D. Foschi

Human intestinal epithelial cells promote the differentiation of tolerogenic dendritic cells.

Objective: In mice, a subpopulation of gut dendritic cells (DCs) expressing CD103 drives the development of regulatory T (Treg) cells. Further, it was recently described that the cross-talk between human intestinal epithelial cells (IECs) and DCs helps in maintaining gut immune homeostasis via the induction of non-inflammatory DCs. In this study, an analysis was carried out to determine whether IECs could promote the differentiation of CD103+ tolerogenic DCs, and the function of primary CD103+ DCs isolated from human mesenteric lymph nodes (MLNs) was evaluated. Methods: Monocyte-derived DCs (MoDCs) and circulating CD1c+ DCs were conditioned or not with supernatants from Caco-2 cells or IECs isolated from healthy donors or donors with Crohn’s disease and analysed for their ability to induce Treg cell differentiation. In some cases, transforming growth factor β (TGFβ), retinoic acid (RA) or thymic stromal lymphopoietin (TSLP) were neutralised before conditioning. CD103+ and CD103− DCs were sorted by fluorescence-activated cell sorting (FACS) from MLNs and used in Treg cell differentiation experiments. Results: It was found that human IECs promoted the differentiation of tolerogenic DCs able to drive the development of adaptive Foxp3+ Treg cells. This control was lost in patients with Crohn’s disease and paralleled a reduced expression of tolerogenic factors by primary IECs. MoDCs differentiated with RA or IEC supernatant upregulated the expression of CD103. Consistently, human primary CD103+ DCs isolated from MLNs were endowed with the ability to drive Treg cell differentiation. This subset of DCs expressed CCR7 and probably represents a lamina propria-derived migratory population. Conclusions: A population of tolerogenic CD103+ DCs was identified in the human gut that probably differentiate in response to IEC-derived factors and drive Treg cell development.

Oxygen free radicals interact with indomethacin to cause gastrointestinal injury

In the present study it was shown that, unlikely MK447, a known oxygen free radical compound, PGE2 is much less effective against indomethacin-induced G.I. ulcers than against ethanol damage. It seems likely that factors other than PG deficiency (such as oxygen free radicals), could be involved in the pathogenesis of NSAID-induced G.I. damage. Some compounds that can capture free radicals (aminopyrine, thiourea and its derivative, MK 447) or that inhibit the lipoxygenase pathway (MK 447, salicylazosulfapyridine, BW 755, benoxaprofen) are able to abolish indomethacin-induced G.I. damage. After irradiation with hydroxyl free radicals, indomethacin reacts with them to cause marked G.I. injury, even at a submaximal dose, one poorly ulcerogenic by itself. The above findings suggest that oxygen free radicals are one of the causal factors in the formation of NSAID-induced G.I. side effects.Some of the data in this paper were presented at Fermo, August 31, 1984 (Advanced course on ‘oxygen and sulfur radicals in chemistry and medicine’) and at the 9th Iuphar International Congress of Pharmacology in London, July 30, 1984.

Are Colonoscopy and Bowel Ultrasound Useful for Assessing Response to Short-Term Therapy and Predicting Disease Outcome of Moderate-to-Severe Forms of Ulcerative Colitis?: A Prospective Study

OBJECTIVES:Mucosal healing has been proposed as an important sign of the efficacy of medical treatment of inflammatory bowel disease; however, direct evidence in ulcerative colitis (UC) is scarce. We evaluated the usefulness of colonoscopy and bowel ultrasound (US) as indexes of response to short-term therapy and as predictors of subsequent outcome in UC.METHODS:A total of 83 patients with moderate-to-severe UC were recruited; endoscopic and US severity was graded 0–3 at entry according to validated scores. Of the recruited patients, 74, who were clinically responsive to steroids, were followed up with repeated colonoscopy and bowel US at 3, 9, and 15 months from recruitment. Concordance between clinical, endoscopic, and US scores at various visits was determined by kappa statistics. Multiple unconditional logistic regression models were used to assess the predictivity of clinical, endoscopic, and US scores measured at 3 and 9 months on the development of endoscopic UC relapse within 15 months.RESULTS:A variable concordance was found over time between endoscopic and clinical score (weighted κ between 0.38 and 0.95), with high and consistent concordance between endoscopic and US scores (weighted κ between 0.76 and 0.90). On logistic regression analysis, moderate-to-severe endoscopic and US scores at 3 months were associated with a high risk of endoscopic activity at 15 months (odds ratio (OR): 5.2; 95% confidence interval (CI): 1.6–17.6 and OR: 9.1; 95% CI: 2.5–33.5, respectively).CONCLUSIONS:Bowel US may be used as a surrogate of colonoscopy in assessing the short-term response of severe forms of UC to therapy. Both US score and endoscopic score after 3 months of steroid therapy predict outcome of disease at 15 months.

Treatment of morbid obesity by intraparietogastric administration of botulinum toxin: a randomized, double-blind, controlled study

Objective:The stomach is the main target organ for bariatric surgery, but no medical treatment has been developed to increase satiety and decrease food intake via gastric pathways. The aim of our study was to investigate whether or not the intraparietogastric administration of botulinum toxin A (BTX), able to modify the motility patterns of the stomach, could be useful for treatment of obesity.Design:Double blind controlled study.Subjects:Twenty-four morbidly obese patients (mean weight (s.e.m.) 116.1±4.89 kg, mean body mass index (BMI) 43.6±1.09 kg/m2) were blindly randomized to receive 200 IU BTX or placebo into the antrum and fundus of the stomach by intraparietal endoscopic administration.Measurements:We evaluated weight loss, BMI changes, satiety score, the maximal gastric capacity for liquids and the gastric emptying time (octanoic acid breath test).Results:The two groups were homogeneous for anthropometric characteristics. Eight weeks after treatment, BTX patients had significantly higher weight loss (11±1.09 vs 5.7±1.1 kg, P<0.001) and BMI reduction (4±0.36 vs 2±0.58 kg/m2, P<0.001) and a higher satiety score on a visual analogic scale (7.63±0.38 vs 4.72±0.44, P<0.001) than controls. Furthermore, BTX patients showed a significantly greater reduction in maximal gastric capacity for liquids (266.6±48 vs 139±31, P<0.001) and a greater prolongation in gastric emptying time (+18.93±8 vs −2.2±6.9 min, P<0.05). No significant side effects or neurophysiologic changes were found.Conclusions:Topical intragastric BTX was effective in reducing food intake and body weight in morbidly obese patients.

The mechanisms of blood vessel closure in humans by the application of ultrasonic energy.

BackgroundThe use of the ultrasonically activated scalpel (UAS) for vessel closure has attained widespread acceptance in many surgical fields. The aim of our study was to investigate the electron microscopic changes to the blood vessels after the application of UAS.MethodsWe collected 10 arterial and 10 venous segments from vessels that had previously been closed by UAS during abdominal operations. The samples were then prepared for ultramicroscopic analysis Pathological changes in the lumen and the three wall layers of the blood vessel were examined under scanning and transmission electron microscopy.ResultsAll of the vessel segments showed similar changes: the presence of a blood clot, endothelial cell condensation, coagulative necrosis of the wall, and charring of the vessel at its tip. The edge of the cut vessel were closed by the coagulation bond, which was tied up by collagen fibrils escaped from denaturation.ConclusionWhen ultrasonic energy is applied to tissues, it changes their structure so as to make a new extracellular matrix.

Comparison of the gastric cytoprotective properties of atropine, ranitidine and PGE2 in rats.

In view of the controversy as to whether antisecretory agents such as H2 antagonists and antimuscarinics might be cytoprotective like the PGs, the oral activity of atropine, ranitidine and PGE2 against absolute ethanol-induced lesions was evaluated in rats. The results showed that atropine and PGE2, but not ranitidine, were effective in preventing absolute ethanol-induced gastric damage. The effects were related to the doses of the ulcerogenic agent and of the cytoprotective compound. The anti-ulcer activity of atropine is considered to be an expression of cytoprotection, since the pathogenesis of ethanol-induced gastric damage was independent of gastric pH and atropine, like PGE2, does not affect basal acid secretion at a fully cytoprotective dose. Some studies were undertaken to elucidate the mechanism of gastric cytoprotection by atropine. The possibility that the anti-muscarinic agent might work as a mild irritant was ruled out since, like PGE2, the agent was still effective in PG-deficient rats. The evidence that neostigmine markedly aggravated gastric damage caused by low doses of absolute ethanol and that atropine completely prevented this damage postulates mechanisms involving specific muscarinic receptor interactions.

Different Effects of Vertical Banded Gastroplasty and Roux-en-Y Gastric Bypass on Meal Inhibition of Ghrelin Secretion in Morbidly Obese Patients

A decrease in ghrelin plasma levels in morbidly obese patients subjected to bariatric surgery has been considered to help increase body weight loss. Contradictory results have been described after Roux-en-Y gastric bypass (RYGBP), and no study to date has compared RYGBP and vertical banded gastroplasty (VBG), the two main operations performed in the United States. We investigated the effects of RYGBP (10 patients) and VBG (12 patients) on basal and postmeal ghrelin plasma levels in 22 morbidly obese patients (20 F and 2 M), mean age 42.1 ± 3.7 years, mean weight 115 ± 3.9 kg, mean body mass index (BMI) 43.5 ± 1.7. Before surgery and after a 20% reduction in BMI, ghrelin concentrations (pg/mL; radioimmunoassay [RIA], DRG Diagnostics, Germany) were measured in all patients 45 min before and for 3 h after a standard liquid meal (Osmolite RTH solution, 500 mL, 504 kcal). The results were expressed as mean ± SD. Differences between times and groups were evaluated by Students t-test and one-way analysis of variance (ANOVA). We found that basal ghrelin plasma levels were reduced after RYGBP (to 73.1 ± 6 pg/mL, p <. 05) but increased after VBG (to 172 ± 26 pg/mL, p <. 0009). After a standard liquid meal, ghrelin plasma levels decreased significantly over 1 h in VBG patients, whereas they remained unchanged in RYGBP patients. Since these results were obtained under the same metabolic and anthropometric conditions, we conclude that RYGBP acts through permanent inhibition of ghrelin secretion, whereas VBG merely restores the mechanisms of ghrelin regulation by nutrients.

Prospective Study of Long-Term Results and Prognostic Factors After Conservative Surgery for Small Bowel Crohn's Disease

BACKGROUND & AIMS Several bowel-sparing techniques have been proposed for treating patients with CD, but there have been no prospective studies analyzing risk factors and long-term outcome. We prospectively evaluated safety and long-term efficacy of conservative surgery for patients with complicated CD. METHODS From 1993-2007, 393 of 502 consecutive patients underwent surgery for complicated CD of the small bowel. Those with colonic involvement were excluded. The Student t test, chi(2) test, Kaplan-Meier estimates, and Cox proportional hazard model were used to analyze postoperative complications and long-term outcome. RESULTS A total of 865 jejunoileal segments underwent 318 small bowel resections and 367 strictureplasties (either classic or nonconventional). There were no deaths; the complication rate was 5.6%, and the cumulative 10-year recurrence rate was 35%. None of the prognostic factors were correlated with postoperative complications. Younger age, an upper jejunoileal location, stricturing behavior, and small-bowel wall thickening 12 months after surgery showed hazard ratios of 2.4 (95% confidence interval [CI], 1-5.4; P = .03), 2.5 (95% CI, 1.3-4.7; P = .004), 2.2 (95% CI, 1.1-4.1; P = .01), and 4.5 (95% CI, 2.3-8.6; P = .000), respectively. Immunomodulator therapy failed to reduce long-term surgical recurrence. CONCLUSIONS Young patients with extended and stricturing disease are at high risk for disease recurrence after surgery. Bowel wall thickening was a reliable prognostic factor for these patients. Conservative surgery is safe and effective in treating patients with jejunoileal CD and should be considered as the first-line surgical treatment, preventing the risk of short bowel syndrome caused by repeated resections.

Immunomodulatory effects of unselected haematopoietic stem cells autotransplantation in refractory Crohn's disease

BACKGROUND Autologous haematopoietic stem cells transplantation (HSCT) has been shown to be effective in refractory Crohns disease. AIM We analysed the effects of HSCT on the immune response of patients treated for moderate-severe Crohns disease, refractory or intolerant to multiple drugs. METHODS Unselected peripheral blood stem cells were collected after mobilisation with cyclophosphamide (CTX) and G-CSF. The conditioning regimen included CTX and rabbit antithymocyte globulin. Blood samples for immunological analyses were collected at baseline, after mobilisation, and 3, 6 and 12 months after transplantation. Immunological analyses evaluated: (1) CD4(+)/CD25(high+)/FoxP3(+) regulatory T cells (T-regs); (2) Toll-like receptor 2-(TLR2) and TRL4-expressing monocytes (CD14(+) cells); (3) IL-12, IL-10, TNF-alpha-production by mitogen-stimulated CD14(+) cells and IFN-gamma production by CD4(+) T cells. Immunological results were compared with healthy donors and associated with clinical and endoscopic response during 12 months of follow-up. RESULTS Overall, T-regs increased, whilst TLR4-expressing cells, as well as TNF-alpha and IL-10, all higher than healthy donors at baseline, significantly decreased after transplantation. Full responders at T(3) had higher T-regs and lower IFN-gamma and IL12. T-regs decreased and IL12 and TLR2 increased in the only relapsed patient. CONCLUSIONS HSCT can induce and maintain clinical and endoscopic remission in refractory Crohns disease, which is associated with immunomodulation.

Late rejection of the mesh after laparoscopic hernia repair.

Abstract. We report the first case of late rejection of a mesh after laparoscopic hernia repair. It occurred in a 48-year-old man who had had a laparoscopic hernia repair by transabdominal preperitoneal approach 3 years earlier. The most characteristic finding was the slow development of a firm mass in the right groin, without pain or fistula. At admission 3 months later, US and CT scans demonstrated a necrotic mass extending into both iliac fossa. The mass was approached through a midline incision. Pus was taken for microscopic examination (negative), and the mesh was removed, along with several staples. Ultramicroscopic examination of the mesh showed breakdown of the fibers, collagen reduction, and no chronic inflammatory cells. No infectious cause of inflammation was identified.