Evanthia Zampeli

High intestinal and systemic levels of decoy receptor 3 (DcR3) and its ligand TL1A in active ulcerative colitis

Decoy receptor-3 (DcR3) is a member of the TNF receptor superfamily of proteins, which has been implicated in anti-apoptotic and anti-inflammatory pathways, via binding to TL1A, LIGHT and Fas-L. The role of the TL1A/DcR3 ligand/receptor pair in ulcerative colitis (UC) has not been studied. We investigated the systemic (peripheral blood) and local (large intestine) expression of DcR3 and TL1A in 64 patients with UC and 56 healthy controls. DcR3 serum concentrations were highly elevated in patients with active UC (P<0.0001 vs. healthy controls). This elevation was clearly related to the presence of intestinal inflammation as it was less frequently observed in patients in remission (P=0.003 vs. active UC) whereas effective treatment resulted in disappearance or significant decrease of serum DcR3 (P=0.006 vs. pre-treatment). Furthermore, DcR3 mRNA transcripts were significantly elevated in inflamed areas of the colon (P=0.002 vs. non-affected of the same patient). In addition to DcR3 elevation, we found increased circulating levels of TL1A in patients with either active or inactive UC in comparison to healthy controls (P<0.001 for both). We conclude that elevated serum DcR3 may serve as an indicator of active colonic inflammation in patients with UC. TL1A/DcR3-mediated pathways may participate in the pathogenesis of UC.

Differential expression of the TL1A/DcR3 system of TNF/TNFR-like proteins in large vs. small intestinal Crohn's disease.

BACKGROUND TNF-like cytokine 1A provides co-stimulatory signals to activated lymphocytes through binding to death-domain receptor-3. Decoy receptor-3 inhibits death-domain receptor-3 signalling, rendering immunocytes resistant to apoptosis. These functions may be important for the pathogenesis of Crohns disease. AIMS To study the mucosal and systemic expression of Decoy receptor-3 and TNF-like cytokine 1A in Crohns disease, in relation to disease activity, localization, and response to treatment. METHODS Soluble Decoy receptor-3 and TNF-like cytokine 1A were measured by ELISA in active or quiescent Crohns disease. Relative mRNA expression in non-affected and inflamed intestinal mucosa was determined by real-time RT-PCR. RESULTS We found significant upregulation of Decoy receptor-3 and its ligands TNF-like cytokine 1A and FasL in inflamed intestinal mucosa of Crohns disease patients. During active disease, Decoy receptor-3 and TNF-like cytokine 1A were detected in the serum in the majority of patients. Intestinal inflammation was strongly associated with these elevations as they were absent during remission and significantly reduced with anti-inflammatory treatment. Regional diversity was observed as Decoy receptor-3 was upregulated in colonic and ileal sites, whereas TNF-like cytokine 1A was preferentially induced in the large bowel mucosa and systemic circulation of patients with colonic involvement. CONCLUSIONS TNF-like cytokine 1A and Decoy receptor-3 are upregulated during active Crohns disease and may participate in disease pathogenesis and offer novel therapeutic opportunities.

Prevalence and Characteristics of Extra-intestinal Manifestations in a Large Cohort of Greek Patients with Inflammatory Bowel Disease

BACKGROUND AND AIMS Extraintestinal manifestations [EIMs] are common in inflammatory bowel disease [IBD]. Data on epidemiology and risk factors of EIMs in IBD patients are limited. The aim of this study was to investigate the prevalence of EIMs in a large cohort of Greek IBD patients and identify risk factors for their development. METHODS The study population consisted of IBD patients, who were followed in eight tertiary Greek hospitals. Demographic and clinical characteristics of patients were analysed. The diagnosis of EIMs was based on standard criteria and on specialist consultation. RESULTS In total, 1860 IBD patients (1001 with Crohns disease [CD], 859 with ulcerative colitis [UC]) were registered. Among them 615 [33.1%] exhibited at least one EIM; 238 patients [38.6%] developed an EIM before IBD diagnosis. An association between active IBD and presence of an EIM was established in 61.1% of the patients. Arthritic [peripheral arthritis], mucocutaneous [erythema nodosum], and ocular [episcleritis] were the most common manifestations. EIMs were more prevalent in females, patients with CD, smokers [for all p <0.0001], patients with extensive UC [p = 0.007], and patients with a previous appendectomy [p < 0.0001] or a major IBD-related surgery [p = 0.012]. CONCLUSIONS About one-third of Greek IBD patients developed at least one EIM. Of those, more than one-third had their EIM diagnosed before IBD, and in about two-thirds it was related to disease activity. EIMs were more frequently present in females and patients with extensive UC in multivariate analysis.

Randomized clinical trial comparing ten day concomitant and sequential therapies for Helicobacter pylori eradication in a high clarithromycin resistance area

BACKGROUND Currently only a few studies compare sequential and concomitant non-bismuth Helicobacter pylori therapies referring to high antibiotic resistance populations. MATERIALS AND METHODS This multicenter prospective randomized clinical trial included 353 H. pylori positive, treatment naïve, patients. All patients had positive CLO-test and/or histology and culture. They received sequential (esomeprazole 40mg, amoxicillin 1g/bid for 5days, followed by 5days of esomeprazole 40mg, clarithromycin 500mg and metronidazole 500mg bid), or concomitant treatment (all drugs taken concomitantly bid for 10days). Eradication was confirmed by (13)C-urea breath test or histology 4-6weeks after treatment. Adverse events and adherence were evaluated. RESULTS Allocated to concomitant were 175 (72F/103M, mean 52.3years, 38.3% smokers, 25.7% ulcer disease) and 178 (87F/91M, mean 52years, 31% smokers, 19.1% ulcer disease) patients to sequential treatment. There were 303/353 (85.8%) positive cultures, with the following resistances: 34% metronidazole, 27.7% clarithromycin, and 7.9% dual. Eradication rates were, respectively, 89.1% (156/175) vs. 78.7% (140/178) by intention to treat (p=0.01, 95% CI=2.7-18) and 93.4%(156/167) vs. 82.8% (140/169) per protocol (p=0.004, 95% CI=3.6-17.6). Overall, adherence was (98.9%, 95% CI=97-100). Eradication rates according to resistance were the following: dual susceptible strains 67/69 (97.1%), 62/67 (92%) (p=0.4), metronidazole single resistant 38/39 (97.4%), 31/39 (79.5%) (p=0.03, 95% CI=3.5-33), clarithromycin single resistant 25/28 (89.3%), 26/31 (83.9%) (p=0.8), and dual resistant 9/12 (75%), 4/11 (36.4%) (p=0.1) for concomitant and sequential regimens, respectively. Side effects were comparable among regimens, except from diarrhea being more frequent among patients treated with concomitant treatment. CONCLUSIONS Concomitant treatment eradication rate overcomes 90% per protocol and has a significant advantage over sequential therapy. This is probably due to its better efficacy on metronidazole resistant strains. Both regimens were well tolerated and safe.

Predictors of response to anti-tumor necrosis factor therapy in ulcerative colitis.

Ulcerative colitis (UC) is an immune-mediated, chronic inflammatory disease of the large intestine. Its course is characterized by flares of acute inflammation and periods of low-grade chronic inflammatory activity or remission. Monoclonal antibodies against tumor necrosis factor (anti-TNF) are part of the therapeutic armamentarium and are used in cases of moderate to severe UC that is refractory to conventional treatment with corticosteroids and/or immunosuppressants. Therapeutic response to these agents is not uniform and a large percentage of patients either fail to improve (primary non-response) or lose response after a period of improvement (secondary non-response/loss of response). In addition, the use of anti-TNF agents has been related to uncommon but potentially serious adverse effects that preclude their administration or lead to their discontinuation. Finally, use of these medications is associated with a considerable cost for the health system. The identification of parameters that may predict response to anti-TNF drugs in UC would help to better select for patients with a high probability to respond and minimize risk and costs for those who will not respond. Analysis of the major clinical trials and the accumulated experience with the use of anti-TNF drugs in UC has resulted to the report of such prognostic factors. Included are clinical and epidemiological characteristics, laboratory markers, endoscopic indicators and molecular (immunological/genetic) signatures. Such predictive parameters of long-term outcomes may either be present at the commencement of treatment or determined during the early period of therapy. Validation of these prognostic markers in large cohorts of patients with variable characteristics will facilitate their introduction into clinical practice and the best selection of UC patients who will benefit from anti-TNF therapy.

Systemic Challenge with Lipopolysaccharide Increases Histamine Levels in the Conjunctiva and Cartilage, but not Hypothalamus of Sprague Dawley rats

Mast cells are found in virtually every organ and upon activation release preformed histamine. Histamine is also found in central neurons and cells in the cartilage [1]. After a variety of inflammatory stimuli, including bacterial products such as lipopolysaccharides (LPS), mast cells release mediators which lead to inflammatory and hypersensitivity responses. Additional to mast cells, other cell types can supply histamine through the induction of histidine decarboxylase [2]. It has been shown that LPS is a potent histidine decarboxylase inducer even in mast cell deficient mice [2], resulting in increases in enzyme activity and subsequently in histamine levels in various tissues [3]. The conjunctiva is susceptible to inflammatory processes and it is accepted that mast cells provide the main source of histamine here [4]. Also, in hyaline cartilage, besides mast cells, chondrocytes contribute to histamine formation when there is an inflammatory stimulus [5]. Finally, the hypothalamus contains both mast cells and neurons to provide a histamine pool in the brain [6]. Therefore, in an initial attempt to evaluate the response of various tissues to inflammatory stimuli, this study sought to investigate the effect(s) of LPS on the histamine content of the rat conjunctiva, cartilage and hypothalamus as well as comparing the histamine levels in two rat strains.

Histamine Levels in Whole Peripheral Blood from Women with Ductal Breast Cancer: A Pilot Study

Increasing evidence relating histamine to cancer suggests that histamine may potentially contribute to the modulation of the inflammatory characteristics of the malignant environment [1– 3]. Although, the available data do not provide direct evidence about the source of histamine [4], histamine receptor antagonists have been reported to inhibit or diminish tumour cell growth [5], however their use in adjuvant cancer therapy [6] remains debatable. In breast cancer patients, serum histamine levels have been reported to be elevated compared to healthy controls [1]. The increased histamine levels in ductal breast cancer tissues have been attributed to increased histamine synthesis and decreased inactivation [1]. Furthermore, it has been reported that human breast cells express all four histamine receptor subtypes and that histamine dose-dependently regulates cancer cell proliferation, indicating that biological responses may be modulated by histamine in both normal and cancer breast cells [2]. Finally, endogenous histamine appears to stimulate the growth of breast tumour implants in mice by suppressing antitumour immunity [3]. However, the available data are inadequate to allow firm conclusions to be drawn on the utility of blood histamine as a biomarker and on the significance of any potential histamine-mediated modulation in the disease. In an attempt to provide additional information, this preliminary study aimed to determine histamine levels in whole peripheral blood obtained from women with breast cancer. Materials and methods

Inflammatory infiltration of metaplastic epithelium and correlation to previous diagnosis of esophagitis and Barrett's length

Abstract Objective. The contact of the gastric refluxate with the lower esophagus results in an inflammatory-mediated tissue damage. The role of inflammation both in the development and in the advance of Barretts esophagus (BE) has not been elucidated. The aim of this study was to assess the inflammatory infiltration in metaplastic Barretts epithelium and to explore the association of microscopic inflammation to healed esophagitis and Barretts length. Material and methods. Inflammatory infiltration was qualitatively evaluated in well-characterized Barretts specimens. Esophagitis was healed prior to histological sampling. Univariate comparative analysis was performed based on BE length. Results. Ninety-eight patients (78 male, mean age 58.3 ± 13.3 yrs) were retrospectively studied. Thirty-three cases with long segment BE (LSBE) (33.7%) were spotted. Inflammatory infiltration was mild, moderate, and severe in 35 (35.7%), 54 (55.1%), and 9 (9.1%) specimens, respectively. The samples with moderate/severe inflammatory infiltration were obtained from patients who had more frequently been diagnosed with esophagitis (p = 0.025). Hiatal hernia (p = 0.001), esophagitis (p = 0.019), and previous use of anti-secretory drugs (p = 0.005) were more common in LSBE. Conclusions. Inflammatory infiltration of Barretts epithelium was largely moderate despite preceding healing of erosions with PPIs. Previous diagnosis of esophagitis correlated to the degree of inflammation. No association of inflammation to Barretts length was established.

Acute Pancreatitis Following Endoscopic Ampullary Biopsies without Attempted Cannulation of the Ampulla of Vater.

A 51-year-old man underwent diagnostic work-up for an abnormal-appearing ampulla of Vater. Three hours after biopsy of the ampulla, the patient presented with intense symptoms suggesting acute pancreatitis, which was later confirmed with laboratory and radiographic examinations. Other causes were excluded and the acute pancreatitis was considered a procedural complication. This is a rarely reported complication that must be taken into consideration when biopsies are performed in the ampulla of Vater.

Synchronous cytomegalovirus and Clostridium difficile infection of the pouch: a trigger for chronic pouchitis?

Pouchitis occurs in up to one half of patients after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Cytomegalovirus (CMV) and Clostridium difficile are among the commonest secondary identifiable etiologies. A 17-year-old male with ulcerative colitis underwent IPAA due to refractory disease. Nine months later he experienced bloody diarrhea and fever. Laboratory testing and endoscopy confirmed pouch inflammation. Testing for C. difficile toxins A and B was positive. Histology revealed affluent inclusion bodies and immunohistochemistry detected reactivity against CMV protein. Treatment with metronidazole and vancomycin offered partial improvement, whereas the addition of gancyclovir led to a successful recovery. One month after completion of treatment symptoms recurred. Repeat testing precluded an identifiable infectious cause and the diagnosis of idiopathic chronic pouchitis was established. The patient is currently on maintenance treatment with the probiotic compound VSL#3.