Subjective expectations regarding longevity and future health: a cross-sectional survey among patients with Crohn's disease

AIM

The aim was to explore the subjective health expectations (sHE) of patients with Crohn's disease (CD) for both the near future and the elderly.

METHOD

A cross-sectional survey was performed in four gastroenterology centres in Hungary. Consecutive outpatients with CD with age ≥ 18 were recruited. Socio-demographic and disease characteristics were recorded and the Crohn's Disease Activity Index (CDAI), Perianal Disease Activity Index, Patients' Global Assessment (PGA) and current pain visual analogue scale (VAS) were assessed. Subjective life expectancy (sLE) was explored and compared to statistical life expectancy. Current health and sHE for 1 year ahead and for ages 60/70/80/90 were assessed using the descriptive system of the EQ-5D-3L.

RESULTS

In all, 206 patients (54.9% men) with a mean age of 34.7 (SD 10.5 years) and disease duration of 10.5 (SD 6.3) years were studied. The CDAI score was 110.5 (SD 77.0) and 66% were treated by biologic drugs. Mean current EQ-5D-3L score was 0.80 (SD 0.17) and patients expected a 0.05 (SD 0.15) improvement within a year (P < 0.05). For ages 60/70/80/90, a mean EQ-5D-3L score of 0.59, 0.38, 0.10 and -0.12 respectively was provisioned. Age, current health status, sLE, PGA and pain VAS showed significant correlation with both 1-year and older age sHE (P < 0.05). Long-term sHE and sLE were negatively affected by the presence of extraintestinal manifestations but not by previous CD-related surgery.

CONCLUSION

Patients with CD expect severe deterioration in health in later life. Given that unrealistic sHE may affect patients' current quality of life and health behaviour, we encourage physicians to explore and consider CD patients' sHE in clinical care.

Predictors of relapse in patients with Crohn's disease in remission after 1 year of biological therapy

BACKGROUND

Some of the most important questions relating to the use of biological therapy in inflammatory bowel diseases concern the duration of maintenance therapy.

AIM

To assess the disease course and frequency of relapse of Crohn's disease (CD) following discontinuation of biological therapy, and to determine predictive factors for relapse.

METHODS

One hundred twenty-one CD patients who had achieved clinical remission following 1 year of biological therapy and for whom biological therapy was then discontinued participated in this prospective observational study. Eighty-seven CD patients had received infliximab and 34 adalimumab. The definition of relapse was an increase of >100 points in CDAI to at least a CDAI of 150 points.

RESULTS

Biological therapy was restarted within 1 year of treatment cessation in 45% of patients. Logistic regression analysis revealed that previous biological therapy (P = 0.011) and dose intensification during the 1-year course of biological therapy (P = 0.024) were associated with the need for and the time to the restarting of biological therapy. Smoking was observed to have an effect that was not statistically significant (P = 0.053).

CONCLUSIONS

Biological therapy was restarted a median of 6 months after discontinuation in almost half of Crohn's disease patients in who had been in clinical remission following 1 year of biological therapy. These results suggest that, in the event of the presence of certain predictive factors, biological therapy should probably be continued for more than 1 year by most patients.

Early clinical remission and normalisation of CRP are the strongest predictors of efficacy, mucosal healing and dose escalation during the first year of adalimumab therapy in Crohn's disease

BACKGROUND

Adalimumab is a fully human monoclonal antibody targeting tumour necrosis factor with proven efficacy in the treatment of Crohn's disease (CD).

AIM

To investigate the predictors of medium-term clinical efficacy and mucosal healing during adalimumab therapy, in patients with CD, in specialised centres approved for biological therapy in Hungary.

METHODS

Data capture of the 201 CD patients was standardised and prospective (male/female: 112/89, median age: 33.0 years, duration: 8 years). Previous infliximab therapy had been administered in 48% of patients, concomitant steroids in 41%, azathioprine in 69% and combined therapy in 27% of patients.

RESULTS

Overall clinical response and remission rates at 24 weeks were 78% and 52%, respectively; at 52 weeks were 69% and 44%, respectively. Endoscopic improvement and healing were achieved in 43% and 24% of patients. In a logistic regression model, clinical efficacy and CRP at week 12, need for combined immunosuppression at induction, shorter disease duration and smoking were identified as independent predictors for 12-month clinical outcome, whereas CRP at week 12, clinical remission at week 24, inflammatory parameters and nonsmoking were associated to endoscopic improvement/healing. Intensification to weekly dosing was needed in 16% of patients. Parallel azathioprine therapy and clinical remission at week 12 were inversely associated with dose escalation.

CONCLUSIONS

Clinical efficacy and normalised CRP at week 12 (early deep clinical remission) are associated with medium-term clinical efficacy and mucosal healing during adalimumab therapy, whereas need for combined immunosuppression at induction and smoking status are predictors for non-response. Parallel azathioprine therapy may decrease the probability for dose escalation.

Anti-TNF-alpha antibody (infliximab) therapy supports the recovery of eNOS and VEGFR2 protein expression in endothelial cells

The aim of this study is to investigate the effect of sera obtained from patients of Crohn's disease treated by anti-TNF-alpha antibody (Infliximab) on the expression of endothelial nitric oxide synthase (eNOS) and vascular endothelial growth factor receptor-2 (VEGFR2) protein in human umbilical vein endothelial cells (HUVEC) cultured in vitro. HUVEC was cultured in the presence of sera derived from patients before and after treatment, or from healthy individuals. Effects of sera on the expression of eNOS and VEGFR2 were monitored by determination of mRNA and protein levels using real time quantitative PCR and Western blot analysis, respectively. The serum of Crohn's patients contained elevated levels of TNF-alpha (34±1.80 pg/mL), which resulted in a decrease in the protein level of eNOS in HUVEC with a simultaneous induction of VEGFR2. Infliximab treatment normalized the expression level of these proteins by decreasing TNF-alpha level, particularly in those cases when clinical healing was also recorded, and it also conferred restitution of the level of angiogenic cytokines. Results suggest that altered angiogenesis possibly contributes to the initiation and perpetuation of inflammatory processes in inflammatory bowel disease (IBD). Endothelial dysfunction, a selective feature of Crohn's disease is beneficially affected by intravascular TNF-alpha neutralization.

[Laboratory diagnostics of pleural effusion]

Pleural effusion is a frequent reason for a pulmonologist's investigation. Many pulmonary and extrapulmonary causes of pleural effusion exist. Heart failure, pneumonia and malignancies are the most frequent among them. Laboratory examination of pleural liquid is a corner stone of diagnostics. We use various biochemical, microbiological, cytologic and other methods. The first step is a differentiation between transudate and exudate. If the laboratory examinations are unsuccessful, we can use invasive procedures - pleural biopsy and thoracoscopy. Despite all modern diagnostic methods the causes of about 15% pleural effusions remain unclear.

NOD1 gene E266K polymorphism is associated with disease susceptibility but not with disease phenotype or NOD2/CARD15 in Hungarian patients with Crohn's disease

BACKGROUND

NOD1/CARD4, a member of the pattern-recognition receptor family, is a perfect candidate as a susceptibility gene for Crohn's disease. Since only limited and conflicting data are available on G796A polymorphisms in inflammatory bowel disease patients, we set out to study the effect of this polymorphism on the susceptibility and course of Crohn's disease in the Hungarian population.

METHODS

Four hundred thirty-four unrelated Crohn's disease patients (age at presentation: 28.6+/-9.6 years, female/male: 210/224, duration of Crohn's disease: 8.2+/-6.9 years) and 200 healthy subjects (blood donors) and 136 non-inflammatory bowel disease gastrointestinal controls with chronic gastritis were investigated. NOD1 G796A was detected by using polymerase chain reaction/restriction fragment length polymorphism. Detailed clinical phenotypes were determined by reviewing the medical charts.

RESULTS

The frequencies of the variant alleles of NOD1 G796A differed significantly between the Crohn's disease patients and both healthy (GG 49.5% vs. 67%; AG 41.5% vs. 28%; and AA 9.0% vs. 5.2%; p<0.0001) and non-inflammatory bowel disease controls with chronic gastritis. Carriage of the single nucleotide polymorphism of NOD1 G796A proved to be a highly significant risk factor for Crohn's disease compared to both healthy (p<0.0001, OR: 2.1, 95% CI: 1.5-2.9) and non-inflammatory bowel disease controls with chronic gastritis (p=0.008). Significant associations were not found between the different genotypes and the demographic data on the patients or the clinical characteristics of Crohn's disease. The different polymorphisms of pattern-recognition receptors (e.g. NOD2/CARD15 SNP8, SNP12 and SNP13 mutations, the TLR4 D299G polymorphism and NOD1 G796A) did not reveal a mutual basis.

CONCLUSIONS

Our results suggest that carriage of the NOD1 G796A mutation increases susceptibility for Crohn's disease in the Hungarian population.

Increased in vivo platelet activation and reduced intravascular endothelium-derived relaxing factor and nitrate/nitrite production in patients with insulin-dependent diabetes mellitus

Limited information seems to be available about the role of reduced endothelial production of endotheliumderived relaxing factor (EDRF)-nitrate/nitrite (NO) in the pathogenesis of diabetic angiopathy in insulindependent diabetes. A report of urinary and serum nitrate/nitrite, glucometabolic parameters, endothelial and in vivo platelet activation markers of 22 insulin dependent diabetics (IDDM) patients are given. Urinary and serum nitrate/nitrite concentrations were reduced in IDDM. This was independent of disease duration, presence of angiopathy and the glucometabolic parameters. A significant and inverse correlation of nitrate/nitrite excretion with endothelial markers (von Willebrand factor, soluble thrombomodulin) was documented. Moreover, reduced nitrate/nitrite excretion was strongly associated with elevated plasmatic beta -thromboglobulin levels. EDRF-NO production is reduced in IDDM and this reduction correlates with endothelial damage. Decreased nitrate/nitrite excretion may also influence in vivo platelet function, which results in increased in vivo platelet activation and suggests that the reduced intravascular production of EDRF-NO might play a role in the pathogenesis of angiopathy in IDDM.

[Hematologic aspects of inflammatory bowel diseases]

Anaemia, thrombocytosis are common secondary changes in inflammatory bowel disease (IBD), reflecting the clinical severity of the IBD cases, too. On the other hand, increased platelet function, fibrinolytic abnormalities, hypercoagulation of IBD patients predispose to thromboembolic events, and they may as well contribute to the local microcirculatory alterations leading to IBD itself. Reduced FXIII levels have been observed in IBD, which seems to be correlated with mucosal repair and might have therapeutic importance, too. Genetic thrombophilia received much attention recently, however, much less is known how frequent they are in IBD, what their clinical significance is, do they modify the clinical course itself. A short, concise review about links between haematology and IBD is given.

[Diagnostic possibilities in gastric leiomyoma in relation to two of our cases]

Two cases of rare, benignant gastric tumors are reported. The suggest that while in the diagnosis of tumors with a mucous membrane involvement endoscopy has doubtless a leading role, tumors not infiltrating the mucous membrane are usually better recognizable by radiological (ultrasonography, computer tomography and double contrast x-ray) methods. An appropriate diagnosis followed by surgical removal of the tumor might result in a complete healing of the patient.

[Detection of Helicobacter pylori in tissue samples of stomach cancer]

The role of Helicobacter pylori in the carcinogenesis of the stomach has been recognised both in intestinal and diffuse forms. The occurrence of the bacterium was studied in this report, with various methods in biopsy samples from the cancerous stomach, as well as the presence of associated gastritis and metaplasia related to the histological type. Retrospective histological examination were performed on endoscopic biopsy samples from 124 patients with distal stomach cancer using haematoxillin-eosin and Giemsa staining and immunohistochemical tests. Out of the 124 samples 69 (55.64%) was positive: 48 with Giemsa staining and further 21 samples showed immunohistochemical positivity on atrophic gastritis samples despite negative Giemsa staining. In view of the presence of gastritis and metaplasia significant difference (p < 0.001) was found between the positive and negative cases. The ratio of the Helicobacter pylori positive samples was high both for intestinal and diffuse type carcinomas. Our results suggest that the presence of Helicobacter pylori infection is important in the development of both types of carcinoma, nevertheless, the hystological type of the tumor is also decisively influenced by the onset of action of other more direct local eliciting factors.

[Current status of the management of upper gastrointestinal hemorrhage at a specialized hospital unit]

The prevalence of bleeding of the gastrointestinal tract is around 100/100,000 adults/year. These events need special diagnostic and therapeutic approach, which previously was located mostly to surgical departments. At the beginning of 1996 a specialized ward ("gastrointestinal bleeding unit, GBU") was created at the 2nd Dept. Medicine of the University Medical School of Debrecen. The authors give an account about their experiences with the first 250 cases, try to establish the optimal and necessary conditions and analyse the consequences of their newly developed "risk-score" system. The overall mortality was 9% during this period and surgical intervention proved to be necessary in only 10 cases. On the basis of the collected experiences, they are convinced that the described and elaborated model can well be used for the proper, up-to-date management of gasrointestinal bleeding disorders. As next they suggest an overall, regional organisation of such units, together with the correct determination and provision of the financial background.

Effect of L-arginine on in vitro plasmin-generation and fibrinogenolysis

L-arginine ahs received much attention in numerous aspects of the regulation of vascular tone and haemostasis. L-arginine seems to be capable to bind to plasminogen, too. The aim of the present paper is to investigate the action of L-arginine on in vitro plasmin generation and fibrino(geno)lysis by chromogenic, kinetic plasmin generation assay and electrophoretic analysis. The acceleration of tPA-induced plasmin generation in the presence of low concentration of L-arginine, along with augmentation of in vitro fibrinogenolysis have been documented. L-arginine may have a role in the modification of fibrinogenolysis, and this role should be considered if arginine is used as an element of some novel antithrombotic agents.

[Nitrogen monoxide (NO) in the function of the gastrointestinal tract and the liver]

This review is concerning with the endothel derived relaxing factor (EDRF) discovered in 1980 and identified as NO in 1987 in the function and activities of the gastrointestinal tract and the liver. It is of importance, that NO seems to basic mediator of the so called nonadrenerg-noncholinerg inhibitory innervation of the bowel, and also takes part in the regulation of mucosal blood supply and secretory function. In portal hypertension elevated cGMP is found in the urine, as evidence of increased nitrogen oxide synthase (NOS) activity. NO may act both as hepatoprotective and cytotoxic factor in the free radical reactions of several liver disease.

The association of reduced endothelium derived relaxing factor-NO production with endothelial damage and increased in vivo platelet activation in patients with diabetes mellitus

The role of reduced endothelial production of EDRF-NO in the pathogenesis of diabetic angiopathy has received much attention, however, most of the rather conflicting data were gained from animal experiments. Limited human experience seems to be available in insulin dependent diabetes, calling attention to decreased EDRF-NO production. Hereby the clinical, as well as laboratory investigation (urinary and serum nitrate/nitrite, lipid peroxidation, glucometabolic parameters, endothelial and in vivo platelet activation markers, etc.) of 35 non-insulin dependent (NIDDM) and 15 insulin dependent diabetics (IDDM) patients are given. Urinary and serum nitrate/nitrite concentrations were proven to be reduced in both patients groups. This change was independent of diabetes duration, presence of macroangiopathy, coronary heart disease and the glucometabolic parameters, however, correlation was registered with lipid peroxidation (total antioxidant status). An inverse correlation of nitrate/nitrite excretion with endothelial markers (von Willebrand factor, soluble thrombomodulin) was documented in NIDDM, this correlation was much stronger in IDDM. Moreover, in IDDM patients reduced nitrate/nitrite excretion was strongly associated with elevated plasmatic beta-thromboglobulin levels. The data presented here support to the hypothesis, that EDRF-NO production is reduced in diabetes and this reduction seems to correlate with endothelial damage. In IDDM the decreased nitrate/nitrite excretion may also lead to increased in vivo platelet activation, which suggests that the reduced amount of EDRF-NO might play a role in the pathogenesis of angiopathy in IDDM.

Attempted suicide with pilocarpine eyedrops

PURPOSE

To alert ophthalmologists about the hazards of poisoning with ophthalmic solutions.

METHODS

We treated an 18-year-old man who attempted suicide by drinking and self-injecting pilocarpine eyedrops. He had severe signs of parasympathomimetic poisoning.

RESULTS

Because of heavy and repeated vomiting and the early administration of intravenous atropine, he fully recovered.

CONCLUSION

Because they are usually stored in household refrigerators and are readily accessible, the potential hazard of poisoning with ophthalmic solutions is worth emphasizing.