The diagnosis and management of CMV colitis in IBD patients shows high practice variation: a national survey among gastroenterologists.

BACKGROUND: Clinical guidelines on cytomegalovirus (CMV) colitis in inflammatory bowel disease (IBD) are hampered by the low quality of evidence. In this study, we aim to explore the attitude and management of CMV colitis in IBD among gastroenterologists. METHODS: A web-based survey was distributed to adult and pediatric gastroenterologists and trainees in academic and general hospitals in the Netherlands. The survey comprised data collection on respondents' demographics, attitudes towards the importance of CMV infection in IBD on a visual analogue scale (from 0 to 100), and diagnostic and therapeutic strategies. RESULTS: A total of 73/131 invited respondents from 32 hospitals completed the survey (response rate of 56%). The importance of CMV infection was scored at a median 74/100. Respondents indicated CMV testing as appropriate in the clinical setting of steroid-refractory colitis (69% of respondents), hospitalized patients with active colitis (64%), immunomodulator or biological refractory colitis (55%) and active colitis irrespective of medication use (14%). CMV diagnostics include histology of colonic biopsies (88% of respondents), tissue CMV PCR (43%), serum CMV PCR (60%), CMV serology (25%) and fecal CMV PCR (4%). 82% of respondents start antiviral therapy after a positive CMV test on colonic biopsies (histology or PCR). CONCLUSIONS: Most Dutch gastroenterologists acknowledge the importance of CMV colitis in IBD. Strategies vary greatly with regard to the indication for testing and diagnostic method, as well as indication for the start of antiviral therapy. These findings underline the need for pragmatic clinical studies on different management strategies, in order to reduce practice variation and improve the quality of care. Summary of the established knowledge on this subject:The clinical significance of CMV-associated colitis in IBD remains a matter of debateRecommendations regarding CMV colitis in current international guidelines are based on low to moderate evidence levels and different diagnostic strategies are proposed What are the significant and/or new findings of this study?We show that there is a high practice variation of diagnosis and management of CMV colitis in IBD amongst adult and pediatric gastroenterologistsThis study underlined the need for pragmatic studies and guidelines on different management strategies including cut-off values to start therapy.

Clinical and endoscopic complications of Epstein-Barr virus in inflammatory bowel disease: an illustrative case series.

BACKGROUND AND AIM: Epstein-Barr virus (EBV) is a proposed trigger in the etiopathogenesis of inflammatory bowel disease (IBD) and is associated with lymphoproliferative diseases. Nevertheless, testing for EBV DNA in the intestinal mucosa and screening for EBV infection before initiation of a drug therapy are not routinely performed. The aim of this article is to increase awareness of the relevance of EBV infection in specific clinical situations. METHODS: In this short communication, we describe the disease course of three IBD patients with EBV infection, varying from EBV reactivation during disease flare up to a trigger of EBV-related mucocutaneous ulcer (EBV-MCU) and haemophagocytic lymphohistiocytosis (HLH). RESULTS: Our first patient was diagnosed with EBV reactivation-associated severe colitis and showed a rapid clinical improvement after induction therapy with infliximab and azathioprine. Without antiviral treatment, the patient remained in complete remission and no complications of EBV were seen. After diagnosing EBV-MCU in the second patient, immunosuppressive medication was discontinued and four infusions of rituximab resulted in a rapid clinical recovery and eventually complete response. After discontinuation of the immunosuppression in our last patient with haemophagocytic lymphohistiocytosis, treatment with a combination of corticosteroid and antiviral therapy resulted in a complete recovery over a time span of several weeks. CONCLUSION: EBV infection has a wide variety of potentially life-threatening clinical manifestations in IBD patients. Testing for EBV in case of a flare up and screening for EBV before the start of immunosuppressive therapy will create awareness for EBV-related symptoms or complications during follow-up.

Rapid test for fecal calprotectin levels in children with Crohn disease.

Assessment of fecal calprotectin, a surrogate marker of mucosal inflammation, is a promising means to monitor therapeutic response in pediatric inflammatory bowel disease, especially if the result is readily available. We tested the performance of a novel calprotectin rapid test, Quantum Blue, versus the conventional enzyme-linked immunosorbent assay in 134 stool samples from 56 pediatric patients with Crohn disease. The intraclass correlation coefficient analysis reflected good agreement (intraclass correlation coefficient 0.97 [95% confidence interval 0.95-0.98]) but agreement was better in lower values, where dilutions were not required. Using a cutoff of 100 µg/g for normal values, the percentage agreement between the 2 tests was 87%. The optimal cutoff values to guide clinical decisions in the therapy of inflammatory bowel disease have yet to be determined.

Complications of single-balloon enteroscopy: a prospective evaluation of 166 procedures.

BACKGROUND AND STUDY AIM: Double-balloon enteroscopy (DBE) has proven to be a relatively safe method for small-bowel evaluation, with a complication rate of 1 %. The main concern after diagnostic DBE is acute pancreatitis. Single-balloon enteroscopy (SBE) has emerged as a viable alternative to DBE. Until now, no incidence of pancreatitis has been reported for SBE. The aims were to evaluate complication rate and occurrence of hyperamylasemia and to identify the risk factors for hyperamylasemia after SBE. PATIENTS AND METHODS: Prospectively, consecutive patients undergoing peroral ("proximal") or combined approach SBE were included. Complications were assessed at 1 and 30 days afterwards. Serum amylase and C-reactive protein (CRP) were assessed immediately before and 2 - 3 hours after SBE. RESULTS: 166 SBE procedures were performed in 105 patients (53-male; mean age 51 years, range 9 - 87). The indications for SBE were: anemia (n = 55), Crohn's disease (n = 31) and abdominal complaints suspicious for inflammatory bowel disease (n = 5), Peutz-Jeghers syndrome (n = 1) and other (n = 13). Therapeutic interventions were performed during 21 procedures (13 %). One perforation (1 / 21 therapeutic interventions, 4.8 %) occurred after dilation of a benign stricture. While 13 patients (16 %) had post-SBE hyperamylasemia, none had complaints suggesting acute pancreatitis. Factors such as sex, indication, procedure duration, number of passes, route of SBE, findings, and/or treatment showed no significant correlation with presence of hyperamylasemia. CONCLUSIONS: SBE appears to be a safe diagnostic endoscopic procedure. The incidence of hyperamylasemia and pancreatitis after peroral SBE seems comparable to that after DBE.

IL-10 signaling in dendritic cells controls IL-1ß-mediated IFNγ secretion by human CD4+ T cells: relevance to inflammatory bowel disease.

Uncontrolled interferon γ (IFNγ)-mediated T-cell responses to commensal microbiota are a driver of inflammatory bowel disease (IBD). Interleukin-10 (IL-10) is crucial for controlling these T-cell responses, but the precise mechanism of inhibition remains unclear. A better understanding of how IL-10 exerts its suppressive function may allow identification of individuals with suboptimal IL-10 function among the heterogeneous population of IBD patients. Using cells from patients with an IL10RA deficiency or STAT3 mutations, we demonstrate that IL-10 signaling in monocyte-derived dendritic cells (moDCs), but not T cells, is essential for controlling IFNγ-secreting CD4+ T cells. Deficiency in IL-10 signaling dramatically increased IL-1ß release by moDCs. IL-1ß boosted IFNγ secretion by CD4+ T cells either directly or indirectly by stimulating moDCs to secrete IL-12. As predicted a signature of IL-10 dysfunction was observed in a subgroup of pediatric IBD patients having higher IL-1ß expression in activated immune cells and macroscopically affected intestinal tissue. In agreement, reduced IL10RA expression was detected in peripheral blood mononuclear cells and a subgroup of pediatric IBD patients exhibited diminished IL-10 responsiveness. Our data unveil an important mechanism by which IL-10 controls IFNγ-secreting CD4+ T cells in humans and identifies IL-1ß as a potential classifier for a subgroup of IBD patients.

Anti-Tumour Necrosis Factor Therapy for Paediatric Crohn's Disease: Improved Benefits Through Treatment Optimisation, Deeper Understanding of Its Risks, and Reduced Costs due to Biosimilar Availability.

Antibodies directed to tumour necrosis factor-α (TNF-α) are very effective in treating paediatric Crohn's disease (CD). Over the last few years, research has provided important new insights into how to optimise this treatment's effectiveness. Research on predictors for anti-TNF treatment responsiveness has revealed potential markers, but data on their accuracy in paediatric CD patients are lagging behind. Also, new evidence has become available on the safety profile of anti-TNF antibodies that suggests the assumed increased malignancy risk seen in patients on anti-TNF and thiopurine combination treatment may be linked more to thiopurine use and not to anti-TNF treatment. In addition, the early results of CT-P13, an infliximab biosimilar, in CD patients confirm the expected similarity with its originator. Thus, the effectiveness of anti-TNF antibody treatment is slowly improving, its malignancy risk is lower than assumed, and its costs are reduced by the introduction of equally effective biosimilars. Together, these trends allow for a more prominent role for anti-TNF antibodies in future treatment of paediatric CD.

Malignancy and mortality in paediatric-onset inflammatory bowel disease: a 3-year prospective, multinational study from the paediatric IBD Porto group of ESPGHAN.

BACKGROUND: Risk benefit strategies in managing inflammatory bowel diseases (IBD) are dependent upon understanding the risks of uncontrolled inflammation vs those of treatments. Malignancy and mortality in IBD have been associated with disease-related inflammation and immune suppression, but data are limited due to their rare occurrence. AIM: To identify and describe the most common causes of mortality, types of cancer and previous or current therapy among children and young adults with paediatric-onset IBD. METHODS: Information on paediatric-onset IBD patients diagnosed with malignancy or mortality was prospectively collected via a survey in 25 countries over a 42-month period. Patients were included if death or malignancy occurred after IBD diagnosis but before the age of 26 years. RESULTS: In total, 60 patients were identified including 43 malignancies and 26 fatal cases (9 due to cancer). Main causes of fatality were malignancies (n = 9), IBD or IBD-therapy related nonmalignant causes (n = 10; including 5 infections), and suicides (n = 3). Three cases, all fatal, of hepatosplenic T-cell lymphoma were identified, all were biologic-naïve but thiopurine-exposed. No other haematological malignancies were fatal. The 6 other fatal cancer cases included 3 colorectal adenocarcinomas and 3 cholangiocarcinomas (CCAs). Primary sclerosing cholangitis (PSC) was present in 5 (56%) fatal cancers (1 colorectal carcinoma, 3 CCAs and 1 hepatosplenic T-cell lymphoma). CONCLUSIONS: We report the largest number of paediatric-onset IBD patients with cancer and/or fatal outcomes to date. Malignancies followed by infections were the major causes of mortality. We identified PSC as a significant risk factor for cancer-associated mortality. Disease-related adenocarcinomas were a commoner cause of death than lymphomas.

Progression of astrocytomas and meningiomas: an evaluation in vitro.

OBJECTIVES/BACKGROUND: In biological terms, progression means that malignancy increases as genetic mutations accumulate leading to increased proliferation and invasion capacity. By verifying the proliferation capacity, human telomerase reverse transcriptase (hTERT) expression and in vitro invasion, in a group of highly malignant glioblastomas, benign meningiomas and astrocytomas, at the initial stage of progression, we have analysed putative progression in vitro for proliferation and telomerase expression. MATERIALS AND METHODS: The relative proliferation status (visualized with Ki-67 antibodies) and presence of hTERT protein was analysed in 27 intracranial tumours (6 astrocytomas, 8 glioblastomas and 13 meningiomas) by immunohistochemistry on paraffin-embedded biopsy tissue, as well as on primary tumour-derived cell cultures. A confrontation model was used to analyse invasiveness in vitro. RESULTS: The mean proliferation indices were 22.3 (SD = 18.1) for glioblastomas and 2.1 (SD = 1.9) for low-grade (LG) astrocytomas. The group of benign meningiomas had a labelling index of 2.2 (SD = 2.7). Mean percentages of staining for hTERT varied between 36.5 (SD = 28.4) for glioblastomas and 10.2 (SD = 8.6) for LG astrocytomas. The group of benign meningiomas had a labelling index of 12.4 (SD = 19.2) for hTERT. A significant difference was seen for Ki-67 (P < 0.05) and hTERT (P < 0.001) in vivo versus in vitro. No difference was seen between the group of invasive and non-invasive tumour-derived cell cultures for the histopathological markers Ki-67 and hTERT (P > 0.05) in vitro. CONCLUSIONS: The elevated expression of hTERT and Ki-67 in vitro provides a potential prognostic tool for early detection of the progression of brain tumours. As tumour cells require telomerase for continued proliferation, the expression of hTERT may mark immortality, leading to indefinite life span. On the other hand, hTERT expression and cell proliferation are not linked directly to invasion in vitro.

Relation between telomerase activity, hTERT and telomere length for intracranial tumours.

Human linear chromosomes are capped by specialized DNA-protein structures called telomeres. The present study analysed the telomerase activity, hTERT protein and telomere length in meningiomas and gliomas in relation to their WHO grading. Fifty-three freshly dissected tumour biopsies were analysed for telomerase activity, hTERT protein expression and telomere length. Telomerase activity was examined in 41 of the 53 biopsies. Telomerase activity was detected in 3 of 35 (8.6%) screened meningiomas (1 benign, 1 atypical and 1 malignant meningioma). For hTERT expression, 56.4% of meningiomas were positive with a mean labelling index (hTERT LI) of 31.3% (SD=26.5) for the hTERT positive meningiomas. The mean telomere length for meningiomas was 6.983 kb (SD=1.969). For gliomas, no active telomerase was detected in 2 low-grade astrocytomas, whereas three of the four screened glioblastomas were positive for telomerase activity. The only hTERT protein positive astrocytoma had a mean labelling index of 9.0%. On the other hand, the hTERT LI for glioblastomas was 53.6% (SD=28.0). The two low-grade astrocytomas had a telomere length of 14.310 and 9.236 kb. The anaplastic astrocytoma had a telomere length of 4.903 kb and the glioblastomas 5.767 kb (SD=2.042). The normal meningeal and neuronal tissue is negative for telomerase activity and hTERT. The length was +/-10.000 kb. These results indicate that telomere shortening may be a critical step in pathogenesis of atypical and malignant meningiomas and gliomas. Critical telomere shortening in vitro was shown to activate telomerase.

Pharmacogenetics of thiopurine therapy in paediatric IBD patients.

BACKGROUND: Azathioprine is widely used in the treatment of children with inflammatory bowel disease. The occurrence and type of adverse events to azathioprine may be related to thiopurine S-methyltransferase (TPMT) enzyme activity and to inosine triphophate pyrophosphatase (ITPase) deficiency. AIM: Investigate frequencies of functional TPMT polymorphisms and ITPA polymorphisms and their association with the occurrence of adverse events during azathioprine therapy in a paediatric inflammatory bowel disease population. METHODS: Seventy-two azathioprine treated paediatric inflammatory bowel disease patients, 47% girls, mean age 12.5 years (range 6.5-17.5), were assessed for TPMT and ITPA polymorphisms and for adverse events. The relation between polymorphisms and adverse events is evaluated. RESULTS: Of all azathioprine treated patients, 11 experienced an adverse event for which azathioprine was stopped: pancreatitis (n = 4), leucopenia (n = 2) and 'general malaise' (n = 5). Of the 11 patients who stopped azathioprine because of adverse events, 10 had wild-type alleles for all investigated genotypes. Genotyping of ITPA 94C>A polymorphisms showed that two patients were homozygous, both tolerated azathioprine well. CONCLUSIONS: No association of functional ITPA and TPMT polymorphisms and the occurrence of azathioprine related adverse events could be detected. Pharmacogenetic assessment prior to thiopurine therapy does not seem warranted.

Digital measurements: a different approach to evaluate bone formation. A technical report.

In this study a digital measurement technique has been proposed to quantify bone formation on histological images. Two standard parietal defects were created in 30 adult rabbits. The animals were divided into six groups. Four animals of each group were randomly chosen as experimental group in which osteopontin-coated hydroxyapatite (OPN-HA) and hydroxyapatite (HA) were inserted alternatively in created defects. To observe the spontaneous healing process of defects, one animal of each group was used as control animal and these created defects did not receive any implants. The animals were sacrificed after 1, 2, 6, 12, 18 and 30 weeks. The histological sections were magnified (x100) and scanned digitally. The newly formed bone surfaces within the healing area were indicated and quantified by means of Adobe Photoshop 7 software. This measuring technique was found to be reliable and reproducible. The results of this study show no significant differences in bone formation between the OPN-HA and non-coated HA defects, although a significant difference in bone formation was measured at the margins of the defects treated with OPN-HA.

Telomerase activity and hTERT protein expression in meningiomas: an analysis in vivo versus in vitro.

BACKGROUND: Telomere length maintenance is essential for tumorigenesis. Most human tumours stabilise their chromosome ends by telomerase, a specialised reverse transcriptase that adds telomeric repeats (TTAGGG) to these ends. The main components of this telomerase complex are a reverse transcriptase (hTERT) and an integral RNA component (hTR). Most typical meningiomas, however, do not have active telomerase, although some express the hTERT component. The aim of this study was to evaluate telomerase activity and its reverse transcriptase for 33 (30 typical and three atypical) meningiomas in vivo and in vitro. MATERIALS AND METHODS: Telomerase activity was examined by the telomeric repeat amplification protocol (TRAP) assay. The protein, telomerase reverse transcriptase, was visualised by immunohistochemistry. RESULTS: In vivo, telomerase activity was detectable in one out of 30 typical meningiomas and in two out of three atypical meningiomas. hTERT protein expression in vivo was positive in 14 out of 33 (42%) cases. The mean percentage of positive nuclei was 12.9% (SD=21.0). In vitro, 22 out of 33 (66%) meningiomas were positive for hTERT, with a mean percentage of positive nuclei of 31.8% (SD=37.1). Only four expressed telomerase activity in vitro, from which three had expressed telomerase activity in vivo. A significant association was found for telomerase activity (p<0.001) and hTERT expression (p<0.001) in vivo versus in vitro; a significant association was found for hTERT expression and telomerase activity in vivo (p<0.05) and in vitro (p<0.05). CONCLUSION: The results of our study suggest that hTERT expression is an early event in carcinogenesis in contrast to telomerase activity. Fast-proliferating hTERT-positive tumour cells may overgrow in vitro by clonal selection.

PCNA, Ki-67 and hTERT in residual benign meningiomas.

BACKGROUND: Relapse in individual patients after incomplete/residual removal of meningiomas cannot be predicted by histology alone as re-growth occurs even in histologically benign meningiomas. MATERIALS AND METHODS: Proliferating cell nuclear antigen (PCNA), Ki-67 and human telomerase reverse transcriptase (hTERT) labelling indices were measured in histological sections derived from residual meningiomas in 37 patients to assess their relationship to relapse. The labelling index (LI) expressed the percentage of tumour cell nuclei immunoreactive for PCNA, Ki-67 or hTERT in 1,000 tumour cells counted per section. The histological specimens comprised the following 2 groups: (i) stable for at least 10 years after initial partial resection of residual meningiomas: 20 specimens; (ii) relapsing between 11 and 145 months after initial resection of residual meningiomas: 17 specimens. RESULTS: The proliferative activity and hTERT expression do not directly correlate with every relapse. The PCNA LI significantly differed in the relapsing group (10.8%) compared to the stable group (5.5%) (p=0.08). The Ki-67 LI also was higher in the relapsing group (2.5%) than in the stable group (2.0%), but not statistically significantly (p=0.9). hTERT LI was significantly higher in the relapsing group (27.8%) than in the stable group (7.2%) (p<0.01). CONCLUSION: The mean PCNA, Ki-67 and hTERT LI were higher in the relapsing group of residual meningiomas than in the stable group, although no statistical difference was found for PCNA and Ki-67. On the other hand, a statistical difference between the two groups of meningiomas was found for hTERT; however, it is no absolute predictor for relapse at the individual patient level.

Osteopontin and bone metabolism in healing cranial defects in rabbits.

Non-collagen proteins such as bone sialoprotein and osteopontin (OPN) form 10% of the extracellular bone matrix. In this study, the influence of OPN on bone repair was investigated. Human OPN (Innogenetics) was produced by a recombinant technique and bonded onto the surface of hydroxyapatite (Interpore 200). Thirty rabbits were divided into six equal groups. A circular defect (10mm) was prepared in each parietal bone. In four rabbits of each group the left and right defects were filled with either OPN-coated hydroxyapatite (OPN-HA) or non-coated hydroxyapatite (HA). One sham animal of each group received no implants. The animals were killed after 1, 2, 6, 12, 18 and 30 weeks. The histological sections were scanned and analysed digitally. There were no statistically significant differences in total bone formation between defects filled with OPN-HA and HA. Bone formation at the borders of the healing area was significantly higher in defects filled with OPN-HA than in those filled with HA. Less bone formation was noted in the OPN-HA and HA groups at the centre of the healing area than at the borders of the healing area and the dural area. Although some animals in the sham group showed a high level of bone formation in the dural area, this was not significantly different to that in the dural area of the other groups. There was no sign of infection or tissue rejection of the graft.

Invasion of rat neurogenic cell lines in embryonic chick heart fragments in vitro.

Invasive properties of 15 continuous neurogenic rat cell lines were investigated in vitro and were compared to their tumorigenicity in inbred BD IX rats. The cell lines were obtained by treating animals with a single transplacental dose of the carcinogen N-ethyl-N-nitrosourea (ENU) and 1) subsequently transferring brain cells into cell culture shortly after treatment or 2) explanting the resultant tumors from the offspring to monolayer cultures. In addition, one continuous nonneoplastic rat fibroblast line and three samples of untreated fetal rat brain cells were investigated. Cells from monolayer cultures were suspended and allowed to form aggregates for 24 hours on a gyratory shaker. The cell aggregates were then brought into contact with and allowed to attach to fragments from 9-days embryonic chick heart and were cultured on a gyratory shaker. All tumorigenic cell lines invaded the heart fragments, as characterized by progressive replacement of heart cells by invading cells. The heart tissue degenerated irreversibly. Nontumorigenic cell lines did not show invasiveness in vitro. Confrontation of cell aggregates and heart fragments in organotypic culture appeared to be a useful method to study directly the invasive properties of malignant transformants of neurogenic cells. The method might also permit prediction of tumorigenicity in the animal.

Characterization of spontaneous, chemicak, and viral transformants of a C3H/3T3-type mouse cell line by transplantation into young chick blastoderms.

Cells from a C3H/3T3-type cell line were transplanted into defects of the lower layer of stage-4 chick blastoderms before and after "spontaneous," chemical, and viral transformation. To check the validity of inhibition of lower-layer defect closure as a criterion of malignancy, we compared the behavior of the lower layer toward these cells with their in vitro growth pattern, their capacity to invade embryonic chick skin explants that were organotypicaly cultured, and their tumorigenicity in syngeneic mice. No false-positive results were observed with either test. The study of the in vitro growth pattern gave false-negative results during the early phase of spontaneous transformation, whereas these cells, exhibiting an untransformed growth pattern, were shown to be malignant by the other tests. We concluded that the inhibition of lower-layer defect closure is a reliable, sensitive and rapid test for the detection of malignancy in tissue-cultured cells from any source.

Adhesion of malignant and nonmalignant cells to cultured embryonic substrates.

To study adhesion, which is probably the initial step in malignant invasion, we associated tissue culture fragments with living substrates in vitro. Malignant HeLa, hepatoma, and PY cells, as well as nonmalignant BHK cells, were transplanted into cultured chick blastoderms and organ fragments from chick embryos. Adhesion was evaluated by time-lapse cinematography, by flushing with Tyrode's solution, and by histological examination after fixation. It was shown that the adhesion of these tissue culture fragments depends on the nature of the substrate. Substrates of connective tissue, mesenchyme, and the basal side of epithelia proved to be adhesive. In contrast, the apical side of intact epithelia was nonadhesive. Perforated epithelia allowed adhesion at the site of the perforation. In the presence of dilysine, HeLa cells adhere to the apical side of epithelia and to the dorsal side of the upper layer of the blastoderm. We concluded that the apical side of intact epithelia constitutes an inappropriate substrate for adhesion of a large variety of cells, in vitro as well as in vivo. Alteration of this characteristic in the presence of dilysine indicates that long-range electrostatic repulsion might be responsible for the nonadhesive character of the epithelia.

Invasiveness of hyperplastic nodule cells from diethylnitrosamine-treated rat liver.

Administration of diethylnitrosamine p.o. to female Sprague-Dawley rats induces hepatocellular lesions antecedent to hepatocarcinoma (altered foci and hyperplastic nodules). We have tested hepatocytes from hyperplastic nodules for their invasiveness in vitro, which is a marker for malignancy. The hyperplastic nodule cells are compared with control liver cells and hepatocarcinoma cells. Control liver tissue and the hepatocarcinoma are collected as fragments taken directly from the rat liver. Nodules, on the other hand, isolated by collagenase perfusion of the liver, are collected on a filter. The fragments of normal liver, the nodules, and the hepatocarcinomas were brought in contact with precultured 9-day-old embryonic chick heart fragments for attachment to each other to form confronting cultures. After attachment, the confronting cultures are incubated at 37 degrees on a gyratory shaker for 24 hr to 14 days. Hepatocytes from the nodules show progressive invasion into the precultured heart fragments in the same way as the hepatocarcinoma cells after 3 to 14 days in vitro. The control hepatocytes from the liver fragments showed no invasion. We conclude from these observations that the cells of the nodules must be considered as malignant altered hepatocytes, for they show progressive invasiveness in vitro.

Top-down Infliximab Study in Kids with Crohn's disease (TISKids): an international multicentre randomised controlled trial.

INTRODUCTION: Crohn's disease (CD) is a chronic inflammatory disease predominantly affecting the gastrointestinal tract. CD usually requires lifelong medication and is accompanied by severe complications, such as fistulae and strictures, resulting in surgery. Infliximab (IFX) is very effective for treating paediatric patients with CD, but is currently only registered for therapy refractory patients-the so-called step-up strategy. We hypothesise that using IFX first-line, that is, top-down, will give more mucosal healing, fewer relapses, less complications, need for surgery and hospitalisation. METHODS AND ANALYSIS: This international multicentre open-label randomised controlled trial includes children, aged 3-17 years, with new-onset, untreated CD with moderate-to-severe disease activity (weighted Paediatric Crohn's Disease Activity Index (wPCDAI)>40). Eligible patients will be randomised to top-down or step-up treatment. Top-down treatment consists of 5 IFX infusions combined with azathioprine (AZA). After these 5 infusions, patients will continue AZA. Patients randomised to step-up will receive standard induction treatment, either oral prednisolone or exclusive enteral nutrition, combined with AZA as maintenance treatment. The primary outcome is clinical remission (wPCDAI<12.5) at 52 weeks without need for additional CD-related therapy or surgery. Total follow-up is 5 years. Secondary outcomes include clinical disease activity, mucosal healing by endoscopy (at week 10 and optionally week 52), faecal calprotectin, growth, quality of life, medication use and adverse events. ETHICS AND DISSEMINATION: Conducted according to the Declaration of Helsinki and Good Clinical Practice. Medical-ethical approval will be obtained for each site. TRIAL REGISTRATION NUMBER: NCT02517684; Pre-results.

[Transition from paediatric to adult care: management of adolescents with inflammatory bowel disease]. / Transitie van kinder- naar volwassenenzorg.

The transfer of adolescent patients with inflammatory bowel disease (IBD) to adult gastroenterology services is often troublesome. Failed transition can have adverse effects on the course of disease. We present two cases of adolescent IBD patients and their transition process. We identify requirements for successful transition and discuss potential barriers. We illustrate and emphasise that the medical teams on each side (paediatric and adult), as well as the patient and the parents should actively participate in the process of transition. The medical team should, preferably during a local transition clinic, regularly evaluate disease knowledge and self-management skills of the patient and make an individual transition plan to fill the gaps in knowledge and/or skills. Patients should be willing to learn to become more independent and parents should be stimulated to create an environment so that their child can actually try to become more independent. Lastly, we present the Rotterdam model for transition of IBD patients.