A176 ASSOCIATIONS OF ANTIBIOTICS, HORMONAL THERAPIES, ORAL CONTRACEPTIVES, AND LONG-TERM NSAIDS WITH INFLAMMATORY BOWEL DISEASE: RESULTS FROM THE PROSPECTIVE URBAN RURAL EPIDEMIOLOGY (PURE) STUDY

Background

The pathogenesis of inflammatory bowel disease (IBD) which includes Crohn’s disease (CD) and ulcerative colitis (UC), is believed to involve activation of the intestinal immune system in response to the gut microbiome among genetically susceptible hosts. IBD has been historically regarded as a disease of developed nations, though in the past two decades there has been a reported shift in the epidemiological pattern of disease. High-income nations with known high prevalence of disease are seeing a stabilization of incident cases, while a rapid rise of incident IBD is being observed in developing nations. This suggests that environmental exposures may play a role in mediating the risk of developing IBD. The potential environmental determinants of IBD across various regions is vast, though medications have been increasingly recognized as one broad category of risk factors.

Purpose

Several medications have been considered to contribute to the etiology of IBD. This study assessed the association between medication use and risk of developing IBD using the Prospective Urban Rural Epidemiology (PURE) cohort.

Method

This was a prospective cohort study of 133,137 individuals between the ages of 20-80 from 24 countries. Country-specific validated questionnaires documented baseline and follow-up medication use. Participants were followed prospectively at least every 3 years. The main outcome was development of IBD, including CD and UC. Short-term (baseline but not follow-up use) and long-term use (baseline and subsequent follow-up use) was evaluated. Results are presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI).

Result(s)

During the median follow-up of 11.0 years [interquartile range (IQR) 9.2-12.2], we recorded 571 incident cases of IBD (143 CD and 428 UC). Higher risk of incident IBD was associated with baseline antibiotic use [aOR: 2.81 (95% CI: 1.67-4.73), p=0.0001] and hormonal medication use [aOR: 4.43 (95% CI: 1.78-11.01), p=0.001]. Among females, previous or current oral contraceptive use was also associated with IBD development [aOR: 2.17 (95% CI: 1.70-2.77), p=5.02E-10]. NSAID users were also observed to have increased risk of IBD [aOR: 1.80 (95% CI: 1.23-2.64), p=0.002], which was driven by long-term users [aOR: 5.58 (95% CI: 2.26-13.80), p<0.001]. All significant results were consistent in direction for CD and UC with low heterogeneity.

Conclusion(s)

Antibiotics, hormonal medications, oral contraceptives, and long-term NSAID use were associated with increased odds of incident IBD after adjustment for covariates.

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Salim Yusuf is supported by the Heart & Stroke Foundation/Marion W. Burke Chair in Cardiovascular Disease. The PURE Study is an investigator-initiated study funded by the Population Health Research Institute, the Canadian Institutes of Health Research (CIHR), Heart and Stroke Foundation of Ontario, support from CIHR’s Strategy for Patient Oriented Research (SPOR) through the Ontario SPOR Support Unit, as well as the Ontario Ministry of Health and Long-Term Care and through unrestricted grants from several pharmaceutical companies, with major contributions from AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, and GlaxoSmithkline, and additional contributions from Novartis and King Pharma and from various national or local organisations in participating countries; these include: Argentina: Fundacion ECLA; Bangladesh: Independent University, Bangladesh and Mitra and Associates; Brazil: Unilever Health Institute, Brazil; Canada: Public Health Agency of Canada and Champlain Cardiovascular Disease Prevention Network; Chile: Universidad de la Frontera; China: National Center for Cardiovascular Diseases; Colombia: Colciencias, grant number 6566-04-18062; India: Indian Council of Medical Research; Malaysia: Ministry of Science, Technology and Innovation of Malaysia, grant numbers 100 -IRDC/BIOTEK 16/6/21 (13/2007) and 07-05-IFN-BPH 010, Ministry of Higher Education of Malaysia grant number 600 -RMI/LRGS/5/3 (2/2011), Universiti Teknologi MARA, Universiti Kebangsaan Malaysia (UKM-Hejim-Komuniti-15-2010); occupied Palestinian territory: the UN Relief and Works Agency for Palestine Refugees in the Near East, occupied Palestinian territory; International Development Research Centre, Canada; Philippines: Philippine Council for Health Research & Development; Poland: Polish Ministry of Science and Higher Education grant number 290/W-PURE/2008/0, Wroclaw Medical University; Saudi Arabia: the Deanship of Scientific Research at King Saud University, Riyadh, Saudi Arabia (research group number RG -1436-013); South Africa: the North-West University, SANPAD (SA and Netherlands Programme for Alternative Development), National Research Foundation, Medical Research Council of SA, The SA Sugar Association (SASA), Faculty of Community and Health Sciences (UWC); Sweden: grants from the Swedish state under the Agreement concerning research and education of doctors; the Swedish Heart and Lung Foundation; the Swedish Research Council; the Swedish Council for Health, Working Life and Welfare, King Gustaf V’s and Queen Victoria Freemasons Foundation, AFA Insurance, Swedish Council for Working Life and Social Research, Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning, grant from the Swedish State under the Läkar Utbildnings Avtalet agreement, and grant from the Västra Götaland Region; Turkey: Metabolic Syndrome Society, AstraZeneca, Turkey, Sanofi Aventis, Turkey; United Arab Emirates (UAE): Sheikh Hamdan Bin Rashid Al Maktoum Award For Medical Sciences and Dubai Health Authority, Dubai UAE.

Disclosure of Interest

C. Pray: None Declared, N. Narula Grant / Research support from: Neeraj Narula holds a McMaster University Department of Medicine Internal Career Award. Neeraj Narula has received honoraria from Janssen, Abbvie, Takeda, Pfizer, Merck, and Ferring, E. C. Wong: None Declared, J. K. Marshall Grant / Research support from: John K. Marshall has received honoraria from Janssen, AbbVie, Allergan, Bristol-Meyer-Squibb, Ferring, Janssen, Lilly, Lupin, Merck, Pfizer, Pharmascience, Roche, Shire, Takeda and Teva., S. Rangarajan: None Declared, S. Islam: None Declared, A. Bahonar: None Declared, K. F. Alhabib: None Declared, A. Kontsevaya: None Declared, F. Ariffin: None Declared, H. U. Co: None Declared, W. Al Sharief: None Declared, A. Szuba: None Declared, A. Wielgosz: None Declared, M. L. Diaz: None Declared, R. Yusuf: None Declared, L. Kruger: None Declared, B. Soman: None Declared, Y. Li: None Declared, C. Wang: None Declared, L. Yin: None Declared, M. Erkin: None Declared, F. Lanas: None Declared, K. Davletov: None Declared, A. Rosengren: None Declared, P. Lopez-Jaramillo: None Declared, R. Khatib: None Declared, A. Oguz: None Declared, R. Iqbal: None Declared, K. Yeates: None Declared, Á. Avezum: None Declared, W. Reinisch Consultant of: Speaker for Abbott Laboratories, Abbvie, Aesca, Aptalis, Astellas, Centocor, Celltrion, Danone Austria, Elan, Falk Pharma GmbH, Ferring, Immundiagnostik, Mitsubishi Tanabe Pharma Corporation, MSD, Otsuka, PDL, Pharmacosmos, PLS Education, Schering-Plough, Shire, Takeda, Therakos, Vifor, Yakult, Consultant for Abbott Laboratories, Abbvie, Aesca, Algernon, Amgen, AM Pharma, AMT, AOP Orphan, Arena Pharmaceuticals, Astellas, Astra Zeneca, Avaxia, Roland Berger GmBH, Bioclinica, Biogen IDEC, Boehringer-Ingelheim, Bristol-Myers Squibb, Cellerix, Chemocentryx, Celgene, Centocor, Celltrion, Covance, Danone Austria, DSM, Elan, Eli Lilly, Ernest & Young, Falk Pharma GmbH, Ferring, Galapagos, Genentech, Gilead, Grünenthal, ICON, Index Pharma, Inova, Janssen, Johnson & Johnson, Kyowa Hakko Kirin Pharma, Lipid Therapeutics, LivaNova, Mallinckrodt, Medahead, MedImmune, Millenium, Mitsubishi Tanabe Pharma Corporation, MSD, Nash Pharmaceuticals, Nestle, Nippon Kayaku, Novartis, Ocera, Omass, Otsuka, Parexel, PDL, Periconsulting, Pharmacosmos, Philip Morris Institute, Pfizer, Procter & Gamble, Prometheus, Protagonist, Provention, Robarts Clinical Trial, Sandoz, Schering-Plough, Second Genome, Seres Therapeutics, Setpointmedical, Sigmoid, Sublimity, Takeda, Therakos, Theravance, Tigenix, UCB, Vifor, Zealand, Zyngenia, and 4SC, Advisory board member for Abbott Laboratories, Abbvie, Aesca, Amgen, AM Pharma, Astellas, Astra Zeneca, Avaxia, Biogen IDEC, Boehringer-Ingelheim, Bristol-Myers Squibb, Cellerix, Chemocentryx, Celgene, Centocor, Celltrion, Danone Austria, DSM, Elan, Ferring, Galapagos, Genentech, Grünenthal, Inova, Janssen, Johnson & Johnson, Kyowa Hakko Kirin Pharma, Lipid Therapeutics, MedImmune, Millenium, Mitsubishi Tanabe Pharma Corporation, MSD, Nestle, Novartis, Ocera, Otsuka, PDL, Pharmacosmos, Pfizer, Procter & Gamble, Prometheus, Sandoz, Schering-Plough, Second Genome, Setpointmedical, Takeda, Therakos, Tigenix, UCB, Zealand, Zyngenia, and 4SC, P. Moayyedi: None Declared, S. Yusuf: None Declared

Chromosomal localisation and genetic variation of the SLC11A1 gene in goats (Capra hircus)

The solute carrier family 11 member A1 (SLC11A1) gene is associated with resistance to infectious diseases. Chromosomal localisation, genomic regions corresponding to functional domains and the genetic variability of microsatellites in the 3' untranslated region (3'-UTR) of this gene were investigated in 427 goats (Capra hircus) of six breeds. Using dual colour fluorescence in situ hybridisation, SLC11A1 was localised to goat chromosome 2. Single strand conformation polymorphism was used to screen for polymorphisms in SLC11A1 exons 2, 10 and 15. There was no variation among goat breeds in the sarcoma homology 3 (SH3) binding motif, the protein kinase C phosphorylation site or the two N-linked glycosylation sites. Exon 15 exhibited variability due to the presence of two polymorphic microsatellites. Genotyping of the upstream guanine-thymine repeat (GTn) at 3'-UTR revealed eight alleles (GT11, GT12, GT14-GT19) in goats, whereas GT13 (present in cattle) was absent. Most goats carried the GT16 allele and no allele was found to be exclusive to only one breed. The coefficient of genetic differentiation value (G(ST)) was 0.084. This microsatellite appears to be an informative DNA marker for genetic linkage analysis in goats.

Polymerase chain reaction for the detection of Mycobacterium tuberculosis DNA in tissue and assessment of its utility in the diagnosis of hepatic granulomas

A polymerase chain reaction (PCR) assay for the rapid identification of Mycobacterium tuberculosis, based on amplification of the IS6110 insertion sequences, was tested in paraffin-embedded tissue from 64 biopsy samples with either positive or negative cultures for Mycobacterium tuberculosis. The utility of this PCR assay in the diagnosis of tuberculosis among patients with hepatic granulomas (HGs) was then tested by examining 43 liver biopsy samples. They were classified as either having definitive or probable tuberculosis or as being of nontuberculous origin, on the basis of clinical and microbiologic data and on their response to antituberculous treatment. PCR was 100% sensitive in the diagnosis of culture-positive M. tuberculosis infection in the lymph node, lung, and liver. The sensitivity of the PCR in the diagnosis of HG of definitive tuberculous origin was 58%, and the specificity was 96%. PCR is a valuable test for the demonstration of mycobacterial DNA in tissues. Although it is not highly sensitive, the DNA amplification method may also be more sensitive than culture in the diagnosis of M. tuberculosis-associated HG.

Third- and fourth-generation implantable cardioverter defibrillators: current status and future development

Implantable cardioverter defibrillator (ICD) therapy has become the mainstay of therapy for patients with a history of sudden cardiac death or life-threatening ventricular arrhythmias. The current generation of ICDs used for secondary prevention combines features for tachycardia reversion with demand ventricular pacing, antitachycardia pacing, programmable shock therapy, and tachycardia events memory. Although demand pacing and defibrillation is indicated for primary prevention usage of ICDs, the application of antitachycardia pacing modes is more controversial. High energy cardioversion and defibrillation shocks remaining the mainstay of sudden death prevention will be redefined as more effective defibrillation shock modes and lead systems are developed. Fourth-generation ICD systems accomplished a significant reduction of device size and almost universal success using an endocardial lead configuration and pectoral implant. A variety of new directions of ICD therapy in clinical practice such as primary prevention applications and the adjunctive role of antiarrhythmic drug therapy are currently being examined in clinical trials. The concepts underlying initiation of tachyarrhythmias are being studied to develop new approaches to tachycardia prevention. These include rate support, subthreshold stimulation, and multiple site pacing. The current developments of ICD therapy promise continued growth of this technology.

Improved direct epifluorescent filter technique for rapid bioburden control in intravenous solutions

Epifluorescence microscopy of the microcolonies obtained after filtration of a deliberately contaminated intravenous solution, was used for the rapid detection and enumeration of the bacteria. The technique is adequate for the test of low volume solution (with low contamination). Also it allows one to detect a single colony forming unit (c.f.u.)/mL, with great correlation between fluorescence counts and pour plate colony counts; the morphology of microcolonies is typical for most of the microorganisms and it allows a primoidentification (for a trained analyst).

Folic acid and vitamin B12 in vitiligo: a nutritional approach

When compared with the normal population, patients with vitiligo often showed diminished blood levels of folic acid. In a group of fifteen patients with vitiligo, folic acid levels were below normal in the serum of eleven patients, in the whole blood of five patients, and in the erythrocytes of six patients. Vitamin B12 serum levels were below normal in five of the fifteen patients. Ascorbic acid plasma levels were also lowered in four of the patients. In eight patients prolonged oral administration of folic acid with simultaneous parenteral treatment with vitamin B12 and oral ascorbic acid was followed by definite repigmentation without side effects.

Murine Taenia crassiceps cysticercosis: H-2 complex and sex influence on susceptibility

Several inbred strains of mice were infected by intraperitoneal injection of ten Taenia crassiceps cysticerci per mouse. Genes linked with the major histocompatibility complex (H-2) were found to influence parasite growth greatly, as demonstrated by the different parasite loads of H-2 congenic mice with BALB background: BALB/c (H-2d) mice were the most susceptible, whereas BALB/k (H-2k) and BALB/b (H-2b) animals were comparatively resistant. Non-H-2 genes had no significant effect on susceptibility in H-2d strains, as reflected by the similar parasite loads in BALB/c, DBA/2, and (BALB/c x DBA/2)F1 mice. Using the H-2b (BALB/b, C57BL/6J) and H-2k (C3H/HeJ, BALB/k, and C3HeB/FeJ) strains, we found that non-H-2 background genes caused a small but significant influence on parasite load. A recombinant mouse strain alleles (Kk, Ik, Sd, Dd) was also susceptible, indicating that S and/or D regions of the H-2d complex are probably involved in the control of resistance to murine cysticercosis. Females of all mouse strains were more susceptible than males. The same effects were observed for H-2 genes and sex, with two strains of T. crassiceps differing in their rate of growth.

Cysticercosis vaccine: cross protecting immunity with T. solium antigens against experimental murine T. crassiceps cysticercosis

Vaccination of mice with an antigen extract from Taenia solium cysticerci induced protection against challenge with T. crassiceps cysticerci as successfully as did antigen extracts from T. crassiceps. Vaccination was more effective in male than in female mice and in the resistant strain (BALB/B) more so than in the susceptible strain (BALB/c). While only the resistant strain was completely protected by vaccination, the parasite load of the susceptible strain was significantly reduced by vaccination. Cross immunity between the human and murine parasites establishes murine T. crassiceps cysticercosis as a convenient laboratory model in which to test promising T. solium antigens aimed at vaccine development against T. solium cysticercosis. Further, results point to strong interactions of the immune system with sexual and histocompatibility factors in the host's dealing with cysticercosis.

Immunodiagnosis of human cysticercosis in cerebrospinal fluid. Antigens from murine Taenia crassiceps cysticerci effectively substitute those from porcine Taenia solium

Tapeworm antigens from Taenia crassiceps performed as well as those antigens from Taenia solium in an enzyme-linked immunosorbent assay for the detection of Cysticercus antibodies in 96 cerebrospinal fluid samples from patients with neurocysticercosis and in 96 CSF samples from patients with other varied neurological ailments. Thus, this manageable murine model of experimental cysticercosis solved the problem of antigen supply for clinical and epidemiological applications, and it provided an immediate means of abundant production of antigens for the wide distribution and standardization of immunodiagnostic tests for cysticercosis.

Deciphering western blots of tapeworm antigens (Taenia solium, Echinococcus granulosus, and Taenia crassiceps) reacting with sera from neurocysticercosis and hydatid disease patients

Complex antigen mixtures displayed in Western blots may be immediately and quantitatively categorized with respect to specificity and immunogenicity by immunoplotting. This involves plotting the frequency with which each antigen band reacts with a set of immune sera against the frequency of the same band when reacted with another set of immune sera. Immunoplotting has proven to be a powerful method of analyzing Western blots of reactions between vesicular fluids from the metacestodes of Taenia solium, E. granulosus, and T. crassiceps, and sera from human cases of neurocysticercosis and hydatid disease. Immunoplotting readily sorts out those antigens useful for discriminative immunodiagnosis from the multitude of bands in the sera of sick and healthy people. It aids in assessing the antigenic similarity between the human parasites and the murine parasite T. crassiceps, validating the latter as an alternative source of antigens for immunodiagnosis of cysticercosis and hydatid disease.

Reliable serology of Taenia solium cysticercosis with antigens from cyst vesicular fluid: ELISA and hemagglutination tests

New levels of reproducibility and sensitivity have been achieved in the detection of anticysticercus antibodies in human sera by using cysticercus vesicular fluid as the source of antigens for both ELISA and hemagglutination assays. Reproducibility both between tests on a serum and between similar sera was significantly improved over typical results using antigens from whole parasite extracts. Sera collected from uninfected individuals in endemic areas gave somewhat elevated values over those collected in nonendemic areas. This necessitated the use of a higher threshold in endemic areas to avoid false positives. With the threshold appropriate for a nonendemic area, both ELISA and hemagglutination were sensitive enough to detect infection in 95% of cases. With the threshold value for sera from an endemic area, these sensitivities were reduced to 80%-90%. A prominent 103-Kd protein of vesicular fluid, not related to antigen B, elicited the strongest antibody response in neurocystercotic patients.

Porphyrin content of the cysticercus of Taenia solium

The strong red fluorescence of the cysticercus of Taenia solium depends on the presence of several porphyrins in the vesicular fluid of the parasite: probably protoporphyrin IX, coproporphyin I or III, and 2 decarboxylated porphyrins intermediate between uroporphyrin and coproporphyrin. Cyst porphyrins associated to form conglomerates of high molecular weight that dissociated in acid solutions and were not antigenic themselves nor associated with antigenic molecules. An appreciable fraction of the porphyrins was capable of undergoing oxidation and reduction, indicating that some of the porphyrins were complexed with metal ions. The metabolic basis for the accumulation of porphyrins is unknown. Preliminary results suggest that conditions deleterious to the cysticercus cause release of porphyrins so that the appearance of porphyrins in the cerebrospinal fluid of neurocysticercotic patients may prove useful in monitoring therapeutic attacks on the parasite.

Determination and prediction of tissue-gas partition coefficients

The head space method for determination of tissue-gas partition coefficients was modified to make it suitable for determination of tissue-gas partition coefficients of water soluble solvents. The method was used to determine tissue-gas partition coefficients of acetone, 2-butanone, methanol, ethanol, 1-propanol, 2-propanol and isobutanol for six representative tissues (muscle, kidney, lung, white and gray matter of brain, and adipose tissue). Blood-gas partition coefficients and distribution between plasma and erythrocytes were also determined. Relation between tissue-blood and fat-blood partition coefficients of 35 hydrophilic and hydrophobic substances of different chemical structure is described by linear correlation equations which can be used for prediction of tissue-gas partition coefficients of any chemical for which blood-gas and fat-gas partition coefficients are known. The correlation equations are based on all currently available data.