Basic and clinical aspects of osteoporosis in inflammatory bowel disease

Exosome-based bone-targeting drug delivery alleviates impaired osteoblastic bone formation and bone loss in inflammatory bowel diseases

Systematic bone loss is commonly complicated with inflammatory bowel diseases (IBDs) with unclear pathogenesis and uncertain treatment. In experimental colitis mouse models established by dextran sulfate sodium and IL-10 knockout induced with piroxicam, bone mass and quality are significantly decreased. Colitis mice demonstrate a lower bone formation rate and fewer osteoblasts in femur. Bone marrow mesenchymal stem/stromal cells (BMSCs) from colitis mice tend to differentiate into adipocytes rather than osteoblasts. Serum from patients with IBD promotes adipogenesis of human BMSCs. RNA sequencing reveals that colitis downregulates Wnt signaling in BMSCs. For treatment, exosomes with Golgi glycoprotein 1 inserted could carry Wnt agonist 1 and accumulate in bone via intravenous administration. They could alleviate bone loss, promote bone formation, and accelerate fracture healing in colitis mice. Collectively, BMSC commitment in inflammatory microenvironment contributes to lower bone quantity and quality and could be rescued by redirecting differentiation toward osteoblasts through bone-targeted drug delivery.

Mass Spectrometric Behavior and Molecular Mechanisms of Fermented Deoxyanthocyanidins to Alleviate Ulcerative Colitis Based on Network Pharmacology

Aims. Ulcerative colitis (UC) is a type of chronic idiopathic inflammatory bowel disease with a multifactorial pathogenesis and limited treatment options. The aim of the present study is to investigate the hydrogen deuterium exchange mass spectrometry (HDX-MS) behaviors of fermented deoxyanthocyanidins and their molecular mechanisms to alleviate UC by using quantum chemistry and network pharmacology. Methods. Tandem MS indicated at least two fragmentation pathways through which deuterated vinylphenol-deoxyanthocyanidins could generate different product ions. Quantum calculations were conducted to determine the transition states of the relevant molecules and analyze their optimized configuration, vibrational characteristics, intrinsic reaction coordinates, and corresponding energies. The potential targets of deoxyanthocyanidins in UC were screened from a public database. The R package was used for Gene Ontology (GO) and KEGG pathway analyses, and the protein–protein interactions (PPIs) of the targets were assessed using Search Tool for the Retrieval of Interacting Genes (STRING). Finally, molecular docking was implemented to analyze the binding energies and action modes of the target compounds through the online tool CB-Dock. Results. Quantum calculations indicated two potential fragmentation pathways involving the six-membered ring and dihydrogen cooperative transfer reactions of the vinylphenol-deoxyanthocyanidins. A total of 146 and 57 intersecting targets of natural and fermented deoxyanthocyanidins were separately screened out from the UC database and significant overlaps in GO terms and KEGG pathways were noted. Three shared hub targets (i.e., PTGS2, ESR1, and EGFR) were selected from the two PPI networks by STRING. Molecular docking results showed that all deoxyanthocyanidins have a good binding potential with the hub target proteins and that fermented deoxyanthocyanidins have lower binding energies and more stable conformations compared with natural ones. Conclusions. Deoxyanthocyanidins may provide anti-inflammatory, antioxidative, and immune system regulatory effects to suppress UC progression. It is proposed for the first time that fermentation of deoxyanthocyanidins can help adjust the structure of the intestinal microbiota and increase the biological activity of the natural compounds against UC. Furthermore, HDX-MS is a helpful strategy to analyze deoxyanthocyanidin metabolites with unknown structures.

Trends and Outcomes of Hip Fracture Hospitalization Among Medicare Beneficiaries with Inflammatory Bowel Disease, 2000-2017

BACKGROUND

Patients with inflammatory bowel disease (IBD) have a higher risk of hip fracture, but lower likelihood of having arthroplasties than non-IBD patients in Nationwide Inpatient Sample. Little is known about hip fracture-associated hospitalization outcomes.

AIMS

We assessed the trends in hip fracture hospitalization rates from 2000 to 2017 and estimated 30-day readmission, 30-day mortality, and length of stay in 2016 and 2017.

METHODS

We estimated trends of age-adjusted hospitalization rates using a piecewise linear regression. Medicare beneficiaries aged ≥ 66 years with Crohn's disease (CD, n = 2014) or ulcerative colitis (UC, n = 2971) hospitalized for hip fracture were identified. We performed propensity score matching to create 1:3 matched samples on age, race/ethnicity, sex, and chronic conditions and compared hospitalization outcomes between matched samples.

RESULTS

In 2017, the age-adjusted hospitalization rates (per 100) were 1.15 [95% CI = (1.07-1.24)] for CD, 0.86 [95% CI = (0.82-0.89)] for UC, and 0.59 [95% CI = (0.59-0.59)] for no IBD. The hospitalization rates for CD and UC decreased from 2000 to 2012 and then increased from 2012 to 2017. Compared to matched cohorts, CD patients had longer hospital stays (5.55 days vs. 5.30 days, p = 0.01); UC patients were more likely to have 30-day readmissions (17.27% vs. 13.71%, p < 0.001), longer hospital stays (5.59 days vs. 5.40 days, p = 0.02), and less likely to have 30-day mortality (3.77% vs. 5.15%, p = 0.003).

CONCLUSIONS

Prevention of hip fracture is important for older adults with IBD, especially CD. Strategies that improve quality of inpatient care for IBD patients hospitalized for hip fracture should be considered.

An analysis of the prevalence of osteoporosis and osteopenia in patients with epidermolysis bullosa: A cross-sectional study

BACKGROUND

Epidermolysis bullosa (EB) patients have multiple risk factors for osteoporosis. There is limited literature describing the prevalence of bone health in EB, particularly in adults and less severe EB types.

OBJECTIVES

To investigate the prevalence of osteopenia or osteoporosis in EB patients from the Australasian Epidermolysis Bullosa Registry (AEBR).

METHODS

Of 417 AEBR patients, 72 underwent a dual energy X-ray absorptiometry scan. Bone mineral density (BMD) T and Z-scores, EB Disease Activity and Scarring Index (EBDASI), and Quality of Life in EB (QOLEB) scores were obtained.

RESULTS

T-scores of RDEB patients were significantly lower than the diagnostic cut-off value for osteopenia. EBDASI and QOLEB scores were inversely correlated with Z-scores. The prevalence of osteoporosis in adults was 75% in severe EB types (RDEB and JEB). In adults with less severe types (EBS and DDEB), the prevalence of osteopenia was 50% and 33%, respectively.

CONCLUSIONS

This is the largest study of osteoporosis in EB to date and the first to include adult patients with EBS. The high prevalence of osteoporosis and osteopenia identified in these patients warrants larger, collaborative international studies. Nevertheless, EB patients with high disease severity and QOL scores, irrespective of type, should receive early osteoporosis screening and prophylaxis.

Updated bone mineral density status in Saudi patients with inflammatory bowel disease

BACKGROUND

Little is known about inflammatory bowel disease (IBD) burden and its impact on bone mineral density (BMD) among adult patients in Saudi Arabia. To the best of our knowledge, our study is the only study to give an update about this health problem in adult Saudi patients with IBD. IBD is a great risk factor for reduced BMD due to its associated chronic inflammation, malabsorption, weight loss and medication side effects. Consequently, screening for reduced BMD among patients with IBD is of utmost importance to curb and control anticipated morbidity and mortality among those patients.

AIM

To assess the relationship between IBD and BMD in a sample of adult Saudi patients with IBD.

METHODS

Ninety adult patients with IBD - 62 Crohn's disease (CD) and 28 ulcerative colitis (UC) - were recruited from King Fahad Specialist Hospital gastroenterology clinics in Buraidah, Al-Qassim. All enrolled patients were interviewed for their demographic information and for IBD- and BMD-related clinical data. All patients had the necessary laboratory markers and dual-energy x-ray absorptiometry scans to evaluate their BMD status. Patients were divided into two groups (CD and UC) to explore their clinical characteristics and possible risk factors for reduced BMD.

RESULTS

The CD group was significantly more prone to osteopenia and osteoporosis compared to the UC group; 44% of the CD patients had normal BMD, 19% had osteopenia, and 37% had osteoporosis, while 78% of the UC patients had normal BMD, 7% had osteopenia, and 25% had osteoporosis (P value < 0.05). In the CD group, the lowest t-score showed a statistically significant correlation with body mass index (BMI) (r = 0.45, P < 0.001), lumbar z-score (r = 0.77, P < 0.05) and femur z-score (r = 0.85, P < 0.05). In the UC group, the lowest t-score showed only statistically significant correlation with the lumbar z-score (r = 0.82, P < 0.05) and femur z-score (r = 0.80, P < 0.05). The ROC-curve showed that low BMI could predict the lowest t-score in the CD group with the best cut-off value at ≤ 23.43 (m/kg2); area under the curve was 0.73 (95%CI: 0.59-0.84), with a sensitivity of 77%, and a specificity of 63%.

CONCLUSION

Saudi patients with IBD still have an increased risk of reduced BMD, more in CD patients. Low BMI is a significant risk factor for reduced BMD in CD patients.

ESR1 Gene Variants Are Predictive of Osteoporosis in Female Patients with Crohn's Disease

Decreased bone mass in patients with inflammatory bowel diseases (IBD) is a clinical problem with extremely severe consequences of osteoporotic fractures. Despite its increasing prevalence and the need for mandatory intervention and monitoring, it is often ignored in IBD patients’ care. Determining the biomarkers of susceptibility to bone mineral density disorder in IBD patients appears to be indispensable. We aim to investigate the impact of estrogen receptor gene (ESR1) gene polymorphisms on bone mineral density (BMD) in patients with ulcerative colitis (UC) and Crohn’s disease (CD), as they may contribute both, to osteoporosis and inflammatory processes. We characterised 197 patients with IBD (97 with UC, 100 with CD), and 41 controls carrying out vitamin D, calcium and phosphorus serum levels, and bone mineral density assessment at the lumbar spine and the femoral neck by dual-energy X-ray absorptiometry (DXA), ESR1 genotyping and haplotype analysis. We observed that women with CD showed the lowest bone density parameters, which corresponded to the ESR1 c.454-397T and c.454-351A allele dose. The ESR1 gene PvuII and XbaI TA (px) haplotype correlated with decreased femoral neck T-score (OR = 2.75, CI = [1.21–6.27], P-value = 0.016) and may be predictive of osteoporosis in female patients with CD.

Does the Antitumor Necrosis Factor-α Therapy Decrease the Vertebral Fractures Occurrence in Inflammatory Bowel Disease?

BACKGROUND/OBJECTIVE

Osteoporosis and osteoporotic fracture risk are extraintestinal manifestations of the inflammatory bowel disease, whose etiopathogenic mechanisms have not been determined yet. Anti-tumor necrosis factor (TNF)-α are used in treatment of inflammatory bowel disease (IBD), but it is unknown if they play a role in osteoporotic fracture prevention. The objective of this study was to know if anti-TNF decreases fracture risk or modifies bone mineral density. To determine the possible risk factors associated with fractures, and assess the incidence of vertebral fractures in IBD patients.

METHODS

Longitudinal prospective cohort study (7 yr of follow-up); which included 71 IBD patients, 23 received anti-TNF-α; the remaining 48 received conventional treatment, constituted the control group. Patients participated in a questionnaire which gathered risk factors associated with the development of osteoporosis and fractures. Radiographs of the dorsolumbar-spine were performed and also a bone density measurement. Their biochemical and bone remodeling parameters were determined.

RESULTS

Although patients who did not receive anti-TNF-α, suffered more fractures but biologic therapy did not reduce the risk of new vertebral fractures. The increase of bone mass was significantly higher the group treated with anti-TNF-α. The increase in the lumbar spine was of 8% and in the femoral neck was of 6.7%. The only determinant factor for the incidence of vertebral fractures was a history of previous fractures (odds ratio of 12.8; confidence interval 95% 2.37-69.9; p = 0.003). The incidence of vertebral fractures in IBD patients was considerably high: 26.7/700 patient-yr.

CONCLUSIONS

Anti-TNF-α, although increased bone mass in these patients, did not reduce the risk of new vertebral fractures. In this study, patients with IBD have a considerably high incidence of fractures. Only the existence of previous vertebral fractures was a predictive factor for consistent fractures.

Clinical and genetic risk factors for decreased bone mineral density in Japanese patients with inflammatory bowel disease

BACKGROUND AND AIM

Patients with inflammatory bowel disease (IBD) are at a high risk of low bone mineral density (BMD). Reportedly, clinical and genetic factors cause low BMD in Caucasians; however, studies in non-Caucasian populations remain scarce.

METHODS

Clinical risk factors for low BMD were investigated in 266 Japanese patients with IBD, and a genome-wide association analysis (GWAS) was performed using linear regression with associated clinical factors as covariates. Genotyping was performed using a population-optimized genotyping array (Japonica array^® ). After quality control, the genotype data of 4 384 682 single-nucleotide polymorphisms (SNPs) from 254 patients with IBD were used for GWAS.

RESULTS

Body mass index, age, and disease duration were independently associated with the BMD of the femoral neck (P = 1.41E - 13, 1.04E - 5, and 1.58E - 3, respectively), and body mass index and sex were associated with the BMD of the lumbar spine (P = 6.90E - 10 and 6.84E - 3, respectively). In GWAS, 118 and 42 candidate SNPs of the femoral neck and lumbar spine, respectively, were identified. Among 118, 111 candidate SNPs of the femoral neck were located within the SLC22A23 gene, which is a known IBD susceptibility gene (minimum P = 1.42E - 07). Among 42, 18 candidate SNPs of the lumbar spine were located within the MECOM gene, which is associated with osteopenia (minimum P = 5.86E - 07). Interestingly, none of the known loci showed a significant association with BMD.

CONCLUSIONS

Although clinical risk factors for low BMD in IBD were similar to those in the general population, genetic risk factors were rather different.

Soluble Tumor Necrosis Factor Alpha Receptor 1, Bone Resorption, and Bone Mineral Density in the Year Following Hip Fractures: The Baltimore Hip Studies

Although inflammation is known to influence bone turnover and bone mineral density (BMD), less is known about role of soluble tumor necrosis factor alpha receptor 1 (sTNFα-R1) in changes in bone turnover and BMD in the year after hip fracture. We studied 245 persons (117 men and 128 women) from the Baltimore Hip Studies. Bone turnover markers of resorption (carboxy-terminal type I collagen cross-links [CTX-I]) and formation (amino-terminal propeptide type I collagen [P1NP]), BMD of the contralateral hip, and sTNFα-R1 were measured within 15 days of hospitalization and 2, 6, and 12 months later. Latent class growth modeling was used to determine sTNFα-R1 trajectories. Weighted generalized estimating equations were used to examine the association of sTNFα-R1 trajectories with serum levels of CTX-I and P1NP and BMD; standardized beta coefficients (βˆ) are reported. Higher baseline sTNFα-R1 was significantly associated with a greater rate of CTX-I change (βˆ = 0.26, p = 0.004). Four distinct sTNFα-R1 trajectories were identified. The two groups with higher sTNFα-R1 levels during the year following fracture had faster increasing levels of CTX-I compared to the group with lowest sTNFα-R1 levels (men: group 3: βˆ = 0.76, p = 0.02; group 4: βˆ = 1.4, p < 0.001; women: group 3; βˆ = 0.67, p = 0.02; group 4: βˆ = 1.3, p = 0.004). Men in the highest sTNFα-R1 group had a greater decline in BMD compared to the lowest sTNFα-R1 group (2-month βˆ = -0.01, p = 0.01; 6-month: βˆ = -0.09, p = 0.001; 12-months: βˆ = -0.1, p < 0.001). An increasing rate of CTX-I was associated with a steeper decline in total hip BMD in those within higher sTNFα-R1 trajectory groups (p < 0.001). CTX-I was significantly increased with sTNFα-R1 in both sexes. CTX-I and the highest sTNFα-R1 trajectory were significantly associated with declines in total hip BMD in men. Interventions that reduce systemic inflammation should be explored to reduce bone resorption and prevent a decline in BMD after hip fracture. © 2018 American Society for Bone and Mineral Research.

siRNA Delivery for Control of Cyclin D1 and E2F1 Expression in Crohn's Disease

Evidence in inflammatory bowel diseases (IBD) supports a connection between inflammation and cancer due to the alteration of the cell cycle with loss of control at the G1/S checkpoint. In this study, we analyze the expression and modulation of CyD1 and E2F1 in colon explants from Crohn's disease (CD) patients. We used ex vivo culture of colon explants from 4 CD patients and 2 healthy controls, stimulated with lipopolysaccharide from Escherichia Coli (EC-LPS). Commercial siRNAs for CyD1 and E2F1 inhibition were encapsulated in Invivofectamine® and in purposely produced nanoliposomal vectors to silencing CyD1 and E2F1 expression. Western blot analysis was used to investigate the effect of siRNA on CyD1, E2F1 and cyclooxygenase 2 (COX-2) expression. In CD patients colon explants, CyD1 and E2F1 increased after the inflammatory stimulus but siRNA silencing attenuated their expression and controlled the COX-2 expression too. These data represent a prelimiary exploration of in vitro siRNA use.

siRNA Delivery for Control of Cyclin D1 and E2F1 Expression in Crohn's Disease

Evidence in inflammatory bowel diseases (IBD) supports a connection between inflammation and cancer due to the alteration of the cell cycle with loss of control at the G1/S checkpoint. In this study, we analyze the expression and modulation of CyD1 and E2F1 in colon explants from Crohn's disease (CD) patients. We used ex vivo culture of colon explants from 4 CD patients and 2 healthy controls, stimulated with lipopolysaccharide from Escherichia Coli (EC-LPS). Commercial siRNAs for CyD1 and E2F1 inhibition were encapsulated in Invivofectamine® and in purposely produced nanoliposomal vectors to silencing CyD1 and E2F1 expression. Western blot analysis was used to investigate the effect of siRNA on CyD1, E2F1 and cyclooxygenase 2 (COX-2) expression. In CD patients colon explants, CyD1 and E2F1 increased after the inflammatory stimulus but siRNA silencing attenuated their expression and controlled the COX-2 expression too. These data represent a prelimiary exploration of in vitro siRNA use.

The c.29T>C polymorphism of the transforming growth factor beta-1 (TGFB1) gene, bone mineral density and the occurrence of low-energy fractures in patients with inflammatory bowel disease

Gastrointestinal tract conditions are frequently associated with low bone mineral density and increased risk of fractures due to osteoporosis, the latter concerning particularly inflammatory bowel disease (IBD) patients. One of the candidate genes involved in osteoporosis is the transforming growth factor beta-1 (TGFB1) whose polymorphisms may be responsible for the development of this disease. The aim of this study was to analyse the frequency of TGFB1 polymorphic variants and determine the association between the c.29T>C TGFB1 polymorphism, and bone mineral density and fractures in IBD patients. The study subjects included 198 IBD patients [100 suffering from Crohn's disease (CD) and 98 from ulcerative colitis (UC)] and 41 healthy volunteers as a control group. Densitometric bone measurements were obtained using dual energy X-ray absorptiometry. The TGFB1 genotyping was conducted using restriction fragments length polymorphism. We conducted an analysis of genotype distribution's concordance with Hardy-Weinberg equilibrium. We found statistically significant differences in lumbar spine (L2-L4) and femoral neck BMD and T-scores between CD, UC and control subgroups. The distribution of TGFB1 polymorphic variants among CD and UC patients was concordant with Hardy-Weinberg equilibrium. There were no statistically significant differences in densitometric parameters (lumbar spine and femoral neck BMD, T-score, and Z-score) between carriers of different TGFB1 polymorphisms among IBD (CD and UC) patients nor among controls. We have found no statistically significant differences in the prevalence of low-energy fractures between groups of different TGFB1 polymorphic variant carriers. The allele dose effect, recessive effect and dominant effect analysis did not show an association between low-energy fractures and the TGFB1 polymorphisms among CD and UC patients. We have not observed an association between the c.29T>C TGFB1 polymorphic variant and the bone mineral density within the cancellous and cortical bones (L2-L4 and femoral neck, respectively), or the occurrence of fractures among the IBD patients and their family members.

Widely differing screening and treatment practice for osteoporosis in patients with inflammatory bowel diseases in the Swiss IBD cohort study

Low bone mineral density (BMD) and osteoporosis remain frequent problems in patients with inflammatory bowel diseases (IBDs). Several guidelines with nonidentical recommendations exist and there is no general agreement regarding the optimal approach for osteoporosis screening in IBD patients. Clinical practice of osteoporosis screening and treatment remains insufficiently investigated.In the year 2014, a chart review of 877 patients included in the Swiss IBD Cohort study was performed to assess details of osteoporosis diagnostics and treatment. BMD measurements, osteoporosis treatment, and IBD medication were recorded.Our chart review revealed 253 dual-energy x-ray absorptiometry (DXA) scans in 877 IBD patients; osteoporosis was prevalent in 20% of tested patients. We identified widely differing osteoporosis screening rates among centers (11%-62%). A multivariate logistic regression analysis identified predictive factors for screening including steroid usage, long disease duration, and perianal disease; even after correction for all risk factors, the study center remained a strong independent predictor (odds ratio 2.3-21 compared to the center with the lowest screening rate). Treatment rates for patients with osteoporosis were suboptimal (55% for calcium, 65% for vitamin D) at the time of chart review. Similarly, a significant fraction of patients with current steroid medication were not treated with vitamin D or calcium (treatment rates 53% for calcium, 58% for vitamin D). For only 29% of patients with osteoporosis bisphosphonate treatment was started. Treatment rates also differed among centers, generally following screening rates. In patients with longitudinal DXA scans, calcium and vitamin D usage was significantly associated with improvement of BMD over time.Our analysis identified inconsistent usage of osteoporosis screening and underuse of osteoporosis treatment in IBD patients. Increasing awareness of osteoporosis as a significant clinical problem in IBD patients might improve patient care.

Novel Biomarkers and the Future Potential of Biomarkers in Inflammatory Bowel Disease

There is increasing importance placed upon noninvasive assessment of gut inflammation. These tools are likely to be the key in differentiating intestinal inflammatory disease from functional disorders and in monitoring the response to intervention in individuals with known inflammatory conditions. Although various noninvasive markers are currently available, they have limitations and do not provide ideal utility. This review focuses on emerging markers of gut inflammation, highlighting the potential of specific markers.

Bone status assessed by quantitative ultrasound in children with inflammatory bowel disease: a comparison with DXA

BACKGROUND

To determine the bone status in children with inflammatory bowel diseases (IBD) using quantitative ultrasound (QUS) measurement at hand phalanges and compare the obtained results with dual-energy X-ray absorptiometry (DXA).

METHODS

Fifty-one children with IBD underwent DXA and QUS measurements at hand phalanges in the year 2013. The control group for the QUS consisted of 460 children. Reference data for DXA comes from Hologic Explorer.

RESULTS

QUS measurements did not differ significantly between IBD patients and healthy controls. There was no difference between UC and CD subjects. DXA measurements in patients with IBD were lower than in the healthy population. Tanner stage and nutritional status correlated with bone status contrary to steroids therapy.

CONCLUSION

Low bone mineral density often complicates IBD in children. QUS is not an appropriate method for the assessment of bone status in children. Nutritional status seems to have a greater impact on bone status than corticosteroids therapy.

Correlation between low bone density and disease activity in patients with ulcerative colitis

BACKGROUND Different clinical and epidemiological studies using dual-energy X-ray absorptiometry have shown an increased prevalence of low bone mineral density in patients with inflammatory bowel diseases. The aim of this study was to assess the correlation between bone density and the disease activity in patients with ulcerative colitis. METHODS In this cross-sectional study, 52 patients with ulcerative colitis (duration of the disease less than 5 years) were invited to our research center, Golestan province, northeast of Iran, during February 2012 up to August 2012. A demographic checklist and Simple Clinical Colitis Activity Index was completed for each patients and 5 cc of blood sample was taken after obtaining the informed consent. We used colorimetry method for measuring serum calcium, UV method for serum phosphorus and ELISA for serum vitamin D. Dual-energy X-ray absorptiometry was done to evaluate the bone density. Data analysis was done using SPSS software version 16. Normality of data was assessed using Kolmogorov- Smirnov test. T and ANOVA tests were used if data had normal distribution. Mann-Whitney U or Kruskal-Wallis tests were used for the remaining data. Correlation between qualitative variables was evaluated by Chi-square test. RESULTS The mean (±SD) age and disease activity of the patients were 37.72 (±12.18) years and 4.78 (±1.98), respectively. There were no correlation between disease activity and mean age. Low bone density was seen in 30.8%, 11.5%, and 15.4% in spine, femur neck, and hip, respectively. There was no relationship between Z-score of total hip, spine, and femur neck with disease activity, age, and duration of disease (p>0.05). CONCLUSION Our results showed an acceptable rate of low bone density in patients with ulcerative colitis without any correlation with the disease activity index.

Nutrient intake and bone mineral density by nutritional status in patients with inflammatory bowel disease

BACKGROUND

Malnutrition among inflammatory bowel disease (IBD) may arise from factors including inadequate dietary intake, malabsorption, and progression of disease. IBD has been reported an increased prevalence of low bone mass. The aims of the present study were to evaluate the nutritional status and to investigate the correlation between bone mineral density (BMD) and nutrient factors in patients with IBD.

METHODS

A total of 41 subjects were classified into normal group (n=21) and malnourished group (n=20) by the subjective global assessment result. We surveyed the dietary habit, nutrient intake, and BMD.

RESULTS

Subjects' average age was 36.7 years old, and included 26 ulcerative colitis and 15 Crohn's disease. The serum C-reactive protein (CRP) was significantly higher and serum calcium was significantly lower in the malnourished group. Lower bone density subjects were more in the malnourished group but no significant difference. Intake of energy, protein, carbohydrate, fiber, iron, sodium, potassium, zinc, vitamin B6, vitamin C and folate were significantly lower in the malnourished group. The BMD of malnourished group showed correlation with triceps skin fold thickness (TSF), CRP, dietary calcium, phosphorous, iron, animal iron, zinc and vitamin.

CONCLUSIONS

The results suggested that adequate intake of nutrients is important to prevent bone loss and systemic education programs are need for IBD patients.

Osteoprotegerin exerts its pro-inflammatory effects through nuclear factor-κB activation

BACKGROUND

Osteoprotegerin (OPG), a soluble member of the tumor necrosis factor (TNF) receptor super-family, is a key factor inhibiting the differentiation and activation of osteoclasts. It has recently been implicated as a disease marker for inflammatory bowel disease (IBD) yet its role in the intestinal epithelial inflammatory response remains unknown.

AIM

The primary objective of this study was to investigate whether OPG has a role in intestinal inflammation and a potential role in IBD pathogenesis.

METHODS

Caco-2 and HT-29 cells were grown in vitro to confluence on culture-permeable supports and then co-cultured with either TNF-α or OPG. After exposure to either TNF-α or OPG, interleukin (IL)-8 protein and mRNA levels were evaluated. Ussing chamber, western blotting, real-time polymerase chain reaction, and immunofluorescence were used to further investigate the effect of OPG on intestinal barrier integrity and function.

RESULTS

Similar to TNF-α, treatment of monolayers with OPG caused increased monolayer permeability and diminished tight junction function and integrity, with loss of tight junction proteins from cell membranes. This was accompanied by elevated IL-8 protein and gene levels (P < 0.05). Western blotting also revealed that OPG, similar to TNF-α, induced NF-κB activation, as shown by inhibition of NF-κB kinase subunit-α phosphorylation.

CONCLUSIONS

These results indicate that OPG has pro-inflammatory properties because it induces gut barrier dysfunction and secretion of other pro-inflammatory cytokines. These results also provide evidence that OPG is likely to exert its pro-inflammatory effects through NF-κB activation and may potently contribute to IBD pathogenesis.

NSAIDs can have adverse effects on bone healing

The science of osteoimmunology, a relatively new field of research, reveals the important interactions between the immune system and skeletal system. Interactions occur between prostaglandin metabolism, inflammatory proteins and bone metabolism. Systemic as well as local sources of inflammation appear to be actively involved in both bone formation and resorption. Non Steroidal Anti-Inflammatory Drugs (NSAIDs) can play a detrimental role in bone fractures, opposing the aim of the intervention, and can have such a negative impact on the synthesis of prostaglandins that they could even promote bone resorption. When used for a prolonged time, NSAIDs can also cause the development of an inflammatory cascade starting from the gastro-intestinal system, possibly resulting in bone resorption. Several studies show that the use of either selective or non-selective NSAIDs are intimately related to disturbances in immunological allostasis, bone metabolism and the inhibition or impediment of bone healing.

Enteropathic spondyloarthritis: from diagnosis to treatment

Enteropathic arthritis (EA) is a spondyloarthritis (SpA) which occurs in patients with inflammatory bowel diseases (IBDs) and other gastrointestinal diseases. Diagnosis is generally established on the medical history and physical examination. It was, generally, made according to the European Spondyloarthropathy Study Group (ESSG) criteria. Rheumatic manifestations are the most frequent extraintestinal findings of IBD with a prevalence between 17% and 39%, and IBD is associated, less frequently, with other rheumatic disease such as rheumatoid arthritis, Sjogren syndrome, Takayasu arteritis, and fibromyalgia. Although the pathogenesis of EA has not been plainly clarified, the most popular theory supposes that joint inflammation occurs in genetically predisposed subjects with bacterial gut infections, provided an important evidence for a possible relationship between inflammation of the gut mucosa and arthritis. The management of patients with EA requires an active cooperation between the gastroenterologist and rheumatologist.

Vertebral fractures in patients with inflammatory bowel disease compared with a healthy population: a prospective case-control study

Background

A prospective study was performed to compare the prevalence of morphometric vertebral fractures (MVF) between patients with inflammatory bowel disease (IBD) and healthy subjects and to identify predictive factors of fracture.

Methods

A total of 107 patients with IBD (53 with Crohn’s disease and 54 with ulcerative colitis) and 51 healthy subjects participated in the study. Information about anthropometric parameters, toxins, previous fractures, and parameters related to this disease were evaluated. The index of vertebral deformity, bone mass density (BMD), and biochemical parameters were calculated.

Results

A total of 72 fractures were detected in 38.32% of patients with IBD, and 10 fractures were detected in 13.73% of healthy subjects; the risk of fracture in patients with IBD was higher than that in control subjects (OR, 4.03; 95% CI, 1.652–9.847; p < 0.002). We found no correlation between fracture and BMD in patients with IBD (lumbar spine, r = −0.103, p = 0.17 and femoral neck, r = −0.138, p = 0.07). Corticosteroid treatment was not associated with prevalent vertebral fractures nor with taking corticosteroids (r = 0.135, p = 0.14) or the duration for which they were taken (r = 0.08, p = 0.38), whereas this relationship was present in the controls (r = −0.365, p = 0.01). In the multivariate analysis, none of the measured parameters were significantly predictive of fracture, only to manifested IBD. Hypovitaminosis D was observed in 55.14% of patients with IBD.

Conclusions

The prevalence of morphometric vertebral fractures is higher in patients with IBD than in the healthy population, without association with BMD or corticoid treatment. Simply having IBD was proven to be a predictive factor of fracture. We observed a high incidence of hypovitaminosis D in patients with IBD.

Low body mass index can identify majority of osteoporotic inflammatory bowel disease patients missed by current guidelines

BACKGROUND

Patients with inflammatory bowel disease (IBD) are at high risk of developing osteoporosis. Our objective was to determine the usefulness of IBD guidelines in identifying patients at risk for developing osteoporosis.

METHODS

We utilized institutional repository to identify patients seen in IBD center and extracted data on demographics, disease history, conventional, and nonconventional risk factors for osteoporosis and Dual Energy X-ray Absorptiometry (DXA) findings.

RESULTS

59% of patients (1004/1703) in our IBD cohort had at least one risk factor for osteoporosis screening. DXA was documented in 263 patients with indication of screening (provider adherence, 26.2%), and of these, 196 patients had DXA completed ("at-risk" group). Ninety-five patients not meeting guidelines-based risk factors also had DXA completed ("not at-risk" group). 139 (70.9%) patients in "at-risk" group had low BMD, while 51 (53.7%) of "not-at-risk" patients had low BMD. Majority of the patients with osteoporosis (83.3%) missed by the current guidelines had low BMI. Multivariate logistic regression analysis showed that low BMI was the strongest risk factor for osteoporosis (OR 3.07; 95% CI, 1.47-6.42; P = 0.003).

CONCLUSIONS

Provider adherence to current guidelines is suboptimal. Low BMI can identify majority of the patients with osteoporosis that are missed by current guidelines.

The contribution of bone to whole-organism physiology

The mouse genetic revolution has shown repeatedly that most organs have more functions than expected. This has led to the realization that, in addition to a molecular and cellular approach, there is a need for a whole-organism study of physiology. The skeleton is an example of how a whole-organism approach to physiology can broaden the functions of a given organ, reveal connections of this organ with others such as the brain, pancreas and gut, and shed new light on the pathogenesis of degenerative diseases affecting multiple organs.

The prevalence and risk factors of decreased bone mineral density in firstly diagnosed ulcerative colitis patients in the eastern region of Turkey

The prevalance of osteoporosis or osteopenia in Turkish population with ulcerative colitis (UC) at the diagnosis time has not been evaluated so far. Therefore we aimed to determine the prevelance and risk factors of decreased bone mineral density (BMD) in UC patients at the diagnosis time in Turkey. We retrospectively evaluated dexa results, demographic and clinical characteristics, and some biochemical markers of bone turnover of the UC patients at the diagnosis time between June 2005 and February 2010 from the gastroenterology clinic records of the university hospital. The study population consisted of firstly diagnosed 63 UC patients (male: female = 27: 36; mean age 41.8 years). 38.1% at lumbar spine and 44.4% at femoral neck of the Turkish UC patients patients had low BMD at the diagnosis time. The occurrence of osteoporosis among Turkish UC patients at the diagnosis time were 8% at lumbar spine and 11% at femoral neck. 30.1% at lumbar spine and 33.3% at femoral neck of the patients had osteopenia at the diagnosis time. Pearson's coefficient of correlation showed significant correlations between low BMD and pancolitis (p<0.01), age, menopause, and symptom duration before the diagnosis (p<0.05).In conclusion, the prevelance of low bone density at the diagnosis time in Turkish UC patients is in accordance with Western and Eastern societies. Pancolitis, age, duration of symptoms, and menopause are predictive factors for low bone density in these patients.

Cooperative role of NF-{kappa}B and poly(ADP-ribose) polymerase 1 (PARP-1) in the TNF-induced inhibition of PHEX expression in osteoblasts

Reduced bone mass is a common complication in chronic inflammatory diseases, although the mechanisms are not completely understood. The PHEX gene encodes a zinc endopeptidase expressed in osteoblasts and contributes to bone mineralization. The aim of this study was to determine the molecular mechanism involved in TNF-mediated down-regulation of Phex gene transcription. We demonstrate down-regulation of the Phex gene in two models of colitis: naive T-cell transfer and in gnotobiotic IL-10(-/-) mice. In vitro, TNF decreased expression of Phex in UMR106 cells and did not require de novo synthesis of a transrepressor. Transfecting UMR-106 cells with a series of deletion constructs of the proximal Phex promoter identified a region located within -74 nucleotides containing NF-κB and AP-1 binding sites. After TNF treatment, the RelA/p50 NF-κB complex interacted with two cis-elements at positions -70/-66 and -29/-25 nucleotides in the proximal Phex promoter. Inhibition of NF-κB signaling increased the basal level of Phex transcription and abrogated the effects of TNF, whereas overexpression of RelA mimicked the effect of TNF. We identified poly(ADP-ribose) polymerase 1 (PARP-1) binding immediately upstream of the NF-κB sites and showed that TNF induced poly(ADP-ribosyl)ation of RelA when bound to the Phex promoter. TNF-mediated Phex down-regulation was completely abrogated in vitro by PARP-1 inhibitor and overexpression of poly(ADP-ribose) glucohydrolase (PARG) and in vivo in PARP-1(-/-) mice. Our results suggest that NF-κB signaling and PARP-1 enzymatic activity cooperatively contribute to the constitutive and inducible suppression of Phex. The described phenomenon likely contributes to the loss of bone mass density in chronic inflammatory diseases, such as inflammatory bowel disease.

How activity of inflammatory bowel disease influences bone loss

Bone loss is a common problem for individuals with inflammatory bowel disease (IBD). The aim of our study was to assess bone mineral density (BMD) in patients with IBD and to investigate the role of corticosteroid (CS) use and duration and activity of disease on BMD. Ninety-two patients (56 men and 36 women) with IBD, of whom 32 had ulcerative colitis (UC) and 60 had Crohn's disease (CD), underwent clinical assessment. Lumbar and femoral neck BMDs were measured by dual-energy X-ray absorptiometry. Osteopenia was observed in 14 patients (43%) with UC and in 24 patients (40%) with CD (p=0.187). Four patients (12%) with UC and 7 patients (11%) with CD had osteoporosis (p=0.308). Femoral BMD decreased in patients with long duration of CS use and correlated inversely with disease activity. Multiple regression analysis of BMD showed that statistically significant risk factors were duration of active disease and body mass index as well. Based on our results, it is necessary to take into account the risk of decreased BMD in patients with IBD. It is most important to achieve disease remission as soon as possible in addition to nutritional support.

Rheumatic manifestations of inflammatory bowel disease

This article reviews the literature concerning rheumatic manifestations of inflammatory bowel disease (IBD), including common immune-mediated pathways, frequency, clinical course and therapy. Musculoskeletal complications are frequent and well-recognized manifestations in IBD, and affect up to 33% of patients with IBD. The strong link between the bowel and the osteo-articular system is suggested by many clinical and experimental observations, notably in HLA-B27 transgenic rats. The autoimmune pathogenic mechanisms shared by IBD and spondyloarthropathies include genetic susceptibility to abnormal antigen presentation, aberrant recognition of self, the presence of autoantibodies against specific antigens shared by the colon and other extra-colonic tissues, and increased intestinal permeability. The response against microorganisms may have an important role through molecular mimicry and other mechanisms. Rheumatic manifestations of IBD have been divided into peripheral arthritis, and axial involvement, including sacroiliitis, with or without spondylitis, similar to idiopathic ankylosing spondylitis. Other periarticular features can occur, including enthesopathy, tendonitis, clubbing, periostitis, and granulomatous lesions of joints and bones. Osteoporosis and osteomalacia secondary to IBD and iatrogenic complications can also occur. The management of the rheumatic manifestations of IBD consists of physical therapy in combination with local injection of corticosteroids and nonsteroidal anti-inflammatory drugs; caution is in order however, because of their possible harmful effects on intestinal integrity, permeability, and even on gut inflammation. Sulfasalazine, methotrexate, azathioprine, cyclosporine and leflunomide should be used for selected indications. In some cases, tumor necrosis factor-α blocking agents should be considered as first-line therapy.

Osteoporosis in adult Sri Lankan inflammatory bowel disease patients

AIM: To determine if inflammatory bowel disease (IBD) is a risk factor for osteoporosis in adult Sri Lankans.

METHODS: We identified eligible subjects from among consecutive patients diagnosed with IBD who attended our outpatient clinic. We included only patients aged between 20 and 70 years. Patients who were pregnant, had significant comorbidity, or were on calcium supplements or treatment for osteoporosis within the past 6 mo, were excluded. Healthy, age- and sex-matched controls were also recruited, in a control to patient ratio of 3:1. Both groups were screened for osteoporosis using peripheral dual energy X-ray absorptiometry scanning.

RESULTS: The study population consisted of 111 IBD patients (male:female = 43:68; mean age 42.5 years) and 333 controls (male:female = 129:204; mean age 43.8 years). The occurrence of osteoporosis among IBD patients (13.5%) was significantly higher than among controls (4.5%) (P = 0.001). The frequency of osteoporosis was not significantly different between ulcerative colitis (14.45%) and Crohn’s disease (10.7%). However, on multivariate analysis, only age (P = 0.001), menopause (P = 0.024) and use of systemic steroids (P < 0.001) were found to be associated independently with the occurrence of osteoporosis, while IBD, severity of disease, number of relapses, duration of illness or treatment other than systemic steroids were not.

CONCLUSION: IBD does not appear to be an independent risk factor for the occurrence of osteoporosis in this population. However, the use of systemic steroids was a risk factor.

Extraintestinal manifestations of inflammatory bowel disease

The idiopathic inflammatory bowel diseases (IBD), Crohn's disease and ulcerative colitis, may be complicated by extraintestinal manifestations (EIMs) in up to 40% of patients. Reports suggest that almost every organ system may be affected. The EIMs are a significant cause of morbidity and may be particularly distressing for the patient. Recent attempts have been made to define the phenotype of IBD in patients of different ethnicities. These studies have highlighted potential racial variations in the prevalence of specific EIMs, findings that are perhaps not surprising given the influence of genetic factors in their pathogenesis. Certain EIMs are related to the activity of the bowel disease, and their management often involves careful monitoring while the IBD is brought under control. Other EIMs, however, typically run a course independent of the IBD activity, and specific, targeted treatments may be required, even including biologic agents such as infliximab.

Potential therapeutic effects of curcumin, the anti-inflammatory agent, against neurodegenerative, cardiovascular, pulmonary, metabolic, autoimmune and neoplastic diseases

Although safe in most cases, ancient treatments are ignored because neither their active component nor their molecular targets are well defined. This is not the case, however, with curcumin, a yellow-pigment substance and component of turmeric (Curcuma longa), which was identified more than a century ago. For centuries it has been known that turmeric exhibits anti-inflammatory activity, but extensive research performed within the past two decades has shown that this activity of turmeric is due to curcumin (diferuloylmethane). This agent has been shown to regulate numerous transcription factors, cytokines, protein kinases, adhesion molecules, redox status and enzymes that have been linked to inflammation. The process of inflammation has been shown to play a major role in most chronic illnesses, including neurodegenerative, cardiovascular, pulmonary, metabolic, autoimmune and neoplastic diseases. In the current review, we provide evidence for the potential role of curcumin in the prevention and treatment of various proinflammatory chronic diseases. These features, combined with the pharmacological safety and negligible cost, render curcumin an attractive agent to explore further.