important for
optimal expression of TL1A, a critical factor in the modulation of gut mucosal
inammation.
P-247
TLR4 Activates the B-Catenin Pathway to Cause Intestinal Neoplasia
Rebeca Santaolalla
1
, Jose Ruiz
1
, Julie Davies
1
, Daniel Sussman
1
, Cristhine Pastor-
ini
1
, Cecilia Espana
1
, Oname Burlingame
1
, Pablo Bejarano
1
, Negar Rassaei
1
, Jeffrey
Ko
2
, Ramanarao Dirisina
2
, Terrence Barrett
2
, Limin Shang
3
, Sergio Lira
4
, Masayuki
Fukata
1
, Maria Abreu
1
1
2
Northwestern University, Chicago, IL, USA,
3
Novimmune, Plan-Les-Ouates, Geneva, Switzerland,
4
Mount Sinai School of Medi-
cine, New York, NY, USA
BACKGROUND: Colonic bacteria have been implicated in the development of co-
lon cancer. We have previously demonstrated that toll-like receptor 4 (TLR4), the
receptor for bacterial lipopolysaccharide, is over-expressed in humans with ulcera-
tive colitis-associated cancer. We aimed to determine whether TLR4 plays a role
as a tumor promoter in the absence of inammation.
METHODS: In vivo studies were performed using villin-TLR4 mice, which we gen-
erated to over-express TLR4 in the intestinal epithelium, and C57BL/6J wild type
mice as controls. Colonic tumorigenesis was induced using the genotoxic agent
azoxymethane (AOM). Cell proliferation was assessed by BrdU labeling, and b-cat-
enin was stained by immunohistochemistry. Colon specimens at baseline and af-
ter AOM were scored for histological inammation by three pathologists blinded
to the mouse strain and treatment. In vitro experiments were performed using
SW480 and IEC-6 intestinal epithelial cell lines.
RESULTS: We found that at baseline villin-TLR4 mice had increased epithelial pro-
liferation as well as longer crypts, compared to wild type mice. In addition, villin-
TLR4 mice developed spontaneous duodenal adenomas. In wild-type mice, AOM
treatment rarely resulted in tumors. By contrast, AOM induced robust colonic tu-
morigenesis in villin-TLR4 mice. Furthermore, villin-TLR4 mice were more likely to
develop larger quantities of tumors than wild-type mice. Histologically, these
tumors ranged from low-grade to high-grade dysplasia and carcinoma in situ sim-
ilar to adenomatous polyps in humans. Moreover, histological scoring of villin-
TLR4 and wild-type mice before and after AOM did not reveal any acute inam-
mation. Tumors arising in villin-TLR4 mice are characterized by intense nuclear b-
catenin staining. In addition, villin-TLR4 mice showed an increase in b-catenin nu-
clear translocation as well as a greater cell proliferation in non-dysplastic colon
compared to wild-type mice. Biochemical studies in colonic epithelial cells lines
revealed that TLR4 activates b-catenin in a PI3K-dependent manner.
CONCLUSION(S): Over-expression of TLR4 increases the risk of colon neoplasia
even in the absence of inammation. Our studies highlight a previously unex-
plored link between innate immune signaling and activation of oncogenic path-
ways, which may be targeted to prevent or treat colorectal cancer.
P-248
Induction of Lipocalin-2 in Colonic Epithelial Cells in Inflammatory Bowel
Disease
Ann stvik
1
, Atle Granlund
2
, Sverre Torp
3
, Arnar Flatberg
1
, Helge Waldum
1
, Terje
Espevik
1
, Jan Damas
1
, Arne Sandvik
1
1
Department of Cancer Research and Molecular Medicine, Faculty of Medicine,
Norwegian University of Technology and Science, Trondheim, Norway, Trondheim,
Sr-Trndelag, Norway,
2
Department of Cancer Research and Molecular Medicine,
Faculty of Medicine, NTNU, University of Trondheim, Trondheim, Sr-Trndelag,
Norway,
3
Department of Laboratory Medicine, Children and Womens Health, Nor-
wegian University of Technology and Science, N-7491 Trondheim, Sr-Trndelag,
Norway
BACKGROUND: In our gene expression analysis on colonic biopsies from an IBD
cohort we found Lipocalin-2 (LCN2) to be among the most upregulated genes in
inamed mucosa compared to un-inamed mucosa of both ulcerative colitis (UC)
and Crohns Disease (CD). The protein LCN2 acts as an acute phase protein and
has antimicrobial properties, making it a part of the innate immune system. We
sought to identify localization and regulation of LCN2 in the colonic mucosa and
also quantify LCN2 in serum.
METHODS: Microarray of colonic biopsies from an IBD population (n = 133) was
done using Illumina Bead Chip technology. Immunohistochemical staining and in
situ hybridization of colonic biopsies was done on a subset of biopsies to identify
cellular sources of LCN2. We studied release of LCN2 from colonic epithelial cell
lines HT-29 and SW620, upon pattern recognition receptor stimulation (PRR).
LCN2 was quantied in serum using ELISA and hsCRP quantied using immuno-
turbidometric method.
RESULTS: LCN2 mRNA was among the 10 most upregulated gene in inamed vs
uninamed mucosa of UC and CD. LCN2 is located to the epithelial cells and inl-
trating neutrophils in inamed mucosa. The LCN2 mRNA synthesis is found solely
in epithelial cells indicating the de novo synthesis to take place in the epithelium.
LCN2 is abundantly and constitutively released from the colonic epithelial cell
line HT-29 and its release is enhanced by both IL1b and the TLR3 ligand polyino-
sinic:polycytidylic acid (poly(I:C)). Serum LCN2 correlates with hsCRP.
CONCLUSION(S): LCN2 is among the most upregulated genes in active IBD. The
epithelial cells of colonic mucosa are an important source of LCN2. LCN2 seems
to be released into the intestinal lumen and has a potential role in shaping the
intestinal bacterial ora. The synthetic dsRNA analog poly(I:C) increased synthesis
and release of LCN2 for colonic epithelial cell line HT-29 and the TLR3 mediates
this release, supporting a role of TLR3 in intestinal homeostasis and mucosal
inammation.
P-249
Antagonizing C5aR Reduces T Cell- IL-10-Dependent Colitis in Pre-Clinical
Models
Umang Jain
1
, Trent Woodruff
2
, Andrew Stadnyk
1
1
Dalhousie University, Halifax, Nova Scotia, Canada,
2
The University of Queens-
land, Brisbane, Queensland, Australia
BACKGROUND: Targeting the complement cascade has not been advanced as a
treatment for the inammatory bowel diseases (IBD) despite growing evidence
that blocking C5a protects from colitis. We have recently shown that PMX205 (a
C5a receptor antagonist) protects from DSS colitis in a specic and mouse strain
independent manner. In that study it was observed that the benecial effect of
PMX205 was associated with elevated levels of IL-4 and IL-10 compared to
inamed control mice. To further test the efcacy of PMX205 in a Th1/Th17 medi-
ated colitis (better resembling Crohns disease) and to observe whether PMX205
mediated protection is IL-10 dependent, we used PMX205 in the IL-10 gene
knockout model of spontaneous colitis. Colitis was accelerated using a non-steroi-
dal anti-inammatory drug, piroxicam.
METHODS: Piroxicam (250ppm) was added to the food of 6 week old IL-10-/- or
wild type (WT) mice (both on C57BL/6 background). Mice were gavaged daily
with PMX205 (-10 mg/kg) or water (control) starting on the same day as piroxi-
cam, for one week. On the day of euthanasia, intestinal permeability was exam-
ined using FITC-dextran. Subsequently, the mice were exsanguinated and their
colons excised and the length measured. Half the colon was used to obtain histo-
logical scores based on the extent of crypt damage, cell inltration, edema, ulcer-
ation and epithelial hyperplasia. To quantify inltrating granulocytes, sections
were stained for F4/80 (macrophages) and Ly6G (neutrophils). The other half of
the colon was rinsed in media with added antibiotics then cultured, and 24 hour
supernatants were analyzed for cytokines and anaphylatoxins.
RESULTS: The colons of WT mice showed very mild inammation on piroxicam
administration (median inammation score of 1.5 versus 1 for healthy WT mice).
IL-10-/- mice receiving piroxicam had increased intestinal permeability, severe pa-
thology characterised by epithelial hyperplasia and cell inltration and increased
mucosal anaphylatoxin levels compared to IL-10-/- mice not receiving piroxicam
(median inammation score of 4 versus 1.5). PMX205 administration to IL-10-/-
mice during the period of piroxicam ingestion did not affect the levels of anaphy-
latoxins indicating that complement activation remained intact. In terms of clini-
cal efcacy, PMX205 signicantly prevented the intestinal barrier loss and colon
shortening. PMX205 treated mice showed less crypt damage, cellular inltration
and epithelial hyperplasia in colon sections. In addition, it signicantly prevented
the colonic production of IL-12 and IL-1 but had no signicant effect on IL-17A,
IFN, IL-4, TNF or IL-6 compared to the control mice. Colon staining revealed that
neither neutrophil nor macrophage inltration was signicantly attenuated in
PMX205 treated mice.
CONCLUSION(S): PMX205 administration, to a signicant extent, ameliorated colo-
nic damage induced by piroxicam in IL-10-/- mice, although its effect was not as
profound as observed in the DSS model of colitis using WT mice. This may be
due to its protective effect being at least partially dependent on IL-10. Neverthe-
less, preventing increased permeability and mucosal inammation are in consen-
sus with other studies showing the benecial effects of PMX205 in pre-clinical
models of IBD, further supporting that it be considered for use in human trials.
P-250
Loss of Reciprocal Regulation of Innate and Adaptive Immunity Causes Colitis
in Alpha(V) Integrin-Deficient Mice
Subhankar Mukhopadhyay
1
, Mridu Acharya
2
, Helena Paidassi
2
, Manjae Kwon
2
,
Marianela Feliu
2
, Adam Lacy-Hulbert
3
1
Oxford University, Oxford, Oxfordshire, UK,
2
Massachusetts General Hospital, Bos-
ton, MA, USA,
3
Massachusetts General Hospital/ Harvard Medical School, Boston,
MA, USA
BACKGROUND: The maintenance of intestinal immune homeostasis involves a
complex interplay between the luminal microbiota, barrier epithelial cells and the
immune system. Inammatory bowel disease (IBD) is thought to arise from the
breakdown of this mutual relationship and dysregulation of immune responses to
commensal bacteria. Although many studies have now established critical roles
for both the adaptive and innate immune systems in this process, how these two
arms of the immune system work together remains poorly understood. We have
previously described the critical role of activation of TGF-beta by Dendritic cells
(DCs), mediated by the alpha(v)beta8 integrin, in regulation of T cell responses.
We showed that deletion of alpha(v) in myeloid cells resulted in the failure to
generate intestinal adaptive regulatory T cells (Tregs), leading to development of
colitis. In this study, we have investigated the role of alpha(v)-mediated TGF-beta
activation in regulation of mucosal innate immune cells and initiation of intestinal
inammation in response to microbial stimulation.
METHODS: To address this question, we have used complementary in vivo and in
vitro approaches. Lymphocyte decient alpha(v) conditional knockout mice
(Itgav-SCID mice) were generated, and T cell adoptive transfer used to dene the
roles of the myeloid lineage and T lymphocytes in development of colitis in this
model system. In parallel, control and alpha(v) decient myeloid cells were stimu-
lated in vitro with microbial components, and the inuence of sub- populations
of intestinal T cells on responses determined. Finally, gene expression analysis
was used to identify candidate innate immune genes contributing to the devel-
opment of colitis in mouse models.
RESULTS: We have found that innate immune cells from alpha(v) decient mice
mount increased inammatory responses to microbial stimulation. Surprisingly,
we nd that this is not due primarily to loss of direct effects of alpha(v) or TGF-
beta activation on myeloid cells. Instead, we have found that increased innate
immune responses are caused by the imbalance in effector and regulatory T cells
in this model. Specically we nd that cytokines derived from effector T cells
from mice with colitis activate macrophages, increasing their production of pro-
inammatory cytokines in response to microbial stimulation. Tregs, through pro-
duction of IL10, suppress this activation, promoting innate immune homeostasis
in the intestine. Hence, we show that intestinal inammation in the alpha-v
knockout model requires the presence of adaptive immune T cells, as well as in-
testinal microbiota. Building on these studies, through microarray and directed
QRT-PCR analysis, we have identied genes expressed by innate immune cells
that may contribute to the development of colitis.
CONCLUSION(S): Together these ndings identify TGF-beta-dependent reciprocal
signaling circuits that occur between the innate and adaptive arms of the
immune system. Innate immune cells instruct regulatory T cells through local
activation of TGF-beta; these Tregs in turn regulate innate immune responses to
microbes. We propose that failure of this regulatory relationship leads to the
emergence of inammatory myeloid cells, that initiate intestinal inammation.
P-251
Adherent-Invasive E. coli (AIEC) Are Potently Pro-Inflammatory for Blood Mono-
cytes, but Not Intestinal Macrophages, in Patients with Crohns Disease
Traci Jester
1
, Lesley Smythies
1
, Richard Stahl
1
, Jayleen Grams
1
, Jamie Cannon
1
,
Heidi Nick
1
, Ken Waites
1
, Arlette Darfeuille-Michaud
2
, Phillip Smith
1
1
University of Alabama at Birmingham, Birmingham, AL, USA,
2
Universite d
Auvergne, Clermont-Ferrand, Auvergne, France
BACKGROUND: The presence of adherent invasive E. coli (AIEC) in the terminal il-
eum is associated with Crohns disease. AIEC survive and replicate in human
monocytes, but the response of human intestinal macrophages to AIEC is not
known. Therefore, we investigated the phagocytic, bactericidal and inammatory
responses to AIEC by primary intestinal macrophages and blood monocytes from
patients with Crohns disease and normal subjects.
METHODS: Intestinal macrophages from patients with Crohns disease (Crohns in-
testinal macrophages) and normal subjects (normal intestinal macrophages) were
isolated from segments of small intestine by enzyme digestion and puried by
elutriation. Blood mononuclear cells were obtained by gradient sedimentation.
Macrophage/monocyte phagocytic and bactericidal responses to AIEC were
assayed at 0.5, 1 and 24 h, and AIEC-inducible cytokine responses at 24 h. To
evaluate responses to AIEC in the presence of Iniximab, cells were pre-incubated
with clinically relevant doses of Iniximab for 4 hours and then assayed for AIEC-
inducible TNF-a. To simulate the response of monocytes newly recruited to the
intestinal mucosa to AIEC, monocytes were pre-incubated prior to the functional
assay in broblast-conditioned medium (F-CM) generated from primary bro-
blasts isolated from the intestinal lamina propria.
RESULTS: Blood monocytes from patients with Crohns disease (Crohns mono-
cytes) and monocytes from normal subjects (normal monocytes) displayed equiv-
alent phagocytic and bactericidal activities for AIEC. However, Crohns monocytes
released higher levels of AIEC-induced TNF-a than normal monocytes. Iniximab
inhibited AIEC-stimulated TNF-a production by normal monocytes in a dose-de-
pendent manner, but signicantly higher doses of Iniximab were required to
achieve equivalent TNF-a suppression by Crohns monocytes. Iniximab also
inhibited the formation of cell clusters, a phenotypic marker of activation, by nor-
mal monocytes exposed to AIEC, but did not affect cluster formation by Crohns
monocytes. Intestinal macrophages phagocytized and killed AIEC more efciently
than blood monocytes. Moreover, Crohns intestinal macrophages and normal in-
testinal macrophages phagocytized AIEC equally, but during the rst 60 minutes
after phagocytosis, Crohns intestinal macrophages killed AIEC less efciently than
normal intestinal macrophages. Importantly, neither Crohns intestinal macro-
phages nor normal intestinal macrophages produced TNF-a in response to AIEC.
Finally, culture of normal monocytes in F-CM induced increased bactericidal activ-
ity similar to that of normal intestinal macrophages, suggesting that factors in
the intestinal stroma promote monocyte phagocytic and bactericidal activity to-
ward AIEC after the monocytes take up residence in the mucosa.
CONCLUSION(S): Blood monocytes from patients with Crohns disease and normal
subjects have similar phagocytic and bactericidal activities, but Crohns mono-
cytes have an enhanced pro-inammatory response to Crohns disease-associated
AIEC. Intestinal macrophages from both Crohns patients and normal subjects
phagocytized and killed AIEC more efciently than monocytes, but AIEC repli-
cated more rapidly in Crohns intestinal macrophages during the early phase of
intracellular replication. Neither Crohns nor normal intestinal macrophages pro-
duced inammatory cytokines in response to AIEC, indicating that the mucosal
down-regulatory mechanism responsible for the inammation anergy characteris-
tic of normal intestinal macrophages is intact in Crohns intestinal macrophages.
Thus, the pro-inammatory cytokines released by mucosal mononuclear phago-
cytes in Crohns disease are likely produced by blood monocytes newly recruited
to the mucosa.
P-252
Lymphotoxin-dependent Control of Intestinal Inflammation
Elise Macho Fernandez
1
, Ekaterina Koroleva
1
, Luke Neill
1
, Yang-Xin Fu
2
, Alexei
Tumanov
1
1
Trudeau Institute, Saranac Lake, NY, USA,
2
BACKGROUND: Immune-based therapeutic approaches for IBD, including anti-
TNF therapy, have shown signicant success during the last decade. Neverthe-
less, many patients are not responsive to these therapies and suffer from severe
side effects. Therefore, an increased understanding of the fundamental immune
mechanisms controlling gut inammation is critical for the rational design and
development of more effective therapies of IBD. Innate lymphoid cells (ILCs)
have recently emerged as key players in regulating the balance between pro-
tective immunity and immunopathology at mucosal surfaces. However, the cel-
lular and molecular pathways that control crosstalk between ILCs and intestinal
epithelial cells during inammation remain poorly understood. Our recent study
revealed that Lymphotoxin (LT), a member of TNF superfamily of cytokines, pro-
duced by RORgt ILCs in the gut is critical for protection against the mucosal
bacterial pathogen Citrobacter rodentium. In the present study, we aimed to
determine how LT signaling controls ILCs to regulate the intestinal
inammation.
METHODS: An acute mouse model of IBD induced by dextran sodium sulfate
(DSS) was used. WT and LT-beta receptor (LTbR)-decient mice were treated with
3.5% DSS in drinking water for 5 days followed by normal water thereafter.
RESULTS: Our data show that LTbR signaling is essential for protection and recov-
ery from DSS-induced colitis. LTbR decient mice failed to upregulate IL-22 in the
colon and succumbed rapidly after DSS administration. By using RORgt-GFP re-
porter mice and cell sorting approach we found the impaired IL-22 production
by distinct populations of ILCs in the colon after DSS-induced inammation.
Recent studies indicated a protective role of IL-22 in IBD by enhancing barrier in-
tegrity and epithelial innate immunity. We found that reduced IL-22 expression in
LTbR-decient mice was associated with defected mucin genes expression and
impaired proliferation of intestinal epithelial cells after DSS-induced injury. Bone
marrow transfer experiments revealed that LTbR expression on both bone mar-
row-derived and radioresistant stromal cells is required for the control of intesti-
nal inammation. To dene which LTbR-expressing cells are essential for protec-
tion, we have generated mice with a specic inactivation of LTbR in intestinal
epithelial cells, and bone marrow-derived cell populations. These mouse models
will help us to further investigate the critical pathways to control intestinal
inammation.
CONCLUSION(S): Our data indicate that LTbR signaling prevents intestinal inam-
mation by controlling the IL-22 protection pathway.
P-253
The Role of RIP2 in Experimental Colitis
Md. Zaki, Thirumala-Devi Kanneganti
St. Jude Childrens Research Hospital, Memphis, TN, USA
BACKGROUND: Human inammatory bowel disease (IBD) constitutes a major
health problem in developed countries. Genome wide association studies sug-
gested that mutation in a gene encoding the intracellular pathogen sensor Nod2
is a predisposing factor for development of IBD. Upon activation by bacterial cell
wall component muramyl dipeptide, NOD2 activates NF-jB and MAP kinase path-
ways through adaptor molecule RIP2. However, the role of RIP2 in IBD pathoge-
nesis has not been examined yet.
METHODS: We studied the role of RIP2 in intestinal inammation using a mouse
model of colitis induced by dextran sulphate sodium (DSS). Wild-type (WT), Nod2-
and Rip2-decient mice were fed with 3% DSS for 5 days followed by drinking
water until the end of the experiment. Body weight changes, rectal bleeding and
diarrhoea was examined daily. Histological changes, cytokine production and bac-
terial growth in the colon tissues were examined at early (day 3 and 5) and delayed
(day 7 and 9) phage of colitis. Activation of NF-kB and MAPK signaling pathways in
colon tissue collected at different time after DSS were also examined.
RESULTS: Similar to Nod2-/- mice, Rip2-/- mice are susceptible to DSS-induced co-
litis with increased body weight loss, diarrhea, rectal bleeding and exacerbated
histological changes in the colon. Increased susceptibility of Rip2-/- mice was
associated with increased translocation of gut commensal bacterial into lamina
propria. To understand the mechanism of RIP2-mediated protection of colon
injury, we analyzed cytokines produced in the colon tissue at day 3, 5 and 7 after
DSS administration. Our results demonstrate that Rip2-/- mice are defective in
production of several key cytokines including IL-6, TNFa, KC, MCP and IL-15 at
early phage of acute colitis.
CONCLUSION(S): Our results suggest that RIP2-dependent signaling pathways are
critically involved in protection against intestinal injury and inammation through
production of several important cytokines. Thus, this study sheds light on the
critical roles RIP2 plays in maintaining intestinal homeostasis, and may open new
avenues in the understanding of IBD pathogenesis.
P-254
Eosinophilic Inflammation and IL-33 Expression In Stricturing Pediatric Crohns
Ileitis
Joanne Masterson
1
, Lindsay Hosford
1
, Kelley Capocelli
1
, Alyson Yeckes
1
, Cheryl
Protheroe
2
, Rachel Harris
1
, James Lee
2
, Glenn Furuta
3
1
University of Colorado Denver, Aurora, CO, USA,
2
Mayo Clinic Scottsdale, Scotts-
dale, AZ, USA,
3
Childrens Hospital Colorado, Aurora, CO, USA
BACKGROUND: Background: Previous studies support a role for eosinophilic
inammation in brosis. Our previous work revealed that ileitis and remodeling
are associated with mucosal eosinophilia. Recent studies have determined an
association of IL-33 with ulcerative colitis and mice treated with IL-33 develop
increased mucosal eosinophils and eosinophil adhesiveness to the extra-cellular
matrix. To date, features of mucosal eosinophilia and IL-33 have not been exten-
sively studied in brotic pediatric Crohns disease. We hypothesized that eosino-
philic inammation was associated with increased IL-33 expression and brosis in
tissues affected by IBD. Objectives: The goal of our study was to measure ileal eo-
sinophilia in human tissue and correlate this with IL-33 expression in well-charac-
terized children with stricturing Crohns disease.
METHODS: Methods: Subject selection-We performed a retrospective study of the
clinical, immunohistochemical features from consecutive children with ileal
Crohns disease who were seen between 2000-2011 at Childrens Hospital Colo-
rado. Patients were subdivided as non-stricturing and stricturing phenotypes
based on this review. As normal controls, we chose children who presented with
abdominal symptoms, showed no histological evidence of colitis and who were
on no steroids, immunobiologics or antibiotics within the month prior to biopsy.
Eosinophilic inammation scoring- Using the tissues from normal subjects as
described above, and based on our previous GI work using eosinophil peroxidase
(EPX) scoring, we developed a scoring system based on 1. Peak number of eosin-
ophils per single high powered eld (hpf ) (40X), 2. Average number of eosino-
phils over 5 randomized hpfs, 3. Level of eosinophil degranulation over 5
randomized hpfs (0-none, 1-limited, 2-some, 3-extensive), and 4. Patchiness i.e.
eosinophil presence and/or activation across the entire specimen. EPX was
assessed for a maximal score of 33 as a cumulative measure of each of these indi-
ces. IL-33 assessment- Ileal tissues were analyzed for IL-33 by standard IHC in epi-
thelial and endothelial cell compartments, lamina propria cells, and extra-cellular
matrix associated cell-free localization. Epithelium was scored as 0-no staining, 1-
faint staining or 2-strong staining according to standardized control archived tis-
sue and all other localizations as 1-present or 0-absent. EPX-mAb and IL-33 IHC
scoring were individually assessed and then correlated. Statistics was performed
by students t-test compared to normal controls.
RESULTS: Listed within the table are relevant data and P values.
CONCLUSION(S): Conclusions: Stricturing and non-stricturing Crohns ileitis have
greater eosinophilic inammation and epithelial IL-33 compared to normal ileal
biopsies. Medical treatments for Crohns lead to improvement of this inamma-
tion but do not appear to inuence the outcome of stricturing disease.
P-255
Epithelial Cell Autophagy in Antibacterial Defense of the Small Intestine
Jamaal Benjamin, Lora Hooper
UT Southwestern Medical Center, Dallas, TX, USA
BACKGROUND: The intestines of all mammals are colonized with a diverse micro-
biota that provide metabolic benets to their hosts. However, this symbiotic rela-
tionship can break down when resident bacteria opportunistically invade the in-
testinal barrier, leading to pathologies such as inammatory bowel disease (IBD)
and bacteremia. As a result, epithelial cell innate immune responses play an
essential role in preventing bacterial invasion of host tissues and maintaining a
symbiotic host-bacterial relationship. Autophagy is emerging as an important
component of innate immunity. Mounting evidence suggests that dysregulation
of autophagy can lead to inammatory bowel disease. Additionally, increased
bacterial invasion of epithelial cells is a hallmark of IBD. Little is known, however,
about the role of autophagy in controlling interactions between intestinal bacte-
ria and the intestinal epithelium in vivo.
METHODS: The present study was conducted to evaluate the role of autophagy
in the epithelial cells of the small intestine. We utilized a known intestinal patho-
gen, Salmonella typhimurium, and monitored enterocyte autophagy activation in
gnotobiotic (germ-free) and conventionally (CV) raised wild-type mice following
intragastric bacterial challenge. Autophagy activation was analyzed via immuno-
uorescence, Western blot analysis and electron microscopy. We next investigated
the role of Toll-like receptors (TLRs) on autophagy activation by utilizing mice de-
cient in myeloid differentiation protein (MyD88), an adaptor molecule essential
for TLR signaling. Finally, we demonstrated a critical role for epithelial cell autoph-
agy by generating mice lacking Atg5, a critical autophagy protein, specically in
the epithelial cells of the small intestine, and monitoring the ability of Salmonella
to translocate to extraintestinal sites including the liver and spleen.
RESULTS: In this study, we demonstrate that small intestinal epithelial cell autoph-
agy is essential for protection against tissue invasion by intestinal pathogens and
opportunistically invasive commensals. We show that small intestinal autophagy
is an early innate immune response that functions in an epithelial cell-intrinsic
MyD88 dependent, NOD2-independent manner. Utilizing mice decient in small
intestinal epithelial cell autophagy (Atg5
DIEC)
, we have determined that epithelial
cell autophagy is required to limit pathogen dissemination to extraintestinal sites,
including the liver and spleen.
CONCLUSION(S): This study represents the rst comprehensive and mechanistic in
vivo dissection of the microbiota capable of activating epithelial cell autophagy, the
pattern recognition receptors (PRRs) required for this activation, as well as the criti-
cal antibacterial role of epithelial cell autophagy in the intestine. A deeper under-
standing of how small intestine epithelial cell autophagy functions will be crucial in
understanding how autophagy mutations predispose for IBD development and
thus improve treatment modalities for both Crohns Disease and ulcerative colitis
P-256
YI
Enteroaggregative Escherichia Coli Seems to Proliferate in the Terminal Portion
of The Colon of IBD Patients
Erika Watanabe, Fernando Romeiro, Ligia Sassaki, Rogeria Keller, Josias
Rodrigues
Unesp Botucatu, Botucatu, Sao Paulo, Brazil
BACKGROUND: Intestinal microbiota is suspected of involvement in the etiology
or complication of the symptoms of inammatory bowel diseases (IBD). Although
not very clear, microbial contribution might consist of an imbalance in indigenous
species composition (dysbiosis) of the bacterial population and/or in the action
of a specic pathogen. Escherichia coli is one of bacteria whose number is aug-
mented in the gut microbiota of IBD patients. This study aimed at identifying,
within this bacterial population, the prevalence of Enteroaggregative E. coli
(EAEC), a category including both pathogenic and innocuous strains.
METHODS: A total of 65 patients [12 diagnosed with Crohns disease (CD), 22
with ulcerative colitis (UC) and 31 control subjects], with no recent antibiotic
treatment history was investigated. The IBD diagnosis was based on clinical and
histopathological criteria. Following conventional bacteriological procedures, feces
collected 3 days before the colonoscopy and stored at 4
C and biopsies freshly

collected from different intestinal mucosal sites were subjected to culture for E.
coli detection. The identication of EAEC among the E. coli isolates were per-
formed by adherence assays in 3h of bacteria contact to HEp-2 epithelial cell
monolayers. This study was approved by the local Committee on Ethics in
Research.
RESULTS: E. coli isolates were cultured from feces (of 6 UC, 3 CD and 4 control
patients) and mucosa of the ileum (of 7 UC, 3 CD, and 2 control patients), proxi-
mal (of 11 UC, 5 CD, and 10 control patients), and distal (of 36 UC, 13 CD, and 31
control patients) colon. When compared with the results of control group, no sig-
nicant difference could be observed in the prevalence of EAEC in the ileum and
proximal colon of both UC and CD patients and in feces of UC patients. Yet, a
higher prevalence o EAEC was observed in the distal colon of both UC
(64%x26%, P = 0.025) and CD (62%x26%, P = 0.002) and in the feces (67%x0%, P
= 0.05) of CD patients.
CONCLUSION(S): EAEC seems to proliferate in distal portion of the colon of IBD
patients, which is the very site where the lesions often concentrate. Some attrib-
utes of this E. coli pathovar such as the ability to form biolm and of inducing
mucus secretion might explain its success in colonizing this region.
P-257
YI
An Oxygen Equilibrium at the Host-Microbial Interface Determined by Phos-
phorescent Nanoprobe Technology
Lindsey Albenberg
1
, Colleen Judge
1
, Tatiana Esipova
2
, Stephanie Grunberg
3
, Jun
Chen
2
, Robert Baldassano
1
, James Lewis
2
, Fredric Bushman
3
, Sergei Vinogradov
2
,
Gary Wu
4
1
Childrens Hospital of Philadelphia, Philadelphia, PA, USA,
2
University of Pennsyl-
vania, Philadelphia, PA, USA,
3
Department of Biochemistry and Biophysics, and
Department of Microbiology, The University of Pennsylvania, Philadelphia, PA,
USA,
4
The Hospital of The University of Pennsylvania, Philadelphia, PA, USA
BACKGROUND: Although the colonic lumen is known to be largely devoid of oxy-
gen, the mechanism by which this anaerobic environment is maintained remains
unclear due to the inability of available technology to quantify oxygen in the in-
testinal tract. Indeed, most microbes in the gut are obligate anaerobes. Accurate
quantication of oxygen in the gut is essential to elucidate the hosts relationship
with its densely populated intestinal microbial community and may be relevant
to various disease states in humans, including inammatory bowel disease (IBD).
For instance, multiple studies have demonstrated signicant alterations in the gut
microbiota in IBD, notably phylum level increases in Proteobacteria and Actinobac-
teria, which contain predominantly oxygen tolerant organisms, and a decrease in
oxygen-sensitive Firmicutes.
METHODS: Phosphorescent nanoprobe (Oxyphor G4
1
), whose phosphorescence
decay time is exquisitely sensitive to environmental oxygen, was administered to
mice either via the drinking water to measure intestinal luminal oxygen or intra-
vascularly via the tail vein to quantify tissue oxygen. A ber-optic time domain
phosphorometer
2
was used to excite G4 and detect phosphorescence at kmax =
635 nm and kmax = 810 nm, respectively. A laparotomy was performed under
isourane anesthesia and the decay pattern of G4 phosphorescence was meas-
ured in various organs. 100% oxygen was delivered via the anesthesia apparatus
for several minutes to determine the effect of host oxygenation on luminal oxy-
gen content.
RESULTS: Intravenous injection of G4 led to signal detection in all tissues, but
ingested G4 was only detected at intestinal segments containing fecal material.
The partial pressure of oxygen (pO2) was remarkably lower in the cecal feces
than in the adjacent tissue. Inspiration of pure O2 led to a rapid, dramatic
increase in cecal tissue pO2 and a delayed, more gradual increase in luminal pO2
(Figure 1). Both effects were reversible once animals were returned to room air.
CONCLUSION(S): This technical advance has revealed a novel complexity in host-
microbial interactions - namely that oxygenation of host colonic tissue affects the
level of oxygen in the feces. Thus, the anaerobic nature of the intestinal lumen is
not static but rather a dynamic equilibrium. We hypothesize that oxygen released
by colonic tissue is consumed by the gut microbiota, thus creating an anaerobic
luminal environment. This concept is supported by our data in human subjects
indicating enrichment of aerobic and facultative anaerobic bacteria adherent to
the rectal mucosa compared to the feces where obligate anaerobic bacteria pre-
dominated (Figure 2). We believe that the colonic oxygen equilibrium may have
great relevance to IBD where the dysbiotic microbiota composition may, in part,
result from an alteration in the redox potential of the colonic environment due
to hyperemia, bleeding, and/or the oxidative nature of the inammatory
response. Studies are underway to further characterize the relationship between
oxygen levels in the gut and the dysbiotic microbiome in IBD. 1. Esipova, TV
et al. Anal Chem, 2011. 83(22): 8756-8765. 2. Vinogradov, SA et al. Rev Sci Ins-
trum, 2001. 72(8): 3396-3406.
P-258
YI
Clostridium Difficile Toxin A-associated DNA Augments the Host Inflammatory
Response
Xiaotong Yang
1
, Dan Li
2
, Hua Xu
2
, Ciaran Kelly
3
, Xinhua Chen
3
1
Institute of Microbiology and Immunology, Shanghai Normal University, Shang-
hai, Shanghai, China,
2
Beth Israel Deaconess Medical Center, Boston, MA, USA,
3
Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
BACKGROUND: Clostridium difcile infection (CDI) is the leading recognized cause
of nosocomial infectious diarrhea in the developed world. The importance of CDI
amongst patients with inammatory bowel disease (IBD) is increasingly being rec-
ognized. Recent studies on CDI in IBD patients have demonstrated a concerning
trend towards increased rates of infection, morbidity, mortality and healthcare
costs. Guidelines now promote testing for C. difcile in IBD patients experiencing
a relapse of colitis. The major virulent factors of C. difcile are two large protein
exotoxins - A and B, which initiate a marked intestinal inammatory response. In
this study we discovered that toxins secreted by Clostridium difcile contain sig-
nicant amounts of bacterial DNA, which was further conrmed (by sequencing)
to be of C. difcile origin. It is known that toll-like receptor 9 (TLR-9) recognizes
bacterial DNA containing CpG dinucleotides and triggers an inammatory
response. In this study, we aim to examine the role of toxins-associated DNA in
the inammatory response in CDI.
METHODS: HT-29 cells, THP-1 cells, wild type (WT) and TLR9 knock-out (TLR9KO)
mouse macrophage lines were stimulated with C. difcile toxins A or its deriva-
tives treated with DNAse I digestion or by heat inactivation. ODN TTAGGG was
used to antagonize TLR9 receptor. Toxin cytotoxicity was measured by standar-
dized cell rounding assay. IL-8 or KC(IL-8 homologue) release was measured by
ELISA.
RESULTS: Both C. difcile toxin A and B contain DNA from C. difcile as deter-
mined by gene sequencing. In vitro pull-down assays demonstrated that both
toxin A and B have strong afnity for DNA. HT-29 intestinal epithelial cells, THP-1
monocytes and macrophages each secreted high levels of IL-8 or KC in response
to toxin A (10nM) stimulation. IL-8 production was attenuated when cells were
treated with the TLR9 antagonist ODN TTAGGG. Heat inactivation of toxin A
demolished its cytotoxicity (i.e. no cell rounding in HT-29 cells), but IL-8 produc-
tion was still induced although at lower levels than by untreated toxins. Digesting
toxin A with DNAse I also reduced IL-8 production in all tested cell lines. Further-
more, compared to wild type control, TLR9 knock-out macrophages produced
signicantly lower amount of KC in response to toxin A.
CONCLUSION(S): We have made the novel observation that C. difcile toxins con-
tain genomic DNA that is bound with high afnity. C. difcile toxin A- associated
DNA augments toxin-induced inammation by activating TLR9 signaling path-
ways. Antagonizing or knocking out the TLR9 receptor results in reduced toxin A
induced inammatory cytokine production. Our data suggest that C. difcile DNA
bound to exotoxins A and/or B and signaling via TLR 9 may be a signicant con-
tributing virulence factor in C. difcile infection.
P-259
YI
Colitis in TLR5-deficiency Mice: Role of the Microbiota
Frederic Carvalho
1
, Omry Koren
2
, Benoit Chassaing
3
, Arlette Darfeuille-Michaud
1
,
Rob Knight
4
, Ruth Ley
2
, Andrew Gewirtz
3
1
Universite dAuvergne, Clermont-Ferrand, Auvergne, France,
2
Cornell University,
Ithaca, NY, USA,
3
4
University of Colo-
rado, Boulder, CO, USA
BACKGROUND: Alterations in genes with innate immune function increase risk for
Crohns disease. It is established that colitis results from breakdown of homeosta-
sis between intestinal microbiota and the mucosal immune system, with both
environmental and genetic inuencing factors. However, the fact that most iden-
tical twin siblings of Crohns disease patients lack disease highlights the impor-
tance of environmental factors including gut microbiota. Herein, we examined
how gut microbiota inuences colitis in mice decient in toll-like receptor 5
(T5KO), which have sub-clinical inammation and are prone to developing spon-
taneous colitis.
METHODS: Composition of the gut microbiota and inammatory markers were
temporally analyzed in colitic T5KO mice, their non-colitic siblings, and closely-
related WT mice. Stools were collected over time after weaning for 10 weeks.
Mice were then euthanized and T5KO mice stratied as having, or lacking, robust
colitis based on exhibition of splenomegaly and colomegaly. Composition of the
microbiota was determined by 454 pyrosequencing of 16s rRNA genes.
Figure 1.
Figure 2.
RESULTS: Loss of TLR5 uniformly resulted in increased levels of inammatory
markers and greater volatility in gut microbiota that eventuated in colitic T5KO
mice having a markedly different microbiota than their non-colitic siblings, whose
microbiota stabilized to a similar composition as WT mice. One striking feature of
gut microbiota of colitic T5KO mice was the transient presence of high levels of
Proteobacteria, and especially Enterobacteria species including E. coli, which
could be observed in close proximity to the gut epithelium. Administration of a
Crohns disease-associated E. coli strain induced chronic colitis in T5KO, but not
WT, mice that persisted well past the time by which both strains of mice had
largely eliminated the bacteria. Of interest, gut microbiota composition analysis
revealed modication in T5KO mice compare to WT after LF82 clearance. This
reveal that LF82 strain could act as an instigator able to modify microbiota to col-
itogenic, as suggested by analysis of LPS and agellin loads.
CONCLUSION(S): Thus, an innate immune deciency can result in unstable gut
microbiota associated with low-grade inammation, and harboring Proteobacteria
can drive and/or instigate chronic colitis.
P-260
Identification of Intracellular Escherichia Coli (IEC), Associated With Crohns Dis-
ease, in Other Intestinal Pathologies
Rodrigo Quera
1
, Marjorie De La Fuente
2
, Mauricio Sabotier
2
, David Diaz-Jimenez
2
,
Daniela Simian
1
, Tamara Perez
3
, Roberto Segovia
3
, Marcela Hermoso
2
1
Clinica Las Condes, Las Condes, Santiago, Chile,
2
Universidad de Chile, Indepen-
dencia, Santiago, Chile,
3
Hospital San Borja Arriaran, Santiago, Chile
BACKGROUND: Several studies have conrmed the presence of adherent-invasive
Escherichia coli (AIEC) in intestinal mucosa of patients with Crohns disease (CD).
AIEC invades intestinal epithelial cells and survives inside macrophages. CD
inammatory disorder, similar to ulcerative colitis (UC), and other intestinal path-
ologies (OP) has been proposed to be the result of an exaggerated immune
response to luminal antigens. The aim of this study was to determine the pres-
ence of IEC strains in patients with CD, UC and OP, and its association with clini-
cal and endoscopic features.
METHODS: For IEC isolation, we evaluated intestinal biopsies from 92 patients: 27
CD, 28 UC, 18 OP and 19 controls. Bacteria were recovered from intestinal biop-
sies using gentamicin-protection assay. Association studies were performed
according to IEC presence, clinical and endoscopic characteristics of patients.
RESULTS: The presence of IEC in 12/27 CD patients was signicantly higher than
control subjects (1/19) (P = 0.0326). This nding was similar to that observed for
UC (p = 0.0126) and OP (P = 0.0028), with 10/28 and 10/18 presented IEC,
respectively. The identication of these bacteria was not associated with gender,
age, extent, location, and severity phenotype (p > 0.05), however patients pre-
senting IEC, 70% were male and 60% presented a colonic location. In the UC
group with isolated bacteria, 50% of patients showed extensive IEC. In the OP
group, 62.5% patients with IEC have been diagnosed with diverticulitis.
CONCLUSION(S): In this study we show that mucosa tissue of patients with other
intestinal disorders, such as ulcerative colitis and diverticulitis, also present IEC,
suggesting a role of these bacteria in the inammatory process. FINANCED BY
FONDECYT GRANT 1120577
P-261
Multiple Bar-Coding 16S Sequencing by Pacbio RS Platform to Study the Gut
Microbiome in Ashkenazi Jews With Crohns Disease
Jianzhong Hu
1
, Ali Bashir
1
, Matthew Pendleton
1
, Zhiheng Pei
2
, Steven Itzkowitz
1
,
Inga Peter
1
1
2
NYU Langone Medical Cen-
ter, New York, NY, USA
BACKGROUND: Crohns disease (CD) results from defects in the mucosal immune
response to luminal factors in genetically susceptible individuals. The role of the
gut microbiome in CD pathogenesis has been suggested by several studies. Until
recently, 454 pyrosequencing approach was considered the gold standard for
Figure 1.
microbiome studies. However, newer, more efcient, and cost-effective technolo-
gies are now available (1). Compared to other next-generation platforms, Pacbio
RS has the advantage of a much shorter sequencing time (-1 hr) and long read
lengths (up to 8kb). However, the embedded, relatively high random sequencing
error rate is considered a limiting factor for applying this technology to 16S-
based taxonomy assignment and phylogenetic analysis. The aim of this study was
to evaluate the performance of Pacbio RS on 16S sequencing of the fecal micro-
biome of Ashkenazi Jews (AJ, a genetically homogeneous high-risk population)
with and without Crohns disease.
METHODS: Stool from 7 AJ-CD patients (in remission) and 8 AJ healthy controls
were analyzed. We established a protocol for multiple 16S rRNA sequencing using
the Pacbio RS system and performed taxon-based and phylogenetic analysis.
Total DNA was extracted from the fecal samples and PCR amplied with unique
16 bp bar-coded primer sets targeting the V3-to-V4 hypervariable regions. PCR
amplicons were pooled in equal molar amounts and sent for library preparation
and sequencing. Control E. coli BL21 strain was used to test the overall classica-
tion rates.
RESULTS: A single run at the movie length of 2x45 minutes generated -55k reads
with -33k reads being longer than 2kb (Figure1a). We used the QIIME pipeline
(2) to assign the 16S rRNA CCS (circular consensus sequencing) reads to the tax-
onomy at phylum, class and family level (Figure1b). Repeated measurements of 2
subjects (P3; P5) showed high correlations at phylum, class and family taxa levels
(r
2
>0.99). The classication rates for the control E. coli were -99.5% at three taxa
levels, respectively. We also used the QIIME pipeline to compare the bacterial
composition in CD patients and unaffected controls. The microbiome diversity
shown by alpha diversity rarefaction plots (Figure2a) was not signicantly differ-
ent between CD and controls. However, the unweighted unifrac PCoA analysis
(Figure2b) clustered microbiota by the disease status. The two pairs of repeated
measurements were closely clustered with each other, as expected. Comparing
each taxon, Clostridia (class level), Ruminococcaceae (family level) and Verrucomi-
crobiaceae (family level) were signicantly less abundant in CD than controls,
consistent with previous studies (3, 4).
CONCLUSION(S): Our data suggest that sequencing error introduced by the Pac-
bio platform is unlikely to affect the classication of common bacterial species in
the gut. Using the 16S deep sequencing on the Pacbio RS platform, we repro-
duced previously observed differences in microbial composition between CD and
controls, suggesting it as a promising method to conduct microbiome studies.
Supported by a CCFA Career Development Award (JH) and grants from The
Chemotherapy Foundation (SI), New York Crohns Foundation (IP), and the
National Cancer Institute UH3CA140233, R01CA159036, and R03CA159414 (ZP).
P-262
Eosinophils Modulate the Composition of Stool Microbiota
Joanne Masterson
1
, Caleb Kelly
1
, Shauna Schroeder
1
, Jonathan Harris
1
, Brandie
Wagner
1
, Mark Stevens
1
, Rui Fang
1
, Lindsay Hosford
1
, Ha Na Choe
1
, James Lee
2
,
Glenn Furuta
3
, Sophie Fillon
1
1
University of Colorado Denver, Aurora, CO, USA,
2
Mayo Clinic Scottsdale, Scotts-
dale, AZ, USA,
3
Childrens Hospital Colorado, Aurora, CO, USA
BACKGROUND: Alterations in the composition of the intestinal microbiota with
reduction of the relative abundance of a major phylum Firmicutes and increase in
Proteobacteria is observed in patients with IBD. Reduction in bacterial diversity
and dysbiosis of the intestinal microbiome contributes to the pathogenesis of
IBD. Animal models have also provided strong evidence for the role of the micro-
biome in IBD (eg. IL-10, Toll-Like Receptor and Myd88 knockout mice). Eosinophil
presence is increased in IBD tissue and these cells generate different molecules
with anti-microbial properties (eg. granule proteins, anti-microbial peptides and
extracellular DNA traps). Moreover, the juxtaposition of intestinal eosinophils to
the epithelium with its bacteria laden luminal surface suggests they may partici-
pate in the maintenance of intestinal immune homeostasis. The aim of this study
was to determine the effect of eosinophils on the composition of the intestinal
microbiota. We hypothesize that resident intestinal microbiota populations are
modulated by eosinophils.
METHODS: To address this hypothesis, we studied two strains of eosinophil de-
cient mice (PHIL and Ddbl-GATA) and their corresponding wild types (C57BL/6
and BALB/c), respectively. Mice were housed in the same animal facility under
specic pathogen free (SPF) conditions and were fed the same chow. Between 8-
12 weeks of age, C57BL/6 (n = 12) and PHIL (n = 9) female and BALB/c (n = 13)
and Ddbl-GATA (n = 13) female mice stool pellets were collected for DNA isola-
tion (Qiagen). Composition of the stool microbiota was determined by metage-
nomic analysis of PCR amplied bacterial 16S rDNA using 454 pyrosequencing,
and phylogenic analysis.
RESULTS: Measurement of microbial load by 16S quantitative PCR did not reveal
differences between C57BL/6 and PHIL mice or BALB/c and Ddbl-GATA. Pyrose-
quencing data revealed that the bacterial genera Shigella and Enterobacter were
uniquely present in the stool from PHIL mice but not in the C57BL/6 and that
Alistipes, Odoribacter and Limibacter were uniquely present in the stool from
Ddbl-GATA mice but not in the BALB/c.
CONCLUSION(S): Absence of eosinophils may increase the susceptibility of mice
to colonization by opportunistic pathogens based on the presence of Shigella
and Enterobacter in the PHIL mice and Alistipes, Limibacter and Odoribacter in
the Ddbl-GATA mice. These results suggest that eosinophils may play a role in
maintaining homeostatic composition of the intestinal microbiota. This work was
supported by a Crohns Colitis Foundation of America Student Research Award
and North American Society of Pediatric Gastroenterology, Hepatology and Nutri-
tion Summer Student Award (CJ Kelly).
P-263
Muc2 Limits Pathogen Burdens and Epithelial Barrier Dysfunction During Sal-
monella Typhimurium Colitis
Maryam Zarepour
1
, Kirandeep Bhullar
1
, Caixia Ma
1
, Tina Huang
1
, Anna Velcich
2
,
Lijun Xia
3
, Bruce Vallance
1
1
Child and Family Research Institute, Vancouver, BC, Canada,
2
Montefiore Medical
Center, Bronx, NY, USA,
3
Oklahoma Medical Research Foundation, Oklahoma City,
OK, USA
BACKGROUND: Commensal as well as pathogenic bacteria have been implicated
as possible triggers of Inammatory Bowel Disease (IBD). The ability of pathogens
to cause episodes of infectious gastroenteritis could play a role in the initiation,
and/or exacerbation of IBD. In fact, an increased risk of IBD has been reported in
individuals who suffer an acute episode of Salmonella gastroenteritis. For Salmo-
nella to cause gastroenteritis, it has to directly infect the epithelial cells lining the
mammalian intestine. Despite many studies exploring Salmonella interactions
with epithelial cells, it is unclear how this pathogen evades and survives the array
of host defenses found in the mammalian intestine. In particular it is unclear how
Salmonella interacts with as well as crosses the mucus layer that protects the
underlying intestinal epithelial cells from such noxious agents. Salmonella enter-
ica serovar Typhimurium is a model organism used to test the virulence factors
involved in Salmonella pathogenesis. To study Salmonellas ability to cause intesti-
nal inammation, most groups use a colitis model relying on streptomycin to
Figure 2.
displace intestinal commensal microbes, resulting in heavy pathogen colonization
of cecal tissues and severe inammation. Although intestinal mucus is the rst
line of defense in the mouse GI tract, its role in providing host defense against
Salmonella is still unclear. The mucus barrier is made up of the highly glycosyla-
ted mucin Muc2, which is secreted by goblet cells. Muc2 glycosylation occurs
within the goblet cell and likely has signicant implications for the function and
effectiveness of the mucus barrier. Glycosylation involves the actions of several
enzymes, for example, Core 3- O derived glycans are synthesized by Core 3 b1,3-
N-acetylglucosaminyltransferase (C3GnT). Mice lacking these glycans still produce
the Muc2 protein, but display a thinner mucus barrier, and show increased sus-
ceptibility to chemical induced colitis.
METHODS: We began our investigations by comparing Salmonella induced colitis
and mucus dynamics in Muc2 decient (-/-) mice, C3GnT-/- mice and wildtype
C57BL/6 mice.
RESULTS: We observed that mucus secretion increased in response to Salmonella
infection in C3GnT-/- and C57BL/6, with Salmonella found within the mucus layer.
In contrast, Muc2-/- mice showed dramatic susceptibility to Salmonella infection,
carrying 100 fold heavier cecal pathogen burdens and developing signicantly
increased barrier disruption compared with C57BL/6 mice. As a result, Muc2 -/-
mice displayed high rates of morbidity and mortality. We also tested the suscepti-
bility of C3GnT -/- mice, nding they carry WT pathogen burdens but developed
exaggerated barrier disruption like Muc2 -/- mice.
CONCLUSION(S): These data suggest that the intestinal mucus layer plays a critical
role in controlling Salmonella intestinal burdens, whereas core-3 glycosylation
plays an important role in controlling intestinal epithelial barrier function.
P-264
Distinct Inflammatory Pathways Induce Altered Intracellular Bacterial Commu-
nity in Murine Colonic Lamina Propria Macrophages
Rishu Dheer, Julie Davies, Sebastian Strobel, Rebeca Santaolalla, Cecilia Espana,
Maria Abreu
BACKGROUND: The intestinal immune system including lamina propria macrophages
protects the host from pathogens and excessive entry of normal gut residing
microbes. Chronic inammation in IBD patients has been associated with polymicro-
bial changes in the normal intestinal microbiota of the host. However, it is not clear
whether this altered microbiota is the cause of the disease or is merely an outcome
of the disease or plays a role in the progression of the disease. Additionally, the ma-
jority of human microbiota studies are done with biopsies or stool samples from
IBD patients and are challenged by the vast heterogeneity of the bacterial popula-
tions in these samples. To overcome this challenge we decided to investigate the
bacteria that have already crossed the intestinal epithelial barrier and thus may play
a role in disease pathogenesis by modulating the host immune response.
METHODS: We compared the intracellular bacterial composition of colonic lamina
propria macrophages isolated from murine models that mimic 3 different inam-
matory pathways: Th1/Th17 (TNBS), Th2 (oxazolone) and epithelial injury (DSS).
RESULTS: Changes in bacterial community composition were evident in all three
models. Most of the DNA sequences obtained from 16S analysis of control and
inammatory macrophages belonged to phylum Firmicutes and Proteobacteria as
opposed to the mucosal or stool samples which are generally predominated by
Bacteroidetes and Firmicutes. Following inammation, the abundance of Firmi-
cutes and Proteobacteria varied between the macrophages from control and
inammatory models.
CONCLUSION(S): The results of this study suggest that inammatory responses
inuence the composition of the phagocytised microbial population in lamina
propria macrophages.
P-265
Characterization of Mucosally Associated Bacteroidales From Pediatric Subjects
With Inflammatory Bowel Disease
Naamah Zitomersky
1
, Benjamin Atkinson
2
, Sarah Franklin
2
, Paul Mitchell
3
,
Laurie Comstock
4
, Scott Snapper
5
, Athos Bousvaros
6
1
Gastroenterology Division, Boston Childrens Hospital, Harvard Medical School,
Boston, MA, USA,
2
Division of Gastroenterology, Boston Childrens Hospital, Bos-
ton, MA, USA,
3
Clinical Research Center, Boston Childrens Hospital, Boston, MA,
USA,
4
Infectious Disease Department, Brigham and Womens Hospital, Harvard
Medical School, Boston, MA, USA,
5
Boston Childrens Hospital and Harvard Medi-
6
Center for Inflammatory Bowel Disease, Boston
BACKGROUND: Inammatory Bowel Disease (IBD) likely arises from an exagger-
ated host immune response to intestinal microbiota. Bacteroidales are numeri-
cally predominant intestinal bacteria and can exert positive and negative host
effects.
METHODS: We performed a comprehensive culture based analysis of Bacteroi-
dales from inamed and uninamed intestinal biopsy tissue from pediatric
patients (5-23 years) with Crohn disease (CD), ulcerative colitis (UC), and control
subjects with the goal of understanding differences in their mucosally adherent
Bacteroidales populations. Biopsies were cultured anaerobically on Bacteroidales
selective plates. Total Bacteroidales per biopsy were quantied by colony counts,
and predominant Bacteroidales species were identied using multiplex PCR and
16S rDNA sequencing.
RESULTS: We obtained intestinal biopsies from 94 patients (39 CD, 24 UC, and
31 controls). 17 patients were treatment naive. Each patient had 3 biopsies cul-
tured from different regions of the intestine. Total Bacteroidales (cfu) per biopsy
did not differ signicantly between groups or at inamed and uninamed sites.
We identied 18 different Bacteroidales species in the study group, with up to
ten different species per biopsy. Biopsies from patients with both CD and UC
had a reduction in the number of species (reduced diversity) compared to con-
trols (192 IBD, 97 control, P = 0.004). Inamed biopsies had reduced Bacteroi-
dales diversity (P = 0.05). B. fragilis producing pathogenic (bft) or anti-colitic
(PSA) factors were not associated with inamed or uninamed tissue
respectively.
CONCLUSION(S): Our study demonstrates tremendous Bacteroidales species diver-
sity from human intestinal biopsies, more than previously reported. IBD associ-
ated inammation results in a reduction in species diversity within the Bacteroi-
dales order.
Author Index
Abell, Rebecca P-134, P-137
Abou-Rejaile, Vinicius P-11, P-110
Abraham, Bincy P-17, P-37, P-154
Abramowicz, Shelly P-121
Abreu, Maria O-27, O-30, P-222, P-240, P-247, P-264
Absah, Imad P-135
Abu-Elmagd, Kareem O-4, P-109
Acame, Nuria P-72
Acharya, Mridu O-25, P-250
Ahearn, Tom P-107
Aherne, Carol P-173, P-236
Alam, Ashfaqul O-22, P-210
Albenberg, Lindsey P-257
Albuquerque, Idblan P-111
Ali, Asif P-75
Ally, Mazer P-12
Almeida, Neogelia P-52, P-66, P-73
Almenta, Isabel P-72, P-114
Alrubaiy, Laith P-34, P-35, P-36, P-97
An, Dingding O-16, P-174
Anderson, Michael O-8, P-145
Andoh, Akira P-113
Andreu, M P-53, P-54
Anna, Kiran P-75
Annaim, Ali P-165
Anton, Kristen P-33, P-70, P-71
Anver, Miriam O-29, P-176
Archer, Stephen P-214
Ardid, Denis P-190, P-243
Aristizabal, Natalia P-13
Arjunan, Krishna P-198
Armbruster, Steven P-81
Armstrong, David P-169
Arnold, Anthony P-193
Aroyo, Nimrod P-235
Asano, Kouichi P-126
Atkinson, Benjamin P-161, P-265
Atreja, Ashish P-50
Ayrizono, Maria de Lourdes P-111
Bailey, Aubrey P-117
Bairdain, Sigrid O-3, P-112
Baldassano, Robert O-15, P-117, P-226, P-257
Bamba, Shigeki P-113
Ban, Hiromitsu P-113
Bancroft, Barbara P-147, P-159
Bao, Richard O-26, P-171
Baptista, Veronica P-8
Barbosa, Moni P-15
Barlow, John P-122
Barnich, Nicolas P-190
Barrenengoa, Julio P-72
Barrett, Terrence O-30, P-247
Bartholomew, Catherine P-6, P-204
Bartuzzi, Paulina P-229
Bashir, Ali P-261
Bass, Julie P-158
Bayless, Amanda O-19, O-23, P-225, P-232
Bayless, Theodore P-49, P-77
Beaulieu, Dawn P-55, P-143
Becker, Brenda P-122
Becker, Courtney O-18, P-245
Begun, Jakob P-227
Beisvag, Vidar P-119
Bejarano, Pablo O-30, P-247
Ben-Horin, Shomron P-26
Benchimol, Eric P-40
Benhayon, David P-44
Benjamin, Jamaal O-13, P-255
Benkov, Keith P-116
Berliner, Shlomo P-235
Bernink, Jochem O-31, P-230
Bhol, Kailash P-203
Bhullar, Kirandeep P-263
Biank, Vincent O-10, P-160, P-239
Binion, David P-44
Bissonnette, Marc P-120, P-214
Blank, Ellen O-10, P-160
Bloomfeld, Richard P-93
Bloomgren, Gary P-129
Boergers, Julie P-147, P-159
Boisvert, Heike P-121
Boldyreva, Oxana P-125
Bollinger, Elizabeth P-7
Bond, Geoffrey O-4, P-109
Boone, David O-14, O-21, P-209, P-212, P-214, P-238
Borum, Marie P-9, P-84, P-85, P-86, P-87, P-88, P-89,
P-95, P-96
Bosurgi, Lidia O-31, P-230
Bousvaros, Athos O-5b, P-121, P-150, P-265
Bowen, Dafydd P-97
Bowers, Brittelle O-19, O-20, O-23, P-219, P-221, P-225,
P-232
Bozic, Carmen P-129
Bracken, Julia P-163
Brant, Steven P-49
Brazil, Jennifer P-206
Bright, Renee P-67
Bruining, David P-122
Bruyninckx, Walter O-19, P-232
Brzezinski, Aaron P-99
Buckner, Jane P-200
Burgunder, Patricia P-131, P-132
Burlingame, Oname O-30, P-247
Burstein, Ezra P-229
S117
Bushman, Fredric P-117, P-257
Butcher, Eugene P-242
Butcher, Mackenzie P-218
Byeon, Jeong-Sik P-45, P-46, P-48
Caldera, Freddy P-1
Callejas, Silvia O-7, P-164
Campbell, Eric O-19, O-20, O-23, P-219, P-221, P-225,
P-232
Canaani, Jonathan P-235
Cannon, Jamie P-251
Cao, James P-204
Capaldo, Cristopher P-211
Capocelli, Kelley P-254
Caravaca, April P-193
Cario, Elke P-191
Carlos, Yepes P-13
Carpenter, Ellen P-158
Carrera Silva, Eugenio Antonio O-31, P-230
Carroll, Ian P-189
Carvalho, Frederic P-190, P-243, P-259
Cave, David P-8
Cea-Calvo, L P-53, P-54
Ceballos, Clare P-116
Cerezo, Carolina P-157
Cerosaletti, Karen P-200
Chan, Lillienne P-229
Chandler, Matthew P-9
Chandrasekharan, Bindu P-196
Chao, Jingdong P-22, P-58, P-59, P-60, P-61, P-62
Chaparro, Aida P-142
Chaparro, M P-54
Chapuy, Laurence P-140
Chassaing, Benoit P-244, P-259
Chauhan, Usha P-169
Chawla, Anupama P-139
Chen, Janice P-200
Chen, Jeremy P-246
Chen, Jun P-257
Chen, Wenli P-33, P-70, P-71
Chen, Xinhua O-17, P-188, P-258
Chen, Yingwei P-82
Chen, Yunzi P-205
Cheung, Wai-yee P-34
Childers, Ryan P-77
Choe, Ha Na P-262
Choquette, Denis P-124
Christensen, Lisbet P-41
Christenson, Kathy P-158, P-163
Chuang, Alice P-209
Chuang, Jim P-209
Church, Peter O-9, P-144
Ciorba, Matthew P-187
Clambey, Eric P-173
Clark, Shawn P-203
Cloney, Deborah P-128
Coelho Filho, Joao P-15
Cohen, Russell P-62
Colgan, Sean O-19, O-20, O-23, P-219, P-221, P-225,
P-232
Collins, Colm P-175
Collins, Judith P-30, P-69
Colombel, Jean-Frederic P-19, P-20, P-21, P-22, P-23,
P-26, P-30, P-58, P-59, P-63, P-64, P-65, P-69, P-155
Comerford, Lawrence P-78
Comiskey, Stephen P-198
Comstock, Laurie P-265
Conrad, Harold P-128
Copsey, Helen P-81
Coqueiro, Fernanda P-52, P-66
Costa, Guilherme O-4, P-109
Costa-Pinto, Frederico P-172
Costidio, Megan P-99
Cotter, Jose P-91, P-100
Cox, Stephen P-115
Coy, Claudio P-111
Crawford, James P-16
Cristiano, Lynda P-129
Cross, Raymond P-57, P-70
Cummings, Richard P-206
DHaens, Geert P-20, P-21, P-22, P-26
Dahan, Stephanie P-116, P-215
Damas, Jan P-119, P-248
Dann, Sara P-195
Darfeuille-Michaud, Arlette P-190, P-251, P-259
Dasgupta, Suryasarathi O-28, P-178
Davies, Julie O-27, O-30, P-222, P-247, P-264
de Barcelos, Ivan P-11, P-110
De La Fuente, Marjorie P-260
de Leon, Lauren P-67
de Madaria, Enrique P-72
de Zoeten, Edwin P-175
Deal, Emily P-242
deBruyn, Jennifer O-6, P-148
deFonseka, Arushi P-10
Delgado, Maria P-244
Delgado Cuevas, Victor O-31, P-230
Denning, Timothy P-199, P-207
DePanicis, Renee P-131
Deslandres, Colette P-140
Dheer, Rishu P-264
Dhere, Tanvi P-107
Dias de Castro, Francisca P-91, P-100
Diaz-Jimenez, David P-260
Diehl, Gretchen O-24, P-241
Diener, Melissa P-62
DiFalco, Janet P-134
Author Index S118
Dillman, Jonathan P-192
Dinwiddie, Darrel P-163
Dirisina, Ramanarao O-30, P-247
Docktor, Michael P-121
Dotan, Iris P-235
Dougherty, Ursula P-120, P-205
Dowd, Scot P-115
Dracker, Robert P-83
Dranove, Jason 0-2, P-138
Drozdov, Ignat P-119
Drubin, David P-118
Dube, Philip P-186
Dubinsky, Marla O-7, P-164
Duff, Kyle P-44
Dulai, Parambir P-106, P-108
Duncan, James P-14
Duncan, Margaret P-121
Dunkin, David P-116, P-215
Dupas, Jean-Louis P-155
Durum, Scott O-29, P-176
Dutta, Usha P-169
Ebach, Dawn P-156
Eckmann, Lars P-195
Ehrentraut, Stefan O-23, P-221, P-225
Ehrlich, Orna P-50
Elias, George P-5
Ellerman, Melissa P-189
Eltzschig, Holger P-173, P-236
Eluri, Swathi P-77
Enomoto, Laura P-92
Erturk-Hasdemir, Deniz O-28, P-178
Esaki, Motohiro P-126
Eschalier, Alain P-190, P-243
Esipova, Tatiana P-257
Espana, Cecilia O-30, P-247, P-264
Espevik, Terje P-119, P-248
Evans, Elisabeth P-3
Ey, Birgit P-191
Eyking, Annette P-191
Fahmy, Marianne P-3
Falaiye, Tolulope P-143
Faltys, Michael P-193
Fan, Jiangao P-82
Fang, Kai P-184, P-185
Fang, Rui P-262
Farias, MariaLucia P-31, P-32
Farkas, Attila P-211
Farrior, Sharmayne O-7, P-164
Farsio, Sara P-170, P-215
Fasanya-Uptagraft, Helen P-4
Fayad, Raja P-182
Feagan, Brian O-1b, P-24, P-25, P-26, P-28, P-30, P-60, P-
61, P-69
Fedyk, Eric P-177
Felber, Barbara O-29, P-176
Feliu, Marianela O-25, P-250
Feng, Rong P-198
Feng, Sharon O-6, P-148
Fidler, Jeff P-122
Fiebiger, Edda P-183
Fillon, Sophie P-262
Finlayson, Samuel P-106, P-108
Fitch, Kara P-131
Flasar, Mark P-57
Flatberg, Arnar P-119, P-248
Fleshner, Phillip P-101
Fletcher, Joel P-122
Flowers, Nicole P-67
Flynn, Kathryn P-70
Fonseca, Kevin O-6, P-148
Formiga, Galdino P-111
Forster, Alan P-40
Forteza, Radia P-223
Foss, John P-198
Fox, Barbara P-203
Fox, Irving O-1a, O-1b, P-26, P-27, P-28
Frances, Ruben P-114
Franklin, Sarah P-265
Frederick, Kimberly P-50
Fredrich, Katherine P-239
Friedman, Joshua O-15, P-226
Friehling, Jane P-104
Frost, Karen O-9, P-144
Fu, Yang-Xin P-252
Fujimoto, Takehide P-113
Fujiyama, Yoshihide P-113
Fukata, Masayuki O-30, P-216, P-247
Fukunaga, Ken P-103, P-133
Fumery, Mathurin P-155
Funari, Vincent O-18, P-245
Furuta, Glenn P-254, P-262
Gagliani, Nicola O-31, P-230
Gallagher, Grant P-104
Gambil, Neil P-14
Garber, John P-217
Garc a de Vicuna, R P-53, P-54
Garg, Pallavi P-201
Gater, Adam P-68
Ge, Wensong P-82
Gebbia, Jennifer O-7, P-164
Geem, Duke P-199
Gelot, Agathe P-190
Genta, Robert P-218
Gerken, Guido P-191
Gewirtz, Andrew P-243, P-244, P-259
Ghosh, Sourav O-31, P-230
Author Index S119
Gibson, Peter P-30, P-69
Girard, Jonathan O-5b, P-150
Glawe, John P-184
Glover, Louise O-19, O-20, O-23, P-219, P-221, P-225,
P-232
Gluck, Nathan P-229
Goday, Praveen O-10, P-160
Goettel, Jeremy P-183, P-237
Gokhale, Ranjana O-10, P-160
Golan, Maya P-205
Goldsmith, Jeffrey P-188
Gomara, Roberto P-162
Gomes, Luanda P-31, P-32
Gomez, F P-53, P-54
Gondim, Flora P-15
Gonzalez-Navajas, Jose P-114
Gordillo, J P-53, P-54
Gourlay, David P-239
Gower-Rousseau, Corinne P-155
Grams, Jayleen P-251
Grand, Richard O-5a, O-5b, P-149, P-150
Granlund, Atle P-119, P-248
Green, Jesse P-6
Greenberg, Deborah P-57
Greenberg, Harry P-242
Greenley, Rachel O-10, P-160
Greenwald, Eric P-169
Gregor, James P-40
Greguska, Kimberly P-239
Grifths, Anne O-9, P-144
Griglione, Nicole P-107
Grimes, Ian P-1
Grimm, Wesley P-214
Grisham, Matthew P-185
Grivennikov, Sergei P-202
Grosen, Anne P-41
Grunberg, Stephanie P-117, P-257
Grunow, John O-8, P-145
Guan, Jack O-9, P-144
Guberman, Irene P-235
Gumidyala, Amitha O-10, P-160
Gustafsson, Bjrn P-119
Gutierrez, Ana P-72, P-114
Guttmann, Astrid P-40
Guzzo, Cynthia P-30, P-69
Hagin, Sarah P-147, P-159
Halpern, Zamir P-235
Hamilton, Ross P-207
Han, Chenglong P-69
Han, Yiping P-47
Hanauer, Stephen P-25, P-26
Hansen, Brian P-68
Hanson, Elaine P-195
Hanson, Miranda O-29, P-176
Harbour, Stacey P-181
Hardt, Marcelo P-127
Haribhai, Dipica P-180
Harper, Jason P-42
Harris, Jonathan P-262
Harris, Rachel P-254
Harris, Ronald P-115
Hashash, Jana P-44
Hasseriis, Sara P-41
Hatton, Robin P-181
Hayes, Chris P-159
Hayward, Michael P-239
He, Bin P-218
Hedge, Shweta P-182
Heintz, Dyer P-151, P-152
Hermoso, Marcela P-260
Hernandez, Ana P-142
Heron, Louise P-68
Hibi, Toshifumi P-79
Hida, Nobuyuki P-103, P-133
Higgins, Peter P-192
Hilgarth, Roland P-211
Hing, Tressia P-233
Hirai, Fumihito P-123
Hisamatsu, Tadakazu P-79
Hixon, Julie O-29, P-176
Hmoud, Bashar P-5
Hoang, Vy P-118
Hodge, Daniel P-2
Hoffman, Barbara O-4, P-109
Hogge, Gary P-63, P-64, P-65
Holderman, MD, William P-90
Holdorf, Amy P-203
Hollenbeak, Christopher P-92
Holler, Ernst P-114
Holubar, Stefan P-106, P-108
Hommel, Kevin P-153
Hong, Li P-130
Hooper, Lora O-13, P-255
Horst, Sara P-55, P-143
Horwitz, Bruce P-237
Hosford, Lindsay P-254, P-262
Hostetter, Jesse P-194
Hotte, Charles P-17
Hou, Jason P-37
Hovhannisyan, Zaruhi P-170, P-215
Hu, Jianzhong P-261
Huang, Bidan P-23
Huang, Tina P-263
Hudson, Catherine P-7
Hudson, Paul P-189
Hutchings, Hayley P-35, P-36
Author Index S120
Hutess, Susan P-49, P-77
Hvas, Christian P-41
Hyun, Jinhee P-216
Ichikawa, Ryan P-246
Iimuro, Masaki P-103, P-133
Iliev, Iliyan O-18, P-245
Imaeda, Hirotsugu P-113
Imamura, Akimichi P-51
Inoue, Nagamu P-79
Isaksen, Morten P-105
Ishii, Manabu P-51
Iskandar, Heba P-187
Itzkowitz, Steven P-261
Iuga, Alina P-215
Iwao, Yasushi P-79
Jacob, Gary P-198
Jain, Umang P-249
Jamal, M. Mazen P-39
Jarnerot, Gunnar P-30, P-69
Jasutkar, Niren P-102
Jedel, Sharon P-130
Jedlicka, Paul O-19, P-232, P-236
Jergens, Albert P-194
Jester, Traci P-251
Jobin, Christian P-213
Johanns, Jewel P-30, P-69
Johnson, Laura P-192
Johnson, Victor O-3, P-112
Judge, Colleen P-257
Juliao, Fabian P-13
Julio, Zuleta P-13
Julsgaard, Mette P-41
Jung, Kee Wook P-45, P-46, P-48
Kadambi, Vivek P-177
Kahn, Stacy O-10, P-160
Kalra, Amita P-56
Kamata, Noriko P-98
Kamekura, Ryuta P-207
Kamen, Diane P-78
Kamikozuru, Koji P-103, P-133
Kanagavelu, Saravana P-216
Kanai, Takanori P-79
Kane, Sunanda P-55, P-63, P-64, P-65
Kanna, Sowjanya P-75
Kanneganti, Thirumala-Devi P-253
Kappelman, Michael P-33, P-70, P-71, P-165
Karin, Michael P-202
Kasper, Dennis O-16, O-28, P-174, P-178
Kathiria, Arwa P-218
Katz, Seymour P-16, P-94
Kaur, Kamaljeet P-182
Keane, David P-203
Keller, Rogeria P-256
Kellermayer, Richard P-115
Kelly, Caleb O-19, O-20, O-23, P-219, P-221, P-225,
P-232, P-262
Kelly, Ciaran O-17, P-188, P-258
Kelly, Maureen P-165
Kelsen, Judith P-117
Kerwood, Fred P-129
Keshavarzian, Ali P-130
Kevil, Christopher P-184, P-185
Khandwalla, Hashim P-37
Khanna, Sahil P-38
Kidd, Mark P-119
Kim, Jin-Ho P-45, P-46, P-48
Kim, Jong Wook P-45, P-46, P-48
Kim, Kyung-Jo P-45, P-46, P-48
Kim, Sandra 0-2, P-138
Kinder, AnneMarie P-104
Kingsmore, Stephen P-163
Kiran, Ravi O-2, P-76, P-99
Kirschner, Barbara O-10, P-160
Kitazono, Takanari P-126
Kitchen, Helen P-68
Kleinubing Jr, Harry P-127
Kleven, Daniel P-141
Knight, Rob P-259
Knyazev, Oleg P-18, P-125
Ko, Jeffrey O-30, P-247
Koch , Stefan P-207
Kokkotou , E P-196
Kolegraff, Keli P-207
Kominsky, Douglas O-19, O-20, O-23, P-219, P-221,
P-225, P-232
Kono, Tomoaki P-103, P-133
Konoplyannikov, Anatoliy P-18, P-125
Koon, Hon Wai P-233, P-234, P-246
Kopel, Sheryl P-147, P-159
Koren, Omry P-259
Koritsky, Darlene O-4, P-109
Koroleva, Ekaterina P-252
Kotze, Lorete P-11, P-110
Kotze, Paulo P-11, P-110, P-111, P-127
Koval, Michael P-211
Krishnarao, Anita P-67
Kron, Martina P-19, P-20, P-21
Kugathasan, Subra P-128
Kuhn, Susan O-6, P-148
Kulkarni, Sakil P-162
Kumar, Gagan P-43
Kumar, Nilay P-43
Kunde, Sachin P-128
Kunz, Jennifer O-10, P-160
Kurmaeva, Elvira O-26, P-171
Kwa, Michael P-132
Author Index S121
Kwal, Jaclyn O-22, P-210
Kwon, John P-209
Kwon, Manjae O-25, P-250
Lacy-Hulbert, Adam O-25, P-250
Lahl, Katharina P-242
Laifenfeld, Daphna P-118
Laitman, Lauren P-215
Landreneau, Stephen P-7
Lastra, PM P-54
Lau, Winnie P-23
Lazar, Andreas P-19, P-20, P-21, P-22, P-60, P-61
Le, Christine P-195
Leal, Raquel P-111
Lee, Jae Yeon P-45
Lee, James P-254, P-262
Lee, Scott P-24, P-25
Legarda, Diana P-231
Leighton, Jonathan O-31, P-230
Leleiko, Neal P-67, P-147, P-157, P-159
Lemos, Antonio P-15
Lemos, Brenda P-203
Leong, John P-217
Leoni, Giovanna O-22, P-210
Lerebours, Eric P-155
Lerner, Diana P-239
Levine, Anne P-161
Levine, Yaakov P-193
Levy, Aaron P-74
Levy, Benjamin P-7
Lewis, James P-23, P-63, P-64, P-65, P-71, P-117, P-257
Lexmond, Willem P-183
Ley, Ruth P-259
Li, Chen P-82
Li, Dan O-17, P-258
Li, Haiying P-229
Li, Hao P-220
Li, Wenqing O-29, P-176
Li, Xiu-Min P-116
Li, Yan Chun P-205
Lien, Chueh O-3, P-112
Lightdale, Jenifer P-161
Lima, Carla P-73
Limketkai, Berkeley P-49
Limsui, David P-56
Linden, Bradley O-3, P-112
Lindholm, Philip P-2
Lipka, Seth P-16, P-94
Lira, Sergio O-30, P-247
Lisboa, Sonyara P-73
Littman, Dan O-24, P-241
Liu, Hongchun P-201
Liu, Renpeng P-206
Liu, Weicheng P-205
Liu, Yu-Jiang P-129
Lobato, Debra P-147, P-159
Loftus, Edward P-38, P-80, P-122
Long, Millie P-33, P-70, P-71
Longman, Randy O-24, P-241
Lopes, Mirella P-52
Lopez, P P-54
Lopez, Rocio P-99
Lord, James P-200
Loreaux, Katherine P-153
Louis, Edouard P-58, P-59
Louis, Nancy P-206
Lu, Zengqi P-143
Lucia-Casadonte, Chantal P-162
Ludvig, Juliano P-127
Lujan, M P-53, P-54
Lundin, Knut P-179
Luthra, Gurinder P-5
Ma, Caixia P-263
MacDermott, Richard P-6, P-204
Macho Fernandez, Elise P-252
Mack, David P-40
Macoritto, Michael P-118
Magalhaes, Joana P-91, P-100
Maharshak, Nitsan P-189, P-235
Maletsky, Kristin O-5b, P-150
Malik, Ahsan P-97
Mallick, Emily P-217
Malutta, Everson P-127
Mani, Sridhar P-220
Manick, Sayeed P-189
Manuel, Douglas P-40
Marano, Colleen P-30, P-69
Marhinshaw, Jeffrey P-187
Mar n-Jimenez, I P-53, P-54
Markus-Kennell, Sheri P-50
Marquez, Juan P-13
Marshall, John P-40, P-169
Martin, Christopher P-33, P-70, P-71
Martinez, Alfonso O-10, P-160
Martins, Juliana P-110
Martinsen, Tom Christian P-119
Masadeh, Maen P-5
Mashukova, Anastasia P-223
Masterson, Joanne P-254, P-262
Mathern, Douglas P-215
Mathur, Jagrati P-56
Matsui, Toshiyuki P-123
Matsumoto, Takayuki [Hyogo] P-103, P-133
Matsumoto, Takayuki [Kyushu] P-126
Matsuno, Rayna P-77
Matsuoka, Katsuyoshi P-79
Maydonovitch, Corinne P-81
Author Index S122
Mayer, Lloyd P-116, P-170, P-224
Maynard, Craig P-181
McLean, Mairi O-29, P-176
McMullan , Shelton P-96
McNally, Michael P-14
McNamee, Eoin O-19, P-173, P-232
McQuaid, Elizabeth P-147, P-159
Meckel, Katherine P-120
Medina-Contreras, Oscar P-199, P-207
Megjugorac, Nicholas P-104
Meleine, Mathieu P-243
Melmed, Gil O-7, P-101, P-164
Melton, Shelby P-229
Mendonca, Laura P-31, P-32
Menezes, Camilla P-52
Merrick, Marjorie P-67
Messer, Jeannette O-14, P-212, P-214
Mihas, Paul P-165
Mikhailova, Svetlana P-18
Milbury, Kate P-168
Milch, Catherine O-1a, O-1b, P-26, P-27, P-28
Miller, Neil P-163
Miller, Tracie P-142
Mills, Paul P-56
Mir, Sabina P-115
Miranda, Adrian O-10, P-160
Miranda, Eron P-110, P-127
Mishima, Yoshiyuki P-197
Mitchell, Keisha P-143
Mitchell, Paul P-265
Mizuno, Shinta P-79
Moawad, Fouad P-2
Moons, David P-192
Moral, I P-53
Moreira, Andre P-111
Moreira, Maria Joao P-91, P-100
Morganstern, Jeffrey P-134, P-137, P-139
Moriyama, Tomohiko P-126
Moseley, Carson P-181
Moskaluk, Christopher P-10
Motoya, Satoshi P-51
Moulton, Dedrick P-143
Mrakotsky, Christine O-5a, O-5b, P-149, P-150
Mucida, Daniel P-172
Muehlbauer, Marcus P-213
Muise, Aleixo O-9, P-144
Mukewar, Saurabh O-2, P-76, P-99
Mukherejee, Subhajit P-220
Mukherjee, Paromita P-220
Mukhopadhyay, Subhankar O-25, P-250
Mulani, Parvez P-58, P-59, P-60, P-61, P-62
Mullen, Kevin P-75
Murphy, Stephen O-14, O-21, P-212, P-214, P-238
Murrell, Zuri P-101
Myung, Seung-Jae P-45, P-46, P-48
Nag, Arpita P-63, P-64, P-65
Naganuma, Makoto P-79
Nagy-Szakal, Dorottya P-115
Nakamura, Shiro P-103, P-133
Nakamura, Shotaro P-126
Nannegari, Veena P-6
Nannegari, Veena P-204
Nantel, Francois P-124
Nassau, Jack P-147, P-159
Natarajan, Yamini P-154
Nava, Porrio P-207
Naymagon, Steven P-92
Neill, Luke P-252
Neish, Andrew O-22, P-210
Nero, Thomas O-21, P-238
Neumann, William P-218
Ng, Aylwin P-227
Nguyen, Douglas P-39
Nguyen, Eve O-10, P-160
Nguyen, Geoffrey P-40
Nguyen, Kim P-195
Nguyen, Kim-Doan P-141
Nick, Heidi P-251
Noe, Joshua O-10, P-160
Nogami, Koji P-103, P-133
Nrgaard, Mette P-41
Nunes, Patr cia P-52, P-66
Nusrat, Asma O-22, P-207, P-210, P-211
OConnor, Judith O-8, P-145
OMalley, Bert P-218
Ogata, Haruhiko P-79
Oh, Sungwhan O-16, P-174
Ohda, Yoshio P-103, P-133
Olandoski, Marcia P-111, P-127
Oliveira, Vanessa P-52
Olsen, Ingrid P-179
Onken, Jane P-4
Orpaz, Naama P-235
Ostanin, Dmitry O-26, P-171
Osterman, Mark P-23
Overstreet, Anne-Marie P-194
stvik, Ann P-119, P-248
Packey, Christopher P-189
Paidassi, Helena O-25, P-250
Panaccione, Remo P-19, P-58, P-59, P-63, P-64, P-65
Pandya, Shivangi P-96
Pankow, Alexis P-146
Pant, Chaitanya O-8, P-145
Pardi, Darrell P-38, P-80, P-122
Paredes, Angelo P-14
Parikh, Asit P-26, P-29
Author Index S123
Park, Sang Hyoung P-45, P-46, P-48
Park, Soo-Kyung P-45, P-46, P-48
Parker, Gerry P-24
Parkos, Charkes P-199, P-206, P-207, P-208, P-211
Paster, Bruce P-121
Pastorini, Cristhine O-30, P-247
Patel, Ankit P-78
Patel, Ashish P-151, P-152
Patel, Neal P-201
Pei, Zhiheng P-261
Pekow, Joel P-120
Pendleton, Matthew P-261
Penninck, Eugenie P-155
Perez, Tamara P-260
Perez Gisbert, J P-13, P-53
Perez-Calle, JL P-53
Perez-Chanona, Ernesto P-213
Peter, Inga P-261
Peterson, Nicholas P-239
Peyrin-Biroulet, Laurent P-155
Philpott, Jessica O-8, P-145
Piazik, Breanne P-106, P-108
Pierre-Louis, Bosny P-24
Pineiro, Victor 0-2, P-138
Pinto, Marco Antonio P-32
Plevy, Scott P-189, P-198
Podolsky, Daniel P-191
Pola, Suresh P-3
Polk, D P-186
Pollack, Paul P-23, P-58
Pollard, Catherine P-68
Pope, Jennifer 0-2, P-138
Portela, Renata P-73
Posivak, Leah P-117
Pothoulakis, Charalabos P-233, P-234, P-246
Pound, Kayla P-175
Prakash, Pia P-9, P-84, P-85, P-86, P-87, P-88, P-89, P-95,
P-96
Protheroe, Cheryl P-254
Pruthi, Shiv P-122
Puga, Ana P-142
Pugas de Carvalho, Ana P-111
Puthoor, Pamela P-175
Quera, Rodrigo P-260
Quesenberry, Michael P-203
Quinn, Grainne P-129
Quintero, Maria Alejandra P-240
Rabizadeh, Shervin O-7, P-164
Ramalho, Andrea P-32
Ramek, Joseph P-16
Ramer-Tait, Amanda P-194
Rao, Suprada P-187
Rassaei, Negar O-30, P-247
Rausell-Palamos, Francisco P-224
Rees, Ian P-97
Reeves-Garcia, Jesse P-162
Regueiro, Miguel O-4, P-44, P-109
Reich, Jason P-9, P-84, P-85, P-86, P-87, P-88, P-89, P-95
Reinert, Steven P-102
Reinisch, Walter P-30, P-69
Reis, Bernardo P-172
Remzi, Feza O-2, P-76
Resnick, Murray P-102
Restrepo, Ricardo P-162
Reyes, Christopher O-18, P-245
Rhee, Lesley O-21, P-238
Ribeiro, Camila P-15, P-73
Rivers, Claudia P-44
Rivkin, Michael O-5a, P-149
Rizzo, Joanne P-62
Roberts, Charles P-163
Roberts, Mary O-4, P-109
Robine, Sylvie P-218
Robinson, Anne P-19, P-20, P-21, P-22, P-23, P-58
Rocha, Juliana P-110
Rocha, Raquel P-52, P-66
Roda, Giulia P-215
Rodrigues, Josias P-256
Rogler, Gerhard P-114
Rogoz, Aneta P-172
Romeiro, Fernando P-256
Rosa, Bruno P-91, P-100
Rosario, Maria O-1a, P-27
Rosen, Michael P-143
Rosenthal, Casey O-7, P-164
Rothlin, Carla O-31, P-230
Rottiers, Pieter O-29, P-176
Rubin, David P-63, P-64, P-65
Rubin, Erin O-4, P-109
Rubin, Jonathan P-192
Ruchkina, Irina P-18, P-125
Rudi, Knut P-105
Ruiz, Jose O-30, P-216, P-247
Russell, Ian P-34
Rustgi, Ankur P-57
Rutgeerts, Paul O-1a, P-26, P-27, P-30, P-69
Sabotier, Mauricio P-260
Sadeghi, Shadi P-107
Saeed, Shehzad P-153
Saeedi, Bejan P-221
Sagynbaeva, Venera P-125
Saites, Constantine O-3, P-112
Salas, Pedro P-223
Salleron, Julia P-155
Salz, Liad O-9, P-144
Salzman, Nita P-191, P-239
Author Index S124
Samson, Susan P-6
San Pablo, William P-158
Sanchez-Paya, Jose P-72
Sandborn, William O-1a, P-3, P-19, P-20, P-21, P-22,
P-23, P-24, P-25, P-26, P-27, P-30, P-58, P-59, P-60,
P-61, P-69
Sandler, Robert P-33, P-70, P-71
Sands, Bruce O-1a, O-1b, P-26, P-27, P-28, P-67
Sandvik, Arne P-119, P-248
Sankoh, Serap O-1a, O-1b, P-27, P-28
Santana, Genoile P-15, P-52, P-66, P-73
Santaolalla, Rebeca O-27, O-30, P-222, P-247, P-264
Sartor, Ryan P-189, P-197
Sassaki, Ligia P-256
Sattin, Bernie P-124
Saunders, Carol P-163
Saville, Benjamin P-143
Savoye, Guillaume P-155
Saxena, Arpit P-182
Scharl, Michael P-114
Scherl, Ellen O-24, P-241
Schmitt, Erica P-180
Schroeder, Shauna P-262
Schuster, Bonnie O-4, P-109
Schwartz, David P-55, P-143
Segovia, Roberto P-260
Seifer, Ronald P-147, P-159
Sekelja, Monika P-105
Sellin, Joseph P-37
Sempere, Laura P-72, P-114
Seth, Berney O-26, P-171
Sferra, Thomas O-8, P-145
Shafran, Ira P-131, P-132
Shah, Birju P-75
Shah, Samir P-67, P-102
Shaikh, Maliha P-130
Shailubhai, Kunwar P-198
Shalon, Linda P-157
Shang, Limin O-30, P-247
Shapiro, Jason P-147, P-157, P-159
Sharma, Piyush P-80
Shen, Bo O-2, P-47, P-76, P-99
Shen, Wei O-29, P-176
Shenhar-Tsarfaty , Shani P-235
Shih, David P-233, P-234, P-246
Shonce, Emmala O-11, P-167
Shouval, Dror P-237
Siegel, Corey P-108
Siegel, Rachael P-104
Silva, Bruno P-15, P-73
Silva, Tianny P-32
Silveira, Naiade P-52, P-66
Silver, Elana P-74
Silverstein, Jared P-157
Simian, Daniela P-260
Singh, Namita P-136
Singh, Siddharth P-38, P-80
Singla, Manish P-2
Sirridge, Christy P-158
Skup, Martha P-60, P-61, P-62
Smita, Halder P-169
Smith, Phillip P-251
Smyrk, Thomas P-122
Smythies, Lesley P-251
Snapper, Scott P-183, P-217, P-237, P-265
Soares-Mota, Marcia P-32
Soden, Sarah P-163
Sogawa, Hiroshi O-4, P-109
Sollid, Ludvig P-179
Soltys, Kyle O-4, P-109
Song, Ying P-116
Soni, Anurag P-1
Soon, Ing Shian O-6, P-148
Soreq, Hermona P-235
Souza, Mariana P-73
Souza, Rhonda P-218
Srinivasan, Gayathri P-244
Srinivasan, Jahnavi P-107
Srinivasan, Shanthi P-196
Srygley, Fletcher P-4
Stadnyk, Andrew P-249
Stahl, Richard P-251
Steidler, Lothar O-29, P-176
Stein, William O-4, P-109
Stephens, Michael O-10, P-160, P-239
Stevens, Mark P-262
Stewart, Charles O-29, P-176
Stidham, Ryan P-192
Strandberg-Larsen, Martin P-68
Strassheim, Derek P-175
Strauss, Richard P-30, P-69
Strobel, Sebastian P-240, P-264
Such, Jose P-114
Sumagin, Ronen P-208
Suorsa, Kristina P-147, P-159
Surlo, Valdiana P-15
Suskind, David P-136
Sussman, Daniel O-30, P-247
Swaminath, Arun O-24, P-241
Swanson, Garth P-130
Sy, Richmond P-26
Szigethy, Eva P-44
Tabernero, S P-53, P-54
Takahashi, Kenichiro P-113
Takatsu, Noritaka P-123
Talwalkar, Jayant P-38
Author Index S125
Tanaka, Hiroki P-51
Tansey, Malu P-196
Targan, Stephan P-246
Taylor, Cormac O-19, P-232
Taylor, Lori P-63, P-64, P-65
Teixeira, Fabio P-127
Teng, Brian P-101
Thacker, Julie P-4
Thakkar, Roopal P-19, P-20, P-21, P-22, P-23, P-58, P-59,
P-60, P-61
Theiss, Arianne P-218
Thomason, Molly O-10, P-160
Thompson, John P-146
Thompson, Winston P-218
Thomson, Ty P-118
Ting, Adrian P-231
Tinsley, Andrew P-92
Tipnis, Neelesh O-10, P-160
Tomer, Gitit P-146
Tonini, Wanessa P-111
Torp, Sverre P-119, P-248
Tosteson, Anne P-108
Tozawa, Katsuyuki P-103, P-133
Tracey, Daniel P-203
Tracy, Kathleen P-57
Trenor, III, Cameron P-161
Tripuraneni, Bhavna O-7, P-164
Tse, Frances P-169
Tsoucas, Daphne O-15, P-226
Tumanov, Alexei P-252
Turck, Dominique P-155
Turner, Henrietta P-181
Tuskey, Anne P-10
Ullman, Thomas P-92
Umeno, Junji P-126
Underhill, David O-18, P-245
Upchurch, Kyle P-180
Uribe, Diana O-31, P-230
Usmani, Kathleen P-139
Vacchio, Anthony P-94
Vallance, Bruce P-263
Van Assche, Gert P-20, P-21, P-22
van de Sluis, Bart P-229
Vanaclocha, F P-53, P-54
Vanderkooi, Otto O-6, P-148
Varadarajan, Nisha P-9, P-84, P-85, P-86, P-87, P-88, P-89,
P-95
Vatn, Morten P-105
Veb, Heidi P-105
Veerappan, Ganesh P-2, P-12, P-14, P-81
Velcich, Anna P-263
Venkatesh, Madhukumar P-220
Venkatsubramani, Narajanan O-10, P-160
Venu, Nanda P-43
Verhave, Menno P-161
Vermani , Samir P-96
Vijay-Kumar, Matam P-243, P-244
Vinogradov, Sergei P-257
Vivio, Emily P-187
Voigt, Robin P-130
Vosqui, Fabio P-15
Waber, Deborah O-5a, O-5b, P-149, P-150
Wachs, Teresa O-12, P-166
Wagner, Brandie P-262
Wahbeh, Ghassan P-136
Waites, Ken P-251
Wald, Flavia P-223
Waldum, Helge P-119, P-248
Wallenstein, Sylvan P-74
Walter, Jennifer O-10, P-160
Walter, Lewins P-201
Walters, Thomas O-9, P-144
Wang, Kepeng P-202
Wang, Xiaowei P-47
Wang, Yaoyu P-121
Wannemuehler, Michael P-194
Watanabe, Erika P-256
Watanabe, Kenji P-98
Watson, Christopher O-5a, P-149
Weaver, Casey P-181
Weber, Nicholas P-122
Weber, Sarah P-121
Weersma, Rinse P-229
Weinfurt, Kevin P-70
Weitzner, Jordan P-141
Werlin, Steven O-10, P-160
White, Betty P-90
Wiest, Reiner P-114
Williams, Calvin P-180
Williams, John P-34, P-35, P-36
Wilson, Farra P-93
Wilson, Keith P-143
Winter, Harland P-115
Wolf, Doug P-19, P-20, P-21, P-22
Woodard, Jill P-107
Woodruff, Trent P-249
Wrobel, Iwona O-6, P-148
Wu, Feng P-209
Wu, Gary P-117, P-257
Wu, Huixia O-22, P-210
Wu, Jianxin P-82
Wu, Xianrui O-2, P-76, P-99
Wurbel, Marc-Andre P-237
Wyant, Tim P-177
Xavier, Ramnik P-227
Xenodemetropoulos, Ted P-169
Author Index S126
Xia, Huiping P-82
Xia, Lijun P-263
Xu, Hua O-17, P-188, P-258
Xu, Jing P-26
Xu, Kathleen P-108
Yajima, Tomoharu P-79
Yamashita, Masaki P-51
Yang, Dong-Hoon P-45, P-46, P-48
Yang, Guoxun P-188
Yang, Jun P-204
Yang, Li-Li P-177
Yang, Mei P-58, P-59, P-60, P-61, P-62
Yang, Min P-62
Yang, Suk-Kyun P-45, P-46, P-48
Yang, Xiaotong O-17, P-258
Yano, Yutaka P-123
Yasaka, Motochika P-123
Yates, Timothy P-162
Ye, Byong Duk P-45, P-46, P-48
Yeckes, Alyson P-175, P-254
Yokoyama, Yoko P-103, P-133
Yoo, Junhwan P-233
Young, Andrew P-244
Yousef, Shatha P-142
Yuan, Shuai P-184
Yue, Andrew P-56
Zacur, George P-153
Zahm, Adam O-15, P-226
Zaki, Md. P-253
Zaltman, Cyrla P-31, P-32
Zanetti , Graziela P-31
Zapater, Pedro P-114
Zarepour, Maryam P-263
Zembrzuska, Hanna P-12
Zhai, Zili P-209
Zhang, Graham P-198
Zhang, Hongyan P-30, P-69
Zhang, Johnathan P-39
Zhang, Songlin O-26, P-171, P-184
Zhang, Xiaolan P-246
Zheng, Libo P-246
Zhou, Qian P-22
Zhu, Xinjun Cindy P-204
Zia, Rabbi P-16
Ziegelbauer, Jennifer P-180
Zisman, Timothy P-42
Zitnik, Ralph P-193
Zitomersky, Naamah P-161, P-265
Zullow, Samantha P-57
Zurakowski, David O-3, P-112
Author Index S127

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Abstracts from the 2012 Advances in Inflammatory Bowel Diseases

T cells inltrating the intestinal lamina propria have been implicated in

T cells by differentiating murine T

T cells are exposed to regions of fulminant hypoxia and

T cells ex vivo and exposed them to ambient hypoxia in vitro

T cell function and may highlight a novel

T cells resulted in a signi-

Treg frequency along with impaired Treg sup-

IL-10 producing Tregs in the colonic lamina propria.

) populations of Treg cells were identied

T cells lacking Treg cells.

T cells. Following colonization with

T cells or an isotype control antibody. Mice then

T cells in H. bilis-colonized mice prior to the DSS treatment period exa-

T cells from E. coli-colonized mice caused only minor increases in disease

dendritic cells and CD11c

subsets of both pop-

T cells were co-transferred

T cells. To investigate suppressive

T cells and IL-10

and/ or B cells from WT or IL-10

T cell recipient DKO mice that

T cells was induced by co-

T cells developed severe colitis with no evidence of

WT T cells and IL-10

T cells equivalent to co-cultured WT or

regulatory T cells. FACS data demonstrated that% of either CBL-

T cells were signicantly lower

T cells, only WT B cells could induce

IL-10-producing regulatory T cells (Tr1 cells) (3.760.3% with WT B cells,

T cells being IL-10 independent. IL-10-pro-

T cells. Colitis was assessed based on clinical,

DCs, aCD3 and

T cells, following 5 days of culture of WT

T cells they developed severe intestinal inammation after 4-5

T cells to become colitogenic. Further work is needed to clarify

T cells with either neutralizing

C and biopsies freshly

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