Flaviviruses Hit a Moving Target.

The enteric nervous system (ENS) is central to intestinal motility and a candidate target for the heterogeneous spectrum of dysmotility diseases. White et al. reveal that relapsing intestinal dysmotility occurs when partial ENS depletion by enteric neurotropic viruses is followed by functional impairment due to intermittent nonspecific intestinal inflammation.

Microbiotas from Humans with Inflammatory Bowel Disease Alter the Balance of Gut Th17 and RORγt+ Regulatory T Cells and Exacerbate Colitis in Mice.

Microbiota are thought to influence the development and progression of inflammatory bowel disease (IBD), but determining generalizable effects of microbiota on IBD etiology requires larger-scale functional analyses. We colonized germ-free mice with intestinal microbiotas from 30 healthy and IBD donors and determined the homeostatic intestinal T cell response to each microbiota. Compared to microbiotas from healthy donors, transfer of IBD microbiotas into germ-free mice increased numbers of intestinal Th17 cells and Th2 cells and decreased numbers of RORγt+ Treg cells. Colonization with IBD microbiotas exacerbated disease in a model where colitis is induced upon transfer of naive T cells into Rag1-/- mice. The proportions of Th17 and RORγt+ Treg cells induced by each microbiota were predictive of human disease status and accounted for disease severity in the Rag1-/- colitis model. Thus, an impact on intestinal Th17 and RORγt+ Treg cell compartments emerges as a unifying feature of IBD microbiotas, suggesting a general mechanism for microbial contribution to IBD pathogenesis.

Multi-omics of the gut microbial ecosystem in inflammatory bowel diseases.

Inflammatory bowel diseases, which include Crohn's disease and ulcerative colitis, affect several million individuals worldwide. Crohn's disease and ulcerative colitis are complex diseases that are heterogeneous at the clinical, immunological, molecular, genetic, and microbial levels. Individual contributing factors have been the focus of extensive research. As part of the Integrative Human Microbiome Project (HMP2 or iHMP), we followed 132 subjects for one year each to generate integrated longitudinal molecular profiles of host and microbial activity during disease (up to 24 time points each; in total 2,965 stool, biopsy, and blood specimens). Here we present the results, which provide a comprehensive view of functional dysbiosis in the gut microbiome during inflammatory bowel disease activity. We demonstrate a characteristic increase in facultative anaerobes at the expense of obligate anaerobes, as well as molecular disruptions in microbial transcription (for example, among clostridia), metabolite pools (acylcarnitines, bile acids, and short-chain fatty acids), and levels of antibodies in host serum. Periods of disease activity were also marked by increases in temporal variability, with characteristic taxonomic, functional, and biochemical shifts. Finally, integrative analysis identified microbial, biochemical, and host factors central to this dysregulation. The study's infrastructure resources, results, and data, which are available through the Inflammatory Bowel Disease Multi'omics Database ( http://ibdmdb.org ), provide the most comprehensive description to date of host and microbial activities in inflammatory bowel diseases.

Age-related patterns of microbial dysbiosis in multiplex inflammatory bowel disease families.

OBJECTIVE: IBD is characterised by dysbiosis, but it remains unclear to what extent dysbiosis develops in unaffected at-risk individuals. To address this, we investigated age-related patterns of faecal and serum markers of dysbiosis in high-risk multiplex IBD families (two or more affected first-degree relatives). DESIGN: Faecal and serum samples were collected from multiplex IBD and control families (95 IBD, 292 unaffected, 51 controls). Findings were validated in independent cohorts of 616 and 1173 subjects including patients with IBD, infants born to mothers with IBD and controls. 16S rRNA gene sequencing and global untargeted metabolomics profiling of faeces and serum were performed. RESULTS: Microbial and metabolomic parameters of dysbiosis progressively decreased from infancy until age 8. This microbial maturation process was slower in infants born to mothers with IBD. After age 15, dysbiosis steadily increased in unaffected relatives throughout adulthood. Dysbiosis was accompanied by marked shifts in the faecal metabolome and, to a lesser extent, the serum metabolome. Faecal and serum metabolomics dysbiosis indices were validated in an independent cohort. Dysbiosis was associated with elevated antimicrobial serologies but not with faecal calprotectin. Dysbiosis metrics differentiated IBD from non-IBD comparably to serologies, with a model combining calprotectin, faecal metabolomics dysbiosis index and serology score demonstrating highest accuracy. CONCLUSION: These findings support that dysbiosis exists as a pre-disease state detectable by faecal and serum biomarkers for IBD risk prediction. Given the expansion of disease-modifying agents and non-invasive imaging, the indices developed here may facilitate earlier diagnoses and improved management in at-risk individuals.

A Proteomics Pipeline for Generating Clinical Grade Biomarker Candidates from Data-Independent Acquisition Mass Spectrometry (DIA-MS) Discovery.

Clinical biomarker development has been stymied by inaccurate protein quantification from mass spectrometry (MS) discovery data and a prolonged validation process. To mitigate these issues, we created the Targeted Extraction Assessment of Quantification (TEAQ) software package that uses data-independent acquisition analysis from a discovery cohort to select precursors, peptides, and proteins that adhere to analytical criteria required for established targeted assays. TEAQ was applied to DIA-MS data from plasma samples acquired on a new high resolution accurate mass (HRAM) mass spectrometry platform where precursors were evaluated for linearity, specificity, repeatability, reproducibility, and intra-protein correlation based on 8- or 11-point loading curves at three throughputs. This data can be used as a general resource for developing other targeted assays. TEAQ analysis of data from a case and control cohort for inflammatory bowel disease (n=492) identified 1110 signature peptides for 326 quantifiable proteins from the 1179 identified proteins. Applying TEAQ analysis to discovery data will streamline targeted assay development and the transition to validation and clinical studies.

Novel Diagnostic Autoantibodies Against Endothelial Protein C Receptor in Patients With Ulcerative Colitis.

There have been many reports on serologic autoantibodies in inflammatory bowel diseases (IBD),1 consisting of ulcerative colitis (UC) and Crohn's disease (CD), and recently Kuwada et al2 reported a new autoantibody against integrin αvß6 with high sensitivity and specificity for UC. Concurrently, we had discovered autoantibodies against endothelial protein C receptor (EPCR) in Takayasu arteritis (TAK), which is sometimes complicated by UC.3 Interestingly, this autoantibody was found in most patients with TAK associated with UC, and we found that the positivity rate in patients with UC without TAK was also high, suggesting that anti-EPCR antibody is a candidate autoantibody useful for the diagnosis of UC.4 To clarify the diagnostic usefulness of anti-EPCR antibodies in patients with IBD and their relationship to several disease subphenotypes and their disease activities, we analyzed the serum samples from patients with IBD and non-IBD control subjects in Japan and the United States.

A Paratope-Enhanced Method to Determine Breadth and Depth TCR Clonal Metrics of the Private Human T-Cell Vaccine Response after SARS-CoV-2 Vaccination.

Quantitative metrics for vaccine-induced T-cell responses are an important need for developing correlates of protection and their use in vaccine-based medical management and population health. Molecular TCR analysis is an appealing strategy but currently requires a targeted methodology involving complex integration of ex vivo data (antigen-specific functional T-cell cytokine responses and TCR molecular responses) that uncover only public antigen-specific metrics. Here, we describe an untargeted private TCR method that measures breadth and depth metrics of the T-cell response to vaccine challenge using a simple pre- and post-vaccine subject sampling, TCR immunoseq analysis, and a bioinformatic approach using self-organizing maps and GLIPH2. Among 515 subjects undergoing SARS-CoV-2 mRNA vaccination, we found that breadth and depth metrics were moderately correlated between the targeted public TCR response and untargeted private TCR response methods. The untargeted private TCR method was sufficiently sensitive to distinguish subgroups of potential clinical significance also observed using public TCR methods (the reduced T-cell vaccine response with age and the paradoxically elevated T-cell vaccine response of patients on anti-TNF immunotherapy). These observations suggest the promise of this untargeted private TCR method to produce T-cell vaccine-response metrics in an antigen-agnostic and individual-autonomous context.

Prevalence and Effect of Genetic Risk of Thromboembolic Disease in Inflammatory Bowel Disease.

BACKGROUND AND AIMS: The largest cause of mortality in patients with inflammatory bowel disease (IBD) remains thromboembolic disease (TED). Recent reports have demonstrated that both monogenic and polygenic factors contribute to TED and 10% of healthy subjects are genetically at high risk for TED. Our aim was to utilize whole-exome sequencing and genome-wide genotyping to determine the proportion of IBD patients genetically at risk for TED and investigate the effect of genetic risk of TED in IBD. METHODS: The TED polygenic risk score was calculated from genome-wide genotyping. Thrombophilia pathogenic variants were extracted from whole-exome sequencing. In total, 792 IBD patients had both whole-exome sequencing and genotyping data. We defined patients at genetically high risk for TED if they had a high TED polygenic risk score or carried at least 1 thrombophilia pathogenic variant. RESULTS: We identified 122 of 792 IBD patients (15.4%) as genetically high risk for TED. Among 715 of 792 subjects whose documented TED status were available, 63 of the 715 patients (8.8%) had TED events. Genetic TED risk was significantly associated with increased TED event (odds ratio, 2.5; P = .0036). In addition, we confirmed an additive effect of monogenic and polygenic risk on TED (P = .0048). Patients with high TED genetic risk more frequently had thrombosis at multiple sites (78% vs 42%, odds ratio, 3.96; P = .048). CONCLUSIONS: Genetic risk (both poly- and monogenic) was significantly associated with TED history. Our results suggest that genetic traits identify approximately 1 in 7 patients with IBD who will experience 2.5-fold or greater risk for TED.

Altered Intestinal ACE2 Levels Are Associated With Inflammation, Severe Disease, and Response to Anti-Cytokine Therapy in Inflammatory Bowel Disease.

BACKGROUND AND AIMS: The host receptor for severe acute respiratory syndrome coronavirus 2, angiotensin-converting enzyme 2 (ACE2), is highly expressed in small bowel (SB). Our aim was to identify factors influencing intestinal ACE2 expression in Crohn's disease (CD), ulcerative colitis (UC), and non-inflammatory bowel disease (IBD) controls. METHODS: Using bulk RNA sequencing or microarray transcriptomics from tissue samples (4 SB and 2 colonic cohorts; n = 495; n = 387 UC; n = 94 non-IBD), we analyzed the relationship between ACE2 with demographics and disease activity and prognosis. We examined the outcome of anti-tumor necrosis factor and anti-interleukin-12/interleukin-23 treatment on SB and colonic ACE2 expression in 3 clinical trials. Univariate and multivariate regression models were fitted. RESULTS: ACE2 levels were consistently reduced in SB CD and elevated in colonic UC compared with non-IBD controls. Elevated SB ACE2 was also associated with demographic features (age and elevated body mass index) associated with poor coronavirus disease 2019 outcomes. Within CD, SB ACE2 was reduced in patients subsequently developing complicated disease. Within UC, colonic ACE2 was elevated in active disease and in patients subsequently requiring anti-tumor necrosis factor rescue therapy. SB and colonic ACE2 expression in active CD and UC were restored by anti-cytokine therapy, most notably in responders. CONCLUSIONS: Reduced SB but elevated colonic ACE2 levels in IBD are associated with inflammation and severe disease, but normalized after anti-cytokine therapy, suggesting compartmentalization of ACE2-related biology in SB and colonic inflammation. The restoration of ACE2 expression with anti-cytokine therapy might be important in the context of severe acute respiratory syndrome coronavirus 2 infection and potentially explain reports of reduced morbidity from coronavirus disease 2019 in IBD patients treated with anti-cytokines.

A model for harmonizing flow cytometry in clinical trials.

Complexities in sample handling, instrument setup and data analysis are barriers to the effective use of flow cytometry to monitor immunological parameters in clinical trials. The novel use of a central laboratory may help mitigate these issues.

Adverse Events After SARS-CoV-2 mRNA Vaccination Among Patients With Inflammatory Bowel Disease.

INTRODUCTION: Patients with immune-mediated inflammatory diseases such as inflammatory bowel disease (IBD) on immunosuppressive and biologic therapies were largely excluded from severe acute respiratory syndrome coronavirus-2 messenger RNA vaccine trials. METHODS: We evaluated adverse events (AE) after messenger RNA vaccination in 246 adults with IBD participating in a longitudinal vaccine registry. RESULTS: In general, AE frequency was similar to that reported in the general population. AEs were more common among younger patients and those with previous COVID-19. AEs were less common in individuals receiving advanced therapies with biologics or small-molecule inhibitors. DISCUSSION: Those with IBD and other immune-mediated inflammatory diseases can be reassured that the AE risk is likely not increased, and may be reduced, while on advanced therapies.

Paradoxical sex-specific patterns of autoantibody response to SARS-CoV-2 infection.

BACKGROUND: Pronounced sex differences in the susceptibility and response to SARS-CoV-2 infection remain poorly understood. Emerging evidence has highlighted the potential importance of autoimmune activation in modulating the acute response and recovery trajectories following SARS-CoV-2 exposure. Given that immune-inflammatory activity can be sex-biased in the setting of severe COVID-19 illness, the aim of the study was to examine sex-specific autoimmune reactivity to SARS-CoV-2 in the absence of extreme clinical disease. METHODS: In this study, we assessed autoantibody (AAB) reactivity to 91 autoantigens previously linked to a range of classic autoimmune diseases in a cohort of 177 participants (65% women, 35% men, mean age of 35) with confirmed evidence of prior SARS-CoV-2 infection based on presence of antibody to the nucleocapsid protein of SARS-CoV-2. Data were compared to 53 pre-pandemic healthy controls (49% women, 51% men). For each participant, socio-demographic data, serological analyses, SARS-CoV-2 infection status and COVID-19 related symptoms were collected by  an electronic survey of questions. The symptoms burden score was constructed based on the total number of reported symptoms (N = 21) experienced within 6 months prior to the blood draw, wherein a greater number of symptoms corresponded to a higher score and assigned as more severe burden. RESULTS: In multivariable analyses, we observed sex-specific patterns of autoreactivity associated with the presence or absence (as well as timing and clustering of symptoms) associated with prior COVID-19 illness. Whereas the overall AAB response was more prominent in women following asymptomatic infection, the breadth and extent of AAB reactivity was more prominent in men following at least mildly symptomatic infection. Notably, the observed reactivity included distinct antigens with molecular homology with SARS-CoV-2. CONCLUSION: Our results reveal that prior SARS-CoV-2 infection, even in the absence of severe clinical disease, can lead to a broad AAB response that exhibits sex-specific patterns of prevalence and antigen selectivity. Further understanding of the nature of triggered AAB activation among men and women exposed to SARS-CoV-2 will be essential for developing effective interventions against immune-mediated sequelae of COVID-19.

Outcomes after Endovascular Stent Placement for Long-Segment Superficial Femoral Artery Lesions.

BACKGROUND: Endovascular intervention is commonly pursued as first-line management of symptomatic, long-segment superficial femoral artery (SFA) disease. The relative effectiveness and comparative long-term outcomes among bare metal stents (BMS), covered stents (CS), and drug-eluting stents (DES) for long-segment SFA lesions remain uncertain. METHODS: A retrospective cohort study identified patients with symptomatic SFA lesions measuring at least 15 cm in length who successfully received an endovascular stent (BMS, CS, or DES). The outcomes were patency, patient presentation upon stent occlusion, amputation-free survival (AFS), and all-cause mortality. Proportional hazards regressions and a multinomial logistic regression model were used to control for significant confounders. RESULTS: A total of 226 procedures were analyzed (BMS: 95 [42%]; CS: 74 [33%]; DES: 57 [25%]). There were no significant differences among the 3 stent types with respect to age, prevalence of either diabetes or end-stage renal disease, or smoking history. The median length of the SFA lesion varied across the cohorts (BMS: 28 cm [interquartile range, IQR 20-30]; CS: 26 cm [IQR 20-30]; DES: 20 cm [IQR 16-25]; P = 0.002). The unadjusted primary patency of BMS at 12, 24, and 48 month following index stent placement was 57%, 47%, and 44%, respectively. This is compared to 62%, 49%, and 42% for CS, and 81%, 66%, and 53% for DES, respectively (log-rank P = 0.044). In adjusted models, however, there were no significant differences in primary patency among the stent types. Compared to CS however, DES was associated with improved primary-assisted patency (hazard ratio [HR] for patency loss: 0.35, P = 0.008) and secondary patency (HR: 0.32, P = 0.011). Across the entire follow-up period, stent occlusions occurred in 38 (40%) BMS cases, 42 (57%) CS, and 11 (19%) DES (P < 0.001). Of these, acute limb ischemia (ALI) occurred in 2 (5%) BMS cases, 14 (33%) CS, and 1 (9%) DES (P = 0.010). After adjustment, the relative risk of presenting with ALI as opposed to claudication was 27 times greater among patients re-presenting with occluded CS compared to BMS (P = 0.020). There were no significant differences in AFS or all-cause mortality across the 3 cohorts. CONCLUSIONS: For long-segment SFA lesions, DES is associated with improved primary-assisted and secondary patency over long-term follow-up. In the event of stent occlusion, CS is associated with an increased risk of ALI.

Long-term outcomes of lower extremity graft preservation using antibiotic beads in patients with early deep wound infections after major arterial reconstructions.

OBJECTIVE: Bypass graft preservation with wound sterilization using serial antibiotic bead exchange has been described in patients presenting with deep wound infections after extremity bypass. The long-term benefits of this approach remain poorly understood. We examined whether graft preservation and wound sterilization with antibiotic beads affect amputation rates and patient survival. METHODS: Patients who underwent operations for aortoiliac or infrainguinal aneurysmal or occlusive arterial disease were retrospectively analyzed. The Infection group included those with patent vascular grafts who developed Szilagyi class II or III deep wound infections within 90 days of index reconstruction and had no evidence of anastomotic or arterial bleeding. All patients in the infection group were managed with graft preservation using serial antibiotic bead exchange every 3 to 5 days until wound cultures became negative. This group was compared with a contemporary group of controls who underwent similar interventions but did not develop wound infections postoperatively. The primary outcome was amputation-free survival, defined as survival without major amputation. Secondary outcomes included major amputations and the occurrence of anastomotic pseudoaneurysms necessitating repair. Inverse propensity score weighting was used for risk adjustment between the groups. RESULTS: Over an 8-year period, we treated 701 patients (infection, 68; controls, 633). Compared with controls, patients in the infection group had a higher body mass index (mean, 28.5 vs 26.3, P = .002) and more prosthetic conduits placed during the index reconstruction. Amputation-free survival for the infection vs the control group was 78 vs 76% at 2 years, 61 vs 66% at 4 years, and 51 vs 57% at 6 years postoperatively (log-rank test, P = .516). Freedom from major amputation for the infection vs the control group was 82 vs 86% at 2 years, 80 vs 82% at 4 years, and 80 vs 76% at 6 years postoperatively (log-rank test, P = .568). In the risk-adjusted model, the presence of treated infection did not affect amputation-free survival (hazard ratio, 0.82; P = .440) or major amputation (hazard ratio, 1.02; P = .949). Anastomotic pseudoaneurysms occurred only in the Infection group (4.4%; P = .001), and were treated with interposition grafts without complications. CONCLUSIONS: Bypass graft preservation with wound sterilization using serial antibiotic bead exchange is associated with excellent limb salvage and survival rates, similar to those of noninfected wounds. With the use of this preservation strategy, close follow-up for timely detection of anastomotic pseudoaneurysms is recommended.

Assessment of foot perfusion: Overview of modalities, review of evidence, and identification of evidence gaps.

Patients with critical limb ischemia have nonhealing wounds and/or ischemic rest pain and are at high risk for amputation and mortality. Accurate evaluation of foot perfusion should help avoid unnecessary amputation, guide revascularization strategies, and offer efficient surveillance for patency. Our aim is to review current modalities of assessing foot perfusion in the context of the practical clinical management of patients with critical limb ischemia.

Arteriovenous fistula maturation rate is not affected by ipsilateral tunneled dialysis catheter.

OBJECTIVE: The effect that ipsilateral tunneled dialysis catheters (TDC) have on arteriovenous fistula (AVF) maturation is unclear. We sought to define this association by comparing AVF maturation rates in patients with contralateral TDC with those with ipsilateral TDC. METHODS: A review of a prospectively maintained database including all AVF creation procedures between 2009 and 2016 was performed. All patients with a TDC in place at the time of AVF creation were included in this study. Clinical and functional maturation rates were compared in patients with contralateral vs ipsilateral dialysis catheters. Categorical variables were analyzed by a two-tailed Fisher's exact test. A P value of less than .05 was considered statistically significant. RESULTS: There were 187 patients who underwent fistula creation with a TDC in place during the study period. Of those, 137 patients had a contralateral TDC and 50 had an ipsilateral TDC. A greater proportion of contralateral patients were first-time dialysis access patients at the time of index AVF creation (67% vs 48%; P = .03). There was no difference in clinical (contralateral 73% vs ipsilateral 78%; P = .57) and functional (contralateral 64% vs ipsilateral 74%) maturation rates between the two groups. The rate of TDC removal after AVF maturation was also not different (contralateral 64% vs ipsilateral 72%; P = .30). There was also no statistical difference in the rates of thrombosis at less than 30 days, outflow stenosis, central stenosis, and steal syndrome. CONCLUSIONS: There was no association between TDC sidedness and AVF maturation or early failure in our cohort. Planning for AVF creation should not be influenced by attempts to avoid an ipsilateral TDC.

Ischemia-induced lower extremity neurologic impairment after fenestrated endovascular aneurysm repair.

OBJECTIVE: Placement of large sheaths in the iliac system during fenestrated endovascular aneurysm repair (FEVAR) leads to lower extremity (LE) ischemia that can be associated with serious neurologic complications. We sought to determine the effect of LE ischemic time on neurologic impairment after FEVAR. METHODS: Consecutive patients who underwent FEVAR at a single institution were analyzed. LE ischemic time was calculated from the time of large sheath (≥18F) insertion to the time of sheath removal from the iliac arteries that led to continuous LE ischemia. The primary outcome was neurologic impairment defined as any new sensory or motor deficit in either LE. Outcomes were analyzed using descriptive statistics and modeled with logistic regression with interaction terms. Each individual LE was used as a unit of analysis. RESULTS: We examined 101 patients (202 lower extremities) who underwent FEVAR over a 5-year period. The median LE ischemic time was 2.75 hours (range, 0.8-5.2 hours). Neurologic impairment developed in 18 extremities (9%). Of those, 12 (67%) developed mild sensory loss, 6 (33%) complete sensory loss, 4 (22%) loss of proprioception, and 2 (11%) motor dysfunction. Sensory deficit was permanent in four limbs (2%) and motor dysfunction in one limb (0.5%). In all other cases, the neurologic examination returned to baseline by postoperative day 15. Duration of LE ischemic time (odds ratio, 6.3; 95% confidence interval, 3.1-12.4; P < .001) and common iliac artery (CIA) stenosis to a lumen of 8 mm or less (odds ratio, 2.7; 95% confidence interval, 1.5-7.3; P = .002) were independent predictors for the development of neurologic impairment. An interaction term between LE ischemic time and CIA stenosis was statistically significant (P = .042), indicating that the presence of CIA stenosis modifies the effect of LE ischemic time. In those with CIA stenosis to a lumen of 8 mm or less, the risk of neurologic impairment increased rapidly after 2.5 hours of LE ischemia, and became nearly certain after 4 hours of ischemic time. By contrast, patients without CIA stenosis tolerated longer ischemic times and demonstrated a less steep increase in the risk for LE neurologic impairment. CONCLUSIONS: LE neurologic impairment after FEVAR is strongly associated with LE ischemic time and CIA occlusive disease to a lumen of 8 mm or less. Our data indicate that, when the LE ischemic time is expected to exceed 2.5 hours (in patients with CIA stenosis) or 3 hours (in patients without CIA stenosis), measures to ensure LE perfusion should be given consideration.

Distal vein patch use and limb events after infragenicular prosthetic bypasses.

OBJECTIVE: In the absence of suitable autologous vein, the use of prosthetic grafts for infragenicular bypasses in peripheral arterial disease has become standard practice. The purpose of this study was to investigate whether creating a vein patch at the distal anastomosis would further improve patency and freedom from major adverse limb events (MALEs). Furthermore, we sought to investigate whether the use of a distal vein patch (DVP) was associated with lower rates of acute limb ischemia (ALI) for those presenting with occluded prosthetic bypass graft. METHODS: The cases of all patients undergoing infragenicular prosthetic bypass grafts between January 2009 and July 2016 were retrospectively reviewed. Demographics of the patients, clinical data, and outcomes (graft patency and MALEs) were collected. Patients were compared according to treatment group (DVP vs no DVP). A Cox regression analysis was used to analyze follow-up results. RESULTS: During the study period, a total of 373 patients underwent infragenicular bypass at our institution; of those, 93 (24.9%) had prosthetic grafts (DVP, 39; no DVP, 54). Overall, 92 (98.9%) patients were male; the mean age was 63.3 ± 6.6 years and did not differ between the two groups. Patients undergoing prosthetic bypass with DVP were more likely to have chronic obstructive pulmonary disease (38.5% vs 14.8%; P = .009) and less likely to have chronic kidney disease (2.6% vs 20.4%; P = .011). Follow-up data were available for all patients for a median of 7.8 months (range, 1-89 months). After adjustment for differences in demographics and clinical data between the two groups, when outcomes were analyzed, MALEs were significantly lower in the DVP group (35.9% vs 57.4%; odds ratio [OR], 0.4; 95% confidence interval [CI], 0.2-0.9; P = .041). Similarly, reintervention rates were significantly lower in the DVP group (30.8% vs 50.0%; OR, 0.4; 95% CI, 0.2-0.9; P = .044). There was a trend toward higher primary patency in the DVP group (46.2% vs 35.2%; OR, 1.5; 95% CI, 0.7-3.5; P = .206) and lower rates of ALI after bypass occlusion (30.0% vs 42.9%; OR, 0.6; 95% CI, 0.2-1.8; P = .345). A Cox regression time-to-event analysis revealed late separation of freedom from MALEs for DVP relative to no DVP (log rank, P = .269). CONCLUSIONS: In this evaluation of infragenicular prosthetic bypass grafts, the creation of a vein patch at the distal anastomosis was associated with lower reintervention rates and a trend toward improved primary patency and MALEs. Furthermore, for those presenting with occluded prosthetic bypass graft, the use of a DVP was associated with a trend toward lower rates of ALI.

NK cells are biologic and biochemical targets of 6-mercaptopurine in Crohn's disease patients.

NK cells, which contribute to immune defense against certain viral infections and neoplasia, are emerging as modifiers of chronic immunologic diseases including transplant rejection and autoimmune diseases. Immunobiology and genetic studies have implicated NK cells as a modifier of Crohn's disease, a condition often treated with thiopurine agents such as 6-mercaptopurine (6-MP). Here, we demonstrate that thiopurines mediate NK cell apoptosis via a caspase 3 and 9 inclusive pathway, and that this process is triggered by thiopurine-mediated inhibition of Rac1. We also show that CD patients in clinical remission maintained on 6-MP have decreased NK cell Rac1 activity, and decreased NK cell numbers in their intestinal biopsies. These observations suggest that thiopurine targeting of NK cells may be a previously unappreciated therapeutic action of these agents in IBD.