POS1083 INCREASED INTESTINAL PERMEABILITY IN PATIENTS WITH PSORIATIC ARTHRITIS CLASSIFIED AS TREATMENT FAILURES DURING THE 26-WEEK FLORA TRIAL

Background

Changes in the integrity of the intestinal wall may be implicated in the gut-joint axis of inflammatory arthritis.1 Yet, the gut barrier is only poorly evaluated in psoriatic arthritis (PsA).2

Objectives

In this exploratory study, we evaluated intestinal permeability before and 26 weeks after one faecal microbiota transplantation (FMT) or sham intervention in adults with PsA.

Methods

We have previously reported the clinical results of a 26-week, double-blind, parallel-group, 1:1 randomised, sham-controlled, superiority trial of gastroscopic-guided FMT as an add-on treatment to methotrexate in 31 adults with active peripheral PsA (FLORA trial, NCT03058900).3 The primary efficacy endpoint was the proportion of participants who experienced treatment failure through 26 weeks, defined as need for more than one intra-articular glucocorticoid injection and/or anti-TNFα inhibition. We encouraged patients not to take nonsteroidal anti-inflammatory drugs during the trial. The FMT material was obtained from one of four healthy blood donors. As part of the trial, we performed a lactulose and mannitol test (L:M test) at baseline (n=31) and at the final 26-week visit (n=26) to assess the permeability of the intestinal wall (higher L:M ratios indicate higher permeability). After an overnight fasting, patients provided a urine sample before ingesting 10 g of lactulose and 5 g of D-mannitol. Samples were collected after 3 hours and stored at −80°C until analysis. No food or drinking (except for water) was allowed during the test. We measured the lactulose-to-mannitol ratio in the urine samples using a Waters Acquity UPLC system coupled to a high-resolution mass spectrometer Waters Xevo G2 QToF (Waters Corp., Milford, MA, USA). MassLynx software (Waters Corporation) was used for data acquisition and visual inspection. We used StataSE-64 to perform the Wilcoxon rank sum and the matched-pairs signed-rank test. Data is presented as median and range. The level of significance was set to 0.05.

Results

At baseline, no significant difference was observed in the L:M ratio between donors (n=4) and patients (n=31) (0.0065 [0–0.063] vs 0.014 [0–0.28]; p=0.50). The L:M ratio increased from baseline to week 26 in both the FMT (0.0020 [-0.27 – 0.32] and the sham group (0.0046 [-0.012 – 0.088]), but only in the sham group differed the baseline L:M ratio significantly from the one measured at week 26 (p=0.92 [FMT] and p=0.032 [sham]). The patients who were classified as treatment failures during the trial (n=7) had a significantly higher L:M ratio at week 26 compared to the patients who were non-failures (n=19) (0.027 [0.017 – 0.33]) vs 0.012 [0 – 0.064], p=0.01), please see Figure 1.

Figure 1.

L:M ratios at week 26 in treatment failures (n=7) and non-failures (n=19), respectively. Higher L:M ratios indicate higher intestinal permeability.

Conclusion

In the FLORA trial, intestinal permeability evaluated by the L:M test did not differ significantly between donors and patients at baseline. Whether the higher intestinal permeability observed in patients classified as treatment failures compared to non-failures at week 26 can be attributed to differences in disease activity and/or the instigation of additional immunosuppression in the failure group during the trial needs further investigation.

References

[1]Gracey E, Vereecke L, McGovern D, et al. Revisiting the gut-joint axis: links between gut inflammation and spondyloarthritis. Nat Rev Rheumatol. 2020;16(8):415-433.

[2]Hecquet S, Totoson P, Martin H, et al. Intestinal permeability in spondyloarthritis and rheumatoid arthritis: A systematic review of the literature. Semin Arthritis Rheum. 2021;51(4):712-718.

[3]Kragsnaes MS, Kjeldsen J, Horn HC, et al. Safety and efficacy of faecal microbiota transplantation for active peripheral psoriatic arthritis: an exploratory randomised placebo-controlled trial. Ann Rheum Dis. 2021;80(9):1158-1167.

Disclosure of Interests

None declared

AB0924-PARE EXPERIENCES AND PERCEPTIONS OF PATIENTS WITH PSORIATIC ARTHRITIS PARTICIPATING IN A TRIAL OF FAECAL MICROBIOTA TRANSPLANTATION: A NESTED QUALITATIVE STUDY

Background:

Patients’ first-hand experiences of faecal microbiota transplantation (FMT) performed in a rheumatological care-setting have yet to be elucidated.

Objectives:

The objectives were to explore participants’ perceptions of being part of an FMT trial thereby identifying potential trial participation effects and enlightening the patient perspective on the outlook for future FMT trials in rheumatic diseases.

Methods:

In a qualitative study nested within a double-blind, randomised, placebo-controlled trial (RCT) testing FMT as a potential new anti-rheumatic treatment,1 semi-structured telephone interviews were conducted following the trial participants’ final 26-week visit. The RCT was conducted at a Danish rheumatology university outpatient clinic with nationwide inclusion. The qualitative study included ten patients with psoriatic arthritis (PsA) who completed the final 26-week trial visit and were unaware of their treatment allocation (one gastroscopic-guided FMT or sham transplantation into the duodenum), see table 1. Qualitative researchers, who did not take part in the RCT, performed the interviews and the primary analysis. The experiences explored related to the conduct of the RCT and changes in the participants’ everyday life. The analysis was carried out using a thematic approach. There was sufficient repetition of ideas in data to conclude data saturation.

Table 1.

Characteristics of the participants.

CharacteristicTotal(n = 10)Female sex, no. (%)7 (70%)Age, yr.53.9 (11.3)Time since diagnosis, yr.a7.4 (4.2, 12.8)Rheumatoid factor IgM negative, no. (%)10 (100%)Anti-citrullinated peptide antibody negative, no. (%)10 (100%)HLA-B27 negative, no. (%)8 (80%)C-reactive protein, mg/L4.5 (3.6)HAQ-DIb1.09 (0.40)Swollen joint 66 count7.4 (3.8)Tender joint 68 count22.8 (7.9)SPARCC enthesitis indexcScore ≥1, no. (%)10 (100%)Score in patients with a score ≥18.7 (4.0)

Data are mean (SD) or n (%) unless otherwise stated.

a Time since diagnosis of psoriatic arthritis is presented as median and interquartile range (IQR).

b Scores on the Health Assessment Questionnaire Disability Index (HAQ-DI) range from 0 to 3, with higher scores indicating greater disability. c Spondyloarthritis Research Consortium of Canada (SPAARC) Enthesitis Index range from 0 to 16, with higher scores indicating more severe disease.

Results:

Participation in the RCT influenced the patients’ understanding of PsA and induced positive changes in their everyday life. Renewed hopes for the future in addition to a feeling of enhanced care contributed to significant trial participation effects.2 We identified several factors related to the RCT that may have promoted these effects (figure 1). FMT was deemed acceptable and safe, and all participants supported more research into the field of microbiota-targeted interventions in rheumatic diseases.

Figure 1.

Factors related to the RCT that may have promoted trial participation effects.

Conclusion:

Discrepancies between the clinical and the research setting should be considered when discussing the clinical relevance of the results of the RCT. Overall, patients with PsA who have participated in an RCT testing FMT find the treatment acceptable and safe encouraging more research into the field of microbiota-targeted interventions in rheumatic diseases. Further research into the potential beneficial and adverse effects of FMT in addition to exploring the magnitude and mechanisms behind FMT trial participation effects in the rheumatological setting are highly needed.

References:

[1]Kragsnaes MS, Kjeldsen J, Horn HC, et al. Efficacy and safety of faecal microbiota transplantation in patients with psoriatic arthritis: protocol for a 6-month, double-blind, randomised, placebo-controlled trial. BMJ open 2018;8:e019231.

[2]McCambridge J, Kypri K, Elbourne D. Research participation effects: a skeleton in the methodological cupboard. J Clin Epidemiol 2014;67:845-9.

Acknowledgements:

The authors thank the patient advisers and all the participants who shared their experiences with us.

Disclosure of Interests:

Maja Skov Kragsnaes Grant/research support from: Novartis 2017 (unrestricted research grant) to cover 3 months PhD salary in relation to the study., Shaun Theodor Sødergren: None declared, Jens Kjeldsen: None declared, Hans Christian Horn: None declared, Heidi Lausten Munk: None declared, Jens Kristian Pedersen: None declared, Camilla Schufri Klinkby: None declared, Maarten de Wit: None declared, Nanna Gram Ahlmark: None declared, Tine Tjørnhøj-Thomsen: None declared, Torkell Ellingsen Grant/research support from: Novartis 2017 (unrestricted research grant)

OP0010 EFFICACY AND SAFETY OF FAECAL MICROBIOTA TRANSPLANTATION FOR ACTIVE PERIPHERAL PSORIATIC ARTHRITIS: A RANDOMISED SHAM-CONTROLLED TRIAL

Background:

Although causality remains to be established, targeting dysbiosis of the intestinal microbiota by faecal microbiota transplantation (FMT) has been proposed as a novel therapeutic option for treatment of extra-intestinal inflammatory diseases.1

Objectives:

In this proof-of-concept study, we evaluated efficacy and safety of FMT in psoriatic arthritis (PsA).2

Methods:

In this double-blind, parallel-group, sham-controlled, superiority trial, we randomly allocated (1:1) adults with active peripheral PsA (≥3 swollen joints) despite ongoing treatment with methotrexate to one gastroscopic-guided FMT or sham transplantation into the duodenum. The transplants (50 g faeces) came from one of four healthy, thoroughly screened, anonymous stool donors.3 The primary efficacy endpoint was the proportion of participants experiencing treatment failure (i.e., needing treatment intensification) through 26 weeks. The first key secondary endpoint was change in Health Assessment Questionnaire Disability Index (HAQ-DI) score from baseline to week 26. Safety was monitored throughout the trial. Trial registration number: NCT03058900, ClinicalTrials.gov.

Results:

Of 97 screened, 31 (32%) underwent randomisation (15 allocated to FMT), all received the assigned intervention, and 30 (97%) completed the 26-week clinical evaluation (Table 1). Treatment failure occurred more frequently in the FMT group than in the sham group (9 [60%] vs 3 [19%]; risk ratio, 3.20; 95% CI, 1.06 to 9.62; P=0.018). During the entire 26 weeks of observation, the rate of the treatment failures was significantly higher in the FMT than in the sham group, see figure 1. Improvement in HAQ-DI score differed between groups (0.07 vs 0.30) by 0.23 points (95% CI, 0.02 to 0.44; P=0.031) in favour of sham. No serious adverse events were observed.

Conclusion:

In this first interventional randomised controlled trial of FMT in immune-mediated arthritis, FMT was inferior to sham in treating active peripheral PsA. FMT did not appear to result in serious adverse events.

Figure 1.

Time-to-event curves by intervention group from baseline to week 26. FMT, faecal microbiota transplantation.

Table 1.

Baseline demographics and disease characteristics.

CharacteristicFMT(n=15)Sham(n=16)Female sex, no. (%)8 (53%)12 (75%)Age, yr.48.9 (16.1)52.4 (11.0)Height, cm175.2 (7.0)169.8 (8.6)Weight, kg93.6 (15.4)92.4 (24.8)Time since diagnosis, yr.a2.6 (0.3 to 5.8)5.6 (0.5 to 8.8)Rheumatoid factor IgM negative, no. (%)b13 (93%)15 (94%)Anti-citrullinated peptide antibody negative, no. (%)b14 (100%)16 (100%)HLA-B27 negative, no. (%)15 (100%)13 (81%)C-reactive protein, mg/L4.98 (7.18)5.54 (5.87)HAQ-DI0.89 (0.51)0.78 (0.50)Swollen joint 66 count7.5 (3.0)6.7 (2.7)Tender joint 68 count14.9 (8.9)17.3 (8.8)SPARCC enthesitis index Score ≥1, no. (%)13 (87%)15 (94%) Score in patients with a score ≥18.1 (4.3)7.2 (3.3)

Data are mean (SD) or n (%) unless otherwise stated. FMT, faecal microbiota transplantation. a Time since diagnosis of psoriatic arthritis is presented as median and interquartile range (IQR). b Presence of rheumatoid factor (IgM) and anti-citrullinated peptide antibody was not accessed in one patient from the FMT group.

References:

[1]Manasson J, Blank RB, Scher JU. The microbiome in rheumatology: Where are we and where should we go? Ann Rheum Dis 2020;79:727-33.

[2]Kragsnaes MS, Kjeldsen J, Horn HC, et al. Efficacy and safety of faecal microbiota transplantation in patients with psoriatic arthritis: protocol for a 6-month, double-blind, randomised, placebo-controlled trial. BMJ Open 2018;8:e019231.

[3]Kragsnaes MS, Nilsson AC, Kjeldsen J, et al. How do I establish a stool bank for fecal microbiota transplantation within the blood- and tissue transplant service? Transfusion 2020;60:1135-41.

Acknowledgements:

We thank all participants for their contribution. We thank CS Klinkby, trial nurse, for assistance in relation to the conduct of the trial visits. We also thank L Albjerg, biomedical laboratory technologist, AC Nilsson, consultant, KF Rasmussen, consultant, and J Georgsen, consultant, at the Department of Clinical Immunology, Odense University Hospital, Denmark, for assisting in the implementation of the FMT stool bank.

Disclosure of Interests:

Maja Skov Kragsnaes Grant/research support from: Novartis 2017 (unrestricted research grant) to support 3 months PhD salary related to the conduct of the trial., Jens Kjeldsen: None declared, Hans Christian Horn: None declared, Heidi Lausten Munk: None declared, Jens Kristian Pedersen: None declared, Søren Andreas Just: None declared, Palle Ahlquist: None declared, Finn Moeller Pedersen: None declared, Maarten de Wit: None declared, Sören Möller: None declared, Vibeke Andersen: None declared, Karsten Kristiansen: None declared, Hanne Marie Holt: None declared, Dorte Kinggaard Holm: None declared, Robin Christensen: None declared, Torkell Ellingsen Grant/research support from: Novartis 2017 (unrestricted research grant)

Does severe bleeding in HHT patients respond to intravenous bevacizumab? Review of the literature and case series

BACKGROUND

Hereditary Haemorrhagic Telangiectasia (HHT) is an autosomal dominant genetic disorder, with a wide variety of clinical manifestations due to the presence of multiple arteriovenous manifestations. Severe bleeding from the gastrointestinal (GI) tract and/or epistaxis presents a significant problem in a subgroup of patients and systemic bevacizumab, an angiogenesis inhibitor, has been suggested to benefit these patients.

OBJECTIVE

To perform a review of the literature concerning the efficacy of systemic bevacizumab in treatment of bleeding from the nose or GI tract in patients with HHT, including patients from our own HHT-center.

METHODS

A literature review was performed using the guideline "Preferred Reporting Items for systematic Reviews and MetaAnalysis statement" (PRISMA).

RESULTS

After careful selection, we finally analysed the results of eight case series and 33 case reports. Among 195 patients 171 (88%) had reduced bleeding after bevacizumab.

CONCLUSIONS

Based on the literature review and data from our own case series, systemic bevacizumab is very promising as treatment for HHT patients with severe epistaxis and/or GI-bleeding. However, care should be taken using bevacizumab, a potent angiogenesis inhibitor; long-term side effects have not been studied in this population. A randomized controlled study is warranted to support the results in HHT patients.

The intestinal tissue homeostasis - the role of extracellular matrix remodeling in inflammatory bowel disease

Introduction: Extracellular matrix (ECM) remodeling of the intestinal tissue is important in inflammatory bowel disease (IBD) due to the extensive mucosal remodeling. There are still gaps in our knowledge as to how ECM remodeling is related to intestinal epithelium homeostasis and healing of the intestinal mucosa.Areas covered: The aim of this review is to highlight the importance of the ECM in relation to the pathogenesis of IBD, while addressing basement membrane and interstitial matrix remodeling, and the processes of wound healing of the intestinal tissue in IBD.Expert opinion: In IBD, basement membrane remodeling may reflect the integrity of the intestinal epithelial-cell homeostasis. The interstitial matrix remodeling is associated with deep inflammation such as the transmural inflammation as seen in fistulas and intestinal fibrosis leading to fibrostenotic strictures, in patients with CD. The interplay between wound healing processes and ECM remodeling also affects the tissue homeostasis in IBD. The interstitial matrix, produced by fibroblasts, holds a very different biology as compared to the epithelial basement membrane in IBD. In combination with integration of wound healing, quantifying the interplay between damage and repair to these sub compartments may provide essential information in IBD patient profiling, mucosal healing and disease management.

Poor Outcomes of Complicated Pouch-Related Fistulas after Ileal Pouch-Anal Anastomosis Surgery

Background and Aims:

Development of a pouch-related fistula tract is an uncommon but highly morbid complication to restorative proctocolectomy with ileal pouch-anal anastomosis. Pouch failure with permanent ileostomy is reported in 21%–30% of patients, yet the factors contributing to pouch excision remain poorly defined. The aim of this study was to determine the incidence and treatment results of complicated pouch-related fistula, as well as to evaluate factors involved in excision after pouch failure.

Material and Methods:

The study was conducted as a retrospective study. All patients with diagnosed pouch-related fistulas were registered with information related to fistula classification, treatments, and outcome.

Results and Conclusion:

The final analysis included 48 (10.7%) of the 447 total ileal pouch-anal anastomosis patients with complicated pouch-related fistulas. Pouch-vaginal fistulas, pouch-perianal fistulas, and other pouch-related fistulas were observed in 19 (63%), 29 (60%), and 10 (21%) patients, respectively, corresponding to an accumulated risk of 8%, 6%, and 2%, respectively. Time from ileal pouch-anal anastomosis surgery to fistula presentation was 24 (0.2–212) months. Overall pouch failure, defined as pouch excision or a diverting stoma, was seen in 34 (71%) patients, while pouch excision was seen in 23 (48%) of the patients. Patients who developed Crohn’s disease had a significantly higher risk of pouch excision, as did patients with an early onset of the fistula after ileal pouch-anal anastomosis ( P = 0.006 and P = 0.007, respectively). In conclusion, the present study demonstrated a high risk of pouch failure in patients with complicated pouch-related fistulas. Furthermore, it showed that Crohn’s disease and the development of early onset fistulas are associated with pouch excision.

Health-related quality of life improves during one year of medical and surgical treatment in a European population-based inception cohort of patients with inflammatory bowel disease--an ECCO-EpiCom study

BACKGROUND & AIMS

Health-related quality of life (HRQoL) is impaired in patients with Inflammatory Bowel Disease (IBD). The aim was prospectively to assess and validate the pattern of HRQoL in an unselected, population-based inception cohort of IBD patients from Eastern and Western Europe.

METHODS

The EpiCom inception cohort consists of 1560 IBD patients from 31 European centres covering a background population of approximately 10.1 million. Patients answered the disease specific Short Inflammatory Bowel Disease Questionnaire (SIBDQ) and generic Short Form 12 (SF-12) questionnaire at diagnosis and after one year of follow-up.

RESULTS

In total, 1079 patients were included in this study. Crohn's disease (CD) patients mean SIBDQ scores improved from 45.3 to 55.3 in Eastern Europe and from 44.9 to 53.6 in Western Europe. SIBDQ scores for ulcerative colitis (UC) patients improved from 44.9 to 57.4 and from 48.8 to 55.7, respectively. UC patients needing surgery or biologicals had lower SIBDQ scores before and after compared to the rest, while biological therapy improved SIBDQ scores in CD. CD and UC patients in both regions improved all SF-12 scores. Only Eastern European UC patients achieved SF-12 summary scores equal to or above the normal population.

CONCLUSION

Medical and surgical treatment improved HRQoL during the first year of disease. The majority of IBD patients in both Eastern and Western Europe reported a positive perception of disease-specific but not generic HRQoL. Biological therapy improved HRQoL in CD patients, while UC patients in need of surgery or biological therapy experienced lower perceptions of HRQoL than the rest.

Health care and patients' education in a European inflammatory bowel disease inception cohort: an ECCO-EpiCom study

BACKGROUND AND AIMS

The EpiCom study and inception cohort was initiated in 2010 in 31 centers from 14 Western and 8 Eastern European countries, covering a 10.1million person background population. Our aim was to investigate whether there is a difference between Eastern and Western Europe in health care and education of patients with inflammatory bowel disease (IBD).

METHODS

A quality of care (QoC) questionnaire was developed in the EpiCom group consisting of 16 questions covering 5 items: time interval between the onset of symptoms and diagnosis, information, education, empathy and access to health care providers.

RESULTS

Of 1,515 patients, 947 (217 east/730 west) answered the QoC questionnaire. Only 23% of all patients had knowledge about IBD before diagnosis. In Eastern Europe, significantly more patients searched out information about IBD themselves (77% vs. 68%, p<0.05), the main source was the Internet (92% vs. 88% p=0.23). In Western Europe, significantly more patients were educated by nurses (19% vs. 1%, p<0.05), while in Eastern Europe, gastroenterologists were easier to contact (80% vs. 68%, p<0.05).

CONCLUSION

Health care differed significantly between Eastern and Western Europe in all items, but satisfaction rates were high in both geographic regions. Because of the low awareness and the rising incidence of IBD, general information should be the focus of patient organizations and medical societies. In Western Europe IBD nurses play a very important role in reducing the burden of patient management.

Environmental factors in a population-based inception cohort of inflammatory bowel disease patients in Europe--an ECCO-EpiCom study

BACKGROUND AND AIMS

The incidence of inflammatory bowel disease (IBD) is increasing in Eastern Europe possibly due to changes in environmental factors towards a more "westernised" standard of living. The aim of this study was to investigate differences in exposure to environmental factors prior to diagnosis in Eastern and Western European IBD patients.

METHODS

The EpiCom cohort is a population-based, prospective inception cohort of 1560 unselected IBD patients from 31 European countries covering a background population of 10.1 million. At the time of diagnosis patients were asked to complete an 87-item questionnaire concerning environmental factors.

RESULTS

A total of 1182 patients (76%) answered the questionnaire, 444 (38%) had Crohn's disease (CD), 627 (53%) ulcerative colitis (UC), and 111 (9%) IBD unclassified. No geographic differences regarding smoking status, caffeine intake, use of oral contraceptives, or number of first-degree relatives with IBD were found. Sugar intake was higher in CD and UC patients from Eastern Europe than in Western Europe while fibre intake was lower (p<0.01). Daily consumption of fast food as well as appendectomy before the age of 20 was more frequent in Eastern European than in Western European UC patients (p<0.01). Eastern European CD and UC patients had received more vaccinations and experienced fewer childhood infections than Western European patients (p<0.01).

CONCLUSIONS

In this European population-based inception cohort of unselected IBD patients, Eastern and Western European patients differed in environmental factors prior to diagnosis. Eastern European patients exhibited higher occurrences of suspected risk factors for IBD included in the Western lifestyle.

Pre-operative use of anti-TNF-α agents and the risk of post-operative complications in patients with Crohn's disease--a nationwide cohort study

BACKGROUND

A possible negative role of pre-operative use of antitumour necrosis factor-alpha (anti-TNF-α) agents on post-operative outcomes in Crohn's disease (CD) patients is still debated.

AIM

To examine the impact of pre-operative anti-TNF-α agents on post-operative outcomes 30 and 60 days after CD surgery in a nationwide Danish cohort. Outcomes were death, reoperation, anastomosis leakage, intra-abdominal abscess and bacteraemia.

METHODS

We identified all patients having surgical procedures from 1 January 2000 to 31 December 2010 (n = 2293). Patients were classified according to use of anti-TNF-α agents within 12 weeks before surgery (exposed) or not (unexposed). Outcomes were obtained from nationwide registries and a bacteraemia registry. Sub-analyses were performed for bacteraemia and for impact of pre-operative timing of anti-TNF-α agents.

RESULTS

Among surgical procedures for CD, 214 were exposed and 2079 were not. We found no increased relative risks of death or abscess drainage 30 or 60 days after follow-up. Among exposed, 7.5% had a reoperation within 30 days vs. 8.6% among unexposed, adjusted odds ratio (OR) = 0.92, 95% confidence interval (CI): 0.52-1.63. Among exposed, 3.8% had an anastomosis leakage within 30 days after surgery vs. 2.8% among unexposed, adjusted OR = 1.33, 95% CI: 0.59-3.02. No further cases of anastomosis leakages appeared within 60 days. Sub-analyses indicated no increased risk of bacteraemia after 30 days and no increased risks when anti-TNF-α agents were given ≤14 days before surgery.

CONCLUSION

We found no significantly increased relative risks of post-operative complications after use of anti-TNF-α agents either 12 weeks or ≤14 days before surgery for Crohn's disease.

Pre-operative use of anti-TNF-α agents and the risk of post-operative complications in patients with ulcerative colitis - a nationwide cohort study

BACKGROUND

It is still controversial whether pre-operative anti-tumour necrosis factor-alpha (anti-TNF-α) agents increase post-operative complications in patients with ulcerative colitis (UC).

AIM

In a nationwide Danish cohort of patients with UC, we aimed to examine the impact of pre-operative use of anti-TNF-α agents on post-operative adverse outcomes after colectomy for UC. Outcomes (within 30 and 60 days after surgery) were reoperation, anastomosis leakage, intra-abdominal abscess, bacteremia and death.

METHODS

Based on the Danish National Patient Registry we identified all UC patients, aged ≥15 years, having their first surgery for UC in the period of 1 January 2003-31 December 2010 (n = 1226). Patients were classified according to use of anti-TNF-α agents within 12 weeks before surgery or not. Outcome data were obtained from Danish registries. Logistic regression analyses were used to estimate adjusted risks [with 95% confidence intervals (CI)] of post-operative outcomes among patients treated with anti-TNF-α agents, relative to those not treated.

RESULTS

A total of 199 UC patients were exposed to anti-TNF-α agents within 12 weeks before colectomy, and 1027 were not. Among exposed, the adjusted odds ratio of reoperation and anastomosis leakage within 30 days after colectomy was 1.07 (95% CI: 0.71-1.59) and 0.52 (95% CI: 0.06-4.11) respectively. No deaths, cases of abscess drainage or bacteremia occurred among exposed within 30 days. Furthermore, no increased relative risks were found within 60 days after colectomy.

CONCLUSIONS

Based on nationwide data on UC patients having colectomies, pre-operative use of anti-TNF-α agents did not increase the risk of post-operative complications.

Prediction of therapy in primary endoscopic retrograde cholangiopancreatography

BACKGROUND AND STUDY AIMS

It seems rational to perform endoscopic retrograde cholangiopancreatography (ERCP) if the probability of endoscopic therapy is high, but to carry out magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) first if this probability is moderate or low. The aim of the present study was to develop a model describing the probability of endoscopic therapy in patients without previous biliary imaging.

PATIENTS AND METHODS

The development of the model was based on stepwise multiple logistic regression applied to 2470 prospectively registered first-time ERCP procedures. The model was evaluated by application to 442 prospectively registered first-time ERCP procedures entered in the database in the following 2 years.

RESULTS

Predictors selected were: age, gender, p-amylase >/= 400 U/l, ln(s-bilirubin), ln(s-alkaline phosphatase), common bile duct (CBD) stone seen on transabdominal ultrasonography, gallbladder stone seen on transabdominal ultrasonography, interaction of dilated bile ducts seen on transabdominal ultrasonography with ln(s-bilirubin), and interaction between age and male gender. The area under the receiver operating characteristic (ROC) curve was 0.875 and there was good fit of the model. A test with a probability cutoff value of 80 % had a positive predictive value (PPV) of 92.8 %. Specificity was 87.1 % and, using this test, 52.4 % of patients would have been selected for primary ERCP. In the application cohort, the frequency of therapy was higher than in the development cohort. The area under the ROC curve was 78.7 %. When used in the evaluation cohort, with a cutoff probability of 80 %, the test had sensitivity 84.0 %, specificity 49.5 %, negative predictive value (NPV) 46.6 % and PPV 85.6 %. Of the patients, 76.7 % would have been selected for ERCP. This would have identified 85.5 % of individuals needing therapeutic ERCP without use first of MRCP or EUS. Test-positive cases constituted 90.3 % of stent insertions and 86.3 % of stone extractions.

CONCLUSIONS

The model is useful for selection of patients for ERCP at our center.

Incomplete remission with short-term prednisolone treatment in collagenous colitis: a randomized study

BACKGROUND

Microscopic colitis is a disease of unknown aetiology characterized by chronic watery diarrhoea and diarrhoea can be eliminated by budesonide but frequently recurs when budesonide is stopped. We studied whether prednisolone could induce remission in patients with disabling, chronic diarrhoea due to microscopic colitis.

METHODS

A double-blind, randomized (3:1) trial of oral prednisolone 50 mg daily or placebo for 2 weeks. Remission was defined as stool weight < or = 200 g/day or frequency < or = 2/day; effect was defined as > 50% reduction of either stool frequency or weight. Six centres screened 31 consecutive patients and included 11 with collagenous colitis and 1 with lymphocytic colitis. Median duration of diarrhoea was 9 months. Patients had a normal colonoscopy, and no evidence of coeliac disease, bile acid or lactose malabsorption. Patients with gastrointestinal infection, previous gastrointestinal surgery, abnormal biochemical screening or recent treatment with immunosuppressive agents were excluded.

RESULTS

Stool weight (grams) declined in 7 of 9 patients given prednisolone and in 1 of 3 receiving placebo; changes in median weight were from 430 to 278 and from 825 to 489, respectively. Stool frequency (per day) declined from 6 to 3 and from 8 to 5. Remission was obtained in 2 and 0, and effect in 5 and 0, respectively (NS; Fisher exact test).

CONCLUSIONS

Prednisolone 50 mg daily for 2 weeks induces incomplete remission in patients with chronic diarrhoea due to collagenous colitis.

Pharmacological monitoring of azathioprine therapy

BACKGROUND

Studies on azathioprine (Aza) treatment in Crohn disease have indicated a positive correlation between clinical remission and a concentration in erythrocytes of the metabolites 6-thioguanine nucleotides (E-6-TGN) above 230 pmol/8 x 10(8) RBC. A concentration of the methylated Aza metabolites (E-6-MMP) above 5000 pmol/8 x 10(8) RBC has been correlated to hepatotoxicity. Thiopurine methyltransferase (TPMT) is responsible for the formation of methylated metabolites and lower E-TGN levels, and TPMT genotyping has been proposed as guidance for dosage. In a cross-sectional study we investigated relationships between the clinical outcome and Aza dose, the TPMT genotype and the Aza metabolite levels among patients with Crohn disease.

METHODS

TPMT genotype (PCR assay), azathioprine metabolite levels (HPLC analysis) and xanthine oxidase (XO) activity were determined once in 71 randomly selected Crohn patients on an unaltered Aza dose for at least 3 months.

RESULTS

None of the doses of Aza, TPMT genotype, E-6-TGN-, E-6-MMP levels or XO activity were significantly related to disease activity (H-B score), (P = 0.18, P = 0.69, P = 0.90, P = 0.54, P = 0.29, respectively). Leucopenia and/or hepatotoxicity were not demonstrated in any patient. Four patients had a heterozygous TPMT genotype (6.1%; 95% CI: 1.68%-14.80%). The 4 TPMT heterozygous patients had higher E-6-TGN levels than did the 67 remaining patients (P = 0.008).

CONCLUSIONS

To explore the applicability of TPMT genotyping, E-6-TGN and E-6-MMP levels for therapeutic drug monitoring, large prospective studies with patient entry at the start of Aza therapy are needed. Until the results of such studies are available, the dose adjustments of Aza should be guided primarily by clinical response and blood counts; metabolite level measurements can only be applied to identify therapeutic non-compliance.

Incomplete remission with short-term prednisolone treatment in collagenous colitis: a randomized study

BACKGROUND

Microscopic colitis is a disease of unknown aetiology characterized by chronic watery diarrhoea and diarrhoea can be eliminated by budesonide but frequently recurs when budesonide is stopped. We studied whether prednisolone could induce remission in patients with disabling, chronic diarrhoea due to microscopic colitis.

METHODS

A double-blind, randomized (3:1) trial of oral prednisolone 50 mg daily or placebo for 2 weeks. Remission was defined as stool weight < or = 200 g/day or frequency < or = 2/day; effect was defined as > 50% reduction of either stool frequency or weight. Six centres screened 31 consecutive patients and included 11 with collagenous colitis and 1 with lymphocytic colitis. Median duration of diarrhoea was 9 months. Patients had a normal colonoscopy, and no evidence of coeliac disease, bile acid or lactose malabsorption. Patients with gastrointestinal infection, previous gastrointestinal surgery, abnormal biochemical screening or recent treatment with immunosuppressive agents were excluded.

RESULTS

Stool weight (grams) declined in 7 of 9 patients given prednisolone and in 1 of 3 receiving placebo; changes in median weight were from 430 to 278 and from 825 to 489, respectively. Stool frequency (per day) declined from 6 to 3 and from 8 to 5. Remission was obtained in 2 and 0, and effect in 5 and 0, respectively (NS; Fisher exact test).

CONCLUSIONS

Prednisolone 50 mg daily for 2 weeks induces incomplete remission in patients with chronic diarrhoea due to collagenous colitis.

Effects of topical ropivacaine on eicosanoids and neurotransmitters in the rectum of patients with distal ulcerative colitis

BACKGROUND

Topical administration of lidocaine has been suggested to have beneficial clinical effects in patients with active ulcerative colitis, but the mechanism of action, if any, remains obscure. As local anaesthetics may exert anti-inflammatory actions through their inhibition of nervous reflexes, we have studied the local effects of a single rectal dose of ropivacaine gel on rectal concentrations of eicosanoids and neurotransmittors in patients with relapsing ulcerative colitis.

METHODS

In a randomized, double-blind, placebo-controlled study, concentrations of leukotriene B4, thromboxane B2 and prostaglandin E2 in rectal dialysates and concentrations of substance P, neurokinin A, somatostatin, vasoactive intestinal polypeptide and calcitonin gene-related peptide in rectal biopsies from 19 patients with active, distally located, ulcerative colitis were measured before and after rectal administration of a 200-mg dose of ropivacaine- or placebo-gel by use of radioimmunoassays. For comparison with normal conditions, concentrations of neuropeptides were measured in another 19 patients with relapsing ulcerative colitis and 14 controls with non-inflamed colon.

RESULTS

No significant changes in concentrations of eicosanoids or neuropeptides were observed after ropivacaine or placebo administration. Baseline concentrations of all neuropeptides, except somatostatin, were significantly lower in active ulcerative colitis than in controls with non-inflamed colon.

CONCLUSIONS

These findings reveal no evidence of anti-inflammatory actions by ropivacaine in active ulcerative colitis and thus provide no rationale for topical treatment with local anaesthetics.

Collagen metabolites in the peripheral and splanchnic circulation of patients with Crohn disease

BACKGROUND

Fragments of collagen arising during synthesis and breakdown have been suggested as markers of fibrous tissue remodelling in Crohn disease. We compared serum concentrations of the C-terminal propeptide of collagen I (PICP), the N-terminal propeptide of collagen III (PIIINP) and the C-terminal telopeptide of type I collagen (ICTP) in the splanchnic and systemic circulation in Crohn disease requiring segmental intestinal resection.

METHOD

15 consecutive patients undergoing surgery due to strictures or continuous inflammation. Male:female ratio was 6:9. Blood was drawn from a peripheral vein prior to surgery. Immediately before intestinal resection, additional samples were drawn from the antecubital vein and from a mesenteric vein draining the affected intestinal segment. PIIINP, PICP and ICTP were measured with radioimmunoassays.

RESULTS

Pre-surgery S-ICTP (median 5.5 microg/L; range 3.2-17.2 microg/L) was significantly increased in peripheral blood compared with healthy controls (median 2.6 microg/L; range 0.6-5.7 microg/L), P < or = 0.05. By contrast, S-PICP (median 98 microg/L; range 62-137 microg/L) and S-PIIINP (median 2.5 microg/L; range 1.2-7.4 microg/L) were significantly lower than S-PICP (median 133 microg/L; range 66-284 microg/L) and S-PIIINP (median 3.4 microg/L; range 1.0-7.1 microg/L) in healthy controls, P < or = 0.05. During surgery. no difference in S-PICP and S-PIIINP was documented between peripheral blood and splanchnic blood. In contrast, S-ICTP was increased in splanchnic blood (median 6.2 microg/L; range 2.7-17.4) compared to peripheral blood (median 5.0 microg/L; range 3.1-13.4) (P=0.05).

CONCLUSION

The present study provides further evidence that the altered intestinal collagen metabolism in Crohn disease is reflected in the local and systemic circulation.

[Cyclosporine treatment of patients with active ulcerative colitis refractory to high-dose glucocorticoid]

In around 30-40% of patients with acute severe ulcerative colitis the disease is refractory to treatment with high-dose glucocorticoids. Adding intravenous cyclosporine to the therapy in these patients has shown encouraging short-term results. Case notes of twenty-three acutely ill patients, who received intravenous cyclosporine during the period 1992 to 1998 due to failure of high-dose glucocorticoid (n = 20) or due to medical complications (n = 3) which made surgery difficult, were reviewed. Eight patients had their first episode of ulcerative colitis whereas 15 had relapse or chronic active disease. Cyclosporine (4 mg/kg/dag) was added to glucocorticoid treatment after a median of 11 days. Clinical remission was achieved in 13 patients (57%) after a median of nine days, of these five subsequently underwent surgery. Ten did not obtain remission and went to surgery. Approximately a third of acutely ill ulcerative colitis patients refractory to standard treatment with high-dose glucocorticoids will benefit from intravenous cyclosporine in the longer term.

Gastrointestinal bleeding in patients with hereditary hemorrhagic telangiectasia

OBJECTIVE

Gastrointestinal bleeding occurs in a number of patients with hereditary hemorrhagic telangiectasia (HHT) and may lead to a high transfusion need. The aim of this study was to estimate the occurrence and severity of gastrointestinal bleeding in a geographically well defined HHT population.

METHODS

All HHT families in the county of Fyn, Denmark, (470,000 population) have been identified. Probands and their first degree relatives, and all descendants from probands for whom one parent had HHT were eligible for inclusion in the study. A total of 77 patients with HHT were identified; of these, 76 patients (mean age: 52 yr) were evaluated and interviewed with regard to gastrointestinal bleeding, that is, a history of either hematemesis or melena. Patients charts were reviewed.

RESULTS

A total of 25 HHT patients (33%) had a history of either hematemesis or melena. Of these, 12 (48%) had received blood transfusions. Seven patients had severe bleeding (that is, > or =6 units of blood within 6 months before inclusion in the study). Endoscopy had been performed in 16 of the 25 (64%) patients. Telangiectatic lesions were documented in nine at upper endoscopy and in one at sigmoidoscopy. Telangiectatic lesions were observed in all patients with severe bleeding, but in two patients epistaxis is likely to have contributed to the anemia. Among 51 HHT patients without a history of gastrointestinal bleeding, only five (10%) had previously received blood transfusions; however, none fulfilled the definition of severe bleeding. In the HHT population 29 patients were > or =60 yr old, but all patients with severe bleeding were > or =60 yr.

CONCLUSIONS

A history of gastrointestinal bleeding is common in patients with HHT (33%). This study documents that 25% of HHT patients > or =60 yr suffer from severe gastrointestinal bleeding.

Markers of coagulation and fibrinolysis as measures of disease activity in inflammatory bowel disease

BACKGROUND

Activation of coagulation and fibrinolysis occurs in patients with inflammatory bowel disease. Our aim was to study the course of a marker for activation of the coagulation cascade, prothrombin fragment 1 + 2 (F1+2), and fibrinolysis, fibrin degradation products (FbDP), in patients with ulcerative colitis and Crohn's disease before and during therapy with glucocorticoids.

METHODS

Twenty-seven patients with active ulcerative colitis and 42 with active Crohn's disease treated with glucocorticoids were studied. Plasma samples were drawn before, during, and at end of therapy or at time of treatment failure. F1+2 and FbDP were measured with commercially available enzyme immunoassays.

RESULTS

Mean base-line concentrations of F1+2 were significantly increased in patients with ulcerative colitis (4.77 +/- 0.50 nmol/l; P < 0.0001) and in Crohn's disease (4.66 +/- 0.59 nmol/l; P < 0.0001) compared with healthy controls (1.57 +/- 0.09 nmol/l). Mean base-line concentrations of FbDP were significantly increased in patients with ulcerative colitis (1264 +/- 161 microg FE/l; P < 0.0001) and in Crohn's disease (491 +/- 51 microg FE/l; P < 0.0001) compared with healthy controls (194 +/- 21 microg FE/l). During treatment with glucocorticoids the plasma concentrations of FbDP decreased in patients with Crohn's disease achieving remission and in patients with ulcerative colitis avoiding surgery but remained unchanged in patients not responding to therapy. In contrast, F1+2 remained increased in patients with Crohn's disease and ulcerative colitis irrespective of outcome.

CONCLUSION

The present data support the concept that coagulation cascade and fibrinolysis is activated in patients with active inflammatory bowel disease. F1+2 and FbDP correlate poorly with the clinical disease activity and acute-phase reactants. The clinical response to treatment with glucocorticoids is accompanied by a decrease in plasma concentrations of FbDP but not in F1+2. FbDP may emerge as a new marker in the assessment of disease activity in patients with inflammatory bowel disease.

Biological variation of International Normalized Ratio for prothrombin times, and consequences in monitoring oral anticoagulant therapy: computer simulation of serial measurements with goal-setting for analytical quality

Oral anticoagulant therapy (OAT) has a well-established efficacy in prophylaxis and treatment of thromboembolic disorders. Because complications are related to intensity of OAT, optimal control of treatment is mandatory. In studies of OAT, as many as 30% of International Normalized Ratio (INR) measurements for prothrombin times fall outside the therapeutic interval. Preanalytical, analytical, and biological variation all contribute to this. Computer simulations of serial INR measurements were performed for various assumed in-treatment setpoints within the therapeutic interval INR 2.0-3.0 and for an "in-treatment within-subject variation" (CV) of 10.1%. Results are presented in difference plots with therapeutic intervals and critical differences. If the in-treatment setpoint is mid-interval (INR = 2.5), only 5% of simulated INR values fall outside the therapeutic interval. Setpoints deviating from the mid-interval and increases in the in-treatment within-subject variation considerably increase the number of observations outside the therapeutic interval and the critical differences. In conclusion, random variation, biological or analytical, and setpoints (targets) deviating from mid-interval explain a substantial number of the INR values outside therapeutic intervals observed in clinical studies. Analytical imprecision should be kept < 5% and analytical bias < +/- 0.2 INR.

Graphical interpretation of analytical data from comparison of a field method with reference method by use of difference plots

Various viewpoints have been offered regarding the appropriate use of scatter plots or difference plots (bias plots or residual plots) in comparing analytical methods. In many of these discussions it seems the basic concepts of identity (within inherent imprecision) and acceptability based on analytical goals (analytical quality specifications) have been forgotten. With the increasing number of Reference Methods in laboratory medicine, these basic concepts are becoming more important in validation of field methods. Here we describe a simple and effective graphical test of these hypotheses (identity and acceptability) by use of difference plots. These plots display the underlying hypothesis before the measured differences are plotted and allow interpretation of the results according to specific criteria. We further describe simple but effective interpretations of the data, when the hypothesis is not fulfilled, by using two data sets drawn from comparisons of field methods for S-creatinine with a Reference Method for this analyte. The difference plot is a graphical tool with related simple statistics for comparison of a field method with a Reference Method, focusing on (a) identity within the inherent analytical imprecision or (b) acceptability within analytical quality specifications. Calculation of the standard deviation of the differences is an indispensable tool for evaluation of aberrant-sample bias (matrix effects).

Serum concentrations of orosomucoid: improved decision-making for tapering prednisolone therapy in patients with active inflammatory bowel disease?

BACKGROUND

The reliability of clinical judgment for the tapering of glucocorticoids in patients with active inflammatory bowel disease has been questioned.

METHODS

The current study compared decision-making strategies on the basis of a combination of disease indices and serum concentrations of orosomucoid (strategy A) and disease indices only (strategy B) for the tapering of prednisolone. Twenty-nine patients with clinically active ulcerative colitis and 59 patients with Crohn's disease and increased concentrations of S-orosomucoid participated. The initial dose of prednisolone was 40 or 75 mg, which was tapered off over a minimum of 6 or 8 weeks.

RESULTS

The tapering schedule was completed in 11 of 44 (25%) patients treated in accordance with strategy A, whereas 28 of 44 patients (64%) and prednisolone completely tapered, in accordance with strategy B. At follow-up 4 of 11 patients (36%) and 17 of 28 patients (61%) treated in accordance with strategies A and B, respectively, had clinical relapse (0.10 > P > 0.05). By means of multiple regression analysis a high serum concentration of orosomucoid and previous disease activity were identified as predictors of relapse.

CONCLUSION

A therapeutic end-point of normalization of an increased level of S-orosomucoid in addition to clinical remission may be difficult to use, as serum concentrations may be continuously increased in spite of clinical remission. However, this goal may still be relevant, as a trend towards higher risk of relapse was found in patients with increased orosomucoid concentrations after completing therapy.

[Legionella infection with rhabdomyolysis]

Rhabdomyolysis complicating infection with Legionella pneumophila has previously been reported and may in some cases have led to acute tubular interstitial necrosis. We report a case of severe Legionnaires' disease complicated with rhabdomyolysis, myoglobinuria and neurological symptoms. Treatment with erythromycin and rifampicin was initiated early in the course of disease. The myoglobinuria was treated with forced diuresis and alkanization and renal failure did not develop. The frequency of rhabdomyolysis as a complication to Legionnaires' disease is not known. In addition, the pathogenesis and possible risk factors have not yet been determined. Considering the seriousness of this complication and until further investigations have been performed we recommend that routine determinations of creatine phosphokinase are performed in the evaluation of these patients.

Selective blockade of leukotriene production by a single dose of the FPL 64170XX 0.5% enema in active ulcerative colitis

5-Lipoxygenase products of arachidonic acid metabolism are thought to play a central role in the secondary amplification of the inflammatory response of several inflammatory diseases, including ulcerative colitis. FPL 64170XX is a selective inhibitor of the enzyme 5-lipoxygenase. Concentrations of leukotriene B4 and prostaglanding E2 in rectal dialysis fluid from 23 males with clinically and sigmoidoscopically active, distally located ulcerative colitis were measured by radioimmunoassays in a double-blind, placebo-controlled, parallel design study before and after rectal administration of an enema containing 0.5% of FPL 64170XX. Repeated measures analysis of leukotriene B4, after adjusting for baseline, showed a significant treatment effect (P = 0.0014). The concentration of leukotriene B4 from rectal dialysates in patients receiving the active drug dropped to 15% (95% confidence interval 5-40%) of the placebo level in the second dialysis following administration of FPL 64170XX 0.5%. By contrast, prostaglanding E2 concentrations doubled (P = 0.0068) in patients receiving FPL 64170XX 0.5% with no change in the placebo group. These findings demonstrate that a single dose of FPL 64170XX 0.5% enema selectively blocks the generation of the 5-lipoxygenase product, leukotriene B4, to a mean of 85% in the target tissue of inflammation. Topical administration of this new leukotriene synthesis inhibitor may prove to be a clinically useful approach to the treatment of active, distally located ulcerative colitis.

Seromarkers of collagen I and III metabolism in active Crohn's disease. Relation to disease activity and response to therapy

Crohn's disease is characterised by gradual development of intestinal fibrotic lesions containing large amounts of collagen type I, III, and V. Measurement of circulating connective tissue metabolites has emerged as a useful tool for assessment of fibroproliferative activity in various diseases. Serum concentrations of procollagen peptides, N-terminal propeptide of type III procollagen (PII-INP), and C-terminal propeptide of type I procollagen (PICP), reflect the synthesis rate of the parent collagens, while the C-terminal telopeptide of type I collagen (ICTP) reflects its degradation. S-PIIINP, S-PICP, and S-ICTP were measured by radioimmunoassays in 29 patients with active Crohn's disease. S-ICTP was significantly increased, median 6.2 micrograms/l (95% CI 5.2 to 8.7 micrograms/l) versus controls 2.6 micrograms/l (2.5 to 2.7 micrograms/l) (p < 0.0001), S-PICP reduced, 100 micrograms/l (80 to 110 micrograms/l) versus 132 micrograms/l (124 to 141 micrograms/l) (p = 0.001), and S-PIIINP did not differ from controls. Patients with sustained clinical remission during prednisolone therapy exhibited an increase in S-PICP (p = 0.0052). S-PIIINP changed significantly (p = 0.0002), however, exhibiting a biphasic pattern. S-ICTP decreased (p = 0.015) in treatment responders but remained above the upper normal limit even when clinical remission had been achieved. Non-responders showed no significant changes in any of the marker molecules of collagen synthesis or degradation. Correlations were found between S-PIIINP and S-PICP (p < 0.005) and S-ICTP (p < 0.02), and between S-ICTP and S-orosomucoid (p < 0.005) and S-C reactive protein (p < 0.02). By contrast, there was no relation between the connective tissue metabolites and Harvey Bradshaw Index. These data provide evidence that collagen I degradation is increased not only in active Crohn's disease, but also in patients entering clinical remission. The concurrent normal/low-normal values of markers of collagen formation may reflect a changed local or systemic elimination of the propeptides.

Interpretation of serial measurements of international normalized ratio for prothrombin times in monitoring oral anticoagulant therapy

Despite careful monitoring of oral anticoagulant treatment (OAT), some international normalized ratio (INR) for prothrombin time values will fall outside the therapeutic range. Considerable changes in serial INR results from OAT patients may be caused by random fluctuation alone, and, for statistical reasons, a fraction of the INR values will fall outside therapeutic range and interfere with dose adjustments. On the basis of therapeutic intervals and statistical evaluation of reference changes, we suggest and discuss an alternative method for interpretation of serial INR measurements. Retrospective evaluation of serial measurements of INR from OAT patients revealed an "overshooting" phenomenon. When a dose was adjusted on the basis of insignificant change in INR value, the subsequent INR value generally fell in the opposite direction. If a further change of dose was initiated because of the new INR value, a similar course in the opposite direction was observed. This "ping-pong" effect renders patients in a fluctuating state of anticoagulation and may introduce increased risk of complications. The suggested method provides an objective criterion for dose adjustments in OAT, which should reduce patients' risk.

Interpretation of serial measurements of international normalized ratio for prothrombin times in monitoring oral anticoagulant therapy

Despite careful monitoring of oral anticoagulant treatment (OAT), some international normalized ratio (INR) for prothrombin time values will fall outside the therapeutic range. Considerable changes in serial INR results from OAT patients may be caused by random fluctuation alone, and, for statistical reasons, a fraction of the INR values will fall outside therapeutic range and interfere with dose adjustments. On the basis of therapeutic intervals and statistical evaluation of reference changes, we suggest and discuss an alternative method for interpretation of serial INR measurements. Retrospective evaluation of serial measurements of INR from OAT patients revealed an "overshooting" phenomenon. When a dose was adjusted on the basis of insignificant change in INR value, the subsequent INR value generally fell in the opposite direction. If a further change of dose was initiated because of the new INR value, a similar course in the opposite direction was observed. This "ping-pong" effect renders patients in a fluctuating state of anticoagulation and may introduce increased risk of complications. The suggested method provides an objective criterion for dose adjustments in OAT, which should reduce patients' risk.

Blockade of leukotriene production by a single oral dose of MK-0591 in active ulcerative colitis

BACKGROUND

5-Lipoxygenase products of arachidonic acid metabolism are thought to play a central role in the secondary amplification of the inflammatory response in a number of human inflammatory diseases, such as ulcerative colitis. MK-0591 (3-(1((4-chlorophenyl)methyl)-3((1,1-dimethyl-ethyl)thio)-5(quinolin+ ++-2ylmethyl-oxy)-1H-indol-2yl)-2,2-dimethyl-propanoate) exerts its effect by binding to the 5-lipoxygenase activating protein, thereby inhibiting the translocation and activation of 5-lipoxygenase.

METHODS

Concentrations of leukotriene B4 (LTB4) and prostaglandin E2 (PGE2) in rectal dialysis fluid, ex vivo biosynthesis of LTB4 in whole blood, and urinary excretion of leukotriene E4 (LTE4) from 16 patients with mild to moderately active distally located ulcerative colitis were measured by use of radioimmunoassays in a double-blind, placebo-controlled parallel-design study before and after oral administration of a 250 mg dose of MK-0591 or placebo.

RESULTS

The mean LTB4 concentration in rectal dialysis fluid was lowered after MK-0591 by > 90% (p < 0.05) from 4 to 8 hours, with a maximum inhibition of 97.5% +/- 3.4% (mean +/- SD) at 20 to 24 hours after dosing, whereas PGE2 was unchanged. In whole blood, MK-0591 decreased ex vivo biosynthesis of LTB4 (p < 0.01), with a maximum inhibition of 96.4% +/- 2.1% at 4 hours after dosing. Urinary excretion of LTE4 was reduced by more than 85% (p < 0.001) from 4 to 48 hours. No adverse events were observed.

CONCLUSION

These findings show that a single oral 250 mg dose of MK-0591 results in nearly complete blockade of systemic leukotriene production and LTB4 formation in the target tissue of inflammation (the rectum). Controlled multiple-dose trials to assess the clinical efficacy of this novel 5-lipoxygenase-activating protein inhibitor seem to be worthwhile.

Treatment of ulcerative colitis with high doses of oral prednisolone. The rate of remission, the need for surgery, and the effect of prolonging the treatment

Treatment of acute attacks of ulcerative colitis in 89 patients with doses of prednisolone above or equal to 40 mg resulted in an overall remission in 67%. Remission rate and colectomy rate were 47% and 42%, respectively, when the disease was severe, 80% and 13% when moderate, and 84% and 3% when mild. The need for surgery was 28% in pancolitis, 11% in left-sided colitis, and 5% in proctitis. After subsequent treatment episodes colectomy was performed in 35% of patients with pancolitis, in 37% with left-sided colitis, and in 5% with proctitis. The median total duration of therapy in patients who went into clinical remission was 4 months, and the median dose just above 3 g prednisolone. Patients who stayed in remission during the follow-up received a significantly higher start dose and total dose of prednisolone in the treatment episode than patients who had a relapse. In 25 patients treatment with doses equal to or above 75 mg of prednisolone was continued beyond 10 days, and 11 patients experienced remission whereas 14 patients had surgery performed. Orally administered corticosteroids produce results comparable to those obtained after the previously suggested intravenous regimen.

[Cesarean section. Changes in frequency and indications in the county of South Jutland during a 10-year period]

During recent years, the frequency of Caesarean section has changed everywhere. Changes during a ten-year period in the Department of Gynaecology in Sønderborg Hospital were registered and involve mainly the groups of imminant foetal death, previous Caesarean section, foeto-pelvic disproportion and placental insufficiency. Alterations in the obstetric services in the County of South Jutland and improved neonatal service have played an important part in development of the frequency of Caesarean section of Sønderborg Hospital.

Morphine inhibits secretion of bicarbonate from the human duodenal mucosa. Possible role of endogenous opioids in the regulation of human duodenal mucosal bicarbonate secretion

Mucus and bicarbonate secreted from the epithelium are thought to be important for the protection of the duodenal mucosa against acid and pepsin, but so far little is known about the regulation of human duodenal mucosal bicarbonate secretion. After isolating a segment of the proximal human duodenum from gastric and pancreaticobiliary secretion we quantified the secretion of bicarbonate from the human duodenal mucosa. The method was evaluated by measurements of basal and prostaglandin E1 analogue-stimulated bicarbonate secretion. The duodenal mucosal bicarbonate secretion was inhibited 70% after intravenous infusion of morphine in a dose of 73.6 micrograms/kg/h and increased after intravenous administration of naloxone. Thus, the inhibition is most likely mediated by mu-receptors, and the results suggest a role of endogenous opioids in the regulation of the secretion of bicarbonate from the human duodenal mucosa.

[Defence mechanisms of the gastroduodenal mucosa. The significance of epithelial and subepithelial factors for the development of acute and chronic ulceration]

Extra-epithelial, epithelial and sub-epithelial defence mechanisms protect the gastroduodenal mucosa against acid and pepsin. The epithelial mechanisms include epidermal growth factor, surface active phospholipids on the luminal membrane of the epithelial cells, sulfhydryl compounds and rapid epithelial restitution after damage. The sub-epithelial mechanisms include mucosal blood flow supplying the mucosa with bicarbonate needed for neutralization of the acid which penetrates the epithelium and the protective effect of the process of acid secretion. Prostaglandins, which partially protect the gastroduodenal mucosa against damaging agents, stimulate several of the abovementioned defensive factors but the precise mechanism of the action of prostaglandins is still unknown. The results of several experiments support the idea of the defensive factors being of importance in the development of acute and chronic gastroduodenal ulceration. At present, the therapeutic possibilities seem to be restricted and nothing indicates that stimulation of the defensive factors, only, is more effective in the treatment of peptic ulcer than inhibition of aggressive factors as acid and pepsin.

Duodenal disappearance rate of acid during inhibition of mucosal bicarbonate secretion

In order to investigate the relation between duodenal mucosal and pancreaticobiliary bicarbonate secretion, we have studied the effect of inhibition of mucosal bicarbonate secretion by indomethacin on the disappearance rate of acid and the concomitant plasma secretin concentrations. 10 healthy subjects were studied twice, with and without indomethacin pretreatment. By means of a double-lumen tube the duodenum was perfused with increasing amounts of acid (0, 3.0, 6.0 and 9.5 mmol/h) and the disappearance rate of acid, pH of duodenal aspirate and plasma secretin were measured. In both experiments nearly all acid, even at the highest acid load, disappeared (pH greater than 6). Inhibition of the duodenal mucosal bicarbonate secretion did not decrease the acid-neutralizing capacity of the human duodenum. In fact, the disappearance rate of acid at the highest acid load was a little greater when mucosal bicarbonate secretion had been inhibited than when not (10.3 +/- 0.5 vs. 9.2 +/- 0.2 mmol/h). The pancreaticobiliary secretion of bicarbonate, as judged by plasma secretin concentrations, increased, however, earlier when mucosal bicarbonate secretion had been inhibited than when not (3.7 vs. 3.0 pmol/l at an acid load of 6.0 mmol/h). This indicates that bicarbonate from the duodenal mucosa normally plays a role in the in lumen neutralization of acid in the human duodenum.

[Defense mechanisms of the gastroduodenal mucosa: the role of mucus and bicarbonate in the development of peptic ulcer]

The existing knowledge of the mucus and bicarbonate production of the gastroduodenal mucosa is reviewed. Mucus and bicarbonate are produced in the surface epithelium of both duodenum and ventricle. The production is regulated by neural stimuli, gastrointestinal hormones and local synthesis of prostaglandins. Several of the factors suspected of being of importance to the development of peptic ulcers also have a negative influence on the production of mucus and bicarbonate. This indicates that mucus and bicarbonate are important in the pathogenesis of peptic ulcer. Two newly registered so-called mucosaprotective anti-ulcer drugs (De-Nol, Succralfat) both exert positive influences on the production of mucus and bicarbonate.