Management of refractory inflammatory bowel disease.

PURPOSE OF REVIEW: Nearly one-third of patients with inflammatory bowel disease (IBD) do not achieve remission despite our best therapies. When this happens, it is critical to understand the reason for treatment failure. Once nonresponse is confirmed, these patients should be referred to an IBD centre for multidisciplinary care. This review will discuss the remaining treatment options, including escalation of biologics to unlicensed doses, combination biologics, nonvalidated therapies and surgical options. It will additionally provide updates in the management of acute severe ulcerative colitis (ASUC). RECENT FINDINGS: There is an increasing interest in combination biologics to treat refractory IBD, although data supporting its safety and effectiveness are limited. The use of hyperbaric oxygen, mesenchymal stem cell therapy and dietary interventions also show early promise in this area. Studies have additionally focused on personalized therapy to identify aggressive phenotypes and predict treatment response in these challenging patients. In ASUC, infliximab and cyclosporine remain mainstays of treatment, and tofacitinib shows promise as a salvage therapy. SUMMARY: Refractory IBD is common, yet large knowledge gaps remain. Recent and ongoing studies have focused on medical, surgical and dietary approaches with mixed success. Larger prospective studies are desperately needed to address this complex issue.

Lemann Index for assessing bowel damage in Crohn's disease: a real world study.

BACKGROUND & AIMS: The Lemann Index (LI), an endpoint to measure cumulative structural bowel damage in Crohn's disease (CD), has been recently updated and validated. We applied this to investigate predictors of bowel damage in a real-world cohort. METHODS: We performed a retrospective study (2008-2022) involving two tertiary referral IBD centers in the US. MR or CT enterographies were reviewed by study radiologists and endoscopy reports by study gastroenterologists, to calculate LI. Baseline and follow-up LI were calculated. We defined high bowel damage as LI ≥2. Factors associated with high LI were identified in patients with ≥2 LI scores using multivariate logistic regression and then assessed for a change in LI (increase vs. no change/decrease) using a multivariate linear mixed-effects model. RESULTS: 447 patients with CD had a median first LI of 7 [IQR, 1.25-14.55]. Median LI scores were significantly different when categorized by disease duration; 2.0 [IQR, 0.6-5.9] for <2 years, 2.6 [IQR, 0.6-9.6] for ≥2 and <10 years, and 12.5 [IQR, 6.4-21.5] for ≥10 years with a p <0.01. Disease duration, presence of perianal disease, elevated C-reactive protein, and Harvey-Bradshaw index, were associated with a high LI at inclusion and increase in LI during follow-up (all p <0.01). CONCLUSIONS: The updated LI quantified cross-sectional and longitudinal cumulative bowel damage in a real-world cohort of patients with CD with predictors identified for a longitudinal increase in LI. Further studies for prospective validation of LI and identification of multi-omic predictors of bowel damage are needed.

Fulminant Guillain-Barré Syndrome and Spontaneous Intraventricular Hemorrhage: A Case Report and Literature Review.

Guillain-Barré syndrome (GBS) is an acute, immune-mediated inflammatory peripheral polyneuropathy that is characterized by flaccid paralysis. A few cases have reported that GBS can be caused by head trauma or neurosurgery, but it has never been associated with intraventricular hemorrhage. Here, we report an uncommon case of fulminant GBS that occurred after spontaneous intraventricular hemorrhage. A 73-year-old woman was admitted to the hospital after sudden unconsciousness and vomiting. A head computed tomography (CT) scan following the incident showed a newly developed intraventricular hemorrhage, which led to an immediate ventriculostomy. After 5 days, the endotracheal tube was removed. Two days later, the external ventricular drainage tube was also removed. At this time, the patient was alert and the neurological examination was normal. However, the patient suddenly presented with acute respiratory failure and bilateral limb weakness 3 days later. An analysis of the patient's cerebrospinal fluid (CSF) revealed that albuminocytologic dissociation was present. The patient was treated with intravenous immunoglobulin (0.4 g/kg/day) for 5 days. Despite timely medical intervention in the hospital, the patient passed away 2 months later. After a cerebral hemorrhagic injury, limb and respiratory muscle weakness can occur on occasion in the ICU. In this context, the potential involvement of GBS should not be ignored. Importantly, the pathogenic mechanism of GBS has been discussed for over a century, and it still remains a mystery. We speculate that the TLR4/NF-κB signaling pathway may be involved in the pathogenesis of GBS following intraventricular hemorrhage. The prognosis of most patients with GBS is usually good, but cerebral hemorrhage and mechanical ventilation may serve as risk factors that exacerbate the condition. This case is reported to remind clinicians to consider the possibility of GBS when patients present limb and respiratory muscle weakness after intraventricular hemorrhage, and to provide a starting point to discuss potential mechanisms of GBS after intraventricular hemorrhage.

Epigenetic Regulation and Its Therapeutic Potential in Pulmonary Hypertension.

Recent advances in epigenetics have made a tremendous impact on our knowledge of biological phenomena and the environmental stressors on complex diseases. Understanding the mechanism of epigenetic reprogramming during the occurrence of pulmonary hypertension (PH) is important for advanced studies and clinical therapy. In this article, we review the discovery of novel epigenetic mechanisms associated with PH including DNA methylation, histone modification, and noncoding RNA interference. In addition, we highlight the role of epigenetic mechanisms in adult PAH resulting from undesirable perinatal environments-Extrauterine growth restriction (EUGR) and Intrauterine growth retardation (IUGR). Lastly, we give a comprehensive summary for the remaining challenges and discuss future methods of epigenetic targeted therapy for pulmonary hypertension.

Using Image-Based Flow Cytometry with a FISH-Based FlowRNA Assay to Simultaneously Detect Intracellular TNF-α Protein and mRNA in Monocytes Following LPS Stimulation.

Existing methods of assessing monocyte inflammatory cytokine (IL-1ß, IL-6, IL-8, and TNF-α) response to in vitro lipopolysaccharide (LPS) stimulation lack the ability to simultaneously detect intracellular mRNA and protein. This procedure takes advantage of new methodologies and instrumentation to simultaneously measure intracellular TNF-α mRNA and protein in CD14(+) monocytes after 1, 3, and 6 h of LPS stimulation. By assessing multiple timepoints, we are able to discern how LPS stimulation affects the temporal relationship between TNF-α mRNA and protein. By using image-based flow cytometry it is possible to co-localize mRNA and protein signals to identify the length of incubation that is needed to initiate protein translation.

Using Image-Based Flow Cytometry to Assess Monocyte Oxidized LDL Phagocytosis Capacity.

The examination of monocyte phagocytosis of modified lipoproteins is important to the understanding of plaque deposition and the development of atherosclerosis. Current methods lack the high-throughput image-based analysis capabilities, which may yield novel information concerning monocyte activity in disease processes. Specifically, this method identifies monocyte phagocytosis of oxidized LDL along with a change in adhesion molecules and scavenger receptors. Our laboratory is currently implementing this method as a means to study how acute dietary modifications alter risk of developing atherosclerosis.

Assessment of Granulocyte Subset Activation: New Information from Image-Based Flow Cytometry.

Analysis of granulocyte function can provide important information about the state of the body's innate immune system. Existing flow cytometry methods that lack image-based analysis capabilities fail to fully evaluate granulocyte function. In the present method, we combine simultaneous detection of phagocytosis and oxidative burst in granulocytes to identify unique subsets of activated granulocytes. This analysis method provides novel information about granulocytes that allows our lab and others to evaluate the effectiveness of nutritional and lifestyle countermeasures, designed to improve immunity.

Using image-based flow cytometry to measure monocyte oxidized LDL phagocytosis: A potential risk factor for CVD?

Obesity and cardiovascular disease is a worldwide health concern that has been a major focus in research for several decades. Among these diseases, atherosclerosis is one of the leading causes of death and disability nationwide. Circulating monocytes are believed to be primary cells responsible for foam cell formation. The present report describes a novel method for measuring monocyte oxLDL phagocytosis capacity using image-based flow cytometry. Human venous blood monocytes were incubated with different concentrations of oxLDL for different lengths of time to optimize the assay. High (post-meal) and low (pre-meal) responder samples were generated by feeding human subjects a high-fat (~85% of daily fat allowance), high-calorie (~65% of daily calorie needs) meal. This is a relevant model with respect to obesity and risk of developing atherogenesis. After the functional assay, classic (CD14+/CD16-) and pro-inflammatory (CD14+/CD16+) monocytes were assessed for oxLDL uptake, adhesion molecule expression (CD11b and CD18), and scavenger receptor expression (CD36) using an image-based flow cytometer (FlowSight). The present method represents a novel advance in methods available to detect the propensity of circulating monocytes to become intima foam cells. We found the assay to be most effective at separating high from low responder samples when using a fixed oxLDL concentration (120 µL/mL) and incubation length (1-h). In a clinical application, this method demonstrated that consuming a single high-fat meal causes an increase in the proportion of monocyte oxLDL phagocytosis and their adhesion capacity, suggesting a higher propensity to become foam cells.

Natural cocoa consumption: Potential to reduce atherogenic factors?

Short-term consumption of flavanol-rich cocoa has been demonstrated to improve various facets of vascular health. The purpose of the present study was to determine the effect of 4 weeks of natural cocoa consumption on selected cardiovascular disease (CVD) biomarkers in young (19-35 years) women of differing body mass indices (BMI; normal, overweight or obese). Subjects (n = 24) consumed a natural cocoa-containing product (12.7 g natural cocoa, 148 kcal/serving) or an isocaloric cocoa-free placebo daily for 4 weeks in a random, double-blind manner with a 2-week washout period between treatment arms. Fasted (>8-h) blood samples were collected before and after each 4-week period. Serum was analyzed to determine lipid profile (chemistry analyzer) and CVD biomarkers (26 biomarkers). EDTA-treated blood was used to assess monocytes (CD14, CD16, v11b and CD62L), while citrate-treated blood was used to measure changes in endothelial microparticles (EMPs; CD42a-/45-/144+) by flow cytometry. Natural cocoa consumption resulted in a significant decrease in haptoglobin (P = .034), EMP concentration (P = .017) and monocyte CD62L (P = .047) in obese compared to overweight and normal-weight subjects. Natural cocoa consumption regardless of BMI group was associated with an 18% increase in high-density lipoprotein (P = .020) and a 60% decrease in EMPs (P = .047). Also, obese subjects experienced a 21% decrease in haptoglobin (P = .034) and a 24% decrease in monocyte CD62L expression in (P = .047) following 4 weeks of natural cocoa consumption. Collectively, these findings indicate that acute natural cocoa consumption was associated with decreased obesity-related disease risk. More research is needed to assess the stability of the observed short-term changes.

Image-based flow cytometry technique to evaluate changes in granulocyte function in vitro.

Granulocytes play a key role in the body's innate immune response to bacterial and viral infections. While methods exist to measure granulocyte function, in general these are limited in terms of the information they can provide. For example, most existing assays merely provide a percentage of how many granulocytes are activated following a single, fixed length incubation. Complicating matters, most assays focus on only one aspect of function due to limitations in detection technology. This report demonstrates a technique for simultaneous measurement of granulocyte phagocytosis of bacteria and oxidative burst. By measuring both of these functions at the same time, three unique phenotypes of activated granulocytes were identified: 1) Low Activation (minimal phagocytosis, no oxidative burst), 2) Moderate Activation (moderate phagocytosis, some oxidative burst, but no co-localization of the two functional events), and 3) High Activation (high phagocytosis, high oxidative burst, co-localization of phagocytosis and oxidative burst). A fourth population that consisted of inactivated granulocytes was also identified. Using assay incubations of 10, 20, and 40-min the effect of assay incubation duration on the redistribution of activated granulocyte phenotypes was assessed. A fourth incubation was completed on ice as a control. By using serial time incubations, the assay may be able to able to detect how a treatment spatially affects granulocyte function. All samples were measured using an image-based flow cytometer equipped with a quantitative imaging (QI) option, autosampler, and multiple lasers (488, 642, and 785 nm).