Serum proteomic profiling at diagnosis predicts clinical course, and need for intensification of treatment in inflammatory bowel disease

BACKGROUND

Success in personalized medicine in complex disease is critically dependent on biomarker discovery. We profiled serum proteins using a novel proximity extension assay [PEA] to identify diagnostic and prognostic biomarkers in inflammatory bowel disease [IBD].

METHODS

We conducted a prospective case-control study in an inception cohort of 552 patients [328 IBD, 224 non-IBD], profiling proteins recruited across six centres. Treatment escalation was characterized by the need for biological agents or surgery after initial disease remission. Nested leave-one-out cross-validation was used to examine the performance of diagnostic and prognostic proteins.

RESULTS

A total of 66 serum proteins differentiated IBD from symptomatic non-IBD controls, including matrix metallopeptidase-12 [MMP-12; Holm-adjusted p = 4.1 × 10-23] and oncostatin-M [OSM; p = 3.7 × 10-16]. Nine of these proteins are associated with cis-germline variation [59 independent single nucleotide polymorphisms]. Fifteen proteins, all members of tumour necrosis factor-independent pathways including interleukin-1 (IL-1) and OSM, predicted escalation, over a median follow-up of 518 [interquartile range 224-756] days. Nested cross-validation of the entire data set allowed characterization of five-protein models [96% comprising five core proteins ITGAV, EpCAM, IL18, SLAMF7 and IL8], which define a high-risk subgroup in IBD [hazard ratio 3.90, confidence interval: 2.43-6.26], or allowed distinct two- and three-protein models for ulcerative colitis and Crohn's disease respectively.

CONCLUSION

We have characterized a simple oligo-protein panel that has the potential to identify IBD from symptomatic controls and to predict future disease course. Further prospective work is required to validate our findings.

Whole Blood Profiling of T-cell-Derived microRNA Allows the Development of Prognostic models in Inflammatory Bowel Disease

BACKGROUND

MicroRNAs [miRNAs] are cell-specific small non-coding RNAs that can regulate gene expression and have been implicated in inflammatory bowel disease [IBD] pathogenesis. Here we define the cell-specific miRNA profiles and investigate its biomarker potential in IBD.

METHODS

In a two-stage prospective multi-centre case control study, next generation sequencing was performed on a discovery cohort of immunomagnetically separated leukocytes from 32 patients (nine Crohn's disease [CD], 14 ulcerative colitis [UC], eight healthy controls) and differentially expressed signals were validated in whole blood in 294 patients [97 UC, 98 CD, 98 non-IBD, 1 IBDU] using quantitative PCR. Correlations were analysed with phenotype, including need for early treatment escalation as a marker of progressive disease using Cox proportional hazards.

RESULTS

In stage 1, each leukocyte subset [CD4+ and CD8+ T-cells and CD14+ monocytes] was analysed in IBD and controls. Three specific miRNAs differentiated IBD from controls in CD4+ T-cells, including miR-1307-3p [p = 0.01], miR-3615 [p = 0.02] and miR-4792 [p = 0.01]. In the extension cohort, in stage 2, miR-1307-3p was able to predict disease progression in IBD (hazard ratio [HR] 1.98, interquartile range [IQR]: 1.20-3.27; logrank p = 1.80 × 10-3), in particular CD [HR 2.81; IQR: 1.11-3.53, p = 6.50 × 10-4]. Using blood-based multimarker miRNA models, the estimated chance of escalation in CD was 83% if two or more criteria were met and 90% for UC if three or more criteria are met.

INTERPRETATION

We have identified and validated unique CD4+ T-cell miRNAs that are differentially regulated in IBD. These miRNAs may be able to predict treatment escalation and have the potential for clinical translation; further prospective evaluation is now indicated.

Faecal microbiota signatures of IBD and their relation to diagnosis, disease phenotype, inflammation, treatment escalation and anti-TNF response in a European Multicentre Study (IBD-Character)

METHOD

We examined faecal samples, using the GA-map™ Dysbiosis Test, to associate gut microbiota composition with Crohn's disease (CD) and ulcerative colitis (UC) and to identify markers for future biomarker identification. We conducted a prospective case-control study (EU-ref. no. 305676) in an inception cohort of 324 individuals (64 CD, 84 UC, 116 symptomatic non-IBD controls and 44 healthy controls) across five European centres and examined 54 predetermined bacterial markers. We categorized patients according to the Montreal Classification and calculated the dysbiosis index (DI). Non-parametric tests were used to compare groups and the Bonferroni correction to adjust for multiple comparisons.

RESULTS

The fluorescent signals (FSSs) for Firmicutes and Eubacterium hallii were lower in inflammatory bowel disease (IBD) vs. symptomatic controls (p<.05). FSS for Firmicutes, Lachnospiraceae, Eubacterium hallii and Ruminococcus albus/bromii were lower, whereas the signal for Bacteroides Fragilis was higher in UC vs. symptomatic controls (p<.05). FSS was higher for Bifidobacterium spp., Eubacterium hallii, Actinobacteria and Firmicutes among patients with ulcerative proctitis, compared to extensive colitis (p<.05). In CD, we observed no association with disease location. The DI correlated with faecal-calprotectin in both CD and in UC (p<.001). In terms of treatment escalation and anti-TNF response, differences were observed for some bacterial markers, but none of these associations were statistically significant.

CONCLUSION

Our data reveal that the GA-map™ Dysbiosis Test holds the potential to characterize the faecal microbiota composition and to assess the degree of dysbiosis in new-onset IBD. On the other hand, our results cannot demonstrate any proven diagnostic or predictive value of this method to support clinical decision making.

Benefits of early lipid-lowering intervention in high-risk patients: the lipid intervention strategies for coronary patients study

BACKGROUND

There is controversy about whether lipid-lowering pharmacotherapy should be initiated immediately after an acute coronary event or only after diet and lifestyle changes have proved inadequate.

OBJECTIVE

This study, known as the Lipid Intervention Strategies for Coronary Patients Study, compared the efficacy of immediate versus deferred simvastatin treatment in conjunction with dietary advice about reducing lipid levels in hypercholesterolemic patients with acute coronary syndromes.

METHODS

This randomized, open-label, parallel-group study included 151 hypercholesterolemic (low-density lipoprotein cholesterol [LDL-C] >3.0 mmol/L) men and women aged 35 to 75 years. Within 4 days of diagnosis of acute myocardial infarction (MI) or unstable angina pectoris, all patients received dietary advice from a specially trained nurse. Subsequently, patients were randomized to 2 treatment groups: 1 group received immediate treatment with simvastatin 40 mg/d; patients in the other group received simvastatin 40 mg/d after 3 months only if their LDL-C remained >3.0 mmol/L.

RESULTS

The immediate-simvastatin group (n = 73) and the deferred-simvastatin group (n = 78) were balanced with respect to baseline characteristics. Of the 151 patients, 25% were women, 25% had concomitant hypertension, and 75% had a diagnosis of MI on enrollment. At 3 months, 90% of the patients receiving dietary advice plus immediate simvastatin treatment had achieved the recommended European target LDL-C level of <3.0 mmol/L, compared with 7% of those treated with diet alone. By 6 months, when 92% of the study participants were receiving simvastatin 40 mg/d, the proportion of patients achieving target LDL-C levels was 92% in the group that received immediate simvastatin therapy and 81% in the group that received deferred simvastatin therapy. The reductions in LDL-C (42%-48%) were considered to be clinically comparable between the 2 groups at 12 months.

CONCLUSIONS

On the basis of these results, we concluded that few patients with hypercholesterolemia and acute coronary syndromes reach the recommended European target LDL-C level of <3.0 mmol/L with dietary advice alone. However, early treatment with simvastatin 40 mg/d combined with dietary advice and follow-up at a dedicated outpatient clinic specializing in coronary heart disease resulted in 9 out of 10 patients reaching a recommended target LDL-C level of <3.0 mmol/L. Initiation of simvastatin therapy while a patient is hospitalized may increase the likelihood of the patient's lipid levels being managed according to current recommendations after he or she is discharged.

Histamine in lambs with abomasal bloat, haemorrhage and ulcers

The median concentration of histamine in abomasal fluid of lambs with abomasal haemorrhage and/or ulcers (group 2) was significantly (P < 0.05) higher than the concentrations in lambs presenting abomasal bloat (group 1) and in the healthy and the diseased controls. In group 2, there was also a strong correlation (R2 = 0.81) between the histamine concentrations in abomasal tissue and abomasal fluid, although the median value of histamine in the abomasal tissue was not statistically higher in this group than in the others. The urine of lambs in group 2 also had numerically higher median concentration of histamine than the other groups. Five out of eight tested strains of Lactobacillus spp. and one out of two strains of Clostridium sordellii, isolated from abomasal contents of lambs with abomasal disease, were strong producers of histamine. Bacterial production is one possible source for the increased histamine concentrations in lambs suffering from abomasal haemorrhage and/or ulcers.

Effects of iron dextran injections on the incidence of abomasal bloat, clinical pathology and growth rates in lambs

A preliminary study revealed significantly lower serum iron concentrations in lambs that developed abomasal bloat about one week later, than in lambs that did not develop bloat. In a subsequent trial, with 754 naturally reared twin lambs from five flocks, iron dextran injections were found to have a preventive effect on the development of abomasal bloat. Clinical signs of abomasal bloat were observed in the placebo-treated lamb of 16 couples and in the iron-treated lamb of six couples (P<0.05). In three further couples, both lambs developed bloat. The iron-treated group had significantly (P<0.001) better average weight gains, both from birth to summer, and from birth to autumn of approximately 0.5 and 1 kg, respectively. There was a reduction in red blood cell values and iron saturation in the placebo group 14 days after treatment but not in the iron-treated lambs. In one of the flocks, there was a decrease in the cumulative incidence of abomasal bloat from 37 per cent to 3 per cent during the period of four years after measures such as later lambing, earlier turnout and iron injections were introduced.

Sarcina -like bacteria, Clostridium fallax and Clostridium sordellii in lambs with abomasal bloat, haemorrhage and ulcers

A study of abomasal disease in lambs aged 2-5 weeks, made during the period 1993-1998, included 67 cases and 45 non-affected controls. Gross pathological findings included various combinations of bloat, haemorrhage and ulcers in the abomasum. Sarcina -like bacteria were found in sections and smears from the abomasum of 79% (53/67) of the cases. From one case, a lamb with abomasal bloat, the anaerobic "packet"-forming Sarcina ventriculi was cultivated from the abomasal contents and identified by biochemical reactions and sequencing of the 16S rRNA gene. Sarcina -like bacteria were observed microscopically in specimens from 94% (44/47) of the lambs with abomasal gas and in 45% (9/20) of those with ulcers or haemorrhage or both but little gas. On culture, abomasal contents from 41 cases yielded Clostridium fallax from 16 (39%) and Clostridium sordellii from eight (20%); abomasal cultures from 30 control lambs were negative for the three bacterial species. Quantitative cultivation, carried out on abomasal contents from live lambs and lambs dead </=3 h, showed that Clostridium perfringens, Escherichia coli and Lactobacillus spp. were present in the majority of both cases and controls, with no significant differences in the mean numbers.

Anaemia in housed lambs: effects of oral iron on clinical pathology and performance

An experiment including 39 pairs of housed twin lambs was performed to evaluate the effect of an oral iron supplement (Fe-MAX Starter) on clinical pathology, growth rates and disease occurrence. Significant differences between the iron supplemented group (Fe-group) and the controls were seen, for varying periods of time, for all red blood cell and iron parameters examined. In spite of this, 25% of the iron supplemented lambs had haemoglobin values below 80 g/L 4 weeks after treatment, whereas 33% of the controls had corresponding values 3 weeks after treatment, indicating that one single iron dose was insufficient to prevent iron deficiency anaemia. No significant positive effect on live weights was seen. However, the Fe-group had a poorer daily weight gain during the first week after dosing (p < 0.01), but a better daily gain during the second (p < 0.01) and third weeks. No effects were seen on disease occurrence. An additional trial with iron dextran injections to 5 untreated 21 days old lambs with varying haemoglobin values, revealed a rapid increase in the red cell distribution in anaemic lambs, with production of macrocytic, mainly normochromic erythrocytes. The new erythrocyte population was visible on the cytogram after 2 to 3 days and on the histogram after 5 days.

Abomasal bloat, haemorrhage and ulcers in young Norwegian lambs

An abomasal syndrome affecting mainly three- to four-week-old lambs was studied by using a case-control design involving 88 cases and 85 controls. The principal clinical signs were tympany and colic. The cases were divided into three groups according to the main gross pathological findings in 82 of them. The 28 lambs in group 1 had abomasal tympany, the 29 lambs in group 2 had severe damage to the abomasal mucosa, and the 25 lambs in group 3 consisted mainly of lambs with various other diseases in combination with abomasal changes. The lambs in group 1 had a significantly (P<0.05) lower mean (se) abomasal pH (2.7 [0.19]) than those in group 2 (4.1 [0.32]), group 3 (3.7 [0.39]) or the controls (3.3 [0.13]). The ruminal pH values ranged from 3.5 to 7.4 but there were no significant differences between the groups. Lambs with ulcers had a significantly (P<0.05) higher frequency of trichophytobezoars, than the cases without ulcers or the controls. The tympanic lambs in group 1 had a significantly higher mean packed cell volume, and higher mean red and white blood cell counts, and a significantly lower mean cell volume and mean cell haemoglobin concentration than the healthy control lambs.

Anaemia in housed lambs: effects of oral iron on clinical pathology and performance

An experiment including 39 pairs of housed twin lambs was performed to evaluate the effect of an oral iron supplement (Fe-MAX Starter) on clinical pathology, growth rates and disease occurrence. Significant differences between the iron supplemented group (Fe-group) and the controls were seen, for varying periods of time, for all red blood cell and iron parameters examined. In spite of this, 25% of the iron supplemented lambs had haemoglobin values below 80 g/L 4 weeks after treatment, whereas 33% of the controls had corresponding values 3 weeks after treatment, indicating that one single iron dose was insufficient to prevent iron deficiency anaemia. No significant positive effect on live weights was seen. However, the Fe-group had a poorer daily weight gain during the first week after dosing (p < 0.01), but a better daily gain during the second (p < 0.01) and third weeks. No effects were seen on disease occurrence. An additional trial with iron dextran injections to 5 untreated 21 days old lambs with varying haemoglobin values, revealed a rapid increase in the red cell distribution in anaemic lambs, with production of macrocytic, mainly normochromic erythrocytes. The new erythrocyte population was visible on the cytogram after 2 to 3 days and on the histogram after 5 days.

[Occupational environment and health among hospital physicians]

66% of the hospital doctors at the Central Hospital, Akershus and Ullevål Hospital responded to a questionnaire concerning different aspects of a doctor's work situation and health. The investigation revealed a large work load and lack of consulting rooms and equipment. Violence, threats, abusive language, risk of infection, high temperatures, cytostatic drugs, narcosic gases, irradiation are all risk factors during daily work for a large percentage of the doctors. Even so, they seem to be fairly satisfied with the organization of the work, and nearly all of them enjoy their work.

[Exposure to blood among hospital physicians]

We used a questionnaire to study the working situation of physicians in two large Norwegian hospitals. During the last six months 40% of the doctors reported one or more episodes of exposure to blood when transfer of infectious agents such as hepatitis B-virus or HIV would have been possible. The fact that so many doctors had been exposed to blood conflicts with the low number reported to the hospital department of the occupational health service. Surprisingly, 40% of the physicians who reported exposure were physicians not taking part in surgical procedures. All hospitals should establish follow-up procedures for employees exposed to blood or other possible infectious agents, and physicians should be urged to follow these routines.

[The risk of exposure to hepatitis B and human immunodeficiency virus among employees at Norwegian hospitals]

During the period from 1986 to 1989 a study was carried out to determine the risk of occupational exposure to hepatitis B virus and human immunodeficiency virus among approximately 5,500 employees at Aker hospital, Ullevål hospital and "Sentralsykehuset" in Akershus. Four hundred and fourteen injuries were reported during the study period of approximately 16,800 man-years, corresponding to an injury rate of 2.4/100 man-years. The majority of injuries occurred during direct patient contact in the wards. Of the known sources 8.2% were HBsAg positive and 16.8% HIV-antibody positive. One attendant contracted hepatitis B during the observation period. No HIV-seroconversion has been observed as yet.