Detecting host responses to microbial stimulation using primary epithelial organoids

The intestinal epithelium is constantly exposed to microbes residing in the lumen. Traditionally, the response to microbial interactions has been studied in cell lines derived from cancerous tissues, e.g. Caco-2. It is, however, unclear how the responses in these cancer cell lines reflect the responses of a normal epithelium and whether there might be microbial strain-specific effects. To address these questions, we derived organoids from the small intestine from a cohort of healthy individuals. Culturing intestinal epithelium on a flat laminin matrix induced their differentiation, facilitating analysis of microbial responses via the apical membrane normally exposed to the luminal content. Here, it was evident that the healthy epithelium across multiple individuals (n = 9) demonstrates robust acute both common and strain-specific responses to a range of probiotic bacterial strains (BB-12Ⓡ, LGGⓇ, DSM33361, and Bif195). Importantly, parallel experiments using the Caco-2 cell line provide no acute response. Collectively, we demonstrate that primary epithelial cells maintained as organoids represent a valuable resource for assessing interactions between the epithelium and luminal microbes across individuals, and that these models are likely to contribute to a better understanding of host microbe interactions.

Personalized B cell response to the Lactobacillus rhamnosus GG probiotic in healthy human subjects: a randomized trial

The specific effects of administering live probiotics in the human gut are not well characterized. To this end, we investigated the immediate effect of Lactobacillus rhamnosus GG (LGG) in the jejunum of 27 healthy volunteers 2 h after ingestion using a combination of global RNA sequencing of human biopsies and bacterial DNA sequencing in a multi-visit, randomized, cross-over design (ClinicalTrials.gov number NCT03140878). While LGG was detectable in jejunum after 2 h in treated subjects, the gene expression response vs. placebo was subtle if assessed across all subjects. However, clustering analysis revealed that one-third of subjects exhibited a strong and consistent LGG response involving hundreds of genes, where genes related to B cell activation were upregulated, consistent with prior results in mice. Immunohistochemistry and single cell-based deconvolution analyses showed that this B cell signature likely is due to activation and proliferation of existing B cells rather than B cell immigration to the tissue. Our results indicate that the LGG strain has an immediate effect in the human gut in a subpopulation of individuals. In extension, our data strongly suggest that studies on in vivo probiotic effects in humans require large cohorts and must take individual variation into account.

Pain perception during colonoscopy in relation to gender and equipment: a clinical study

Objectives A trend for gender-related differences in pain perception during colonoscopies has previously been observed. No consecutive clinical studies have been conducted to confirm such a relation. We aimed to investigate gender-related differences during the colonoscopy procedure, and the impact of endoscopic equipment and psychological factors on pain management. Methods In a consecutive clinical study, 391 patients referred for colonoscopy reported pain perception on a 0-10 visual analogue scale (VAS) after the procedure. A sub-group of patients (n=38) were given alternate instructions expertly tailored by a psychologist and their VAS scores were compared with those from the main study population. Data from a previous study from the same specialist practice and same source patient population using previous-generation equipment was included for comparison. Results No overall gender-related difference in VAS reports was found. There was no reduction in VAS when alternate instructions were given. Female patients were, however, more likely to benefit from light sedation (p=0.012). When compared with previous-generation endoscopes, the current generation equipment resulted in a VAS drop of 1.9 points for women and 1.6 for men (p<0.009) and washed out a previously observed gender-related difference. Conclusion No overall gender-related differences were found for pain experience during the colonoscopy procedure. Access to up-to-date endoscopic equipment can reduce procedure-related patient discomfort considerably, even at the expert level of a consultant physician. Implications Gastroenterologists should consider utilizing high-end endoscopic equipment to improve pain management and reduce VAS to very acceptable levels.

Impact of feedback and monitoring on colonoscopy withdrawal times and polyp detection rates

Background

Previous studies have shown colonoscopy withdrawal time (WT) to be a reliable surrogate indicator for polyp detection rate (PDR) and adenoma detection rate (ADR) in colonoscopy. Our aim was to assess the impact of feedback and monitoring of WT on PDR in routine colonoscopies with long-term follow-up.

Materials and methods

A total of 307 colonoscopies were performed in three separate clinical scenarios. First, PDR and WT were recorded without the staff being aware of the specific objective of the study. Before the second scenario, the staff was given interventional information and feedback on WTs and PDRs from the first scenario and was encouraged to aim for a minimum WT of 8 min. Retention of knowledge gained was reassessed in the third scenario 1 year later.

Results

The PDR in the first two scenarios differed significantly (p<0.01), with a more than 90% increase in PDR after intervention from 22% to 42% (95% CI 1.44 to 4.95), although the mean WT did not change (6.8 vs 7.2 min; p>0.05). The increase in PDR between the first and second scenarios was retained in the third follow-up scenario 1 year later where the WT of both polyp-positive and polyp-negative colonoscopies was found to be longer.

Conclusions

PDR almost doubled from the first to the second scenario of a real-life colonoscopy setting, indicating that awareness of WT is crucial. The knowledge gained from this intervention in routine practice was even retained after a year.

Confocal laser endomicroscopy: a novel method for prediction of relapse in Crohn's disease

BACKGROUND AND STUDY AIMS

Confocal laser endomicroscopy (CLE) has been shown to predict relapse in ulcerative colitis in remission, but little is currently known about its role in Crohn's disease. The aim of this study was to identify reproducible CLE features in patients with Crohn's disease and to examine whether these are risk factors for relapse.

PATIENTS AND METHODS

This was a single-center prospective feasibility study of CLE imaging in patients with Crohn's disease. CLE imaging was performed in the terminal ileum and four colorectal sites, and was correlated with histopathology and macroscopic appearance. Clinical relapse, defined as the need for treatment escalation or surgical intervention, was recorded during follow-up.

RESULTS

The study included 50 patients: 39 with Crohn's disease (20 in remission), and 11 controls. Ileal fluorescein leakage and microerosions were significantly more frequent in patients with endoscopically active Crohn's disease compared with patients with inactive Crohn's disease and controls (P = 0.005 and (P = 0.006, respectively). The same applied to colorectal fluorescein leakage and vascular alterations ((P = 0.043 and (P = 0.034, respectively). During a 12-month follow-up period, ileal fluorescein leakage and microerosions were significant risk factors for relapse in the subgroup of patients in remission (log rank (P = 0.009 and (P = 0.007, respectively) as well as in the entire group of patients with Crohn's disease (log rank (P = 0.006 and (P = 0.01, respectively). Inter- and intraobserver reproducibility was almost perfect (κ > 0.80) or substantial (κ > 0.60) for the majority of CLE parameters.

CONCLUSIONS

CLE can identify reproducible microscopic changes in the terminal ileum that are risk factors for relapse in patients with otherwise inactive Crohn's disease.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01738529).

Biodegradable stents for the treatment of bowel strictures in Crohn's disease: technical results and challenges

BACKGROUND AND STUDY AIMS

In patients with Crohn's disease, the idea of biodegradable stents for treatment of bowel strictures with limited effect of endoscopic balloon dilation is tempting and initial results have been promising. The aim of this study was to evaluate the technical and clinical success of biodegradable stents for treatment of inflamed Crohn's strictures refractory to endoscopic balloon dilatation.

PATIENTS AND METHODS

Consecutive patients treated with biodegradable stents due to Crohn's disease and inflamed bowel strictures refractory to endoscopic balloon dilatation were included. Technical and clinical success were evaluated.

RESULTS

Six patients were included in the study. Technical success was obtained in five patients (83 %). Clinical success was limited to one patient (20 %); failure was observed due to mucosal overgrowth (n = 2), stent migration (n = 1), and stent collapse (n = 1).

CONCLUSIONS

In Crohn's disease, it is technically feasible to treat bowel strictures with biodegradable stents. However, we have stopped using biodegradable stents due to lack of clinical success and side effects such as mucosal overgrowth and stent collapse.

Serial intralesional injections of infliximab in small bowel Crohn's strictures are feasible and might lower inflammation

BACKGROUND

Crohn's disease can cause strictures throughout the gastrointestinal tract. Endoscopic balloon dilatation is a well-established treatment, but recurrence is seen in up to three out of four cases. Infliximab is playing an increasingly important role in the modern systemic treatment of severe Crohn's disease. Combining the anti-inflammatory effects of infliximab with the proven effect of endoscopic balloon dilatation could possibly improve outcome. In small studies, intralesional injections in perianal fistulas have been effective and endoscopic injection therapy in colonic strictures is feasible.

OBJECTIVE

We wanted to assess whether serial intralesional injection of infliximab in small bowel strictures is feasible and reduces local inflammation.

METHODS

We included six patients with Crohn's disease and inflammatory small bowel strictures. They were treated with endoscopic serial balloon dilatation. Subsequent to each dilatation, 40 mg infliximab was injected submucosally. A modified simplified endoscopic score for Crohn's disease was used for the involved area before the initial treatment and at the final follow-up after six months. Complications and development of symptoms were registered.

RESULTS

Balloon dilatation and serial injection of infliximab were accomplished in five out of six patients. One patient completed the serial balloon dilatations and follow-up but received only one infliximab injection. The modified simplified endoscopic score for Crohn's disease decreased in all patients. There were no adverse events registered and all patients described themselves as feeling well.

CONCLUSIONS

Combining balloon dilatation of strictures with serial intralesional injection of infliximab in Crohn's disease of the small bowel is feasible and seems successful in reducing inflammation.

[Successful endoscopic dilatation of a stenosis in relation to an ileorectal anastomosis by acute ileus]

Endoscopic dilatation is a treatment option for patients with Crohns disease suffering from stenosis in relation to an ileorectal anastomosis. We present a case of a patient with Crohns disease who was admitted with acute obstructive symptoms due to a stensosis of the ileorectal anastomosis. The patient was septic. We performed a successful endoscopic dilatation in the acute phase and the patient was discharged few days after an uneventful recovery. Endoscopic dilatation of an ileorectal anastomsis in patients with Crohns disease is a treatment option in the acute setting when performed by experienced endoscopists.

IBD medications during pregnancy and lactation

IBD often affects patients during their peak reproductive years. Several drugs are available for the treatment of IBD and new drugs are continuously in the pipeline. As long-term administration of medications is often necessary, the safety of drug therapy during pregnancy and breast-feeding needs to be considered in daily clinical practice. The aim of this Review is to summarize the latest information concerning the safety of medications used to treat IBD during pregnancy and lactation, as well as their effect on fertility. Although only thalidomide and methotrexate are absolutely contraindicated during pregnancy and breast-feeding, alternatives to ciprofloxacin, natalizumab and sodium phosphate should also be considered for pregnant women. Breast-feeding is also discouraged while on treatment with ciclosporin, metronidazole and ciprofloxacin. However, therapy with 5-aminosalicylic acid preparations, glucocorticoids, thiopurines and TNF inhibitors are acceptable during pregnancy and lactation. Pregnant women who have symptomatic IBD or who require therapy should have the opportunity to discuss any associated risks to their pregnancy and infant with the appropriate consultants. By ensuring that the patient and her family are informed, the clinical outcome might be optimized.

Colonoscopy results are not enhanced by use of magnet endoguide in specialist practice

INTRODUCTION

It is discussed whether the use of a magnetic positioning device (OLYMPUS; UPD (unit of magnetic positioning device)) enhances the success of the colonoscopic procedure. Concern for patient compliance and endoscopic efficiency has been voiced in connection with the implementation of colon cancer screening. UPD has been proposed as a tool for optimization of results and reduction of patient discomfort. In this study, we aimed to qualify the debate by examining the success rate and patient discomfort in an unselected colonoscopy population referred to specialist clinics with experienced investigators. Furthermore, the study assessed the effect of using a UPD.

MATERIAL AND METHODS

A total of 1,068 consecutive patients referred for colonoscopy were enrolled and randomised for investigation with or without use of UPD. The evaluation endpoints were: success rate (coecum visualised, ileal intubation was carried out at the investigator's discretion), duration of procedure, and patient discomfort indicated by the patient as a visual analogue scale score.

RESULTS

No significant differences between the two investigational procedures were demonstrated in relation to the chosen endpoints.

CONCLUSION

UPD is convenient to have, but not a necessity for colonoscopy.

FUNDING

The study was supported by the Danish Association of Medical Specialists.

TRIAL REGISTRATION

The study was approved by the Danish Data Protection Agency, journal no. 2009-41-3716, the National Ethics Committee, journal no.: H-1-2009-80, and registered with ClinicalTrials.gov., protocol no: NCT01055782.

Endoscopic balloon dilatation for Crohn's strictures of the gastrointestinal tract is feasible

INTRODUCTION

Despite optimized medical treatment, Crohn´s disease can cause gastrointestinal (GI) strictures, which requires surgical intervention. Lately, endoscopic balloon dilatation has been established as an alternative to surgery. In the following, we report our experiences with endoscopic dilatation of strictures in the gastrointestinal tract caused by Crohn´s disease.

MATERIAL AND METHODS

From January 2005 to February 2011, 23 patients with Crohn´s disease were referred for endoscopic dilatation. Based on data derived from this cohort, a retrospective analysis was made. Patients with Crohn´s disease, obstructive GI symptoms and known bowel strictures were included. Their mean age was 39 years (20-59 years) and 65% were female. Prior to the procedure, all patients had been evaluated by barium small-bowel follow through, abdominal magnetic resonance imaging and/or endoscopy.

RESULTS

Dilatation was performed in 19/23 (83%) patients. During a mean follow-up period of 21 months (range 1-47 months), relapse was observed in 14/19 patients (74%). Five patients (26%) were referred to surgery due to complications (n = 1) or multiple relapses (n = 4). A total of 54 endoscopic dilatations were performed during the study period. Only one complication (perforation) was experienced, which resulted in a complication rate of 1.9%.

CONCLUSION

Endoscopic dilatation in patients with Crohn´s disease with obstructive GI symptoms seems safe. In three out of four patients, surgery was avoided during a mean follow-up of two years. Further optimisation of the procedure is needed to lower the rate of recurrence.

Expression of the genes dual oxidase 2, lipocalin 2 and regenerating islet-derived 1 alpha in Crohn's disease

OBJECTIVE

A global gene expression profile of non-inflamed colonic mucosal cells from patients with Crohn's disease (CD) and of colonic mucosal cells from controls was performed.

MATERIAL AND METHODS

Tissue specimens from macroscopically non-inflamed descending colon were obtained colonoscopically from 33 CD patients and from 17 control subjects. All controls and 10 CD patients were medication-free at the time of colonoscopy. The Human Genome U133 Plus 2.0 GeneChip Array was used for gene profiling. Hybridization data were analysed with dChip software. Results were confirmed by real-time reverse transcriptase polymerase chain reaction (RT-PCR). Protein product expression of selected genes was assessed by immunohistochemistry using the Envision+ visualization technique.

RESULTS

The expression profile was not homogeneous with the statistical cut-point settings applied. In comparison with controls, it was found that 19 CD patients had three differentially expressed genes, two of them related to the innate immune system: dual oxidase 2 on chromosome 15 (DUOX2, fold change 4.1) and lipocalin 2 on chromosome 9 (LCN2, fold change 3.1). The third gene, regenerating islet-derived 1 alpha (REG1A, fold change 3.9), codes for a mitogenic protein; this could not be confirmed by RT-PCR. Medication-free patients had no differentially expressed genes as compared with controls. Immunohistochemistry indicated that these proteins were produced by epithelial cells (REG1A, LCN2) and leucocytes (DUOX2 and LCN2).

CONCLUSIONS

As compared with controls, non-inflamed colonic mucosal cells contain two up-regulated genes related to the innate immune system. Up-regulation of these genes, known to be induced by microorganisms, suggests either increased microflora antigenicity or an altered function in mucosal barrier defence.

Histopathology of the gastric oxyntic mucosa in two different patient groups during long-term treatment with omeprazole

OBJECTIVES

Hypochlorhydria, hypergastrinaemia, inflammation and Helicobacter pylori infection, dose and duration of omeprazole treatment may separately, or in combination, influence the proliferation of enterochromaffin-like (ECL) cells and parietal cell changes in gastric mucosa. To assess the effects of these variables comparisons were carried out in patients with the acid related Zollinger-Ellison syndrome (ZES) versus patients with progressive systemic sclerosis (PSS) and gastro-oesophageal reflux disease.

METHODS

Twenty-five patients with PSS and 16 patients with ZES were included and received continuous omeprazole treatment for a mean of 7.5 and 9 years. The patients were investigated every 6-12 months with endoscopy, biopsies and histology, and plasma gastrin measurements. PSS patients were titrated by 24 h pH-metry to oesophageal pH>4, and all ZES patients were titrated to a basal acid output of zero H+.

RESULTS

Changes towards diffuse and linear ECL cell hyperplasia were observed in 41% of the PSS patients. Micronodular hyperplasia and neoplasia were not seen. In the ZES patients changes towards linear and micronodular hyperplasia were observed in all patients. Two patients developed ECL cell carcinoids; one of these had MEN-1 syndrome. Also parietal cell changes were more pronounced in the ZES group than in the PSS group.

CONCLUSIONS

In patients without intrinsic acid hypersecretion and hypergastrinaemia significant proliferation of ECL cells is not an issue irrespective of gastric mucosal inflammation, omeprazole dose, duration of treatment and acid inhibition. The level of gastrin secretion and high plasma gastrin appear to accelerate ECL cell proliferation and parietal cell changes possibly influenced by chronic gastritis and H. pylori infection.

Upregulation of interleukin-12 and -17 in active inflammatory bowel disease

BACKGROUND

Cytokines are essential mediators of the intestinal inflammation during active episodes of inflammatory bowel disease (IBD). Interleukin (IL)-12 and IL-17 are potent immunoregulatory cytokines whose roles in the pathogenesis of IBD are unknown. The aim of this study was to evaluate the colonic expression of IL-12 and IL-17 genes in IBD.

METHODS

Fifty-one patients (22 with ulcerative colitis (UC), 17 with Crohn disease (CD), and 12 controls) who underwent colonoscopy were included. IBD disease activity was determined using a clinical grading scale. The degree of inflammation, as well as the content of CD4+ T cells (synthesizing IL-17) and CD68+ macrophages (synthesizing IL-12) in colonic biopsies, was determined. The amounts of IL-12 and IL-17 mRNA were assessed by RT-PCR, using GAPDH as an internal standard.

RESULTS

In colonic specimens, IL-17 mRNA expression was increased in moderately and severely active UC (P = 0.03) and in all degrees of activity in CD (P < 0.04). Levels of IL-12 mRNA were upregulated in both active UC and active CD compared to controls (P < 0.02). In cases of remission, IL-12 mRNA expression was similar to that found in control samples. Compared to controls, histological examination showed significant differences in signs of chronic and acute inflammation in UC (P < 0.01) and CD (P < 0.02), revealing a high correlation between clinical disease activity and histological scoring (r2 = 0.92, P < 0.005). Whereas CD4+ T cells were observed in lymphocyte aggregates located profound in the lamina propria, CD68+ macrophages were primarily found just underneath the surface epithelium. The density of CD4+ and CD68+ cells correlated significantly with the amounts of IL-17 and IL-12 mRNA, respectively (P < 0.05).

CONCLUSION

The expression of both IL-12 and IL-17 mRNA is induced in active UC and CD and may thus be involved in sustaining the intestinal inflammation in IBD. Inhibition of IL-12 or IL-17 might be future therapeutic targets in IBD.

Expression of 5-lipoxygenase mRNA is unchanged in the colon of patients with active inflammatory bowel disease

BACKGROUND

In inflammatory bowel disease (IBD) the disease activity correlates with colonic concentrations of leukotrienes (LTs). The enzyme 5-lipoxygenase (5-LO) is responsible for the enzymatic production of LTs. It has previously been demonstrated in experimental models of inflammation, that 5-LO is activated through intracellular translocation of the pre-formed enzyme, and increased constitutive activation of 5-LO has been demonstrated in idiopathic pulmonary fibrosis. The objective of the present study was to investigate whether de novo synthesis of 5-LO is increased in patients with quiescent IBD, or is induced during acute exacerbations of IBD.

METHODS

Sixty-one individuals were included in the study. Twenty-eight had ulcerative colitis (UC), 21 had Crohn's disease (CD), and 12 were healthy controls. A standard rigid rectoscopy was performed in all individuals. The degree of inflammation was assessed using a semi-quantitative scale. A mucosal biopsy was taken from the most inflamed area as judged macroscopically. mRNA for 5-LO was detected using a RT-PCR technique, and the assay applied was evaluated by control experiments.

RESULTS

The expression of mRNA for 5-LO in colonic biopsies was similar in IBD patients with quiescent disease and healthy controls. When grouped according to endoscopically assessed disease activity the fraction of patients demonstrating 5-LO mRNA in colonic biopsies showed no significant change (p > 0,6; chi2 -test for trend).

CONCLUSIONS

This study demonstrates no significant relationship between endoscopically assessed disease activity and relative presence of mRNA for 5-LO in colonic biopsies. Thus, there is no evidence of increased expression of 5-LO mRNA in either quiescent or active stages of IBD.

Colonic expression and synthesis of interleukin 13 and interleukin 15 in inflammatory bowel disease

A dysregulated local immune reaction with unbalanced cytokine expression seems essential in inflammatory bowel disease (IBD), i.e. ulcerative colitis (UC) and Crohn's disease (CD). Since the roles of interleukin (IL-)13 and IL-15 remain unclear, this study aimed at studying intestinal expression of IL-13 and IL-15 in IBD.

METHODS

In colonic biopsies from 24 UC, 18 CD, and 12 controls IL-13 and IL-15 were measured using ELISA, and their gene expressions were assessed by RT-PCR. Leukocytes were visualised histochemically.

RESULTS

Concentrations of IL-13 were decreased in UC (median 56 pg/mg tissue; interquartile range 30-99 pg/mg) compared to CD (82 pg/mg tissue; 41-122;P=0.004) and controls (83 pg/mg tissue; 18-134;P>0.05), and lower in active UC (53 pg/mg tissue; 33-96) than in inactive UC (80 pg/mg tissue; 65-99;P=0.02). IL-15 concentrations were higher in CD patients (34 pg/mg tissue; 24-53) as compared to controls (20 pg/mg tissue; 15-21;P=0.001) whilst being 22 pg/mg tissue (15-32) in UC. IL-13 mRNA and IL-15 mRNA were detected in 20% and 15%, respectively. Infiltration of leukocytes correlated inversely with IL-13 levels (P=0.02).

CONCLUSION

Active UC is associated with decreased colonic IL-13 suggesting that IL-13 levels are diminished as a part of UC exacerbations, or that exacerbations follow active downregulation of IL-13.

Expression of cyclooxygenase-2 mRNA in active inflammatory bowel disease

OBJECTIVES

In inflammatory bowel disease (IBD), increased amounts of prostaglandins correlate to disease activity. Prostaglandins are produced via the cyclooxygenase (COX) pathway and exhibit both pro- and anti-inflammatory effects. Whereas COX-1 is a constitutive enzyme present at all times and is thought to produce the cytoprotective prostaglandins, COX-2 represents the inducible form of cyclooxygenase leading to production of proinflammatory prostaglandins. In inflammatory bowel disease it is yet unclear whether COX-2 plays a role in the inflammatory response. The purpose of this study was to evaluate the role of COX-2 in inflammatory bowel disease.

METHODS

Of the 44 individuals included in the study, 22 had ulcerative colitis, 11 had Crohn's disease, and 11 were healthy controls. Standard rigid rectoscopy was performed. The degree of inflammation was assessed using a semiquantitative scale. A biopsy was taken from the most affected area. mRNAs for COX-1 and COX-2 were detected using reverse transcription-polymerase chain reaction.

RESULTS

The fraction of patients demonstrating COX-2 mRNA significantly increased with increasing disease activity (p < 0.005), whereas the fraction of patients demonstrating COX-1 mRNA remained unchanged (p > 0.05).

CONCLUSIONS

This study demonstrates a clear relationship between endoscopic activity and relative presence of mRNA for COX-2. In contrast mRNA for COX-1 is detected equally often. This indicates that COX-2 is involved in the acute inflammatory response of chronic inflammatory bowel disease.

A simple filter-paper technique allows detection of mucosal cytokine levels in vivo in ulcerative colitis. Interleukin-1 and interleukin-1-receptor antagonist

A simple filter-paper method for in vivo assessment of cytokines in intestinal mucosa of patients with ulcerative colitis (UC) was developed and evaluated. Twenty-eight patients were included. Twenty-three patients had ulcerative colitis (UC) and five irritable bowel syndrome (IBS). Inflammation was assessed endoscopically. Through a rectoscope, filter paper was applied to the macroscopically most inflamed area of the rectal mucosa until soaked. The filter paper was transferred to a buffer solution, and IL-1 beta and IL-1ra were assessed using ELISA. Positive correlations between endoscopic grading and In(IL-1 beta) (P < 0.0001) and In(IL-1ra) (P < 0.001) and a negative correlation between endoscopic grading and In(IL-1ra /IL-1 beta) (P < 0.02) were found. In measurements during and after a flare-up no significant change in IL-1ra but a significant decrease in IL-1 beta was detected, which is in agreement with investigations on biopsies. In conclusion, the filter-paper technique is an easily applicable, low-risk method that provides a means of monitoring cytokines in vivo in UC.

Monitoring of omeprazole treatment in gastro-oesophageal reflux disease

OBJECTIVE

To test our standard dosing regimen in omeprazole treatment of gastro-oesophageal reflux disease (GORD) and to determine whether 'non-responders' could be pinpointed.

DESIGN

A reverse dose-response examination using increasing doses of omeprazole. The study was conducted as an open consecutive clinical study. Response was measured by 24-h pH-metry, symptoms, endoscopy and histopathology.

SETTING

All patients had been referred to one of the partaking departments for evaluation of oesophageal reflux symptoms.

PATIENTS

A total of 62 patients were included, 29 with systemic sclerosis and 33 consecutively included patients suffering from idiopathic oesophageal reflux.

RESULTS

Approximately one-third of the patients required doses higher than 40 mg of omeprazole/day (up to 140 mg/day) to abolish GOR. No cases of tachyphylaxia or bile-induced oesophagitis were seen in this study. In all patients subjected to dose titration we were able to achieve healing of oesophagitis assessed by symptom scoring, endoscopy and histopathology. No prediction of final dose of omeprazole could be made.

CONCLUSION

Four weeks after reaching a dose level of omeprazole that ensured the abolition of GOR, healing of oesophagitis according to endoscopic/histological evaluation was obtained in all patients. Persistent oesophagitis, i.e. bile induced, was not found.

Morning or evening dosage of omeprazole for gastro-oesophageal reflux disease?

BACKGROUND AND AIMS

When routinely checking patients receiving omeprazole treatment for gastro-oesophageal reflux, we have been finding patients with surprisingly low nocturnal gastric pH. The aim of this study was to evaluate the impact of timing of the 40 mg omeprazole once daily regimen.

METHODS

We evaluated the difference in effect of 40 mg omeprazole, given as a morning or evening dose, in 17 patients with gastro-oesophageal reflux disease. Gastric and oesophageal pH was recorded by portable 24-h two-channel pH-metry in a cross-over design of 14 days of morning and 14 days of evening administration.

RESULTS

In five patients pathological reflux was abolished by both regimens, four only during morning dosage, and three only during evening dosage. In the remaining five patients abolition of pathological reflux was not achieved. The therapeutic outcome and patient preference for morning or evening administration were closely related to the individual oesophageal pH curves. Patients with reflux induced by physical activity had a clear preference for morning dosage, patients with nocturnal reflux showed a clear preference for evening dosage. Gastric pH profiles showed a high inter-individual variation; paired statistics, however, revealed a significant impact of dosage timing on the gastric pH profile. After morning dosage the work-day part (the first 7 h) of the gastric pH profile is 0.72 +/- 0.91 (mean difference of pairs +/- s.d.) higher than after evening dosage (P < 0.01). After evening dosage the gastric pH during the supine period is 0.64 +/- 0.83 (mean difference of pairs +/- s.d.) higher than after morning dosage (P = 0.02).

CONCLUSION

The timing of a 40 mg omeprazole dosage regimen has a clinically significant impact on the 24-h pH profile, and that--by relating to the patient 24-hour oesophageal pH-metry in combination with the patient symptomatology--the timing of this dosage is highly important for therapeutic efficacy.

Circulating soluble intercellular adhesion molecule-1 (sICAM-1) in active inflammatory bowel disease

Intercellular adhesion molecule (ICAM)-1 promotes the initial interaction between macrophages and T cells during immune activation. We have measured serum levels of soluble ICAM-1 (sICAM-1) by ELISA in 27 patients with ulcerative colitis (UC), 31 with Crohn's disease (CD), and 29 healthy subjects. The median sICAM-1 serum concentration was significantly increased in inflammatory bowel disease (IBD) patients (355 ng/ml, range 195-855) compared to controls (245 ng/ml, 155-580) (P = 0.001). Variance analysis for trend showed that sICAM-1 levels were significantly higher in patients with active CD and UC, compared to those with inactive disease and controls (P = 0.00002). The concentration of sICAM-1 was higher in CD patients (365 ng/ml 230-470) compared to UC (300 ng/ml 195-855) (P = 0.01). Furthermore, weak but significant correlations were found between serum levels of sICAM-1 and: soluble IL-2 receptors, orosomucoid, and C-reactive protein. It is suggested that increased circulating sICAM-1 levels may reflect increased adhesiveness and signal transmission across cells, probably as a result of shedding of the parent molecule during local cellular immunoresponses in vivo.

Omeprazole in the long-term treatment of severe gastro-oesophageal reflux disease in patients with systemic sclerosis

Twenty-five patients with systemic sclerosis and severe gastro-oesophageal reflux disease were treated with 20-80 mg omeprazole daily for up to 5 years. Efficacy of treatment was assessed by symptom score, by endoscopic and histopathological surveillance of the oesophageal and gastric mucosa, and by laboratory screening including serum gastrin concentration. Statistically significant relief of symptoms and healing of oesophagitis confirmed the efficacy of this treatment. However, complete healing of oesophagitis was not achieved in half of the patients due to residual gastro-oesophageal acid reflux. Repeated adjustments of the maintenance dose of omeprazole may be needed for this group of patients. From the safety point-of-view, nothing was observed to discourage the long-term use of omeprazole in this group of patients.

Enterocyte function in progressive systemic sclerosis as estimated by the deconjugation of pteroyltriglutamate to folic acid

As a measure of enterocyte function, the deconjugation of pteroyl-L-glutamyl-gamma-L-glutamyl-gamma-L-glutamic acid to folic acid and subsequent active absorption was measured in 19 patients with progressive systemic sclerosis and compared with 14 controls. The absorption step of folic acid was identical in the two groups, while deconjugation of pteroyl-L-glutamyl-gamma-L-glutamyl-gamma-L-glutamic acid was significantly decreased in the patients with progressive systemic sclerosis. This observation suggests a primary epithelial defect of the small intestine in patients with progressive systemic sclerosis.

Changes in liver histology during methotrexate therapy of psoriasis correlated to the concentration of methotrexate and folate in erythrocytes

To investigate, whether an assessment of the folate and methotrexate concentrations in erythrocytes could be used to indicate incipient histological liver changes, these 2 parameters were related to liver histology in series of liver biopsies (means 4.3 biopsies) from 31 long-term methotrexate-treated psoriasis patients. Logistic regression analysis showed that the probability of changes in liver histology during methotrexate therapy increased significantly with increasing erythrocyte methotrexate concentrations and with decreasing erythrocyte folate concentration. The application of these variables as a decisive criterion when to institute liver biopsy surveillance needs further studies, but can probably help reduce the number of liver biopsies to be taken during long-term methotrexate therapy considerably.

The effects of carbamazepine and valproate on folate metabolism in man

The effect of carbamazepine and valproate treatment on folate metabolism was studied in 11 epileptic patients. The absorption of folic acid and of Pteroyl-gamma-L-glutamyl-gamma-L-glutamyl-L-glutamic acid, a synthetic substrate for intestinal folate deconjugase , was measured prior to and after 2 months of antiepileptic therapy with either carbamazepine (5 cases) or valproate (6 cases). After 2 months' treatment, the area under plasma concentration versus time curve was significantly decreased and t-max (time when maximal plasma concentration is obtained) was significantly prolonged. No inhibition of intestinal folate deconjugation was observed and the liver metabolism of folic acid was found to be unaffected by the treatment. These findings are interpreted as an inhibition of intestinal folic acid absorption caused by the antiepileptic therapy.

Entero-hepatic cycling of methotrexate estimated by use of the D-isomer as a reference marker

The absorption and elimination kinetics of 4-amino-N10-methylpteroyl-D-glutamic acid (D-MTX), the optical isomer of methotrexate (L-MTX), were examined. Test doses of 10 mg D-MTX were administered i.v. and orally to nine patients and its plasma concentration and urinary excretion were followed. The plasma curves after an i.v. bolus injection of D-MTX declined strictly biexponentially and reached zero after about 16 h. The elimination rate constants were estimated as the terminal first order rate constants. The absorption of orally administered D-MTX, estimated by its 24 h urinary recovery, in all cases was less than 3% of the dose administered. The insignificant intestinal absorption made it possible to estimate the renal and biliary secretion rates of D-MTX from the overall elimination rate constant and from the fraction of the dose excreted in urine. In three of the patients, elimination rate constants both for D-MTX and L-MTX were obtained. The renal elimination rates of the two compounds were found to be nearly identical. The median ratio of biliary/renal excretion of D-MTX was 0.94 (range 0.41-1.50), which indicates extensive entero-hepatic cycling and active absorption of L-MTX at the therapeutic dose levels used in psoriasis.

Nonlinear renal elimination kinetics of methotrexate due to saturation of renal tubular reabsorption

The plasma concentration and urinary excretion of methotrexate were followed in twelve psoriatic patients after intravenous and oral doses of methotrexate ranging from 7.5 to 30 mg. In six of the patients, a nonlinear relation was found between the fractional amount of methotrexate excreted in the urine and the corresponding area under the plasma concentration-time curve. The methotrexate clearance was found to be increased during the initial high plasma concentration, probably due to saturation of the tubular reabsorption of methotrexate. Considerable interindividual variation was found in the apparent saturation point of the active reabsorption, but up to 500-800 ng/ml first order kinetics still applied. At plasma concentrations below saturation, the renal clearance of methotrexate ranged from 52-102 ml/min (mean +/- SD, 83 +/- 19.4 ml/min).

Pharmacokinetics of methotrexate in erythrocytes in psoriasis

The intraerythrocytic levels of folate and methotrexate were measured in 25 patients on long-term methotrexate therapy for recalcitrant psoriasis. The mean steady state concentration of methotrexate in erythrocytes was 85 nmol/l and the mean erythrocyte folate concentration was 729 nmol/l. A linear correlation was not observed between these parameters, but the greatest methotrexate accumulation was found in cells at the lower end of the erythrocyte folate concentration range. In 5 patients started on methotrexate therapy the erythrocyte concentrations of methotrexate and folate were followed over 6 months. 3-4 days after the first dose, methotrexate had been accumulated against a concentration gradient in the erythrocytes. The methotrexate concentration increased steadily until the steady state level was reached after 4-6 weeks. The steady state level was maintained during the 6 month observation period. The erythrocyte folate concentration did not change during this period. The data suggest that methotrexate polyglutamate synthesis within the circulating erythrocyte is a major cause of methotrexate accumulation in these cells.

Methotrexate in the plasma and cerebrospinal fluid of children treated with intermediate dose methotrexate

Serious complications can follow treatment with intermediate dose methotrexate of acute lymphoblastic leukemia in childhood. Toxicity has been shown to be correlated to plasma methotrexate concentrations. During intravenous infusions of methotrexate (500 mg/m2) the mean concentrations achieved 1 to 41/2 hours after the start of infusion were 1.3 X 10(-7) mol/l in cerebrospinal fluid and 1.7 X 10(-5) mol/l in plasma. At 72 hours after start of methotrexate infusion, plasma methotrexate concentrations were significantly higher in cases with symptoms of toxicity. In all the children who developed toxic symptoms 72-hour plasma methotrexate concentration was above 1 X 10(-7) mol/l. Assuming that leucovorin is given 48 hours after the start of methotrexate infusion, 72-hour plasma methotrexate is suitable for detection of patients at risk for toxicity. In children treated with intermediate dose methotrexate we therefore recommend estimating plasma methotrexate concentration 72 hours after the start of infusion, and instituting supplementary leucovorin when plasma methotrexate concentration exceeds 1 X 10(-7) mol/l.

Radioimmunoassay for pteroylglutamic acid

I describe a radioimmunoassay for specific determination of pteroylglutamate in plasma, erythrocytes, and urine. Antiserum was raised in rabbits immunized with a conjugate of pteroylglutamic acid and methylated bovine serum albumin. The lowest detection limit of the assay was 0.1 microgram/L; the coefficient of variation ranged from 4.01 to 14.63%. No significant interference was demonstrated from tetrahydrofolic acid, 5-methyl-tetrahydrofolic acid, or methotrexate. Under normal sampling and storing conditions dihydrofolic acid was oxidized to pteroylglutamic acid and estimated as such in the assay. The clinical applicability of the assay is demonstrated by measurements of pteroylglutamate absorption rates after oral doses of pteroylglutamic acid or pteroyltriglutamic acid and by the estimation of the accumulation of pteroylglutamate and dihydrofolate in plasma during therapy with methotrexate.

Radioimmunoassay for pteroylglutamic acid

I describe a radioimmunoassay for specific determination of pteroylglutamate in plasma, erythrocytes, and urine. Antiserum was raised in rabbits immunized with a conjugate of pteroylglutamic acid and methylated bovine serum albumin. The lowest detection limit of the assay was 0.1 microgram/L; the coefficient of variation ranged from 4.01 to 14.63%. No significant interference was demonstrated from tetrahydrofolic acid, 5-methyl-tetrahydrofolic acid, or methotrexate. Under normal sampling and storing conditions dihydrofolic acid was oxidized to pteroylglutamic acid and estimated as such in the assay. The clinical applicability of the assay is demonstrated by measurements of pteroylglutamate absorption rates after oral doses of pteroylglutamic acid or pteroyltriglutamic acid and by the estimation of the accumulation of pteroylglutamate and dihydrofolate in plasma during therapy with methotrexate.

Anxiety and sedation during a stressful situation after single dose of diazepam versus N-desmethyldiazepam--a controlled trial

Twenty milligram diazepam (DZ) was compared with 20 mg of its main metabolite N-desmethyldiazepam (NDDZ) as single dose, oral premedication in a genuine stressful situation. Fifty patients participated in the randomized, double-blind controlled study. Anxiety and sedation were measured the day before an operation and one hour after premedication, just before the operation. NDDZ was significantly less sedative while the degree of anxiety was rated equal in the two groups. The results may support the hypothesis that a competition between DZ and NDDZ can explain the shift in the effect profile of DZ during long term treatment.

Kinetics and neuropsychologic effects of IV diazepam in the presence and absence of its active N-desmethyl metabolite in humans

In 12 healthy volunteers the kinetics and neuropsychological actions of IV diazepam (DZ) (single dose) were studied with and without the presence of its main metabolite N-desmethyldiazepam (NDDZ). Both the maximal plasma concentration and the steepness of the alpha-slope were correlated with variations in the corresponding continuous reaction time (CRT). EEG profiles, CRT and clinical ratings for anxiety and sedation all showed significant changes between the situations with the metabolite present or absent, but no significant correlation could be found with the kinetic pattern of DZ in the two situations. Tolerance to NDDZ did not develop. The results indicate that the presence of the active metabolite changes the pharmacodynamic profile of the parent compound probably by an interaction at the receptor site between DZ and NDDZ. Changes in the spectrum of effects during long-term therapy with DZ may, therefore, partly be explained in this way.

Noninvasive assessment of cardiac motion: comparison of the apexcardiogram and cardiokymorgram

The apexcardiogram (ACG) and cardiokymogram (CKG) (displacement cardiogram) tracings were compared in 45 patients with a variety of cardiac diseases and in 16 normal subjects. The ACG and CKG were generally comparable in waveform and timing of standard tracing intervals; however, on a case by case comparison frequent discrepancies between the ACG and CKG were observed. In 13 patients where no ACG could be recorded, an interpretable CKG tracing was obtained. However, the CKG produced frequent artifacts, mirror images, was very sensitive to probe position, and was judged to be of limited advantage over the ACG.

Production of Methotrexate antiserum in rabbits: the significance of immunogen solubility, hapten content, and mode of administration of the antibody response

A method for raising specific antibodies of high avidity against Methotrexate in rabbits is described. The antibody response was tested after intramuscular and after multi-site intradermal adminstration of three different immunogens. Antisera of high specificity and avidity were obtained by multi-site intradermal administration of a water-soluble immunogen with high hapten content (40 mol hapten/mol protein). A water-soluble immunogen with low hapten content (15-18 mol hapten/mol protein) resulted in antisera of high specificity but low avidity. No antibody response was obtained with a water-insoluble immunogen with high hapten content (40 mol hapten/mol protein).

Clinical and psychological effects of intravenous diazepam related to plasma levels. A controlled, double-blind, cross-over study in oral surgery involving local analgesia

In a controlled, double-blind, cross-over study with diazepam (DZ) and placebo (PL) various clinical, psychological, and pharmacological parameters were studied in 33 patients having identical impacted third molars removed. The patients were admitted to the study consecutively and nonparametric statistics were used throughout the study for the evaluation (Wilcoxon's matched-pairs signed test). The following aspects were examined: Continous reaction times (CRT), rating scales (a.m. Beecher), blood pressure, pulse, plasma concentration of DZ and of N-desmethyldiazepam, visual changes, amnesia, adverse reactions, recalling of duration of surgery, orientation in time, phlebitis, and final evaluation performed by the patient. The operative conditions were found to be excellent, and only a few adverse effects were noticed. The patients expressed an overall enthusiasm about the sedation. In the rating scales only the predominantly sedative items were affected and not the anxiolytic ones. Neither the heart rate nor the systolic blood pressure were significantly changed; on the contrary, the DZ-group was less affected than the PL-group when maximum increases in the systolic blood pressure were compared in the two groups. The continuous reaction times were significantly correlated to the plasma concentrations of diazepam, especially 1 hour after sedation. The reported recurrence of initial clinical symptoms 6 hours after sedation due to the N-desmethyldiazepam could not be demonstrated in this study. The CRT has proved itself to be of great value in discriminating between different kinds of cerebral affections; the patients with DZ-intoxication showed significantly faster CRT 1 hour after injection than did patients suffering from well-documented cerebral disorders such as organic brain damage or hepatic encephalopathia.

Neuropsychologic effects of diazepam related to single dose kinetics and liver function

The neurophysiologic and neuropsychologic effects and their relation to the kinetics of diazepam (DZ) were studied in 10 patients with impaired liver function of various degrees and in three normal subjects after 10 mg DZ i.v. The plasma concentration data were treated according to a two-compartment open model. Neurophysiologic effect measurements were obtained from galvanic skin response, continuous reaction times (CRT), heart rate, and averaged evoked potentials; neuropsychologic measurements were obtained from trail making A + B, hidden pattern, word fluency, and subtraction tests; in addition, clinical effects were rated by Beechers Mood Scale and Spielbergers Anxiety Scale. Except for trail making A and word fluency all tests discriminated well between the experimental conditions with or without diazepam. No difference from normal in the response to acute diazepam administration could be detected in patients with reduced liver function. A linear correlation between prolongation in CRT and DZ log plasma concentration was demonstrated in the entire, heterogenous patient material. In the clinical ratings only items of a predominantly sedative and autonomic significance responded to the diazepam injection, while predominantly anxiolytic items did not.

Kinetics and dose calculations of amikacin in the newborn

The pharmacokinetics of a new aminoglycoside, amikacin, was evaluated in 37 infants between 1 and 34 days old. Fifteen were below 2,500 gm in weight. Initial studies, including intravenous infusion in some of the infants, indicated that the disposition of amikacin was best described by a 2 compartment model. The absorption was evaluated in 8 of the infants after intramuscular injection of 7.5 mg amikacin per kilogram of body weight. The absorption rate, estimated by the tmax, was significantly faster than reported in adults. The total body clearance and apparent volume of distribution were studied in 22 infants after the same dose of amikacin intramuscularly. The body clearance expressed in relation to body surface or body weight was significantly less than in adults and correlated with the postnatal age. No correlation could be demonstrated between clearance and gestational age or birth weight. The volume of distribution per kilogram was significantly greater than in adults. On the basis of the derived kinetic parameters, a dose schedule is presented. In 5 children there was a reasonable agreement between the measured and predicted serum levels.