Pyoderma Gangrenosum and inflammatory bowel disease: a combined medical and surgical approach - case report and literature review

OBJECTIVE

Pyoderma Gangrenosum (PG) is an immune-mediated neutrophilic dermatosis, characterized by large painful ulcers occurring in various body segments. It can be associated to Inflammatory Bowel Disease (IBD) including both Ulcerative Colitis and Crohn Disease. Prompt and effective management is fundamental, due to its high morbidity and mortality rates. By presenting our clinical experience, we aimed at showing the efficacy of a combined therapeutic approach, in which the best of every specialty cooperates managing this hazardous disease.

PATIENTS AND METHODS

We report on two patients attending our outpatient clinic with ulcerative skin lesions at the level of the back. Patient 1 suffered from Crohn disease and Patient 2 presented a positive history of abdominal pain, diarrhea with mucus and blood in the stool. Histological exam was performed with final diagnosis of PG associated with IBD. A Literature review was carried out in order to highlight the role of combined clinical-surgical management of PG in adult patients with IBD.

RESULTS

Complete resolution of the lesions was achieved in 4 months and 3 months for each patient respectively without relapse. PubMed was searched from 2000 to 2020 with the following keywords: (Pyoderma) AND/OR (Pyoderma Gangrenosum) AND (Inflammatory Bowel Disease) AND/OR (Ulcerative Colitis) AND/OR (Crohn Disease) AND (Management). Seven papers were included (4 case reports, 2 case series, 1 comprehensive review) and reviewed using a descriptive checklist.

CONCLUSIONS

PG should be treated by dedicated multidisciplinary teams, in which every specialist plays a crucial role from the diagnosis to the treatment and up to the long-term follow-up.

The role of gluten-free diet in nonalcoholic fatty liver disease development

OBJECTIVE

Celiac Disease (CD) is an autoimmune disease involving the small bowel, generated by the ingestion of gluten-containing foods in genetically predisposed subjects. Currently, the unique therapy for CD is the absolute adherence to gluten-free diet, but this treatment has been related to the onset of non-alcoholic fatty liver disease (NAFLD). In this systematic review, we provide an update from the most recent studies on the risk of developing NAFLD patients adhering to GFD.

MATERIALS AND METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement (PRISMA) criteria, we performed a systematic literature search on PubMed and Google Scholar from 2012 to 2021.

RESULTS

In the present systematic review, eight studies investigated how GFD in CD patients may be a risk factor for the onset of NAFLD from a minimum of six months to the maximum follow-up period represented by a median of 10 years.

CONCLUSIONS

Present systematic review evaluates how GFD plays a key role in NAFLD for consumption of products rich in saturated fats and carbohydrates that promotes accumulation of lipids and lead to hepatic steatosis and inflammation.

Multifaceted pathogenesis of liver steatosis in inflammatory bowel disease: a systematic review

OBJECTIVE

Non-Alcoholic Fatty Liver Disease (NAFLD), as a hepatic manifestation of metabolic syndrome (MET)-related obesity, insulin resistance, dyslipidemia, and hypertension, is the main cause of chronic liver disease. Inflammatory Bowel Diseases (IBD), (Crohn's Disease (CD) and Ulcerative Colitis (UC)), are often associated with extraintestinal manifestations. Of these, NAFLD is one of the most frequently reported. To highlight the etiopathogenesis of NAFLD in IBD, we performed a systematic review emphasizing the relationship between NAFLD genetic alterations, metabolic syndrome, and drugs.

MATERIALS AND METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement (PRISMA) criteria, we performed a systematic literature search on PubMed, Google Scholar, and Web of Science for literature updated from 2010 to 1 March 2021. Inclusion criteria for studies were observational design and Randomized Controlled Trials (RCTs); written in English; primary research only; based on adult patients, and human research only.

RESULTS

We identified nine studies on the link between NAFLD and IBD. Among these, two described the genetic predisposition to NAFLD of patients with IBD. Four reported an association between MetS and NAFLD in IBD patients. Regarding medications, none of four studies included, detected a relationship between NAFLD onset and IBD treatment (corticosteroids, immunomodulators, methotrexate, or biologics).  However, a retrospective study showed a protective effect of anti-TNF alpha therapies against altered liver enzymes.

CONCLUSIONS

In this interplay between genetic, metabolic, drug, and inflammatory factors, the underlying pathogenic mechanisms behind NAFLD in IBD are still far from clear. Further studies are needed to better clarify the role of individual components influencing the development of NAFLD in IBD.

POS1457-HPR GASTROINTESTINAL SYMPTOMS AND RHEUMATIC DISEASES: TWO SIDES OF THE SAME COIN

Background:

Patients with Rheumatic Diseases (RD) often show different symptoms besides the osteoarticular ones. Healthcare workers can evaluate the impact of specific symptoms on RD patients’ quality of life in order to improve global management.

Objectives:

The aim of this study was to assess the presence of gastrointestinal symptoms in RD patients through Patients Reported Outcomes.

Methods:

We carried out a cross-sectional study of 101 RD patients compared with 202 healthy volunteers. Healthcare workers invited patients and volunteers to complete questionnaires on gastrointestinal symptoms, through seven domains (belly pain, constipation, diarrhea, disrupted swallowing, gas and bloating, nausea and vomiting, gastroesophageal reflux) of the Patient-Reported Outcomes Measurement Information System (PROMIS®).

Results:

Among 101 RD patients, 34 (33.6%) had a diagnosis of Rheumatoid Arthritis, 23 (22.7%) had a diagnosis of Psoriatic Arthritis, 12 (11.8%) had axial spondyloarthritis; 18 (17.8%) had Systemic Sclerosis, 8 (7.9%) were classified as Connectivitis (i.e.Lupus, Sjögren Syndrome), and finally 6 (5.9%) had vasculitis. Median disease duration was 7±5 years and just under half (45.5%) of RD patients had active disease according to specific disease activity index. As shown in Table 1, no significant differences were found between patients and controls with regard to demographic and anthropometric characteristics except for sex, since males were 25.7% (n=26) in RD patients and 125 (61,8%) in healthy volunteers. In our study, Patients reported significantly greater gastrointestinal symptoms than healthy controls. More specifically, as shown in Figure 1A, median T score for belly pain, constipation, diarrhea and disrupted swallowing were significantly higher in the RD patients than in healthy controls (50.2 ± 14 vs 41.7 ± 12 p<0.001; 51.5 ± 10 vs 42.2 ± 9 p <0.001; 45.3 ± 8 vs 42 ± 5 p <0.001; 51.1 ± 10 vs 44.6 ± 7 p <0.001) respectively. Moreover, also regarding others domains (gas and bloating, nausea and vomiting and gastroesophageal reflux), patients reported a median T score worse than healthy controls (Figure 1B).

Figure 1.

Median T Score stratified by study group. Data are shown as mean and standard deviation. The overall p-value was calculated by the Mann–Whitney non-parametric test for independent samples.

Conclusion:

Firstly, this study highlights the need to investigate further the association between Rheumatic Diseases and gastrointestinal symptoms as potential patterns of underlying diseases and, secondly, the need to adopt validated questionnaires in clinical practice that can help healthcare professionals to detect underestimated symptoms.

References:

[1]P. T. Kröner, O. A. Tolaymat, A. W. Bowman, A. Abril, e B. E. Lacy, «Gastrointestinal Manifestations of Rheumatological Diseases», Am. J. Gastroenterol., vol. 114, n. 9, pagg. 1441–1454, 2019.

[2]J. P. Witter, «The Promise of Patient-Reported Outcomes Measurement Information System-Turning Theory into Reality: A Uniform Approach to Patient-Reported Outcomes Across Rheumatic Diseases», Rheum. Dis. Clin. North Am., vol. 42, n. 2, pagg. 377–394, 2016

Table 1.Patients(N= 101)Healthy(N= 202)pDemographic and AnthropometricAge (years)60±1354.2 ±15nsGender n male (%)26 (25,7)125 (61,8)<0,001BMI (Kg/m2)26,4±425,5±4nsSmoke n (%)51(50,5)97(48)nsPhysical Activity (%)27(26,7)62(30,7)nsRheumatoid Arthritis34(33,6)-Psoriatic Arthritis23(22,7)-Spondyloarthritis12(11,8)-Systemic Sclerosis18(17,8)-Connectivitis8(7,9)-Vasculitis6(5,9)-Disease duration (years)7±5-Disease Activity n yes (%)46(45,5)-Medications n (% patients)-NSAID11(10,9)-Steroids26(25,7)-Biological Treatment54(53,5)-Methotrexate34(33,7)-

Continuous variables are shown as mean ± standard deviation. Categorical variables are presented as number and proportion. The overall p-value was calculated by the Mann–Whitney non-parametric test for independent samples and by Chi-square test as appropriate.

Disclosure of Interests:

None declared

AB0861-HPR MENTAL DISORDERS AND GASTROINTESTINAL SYMPTOMS IN RHEUMATIC DISEASES: A CROSS-SECTIONAL STUDY

Background:

Several studies agree that patients with chronic diseases are more likely to have mental health problems. Moreover, Rheumatic Diseases (RD) patients may show gastrointestinal symptoms as result of primary inflammation, secondary involvement or as treatment consequences. A better understanding of the potential association among such symptoms can help to improve treatment and quality of life.

Objectives:

The aim of this study was to evaluate the impact of gastrointestinal symptoms (GI) on mental and social health in RD patients.

Methods:

We performed a cross-sectional study of 69 RD patients with primarily osteoarticular symptoms. Patients completed questionnaires on GI symptoms (belly pain, constipation, diarrhea, disrupted swallowing, gas and bloating, nausea and vomiting, gastroesophageal reflux) and psychosocial changes (anxiety, depression, fatigue, sleep disturbance, pain interference, physical function, satisfaction with participation in social roles), of the Patient-Reported Outcomes Measurement Information System (PROMIS).

Results:

Among 69 patients, 34 (49.3%) had a diagnosis of Rheumatoid Arthritis; 35 (50.7%) had axial spondyloarthritis (i.e. Psoriatic arthritis and Ankylosing Spondylitis). Median disease duration was 7,6±4 years and over one-third (36.2%) of patients had active disease. Most patients reported psychosocial changes and GI symptoms, as shown in Table 1. More specifically, figure 1 (A-G) shows that fatigue was associated with belly pain and bloating (p<0.001), and with constipation, diarrhea, disrupted swallowing and gastroesophageal reflux (p<0.01). Anxiety was related to disrupted swallowing and gastroesophageal reflux (p<0.01) whereas depressive symptoms were associated with belly pain (p<0.001), bloating and gastroesophageal reflux (p<0.01). Moreover, all gastrointestinal symptoms affected sleep quality. Finally, such symptoms significantly affected patients’ social domain especially regarding satisfaction with participation in social roles (p<0.05 for belly pain and diarrhea, p<0.01 for bloating and disrupted swallowing) and physical functions (p<0.001 for belly pain, diarrhea, disrupted swallowing; p<0.01 for constipation, bloating and nausea and vomiting; p<0.05 for gastroesophageal reflux).

Table 1.N = 69YesMedian t-Score± SDMental and social Health PROMISAnxiety, n (%)48(69,6)55,2±10Depression, n (%)40(58)51,8±10Fatigue, n (%)52(75,4)57,7±10Sleep Disturbance, n (%)44(63,8)52±10Pain interference, n (%)62(89,9)60,9±8Physical Function, n (%)64(92,8)39,4±8Satisfaction with participation in social roles, n (%)21 (30,4)45,2±10GI-PROMISBelly pain, n (%)35(50,7)50,6±14Constipation, n (%)36(52,2)51,2±10Diarrhea, n (%)20(29)45,2±8Disrupted Swallowing, n (%)31(44,9)51±10Gas and Bloating, n (%)54(78,3)55,5±8Nausea and Vomiting, n (%)32(46,4)49,9±8Gastroesophageal Reflux, n (%)27(39,1)49,1±11

Continuous variables are expressed as median and standard deviation. Categorical variables are expressed as number and proportion. GI and psychosocial changes scores were dichotomized for the use of categorical variables.

Figure 1.

A–G: GI symptoms in RD patients across dichotomized psychosocial symptoms (Yes in Black/No in grey). The overall p-value was calculated by the Mann–Whitney non-parametric test for independent samples.

Conclusion:

This study highlights the association between GI symptoms and psychosocial changes in RD patients. The use of validated Patients-Reported Outcomes, especially in clinical practice, may help to better define the impact of such symptoms on patients’ quality of life and then evaluate patients’ needs in a global dimension.

References:

[1]P. T. Kröner, O. A. Tolaymat, A. W. Bowman, A. Abril, e B. E. Lacy, Gastrointestinal Manifestations of Rheumatological Diseases, Am. J. Gastroenterol., 2019.

[2]Mancina RM et al. Gastrointestinal Symptoms of and Psychosocial Changes in Inflammatory Bowel Disease: A Nursing-Led Cross-Sectional Study of Patients in Clinical Remission. Medicina (Kaunas). 2020 Jan 20;56(1):45.

Disclosure of Interests:

None declared

Effects of Extra Virgin Olive Oil Polyphenols on Beta-Cell Function and Survival

Extra virgin olive oil (EVOO) is a major component of the Mediterranean diet and is appreciated worldwide because of its nutritional benefits in metabolic diseases, including type 2 diabetes (T2D). EVOO contains significant amounts of secondary metabolites, such as phenolic compounds (PCs), that may positively influence the metabolic status. In this study, we investigated for the first time the effects of several PCs on beta-cell function and survival. To this aim, INS-1E cells were exposed to 10 μM of the main EVOO PCs for up to 24 h. Under these conditions, survival, insulin biosynthesis, glucose-stimulated insulin secretion (GSIS), and intracellular signaling activation (protein kinase B (AKT) and cAMP response element-binding protein (CREB)) were evaluated. Hydroxytyrosol, tyrosol, and apigenin augmented beta-cell proliferation and insulin biosynthesis, and apigenin and luteolin enhanced the GSIS. Conversely, vanillic acid and vanillin were pro-apoptotic for beta-cells, even if they increased the GSIS. In addition, oleuropein, p-coumaric, ferulic and sinapic acids significantly worsened the GSIS. Finally, a mixture of hydroxytyrosol, tyrosol, and apigenin promoted the GSIS in human pancreatic islets. Apigenin was the most effective compound and was also able to activate beneficial intracellular signaling. In conclusion, this study shows that hydroxytyrosol, tyrosol, and apigenin foster beta-cells’ health, suggesting that EVOO or supplements enriched with these compounds may improve insulin secretion and promote glycemic control in T2D patients.

THU0618-HPR PSYCHOSOCIAL CHANGES IN RHEUMATIC DISEASE: A NURSING LED CROSS-SECTIONAL STUDY

Background:

Nursing management in Rheumatic Diseases (RD) is focused on global patient care. Starting from basic knowledge of diagnostic and therapeutic management, nurses can assess the impact of RD on patients’ quality of life not only at the physical level, but also at the psychological, social, and emotional levels.

Objectives:

To evaluate psycosocial changes in RD patients through nursing-led Patient-Reported Outcomes

Methods:

We performed a cross-sectional study of 100 RD patients compared with 100 healthy volunteers matched for age, sex and BMI. Specialist nurses invited patients and volunteers to complete questionnaires on quality of life through seven domains (anxiety, depression, fatigue, sleep disturbance, pain interference, physical functions and satisfaction with participation in social roles) of the Patient-Reported Outcomes Measurement Information System (PROMIS).

Results:

Among 100 RD patients, 52 (52%) had a diagnosis of Rheumatoid Arthritis; 17 (17%) had a diagnosis of axial spondylorthritis (Ankylosing Spondylitis and Psoriatic Artritis); 25 (25%) had connectivitis (i.e. Lupus, Systemic Sclerosis, Sjögren Syndrome), and finally 6 (6%) had vasculitis. Median disease duration was 7±5 years. Just under half (43%) of RD patients had active disease measured by specific disease activity index. As shown in table 1, no significant difference highlight between the two groups with regard to anthropompetric and demographic characteristics. We found that patients report significantly greater psychosocial changes than healthy controls. More specifically, as shown in figure 1A, mean T score for anxiety, depression, fatigue and sleep disturbances were significantly higher in the RD patients than in healthy controls (56 ± 9 vs 48 ± 8 p<0.001; 52 ± 9 vs 46 ± 8 p <0.001; 58 ± 8vs 48 ± 8 p <0.001; 52 ± 10 vs 44 ± 8 p <0.001) respectively. Moreover, also in the social dimension in terms of pain interference, physical functions and satisfaction with participation in social roles, patients showed a median T score worse than healthy controls (Fig.1B).

Table 1Patients(N=100)Healthy(N=100)pDemographic and AnthropometricAge (years)52.5±1151±18nsGender n male (%)43 (43)47 (47)nsBMI (Kg/m2)25.1±427.8±4nsSmoke n (%)52 (52)46 (46)nsMarital Status n not married (%)42(42)41 (41)nsOccupation n yes (%)31 (31)35 (35)nsEducation level n degree (%)54 (54)64 (64)nsRheumatoid Arthritis52 (52)-Axial Spondylorthritis17 (17)-Connectivitis25 (25)-Vasculitis6 (6)-Disease duration (years)7.1±5.18-Disease Activity n yes (%)43 (43)-Medications n (% patients)-NSAID7 (7)-Steroids26 (26)-Biological Treatment54 (54)-Methotrexate34 (34)-

Continuous variables are shown as mean ± standard deviation. Categorical variables are presented as number and proportion. The overall p-value was calculated by the Mann–Whitney non-parametric test for independent samples and by Chi-square test as appropriate

Figure 1.

Median T Score stratified by study group. Data are shown as mean and standard deviation. The overall p-value wascalculated by the Mann–Whitney non-parametric test for independent samples.

Conclusion:

This exploratory study highlights the need to adopt validated questionnaires in clinical practice, and demonstrates that PROMIS is a valid, objective, and standardized instrument that can help nursing staff to better define the consequences of the disease in a patient’s daily life.

References:

[1]Minnock P, McKee G, Kelly A, et al. Nursing sensitive outcomes in patients with rheumatoid arthritis: a systematic literature review.Int. J. Nurs. Stud., 77 (2017), pp. 115-129

[2]Bartlett SJ, Orbai AM, Duncan T, et al. Reliability and validity of selected PROMIS measures in people with rheumatoid arthritis. PloS One. 2015

Disclosure of Interests:

None declared

Irisin increases the expression of anorexigenic and neurotrophic genes in mouse brain

BACKGROUND

Irisin, a newly discovered muscle-derived hormone, acts in different organs and tissues, improving energy homeostasis. In this study, we assessed, for the first time, the effects of intraperitoneal irisin injections on circulating levels of leptin and ghrelin, mRNA expression of the major hypothalamic appetite regulators and brain neurotrophic factors, as well as feeding behaviour in healthy mice.

METHODS

Twelve male 6-week-old C57BL/6 mice were randomized into two groups and intraperitoneally injected daily with irisin (0.5 μg/g body weight) or vehicle (phosphate-buffered saline [PBS]) for 14 days. On the last day of observation, leptin and ghrelin levels were measured with an enzyme-linked immunosorbent assay (ELISA). mRNA levels of genes of interest were analysed by quantitative reverse transcription polymerase chain reaction (qRT-PCR) in brain extracts.

RESULTS

Irisin administration did not change leptin or ghrelin serum concentrations. However, irisin injection increased CART, POMC, NPY, and BDNF mRNA levels, without affecting the mRNA expression of AgRP, orexin, PMCH, and UCP2. Finally, over the time frame of irisin treatment, body weight and feeding behaviour were unaltered.

CONCLUSIONS

These results suggest that intraperitoneal injection of irisin, although without effects on feeding behaviour and body weight, can increase the expression of anorexigenic and neurotrophic genes in mouse brain.

The Myokine Irisin Is Released in Response to Saturated Fatty Acids and Promotes Pancreatic β-Cell Survival and Insulin Secretion

This study explored the role of irisin as a new pancreatic β-cell secretagogue and survival factor and its potential role in the communication between skeletal muscle and pancreatic β-cells under lipotoxic conditions. Recombinant irisin stimulated insulin biosynthesis and glucose-stimulated insulin secretion (GSIS) in a PKA-dependent manner and prevented saturated fatty acid-induced apoptosis in human and rat pancreatic β-cells, as well as in human and murine pancreatic islets, via AKT/BCL2 signaling. Treatment of myotubes with 0.5 mmol/L palmitate for 4 h, but not with oleate, promoted an increase in irisin release in the culture medium. Moreover, increased serum levels of irisin were observed in mice fed with a high-fat diet. Mouse serum rich in irisin and the conditioned medium from myotubes exposed to palmitate for 4 h significantly reduced apoptosis of murine pancreatic islets and insulin-secreting INS-1E cells, respectively, and this was abrogated in the presence of an irisin-neutralizing antibody. Finally, in vivo administration of irisin improved GSIS and increased β-cell proliferation. In conclusion, irisin can promote β-cell survival and enhance GSIS and may thus participate in the communication between skeletal muscle and β-cells under conditions of excess saturated fatty acids.

Beta-glucan, inositol and digestive enzymes improve quality of life of patients with inflammatory bowel disease and irritable bowel syndrome

OBJECTIVE

To evaluate the efficacy of a mixture of beta-glucan, inositol and digestive enzymes in improving gastrointestinal symptoms in patients affected by inflammatory bowel disease (IBD)-irritable bowel syndrome (IBS).

PATIENTS AND METHODS

The study was conducted at the IBD Unit of the University of Catanzaro. Forty-three IBD patients with IBS symptoms were included in the study. IBD diagnosis was performed by clinical, endoscopic, histological and radiological criteria. Patients were in clinical remission and in treatment only with systemical and topical mesalamine. All study participants fulfilled the Rome III criteria for the diagnosis of IBS. The study participants were randomized into 2 groups: group A (n=23) received conventional treatment (systemical and topical mesalamine) plus a mixture of beta-glucan, inositol and digestive enzymes (one tablet after lunch and dinner) for four consecutive weeks; group B (n=20) received only conventional treatment. The prevalence and intensity of gastrointestinal (GI) symptoms were evaluated both at the enrollment (T0) and after four weeks of treatment (T1).

RESULTS

Patients who received mesalamine plus the mixture of beta-glucan, inositol and digestive enzymes (group A) reported a reduction in abdominal pain together with reduction in bloating and flatulence after four weeks of treatment. Importantly, an overall improvement in the general well-being has been recorded. Patients who underwent only mesalamine treatment (group B) reported a mild reduction in the evacuative urgency without any other improvements.

CONCLUSIONS

We have shown that supplementation with a mixture of beta-glucan, inositol and digestive enzymes reduces bloating, flatulence and abdominal pain, improving the overall clinical condition of IBD-IBS patients.

Long-Term Exposure of Pancreatic β-Cells to Palmitate Results in SREBP-1C-Dependent Decreases in GLP-1 Receptor Signaling via CREB and AKT and Insulin Secretory Response

The effects of prolonged exposure of pancreatic β-cells to high saturated fatty acids on glucagon-like peptide-1 (GLP-1) action were investigated. Murine islets, human pancreatic 1.1B4 cells, and rat INS-1E cells were exposed to palmitate for 24 hours. mRNA and protein expression/phosphorylation were measured by real-time RT-PCR and immunoblotting, respectively. Specific short interfering RNAs were used to knockdown expression of the GLP-1 receptor (Glp1r) and Srebf1. Insulin release was assessed with a specific ELISA. Exposure of murine islets, as well as of human and INS-1E β-cells, to palmitate reduced the ability of exendin-4 to augment insulin mRNA levels, protein content, and release. In addition, palmitate blocked exendin-4-stimulated cAMP-response element-binding protein and v-akt murine thymoma viral oncogene homolog phosphorylation, whereas phosphorylation of MAPK-ERK kinase-1/2 and ERK-1/2 was not altered. Similarly, RNA interference-mediated suppression of Glp1r expression prevented exendin-4-induced cAMP-response element-binding protein and v-akt murine thymoma viral oncogene homolog phosphorylation, but did not impair exendin-4 stimulation of MAPK-ERK kinase-1/2 and ERK-1/2. Both islets from mice fed a high fat diet and human and INS-1E β-cells exposed to palmitate showed reduced GLP-1 receptor and pancreatic duodenal homeobox-1 (PDX-1) and increased sterol regulatory element-binding protein (SREBP-1C) mRNA and protein levels. Furthermore, suppression of SREBP-1C protein expression prevented the reduction of PDX-1 and GLP-1 receptor levels and restored exendin-4 signaling and action. Finally, treatment of INS-1E cells with metformin for 24 h resulted in inhibition of SREBP-1C expression, increased PDX-1 and GLP-1 receptor levels, consequently, enhancement of exendin-4-induced insulin release. Palmitate impairs exendin-4 effects on β-cells by reducing PDX-1 and GLP-1 receptor expression and signaling in a SREBP-1C-dependent manner. Metformin counteracts the impairment of GLP-1 receptor signaling induced by palmitate.

The epidemiology of life-threatening complications associated with reproductive process in public hospitals in Argentina

OBJECTIVE

To analyse life-threatening obstetric complications that occurred in public hospitals in Argentina.

DESIGN

Multicentre collaborative cross-sectional study.

SETTING

Twenty-five hospitals included in the Perinatal Network of Buenos Aires Metropolitan Area.

POPULATION

Women giving birth in participating hospitals during a 1-year period.

METHODS

All cases of severe maternal morbidity (SMM) and maternal mortality (MM) during pregnancy (including miscarriage and induced abortion), labour and puerperium were included. Data were collected prospectively.

MAIN OUTCOME MEASURES

Identification criteria, main causes and incidence of SMM; case-fatality rates, morbidity-mortality index and effective intervention's use rate.

RESULTS

A total of 552 women with life-threatening conditions were identified: 518 with SMM, 34 with MM. Identification criteria for SMM were case-management (48.9%), organ dysfunction (15.2%) and mixed criteria (35.9%). Incidence of SMM was 0.8% (95% confidence interval [95% CI] 0.73-0.87%) and hospital maternal death ratio was 52.3 per 100 000 live births (95% CI 35.5-69.1). Main causes of MM were abortion complications and puerperal sepsis; main causes of SMM were postpartum haemorrhage and hypertension. Overall case-fatality rate was 6.2% (95% CI 4.4-8.6): the highest due to sepsis (14.8%) and abortion complications (13.3%). Morbidity-mortality index was 15:1 (95% CI 7.5-30.8). Use rate of known effective interventions to prevent or treat main causes of MM and SMM was 52.3% (95% CI 46.9-57.7).

CONCLUSIONS

This study describes the importance of life-threatening obstetric complications that took place in public hospitals with comprehensive obstetric care and the low utilisation of known effective interventions that may decrease rates of SMM and MM. It also provides arguments that justify the need to develop a surveillance system for SMM.

Surgery for a gastric Dieulafoy's lesion reveals an occult bleeding jejunal diverticulum. A case report

Background

Jejunal diverticulosis is an uncommon disease and usually asymptomatic. It can be complicated not only by diverticulitis, but by hemorrhage, perforation, intussusception, volvulus, malabsorption and even small bowel obstruction due to enteroliths formed and expelled from these diverticula.

Methods

We describe a case of an occult bleeding jejunal diverticulum, casually discovered in a patient that was taken to surgery for a Dieulafoy’s lesion after unsuccessful endoscopic treatment. We performed a gastric resection together with an ileocecal resection.

Macroscopic and microscopic examinations confirmed the gastric Dieulafoy’s lesion and demonstrated the presence of another source of occult bleeding in asymptomatic jejunal diverticulum.

Discussion

The current case emphasizes that some gastrointestinal bleeding lesions, although rare, can be multiple and result in potentially life-threatening bleeding. The clinician must be mindful to the possibility of multisite lesions and to the correlation between results of the investigations and clinical condition of the bleeding patient.

Interendothelial junctions and their role in the control of angiogenesis, vascular permeability and leukocyte transmigration

Endothelial cell-cell junctions play an important role in vascular hemostasis. The two junctional proteins VE-cadherin and JAM-1 are localized at adherens and tight junctions, respectively. VE-cadherin is only expressed by endothelial cells, suggesting that it can exert cell specific function. Absence of VE-cadherin or blocking of its adhesive activity prevents a normal organization of new vascular structures, suggesting that VE-cadherin may be a molecular target of antiangiogenic therapy. In addition, the ability of permeability-increasing agents and adherent leukocytes to modify VE-cadherin/catenin organization may be related to a role in the control of vascular permeability and leukocyte infiltration. JAM-1 is an integral membrane protein expressed in endothelial and epithelial cells. Its extracellular domain can dimerize and bind homophilically. The intracellular domain (and in particular a PDZ-binding motif) enables JAM-1 to interact with structural and signaling proteins. Study of the molecular interactions of JAM-1 may help explain mechanisms of JAM-mediated function, such as control of paracellular permeability and leukocyte transmigration.

Development of endothelial cell lines from embryonic stem cells: A tool for studying genetically manipulated endothelial cells in vitro

Totipotent embryonic stem cells can be induced to differentiate to endothelium in vitro. This may be a useful tool for obtaining cultures of genetically manipulated endothelial cells because embryonic stem cells are relatively easy to transfect and are commonly used for gene inactivation experiments in mice. However, embryonic stem cell-derived endothelial cells could not be easily separated from embryoid bodies and maintained in culture. In this study, we describe the isolation and characterization of immortalized endothelial cell lines obtained from embryonic stem cells differentiated in vitro. The cell lines were analyzed for expression of endothelial cell markers, including growth factor receptors and adhesion molecules, and compared with endothelial cells obtained from the yolk sac, the embryo proper, or the heart microcirculation of the adult. We propose that this approach may be useful for obtaining endothelial cells carrying gene mutations that are lethal at very early stages of development.

Targeted deficiency or cytosolic truncation of the VE-cadherin gene in mice impairs VEGF-mediated endothelial survival and angiogenesis

Vascular endothelial cadherin, VE-cadherin, mediates adhesion between endothelial cells and may affect vascular morphogenesis via intracellular signaling, but the nature of these signals remains unknown. Here, targeted inactivation (VEC-/-) or truncation of the beta-catenin-binding cytosolic domain (VECdeltaC/deltaC) of the VE-cadherin gene was found not to affect assembly of endothelial cells in vascular plexi, but to impair their subsequent remodeling and maturation, causing lethality at 9.5 days of gestation. Deficiency or truncation of VE-cadherin induced endothelial apoptosis and abolished transmission of the endothelial survival signal by VEGF-A to Akt kinase and Bcl2 via reduced complex formation with VEGF receptor-2, beta-catenin, and phosphoinositide 3 (PI3)-kinase. Thus, VE-cadherin/ beta-catenin signaling controls endothelial survival.