Real-World Outcomes of Patients Starting Intravenous and Transitioning to Subcutaneous Vedolizumab in Inflammatory Bowel Disease

BACKGROUND

Real-world data on starting intravenous (IV) vedolizumab (VDZ) and transitioning to subcutaneous (SC) treatment in inflammatory bowel disease (IBD) are scarce.

AIMS

To assess treatment outcomes of patients with IBD starting IV VDZ and switching to SC VDZ in routine clinical care.

METHODS

Adult patients with IBD switching from IV to SC VDZ treatment between 1 March 2020 and 31 December 2021 were identified from the Swedish IBD quality register. The primary outcome was SC VDZ persistence. Secondary outcomes included clinical remission, changes in quality of life (QoL) according to EuroQual 5-Dimensions 5-Levels (EQ-5D-5L) and the Short-Health Scale (SHS) and inflammatory markers, including faecal Calprotectin (FCP).

RESULTS

Altogether, 406 patients with IBD (Crohn's disease, n = 181; ulcerative colitis, n = 225) were identified. After a median follow-up of 30 months from starting IV VDZ treatment, the persistence rates were 98%(178/181) in Crohn's disease and 94% (211/225) in ulcerative colitis. Most patients (84%) transitioned during maintenance therapy, and the median follow-up from switch to SC VDZ was 10 months. Compared to baseline, statistically significant improvements were observed in all domains of the SHS, EQ-5D index value and visual analogue scale. Median (interquartile range) FCP concentrations (μg/g) decreased from 459 (185-1001) to 65 (26-227) in Crohn's disease (n = 45; p < 0.001) and from 646 (152-1450) to 49 (20-275) in ulcerative colitis (n = 58; p < 0.001).

CONCLUSION

Initiating IV VDZ and switching to SC treatment was associated with high persistence rates and improvements in measures of QoL and FCP. These findings are reassuring for patients who start IV VDZ and switch to SC VDZ.

Anti-Saccharomyces cerevisiae Antibodies Are Only Modestly More Common in Subjects Later Developing Crohn's Disease

BACKGROUND

The pathogenic processes in the preclinical phase of inflammatory bowel disease (IBD) are mainly unknown.

AIMS

To study typical antibodies for IBD in the preclinical phase in a cohort of Northern Sweden.

METHODS

Antibodies typical for IBD (ASCA, pANCA, lactoferrin-ANCA, antibodies to goblet cells, and pancreas antigen) were analyzed in 123 subjects with preclinical ulcerative colitis (UC), 54 subjects with preclinical Crohn's disease (CD) and in 390 sex- and age-matched controls. In addition, in a subset of subjects, inflammatory markers (CRP, albumin, calprotectin and ferritin) were measured in plasma.

RESULTS

The mean years between blood samples and IBD diagnosis were for UC 5.1 (SD 3.5) years and CD 5.6 (SD 3.5) years. There was no difference in the proportion of overall positive antibodies between subjects who later developed IBD compared to controls (16.9% vs. 12.3%; p = 0.137). The subjects who later developed CD had a significantly higher proportion of positive ASCA compared to controls (9.3% vs 2.8%; p = 0.034), but for all other antibodies, there were no differences compared to control subjects. Subjects with preclinical IBD and elevated antibodies showed significantly higher plasma calprotectin levels compared to subjects without antibodies (980 μg/L vs 756 μg/L; p = 0.042), but there was no difference in the levels of CRP, albumin and ferritin.

CONCLUSIONS

We found no significant increase in antibodies typical for IBD years before diagnosis except for ASCA, which was slightly more common in subjects who later developed CD. Very few subjects had detectable antibodies to goblet cells and pancreas antigen.

Health promotion research in the Nordic countries - a scoping review of PhD dissertations 2008-2018

Background

The Nordic countries are welfare states that also have been claimed to be in the forefront in developing health promotion, in relation to theory, research, policy and practice. This scoping review was performed by members of the Nordic Health Promotion Research Network with the objectives to collect and identify the scope and theoretical basis of doctoral (PhD) dissertations on health promotion in a Nordic context.

Methods

Searches for dissertations, published 2008-2018, were performed in several databases in Denmark, Finland, Iceland, Norway, and Sweden. Those labelled “health promotion” present in titles, abstract or key words were included in the scoping review. Data was extracted based on a common template including title, aims, university, individual-national level, setting, type of study and collaboration.

Results

The search strategy had to be modified to include manual searches at university sites as no national data base was available. In total, 353 health promotion dissertations had been published at 41 different universities. Most dissertations were Swedish (193), while 56 came from Denmark, 53 from Norway and 51 from Finland, but non from Iceland. The main content was lifestyle (28%), mental or psychosocial health (14%), critical health promotion (8%), empowerment (7%) or refugee and immigrants (5%). The most common approach was settings (31%), including health care setting (14%), followed by societal (28%) and individual (28%) approaches. Mixed methods approach was most common research method (45%) followed by quantitative (32%) and qualitative methods (23%). Large country variations were seen in the health promotion.

Conclusions

Health promotion research in the Nordic countries can be characterised by focusing on lifestyle, settings approach, and primarily using a mixed methods approach. However, there are large variations between different health promotion PhDs, also including dissertations on critical health promotion and empowerment.

Key messages

Analysis of PhD dissertations can contribute to more comprehensive insight in disciplinary development. The research training will have implications for the future public health workforce. The Nordic collaboration enabled an extensive scoping review of PhD dissertations on health promotion research in the Nordic countries and shows what has characterized the field of research.

On the time trends among school-aged children in the Nordic countries

Long-term trends in mental health of school-aged children can be analysed in the HBSC study. In Sweden the proportion of the children that report at least two weekly health complaints during the last six months has increased from the first data collection 1985/1985 to the latest 2017/2018 among all age groups for both girls and boys. Among the 11-year-old it reached 41 % among girls and 30 % boys, and among 15-year-old girls 62 % and boys 35 %. Can we trust this?

The prevalence of two or more weekly health complaints showed large differences by country over time and especially in 2014, when Iceland and Sweden showed an almost 10%-point larger prevalence of multiple weekly symptoms (about 35%) than Denmark, Finland and Norway (about 25%). Norway was the only country to show a decline during 2002-2014.

The prevalence of sleep difficulties has increased over the 12-year period in Denmark, Iceland, and Finland. In Sweden the prevalence fell from 26% to 21% from 2002 to 2006 but rose by 10% points from 2010 to 2014. Only Norway showed a positive development over the 12-year period; the prevalence declined in 2014 to 17% the lowest prevalence of sleep difficulties in any of the five Nordic countries.

The trend of excellent self-rated health for Nordic adolescents indicates a small overall improvement between 2002 and 2006 but a stable trend in the following periods up until 2014. Finland and especially Sweden shows a decline in the prevalence of students having an excellent self-rated health. The only country to show a positive development in the prevalence of students having excellent self-rated health from 2002 to 2014, is Norway. The overall prevalence of adolescents having high life satisfaction has declined in most of the Nordic countries examined.

Supporting implementation of resilience training among school-aged children – RESCUR in Sweden

Issue

What is needed to facilitate implementation of an intervention when scaling up and scaling out the program?

Description of the problem

RESCUR: Surfing the Waves (Jag vill, jag kan, jag törs!) is a new resilience curriculum, developed in 2012-2015 by researchers in six European Universities, to foster the psychosocial development of children and give them tools to deal with challenging situations. It aims at increasing children's resilience, i.e. their capacity to cope with disadvantages, crises, changes and stress without breaking down. The RESCUR project in Sweden consists of a Randomized Controlled Trial among children of the ages 6-12 in schools or social services. RESCUR is a pedagogic material, which requires training before getting access to the intervention. The training consists of two days and a follow-up day as well as observation and supervision. The project has been evaluated from two perspectives: implementation and effects. For a theoretically promising method to work at all, the method must be implemented effectively and correctly. Implementation was documented through self-evaluations, reported by group leaders after six months, and observations made according to a formalized checklist. The implementation of the method is fundamental to properly evaluating the effects of the method.

Results

The model used to train and support people who implemented the intervention seems to have worked according to the self-reports and the observations of lessons, which noted good implementation quality in the activities that were carried out every week by the majority of teachers and group leaders. The observed implementation was exemplary or very strong among 56 % in schools (n = 41) and 41 % in social services (n = 12).

Lessons

An important challenge in health promotion is ensuring that an intervention is implemented in an efficient way. Recruiting participants and training implementers are basic requirements for successful trials.

Key messages

The implementation of the health promoting method is fundamental to properly evaluating the effects of the method. Therefore, an educational and monitoring component is needed. Different implementers can achieve the high-quality implementation of an intervention. Training, observation, feedback, supervision and educational material all supported the implementation of RESCUR.

Setting the scene: controversies on trends in mental health among adolescents in the Nordic countries

At present there are different positions regarding trends in adolescent mental health. Can we trust trend data on the mental health among adolescents in the Nordic countries? Some question the trustworthiness of adolescent self-reports, which describe ordinary daily hassles as health complaints, which cannot be interpreted as signs of mental disorders. In addition, today there is a more open climate for talking about mental issues, which can lead to an overestimation of the prevalence of mental disorders.

Statistics on mental health services statistics report increased psychopharmaceutic prescriptions as well as consumption of professional care. Such data argues for increased governmental investment in adolescent mental health services. Is this pattern due to increased availability of mental health services and/or increased prevalence of mental health problems in the adolescent population?

A concern is that data availability influences policymaking and allocation of resources. If there is an emphasis on self-reported data from adolescents that may an increased risk of medicalization of young people's dealing with their daily lives. If on the other hand the reported problems among young people is disregarded, this would be against the UN Child Convention.

The survey data has important qualities especially if the data is analysed and reported properly. The validation of survey measure has been done both regarding psychometric quality and content validity. Advanced analysis of the data can draw a more nuanced picture. Moreover, some screening instruments have been developed as a first step towards making diagnosis. Instead the HBSC surveys ask boys and girls about their health and well-being, social environment and health behaviours. HBSC uses findings at national and international levels to gain new insights into young people's health and wellbeing, understand the social determinants of health, and inform policy and practice to improve young people's lives.

SAT0253 ANTI-NEUTROPHIL CYTOPLASMATIC ANTIBODIES PREDATE SYMPTOM ONSET OF ANCA-ASSOCIATED VASCULITIS. A CASE-CONTROL STUDY

Background:

Presence of anti-neutrophil cytoplasmatic autoantibodies (ANCA) is important for the diagnosis of ANCA-associated vasculitis (AAV) and reflects on-going immune processes. The timing of the antibody development and its contribution to disease is not well established.

Objectives:

To investigate the presence of proteinase 3 (PR3)- and myeloperoxidase (MPO)-ANCA in blood samples collected from healthy individuals who subsequently developed AAV.

Methods:

The Swedish National Patient Register of inpatient care and the Swedish Cause of Death Register were used to identify individuals assigned ICD codes for AAV (1) in the discharge summary or cause of death, respectively. The resulted cohort was then linked to the registers of 4 different biobanks to identify those with available predating blood samples. Diagnoses of AAV were confirmed and time point for onset of symptoms was identified by reviewing all available case records (1); 68 were classified as granulomatosis with polyangiitis (GPA), 14 as microscopic polyangiitis (MPA), and 4 as eosinophilic GPA (EGPA). The 86 cases (36 males, 50 females) had a mean (SD) age of 51.9 (16.9) years at sampling, with ≥1 sample (26% plasma, 74% serum samples). The sampling time point before onset of symptoms was mean (SD); 4.4 (3.1) years. Serum and plasma control samples (n=198; 82 males, 116 females; mean age (SD); 52.0 (16.5) years) were identified and matched for sex, age and date of sampling. The samples were first screened for ANCA using high sensitive ELISA (ORGANTEC diagnostika, Germany) and samples close to or above cut-off level were further analysed for capture PR3- and capture MPO-ANCA (ELISA; SVAR Life Science, Sweden). For each case one control sample was included for the ANCA specificity tests. Statistical calculations were performed using SPSS software.

Results:

In ANCA-screen 36.0% of the cases and 2.6 % of controls tested positive (p<0.001). 23/52 (44.2%) of the cases were PR3-ANCA positive (OR 56.3; 95% CI 7.26-436.62) and 8/52 (15.4%) were MPO-ANCA positive (OR 4.18; 95% CI 1.05-16.62). The mean (SD) predating time for PR3-ANCA positivity was 3.73 (3.49) years and for MPO-ANCA positivity 2.11 (1.46) years. Cases with positive predating PR3-ANCA were younger (46.0±19.4 vs 65.6±12.0 years; P<0.001) than cases with a negative predating PR3-ANCA. MPO-ANCA positive vs. MPO-ANCA negative pre-dating cases had more often severe disease (kidney/lung/peripheral nervous system) (OR 15.08; 95% CI 1.68—135.54) at disease onset. Furthermore, predating MPO-ANCA positive vs predating PR3-ANCA positive cases had significantly more often severe manifestations at disease onset (87.5% vs 28.6%; p<0.05). Cases positive vs. negative for MPO-ANCA in predating samples were less often classified as GPA (37.5% vs 86.4%; p<0.01) and more often as MPA (62.5% vs 13.6%; p<0.05).

Conclusion:

The production of both PR3 and MPO-ANCA starts already years before onset of symptoms of AAV. Presence of MPO-ANCA appeared closer to symptom onset and with more severe disease presentation. Differences in the disease phenotype and disease severity were evident between the two ANCA serotypes.

References:

[1]Watts et al. Ann Rheum Dis 2007;66:222-22

Acknowledgments: :

Vasculitis Foundation, USA

Disclosure of Interests:

Ewa Berglin: None declared, Aladdin J Mohammad Speakers bureau: lecture fees from Roche and Elli Lilly Sweden, PI (GiACTA study), Johanna Dahlqvist: None declared, Catharina Eriksson: None declared, Johanna Sjöwall: None declared, Solbritt Rantapää Dahlqvist: None declared

Fluconazole Therapy for Fungal Peritonitis in Continuous Ambulatory Peritoneal Dialysis (CAPD): A Case Report

Fluconazole proved effective in treating fungal peritonitis caused by Trichosporon cutaneum. Fluconazole seems to offer several advantages over other antifungal drugs in the treatment of fungal peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients.

Urban residential greenness and adiposity: A cohort study in Stockholm County

BACKGROUND

Increasing evidence suggests that exposure to residential greenness is associated with positive health outcomes among urban populations. However, few studies have considered effects on adiposity development in a longitudinal setting.

OBJECTIVES

This study aimed to explore the association between long-term exposure to urban residential greenness and markers of adiposity.

METHODS

A cohort of 5126 adults from five municipalities in Stockholm County was examined clinically at baseline (1992-1998) and follow-up (2002-2006) after on average nine years. Time-weighted average exposure to urban greenness was estimated by Normalized Difference Vegetation Index (NDVI) within 100 m, 250 m, and 500 m buffers around the residential addresses of each participant. Multiple linear and Poisson regression models were used to estimate associations between greenness and change in weight and waist circumference as well as risk of overweight, obesity and central obesity. Co-exposures to air pollution, traffic noise and distance to water were also examined.

RESULTS

In women, higher levels of residential greenness were associated with a reduced increase in waist circumference during follow-up (β = -0.11 cm/year, 95% CI -0.14; -0.08 per one interquartile range increase in NDVI) and decreased risk for central obesity (IRR = 0.88: 95% CI 0.79; 0.99) in the 500 m buffer. No associations were observed for men or with regard to weight development or the risk of developing overweight or obesity. Exposure to low NDVI levels in combination with high NO_x from road traffic and transportation noise as well as long distance to water rendered statistically significant increases in waist circumference in both sexes.

CONCLUSION

Higher long-term exposure to greenness was associated with a reduced increase in waist circumference and lower risk of central adiposity in women but not in men. In both sexes, low NDVI exposure in combination with other environmental risk factors appeared particularly harmful.

IgG4 anti-infliximab in treated patients: Clinical impact and temporal evolution

BACKGROUND

Infliximab (IFX) carries potential risk of immunogenicity with the production of anti-drug antibodies (ADA). ADA may belong to different isotypes and are usually measured by ELISA bridging assay. This test is not designed to detect IgG4 antibodies. The aim was to measure IgG4 anti-IFX antibodies in a cohort of IFX-treated patients and to evaluate their relationship with ADA and their clinical impact.

METHODS

Anti-drug antibodies were detected using a bridging ELISA in the serum of 222 treated patients with different clinical outcomes to IFX. The same samples were analyzed for IgG4 anti-IFX antibodies using an experimental ImmunoCAP assay with reduced serum IgG4 background levels. A longitudinal evaluation was performed in a subgroup of 38 patients to define the temporal evolution of IgG4 anti-IFX.

RESULTS

IgG4 anti-IFX was found in 26.6% of patients. Eighty of 222 patients were ADA+ (36%) and the majority (57/80, 71.3%) had IgG4 anti-IFX. Two IgG4-positive but ADA-negative patients were identified. IgG4 anti-IFX levels correlated with the serum levels of ADA. IgG4 anti-IFX was more common in both reactive and nonresponder patients than in tolerant/responder patients. Patients who had experienced IgE-mediated reactions displayed significantly higher IgG4 anti-IFX than IgE-negative reactive patients. The majority of patients tested positive for IgG4 anti-IFX after the first seven infusions.

CONCLUSIONS

IgG4 anti-IFX is common in treated patients and a large part of ADA producing patients produce IgG4 antibodies. The IgG4 anti-IFX response does not prevent hypersensitivity reactions to IFX and correlates with the IgE anti-IFX response.

Changes in medical management and colectomy rates: a population-based cohort study on the epidemiology and natural history of ulcerative colitis in Örebro, Sweden, 1963-2010

BACKGROUND

Whether the epidemiology of ulcerative colitis (UC) has changed during recent decades is partly unknown.

AIM

To depict temporal trends in the epidemiology and medical treatment of UC as well as the long-term risk of progression in disease extent and colectomy, during 1963-2010.

METHODS

Patients were identified by evaluation of all medical records in the archive of the Colitis Clinic, Örebro University Hospital. Comparisons were made between three time periods, 1963-1975, 1976-1990 and 1991-2005.

RESULTS

The annual age-standardised incidence increased from 3.5 to 18.5 per 100 000 during the study period (P < .01). Correspondingly, the prevalence increased from 44 to 474 per 100 000 between 1965 and 2010. A higher proportion of males than females had extensive colitis at diagnosis (odds ratio: 1.55; 95% CI 1.17-2.05; P < .01). The risk for progression in disease extent was 34.5% and 18.5% at 10 years, for patients with proctitis and left-sided colitis, respectively (P < .01). The use of 5-aminosalicylates, within 10 years, rise from 79% to 92% between 1963-1975 and 1976-1990 (P < .01). Thiopurine use increased from 7% in 1976-1990 to 34% during 1991-2005 (P < .01). The colectomy rate at 10 years was 13.5% (95% CI 11.1%-15.8%), and the risk was lower among patients diagnosed in 1991-2005 compared to 1963-1975 (adjusted hazard ratio: 0.61; 95% CI 0.39-0.94; P = .02).

CONCLUSION

The incidence and prevalence of UC increased over time, and the observed prevalence in 2010 is among the highest reported. In parallel, a decrease in colectomy rates was observed during the most recent decades, potentially reflecting improved medical treatment.

Abnormal expression of chemokine receptors on T-cells from patients with systemic lupus erythematosus

The expressionof chemokinereceptors on T-cells and chemokinelevels in the blood was studied in 23 patients with SLE (ACR criteria), seven patients with rheumatoid arthritis (RA) and in 15 healthy controls using flow cytometry, RT-PCR and ELISA. The cell surface expression of the chemokine receptors CXCR5 and CCR6 was decreased in SLE patients compared with controls (P 0.051 and P 0.002, respectively). The decrease of CXCR5 was confined to SLE patients with inactive disease (SLEDAI < 6) compared with active disease (SLEDAI ≥6) and controls. CXCR2 and CCR1 were increased in patients with active SLE compared with patients with inactive disease (P 0.001 and P 0.01, respectively) and with controls (P 0.02 and P 0.053, respectively). The levels of the chemokines MIP-1b MCP-1, SDF-1a, IP-10 and RANTES were significantly elevated in SLE patients compared with controls. Patients with renal involvement had increased surface expression of CXCR3 and CCR3 (P 0.04 in both) and a lower level of soluble IP-10 compared with patients without renal disease (P 0.025) and compared with controls (P 0.001). The ratio between CCR5 and CCR3 was significantly increased in RA patients compared with SLE patients and controls supporting a Th1 overweight in RA. In conclusion, patients with SLE showed abnormal T-cell expression of several chemokine receptors and levels of soluble chemokines in their plasma/serum.

Wheat allergy in children - new tools for diagnostics

BACKGROUND

The detection of wheat-specific IgE in children often leads to a suspicion of wheat allergy, but little information is available on the most reliable wheat allergens for predicting clinical reactivity.

OBJECTIVE

To evaluate the role of allergenic components of wheat in wheat allergy diagnostics.

METHODS

One hundred and eight children (median age 1.5 years; range 0.6-17.3 years) with suspected wheat allergy underwent open or double-blinded, placebo-controlled oral wheat challenges. Responsiveness to different allergenic components of wheat was studied by skin prick tests and by determination of serum IgE antibodies using a semi-quantitative microarray assay.

RESULTS

Thirty (28%) children reacted with immediate symptoms, and 27 (25%) with delayed symptoms to ingested wheat, whereas 51 (47%) children exhibited no reactions in oral wheat challenges. Positive IgE responses to any of the 12 allergenic components of wheat was seen in 93%, 41%, and 43% of those with immediate, delayed or no reactions to ingested wheat, respectively (P < 0.001 to P < 0.05 in every comparisons between those with immediate reactions and those with no reactions). Positive IgE responses to ≥5 different allergenic components improved significantly the diagnostic accuracy (with a positive likelihood ratio (LR+) of 5.10). Alpha-amylase inhibitors (AAI), in particular dimeric AAI 0.19 (LR+ 6.12), alpha-, beta-, and gamma-gliadins (LR+ from 3.57 to 4.53), and high-molecular-weight (HMW) glutenin subunits (LR+ 4.37) were the single allergenic components of wheat differentiating most effectively those with immediate symptoms from those who did not exhibit any reactions.

CONCLUSIONS AND CLINICAL RELEVANCE

Wheat allergy diagnostics is difficult, even using sophisticated component methods. Our results confirm earlier findings about gliadins and identify the dimeric AAI 0.19, as a relevant allergen in clinically reactive patients when compared to non-reactive subjects. The accuracy of wheat allergy diagnosis may be improved by measuring IgE responses to several components of wheat.

Cytokines in relation to autoantibodies before onset of symptoms for systemic lupus erythematosus

OBJECTIVES

A number of cytokines and chemokines were analysed and related to autoantibodies in blood samples pre-dating the onset of symptoms of systemic lupus erythematosus.

METHODS

Thirty-five patients with systemic lupus erythematosus (American College of Rheumatology criteria) were identified as having donated blood samples, prior to symptom onset, to the Biobank of northern Sweden. Altogether, 140 age- and sex-matched controls were also identified. The concentrations of interferon-α, interleukin-4, interleukin-9, interleukin-10, interferon inducible protein-10 and monocyte chemotactic protein-1 were analysed using multiplex technology and related to autoantibodies (ANA, ENA, anti-dsDNA and anti-histone antibodies) analysed from the same blood sample.

RESULTS

The interferon-γ inducible protein-10 levels were higher in the pre-symptomatic individuals than in controls (p < 0.05) and correlated with interferon-α (p < 0.01). The interferon-γ inducible protein-10 and interferon-α concentrations were significantly increased in individuals positive for autoantibodies: interferon-γ inducible protein-10 for ANA; anti-SSA/Ro and anti-Jo-1 antibodies; interferon-α with anti-SSB/La antibodies. The levels of interleukin-10, interferon-γ inducible protein-10 and monocyte chemotactic protein-1 increased significantly from the pre-symptomatic individuals to after onset of systemic lupus erythematosus.

CONCLUSIONS

An increased concentration of interferon-γ inducible protein-10 pre-dated the onset of systemic lupus erythematosus and was related to autoantibodies before the onset of disease. The levels of interferon-γ inducible protein-10 and interferon-α were correlated. These findings support the proposal that the interferon system is important early in the pathogenesis of systemic lupus erythematosus and autoantibody formation.

Changes in chemokines and their receptors in blood during treatment with the TNF inhibitor infliximab in patients with rheumatoid arthritis

OBJECTIVES

Chemokines are involved in leucocyte recruitment into inflammatory sites. The release of certain chemokines is augmented by tumour necrosis factor (TNF). Infliximab, a monoclonal antibody that blocks the effects of TNF, is used for treatment of rheumatoid arthritis (RA). The effect of TNF blockage on chemokines is not fully understood. The aim of this study was to analyse the effects on chemokines and their receptors on peripheral mononuclear cells of anti-TNF treatment in RA patients.

METHOD

Twelve patients with established RA who started treatment with infliximab and nine patients with early RA treated with other anti-rheumatic drugs were followed clinically for 30 weeks and chemokine levels in blood samples were analysed along with chemokine receptor expression on the surface of T cells and monocytes. Nine healthy subjects were included as a control group.

RESULTS

The chemokine CXCL10/IP-10 was significantly higher in RA patients than in healthy controls (p = 0.012). Two weeks after infliximab infusion, CXCL10/IP-10, CCL2/MCP-1, and CCL4/MIP-1β had decreased significantly (p = 0.005, 0.037, and 0.028, respectively), and after 30 weeks of treatment, soluble CD26 was significantly increased (p = 0.050). Several chemokine receptors on T cells were elevated in RA patients at inclusion. The expression of CCR2 and CXCR1 on T cells decreased significantly after infliximab treatment.

CONCLUSIONS

The chemokines CXCL10/IP-10, CCL2/MCP-1, and CCL4/MIP-1β, mainly targeting the T-helper (Th)1 immune response, decreased after treatment with anti-TNF, suggesting a more pronounced effect on Th1 activity than on Th2-mediated response. Several chemokine receptors on blood T cells were elevated in RA patients, suggesting that they may be involved in the recruitment of T lymphocytes from the blood to affected tissues.

IgE detection to α/β/γ-gliadin and its clinical relevance in wheat-dependent exercise-induced anaphylaxis

Wheat-dependent exercise-induced anaphylaxis (WDEIA) is characterized by anaphylactic reactions after wheat ingestion and physical exercise. IgE antibodies to recombinant ω(5) -gliadin are detectable in a majority of WDEIA patients, but other wheat allergens may also play a role in elicitation of WDEIA. Here, we performed a comprehensive analysis of IgE reactivity to different wheat proteins in 17 patients with confirmed WDEIA by ImmunoCAP research prototypes and a semi-quantitative microarray immunoassay with α/β/γ-gliadin, high-molecular-weight (HMW) glutenin, alpha-amylase inhibitor (AAI) dimer, and wheat lipid transfer protein (LTP). By ImmunoCAP, IgE to recombinant ω(5) -gliadin was detectable in 14/17 patients (82%), to α/β/γ-gliadin in 82% including the three patients lacking IgE to ω(5) -gliadin, and to HMW glutenin in 59%. The microarray revealed specifically γ-gliadin as the second most important allergen. These results demonstrate the additional diagnostic value of α/β- and γ-gliadin in particular in ω(5) -gliadin-negative patients in the diagnosis of WDEIA.

Interleukin-6 and soluble interleukin-2 receptor alpha-markers of inflammation in patients with psoriatic arthritis?

OBJECTIVE

To evaluate a possible systemic effect of joint inflammation in contrast to skin disease only, by measuring IL-6 and IL-2sRalpha.

METHODS

Two hundred and nineteen patients (111 male / 108 female, age 50.4+/-14.5 yrs (mean+/-SD)) with psoriasis were clinically and laboratory examined. 134 patients had inflammatory joint manifestations defined as peripheral arthritis and/or axial disease, of whom 37 had measurable inflammation, defined as ESR >25 mm/h and/or CRP >15 mg/L.

RESULTS

Interleukin-6 was significantly higher in patients with joint disease and measurable inflammation ((median, Q1-Q3) 4.07, 0.92-14.60), and in patients without measured inflammation (1.22, 0.70-3.46), compared to patients with skin disease only (0.70, 0.70-1.73, p<0.001 and p=0.002 respectively). The difference between the two groups of patients with inflammatory joint manifestations was significant (p=0.001). The levels of IL-6 correlated with the actual number of joints affected with arthritis (p<0.001; rs=0.248), ESR (p<0.001; rs=0.459), CRP (p<0.001; rs=0.314) and IL-2sRalpha (p=0.002; rs=0.210). The levels of IL-2sRalpha. did not differ between the 3 groups.

CONCLUSION

In this study, IL-6 was significantly higher in patients with psoriasis and inflammatory joint disease with or without routine measurable inflammatory activity compared with patients having psoriasis of the skin. We found that patients with psoriasis and joint inflammation may have systemic effects that could be captured by serum measurements of IL-6. Soluble IL-2Ralpha was not a marker of inflammation in this study.

A well-being programme in severe mental illness. Baseline findings in a UK cohort

INTRODUCTION

Patients with severe mental illness (SMI) have higher rates of cardiovascular disease (CVD) morbidity and mortality than the general population. In the UK, data were limited regarding the known prevalence of physical health screening of SMI patients.

AIMS

A total of 966 patients with SMI from seven geographically varied regions in the UK agreed to participate in a 2-year nurse-led intervention (Well-being Support Programme), designed to improve their overall physical health by providing basic physical health checks, health promotion advice, weight management and physical activity groups in secondary care.

RESULTS

At baseline, only 31% of participants had undergone a recent physical health check. There were high rates of obesity (BMI > 30 in 49%), glucose abnormalities (12.4%), hypertension/prehypertension (50%), hyperlipidaemia (71%), poor diet (32%), low exercise levels (37.4%) and smoking (50%).

CONCLUSIONS

Patients with SMI where healthcare professionals have concerns regarding their physical health, have potentially modifiable risk factors for CVD, which remain undiagnosed. Programmes designed to address the physical health problems in SMI need to be implemented and evaluated in this already marginalised group of people.

Autoantibody formation in patients with rheumatoid arthritis treated with anti-TNF alpha

BACKGROUND

Research on autoantibody formation in patients treated with TNF alpha inhibitors has produced contradictory results.

OBJECTIVE

To study the prevalence of autoantibodies in patients with rheumatoid arthritis treated with the TNF alpha inhibitor infliximab.

METHODS

53 patients (48 female, 11 male) treated with infliximab for rheumatoid arthritis were followed for autoantibody production before treatment and after 14, 30, and 54 weeks. Six patients treated with etanercept were studied for comparison. The analyses included antibodies against nuclear antigens (ANA), extractable nuclear antigens, double stranded (ds)DNA (by ELISA, IIF on Crithidia luciliae for IgM and IgG, and Farr assay), nucleosomes, cardiolipin, smooth muscle, mitochondria, proteinase 3, and myeloperoxidase antigens.

RESULTS

The number of patients treated with infliximab who developed antibodies against dsDNA of both IgG and IgM class (tested by IIF) increased significantly. The prevalence of patients positive for IgG class increased to 66% at 30 weeks and 45% at 54 weeks, and of IgM class to 85% and 70%, respectively. The titre and number of patients expressing antibodies against nucleosomes and ANA also increased significantly. The number of rheumatoid factor or anticardiolipin positive patients was stable and there was no increase in antibodies against the other antigens. A lupus-like syndrome was seen in one patient. No patient treated with etanercept developed any of these autoantibodies.

CONCLUSIONS

Patients treated with infliximab may develop anti-dsDNA antibodies of both IgM and IgG class, anti-nucleosome antibodies, and ANA, with a gradual increase until 30 weeks.

Inflammatory mechanisms associated with brain damage induced by kainic acid with special reference to the interleukin-1 system

The evidence of inflammatory processes in the clinical manifestations and neuropathological sequelae of epilepsy have accumulated in the last decade. Administration of kainic acid, an analogue of the excitatory amino acid glutamate, induces a characteristic behavioural syndrome and a reproducible pattern of neurodegeneration in several brain areas, closely resembling human temporal lobe epilepsy. Results from studies using the kainic acid model indicate that manipulation of pro- and anti-inflammatory cytokines can modify the outcome with regard to the behavioural syndrome as well as the neuropathological consequences. Interleukin-1 is one of the most important cytokines and has several actions in the brain that are critical for the host defense against injury and infection, and it is involved in the initiation of early stages of inflammation. It is believed that interleukin-1 plays a pivotal role in the neuroinflammation associated with certain forms of neurodegeneration, including cerebral ischemia, trauma and excitotoxic brain injury. In this review, we have summarized the experimental data available with regard to the involvement of the interleukin-1 system in kainic acid-induced changes in the brain and emphasized the modulatory role of interleukin-1beta in this model of epilepsy

[Chronic diarrhea and weight loss. Diverticulosis of the small intestine with bacterial overgrowth]

Chronische Durchfälle und Gewichtsverlust mit Hypalbuminämie und Vitamin B12-Mangel führten bei einer 77-jährigen Frau zur Diagnose einer Dünndarmdivertikulose. Die Symptomatik war Folge eines Malabsorptionssyndromes aufgrund einer bakteriellen Überwucherung. Eine siebentägige Therapie mit Ciprofloxacin brachte die Durchfälle zum Verschwinden und die Patientin begann wieder an Gewicht zuzunehmen.

Drug targeting to the brain: transfer of picolinic acid along the olfactory pathways

Picolinic acid (PA) protects against quinolinic acid- and kainic acid-induced neurotoxicity in the brain. To study the uptake of PA to the brain, we administered [3H]PA via a unilateral nasal instillation or iv injection to mice. Autoradiography demonstrated a rapid uptake of radioactivity in the olfactory nerve layer and in the ipsilateral olfactory bulb (OB) following nasal instillation of [3H]PA. After 4 h, there was a high level of radioactivity in the central parts of the ipsilateral OB and olfactory peduncle. Moreover, iv injection of [3H]PA demonstrated a selective uptake and retention of radioactivity in the OB. Gas chromatography-mass spectrometry (GC-MS) demonstrated the presence of PA and PA-glycine conjugate in the OB. In mice with reduced peripheral olfactory innervations there was a decreased uptake of [3H]PA in the OB as compared to controls suggesting that an intact olfactory neuroepithelium is a prerequisite for an uptake of PA to the OB. There is an increased interest in brain targeting of drugs with limited ability to pass the blood-brain barrier. The present results demonstrate that PA fulfils structural requirements for a transfer along the olfactory pathways to the brain.

Effects of kainic acid on rat body temperature: unmasking by dizocilpine

The effects of intraperitoneal (i.p.) administration of kainic acid (KA) and dizocilpine, alone or in combination, on body temperature of freely moving rats were examined. Injection of saline or dizocilpine (3.0 or 5.0 mg/kg) was followed after an hour by injection of saline or KA (10 mg/kg) and the body temperature was measured at different time points during the first 5 h. KA alone produced an initial short-lasting hypothermia followed by a longer-lasting hyperthermic effect. Administration of dizocilpine alone produced an early increase in core temperature. Pretreatment of KA-injected rats with dizocilpine potentiated the KA-induced hypothermic effect at 30 min and dose-dependently reduced the temperature measured at 1 h after KA-injection without influencing the ensuing hyperthermia.These data suggest that the KA-induced changes in body temperature do not necessarily involve the activation of NMDA-receptors as opposed to KA-induced behavioural changes that are blocked by dizocilpine in a dose-dependent manner. It is unlikely, therefore, that the KA-induced hyperthermia is a result of the KA-induced seizure motor activity. Furthermore, our findings indicate that KA-induced changes in core temperature may be used as a criterion of drug-responsiveness when the behavioural changes are blocked, e.g. with dizocilpine.

Effects of alpha-MSH on kainic acid induced changes in core temperature in rats

The effects of intraperitoneal (i.p.) administration of kainic acid (KA) and alpha-melanocyte-stimulating hormone (alpha-MSH) alone or in combination, on core temperature of freely moving rats were examined. KA or saline was administered once (10 mg/kg) and alpha-MSH or saline was given repeatedly i.e. 10 min before and 10, 30 and 60 min after the administration of saline or KA. Two doses of alpha-MSH were used: 0.5 and 2.5 mg/kg. KA alone produced a biphasic effect on core temperature, i.e. an initial short-lasting hypothermia followed by hyperthermia that lasted about 6 h. The higher dose of alpha-MSH had a potentiating effect on KA-induced hypothermia, while the lower dose of alpha-MSH increased the hyperthermia produced by KA. alpha-MSH administered alone produced a late (3 h), dose-dependent increase in core temperature. It is conceivable that repeated administration of alpha-MSH in the doses used in our study may cause a cumulative effect in raising body temperature for a limited period of time. The previously described interactions between KA and alpha-MSH, respectively, with dopaminergic and serotoninergic systems may account for the effects on core temperature in rats observed in our study.

Protection by glutathione of neutrophils against the toxic effects of peritoneal dialysis fluid

The possibility of reducing the cytotoxic effect of heat-sterilized peritoneal dialysis (PD) fluid by addition of antioxidants/scavengers during incubation of titanium-adhering cells was investigated. Capillary blood from healthy donors was placed in drops on commercially available titanium pieces and incubated in a humidified chamber at 37 degrees C for 60min. After incubation the adherent polymorphonuclear leukocytes were immersed for 1-4h in PD-fluid, pH 7.4, containing 2.5% glucose with glutathione (GSH), superoxide dismutase, catalase or dithiothreitol (DTT). Luminol- or isoluminol-amplified chemiluminescence was used to measure the zymosan- and phorbol myristate acetate (PMA)-stimulated respiratory burst activity, as an indicator of the cytotoxicity of the PD-fluids. Heat sterilized PD-fluid had inhibitory effect on zymosan-induced respiratory burst and impaired both the extracellular and intracellular PMA-induced respiratory burst. Addition of GSH to the PD-fluid resulted in reduction of cytotoxical effects on the zymosan-induced and extracellular PMA-induced respiratory burst. The intracellular respiratory burst was not affected. The present results show that GSH and DTT have the ability to protect polymorphonuclear leukocytes against the cytotoxic effects of the PD-fluid by keeping the cell membrane in a reduced state.

Psycho-social determinants for sexual partner referral in Uganda: quantitative results

The purpose of this study was to investigate the factors influencing sexual partner referral using the Attitude-Social influence self-Efficacy model as a guiding theoretical framework. The data was collected in an interview survey with 236 women and 190 men attending a sexually transmitted disease clinic in Kampala, Uganda. Intention, attitude, subjective norm, self-efficacy, and past behaviour in relation to partner referral as well as partner type were collected at time 1. At time 2 (1 month later), sexual partner referral was assessed. Intention, self-efficacy, and previous behaviour predicted partner referral for women whereas intention, partner type and previous behaviour predicted partner referral for men. For the women the strongest predictors for intention were self-efficacy followed by attitude and partner type. For the men the strongest predictor was attitude followed by partner type and self-efficacy. Social influence was a better predictor of intention for women than for men. An analysis of underlying cognitive beliefs discriminating those who referred and those who did not refer the sexual partner showed that attitudinal beliefs were the most important for men whereas self-efficacy beliefs were the most important for women. The targeting of the gender-based discriminatory beliefs in intervention may improve compliance with sexual partner referral.

Treatment with cisplatin and etoposide in patients with neuroendocrine tumors

BACKGROUND

Patients with malignant endocrine pancreatic tumors (EPTs) are responsive to combinations of chemotherapy with streptozotocin and 5-fluorouracil/doxorubicin, whereas patients with malignant carcinoids are not. For both categories of patients, alpha-interferon and/or somatostatin analogs can produce long-lasting responses. Cisplatin in combination with etoposide has been suggested to be effective in patients with malignant neuroendocrine carcinomas. The authors used this therapy as second-line or third-line treatment in patients with poorly differentiated and/or rapidly progressing disease.

METHODS

Thirty-six patients with histopathologically verified malignant neuroendocrine tumors were included: Eighteen tumors were of foregut origin, of which 5 were atypical, and 15 tumors were EPTs, of which 4 were poorly differentiated endocrine carcinomas. Three tumors were of midgut origin. The median patient age was 47.5 years. The median duration of disease from the time of diagnosis was 12 months. All patients had metastatic disease. Thirty of 36 patients had received previous treatment. Etoposide was given at a dose of 100 mg/m(2) per day for 3 days, and cisplatin was given at a dose of 45 mg/m(2) on Days 2 and 3 as a continuous intravenous infusion that was repeated every 4 weeks.

RESULTS

Ten of 18 patients with foregut carcinoids (56%) responded radiologically and/or biochemically, with a median duration of 9 months; and 7 of 14 patients with EPTs (50%) responded radiologically and/or biochemically, with a median duration of 9 months. No difference in response was seen between patients with atypical or typical foregut carcinoids or between patients with well differentiated or poorly differentiated endocrine pancreatic carcinoma. Nineteen of 36 patients (53%) experienced World Health Organization (WHO) Grade 1-2 nephrotoxicity, and 23 patients (64%) suffered from WHO Grade 3-4 neutropenia.

CONCLUSIONS

The combination of cisplatin and etoposide can produce significant responses in patients with heavily pretreated and poorly differentiated/rapidly progressing neuroendocrine tumors. The toxicity is considerable, and nephrotoxicity is the dose limiting factor.

Treatment with cisplatin and etoposide in patients with neuroendocrine tumors

BACKGROUND

Patients with malignant endocrine pancreatic tumors (EPTs) are responsive to combinations of chemotherapy with streptozotocin and 5-fluorouracil/doxorubicin, whereas patients with malignant carcinoids are not. For both categories of patients, alpha-interferon and/or somatostatin analogs can produce long-lasting responses. Cisplatin in combination with etoposide has been suggested to be effective in patients with malignant neuroendocrine carcinomas. The authors used this therapy as second-line or third-line treatment in patients with poorly differentiated and/or rapidly progressing disease.

METHODS

Thirty-six patients with histopathologically verified malignant neuroendocrine tumors were included: Eighteen tumors were of foregut origin, of which 5 were atypical, and 15 tumors were EPTs, of which 4 were poorly differentiated endocrine carcinomas. Three tumors were of midgut origin. The median patient age was 47.5 years. The median duration of disease from the time of diagnosis was 12 months. All patients had metastatic disease. Thirty of 36 patients had received previous treatment. Etoposide was given at a dose of 100 mg/m(2) per day for 3 days, and cisplatin was given at a dose of 45 mg/m(2) on Days 2 and 3 as a continuous intravenous infusion that was repeated every 4 weeks.

RESULTS

Ten of 18 patients with foregut carcinoids (56%) responded radiologically and/or biochemically, with a median duration of 9 months; and 7 of 14 patients with EPTs (50%) responded radiologically and/or biochemically, with a median duration of 9 months. No difference in response was seen between patients with atypical or typical foregut carcinoids or between patients with well differentiated or poorly differentiated endocrine pancreatic carcinoma. Nineteen of 36 patients (53%) experienced World Health Organization (WHO) Grade 1-2 nephrotoxicity, and 23 patients (64%) suffered from WHO Grade 3-4 neutropenia.

CONCLUSIONS

The combination of cisplatin and etoposide can produce significant responses in patients with heavily pretreated and poorly differentiated/rapidly progressing neuroendocrine tumors. The toxicity is considerable, and nephrotoxicity is the dose limiting factor.

The respiratory burst response of surface-adhering leukocytes. A key to tissue engineering

Biomaterials implanted into tissue will participate in the complex signalling between cells during wound healing. Recent studies have revealed that crucial cellular signalling pathways are regulated by the extra- and intracellular redox states and that reactive oxygen species function as intercellular signal molecules. Biomaterials have been shown to affect the respiratory burst response of surface-adhering leukocytes, thus interfering with major regulatory functions of cells also in surrounding tissues. The respiratory burst of surface-adhering leukocytes may thus be a key event in the understanding of biomaterial interaction with tissues, and the aim of this review is to highlight this field of research.

Treatment with cisplatin and etoposide in patients with neuroendocrine tumors

BACKGROUND

Patients with malignant endocrine pancreatic tumors (EPTs) are responsive to combinations of chemotherapy with streptozotocin and 5-fluorouracil/doxorubicin, whereas patients with malignant carcinoids are not. For both categories of patients, alpha-interferon and/or somatostatin analogs can produce long-lasting responses. Cisplatin in combination with etoposide has been suggested to be effective in patients with malignant neuroendocrine carcinomas. The authors used this therapy as second-line or third-line treatment in patients with poorly differentiated and/or rapidly progressing disease.

METHODS

Thirty-six patients with histopathologically verified malignant neuroendocrine tumors were included: Eighteen tumors were of foregut origin, of which 5 were atypical, and 15 tumors were EPTs, of which 4 were poorly differentiated endocrine carcinomas. Three tumors were of midgut origin. The median patient age was 47.5 years. The median duration of disease from the time of diagnosis was 12 months. All patients had metastatic disease. Thirty of 36 patients had received previous treatment. Etoposide was given at a dose of 100 mg/m(2) per day for 3 days, and cisplatin was given at a dose of 45 mg/m(2) on Days 2 and 3 as a continuous intravenous infusion that was repeated every 4 weeks.

RESULTS

Ten of 18 patients with foregut carcinoids (56%) responded radiologically and/or biochemically, with a median duration of 9 months; and 7 of 14 patients with EPTs (50%) responded radiologically and/or biochemically, with a median duration of 9 months. No difference in response was seen between patients with atypical or typical foregut carcinoids or between patients with well differentiated or poorly differentiated endocrine pancreatic carcinoma. Nineteen of 36 patients (53%) experienced World Health Organization (WHO) Grade 1-2 nephrotoxicity, and 23 patients (64%) suffered from WHO Grade 3-4 neutropenia.

CONCLUSIONS

The combination of cisplatin and etoposide can produce significant responses in patients with heavily pretreated and poorly differentiated/rapidly progressing neuroendocrine tumors. The toxicity is considerable, and nephrotoxicity is the dose limiting factor.

Rat tooth pulp cells elicit neurite growth from trigeminal neurones and express mRNAs for neurotrophic factors in vitro

Molecular factors control the developmental ingrowth of axons to the tooth pulp. Here we examine the ability of pulpal cells to induce neurite outgrowth from neonatal rat trigeminal neurones (TGNs) in vitro. We found that TGNs emitted neurites and formed networks of branches in relation to pulpal cells. Neurones co-cultured with a mixture of pulpal cells and 3T3 fibroblasts formed networks exclusively in relation to the pulpal cells. Cultivated pulpal cells and pulpal tissue produced mRNAs for all neurotrophins and members of the glial cell line-derived neurotrophic factor family. Hence, rat pulpal cells have neuritogenic effects on single TGNs in vitro, that may be associated with secretion of neurotrophic factors.

Cellular reactions and bone apposition to titanium surfaces with different surface roughness and oxide thickness cleaned by oxidation

Titanium surfaces with three different surface characteristics were exposed to an intraperitoneal milieu in mouse or rat, or inserted into rabbit bone. The cleaning regimen of the TiO2 surfaces in this study included oxidation by heat or acid and a final rinsing and storage in water. Intraperitoneal exposure ranged from 1 to 64 min and the healing period in bone was 6 weeks. Cell recruitment to the surfaces was quantified by acridine orange staining and specific antibodies directed against cell membrane antigens. Removal torque, bone-to-metal contact, total bone area and histological evaluations were used to evaluate fixture stability and the healing-in of the implants. After the healing period of 6 weeks only a transient significant difference was seen in the total number of cells adherent on the surfaces. No significant differences were observed between any of the surfaces for removal torque, bone-to-metal contact, or bone area. The areas lacking bone-to-metal contact were filled with normal vascularised connective tissue with no signs of fibrous capsule formation or giant cells. These findings differ from findings published earlier of Ti implants that underwent a cleaning regimen with alcohol as the final rinsing step. The tissues around the implants were richly vascularised and there was continued bone growth toward the surfaces. The bone-to-metal contact in this study was lower than that seen with alcohol-cleaned TiO2.