Changes in adaptive and innate immunity in patients with acute pancreatitis and systemic inflammatory response syndrome.

BACKGROUND: Acute pancreatitis is a form of inflammation with clinical features ranging from pancreatic inflammation to fatal systemic manifestations. The aim of this study was to clarify changes in lymphocyte subsets and alterations in the functioning of natural killer (NK) cells. PATIENTS AND METHODS: Forty-five patients were enrolled into the study; 35 with acute pancreatitis and systemic inflammatory response syndrome (SIRS) and 10 healthy subjects. Blood was sampled early from all patients. Blood immune cells were studied on days 1 and 4 by flow cytometry. Tumor necrosis factor-α (TNFα) and interleukin (IL)-6 were estimated from supernatants of NK cells before/after stimulation with lipopolysaccharide (LPS). RESULTS: Apoptosis in patients was significantly different on days 1 and 4 compared with controls. Apoptosis of CD4(+) lymphocytes was significantly correlated with the days to resolution of SIRS (r = +0.586, p = 0.022). Significant differences were observed in TNFα and IL-6 on day 1 with/without LPS stimulation between patients and healthy individuals. Significantly increased levels of TNFα and IL-6 were found after LPS stimulation compared with unstimulated supernatants in day 1. CONCLUSION: NK cells altered their secretory status when stimulated with LPS. This finding could be explained by the cellular reprogramming of NK cells in the field of acute pancreatitis and SIRS.

Diffuse malignant peritoneal mesothelioma presenting as intestinal obstruction.

Diffuse malignant peritoneal mesothelioma (DMPM) represents 90% of all peritoneal forms of mesothelioma. It affects mainly patients 50-69 years old. In 50% of cases there is a history of asbestos exposure. The clinical presentation of the disease is not characteristic: nonspecific abdominal pain, weight loss, and abdominal distension are common. Ascites occurs in 90% of the patients. Bowel obstruction is a late manifestation. We present three patients with DMPM, without a history of asbestos exposure and without ascites, who presented with complete bowel obstruction. All patients underwent emergency operations, and palliative surgical procedures were performed. Each patient died within 3 to 6 months postoperatively.

Prognostic factors in patients with locally advanced (unresectable) or metastatic pancreatic adenocarcinoma: a retrospective analysis.

BACKGROUND: Most patients with pancreatic adenocarcinoma are diagnosed with locally advanced (unresectable) or metastatic disease. The aim of this study was to investigate possible prognostic factors of survival in such patients. PATIENTS AND METHODS: Two hundred and fifteen patients were studied retrospectively. Twenty-four potential prognostic variables (demographics, clinical parameters, biochemical markers, treatment modality) were examined. RESULTS: Mean survival was 29.0 weeks. 21.9% survived more than 36 weeks. On multivariate analysis, 10 factors had an independent effect on survival: tumour localisation, metastasis, performance status, jaundice, weight loss, C reactive protein, CEA, CA 19-9, palliative surgery and chemotherapy. Patients managed only with palliative care had a hazard ratio of 8.94 versus those offered a combination of palliative surgery and chemotherapy. CONCLUSION: Many factors could be used as predictors of survival in patients with advanced or metastatic pancreatic cancer. Chemotherapy and palliative surgery are associated with increased survival, and should be offered to all eligible patients.

Association of polymorphisms of NOD2, TLR4 and CD14 genes with susceptibility to gastric mucosa-associated lymphoid tissue lymphoma.

BACKGROUND: The clinical course of Helicobacter pylori infection is highly variable and is influenced by both microbial and host factors, including the genetic composition of the infecting strains and variations in the host immune responses. A genetic risk profile for gastric cancer has been identified, but genetic susceptibility to develop gastric mucosa-associated lymphoid tissue (MALT) lymphoma is unclear. The aim of this study was to evaluate the relationship between NOD2, TLR4 and CD14 genetic polymorphisms and the development of gastric MALT-lymphoma. MATERIALS AND METHODS: Fifty-six patients with primary gastric MALT lymphoma and 51 patients with H. pylori infection were enrolled in this study. The polymorphisms were detected by the PCR-restriction fragment length polymorphism (RFLP) method of allele-specific PCR. RESULTS: No polymorphisms in the NOD2 and TLR4 genes were found to be associated with the development of gastric MALT lymphoma. Carriers of the CD14 gene -159T allele had a marginally increased risk of developing gastric MALT lymphoma than the controls (p=0.042). CONCLUSION: The -159C/T genetic polymorphism of the CD14 gene may be implicated in the development of gastric MALT lymphoma.

TGF-betaRII, BAX, IGFIIR, caspase-5, hMSH3 and hMSH6 alterations are not associated with microsatellite instability or p53 mutations in invasive urothelial carcinoma of the urinary bladder.

AIM: The aim of this study was to determine the potential synchronous contribution of alterations in TGF-betaRII, BAX, IGFIIR, caspase-5, hMSH3 and hMSH6 genes to the development and clinical outcome of bladder cancer, in relation to p53 mutations, microsatellite status and hMLH1/hMSH2 expression. METHODS: Molecular biology techniques as well as immunohistochemistry were applied in 69 samples from patients with urothelial carcinoma. RESULTS: Microsatellite alterations were observed in TGF-betaRII(A)(10 )(16%) and BAX(G)(8 )(3%), irrespective of the presence of p53 mutations, but not in IGFIIR(G)(8), caspase-5(A)(10, ) hMSH3(A)(8) and hMSH6(C)(8). A statistically significant correlation could be found only between hMLH1 expression and the presence of microsatellite instability (Fisher's exact test, p = 0,013). Survival analysis indicated that apart from grade and T-category, hMLH1 expression was the only parameter significantly affecting overall survival (p = 0.021 in univariate and p = 0.015 in multivariate analysis) and recurrence-free survival (p = 0.0463 in univariate and p = 0.022 in multivariate analysis). CONCLUSIONS: We conclude that alterations of the examined target genes of MSI are rare in urinary bladder carcinoma and they are not associated with microsatellite instability or the presence of p53 mutations.

Monocytes in systematic inflammatory response syndrome: differences between sepsis and acute pancreatitis.

AIM: To unravel the differences between systematic inflammatory response syndrome (SIRS) of acute pancreatitis compared to the same syndrome in sepsis. METHODS: Twenty-five patients were enrolled, 12 with sepsis and 13 acute pancreatitis. After diagnosis 20 mL blood was sampled. Half were assayed for isolation of monocytes and 10 mL was centrifuged for serum test of tumor necrosis factor alpha (TNFalpha and interleukin-6 (IL-6). Half of monocytes were incubated in the presence of patients' serum and supernatants were collected. The other half was treated for estimation of optical photometry under caspase-3 inhibition. TNFalpha and IL-6 were estimated by an enzyme immunoassay. RESULTS: median+/-SE of serum IL-6 in septic patients and acute pancreatitis patients was 192.30+/-35.40 ng/L and 21.00+/-16.05 ng/L, respectively (P<0.01). Respective values of caspase-3 were 0.94+/-0.17 pmol/min 10(4) cells and 0.34+/-0.09 pmol/min 10(4) cells (P<0.05). IL-6 of monocyte supernatants of patients with sepsis was significantly increased after addition of patients' serum, while that of patients with acute pancreatitis did not show significant difference. CONCLUSION: The data have shown that monocyte activity is different between acute pancreatitis and sepsis. This phenomenon might be explained as a different pathway to the pro-inflammatory cytokines release or could be a novel anti-inflammatory response in acute pancreatitis.

Role of soluble triggering receptor expressed on myeloid cells in inflammatory bowel disease.

AIM: To investigate the probable role of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in the pathogenesis of inflammatory bowel disease (IBD). METHODS: Fifty-eight patients were enrolled; nineteen healthy volunteers served as controls; 8 patients were diagnosed with Crohn's disease, and 31 with ulcerative colitis. Clinical and endoscopic activity indexes of patients with Crohn's disease and ulcerative colitis respectively were estimated. Upon admission blood was sampled; sTREM-1 and TNFalpha were measured by an immunoassay and malondialdehyde (MDA) by the thiobarbitourate assay, after passage through an HPLC system. RESULTS: Median +/- SE of TNFalpha of controls, patients with Crohn's disease and patients with ulcerative colitis were 6.02 +/- 3.94, 7.98 +/- 5.08 (P = NS vs controls), and 8.45 +/- 4.15 ng/L (P = 0.018 vs controls) respectively. Respective values of sTREM-1 were 53.31 +/- 32.93, 735.10 +/- 197.17 (P = 0.008 vs controls) and 435.82 +/- 279.71 ng/L (P = 0.049 vs controls). sTREM-1 was positively correlated with Crohn's disease activity index and clinical and endoscopic activity indexes of ulcerative colitis (P = 0.002, 0.001 and 0.009, respectively). sTREM-1 of patients with ulcerative colitis was positively correlated with TNFalpha (P = 0.001). CONCLUSION: sTREM-1 seems to behave as a novel mediator in IBD in correlation with the degree of the inflammatory reaction of the intestinal mucosa.

Retinol-binding protein, acute phase reactants and Helicobacter pylori infection in patients with gastric adenocarcinoma.

AIM: To determine the serum levels of c-reactive protein (CRP), transferrin (TRF), a2-macroglobulin (A2M), ceruloplasmin (CER), a1-acid glycoprotein (AAG), pre-albumin (P-ALB) and retinol-binding protein (RBP) in gastric carcinoma patients and to explore their possible correlation with underlying Helicobacter pylori (H pylori) infection. METHODS: We measured the serum levels of CRP, TRF, A2M, CER, AAG, P-ALB, and RBP in 153 preoperative patients (93 males; mean age: 63.1+/-11.3 years) with non-cardia gastric adenocarcinoma and 19 healthy subjects. RESULTS: The levels of CRP, CER, RBP, and AAG in cancer patients were significantly higher than those in healthy controls (P<0.0001), while no difference was found regarding the TRF, P-ALB, and A2M levels. Cancer patients with H pylori infection had significantly lower RBP values compared to non-infected ones (P<0.0001) and also higher values of CRP and AAG (P = 0.09 and P = 0.08, respectively). CONCLUSION: High serum levels of CRP, CER and AAG in cancer patients do not seem to be related to H pylori infection. Retinol-binding protein seems to discriminate between infected and non-infected patients with gastric carcinoma. Further studies are needed to explore if it is directly involved in the pathogenesis of the disease or is merely an epiphenomenon.

Lipid peroxidation in chronic gastritis; any influence of Helicobacter pylori?

In an attempt to investigate the significance of lipid peroxidation in the pathogenesis of gastritis associated with or without Helicobacter pylori infection, malonodialdehyde (MDA) levels were measured by the thiobarbiturate assay in the gastric juice of 101 patients undergoing upper GI endoscopy and correlated with histopathological findings. Elevated MDA levels were found in all patients with gastritis compared with controls. MDA levels were significantly correlated with the extent of the mucosal inflammation and with disease activity in patients with reactive gastritis. In patients with H. pylori associated gastritis MDA levels were not correlated with disease activity but rather with the degree of atrophy. In this case, MDA levels were equal or even less than in patients with reactive gastritis. MDA levels were not affected by the history of consumption of PPIs, of H(2)-blockers or of NSAIDs over the last month before the endoscopy. It is concluded that lipid peroxidation is a mechanism involved in the pathogenesis of gastritis associated or not to H. pylori infection.

Can soluble triggering receptor expressed on myeloid cells (sTREM-1) be considered an anti-inflammatory mediator in the pathogenesis of peptic ulcer disease?

Soluble triggering receptor expressed on myeloid cells (sTREM-1) is a novel mediator involved in the pathogenesis of peptic ulcer disease. To investigate the potential role of sTREM-1 in the anti-inflammatory response in chronic gastritis, sTREM-1 was compared with other anti-inflammatory mediators of gastritis. Forty patients with dyspepsia were enrolled: 20 with peptic ulcer and 20 controls without any macroscopic abnormalities. All patients were examined by endoscopy; gastric juice was aspirated and biopsy specimens were collected from the antrum and corpus of the stomach. sTREM-1, interleukin (IL)-8, and IL-10 were estimated by enzyme immunoassays. Median sTREM-1 in patient controls and in patients with peptic ulcer disease was 3.91 and 44.27 pg/ml, respectively (P=0.006). Respective values of IL-8 were 1856.97 and 2030.66 pg/ml (P=0.023); those of IL-10 were 16.92 and 18.43 pg/ml (NS). The odds ratio for the presence of peptic ulcer in the event of a concentration of sTREM-1 higher than 15 pg/ml was 23.22 (95% CI, 2.58-208.62; P=0.002). A positive correlation was found between the ratios of IL-8/sTREM-1 and IL-8/IL-10 (r (s), + 0.365; P=0.021). In conclusion, sTREM-1 is an independent factor for the generation of peptic ulcer disease and might behave as an anti-inflammatory mediator in chronic gastritis.

Application of discriminant analysis and quantitative cytologic examination to gastric lesions.

OBJECTIVE: To investigate of the potential value of morphometry and discriminant analysis for the classification of benign and malignant gastric cells and lesions. STUDY DESIGN: The data set consisted of 13,300 cells from 120 cases composed of 30 cases of cancer, 26 cases of gastritis and 64 cases of ulcer according to the final histologic diagnosis. The cytologic diagnosis was divided into 5 categories (gastritis, ulcer, inflammatory dysplasia, cancer and true dysplasia). Classification was attempted at 2 levels: the cell level to classify individual cells and the case level to classify individual cases. For the cellular classification the measured cells from 50% of available cases were selected as a training set to construct a model. The cells from the remaining cases were used as a test set to validate the model. Similarly for case classification, the same 50% of cases that were used for cell classification were used as a training set and the remaining cases as a test set. Images of routinely processed gastric smears stained by the Papanicolaou technique were analyzed by a customized image analysis system. RESULTS: Application of discriminant analysis on the test set gave correct classification of 98.4% of benign cells and 67.1% of malignant cells. On case classification, 100% accuracy was achieved for benign and malignant cases, both for the training and test sets. CONCLUSION: The application of discriminant analysis described in this paper could produce significant classification results at the cellular and individual case level.

Alterations in the proliferating compartment of gastric mucosa during Helicobacter pylori infection: the putative role of epithelial cells expressing p27(kip1).

The proliferating zone contains stem cells that give rise to all epithelial cells of the gastric mucosa. In the present study, we investigated the turnover of gastric epithelial cells in the proliferating zone of Helicobacter pylori-infected mucosa, with or without intestinal metaplasia, before and after eradication of the microorganism. In addition, we studied the topographical distribution of the cyclin dependent kinase inhibitor p27(Kip1), which plays a critical role in cell cycle progression and differentiation programs. Twenty-eight patients (22 male), aged 32-78 years and with dyspeptic symptoms, were endoscoped, and gastric biopsies were obtained from antrum and corpus for histopathological examination and the Campylobacter-like organisms test; eradication therapy was given to infected patients, and all patients were re-endoscoped after 105 +/- 33 days (mean +/- SD). The kinetics of gastric epithelial cells and p27(Kip1) status was assessed by means of immunohistochemistry and TUNEL (Tdt-mediated dUTP-biotin nick end labeling) assay. Twenty-one (21) of 28 patients were H. pylori positive, and 7 were found H. pylori negative and served as controls. In antrum, intestinal metaplasia was detected in 7/21 (33.3%). In H. pylori gastritis, Ki67 expression was found increased in the proliferating zone, compared with normal (P =.03); analogous results were obtained with the other proliferation markers, namely retinoblastoma protein and topoisomerase IIalpha. An inverse relationship between proliferation index and atrophy was disclosed (P =.02). A reduction in the proliferation index was observed after eradication, albeit not significant. Apoptotic epithelial cells were found significantly increased (P <.01) in H. pylori gastritis, and a significant reduction was observed after eradication (P <.01). In addition, apoptotic index was found to correlate with H. pylori density. The topographical study of p27(Kip1) revealed a p27(kip1)-positive epithelial cell population that resided deep in the proliferating zone; these cells were considered to be stem cells and were found significantly increased in areas with intestinal metaplasia (P <.05); in H. pylori gastritis, there was also an increase that did not reach statistical significance. H. pylori infection induces apoptosis and increases proliferation in the proliferating zone. The increased cellular turnover, together with the increased number of putative p27(Kip1)-positive stem cells in the context of intestinal metaplasia, provides further evidence for the role of H. pylori infection in gastric carcinogenesis.

Inflammatory bowel disease in Greece-- a hospital-based clinical study of 172 consecutive patients.

BACKGROUND: It has been suggested that inflammatory bowel disease (IBD) has a milder course in Greece than in other Western countries. The purpose of our study was to assess the clinical picture of IBD in a hospital-based sample of IBD patients, followed from January 1986 to May 2001. MATERIAL/METHODS: Retrospective study of 172 patients: 130 with UC followed up for 1-360 months (mean 66+/-57 months) and 42 with CD for 1-240 months (mean: 51.85+/-63.68 months). RESULTS: 63 UC patients (48%) required hospitalization, 30 (23%) on the first attack; 72 (55%) had left sided colitis and 23 (18%) pancolitis; in 6 cases, (5%), surgical intervention was indicated at onset, 4 (3%) were operated. During FU, 15 patients (11.5%) were operated, 4 (3%) as medical emergencies, 3 (2%) due to colon cancer, the others for intractable colitis or long-standing disease; 5 patients (4%) developed toxic dilation of the colon, 3 (2%) developed colon cancer and 4 (4%) extraintestinal malignancies. 7 patients (5%) died; 2 (1.5%) due to the disease and the remainder for other causes. 19 CD patients (45%) had ileocolitis and 14 (33%) colitis; 22 (52%) needed hospitalization on the first attack. In 12 patients (29%) surgical intervention was required on initial onset or during FU. One patient developed colon cancer (2%). Two men died (5%) from myocardial infarction. CONCLUSIONS: IBD does not have a milder course in Greece than in other European populations.