Jean-Louis Frossard

Low dose oral cannabinoid therapy reduces progression of atherosclerosis in mice

Atherosclerosis is a chronic inflammatory disease, and is the primary cause of heart disease and stroke in Western countries. Derivatives of cannabinoids such as delta-9-tetrahydrocannabinol (THC) modulate immune functions and therefore have potential for the treatment of inflammatory diseases. We investigated the effects of THC in a murine model of established atherosclerosis. Oral administration of THC (1 mg kg-1 per day) resulted in significant inhibition of disease progression. This effective dose is lower than the dose usually associated with psychotropic effects of THC. Furthermore, we detected the CB2 receptor (the main cannabinoid receptor expressed on immune cells) in both human and mouse atherosclerotic plaques. Lymphoid cells isolated from THC-treated mice showed diminished proliferation capacity and decreased interferon-γ secretion. Macrophage chemotaxis, which is a crucial step for the development of atherosclerosis, was also inhibited in vitro by THC. All these effects were completely blocked by a specific CB2 receptor antagonist. Our data demonstrate that oral treatment with a low dose of THC inhibits atherosclerosis progression in the apolipoprotein E knockout mouse model, through pleiotropic immunomodulatory effects on lymphoid and myeloid cells. Thus, THC or cannabinoids with activity at the CB2 receptor may be valuable targets for treating atherosclerosis.

Performance of endosonography-guided fine needle aspiration and biopsy in the diagnosis of pancreatic cystic lesions

OBJECTIVE:Preoperative diagnosis of cystic lesions of the pancreas remains difficult despite improvement in imaging modalities and cystic fluid analysis. The aim of our study was to assess the performance of endoscopic ultrasonography (EUS) and EUS-guided fine needle aspiration (FNA) in the diagnosis of pancreatic cystic lesions.METHODS:Data from a series of 127 consecutive patients with pancreatic cystic lesions were prospectively studied. EUS and EUS-guided FNA were performed in all patients, and cystic material was used for cytological and histological analysis as well as for biochemical and tumor markers analysis. Performance of EUS diagnosis, biochemical and tumor markers, and FNA diagnosis were compared with the final histological diagnosis obtained at surgery or postmortem examination. Sixty-seven patients underwent surgery and therefore constituted our study group.RESULTS:EUS provided a tentative diagnosis in 113 cases (89%). Cytohistological FNA provided a diagnosis in 98 cases (77%). When the results of EUS and EUS-guided FNA were compared with the final diagnosis (67 cases), EUS correctly identified 49 cases (73%), whereas FNA correctly identified 65 cases (97%). Sensitivity, specificity, positive predictive value, and negative predictive value of EUS and EUS-guided FNA to indicate whether a lesion needed further surgery were 71% and 97%, 30% and 100%, 49% and 100%, and 40% and 95%, respectively. Carbohydrate antigen 19–9 > 50,000 U/ml had a 15% sensitivity and a 81% specificity to distinguish mucinous cysts from other cystic lesions, whereas it had a 86% sensitivity and a 85% specificity to distinguish cystadenocarcinoma from other cystic lesions.CONCLUSIONS:EUS-guided FNA is a valuable tool in the preoperative diagnostic assessment of pancreatic cystic lesions.

Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

This article is part of a combined publication that expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about endoscopic ultrasound (EUS)-guided sampling in gastroenterology, including EUS-guided fine needle aspiration (EUS-FNA) and EUS-guided trucut biopsy (EUS-TCB), of submucosal tumors, diffuse esophageal/gastric wall thickening, pancreatic solid masses and cystic-appearing lesions, mediastinal lesions unrelated to lung or esophageal cancer, cancer of the esophagus, stomach, and rectum, lymph nodes of unknown origin, adrenal gland masses, and focal liver lesions. False-positive cytopathological results and needle tract seeding are also discussed. The present Clinical Guideline describes the results of EUS-guided sampling in the different clinical settings, considers the role of this technique in patient management, and makes recommendations on circumstances that warrant its use. A two-page executive summary of evidence statements and recommendations is provided. A separate Technical Guideline describes the general technique of EUS-guided sampling, particular techniques to maximize the diagnostic yield depending on the nature of the target lesion, and sample processing. The target readership for the Clinical Guideline mostly includes gastroenterologists, oncologists, internists, and surgeons while the Technical Guideline should be most useful to endoscopists who perform EUS-guided sampling.

Combination of steroids with infliximab or placebo in severe alcoholic hepatitis: a randomized controlled pilot study☆

BACKGROUND/AIMS The aim of this study is to evaluate the tolerance and effects of infliximab combined with steroids in severe alcoholic hepatitis (AH). METHODS Twenty patients with biopsy-proven severe AH (Maddreys score>32) received prednisone 40 mg/day for 28 days and either infliximab 5mg/kg IV (group A) or placebo (group B) at day 0. Histology, plasma interleukin-6 (IL-6) and interleukin-8 (IL-8) were measured at baseline and at day 10. RESULTS Infliximab was well tolerated. Histology showed no significant changes. At day 28, Maddreys score significantly improved in group A (39 (32-53) to 12 (7-52), P<0.05 vs. baseline) but not in group B (44 (33-50) to 22 (2-59), P=NS). At day 10, IL-6 and IL-8 decreased in group A (25 pg/ml (10-85 pg/ml) to 4.5 pg/ml (2-25 pg/ml); 301 pg/ml (107-1207 pg/ml) to 14 6 pg/ml (25-252 pg/ml), P<0.01, P<0.05 vs. baseline, respectively). In group B, changes were not significant (38 pg/ml (13-116 pg/ml) to 16 pg/ml (4-128); 315 pg/ml (26-1698 pg/ml) to 110 pg/ml (27-492 pg/ml)). CONCLUSIONS In severe AH, infliximab was well tolerated and associated with significant improvement in Maddreys score at day 28. Although the size of this study does not allow comparison between groups, these promising results should encourage larger trials assessing the effects of this therapy on survival.

Granulocyte-Colony Stimulating Factor Induces Proliferation of Hepatic Progenitors in Alcoholic Steatohepatitis : A Randomized Trial

Liver failure is the major cause of death in alcoholic steatohepatitis (ASH). In experimental hepatitis, granulocyte‐colony stimulating factor (G‐CSF) mobilizes hematopoietic stem cells, induces liver regeneration, and improves survival. We studied the short‐term effects of G‐CSF on CD34+ stem cell mobilization, liver cell proliferation, and liver function in patients with ASH. Twenty‐four patients (mean age 54 years) with alcoholic cirrhosis [Child‐Turcotte‐Pugh score 10 (7–12)] and concomitant biopsy‐proven ASH [Maddrey score 36 (21‐60)] were randomized to standard care associated with 5 days of G‐CSF (10 μg/kg/day, group A, n = 13) or standard care alone (group B, n = 11). Serial measurement of CD34+ cells, liver tests, cytokines [hepatocyte growth factor (HGF); tumor necrosis factor α; tumor necrosis factor‐R1; interleukin‐6; alfa‐fetoprotein], and 13C‐aminopyrine breath tests were performed. Proliferating hepatic progenitor cells [HPC; double immunostaining (Ki67/cytokeratin 7)], histology, and neutrophils were assessed on baseline and day 7 biopsies. Abstinent alcoholic patients with cirrhosis served as controls for immunohistochemistry. G‐CSF was well tolerated. At day 7, both CD34+ cells (+747% versus −6%, P < 0.003), and HGF (+212% versus −7%, P < 0.03) increased in group A but not in group B. Cytokines and aminopyrine breath test changes were similar between groups. On repeat biopsy, a >50% increase in proliferating HPC was more frequent in group A than in group B (11 versus 2, P < 0.003). Changes in Ki67+/cytokeratin 7+ cells correlated with changes in CD34+ cells (r = 0.65, P < 0.03). Neutrophils and histological changes were similar in both groups. Conclusion: G‐CSF mobilizes CD34+ cells, increases HGF, and induces HPC to proliferate within 7 days of administration. Larger trials would be required to determine whether these changes translate into improved liver function. (HEPATOLOGY 2008.)

Choledocholithiasis : a prospective study of spontaneous common bile duct stone migration

BACKGROUND The rate of spontaneous migration of bile duct stones through the duodenal papilla is not well known. Endoscopic retrograde cholangiography (ERC) has been the standard method to diagnose bile duct stones, but accumulating data show there is a good agreement between ERC and endoscopic ultrasonography (EUS). The aim of the study was to evaluate the incidence and time course of stone migration in patients with bile duct stones by analyzing discrepancies between EUS and ERC as a function of the elapsed time between these two procedures. Stone migration was considered as the absence of stones at time of ERC regardless of the number of stones seen at EUS. METHODS The main criterion for inclusion was the presence of bile duct stone as shown by EUS. Ninety-two consecutive patients were prospectively included in this study. RESULTS Choledocholithiasis was absent at ERC in 12 patients. In univariate analysis, presence of gallbladder was significantly associated with an increased rate of stone migration (correction for multiple testing would remove this statistical significance). The size of the stone was the only independent factor to predict migration. CONCLUSION Migration occurred in about 21% of cases within 1 month. Our study emphasizes the need to analyze carefully the results of comparative imaging studies of bile duct stones.

Early prediction of acute pancreatitis: Prospective study comparing computed tomography scans, Ranson, Glasgow, acute physiology and chronic health evaluation II scores, and various serum markers

The aim of this study was to assess the predictability of the outcome of acute pancreatitis using the Ranson, Glasgow, and Acute Physiology and Chronic Health Evaluation (APACHE) II scores, the computed tomography (CT) scan, and several serum markers. Altogether, 137 consecutive patients with acute pancreatitis confirmed by CT scan were prospectively included. Blood samples were obtained daily for 6 days. The predictive value of each parameter was studied by univariate and multivariate analyses comparing mild and severe pancreatitis. A total of 111 attacks were graded as mild (81%) and 26 as severe (19%). Ranson (p=0.3) and APACHE II (p=0.049) scores appeared insufficiently predictive in the univariate analysis. Pancreatic imaging by CT scan was insufficiently predictive (p>0.05), whereas the presence of extrapancreatic fluid collections was more indicative of outcome (p<0.05). With the univariate analysis, the four most reliable serum markers were pancreatic amylase (p<0.001), neutrophil elastase (p<0.05), albumin (p<0.002), and C-reactive protein (p<0.001). Results became homogeneous when the CT results were added; serum albumin plus extrapancreatic fluid collections (negative predictive value 92%–96% and positive predictive value 67%–100%) comprised the best indicator of severity. None of the parameters tested achieved sufficient predictability when used alone. Serum albumin plus extrapancreatic fluid collections comprise the best indicator of severity at the time of admission.RésuméLe but de cette étude a été d’évaluer dans la pancréatite aiguë la valeur prédictive des scores de Ranson, de Glasgow et d’APACHE II, la tomodensitométrie (TDM) et plusieurs marqueurs sériques. On a inclus dans cette étude de façon prospective 137 patients consécutifs ayant une pancréatite aiguë confirmée par TDM. On a prélevé du sang tous les jours pendant six jours. La valeur prédictive de tous les paramètres a été comparée par analyse uni- et multivariée. En ce qui concerne la gravité de la pancréatite, 111 crises ont été classées «modérées» (81%) et 26, «évères» (19%). La prédiction de gravité par des scores de Ranson (p=0.3) et d’APACHE II (p=0.049) n’étaient pas significativement discriminative en analyse univariée. L’imagerie du pancréas par TDM n’était pas prédictive de façon significative (p τ; 0.05) alors que la présence de collections liquidiennes extra pancréatiques était plus prédictive en ce qui concerne l’évolution (p<0.05). En analyse univariée, les quatre marqueurs les plus fiables étaient ï’amylase d’origine pancréatique (p<0.001), l’élastase neutrophile (p<0.05), l’albumine (p<0.002) et la CRP (p<0.001). Les résultats étaient plus homogènes lorsqu’on a ajouté des données supplémentaires provenant de la TDM: la combinaison d’albumine dans le sérum + collections liquidiennes extrapancréatiques (valeur predictive negative allant de 92 à 96% et valeur predictive positive, de 67 à 100%) était le meilleur indicateur de sévérité. Utilisé seul, aucun des paramètres testés n’était suffisamment prédictif. La combinaison d’albumine dans le sérum + collections liquidiennes extra pancréatiques est le meilleur indicateur de sévérité au moment de l’admission.ResumenEl objetivo de este trabajo fue averiguar el valor diagnóstico en pancreatitis agudas de: las punctuaciones de Ranson, Glasgow y APACHE II, la tomografía axial computarizada (CT) y de diversos marcadores séricos. Se estudiaron prospectivamente 137 pacientes con pancreatitis aguda cuyo diagnóstico fue confirmado mediante CT. El valor diagnóstico de todos los parámetros estudiados se comparó entre pacientes con una pancreatitis leve o grave, mediante análisis uni y multivariante. Se registraron 111 casos de pancreatitis leves (81%) y 26 graves (19%). Las puntuaciones de Ranson (p=0.3) y del APACHE II (p=0.049) no tienen suficiente valor diagnóstico en un análisis uni-variante. La imagen del páncreas obtenida con CT tampoco tuvo valor diagnóstico suficiente (p<0.05) mientras que la existencia de colecciones líquidas extrapancreáticas tuvieron más valor por lo que al pronóstico se refiere (p<0.05). En un análisis univariante los marcadores séricos más fiables fueron la amilasa pancreática (p<0.001) la elastasa de los neutrófilos (p<0.05) la albúmina (p<0.002) y la proteína C reactiva (CRP) (p<0.001). Los resultados se homogeneizaron al añadirse a estos parámetros séricos las imágenes obtenidos por CT. Así, la albúmina sérica + colecciones líquidas extrapancreáticas (valor diagnóstico negativo entre el 92–96% y positivo en el 67–100% de los casos) constituyeron el mejor indicador por lo que a la gravedad se refiere. Ninguno de los parámetros estudiados tienen, por sí solos, valor diagnóstico o pronóstico alguno. La albúmina sérica + colecciones líquidas extrapancreáticas constituyen, al ingreso, el mejor indicador de la gravedad del cuadro pancreático.

The role of inflammatory and parenchymal cells in acute pancreatitis

The infiltration of inflammatory cells into the pancreas is an early and central event in acute pancreatitis that promotes local injury and systemic complications of the disease. Recent research has yielded the important finding that resident cells of the pancreas (particularly acinar and pancreatic stellate cells) play a dynamic role in leukocyte attraction via secretion of chemokines and cytokines and expression of adhesion molecules. Significant progress has been made in recent years in our understanding of the role of leukocyte movement (adhesion to the blood vessel wall, transmigration through the blood vessel wall and infiltration into the parenchyma) in the pathophysiology of acute pancreatitis. This review discusses recent studies and describes the current state of knowledge in the field. It is clear that detailed elucidation of the numerous processes in the inflammatory cascade is an essential step towards the development of improved therapeutic strategies in acute pancreatitis. Studies to date suggest that combination therapy targeting different steps of the inflammatory cascade may be the treatment of choice for this disease. Copyright

Rapid changes in alcoholic hepatitis histology under steroids: correlation with soluble intercellular adhesion molecule-1 in hepatic venous blood

BACKGROUND/AIMS In alcoholic hepatitis (AH), enhanced expression of intercellular adhesion molecule-1 (ICAM-1) correlates to neutrophil infiltration and histology. In severe AH under steroids, the evolution of the hepatocyte membranous ICAM-1 expression and its soluble form (sICAM-1) is not known. METHODS Twenty-six consecutive patients with biopsy-proven severe AH had liver tissue studies for hepatocyte membranous ICAM-1 expression by immunostaining. Lobular neutrophils (mean per high power field) were counted after chloracetate esterase staining. Histological damage was assessed semiquantitatively. Circulating levels of sICAM-1 and TNFalpha in peripheral and hepatic vein were measured using immunoassays. After 8 days on steroids, 19 patients had repeat biopsy. RESULTS At baseline, hepatocyte membranous ICAM-1 correlated both to histology (r=0.55, P<0.01) and to lobular neutrophils (r=0.56, P<0.01). On steroids, sICAM-1 in hepatic vein and TNFalpha in both vascular beds decreased. Hepatocyte membranous ICAM-1 and hepatocellular damage decreased, but lobular neutrophils increased. Changes in sICAM-1 in hepatic vein correlated to histological changes (r=0.68, P<0.01). CONCLUSIONS In severe AH under steroids, the short term histological improvement was associated with a decrease in circulating TNFalpha, a decrease in ICAM-1 expression, and correlated to hepatic vein sICAM-1 changes.

Autologous bone marrow mononuclear cell transplantation in patients with decompensated alcoholic liver disease: a randomized controlled trial.

Objective Impaired liver regeneration is associated with a poor outcome in patients with decompensated alcoholic liver disease (ALD). We assessed whether autologous bone marrow mononuclear cell transplantation (BMMCT) improved liver function in decompensated ALD. Design 58 patients (mean age 54 yrs; mean MELD score 19, all with cirrhosis, 81% with alcoholic steatohepatitis at baseline liver biopsy) were randomized early after hospital admission to standard medical therapy (SMT) alone (n = 30), including steroids in patients with a Maddrey’s score ≥32, or combined with G-CSF injections and autologous BMMCT into the hepatic artery (n = 28). Bone marrow cells were harvested, isolated and reinfused the same day. The primary endpoint was a ≥3 points decrease in the MELD score at 3 months, corresponding to a clinically relevant improvement in liver function. Liver biopsy was repeated at week 4 to assess changes in Ki67+/CK7+ hepatic progenitor cells (HPC) compartment. Results Both study groups were comparable at baseline. After 3 months, 2 and 4 patients died in the BMMCT and SMT groups, respectively. Adverse events were equally distributed between groups. Moderate alcohol relapse occurred in 31% of patients. The MELD score improved in parallel in both groups during follow-up with 18 patients (64%) from the BMMCT group and 18 patients (53%) from the SMT group reaching the primary endpoint (p = 0.43 (OR 1.6, CI 0.49–5.4) in an intention to treat analysis. Comparing liver biopsy at 4 weeks to baseline, steatosis improved (p<0.001), and proliferating HPC tended to decrease in both groups (−35 and −33%, respectively). Conclusion Autologous BMMCT, compared to SMT is a safe procedure but did not result in an expanded HPC compartment or improved liver function. These data suggest either insufficient regenerative stimulation after BMMCT or resistance to liver regenerative drive in patients with decompensated alcoholic cirrhosis. Trial Registration Controlled-Trials.com ISRCTN83972743.