Presenting phenotype of paediatric inflammatory bowel disease in Wessex, Southern England 2010-2013

AIM

There has been at least a twofold increase in the incidence of paediatric inflammatory bowel disease (PIBD) over the last 20 years; we report the presenting features from 2010 to 2013 and compare with previous data.

METHODS

All patients diagnosed with PIBD at University Hospitals Southampton from 2010 to 2013 were identified from an in-house database. Data were obtained from paper and electronic notes. Height, weight and BMI SDS are presented as median values (95% CI).

RESULTS

One hundred and seventy-two patients were included (median age at diagnosis 13.5, 115 male); Crohn's disease (CD) - 107, UC - 50, inflammatory bowel disease unclassified (IBDU) - 15. The most common presenting features of CD were abdominal pain (86%), diarrhoea (78.5%) and weight loss (56.1%); 42.1% of patients had all three. In UC blood in stool (92%), diarrhoea (92%) and abdominal pain (88%) were the most common; all three in 76% of patients. CD presented with ileocolonic disease in 52.5%. UC presented with pancolitis in 64%. There was growth delay in CD: height -0.37 (-0.60 to -0.14); weight -1.09 (-1.35 to -0.83). Growth was maintained in UC: height 0.53 (0.19 to 0.87); weight 0.14 (-0.20 to 0.48).

CONCLUSION

Paediatric inflammatory bowel disease phenotype remains as extensive despite increasing incidence. Although the classical phenotype is common, a reasonable proportion present with atypical features, normal growth and normal blood markers.

Bone loss in a new rodent model combining spinal cord injury and cast immobilization

OBJECTIVES

Characterize bone loss in our newly developed severe contusion spinal cord injury (SCI) plus hindlimb immobilization (IMM) model and determine the influence of muscle contractility on skeletal integrity after SCI.

METHODS

Female Sprague-Dawley rats were randomized to: (a) intact controls, (b) severe contusion SCI euthanized at Day 7 (SCI-7) or (c) Day 21 (SCI-21), (d) 14 days IMM-alone, (e) SCI+IMM, or (f) SCI+IMM plus 14 days body weight supported treadmill exercise (SCI+IMM+TM).

RESULTS

SCI-7 and SCI-21 exhibited a >20% reduction in cancellous volumetric bone mineral density (vBMD) in the hindlimbs (p⋜0.01), characterized by reductions in cancellous bone volume (cBV/TV%), trabecular number (Tb.N), and trabecular thickness. IMM-alone induced no observable bone loss. SCI+IMM exacerbated cancellous vBMD deficits with values being >45% below Controls (p⋜0.01) resulting from reduced cBV/TV% and Tb.N. SCI+IMM also produced the greatest cortical bone loss with distal femoral cortical area and cortical thickness being 14-28% below Controls (p⋜0.01) and bone strength being 37% below Controls (p⋜0.01). SCI+IMM+TM partially alleviated bone deficits, but values remained below Controls.

CONCLUSIONS

Residual and/or facilitated muscle contractility ameliorate bone decrements after severe SCI. Our novel SCI+IMM model represents a clinically-relevant means of assessing strategies to prevent SCI-induced skeletal deficits.

Comparison of scar thickness measurements using trans-vaginal sonography and MRI in cases of pregnancy with previous caesarean section. Do they correlate with actual scar thickness?

The aim of this study was to evaluate scar thickness in cases of pregnancy with previous caesarean section, by trans-vaginal sonography (TVS) and magnetic resonance imaging (MRI), and to correlate precision of radiologically-measured scar thickness with actual measurement of scar thickness. A total of 35 pregnant patients with previous caesarean section planned for elective caesarean section, were evaluated prospectively. Their scar thickness was measured by TVS and MRI on the day of elective repeat caesarean section. These measurements were correlated with each other and with scar thickness measured during elective repeat caesarean section by using a caliper. The correlation coefficients between scar thickness measured by TVS and MRI with peroperative evaluation with a caliper, were +0.72 and +0.59, respectively. The study concluded that as MRI is a costlier modality and TVS has better correlation coefficient with actual scar thickness, TVS can be considered to be the better modality for antenatal scar thickness measurement.

Rising incidence of paediatric inflammatory bowel disease (PIBD) in Wessex, Southern England

BACKGROUND

There has been a significant increase in the incidence of paediatric inflammatory bowel disease (PIBD) over the last 25 years although there is no recent data from England. We aimed to analyse changes in incidence within a defined English population over the last decade and compare this to recent and historical incidence data from comparable studies.

METHODS

The new diagnosis incidence of PIBD (age less than or equal to 16 years) was recorded from a prospective database for a geographically defined area within Southern England (2002-2012). Data were analysed for two separate time periods (cohort 1:2002-2006 and cohort 2:2008-2012) and compared to data from the British Paediatric Surveillance Unit (BPSU) survey in 1998/1999. Data were analysed by age, sex and disease type.

RESULTS

There has been an increase in incidence of PIBD from 6.39/100,000/year during cohort 1 to 9.37/100,000/year during cohort 2 (p=0.0002). This compares with the BPSU incidence data in England (1998-1999) of 5.2/100,000/year. There was no statistically significant difference in median age of diagnosis between cohorts (p=0.46). The incidence of Crohn's disease (CD) was 3.8/100,000/year in cohort 1 rising to 5.85/100,000/year in cohort 2 (p=0.001). The incidence of ulcerative colitis (UC) was 2.01/100,000/year in cohort 1 rising to 2.62/100,000/year in cohort 2 (p=0.1458). Overall PIBD incidence is higher in males in cohort 1 (male-to-female ratio 1.35:1) and cohort 2 (male-to-female ratio 1.5:1).

CONCLUSIONS

The incidence of PIBD continues to increase with a rise of almost 50% in the last decade in Southern England. The reasons for this increase remain unclear.

EPA Guidance on Tobacco Dependence and Strategies for Smoking Cessation in People with Mental Illness

Tobacco dependence is the most common substance use disorder in adults with mental illness. The prevalence rates for tobacco dependence are two to four times higher in these patients than in the general population. Smoking has a strong, negative influence on the life expectancy and quality of life of mental health patients, and remains the leading preventable cause of death in this group. Despite these statistics, in some countries smokers with mental illness are disadvantaged in receiving intervention and support for their tobacco dependence, which is often overlooked or even tolerated. This statement from the European Psychiatric Association (EPA) systematically reviews the current evidence on tobacco dependence and withdrawal in patients with mental illness and their treatment. It provides seven recommendations for the core components of diagnostics and treatment in this patient group. These recommendations concern: (1) the recording process, (2) the timing of the intervention, (3) counselling specificities, (4) proposed treatments, (5) frequency of contact after stopping, (6) follow-up visits and (7) relapse prevention. They aim to help clinicians improve the care, health and well-being of patients suffering from mental illness.

Bacterial translocation - impact on the adipocyte compartment

Over the last decade it became broadly recognized that adipokines and thus the fat tissue compartment exert a regulatory function on the immune system. Our own group described the pro-inflammatory function of the adipokine leptin within intestinal inflammation in a variety of animal models. Following-up on this initial work, the aim was to reveal stimuli and mechanisms involved in the activation of the fat tissue compartment and the subsequent release of adipokines and other mediators paralleled by the infiltration of immune cells. This review will summarize the current literature on the possible role of the mesenteric fat tissue in intestinal inflammation with a focus on Crohn’s disease (CD). CD is of particular interest in this context since the transmural intestinal inflammation has been associated with a characteristic hypertrophy of the mesenteric fat, a phenomenon called “creeping fat.” The review will address three consecutive questions: (i) What is inducing adipocyte activation, (ii) which factors are released after activation and what are the consequences for the local fat tissue compartment and infiltrating cells; (iii) do the answers generated before allow for an explanation of the role of the mesenteric fat tissue within intestinal inflammation? With this review we will provide a working model indicating a close interaction in between bacterial translocation, activation of the adipocytes, and subsequent direction of the infiltrating immune cells. In summary, the models system mesenteric fat indicates a unique way how adipocytes can directly interact with the immune system.

Adipokines from local fat cells shape the macrophage compartment of the creeping fat in Crohn's disease

OBJECTIVE

The creeping fat in Crohn's disease (CD) is infiltrated by macrophages; local adipokine levels are increased. This study aimed to link these observations to define a role for macrophages in the pathology of human CD.

METHODS

Human peripheral blood CD14 cells were polarised in vitro into M1 and M2 macrophages. The effects on adipokine receptors, phenotypic surface markers, cytokines and chemokines were assessed after treatment with leptin and adiponectin. Immunohistochemistry visualised macrophage subtypes in samples of mesenteric fat tissue from patients with CD. The chemotactic potential of secreted macrophage products was determined by T cell migration and chemokine production in vitro.

RESULTS

Although both adipokines altered the phenotype and function of M1 and M2 macrophages, M2 macrophages were more susceptible. M1 responded to leptin by increased cytokine production, but the stronger effect was seen in M2 macrophages with high expression of interleukin (IL)-10, IL-6 and tumour necrosis factor α. Adiponectin exerted similar effects and led to upregulated mannose receptor expression by M2 macrophages. Large macrophage numbers within the mesenteric fat tissue of patients with CD comprise a unique infiltration predominantly of M2 macrophages, leading to an IL-10-rich environment. While leptin increased the potency of both subtypes to attract CD3 T cells, adiponectin only affected M2 macrophages.

CONCLUSION

The adipocyte-dependent microenvironment within the creeping fat of patients with CD modulates the local macrophage compartment to a preference for the M2 subtype. The findings in this study with human cells suggest a protective role for the mesenteric fat in CD in terms of an enveloping barrier with the potential to limit intestinal inflammation.

Mesenteric fat - control site for bacterial translocation in colitis?

In Crohn's disease bacteria could be detected in the adjacent mesenteric fat characterized by hypertrophy of unknown function. This study aimed to define effector responses of this compartment induced by bacterial translocation during intestinal inflammation. Dextran sulfate sodium-induced colitis served as a model of intestinal inflammation. Translocation of peptides and bacteria into mesenteric fat was evaluated. Innate functions of mesenteric fat and epithelium were characterized at whole tissue, cellular, and effector molecule levels. Orally applied peptides translocated in healthy wild-type (WT) mice. Bacterial translocation was not detected in healthy and acute but increased in chronic colitis. Mesenteric fat from colitic mice released elevated levels of cytokines and was infiltrated by immune cells. In MyD88(-/-) mice bacterial translocation occurred in health and increased in colitis. The exaggerated cytokine production in mesenteric fat accompanying colonic inflammation in WT mice was less distinct in MyD88(-/-) mice. In vitro studies revealed that fat not only increases cytokine production following contact with bacterial products, but also that preadipocytes are potent phagocytes. Colonic inflammation is accompanied by massive cytokine production and immune cell infiltration in adjacent adipose tissue. These effects can be considered as protective mechanisms of the mesenteric fat in the defense of bacterial translocation.

Heterotopic pancreas presenting as ileoileal intussusception

Heterotopic, aberrant or ectopic pancreas is defined as the presence of pancreatic tissue in topographic anomaly, with no anatomical, neural or vascular connection to the normal pancreas. It is a rare condition found mainly in stomach, duodenum and jejunum. Ileal heterotopic pancreas is an uncommon condition and has been rarely reported in children so far. Hereby we report a case of heterotopic pancreas presenting as ileal poyp leading to ileoileal intussusception in a 12 year child.

[Prevention of burnout by stress management]

Burnout is a possible consequence of excessive demands, high levels of stress, or a consequence of lack of resources for coping with difficult tasks. Systematic stress management might be effective in reducing the risk for development of a burnout syndrome. Based on a literature search on available research papers and meta-analyses in Medline and Pubmed, current findings on the content and effectiveness of stress management programs are reported for different target groups. Stress management programs can be divided into programs focusing on primary, secondary, and tertiary prevention. In contrast to primary prevention programs, secondary and tertiary preventive programs focus on the specific needs of different target groups. Cognitive-behavioral programs have been shown to be the most effective interventions. A combination of psycho-educational treatment with follow-up or booster sessions increases the long-term outcome in the prevention of burn-out syndromes. Beside the duration of the program, focus on problems and sustainability of supply is important for the long-term effectiveness in secondary and tertiary prevention.

The role of visceral fat

Until a decade ago, fat tissue had been exclusively considered as an endocrine organ. The emerging functional characterization of adipokines as well as adipocytes and preadipocytes suggested for the first time a close link between the endocrine and the immune system. This is emphasized by the changes of the expression pattern of adipokines when the fat tissue is adjacent to inflamed sites. In addition, adipokines are capable of regulating adaptive and acquired immune responses. Remarkably, adipocytes express functional pattern recognition receptors and can consequently respond to bacterial and viral antigens. This seems to be highly relevant for intestinal inflammation and here in particular transmural inflammation where bacteria or bacterial antigens translocalize into the mesenteric fat tissue. Besides phagocytosis of these antigens, adipocytes as well as preadipocytes can be activated resulting in a release of adipokines and chemokines mediating the infiltration of immune cells thus allowing for an immune response. Recent data suggest that the adipokine milieu of the fat tissue closely regulates the polarization of infiltrating immune cells. This is of increasing interest since the pattern of infiltrating cells allows for a characterization of the underlying disease. Thus, in obesity pro-inflammatory M1 macrophages dominate this site. Remarkably, in colorectal carcinoma the presence of M1 and M2 macrophages represents a prognostic marker for the disease course. In conclusion, the visceral fat tissue represents a complex organ with multifaceted function linking the endocrine and the immune system.

[Substance use associated disorders: frequency in patients with schizophrenic and affective psychoses]

BACKGROUND

Alcohol and substance use disorders (ASUD) are considered to be among the most frequent comorbidities in schizophrenic and affective psychoses and have a significant negative influence on their course and prognosis. In the present study patients with diagnosis from the ICD-10 category F2 or F3 were examined regarding a substance use disorder in a multicentre cross-section evaluation at nine psychiatric hospitals in Baden-Württemberg. The aim of this study is to discuss the current research on substance use disorders and psychosis comorbidity regarding the theoretical models by means of collected data.

METHODS

The examination of 50 consecutive admissions per centre is based on a shortened version of the European Severity Index (Europ ASI). An initial urine drug screening was carried out with all patients after admission. Statistical assessment was based on percentage distributions, mean values, standard deviations and suitable correlation analysis.

RESULTS

The representative sample included 448 patients. A proportion of 169 patients (37.7%) had a dual diagnosis F2 and F1 and a proportion of 144 patients (32.1%) had a dual diagnosis F3 and F1; 64 patients (14.3%) had an F2 diagnosis and 71 patients (15.8%) had an F3 diagnosis without ASUD. Apart from lifetime use of alcohol (n = 268) and tobacco (n = 325) hypnotics/tranquilizers (n = 214), cannabis (n = 156), opioids (n = 71), stimulants (n = 96) and hallucinogens (n = 36) were consumed. The most frequent combination and long-term intake consisted of tobacco, alcohol, hypnotics/tranquilizer, cannabis and psychostimulants especially in men with schizophrenic disorders. Regarding motivation before first substance use general psychological adjustment disorders (51%), peer impact (42%) and unspecific affective symptoms were predominant.

CONCLUSIONS

Altogether the present study clearly demonstrates that patients suffering from schizophrenia, affective disorders and ASUD have significantly higher rates of more severe substance use disorders in their psychosocial environment and more suicidal behaviour than patients without substance misuse. The high rate in the cross-sectional prevalence of tobacco, alcohol, cannabis and psychostimulant use calls for more effective drug prevention.

The distinct roles of MMP-2 and MMP-9 in acute DSS colitis

Expression of gelatinases A and B, also referred to matrixmetalloproteinases (MMP)-2 and -9, respectively, is increased in inflamed tissues of experimental intestinal inflammation and humans with inflammatory bowel disease (IBDs). Given that we recently reported that treatment with the selective gelatinase inhibitor RO28-2653 ameliorates acute dextrane sulfate sodium (DSS) colitis, we asked whether gelatinase A or B expression is pivotal in mediating large intestinal inflammation. Results from our study reveal that symptoms of acute DSS colitis as well as histopathological colonic changes were ameliorated in MMP-2-, but not MMP-9-deficient mice, and were paralleled by a diminished influx of immune cells. In MMP-2-deficient mice, we observed lower expression of pro-inflammatory cytokines including interferon-γ (IFN-γ), tumor necrosis factor-α (TNF-α), and IL-6 in colonic biopsies and less overgrowth of the colonic lumen by potentially pro-inflammatory enterobacteria from the commensal gut microbiota. We conclude that rather MMP-2 than MMP-9 is causative for the establishment of DSS colitis in mice. The discrepancy of these data to prior reports might be due to substantial differences in the intestinal microbiota composition of the mice bred at different animal facilities impacting susceptibility to inflammatory stimuli. Consequently, a detailed survey of the gut microbiota should be implemented in immunological/inflammatory studies in the future in order to allow comparison of data from different facilities.

What you eat is what you get: Novel Campylobacter models in the quadrangle relationship between nutrition, obesity, microbiota and susceptibility to infection

Enterocolitis caused by Campylobacter jejuni-infections represents an important socioeconomic burden worldwide. Recent results from novel murine infection models reveal that the intestinal microbiota is essential for maintaining colonization resistance against C. jejuni. We extended these studies to investigate the role of nutrition and obesity in susceptibility to C. jejuni-infection. Gnotobiotic (GB) mice generated by antibiotic treatment, which were fed with a human cafeteria diet (CAF), as well as obese (ob/ob) mice with a conventional microbiota harbored higher Escherichia coli loads in their colon as compared to respective controls. Following oral infection, C. jejuni 43431 ATCC readily colonized the intestines of CAF and ob/ob mice, whereas GB mice fed with a standard chow (MUD) eradicated the pathogen within days. Furthermore, live C. jejuni translocated into mesenteric lymph nodes of CAF, but not MUD mice. Strikingly, stably infected animals developed enterocolitis as indicated by increased numbers of immune and apoptotic cells in the colon in situ. We conclude that a specific human diet and obesity render mice susceptible to C. jejuni infection. The corresponding murine models are excellently suited for the study of C. jejuni pathogenesis and will help to get further insights into interplays between C. jejuni, microbiota, diet, obesity and immunity.