Probiotics in the treatment of human inflammatory bowel diseases: update 2008

Probiotic research and clinical trials have been forging ahead over the last decade. Although much has been learnt in relation to probiotic intestinal epithelial-mucosal immune interactions, the evidence for substantial clinical efficacy of probiotics continues to progress much slower. This review outlines the probiotic clinical studies before 2005 that formed the foundation of probiotic clinical trials in inflammatory bowel disease and then examines indepth those inflammatory bowel disease probiotic clinical trials published after 2005 that are leading to new understanding of the role of probiotics in the induction and remission of inflammatory bowel disease in humans.

Thiopurine-induced myelotoxicity in patients with inflammatory bowel disease: a review

AIM

Probably, the most important and potentially lethal adverse event of azathioprine (AZA) and mercaptopurine (MP) is myelosuppression. Our aim was to conduct a review of AZA/MP-induced myelotoxicity in inflammatory bowel disease (IBD) patients.

METHODS

Bibliographical searches were performed in MEDLINE/EMBASE. The studies evaluating thiopurine-induced myelotoxicity in patients with IBD were reviewed. The cumulative incidence and the incidence rate of AZA/MP-induced myelotoxicity were calculated by a meta-analysis.

RESULTS

In total, 66 studies (8,302 patients) were included. The cumulative incidence of AZA/MP-induced myelotoxicity was 7% (95% confidence interval [CI] 6-8%). The incidence rate (per patient and year of treatment) of the drug-induced myelotoxicity was 3% (95% CI 3-4%). The risk was roughly similar with AZA and with MP (7%vs 9%). The duration of AZA/MP treatment in patients with myelotoxicity ranged from 12 days to 27 yr. The cumulative incidence of infections among AZA/MP-induced myelotoxicity patients was 6.5%. The cumulative incidence of severe myelotoxicity was 1.1% (incidence rate 0.9%). Three deaths were reported due to myelotoxicity (cumulative incidence 0.06%, 95% CI 0.02-0.17%). The risk of death among patients who developed myelotoxicity was 0.94% (95% CI 0.32-2.70%).

CONCLUSION

The incidence rate of myelotoxicity in IBD patients receiving AZA/MP is approximately 3% per patient and year of treatment. Although bone marrow toxicity may develop at any time after starting the therapy, this happens more frequently during the first months. The incidence rate of severe myelotoxicity is less than 1% per patient and year of treatment, and the mortality risk is less than 0.1% (which means that the risk of death among IBD patients who develop myelotoxicity is approximately 1%).

Protein-losing enteropathy after Fontan operation

Protein-losing enteropathy (PLE) is a poorly understood and enigmatic disease process affecting patients with single ventricle after Fontan operation. In those afflicted, PLE after Fontan operation results in significant morbidity and mortality. The pathophysiology of the disease is unknown; however, a proposed mechanism incorporates a combination of phenomena including: (1) altered hemodynamics, specifically low cardiac output; (2) increased mesenteric vascular resistance; (3) systemic inflammation; and (4) altered enterocyte basal membrane glycosaminoglycan make-up. A paradigm for the clinical management of PLE after Fontan operation is proposed.

Nasal pepsin assay and pH monitoring in chronic rhinosinusitis

OBJECTIVES/HYPOTHESIS

The primary objective of this study was to determine the relationship between chronic rhinosinusitis (CRS) and laryngopharyngeal reflux (LPR). We also investigated the diagnostic value of pepsin in nasal lavage by means of fluorometric assay as compared with 24-hour dual-probe pH monitoring.

STUDY DESIGN AND METHODS

This is a controlled, prospective study from a retrospective dataset of 33 patients recruited for endoscopic sinus surgery between 2005 and 2006 in a tertiary care referral center (Hacettepe University Medical Center). All patients underwent 24-hour dual-probe pH monitoring and nasal lavage fluid investigation for pepsin. A fluorometric pepsin assay using casein-fluorescein isothiocyanate in nasal lavage fluid was used to detect LPR. The control group included 20 patients who were proven not to have sinusitis.

RESULTS

A higher incidence of pharyngeal acid reflux events was found in patients with CRS (29 of 33, 88%) compared with the control patients (11 of 20, 55%). The difference was statistically significant (P = .01). The fluorometric pepsin assay was correlated to the results of 24-hour dual-probe monitoring for LPR diagnosis with a 100% sensitivity and 92.5% specificity. These data suggest that an association between CRS and LPR is present and that the detection of pepsin in nasal lavage fluid may provide a noninvasive and feasible method of LPR screening.

Impact of clinical pathways in surgery

BACKGROUND

One strategy to reduce the consumption of resources associated to specific procedures is to utilize clinical pathways, in which surgical care is standardized and preset by determination of perioperative in-hospital processes. The aim of this prospective study was to establish the impact of clinical pathways on costs, complication rates, and nursing activities.

METHOD

Data was prospectively collected for 171 consecutive patients undergoing laparoscopic cholecystectomy (n = 50), open herniorrhaphy (n = 56), and laparoscopic Roux-en-Y gastric bypass (n = 65).

RESULTS

Clinical pathways reduced the postoperative hospital stay by 28% from a mean of 6.1 to 4.4 days (p < 0.001), while the 30-day readmission rate remained unchanged (0.5% vs. 0.45%). Total mean costs per case were reduced by 25% from euro 6,390 to euro 4,800 (p < 0.001). Costs for diagnostic tests were reduced by 33% (p < 0.001). Nursing hours decreased, reducing nursing costs by 24% from euro 1,810 to euro 1,374 (p < 0.001). A trend was noted for lower postoperative complication rates in the clinical pathway group (7% vs. 14%, p = 0.07).

CONCLUSIONS

This study demonstrates clinically and economically relevant benefits for the utilization of clinical pathways with a reduction in use of all resource types, without any negative impact on the rate of complications or re-hospitalization.

Alternative strategies for the use of infliximab in pediatric inflammatory bowel disease

Infliximab is approved for the induction and 1-year maintenance of remission in pediatric Crohn's disease unresponsive to conventional therapy. Despite significant experience with the use of this agent in children and adolescents who have inflammatory bowel disease, many questions about its optimal use remain. Recent safety concerns raised debate over the common practice of using infliximab in combination with conventional immunomodulatory agents. Additionally, although regularly scheduled administration maintains remission more effectively than episodic therapy, it is not known whether all patients who start infliximab must continue it for maintenance. Some patients may be able to use infliximab for induction and another agent for maintenance. Finally, the optimal placement of infliximab in the algorithm for the medical treatment of pediatric inflammatory bowel disease remains an open question.

IBD patients need in health quality of care ECCO consensus

INTRODUCTION

: Inflammatory bowel diseases (IBD) is a lifelong disorder with increasing incidence and prevalence. IBD primarily affects young people's productivity in addition to direct and indirect costs. The chronic nature of the disease and the patients' requirement of frequent and easy access to the Health Care providers regarding lifelong medication, social and psychological support and regular follow-up in out-patient clinics are important considerations to address.

AIM AND METHODS

: To define IBD patient needs in Quality of Health Care (QoHC) in Europe based on up- to date available evidence. The working group consisted of doctors, nurses and patient organizations from 12 European countries and Israel. Pub Med searching was performed as defined in the Delta Method. Each recommendation was graded (RG) in accordance with level of evidence (EL) based on Evidence Based Medicine, Oxford Centre. During UEGW 2007 the group reconvened to agree on the final version for each chapter of guideline statement

RESULTS

: Pub Med search led to 6 RCT, 7 reviews, 63 original articles, but no meta-analysis regarding "Information"; "Education"; "Primary Care", "Quality of life", "Psychological help" and "Benchmarking of Health Care systems" in IBD. Seven ECCO statements have been worked out.

CONCLUSION

: Evidence-based medicine in QoHC is limited. It is concluded that optimizing QoHC by "information"; "education", "benchmarking" and "psychological analysis" helps the patient to understand the disease and comply with its therapy, increasing QoL, reducing depression and anxiety. Future aspects regarding more evidence-based science and optimization of QoHC in IBD throughout Europe have been proposed.

Esophageal, gastric, and duodenal manifestations of IBD and the role of upper endoscopy in IBD diagnosis

Upper gastrointestinal (GI) tract inflammation in inflammatory bowel disease has become increasingly recognized, even in the absence of specific localizing symptoms, as patients more frequently undergo upper endoscopy. Although the recent Montreal classification system allowed classification of upper GI involvement in Crohn's disease (CD), independent of other locations, a consensus regarding the definition of what qualifies as significant "involvement" is still lacking. Reported incidence data vary considerably depending on the definitions used and the selected target population. Pediatric data suggest that upper endoscopy is useful in differentiating CD from ulcerative colitis, when inflammation is otherwise predominantly confined to the colon; however, this question has yet to be studied in adults. Infliximab therapy for upper GI-CD seems as effective as that seen for more distal GI inflammation.

Outcome of surgical resection for protein-losing enteropathy in systemic lupus erythematosus

Protein-losing enteropathy (PLE) is an uncommon manifestation associated with systemic lupus erythematosus (SLE). Here, a case with SLE and concomitant hypoalbuminemia is reported. Technetium-99m albumin scintigraphy demonstrated a localized lesion in the ascending colon, and the diagnosis of SLE-related PLE was established. Due to a poor response to medical treatment, this patient received surgical resection, but relapse still developed later on. Recurrent protein-lose from the remaining of the colon was documented by repeated images. This report discusses the management of SLE-related PLE and the role of nuclear medicine scintigraphy in the investigation of PLE.

High diagnostic yield of gastrointestinal endoscopy in children with intestinal failure

PURPOSE

Children with intestinal failure (IF) often have gastrointestinal (GI) symptoms, including bleeding, increased stool output, and feeding intolerance. The use of endoscopic assessment of these symptoms has not been previously reported. This report evaluates the diagnostic yield of GI endoscopy in the setting of IF.

METHODS

After institutional review board approval, we reviewed the medical records (including endoscopy, pathology and microbiology data) of patients with IF who underwent GI endoscopies between September 1999 and March 2007.

RESULTS

Twenty-seven patients underwent 61 GI endoscopies: 34 esophagogastroduodenoscopies, 17 colonoscopies, 7 flexible sigmoidoscopies, and 3 ileoscopies. Indications for endoscopy, which were not mutually exclusive, included chronic diarrhea (39%, n = 24), GI bleeding (36%, n = 22), suspected bacterial overgrowth (36%, n = 22), and suspected peptic disease (15%, n = 9). Based on gross endoscopic appearance, histopathology, or microbiology, 43 (70%) procedures yielded abnormalities. These included infectious (20%, n = 12), anatomical (18%, n = 11), peptic (15%, n = 9), allergic (15%, n = 9), and other (2%, n = 1) findings. Eleven (73%) of 15 duodenal cultures grew a spectrum of 17 bacterial species. Overall, 24 (89%) of 27 patients had gross endoscopic, histopathologic, or microbiologic abnormalities.

CONCLUSIONS

In pediatric patients with IF, diagnostic upper and lower GI endoscopies yield high rates of abnormalities and can help guide clinical management.

S100 calgranulin proteins S100A8, S100A9 and S100A12 are expressed in the inflamed gastric mucosa of Helicobacter pylori-infected children

The expression of the inflammatory S100 calgranulin proteins (S100A8, S100A9 and S100A12) in normal and Helicobacter pylori-infected gastric mucosa of children were examined. S100A8, S100A9 and S100A12, which were virtually absent in normal gastric mucosa, were highly expressed in H pylori-infected mucosa. This expression correlated with the severity of gastritis (r=0.9422, P<0.05). S100 calgranulins may be involved in bacterial-induced gastritis and may limit bacterial growth.

Frequency and clinical correlations of granulomas in children with Crohn disease

BACKGROUND

Granulomas are pathognomonic findings of Crohn disease (CD); however, their occurrence and clinical significance are not well characterized. Our aim was to determine the frequency and distribution of granulomas in untreated and treated patients with CD and their relation to age and disease severity.

PATIENTS AND METHODS

Records from patients with CD undergoing colonoscopy with terminal ileum biopsy over 7 years were reviewed. Clinical information and laboratory, pathology, and radiology results were recorded. The frequency and distribution of granulomas were determined.

RESULTS

From 376 patients with CD, 75% underwent concurrent esophagogastroduodenoscopy and colonoscopy. Of those, 65% (184/282) were untreated. Granulomas were identified in 48% (136/282) of all patients and in 61% (112/184) of untreated patients and 24.5% (24/98) of treated patients (P < 0.0005). The upper tract and terminal ileum biopsies were essential to the identification of 42% of patients with granulomas. The presence of granulomas at diagnosis was related to anti-Saccharomyces cerevisiae antibodies, hypoalbuminemia, perianal disease, and gastritis at presentation (P = 0.03, P = 0.008, P = 0.03, and P = 0.001), respectively, and to perianal disease and infliximab treatment at the latest visit (P = 0.02 and P = 0.01), respectively. Granulomas were not related to age, sex, ethnicity, weight and height z scores, hemoglobin, C-reactive protein, erythrocyte sedimentation rate, CARD15/NOD2 mutations, abdominal surgery, or stricturing or fistulizing disease.

CONCLUSIONS

Granulomas were identified in 61% of fully investigated pediatric patients with CD at diagnosis, including a substantial proportion of patients in whom colonoscopy to the cecum would have been insufficient for diagnosis. Granulomas were more frequent in untreated patients (P < 0.0005), and their prevalence was not affected by age. The presence of granulomas at diagnosis was associated with perianal disease, gastritis, hypoalbuminemia, anti-Saccharomyces cerevisiae antibodies, and infliximab treatment.

Enhanced gastric IL-18 mRNA expression in Helicobacter pylori-infected children is associated with macrophage infiltration, IL-8, and IL-1 beta mRNA expression

OBJECTIVE

To investigate IL-18 mRNA expression in the gastric mucosa in Helicobacter pylori-infected children and its association with macrophage infiltration, IL-8, and IL-1 beta mRNA expression.

METHODS

From 39 children, blood samples were taken for IL-1 beta gene polymorphism analysis and antral biopsies were obtained for histology (including macrophage immunostaining), culture and semiquantitative analysis of IL-18, IL-8, IL-1 beta, and CD14 mRNA expression by reverse transcription-PCR (RT-PCR). RT-PCR was used for H. pylori ureA and cagA mRNA detection in gastric tissue.

RESULTS

H. pylori-infected patients had significantly higher IL-18, IL-8, and IL-1 beta transcript levels and macrophage numbers in the antral mucosa than H. pylori-negative children. IL-1 beta-511/31 gene polymorphism had no impact on gastric IL-1 beta mRNA levels. IL-18 mRNA expression correlated with mRNA expression of IL-8 and IL-1 beta, and transcript levels of all three cytokines were associated with macrophage infiltration and CD14 mRNA expression in the gastric tissue. Significant correlation was also observed between macrophage numbers and histological parameters of gastritis.

CONCLUSION

These results suggest that interleukin(IL)-18 and macrophages may have an important function in gastric inflammatory response to H. pylori infection in children. IL-18, and possibly CD14 receptor signalling pathway, may be involved in macrophage activation and subsequent IL-8 and IL-1 beta release.

Lipid-laden macrophage index is not an indicator of gastroesophageal reflux-related respiratory disease in children

BACKGROUND

The lipid-laden macrophage index has been used to evaluate for gastroesophageal reflux-related respiratory disease, but the relationship between reflux detected by pH probe and the lipid-laden macrophage index is uncertain despite widespread use of the lipid-laden macrophage index in clinical decision-making. It was the aim of this study to correlate reflux as detected by multichannel intraluminal impedance with the lipid-laden macrophage index.

METHODS

Patients undergoing both pH multichannel intraluminal impedance testing and bronchoscopy between January 2002 and January 2006 were identified. Baseline characteristics were compared by using parametric and nonparametric testing. Reflux profiles were correlated with the lipid-laden macrophage index by using Spearman correlations.

RESULTS

There was no significant correlation between the lipid-laden macrophage index and the number of acid or nonacid reflux events. There also was no significant correlation between the lipid-laden macrophage index and the amount of full-column reflux. There was no significant difference between the mean lipid-laden macrophage index in patients with and without esophagitis. Finally, in patients who underwent fundoplication (n = 13) for intractable respiratory disease, there was no significant difference in any of the reflux parameters between patients who did and did not experience clinical improvement after fundoplication. There was, however, a higher lipid-laden macrophage index in patients with no symptomatic improvement compared with patients with symptomatic improvement.

CONCLUSIONS

Lipid-laden macrophage index lacks the specificity necessary to detect reflux-related respiratory disease.

Fecal S100A12 and fecal calprotectin as noninvasive markers for inflammatory bowel disease in children

BACKGROUND

Fecal calprotectin is a sensitive marker for gut inflammation. Recently, we have established that a related protein, S100A12, is elevated in the feces of children with inflammatory bowel disease (IBD). This may represent a specific and sensitive disease marker. The objective was to investigate the utility of fecal S100A12, in comparison to fecal calprotectin and standard inflammatory markers, as a screening marker for IBD in children with gastrointestinal symptoms.

METHODS

Stool samples were obtained from 61 children presenting with gastrointestinal symptoms requiring endoscopy. Fecal S100A12, calprotectin, and serum S100A12 levels were measured and correlated to final diagnosis and standard tests (ESR, CRP, platelet count, and albumin).

RESULTS

Children diagnosed with IBD (n = 31) had elevated fecal S100A12 (median 55.2 mg/kg) and calprotectin (median 1265 mg/kg) levels compared with the children without IBD (n = 30; S100A12: median 1.1 mg/kg, P < 0.0001; calprotectin: median 30.5 mg/kg; P < 0.0001). The sensitivity and specificity of fecal S100A12 (cutoff 10 mg/kg) for the detection of IBD were both 97%, whereas fecal calprotectin (cutoff 50 mg/kg) gave a sensitivity of 100% and a specificity of 67%.

CONCLUSIONS

Both fecal markers were superior to the sensitivities and specificities of any standard inflammatory test. Both fecal S100A12 and calprotectin are sensitive markers of gastrointestinal inflammation, but fecal S100A12 provided exceptional specificity in distinguishing children with IBD from children without IBD. Fecal S100A12 is a simple, noninvasive test that can be used to screen and select children warranting further invasive and laborious procedures such as endoscopy for the investigation of their gastrointestinal symptoms.

Enteral feeding

PURPOSE OF REVIEW

Enteral nutrition is a widely used therapy for nutritional treatment of patients with multiple pathologies. The present review selects important evidenced-based papers from 2006 and 2007 and critically reviews them for the reader.

RECENT FINDINGS

Use of synbiotics and probiotics is gaining acceptance. Supplements such as glutamine may be important for wound healing. Enteral feeding in malnourished patients may result in rapid growth of gut mucosal protein. Antibiotics are important for reduction of postpercutaneous endoscopic gastrostomy infections. Early enteral nutrition in burn patients blunts the hypermetabolic response. Polymeric enteral formulations in vitro have a direct anti-inflammatory effect on enterocytes. Enteral nutrition, however, does not appear better than steroid use for induction of remission in Crohn's disease. Long-term (12-week) infusion of immune-enhancing enteral formulas in a nonsurgical patient group is well tolerated and safe. Finally, large reviews of enteral nutrition and their efficacy for specific disease states continue to demonstrate the difficulty in interpreting multiple small clinical studies.

SUMMARY

Enteral nutrition continues as a highly used medical therapy, usually as an adjuvant for other pharmacologic and supportive therapies. Multiple small clinical trials, observational studies and retrospective reviews must be analyzed to develop 'best practice' guidelines with enteral nutrition.

Systematic review: nutritional therapy in paediatric Crohn's disease

BACKGROUND

At least 25% of individuals diagnosed with Crohn's disease (CD) have onset of disease in childhood. Almost all children with CD have nutritional impairments, such as weight loss or stunting, at diagnosis or subsequently. Nutritional therapy (exclusive enteral nutrition) is established as a valid and effective treatment in paediatric CD. The advantages of this approach are induction of remission and control of inflammatory changes, mucosal healing, positive benefits to growth and overall nutritional status, and avoidance of other medical therapies.

AIM

To provide a comprehensive up-to-date review of the roles of nutritional therapy in CD and of the data supporting this therapy.

METHODS

A search of PubMed was performed with search terms 'enteral nutrition', 'nutritional therapy', 'Crohn disease' and 'children'. Relevant articles were selected from this search. In addition, the reference lists of available articles were reviewed for further relevant articles.

RESULTS

Nutritional therapy offers numerous benefits in the management of CD. Recent work has begun to elucidate the likely mechanisms of this therapy. These include direct mucosal anti-inflammatory effects and alteration of intestinal microflora.

CONCLUSION

Further studies are required to define longer-term effects of nutritional therapy in patients with CD.

Specific considerations in the treatment of pediatric inflammatory bowel disease

Inflammatory bowel disease is one of the most prevalent chronic inflammatory disorders and commonly presents during childhood or adolescence. Occurring during a critical period of growth and development, pediatric Crohn's disease and ulcerative colitis require special consideration. Children often experience growth failure, malnutrition, pubertal delay and bone demineralization. Medical treatment must be optimized to promote clinical improvement and reverse growth failure with minimal toxicity. In addition to pharmacologic and surgical interventions, nutritional therapies play a vital role in the management of pediatric inflammatory bowel disease. This review will outline the epidemiology and clinical complications that are unique to pediatric inflammatory bowel disease, current trends, and recent advances in nutritional and pharmacologic treatment, and projected future therapeutic direction.

Pepsin, a marker of gastric contents, is increased in tracheal aspirates from preterm infants who develop bronchopulmonary dysplasia

OBJECTIVE

The objective of this study was to study the association between pepsin in tracheal aspirate samples and the development of bronchopulmonary dysplasia in preterm infants.

METHODS

Serial tracheal aspirate samples were collected during the first 28 days from mechanically ventilated preterm neonates. Bronchopulmonary dysplasia was defined as the need for supplemental oxygen at 36 weeks' postmenstrual age. An enzymatic assay with a fluorescent substrate was used to detect pepsin. Total protein was measured by the Bradford assay to correct for the dilution during lavage. Immunohistochemistry using antibody against human pepsinogen was performed in 10 lung tissue samples from preterm infants.

RESULTS

A total of 256 tracheal aspirate samples were collected from 59 preterm neonates. Pepsin was detected in 234 (91.4%) of 256 of the tracheal aspirate samples. Twelve infants had no bronchopulmonary dysplasia, 31 infants developed bronchopulmonary dysplasia, and 16 infants died before 36 weeks' postmenstrual age. The mean pepsin concentration was significantly lower in infants with no bronchopulmonary dysplasia compared with those who developed bronchopulmonary dysplasia or developed bronchopulmonary dysplasia/died before 36 weeks' postmenstrual age. Moreover, the mean pepsin level was significantly higher in infants with severe bronchopulmonary dysplasia compared with moderate bronchopulmonary dysplasia. The mean pepsin level in tracheal aspirate samples from the first 7 days was also lower in infants with no bronchopulmonary dysplasia compared with those who developed bronchopulmonary dysplasia or developed bronchopulmonary dysplasia/died before 36 weeks' postmenstrual age. Pepsinogen was not localized in the lung tissues by immunohistochemistry.

CONCLUSION

The concentration of pepsin was increased in the tracheal aspirate of preterm infants who developed bronchopulmonary dysplasia or died before 36 weeks' postmenstrual age. Recovery of pepsin in tracheal aspirate samples is secondary to gastric aspiration, not by hematogenous spread or local synthesis in the lungs. Chronic aspiration of gastric contents may contribute in the pathogenesis of bronchopulmonary dysplasia.

Dietary modifications, nutritional supplements and alternative medicine in paediatric patients with inflammatory bowel disease

BACKGROUND

Data on use of complementary and alternative medicine in children with inflammatory bowel disease are scarce.

AIM

To assess prevalence, predictors and parental attitude to the use of complementary and alternative medicine in a paediatric population with inflammatory bowel disease in the west of Scotland.

METHODS

Questionnaire survey encompassing alternative therapists, nutritional supplements and dietary modifications used in the management of inflammatory bowel disease was used. Demographics, disease and treatment data were also collected.

RESULTS

86 guardians completed the survey. 61% had used at least one type and 37% were using complementary and alternative medicine recently. The most common types were probiotics (44%) and dairy-free diet (28%). Higher parental education and young parental age were predictors of complementary and alternative medicine use. An increased number of oral steroid courses and prior use of complementary and alternative medicine for other health reasons were associated with use of alternative therapists. Personal recommendation and to complement conventional medicine were the main reasons for using complementary and alternative medicine. 48% judged complementary and alternative medicine at least partially effective. 86% agreed that doctors should be supportive of use. 89% would give complementary and alternative medicine to their children.

CONCLUSIONS

Use of complementary and alternative medicine was higher in children with IBD than in adults with the same disease. The gastrointestinal nature of the disease could explain the high use of nutritional supplements and dietary modifications in this survey.

Regulation of IL-18 in Helicobacter pylori infection

The gastric mucosal immune response is thought to be comprised predominantly of the Th1 type; however, there are limited data regarding the role of IL-18 in Helicobacter pylori-induced inflammation. We investigated IL-18 levels in gastric mucosal biopsy specimens as well as in isolated gastric epithelial cells and lamina propria mononuclear cells. We also investigated IL-18 levels in gastric epithelial cells and the monocyte cell line THP-1 cocultured with H. pylori. In both systems, IL-18 levels were markedly enhanced in H. pylori-infected epithelial cells and monocytes. IL-18 levels in H. pylori-infected gastric mucosa were well correlated with the severity of gastric inflammation, confirming that H. pylori-induced IL-18 plays an important role in gastric injury. Virulence factors of H. pylori; the cag pathogenicity island and OipA affected IL-18 induction in different manners. Up-regulation of IL-18 mRNA/protein in epithelial cells was dependent on both virulence factors. Interestingly, up-regulation of IL-18 mRNA in monocytes was independent of both factors, whereas IL-18 protein was OipA dependent-cag pathogenicity island independent, indicating that OipA regulates IL-18 induction in monocytes at the posttranscriptional level. IL-18 levels in the gastric biopsy specimens showed similar patterns to those in lamina propria mononuclear cells with respect to virulence factors, suggesting that submucosal monocytes/macrophages are the main source of IL-18 induced by H. pylori infection. H. pylori appeared to regulate the ERK/JNK-->AP-1 pathway in both cell types. In addition, OipA and its related p38 pathway may be closely involved in IL-18 induction in H. pylori-infected gastric mucosa and may contribute to gastric injury.

Identification of the major antigenic protein of Helicobacter cinaedi and its immunogenicity in humans with H. cinaedi infections

Helicobacter cinaedi infection is now recognized as an increasingly important emerging disease. Its pathogenesis and epidemiological features are not fully understood, however. Here, we investigated the antigenic protein of H. cinaedi and the immunological response to it in H. cinaedi-infected patients. We constructed a genomic library of H. cinaedi from an H. cinaedi clinical isolate, and various H. cinaedi recombinant proteins were expressed. We identified the 30-kDa protein, encoded in an 822-bp H. cinaedi genome, as a major antigen, which was specifically recognized by serum from an H. cinaedi-immunized rabbit and H. cinaedi-infected patients. The gene encoding this 30-kDa antigen had high sequence similarity with genes encoding putative membrane proteins of bacteria. To evaluate whether the 30-kDa protein can be applied in serological testing for H. cinaedi infections, the recombinant protein was expressed in Escherichia coli as a His-tagged fusion protein and purified by Ni(2+) affinity chromatography. Western blot analysis revealed strong immunoreactivity of the 31-kDa fusion protein with serum antibody from patients infected with H. cinaedi, but such an immunoreaction was absent or was very weak with uninfected control serum. An enzyme-linked immunosorbent assay using this H. cinaedi major antigen showed significantly high antibody titers for H. cinaedi-infected subjects compared with those of various control groups. We therefore conclude that the 30-kDa putative membrane protein is a major antigen of H. cinaedi and is useful for immunological and serological testing for clinical diagnosis and for further epidemiological study of H. cinaedi infection in humans.

Efficacy and safety of tacrolimus in refractory ulcerative colitis and Crohn's disease: a single-center experience

BACKGROUND

The published experience regarding the use of tacrolimus in Crohn's disease (CD) and ulcerative colitis (UC) refractory to more commonly used medical therapy has been fairly limited. Our objective was to describe our experience with its use in a cohort of patients which, to our knowledge, represents the largest North American cohort described to date.

METHODS

This was a retrospective, single-center chart analysis. Patients were identified by compiling all hospital discharges with principle diagnoses of ICD-9 codes for 555.0-555.9 (regional enteritis) and 556.0-556.9 (ulcerative colitis) from January 1, 2000, to October 31, 2005, and then cross-referencing the electronic charts for tacrolimus serum concentrations ordered during this time period. Additional patients were identified through verbal communication with participating clinicians. Information abstracted included proportion with clinical response and remission (using a modified disease activity index), ability to wean from steroids, need for surgery / time to surgery, and side-effect profile.

RESULTS

In all, 32 UC patients and 15 CD patients were identified. The mean disease duration was: UC 81 months (range, 1 month to 37 years), CD 100 months (range, 1 month to 35 years). The disease distribution for UC was: pancolitis 12 (37.5%), extensive colitis 6 (18.8%), left-sided 11 (34.4%), and proctitis 3(9.4%). For CD this was: TI 2 (13.3%), small bowel 2 (13.3%), colonic 3 (20.7%), ileocolonic 7(46.7%), and perianal 1 (6.7%). The duration of tacrolimus treatment for UC was mean, 29 weeks. For CD it was mean, 9.9 weeks. In all, 30/32 UC and 7/15 CD patients were on steroids; 4/30 UC and 0/7 CD patients were able to subsequently wean off steroids. In all, 12/32 UC patients proceeded to colectomy. Mean time to colectomy was 28 weeks and 6/15 CD patients proceeded to a resective surgery. The mean time to surgery was 22 weeks. In all, 22/32 UC patients achieved a clinical response; 3/32 achieved remission and 8/15 CD patients achieved a clinical response; 1/15 achieved remission. Adverse reactions were generally mild. In 6 patients the drug had to be discontinued because of an adverse reaction. There were no opportunistic infections identified, no cases of renal insufficiency related to drug administration, and no deaths while on the medicine.

CONCLUSIONS

Our experience with tacrolimus in UC and CD indicates that it is safe and relatively well tolerated, although its clinical efficacy is quite variable. More prospective studies assessing its use are necessary.

Fas Ag-FasL coupling leads to ERK1/2-mediated proliferation of gastric mucosal cells

When cells within the gastric mucosa progress from metaplasia to dysplasia to cancer, they acquire a Fas Ag apoptosis-resistant phenotype. It is unusual to completely abolish the pathway, suggesting other forms of Fas Ag signaling may be important or even necessary for gastric cancer to progress. Little is known about alternate signaling of the Fas Ag pathway in gastric mucosal cells. Using a cell culture model of rat gastric mucosal cells, we show that gastric mucosal cells utilize a type II signaling pathway for apoptosis. Under conditions of low receptor stimulation or under conditions where apoptosis is blocked downstream of the death-inducing signal complex, Fas Ag signaling proceeds toward proliferative signaling. Under conditions favoring proliferative signaling, cFLIP is recruited to the Fas-associated death domain-like interleukin-1beta-converting enzyme at the death-inducing signal complex and activates ERK1/2. ERK1/2 in turn activates NF-kappaB. ERK1/2 stimulates proliferation, whereas NF-kappaB activation results in upregulation of the antiapoptotic protein survivin, further promoting proliferation over apoptosis. These results suggest that factors that inhibit apoptosis confer a growth advantage to the cells beyond the survival advantage of avoiding apoptosis and in effect convert the Fas Ag signaling pathway from a tumor suppressor to a tumor promoter.

Current treatment of inflammatory bowel disease in children

Children with inflammatory bowel disease present formidable therapeutic challenges. As both Crohn's disease and ulcerative colitis remain medically incurable conditions associated with potentially significant morbidity, the focus of treatment must be to reduce or eliminate symptoms, optimize nutritional status, promote normal growth and development, prevent complications and minimize the potential psychological effects of these chronic illnesses. This review focuses on the evidence supporting the treatments currently used in children with inflammatory bowel disease, and suggests potential treatment algorithms for particular clinical circumstances.

Assessment of the prevalence of microaspiration by gastric pepsin in the airway of ventilated children

AIM

Mechanically ventilated patients are at risk for aspiration of gastric contents. The aim of this observational study was to determine the prevalence of micro-aspiration in children with cuffed and uncuffed endotracheal (ET) tubes and with tracheostomies and to assess the effect of feeding status on aspiration. Micro-aspiration was determined by measuring gastric pepsin in tracheal aspirates.

METHODS

We studied 27 children on ventilators in paediatric intensive care unit (PICU) and 10 children undergoing elective surgeries for various indications. Tracheal aspirates were collected from children on ventilatory support in the intensive care unit during medically indicated suctioning and from the group of children undergoing elective surgery in the operation room. Pepsin was detected by enzymatic assay.

RESULTS

Overall 70% of cases in PICU were positive for pepsin in at least one of the aspirates. Pepsin positivity was significantly lower in the cuffed group than in the uncuffed and tracheostomy groups. Tube feedings did not significantly influence the prevalence of pepsin positivity.

CONCLUSIONS

Measurement of gastric pepsin in tracheobronchial fluid is a sensitive tool to detect aspirations in mechanically ventilated children and to assess the efficacy of preventive measures in PICU settings.

The pathogenesis of Helicobacter pylori-induced gastro-duodenal diseases

Helicobacter pylori is the main cause of peptic ulceration, distal gastric adenocarcinoma, and gastric lymphoma. Only 15% of those colonized develop disease, and pathogenesis depends upon strain virulence, host genetic susceptibility, and environmental cofactors. Virulence factors include the cag pathogenicity island, which induces proinflammatory, pro-proliferative epithelial cell signaling; the cytotoxin VacA, which causes epithelial damage; and an adhesin, BabA. Host genetic polymorphisms that lead to high-level pro-inflammatory cytokine release in response to infection increase cancer risk. Pathogenesis is dependent upon inflammation, a Th-1 acquired immune response and hormonal changes including hypergastrinaemia. Antral-predominant inflammation leads to increased acid production from the uninflamed corpus and predisposes to duodenal ulceration; corpus-predominant gastritis leads to hypochlorhydria and predisposes to gastric ulceration and adenocarcinoma. Falling prevalence of H. pylori in developed countries has led to a falling incidence of associated diseases. However, whether there are disadvantages of an H. pylori-free stomach, for example increased risk of esosphageal adenocarcinoma, remains unclear.

Integrative approaches to childhood constipation and encopresis

Constipation and encopresis (fecal soiling) are common childhood disorders that may lead to significant functional impairment. The etiology and course of constipation and encopresis are increasingly conceptualized from a broad biopsychosocial perspective, and therefore a holistic approach to assessment and treatment is indicated. Many children experience symptoms of chronic constipation and/or encopresis that are only partially responsive to conventional medical therapy. Complementary/alternative therapies can often help in the treatment of constipation/encopresis and are well accepted by patients and families.

A tertiary amino-containing polymethacrylate polymer protects mucus-covered intestinal epithelial monolayers against pathogenic challenge

PURPOSE

We examined the cytoprotective influences of the mucoadhesive polymer, poly(DMAEMA), on human mucus-producing intestinal epithelial monolayers against two bacterial exotoxins and S. typhimurium. Direct anti-bacterial effects were also assessed against S. typhimurium.

METHODS

In the presence and absence of mucus, untreated or poly(DMAEMA)-exposed monolayers were challenged with S. typhimurium or supernatants containing either cholera (CTx) or C. difficile toxins. Assays included LDH, cytokine secretion, cyclic AMP (cAMP) and microscopy to visualise bacterial adherence by monolayers. The minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of poly(DMAEMA) against S. typhimurium were established, along with a time-kill study.

RESULTS

CTx and C. difficile toxin induced LDH release from E12 monolayers. CTx also elevated intracellular epithelial cAMP, while S. typhimurium induced basolateral IL-8 secretion. Pre-treatment of E12 monolayers with poly(DMAEMA) reduced these effects, but only in the presence of mucus. The polymer co-localised with S. typhimurium in mucus and reduced bacteria-epithelia association. Poly(DMAEMA) was directly bactericidal against S. typhimurium at 1 mg/ml within 30 min.

CONCLUSIONS

Poly(DMAEMA) may have potential as a non-absorbed polymer therapeutic against infection. These effects were mediated by a combination of physical interaction with mucus and by direct bacterial killing.

Complementary medicine use in multi-ethnic paediatric outpatients

OBJECTIVE

To determine the prevalence and determinants of complementary medicine (CM) use in a multi-ethnic paediatric outpatient population.

METHODOLOGY

A parent-completed questionnaire survey of paediatric outpatients attending general and sub-specialist outpatient clinics at a North West London hospital during September to December 2005.

RESULTS

Parents' use of CM for their children in this multi-ethnic population was higher than expected at 37%. Use was correlated with parental CM use and education but independent of ethnic group. Parental CM use and child's health status were significant predictors of child CM use. The main reason for using CM was word of mouth (45%) and the main source of information was friends and family (51%). The most popular treatments used for children were homeopathy and herbal medicine (used by 30% and 28% of CM users, respectively). 88% of CM was bought over the counter and 53% of CM use was not reported to their doctor. Parents also used traditional complementary remedies for their children.

CONCLUSIONS

These results suggest that CM use in children is higher than previously estimated in the UK. This indicates the need for greater professional awareness of CM as part of clinical care. There is a need to acknowledge the beliefs that inform parents' decision-making process.

Evaluation of apoptosis induction using PARP cleavage on gastric adenocarcinoma and fibroblast cell lines by different strains of Helicobacter pylori

Helicobacter pylori is one of the most common pathogens affecting humans and is the major environmental factor in the development of gastric cancer increasing from 4 to 6 folds the risk of its development. Variations in cancer risk among H. pylori infected individuals may correlate to difference in H. pylori strains, variable host characteristics and specific interactions between host and microbial determinants. To determine the effect of different strains of H. pylori on cellular apoptosis this study was designed an in vitro model using AGS and HEF cell lines. After specified time intervals total cell proteins was extracted and subjected to SDS-PAGE and immunoblotting using anti poly ADP-ribose polymerase (PARP) antibody. Decrease in densitometric value of PARP was indicative of higher level of apoptosis. The ability of apoptosis induction in AGS and HEF cell lines by wild type (cagA+/vacA+), cagA-/vacA+, vacA-/cagA+ and double negative (cagA-/vacA-) strains were significantly different. The assessed apoptosis in AGS cell line co-cultured with wild type strain was 3.22 +/- 0.2 in 24 h, 2.8 +/- 0.1 in 48 and 2.1 +/- 0.09 in 72 h of incubation time. Similar assessment with cagA-/vacA+ strains in AGS cells was 4.17 +/- 1.49 in 24 h, 3.32 +/- 0.45 in 48 h and 2.32 +/- 0.61 in 72 h incubation. A variation in apoptotic potential between the H. pylori strains on two cells (AGS and HEF) was observed. Based on present results, it is concluded that H. pylori strains as well as target cell types are important in pathogenesis and induction of apoptosis during a specified time interval.

Emerging role of IL-23/IL-17 axis in H pylori-associated pathology

Colonization of stomach by H pylori is followed by a marked infiltration of the mucosa with polymorphonuclear leukocytes, macrophages, and lymphocytes that very often remains asymptomatic, but in some circumstances can lead to the development of gastroduodenal ulceration, gastric carcinoma, and mucosa-associated lymphoid tissue lymphoma. The molecular mechanisms by which H pylori triggers and maintains the local immune response are complex, but there is evidence that cytokines produced by both immune and non-immune cells contribute to amplify the ongoing inflammation. H pylori infection is associated with a marked mucosal induction of T helper (Th) type 1 and Th17-type cytokines that is governed by specific antigen-presenting cell-derived molecules, such as interleukin (IL)-12 and IL-23. In this paper, we will review the available data on the expression and role of IL-23 and IL-17 in H pylori-related gastritis.

The CUPDAY Study: prebiotic-probiotic milk product in 1-3-year-old children attending childcare centres

AIM

The aim of the study was to evaluate the efficacy of a milk product containing probiotics and prebiotics (CUPDAY Milk) on the incidence of diarrhoea in children attending daycare centres.

METHODS

The study was undertaken in a randomized controlled trial with 496 children aged 1-3 years attending 29 childcare centres in Perth, Australia. The endpoint for the study was the number of days in which children were recorded as having four or more stools. The diarrhoeal rates were analyzed by Poisson regression using 'intention to treat' (all children) and 'reduced' (children enrolled for more than 10 days) data sets.

RESULTS

There was no difference in demographic characteristics between the case and control groups. In the 'intention to treat' analysis, a total of 41 745 child-days were included in the study. The adjusted risk ratio for those consuming the 'Cupday' milk drink was 0.82 (95% CI 0.73-0.94) for the intention to treat sample (n = 496) and 0.80 (95% CI 0.70-0.91) for the reduced sample (n = 315). The children consuming the 'Cupday' drink had a 20% reduction in the number of days experiencing four or more stools per day.

CONCLUSION

A milk containing probiotics and prebiotics reduced the number of days children attending child care who had four or more stools by 20%.

Serum and mucosal S100 proteins, calprotectin (S100A8/S100A9) and S100A12, are elevated at diagnosis in children with inflammatory bowel disease

OBJECTIVE

Various markers characterize the complex inflammatory processes seen in chronic inflammatory bowel disease (IBD) including calprotectin, a complex of two S100 proteins, which has been evaluated and validated as a faecal marker of inflammation. However, the systemic and mucosal expression patterns of calprotectin and related S100 proteins are not well characterized in this disease. The objective of this study was to assess serum and mucosal levels of calprotectin, S100A12 and soluble receptor for advanced glycation end products (sRAGE), a putative S100 ligand, in a paediatric population with IBD.

MATERIAL AND METHODS

Children were enrolled at diagnosis of IBD, along with groups of children without IBD. Standard inflammatory markers and disease activity scores were collated. Calprotectin, S100A12 and sRAGE levels in serum and biopsy culture supernatants were measured by ELISA and tissue distribution of S100 proteins was investigated by immunohistochemistry.

RESULTS

Serum and mucosal calprotectin and S100A12 levels were increased in children with IBD as compared with non-IBD controls. Serum calprotectin levels correlated with S100A12 levels and with disease activity scores in children with IBD. sRAGE levels were not increased in IBD. S100A8, S100A9 and S100A12 were abundantly expressed throughout the lamina propria and epithelium in inflamed mucosa. In contrast, these proteins were present in the lamina propria, but not the epithelium, in non-inflamed mucosa.

CONCLUSIONS

Serum calprotectin and S100A12 are increased in children with IBD and indicate disease activity. Elevated levels of these proteins are present in the colonic mucosa and may contribute to the pathogenesis of IBD. Furthermore, an imbalance between sRAGE and S100A12 may contribute to inflammatory changes present in IBD.

Isolation and characterization of a novel helicobacter species, "Helicobacter macacae," from rhesus monkeys with and without chronic idiopathic colitis

Chronic idiopathic colitis is a common clinical entity in young captive rhesus monkeys. Eight isolates, cultured from five monkeys in colony 1 with endemic diarrhea and three from colony 2 without diarrhea, were grown under microaerobic conditions on selective agar and were classified by full 16S rRNA sequence, biochemical, and phenotypic analysis as a novel helicobacter, "Helicobacter macacae" (proposed name). All eight strains of H. macacae had 99.5% identical 16S rRNA sequences.

Prospective evaluation of faecal neutrophil-derived proteins in identifying intestinal inflammation: combination of parameters does not improve diagnostic accuracy of calprotectin

BACKGROUND

Differentiating symptoms of irritable bowel syndrome from those of organic intestinal disease is a common clinical problem. Several neutrophil-derived proteins have been proposed as a marker of inflammatory bowel disease.

AIM

To compare the diagnostic value of faecal calprotectin, lactoferrin and polymorphonuclear neutrophil-elastase in distinguishing inflammatory bowel disease from irritable bowel syndrome.

METHODS

Eighty-eight adult patients with a history of chronic diarrhoea of unknown origin were screened. All patients underwent a complete work-up to identify the underlying cause. In addition, a single stool sample was assayed for faecal calprotectin, lactoferrin and polymorphonuclear neutrophil-elastase by enzyme-linked immunosorbent assay.

RESULTS

Within the study cohort inflammatory bowel disease was diagnosed in 45 patients and irritable bowel syndrome in 31 patients. The sensitivity and specificity of calprotectin for inflammatory bowel disease were 93% and 100%, respectively. In contrast, the respective diagnostic values for lactoferrin and polymorphonuclear neutrophil-elastase were 82% and 100% and 84% and 87%, respectively. Neither combination of markers did improve the diagnostic power compared with calprotectin alone.

CONCLUSIONS

Although all faecal biomarkers studied provide a reliable and simple non-invasive means in the differentiation of inflammatory bowel disease and irritable bowel syndrome, calprotectin appears to represent the most accurate marker to discriminate between these two common causes of chronic diarrhoea.

Non-pylori Helicobacteraceae in the upper digestive tract of asymptomatic Venezuelan subjects: detection of Helicobacter cetorum-like and Candidatus Wolinella africanus-like DNA

BACKGROUND

The spectrum of human non-pylori Helicobacter infections is expanding, with species such as H. heilmannii and H. felis occasionally being associated with gastritis. However, the existence of non-pylori Helicobacter colonization in asymptomatic subjects has not been evaluated. The aim of this study was to investigate whether Helicobacter species other than pylori are present in the upper digestive tract of asymptomatic human subjects.

MATERIALS AND METHODS

A Helicobacteraceae-specific semi-nested polymerase chain reaction (PCR) assay was used to detect Helicobacter-like organisms in the upper digestive tract of 91 Venezuelan volunteers (aged 18-68 years, 41 females, 50 males). Species were identified by denaturing gradient gel electrophoresis analysis and sequencing of the PCR products.

RESULTS

We detected DNA sharing 99-100% sequence identity in over 300-400 bp with the 16S rRNA genes of H. pylori, H. cetorum, and Candidatus Wolinella africanus in 76%, 16%, and 15% of the subjects, respectively. Multiple colonization was documented in 10% of the subjects: H. cetorum and Candidatus W. africanus (4%), H. pylori and Candidatus W. africanus (4%), and H. pylori and H. cetorum (2%).

CONCLUSIONS

Our results suggest that non-pylori Helicobacteraceae colonization is relatively common in the Venezuelan asymptomatic population. This is the first report documenting the presence of H. cetorum DNA in the human upper digestive tract, and the second report of the recently discovered Candidatus W. africanus.

Extragastric manifestations of Helicobacter pylori infection -- other Helicobacters

Today there is evidence that Helicobacter pylori has a critical role in different extragastric diseases. The discovery of a number of other novel Helicobacter species has stimulated the research in different extragastric diseases, in which an infectious hypothesis is plausible. Enterohepatic Helicobacter species have been hypothesized to play a role in different disorders, including hepatocellular carcinoma, gallstones formation and cholangiocellular carcinoma, as well as enteric diseases and inflammatory bowel diseases. Concerning the extragastric manifestations of H. pylori infection, idiopathic thrombocytopenic purpura, and sideropenic anemia represent, based on the current data, the diseases in which the pathogenic link appears to be strongest. There is also an increasing evidence for a possible association of H. pylori with cardiovascular disease.

Factors influencing complementary and alternative medicine use in a multisite pediatric oncology practice

PURPOSE

Complementary and alternative medicine (CAM) use in children is common although estimates of prevalence vary widely. We studied CAM use in our multisite pediatric oncology practice and evaluated factors influencing CAM use.

PATIENTS AND METHODS

We conducted an anonymous cross-sectional survey of 274 parents of children treated at the combined Nemours oncology practice in Florida and Delaware. Prevalence of CAM use was determined and binary logistic regression was used to evaluate factors related to CAM use in children.

RESULTS

The prevalence of CAM use among children and parents was 24.5% and 66.7%, respectively. Intensity of parent's use of CAM and geographic region were significantly associated with CAM use in children. The odds of CAM use in children increased with increasing use among parents. When parents used 6 or more therapies children were 33 times more likely to use CAM compared with those whose parents did not use CAM (odds ratio=33.3; 95% confidence interval, 10.4-106.2, P<0.01). Children in Florida were more likely to use CAM compared with children in Delaware (odds ratio=3.0; 95% confidence interval, 1.6-5.8, P<0.01).

CONCLUSIONS

These results indicate that children's use of CAM is significantly related to the intensity of parent's use regardless of parent's race, sex, education, household income, or child's sex or age. Clinicians should consider parental use and intensity of CAM use. Assessing CAM use should include classifications established by the National Center for CAM and a standard format for inquiring about CAM use should be developed.