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Lucaciu LA, Ilieș M, Vesa ȘC, Seicean R, Din S, Iuga CA, Seicean A. Serum Interleukin (IL)-23 and IL-17 Profile in Inflammatory Bowel Disease (IBD) Patients Could Differentiate between Severe and Non-Severe Disease. J Pers Med 2021; 11:jpm11111130. [PMID: 34834482 PMCID: PMC8621192 DOI: 10.3390/jpm11111130] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/22/2021] [Accepted: 10/28/2021] [Indexed: 02/04/2023] Open
Abstract
Interleukin (IL)-17 and IL-23 are crucial for mediating gut mucosal inflammation in inflammatory bowel disease (IBD), which has led to new therapeutic strategies. We assessed the relevancy of IL-17 and IL-23 serum levels as potential biomarkers towards severe IBD discrimination and disease-related complications. Sixty-two patients diagnosed with Crohn's disease (CD) and ulcerative colitis (UC) were included. Serum IL-17 and IL-23 were measured by sandwich enzyme-linked immunosorbent assays (ELISA). IL-23 and fecal calprotectin (FCal) were significantly higher in severe CD (p < 0.001) and UC (p < 0.001 and p = 0.001, respectively), compared to mild or moderate. Elevated C-reactive protein (CRP) was correlated with severe disease only in CD (p = 0.008), whereas for UC, disease severity was associated with increased IL-17 values (p < 0.001). Diagnostic role of IL-23 was superior to FCal in discriminating between severe and mild to moderate CD (p < 0.001). IL-23 levels were also significantly higher in CD patients with intestinal complications (p = 0.04). Both IL-17 and IL-23 correlate with IBD severity, and IL-23 might be a promising novel biomarker for severe CD. Identifying the dominant IL pathway involved in IBD severity could serve as guidance for clinical decision-making on biologic therapy.
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Affiliation(s)
- Laura A. Lucaciu
- Department of Gastroenterology and Hepatology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Victor Babeș Street No. 8, 400000 Cluj-Napoca, Romania; (L.A.L.); (A.S.)
| | - Maria Ilieș
- Department of Proteomics and Metabolomics, MedFuture-Research Centre for Advanced Medicine, “Iuliu Haţieganu” University of Medicine and Pharmacy, Victor Babeș Street No. 8, 400000 Cluj-Napoca, Romania; (M.I.); (C.A.I.)
| | - Ștefan C. Vesa
- Department of Pharmacology, Toxicology and Clinical Pharmacology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Victor Babeș Street No. 8, 400000 Cluj-Napoca, Romania
- Correspondence:
| | - Radu Seicean
- Department of General Surgery, First Surgical Clinic, “Iuliu Haţieganu” University of Medicine and Pharmacy, Victor Babeș Street No. 8, 400000 Cluj-Napoca, Romania;
| | - Shahida Din
- Edinburgh IBD Unit, Western General Hospital, Edinburgh EH4 2XU, UK;
| | - Cristina Adela Iuga
- Department of Proteomics and Metabolomics, MedFuture-Research Centre for Advanced Medicine, “Iuliu Haţieganu” University of Medicine and Pharmacy, Victor Babeș Street No. 8, 400000 Cluj-Napoca, Romania; (M.I.); (C.A.I.)
- Department of Pharmaceutical Analysis, Faculty of Pharmacy, “Iuliu Haţieganu” University of Medicine and Pharmacy, Victor Babeș Street No. 8, 400000 Cluj-Napoca, Romania
| | - Andrada Seicean
- Department of Gastroenterology and Hepatology, “Iuliu Haţieganu” University of Medicine and Pharmacy, Victor Babeș Street No. 8, 400000 Cluj-Napoca, Romania; (L.A.L.); (A.S.)
- “Prof. Dr. Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, Croitorilor Street No. 19-21, 400162 Cluj-Napoca, Romania
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Genetic Variants of DMBT1 and SFTPD and Disease Severity in Paediatric Inflammatory Bowel Disease—A Polish Population-Based Study. CHILDREN 2021; 8:children8110946. [PMID: 34828659 PMCID: PMC8618964 DOI: 10.3390/children8110946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/08/2021] [Accepted: 10/09/2021] [Indexed: 11/16/2022]
Abstract
Deleted in malignant brain tumours 1 protein (DMBT1) and surfactant protein D (SFTPD) are antimicrobial peptides previously linked to inflammatory bowel disease (IBD) susceptibility. This study attempts to link the most potential IBD-associated polymorphisms in DMBT1 and SFTPD with the disease severity in children. A total of 406 IBD patients (Crohn’s disease (CD) n = 214 and ulcerative colitis (UC) n = 192) were genotyped using hydrolysis probe assay. Clinical expression was described by disease activity scales, albumin and C-reactive protein levels, localisation and behaviour (Paris classification), systemic steroid, immunosuppressive, biological, and surgical treatment, number of exacerbation-caused hospitalisations, relapses and nutritional status. IBD patients with the risk genotype (AA) in DMBT1 rs2981804 had more frequent biological treatment (AA: vs. AG/GG; p = 0.012), concomitant diseases (AA vs. AG vs. GG; p = 0.015) and cutaneous manifestations (AA vs. AG/GG, p = 0.008). In UC, rs2981804 genotypes might be linked with albumin concentrations at diagnosis (AA vs. AG vs. GG; p = 0.009). In CD, DMBT1 rs2981745 was significantly associated with the number of severe relapses per year of disease (p = 0.020) and time-to-immunosuppression (p = 0.045). SFTPD was seemingly found to be associated with age at first immunosuppression in IBD (CC vs. CT vs. TT; p = 0.048). In conclusion, selected polymorphisms of DMBT1 and SFTPD might be associated with some disease severity measures in children with IBD. However, the magnitude of associations and their clinical relevance might be minor.
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Starr AE, Deeke SA, Ning Z, de Nanassy J, Singleton R, Benchimol EI, Mack DR, Stintzi A, Figeys D. Associations between Cellular Energy and Pediatric Inflammatory Bowel Disease Patient Response to Treatment. J Proteome Res 2021; 20:4393-4404. [PMID: 34424714 DOI: 10.1021/acs.jproteome.1c00341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Inflammatory bowel diseases (IBDs), including Crohn's disease (CD) and ulcerative colitis, are chronic diseases of the gastrointestinal tract, with an unknown etiology, that affect over 6.8 million people worldwide. To characterize disease pathogenesis, proteomic and bioinformatic analyses were performed on colon biopsies collected during diagnostic endoscopy from 119 treatment-naïve pediatric patients, including from 78 IBD patients and 41 non-IBD patients who served as controls. Due to the presence of noninflamed and/or inflamed regions in IBD patients, up to two biopsies were obtained from IBD patients as compared to a single noninflamed biopsy from non-IBD pediatric control patients. Additional biopsies were obtained and analyzed from 33 of the IBD patients after IBD-directed therapeutic intervention for comparison of pre- and post-treatment proteomes. SuperSILAC was utilized to perform quantitative analysis of homogenized tissues, which were processed by filter-aided sample preparation. Hierarchical clustering and principal component analyses revealed proteomic patterns that distinguished inflamed from noninflamed tissues independent of therapy. Gene ontology revealed that proteins downregulated in inflammation are associated with metabolism, whereas upregulated proteins contribute to protein processing. A comparison of pre- and post-treatment proteomes from CD patients identified over 100 proteins that are significantly different between patients who responded and those who did not respond to therapy, including creatine kinase B and basigin.
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Estruch J, Johnson J, Ford S, Yoshimoto S, Mills T, Bergman P. Utility of the combined use of 3 serologic markers in the diagnosis and monitoring of chronic enteropathies in dogs. J Vet Intern Med 2021; 35:1306-1315. [PMID: 33960552 PMCID: PMC8163139 DOI: 10.1111/jvim.16132] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 03/26/2021] [Accepted: 04/07/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Dogs with chronic enteropathies (CE) displayed elevated IgA seropositivity against specific markers that can be used to develop a novel test. OBJECTIVE To assess a multivariate test to aid diagnosis of CE in dogs and to monitor treatment-related responses. ANIMALS One hundred fifty-seven dogs with CE/inflammatory bowel disease (IBD), 24 dogs non-IBD gastrointestinal disorders, and 33 normal dogs. METHODS Prospective, multicenter, clinical study that enrolled dogs with gastrointestinal disorders. Serum sample collected at enrollment and up to 3 months follow-up measuring OmpC (ACA), canine calprotectin (ACNA), and gliadin-derived peptides (AGA) by ELISA. RESULTS Seropositivity was higher in CE/IBD than normal dogs (66% vs 9% for ACA; 55% vs 15% for ACNA; and 75% vs 6% for AGA; P < .001). When comparing CE/IBD with non-IBD disease, ACA and ACNA displayed discriminating properties (66%, 55% vs 12.5%, 29% respectively) while AGA separated CE from normal cohorts (54% vs 6%). A 3-marker algorithm at cutoff of ACA > 15, ACNA > 6, AGA > 60 differentiates CE/IBD and normal dogs with 90% sensitivity and 96% specificity; and CE/IBD and non-IBD dogs with 80% sensitivity and 86% specificity. Titers decreased after treatment (47%-99% in ACA, 13%-88% in ACNA, and 30%-85% in AGA), changes that were concurrent with clinical improvements. CONCLUSION AND CLINICAL IMPORTANCE An assay based on combined measurements of ACA, ACNA, and AGA is useful as a noninvasive diagnostic test to distinguish dogs with CE/IBD. The test also has the potential to monitor response to treatment.
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Affiliation(s)
| | | | - Sarah Ford
- Department of Internal MedicineBlue Pearl SpecialtyScottsdaleArizonaUSA
| | - Sean Yoshimoto
- Department of Internal MedicineWest LA Animal HospitalLos AngelesCaliforniaUSA
| | - Tracy Mills
- Department of Clinical StudiesWest LA Animal HospitalLos AngelesCaliforniaUSA
| | - Philip Bergman
- Department of Internal MedicineKatonah Bedford Veterinary CenterNew YorkNew YorkUSA
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Ding NS, McDonald JAK, Perdones-Montero A, Rees DN, Adegbola SO, Misra R, Hendy P, Penez L, Marchesi JR, Holmes E, Sarafian MH, Hart AL. Metabonomics and the Gut Microbiome Associated With Primary Response to Anti-TNF Therapy in Crohn's Disease. J Crohns Colitis 2020; 14:1090-1102. [PMID: 32119090 DOI: 10.1093/ecco-jcc/jjaa039] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Anti-tumour necrosis factor [anti-TNF] therapy is indicated for treatment of moderate to severe inflammatory bowel disease [IBD], but has a primary non-response rate of around 30%. We aim to use metabonomic and metataxonomic profiling to identify predictive biomarkers of anti-TNF response in Crohn's disease. METHODS Patients with luminal Crohn's disease, commencing anti-TNF therapy, were recruited with urine, faeces, and serum samples being collected at baseline and 3-monthly. Primary response was defined according to a combination of clinical and objective markers of inflammation. Samples were measured using three UPLC-MS assays: lipid, bile acid, and Hydrophillic Interaction Liquid Chromatography [HILIC] profiling with 16S rRNA gene sequencing of faeces. RESULTS Samples were collected from 76 Crohn's disease patients who were anti-TNF naïve and from 13 healthy controls. There were 11 responders, 37 non-responders, and 28 partial responders in anti-TNF-treated Crohn's patients. Histidine and cysteine were identified as biomarkers of response from polar metabolite profiling [HILIC] of serum and urine. Lipid profiling of serum and faeces found phosphocholines, ceramides, sphingomyelins, and triglycerides, and bile acid profiling identified primary bile acids to be associated with non-response to anti-TNF therapy, with higher levels of phase 2 conjugates in non-responders. Receiver operating curves for treatment response demonstrated 0.94 +/ -0.10 [faecal lipid], 0.81 +/- 0.17 [faecal bile acid], and 0.74 +/- 0.15 [serum bile acid] predictive ability for anti-TNF response in Crohn's disease. CONCLUSIONS This prospective, longitudinal cohort study of metabonomic and 16S rRNA gene sequencing analysis demonstrates that a range of metabolic biomarkers involving lipid, bile acid, and amino acid pathways may contribute to prediction of response to anti-TNF therapy in Crohn's disease. PODCAST This article has an associated podcast which can be accessed at https://academic.oup.com/ecco-jcc/pages/podcast.
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Affiliation(s)
- N S Ding
- St Vincent's Hospital, Inflammatory Bowel Disease, Melbourne, VIC, Australia.,St Mark's Hospital, Inflammatory Bowel Disease Unit, London, UK.,Division of Computational Systems Medicine, Department of Surgery and Cancer, Imperial College London, London, UK
| | - J A K McDonald
- Division of Digestive Diseases, Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
| | - A Perdones-Montero
- Division of Computational Systems Medicine, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Douglas N Rees
- Division of Digestive Diseases, Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
| | - S O Adegbola
- St Mark's Hospital, Inflammatory Bowel Disease Unit, London, UK.,Division of Computational Systems Medicine, Department of Surgery and Cancer, Imperial College London, London, UK
| | - R Misra
- St Mark's Hospital, Inflammatory Bowel Disease Unit, London, UK.,Division of Computational Systems Medicine, Department of Surgery and Cancer, Imperial College London, London, UK
| | - P Hendy
- St Mark's Hospital, Inflammatory Bowel Disease Unit, London, UK
| | - L Penez
- St Mark's Hospital, Inflammatory Bowel Disease Unit, London, UK
| | - J R Marchesi
- School of Biosciences, Cardiff University, Cardiff, UK.,Division of Digestive Diseases, Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
| | - E Holmes
- Division of Computational Systems Medicine, Department of Surgery and Cancer, Imperial College London, London, UK.,Institute of Health Futures, Murdoch University, Perth, WA, Australia
| | - M H Sarafian
- Division of Computational Systems Medicine, Department of Surgery and Cancer, Imperial College London, London, UK
| | - A L Hart
- St Mark's Hospital, Inflammatory Bowel Disease Unit, London, UK.,Division of Computational Systems Medicine, Department of Surgery and Cancer, Imperial College London, London, UK
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Chen B, Gao X, Zhong J, Ren J, Zhu X, Liu Z, Wu K, Kalabic J, Yu Z, Huang B, Kwatra N, Doan T, Robinson AM, Chen MH. Efficacy and safety of adalimumab in Chinese patients with moderately to severely active Crohn's disease: results from a randomized trial. Therap Adv Gastroenterol 2020; 13:1756284820938960. [PMID: 32733600 PMCID: PMC7370564 DOI: 10.1177/1756284820938960] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 03/06/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND AND AIMS Efficacy of adalimumab in Crohn's disease (CD) has not been shown in China. The aim of this study was to evaluate the efficacy and safety of adalimumab in Chinese patients with CD. METHODS This 26-week, multicenter, phase III study evaluated patients with moderately to severely active CD and elevated high-sensitivity C-reactive protein (⩾3 mg/l) who were naïve to anti-tumor necrosis factor therapy. Patients were randomized to double-blind adalimumab 160/80 mg at weeks 0/2 and 40 mg at weeks 4/6 or placebo at weeks 0/2 followed by blinded adalimumab 160/80 mg at weeks 4/6. At week 8, all patients received open-label 40 mg adalimumab every other week through week 26. The primary endpoint was clinical remission [CD activity index (CDAI) <150] at week 4. Clinical remission at week 26 was assessed in week-8 responders (decrease in CDAI ⩾70 points at week 8 from baseline) and compared with a clinically meaningful threshold of 30%. Adverse events (AEs) were recorded throughout the study. RESULTS At baseline, 205 patients were enrolled, with mean [standard deviation (SD)] age of 32.9 (9.9) years and CD duration of 2.7 (3.0) years. At week 4, 38/102 patients (37%) receiving adalimumab and 7/103 (7%) receiving placebo (p < 0.001) achieved clinical remission. Among week-8 responders, 93/144 (65%) achieved clinical remission at week 26 (p < 0.001). No unexpected AEs and no malignancies, active tuberculosis, or deaths were reported. CONCLUSIONS Adalimumab induced and maintained remission in Chinese patients with CD. Safety results were consistent with the known safety profile of adalimumab. CLINICALTRIALSGOV IDENTIFIER NCT02499783.
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Affiliation(s)
- Baili Chen
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiang Gao
- The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jie Zhong
- Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jianlin Ren
- Zhongshan Hospital Xiamen University, Xiamen, China
| | - Xuan Zhu
- The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhanju Liu
- Shanghai Tenth People’s Hospital, Shanghai, China
| | - Kaichun Wu
- The First Affiliated Hospital of Fourth Military Medical University, Xi’an, China
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Sprockett D, Fischer N, Boneh RS, Turner D, Kierkus J, Sladek M, Escher JC, Wine E, Yerushalmi B, Dias JA, Shaoul R, Kori M, Snapper SB, Holmes S, Bousvaros A, Levine A, Relman DA. Treatment-Specific Composition of the Gut Microbiota Is Associated With Disease Remission in a Pediatric Crohn's Disease Cohort. Inflamm Bowel Dis 2019; 25:1927-1938. [PMID: 31276165 PMCID: PMC7185687 DOI: 10.1093/ibd/izz130] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The beneficial effects of antibiotics in Crohn's disease (CD) depend in part on the gut microbiota but are inadequately understood. We investigated the impact of metronidazole (MET) and metronidazole plus azithromycin (MET+AZ) on the microbiota in pediatric CD and the use of microbiota features as classifiers or predictors of disease remission. METHODS 16S rRNA-based microbiota profiling was performed on stool samples from 67 patients in a multinational, randomized, controlled, longitudinal, 12-week trial of MET vs MET+AZ in children with mild to moderate CD. Profiles were analyzed together with disease activity, and then used to construct random forest models to classify remission or predict treatment response. RESULTS Both MET and MET+AZ significantly decreased diversity of the microbiota and caused large treatment-specific shifts in microbiota structure at week 4. Disease remission was associated with a treatment-specific microbiota configuration. Random forest models constructed from microbiota profiles before and during antibiotic treatment with metronidazole accurately classified disease remission in this treatment group (area under the curve [AUC], 0.879; 95% confidence interval, 0.683-0.9877; sensitivity, 0.7778; specificity, 1.000; P < 0.001). A random forest model trained on pre-antibiotic microbiota profiles predicted disease remission at week 4 with modest accuracy (AUC, 0.8; P = 0.24). CONCLUSIONS MET and MET+AZ antibiotic regimens in pediatric CD lead to distinct gut microbiota structures at remission. It may be possible to classify and predict remission based in part on microbiota profiles, but larger cohorts will be needed to realize this goal.
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Affiliation(s)
- Daniel Sprockett
- Department of Microbiology & Immunology, Stanford University School of Medicine, Stanford, California, USA
| | - Natalie Fischer
- Division of Infectious Diseases & Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Rotem Sigall Boneh
- Pediatric Gastroenterology and Nutrition Unit, Wolfson Medical Center, Holon, Israel
| | - Dan Turner
- The Juliet Keidan Institute of Pediatric Gastroenterology & Nutrition, Shaare Zedek Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Jarek Kierkus
- Department of Gastroenterology, Hepatology, Feeding Disorders and Pediatrics, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Malgorzata Sladek
- Department of Pediatrics, Gastroenterology and Nutrition, Jagiellonian University Medical College, Cracow, Poland
| | - Johanna C Escher
- Department of Pediatric Gastroenterology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Eytan Wine
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Baruch Yerushalmi
- Pediatric Gastroenterology Unit, Soroka University Medical Center, and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Jorge Amil Dias
- Department of Pediatrics, Hospital de Sao Joao, Porto, Portugal
| | - Ron Shaoul
- Pediatric Gastroenterology Unit, Ruth Children’s Hospital, Rambam Medical Center, Haifa, Israel
| | - Michal Kori
- Pediatric Day Care Unit, Kaplan Medical Center, Rehovot, Israel
| | - Scott B Snapper
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital, Boston, Massachusetts, USA
- Division of Gastroenterology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Susan Holmes
- Department of Statistics, Stanford University, Stanford, California, USA
| | - Athos Bousvaros
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Arie Levine
- Pediatric Gastroenterology and Nutrition Unit, Wolfson Medical Center, Holon, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David A Relman
- Department of Microbiology & Immunology, Stanford University School of Medicine, Stanford, California, USA
- Division of Infectious Diseases & Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Infectious Diseases Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
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Impaired nutritional status in outpatients in remission or with active Crohn's disease – classified by objective endoscopic and imaging assessments. Clin Nutr ESPEN 2019; 33:60-65. [DOI: 10.1016/j.clnesp.2019.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/15/2019] [Accepted: 07/16/2019] [Indexed: 12/15/2022]
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Magro F, Lopes S, Silva M, Coelho R, Portela F, Branquinho D, Correia L, Fernandes S, Cravo M, Caldeira P, Tavares de Sousa H, Patita M, Lago P, Ramos J, Afonso J, Redondo I, Machado P, Philip G, Lopes J, Carneiro F. Soluble human Suppression of Tumorigenicity 2 is associated with endoscopic activity in patients with moderate-to-severe ulcerative colitis treated with golimumab. Therap Adv Gastroenterol 2019; 12:1756284819869141. [PMID: 31516554 PMCID: PMC6719471 DOI: 10.1177/1756284819869141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/17/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Suppressor of Tumorigenicity 2 (ST2) is an IL33 receptor detected in the mucosa and serum of ulcerative colitis (UC) patients. We evaluated soluble ST2 (sST2) as a surrogate biomarker of disease outcome and therapeutic response, in moderate-to-severe UC patients treated with golimumab. METHODS We conducted an open-label single-arm multicentre prospective study. At screening/baseline, week 6 (W6) and week 16 (W16), clinical and endoscopic activity (total Mayo score), histologic activity (Geboes index) and biomarkers were evaluated. RESULTS From 38 patients, 34 (89.5%) completed W6 and 29 (76.3%) completed W16. Mean age (±SD) was 34.6 ± 12.6 years; 55.9% were female. At W16, 62.1% achieved clinical response. Patients with endoscopic activity at W6 (n = 20) had higher baseline sST2 (median, 24.5 versus 18.7 ng/ml, p = 0.026) and no decrease from baseline (median change, 0.8 versus -2.7, p = 0.029). At W6, sST2 levels correlated with endoscopic activity (rs = 0.45, p = 0.007) but not with histological activity (rs = 0.25, p = 0.151). The best cut-offs for endoscopic activity were sST2 = 16.9 ng/ml (sensitivity = 85%; specificity = 71%) and faecal calprotectin (FC) = 353 μg/g (sensitivity = 90%, specificity = 67%). Patients with histological activity at W6 (n = 27) had higher baseline ST2 levels (median, 23.0 versus 13.7 ng/ml, p = 0.035). sST2 did not correlate with FC or serum C-reactive protein. FC levels correlated with histological activity and baseline FC were higher when Geboes ⩾3.1 at W6. CONCLUSIONS sST2 may be a surrogate biomarker of UC activity and therapeutic response as it correlates with endoscopic and clinical activity at W6 of golimumab treatment, and subjects with endoscopic and histological activity at W6 had higher baseline ST2 levels.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Paulo Caldeira
- Centro Hospitalar Universitário do Algarve, Faro, Portugal
- Departamento de Ciências Biomédicas e Medicina, Universidade do Algarve, Faro, Portugal
- ABC–Algarve Biomedical Centre, Universidade do Algarve, Faro, Portugal
| | - Helena Tavares de Sousa
- Centro Hospitalar Universitário do Algarve, Faro, Portugal
- Departamento de Ciências Biomédicas e Medicina, Universidade do Algarve, Faro, Portugal
- ABC–Algarve Biomedical Centre, Universidade do Algarve, Faro, Portugal
| | | | - Paula Lago
- Centro Hospitalar do Porto, Porto, Portugal
| | - Jaime Ramos
- Centro Hospitalar Lisboa Central, Lisboa, Portugal
| | | | | | | | | | - Joanne Lopes
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Fátima Carneiro
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Instituto de Patologia e Imunologia Molecular da Universidade do Porto (Ipatimup), i3S-Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
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Koliani-Pace JL, Siegel CA. Prognosticating the Course of Inflammatory Bowel Disease. Gastrointest Endosc Clin N Am 2019; 29:395-404. [PMID: 31078243 DOI: 10.1016/j.giec.2019.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Both Crohn's disease and ulcerative colitis are inflammatory bowel diseases (IBD) that can lead to progressive irreversible bowel damage. Selecting the most appropriate therapy for patients is a challenge because not all patients diagnosed with IBD have complications, and the amount of time to develop a complication is different for individuals. Models using patient characteristics, genetics, and immune responses help identify those patients who require early aggressive therapy with a goal to modify their disease course. Future research will help identify the role that the microbiome, metagenomics, metaproteomics, and microRNAs play in a patient prognosis.
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Affiliation(s)
- Jenna L Koliani-Pace
- Inflammatory Bowel Disease Center, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Dartmouth-Hitchcock, 1 Medical Center Drive, Lebanon, NH 03766, USA
| | - Corey A Siegel
- Inflammatory Bowel Disease Center, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
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11
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Song JH, Hong SN, Lee JE, Kim K, Kim TJ, Kim ER, Chang DK, Kim YH. C-Reactive protein reduction rate following initiation of anti-tumor necrosis factor α induction therapy predicts secondary loss of response in patients with Crohn's disease. Scand J Gastroenterol 2019; 54:876-885. [PMID: 31303093 DOI: 10.1080/00365521.2019.1638962] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background/aim: The objective of this study is to identify clinical predictors of primary non-response (PNR) and secondary loss of response (LOR), in Crohn's disease (CD) patients treated with anti-tumor necrosis factor α (anti-TNF) agents. Methods: This retrospective, longitudinal, and observational cohort study included 283 patients with CD who received anti-TNF treatments from November 2006 to July 2017 at Samsung Medical Center, Seoul, Korea. Results: A total of 212 patients with CD were eligible and based on clinical responses, divided into three groups: PNR, LOR, and responder groups. PNR occurred in 13 patients (6.1%). C-Reactive protein (CRP) level at initiation of anti-TNF (baseline CRP) was a possible predictor of PNR compared to the non-PNR group (baseline CRP >1 mg/dl, OR = 4.34, 95% CI = 1.06-17.83, p = .042). During maintenance therapy, incidence of LOR was 12.2% at 1-year, 23.6% at 2-years, 36.3% at 3-years, and 52.1% at 5-years. Combining baseline CRP level and CRP reduction rate [(CRP at 12-14 weeks-baseline CRP)/baseline CRP] was a possible predictor of 1-year LOR compared to the responder group (baseline CRP >1 mg/dl and CRP reduction rate > -70%, OR = 18.86, 95% CI = 3.40-104.55, p = .001). In the Cox hazard proportional model, a combination of baseline CRP level and CRP reduction rate was possible predictors of long-term LOR during maintenance therapy (baseline CRP >1 mg/dl and CRP reduction rate > -70%, HR = 5.84, 95% CI = 2.75-12.41, p < .001). Conclusions: Baseline CRP level and CRP reduction rate might be clinical predictors for PNR or LOR to anti-TNF in patients with CD, and could guide proper therapeutic interventions in patients with CD.
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Affiliation(s)
- Joo Hye Song
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul , Korea
| | - Sung Noh Hong
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul , Korea
| | - Jung Eun Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul , Korea
| | - Kyunga Kim
- Research Institute for Future Medicine, Samsung Medical Center, Biostatistics and Clinical Epidemiology Center , Seoul , Korea
| | - Tae Jun Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul , Korea
| | - Eun Ran Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul , Korea
| | - Dong Kyung Chang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul , Korea
| | - Young-Ho Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul , Korea
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12
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Scaioli E, Belluzzi A, Ricciardiello L, Del Rio D, Rotondo E, Mena P, Derlindati E, Danesi F. Pomegranate juice to reduce fecal calprotectin levels in inflammatory bowel disease patients with a high risk of clinical relapse: Study protocol for a randomized controlled trial. Trials 2019; 20:327. [PMID: 31171016 PMCID: PMC6554985 DOI: 10.1186/s13063-019-3321-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 03/25/2019] [Indexed: 12/12/2022] Open
Abstract
Background Inflammatory bowel disease (IBD) is a chronic condition characterized by recurrent episodes of intestinal inflammation and is thought to be related to an autoimmune reaction to genetic and environmental factors. Although evidence indicates that a polyphenolic-rich diet plays an important role in modulating aspects of chronic inflammation, few studies have focused on the effect of ellagitannin (ET)-rich food consumption on long-term remission maintenance in IBD patients with a high risk of clinical relapse. Therefore, we hypothesize that supplementation with a pomegranate juice, a naturally rich source of ETs, could significantly modulate the markers of mucosal and systemic inflammation relative to a control group receiving a placebo. Methods/design This double-blind, randomized controlled trial includes patients with IBD involving the colorectum who have been in stable therapy for at least the three previous months and have a high risk of clinical relapse. Participants are randomly allocated to one of two groups: active supplementation (125 mL of cv. Wonderful pomegranate juice) or placebo (125 mL) taken twice daily for 12 weeks. The primary outcome is changes in the fecal neutrophil-derived protein calprotectin, a surrogate marker of mucosal improvement, between the two groups from baseline to 12 weeks later. The secondary outcomes include transcriptomic changes in peripheral blood mononuclear cells and intestinal biopsies and changes in circulating inflammatory markers and trimethylamine-N-oxide levels. Pomegranate ET-derived metabolites are identified and quantified in plasma and urine samples. Discussion The results will provide information on the possible reduction of fecal calprotectin levels following the consumption of pomegranate juice. The findings will also show the in vivo metabolism of pomegranate ETs. Finally, the effect of 12-week pomegranate juice consumption on local and systemic inflammatory markers will be elucidated, which will likely provide additional insights into the maintenance of remission in IBD patients. Trial registration ClinicalTrials.gov, NCT03000101. Registered on 21 December 2016. Electronic supplementary material The online version of this article (10.1186/s13063-019-3321-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eleonora Scaioli
- Gastroenterological Unit, Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Andrea Belluzzi
- Gastroenterological Unit, St. Orsola-Malpighi Hospital, Via Massarenti 9, 40138, Bologna, Italy
| | - Luigi Ricciardiello
- Gastroenterological Unit, Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Daniele Del Rio
- Department of Veterinary Science, University of Parma, Strada del Taglio, 10, 43126, Parma, Italy
| | - Enrica Rotondo
- Human Nutrition Unit, Department of Agricultural and Food Sciences, Campus of Food Science, University of Bologna, Piazza Goidanich, 60, 47521, Cesena, FC, Italy
| | - Pedro Mena
- Human Nutrition Unit, Department of Food and Drug, University of Parma, Medical School, Building C, Via Volturno 39, 43125, Parma, Italy
| | - Eleonora Derlindati
- Human Nutrition Unit, Department of Agricultural and Food Sciences, Campus of Food Science, University of Bologna, Piazza Goidanich, 60, 47521, Cesena, FC, Italy.,Endocrinology and Metabolism Unit, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Francesca Danesi
- Human Nutrition Unit, Department of Agricultural and Food Sciences, Campus of Food Science, University of Bologna, Piazza Goidanich, 60, 47521, Cesena, FC, Italy.
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Yoon JW, Ahn SI, Jhoo JW, Kim GY. Antioxidant Activity of Yogurt Fermented at Low Temperature and Its Anti-inflammatory Effect on DSS-induced Colitis in Mice. Food Sci Anim Resour 2019; 39:162-176. [PMID: 30882084 PMCID: PMC6411250 DOI: 10.5851/kosfa.2019.e13] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 02/18/2019] [Accepted: 02/19/2019] [Indexed: 01/01/2023] Open
Abstract
This study was performed to evaluate the antioxidant activity of yogurt fermented
at low temperature and the anti-inflammatory effect it has on induced colitis
with 2.5% dextran sodium sulfate (DSS) in Balb/c mice. Yogurt premix were
fermented with a commercial starter culture containing Lactobacillus
acidophilus, Bifidobacterium lactis,
Streptococcus thermophilus, and Lactobacillus
delbrueckii subsp. bulgaricus at different
temperatures: 22°C (low fermentation temperature) for 27 h and
37°C (general fermentation temperature) for 12 h. To measure antioxidant
activity of yogurt samples, DPPH, ABTS+ and ferric reducing
antioxidant potential (FRAP) assays were conducted. For animal experiments,
inflammation was induced with 2.5% DSS in Balb/c mice. Yogurt fermented
at low temperature showed higher antioxidant activity than that of the yogurt
fermented at general temperature. In the inflammatory study, IL-6 (interleukin
6) was decreased and IL-4 and IL-10 increased significantly in DSS group with
yogurt fermented at general temperature (DYG) and that with yogurt fermented at
low temperature (DYL) compared to that in DSS-induced colitic mice (DC),
especially DYL had higher concentration of cytokines IL-4, and IL-10 than DYG.
MPO (myeloperoxidase) tended to decrease more in treatments with yogurt than DC.
Additionally, yogurt fermented at low temperature had anti-inflammatory
activity, although there was no significant difference with general
temperature-fermented yogurt (p>0.05).
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Affiliation(s)
- Ji-Woo Yoon
- Department of Applied Animal Science, College of Animal Life Sciences, Kangwon National University, Chuncheon 24341, Korea
| | - Sung-Il Ahn
- Department of Applied Animal Science, College of Animal Life Sciences, Kangwon National University, Chuncheon 24341, Korea
| | - Jin-Woo Jhoo
- Department of Applied Animal Science, College of Animal Life Sciences, Kangwon National University, Chuncheon 24341, Korea
| | - Gur-Yoo Kim
- Department of Applied Animal Science, College of Animal Life Sciences, Kangwon National University, Chuncheon 24341, Korea
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Park SY, Kim JY, Lee SM, Chung JO, Seo JH, Kim S, Kim DH, Park CH, Ju JK, Joo YE, Lee JH, Kim HS, Choi SK, Rew JS. Lower expression of endogenous intestinal alkaline phosphatase may predict worse prognosis in patients with Crohn's disease. BMC Gastroenterol 2018; 18:188. [PMID: 30558547 PMCID: PMC6296121 DOI: 10.1186/s12876-018-0904-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 11/08/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUNDS Intestinal alkaline phosphatase (IAP) plays important role in gut homeostasis. We aimed to evaluate the expression of endogenous IAP and to assess the clinical course according to the expression of endogenous IAP in patients with Crohn's disease (CD). METHODS A total of 32 consecutive patients (14 males) with CD were included in the study. We measured the level of endogenous iAP in inflamed and noninflamed colonic mucosa. To verify the inflammation status, we measured the level of mRNA for IL-6, TNF-α, and TLR-4. We monitored the clinical courses of patients during follow-up after acquisition of biopsy specimens. RESULTS Median age of patients was 22.5 years (range, 15-49). Median CD activity index (CDAI, range) was 93.7 (22.8~ 154.9). There were colonic involvements in all patients and perianal involvement in 43.8% patients. The mRNA levels of IL-6 (p = 0.005) and TLR-4 (p = 0.013) in inflamed mucosa were significantly higher than those in non-inflamed mucosa. However, there was no difference of expression of TNF-α mRNA (p = 0.345). During a 14-month follow-up (range, 9 months-54 months), there were 19 patients with clinical recurrences. There were 9 patients (9/19, 47.4%) with IAP expression ratio (inflamed to non-inflamed) ≤ 1.0 in patients with clinical recurrence while there was one patient (1/13, 7.7%) with IAP ratio ≤ 1.0 in patients without clinical recurrence (p = 0.024). CONCLUSION Lower expression of IAP in inflamed mucosa compared to non-inflamed mucosa may be associated with clinical recurrence in patients with CD.
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Affiliation(s)
- Seon-Young Park
- Division of Gastroenterology and Hepatology, Chonnam National University Medical School, Gwangju, South Korea
| | - Ji-Young Kim
- Division of Gastroenterology and Hepatology, Chonnam National University Medical School, Gwangju, South Korea
| | - Su-Mi Lee
- Division of Gastroenterology and Hepatology, Chonnam National University Medical School, Gwangju, South Korea
| | - Jin Ook Chung
- Division of Endocrinology and Metabolism, Chonnam National University Medical School, Gwangju, South Korea
| | - Ji-Ho Seo
- Division of Gastroenterology and Hepatology, Chonnam National University Medical School, Gwangju, South Korea
| | - SunMin Kim
- Division of Gastroenterology and Hepatology, Chonnam National University Medical School, Gwangju, South Korea
| | - Dong Hyun Kim
- Division of Gastroenterology and Hepatology, Chonnam National University Medical School, Gwangju, South Korea
| | - Chang-Hwan Park
- Division of Gastroenterology and Hepatology, Chonnam National University Medical School, Gwangju, South Korea
| | - Jae-Kyun Ju
- Department of Surgery, Chonnam National University Medical School, Gwangju, South Korea
| | - Young-Eun Joo
- Division of Gastroenterology and Hepatology, Chonnam National University Medical School, Gwangju, South Korea
| | - Jae-Hyuk Lee
- Department of Pathology, Chonnam National University Medical School, Gwangju, South Korea
| | - Hyun-Soo Kim
- Division of Gastroenterology and Hepatology, Chonnam National University Medical School, Gwangju, South Korea. .,Department of Internal Medicine, Chonnam National University Medical School, 42, Jaebongro, Dong-ku, Gwangju, 501-757, Korea.
| | - Sung-Kyu Choi
- Division of Gastroenterology and Hepatology, Chonnam National University Medical School, Gwangju, South Korea
| | - Jong-Sun Rew
- Division of Gastroenterology and Hepatology, Chonnam National University Medical School, Gwangju, South Korea
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16
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Lichtenstein GR, Loftus EV, Isaacs KL, Regueiro MD, Gerson LB, Sands BE. ACG Clinical Guideline: Management of Crohn's Disease in Adults. Am J Gastroenterol 2018; 113:481-517. [PMID: 29610508 DOI: 10.1038/ajg.2018.27] [Citation(s) in RCA: 744] [Impact Index Per Article: 124.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 01/11/2018] [Indexed: 02/06/2023]
Abstract
Crohn's disease is an idiopathic inflammatory disorder of unknown etiology with genetic, immunologic, and environmental influences. The incidence of Crohn's disease has steadily increased over the past several decades. The diagnosis and treatment of patients with Crohn's disease has evolved since the last practice guideline was published. These guidelines represent the official practice recommendations of the American College of Gastroenterology and were developed under the auspices of the Practice Parameters Committee for the management of adult patients with Crohn's disease. These guidelines are established for clinical practice with the intent of suggesting preferable approaches to particular medical problems as established by interpretation and collation of scientifically valid research, derived from extensive review of published literature. When exercising clinical judgment, health-care providers should incorporate this guideline along with patient's needs, desires, and their values in order to fully and appropriately care for patients with Crohn's disease. This guideline is intended to be flexible, not necessarily indicating the only acceptable approach, and should be distinguished from standards of care that are inflexible and rarely violated. To evaluate the level of evidence and strength of recommendations, we used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The Committee reviews guidelines in depth, with participation from experienced clinicians and others in related fields. The final recommendations are based on the data available at the time of the production of the document and may be updated with pertinent scientific developments at a later time.
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Affiliation(s)
- Gary R Lichtenstein
- Department of Medicine, Division of Gastroenterology, Hospital of the University of Pennsylvania, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kim L Isaacs
- Department of Medicine, Division of Gastroenterology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA
| | - Miguel D Regueiro
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lauren B Gerson
- Department of Medicine, Division of Gastroenterology, California Pacific Medical Center, San Francisco, California, USA
| | - Bruce E Sands
- Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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17
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Togre N, Bhoj P, Goswami K, Tarnekar A, Patil M, Shende M. Human filarial proteins attenuate chronic colitis in an experimental mouse model. Parasite Immunol 2018; 40. [DOI: 10.1111/pim.12511] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 12/15/2017] [Indexed: 12/15/2022]
Affiliation(s)
- N. Togre
- Department of Biochemistry & JB Tropical Disease Research Center; Mahatma Gandhi Institute of Medical Sciences; Sevagram Maharashtra India
| | - P. Bhoj
- Department of Biochemistry & JB Tropical Disease Research Center; Mahatma Gandhi Institute of Medical Sciences; Sevagram Maharashtra India
| | - K. Goswami
- Department of Biochemistry & JB Tropical Disease Research Center; Mahatma Gandhi Institute of Medical Sciences; Sevagram Maharashtra India
| | - A. Tarnekar
- Department of Anatomy; Mahatma Gandhi Institute of Medical Sciences; Sevagram Maharashtra India
| | - M. Patil
- University Department of Biochemistry; RTM Nagpur University; Nagpur Maharashtra India
| | - M. Shende
- Department of Anatomy; Mahatma Gandhi Institute of Medical Sciences; Sevagram Maharashtra India
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18
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Cohen SA. Alas, Who and What Can We Trust? Patients, Parents, Surrogate Markers, or the Specific Carbohydrate Diet. J Pediatr Gastroenterol Nutr 2017; 65:266-267. [PMID: 28829341 DOI: 10.1097/mpg.0000000000001665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Stanley A Cohen
- Children's Center for Digestive Health Care, Children's Healthcare of Atlanta, Atlanta, GA
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