Reduced 30-day gastrostomy placement mortality following the introduction of a multidisciplinary nutrition support team: a cohort study.

BACKGROUND: Percutaneous endoscopic gastrostomy feeding allows patients with dysphagia to receive adequate nutritional support, although gastrostomy insertion is associated with mortality. A nutrition support team (NST) may improve a gastrostomy service. The present study aimed to evaluate the introduction of a NST for assessment and follow-up of patients referred for gastrostomy. METHODS: We included adult inpatients referred for gastrostomy insertion consecutively between 1 October 2010 and 31 March 2013. During the first 6 months, a multidisciplinary NST assessment service was implemented. Patient characteristics, clinical condition, referral appropriateness and follow-up were documented prospectively. We compared the frequencies of appropriate referrals, 30-day mortality and mental capacity/consent assessment time spent between the 6 months implementation phase and 2 years following establishment of the assessment service ('established phase'). RESULTS: In total, 309 patients were referred for gastrostomy insertion and 199 (64%) gastrostomies placed. The percentage of appropriate referrals rose from 72% (61/85) during the implementation phase to 87% (194/224) during the established phase (P = 0.002). Thirty-day mortality reduced from 10% (5/52) to 2% (3/147) (P = 0.01), whereas time allocated to assessment of mental capacity and attainment of informed consent rose from mean 3 days (limits of normal variation 0-7) to mean 6 (0-13) days. CONCLUSIONS: The introduction of a NST to assess and select patients referred for gastrostomy placement was associated with a rise in the frequency of appropriate referrals and a decrease in 30-day mortality following gastrostomy insertion. Concomitantly, time spent on patient assessment and attainment of informed consent increased.

Mucosal and systemic immune modulation by Trichuris trichiura in a self-infected individual.

Helminthic therapy of immune-mediated diseases has gained attention in recent years, but we know little of how helminths modulate human immunity. In this study, we investigated how self-infection with Trichuris (T.) trichiura in an adult man without intestinal disease affected mucosal and systemic immunity. Colonic mucosal biopsies were obtained at baseline, during T. trichiura infection, and after its clearance following mebendazole treatment. Unexpectedly, the volunteer experienced a Campylobacter colitis following T. trichiura clearance, and this served as a positive infectious control. Trichuris trichiura colonization induced equally increased expressions of T-helper (h)1-, Th2-, Th17- and Treg-associated cytokines and transcription factors, measured by quantitative polymerase chain reaction. We observed several indicators of modulation of systemic immunity during the T. trichiura infection. Plasma eosinophils and anti-Trichuris antibodies rose markedly during the inoculation phase, and a shift towards a Th2-dominated T cell response at the expense of the Th1-response was observed in circulating T cells. Taken together, our findings corroborate that helminths modulate regional and systemic human immunity.

The effect of fresh frozen plasma in critically ill patients.

BACKGROUND: Critically ill patients often receive fresh frozen plasma (FFP) if they have abnormal conventional coagulation tests. The aim of this study was to investigate the effect of FFP transfusion judged by a wide range of coagulation tests. METHODS: We included 30 critically ill patients receiving FFP and 30 critically ill patients who did not receive FFP. For patients receiving FFP, blood samples were obtained before and 1 h after FFP transfusion. Conventional coagulation tests, thromboelastometry (ROTEM® , EXTEM, INTEM and FIBTEM) and thrombin generation were performed. Systematic recording of vital signs was performed for all patients. RESULTS: The median values of the conventional coagulation tests were abnormal before and after FFP (PT: (normal > 0.6) median 0.3 before vs. 0.3 after; INR: (normal < 1.2) median 2 before vs. 1.7 after; APTT: (normal < 38 s) median 45 s before vs. 42 s after). Eight of nine ROTEM® parameters were within the reference interval judged by median values before FFP transfusion, and all median parameters were within the reference interval after FFP transfusion. Median in three of four thrombin generation parameters was within the reference interval both before and after FFP transfusion. CONCLUSION: Patients presented abnormal conventional coagulation tests both before and after FFP transfusion. In contrast, ROTEM® and thrombin generation parameters were mainly within the reference interval both before and after FFP transfusion. FFP transfusions caused only negligible, although statically significant, improvements on coagulation measurements judged by conventional coagulation tests, ROTEM® and thrombin generation.

Soluble CD163, a specific macrophage activation marker, is decreased by anti-TNF-α antibody treatment in active inflammatory bowel disease.

Activated macrophages shed the haemoglobin-haptoglobin scavenger receptor CD163 into the circulation as soluble(s)-CD163. We measured sCD163 as an in vivo macrophage activation marker in patients with Crohn's disease (CD) or ulcerative colitis (UC) receiving antitumour necrosis factor (TNF)-α antibody or prednisolone treatment. We also investigated the CD163 expression on circulating monocytes. 58 patients with CD, 40 patients with UC and 90 healthy controls (HC) were included. All patients had active disease at inclusion and were followed for 6 weeks of anti-TNF-α antibody or prednisolone treatment. We measured plasma sCD163 levels at baseline, 1 day, 1 week and 6 weeks after initiating treatment. CD163 expression on circulating CD14(+) monocytes was measured in 21 patients with CD receiving anti-TNF-α antibody treatment. Baseline sCD163 levels were elevated in patients with CD [1.99 (1.80-2.18) mg/l] and in patients with UC [2.07 (1.82-2.32) mg/l] compared with HC [1.51 (1.38-1.63) mg/l] (P < 0.001). Anti-TNF-α antibody treatment induced a rapid decrease in sCD163 levels in patients with CD and in patients with UC 1 day after treatment initiation (P < 0.05). One week of prednisolone treatment did not induce a reduction in sCD163 levels. Anti-TNF-α treatment normalized sCD163 levels in patients with UC, whereas patients with CD exhibited sustained increased sCD163 levels. In patients with CD, CD163 expression on CD14(+) monocytes was increased compared with HC. This study highlights that active CD and UC are associated with increased macrophage activation, as indicated by elevated sCD163 levels and monocytic CD163 expression. Anti-TNF-α antibody treatment induced a rapid decrease in sCD163 levels, suggesting a specific effect on macrophage activation in inflammatory bowel diseases.

Brain death increases COX-1 and COX-2 expression in the renal medulla in a pig model.

BACKGROUND: Brain death is linked to a systemic inflammatory response that includes prostaglandins and cytokines among its mediators. The levels of cyclooxygenase-1 and cyclooxygenase-2 (COX-1 and COX-2) affect graft survival, but it remains unknown whether these enzymes are modified during brain death. The aims of this study were to investigate the organ expression of COX and to analyse the cytokine response in the plasma, cerebrospinal fluid (CSF), and organs in a porcine model of intracerebral haemorrhage and brain death. METHODS: Twenty pigs were randomly assigned to either a brain death group or a control group. Brain death was induced by an intracerebral injection of blood, and the animals were observed over the next 8 h. Tissue samples were tested for COX-1, COX-2 messenger RNA (mRNA) expression (heart, lung, and kidney), haeme oxygenase-1 (HO-1) (kidney), interleukin-1ß (IL-1ß), IL-6, IL-8, IL-10, and tumour necrosis factor-α. These cytokines were also measured at eight time points in the plasma and CSF. RESULTS: At the organ level, the levels of COX-1 and COX-2 mRNA expression were increased only in the renal medulla (P = 0.03 and P = 0.02, respectively). The cytokine levels in the tissue, plasma, and CSF revealed no differences between the groups. HO-1 expression decreased (P = 0.0088). CONCLUSION: Brain death increases the expression of COX-1 and COX-2 mRNA in the renal medulla. The release of cytokines into the plasma and CSF did not vary between the groups.

Thromboelastometry as a supplementary tool for evaluation of hemostasis in severe sepsis and septic shock.

BACKGROUND: Sepsis leads to disruption of hemostasis, making early evaluation of coagulation essential. The aim of this study was to provide a detailed investigation of coagulation and the use of blood products in patients with severe sepsis or septic shock, admitted to a multidisciplinary intensive care unit. METHODS: Thirty-six patients with severe sepsis or septic shock were included in this prospective observational study. Blood samples and information on transfusion of blood products were obtained for up to 3 consecutive days, and day 7 if the patient was still in the intensive care unit. Thromboelastometry (ROTEM(®)), analyses of thrombin generation, and conventional coagulation tests were performed. RESULTS: ROTEM(®) revealed an overall normo-coagulable state among patients with severe sepsis or septic shock. Conventional coagulation analyses showed divergent results with hypercoagulable trends in terms of reduced antithrombin and acute phase response with increased fibrinogen and fibrin d-dimer, and on the other hand, coagulation disturbances with a decreased prothrombin time and prolonged activated partial thromboplastin time. This hypocoagulabe state was supported by a delayed and reduced thrombin generation. Twelve patients experienced 21 independent transfusion episodes with fresh frozen plasma. Of these, only five (22%) transfusions were performed because of active bleeding. CONCLUSION: ROTEM(®) demonstrated an overall normo-coagulation, whereas the conventional coagulation tests and thrombin generation analyses mainly reflected hypocoagulation. Given the dynamic and global features of ROTEM(®), this analysis may be a relevant supplementary tool for the assessment of hemostasis in patients with severe sepsis or septic shock.

Pulmonary function after hemorrhagic shock and resuscitation in a porcine model.

BACKGROUND: Hemorrhagic shock may trigger an inflammatory response and acute lung injury. The combination adenosine, lidocaine (AL) plus Mg(2+) (ALM) has organ-protective and anti-inflammatory properties with potential benefits in resuscitation.The aims of this study were to investigate: (1) pulmonary function and inflammation after hemorrhagic shock; (2) the effects of ALM/AL on pulmonary function and inflammation. METHODS: Pigs (38 kg) were randomized to: sham + saline (n = 5); sham + ALM/AL (n = 5); hemorrhage control (n = 11); and hemorrhage + ALM/AL (n = 9). Hemorrhage animals bled to a mean arterial pressure (MAP) of 35 mmHg for 90 min, received resuscitation with Ringer's acetate and 20 ml of 7.5% NaCl with ALM to a minimum MAP of 50 mmHg, after 30 min shed blood and 0.9% NaCl with AL were infused. Hemorrhage controls did not receive ALM/AL. Primary endpoints were pulmonary wet/dry ratio, PaO2 /FiO2 ratio (partial pressure of arterial oxygen to the fraction of inspired oxygen), cytokine and protein measurements in bronchoalveolar lavage fluid (BALF) and lung tissue, neutrophil invasion and blood flow in lung tissue. RESULTS: In the hemorrhage groups, wet/dry ratio increased significantly compared with the sham groups. PaO2 /FiO2 ratio decreased during shock but normalized after resuscitation. BALF did not indicate significant pulmonary inflammation, oxidative stress or increased permeability. Intervention with ALM caused a temporary increase in pulmonary vascular resistance and reduced urea diffusion across the alveolar epithelia, but had no effect on wet/dry ratio. CONCLUSION: Hemorrhagic shock and resuscitation did not cause acute lung injury or pulmonary inflammation. The question whether ALM/AL has the potential to attenuate acute lung injury is unanswered.

Brain death induced by cerebral haemorrhage - a new porcine model evaluated by CT angiography.

BACKGROUND: Brain death and complications to brain death affects the function of organs in the potential donor. Previous animal models of brain death have not been able to fully elucidate the mechanisms behind this organ dysfunction, and none of the available animal models mimic the most common insult prior to brain death: intracerebral haemorrhage. The objective of this study was to develop a large animal model of brain death based on a controlled intracerebral haemorrhage and verified by computerised tomographic angiography (CTA). METHODS: Twenty pigs (range: 26.6-31.2 kg) were randomised to brain death or control. Brain death was induced by infusion of blood through a stereotaxically placed needle in the internal capsule. Brain death was confirmed by the measured intracranial pressure (ICP), lack of corneal and pupillary light reflexes, and atropine test. CTA was performed 120-180 min after brain death. The pigs were observed for 8 h after brain death. RESULTS: Brain death was declared when the ICP exceeded mean arterial pressure after a median of 36 min (range: 28-51 min). Significant increases in heart rate, and mean arterial pressure (MAP) were followed by a steep decrease. With fluid therapy, the animals demonstrated haemodynamic stability. Reflexes disappeared, and atropine did not induce an increase in heart rate in the brain dead animals. CTA confirmed loss of cerebral circulation. CONCLUSION: This study offers a standardised, clinically relevant porcine model of brain death induced by a haemorrhagic attack. Brain death was verified by the disappearance of corneal and pupil reflex, atropine test, and CTA.

Toll-like receptor-induced granulocyte-macrophage colony-stimulating factor secretion is impaired in Crohn's disease by nucleotide oligomerization domain 2-dependent and -independent pathways.

Pattern recognition receptors (PRRs) are an integral part of the innate immune system and govern the early control of foreign microorganisms. Single nucleotide polymorphisms (SNPs) in the intracellular pattern recognition receptor nucleotide-binding oligomerization domain-containing protein (NOD2, nucleotide oligomerization domain 2) are associated with Crohn's disease (CD). We investigated the impact of NOD2 polymorphisms on cytokine secretion and proliferation of peripheral blood mononuclear cells (PBMCs) in response to Toll-like receptor (TLR) and NOD2 ligands. Based on NOD2 SNP analyses, 41 CD patients and 12 healthy controls were studied. PBMCs were stimulated with NOD2 and TLR ligands. After 18 h culture supernatants were measured using multiplex assays for the presence of human cytokines granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin (IL)-1 beta and tumour necrosis factor (TNF)-alpha. In CD patients, TLR-induced GM-CSF secretion was impaired by both NOD2-dependent and -independent mechanisms. Moreover, TNF-alpha production was induced by a TLR-2 ligand, but a down-regulatory function by the NOD2 ligand, muramyl dipeptide, was impaired significantly in CD patients. Intracellular TLR ligands had minimal effect on GM-CSF, TNF-alpha and IL-1beta secretion. CD patients with NOD2 mutations were able to secrete TNF-alpha, but not GM-CSF, upon stimulation with NOD2 and TLR-7 ligands. CD patients have impaired GM-CSF secretion via NOD2-dependent and -independent pathways and display an impaired NOD2-dependent down-regulation of TNF-alpha secretion. The defect in GM-CSF secretion suggests a hitherto unknown role of NOD2 in the pathogenesis of CD and is consistent with the hypothesis that impaired GM-CSF secretion in part constitutes a NOD2-dependent disease risk factor.

Early changes in vitamin B12 uptake and biomarker status following Roux-en-Y gastric bypass and sleeve gastrectomy.

BACKGROUND & AIMS: Bariatric surgery increases the risk of micronutrient deficiencies, including vitamin B12 (B12) deficiency. We analysed early changes in biomarkers of B12 status following bariatric surgery. METHODS: We prospectively included adult patients (n = 27) referred for either Roux-en-Y Gastric Bypass (RYGB) (n = 19) or Sleeve Gastrectomy (SG) (n = 8). Blood samples were drawn before surgery and 2 and 6 months following surgery for measurement of B12, holotranscobalamin (holoTC), and methylmalonic acid (MMA). The B12 absorption capacity was estimated from the increase in plasma holoTC two days after a standardised oral B12 challenge. RESULTS: B12 status decreased following both RYBG and SG. While a decrease in plasma B12 was not evident until 6 months postoperatively, we observed a statistically significant decrease in plasma holoTC and increase in MMA already 2 months postoperatively. These changes were more pronounced at 6 months post surgery. Correspondingly, the B12 absorption capacity was decreased following surgery. CONCLUSIONS: HoloTC and MMA were superior to B12 to detect early changes in B12 status following bariatric surgery. Our data challenge the current concept that liver B12 stores secure long-term maintenance of B12 status. They indicate that B12 treatment in pharmacological doses may be warranted immediately after surgery.

PO-20 - Crosstalk between the lectin pathway and haemostasis in patients with pulmonary cancer.

INTRODUCTION: Recent research has focused on the complement system in cancer, including the lectin pathway of complement activation. Mannose-binding lectin (MBL), a key activator of the lectin pathway, can bind to tumor cell surfaces in vitro, and lectin pathway activation is increased in several types of cancer. The exact role of the complement system in cancer is currently discussed. However, one possible consequence of the increased complement activation could be contribution to the increased thrombosis risk which cancer patients experience. Proteins of the lectin pathway can activate coagulation and impair fibrinolysis in vitro, but the significance of this in a clinical setting is not well understood. AIM: We aim to investigate associations between lectin pathway and haemostatic activation in patients with lung cancer undergoing thoracoscopic surgery. MATERIALS AND METHODS: Patients with lung cancer (n=60) eligible for thoracoscopic tumor resection were included as part of a randomized controlled trial, the COPPVATS project (EudraCT no: 2012-002409-23), conducted at the Department of Thoracic Surgery, Aarhus University Hospital. Exclusion criteria were arterial or venous thrombosis within the last three months, other systemic disease than cancer, and anticoagulant treatment prior to inclusion. Blood samples were obtained the day before surgery, perioperatively, and on the 1st and 2nd postoperative days. Laboratory analyses on the complement system include MBL, MBL-associated protease (MASP)-1 and -2, MBL-MASP complex, ficolin-1, -2, and -3 and complement factor C3b. Haemostasis was evaluated with routine coagulation parameters (INR, APTT, fibrinogen, fibrin d-dimer), platelet function, and tissue factor-induced thrombin generation. RESULTS: Recruitment of the study subjects is concluded, and laboratory work is in progress. The complement analyses and data processing will be performed during early spring 2016, so that results will be ready for presentation on the conference. CONCLUSIONS: The present project will provide new knowledge on lectin pathway activation and the pathogenesis of thrombosis in cancer patients. In the long term, this will help improve the individual risk assessment and lead to new studies on thromboprophylaxis and treatment in conditions with increased complement activation.

PO-62 - Remote ischemic preconditioning in head and neck cancer reconstruction - a randomized controlled trial.

INTRODUCTION: In reconstructive head and neck cancer surgery, tissue flaps are transferred to the surgical defect and revascularized by anastomosis of small vessels. Cancer patients are in a hypercoagulable state with high risk of peri- and postoperative thrombotic events. Thrombosis to the tissue flap anastomoses or microcirculation is the main reason for total flap necrosis with potential fatal consequences for the patient. Remote ischemic preconditioning (RIPC), where brief cycles of upper extremity ischemia are induced with an inflatable tourniquet, triggers a global protection of tissues subjected to ischemia-reperfusion injury. RIPC has also been shown to impact the coagulation system. AIM: The aim of the trial is to investigate, if RIPC attenuates platelet aggregation during reconstructive head and neck cancer surgery. MATERIALS AND METHODS: Sixty patients with head and neck cancer will be included in the trial. The subjects will be randomized to RIPC or sham during surgery. RIPC is administered by four 5-minute cycles of upper extremity ischemia, each separated by five minutes of reperfusion. Blood samples will be drawn preoperatively, before RIPC/sham, 3 hours after RIPC/ sham, 6 hours after RIPC/sham, and on the first postoperative day. Platelet aggregation will be measured with the Multiplate® analyzer using collagen, ADP and TRAP as agonists. Furthermore, platelet count, mean platelet volume, immature platelet fraction, and von Willebrand factor antigen are determined. RESULTS: The trial is ongoing. Preliminary results will be presented at ICTHIC 2016. CONCLUSIONS: If RIPC proves to attenuate platelet aggregation, it could become a novel antithrombotic treatment in oncologic reconstructive surgery. Hence, morbidity and mortality related to surgery is reduced, and adjuvant oncologic therapy can be initiated in timely fashion.

Refeeding encephalopathy in a patient with severe hypophosphataemia and hyperammonaemia.

The refeeding syndrome is a potentially fatal condition that affects multiple organ systems. It is the consequence of fluid and electrolyte shifts that may occur in a malnourished patient following the introduction of nutrition therapy. The most prominent characteristic is hypophosphataemia. Although hyperammonaemia is usually seen in decompensated liver cirrhosis or acute liver failure, it may occur in other settings. We report a clinical case of prolonged and severe encephalopathy accompanied by hypophosphataemia and hyperammonaemia in a 59-year-old woman with no preexisting liver disease, urea cycle defects or portosystemic shunting. We suggest that these biochemical abnormalities were caused by uncontrolled refeeding and that the clinical picture was consistent with refeeding encephalopathy.

Quality and safety impact on the provision of parenteral nutrition through introduction of a nutrition support team.

BACKGROUND/OBJECTIVES: Parenteral nutrition (PN) should be provided to the malnourished patient if enteral feeding is insufficient or unsafe. A nutrition support team (NST) may improve PN services. We compared the use and complications of hospital PN before and after the implementation of an NST. SUBJECTS/METHODS: All inpatients referred for PN outside of the intensive care unit and the intestinal failure unit were prospectively included from 2009 to 2012. The NST was introduced in 2010. Quality improvement methodology was applied. RESULTS: In 2009, a mean of 16 (limits of normal variation 4-28) patients were referred for PN each month. After introduction of the NST, this rose to 26 (10-42) referrals per month. The percentage of referrals where PN was not initiated increased from 5.3% in 2009 to 10.1% in 2012 (P=0.03). This increase was restricted to teams that infrequently referred for PN, and enteral nutrition could replace PN in 31 of 51 patients (61%) as compared with 8 of 32 (25%) patients referred from teams that frequently referred for PN (P=0.001). The frequency of PN started owing to an insufficient oral or enteral intake decreased from 11% to 3% (P=0.01). The catheter-related bloodstream infection rate dropped from 6.7 to 0.7 episodes per 1000 catheter days (P<0.001). CONCLUSIONS: Introduction of an NST increased both the total PN use and the percentage of referrals where enteral nutrition could replace PN. Medical specialty influenced the referral pattern and the likelihood that a referral resulted in PN being initiated. Safety of PN catheters improved significantly following NST introduction.

Clinical trial: vitamin D3 treatment in Crohn's disease - a randomized double-blind placebo-controlled study.

BACKGROUND: Vitamin D has immune-regulatory functions in experimental colitis, and low vitamin D levels are present in Crohn's disease. AIM: To assess the effectiveness of vitamin D3 treatment in Crohn's disease with regard to improved disease course. METHODS: We performed a randomized double-blind placebo-controlled trial to assess the benefits of oral vitamin D3 treatment in Crohn's disease. We included 108 patients with Crohn's disease in remission, of which fourteen were excluded later. Patients were randomized to receive either 1200 IU vitamin D3 (n = 46) or placebo (n = 48) once daily during 12 months. The primary endpoint was clinical relapse. RESULTS: Oral vitamin D3 treatment with 1200 IU daily increased serum 25OHD from mean 69 nmol/L [standard deviation (s.d.) 31 nmol/L] to mean 96 nmol/L (s.d. 27 nmol/L) after 3 months (P < 0.001). The relapse rate was lower among patients treated with vitamin D3 (6/46 or 13%) than among patients treated with placebo (14/48 or 29%), (P = 0.06). CONCLUSIONS: Oral supplementation with 1200 IE vitamin D3 significantly increased serum vitamin D levels and insignificantly reduced the risk of relapse from 29% to 13%, (P = 0.06). Given that vitamin D3 treatment might be effective in Crohn's disease, we suggest larger studies to elucidate this matter further. ClinicalTrial.gov(NCT00122184).

Osteopontin, a protein with cytokine-like properties, is associated with inflammation in Crohn's disease.

In Crohn's disease (CD) mucosal T-cells produce increased interferon-gamma (IFN-gamma) and tumour necrosis factor-alpha (TNF-alpha) levels and TNF-alpha antibody treatment [Infliximab (Ifx)] is effective. Osteopontin (OPN), a glycoprotein stimulating activated T-lymphocytes, may be involved in the disturbed immune-regulation but also in normal immune-homeostasis and mucosal repair, since it is expressed in many tissues and present in human milk. This study investigates plasma-OPN levels in CD patients during Ifx treatment and the in vitro effect of OPN on intestinal T cells. Thirty-seven CD patients received three Ifx doses at week 0, 2 and 6. Blood samples, colonic biopsies and clinical scores were obtained before treatment and at week 8, 26 and 52. In-vivo activated T-cell cultures were established from colonic biopsies in the presence of interleukin (IL)-2 and IL-4. The in vitro effect of OPN stimulation on T-cell IFN-gamma, TNF-alpha, and IL-10 production was measured. Plasma-OPN was increased in active CD (increased CRP-level) compared with quiescent disease (P = 0.02) and declined after three Ifx doses (P = 0.04). It was inversely correlated with in vitro T-cell IL-10 production. OPN increased CD69 and CD25 expression and enhanced T-cell IFN-gamma and TNF-alpha production in a dose-dependent fashion with higher levels in CD than in healthy controls (HC), but induced a concomitant higher IL-10 production in HC than CD. In conclusion, plasma-OPN levels are related to CD inflammation. In vitro, OPN-stimulated IL-10 production increases less in T-cell cultures from CD patients than from HC, indicating that IL-10 deficiency may be involved in the defect immune-regulation in CD, even after OPN stimulation.

FoxP3(+)CD4(+)CD25(+) T cells with regulatory properties can be cultured from colonic mucosa of patients with Crohn's disease.

Summary CD4(+)CD25(+) regulatory T cells (T(regs)) are involved in the maintenance of peripheral tolerance and ensure a balanced immune response competent of fighting pathogens and at the same time recognizing commensals as harmless. This feature is lost in Crohn's disease (CD). The forkhead/winged helix transcription factor FoxP3 is a master gene for T(reg) function and defects in the FoxP3 gene lead to a clinical picture similar to inflammatory bowel disease (IBD). Murine colitis can be cured by adoptive transfer of T(regs) and ex vivo-generated gut-specific T(regs) represent an attractive option for therapy in CD. Thus, defective T(regs) could contribute to the development of CD. We cultured biopsies of colonic mucosa in the presence of high concentrations of interleukin (IL)-2 and IL-4 to overcome the anergic nature of naturally occurring CD4(+)CD25(+) T(regs) in the mucosa. We investigated the expression of FoxP3 and regulatory potential of gut-derived CD4(+)CD25(+) T cells cultured from patients with CD and healthy individuals. The FoxP3 expression was analysed by reverse transcriptase polymerase chain reaction (RT-PCR), and the suppressive effect of FoxP3(+)CD4(+)CD25(+) T cells on proliferation and cytokine production of autologous CD4(+) T cells was assessed by flow cytometry. Cultured gut-derived T cells with CD4(+)CD25(+) phenotype expressed FoxP3 and were able as the freshly isolated T(regs) from peripheral blood to suppress proliferation and cytokine production of autologous CD4(+) T cells. Thus, we demonstrate that FoxP3(+)CD4(+)CD25(+) T cells with regulatory properties can be propagated in vitro from inflamed mucosa of CD patients, which may be of interest in adoptive immunotherapy.