Phenotype and natural history of elderly onset inflammatory bowel disease: a multicentre, case-control study

BACKGROUND

Onset during old age has been reported in upto 10% of total cases of inflammatory bowel disease (IBD).

AIM

To evaluate phenotypic characteristics and the use of therapeutic resources in patients with elderly onset IBD.

METHODS

Case-control study including all those patients diagnosed with IBD over the age of 60 years since 2000 who were followed-up for >12 months, identified from the IBD databases. Elderly onset cases were compared with IBD patients aged 18 to 40 years at diagnosis, matched by year of diagnosis, gender and type of IBD (adult-onset).

RESULTS

One thousand three hundred and seventy-four elderly onset and 1374 adult-onset cases were included (62% ulcerative colitis (UC), 38% Crohn's disease (CD)). Among UC patients, elderly onset cases had a lower proportion of extensive disease (33% vs 39%; P < 0.0001). In CD, elderly onset cases showed an increased rate of stenosing pattern (24% vs 13%; P < 0.0001) and exclusive colonic location (28% vs 16%; P < 0.0001), whereas penetrating pattern (12% vs 19%; P < 0.0001) was significantly less frequent. Regarding the use of therapeutic resources, there was a significantly lower use of corticosteroids (P < 0.0001), immunosuppressants (P < 0.0001) and anti-TNFs agents (P < 0.0001) in elderly onset cases. Regarding surgery, we found a significantly higher surgery rate among elderly onset UC cases (8.3% vs 5.1%; P < 0.009). Finally, elderly onset cases were characterised by a higher rate of hospitalisations (66% vs 49%; P < 0.0001) and neoplasms (14% vs 0.5%; P < 0.0001).

CONCLUSIONS

Elderly onset IBD shows specific characteristics and they are managed differently, with a lower use of immunosuppressants and a higher rate of surgery in UC.

Extracolonic Cancer in Inflammatory Bowel Disease: Data from the GETECCU Eneida Registry

OBJECTIVES

The objective of this study was (a) To know the prevalence and distribution of extracolonic cancer (EC) in patients with inflammatory bowel disease (IBD); (b) To estimate the incidence rate of EC; (c) To evaluate the association between EC and treatment with immunosuppressants and anti-tumor necrosis factor (TNF) agents.

METHODS

This was an observational cohort study.

INCLUSION CRITERIA

IBD and inclusion in the ENEIDA Project (a prospectively maintained registry) from GETECCU.

EXCLUSION CRITERIA

Patients with EC before the diagnosis of IBD, lack of relevant data for this study, and previous treatment with immunosuppressants other than corticosteroids, thiopurines, methotrexate, or anti-TNF agents. The Kaplan-Meier method was used to evaluate the impact of several variables on the risk of EC, and any differences between survival curves were evaluated using the log-rank test. Stepwise multivariate Cox regression analysis was used to investigate factors potentially associated with the development of EC, including drugs for the treatment of IBD, during follow-up.

RESULTS

A total of 11,011 patients met the inclusion criteria and were followed for a median of 98 months. Forty-eight percent of patients (5,303) had been exposed to immunosuppressants or anti-TNF drugs, 45.8% had been exposed to thiopurines, 4.7% to methotrexate, and 21.6% to anti-TNF drugs. The prevalence of EC was 3.6%. In the multivariate analysis, age (HR=1.05, 95% CI=1.04-1.06) and having smoked (hazards ratio (HR)=1.47, 95% confidence interval (CI)=1.10-1.80) were the only variables associated with a higher risk of EC.

CONCLUSIONS

Neither immunosuppressants nor anti-TNF drugs seem to increase the risk of EC. Older age and smoking were associated with a higher prevalence of EC.

Effect of partially protected butyrate used as feed additive on growth and intestinal metabolism in sea bream (Sparus aurata)

Butyrate is a short-chain fatty acid extensively used in animal nutrition since it promotes increases in body weight and other multiple beneficial effects on the intestinal tract. Although such effects have been demonstrated in several species, very few studies have assessed them in fish. On the other hand, little is known about the metabolic processes underlying these effects. In the present work, growth parameters and changes in more than 80 intestinal metabolites (nucleotides, amino acids and derivatives, glycolytic intermediates, redox coenzymes and lipid metabolism coenzymes) have been quantified in juvenile sea bream fed a butyrate-supplemented diet. Results showed a significant increase in the weight of fish receiving butyrate, while metabolomics provided some clues on the suggested effects of this feed additive. It seems that butyrate increased the availability of several essential amino acids and nucleotide derivatives. Also, the energy provision for enteric cells might have been enhanced by a decrease in glucose and amino acid oxidation related to the use of butyrate as fuel. Additionally, butyrate might have increased transmethylation activity. This work represents an advance in the knowledge of the metabolic consequences of using butyrate as an additive in fish diets.

Effects of haptoglobin polymorphisms and deficiency on susceptibility to inflammatory bowel disease and on severity of murine colitis

BACKGROUND

Haptoglobin (Hp) is a haemoglobin-binding protein with immunomodulatory properties. Its gene (16q22) harbours a common polymorphism with two different alleles: Hp1 and Hp2. Genotype Hp22 has been shown to be over-represented in different immune diseases. Results in Crohn's disease (CD) are contradictory.

AIMS

To determine whether Hp plays a role in inflammatory bowel disease, both genetically and functionally.

METHODS

1061 patients with CD, 755 with ulcerative colitis (UC) and 152 with primary sclerosing cholangitis, as well as 452 healthy controls, were genotyped using touch-down PCR. To confirm association results, 464 CD trios and 151 UC trios were genotyped. Serum Hp concentrations were determined in 62 individuals of different genotype. Colitis was induced in mice with dextran sulphate sodium (DSS) and oxazolone (Oxa). Cytokine production was evaluated by mRNA quantification in colonic tissue and ELISA on supernatants of mesenteric lymph node cells.

RESULTS

Prevalence of Hp2 was higher in CD and UC than in controls. In the confirmatory cohorts, Hp2 was over-transmitted to the affected offspring. Serum Hp concentrations were higher in individuals with genotypes Hp11 and Hp21 than in those with Hp22 (1.38 vs 0.89 g/l). DSS- and Oxa-induced colitis were more severe in Hp-deficient mice than in control mice and accompanied by higher concentrations (although not statistically significantly different) of tissue mRNA for cytokines. Interleukin-17 production was significantly higher in the presence of Hp-deficient serum compared with wild-type serum.

CONCLUSIONS

The Hp gene may play a role in susceptibility to inflammatory bowel disease. Its implication in other immune diseases underscores the common pathways between these diseases. Experimental models of colitis showed that Hp has a protective role in inflammatory colitis, most likely by inhibiting the production of Th1 and Th17 cytokines.

Differences in expression and activity of 11beta-hydroxysteroid dehydrogenase type 1 and 2 in human placentas of term pregnancies according to birth weight and gender

BACKGROUND

Fetal exposure to maternal glucocorticoids may determine fetal growth and the programing of later disorders. Availability of the glucocorticoids in the placenta is regulated by the 11beta-hydroxysteroid dehydrogenase (11beta-HSDs) enzymes. To date, there are discrepancies with regard to cortisol (F) cord blood levels in fetuses with intrauterine growth retardation in different species. Objective To study the expression and activity of 11beta-HSDs in placentas from full term small for gestational age (SGA), appropriate for gestational age (AGA) and large for gestational age (LGA) newborns, and cortisol cord blood concentration.

METHODS

Twenty-five placentas from AGA, 24 SGA and 25 LGA were collected.

RESULTS

SGA newborns had significantly lower and LGA newborns had significantly higher birth weight, birth length, head circumference, and placental weight than AGA counterparts. We observed a direct correlation between placental weight and birth weight, birth length and head circumference, and higher cord F levels in SGA newborns. The 11beta-HSD1 expression was similar among the SGA, AGA, and LGA placentas. However, within the placentas of SGA newborns, the 11beta-HSD1 mRNA levels were significantly reduced in the chorionic plate compared with basal plate. An inverse correlation between cord F levels and activity of 11beta-HSD1 in the chorionic plate of the SGA placentas was detected. The 11beta-HSD2 activity was seven- to eightfold higher compared with 11beta-HSD1 in the placentas, and there was a lower 11beta-HSD2 activity in females' SGA placentas compared with the male SGA placentas.

CONCLUSION

We observed a lower expression and activity of 11beta-HSD1 in the chorionic plate of the SGA placentas, suggesting a possible compensatory mechanism to diminish the higher cortisol fetal concentrations observed in fetuses with intrauterine growth restriction.

Glucagon-like peptide-1 (GLP-1) and glucose metabolism in human myocytes

Glucagon-like peptide-1 (GLP-1) has been shown to have insulin-like effects upon the metabolism of glucose in rat liver, muscle and fat, and on that of lipids in rat and human adipocytes. These actions seem to be exerted through specific receptors which, unlike that of the pancreas, are not - at least in liver and muscle - cAMP-associated. Here we have investigated the effect, its characteristics, and possible second messengers of GLP-1 on the glucose metabolism of human skeletal muscle, in tissue strips and primary cultured myocytes. In muscle strips, GLP-1, like insulin, stimulated glycogen synthesis, glycogen synthase a activity, and glucose oxidation and utilization, and inhibited glycogen phosphorylase a activity, all of this at physiological concentrations of the peptide. In cultured myotubes, GLP-1 exerted, from 10(-13) mol/l, a dose-related increase of the D-[U-(14)C]glucose incorporation into glycogen, with the same potency as insulin, together with an activation of glycogen synthase a; the effect of 10(-11) mol/l GLP-1 on both parameters was additive to that induced by the equimolar amount of insulin. Synthase a was still activated in cells after 2 days of exposure to GLP-1, as compared with myotubes maintained in the absence of peptide. In human muscle cells, exendin-4 and its truncated form 9-39 amide (Ex-9) are both agonists of the GLP-1 effect on glycogen synthesis and synthase a activity; but while neither GLP-1 nor exendin-4 affected the cellular cAMP content after 5-min incubation in the absence of 3-isobutyl-1-methylxantine (IBMX), an increase was detected with Ex-9. GLP-1, exendin-4, Ex-9 and insulin all induced the prompt hydrolysis of glycosylphosphatidylinositols (GPIs). This work shows a potent stimulatory effect of GLP-1 on the glucose metabolism of human skeletal muscle, and supports the long-term therapeutic value of the peptide. Further evidence for a GLP-1 receptor in this tissue, different from that of the pancreas, is also illustrated, suggesting a role for an inositolphosphoglycan (IPG) as at least one of the possible second messengers of the GLP-1 action in human muscle.

GLP-1 effect upon the GPI/IPG system in adipocytes and hepatocytes from diabetic rats

GLP-1 (glucagon-like peptide 1), proposed as a possible tool for Type 2 diabetes therapy, has insulin-like effects upon glucose metabolism in extrapancreatic tissues, whose plasma membranes contain specific receptors for the peptide, being those, at least in liver and muscle, not associated to the adenylate cyclase/cAMP system. GLP-1, as insulin, modulates the content of glycosylphosphatidylinositols (GPIs)--precursors of inositolphosphoglycans (IPGs), considered mediators of insulin action--in several extrapancreatic cell lines and in normal rat hepatocytes and adipocytes. In the present paper, we document that in a streptozotocin-induced Type 2 diabetic rat model, GLP-1, as insulin, provokes a rapid decrease of the [myo-3H-inositol]GPI content in isolated adipocytes--indicative of its hydrolysis and immediate short-lived generation of IPG--as that previously observed in normal animals; in hepatocytes, GLP-1, but not insulin, induced a reduction in the cellular GPI, although delayed in relation to normal rats. In adipocytes from streptozotocin-induced Type 1 diabetic rats, GLP-1, as insulin, seems to induce a reduction in the cellular GPI content, which was smaller and occurred later than that provoked in the Type 2 diabetic model; in the hepatocytes, GLP-1 and insulin failed to affect the control GPI content at any time tested. In Type 2 diabetic rat, the hepatocyte retains its response capability to GLP-1, but not to insulin, suggesting that the peptide could be bypassing possible defective steps in the insulin signaling pathway in the liver of this diabetic model.

Effect of GLP-1 on lipid metabolism in human adipocytes

We have studied the effect of several doses of GLP-1, compared to that of insulin and glucagons, on lipogenesis, lipolysis and cAMP cellular content, in human adipocytes isolated from normal subjects. In human adipocytes, GLP-1 exerts a dual action, depending upon the dose, on lipid metabolism, being lipogenic at low concentrations of the peptide (ED50, 10(-12) M), and lipolytic only at doses 10-100 times higher (ED50, 10(-10) M); both effects are time- and GLP-1 concentration-dependent. The GLP-1 lipogenic effect is equal in magnitude to that of equimolar amounts of insulin; both hormones apparently act synergically, and their respective action is abolished by glucagon. The lipolytic effect of GLP-1 is comparable to that of glucagon, apparently additive to it, and the stimulated value induced by either one is neutralized by the presence of insulin. In the absence of IBMX, GLP-1, at 10(-13) and 10(-12) M, only lipogenic doses, does not modify the cellular content of cAMP, while from 10(-11) M to 10(-9) M, also lipolytic concentrations, it has an increasing effect; in the presence of IBMX, GLP-1 at already 10(-12) M increased the cellular cAMP content. In human adipocytes, GLP-1 shows glucagon- and also insulin-like effects on lipid metabolism, suggesting the possibility of GLP-1 activating two distinct receptors, one of them similar or equal to the pancreatic one, accounting cAMP as a second messenger only for the lipolytic action of the peptide.

Inositolphosphoglycans possibly mediate the effects of glucagon-like peptide-1(7-36)amide on rat liver and adipose tissue

Insulin-like effects of glucagon-like peptide-1(7-36)amide (GLP-1) in rat liver, skeletal muscle and fat, and also the presence of GLP-1 receptors in these extrapancreatic tissues, have been documented. In skeletal muscle and liver, the action of GLP-1 is not associated with an activation of adenylate cyclase, and in cultured murine myocytes and hepatoma cell lines, it was found that GLP-1 provokes the generation of inositolphosphoglycan molecules (IPGs), which are considered second messengers of insulin action. In the present work, we document in isolated normal rat adipocytes and hepatocytes that GLP-1 exerts a rapid decrease of the radiolabelled glycosylphosphatidylinositols (GPIs)--precursors of IPGs--in the same manner as insulin, indicating their hydrolysis and the immediate short-lived generation of IPGs. Thus, IPGs could be mediators in the GLP-1 actions in adipose tissue and liver, as well as in skeletal muscle, through GLP-1 receptors which are, at least functionally, different from that of the pancreatic B-cell.

Preserved GLP-I effects on glycogen synthase a activity and glucose metabolism in isolated hepatocytes and skeletal muscle from diabetic rats

To search if biological effects of GLP-I on glucose metabolism in extrapancreatic tissue are present in diabetic states, we have studied the action of GLP-I and insulin on glycogen-enzyme activity, glycogen synthesis, and glucose metabolism in isolated hepatocytes and soleus muscle from adult streptozotocin (STZ)- and neonatal STZ-treated diabetic rats. This work confirms the previously reported insulin-like effects of GLP-I on glucose metabolism in both muscle and liver tissue from normal rats (control). The present study extends those observations to the muscle and liver tissue of diabetic animals. In both muscle and liver tissue, the metabolism of D-glucose, in the absence of added peptides, was more severely affected in adult STZ (IDDM model) than in neonatal STZ (nSTZ; NIDDM model) rats, and the magnitude of hormonal effect on metabolic variables was lower in diabetic rats than in control rats, as a rule. Nevertheless, in liver and muscle tissue of diabetic rats, GLP-I was able to increase glycogen synthase activity, augment the net rate of D-[U-14C]glucose incorporation into glycogen, and increase D-[5-3H]glucose utilization, D-[U-14C]glucose oxidation, and lactate production. In conclusion, GLP-I exerts insulin-like effects on D-glucose metabolism in both muscle and liver tissue in IDDM or NIDDM animal models, and present observations reinforce the view that GLP-I may represent a most promising tool in the treatment of diabetic patients.

Preference for guanosine at first codon position in highly expressed Escherichia coli genes. A relationship with translational efficiency

The variation in base composition at the three codon sites in relation to gene expressivity, the latter estimated by the Codon Adaptation Index, has been studied in a sample of 1371 Escherichia coli genes. Correlation and regression analyses show that increasing expression levels are accompanied by higher frequencies of base G at first, of base A at second and of base C at third codon positions. However, correlation between expressivity and base compositional biases at each codon site was only significant and positive at first codon position. The preference for G-starting codons as gene expression level increases is discussed in terms of translational optimization.

[Chronotropic competence in patients with the sick sinus syndrome wearing AAI or DDD pacemakers]

The prevalence of chronotropic incompetence in patients with sinus node disease (SND) is not well defined. To assess this, we evaluated 18 patients (7 men, 11 women; mean age: 64 +/- 11) with SND and permanent pacemakers (AAI/DDD) with Holter monitoring and treadmill stress test. Only 2 patients received active cardiac drugs (1, L-dopa an 1 propafenone). The treadmill tests results were compared with a control group of 15 men and 18 women (mean age: 66 +/- 5, p = NS) without organic heart disease. During ambulatory activity all pacemaker patients increased their own cardiac rate to a value higher than the programmed basic pacemaker rate. In 8 patients the maximal rate attained was over 100/min (mean 95 +/- 19/min). The maximal rate during treadmill test in pacemaker patients was 131 +/- 25 (control group 138 +/- 14, p = NS). Exercise tolerance in METs was similar in pacemaker patients (5.2 +/- 2.6) and in controls (5.8 +/- 1.2) (p = NS). Two pacemaker patients (12%) didn't reach 100/min during stress test. Most patients with SND and permanent pacemakers (AAI/DDD) are able to increase cardiac rate during exercise. Rate responsive pacing (AAIR/DDDR) should be limited to a minority of patients with true chronotropic incompetence.

[The efficacy of propafenone in preventing recurrent auricular fibrillation and flutter]

In order to investigate the efficacy of propafenone in the prevention of paroxysmal flutter or fibrillation, we treated 21 patients without left ventricular disfunction. Age was 60 +/- 14 (mean +/- sd) years, left atrial diameter by echocardiography 37 +/- 7 mm, cardiothoracic index 0.48 +/- 0.05 (0.41-0.57) and P wave duration 100 +/- 17 ms. The frequency of recurrences before treatment was: daily in five (23%), weekly or more in eight (38%), monthly-weekly in seven (33%) and quarterly-monthly in one (5%). Propafenone (671 +/- 187 mg/24 h) was given after recurrences were demonstrated under treatment with 1-3 antiarrhythmic drugs per patient. During 8.9 +/- 3.5 months of follow-up (range 6-19) 5 patients (23%) were completely free of recurrences; in seven (33%) the incidence decreased by greater than 50% with a marked decrease in duration. Side effects appeared in 12 cases (57%), leading to its discontinuation in four (19%). Arrhythmogenic effects were observed in 2 cases (9%). Propafenone is effective in greater than 50% of patients with paroxysmal atrial flutter or fibrillation, resistant to other antiarrhythmic agents. The incidence of side effects is high, but they are usually not severe and reversible.

[Post-infarction thrombosis of the right ventricle]

Right ventricular mural thrombosis is not commonly detected and in most cases is related to the use of monitoring, infusion, or pacing catheters. We report right ventricular mural thrombosis, complicated by pulmonary embolism, in 2 cases of inferior wall myocardial infarction with right ventricular involvement. None of the patients had been monitored by means of right ventricular catheterization. Bidimensional echocardiography allowed visualization of the thrombi, and demonstrated their resolution after anticoagulant treatment.