Inflammatory Bowel Disease Therapies Adversely Affect Fertility in Men- A Systematic Review and Meta-analysis.

BACKGROUND AND AIMS: Sexual functions are sometimes adversely affected by the therapeutic drugs delivered for treating IBD. Much attention has been focused on pregnancy/sexual issues in women. Relatively less attention has been poured in to address this issue in men. This systematic review assesses the drugs having potential detrimental effects on fertility in men. METHODS: Three databases were searched by two researchers independently for potentially relevant publications between 1964 to 2015 and 249 papers were retrieved. Studies that dealt with sexual problems after IBD drugs administration were included in the purview of this review. RESULTS: Fourteen studies with 327 human patients and 110 animals were analysed. Sulphasalazine treated patients had lower spermatozoa count, lower sperm motility and higher risk of oligospermia compared to mesalazine treated ones. Biologics seem to be safe to use while attempting to conceive however, proper clinical studies reporting male fertility problems in IBD patients are lacking. Azathioprine caused oligospermia but a meta-analytical approach was not possible due to heterogeneity in studies. Some animal studies showed methotrexate affects abnormal testis structure and spermatogenesis. CONCLUSION: This study summarises the current literature and safety issues affecting fertility parameters in men and animals treated with IBD therapeutic drugs, which can further assist clinicians in better management of adult male IBD patients.

Intestinal Surgery for Crohn's Disease: Role of Preoperative Therapy in Postoperative Outcome.

PURPOSES: Patients affected by Crohn's disease (CD) require lifelong medical therapy, but they can also often require abdominal surgery. The effect of CD therapy on postoperative course is still unclear. The aim of this study was to evaluate the effect of preoperative medical therapy on the outcome of intestinal surgery in these patients. METHODS: Data from a consecutive series of 167 patients with CD operated on at the University of Padova Hospital from 2000 to 2013 were retrieved. Data of preoperative therapy during the 6 months before surgery were available for 146 patients who were enrolled in this retrospective study. Clinical data and surgical details were retrieved and postoperative complications and reoperation were considered outcome measures. Univariate and multivariate analysis were performed. RESULTS: No significant difference was observed between patients without data about their preoperative therapy and those with them. Eight patients underwent reoperation in the first 30 postoperative days: two of them for anastomotic leak, three for bleeding, one for obstruction and two for abdominal wound dehiscence. At multivariate analysis, preoperative adalimumab and budesonide resulted to be an independent predictor of reoperation (OR = 7.67 (95% CI = 1.49-39.20), p = 0.01 and OR = 6.7749 (95% CI = 0.98-46.48), p = 0.05, respectively). At multivariate analysis neither pharmacological nor clinical variables resulted to predict anastomotic leak. CONCLUSIONS: In our series, adalimumab seemed to be associated to early reoperation after intestinal surgery. This may be due to a worst disease severity in patients who needed surgery in spite of biological therapy. Preoperative tapering of budesonide dose seems a safe option before elective abdominal surgery for CD.

Mongersen, an oral SMAD7 antisense oligonucleotide, and Crohn's disease.

BACKGROUND: Crohn's disease-related inflammation is characterized by reduced activity of the immunosuppressive cytokine transforming growth factor ß1 (TGF-ß1) due to high levels of SMAD7, an inhibitor of TGF-ß1 signaling. Preclinical studies and a phase 1 study have shown that an oral SMAD7 antisense oligonucleotide, mongersen, targets ileal and colonic SMAD7. METHODS: In a double-blind, placebo-controlled, phase 2 trial, we evaluated the efficacy of mongersen for the treatment of persons with active Crohn's disease. Patients were randomly assigned to receive 10, 40, or 160 mg of mongersen or placebo per day for 2 weeks. The primary outcomes were clinical remission at day 15, defined as a Crohn's Disease Activity Index (CDAI) score of less than 150, with maintenance of remission for at least 2 weeks, and the safety of mongersen treatment. A secondary outcome was clinical response (defined as a reduction of 100 points or more in the CDAI score) at day 28. RESULTS: The proportions of patients who reached the primary end point were 55% and 65% for the 40-mg and 160-mg mongersen groups, respectively, as compared with 10% for the placebo group (P<0.001). There was no significant difference in the percentage of participants reaching clinical remission between the 10-mg group (12%) and the placebo group. The rate of clinical response was significantly greater among patients receiving 10 mg (37%), 40 mg (58%), or 160 mg (72%) of mongersen than among those receiving placebo (17%) (P=0.04, P<0.001, and P<0.001, respectively). Most adverse events were related to complications and symptoms of Crohn's disease. CONCLUSIONS: We found that study participants with Crohn's disease who received mongersen had significantly higher rates of remission and clinical response than those who received placebo. (Funded by Giuliani; EudraCT number, 2011-002640-27.).

CD80-CD28 signaling controls the progression of inflammatory colorectal carcinogenesis.

In patients with ulcerative colitis (UC) the cumulative risk of colon cancer is lower than the actual rate of dysplasia suggesting an efficient immune surveillance mechanism. Since the co-stimulatory molecule CD80 is overexpressed in dysplastic colonic mucosa of UC patients and T-cell activation entails effective costimulation, we aimed to evaluate the functional implication of CD80 signaling in colonic UC-associated carcinogenesis. In humans, we observed that the percentage of CD80+ and HLA-A+ IEC was increased in the dysplastic colonic mucosa of UC patients. In vitro, IEC activated CD8+ T-cells through a CD80-dependent pathway. Finally, in the AOM/DSS-induced colonic adenocarcinoma model CD80 signaling inhibition significantly increased the frequency and extension of high-grade dysplasia, whereas enhancing CD80 activity with an anti-CTLA4 antibody significantly decreased colonic dysplasia. In conclusion, CD80 signaling between IEC and T-cells represents a key factor controlling the progression from low to high grade dysplasia in inflammatory colonic carcinogenesis.

HLA-DQA1-HLA-DRB1 variants confer susceptibility to pancreatitis induced by thiopurine immunosuppressants.

Pancreatitis occurs in approximately 4% of patients treated with the thiopurines azathioprine or mercaptopurine. Its development is unpredictable and almost always leads to drug withdrawal. We identified patients with inflammatory bowel disease (IBD) who had developed pancreatitis within 3 months of starting these drugs from 168 sites around the world. After detailed case adjudication, we performed a genome-wide association study on 172 cases and 2,035 controls with IBD. We identified strong evidence of association within the class II HLA region, with the most significant association identified at rs2647087 (odds ratio 2.59, 95% confidence interval 2.07-3.26, P = 2 × 10(-16)). We replicated these findings in an independent set of 78 cases and 472 controls with IBD matched for drug exposure. Fine mapping of the HLA region identified association with the HLA-DQA1*02:01-HLA-DRB1*07:01 haplotype. Patients heterozygous at rs2647087 have a 9% risk of developing pancreatitis after administration of a thiopurine, whereas homozygotes have a 17% risk.

Time trends and outcome of gastrointestinal bleeding in the Veneto region: a retrospective population based study from 2001 to 2010.

BACKGROUND: Gastrointestinal bleeding is the most frequent emergency for gastroenterologists. Despite advances in management, an improvement in mortality is still not evident. AIM: Determining time trends of gastrointestinal bleeding hospitalization and outcomes from 2001 to 2010 in the Veneto Region (Italy). PATIENTS AND METHODS: Data of patients admitted with gastrointestinal bleeding from Veneto regional discharge records were retrospectively evaluated. Chi-squared and multivariate logistic regression model were used. RESULTS: Overall, 44,343 patients (mean age 64.2 ± 8.6 years) with gastrointestinal bleeding were analysed: 23,450 (52.9%) had upper, 13,800 (31.1%) lower, and 7093 (16%) undefined gastrointestinal bleeding. Admission rate decreased from 108.0 per 100,000 in 2001 to 80.7 in 2010, mainly owing to a decrease in upper gastrointestinal bleeding (64.4 to 35.9 per 100,000, p<0.05). Reductions in hospital fatality rate (from 5.3% to 3%, p<0.05), length of hospital stay (from 9.3 to 8.7 days, p<0.05), and need for surgery (from 5.6% to 5%, p<0.05) were observed. Surgery (OR: 2.97, 95% CI: 2.59-3.41) and undefined gastrointestinal bleeding (OR: 2.89, 95% CI: 2.62-3.19) were found to be risk factors for mortality. CONCLUSIONS: Patient admissions for gastrointestinal bleeding decreased significantly over the years, owing to a decrease in upper gastrointestinal bleeding. Improved outcomes could be related to regional dedicated clinical gastroenterological management.

Mucosal immune environment in colonic carcinogenesis: CD80 expression is associated to oxidative DNA damage and TLR4-NFκB signalling.

BACKGROUND: CD80 has been thought to play an active role in immunosurveillance as it has been found to be up-regulated in ulcerative colitis (UC) patients with dysplasia. The aim of the present study was to analyse early events in UC-related and non-inflammatory carcinogenesis with reference to CD80 expression to clarify what stimuli are involved in its up-regulation in these patients. PATIENTS AND METHODS: Sixty-two patients affected with UC, UC with dysplasia, UC and cancer, colonic adenoma, or colonic cancer and 11 healthy subjects were enroled in our study. Tissue samples were taken from surgical specimens during colonic resection or during colonoscopy. Mucosal mRNA expression of Toll-like receptor-4 (TLR4) and nuclear factor-kappaB (NF-κB) was quantified with Real Time RT-PCR. TLR4, ß-catenin and p53 expressions were analysed by immunohistochemistry. Mucosal levels of activated NF-κB were measured with immunometric assays while 8-Hydroxydeoxyguanosine (8-OHdG) levels were quantified by high-performance liquid chromatography with electrochemical detection (HPLC-ED). Non-parametric tests were used for statistical analysis. RESULTS: 8-OHdG mucosal levels were higher in the patients with UC + dysplasia with respect to those in the patients with UC only (p=0.03). CD80 mRNA mucosal levels were directly correlated with 8-OHdG mucosal levels (τ=0.26, p=0.04), TLR4 protein expression (τ=0.45, p<0.01) and NF-κB mRNA expression and activity (τ=0.24, p=0.02; τ=0.34, p=0.02, respectively). CD80 protein expression, instead, was directly correlated with 8-OHdG mucosal levels (τ=0.19, p=0.05) and inversely correlated with TLR4 mRNA expression (τ=-0.25, p=0.03). CONCLUSION: Oxidative DNA damage peaked in UC-related dysplasia and was found to be directly correlated to CD80 expression. The direct correlation between TLR4 protein expression and CD80 mRNA and the indirect correlation between CD80 protein and TLR4 mRNA expressions give substance to the hypothesis that they play a role in immunosurveillance. No significant correlations between CD80 expression and p53 and ß-catenin accumulation during oncogenesis were, instead, observed.

Mucosal immune environment in colonic carcinogenesis: CD80 up-regulation in colonic dysplasia in ulcerative colitis.

BACKGROUND: In patients with ulcerative colitis (UC) the inconsistency between the rate of dysplasia and actual cancer incidence suggests the presence of an immunosurveillance mechanism. The aim of our study was to analyse the expression of CD80 and CD86 during the different stages of UC-associated and in non-inflammatory carcinogenesis. PATIENTS AND METHODS: Sixty-two patients affected with UC, UC with colonic dysplasia, UC and cancer, colonic adenoma, or colonic cancer and 11 healthy subjects were enrolled in our study. Tissue samples were taken from surgical specimens during colonic resection or during colonoscopy. Mucosal mRNA expression of CD80 and CD86 was quantified with real time polymerase chain reaction (RT-PCR). CD80, CD86 and p53 expressions and lamina propria mononuclear cell populations (CD3, CD20 and CD68) were analysed by immunohistochemistry. Mucosal levels of IL-1ß, IL-2 and IFN-γ were measured with immunometric assays. RESULTS: Among UC patients, CD80 protein expression was higher in those with dysplasia (p=0.017). In non-inflammatory carcinogenesis pathway CD80 protein and mRNA expressions were lower compared to the corresponding steps in the UC pathway. CD80 expression was directly correlated with the lamina propria mononuclear cell populations (T and B lymphocytes and monocytes). CD80 protein, but not CD80 mRNA, expression was significantly and directly correlated with IL-2 expression. CONCLUSION: CD80 resulted to be up-regulated in UC with dysplasia, while it was down-regulated in cancer. CD80 mucosal levels correlate with lamina propria T-cell and with IL-2 expression suggesting that it may elicit an active role in the immunosurveillance mechanism.

Subclinical intestinal inflammation in patients with Crohn's disease following bowel resection: a smoldering fire.

BACKGROUND/AIMS: Fecal lactoferrin is the direct expression of intestinal inflammation in Crohn's disease (CD). The aim of this study was to analyze the in vivo intimate correlation between intestinal and systemic inflammation in CD patients in clinical remission following bowel resection. The secondary end point was to evaluate the prognostic value of lactoferrin levels and serum cytokines in terms of need of surgery for recurrence in these patients. PATIENTS AND METHODS: Fecal lactoferrin and serum cytokine (interleukin (IL)-1beta, IL-6, IL-12, tumor necrosis factor (TNF)-alpha, and transforming growth factor (TGF)-beta1) levels were assessed; hematological and biochemical investigations were carried out, and Crohn's Disease Activity Index was evaluated in the 36 patients who had undergone bowel resection. The prognostic value of lactoferrin and cytokine levels in terms of surgical recurrence was assessed by re-calling patients after 24 months from the enrolment in the study. RESULTS: All patients, evaluated after a follow-up of 36 +/- 5 months, were in clinical remission. Fecal lactoferrin levels were found to be significantly correlated with IL-6 (R = 0.431, p = 0.025) and C-reactive protein (CRP; R = 0.507, p = 0.007), while no correlation was observed between lactoferrin and IL-1beta, IL-12, TNF-alpha, or TGF-beta1. Reoperation for anastomotic recurrence tended to occur significantly more frequently in patients with higher IL-6 (p = 0.10). CONCLUSIONS: Subclinical intestinal inflammation, expressed by fecal lactoferrin, seems to keep the systemic inflammation alive in CD patients through the IL-6-CRP cascade. IL-6 seems to be predictive of the outcome of CD patients undergoing surgery.

Intestinal surgery for Crohn's disease: predictors of recovery, quality of life, and costs.

INTRODUCTION: The aim of this prospective study was to analyze the impact of different surgical techniques on patients undergoing intestinal surgery for Crohn's disease (CD) in terms of recovery, quality of life, and direct and indirect costs. PATIENTS AND METHODS: Forty-seven consecutive patients admitted for intestinal surgery for CD were enrolled in this prospective study. Surgical procedures were evaluated as possible predictors of outcome in terms of disability status (Barthel's Index), quality of life (Cleveland Global Quality of Life score), body image, disease activity (Harvey-Bradshaw Activity Index), and costs (calculated in 2008 Euros). Univariate and multivariate analyses were performed. RESULTS: Significant predictors of a long postoperative hospital stay were the creation of a stoma, postoperative complications, disability status on the third post-operative day, and surgical access (R (2) = 0.59, p < 0.01). Barthel's index at discharge was independently predicted by laparoscopic-assisted approach, ileal CD, and colonic CD (R (2) = 0.53, p < 0.01). The disability status at admission showed to be an independent predictor of quality of life score at follow-up. The overall cost for intestinal surgery for CD was 12,037 (10,117-15,795) euro per patient and stoma creation revealed to be its only predictor (p = 0.006). CONCLUSIONS: Laparoscopy was associated with a shorter postoperative length of stay; stoma creation was associated with a long and expensive postoperative hospital stay, and stricturoplasty was associated with a slower recovery of bowel function.

Restorative proctocolectomy for inflammatory bowel disease: the Padova prognostic score for colitis in predicting long-term outcome and quality of life.

BACKGROUND: In 10-20% of cases, it is impossible to distinguish between ulcerative colitis and Crohn's colitis, affecting the possibility to predict the long-term outcome after restorative proctocolectomy (RPC). The study aimed to assess the accuracy of a new prognostic score for inflammatory bowel diseases (IBD) colitis [the Padova Prognostic Score for Colitis (PPSC)] in predicting long-term clinical/functional outcome and quality of life after RPC. MATERIALS AND METHODS: The PPSC was created by the integration of histological and clinical information. The accuracy of the PPSC was tested in predicting long-term clinical outcome (i.e. pouch complications/survival) and quality of life of 58 consecutive patients who had undergone RPC in our institute from 1984 to 2004. Clinical outcome was assessed with an ad hoc functional questionnaire and the revision of the hospital and outpatients clinic notes. Quality of life surveys were carried out with the Padova IBD Quality of Life (PIBDQL) and with Cleveland Global Quality of Life (CGQL) scores. RESULTS: The PPSC predicted pouch fistulae (accuracy = 84.5%; sensitivity = 50%; specificity = 90%) and changes in sexual life (accuracy = 71%; sensitivity = 23%; specificity = 87%). The PPSC also predicted the PIBDQL score with an accuracy of 62%, a sensitivity of 28% and a specificity of 97%, whilst it predicted the CGQL score with an accuracy of 29%, a sensitivity of 12% and a specificity of 80%. The PPSC failed to predict pouchitis or pouch failure. CONCLUSIONS: The Padova Prognostic Score for Colitis proved effective in predicting pouch fistulae or abscesses, but not pouchitis and pouch failure. The PPSC was accurate in predicting disease-specific quality of life.

Successful prophylaxis with valaciclovir for relapsing HSV-1 in a girl treated with infliximab for moderate Crohn's disease.

Biological agents such as inhibitors of tumour necrosis factor alpha (TNF-alpha ) are associated with the development of opportunistic infections. Although there are no international recommendations for the management of opportunistic infections, their prevention is a key safety issue for patients with inflammatory bowel disease (IBD). We report that chemoprophylaxis with oral valaciclovir was effective in preventing Herpes simplex virus (HSV-1) reactivation in a girl treated with infliximab for Crohn's disease.

TGF-beta1 and IGF-1 production and recurrence of Crohn's disease after ileo-colonic resection.

BACKGROUND: Recurrence after surgery is a major problem in the treatment of Crohn's disease (CD). Alteration of healing processes may play a role in this phenomenon. Transforming growth factor beta (TGF-beta) and insulin-like growth factor (IGF-1) have pro-fibrogenic properties and are involved in wound-healing mechanisms. The aim of this study was to assess their role in the CD recurrence after ileo-colonic resection. PATIENTS AND METHODS: Twenty patients with CD, who underwent ileo-colonic resection in the period between 1999 and 2005, were enrolled in this study. Tissue samples were obtained from macroscopically diseased and healthy ileum. The TGF-beta1 and IGF-1 mRNAs were quantified by real-time polymerase chain reaction using glyceraldehyde 3-phosphate dehydrogenase as the housekeeping gene. Histological severity of the disease was assessed to quantify the ileal inflammation. Patients' follow-up was investigated. Comparisons and correlations were carried out with nonparametric tests and survival analysis was performed. RESULTS: Histological inflammation was moderately severe in the diseased bowel, while it was absent in healthy segments (P < 0.01). TGF-beta1 production in healthy bowels showed a direct correlation with clinical CD recurrence (tau = 0.43, P = 0.04) and survival analysis showed that patients who expressed high TGF-beta1 mRNA transcripts in healthy intestines had higher cumulative recurrence rates than those who expressed low TGF-beta1 mRNA levels (P = 0.02). CONCLUSION: Our study suggests that the high levels of TGF-beta1 in healthy bowels of patients who undergo ileo-colonic resection for CD are associated with early clinical disease recurrence, while there seems to be no association between IGF-1 and CD recurrence.

TGF-beta1 and IGF-1 and anastomotic recurrence of Crohn's disease after ileo-colonic resection.

BACKGROUND: After bowel resection, Crohn's disease (CD) recurs frequently in the site of the anastomosis. Alteration of normal healing processes may play a role in this phenomenon. Transforming growth factor beta (TGF-beta) and insulin-like growth factor (IGF-1) are involved in wound healing mechanisms with pro-fibrogenic properties. The aim of this study was to assess the expression of TGF-beta1 and insulin-like growth factor 1 (IGF-1) in the different zones of the bowel wall to understand why side-to-side anastomosis are associated to a lower recurrence rate compared to end-to-end ones. PATIENTS AND METHODS: Seventeen patients affected by CD who underwent ileo-colonic resection from 2004 to 2005 were enrolled in this study. Full-thickness tissue samples were obtained from the mesenteric, the lateral, and the anti-mesenteric sides of the macroscopically diseased and healthy ileum for each patient. TGF-beta1 and IGF-1 messenger RNAs (mRNAs) were quantified by real-time polymerase chain reaction. Myeloperoxidase activity and histological disease activity were assessed to quantify the ileal inflammation. Vimentin, desmin, and alpha-smooth muscle actin were stained with immunohistochemistry to assess the fibroblast, smooth muscle cell, and myofibroblasts populations. Comparisons and correlations were carried out with nonparametric tests. RESULTS: In diseased ileum, TGF-beta1 mRNA transcripts in the antimesenteric side were significantly lower than those of the mesenteric side (p = 0.05), and a significant correlation between TGFbeta-1 levels in diseased bowel and the sampling site was observed (tau = 0.36, p = 0.03). On the contrary, neither the IGF-1 mRNA transcripts nor the distribution of fibroblast, smooth muscle cell, and myofibroblasts populations showed any relation with the sampling site. CONCLUSION: TGF-beta1 mRNA expression was lower in the anti-mesenteric side of the diseased ileum, and this was consistent with the success of side-to-side anastomosis in preventing CD recurrence. Since high expression of TGF-beta1 was associated to early recurrence, it seems rationale to construct the anastomosis on the anti-mesenteric side of the bowel.

Lactobacillus crispatus M247-derived H2O2 acts as a signal transducing molecule activating peroxisome proliferator activated receptor-gamma in the intestinal mucosa.

BACKGROUND & AIMS: Accumulating evidence indicates that the peroxisome proliferator activated receptor (PPAR)-gamma is a major player in maintaining intestinal mucosa homeostasis, but whether PPAR-gamma is directly involved in probiotic-mediated effects and the molecular events involved in its activation are not known. METHODS: We investigated the role of PPAR-gamma in the immunomodulatory effects of Lactobacillus crispatus M247 on intestinal epithelial cells (IEC) and the role of probiotic-derived H(2)O(2) on PPAR-gamma activity. RESULTS: L crispatus M247 supplementation in mice significantly increased PPAR-gamma levels and transcriptional activity in the colonic mucosa. L crispatus M247 induced PPAR-gamma nuclear translocation and enhanced transcriptional activity in epithelial (CMT-93) cells, as demonstrated by the increased luciferase activity of a PPAR-gamma-responsive element, PPAR-gamma-responsive gene up-regulation, and reduced activity of an nuclear factor-kappaB-responsive element. Pharmacologic PPAR-gamma inhibition or silencing by small interfering RNA cancelled the L crispatus M247-mediated effects in CMT-93 cells. Because Lactobacillus strains producing little H(2)O(2) failed to activate PPAR-gamma, we investigated the role of L crispatus M247-derived H(2)O(2) in PPAR-gamma activation. L crispatus M247 induced a transient rise in intracellular H(2)O(2) and PPAR-gamma transcriptional activity was cancelled by antioxidant or H(2)O(2) scavenger. Toll-like receptor (TLR)-2 was not required for PPAR-gamma up-regulation mediated by L crispatus M247 in mice, although the protective effects of L crispatus M247 on dextran sodium sulfate-induced colitis were less pronounced in TLR-2(-/-) mice. CONCLUSIONS: L crispatus M247 uses H(2)O(2) as a signal transducing molecule to induce PPAR-gamma activation in IEC, directly modulating epithelial cell responsiveness to inflammatory stimuli.

A multicenter, randomized, double-blind trial of everolimus versus azathioprine and placebo to maintain steroid-induced remission in patients with moderate-to-severe active Crohn's disease.

OBJECTIVES: A prospective study was undertaken to compare the efficacy of everolimus versus azathioprine or placebo in maintaining steroid-induced remission in active Crohn's disease (CD) and assess the safety and pharmacokinetics of everolimus. METHODS: This was a randomized, double-blind, placebo-controlled, proof-of-concept study in adults with moderate-to-severe active CD. The patients received oral steroids for a rapid induction of remission plus everolimus 6 mg/day, azathioprine 2.5 mg/kg/day, or placebo as maintenance treatment. The main outcome measure was the treatment success, defined as a steroid-free remission by the end of month 3 and maintained until study cutoff without the use of prohibited efficacy treatments. RESULTS: Following an interim analysis, the study was terminated before enrollment was completed due to the lack of efficacy. The full intent-to-treat population comprised 138 patients. Only 96 patients who entered the study > or =7 months prior to data cutoff were included in the primary efficacy population. The treatment success was achieved in 13 of 38 everolimus patients, 22 of 36 azathioprine patients, and 8 of 22 placebo patients. Using the Kaplan-Meier estimates at month 7, the incidence of treatment success was 22.0% with everolimus group (95% confidence interval [CI] 6.7-37.3%, P= 0.610 vs placebo), 38.3% with azathioprine group (95% CI 20.6-55.9%, P= 0.500 vs placebo), and 28.8% with placebo group (95% CI 7.7-49.9%). The type and incidence of adverse events in the everolimus cohort were similar to those reported in the approved transplantation indications. CONCLUSIONS: The safety and tolerability of everolimus (6 mg/day) in patients with active CD were comparable to azathioprine. At this dose, everolimus is not more efficacious in achieving a steroid-free remission in active CD than the comparators.

Restorative proctocolectomy for ulcerative colitis: impact on lipid metabolism and adipose tissue and serum fatty acids.

The aim of this prospective study was to evaluate the changes of the metabolism of circulating and storage lipids in patients with ulcerative colitis after restorative proctocolectomy. Fifteen consecutive patients and 15 sex- and age-matched healthy controls were enrolled. Disease activity, diet, inflammatory parameters, plasma lipoprotein concentrations, and fatty acids (FA) of serum phospholipids and of the subcutaneous adipose tissue were assessed at colectomy and at ileostomy closure. In ulcerative colitis patients, total cholesterol and docosahexaenoic acid were lower than in healthy subjects (p < 0.01 and p < 0.05). The median interval between colectomy and ileostomy closure was 6 (range 2-9) months. During that interval, the inflammatory parameters improved, high-density lipoproteins (HDL) cholesterol increased (p < 0.01), and low-density (LDL) cholesterol decreased (p = 0.01). At ileostomy closure, serum arachidonic acid levels were increased (p = 0.04), whereas serum oleic acid level was decreased (p = 0.02). In this interval, no significant alteration, either in serum n-3 FA precursors or in the FA of subcutaneous adipose tissue, was observed. The increase of serum arachidonic acid after colectomy might suggest a lower utilization for inflammatory process. The reduction of LDL cholesterol is an index of malabsorption probably due to the accelerated transit and to the exclusion of the terminal ileum caused by the covering ileostomy.

Effect of penicillamine and zinc on iron metabolism in Wilson's disease.

OBJECTIVE: The physiology of iron metabolism in Wilson's disease is largely unknown, and there is a paucity of data on the real presence and progression of iron accumulation. The purpose of this study was to assess the iron metabolism parameters, including hepatic iron concentration, in follow-up liver biopsies and serum, and urinary pro-hepcidin. MATERIAL AND METHODS: Twenty-three Wilson's disease patients undergoing long-term treatment were enrolled in the study. RESULTS: Hepatic iron content was significantly increased in penicillamine-treated patients compared with zinc-treated patients. Serum and urinary pro-hepcidin concentrations were significantly higher in Wilson's disease patients than in healthy volunteers, despite a normal biochemical pattern of iron metabolism. CONCLUSIONS: Long-term penicillamine treatment seems to be responsible for a more marked iron accumulation in the liver. This observation may justify a revision of long-term Wilson's disease treatment modalities with penicillamine. The finding that serum and urinary pro-hepcidin is significantly increased in Wilson's disease patients compared with healthy volunteers suggests a role for hepcidin in iron metabolism in Wilson's disease, but this needs to be confirmed by a study of hepatic hepcidin expression in these patients.

Aggregating phenotype in Lactobacillus crispatus determines intestinal colonization and TLR2 and TLR4 modulation in murine colonic mucosa.

The colonic microbiota is a major modulator of the mucosal immune system; therefore, its manipulation through supplementation with probiotics may significantly affect the host's immune responses. Since different probiotics seem to exert various effects in vivo, we tested the relevance of the autoaggregation phenotype on the intestinal persistence of lactobacilli and their ability to modulate the host's innate immune responses. After 14 days of diet supplementation, the aggregating strain Lactobacillus crispatus M247 but not aggregation-deficient isogenic mutant MU5 was recovered from the feces and colonic mucosa of mice. This observation was confirmed by strain-specific PCR amplification and by Lactobacillus-specific denaturing gradient gel electrophoresis analysis. Indeed, L. crispatus M247 increased Toll-like receptor 2 (TLR2) mRNA levels, while it reduced TLR4 mRNA and protein levels in the colonic mucosa, whereas MU5 was ineffective. In colonic epithelial cells (CMT-93 cells) L. crispatus M247 but not MU5 induced time-dependent extracellular signal-regulated kinase-1 (ERK1) tyrosine phosphorylation and TLR modulation, which were abolished in the presence of PD98059 (an ERK1 inhibitor). To assess the functional relevance of probiotic-induced TLR modulation, we determined the consequences of L. crispatus preexposure on TLR4 (lipopolysaccharide [LPS]) and TLR2 [Pam3Cys-Ser-(Lys)4] ligand-mediated effects in intestinal epithelial cells. Preexposure to L. crispatus M247 blunted LPS-induced interleukin-6 (IL-6) release and inhibition of CMT-93 migration over a wound edge, whereas it enhanced TLR2-mediated IL-10 up-regulation. In summary, the aggregation phenotype is required for L. crispatus persistence in the colon and for modulation of TLR2/TLR4 expression through an ERK-dependent pathway. We speculate that the aggregation phenotype in L. crispatus M247 is required to temper epithelial cell responsiveness to bacterial endotoxins, which thus affects the evolution of intestinal inflammatory processes.

Fecal lactoferrin and calprotectin after ileocolonic resection for Crohn's disease.

PURPOSE: This study was designed to assess the role of fecal lactoferrin and calprotectin as markers of intestinal inflammation in patients with Crohn's disease who have undergone ileocolonic resection. METHODS: Sixty-three patients who had undergone ileocolonic resection for Crohn's disease with a median follow-up of 40.5 (range, 5-102) months were enrolled. Clinical examination and blood test were performed, and fecal lactoferrin and calprotectin levels were dosed. The predictors for fecal lactoferrin and calprotectin levels that resulted to be significant at the univariate analyses were included in two multiple regression analysis models. RESULTS: The mean lactoferrin level was 21 +/- 3.9 microg/g and the mean calprotectin fecal level was 247 +/- 22.7 ng/ml. C-reactive protein levels (P < 0.01), calprotectin levels (P < 0.01), and the presence of clinical recurrence (P = 0.04) resulted to be independent predictors of lactoferrin levels. Only lactoferrin levels resulted to be an independent predictor for calprotectin fecal levels (P < 0.01). CONCLUSIONS: Crohn's disease patients maintain high fecal levels of lactoferrin and calprotectin at long-term follow-up after resection of the diseased bowel even in case of clinical remission. The significant correlation between the two fecal markers may be the expression of the ongoing intestinal inflammation. Only lactoferrin significantly correlated with C-reactive protein and showed a reliable threshold value for systemic inflammation. Lactoferrin fecal levels may be a reliable indicator for intestinal inflammation influencing the systemic inflammatory status. The third predictor of lactoferrin fecal level was the presence of episodes of clinical recurrence during the postoperative follow-up.