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Elfiky AMI, Hageman IL, Becker MAJ, Verhoeff J, Li Yim AYF, Joustra VW, Mulders L, Fung I, Rioja I, Prinjha RK, Smithers NN, Furze RC, Mander PK, Bell MJ, Buskens CJ, D’Haens GR, Wildenberg ME, de Jonge WJ. A BET Protein Inhibitor Targeting Mononuclear Myeloid Cells Affects Specific Inflammatory Mediators and Pathways in Crohn’s Disease. Cells 2022; 11:cells11182846. [PMID: 36139421 PMCID: PMC9497176 DOI: 10.3390/cells11182846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/08/2022] [Accepted: 09/06/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Myeloid cells are critical determinants of the sustained inflammation in Crohn’s Disease (CD). Targeting such cells may be an effective therapeutic approach for refractory CD patients. Bromodomain and extra-terminal domain protein inhibitors (iBET) are potent anti-inflammatory agents; however, they also possess wide-ranging toxicities. In the current study, we make use of a BET inhibitor containing an esterase sensitive motif (ESM-iBET), which is cleaved by carboxylesterase-1 (CES1), a highly expressed esterase in mononuclear myeloid cells. Methods: We profiled CES1 protein expression in the intestinal biopsies, peripheral blood, and CD fistula tract (fCD) cells of CD patients using mass cytometry. The anti-inflammatory effect of ESM-iBET or its control (iBET) were evaluated in healthy donor CD14+ monocytes and fCD cells, using cytometric beads assay or RNA-sequencing. Results: CES1 was specifically expressed in monocyte, macrophage, and dendritic cell populations in the intestinal tissue, peripheral blood, and fCD cells of CD patients. ESM-iBET inhibited IL1β, IL6, and TNFα secretion from healthy donor CD14+ monocytes and fCD immune cells, with 10- to 26-fold more potency over iBET in isolated CD14+ monocytes. Transcriptomic analysis revealed that ESM-iBET inhibited multiple inflammatory pathways, including TNF, JAK-STAT, NF-kB, NOD2, and AKT signaling, with superior potency over iBET. Conclusions: We demonstrate specific CES1 expression in mononuclear myeloid cell subsets in peripheral blood and inflamed tissues of CD patients. We report that low dose ESM-iBET accumulates in CES1-expressing cells and exerts robust anti-inflammatory effects, which could be beneficial in refractory CD patients.
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Affiliation(s)
- Ahmed M. I. Elfiky
- Tytgat Institute for Liver and Intestinal and Research, Amsterdam Gastroenterology & Metabolism, Amsterdam University Medical Centers, University of Amsterdam, 1105 BK Amsterdam, The Netherlands
- Immunology Research Unit, GSK Medicines Research Centre, Stevenage SG1 2FX, UK
| | - Ishtu L. Hageman
- Tytgat Institute for Liver and Intestinal and Research, Amsterdam Gastroenterology & Metabolism, Amsterdam University Medical Centers, University of Amsterdam, 1105 BK Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam Gastroenterology Endocrinology Metabolism (AGEM), University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Marte A. J. Becker
- Tytgat Institute for Liver and Intestinal and Research, Amsterdam Gastroenterology & Metabolism, Amsterdam University Medical Centers, University of Amsterdam, 1105 BK Amsterdam, The Netherlands
| | - Jan Verhoeff
- Tytgat Institute for Liver and Intestinal and Research, Amsterdam Gastroenterology & Metabolism, Amsterdam University Medical Centers, University of Amsterdam, 1105 BK Amsterdam, The Netherlands
- Department of Molecular Cell Biology & Immunology, Amsterdam Infection & Immunity Institute and Cancer Center Amsterdam, Amsterdam University Medical Centers, Free University Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Andrew Y. F. Li Yim
- Tytgat Institute for Liver and Intestinal and Research, Amsterdam Gastroenterology & Metabolism, Amsterdam University Medical Centers, University of Amsterdam, 1105 BK Amsterdam, The Netherlands
- Immunology Research Unit, GSK Medicines Research Centre, Stevenage SG1 2FX, UK
- Genome Diagnostics Laboratory, Department of Clinical Genetics, Amsterdam Reproduction & Development, Amsterdam University Medical Centers, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Vincent W. Joustra
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam Gastroenterology Endocrinology Metabolism (AGEM), University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Lieven Mulders
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam Gastroenterology Endocrinology Metabolism (AGEM), University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Ivan Fung
- Tytgat Institute for Liver and Intestinal and Research, Amsterdam Gastroenterology & Metabolism, Amsterdam University Medical Centers, University of Amsterdam, 1105 BK Amsterdam, The Netherlands
| | - Inmaculada Rioja
- Immunology Research Unit, GSK Medicines Research Centre, Stevenage SG1 2FX, UK
| | - Rab K. Prinjha
- Immunology Research Unit, GSK Medicines Research Centre, Stevenage SG1 2FX, UK
| | | | - Rebecca C. Furze
- Immunology Research Unit, GSK Medicines Research Centre, Stevenage SG1 2FX, UK
| | - Palwinder K. Mander
- Immunology Research Unit, GSK Medicines Research Centre, Stevenage SG1 2FX, UK
| | - Matthew J. Bell
- Immunology Research Unit, GSK Medicines Research Centre, Stevenage SG1 2FX, UK
| | - Christianne J. Buskens
- Department of Surgery, Amsterdam UMC, University of Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Geert R. D’Haens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam Gastroenterology Endocrinology Metabolism (AGEM), University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Manon E. Wildenberg
- Tytgat Institute for Liver and Intestinal and Research, Amsterdam Gastroenterology & Metabolism, Amsterdam University Medical Centers, University of Amsterdam, 1105 BK Amsterdam, The Netherlands
| | - Wouter J. de Jonge
- Tytgat Institute for Liver and Intestinal and Research, Amsterdam Gastroenterology & Metabolism, Amsterdam University Medical Centers, University of Amsterdam, 1105 BK Amsterdam, The Netherlands
- Department of Surgery, University of Bonn, 53127 Bonn, Germany
- Correspondence: ; Tel.: +31205668163 or +31625387973
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Lee MJ, Freer C, Adegbola S, Elkady S, Parkes M, Hart A, Fearnhead NS, Lobo AJ, Brown SR. Patients with perianal Crohn's fistulas experience delays in accessing anti-TNF therapy due to slow recognition, diagnosis and integration of specialist services: lessons learned from three referral centres. Colorectal Dis 2018; 20:797-803. [PMID: 29569419 DOI: 10.1111/codi.14102] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 03/01/2018] [Indexed: 12/30/2022]
Abstract
AIM Crohn's anal fistula should be managed by a multidisciplinary team. There is no clearly defined 'patient pathway' from presentation to treatment. The aim of this study was to describe the patient route from presentation with symptomatic Crohn's anal fistula to starting anti-tumour necrosis factor (anti-TNF) therapy. METHOD Case note review was undertaken at three hospitals with established inflammatory bowel disease services. Patients with Crohn's anal fistula presenting between 2010 and 2015 were identified through clinical coding and local databases. Baseline demographics were captured. Patient records were interrogated to identify route of access, and clinical contacts during the patient pathway. RESULTS Seventy-nine patients were included in the study, of whom 54 (68%) had an established diagnosis of Crohn's disease (CD). Median time from presentation to anti-TNF therapy was 204 days (174 vs 365 days for existing and new diagnosis of CD, respectively; P = 0.019). The mean number of surgical outpatient attendances, operations and MRI scans per patient was 1.03, 1.71 and 1.03, respectively. Patients attended a mean of 1.49 medical clinics. Seton insertion was the most common procedure, accounting for 48.6% of all operations. Where care episodes ('clinical events per 30 days') were infrequent this correlated with prolongation of the pathway (r = -0.87; P < 0.01). CONCLUSION This study highlights two key challenges in the treatment pathway: (i) delays in diagnosis of underlying CD in patients with anal fistula and (ii) the pathway to anti-TNF therapy is long, suggesting issues with service design and delivery. These should be addressed to improve patient experience and outcome.
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Affiliation(s)
- M J Lee
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - C Freer
- Addenbrookes Hospital, Cambridge, UK
| | | | - S Elkady
- St Mark's Hospital, Harrow, UK.,University of Alexandria, Alexandria, Egypt
| | - M Parkes
- Addenbrookes Hospital, Cambridge, UK
| | - A Hart
- St Mark's Hospital, Harrow, UK
| | | | - A J Lobo
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Braithwaite GC, Lee MJ, Hind D, Brown SR. Prognostic factors affecting outcomes in fistulating perianal Crohn's disease: a systematic review. Tech Coloproctol 2017. [PMID: 28639073 PMCID: PMC5550543 DOI: 10.1007/s10151-017-1647-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND One in three patients with Crohn's disease will develop a perianal fistulae, and one third of these will achieve long-term healing or closure. A barrier to conducting well-designed clinical trials for these patients is a lack of understanding of prognostic factors. This systematic review sets out to identify factors associated with prognosis of perianal Crohn's fistulae. METHODS This review was registered on the PROSPERO database (CRD42016050316) and conducted in line with PRISMA guidelines along a predefined protocol. English-language studies assessing baseline factors related to outcomes of fistulae treatment in adult patients were included. Searches were performed on MEDLINE and Embase databases. Screening of abstracts and full texts for eligibility was performed prior to extraction of data into predesigned forms. Bias was assessed using the QUIPS tool. RESULTS Searches identified 997 papers. Following removal of duplicates and secondary searches, 923 were screened for inclusion. Forty-seven papers were reviewed at full-text level and 13, 2 of which were randomised trials, were included in the final qualitative review. Two studies reported distribution of Crohn's disease as a prognostic factor for healing. Two studies found that CARD15 mutations decreased response of fistulae to antibiotics. Complexity of fistulae anatomy was implicated in prognosis by 4 studies. CONCLUSIONS This systematic review has identified potential prognostic markers, including genetic factors and disease behaviour. We cannot, however, draw robust conclusions from this heterogeneous group of studies; therefore, we recommend that a prospective cohort study of well-characterised patients with Crohn's perianal fistulae is undertaken.
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Affiliation(s)
| | - M J Lee
- University of Sheffield Medical School, Sheffield, UK. .,Department of General Surgery, Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK.
| | - D Hind
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - S R Brown
- Department of General Surgery, Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK.,Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
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Marshall JH, Baker DM, Lee MJ, Jones GL, Lobo AJ, Brown SR. Assessing internet-based information used to aid patient decision-making about surgery for perianal Crohn's fistula. Tech Coloproctol 2017; 21:461-469. [PMID: 28643034 PMCID: PMC5495846 DOI: 10.1007/s10151-017-1648-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 05/18/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Decision-making in perianal Crohn's fistula (pCD) is preference sensitive. Patients use the internet to access healthcare information. The aim of this study was to assess the online information and patient decision aids relating to surgery for pCD. METHODS A search of Google™ and the Decision Aids Library Inventory (DALI) was performed using a predefined search strategy. Patient-focussed sources providing information about pCD surgery were included in the analysis. Written health information was assessed using the International Patient Decision Aids Standards (IPDAS) and DISCERN criteria. The readability of the source content was assessed using the Flesch-Kincaid score. RESULTS Of the 201 sources found, 187 were excluded, leaving 14 sources for analysis. Three sources were dedicated to pCD, and six sources mentioned pCD-specific outcomes. The most common surgical intervention reported was seton insertion (n = 13). The least common surgical intervention reported was proctectomy (n = 1). The mean IPDAS and DISCERN scores were 4.43 ± 1.65 out of 12 (range = 2-8) and 2.93 ± 0.73 out of 5 (range = 1-5), respectively. The mean reading ease was US college standard. CONCLUSIONS We found no patient decision aids relating to surgery for pCD. The online sources relating to surgery for pCD are few, and their quality is poor, as seen in the low IPDAS and DISCERN scores. Less than half of the sources mentioned pCD-specific outcomes, and three sources were solely dedicated to providing information on pCD. Healthcare professionals should look to create a patient tool to assist decision-making in pCD.
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Affiliation(s)
- J. H. Marshall
- The Medical School, University of Sheffield Medical School, Sheffield, S10 2RX UK
| | - D. M. Baker
- The Medical School, University of Sheffield Medical School, Sheffield, S10 2RX UK
| | - M. J. Lee
- The Medical School, University of Sheffield Medical School, Sheffield, S10 2RX UK
- Department of General Surgery, Sheffield Teaching Hospitals, Sheffield, UK
| | - G. L. Jones
- Department of Psychology, Leeds Beckett University, Leeds, UK
| | - A. J. Lobo
- Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
| | - S. R. Brown
- Department of General Surgery, Sheffield Teaching Hospitals, Sheffield, UK
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Sheedy SP, Bruining DH, Dozois EJ, Faubion WA, Fletcher JG. MR Imaging of Perianal Crohn Disease. Radiology 2017; 282:628-645. [PMID: 28218881 DOI: 10.1148/radiol.2016151491] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Pelvic magnetic resonance (MR) imaging is currently the standard for imaging perianal Crohn disease. Perianal fistulas are a leading cause of patient morbidity because closure often requires multimodality treatments over a prolonged period of time. This review summarizes clinically relevant anal sphincter anatomy, imaging methods, classification systems, and treatment objectives. In addition, the MR appearance of healing perianal fistulas and fistula complications is described. Difficult imaging tasks including the assessment of rectovaginal fistulas and ileoanal anastomoses are highlighted, along with illustrative cases. Emerging innovative treatments for perianal Crohn disease are now available and have the promise to better control sepsis and maintain fecal continence. Different treatment modalities are selected based on fistula anatomy, patient factors, and management goals (closure versus sepsis control). Radiologists can help maximize patient care by being familiar with MR imaging features of perianal Crohn disease and knowledgeable about what features may influence therapy decisions. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- Shannon P Sheedy
- From the Departments of Radiology (S.P.S., J.G.F.), Internal Medicine (D.H.B., W.A.F.), and Surgery (E.J.D.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - David H Bruining
- From the Departments of Radiology (S.P.S., J.G.F.), Internal Medicine (D.H.B., W.A.F.), and Surgery (E.J.D.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Eric J Dozois
- From the Departments of Radiology (S.P.S., J.G.F.), Internal Medicine (D.H.B., W.A.F.), and Surgery (E.J.D.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - William A Faubion
- From the Departments of Radiology (S.P.S., J.G.F.), Internal Medicine (D.H.B., W.A.F.), and Surgery (E.J.D.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Joel G Fletcher
- From the Departments of Radiology (S.P.S., J.G.F.), Internal Medicine (D.H.B., W.A.F.), and Surgery (E.J.D.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
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Risk factors of surgical site infections in patients with Crohn's disease complicated with gastrointestinal fistula. Int J Colorectal Dis 2017; 32:635-643. [PMID: 28091846 DOI: 10.1007/s00384-017-2751-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Surgical site infection (SSI) is the most common complication following surgical procedures. This study aimed to determine risk factors associated with SSI in patients with Crohn's disease (CD) complicated with gastrointestinal fistula. METHODS This was a retrospective review of patients who underwent surgical resection in gastrointestinal fistula patients with CD between January 2013 and January 2015, identified from a prospectively maintained gastrointestinal fistula database. Demographic information, preoperative medication, intraoperative findings, and postoperative outcome data were collected. Univariate and multivariate analysis was carried out to assess possible risk factors for SSI. RESULTS A total of 118 patients were identified, of whom 75.4% were men, the average age of the patients was 34.1 years, and the average body mass index (BMI) was 18.8 kg/m2. The rate of SSI was 31.4%. On multivariate analysis, preoperative anemia (P = 0.001, OR 7.698, 95% CI 2.273-26.075), preoperative bacteria present in fistula tract (P = 0.029, OR 3.399, 95% CI 1.131-10.220), and preoperative enteral nutrition (EN) <3 months (P < 0.001, OR 11.531, 95% CI 3.086-43.079) were predictors of SSI. Notably, preoperative percutaneous abscess drainage was shown to exert protection against SSI in fistulizing CD (P = 0.037, OR 0.258, 95% CI 0.073-0.920). CONCLUSION Preoperative anemia, bacteria present in fistula tract, and preoperative EN <3 months significantly increased the risk of postoperative SSI in gastrointestinal fistula complicated with CD. Preoperative identification of these risk factors may assist in risk assessment and then to optimize preoperative preparation and perioperative care.
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Manieri NA, Mack MR, Himmelrich MD, Worthley DL, Hanson EM, Eckmann L, Wang TC, Stappenbeck TS. Mucosally transplanted mesenchymal stem cells stimulate intestinal healing by promoting angiogenesis. J Clin Invest 2015; 125:3606-18. [PMID: 26280574 DOI: 10.1172/jci81423] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 07/08/2015] [Indexed: 12/16/2022] Open
Abstract
Mesenchymal stem cell (MSC) therapy is an emerging field of regenerative medicine; however, it is often unclear how these cells mediate repair. Here, we investigated the use of MSCs in the treatment of intestinal disease and modeled abnormal repair by creating focal wounds in the colonic mucosa of prostaglandin-deficient mice. These wounds developed into ulcers that infiltrated the outer intestinal wall. We determined that penetrating ulcer formation in this model resulted from increased hypoxia and smooth muscle wall necrosis. Prostaglandin I₂ (PGI₂) stimulated VEGF-dependent angiogenesis to prevent penetrating ulcers. Treatment of mucosally injured WT mice with a VEGFR inhibitor resulted in the development of penetrating ulcers, further demonstrating that VEGF is critical for mucosal repair. We next used this model to address the role of transplanted colonic MSCs (cMSCs) in intestinal repair. Compared with intravenously injected cMSCs, mucosally injected cMSCs more effectively prevented the development of penetrating ulcers, as they were more efficiently recruited to colonic wounds. Importantly, mucosally injected cMSCs stimulated angiogenesis in a VEGF-dependent manner. Together, our results reveal that penetrating ulcer formation results from a reduction of local angiogenesis and targeted injection of MSCs can optimize transplantation therapy. Moreover, local MSC injection has potential for treating diseases with features of abnormal angiogenesis and repair.
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