Safety of thiopurines and anti-TNF-α drugs during pregnancy in patients with inflammatory bowel disease

OBJECTIVES

The safety of thiopurines and anti-tumor necrosis factor-α (TNF-α) drugs during pregnancy remains controversial, as the experience with these drugs in this situation is limited. Our aim is to assess the safety of thiopurines and anti-TNF-α drugs for the treatment of inflammatory bowel disease (IBD) during pregnancy.

METHODS

Retrospective, multicenter study in IBD patients. Pregnancies were classified according to the therapeutic regimens during pregnancy or during the 3 months before the conception: non-exposed group, pregnancies exposed to thiopurines alone (group A), and pregnancies exposed to anti-TNF-α drugs (group B). An unfavorable Global Pregnancy Outcome (GPO) was considered if pregnancy developed with obstetric complications in the mother and in the newborn.

RESULTS

A total of 187 pregnancies in the group A, 66 pregnancies in the group B, and 318 pregnancies in the non-exposed group were included. The rate of unfavorable GPO was different among the three groups (31.8% in non-exposed group, 21.9% in group A, and 34.8% in group B), being lower in pregnancies under thiopurines than among non-exposed (P = 0.01). The rate of pregnancy complications was similar among the three groups (27.7% in non-exposed, 20.9% in group A, and 30.3% in group B). The rate of neonatal complications was different among the three groups (23.3% in non-exposed group, 13.9% in group A, and 21.2% in group B), being lower in pregnancies under thiopurines than among non-exposed (P = 0.01). In the multivariate analysis, the treatment with thiopurines (odds ratio = 0.6; 95% confidence interval = 0.4-0.9, P = 0.02) was the only predictor of favorable GPO, whereas maternal age >35 years at conception was the only predictor of unfavorable GPO. The treatment with anti-TNF-α drugs was not associated with an unfavorable GPO.

CONCLUSION

The treatment with thiopurines and anti-TNF-α drugs does not seem to increase the risk of complications during pregnancy and does seem to be safe for the newborn.

Evolution After Anti-TNF Discontinuation in Patients With Inflammatory Bowel Disease: A Multicenter Long-Term Follow-Up Study

OBJECTIVES

The aims of this study were to assess the risk of relapse after discontinuation of anti-tumor necrosis factor (anti-TNF) drugs in patients with inflammatory bowel disease (IBD), to identify the factors associated with relapse, and to evaluate the overcome after retreatment with the same anti-TNF in those who relapsed.

METHODS

This was a retrospective, observational, multicenter study. IBD patients who had been treated with anti-TNFs and in whom these drugs were discontinued after clinical remission was achieved were included.

RESULTS

A total of 1,055 patients were included. The incidence rate of relapse was 19% and 17% per patient-year in Crohn's disease and ulcerative colitis patients, respectively. In both Crohn's disease and ulcerative colitis patients in deep remission, the incidence rate of relapse was 19% per patient-year. The treatment with adalimumab vs. infliximab (hazard ratio (HR)=1.29; 95% confidence interval (CI)=1.01-1.66), elective discontinuation of anti-TNFs (HR=1.90; 95% CI=1.07-3.37) or discontinuation because of adverse events (HR=2.33; 95% CI=1.27-2.02) vs. a top-down strategy, colonic localization (HR=1.51; 95% CI=1.13-2.02) vs. ileal, and stricturing behavior (HR=1.5; 95% CI=1.09-2.05) vs. inflammatory were associated with a higher risk of relapse in Crohn's disease patients, whereas treatment with immunomodulators after discontinuation (HR=0.67; 95% CI=0.51-0.87) and age (HR=0.98; 95% CI=0.97-0.99) were protective factors. None of the factors were predictive in ulcerative colitis patients. Retreatment of relapse with the same anti-TNF was effective (80% responded) and safe.

CONCLUSIONS

The incidence rate of inflammatory bowel disease relapse after anti-TNF discontinuation is relevant. Some predictive factors of relapse after anti-TNF withdrawal have been identified. Retreatment with the same anti-TNF drug was effective and safe.

Unilateral facetectomy approach for lateral lumbar disc herniation

Forty-one patients with herniated lumbar discs in a lateral location underwent unilateral complete facetectomy for removal of their disc herniation. The diagnosis was made by computerized tomography in all patients. The follow-up period varied between 4 and 60 months, with an average of 22.4 months. All patients underwent dynamic lumbar spine x-ray films with flexion and extension exposures at various times during their follow-up period. The results were excellent in 35 patients, good in three, and poor in three. One patient suffered spinal instability postoperatively and required lumbar fusion because of back pain. Unilateral facetectomy gives an excellent view of the affected nerve root and the herniated disc, and the risk of spinal instability is very low.

A population-based clinical trial with the SPf66 synthetic Plasmodium falciparum malaria vaccine in Venezuela

A phase III malaria vaccine trial in 13 villages in an endemic area, South Venezuela, compared incidence rates of Plasmodium falciparum and Plasmodium vivax infections in 1422 vaccinated and 938 nonvaccinated subjects over 18 months. The SPf66 vaccine was given in three doses, on days 0, 20, and 112. Vaccination was complete in 976 subjects (68.7%). Minor side effects requiring no treatment were reported by 123 (12.6%), with an apparent increase in frequency from the first to the third vaccine dose. No autoimmune evidence was observed in a sample of subjects. Antibodies against SPf66 were present at low titers in 24.7% of tested subjects before vaccination, increasing to 53.6% after the second dose and to 73.6% after the third dose; 26.4% of subjects initially seronegative never seroconverted. The SPf66 malaria vaccine showed a protective efficacy of 55% (95% confidence interval, 21%-75%) against P. falciparum and of 41% (19%-57%) against P. vivax malaria.

Labiomandibular, transoral approach to chordomas in the clivus and upper cervical spine

Three patients with chordomas of the clivus and the upper cervical spine underwent the removal of their tumors through a transoral approach with labiomandibular splitting and microsurgical techniques. This surgical approach provided excellent visualization of the anterior craniocervical area and allowed a gross total removal in each case. Although the lesions in our patients were chordomas, this approach could also be used for other surgical lesions in this area.

Cortical atrophy and other brain magnetic resonance imaging (MRI) changes after extremely high-altitude climbs without oxygen

The purpose of the present study is to detect by means of MRI any structural changes in the brain and their correlation with the clinical history of climbers who have ascended to extremely high altitudes without supplementary oxygen. Clinical history, neurological examinations and brain MRI were obtained from a group of 26 climbers who ascended to over 7000 m without supplementary oxygen, and the results were compared with a control group (n = 21) of healthy subjects. All the MRI studies were carried out between 26 days and 36 months after return to sea level. Significant neuropsychological disorders were experienced by all climbers during the ascent with residual neurobehavioural impairment after returning to sea level in 58% of them. The neurological examination was normal in all subjects. Almost half of the climbers showed MRI abnormalities (46%). Characteristic signal patterns of cortical atrophy were detected in five subjects. Periventricular hyperintensity lesions in the T2-weighted images were observed in other five climbers. Both types of lesions were found in two subjects. These pathological findings did not correlate with age, sex, clinical symptoms, maximal altitude reached, or length of exposure to extreme altitude. The exact long-term pathological significance of these MRI abnormalities is as yet unknown.

Characterization of gene expression of VIP and VIP1-receptor in rat peritoneal lymphocytes and macrophages

In the present report we show the gene expression pattern of VIP and VIP1 receptor in two peritoneal cell populations, macrophages and lymphocytes by reverse transcription (RT) and polymerase chain reaction (PCR). Only in the lymphoid cells we have obtained a specific VIP cDNA product of 458 bp identical in size to the one obtained from cerebral cortex. On the other hand, we have obtained in both peritoneal populations lymphocytes and macrophages, a specific VIP1 receptor cDNA product of 311 bp identical in size to that obtained from lung. These results have been confirmed by Southern blot hybridization. Our findings suggest an autocrine/paracrine action of VIP in peritoneal microenvironment, supporting an immunoregulatory role for this neuropeptide.

Vasoactive intestinal peptide (VIP) mRNA expression in rat T and B lymphocytes

Different evidence suggests that VIP has immunoregulatory functions and may be secreted by different cells involved in inflammatory and immune responses. In the present study, we demonstrate by reverse transcription (RT) and polymerase chain reaction (PCR) VIP gene expression in rat thymocytes and T and B cells derived from spleen and lymph nodes. We have obtained a specific VIP cDNA product of 458 bp identical in size to that obtained from cerebral cortex. These results have been confirmed by Southern blot analysis. VIP message has also been detected in the T-T hybridoma YH-1633 and in a non-immune cell line, the pheochromocytoma PC 12. VIP gene expression in central and peripheral lymphoid organs suggests that VIP may be a T and B cell-derived cytokine involved in T-cell differentiation and in cell immune responses.

Expression of vasoactive intestinal peptide in lymphocytes: a possible endogenous role in the regulation of the immune system

Experimental evidence is accumulating showing that vasoactive intestinal peptide (VIP) acts as an immunoregulatory peptide. Findings from our laboratory and others indicate that cells of the immune system are able to produce VIP. We have detected immunoreactivity for VIP in lymphocytes by immunohistochemical methods at specific locations of both central and peripheral lymphoid organs. Double immunofluorescence staining and flow cytometry analysis indicate that both T and B lymphocytes contain VIP that has been proved to be mostly VIP 1-28 by high-performance liquid chromatography and radioimmunoassay. VIP has been also demonstrated by 'in situ' hybridization and reverse transcription followed by polymerase chain reaction. We have also detected induction of VIP in splenic lymphocytes after mitogenic stimulation. Lymphocytes should be sensitive to the endogenously produced VIP because we have also detected VIP receptor expression in different populations of lymphocytes. All this evidence indicates that VIP is an endogenous autocrine modulator of immune function.

A new approach to the assessment of anaerobic metabolism: measurement of lactate in saliva

OBJECTIVE

To test the hypothesis that saliva lactate concentrations may reflect those present in blood and that saliva lactate can be used as a very convenient and useful variable in the study of anaerobic metabolism.

METHODS

Parallel determinations were made of lactate in saliva and in capillary blood samples, obtained at 3 min intervals from nine individuals during the performance of a maximum graded exercise test on a cycle ergometer against increasing workloads (from 25 up to a maximum of 300 W). Lactate determinations were done by means of an electroenzymatic method using 25 microliters samples in both types of fluids.

RESULTS

For each situation, the concentration of lactate in saliva was shown to be about 15% of that in plasma but it followed the same pattern of evolution during the exercise test. A good correlation (r = 0.81) between blood and saliva lactate concentrations was found. The precision of the method was very good, with a coefficient of variation ranging (n = 10) between 2.2% for samples with very low lactate concentrations and 0.7% for sample with moderate lactate concentrations. Lactate appeared to be very stable in saliva over a period of 40 days after collection, when kept at 4 degrees C. The values obtained after this period were virtually identical to those shown in fresh samples.

CONCLUSIONS

Determination of lactate in saliva can be used as an alternative to determination in blood, overcoming most of the drawbacks of the procedures being used at present, since the collection of the samples required no special expertise.

Vasoactive intestinal peptide modulation of adherence and mobility in rat peritoneal lymphocytes and macrophages

In this work, the effects of vasoactive intestinal peptide (VIP) in a concentration range from 10(-13) to 10(-7) M were studied in vitro on two common activities of peritoneal rat lymphocytes and macrophages: adherence and mobility (spontaneous and chemotaxis). The results show that VIP stimulated the adherence of the two cells studied, and increased the macrophage mobility but decreased this activity in lymphocytes. Moreover, a specific protein kinase C (PKC) activator such as phorbol myristate acetate (PMA, 50 ng/ml) also stimulated significantly the adherence and chemotaxis of both macrophages and lymphocytes. By contrast, a PKC inhibitor, retinal (2 x 10(-5) M), decreased significantly these capacities. Macrophages incubated with both VIP and PMA in relation to those incubated with VIP or PMA showed an increase in adherence and chemotaxis, whereas in lymphocytes adherence was also increased but chemotaxis decreased. The incubation with forskolin (10(-5) M), an enhancer of intracellular cAMP levels, produced an inhibitory effect of the chemotaxis activity in both types of cells. VIP prevented this inhibitory effect of forskolin in macrophages but not in lymphocytes. In addition, VIP was chemoattractant for macrophages but not for lymphocytes. The present study proves that VIP proves that VIP has a coronary effect on the two principal and representative types of immune cells in the rat peritoneum: lymphocytes and macrophages, stimulating macrophage chemotaxis through PKC activation and inhibiting lymphocyte chemotaxis through adenylate cyclase activation.

Gene expression of VIP receptor in rat lymphocytes

In the present report we analyze by reverse transcription (RT) and polymerase chain reaction (PCR) the expression of vasoactive intestinal peptide receptors (VIP-R) in rat thymocytes and peripheral T and B lymphocytes. We have obtained a specific VIP-R cDNA product of 311 bp identical in size to that obtained from lung. These results have been confirmed by Southern hybridization analysis. VIP receptor gene expression in central and peripheral lymphoid organs support the notion that VIP is a immunomodulatory peptide.

Transluminal dilatation of internal carotid artery in fibromuscular dysplasia: a preliminary report

A patient with transient ischemic attacks and fibromuscular dysplasia of the internal carotid artery was treated by Grüntzig balloon-catheter dilatation of the involved area of the internal carotid artery. The clinical and angiographic results were excellent.

Maternal soluble tumour necrosis factor receptor type 2 (sTNFR2) and adiponectin are both related to blood pressure during gestation and infant's birthweight

OBJECTIVE

Tumour necrosis factor alpha (TNF-alpha) and adiponectin are strongly related to insulin sensitivity; insulin resistance of pregnancy is a major determinant of infant's birthweight. We aimed to study the contributions of maternal serum concentrations of soluble TNF-alpha receptors (sTNFR1 and sTNFR2) and adiponectin to infant's birthweight.

DESIGN

Cross-sectional, hospital-based study of insulin sensitivity during gestation.

PATIENTS

Fifty-one healthy women with uncomplicated pregnancy and delivery (except for elective Caesarian section) and their healthy newborn infants. measurements Maternal blood levels of glucose, insulin, glycosylated haemaglobin (HbA1c), sTNFR1, sTNFR2 and adiponectin at delivery; cord-blood levels of sTNFR1, sTNFR2 and adiponectin.

RESULTS

At delivery, maternal sTNFR2 correlated with systolic blood pressure (SBP; r = 0.38, P = 0.005). In multiple regression analyses, SBP and HbA1c were independent predictors of sTNFR2, explaining 18 and 7% of its variance, respectively; insulin resistance index (HOMA-IR), body mass index at delivery and SBP were independent predictors of adiponectin, explaining 15, 8 and 7% of its variance, respectively. Both maternal sTNFR2 and SBP were negatively correlated with infant's birthweight (r = -0.28, P = 0.04 and r = -0.36, P = 0.01 respectively, adjusted for sex and gestational age). In multivariate regression analyses, infant's sex and either maternal sTNFR2 or adiponectin were independent predictors of infant's birthweight, each explaining between 6 and 9% of birthweight variance. Further addition of maternal SBP to these models revealed that this variable was the main predictor of infant's birthweight, explaining 13% of its variance.

CONCLUSIONS

Maternal sTNFR2 and adiponectin are independently related to both maternal blood pressure and infant's birthweight in uncomplicated pregnancy. The contributions of the TNF-alpha system and adiponectin to hypertensive disorders of pregnancy and fetal growth merit further studies.

HOXB homeobox gene expression in cervical carcinoma

The homeobox (HOX) genes are a family of transcription factors that bind to specific DNA sequences in target genes regulating gene expression. Thirty-nine HOX genes have been mapped in four conserved clusters: A, B, C, and D; they act as master genes regulating the identity of body segments along the anteroposterior axis of the embryo. The role played by HOX genes in adult cell differentiation is unclear to date, but growing evidence suggests that they may play an important role in the development of cancer. To study the role played by HOX genes in cervical cancer, in the present work, we analyzed the expression of HOXB genes and the localization of their transcripts in human cervical tissues. Reverse transcription-polymerase chain reaction analysis and nonradioactive RNA in situ hybridization were used to detect HOXB expression in 11 normal cervical tissues and 17 cervical carcinomas. It was determined that HOXB1, B3, B5, B6, B7, B8, and B9 genes are expressed in normal adult cervical epithelium and squamous cervical carcinomas. Interestingly, HOXB2, HOXB4, and HOXB13 gene expression was found only in tumor tissues. Our findings suggest that the new expression of HOXB2, HOXB4, and B13 genes is involved in cervical cancer.

A cysteine protease from Taenia solium metacestodes induce apoptosis in human CD4+ T-cells

Here we investigated whether the depletion of CD4+ lymphocytes, observed in mononuclear cells incubated with Taenia solium metacestode E/S products or with living cysts was due to apoptosis. Using the deoxynucleotidyl transferase-mediated dUTP nick-end labelling (TUNEL), electron microscopy and DNA gel electrophoresis, we found signs of apoptosis in these cells. Results showed that cysteine protease activity was responsible for this effect, since E-64 prevented cell death in all cases. Electron microscopy studies showed that lymphocytes exhibited features of apoptosis such as cellular membrane integrity, strangling and fragmentation of nuclei, chromatin condensation, apoptotic bodies and loss of microvilli. In contrast, lymphocytes co-cultured with living metacestodes plus E-64 exhibited integrity of their structures. DNA fragmentation was detected by TUNEL assays and DNA gel electrophoresis. The results suggested that cell death induced by the cysteine protease from the T. solium metacestode may be involved in down-regulation of cell-mediated responses in infected hosts.

Taenia solium: a cysteine protease secreted by metacestodes depletes human CD4 lymphocytes in vitro

Excreted/secreted products from Taenia solium metacestodes cultured in vitro were analyzed for peptidase activity using peptide substrates Z-Phe-Arg-AFC, Arg-AFC, and Z-Gly-Gly-Arg-AFC and zymography studies. Specific inhibitor profiles revealed mainly cysteine and metalloprotease activities. Hydrolysis of substrate Z-Phe-Arg-AFC was augmented by the addition of L-cysteine and acid pH, consistent with cysteine protease activity. Cysteine protease activity was more prominent in supernatants from living metacestodes cultured in PBS than in either RPMI or RPMI plus fetal calf serum and was proportional to the number of metacestodes. Flow cytometry analysis showed depletion of human T lymphocytes cultured with living T. solium metacestodes. CD4(+) expression was significantly decreased when metacestode E/S products and L-cysteine were added to lymphocyte cultures (P = 0.027). This peptidase activity was inhibited by E-64 indicating that the depletion of CD4(+) cells was due to cysteine protease activity. Thus, T. solium metacestodes produce excretory/secretory proteases. These enzymes may cleave molecules critical for the host immune response allowing the parasites to survive in the host tissues.

Training model for teaching endoscopic submucosal dissection of gastric tumors

INTRODUCTION

The elevated risk of complications and technical complexity of endoscopic submucosal dissection (ESD) has limited its implementation in our medical system.

OBJECTIVE

To design and evaluate a training program for learning the ESD technique.

METHODS

Four endoscopists with no experience with ESD underwent a 4-step training program: 1) review of the existing literature, didactic material, and theoretical aspects of ESD; 2) ESD training in an ex-vivo animal model; 3) ESD training in an in-vivo animal model (supervised by ESD expert); and 4) ESD performance in a patient. A standard gastroscope and an ESD knife (IT, Flex or Hook-knife Olympus) were employed. The classical ESD technique was performed: rising of the lesion, circumferential incision, and submucosal dissection.

RESULTS

Ex-vivo animal model: 6 x swine stomach/esophagus -cost < 100 euro; 6 x ESD: antrum (n = 2), body (n = 3) and fundus/cardia (n = 1)-; size of resected specimen: 4-10 cm; ESD duration: 105-240 minutes; therapeutic success: 100%; complications: perforation (1/6: 16%) sealed with clips. In-vivo animal model: 6 ESD (antrum/body of stomach: 4; esophagus: 2); size: 2-5 cm; duration: 40-165 minutes; success: 100%; complications: 0%.

PATIENT

ESD of a gastric lesion located in the antrum/body; size: 3 cm; duration 210 minutes; a complete resection was achieved; no complications.

CONCLUSIONS

The results of the present study support the usefulness of this model for learning ESD in our system.

Lumbar disc disease in children

The clinical experience with lumbar disc disease in 38 patients at a large children's hospital is reviewed. Thirty children underwent surgical treatment; eight patients were not operated upon. The surgical results were excellent, with 93% of the children cured or markedly improved on follow-up. The main differential aspects of lumbar disc disease between children and adults are emphasized.

Effects of arsenite on cell cycle progression in a human bladder cancer cell line

Bladder cancer is one of the most important diseases associated with arsenic (As) exposure in view of its high prevalence and mortality rate. Experimental studies have shown that As exposure induces cell proliferation in the bladder of sodium arsenite (iAsIII) subchronically treated mice. However, there is little available information on its effects on the cell cycle of bladder cells. Thus, our purpose was to evaluate the effects of iAsIII on cell cycle progression and the response of p53 and p21 on the human-derived epithelial bladder cell line HT1197. iAsIII treatment (1-10 microM) for 24 h induced a dose-dependent increase in the proportion of cells in S-phase, which reached 65% at the highest dose. A progressive reduction in cell proliferation was also observed. BrdU was incorporated to cellular DNA in an interrupted form, suggesting an incomplete DNA synthesis. The time-course of iAsIII effects (10 microM) showed an increase in p53 protein content and a transient increase in p21 protein levels accompanying the changes in S-phase. These effects were correlated with iAs concentrations inside the cells, which were not able to metabolize inorganic arsenic. Our findings suggest that p21 was not able to block CDK2-cyclin E complex activity and was therefore unable to arrest cells in G1 allowing their progression into the S-phase. Further studies are needed to ascertain the mechanisms underlying the effects of iAsIII on the G1 to S phase transition in bladder cells.

Differential VIP and VIP1 receptor gene expression in rat thymocyte subsets

Nervous, endocrine, and immune systems share a large number of regulatory molecules including hormones and neuropeptides. Vasoactive intestinal peptide (VIP) plays an important role in a variety of immunological functions. In the present report, we sorted purified thymocytes of the four major thymic subsets defined by CD4 and CD8 phenotypes. We demonstrate by reverse transcription (RT) and polymerase chain reaction (PCR) both VIP and VIP1 receptor gene expression in double positive (CD4+CD8+) and single positive (CD4+CD8-, CD4-CD8+) thymocyte subsets. Double negative thymocytes (CD4-CD8-) lack VIP and VIP1 receptor gene expression.

New evidence from magnetic resonance imaging of brain changes after climbs at extreme altitude

The aim of the present study was to look for anatomical changes in climbers' brains, using magnetic resonance imaging (MRI), after extremely high-altitude climbs and to relate them to possible associated risk factors. Clinical history, neurological examinations and MRI were carried out on a group of nine climbers before and after climbing to over 7500 m without the use of supplementary oxygen. None of the subjects showed any neurological dysfunctions. In five climbers MRI abnormalities (high signal areas, cortical atrophy) were observed before the expedition. After the descent, two of them showed new high intensity signal areas recorded by MRI. Both subjects suffered severe neurological symptoms during the climb. The present study suggested that the brain changes observed by MRI could be related to the severity of clinical events at high altitude. However, we do not know the exact meaning of such MRI findings or the reason for their location, predominantly in posterior regions of the brain. The new evidence that a high percentage of climbers show MRI brain abnormalities, and especially the appearance of changes after the ascent, reinforces the possibility of a potential neurological risk in high-altitude climbing.

Lymphoid cell subpopulations containing vasoactive intestinal peptide in the rat

In the present study we describe the cell types containing immunoreactive vasoactive intestinal peptide (IR-VIP) in rat thymus, spleen, and lymph nodes. Indirect immunofluorescence staining and flow cytometry indicated that all lymphoid organs studied contained VIP-positive cells, with the spleen and lymph nodes having a higher proportion than the thymus. Vasoactive intestinal peptide was found in both lymphocytes and nonlymphoid cells, lymphocytes predominating among VIP-positive cells. Double immunofluorescent staining and flow cytometry showed that all lymphoid subpopulations identified contained variable proportions of VIP-positive lymphocytes. Immunocytochemical staining of cell suspensions for both light and electron microscopy showed the cytoplasmic localization of the IR-VIP. These findings, coupled to our previous results, are consistent with the idea that VIP may have a lymphoid origin and could be active in local immune responses.