1
|
Dignass A, Stremmel W, Horyński M, Poyda O, Armerding P, Fellermann K, Langhorst J, Kuehbacher T, Uebel P, Stein J, Novacek G, Avalueva E, Oliinyk O, Hasselblatt P, Dorofeyev A, Heinemann H, Mueller R, Greinwald R, Reinisch W. Modified-Release Phosphatidylcholine (LT-02) for Ulcerative Colitis: Two Double-Blind, Randomized, Placebo-Controlled Trials. Clin Gastroenterol Hepatol 2024; 22:810-820.e7. [PMID: 37806372 DOI: 10.1016/j.cgh.2023.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 09/06/2023] [Accepted: 09/26/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND & AIMS The aim of this study was to evaluate the efficacy of LT-02, a novel modified-release phosphatidylcholine (PC) formulation, for induction and maintenance of remission in patients with mild to moderate ulcerative colitis (UC) and inadequate response to mesalamine. METHODS LT-02 was evaluated in a multicenter double-blind, randomized, placebo-controlled study comprising a 12-week induction trial (PCG-2), followed by a 48-week maintenance trial (PCG-4). In PCG-2, patients were randomized 1:1:1 to treatment with 0.8 g LT-02 4 times daily (QID), 1.6 g LT-02 twice daily (BID), or placebo, respectively. All patients continued to take a standard dose of oral mesalamine (≥2.4 g/day). The primary end point in PCG-2 was deep remission. Patients achieving remission at week 12 were randomly assigned 2:1:1 to 1.6 g LT-02 BID, placebo, or 500 mg mesalamine (3 times daily), respectively, in PCG-4; the primary end point was remission at 48 weeks. RESULTS PCG-2 was terminated early for futility after a prespecified interim analysis; 466 patients (of 762 planned) were randomized. There was no statistically significant difference in deep remission at week 12 (placebo, 13.5%; LT-02 BID, 14.2%; LT-02 QID, 9.7%). In PCG-4, 150 patients (of approximately 400 planned) were randomized. There was no statistically significant difference in remission rates at week 48 (LT-02 BID, 49.3%; mesalamine, 50.0%; placebo, 43.2%). LT-02 was safe. CONCLUSIONS Despite prior evidence of beneficial effects of PC in phase 2 trials, our induction study with LT-02 in patients with mild to moderate UC was terminated prematurely for futility. Signals of efficacy in maintenance therapy require confirmation in an adequately powered maintenance trial. LT-02 was safe and well-tolerated. CLINICALTRIALS gov: NCT02280629, NCT02142725.
Collapse
Affiliation(s)
- Axel Dignass
- Department of Medicine I, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany.
| | - Wolfgang Stremmel
- Department of Gastroenterology, University Hospital of Heidelberg, Heidelberg, Germany
| | | | - Oleksandr Poyda
- Department of Proctology, O.O. Bogomolets National Medical University, Kyiv, Ukraine
| | | | - Klaus Fellermann
- Division of Gastroenterology, Medical Department I, Campus Lübeck, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Jost Langhorst
- Department of Internal and Integrative Medicine, Kliniken Essen-Mitte, Essen, Germany
| | - Tanja Kuehbacher
- Internal Medicine/Gastroenterology, Asklepios Westklinikum Hamburg, Hamburg, Germany
| | - Peter Uebel
- Study Center for Internal Medicine, Haus der Gesundheit, Ludwigshafen, Germany
| | - Juergen Stein
- Interdisciplinary Crohn Colitis Centre Rhein-Main, Frankfurt am Main, Germany
| | - Gottfried Novacek
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Elena Avalueva
- North-Western State Medical University named after I. I. Mechnikov of the Ministry of Health of the Russian Federation, St Petersburg, Russia
| | | | - Peter Hasselblatt
- Department of Medicine II and Medical Faculty, Medical Center University of Freiburg, Freiburg, Germany
| | - Andrey Dorofeyev
- Ukrainian-German Anti-ulcer Gastroenterology Centre, Kyiv, Ukraine
| | - Heidrun Heinemann
- Department of Clinical Research, Dr. Falk Pharma GmbH, Freiburg, Germany
| | - Ralph Mueller
- Department of Clinical Research, Dr. Falk Pharma GmbH, Freiburg, Germany
| | - Roland Greinwald
- Department of Clinical Research, Dr. Falk Pharma GmbH, Freiburg, Germany
| | - Walter Reinisch
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
2
|
Fellermann K, Schiefke I, Rácz I, Derova J, Jonaitis L, Wehrum S, Nacak T, Greinwald R. Efficacy and safety of prolonged release budesonide granules in mesalazine-refractory ulcerative colitis: A multi-centre Phase IIa study (TOPICAL-1). United European Gastroenterol J 2020; 8:1186-1195. [PMID: 33028169 DOI: 10.1177/2050640620962632] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND In patients with mesalazine-refractory ulcerative colitis, systemic corticosteroids are the treatment of choice. OBJECTIVE To evaluate the efficacy and safety of prolonged release budesonide granules for the induction of remission in patients with mesalazine-refractory ulcerative colitis. METHODS Patients with mesalazine-refractory ulcerative colitis discontinued mesalazine at baseline and received 9 mg prolonged release budesonide granules daily for 8 weeks in this open-label, phase IIa study, followed by a 2-week follow-up phase wherein patients continued treatment on alternate days (EudraCT number 2014-005635-14; ClinicalTrials.gov identifier NCT02550418). The primary endpoint was clinical remission (Clinical Activity Index ≤4; stool frequency <18 per week; absence of rectal bleeding) at Week 8. Secondary endpoints included clinical, endoscopic and histological measures of disease at Week 8. A post hoc analysis assessed histo-endoscopic mucosal healing. Treatment-emergent adverse events and morning cortisol levels were assessed throughout the treatment and follow-up phases. RESULTS A total of 61 patients were included in the intention-to-treat population; 50 were included in the follow-up analysis set. Clinical remission was achieved in 29 patients (47.5%; 95% confidence interval: 34.6-60.7%) by Week 8. Mean stool and bloody stool frequency decreased significantly from 32.5 to 22.9 per week (p<0.0001) and from 17.6 to 8.1 per week (p<0.0001), respectively. Rates of mucosal healing, endoscopic remission and histological remission were 58.0%, 54.0% and 36.0%, respectively. Histo-endoscopic mucosal healing was achieved by 34.0% of patients. Twenty-four patients (39.3%) experienced treatment-emergent adverse events, of which gastrointestinal disorders (16.4%) were the most common. Mean morning cortisol levels were not significantly suppressed by Week 8. CONCLUSIONS Treatment with prolonged release budesonide granules for 8 weeks was associated with clinical, endoscopic and histological remission and demonstrated a favourable safety profile in patients with mesalazine-refractory ulcerative colitis. These results warrant further investigation into the potential of prolonged release budesonide granules as an alternative treatment for this patient population.
Collapse
Affiliation(s)
- Klaus Fellermann
- Department of Internal Medicine I, University Hospital Schleswig Holstein, Lübeck, Germany
| | - Ingolf Schiefke
- Department of Gastroenterology, Hepatology, Diabetology and Endocrinology, Klinikum St Georg gGmbH and Internal Medicine, EUGASTRO GmbH, Leipzig, Germany
| | - István Rácz
- Department of Internal Medicine, Petz Aladár County Hospital, Győr, Hungary
| | - Jelena Derova
- Department of Gastroenterology, Latvian Maritime Medical Centre, Riga, Latvia
| | - Laimas Jonaitis
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Sarah Wehrum
- Clinical Research and Development Department, Dr Falk Pharma GmbH, Freiburg, Germany
| | - Tanju Nacak
- Clinical Research and Development Department, Dr Falk Pharma GmbH, Freiburg, Germany
| | - Roland Greinwald
- Clinical Research and Development Department, Dr Falk Pharma GmbH, Freiburg, Germany
| |
Collapse
|
3
|
Grupp A, Kimmel M, Fritz P, Voggenreiter B, Stöltzing H, Kuhlmann U, Stange EF, Mettang T, Fellermann K, Alscher DM. The Expression Patterns of Peritoneal Defensins. Perit Dial Int 2020. [DOI: 10.1177/089686080702700611] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Local defense mechanisms are important for the integrity of the peritoneum, but few details are known about the expression patterns of antimicrobial proteins such as human defensin in normal and damaged peritoneum. Methods Part A: The expression of different defensins in normal ( n = 12), inflamed ( n = 5), and metastatic peritoneum ( n = 4) and in cultured human peritoneal mesothelial cells was analyzed using mRNA and immunohistochemistry. Part B: Using immunohistochemistry the expression of different defensins was analyzed in different subgroups: healthy controls ( n = 25), patients with chronic appendicitis ( n = 25) or acute appendicitis ( n = 10), and end-stage renal disease patients ( n = 25, with 15 on peritoneal dialysis). Results Part A: Human neutrophil peptides (HNP) 1 and 3 and human β-defensins (HBD) 1 to 3 mRNA were detected in peritoneal specimens. In addition, HNP1,3, HBD1, HBD2, and HBD3 proteins were detected using immunohistochemistry. Part B: HBD1 showed a constitutive expression in mesothelium, while HBD2 and HNP1,3 were associated with inflammation. Decreased expressions of HNP1,3 were observed in end-stage renal disease patients and in patients on peritoneal dialysis. Conclusions For the first time, the expression patterns of defensins in normal and damaged peritoneum have been described. The reduced expression of some defensins in end-stage renal disease is of potential clinical interest against the background of the frequent infective complications seen in peritoneal dialysis.
Collapse
Affiliation(s)
- Alexander Grupp
- Division of General Internal Medicine and Nephrology, Germany
- Division of Gastroenterology, Hepatology and Endocrinology, Department of Internal Medicine, Wiesbaden, Germany
| | - Martin Kimmel
- Division of General Internal Medicine and Nephrology, Germany
| | - Peter Fritz
- Division of Pathology, Department of Diagnostic Medicine, Wiesbaden, Germany
| | - Bernd Voggenreiter
- Division of General Surgery, Department of Surgery, Robert-Bosch Krankenhaus, Stuttgart
| | - Hartmut Stöltzing
- Division of General Surgery, Department of Surgery, Robert-Bosch Krankenhaus, Stuttgart
| | - Ulrich Kuhlmann
- Division of General Internal Medicine and Nephrology, Germany
| | - Eduard F. Stange
- Division of Gastroenterology, Hepatology and Endocrinology, Department of Internal Medicine, Wiesbaden, Germany
| | - Thomas Mettang
- Fachbereich Nephrologie, Deutsche Klinik für Diagnostik, Wiesbaden, Germany
| | - Klaus Fellermann
- Division of Gastroenterology, Hepatology and Endocrinology, Department of Internal Medicine, Wiesbaden, Germany
| | | |
Collapse
|
4
|
Bär F, Kühbacher T, Dietrich NA, Krause T, Stallmach A, Teich N, Schreiber S, Walldorf J, Schmelz R, Büning C, Fellermann K, Büning J, Helwig U. Vedolizumab in the treatment of chronic, antibiotic-dependent or refractory pouchitis. Aliment Pharmacol Ther 2018; 47:581-587. [PMID: 29266360 DOI: 10.1111/apt.14479] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 07/27/2017] [Accepted: 11/30/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND The most common complication after ileal pouch anal anastomosis in up to 50% of patients is an acute pouchitis. The majority of patients respond to antibiotic treatment. However, 10%-15% develops chronic antibiotic-dependent or refractory pouchitis which is usually hard to treat. AIM To evaluate the effectiveness of vedolizumab in patients with chronic pouchitis. METHODS Patients with chronic antibiotic-dependent or refractory pouchitis were treated with vedolizumab (300 mg at week 0, 2, 6 and 10) in 10 IBD centres and retrospectively registered. Data were recorded until week 14 of vedolizumab treatment. In total 20 patients (12 male, median age 43 years) were included for analysis. The effectiveness was measured using the Oresland Score (OS) at week 2, 6, 10 and 14 and the pouch disease activity index (PDAI) at week 0 and 14. RESULTS The mean OS declined from 6.8 (range 2-12) to 3.4 (range 0-11). Concordantly, the mean PDAI after 14 weeks of treatment dropped from 10 (range 5-18) to 3 (range 0-10). Only three patients reported moderate side effects. No serious side effects were recorded. In addition, symptomatic co-medication such as loperamide and tincture of opium could be terminated in 8 out of 12 patients as well as antibiotic treatment could be stopped in 17 out of 19 patients. CONCLUSION Our data indicate that vedolizumab could be an option in the treatment of patients with chronic, antibiotic-dependent or refractory pouchitis.
Collapse
Affiliation(s)
- F Bär
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Luebeck, Germany
| | - T Kühbacher
- Asklepios Westklinikum Hamburg, Hamburg, Germany
| | - N A Dietrich
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Luebeck, Germany
| | - T Krause
- Gastroenterology Opernstraße, Kassel, Germany
| | - A Stallmach
- Department of Internal Medicine IV (Gastroenterology, Hepatology, Infectious Diseases), University Hospital Jena, Jena, Germany
| | - N Teich
- Practice for Digestive and Metabolic Diseases, Leipzig, Germany
| | - S Schreiber
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany
| | - J Walldorf
- Department of Internal Medicine I, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - R Schmelz
- Department of Gastroenterology, University Hospital of Dresden, Dresden, Germany
| | - C Büning
- Department of Internal Medicine, Hospital Waldfriede, Berlin, Germany
| | - K Fellermann
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Luebeck, Germany
| | - J Büning
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Luebeck, Germany
| | - U Helwig
- Practice of Internal Medicine, Oldenburg, Germany
| | | |
Collapse
|
5
|
Bär F, Krause T, Stallmach A, Teich N, Maaser C, Maul J, Helwig U, Fellermann K, Büning J. Cyclophosphamide Pulse Therapy in Severe Refractory Crohn's Disease: A Retrospective Multicenter Case Series. Inflamm Intest Dis 2017; 2:139-146. [PMID: 30018965 DOI: 10.1159/000481820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 09/24/2017] [Indexed: 11/19/2022] Open
Abstract
Background and Aims In Crohn's disease (CD) patients still remain refractory to current regimens, including biologicals. Previous data from small single-center studies indicated cyclophosphamide pulse therapy (CPT) to be effective for induction of remission at least in steroid-refractory cases. The aim of the present study was to study the efficacy and safety of CPT in mainly tumor necrosis factor (TNF)-refractory complicated CD patients. Methods Patients with refractory CD undergoing CPT were identified in 13 centers of the German IBD Study Group and retrospectively registered. In total, 41 patients (12 male, 29 female, median age 36 years, range 18-72 years) were included for analysis. Seventy-eight percent of these had previously been treated with thiopurines and 90% had previously received anti-TNF antibodies. Former steroid treatment was found throughout the cohort. Results Patients received a median number of 5 (1-13) pulses every 28 (13-54) days in a period of 120 (12-411) days. A median dose of 766 (600-1,200) mg and a median cumulative dose of 4,500 (750-9,750) mg was given. A clinical response (reduction in the Harvey-Bradshaw Index [HBI] ≥2 points) was found in 68% of the patients and clinical remission (HBI <5 points) in 32%. Steroids could be reduced from 31 to 12 mg per day over all patients. Side effects were recorded in 71% (n = 29) of the patients. Three patients terminated CPT due to side effects. No patient died. Conclusion Our data point to CPT as a therapeutic alternative for induction of remission in patients with severe refractory courses of CD including TNF antagonists. CPT might serve as bridging for maintenance treatment.
Collapse
Affiliation(s)
- Florian Bär
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | | | - Andreas Stallmach
- Department of Internal Medicine IV (Gastroenterology, Hepatology, Infectious Diseases), University Hospital of Jena, Jena, Germany
| | - Niels Teich
- Practice for Digestive and Metabolic Diseases, Leipzig, Germany
| | - Christian Maaser
- Department of Internal Medicine, Hospital Lüneburg, Lüneburg, Germany
| | - Jochen Maul
- Charité Medical School, University of Berlin, Berlin, Germany
| | - Ulf Helwig
- Practice of Internal Medicine, Oldenburg, Germany
| | - Klaus Fellermann
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Jürgen Büning
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | | |
Collapse
|
6
|
Muhl Chair E, Fellermann K, Angele MK, Hartl WH, Hummel R, Hunold P, Kähler G, Wellner UF. Management of Complications after Major Gastrointestinal Surgery. Visc Med 2017; 33:212-215. [PMID: 28785570 DOI: 10.1159/000475540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Elke Muhl Chair
- Operative Intensivmedizin IOI-II/37a, Department of Anesthesiology and Intensive Care, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | | | - Martin K Angele
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the Ludwig-Maximilian University (LMU) Munich, Munich, Germany
| | - Wolfgang H Hartl
- Department of General, Visceral, Vascular and Transplantation Surgery, Hospital of the Ludwig-Maximilian University (LMU) Munich, Munich, Germany
| | - Richard Hummel
- Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Peter Hunold
- Clinic for Radiology and Nuclear Medicine, University of Lübeck, Lübeck, Germany
| | - Georg Kähler
- Central Interdisciplinary Endoscopy Unit, Medical Faculty Mannheim, Heidelberg University, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Ulrich F Wellner
- Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| |
Collapse
|
7
|
Pagel R, Bär F, Schröder T, Sünderhauf A, Künstner A, Ibrahim SM, Autenrieth SE, Kalies K, König P, Tsang AH, Bettenworth D, Divanovic S, Lehnert H, Fellermann K, Oster H, Derer S, Sina C. Circadian rhythm disruption impairs tissue homeostasis and exacerbates chronic inflammation in the intestine. FASEB J 2017; 31:4707-4719. [PMID: 28710114 DOI: 10.1096/fj.201700141rr] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 06/27/2017] [Indexed: 12/19/2022]
Abstract
Endogenous circadian clocks regulate 24-h rhythms of physiology and behavior. Circadian rhythm disruption (CRD) is suggested as a risk factor for inflammatory bowel disease. However, the underlying molecular mechanisms remain unknown. Intestinal biopsies from Per1/2 mutant and wild-type (WT) mice were investigated by electron microscopy, immunohistochemistry, and bromodeoxyuridine pulse-chase experiments. TNF-α was injected intraperitoneally, with or without necrostatin-1, into Per1/2 mice or rhythmic and externally desynchronized WT mice to study intestinal epithelial cell death. Experimental chronic colitis was induced by oral administration of dextran sodium sulfate. In vitro, caspase activity was assayed in Per1/2-specific small interfering RNA-transfected cells. Wee1 was overexpressed to study antiapoptosis and the cell cycle. Genetic ablation of circadian clock function or environmental CRD in mice increased susceptibility to severe intestinal inflammation and epithelial dysregulation, accompanied by excessive necroptotic cell death and a reduced number of secretory epithelial cells. Receptor-interacting serine/threonine-protein kinase (RIP)-3-mediated intestinal necroptosis was linked to increased mitotic cell cycle arrest via Per1/2-controlled Wee1, resulting in increased antiapoptosis via cellular inhibitor of apoptosis-2. Together, our data suggest that circadian rhythm stability is pivotal for the maintenance of mucosal barrier function. CRD increases intestinal necroptosis, thus rendering the gut epithelium more susceptible to inflammatory processes.-Pagel, R., Bär, F., Schröder, T., Sünderhauf, A., Künstner, A., Ibrahim, S. M., Autenrieth, S. E., Kalies, K., König, P., Tsang, A. H., Bettenworth, D., Divanovic, S., Lehnert, H., Fellermann, K., Oster, H., Derer, S., Sina, C. Circadian rhythm disruption impairs tissue homeostasis and exacerbates chronic inflammation in the intestine.
Collapse
Affiliation(s)
- René Pagel
- Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Florian Bär
- Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Torsten Schröder
- Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany.,Institute of Nutritional Medicine, University Hospital Schleswig-Holstein, Lubeck, Germany.,Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Annika Sünderhauf
- Institute of Nutritional Medicine, University Hospital Schleswig-Holstein, Lubeck, Germany
| | - Axel Künstner
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany.,Guest Group Evolutionary Genomics, Max Planck Institute for Evolutionary Biology, Plon, Germany
| | - Saleh M Ibrahim
- Lübeck Institute of Experimental Dermatology, University of Lübeck, Lübeck, Germany
| | - Stella E Autenrieth
- Department of Internal Medicine II, University of Tübingen, Tubingen, Germany
| | - Kathrin Kalies
- Institute of Anatomy, University of Lübeck, Lubeck, Germany
| | - Peter König
- Institute of Anatomy, University of Lübeck, Lubeck, Germany
| | - Anthony H Tsang
- Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Dominik Bettenworth
- Department of Medicine B, University Hospital of Münster, Munster, Germany; and
| | - Senad Divanovic
- Division of Immunobiology, Cincinnati Children's Hospital Research Foundation, University of Cincinnati, Cincinnati, Ohio, USA
| | - Hendrik Lehnert
- Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Klaus Fellermann
- Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Henrik Oster
- Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Stefanie Derer
- Institute of Nutritional Medicine, University Hospital Schleswig-Holstein, Lubeck, Germany
| | - Christian Sina
- Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany; .,Institute of Nutritional Medicine, University Hospital Schleswig-Holstein, Lubeck, Germany
| |
Collapse
|
8
|
Schölmerich J, Fellermann K, Seibold FW, Rogler G, Langhorst J, Howaldt S, Novacek G, Petersen AM, Bachmann O, Matthes H, Hesselbarth N, Teich N, Wehkamp J, Klaus J, Ott C, Dilger K, Greinwald R, Mueller R. A Randomised, Double-blind, Placebo-controlled Trial of Trichuris suis ova in Active Crohn's Disease. J Crohns Colitis 2017; 11:390-399. [PMID: 27707789 PMCID: PMC5881737 DOI: 10.1093/ecco-jcc/jjw184] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 10/05/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS To investigate the efficacy and safety of three different dosages of embryonated, viable eggs of Trichuris suis [TSO] versus placebo for induction of remission in mildly-to-moderately active ileocolonic, uncomplicated Crohn's disease [CD]. METHODS Adults with active CD [n = 252] randomly received six fortnightly doses of 250, 2500, or 7500 TSO/15 ml suspension/day [TSO 250, TSO 2500, TSO 7500], or 15 ml placebo solution/day, in a double-blind fashion, with 4 weeks' follow-up. Primary endpoint was the rate of clinical remission [Crohn's Disease Activity Index [CDAI] < 150] at end of treatment, ie at Week 12 or withdrawal. Secondary endpoints included the course of clinical remission, rate of clinical response, change in CDAI, change in markers of inflammation, mucosal healing, and Physician's Global Assessment. RESULTS Clinical remission at Week 12 occurred in 38.5%, 35.2%, and 47.2% of TSO 250, TSO 2500, and TSO 7500 patients, respectively, and in 42.9% of placebo recipients. TSO induced a dose-dependent immunological response. There was no response regarding laboratory markers of inflammation. Other secondary efficacy variables also showed no advantage of TSO over placebo for treatment of active CD. Administration of TSO did not result in any serious adverse drug reaction. Review of non-serious suspected adverse drug reactions following TSO did not reveal any safety concerns. CONCLUSIONS Administration of 250-7500 TSO fortnightly over 12 weeks was safe and showed a dose-dependent immunological response, but no TSO dose showed a clinically relevant effect over placebo for induction of clinical remission or response in mildly-to-moderately active, ileocolonic CD.
Collapse
Affiliation(s)
- Jürgen Schölmerich
- Klinikum der Johann Wolfgang Goethe-Universität Frankfurt am Main, Frankfurt am Main, Germany
| | | | - Frank W. Seibold
- Spital Netz Bern Tiefenau, Abt. Gastroenterologie, Bern, Switzerland
| | - Gerhard Rogler
- University of Zurich, Division of Gastroenterology and Hepatology, Zurich, Switzerland
| | - Jost Langhorst
- Kliniken Essen-Mitte, University of Duisburg-Essen, Integrative Gastroenterologie, Essen, Germany
| | - Stefanie Howaldt
- Hamburgisches Forschungsinstitut für CED, HaFCED GmbH&Co.KG, Hamburg, Germany
| | - Gottfried Novacek
- Medizinische Universität Wien, Universitätsklinik für Innere Medizin III, Vienna, Austria
| | - Andreas Munk Petersen
- Hvidovre University Hospital, Department of Gastroenterology and Department of Clinical Microbiology, Hvidovre, Denmark
| | | | - Harald Matthes
- Gemeinschaftskrankenhaus Havelhöhe, Abt. Gastroenterologie, Berlin, Germany
| | | | - Niels Teich
- Internistische Gemeinschaftspraxis für Verdauungs- und Stoffwechselkrankheiten Leipzig & Schkeuditz, Leipzig, Germany
| | - Jan Wehkamp
- Robert-Bosch-Krankenhaus, Abt. Innere Medizin I, Stuttgart, Germany
| | - Jochen Klaus
- Universitätsklinikum Ulm, Klinik für Innere Medizin I, Ulm, Germany
| | - Claudia Ott
- University Hospital of Regensburg, Dept. of Internal Medicine I, Regensburg, Germany
| | | | | | | | | |
Collapse
|
9
|
Jendrek ST, Gotthardt D, Nitzsche T, Widmann L, Korf T, Michaels MA, Weiss KH, Liaskou E, Vesterhus M, Karlsen TH, Mindorf S, Schemmer P, Bär F, Teegen B, Schröder T, Ehlers M, Hammers CM, Komorowski L, Lehnert H, Fellermann K, Derer S, Hov JR, Sina C. Anti-GP2 IgA autoantibodies are associated with poor survival and cholangiocarcinoma in primary sclerosing cholangitis. Gut 2017; 66:137-144. [PMID: 27406039 DOI: 10.1136/gutjnl-2016-311739] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 06/19/2016] [Accepted: 06/20/2016] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Pancreatic autoantibodies (PABs), comprising antibodies against glycoprotein 2 (anti-GP2), are typically associated with complicated phenotypes in Crohn's disease, but have also been observed with variable frequencies in patients with UC. In a previous study, we observed a high frequency of primary sclerosing cholangitis (PSC) in patients with anti-GP2-positive UC. We therefore aimed to characterise the role of anti-GP2 in PSC. DESIGN In an evaluation phase, sera from 138 well-characterised Norwegian patients with PSC were compared with healthy controls (n=52), and patients with UC without PSC (n=62) for the presence of PABs by indirect immunofluorescence. Further, 180 German patients with PSC served as a validation cohort together with 56 cases of cholangiocarcinoma without PSC, 20 of secondary sclerosing cholangitis (SSC) and 18 of autoimmune hepatitis. RESULTS Anti-GP2 IgA specifically occurred at considerable rates in large bile duct diseases (cholangiocarcinoma=36%, PSC and SSC about 50%). In PSC, anti-GP2 IgA consistently identified patients with poor survival during follow-up (Norwegian/German cohort: p Log Rank=0.016/0.018). Anti-GP2 IgA was associated with the development of cholangiocarcinoma in both PSC cohorts, yielding an overall OR of cholangiocarcinoma in patients with anti-GP2 IgA-positive PSC of 5.0 (p=0.001). Importantly, this association remained independent of disease duration, bilirubin level and age. CONCLUSIONS Anti-GP2 IgA can be hypothesised as a novel marker in large bile duct diseases. In particular, in PSC, anti-GP2 IgA identified a subgroup of patients with severe phenotype and poor survival due to cholangiocarcinoma. Anti-GP2 IgA may therefore be a clinically valuable tool for risk stratification in PSC.
Collapse
Affiliation(s)
- Sebastian Torben Jendrek
- Molecular Gastroenterology, Medical Department 1, University of Lübeck, Lübeck, Germany.,Institute for Anatomy, University of Lübeck, Lübeck, Germany
| | - Daniel Gotthardt
- Section of Liver Transplantation, Medical Department IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Nitzsche
- Institute for Experimental Immunology, Euroimmun Corp., Lübeck, Germany
| | - Laila Widmann
- Section of Liver Transplantation, Medical Department IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Tobias Korf
- Molecular Gastroenterology, Medical Department 1, University of Lübeck, Lübeck, Germany
| | - Maike Anna Michaels
- Molecular Gastroenterology, Medical Department 1, University of Lübeck, Lübeck, Germany
| | - Karl-Heinz Weiss
- Section of Liver Transplantation, Medical Department IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Evaggelia Liaskou
- Centre for Liver Research and NIHR Birmingham Liver Biomedical Research Unit, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Mette Vesterhus
- Department of Transplantation Medicine, Norwegian PSC Research Center, Oslo University Hospital Rikshospitalet, Oslo, Norway.,National Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, Bergen, Norway
| | - Tom Hemming Karlsen
- Department of Transplantation Medicine, Norwegian PSC Research Center, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Division of Cancer Medicine, Surgery and Transplantation, Research Institute of Internal Medicine and Section of Gastroenterology, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine and K. G. Jebsen Inflammation Research Centre, University of Oslo, Oslo, Norway
| | - Swantje Mindorf
- Institute for Experimental Immunology, Euroimmun Corp., Lübeck, Germany
| | - Peter Schemmer
- Department of General, Visceral and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Florian Bär
- Molecular Gastroenterology, Medical Department 1, University of Lübeck, Lübeck, Germany
| | - Bianca Teegen
- Institute for Experimental Immunology, Euroimmun Corp., Lübeck, Germany
| | - Torsten Schröder
- Molecular Gastroenterology, Medical Department 1, University of Lübeck, Lübeck, Germany.,Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Marc Ehlers
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | | | - Lars Komorowski
- Institute for Experimental Immunology, Euroimmun Corp., Lübeck, Germany
| | - Hendrik Lehnert
- Molecular Gastroenterology, Medical Department 1, University of Lübeck, Lübeck, Germany
| | - Klaus Fellermann
- Molecular Gastroenterology, Medical Department 1, University of Lübeck, Lübeck, Germany
| | - Stefanie Derer
- Molecular Gastroenterology, Medical Department 1, University of Lübeck, Lübeck, Germany
| | - Johannes Roksund Hov
- Department of Transplantation Medicine, Norwegian PSC Research Center, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Division of Cancer Medicine, Surgery and Transplantation, Research Institute of Internal Medicine and Section of Gastroenterology, Oslo University Hospital Rikshospitalet, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine and K. G. Jebsen Inflammation Research Centre, University of Oslo, Oslo, Norway
| | - Christian Sina
- Molecular Gastroenterology, Medical Department 1, University of Lübeck, Lübeck, Germany
| |
Collapse
|
10
|
Weitz G, Woitalla J, Wellhöner P, Schmidt K, Büning J, Fellermann K. Comorbidity in acute pancreatitis relates to organ failure but not to local complications. Z Gastroenterol 2016; 54:226-30. [DOI: 10.1055/s-0041-106593] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
11
|
Schröder T, Kucharczyk D, Bär F, Pagel R, Derer S, Jendrek ST, Sünderhauf A, Brethack AK, Hirose M, Möller S, Künstner A, Bischof J, Weyers I, Heeren J, Koczan D, Schmid SM, Divanovic S, Giles DA, Adamski J, Fellermann K, Lehnert H, Köhl J, Ibrahim S, Sina C. Mitochondrial gene polymorphisms alter hepatic cellular energy metabolism and aggravate diet-induced non-alcoholic steatohepatitis. Mol Metab 2016; 5:283-295. [PMID: 27069868 PMCID: PMC4812012 DOI: 10.1016/j.molmet.2016.01.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 01/18/2016] [Accepted: 01/25/2016] [Indexed: 02/07/2023] Open
Abstract
Objective Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease and is associated with an enhanced risk for liver and cardiovascular diseases and mortality. NAFLD can progress from simple hepatic steatosis to non-alcoholic steatohepatitis (NASH). However, the mechanisms predisposing to this progression remain undefined. Notably, hepatic mitochondrial dysfunction is a common finding in patients with NASH. Due to a lack of appropriate experimental animal models, it has not been evaluated whether this mitochondrial dysfunction plays a causative role for the development of NASH. Methods To determine the effect of a well-defined mitochondrial dysfunction on liver physiology at baseline and during dietary challenge, C57BL/6J-mtFVB/N mice were employed. This conplastic inbred strain has been previously reported to exhibit decreased mitochondrial respiration likely linked to a non-synonymous gene variation (nt7778 G/T) of the mitochondrial ATP synthase protein 8 (mt-ATP8). Results At baseline conditions, C57BL/6J-mtFVB/N mice displayed hepatic mitochondrial dysfunction characterized by decreased ATP production and increased formation of reactive oxygen species (ROS). Moreover, genes affecting lipid metabolism were differentially expressed, hepatic triglyceride and cholesterol levels were changed in these animals, and various acyl-carnitines were altered, pointing towards an impaired mitochondrial carnitine shuttle. However, over a period of twelve months, no spontaneous hepatic steatosis or inflammation was observed. On the other hand, upon dietary challenge with either a methionine and choline deficient diet or a western-style diet, C57BL/6J-mtFVB/N mice developed aggravated steatohepatitis as characterized by lipid accumulation, ballooning of hepatocytes and infiltration of immune cells. Conclusions We observed distinct metabolic alterations in mice with a mitochondrial polymorphism associated hepatic mitochondrial dysfunction. However, a second hit, such as dietary stress, was required to cause hepatic steatosis and inflammation. This study suggests a causative role of hepatic mitochondrial dysfunction in the development of experimental NASH. C57BL/6J-mtFVB/N mice (mt-ATP8, nt7778 G/T) display hepatic mitochondrial dysfunction. C57BL/6J-mtFVB/N mice display alterations in hepatic energy metabolism. C57BL/6J-mtFVB/N mice show no spontaneous hepatic steatosis or inflammation. C57BL/6J-mtFVB/N mice are susceptible to diet induced NASH. Study demonstrates causative role of mitochondrial dysfunction for NASH development.
Collapse
Key Words
- ALT, alanine aminotransferase
- AMP, adenosine monophosphate
- AMPK, AMP-activated proteinkinase
- ATP, adenosine triphosphate
- ATP8, ATP synthase protein 8
- Arg, arginine
- Asp, aspartic acid
- B6-mtB6, C57BL/6
- B6-mtFVB, C57BL/6-mtFVB/N
- C0, free dl-carnitine
- C16, hexadecanoyl-l-carntine
- C18, octadecanoyl-l-carnitine
- CD, control diet
- CD3, cluster of differentiation receptor 3
- CPT I, carnitine-palmitoyltransferase I
- CYP51A1, cytochrome P450, family 51, subfamily A, polypeptide 1
- GAPDH, glyceraldehyde 3-phosphate dehydrogenase
- Gr1, granulocyte differentiation antigen 1
- H&E, hematoxylin–eosin staining
- H2O2, hydrogen peroxide
- Hsd17b7, 17-beta-hydroxysteroid dehydrogenase type 7
- IDI1, isopentenyl-diphosphate delta isomerase 1
- IL, interleukin
- IPA, ingenuity pathway analysis
- KEGG, Kyoto Encyclopedia of Genes and Genomes
- Lipid metabolism
- Ly6G, lymphocyte antigen 6 complex, locus G
- MCDD, methionine and choline deficient diet
- MSMO1, methylsterol monooxygenase 1
- Met, methionine
- Mitochondrial dysfunction
- Mitochondrial gene polymorphism
- NAFL, non-alcoholic liver steatosis
- NAFLD
- NAFLD, non-alcoholic fatty liver disease
- NAS, NAFLD activity score
- NASH, non-alcoholic steatohepatitis
- ND3, NADH dehydrogenase subunit 3
- OCR, oxygen consumption rate
- OXPHOS, oxidative phosphorylation system
- PBS, phosphate buffered saline
- ROS, reactive oxygen species
- SNPs, single nucleotide polymorphisms
- SOD2, superoxide dismutase 2
- STRING, Search Tool for the Retrieval of Interacting Genes/Proteins
- Steatohepatitis
- TNFα
- TNFα, tumor necrosis factor alpha
- Tyr, tyrosine
- WD, western-style diet
- mt, mitochondrial
- pAMPK, phosphorylated AMP-activated proteinkinase
Collapse
Affiliation(s)
- Torsten Schröder
- University of Lübeck, Department of Medicine I, Ratzeburger Allee 160, D-23538 Lübeck, Germany; University of Lübeck, Institute for Systemic Inflammation Research, Ratzeburger Allee 160, D-23538 Lübeck, Germany
| | - David Kucharczyk
- University of Lübeck, Department of Medicine I, Ratzeburger Allee 160, D-23538 Lübeck, Germany
| | - Florian Bär
- University of Lübeck, Department of Medicine I, Ratzeburger Allee 160, D-23538 Lübeck, Germany
| | - René Pagel
- University of Lübeck, Department of Medicine I, Ratzeburger Allee 160, D-23538 Lübeck, Germany; University of Lübeck, Institute of Anatomy, Ratzeburger Allee 160, D-23538 Lübeck, Germany
| | - Stefanie Derer
- University of Lübeck, Department of Medicine I, Ratzeburger Allee 160, D-23538 Lübeck, Germany
| | - Sebastian Torben Jendrek
- University of Lübeck, Department of Medicine I, Ratzeburger Allee 160, D-23538 Lübeck, Germany; University of Lübeck, Institute of Anatomy, Ratzeburger Allee 160, D-23538 Lübeck, Germany
| | - Annika Sünderhauf
- University of Lübeck, Department of Medicine I, Ratzeburger Allee 160, D-23538 Lübeck, Germany
| | - Ann-Kathrin Brethack
- University of Lübeck, Department of Medicine I, Ratzeburger Allee 160, D-23538 Lübeck, Germany
| | - Misa Hirose
- University of Lübeck, The Lübeck Institute of Experimental Dermatology, Ratzeburger Allee 160, D-23538 Lübeck, Germany
| | - Steffen Möller
- University of Lübeck, The Lübeck Institute of Experimental Dermatology, Ratzeburger Allee 160, D-23538 Lübeck, Germany; Rostock University Medical Center, Institute for Biostatistics and Informatics in Medicine and Ageing Research, Ernst-Heydemann-Straße 8, D-18057 Rostock, Germany
| | - Axel Künstner
- University of Lübeck, The Lübeck Institute of Experimental Dermatology, Ratzeburger Allee 160, D-23538 Lübeck, Germany; Max Planck Institute for Evolutionary Biology, Guest Group Evolutionary Genomics, August-Thienemann-Straße 2, 24306 Plön, Germany
| | - Julia Bischof
- University of Lübeck, The Lübeck Institute of Experimental Dermatology, Ratzeburger Allee 160, D-23538 Lübeck, Germany
| | - Imke Weyers
- University of Lübeck, Institute of Anatomy, Ratzeburger Allee 160, D-23538 Lübeck, Germany
| | - Jörg Heeren
- University Hospital Hamburg-Eppendorf, Department of Biochemistry and Molecular Cell Biology, Martinistraße 52, D-20246 Hamburg, Germany
| | - Dirk Koczan
- University of Rostock, Institute of Immunology, Schillingallee 70, D-18057 Rostock, Germany
| | | | - Senad Divanovic
- Cincinnati Children's Hospital Research Foundation, University of Cincinnati, Division of Immunobiology, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
| | - Daniel Aaron Giles
- Cincinnati Children's Hospital Research Foundation, University of Cincinnati, Division of Immunobiology, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
| | - Jerzy Adamski
- Helmholtz Center, German Research Center for Environmental Health, Institute of Experimental Genetics, Genome Analysis Center, Ingolstaedter Landstraße 1, D-85764 Neuherberg, Germany; Technische Universität München, Lehrstuhl für Experimentelle Genetik, Liesel-Beckmann-Straße 4, 85350 Freising-Weihenstephan, Germany; German Center for Diabetes Research (DZD), Ingolstaedter Landstraße 1, 85764 Neuherberg, Germany
| | - Klaus Fellermann
- University of Lübeck, Department of Medicine I, Ratzeburger Allee 160, D-23538 Lübeck, Germany
| | - Hendrik Lehnert
- University of Lübeck, Department of Medicine I, Ratzeburger Allee 160, D-23538 Lübeck, Germany
| | - Jörg Köhl
- University of Lübeck, Institute for Systemic Inflammation Research, Ratzeburger Allee 160, D-23538 Lübeck, Germany; Cincinnati Children's Hospital Research Foundation, University of Cincinnati, Division of Immunobiology, 3333 Burnet Avenue, Cincinnati, OH 45229-3026, USA
| | - Saleh Ibrahim
- University of Lübeck, The Lübeck Institute of Experimental Dermatology, Ratzeburger Allee 160, D-23538 Lübeck, Germany
| | - Christian Sina
- University of Lübeck, Department of Medicine I, Ratzeburger Allee 160, D-23538 Lübeck, Germany.
| |
Collapse
|
12
|
Affiliation(s)
- S. Jendrek
- University Hospital of Lübeck, Department of Gastroenterology, Lübeck, Germany
| | - K. Schmidt
- University Hospital of Lübeck, Department of Gastroenterology, Lübeck, Germany
| | - K. Fellermann
- University Hospital of Lübeck, Department of Gastroenterology, Lübeck, Germany
| |
Collapse
|
13
|
Schmidt KJ, Müller N, Dignass A, Baumgart DC, Lehnert H, Stange EF, Herrlinger KR, Fellermann K, Büning J. Long-term Outcomes in Steroid-refractory Ulcerative Colitis Treated with Tacrolimus Alone or in Combination with Purine Analogues. J Crohns Colitis 2016; 10:31-7. [PMID: 26419459 DOI: 10.1093/ecco-jcc/jjv175] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 09/02/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Tacrolimus is recommended for the treatment of steroid-refractory ulcerative colitis (UC). Concomitantly started purine analogues (PAs) are used for the maintenance of remission, though their therapeutic relevance remains uncertain. Here we studied the role of PAs in the long-term outcome of steroid-refractory UC after tacrolimus treatment. METHODS In five centres, charts of tacrolimus-treated UC patients with a steroid-refractory moderate to severe course were reviewed. Long-term efficacy was determined by colectomy rates and clinical remission in cases of colectomy-free survival for 3 months. RESULTS We identified 156 patients (median age 34 years) with a median Lichtiger score of 12 (4-17) and pancolitis (E3) in 65% (101). The Kaplan-Meier curve for colectomy-free survival after month 3 showed a benefit in the PA group (p = 0.02). In patients treated with PA clinical remission was achieved in 82% (65/79) vs 67% (39/58) in those not treated with PA (p = 0.02). Time to colectomy was 2 years (median, 0.7-5.8) in the PA group and 0.8 years (0.3-4.7) in the group not treated with PAs (p = 0.02). Time to relapse was 1.2 years (median, 0.3-6.2) in patients with PA treatment and 0.5 years (0.3-3.9) in those without PA treatment (p = 0.05). Overall, clinical remission was achieved in 67% (104/156) of patients. Colectomy was performed in 29% (45/156) 0.5 years (median, 0.04-5.79) after initiation of tacrolimus. Ten (6%) patients had to stop tacrolimus due to adverse events and two (without PA treatment) died. CONCLUSIONS Our study supports the efficacy of tacrolimus in steroid-refractory UC. Purine analogues appear to be beneficial for the long-term outcome of these patients.
Collapse
Affiliation(s)
- K J Schmidt
- Department of Internal Medicine I, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - N Müller
- Department of Internal Medicine I, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - A Dignass
- Department of Internal Medicine I, Agaplesion Markus Hospital, Frankfurt, Germany
| | - D C Baumgart
- Department of Gastroenterology and Hepatology, Charite Medical School, Humboldt University of Berlin, Berlin, Germany
| | - H Lehnert
- Department of Internal Medicine I, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - E F Stange
- Department of Gastroenterology, Hepatology and Endocrinology, Robert Bosch Hospital, Stuttgart, Germany
| | - K R Herrlinger
- Department of Internal Medicine I, Asklepios Klinik Nord, Hamburg, Germany
| | - K Fellermann
- Department of Internal Medicine I, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - J Büning
- Department of Internal Medicine I, University Hospital of Schleswig-Holstein, Lübeck, Germany
| |
Collapse
|
14
|
Bernatik T, Schuler A, Kunze G, Mauch M, Dietrich CF, Dirks K, Pachmann C, Börner N, Fellermann K, Menzel J, Strobel D. Benefit of Contrast-Enhanced Ultrasound (CEUS) in the Follow-Up Care of Patients with Colon Cancer: A Prospective Multicenter Study. Ultraschall Med 2015; 36:590-593. [PMID: 26544634 DOI: 10.1055/s-0041-107833] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
PURPOSE According to the German guidelines on colorectal cancer, unenhanced ultrasound is recommended for follow-up. On the other hand, ultrasound and radiology societies specify the use of contrast-enhanced ultrasound for ruling out liver metastases. Studies focusing on the follow-up of cancer patients are lacking. The goal of this multicenter study initiated by the German Ultrasound Society (DEGUM) was to determine the potential benefit of contrast-enhanced ultrasound in the follow-up of patients with colon cancer. MATERIALS AND METHODS Follow-up patients with colon cancer (UICC > IIa) were investigated. As scheduled according to the German guidelines, unenhanced ultrasound was performed followed by contrast-enhanced ultrasound. All liver lesions were recorded. In case of additional metastases detected on contrast-enhanced ultrasound, contrast-enhanced CT, MRI or biopsy was performed to confirm additional liver metastases. RESULTS A total of 45 liver metastases were detected in 26/290 patients (= 9 %) using unenhanced ultrasound. A further 28 metastases were detected on contrast-enhanced ultrasound in these 26 patients. In 18 patients showing no liver metastases, 40 additional metastases were detected on unenhanced ultrasound. This means that 44 patients with a total of 113 liver metastases were detected on contrast-enhanced ultrasound (p = 0.0006). CONCLUSION Contrast-enhanced ultrasound should be recommended in the follow-up of patients with colon cancer in addition to unenhanced ultrasound - the up-to-date standard.
Collapse
Affiliation(s)
- T Bernatik
- Dept. of Internal Medicine, Kreisklinik Ebersberg, Germany
| | - A Schuler
- Dept. of Internal Medicine, Helfenstein Klinik, Geislingen, Germany
| | - G Kunze
- Dept. of Internal Medicine, KH Villingen-Schwenningen, Villingen-Schwenningen, Germany
| | - M Mauch
- Dept. of Internal Medicine, Kreisklinik Sigmaringen, Germany
| | - C F Dietrich
- Dept. of Internal Medicine2, Caritas-Krankenhaus, Bad Mergentheim, Germany
| | - K Dirks
- Dept. of Internal Medicine, Rems-Murr-Klinik, Winnenden, Germany
| | - C Pachmann
- Dept. of Internal Medicine, Israelisches Krankenhaus, Hamburg, Germany
| | - N Börner
- MED Facharztzentrum, Gastroenterologische Praxis, Mainz, Germany
| | - K Fellermann
- Dept. of Internal Medicine1, university, Lübeck, Germany
| | - J Menzel
- Dept. of Internal Medicine2, Klinikum Ingolstadt, Germany
| | - D Strobel
- Dept. of Medicine 1, University of Erlangen, Germany
| |
Collapse
|
15
|
Weitz G, Woitalla J, Wellhöner P, Schmidt K, Büning J, Fellermann K. Does etiology of acute pancreatitis matter? A review of 391 consecutive episodes. JOP 2015; 16:171-5. [PMID: 25791551 DOI: 10.6092/1590-8577/2959] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
CONTEXT Acute pancreatitis can be triggered by a variety of factors ranging from short lasting to sustained disruptions. It is plausible that the characteristics and course of disease differ among etiologies. Data distinguishing characteristics of patients with pancreatitis of biliary, alcoholic, idiopathic or other origin are scarce and conflicting. OBJECTIVE To compare patients' characteristics, baseline parameters on admission, and outcome in patients with an episode of acute pancreatitis in whom the etiology was thoroughly determined. DESIGN Retrospective study. SETTING Single center. PATIENTS Three-hundreds and 91 consecutive episodes of acute pancreatitis through the years 2008 to 2011. MAIN OUTCOME MEASURES Gender, age, body mass index, Charlson comorbidity index, history of pancreatitis, heart rate, blood pressure, plasma lipase, hematocrit, plasma creatinine, white blood cell count, rate of persistent organ failure and necrosis, maximum C-reactive protein, duration of hospitalization, mortality. RESULTS There were marked differences between the groups. Biliary etiology was associated with higher age and body weight, female predominance, higher plasma lipase, and a favourable outcome. Alcoholic etiology had male predominance, a tendency for initial hemoconcentration, a lower plasma lipase, and the highest rate of necrosis. Idiopathic etiology had the highest rate of persistent organ failure and the highest mortality. CONCLUSIONS Biliary, alcoholic and idiopathic acute pancreatitis should be treated as distinct entities. While alcoholic episodes have the highest risk of necrosis, the worst outcome was observed in the idiopathic group. Hence, finding no causality for an episode of acute pancreatitis after thorough investigation might be a predictor for poor outcome. Larger studies are warranted to confirm this.
Collapse
Affiliation(s)
- Gunther Weitz
- Gastroenterology, Medical Department I, University Hospital of Schleswig-Holstein, Campus Lübeck. Lübeck, Germany.
| | | | | | | | | | | |
Collapse
|
16
|
Abstract
INTRODUCTION Therapeutic peptides in inflammatory bowel diseases essentially comprise cytokines affecting immune response, growth factors and monoclonal antibodies directed against key targets of mucosal inflammation, in particular, tumor necrosis factor-a (TNF-a). The latter have revolutionized standard medical treatment which previously was restricted to mesalamine, corticosteroids or classical immunosuppressants. AREAS COVERED We review current evidence of the use of the so-called biologicals, including the well-established TNF-a antagonists and novel peptides and monoclonal antibodies developed for these diseases. The focus is on controlled clinical trials and meta-analyses, if available. Limitations and biases of these studies are important but tend to be ignored. Safety is also an important issue with opportunistic infections and lymphoma as relevant risks. There is significant heterogeneity between different countries, guidelines and opinions within the scientific community regarding clinical indications, even apart from pharmacoeconomics and reimbursement. EXPERT OPINION TNF blockers have greatly extended medical options in inflammatory bowel diseases. Their more or less extensive use in nearly all patients or only a few selected indications is a matter of debate. It proved difficult to reproduce this success with other antibody targets as well as with immunomodulatory cytokines and growth factors. The most promising novel peptide is vedolizumab, an antibody against α4β7 integrin.
Collapse
|
17
|
Weitz G, Woitalla J, Wellhöner P, Schmidt K, Büning J, Fellermann K. Detrimental effect of high volume fluid administration in acute pancreatitis - a retrospective analysis of 391 patients. Pancreatology 2014; 14:478-83. [PMID: 25451185 DOI: 10.1016/j.pan.2014.07.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 06/23/2014] [Accepted: 07/09/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Early fluid resuscitation is recommended for the therapy of acute pancreatitis in order to prevent complications. There are, however, no convincing data supporting this approach. METHODS We reviewed 391 consecutive cases of confirmed acute pancreatitis. Admitting physicians had been advised to administer an aggressive fluid resuscitation in the early phase of disease, if possible. We tested whether disease severity according to the revised Atlanta Classification, local complications, and maximum C-reactive protein levels were predictable by the initial volume therapy in logistic and linear regression models, respectively. We also determined which parameters on admission encouraged a more aggressive fluid resuscitation. RESULTS The recorded fluid administered within the first 24 h was 5300 [3760; 7100] ml (median [1st; 3rd quartile]). More aggressive volume therapy was associated with disease severity and a higher rate of local complications. There was a linear relationship between administered volume and the maximum C-reactive protein. The amount of administered fluid was significantly attributed to age, hematocrit, and white blood cell count on admission. When adjusted for these parameters the impact of administered volume on outcome was still present but attenuated. CONCLUSIONS We found detrimental effects of fluid therapy on major outcome parameters throughout the whole range of administered volume. More volume was administered in younger patients and in patients with evidence of hemoconcentration and inflammation. The adverse effects of volume therapy persisted after elimination of these parameters. Caution should therefore be advised with regards to volume therapy in patients with acute pancreatitis.
Collapse
Affiliation(s)
- Gunther Weitz
- Medical Department I, Gastroenterology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.
| | - Julia Woitalla
- Medical Department I, Gastroenterology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Peter Wellhöner
- Medical Department I, Gastroenterology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Klaus Schmidt
- Medical Department I, Gastroenterology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Jürgen Büning
- Medical Department I, Gastroenterology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Klaus Fellermann
- Medical Department I, Gastroenterology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| |
Collapse
|
18
|
Herrlinger K, Fellermann K, Stange E. Therapie chronisch-entzündlicher Darmerkrankungen. Internist (Berl) 2014; 55:906-17. [DOI: 10.1007/s00108-013-3442-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
19
|
Bär F, Föh B, Pagel R, Schröder T, Schlichting H, Hirose M, Lemcke S, Klinger A, König P, Karsten CM, Büning J, Lehnert H, Fellermann K, Ibrahim SM, Sina C. Carboxypeptidase E modulates intestinal immune homeostasis and protects against experimental colitis in mice. PLoS One 2014; 9:e102347. [PMID: 25051500 PMCID: PMC4106776 DOI: 10.1371/journal.pone.0102347] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 06/18/2014] [Indexed: 12/24/2022] Open
Abstract
Enteroendocrine cells (EEC) produce neuropeptides, which are crucially involved in the maintenance of the intestinal barrier. Hence, EEC dysfunction is suggested to be involved in the complex pathophysiology of inflammatory bowel disease (IBD), which is characterized by decreased intestinal barrier function. However, the underlying mechanisms for EEC dysfunction are not clear and suitable models for a better understanding are lacking. Here, we demonstrate that Carboxypeptidase E (CPE) is specifically expressed in EEC of the murine colon and ileum and that its deficiency is associated with reduced intestinal levels of Neuropeptide Y (NPY) and Peptide YY (PYY), which are both produced by EEC. Moreover, cpe−/− mice exhibit an aggravated course of DSS-induced chronic colitis compared to wildtype littermates. In addition, we observed elevated mucosal IL-6 and KC transcript levels already at baseline conditions in cpe−/− mice. Moreover, supernatants obtained from isolated intestinal crypts of cpe−/− mice lead to increased IL-6 and KC expression in MODE-K cells in the presence of LPS. This effect was reversible by co-administration of recombinant NPY, suggesting a CPE mediated immunosuppressive effect in the intestines by influencing the processing of specific neuropeptides. In this context, the chemotaxis of bone marrow derived macrophages towards respective supernatants was enhanced. In conclusion, our data point to an anti-inflammatory role of CPE in the intestine by influencing local cytokine levels and thus regulating the migration of myeloid immune cells into the mucosa. These findings highlight the importance of EEC for intestinal homeostasis and propose EEC as potential therapeutic targets in IBD.
Collapse
Affiliation(s)
- Florian Bär
- Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany
- Institute of Anatomy, University of Lübeck, Lübeck, Germany
| | - Bandik Föh
- Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - René Pagel
- Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Torsten Schröder
- Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Heidi Schlichting
- Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Misa Hirose
- Department of Dermatology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Susanne Lemcke
- Department of Dermatology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Antje Klinger
- Institute of Anatomy, University of Lübeck, Lübeck, Germany
| | - Peter König
- Institute of Anatomy, University of Lübeck, Lübeck, Germany
| | - Christian M. Karsten
- Institute for Systemic Inflammation Research, University of Lübeck, Lübeck, Germany
| | - Jürgen Büning
- Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Hendrik Lehnert
- Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Klaus Fellermann
- Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Saleh M. Ibrahim
- Department of Dermatology, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Christian Sina
- Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany
- * E-mail:
| |
Collapse
|
20
|
Abstract
BACKGROUND/AIMS Adverse events in anti-TNF treatment can be divided into allergic reactions with an acute and delayed onset, infectious complications in relation to the underlying disease, and without. Last but not least, there is the unresolved question of tumor induction and propagation. All of these may account for morbidity and eventually mortality. METHODS Literature-based review to update current knowledge about safety and adverse events of TNF blockers. RESULTS Major drawbacks are infectious complications with the use of anti-TNF-α antibodies. The risk is increased in inflammatory bowel disease in general and in the perioperative setting of Crohn's disease patients. The number of tuberculosis cases has decreased since meticulous testing prior to treatment start is mandatory. An excess mortality that has been reported from referral centers is neither documented in randomized controlled trials nor in real-life settings. Regarding malignancies, lymphoma and skin cancer are a concern. The incidence of lymphoma may be raised, but this has also been debated with the use of thiopurines. Skin cancer, especially melanoma, is more common in inflammatory bowel disease and may be associated with the use of biologics. Overall, most studies do not address the influence of active inflammation or co-administration of other drugs. Hence, the risk attributable to TNF blockers alone is currently ill-defined. CONCLUSION Treatment with anti-TNF-α antibodies is an option with substantial risks. Most problems can be prevented by thorough workup of the patient.
Collapse
Affiliation(s)
- Klaus Fellermann
- Division of Gastroenterology, Department of Internal Medicine I, University Hospital of Schleswig-Holstein, Lübeck, Germany
| |
Collapse
|
21
|
Bär F, Bochmann W, Widok A, von Medem K, Pagel R, Hirose M, Yu X, Kalies K, König P, Böhm R, Herdegen T, Reinicke AT, Büning J, Lehnert H, Fellermann K, Ibrahim S, Sina C. Mitochondrial gene polymorphisms that protect mice from colitis. Gastroenterology 2013; 145:1055-1063.e3. [PMID: 23872498 DOI: 10.1053/j.gastro.2013.07.015] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 06/11/2013] [Accepted: 07/20/2013] [Indexed: 12/30/2022]
Abstract
BACKGROUND & AIMS Dysregulated energy homeostasis in the intestinal mucosa frequently is observed in patients with ulcerative colitis (UC). Intestinal tissues from these patients have reduced activity of the mitochondrial oxidative phosphorylation (OXPHOS) complex, so mitochondrial dysfunction could contribute to the pathogenesis of UC. However, little is known about the mechanisms by which OXPHOS activity could be altered. We used conplastic mice, which have identical nuclear but different mitochondrial genomes, to investigate activities of the OXPHOS complex. METHODS Colitis was induced in C57BL/6J wild-type (B6.B6) and 3 strains of conplastic mice (B6.NZB, B6.NOD, and B6.AKR) by administration of dextran sodium sulfate or rectal application of trinitrobenzene sulfonate. Colon tissues were collected and analyzed by histopathology, immunohistochemical analysis, and immunoblot analysis; we also measured mucosal levels of adenosine triphosphate (ATP) and reactive oxygen species, OXPHOS complex activity, and epithelial cell proliferation and apoptosis. RESULTS We identified mice with increased mucosal OXPHOS complex activities and levels of ATP. These mice developed less-severe colitis after administration of dextran sodium sulfate or trinitrobenzene sulfonate than mice with lower mucosal levels of ATP. Colon tissues from these mice also had increased enterocyte proliferation and transcription factor nuclear factor-κB activity, which have been shown to protect the mucosal barrier-defects in these processes have been associated with inflammatory bowel disease. CONCLUSIONS Variants in mitochondrial DNA that increase mucosal levels of ATP protect mice from colitis. Increasing mitochondrial ATP synthesis in intestinal epithelial cells could be a therapeutic approach for UC.
Collapse
Affiliation(s)
- Florian Bär
- Medical Department I, University Hospital Schleswig-Holstein, Lübeck, Germany; Institute of Anatomy, University of Lübeck, Lübeck, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Komorowski L, Teegen B, Probst C, Aulinger-Stöcker K, Sina C, Fellermann K, Stöcker W. Autoantibodies against exocrine pancreas in Crohn's disease are directed against two antigens: the glycoproteins CUZD1 and GP2. J Crohns Colitis 2013; 7:780-90. [PMID: 23140841 DOI: 10.1016/j.crohns.2012.10.011] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 10/15/2012] [Accepted: 10/17/2012] [Indexed: 12/26/2022]
Abstract
BACKGROUND Autoantibodies against exocrine pancreas (PAb) have been reported to be pathognomonic markers of Crohn's disease (CD). Recently, the glycoprotein GP2 has been proposed as the exclusive target for PAb but two equally prevalent binding patterns can be observed in the indirect immunofluorescence test (IIFT) using cryosections of human pancreas: a reticulogranular and a droplet pattern. AIM To identify autoantigens corresponding to the staining patterns. METHODS Different lectins were screened for their ability to immobilize PAb-reactive glycoproteins from cell free human pancreas. The glycoproteins were then purified via UEA-I affinity chromatography and identified by mass spectrometry. The two candidate autoantigens were separately expressed in HEK293 cells, and the recombinant cells applied as substrates in IIFT to analyze sera from 96 patients with CD, 89 controls and hybridoma supernatants during the generation of murine monoclonal antibodies. RESULTS The UEA-I eluate was able to neutralize PAb reactivity of both patterns in IIFT. It contained two major constituents which were identified as the glycoproteins CUZD1 and GP2. With the recombinant cells, 35.4% of the CD patients exhibited positive reactions (CUZD1 alone 19.8%, GP2 alone 9.4%, and both antigens 6.2%). The reaction with the CUZD1 expressing cells was strictly correlated to the reticulogranular pattern, whereas the antibodies causing the droplet pattern stained the GP2 expressing cells. Antigen-capture ELISA using the newly generated monoclonal antibodies against CUZD1 and GP2 verified this relationship. CONCLUSIONS The concordant reactivities of the different platforms can be regarded as a proof for the authenticity of the two identified autoantigens.
Collapse
Affiliation(s)
- Lars Komorowski
- Institute of Experimental Immunology, Euroimmun AG, Luebeck, Germany.
| | | | | | | | | | | | | |
Collapse
|
23
|
Herrlinger KR, Diculescu M, Fellermann K, Hartmann H, Howaldt S, Nikolov R, Petrov A, Reindl W, Otte JM, Stoynov S, Strauch U, Sturm A, Voiosu R, Ammendola A, Dietrich B, Hentsch B, Stange EF. Efficacy, safety and tolerability of vidofludimus in patients with inflammatory bowel disease: the ENTRANCE study. J Crohns Colitis 2013; 7:636-43. [PMID: 23078909 DOI: 10.1016/j.crohns.2012.09.016] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 09/05/2012] [Accepted: 09/19/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Vidofludimus (SC12267) is a novel oral immunomodulator inhibiting dihydroorotate dehydrogenase (DHODH) and the expression of proinflammatory cytokines including interleukin-17 (IL17A and IL17F) and interferon-gamma. The objective of the study was to explore the efficacy, safety and tolerability of vidofludimus in steroid-dependent inflammatory bowel disease (IBD). METHODS The open label uncontrolled ENTRANCE study (ClinicalTrials.gov NCT00820365) has been conducted at 13 study centers in Germany, Bulgaria and Romania. Thirty-four steroid-dependent patients with a confirmed diagnosis of Crohn's disease (CD) or ulcerative colitis (UC) were treated with a once daily 35mg oral dose of vidofludimus over 12weeks. Steroids were tapered during the first 8weeks followed by a steroid-free treatment period of 4weeks. Complete response was defined as steroid-free clinical remission at week 12; partial response was defined as being in remission at steroid dose equal or lower than the individual patient's threshold dose for relapse. RESULTS Of the thirty-four patients enrolled in this trial 26 were evaluable for primary efficacy assessment. After completion of the 12weeks treatment phase 8 out of 14 (57.1%) patients with CD and 6 out of 12 (50.0%) patients with UC were in steroid-free remission (complete responders). Another 4 (28.6%) patients in CD and 5 (41.7%) patients in UC were partial responders. Vidofludimus was well tolerated, no drug-related serious adverse events were observed. CONCLUSIONS This trial provides first evidence of clinical efficacy of vidofludimus in IBD. Although the safety and tolerability profile seems favorable, long-term controlled studies are needed to further investigate its potential as novel IBD therapy.
Collapse
Affiliation(s)
- K R Herrlinger
- Robert-Bosch-Hospital Stuttgart, Gastroenterology & Endocrinology, Stuttgart, Germany.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Bär F, Sina C, Hundorfean G, Pagel R, Lehnert H, Fellermann K, Büning J. Inflammatory bowel diseases influence major histocompatibility complex class I (MHC I) and II compartments in intestinal epithelial cells. Clin Exp Immunol 2013; 172:280-9. [PMID: 23574324 DOI: 10.1111/cei.12047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2012] [Indexed: 12/19/2022] Open
Abstract
Antigen presentation by intestinal epithelial cells (IEC) is crucial for intestinal homeostasis. Disturbances of major histocompatibility complex class I (MHC I)- and II-related presentation pathways in IEC appear to be involved in an altered activation of CD4(+) and CD8(+) T cells in inflammatory bowel disease. However, a comprehensive analysis of MHC I- and II-enriched compartments in IEC of the small and large bowel in the healthy state as opposed to inflammatory bowel diseases is lacking. The aim of this study was to characterize the subcellular expression of MHC I and II in the endocytic pathway of IEC throughout all parts of the intestinal tract, and to identify differences between the healthy state and inflammatory bowel diseases. Biopsies were taken by endoscopy from the duodenum, jejunum, ileum and colon in healthy individuals (n = 20). In Crohn's disease (CD), biopsies were obtained from the ileum and colon and within the colon from ulcerative colitis (UC) patients (n = 15). Analysis of IEC was performed by immunoelectron microscopy. MHC I and II were identified in early endosomes and multi-vesicular, multi-lamellar, electrondense and vacuolar late endosomes. Both molecules were enriched in multi-vesicular bodies. No differences were found between the distinct parts of the gut axis. In CD and UC the expression of MHC I and II showed a shift from multi-vesicular bodies towards the basolateral membranes. Within the multi-vesicular bodies, MHC I and II moved from internal vesicles to the limiting membranes upon inflammation in CD and UC. MHC I- and II-enriched compartments in IEC were identical in all parts of the small and large bowel. CD and UC appear to modulate the MHC I- and II-related presentation pathways of exogenous antigens in IEC.
Collapse
Affiliation(s)
- F Bär
- Department of Internal Medicine I, University Hospital of Schleswig-Holstein, Institute of Anatomy, University of Lübeck, Lübeck, Germany
| | | | | | | | | | | | | |
Collapse
|
25
|
Abstract
Although a great variety of new drugs have been introduced for the therapy of inflammatory bowel diseases so far, a definite cure of the disease is still out of scope. An anti-inflammatory approach to induce remission followed by maintenance therapy with immunosupressants is still the mainstay of therapy. Thiopurines comprising azathioprine and its active metabolite mercaptopurine as well as tioguanine, are widely used in the therapy of chronic active inflammatory bowel disease (IBD). Their steroid sparing potential and efficacy in remission maintenance are out of doubt. Unfortunately, untoward adverse events are frequently observed and may preclude further administration or be life threatening. This review will focus on new aspects of thiopurine therapy in IBD, its efficacy and safety.
Collapse
|
26
|
Fellermann K. Endoskopie als Baustein der interventionellen Therapie infizierter Pankreasnekrosen. Visc Med 2013. [DOI: 10.1159/000348422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
27
|
Schmidt KJ, Fellermann K, Büning J. Letter: short-term efficacy of tacrolimus in steroid-refractory ulcerative colitis - authors' reply. Aliment Pharmacol Ther 2013; 37:502. [PMID: 23336691 DOI: 10.1111/apt.12214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 12/22/2012] [Indexed: 12/08/2022]
|
28
|
Muhl E, Fellermann K. Sepsisquelle Abdomen - zwischen interventioneller, chirurgischer und intensivmedizinischer Therapie. Visc Med 2013. [DOI: 10.1159/000348285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
29
|
Schmidt KJ, Herrlinger KR, Emmrich J, Barthel D, Koc H, Lehnert H, Stange EF, Fellermann K, Büning J. Short-term efficacy of tacrolimus in steroid-refractory ulcerative colitis - experience in 130 patients. Aliment Pharmacol Ther 2013; 37:129-36. [PMID: 23121200 DOI: 10.1111/apt.12118] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 06/16/2012] [Accepted: 10/09/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND Steroid-refractory ulcerative colitis (UC) remains a challenging condition warranting surgery upon failure of pharmacological treatment. Calcineurin inhibitors or infliximab are alternatives in this situation. Data on the efficacy and safety of tacrolimus in this setting are limited. AIM To study the short-term efficacy and safety of tacrolimus in moderate-to-severe steroid-refractory UC. The role of thiopurines in this situation and predictors of colectomy were evaluated. METHODS In three centers, all charts from tacrolimus-treated patients with steroid-refractory UC were reviewed. Efficacy was assessed by colectomy-free survival and clinical remission at 3 months. RESULTS We identified 130 patients with pancolitis in 75 (59%), left-sided disease in 35 (27%) and proctitis in 18 patients (14%) (disease localisation not obtainable in two patients). The median age was 40 (range: 18-81). Clinical activity according to the median Lichtiger score decreased from 13 (range: 4-17) at baseline to 3 (0-14) at week 12. Eighteen patients underwent colectomy within the first 3 months of treatment with tacrolimus (14%). Clinical remission was achieved in 94 patients (72%) in this period. Thiopurines given in parallel to tacrolimus tended to limit colectomy and significantly increased remission (P = 0.002) in the short-term. No other predictors of colectomy or remission were identified. Side effects were noticed in 53% of patients and no severe events occurred. CONCLUSION This large survey confirms the efficacy and safety of tacrolimus in patients with steroid-refractory ulcerative colitis.
Collapse
Affiliation(s)
- K J Schmidt
- Department of Internal Medicine I, University Hospital of Schleswig-Holstein, Lübeck, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Bünger S, Haug U, Kelly M, Posorski N, Klempt-Giessing K, Cartwright A, Fitzgerald SP, Toner V, McAleer D, Gemoll T, Laubert T, Büning J, Fellermann K, Bruch HP, Roblick UJ, Brenner H, von Eggeling F, Habermann JK. A novel multiplex-protein array for serum diagnostics of colon cancer: a case-control study. BMC Cancer 2012; 12:393. [PMID: 22954206 PMCID: PMC3502594 DOI: 10.1186/1471-2407-12-393] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Accepted: 08/31/2012] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND More than 1.2 million new cases of colorectal cancer are reported each year worldwide. Despite actual screening programs, about 50% of the patients are diagnosed at advanced tumor stages presenting poor prognosis. Innovative screening tools could aid the detection at early stages and allow curative treatment interventions. METHODS A nine target multiplex serum protein biochip was generated and evaluated using a training- and validation-set of 317 highly standardized, liquid nitrogen preserved serum samples comprising controls, adenomas, and colon cancers. RESULTS Serum levels of CEA, IL-8, VEGF, S100A11, MCSF, C3adesArg, CD26, and CRP showed significant differences between cases and controls. The largest areas under the receiver operating characteristics curve were observed for CEA, IL-8, and CRP. At threshold levels yielding 90% specificity, sensitivities for CEA, IL-8 and CRP were 26%, 22%, and 17%, respectively. The most promising marker combinations were CEA + IL-8 reaching 37% sensitivity at 83% specificity and CEA + CRP with 35% sensitivity at 81% specificity. In an independent validation set CEA + IL-8 reached 47% sensitivity at 86% specificity while CEA + CRP obtained 39% sensitivity at 86% specificity. Early carcinomas were detected with 33% sensitivity for CEA + IL-8 and 28% for CEA + CRP. CONCLUSIONS Apart from CEA, IL-8, and CRP, the screening value of additional blood markers and the potential advantage of combining serum biochip testing with fecal occult blood testing needs to be studied. Multiplex biochip array technology utilizing serum samples offers an innovative approach to colorectal cancer screening.
Collapse
Affiliation(s)
- Stefanie Bünger
- Laboratory for Surgical Research, Department of Surgery, University of Lübeck, Ratzeburger Allee 160, D-23538, Lübeck, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Menne J, Nitschke M, Stingele R, Abu-Tair M, Beneke J, Bramstedt J, Bremer JP, Brunkhorst R, Busch V, Dengler R, Deuschl G, Fellermann K, Fickenscher H, Gerigk C, Goettsche A, Greeve J, Hafer C, Hagenmüller F, Haller H, Herget-Rosenthal S, Hertenstein B, Hofmann C, Lang M, Kielstein JT, Klostermeier UC, Knobloch J, Kuehbacher M, Kunzendorf U, Lehnert H, Manns MP, Menne TF, Meyer TN, Michael C, Münte T, Neumann-Grutzeck C, Nuernberger J, Pavenstaedt H, Ramazan L, Renders L, Repenthin J, Ries W, Rohr A, Rump LC, Samuelsson O, Sayk F, Schmidt BMW, Schnatter S, Schöcklmann H, Schreiber S, von Seydewitz CU, Steinhoff J, Stracke S, Suerbaum S, van de Loo A, Vischedyk M, Weissenborn K, Wellhöner P, Wiesner M, Zeissig S, Büning J, Schiffer M, Kuehbacher T. Validation of treatment strategies for enterohaemorrhagic Escherichia coli O104:H4 induced haemolytic uraemic syndrome: case-control study. BMJ 2012; 345:e4565. [PMID: 22815429 PMCID: PMC3400392 DOI: 10.1136/bmj.e4565] [Citation(s) in RCA: 225] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the effect of different treatment strategies on enterohaemorrhagic Escherichia coli O104:H4 induced haemolytic uraemic syndrome. DESIGN Multicentre retrospective case-control study. SETTING 23 hospitals in northern Germany. PARTICIPANTS 298 adults with enterohaemorrhagic E coli induced haemolytic uraemic syndrome. MAIN OUTCOME MEASURES Dialysis, seizures, mechanical ventilation, abdominal surgery owing to perforation of the bowel or bowel necrosis, and death. RESULTS 160 of the 298 patients (54%) temporarily required dialysis, with only three needing treatment long term. 37 patients (12%) had seizures, 54 (18%) required mechanical ventilation, and 12 (4%) died. No clear benefit was found from use of plasmapheresis or plasmapheresis with glucocorticoids. 67 of the patients were treated with eculizumab, a monoclonal antibody directed against the complement cascade. No short term benefit was detected that could be attributed to this treatment. 52 patients in one centre that used a strategy of aggressive treatment with combined antibiotics had fewer seizures (2% v 15%, P = 0.03), fewer deaths (0% v 5%, p = 0.029), required no abdominal surgery, and excreted E coli for a shorter duration. CONCLUSIONS Enterohaemorrhagic E coli induced haemolytic uraemic syndrome is a severe self limiting acute condition. Our findings question the benefit of eculizumab and of plasmapheresis with or without glucocorticoids. Patients with established haemolytic uraemic syndrome seemed to benefit from antibiotic treatment and this should be investigated in a controlled trial.
Collapse
Affiliation(s)
- Jan Menne
- Medical School Hannover, Hannover, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Bär F, Sina C, Schmidt KJ, Vogt FM, Roblick U, Lehnert H, Büning J, Fellermann K. [CEUS as a tool to uncover an unusual cause of obstructive jaundice]. Z Gastroenterol 2012; 50:449-52. [PMID: 22581699 DOI: 10.1055/s-0031-1282012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Aneurysms within the visceral arteries are rare. Among these, aneurysms of the splenic artery occur most frequently followed by aneurysms of the hepatic arteries. An early diagnosis is easily missed and almost all patients become symptomatic with an acute rupture associated with high mortality. Here we demonstrate the case of a 76-year-old patient who presented with acute upper abdominal pain accompanied by a single episode of vomiting and pyrexia of 39 °C. Laboratory results presented the picture of an obstructive jaundice without evidence for accompanying pancreatitis. Inflammatory markers were within normal limits at onset, but increased dramatically within the next few days. An acute calculous cholecystitis was diagnosed on abdominal ultrasound whereas gastroscopy revealed no relevant changes. Computed tomography was suspicious for pancreatitis of the head with obstruction of the bile duct. Choledocholithiasis was ruled out by ERCP, but symptoms persisted despite papillotomy. Due to raising inflammatory markers and an ongoing impairment of the patients condition, an abdominal CT scan was repeated which revealed the suspicion of a ruptured aneurysm of the common hepatic artery. At the time of transferral we were able to confirm the diagnosis by contrast-enhanced ultrasound and angiography. The patient was immediately forwarded to surgery due to lack of satisfactory endovascular procedures. In summary, the patient suffered from a ruptured spurial aneurysm of the right gastric artery thereby obstructing the common bile duct. Beside CT scans and angiography, this case documents a pivotal role for contrast-enhanced ultrasound in the work-up of visceral artery aneurysms.
Collapse
Affiliation(s)
- F Bär
- Medizinische Klinik I, Universitätsklinikum Schleswig Holstein, Lübeck.
| | | | | | | | | | | | | | | |
Collapse
|
33
|
Nitschke M, Sayk F, Härtel C, Roseland RT, Hauswaldt S, Steinhoff J, Fellermann K, Derad I, Wellhöner P, Büning J, Tiemer B, Katalinic A, Rupp J, Lehnert H, Solbach W, Knobloch JKM. Association between azithromycin therapy and duration of bacterial shedding among patients with Shiga toxin-producing enteroaggregative Escherichia coli O104:H4. JAMA 2012; 307:1046-52. [PMID: 22416100 DOI: 10.1001/jama.2012.264] [Citation(s) in RCA: 122] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT An outbreak of Shiga toxin-producing enteroaggregative Escherichia coli (STEC O104:H4) infection with a high incidence of hemolytic uremic syndrome (HUS) occurred in Germany in May 2011. Antibiotic treatment of STEC infection is discouraged because it might increase the risk of HUS development. However, antibiotic therapy is widely used to treat enteroaggregative E coli infection. In the German outbreak, a substantial number of patients received prophylactic azithromycin treatment as part of a therapeutic regimen with the C5 antibody eculizumab. OBJECTIVE To analyze the duration of bacterial shedding in patients with STEC infection who did and did not receive oral azithromycin therapy. DESIGN, SETTING, AND PATIENTS At a single center in Lübeck, Germany, 65 patients with STEC infection, including patients with HUS as well as STEC-infected outpatients without manifestation of HUS, were investigated between May 15 and July 26, 2011, and were monitored for a mean of 39.3 days after onset of clinical symptoms. MAIN OUTCOME MEASURE Carriage of STEC after azithromycin therapy. RESULTS Twenty-two patients received oral azithromycin and 43 patients did not receive antibiotic treatment. Among antibiotic-treated patients, long-term STEC carriage (>28 days) was observed in 1 of 22 patients (4.5%; 95% CI, 0%-13.3%) compared with 35 of 43 patients (81.4%; 95% CI, 69.8%-93.0%) who were not treated with antibiotics (P < .001). All 22 patients receiving azithromycin treatment had at least 3 STEC-negative stool specimens after the completion of treatment, and no recurrence of STEC was observed in these patients. As proof of principle, 15 patients who initially were not treated with antibiotics and were long-term STEC carriers were treated with oral azithromycin given for 3 days and subsequently had negative stool specimens. CONCLUSION Treatment with azithromycin was associated with a lower frequency of long-term STEC O104:H4 carriage.
Collapse
Affiliation(s)
- Martin Nitschke
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Meinhardt C, Büning J, Fellermann K, Lehnert H, Schmidt KJ. Cyclophosphamide therapy in Sweet's syndrome complicating refractory Crohn's disease − Efficacy and mechanism of action. J Crohns Colitis 2011; 5:633-7. [PMID: 22115387 DOI: 10.1016/j.crohns.2011.07.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 07/24/2011] [Accepted: 07/25/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Sweet's syndrome is a rare extraintestinal manifestation of Crohn's disease that is usually treated by corticosteroids. Cyclophosphamide therapy has been shown to be effective in steroid-refractory Crohn's disease with extraintestinal manifestations. The mechanism of action remains obscure. Here, we report about a case of steroid-refractory Sweet's syndrome accompanying Crohn's colitis treated by cyclophosphamide. METHODS At baseline and two weeks after initiating cyclophosphamide pulse therapy, clinical symptoms were evaluated and apoptosis in mononuclear cells of the colon mucosa was quantified via immunofluorescence TUNEL-labeling. Ongoing clinical follow-up lasts for more than three years. RESULTS Cyclophosphamide pulse therapy resulted in complete resolution of luminal activity and extraintestinal manifestations. TUNEL-marked CD4(+), CD8(+) and CD68(+) cells in intestinal biopsies showed a 338% increase as compared to baseline. CONCLUSIONS Cyclophosphamide therapy was highly effective in steroid-refractory Crohn's colitis accompanied by Sweet's syndrome for induction of remission. Furthermore, apoptosis of mononuclear cells in the colon mucosa, including CD68(+) macrophages as well as CD4(+) and CD8(+) cells, appears to be a component of the anti-inflammatory effect of cyclophosphamide in Crohn's disease.
Collapse
Affiliation(s)
- Christian Meinhardt
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | | | | | | | | |
Collapse
|
35
|
Rades D, Moehler M, Schmidberger H, Fellermann K, Buerk C. 6526 POSTER Phase I Study of Definitive Chemoradiation With Cisplatin/5-FU Plus Cetuximab in Unresectable Esophageal Cancer. Eur J Cancer 2011. [DOI: 10.1016/s0959-8049(11)71837-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
36
|
Abstract
Defensins are endogenous antibiotics with microbicidal activity against Gram-negative and Gram-positive bacteria, fungi, enveloped viruses and protozoa. A disturbed antimicrobial defense, as provided by Paneth- and other epithelial cell defensins, seems to be a critical factor in the pathogenesis of inflammatory bowel diseases. Conspicuously, there is a relative lack of Paneth cell beta-defensins HD-5 and HD-6 in ileal Crohn's disease, both in the absence of a pattern recognition receptor NOD2 mutation and, even more pronounced, in its presence. This deficit is independent of concurrent active inflammation and results in a diminished antibacterial killing by the mucosa. The Crohn's disease mucosa has not only a significant lack in killing different Escherichia coli but also an impaired ability in clearing Staphylococcus aureus as well as anaerobic micro-organisms. Thus, this dysfunction in antibacterial barrier seems to be broad and is not restricted to a single bacterial strain. In addition to directly controlling barrier function, Paneth cell defensins also regulate the composition of the bacterial stool flora. In the majority of patients, the Paneth cell deficiency is mediated by WNT signalling which suggests a disturbed Paneth cell differentiation in ileal Crohn's disease. In contrast, colonic Crohn's disease is characterised by an impaired induction of mucosal beta-defensins, partly due to a low copy number of the beta-defensin gene cluster. Therefore it seems plausible that bacteria take advantage of a niche formed by defensin deficiency. This would represent a paradigm shift in understanding Crohn's disease and provides a target for future therapeutic strategies.
Collapse
Affiliation(s)
- J Wehkamp
- Dr. Margarete Fischer-Bosch - Institute of Clinical Pharmacology, and Robert Bosch Hospital; Internal Medicine I, Auerbachstr. 112, 70376 Stuttgart, Germany.
| | | | | |
Collapse
|
37
|
Fellermann K. [Not Available]. Med Klin (Munich) 2010; 105:442-443. [PMID: 20593573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
|
38
|
Fellermann K. [Not Available]. Med Klin (Munich) 2010; 105:441. [PMID: 20593572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
|
39
|
Herrlinger KR, Barthel DN, Schmidt KJ, Büning J, Barthel CS, Wehkamp J, Stange EF, Fellermann K. Infliximab as rescue medication for patients with severe ulcerative/indeterminate colitis refractory to tacrolimus. Aliment Pharmacol Ther 2010; 31:1036-41. [PMID: 20175769 DOI: 10.1111/j.1365-2036.2010.04267.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The calcineurin inhibitor tacrolimus and the anti-TNF-antibody infliximab are established options in steroid-refractory ulcerative colitis (UC). AIM To evaluate the efficacy of infliximab-salvage therapy in patients with refractory UC failing to respond to tacrolimus. METHODS Twenty-four patients were enrolled in this evaluation. Reasons for tacrolimus therapy were steroid-refractory disease in 19 patients and steroid-dependency in five patients. All patients receiving infliximab had tacrolimus-refractory active disease (Lichtiger score >10) and were treated with 5 mg/kg at weeks 0, 2 and 6 and every 8 weeks thereafter, if tolerated. RESULTS Six of 24 patients (25%) achieved remission following infliximab infusion and four of 24 (17%) had an initial response only, but underwent proctocolectomy later because of loss of response (3) or development of a delayed hypersensitivity reaction (1). Fourteen patients (58%) completely failed to respond with 10 undergoing colectomy. Eight patients experienced side effects under infliximab, including two infectious complications (herpes zoster and herpes pneumonia). CONCLUSIONS Infliximab offers a therapeutic option as rescue therapy in about a quarter of patients with active UC after failing to respond to tacrolimus. This benefit has to be weighed against the risks of infectious complications.
Collapse
Affiliation(s)
- K R Herrlinger
- Department of Gastroenterology, Hepatology and Endocrinology, Robert-Bosch-Hospital, Stuttgart, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
40
|
Abstract
The broad spectrum of chronic inflammatory bowel diseases encompasses the two main entities Crohn's disease (CD) and ulcerative colitis (UC). Rapid action and long-term duration is the superordinate goal in most therapeutic approaches facing chronic inflammation including inflammatory bowel diseases (IBD) for induction and maintenance of remission. The availability of antibodies targeting TNF-alpha or alpha 4 integrin has recently offered new opportunities apart from classical remedies for the treatment of CD, a major challenge for future therapeutic concepts. Classical way of treating CD is an escalation scheme ("step-up") whereas the novel and still controverse approach ("top-down") favors a biological as initial drug. Today, four biologicals have proven efficacy and safety in CD treatment strategies and have received approval by FDA and, with the exception of natalizumab and certolizumab, by EMEA. Infliximab was the first TNF-alpha blocker and extended the care in CD. Adalimumab and certolizumab pegol followed as humanized second generation TNF-alpha blockers. Another targeted therapy option is natalizumab, an alpha 4 integrin monoclonal antibody, which blocks the migration of leukocytes into inflamed gut tissue. Nevertheless, a considerable number of patients remain refractory, lose response or render intolerant to these biologicals. An overall long lasting remission of less than 30% with scheduled administration of TNF-alpha blockers in patients with steroid dependent or refractory CD seems to be lifelike and alternative therapeutic options are warranted. Broad acting antimetabolites come into focus again and recent data provide substantial evidence for the efficacy and safety of cyclophosphamide pulse therapy in ileocolonic, refractory CD. This therapeutic option should be kept in mind as a reasonable agent to target the inflammatory process in severely disabled patients. Hence, targeted therapy in CD seems to be still a myth at present owing to the complex nature of disease.
Collapse
Affiliation(s)
- Klaus J Schmidt
- Department of Internal Medicine I, University Hospital of Schleswig-Holstein, Ratzeburger Allee 160, D-23538 Lübeck, Germany.
| | | | | | | | | |
Collapse
|
41
|
Borcherding F, Nitschke M, Hundorfean G, Rupp J, von Smolinski D, Bieber K, van Kooten C, Lehnert H, Fellermann K, Büning J. The CD40-CD40L pathway contributes to the proinflammatory function of intestinal epithelial cells in inflammatory bowel disease. Am J Pathol 2010; 176:1816-27. [PMID: 20133813 DOI: 10.2353/ajpath.2010.090461] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In inflammatory bowel diseases (IBD), intestinal epithelial cells (IECs) are involved in the outbalanced immune responses toward luminal antigens. However, the signals responsible for this proinflammatory capacity of IECs in IBD remain unclear. The CD40/CD40L interaction activates various pathways in immune and nonimmune cells related to inflammation and was shown to be critical for the development of IBD. Here we demonstrate CD40 expression within IECs during active IBD. Endoscopically obtained biopsies taken from Crohn's disease (n = 112) and ulcerative colitis patients (n = 67) consistently showed immunofluorescence staining for CD40 in IECs of inflamed ileal or colonic mucosa. In noninvolved mucosa during active disease, tissue obtained during Crohn's disease or ulcerative colitis in remission and biopsies from healthy controls (n = 38) IECs almost entirely lacked CD40 staining. Flow cytometry and RT-PCR analysis using different intestinal epithelial cell lines (HT29, SW480, and T84) showed IFN-gamma to effectively induce CD40 in IECs. Cells were virtually unresponsive to LPS or whole E. coli regarding CD40 expression. In addition, a moderate induction of CD40 was found in response to TNF-alpha, which exerted synergistical effects with IFN-gamma. CD40 ligation by CD40L-transfected murine fibroblasts or soluble CD40L increased the secretion of IL-8 in IFN-gamma pretreated HT29 cells. Our findings provide evidence for the epithelial expression and modulation of CD40 in IBD-affected mucosa and indicate its involvement in the proinflammatory function of IECs.
Collapse
Affiliation(s)
- Frauke Borcherding
- Department of Internal Medicine I, University Hospital of Schleswig-Holstein, Ratzeburger Allee 160, D-23538 Lübeck, Germany.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Kübler I, Koslowski MJ, Gersemann M, Fellermann K, Beisner J, Becker S, Rothfuss K, Herrlinger KR, Stange EF, Wehkamp J. Influence of standard treatment on ileal and colonic antimicrobial defensin expression in active Crohn's disease. Aliment Pharmacol Ther 2009; 30:621-33. [PMID: 19549264 DOI: 10.1111/j.1365-2036.2009.04070.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Crohn's Disease (CD), a chronic intestinal inflammation, is currently treated primarily by therapeutics which are directed against inflammatory responses. Recent findings though suggest a central role of the innate immune barrier in the pathophysiology. Important factors providing this barrier are antimicrobial peptides like the alpha- and beta-defensins. Little is known about in vivo effects of common drugs on their expression. AIM To analyse the influence of corticosteroids, azathioprine and aminosalicylate treatment on ileal and colonic antimicrobial peptides in active CD and also assess the role of inflammation. METHODS We measured the expression of antimicrobial peptides and pro-inflammatory cytokines in 75 patients with active CD. RESULTS Ileal and colonic alpha- and beta-defensins as well as LL37 remained unaffected by corticosteroids, azathioprine or aminosalicylate treatment. Additionally, we did not observe a negative coherency between Paneth cell alpha-defensins and any measured cytokines. HBD2 and LL37 unlike HBD1 levels were linked to inflammatory cytokines and increased in highly inflamed samples. CONCLUSIONS Current oral drug treatment seems to have no major effect on the expression of antimicrobial peptides. In contrast to HBD2 and LL37, ileal levels of HD5 and HD6 and colonic HBD1 level are independent of current inflammation. Innovative drugs should aim to strengthen protective innate immunity.
Collapse
Affiliation(s)
- I Kübler
- Robert-Bosch-Hospital, Stuttgart, Germany
| | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Schmidt KJ, Fellermann K, Wellhöner P, Weitz G, Homann N, Herrlinger K, Lehnert H, Ludwig D, Büning J. Clinical trial: cyclophosphamide pulse therapy - a promising therapeutic alternative in refractory Crohn's disease. Aliment Pharmacol Ther 2009; 29:1230-9. [PMID: 19302074 DOI: 10.1111/j.1365-2036.2009.03999.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In severe steroid-refractory Crohn's disease (CD), established therapies fail in a relevant proportion of patients. Recent pilot studies indicated the efficacy of cyclophosphamide pulse therapy in these patients. AIM To provide further and substantial evidence for the rationale to apply cyclophosphamide pulse therapy as therapeutic option in severe courses of CD. METHODS Fifteen patients with steroid-refractory (n = 13) or steroid-dependent (n = 2) CD received 2-6 (median 3) monthly pulses of 750 mg cyclophosphamide in an open-label fashion. Eleven patients were on concomitant immunosuppression (azathioprine/mercaptopurine n = 9; methotrexate n = 2). RESULTS Thirteen of 15 patients (87%) had a clinical response (CDAI decrease >100). Ten patients (67%) went into remission (CDAI <150) after 8 weeks. Steroid-free remission was achieved in eight patients (54%). Two patients (13%) failed to respond. Median CDAI decreased from 420 (245-550) to 100 (26-538) at week 8. Remission lasted 16 months (median, range 4-40). In three patients, arthritis, erythema nodosum and episcleritis completely resolved. Cyclophosphamide pulse therapy administration was well tolerated in all subjects. CONCLUSIONS Cyclophosphamide pulse therapy is safe and highly effective for induction and maintenance of remission in steroid-refractory/-dependent CD. There is a strong need for additional experience to improve the setting of the encouraging cyclophosphamide treatment in CD.
Collapse
Affiliation(s)
- K J Schmidt
- Department of Internal Medicine I, University Hospital of Schleswig-Holstein, Lübeck, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Möndel M, Schroeder BO, Zimmermann K, Huber H, Nuding S, Beisner J, Fellermann K, Stange EF, Wehkamp J. Probiotic E. coli treatment mediates antimicrobial human beta-defensin synthesis and fecal excretion in humans. Mucosal Immunol 2009; 2:166-72. [PMID: 19129752 PMCID: PMC10026704 DOI: 10.1038/mi.2008.77] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Inducible epithelial human beta-defensins (hBD) play an important role in intestinal barrier function. In vitro studies showed that clinically effective probiotics induce antimicrobial hBD-2. Here, we aimed to assess the in vivo effect in healthy volunteers and also addressed how defensins affect probiotic survival. Symbioflor 2 containing one strain of several viable genotypes of Escherichia coli was administered to 23 healthy individuals. After 3 weeks, fecal hBD-2 peptide was increased in 78% (mean 3.7-fold; P<0.0001). Interestingly, the fecal hBD-2 peptide was still elevated 9 weeks after treatment (P=0.008). In vitro studies revealed that this effect was mediated by only one out of three tested E. coli genotypes and comparable to probiotic E. coli Nissle 1917 (10- to 15-fold). Functional assays showed that all tested bacteria were similarly killed by defensins allowing to speculate about a suicidal character of this effect. Defensin induction seems to be a common and important mechanism of probiotic treatment.
Collapse
Affiliation(s)
- M Möndel
- Dr Margarete Fischer-Bosch-Institute of Clinical Pharmacology and University of Tübingen, Stuttgart, Germany
| | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Koslowski MJ, Kübler I, Chamaillard M, Schaeffeler E, Reinisch W, Wang G, Beisner J, Teml A, Peyrin-Biroulet L, Winter S, Herrlinger KR, Rutgeerts P, Vermeire S, Cooney R, Fellermann K, Jewell D, Bevins CL, Schwab M, Stange EF, Wehkamp J. Genetic variants of Wnt transcription factor TCF-4 (TCF7L2) putative promoter region are associated with small intestinal Crohn's disease. PLoS One 2009. [PMID: 19221600 DOI: 10.1371/journal.pone.00 04496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Reduced expression of Paneth cell antimicrobial alpha-defensins, human defensin (HD)-5 and -6, characterizes Crohn's disease (CD) of the ileum. TCF-4 (also named TCF7L2), a Wnt signalling pathway transcription factor, orchestrates Paneth cell differentiation, directly regulates the expression of HD-5 and -6, and was previously associated with the decrease of these antimicrobial peptides in a subset of ileal CD. To investigate a potential genetic association of TCF-4 with ileal CD, we sequenced 2.1 kb of the 5' flanking region of TCF-4 in a small group of ileal CD patients and controls (n = 10 each). We identified eight single nucleotide polymorphisms (SNPs), of which three (rs3814570, rs10885394, rs10885395) were in linkage disequilibrium and found more frequently in patients; one (rs3814570) was thereby located in a predicted regulatory region. We carried out high-throughput analysis of this SNP in three cohorts of inflammatory bowel disease (IBD) patients and controls. Overall 1399 healthy individuals, 785 ulcerative colitis (UC) patients, 225 CD patients with colonic disease only and 784 CD patients with ileal involvement were used to determine frequency distributions. We found an association of rs3814570 with ileal CD but neither with colonic CD or UC, in a combined analysis (allele positivity: OR 1.27, 95% CI 1.07 to 1.52, p = 0.00737), which was the strongest in ileal CD patients with stricturing behaviour (allele frequency: OR 1.32, 95% CI 1.08 to1.62, p = 0.00686) or an additional involvement of the upper GIT (allele frequency: OR 1.38, 95% CI 1.03 to1.84, p = 0.02882). The newly identified genetic association of TCF-4 with ileal CD provides evidence that the decrease in Paneth cell alpha-defensins is a primary factor in disease pathogenesis.
Collapse
Affiliation(s)
- Maureen J Koslowski
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, University of Tübingen, Stuttgart, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Nuding S, Zabel LT, Enders C, Porter E, Fellermann K, Wehkamp J, Mueller HAG, Stange EF. Antibacterial activity of human defensins on anaerobic intestinal bacterial species: a major role of HBD-3. Microbes Infect 2009; 11:384-93. [PMID: 19397883 DOI: 10.1016/j.micinf.2009.01.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Revised: 01/04/2009] [Accepted: 01/06/2009] [Indexed: 11/27/2022]
Abstract
Defensins are natural mucosal antimicrobial peptides and their broad spectrum activity against aerobic or facultative anaerobic bacteria has been well investigated. The aim of this study was to systematically examine the antibacterial activity of the small intestinal Paneth cell derived alpha-defensin HD5 and the major colonic beta-defensins HBD-1-3 against strict anaerobic intestinal bacteria. The antibacterial activity was assessed with a flow cytometric assay employing a membrane potential sensitive dye as marker for loss of cell viability. The majority of the tested strains belonging to the dominant anaerobe genera of the gut, Bacteroides and Parabacteroides, were only minimally affected by the constitutively expressed defensins HD5 and HBD-1. The inducible defensin HBD-2 had a limited antibacterial effect, whereas the inducible HBD-3 exhibited potent activity against most strains. The effect of HBD-3 on Bacteroides sp. appeared to be dependent on the presence of oxygen. Bacteroides fragilis strains isolated from blood during bacteremia or from extraintestinal infections were more resistant to HBD-3 than strains from the physiological gut flora. Thus, defensin resistance is not only species- but also strain-specific and may be clinically relevant in the host-bacteria interaction influencing mucosal translocation and systemic infection.
Collapse
Affiliation(s)
- Sabine Nuding
- Dr Margarete Fischer-Bosch-Institute of Clinical Pharmacology Stuttgart and University of Tuebingen, Auerbachstr. 112, 70376 Stuttgart, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Gersemann M, Becker S, Kübler I, Koslowski M, Wang G, Herrlinger KR, Griger J, Fritz P, Fellermann K, Schwab M, Wehkamp J, Stange EF. Differences in goblet cell differentiation between Crohn's disease and ulcerative colitis. Differentiation 2008; 77:84-94. [PMID: 19281767 DOI: 10.1016/j.diff.2008.09.008] [Citation(s) in RCA: 194] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Revised: 06/23/2008] [Accepted: 07/02/2008] [Indexed: 02/06/2023]
Abstract
Goblet cells are mucin-secreting intestinal cells forming the mucus layer that protects the mucosal surface. Ulcerative colitis (UC) has been associated with a defective colonic mucus layer and a reduced number of goblet cells. In experimental animals, colonic goblet cell differentiation is regulated by interacting transcription factors Hath1, KLF4 and the Notch, as well as Wnt pathways, whereas data in humans are limited. We investigated goblet cell differentiation factors and mucins in controls and in inflammatory bowel diseases (IBDs). We performed real-time PCR for Hath1, KLF4, several ligands, receptors and target genes of the Notch and Wnt pathways, as well as several mucins in biopsies from the sigmoid colon of controls (n=21), Crohn's disease (CD, n=48) and UC (n=40). In addition, Hath1 protein was quantitated with Western blot and localized with immunohistochemistry. Notably, the degree of inflammation as measured by IL-8 and histology was similar in both disease entities. The proportion of goblet cells was lowered in both IBDs, but specifically diminished in the upper third of the crypt in UC. Comparable levels of inflammation induced both Hath1 (2.0-fold, p<0.001) and KLF4 (1.8-fold for KLF4, p=0.031) mRNA expression in CD but not in UC (0.8-0.9-fold, ns). The differential induction was confirmed for Hath1 protein using Western blot. Hath1 immunostaining was found mostly in the lower half of the colonic crypts. Hath1, KLF4 and the Notch target gene Hes1 were significantly (p<0.001) and positively correlated. Moreover, both Hath1 and KLF4 were correlated (p<0.001) with MUC1, MUC2 as well as MUC4 in all control and IBD cohorts. The results indicate that both transcription factors are key regulators of goblet cell differentiation and mucin formation in the human colon. Conspicuously, inflammation is associated with an enhanced goblet cell differentiation in CD but not in UC, a defect possibly of pathogenic importance.
Collapse
Affiliation(s)
- Michael Gersemann
- Department of Internal Medicine I, Robert Bosch Hospital, Stuttgart, Germany
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Abstract
Crohn’s disease may prinicipally involve the whole gastrointestinal tract. Most commonly, the inflammation occurs in the small intestine and/or in the colon with stable disease location over the years. The pathogenesis of both disease phenotypes is complex, the likely primary defect lies in the innate rather than adaptive immunity, particularly in the chemical antimicrobial barrier of the mucosa. Crohn’s ileitis is associated with a reduced expression of the Wnt signalling pathway transcription factor T-cell factor 4 (TCF4), which is regulating Paneth cell differentiation. As a result, the alpha-defensins and principal Paneth cell products HD5 and HD6 are deficiently expressed in ileal disease, independent of current inflammation. In contrast, Crohn’s colitis is typically associated with an impaired induction of the beta-defensins HBD2 and HBD3 caused by fewer gene copy numbers in the gene locus of the beta-defensins on chromosome 8. This ileal and colonic defect in innate defence mediated by a deficiency of the protective alpha- and beta-defensins may enable the luminal microbes to invade the mucosa and trigger the inflammation. A better understanding of the exact molecular mechanisms behind ileal and colonic Crohn’s disease may give rise to new therapeutic strategies based on a stimulation of the protective innate immune system.
Collapse
|
49
|
Fellermann K, Stange EF. How effective is natalizumab induction therapy in patients with Crohn's disease? Nat Clin Pract Gastroenterol Hepatol 2008; 5:78-79. [PMID: 18073717 DOI: 10.1038/ncpgasthep1031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2007] [Accepted: 09/24/2007] [Indexed: 05/25/2023]
|
50
|
Abstract
Recent evidence suggests that probiotic bacteria may stabilize gut barrier function via induction of anti-microbial peptides such as defensins. This study aimed to elucidate the induction mechanism of the human beta defensin-2 (hBD-2) gene by different probiotic lactobacillus strains. The expression of hBD-2 mRNA peaked at 6 h of incubation upon treatment of Caco-2 cells and increased with higher dosage of various probiotic bacteria. Deletion of nuclear factor (NF)-kappaB and activator protein-1 (AP-1) binding sites on the hBD-2 promoter resulted in a complete abrogation of promoter activation by probiotics. As revealed by the use of specific mitogen-activated protein kinase (MAPK) inhibitors the hBD-2 induction was dependent on the MAPK extracellular regulated kinase (ERK 1/2), p38 and c-Jun N-terminal kinase (JNK), although to varying degrees. Several Lactobacillus strains and VSL#3, a probiotic cocktail of four lactobacilli, three bifidum and one streptococcus species, induced the secretion of the hBD-2 peptide into the culture media as shown by enzyme-linked immunosorbent assay (ELISA). Thus, the present study suggests that lactobacilli and the VSL#3 bacterial mixture strengthen intestinal barrier functions through the up-regulation of hBD-2 via induction of proinflammatory pathways including NF-kappaB and AP-1 as well as MAPKs.
Collapse
Affiliation(s)
- M Schlee
- Dr Margarete Fischer-Bosch-Institute of Clinical Pharmacology and University of Tübingen, Stuttgart, Germany.
| | | | | | | | | | | |
Collapse
|