[IBD ahead 2010--Answering important questions in Crohn's disease treatment]

The treatment of patients with inflammatory bowel disease has become more complex in recent years through the introduction of various immunosuppressive agents as well as the approval of monoclonal antibodies against TNF-α and patients receiving such treatment must be carefully monitored. National and international guidelines define a diagnostic and therapeutic context for the practitioner, but can only partially respond to specific questions on the procedure for individual patients. Within the framework of a project initiated by Abbott entitled "IBD ahead" 38 German IBD experts have elaborated concrete proposals for dealing with corticosteroids, immunosuppressants and TNF-α antibodies on the basis of the published literature and their own personal experience in order to close the gap between these guidelines and daily clinical practice. Statements were developed on the choice of correct timing of initiation, dose and duration of the individual substances and on how to proceed with patients exhibiting treatment failure. Moreover, recommendations are also made on drug combination strategies, safety monitoring and the risks regarding the development of infectious complications and malignancies. These recommendations are illustrated by case studies from everyday practice in participating centres.

Review article: defining remission in ulcerative colitis

BACKGROUND

There is no international agreement on scoring systems used to measure disease activity in ulcerative colitis, nor is there a validated definition for disease remission.

AIM

To review the principles and components for defining remission in ulcerative colitis and propose a definition that will help improve patient outcomes.

METHODS

A review of current standards of remission from the perspective of clinical trials, guidelines, clinical practice and patients was conducted by the authors. Selected literature focused on the components of a definition of remission, the utility of a definition and treatment strategies, based on current definitions.

RESULTS

Different definitions of remission affect the assessment of outcome and make it difficult to compare trials. In the clinic, endoscopy is rarely used to confirm remission, because mucosal healing has only recently begun to be related to the duration of subsequent remission in a way that will affect clinical practice. Histopathology may be the ultimate arbiter of mucosal healing. There is no agreement on the definition of remission in current guidelines. Patient-defined remission may predict endoscopic remission, but has yet to be shown to predict duration of remission.

CONCLUSIONS

A standard based on clinical symptoms and endoscopy is proposed. Histopathology is a third dimension of remission that may have prognostic value. The definition of remission should help predict long-term outcome. The expectations of patients and their physicians need to be raised, as the goal of treatment of active ulcerative colitis should be to induce remission.

The methane cycle in ferruginous Lake Matano

In Lake Matano, Indonesia, the world's largest known ferruginous basin, more than 50% of authigenic organic matter is degraded through methanogenesis, despite high abundances of Fe (hydr)oxides in the lake sediments. Biogenic CH₄ accumulates to high concentrations (up to 1.4 mmol L⁻¹) in the anoxic bottom waters, which contain a total of 7.4 × 10⁵ tons of CH₄. Profiles of dissolved inorganic carbon (ΣCO₂) and carbon isotopes (δ¹³C) show that CH₄ is oxidized in the vicinity of the persistent pycnocline and that some of this CH₄ is likely oxidized anaerobically. The dearth of NO₃⁻ and SO₄²⁻ in Lake Matano waters suggests that anaerobic methane oxidation may be coupled to the reduction of Fe (and/or Mn) (hydr)oxides. Thermodynamic considerations reveal that CH₄ oxidation coupled to Fe(III) or Mn(III/IV) reduction would yield sufficient free energy to support microbial growth at the substrate levels present in Lake Matano. Flux calculations imply that Fe and Mn must be recycled several times directly within the water column to balance the upward flux of CH₄. 16S gene cloning identified methanogens in the anoxic water column, and these methanogens belong to groups capable of both acetoclastic and hydrogenotrophic methanogenesis. We find that methane is important in C cycling, even in this very Fe-rich environment. Such Fe-rich environments are rare on Earth today, but they are analogous to conditions in the ferruginous oceans thought to prevail during much of the Archean Eon. By analogy, methanogens and methanotrophs could have formed an important part of the Archean Ocean ecosystem.

Exaggerated inflammatory response of primary human myeloid dendritic cells to lipopolysaccharide in patients with inflammatory bowel disease

Inflammatory bowel disease (IBD) results from a breakdown of tolerance towards the indigenous flora in genetically susceptible hosts. Failure of dendritic cells (DC) to interpret molecular microbial patterns appropriately when directing innate and adaptive immune responses is conceivable. Primary (conventional, non-monocyte generated) CD1c(+)CD11c(+)CD14(-)CD16(-)CD19(-) myeloid blood or mucosal dendritic cells (mDC) from 76 patients with Crohn's disease (CD) or ulcerative colitis (UC) in remission, during flare-ups (FU) and 76 healthy or non-IBD controls were analysed by fluorescence activated cell sorter (FACS) flow cytometry and real-time polymerase chain reaction. Cytokine secretion of freshly isolated, cultured and lipopolysaccharide (LPS)-stimulated highly purified mDC (purity >95%) was assessed using cytometric bead arrays (CBA). More cultured and stimulated circulating mDC express CD40 in IBD patients. Stimulated circulating mDC from IBD patients secrete significantly more tumour necrosis factor (TNF)-alpha and interleukin (IL)-8. Toll-like receptor (TLR)-4 expression by mDC was higher in remission and increased significantly in flaring UC and CD patients compared with remission (P < 0.05) and controls (P < 0.001). Fluorochrome-labelled LPS uptake by mDC was evaluated at different time-points over 24 h by measuring mean fluorescence intensity (MFI). Circulating mDC from IBD patients take up more LPS and the uptake begins earlier compared with controls (P < 0.05 in CD-FU and UC-FU at 24 h). The frequency of mucosal mDC (P < 0.05) and the number of CD40 expressing mucosal mDC is significantly greater in UC and CD compared with non-IBD controls (P < 0.001 versus P < 0.01, respectively). Our data suggest an aberrant LPS response of mDC in IBD patients, resulting in an inflammatory phenotype and possibly intestinal homing in acute flares.

Factor VIII is a positive regulator of platelet function

FVIII is an important cofactor in the tenase coagulation factor complex, lack of FVIII causes severe bleeding, whereas high FVIII levels seem to be associated with venous and arterial thromboembolism. Resting platelets do not bind FVIII, but activated platelets bind unactivated FVIII if vWF is not present. We investigated a possible influence of platelet bound FVIII on platelet function itself as it is unclear if there is a direct effect of FVIII on platelet function. The influence of FVIII on platelet function was investigated by flow cytometric analysis of P-selectin expression (CD62P) and PAC-1 binding before and after submaximal stimulation with TRAP-6 (5 microM final concentration), by confocal microscopy and by platelet aggregometry. For flow cytometry and confocal microscopy, washed platelets were incubated with human recombinant FVIII for 5 min at 37 degrees C. Analysis of platelet surface area was measured by computerized image analysis. Treatment with FVIII only caused no changes in P-selectin expression or PAC-1 binding, respectively. Stimulation of platelets with TRAP-6 increased the expression of P-selectin (445%) and PAC-1 binding (934%) as expected. These effects were further increased when platelets were stimulated with TRAP-6 and FVIII (P-selectin 499%, difference not significant; PAC-1 1626%, P < 0.05. Values were expressed in%, related to unstimulated, buffer treated platelets). Platelet spreading on fibrinogen was significantly increased when platelets were treated with FVIII and TRAP-6 compared to TRAP-6 alone (368 vs. 307 average pixel/platelet, P<0.05). In addition platelet aggregation was enhanced when platelets were stimulated with FVIII and TRAP-6 compared to TRAP-6 alone. FVIII can act as a positive regulator of platelet function in TRAP-co-stimulated platelets. We hypothesize that FVIII induced increase in platelet activation might contribute to venous and even arterial thrombus formation in patients with high FVIII levels.

Changes of the left ventricle after myocardial infarction--estimation with cine magnetic resonance imaging during the first six months

BACKGROUND

In recent years, the interest of cardiologists has focused increasingly on the morphologic and functional changes of the left ventricle after myocardial infarction (MI), due to their great prognostic significance for the patient.

HYPOTHESIS

The aim of this study was to evaluate changes in left ventricular morphology and function during the first 6 months following MI.

METHODS

In all, 61 patients (17 women, 44 men, age 36-83 years) were examined with cine magnetic resonance imaging (CMRI) 1, 4, and 26 weeks after myocardial infarction. Thirty-two patients had anterior MI and 29 patients had posterior MI. According to enzyme-derived infarct weight, 15 patients had small infarcts (< 20 g), 19 had intermediate-sized infarcts (20-40 g), and 27 patients had large infarcts (> 40 g). CMRI was performed in the true short axis of the left ventricle. In each examination, left ventricular end-diastolic and end-systolic volume indices (LVEDVI, LVESVI), stroke volume index (LVSVI), ejection fraction (LVEF), and regional thickness, mass, and motility of the myocardial wall-diastolic thickness (IDdia), infarct mass (IM) and motility (IMOT) of the infarct area and diastolic and systolic thickness (VDdia, VDsys), muscular mass (VM), and motility (VMOT)-were determined. In addition, patients were divided into subgroups according to New York Heart Association (NYHA) functional status at baseline.

RESULTS

In the total group, LVEDVI increased from 73.9 +/- 23.5 ml/m2 to 85.4 +/- 28.1 ml/m2 (p < 0.001) and LVESVI from 40.5 +/- 19.4 ml/m2 to 51.2 +/- 29.0 ml/m2 (p < 0.001). In the subgroups the development depended on infarct size and location. LVSVI and LVEF remained more or less constant except for large anterior infarctions. All changes of the myocardial wall depended on infarct size and location: In all patients IDdia decreased from 10.4 +/- 1.6 mm to 8.9 +/- 1.7 mm (p < 0.001), IMOT from 2.0 +/- 1.6 mm to 0.5 +/- 2.9 mm (p < 0.001). IM increased from 41 +/- 21 g to 45 +/- 25 g (p < 0.001). In the total group, VDdia increased from 11.9 +/- 1.6 mm to 12.4 +/- 1.8 mm (p < 0.05), VDsys from 16.6 +/- 2.5 mm to 17.2 +/- 3.1 mm (p < 0.05). In the subgroups changes varied: VDdia and VDsys decreased markedly in large anterior wall infarctions. VM increased in the total cohort from a mean of 246 +/- 66 g to 276 +/- 80 g (p < 0.001). VMOT decreased from 7.1 +/- 2.4 mm to 6.3 +/- 2.7 mm (p < 0.05). Loss of motility was most pronounced in anterior infarctions. The volume-mass ratio, a measure of the success of compensation of volume increase by myocardial hypertrophy, decreased in small infarcts, remained unchanged in intermediate infarcts, and increased in large infarcts. There was a trend toward improvement of the NYHA functional status during the observation period.

CONCLUSIONS

Changes of the left ventricular chamber during the first 6 months following MI are dependent on its size and location, with large anterior infarctions having the worst course. Myocardial wall remodeling is also dependent on infarct size and location, and the volume-mass ratio increases in the presence of large areas of necrosis, indicating the non-compensatory effect of myocardial hypertrophy. However, these changes have no clinical effect during the first half year after MI.

Prevalence of ventricular late potentials in patients with obstructive sleep apnea syndrome

BACKGROUND

It is known from various cardiac disorders that the presence of ventricular late potentials (VLP) in the signal-averaged electrocardiogram (ECG) is associated with an increased risk of sudden cardiac death.

HYPOTHESIS

In view of the increased cardiovascular mortality of patients with obstructive sleep apnea syndrome (OSAS), we assessed the prevalence of VLP in these patients.

METHODS

In all, 118 consecutive patients with polysomnographically verified OSAS were prospectively studied; 21 snorers without evidence of a sleep-related breathing disorder served as a control group. Signal-averaged ECG and 24-h Holter ECG were performed in all patients and controls, and left ventricular function was determined by radionuclide ventriculography in the OSAS group. Furthermore, patients and controls were followed for up to 45.5 months for arrhythmic events, syncopes, or sudden cardiac death.

RESULTS

An abnormal signal-averaged ECG was seen in seven patients (5.9%) and in one snorer (4.8%). Patients with and without VLP did not differ with respect to age, body mass index, left ventricular ejection fraction, or ectopic activity in the 24-h Holter ECG, but the former had significantly higher mean (standard deviation) apnea/hypopnea indices [55.4 (25.2)/h vs. 37.4 (22.6)/h; p < 0.05]. Of the 118 patients, 110 could be followed for 26.7 (7.9) months. During this period, two patients had syncopes and one patient had sudden cardiac death. The seven patients with VLP remained free of events during the follow-up period, as did the 21 snorers.

CONCLUSIONS

Patients with OSAS have a low prevalence of VLP in the signal-averaged ECG, not exceeding that in normal subjects. Moreover, abnormal signal-averaged ECGs do not appear to be useful as a prognostic marker.

Heterozygosity for IL23R p.Arg381Gln confers a protective effect not only against Crohn's disease but also ulcerative colitis

BACKGROUND

A recent study reported that a non-synonymous single nucleotide polymorphism (rs11209026, p.Arg381Gln) located in the IL23R gene is a protective marker for inflammatory bowel disease.

AIM

To analyse the frequency of p.Arg381Gln in three independent European inflammatory bowel disease cohorts and to evaluate how this variant influences disease behaviour.

METHODS

We assessed a European cohort of 919 inflammatory bowel disease patients and compared the IL23R p.Arg381Gln genotype frequency with 845 healthy controls. Inflammatory bowel disease patients originated from Germany [Crohn's disease (CD): n = 318; ulcerative colitis (UC): n = 178], Hungary (CD: n = 148; UC: n = 118) and the Netherlands (CD: n = 157). Ethnically matched controls were included. We performed subtyping analysis in respect to CARD15 alterations and clinical characteristics.

RESULTS

The frequency of the glutamine allele of p.Arg381Gln was significantly lower in inflammatory bowel disease patients compared with controls in a pooled analysis of all three cohorts (P < 0.000001) as well as in the individual cohorts (Germany: P = 0.001, Hungary: P = 0.02 and the Netherlands: P = 0.0002). The p.Arg381Gln genotype distribution was similar between CD and UC. We did not observe either statistical interactions between p.Arg381Gln and CARD15 variants or any significant associations between p.Arg381Gln genotype and subphenotypes.

CONCLUSIONS

The p.Arg381Gln IL23R variant confers a protective effect against both CD and UC, but does not determine disease phenotype.

[Acute pancreatitis and duodenobiliary fistula--a rare complication of Crohn's disease]

HISTORY

A 53-year-old man with long-standing Crohn's disease presented with recurrent abdominal pain and vomiting; lipase levels were elevated.

INVESTIGATIONS AND DIAGNOSIS

At admission ultrasound demonstrated a swollen head of the pancreas, dilated pancreatic and intrahepatic bile ducts and peripancreatic fluid. At upper gastrointestinal endoscopy a 10 mm bleeding ulcer was identified, which histologically proved to be epitheloid cell-containing granulomas. A fistula connecting to the hepatocholedochal duct was identified at the floor of the ulcer. Helicobacter pylori was not demonstrated.

TREATMENT AND COURSE

After sphincterotomy of the papilla of Vater concrements were extracted and a stent was implanted into the common bile duct. Ultimately a total of five stents were consecutively implanted via the major papilla, closing the fistula. After three years all stents were removed and pancreatitis did not recur.

CONCLUSION

The differential diagnosis of abdominal pain in patients with Crohn's disease is often difficult and should include fistulas of the upper gastrointestinal tract which may be treated endoscopically.

Escherichia coli strain Nissle 1917 ameliorates experimental colitis via toll-like receptor 2- and toll-like receptor 4-dependent pathways

Toll-like receptors (TLRs) are key components of the innate immune system that trigger antimicrobial host defense responses. The aim of the present study was to analyze the effects of probiotic Escherichia coli Nissle strain 1917 in experimental colitis induced in TLR-2 and TLR-4 knockout mice. Colitis was induced in wild-type (wt), TLR-2 knockout, and TLR-4 knockout mice via administration of 5% dextran sodium sulfate (DSS). Mice were treated with either 0.9% NaCl or 10(7) E. coli Nissle 1917 twice daily, followed by the determination of disease activity, mucosal damage, and cytokine secretion. wt and TLR-2 knockout mice exposed to DSS developed acute colitis, whereas TLR-4 knockout mice developed significantly less inflammation. In wt mice, but not TLR-2 or TLR-4 knockout mice, E. coli Nissle 1917 ameliorated colitis and decreased proinflammatory cytokine secretion. In TLR-2 knockout mice a selective reduction of gamma interferon secretion was observed after E. coli Nissle 1917 treatment. In TLR-4 knockout mice, cytokine secretion was almost undetectable and not modulated by E. coli Nissle 1917, indicating that TLR-4 knockout mice do not develop colitis similar to the wt mice. Coculture of E. coli Nissle 1917 and human T cells increased TLR-2 and TLR-4 protein expression in T cells and increased NF-kappaB activity via TLR-2 and TLR-4. In conclusion, our data provide evidence that E. coli Nissle 1917 ameliorates experimental induced colitis in mice via TLR-2- and TLR-4-dependent pathways.

Multiple corticosteroid receptors in fish: from old ideas to new concepts

The effect of corticosteroid hormones in fish are mediated through intracellular receptors that act as ligand-binding transcription factors. Many studies have been devoted to cortisol binding using radiolabeled ligand in fish and allowed characterization of a single class of high affinity binding sites in various tissues. Molecular characterization of cortisol receptors has only been initiated recently by cloning the different receptor forms: Following a isolation of a first glucocorticoid receptor (GR), a mineralocorticoid receptor (MR) was described and the presence of various GR isoforms was recently reported. Sequence comparison and phylogenetic analysis of these sequences confirm that fish possess both GR and MR and that GR gene is duplicated. The importance of these various corticosteroid receptor forms is also illustrated by analysis of their transcriptional activity. When tested in human cell lines, these receptors showed functionally distinct actions on GR-sensitive promotors, thus suggesting a more complicated corticosteroid signaling system than initially anticipated from binding studies. These results also suggest that, whereas cortisol is certainly the physiological ligand for GR, this may not be the case for MR which showed high sensitivity for deoxycorticosterone (DOC) and aldosterone. As this last hormone is probably absent in fish, these results raise the question as to whether DOC could be a physiological ligand for MR in fish. Information on DOC effect in fish is very scarce and clarification of the differential osmoregulatory roles of cortisol and DOC in fish needs ellucidation. This will require analysis of all actors of the corticosteroid signaling system at pre-receptor, receptor, and post-receptor levels.

Regulation of host cell survival by intracellular Plasmodium and Theileria parasites

Plasmodium and Theileria parasites are obligate intracellular protozoa of the phylum Apicomplexa. Theileria infection of bovine leukocytes induces transformation of host cells and infected leukocytes can be kept indefinitely in culture. Theileria-dependent host cell transformation has been the subject of interest for many years and the molecular basis of this unique phenomenon is quite well understood. The equivalent life cycle stage of Plasmodium is the infection of mammalian hepatocytes, where parasites reside for 2-7 days depending on the species. Some of the molecular details of parasite-host interactions in P. berghei-infected hepatocytes have emerged only very recently. Similar to what has been shown for Theileria-infected leukocytes these data suggest that malaria parasites within hepatocytes also protect their host cell from programmed cell death. However, the strategies employed to inhibit host cell apoptotic pathways appear to be different to those used by Theileria. This review discusses similarities and differences at the molecular level of Plasmodium- and Theileria-induced regulation of the host cell survival machinery.