Hans Herfarth

Lactobacillus GG in inducing and maintaining remission of Crohn's disease.

BackgroundExperimental studies have shown that luminal antigens are involved in chronic intestinal inflammatory disorders such as Crohns disease and ulcerative colitis. Alteration of the intestinal microflora by antibiotic or probiotic therapy may induce and maintain remission. The aim of this randomized, placebo-controlled trial was to determine the effect of oral Lactobacillus GG (L. GG) to induce or maintain medically induced remission.MethodsEleven patients with moderate to active Crohns disease were enrolled in this trial to receive either L. GG (2 × 109 CFU/day) or placebo for six months. All patients were started on a tapering steroid regime and received antibiotics for the week before the probiotic/placebo medication was initiated. The primary end point was sustained remission, defined as freedom from relapse at the 6 months follow-up visit. Relapse was defined as an increase in CDAI of >100 points.Results5/11 patients finished the study, with 2 patients in each group in sustained remission. The median time to relapse was 16 ± 4 weeks in the L. GG group and 12 ± 4.3 weeks in the placebo group (p = 0.5).ConclusionIn this study we could not demonstrate a benefit of L. GG in inducing or maintaining medically induced remission in CD.

The Potential of Adiponectin in Driving Arthritis

Articular adipose tissue is a ubiquitous component of human joints, but its local functions are largely unknown. Because recent studies revealed several links between adipose tissue, adipocytokines, and arthritis, we investigated the expression of the adipocytokine adiponectin and its functional role in articular adipose tissue and synovium of patients with different arthritides. In contrast to its protective role in endocrinological and vascular diseases, adiponectin was found to be involved in key pathways of inflammation and matrix degradation in the human joint. The effects of adiponectin in human synovial fibroblasts appear to be highly selective by inducing only two of the main mediators of rheumatoid arthritis pathophysiology, IL-6 and matrix metalloproteinase-1, via the p38 MAPK pathway. Owing to the observation that these effects could be inhibited by different TNF-α inhibitors, adipocytokines such as adiponectin may also be key targets for therapeutic strategies in inflammatory joint diseases. In summary, articular adipose tissue and adipocytokines cannot be regarded as innocent bystanders any more in chronic inflammatory diseases such as arthritis.

A novel MCP-1 gene polymorphism is associated with hepatic MCP-1 expression and severity of HCV-related liver disease.

BACKGROUND AND AIMS Factors influencing the progression of chronic hepatitis C virus (HCV) infection are poorly understood. Monocyte chemotactic protein-1 (MCP-1) is a potent chemokine, and its hepatic expression is up-regulated during chronic HCV infection mainly in activated hepatic stellate cells (HSC). In this study, we investigated the correlation of the functional -2518 MCP-1 promoter polymorphism with hepatic MCP-1 expression and the disease outcome in patients with HCV. METHODS MCP-1 genotyping was performed in 206 patients and 139 healthy controls. Hepatic MCP-1 messenger RNA (mRNA) expression was quantified by real-time PCR in 58 HCV patients. Cytokine-induced MCP-1 secretion of activated human HSC (n = 13) was determined by enzyme-linked immunosorbent assay (ELISA). Mobility-shift assays were performed using probes corresponding to the MCP-1 promoter sequence (-2511 to -2528) with or without the A to G mutation at -2518. RESULTS Frequency of MCP-1 genotypes did not differ between HCV patients and controls. However, carriers of the G allele were significantly more frequent in HCV patients with more advanced fibrosis and severe inflammation. In accordance, hepatic MCP-1 mRNA levels were significantly higher in patients with more advanced fibrosis and in patients carrying the G allele. Furthermore, cytokine-induced MCP-1 secretion of HSC isolated from carriers of the G allele was significantly higher, and there was binding activity in nuclear extracts from activated HSC specifically to the G allele, providing a potential mechanism for the differences seen. CONCLUSIONS Inheritance of the -2518 MCP-1 G allele, which appears to affect hepatic MCP-1 expression, may predispose HCV patients to more severe hepatic inflammation and fibrosis.

Abdominal MRI after enteroclysis or with oral contrast in patients with suspected or proven Crohn's disease

BACKGROUND & AIMS Diagnostic results of magnetic resonance (MR) enteroclysis correlate highly with those from conventional enteroclysis; nevertheless, intubation of the patient and positioning of an intestinal tube is still necessary for the examination, which is often remembered as the most embarrassing part of the examination by the patient. A more comfortable and highly sensitive examination of the small bowel therefore would increase patient acceptance for recurring examinations, which are often necessary, for example, in patients with Crohns disease. This study evaluates the diagnostic efficacy of abdominal MR imaging (MRI) of the small bowel after drinking contrast agent only compared with conventional enteroclysis and abdominal MRI performed after enteroclysis in patients with suspected or proven Crohns disease. METHODS Twenty-one patients with Crohns disease referred for conventional enteroclysis underwent abdominal MRI after enteroclysis. Additionally, 1 to 3 days before or after these examinations, abdominal MRI was performed using only orally administered contrast. All MRI examinations were performed using a 1.5T scanner. RESULTS All pathological findings on conventional enteroclysis were shown correctly with MRI after enteroclysis and MRI after oral contrast only. Additional information by MRI was obtained in 6 of 21 patients. No statistically significant differences were found in assessing the diagnostic efficacy of the 3 examinations. CONCLUSIONS Abdominal MRI with oral contrast only can be used as a diagnostic tool for evaluation of the small bowel in patients with Crohns disease and has the potential to replace conventional enteroclysis as follow-up.

Comparison of capsule endoscopy and magnetic resonance (MR) enteroclysis in suspected small bowel disease

Background and aimsSmall bowel MR enteroclysis and wireless capsule endoscopy (WCE) are new diagnostic tools for the investigation of the small bowel. The aim of this study was to compare the diagnostic yield of WCE with MR enteroclysis in the detection of small bowel pathologies.MethodsA total of 36 patients were included in the study. Indications for imaging of the small bowel were proven or suspected small bowel Crohn’s disease (CD; n=18), obscure gastrointestinal (GI) bleeding (n=14) and tumour surveillance (n=4).ResultsIn patients with Crohn’s disease WCE detected significantly more inflammatory lesions in the first two segments of the small bowel compared with MR enteroclysis (12 patients vs. 1 patient, p=0.016). In 5 out of 14 (36%) patients with GI bleeding, angiodysplasia was detected as a possible bleeding source. Three of these patients had active bleeding sites detected by WCE. One patient had scattered inflammation of the mucosa. MR enteroclysis did not reveal any intestinal abnormalities in this patient group. MR enteroclysis provided extraintestinal pathologies in 10 out of 36 (28%) patients.ConclusionIn patients with Crohn’s disease WCE revealed significantly more inflammatory lesions in the proximal and middle part of the small bowel in comparison to MR enteroclysis, whereas in patients with obscure GI bleeding WCE was superior to MR enteroclysis.

Pharmacogenetic investigation of the TNF/TNF-receptor system in patients with chronic active Crohn's disease treated with infliximab

Infliximab (anti-TNF-α monoclonal antibody) induces remission in 30–40% of Crohns disease patients. Treatment response is a stable trait. Two cohorts from independent, prospective clinical trials of infliximab in Crohns disease were studied. Hypotheses were generated in an exploratory cohort (n = 90) and then tested in a confirmatory cohort (n = 444), using a statistical design, which is stable against type 1 and type 2 errors. In the exploratory cohort, the mutant 196Arg allele of TNFR-II (exon 6 polymorphism) and a novel silent polymorphism in exon 2 of TNFR-II were associated with lack of response to infliximab (83.3% in homozygote mutant 196 Arg patients vs 36.9% in heterozygotes and wild-type homozygotes (P = 0.036) and 85.7% in homozygote mutant exon 2 patients vs 36.1% (P = 0.01), respectively). None of the homozygote mutant individuals (0/6) achieved clinical remission, whereas the remission rate was 35.7% (30/84) in wild-type homozygotes and heterozygotes. In the large second cohort, the observed genotype–phenotype associations were not replicated. Other polymorphisms (TNF-α promoter −238, −308, −376, −857, −1031, TNF-R-I −609, +36 (exon 1), TNF-R-II 1663, 1690 (3′-UTR)) were not associated with treatment response in both cohorts (P > 0.5). None of the polymorphisms was associated with refractory Crohns disease itself when compared to healthy controls. In a two-cohort study, a series of polymorphisms in the TNF, the TNF-R-I and in the TNF-R-II genes could be thoroughly excluded as pharmacogenetic markers for a treatment response to infliximab and as etiologic factors for Crohns disease, respectively. The discrepancy between the two cohorts observed for the TNF-R-II exon 6 and exon 2 polymorphism may point to a weak effect on treatment response but also serves to illustrate the need for a sequential exploratory/confirmatory design in pharmacogenetic studies.

CpG motifs of bacterial DNA exacerbate colitis of dextran sulfate sodium-treated mice

Inflammatory bowel disease (IBD) is characterized by a dysregulated intestinal immune response with elevated levels of the Th1 cytokines TNF, IL‐12 and IFN‐γ. The luminal flora has been implicated as a major factor contributing to the initiation and perpetuation of chronic intestinal inflammation by as yet unknown mechanisms. Bacterial DNA contains unmethylated cytosine‐guanosine dinucleotides (CpG) which strongly activate Th1‐mediated immune responses. To test whether these CpG‐motifs contribute to intestinal inflammation we treated mice with dextran‐sulfate‐sodium (DSS)‐induced acute or chronic colitis for 5 days with CpG‐containing oligodeoxynucleotides (CpG‐ODN). Colonic inflammation was assessed by histological scoring. Colonic cytokine RNA was quantified by reverse transcription‐PCR and cytokine secretion from mesenterial lymph node cells by ELISA. In chronic colitis, CpG‐ODN treatment severely aggravated inflammation by 50%. Colonic expression of IFN‐γ and TNF was elevated (200‐ and 150‐fold, respectively) and IFN‐γ and IL‐12 secretion from lymph node cells was increased 5,000‐ and 8‐fold, respectively, compared to GpG‐ODN‐treated controls. Similar effects were obtained in acute colitis. In conclusion, CpG‐motifs of bacterial DNA have proinflammatory activity by strengthening the Th1 arm of immunity in DSS‐induced colitis, and might therefore play asignificant role in the initiation and perpetuation of inflammation in IBD.

Comparison of magnetic resonance imaging colonography with conventional colonoscopy for the assessment of intestinal inflammation in patients with inflammatory bowel disease: a feasibility study

Aim: Magnetic resonance imaging (MRI) based colonography represents a new imaging tool which has mainly been investigated for polyp screening. To evaluate this approach for patients with inflammatory bowel disease (IBD), we compared MRI based colonography with conventional colonoscopy for assessing the presence and extent of colonic inflammation. Patients and methods: In 22 consecutive patients with suspected or known IBD, MRI colonography was performed immediately before conventional colonoscopy. After bowel cleansing, a T1 positive contrast agent was applied rectally. In addition to T2 weighted sequences, T1 weighted two dimensional and three dimensional Flash acquisitions as well as volume rendered virtual endoscopy were performed. All images were evaluated with regard to typical MRI features of inflammation. The results were compared with colonoscopy findings. Results: Distension and image quality was assessed as good to fair in 97.4% of all colonic segments. Only four of 154 segments were considered non-diagnostic. With colonoscopy serving as the gold standard, the sensitivity for correctly identifying inflammation on a per segment analysis of the colon was 31.6% for Crohn’s disease (CD) and 58.8% for ulcerative colitis (UC). In CD, in most cases mild inflammation was not diagnosed by MRI while in UC even severe inflammation was not always depicted by MRI. Virtual endoscopy did not add any relevant information. Conclusion: MRI based colonography is not suitable for adequately assessing the extent of colonic inflammation in patients with IBD. Only severe colonic inflammation in patients with CD can be sufficiently visualised.

Contrasting activity of cytosin-guanosin dinucleotide oligonucleotides in mice with experimental colitis

Intestinal inflammation in inflammatory bowel disease (IBD) and experimental models of colitis is characterized by a dysregulated intestinal immune response with elevated levels of Th1 cytokines. The luminal flora has been implicated as a major factor contributing to the initiation and perpetuation of inflammation in experimental colitis by mechanisms not known. Bacterial DNA contains unmethylated cytosin–guanosin dinucleotides (CpG) which strongly activate Th1‐mediated immune responses. To test whether these CpG‐motifs modulate intestinal inflammation we treated mice with dextran sulphate sodium (DSS)‐induced colitis with CpG‐containing oligodeoxynucleotides (CpG‐ODN). CpG‐ODN given after the onset of DSS colitis aggravated the disease, as indicated by a significantly increased loss of body weight and a 30% increase of the histological score. Further, we found a severe increase of proinflammatory cytokines (interleukin (IL)‐6: 40‐fold; interferon (IFN)‐γ : 11‐fold). In a pretreatment setting CpG‐ODN reduced weight loss significantly and reduced intestinal inflammation by 45%. Colonic IFN‐γ and IL‐6 mRNA levels were reduced by 75%, and IL‐10 was elevated by 400% compared to controls. The prophylactic CpG‐effect was not imitated by IL‐12 because IL‐12 pretreatment was not protective. In time‐course experiments, CpG‐ODN pretreatment over 5 days resulted in a tolerance effect concerning its IFN‐γ‐inducing quality, and during the following days of colitis induction IL‐10 secretion from mesenterial lymph node cells was elevated compared to controls. Therefore, the prophylactic effect of CpG‐ODN might be explained by its tolerizing effect and/or the increased ability for IL‐10 production during the consecutive intestinal inflammation.

Adiponectin represents an independent cardiovascular risk factor predicting serum HDL-cholesterol levels in type 2 diabetes

Low levels of high‐density lipoprotein (HDL)‐cholesterol represent an independent cardiovascular risk factor and, besides reduced physical activity, mechanisms leading to decreased HDL‐cholesterol levels are not known. We aimed to test the hypothesis, that adiponectin provides a missing link between type 2 diabetes and low levels of HDL‐cholesterol, independent from common metabolic risk factors. 523 patients with type 2 diabetes were investigated for adiponectin serum levels and parameters of lipid metabolism. Even after correction for age, gender, BMI and fasting insulin concentration, serum levels of adiponectin were highly significant (P<0.0001) and positively (regression analysis: r=0.86) associated with HDL‐cholesterol levels in type 2 diabetes. Conclusion: adiponectin seems to predict HDL‐cholesterol levels in patients with diabetes mellitus type 2. Low levels of adiponectin are associated with low levels of HDL‐cholesterol independently from common metabolic risk factors and therefore represent an independent cardiovascular risk factor in type 2 diabetes. Thus, adiponectin is a potentially new drug target in the treatment of dyslipidaemia.