IBD-PODCAST Spain: A Close Look at Current Daily Clinical Practice in IBD Management

BACKGROUND

Crohn's disease (CD) and ulcerative colitis (UC) are inflammatory bowel diseases (IBD) that contributes in part to irreversible bowel damage and long-term complications, reduced quality of life, invalidity, and economic burden. Suboptimal control of IBD is associated with higher healthcare resource utilization (HCRU), impaired quality of life (QoL), and reduced work productivity.

AIMS

The IBD-PODCAST study aimed to assess the proportion of IBD patients with suboptimal control and its associated impact.

METHODS

IBD-PODCAST is a cross-sectional, multicenter study that aimed to characterize the CD and UC population with optimal or suboptimal control according to the STRIDE-II criteria and patient- and physician-reported measures. Here we present the results of the Spanish cohort (n = 396).

RESULTS

A total of 104/196 (53.1%) CD and 83/200 (41.5%) UC patients were found to have suboptimal disease control. Long-term treatment targets according to STRIDE-II were applied in 172 (87.8%) CD and 181 (90.5%) UC patients. 125 of 172 (72.7%) CD and 74 of 181 (40.9%) UC patients were currently treated with targeted immunomodulators. Patients with CD and UC and suboptimal disease control showed impaired QoL, higher HCRU and direct costs, and also loss of work productivity compared to those with optimal control.

CONCLUSION

Despite a high rate of targeted immunomodulator therapy, a substantial proportion of IBD patients show suboptimal disease control according to the STRIDE II criteria. Those patients with suboptimal disease control exhibit impaired QoL, less work productivity, and higher HCRU, suggesting that there is considerable need for better treatment approaches in IBD.

Thiopurine methyl-transferase activity and azathioprine metabolite concentrations do not predict clinical outcome in thiopurine-treated inflammatory bowel disease patients

BACKGROUND

Low thiopurine-methyl-transferase (TPMT) activity and high 6-thioguanine-nucleotide (6TGN) concentrations have been linked to therapeutic success in inflammatory bowel disease patients treated with thiopurines; however, this has not been implemented in clinical practice.

AIM

To identify a therapeutic threshold value for TPMT or 6TGN concentrations, and their capability to predict treatment safety and efficacy.

METHODS

Prospective multicentre study including steroid-resistant/dependent patients starting thiopurines. The TPMT activity was determined at inclusion (>5 U/mL required). Azathioprine metabolites [6TGN, 6-methyl-mercaptopurine ribonucleotides (6MMP), and 6TGN/6MMP and 6TGN/TPMT ratios] were periodically monitored during steroid tapering and after withdrawal for 6 months or until a new flare occurred.

RESULTS

A total of 113 patients were analysed (62% clinical response). Areas under the receiver operating characteristic (ROC) curve (AUC) relating clinical response and metabolite levels at 2, 4 and 6 months after steroid withdrawal were less than 0.7. The AUCs relating final response and initial TPMT activity or metabolite concentrations at 2, 4, 8 and 16 weeks after starting thiopurines were less than 0.7. No cut-off point with worthwhile sensitivity/specificity was found. Eight (7%) patients developed thiopurine-related toxicity that could not be linked to TPMT activity or 6TGN levels.

CONCLUSIONS

Our results do not support determination of TPMT activity or 6TGN concentrations to predict treatment outcome, and no useful serum metabolites threshold value to adjust the drug's dose was identified.

Predictors of response to infliximab in patients with fistulizing Crohn's disease

OBJECTIVE

To evaluate the efficacy and toxicity of infliximab for the treatment of fistulizing Crohn's disease.

METHODS

Consecutive patients with fistulizing Crohn's disease receiving infliximab were prospectively enrolled. Partial response was defined as a reduction of 50% or more from base-line in the number of draining fistulae. Complete response was defined as the closure of all fistulae. The influence of different variables on the efficacy of infliximab was evaluated.

RESULTS

108 patients were included. The disease was inflammatory plus fistulizing in 18% and only fistulizing in 82%. After the third infusion of infliximab the response was partial in 26% and complete in 57%. Response (%) rates (partial/complete) depending on fistula location were: enterocutaneous (25/68%), perianal (35/60%), rectovaginal (36/64%), and enterovesical (20/40%). None of the studied variables (including concomitant immunosuppressive therapy) correlated with efficacy of infliximab in the multivariate analysis. Incidence of adverse effects (21%) depending on the dose of infliximab was: first dose (5.6%), second (7.4%), and third (11.1%).

CONCLUSIONS

Infliximab is an efficacious treatment for fistulizing Crohn's disease. Partial response was achieved in approximately one third of the patients, and complete response in more than half. No studied variable was predictive of response. Adverse effects were relatively infrequent and mild.

An increased expression of nucleolin is associated with a physiological nucleolar segregation

Nucleolar segregation is the most striking cellular phenotypic feature of cold-acclimatized carp and depicts the cyclical reprogramming that the physiology of the fish undergoes between summer and winter, where a clear differential expression of some nucleolar related genes occurs. We characterized carp nucleolin, a nucleolar protein involved in multiple steps of ribosome biogenesis, and evaluated its expression upon fish acclimatization. We show that the carp cDNA deduced amino acid sequence exhibits the same tripartite structural organization found in other species. Nevertheless, we observed that nucleolin mRNA expression was strongly induced in the cold-adapted carp as was the nuclear protein content, assessed by immunocytochemistry in liver sections. The physiological up-regulation of nucleolin in the cold-acclimatized carp, where rRNA transcription and processing are depressed concomitantly with the nucleolus segregation, is consistent with the notion that nucleolin plays a fundamental role in repressing rRNA synthesis.

Environmental reprogramming of the expression of protein kinase CK2beta subunit in fish

The dramatic segregation of the nucleolar components in winter-acclimatized carp is the most striking cellular-phenotypical feature observed during the seasonal adaptation of this fish toward the circannual changes in its habitat. Our studies also show that the carp habitat temperature and photoperiod winter conditions provoke a remarkable reduction of both rRNA transcription and the processing of their precursors. To gain knowledge on the mechanisms involved in the regulation of nucleolar activity during the seasonal adaptation process, we studied the behavior of some genes, specifically snoRNA U3 and protein kinase CK2. Consistent with the reduction in the synthesis and processing of pre-rRNA observed during the cold season, the level of CK2beta expression decreases in winter when compared to that attained in summer. Similarly, in winter, liver and kidney cells contain lower levels of CK2beta subunit protein compared to summer. CK2 is associated with or modifies different factors and enzymes involved in the nucleolar activity; therefore, its higher or lower content could be part of the molecular mechanisms underlying the nucleolar seasonal changes that occur during the compensatory acclimatization process.

In situ hybridization of somatolactin transcripts in the pituitary glands from acclimatized carp (Cyprinus carpio)

We isolated and cloned a carp somatolactin SL DNA fragment, of which 78% of the nucleotides were identical to the corresponding salmon SL sequence. The results obtained upon Northern blot hybridization of carp pituitary RNA allowed the identification of two transcripts as described for other fish. When the content of SL transcripts in pituitary sections from summer- and winter-acclimatized carp was quantified by in situ hybridization assays, we found no significant differences between the two seasons. In salmonids, plasma SL reaches higher levels in summer than in winter in synchrony with the water temperature cycle; in the eurythermal carp, however, the complex adaptive responses imposed by seasonal environmental changes do not seem to include the regulation of the somatolactin detected with the probe used at the transcriptional level in pituitary glands.

Seasonal adaptation modulates the expression of the protein kinase CK2 beta subunit gene in the carp

Carp fish seasonal acclimatization induces a cyclical transcriptional modulation of several genes. Its most dramatic expression results in a concomitant structural rearrangement of the nucleolar components that phenotypically represents profound shifts in the level of ribosomal RNA synthesis. In connection with the recent studies that implicate CK2 in the control of rRNA synthesis in vertebrates, we characterized the cDNA of carp protein kinase CK2beta subunit and assessed its transcriptional behavior in winter- and summer-acclimatized fish. We found a remarkable differential gene expression of CK2beta subunit between summer- and winter-acclimatized carp which correlates with the modulatory pattern observed in rRNA transcription.

Transcription factor pit-1 expression is modulated upon seasonal acclimatization of eurythermal ectotherms: identification of two pit-1 genes in the carp

A second Pit-1 gene in carp (Cyprinus carpio), including the complete structural gene and 1.1 kb of promoter region, was identified and completely sequenced. The exon-intron structure was determined, and reverse transcription-polymerase chain reaction (RT-PCR) experiments suggest that only one Pit-1 splice variant is present in carp pituitary. The effect of seasonal acclimatization on the extent of Pit-1 gene expression was studied in summer- and winter-acclimatized carp. Quantitative RT-PCR analysis revealed a clear increase of Pit-1 mRNA in the pituitaries from summer-acclimatized carp compared with the winter-adapted fish. In situ hybridization of pituitary gland sections with riboprobes representing the complete 5'-transactivating region of carp Pit-1 depicted a significantly higher Pit-1 mRNA level in the rostral pars distalis of the summer-acclimatized fish where prolactin is expressed in a manner that resembles the seasonal increase observed in the proximal pars distalis and the pars intermedia. The cell- and temporal-specific transcription of Pit-1 supports its role in the molecular mechanisms that underly the acclimatization process undergone by eurythermal fish as a result of the physical effects of seasonal changes on their habitat.

Ribosomal internal transcribed spacer 2 (ITS2) exhibits a common core of secondary structure in vertebrates and yeast

Molecular mechanisms of ITS2 processing, a eukaryotic insertion between the 5.8S and LSU rRNA, remain largely elusive even in yeast. To delineate ITS2 structural and functional features which could be common to eukaryotes, we first produced phylo-genetically supported folding models in the vertebrate lineage, then tested them in deeper branchings and, more particularly, among yeasts. ITS2 comparisons between four Teleostei, a Chondrichthyes specimen and two jawless organisms have revealed a common folding architecture in four to five domains of secondary structure emerging from a preserved structural core. This folding, largely reminiscent of ITS2 architecture in mammals, is also preserved in amphibia and in chicken, despite dramatic sequence variations. Preferential conservation is located around a central loop and at the apex of a long stem in the ITS2 3'-half. Interestingly, these two independent structural features contain, respectively, the 3'-ends of the two transient rRNA precursors 8S and 12S RNA identified in mammals, suggesting a preservation of these intermediates of processing over the entire vertebrate group. Surprising similarities between the vertebrate ITS2 folding shape and that of invertebrates as well as protista have made intriguing the significant differences from the yeast model. A detailed comparative analysis including four relatively close species and Schizosaccharomyces pombe, a deep yeast branching, has revealed an alternative phylogenetically supported four-domain folding presenting strong similarities to the vertebrate model. Remarkably, the two best conserved regions of vertebrates have unambiguously preserved counterparts which are also sites for internal processing in yeast. Therefore, molecular mechanisms involved in ITS2 excision in vertebrates and yeast might be more closely related than currently believed and might require a very similar trans -acting machinery.

Effect of seasonal acclimatization on the expression of the carp transcription factor Pit-1

We isolated a clone comprising four exons of the carp Pit-1 gene. Using synthetic oligonucleotide probes derived from the carp Pit-1 sequence Pit-1 expression was assessed by in situ hybridization in pituitary sections from summer- and winter-acclimatized carp. Semiquantitative analyses of the hybridization signals revealed a significant higher Pit-1 expression in the proximal pars distalis (PPD) and pars intermedia (PI) of the pituitary glands from summer-acclimatized carp, compared to the winter-acclimatized fish. In both adaptive states, relative to the PPD and PI, only a basal Pit-1 expression was detected in the rostral pars distalis. Thus, during seasonal acclimatization of an eurythermal fish, Pit-1 seems to be involved in the mechanisms that underlie the compensatory response.

A PCR-based assay for the identification of the fish pathogen Renibacterium salmoninarum

By means of a one-step one-tube extraction from less than 1 mg of tissue it is possible to identify, via the polymerase chain reaction, Renibacterium salmoninarum in salmon with bacterial kidney disease. A 149-bp DNA sequence unique to R. salmoninarum was specifically amplified and its nature confirmed by Southern hybridization using a non-isotopically labelled probe. The sensitivity of the approach allowed the detection of 22 R. salmoninarum cells. The procedure was successfully applied in the identification of the causative agent of bacterial kidney disease in kidney tissue from infected fishes.

Oral administration of insulin in winter-acclimatized carp (Cyprinus carpio) induces hepatic ultrastructural changes

1. The intestinal absorption of insulin in carps was assessed examining the transepithelial passage of ingested gold-labeled hormone by electron microscopy. Insulin transfer occurred mainly through the intercellular spaces between the enterocytes. 2. When reaching the lamina propria, the gold-labeled hormone gathered predominantly around the granules of the granular cells, and therefore can enter the circulatory system via the blood capillaries which are found in close contact with these cells. 3. Winter-acclimatized carp were also capable of internalizing the hormone when fed with insulin. 4. Furthermore, the absorbed hormone revealed full activity in regard to the observed changes in the ultrastructure of the liver cells of the treated cold-adapted fish. 5. The fish ingesting the hormone underwent the same type of hepatic ultrastructure reprogramming observed when winter-acclimatized carps are injected intraperitoneally with insulin, i.e. conversion to a phenotype corresponding to hepatocytes from summer-adapted carp. 6. The oral absorption of insulin by winter-acclimatized fish and its effect in reversing the cold-adaptive state might be useful for the fish culturing industry.

Opioid peptides in pseudocyesis

Five women with pseudocyesis were evaluated during a two-year period. A random, nontimed blood sample was obtained from each woman at the time of initial encounter that revealed a hormone pattern most consistent with polycystic ovarian disease; mean (+/- SE) concentration of luteinizing hormone (LH) was 14.2 +/- 2.1 mIU/mL, follicle-stimulating hormone (FSH) was 3.3 +/- 0.7 mIU/mL, prolactin (PRL) was 23.5 +/- 1.3 ng/mL, estrone was 74.7 +/- 15.0 pg/mL, and estradiol was 54.7 +/- 13.0 pg/mL. In four of these patients, serum progesterone concentration was elevated over expected follicular phase values. The opiate antagonist, naloxone, was administered to four women before disclosure of their diagnosis. Naloxone treatment failed to induce LH or PRL release. Because naloxone did not cause a change in hormone concentration, naloxone-sensitive opioid mechanisms are apparently not involved in this disorder. After resolution of pseudocyesis, naloxone-induced LH release was appropriate for the phase of the cycle in which the narcotic blocking agent was administered.

Allozymic and morphological differentiation in the South American frogs genus Eupsophus

Four species of frogs genus Eupsophus were examined using electrophoresis at 19 loci, and 10 morphological characters employing discriminant analysis. The allozymic and morphological differentiation patterns do not agree. It is suggested that selective pressures are responsible for the incongruence of both sets of characters.

Rape crisis intervention in the emergency room: a new challenge for social work

The emerging role of the social worker in the context of rape crisis programs housed in hospital emergency rooms is examined. A brief review of the psychological impact of rape on its victims is offered as a background for delineating this role. The emergency room setting is analyzed in terms of the advantages and disadvantages it presents for this type of crisis intervention. Significant issues of care for the social worker in this setting are discussed, and an outline of tasks for this role is proposed.

On the therapeutic aspects of psychiatric admission

Notwithstanding the current interest in different aspects of admission to psychiatric facilities, the actual procedures for admission have been neglected. Their therapeutic importance is here emphasized using the notion of a therapeutic contract that incorporates patients, families and professionals. Clarification of expectations and roles among the parties to this contract is essential to achieving an understanding of the patient-clinician relationship. An admission conference is proposed as conductive to reaching these goals.