Advanced heart failure and cardiac arrhythmia in a young adult survivor of childhood cancer.

The goal of this case report is to describe the young childhood cancer survivor who was treated for nonHodgkin lymphoma with chemotherapy containing anthracycline doxorubicin and who developed symptoms of serious cardiovascular damage 27 years after diagnosis of cancer. The patient is in longterm complete remission of the lymphoma. He started guideline medical therapies for chronic heart failure and had a cardioverter defibrillator implanted for primary prevention of sudden cardiac death. He is currently a candidate for heart transplantation.

Profiling of volatile substances by direct thermal desorption gas chromatography high-resolution mass spectrometry for flagging a characterising flavour in cigarette tobacco.

This paper describes an analytical method that supports the implementation of articles 9 and 10 of the WHO Framework Convention on Tobacco Control (FCTC) regarding the provisions on the reduction of the palatability and attractiveness of tobacco products regarding flavour ingredients. This study aimed to develop a screening method to identify cigarettes that may have a characterising flavour to support the implementation of the ban of characterising flavours of tobacco products, as laid down in the US and EU law. An analytical method combining direct thermal desorption and GC-QTOF MS was developed for acquiring the profile of volatile and semi-volatile substances in tobacco. A database of flavour additives was created comprising 133 compounds. A group of cigarettes without a declared characterising flavour was used to establish a reference profile of flavouring chemicals commonly present in tobacco products. A reference profile was modelled both by the means of principal component analysis (PCA) and based on the calculation of threshold values specified as 95th percentile of measured compounds' relative responses. Cigarettes and roll-your-own tobacco labelled as flavoured were analysed to evaluate the discrimination power of the method. A constructed model of the reference cigarettes allowed the differentiation of the flavoured tobacco products from the reference group. The method allows drawing conclusions on the chemical profiles of flavour constituents of tobacco products at even sensorial subliminal concentration levels and is suitable for both the initial screening of products on the market for characterising flavours and for confirmatory purposes after sensory analysis.

Identification of Cigarette Brands by Soft Independent Modeling of Class Analogy of Volatile Substances.

INTRODUCTION: This study aimed to develop a method for discriminating cigarette brands based on the profiles of volatile components extracted from the tobacco fraction of the finished cigarettes to authenticate branded cigarettes of unknown origin. METHODS: An analytical method comprising direct thermal desorption coupled with gas chromatography-quadrupole time-of-flight mass spectrometry was developed for acquiring volatile profiles of cigarettes. About 290 samples of commercially available cigarettes were analyzed. Within this batch, 123 samples represented four popular cigarette brands. They were selected for in-depth characterization. Multivariate analysis was used to investigate the interrelations among volatile compounds of cigarettes and to identify characteristic markers for the cigarette discrimination. Supervised pattern recognition techniques were used for designing classification models. RESULTS: Principal component analysis covering all detected volatiles allowed the differentiation of cigarettes based on the brand. A number of 56 volatile components were identified as markers with high discrimination power. These compounds were used for establishing classification models. A method of soft independent modeling of class analogy developed for the four studied cigarette brands proved to be efficient in the classification of unknown cigarettes, with accuracy between 95.9% and 100%. CONCLUSIONS: The data evaluation by soft independent modeling of class analogy was highly accurate in classification of unknown cigarettes with a low rate of false positives and false negatives. The developed models can be used for discrimination of genuine from non-genuine products with high level of probability. IMPLICATIONS: Profiling of volatiles, which is commonly used for authentication of different food commodities, was applied for the characterization of cigarette tobacco for the purpose of authentication a cigarette brand. Volatile components with a high discrimination power were identified by means of multivariate statistical methods and used for establishing of a classification model. The classification model was able to discriminate genuine from non-genuine cigarettes with a high level of prediction accuracy. This model could be a powerful tool for tobacco control to judge the authenticity of cigarettes.

Profiling of Amino Acids in Urine Samples of Patients Suffering from Inflammatory Bowel Disease by Capillary Electrophoresis-Mass Spectrometry.

Urine represents a convenient biofluid for metabolomic studies due to its noninvasive collection and richness in metabolites. Here, amino acids are valuable biomarkers for their ability to reflect imbalances of different biochemical pathways. An impact of amino acids on pathology, prognosis and therapy of various diseases, including inflammatory bowel disease (IBD), is therefore the subject of current clinical research. This work is aimed to develop a capillary electrophoresis-tandem mass spectrometry (CE-MS/MS) method for the quantification of the 20 proteinogenic amino acids in human urine samples obtained from patients suffering from IBD and treated with thiopurines. The optimized CE-MS/MS method, with minimum sample preparation (just "dilute and shoot"), exhibited excellent linearity for all the analytes (coefficients of determination were higher than 0.99), with inter-day and intra-day precision yielding relative standard deviations in the range of 0.91-15.12% and with accuracy yielding relative errors in the range of 85.47-112.46%. Total analysis time, an important parameter for the sample throughput demanded in routine practice, was shorter in ca. 17% when compared to established CE-MS methods. Favorable performance of the proposed CE-MS/MS method was also confirmed by the comparison with corresponding ultra-high performance liquid chromatography-mass spectrometry (UHPLC-MS) method. Consistent data for the investigated amino acid metabolome were obtained using both methods. For the first time, the amino acid profiling by CE-MS approach was applied on the clinical IBD samples. Here, significant differences observed in the concentration levels of some amino acids between IBD patients undergoing thiopurine treatment and healthy volunteers could result from the simultaneous action of the disease and the corresponding therapy. These findings indicate that amino acids analysis could be a valuable tool for the study of mechanism of the IBD treatment by thiopurines.

Analytical and Sample Preparation Protocol for Therapeutic Drug Monitoring of 12 Thiopurine Metabolites Related to Clinical Treatment of Inflammatory Bowel Disease.

Thiopurines (TP) represent an important therapeutic tool for the treatment of inflammatory bowel diseases (IBD) in the current situation of rising incidence and health care costs. The results of multiple clinical studies aimed at finding correlations between levels of TP metabolites and response of IBD patients to the treatment are, however, often controversial due to variability in analytical and sample preparation procedures among these studies. In this work, therefore, an updated analytical and sample preparation procedure for therapeutic drug monitoring (TDM) of TP metabolites in blood samples obtained from patients with IBD was proposed to establish a unified protocol. An advanced analytical method based on ion-exchange liquid chromatography hyphenated with tandem mass spectrometry (IEC-ESI-MS/MS) was used for the determination of the profiles of 12 individual TP metabolites in the particular steps of sample preparation procedure including blood collection, red blood cells (RBC) isolation, lysis, and storage. Favorable performance parameters of the IEC-ESI-MS/MS method (LLOQs 1⁻10 nmol/L, accuracy 95⁻105%, intra-day and inter-day precision < 10%, selectivity demonstrated via no sample matrix interferences) and acceptable stability (peak area fluctuations < 15%) of clinical samples under the proposed sample preparation conditions {(i) EDTA anticoagulant tube for the blood collection; (ii) 4 °C and 4 h between the sample collection and RBC isolation; (iii) phosphate-buffered saline for RBC washing and re-suspendation; (iv) -20 °C for RBC lysis and short-term storage; (v) 50 mmol/L phosphate buffer, pH 7.4, 10 mmol/L DTT as a stabilizing medium for TPN in RBC lysates} demonstrated the suitability of such protocol for a well-defined and reliable routine use in studies on thiopurines TDM.

Assessment of critical steps of a GC/MS based indirect analytical method for the determination of fatty acid esters of monochloropropanediols (MCPDEs) and of glycidol (GEs).

Fatty acid esters of 2- and 3-chloropropanediol (MCPDEs) and fatty acid esters of glycidol (GEs) are commonly monitored in edible fats and oils. A recommendation issued by the European Commission emphasizes the need of generating data on the occurrence of these substances in a broad range of different foods. So far, analytical methods for the determination of MCPDEs and GEs are fully validated only for oils, fats and margarine. This manuscript presents the assessment of critical steps in the AOCS Cd 29a-13 method for the simultaneous determination of MCPDEs and GEs in the fat phase obtained from bakery and potato products, smoked and fried fish and meat, and other cereal products. The trueness of the method is affected by the additional formation of 3-MBPD esters from monoacylglycerols (MAGs), which are frequently present in food. The overestimation of GE contents for some samples was confirmed by the comparison of results with results obtained by an independent analytical method (direct analysis of GE by HPLC-MS/MS). An additional sample pre-treatment by SPE was introduced to remove MAGs from fat prior to the GEs conversion, while the overall method sensitivity was not significantly affected. Trueness of the determination of GEs by the modified analytical procedure was confirmed by comparison with a direct analysis of GEs. The potential impact on accuracy of results of the final sample preparation step of the analytical procedure, the derivatization of free forms MCPD and MBPD with PBA, was evaluated as well. Different commercial batches of PBA showed differences in solubility in a non-polar organic solvent. The PBA derivatization in organic solvent did not affect precision and trueness of the method due to the isotopic standard dilution. However, method sensitivity might be significantly compromised.

Capillary Electrophoresis Hyphenated with Mass Spectrometry for Determination of Inflammatory Bowel Disease Drugs in Clinical Urine Samples.

Azathioprine is the main thiopurine drug used in the treatment of immune-based inflammations of gastrointestinal tract. For the purpose of therapy control and optimization, effective and reliable analytical methods for a rapid drug monitoring in biological fluids are essential. Here, we developed a separation method based on the capillary electrophoresis (CE) hyphenated with tandem mass spectrometry (MS/MS) for the simultaneous determination of azathioprine and its selected metabolites (6-thioguanine, 6-mercaptopurine, and 6-methylmercaptopurine) as well as other co-medicated drugs (mesalazine, prednisone, and allopurinol). The optimized CE-MS/MS conditions provided a very efficient and stable system for the separation and sensitive detection of these drugs in human urine matrices. The developed method was successfully applied for the assay of the targeted drugs and their selected metabolites in urine samples collected from patients suffering from inflammatory bowel disease (IBD) and receiving azathioprine therapy. The developed CE-MS/MS method, due to its reliability, short analysis time, production of complex clinical profiles, and favorable performance parameters, evaluated according to FDA guidelines for bioanalytical method validation, is proposed for routine clinical laboratories to optimize thiopurine therapy, estimate enzymatic activity, and control patient compliance with medication and co-medication.

Preconception Care Reduces Relapse of Inflammatory Bowel Disease During Pregnancy.

BACKGROUND & AIMS: Women with inflammatory bowel disease (IBD) may have incorrect beliefs about their disease and its medication in relation to pregnancy. We studied the effects of preconception care (PCC) on patients' behavior during pregnancy, disease relapse during pregnancy, and birth outcomes. METHODS: In a prospective study, we followed up all women with IBD seen at the preconception outpatient clinic at Erasmus MC-University Medical Center in Rotterdam, The Netherlands (from 2008 through 2014). We compared patients who received PCC before they became pregnant (PCC group; n = 155) with patients who visited the clinic after they already were pregnant (no-PCC group; n = 162). We collected data on lifestyle, medication adherence, planning of conception, disease activity, and birth outcomes. We compared adherence to medical advice, rates of disease relapse during pregnancy, and birth outcomes. RESULTS: The PCC group was on average younger than the no-PCC group (29.7 vs 31.4 y; P = .001), and a greater proportion were nulliparous (76.1% vs 51.2%; P = .0001). PCC was associated with adherence to IBD medication during pregnancy (adjusted odds ratio [aOR],5.69; 95% confidence interval [CI], 1.88-17.27), adequate folic acid intake (aOR, 5.26; 95% CI, 2.70-10.26), and smoking cessation (aOR, 4.63; 95% CI, 1.22-17.55). PCC reduced disease relapse during pregnancy independent of parity, disease duration, or disease activity before conception (aOR, 0.51; 95% CI, 0.28-0.95). The PCC group was less likely to deliver babies of low birth weight (aOR, 0.08; 95% CI, 0.01-0.48). CONCLUSIONS: In a prospective study, we found that preconception care reduces IBD relapse during pregnancy by promoting adherence to medication and smoking cessation. Preconception also reduces risk for babies of low birth weight.

Effects of discontinuing anti-tumor necrosis factor therapy during pregnancy on the course of inflammatory bowel disease and neonatal exposure.

BACKGROUND & AIMS: We assessed the course of inflammatory bowel disease (IBD) among pregnant women who stopped taking anti-tumor necrosis factor (TNF) agents. We also analyzed levels of anti-TNF agents in cord blood samples. METHODS: We followed 31 pregnancies in 28 women with IBD between April 2006 and April 2011 who were treated with anti-TNF agents (18 received infliximab, and 13 received adalimumab) during pregnancy. We used enzyme-linked immunosorbent assays to measure levels of anti-TNF agents in cord blood collected from 18 newborns (12 whose mothers took infliximab, and 6 whose mothers took adalimumab). RESULTS: Among the patients taking infliximab, 12 (71%) discontinued treatment before gestational week 30; all patients remained in remission. All the patients taking adalimumab discontinued treatment before gestational week 30; two patients had relapses of IBD. There were 28 live births, 1 miscarriage among patients taking infliximab (at gestational week 6), and 2 miscarriages among patients taking adalimumab (at weeks 6 and 8); there were no congenital malformations. The mean cord blood level of infliximab was 6.4 ± 1.6 µg/mL; it was significantly lower among women who received the drug 10 weeks or less before delivery (2.8 ± 1.1 µg/mL) than those who received infliximab closer to delivery (10 ± 2.3 µg/mL; P = .02). Adalimumab was detected in 5 samples of cord blood (mean concentration, 1.7 ± 0.4 µg/mL); 1 cord blood sample from a woman who discontinued the treatment at gestational week 22 had an undetectable level of the drug. CONCLUSIONS: Discontinuation of anti-TNF therapy appears to be safe for pregnant women with quiescent IBD. However, these drugs are still detected in cord blood samples.

Donor-transmitted metastasis of colorectal carcinoma in a transplanted liver.

A 62-year-old man with alcoholic liver cirrhosis underwent liver transplantation. The transplantation went uneventful and the ultrasound imaging of the liver performed after transplantation did not show any abnormalities. Eighteen months later, an intra-hepatic focal lesion was found on ultrasound. A contrast-enhanced ultrasound revealed a lesion with a malignant pattern of contrast uptake. The histo-pathological and subsequent molecular-pathological analysis concluded a colorectal metastasis of donor origin. The donor had no history of malignancy but no complete autopsy had been performed which illustrates the importance of the meticulous donors` screening. Transplanted patients carry a high risk of developing malignancy in general but donor related-tumors are very rare. The therapeutic considerations differ substantially between recipient- and donor-related malignancies. Therefore, considering the possibility of donor-related tumor by raising suspicion of malignant lesion with appropriate imaging and distinction from recipient-related malignancy by molecular analysis are crucial for proper therapeutic decision.

Life Stressors in Patients with Inflammatory Bowel Disease: Comparison with a Population-Based Healthy Control Group in the Czech Republic.

BACKGROUND: Stress has been suggested to play a potential role in inflammatory bowel disease (IBD) pathogenesis, but studies focussing on the occurrence of specific life stress events among IBD patients are scarce. Therefore, the aim of the present study was to explore the association between various life stress events and IBD. METHODS: Patients with IBD (N = 98, mean age: 38.45, 54.1% men) were compared to a group of healthy controls (N = 405, mean age: 36.45, 58.0% men) originating from a health survey conducted on a representative population sample of Czech adults. The Life Stressor Checklist-Revised (LSC-R) was used to assess the stressors. RESULTS: IBD patients had higher odds of reporting life stressors overall (p < 0.001), life stressors before the age of 16 (p < 0.004) and a higher score in traumatic stress (p < 0.005) and interpersonal violence (p < 0.001) when compared to the control group. Gender- and diagnosis-related differences are discussed. CONCLUSION: Reporting life stressors experienced during childhood or adulthood is strongly associated with IBD. This should be considered in illness management, especially in a severe course of IBD.

Reproductive wish represents an important factor influencing therapeutic strategy in inflammatory bowel diseases.

OBJECTIVE: Inflammatory bowel disease (IBD) affects patients in reproductive age but little is known about the peri-conceptional use of medication for IBD. The aim of this study was to assess the type of medication used by IBD patients with the desire to reproduce and changes in medication in the peri-conceptional period. MATERIAL AND METHODS: IBD patients with active conception plans and pregnant patients were prospectively recruited from the outpatient clinic of a single academic medical center. IBD-related medication and changes in this medication for reasons of a desire to conceive or pregnancy were analyzed. RESULTS: In total, 61 patients (51 females; 40 with Crohn's disease, 21 with ulcerative colitis) were included. Thirteen patients (21%) used no medication, 44 (72%) used monotherapy and four (7%) used combination treatment. Of patients on monotherapy, 11 (19%) used 5-aminosalicylates, five (9%) used steroids, 11 (19%) used thiopurines, five (9%) used methotrexate and 11 (19%) used anti-tumor necrosis factor agents. Thirty-seven patients (61%) consulted a physician prior to conception. About one-third of these patients required a change in their medication due to their conception plans. CONCLUSIONS: In a referral center, the majority of IBD patients with conception plans require medication for which limited information on the safety of peri-conceptional use is available. In addition, the desire to reproduce leads to medication changes in about one-third of these patients.

Impact of double-balloon enteroscopy findings on the management of Crohn's disease.

OBJECTIVE: It is estimated that 10%-30% of Crohn's disease (CD) patients have small-bowel lesions, but the exact frequency and clinical relevance of these findings are unknown. Double-balloon enteroscopy (DBE) enables endoscopic visualization of the small bowel. The aim of this study was to evaluate the use of DBE for detecting small-bowel lesions in CD patients suspected of having small-bowel involvement. Furthermore, the clinical impact of adjusting treatment in these patients was assessed. MATERIAL AND METHODS: A prospective study was performed in a tertiary referral center. CD patients suspected of small-bowel involvement and in whom distal activity had previously been excluded were included. All patients underwent DBE, followed by step-up therapy in patients with small-bowel lesions. The presence of small-bowel lesions during DBE was noted and clinical outcome was assessed after adjusting therapy. RESULTS: Thirty-five patients (70%) showed small-bowel lesions; these lesions could not be assessed by conventional endoscopy in 23 (46%). At 1-year follow-up, step-up therapy in 26 patients (74%) led to clinical remission in 23 (88%). This was confirmed by a significant decrease in Crohn's disease activity index and mucosal repair on second DBE. CONCLUSIONS: DBE showed a high frequency of small-bowel lesions in known CD patients with clinically suspected small-bowel activity. Most of these lesions were not accessible for conventional endoscopy. Adjusting treatment in patients with small-bowel CD involvement led to clinical remission and mucosal repair in the majority of cases.

Influence of battery power setting on carbonyl emissions from electronic cigarettes.

INTRODUCTION: Although e-cigarettes share common features such as power units, heating elements and e-liquids, the variability in design and possibility for customization represent potential risks for consumers. A main health concern is the exposure to carbonyl compounds, which are formed from the main components of e-liquids, propylene glycol and glycerol, through thermal decomposition. Levels of carbonyl emissions in e-cigarette aerosols depend, amongst others, on the power supplied to the coil. Thus, e-cigarettes with adjustable power outputs might lead to high exposures to carbonyls if the users increase the power output excessively. The aim of this work was to elucidate the generation of carbonyls in relation to undue battery power setting. METHODS: Carbonyl emissions were generated by two modular e-cigarettes equipped with two atomizers containing coils of different resistance following the ISO 20768:2018 method. The battery power output was increased from the lower wattage level to above the power range recommended by the producer. Carbonyls were trapped by a 2,4-dinitrophenylhydrazine (DNPH) solution and analysed by LC-MS/MS. RESULTS: The amount of carbonyl emissions increased with increasing power setting. An exponential incline was observed when the applied power level exceeded the recommended power range. Exceeding the recommended power range by just 5 watts resulted in up to twenty times the amount of carbonyls emitted at the recommended upper power level. Generation of acetaldehyde and acrolein next to other carbonyls was prominent at high power outputs. CONCLUSIONS: E-cigarettes with customisable power setting might generate high amounts of carbonyls if the battery power output is set by the consumer to levels above the recommended range. This represents a high risk of exposure to carbonyls and thus should be avoided by integrating safety features in e-cigarette devices to limit the possible power settings to the range specified by the manufacturer.

Simultaneous determination of twelve biogenic amines in human urine as potential biomarkers of inflammatory bowel diseases by capillary electrophoresis - tandem mass spectrometry.

Biogenic amines (BA) are a broad group of biologically active substances, the presence of which in the human body can provide important diagnostic information for many various pathologies, including chronic inflammation. In this work, a capillary electrophoresis (CE) hyphenated with tandem mass spectrometry (MS/MS) method was developed for the simultaneous determination of twelve BA (histamine, serotonin, dopamine, norepinephrine, epinephrine, putrescine, cadaverine, spermine, spermidine, tyramine, tryptamine, phenylethylamine) in human urine as potential biomarkers of inflammatory bowel diseases (IBD). The electrophoretic separations were carried out in an uncoated fused silica capillary (I.D. 50 µm) using 50 mM formic acid (pH 2.0) as a background electrolyte. A reliable identification of the analytes was based on the combination of time resolution in CE and mass resolution in triple quadrupole MS/MS. The total analysis time of the proposed CEMS/MS method was less than 10 min with the limits of detection in the range of 4.47-144 ng/mL. The intra- and inter-day accuracy ranged in the intervals 89.75-109.4% and 89.99-110.2%, respectively, with the RSD values for the intra- and inter-day precision lower than 14 and 13 %, respectively. The recovery values for the samples spiked at three concentration levels ranged from 81.73-105.6% with a precision not exceeding 9.9 %. The favorable performance parameters of the CEMS/MS method highlighted its usefulness for routine clinical applications. In this work, the CEMS/MS method was applied, for the first time, to the analytical profiling of the BA in clinical human samples. The obtained results showed a statistically significant decrease of serotonin and norepinephrine, and an increase of histamine and spermidine, in the studied group of IBD patients when compared with the control group. These findings could be utilized in studying and clarifying the mechanisms of IBD or relevant therapy.

Porous graphitic carbon based chromatography hyphenated with mass spectrometry: A new strategy for profiling thiopurine nucleotides in patients with inflammatory bowel diseases.

Thiopurine (TP) treatment is discontinued in up to 30% of patients suffering from inflammatory bowel diseases (IBD) due to various adverse effects. Therapeutic drug monitoring of biologically active TP metabolites, i.e. thiopurine nucleotides (TPN), can help to optimize the efficacy and safety of the TP treatment. In our work, a novel strategy for TPN profiling, based on a porous graphitic carbon (PGC) chromatography, was developed. The validated PGC-MS method was compared with ion-exchange LC-MS, a currently leading analytical approach established for the determination of TPN. The innovative approach enabled an enhancement of several key performance parameters demanded in a clinical routine use, namely (i) selectivity (time- and mass-recognition of all 12 TPN in one run), (ii) sensitivity (2-5-fold increase in intensities of the analytical signals), (iii) sample throughput (25% shorter analysis time). Application of the novel TPN profiling strategy to a pilot clinical study (12 patients) revealed significantly higher levels of 6-methylthioguanine 5'-diphosphate (MeTGDP) in non-responsive IDB patients treated with azathioprine. Some other TPN are very close to the critical level (p = 0.05) and they will need larger groups of IBD patients to confirm definitively their relevance. In conclusion, the developed PGC-MS method represents a significant improvement to currently available methods for detailed profiling of TPN and its use in bigger clinical studies should lead to a better understanding of the relationship between TPN profiles and therapeutic outcome.

Seasonal changes of circulating 25-hydroxyvitamin D correlate with the lower gut microbiome composition in inflammatory bowel disease patients.

Higher probability of the development of Crohn's disease (CD) and ulcerative colitis (UC) as a possible consequence of the north-south gradient has been recently suggested. Living far north or south of the equator is manifested in fluctuation of vitamin D (vitD) levels depending on the season in both healthy and affected individuals. In the present study we investigate the possible link between the seasonal serum vitD level to the microbial composition of the lower gut of Inflammatory Bowel disease (IBD) patients using 16S rRNA sequencing. Decrease of serum vitD level in winter/spring season in a cohort of 35 UC patients and 39 CD patients was confirmed. Low gut microbiota composition of patients with IBD correlated with the serum level of 25(OH)D that directly coupled to seasonal variability of the sunshine in the central European countries. It is supposed to be related to increased abundance of Actinobacteria and Proteobacteria in UC and Actinobacteria, Fusobacteria, Firmicutes and Bacteroidetes in CD. In summer/autumn period, we observed a reduction in abundance of bacterial genera typical for inflammation like Eggerthella lenta, Fusobacterium spp., Bacteroides spp., Collinsella aerofaciens, Helicobacter spp., Rhodococcus spp., Faecalibacterium prausnitzii; and increased abundance of Pediococcus spp. and Clostridium spp. and of Escherichia/Shigella spp.

Effectiveness of ustekinumab dose escalation in Crohn's disease patients with insufficient response to standard-dose subcutaneous maintenance therapy.

BACKGROUND: Ustekinumab is effective in Crohn's disease. However, a substantial proportion of patients will not respond or lose response to ustekinumab. The current evidence to support the effectiveness of dose-optimisation for ustekinumab nonresponse is limited. AIM: To assess the effectiveness of dose escalation of ustekinumab. METHODS: This was a multicentre retrospective cohort study. We included active Crohn's disease patients who received a standard-dose intravenous induction and at least one subcutaneous ustekinumab 90 mg dose. All enrolled patients received dose escalation by either shortening the interval between the doses to every 4 or 6 weeks, intravenous reinduction or a combination of strategies. The primary outcome of the study was clinical response at week 16 after dose escalation. RESULTS: A total of 142 patients (22 centres/14 countries) were included. The patients were dose-escalated after a median treatment duration of 30 weeks. At week 16 from escalation, 73/142 (51.4%) responded to treatment, including 55/142 (38.7%) in clinical remission. Corticosteroid-free remission was achieved in 6/34 (17.6%) patients on corticosteroids at the time of escalation; 118/142 (83%) continued treatment beyond week 16. Follow-up data beyond week 16 were available for 74/118 (62.7%) patients. On the last follow-up, 51/98 (52%) patients with available data responded to treatment, including 41/98 (42%) in clinical remission. CONCLUSIONS: Intensification of ustekinumab maintenance dosage was effective in over 50% of the patients. This strategy should be considered in patients who are nonresponsive to every 8 weeks ustekinumab maintenance dosing.

Positive pharmacokinetic effect of azathioprine co-medication on infliximab trough levels is dose-dependent.

BACKGROUND: Thiopurines seem to have positive effect on the pharmacokinetics of anti-tumor necrosis factor biologics. It has been suggested that a reduced dose of thiopurines is sufficient to achieve this synergism. AIMS: To assess the differences of infliximab (IFX) trough levels according to the dose of concomitantly used azathioprine (AZA). PATIENTS & METHODS: All IBD patients treated with IFX (Remicade®) in two IBD centres between November 2015 and April 2017 were eligible. Infliximab trough levels were assessed by ELISA (Ridascreen®, R-Biopharm). The differences in IFX trough levels according to AZA dose were analyzed statistically. RESULTS: In total, 125 patients were included, 42 pts (33.6%) on infliximab monotherapy, 83 pts (66.4%) using combined immune suppression. The respective median IFX levels according to AZA dose were as follows: group 1 (no concomitant AZA) 2.83 µg/ml (range 0-12); group 2 (AZA dose less than 1 mg/kg) 4.91 µg/ml (range 0.09-15.36); group 3 (AZA dose 1 < 2 mg/kg) 5.67 (range 0.16-16.97); group 4 (AZA dose above 2 mg/kg) 7.53 µg/ml (range 1.15-8.73). The differences in IFX trough levels between the respective groups according to AZA dose were statistically significant (p = 0.0159). CONCLUSION: The positive effect of azathioprine on infliximab levels seems to be dependent on the dose of concomitantly used azathioprine.

Muramyl dipeptide-induced differential gene expression in NOD2 mutant and wild-type Crohn's disease patient-derived dendritic cells.

BACKGROUND: Mutations in the gene encoding the nucleotide-binding oligomerization domain 2 (NOD2) protein are associated with Crohn's disease (CD), but the mechanism underlying this is not completely understood. To study the mechanism of CD resulting from NOD2 mutations, we analyzed NOD2-dependent whole-genome expression profiles of patient-derived antigen-presenting cells. PATIENTS AND METHODS: Monocyte-derived dendritic cells (DCs) from CD carriers of double-dose NOD2 mutations, wild-type CD patients, and wild-type healthy volunteers were stimulated with the NOD2 ligand muramyl dipeptide. Whole-genome microarrays were used to assess the differential gene expression. The clustering of significantly changed genes was analyzed by online gene ontology mapping software. RESULTS: In the DCs from the wild-type CD patient group, 683 genes were significantly changed, with most of the genes clustering in the pathways of inflammatory response. In addition, a significant number of genes clustered in the apoptosis regulation-related pathway. In the DCs from the healthy volunteer group, only 50 genes were significantly changed, predominantly those belonging to the response to pathogen pathway. Analysis of differentially expressed gene ontology pathways in the DCs from the NOD2 mutant CD patient group showed that the transcription of pathogen response genes was absent. In this group, 298 genes were significantly changed, predominantly clustering in the negative apoptosis regulation and cell organization and biogenesis pathways. CONCLUSIONS: Our results suggest that NOD2 mutations may result in perpetuation of mucosal inflammation through insufficient pathogen elimination. Further, these observations implicate a possible role of defective regulation of dendritic cell apoptosis in CD pathogenesis.