Correlation Between Serum and Fecal Biomarkers and Patient-Reported Outcomes in Patients with Crohn's Disease and Ulcerative Colitis

BACKGROUND

Patient-reported outcomes (PROs), such as the short CD activity index (sCDAI) and partial Mayo Score (PMS), are used to define clinical remission in IBD, but may not represent the true degree of inflammation and endoscopy is invasive. Non-invasive testing options include c-reactive protein (CRP) and fecal calprotectin (FCP).

AIM

The aim of this study was to assess the degree of correlation of non-invasive biomarkers with PROs and the impact other clinical variables can have on their levels.

METHODS

We reviewed data collected from the prospective cohort, Study of a Prospective Adult Research Cohort with IBD (SPARC-IBD), comprised of over 3000 patients from 17 tertiary referral centers. Demographic and clinical variables were analyzed by disease type, disease severity was based on PROs, and baseline CRP and FCP were measured. For comparative analysis, we performed Fisher's exact test and Welch's t test, where p < 0.05 was significant.

RESULTS

1547 patients were included; 63% had CD, 56% were female, with an average disease duration of 13.6 years. CRP and FCP were associated with symptom severity in inflammatory CD. CRP was useful to differentiate symptoms across different disease locations in CD, whereas FCP was associated with symptom severity in Crohn's colitis only. For UC, FCP was able to distinguish symptom severity better in distal UC, whereas in extensive or pancolitis, it was useful only to distinguish severe symptoms from other categories of symptom severity.

CONCLUSION

PROs correlate with CRP and FCP; however, disease location and phenotype impact their ability to distinguish symptom severity.

Low-dose pulsed vs standard pulsed fluoroscopy during ERCP to reduce radiation without change in image quality: Prospective randomized study

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) poses the risk of radiation exposure (RE) to patients and staff and increases the risk of adverse biological effects such as cataracts, sterility, and cancer. Newer fluoroscopy equipment (C-Arm) provides options to limit radiation in the form of lower radiation dose and frame rate or time-limited "pulsed" settings. However, the impact of lower settings on image quality has not been assessed, and no standard protocol exists for fluoroscopy settings used during ERCP. Patients and methods This was a single-center, double-blind, prospective randomized study of consecutive adult patients undergoing standard-of-care ERCP at a tertiary academic medical center. Patients were randomized into two groups: 1) standard-dose pulsed and 2) low-dose pulsed. Pulsed mode (8 fps) was defined as x-ray exposure either in the manufacturer standard-dose or low-dose settings limited to 3 seconds each time the foot-operated switch was depressed. Results Seventy-eight patients undergoing ERCP were enrolled and randomized. No difference in age, gender, or body mass index was found between the two groups. No significant difference in image quality was found between standard-dose and low-dose fluoroscopy P = 0.925). The low-dose group was exposed to significantly less radiation when compared with standard-dose P < 0.05). Fluoroscopy time (minutes) was similar in both groups (2.0 vs 1.9), further suggesting that group assignment had no impact on image quality or procedure time. Conclusions Low-dose pulsed fluoroscopy is a reliable method that substantially reduces radiation without compromising image quality or affecting procedure or fluoroscopy times. This underscores the need for standardization in ERCP fluoroscopy settings to limit radiation exposure.

ExpLOring the role of the intestinal MiCrobiome in InflammATory bowel disease-AssocIated SpONdylarthritis (LOCATION-IBD)

Background

Inflammatory Bowel Disease (IBD)-associated arthritis is a frequent and potentially debilitating complication of IBD, that can affect those with or without active intestinal disease, and is often difficult to treat. The microbiome is known to play a role in IBD development and has been shown to be associated with inflammatory arthritis without concomitant IBD, but its role in IBD-associated arthritis is still unexplored. Further, disease localization is associated with development of IBD-associated arthritis, and stool compositional profiles are predictive of disease localization, yet mucosal location-specific microbiomes have not been well characterized. To address this gap in understanding, we designed a study (LOCATION-IBD) to characterize the mucosa-associated intestinal microbiome and metabolome in IBD-associated arthritis.

Methods

Adults with an established diagnosis of IBD undergoing clinical colonoscopy between May of 2021 and February of 2023 were invited to participate in this study; those interested in participation who met inclusion criteria were enrolled. Prior to enrollment, participants were stratified into those with or without IBD-associated arthritis. All participants were interviewed and had clinical and demographic data collected, and 97.8% completed clinical colonoscopy with biopsy collection.

Results and conclusion

A total of 182 participants, 53 with confirmed IBD-associated arthritis, were enrolled in this study, resulting in 1151 biopsies obtained for microbiome and metabolome analysis (median 6, mean 6.3 per participant). Clinical and demographic data obtained from the study population will be analyzed with microbiome and metabolome data obtained from biopsies, with the goal of better understanding the mechanisms underpinning the host-microbiome relationship associated the development of IBD-associated arthritis.

Matrix metalloproteinases as biomarkers and therapeutic targets in colitis-associated cancer

Colorectal cancer (CRC) remains a major cause of morbidity and mortality. Therapeutic approaches for advanced CRC are limited and rarely provide long-term benefit. Enzymes comprising the 24-member matrix metalloproteinase (MMP) family of zinc- and calcium-dependent endopeptidases are key players in extracellular matrix degradation, a requirement for colon tumor expansion, invasion, and metastasis; hence, MMPs are an important research focus. Compared to sporadic CRC, less is known regarding the molecular mechanisms and the role of MMPs in the development and progression of colitis-associated cancer (CAC) - CRC on a background of chronic inflammatory bowel disease (IBD) - primarily ulcerative colitis and Crohn's disease. Hence, the potential of MMPs as biomarkers and therapeutic targets for CAC is uncertain. Our goal was to review data regarding the role of MMPs in the development and progression of CAC. We sought to identify promising prognostic and therapeutic opportunities and novel lines of investigation. A key observation is that since MMPs may be more active in early phases of CAC, using MMPs as biomarkers of advancing neoplasia and as potential therapeutic targets for adjuvant therapy in those with advanced stage primary CAC rather than overt metastases may yield more favorable outcomes.

Gastroenterology Fellowship and Postdoctoral Training in Omics and Statistics-Part II: How Can It Be Achieved?

Data are being generated, collected, and aggregated in massive quantities at exponentially increasing rates. This "big data," discussed in depth in the first section of this two-part series, is increasingly important to understand the nuances of the gastrointestinal tract and its complex interactions and networks involving a host of other organ systems and microbes. Creating and using these datasets correctly requires comprehensive training; however, current instruction in the integration, analysis, and interpretation of big data appears to lag far behind data acquisition. While opportunities exist for those interested in acquiring the requisite training, these appear to be underutilized, in part due to widespread ignorance of their existence. Here, to address these gaps in knowledge, we highlight existing big data learning opportunities and propose innovative approaches to attain such training. We offer suggestions at both the undergraduate and graduate medical education levels for prospective clinical and basic investigators. Lastly, we categorize training opportunities that can be selected to fit specific needs and timeframes.

Gastroenterology Fellowship and Postdoctoral Training in Omics and Statistics-Part I: Why Is It Needed?

A multitude of federally and industry-funded efforts are underway to generate and collect human, animal, microbial, and other sources of data on an unprecedented scale; the results are commonly referred to as "big data." Often vaguely defined, big data refers to large and complex datasets consisting of myriad datatypes that can be integrated to address complex questions. Big data offers a wealth of information that can be accessed only by those who pose the right questions and have sufficient technical knowhow and analytical skills. The intersection comprised of the gut-brain axis, the intestinal microbiome and multi-ome, and several other interconnected organ systems poses particular challenges and opportunities for those engaged in gastrointestinal and liver research. Unfortunately, there is currently a shortage of clinicians, scientists, and physician-scientists with the training needed to use and analyze big data at the scale necessary for widespread implementation of precision medicine. Here, we review the importance of training in the use of big data, the perils of insufficient training, and potential solutions that exist or can be developed to address the dearth of individuals in GI and hepatology research with the necessary level of big data expertise.

Microstructural alterations of major thalamic nuclei in the chronic pediatric spinal cord injured population

Background

The brain undergoes reorganization following spinal cord injury (SCI), but little is known about how the thalamus is affected in pediatric SCIs.

Purpose

To characterize microstructural alterations in the thalamus after SCI with diffusion tensor imaging (DTI) metrics.

Methods

18 pediatric participants with chronic SCI (8-20 years) were stratified using the American Spinal Injury Association Impairment Scale (AIS) into groups: A, B, and C/D. DTI of the brain used a 3 T Siemens Verio MRI using the parameters: 20 directions, number of averages = 3, b = 1000 s/mm2, voxel size = 1.8 mm × 1.8 mm, slice thickness = 5 mm, TE = 95 ms, TR = 4300 ms, 30 slices, FOV = 230 × 230 mm2, matrix = 128 × 128, acquisition time = 4:45 min. Diffusion data was processed to generate DTI metrics FA, MD, AD, and RD.

Data analysis

DTI metrics were acquired by superimposing the AAL3 thalamic atlas onto participant diffusion images registered to MNI152 space. We utilized a multiple Mann-Whitney U-test to compare between AIS groups, considering values of p ≤ 0.05 as significant.

Results

FA, AD, RD, and MD significantly differed in thalamic nuclei between AIS groups A vs B and B vs C/D. Significant nuclei include the right ventral anterior, left intralaminar, bilateral lateral pulvinar, and right lateral geniculate.

Conclusion

Our findings suggest the presence of microstructural alterations based on SCI severity in pediatric patients. These results are encouraging and warrant further study.

Factors Associated With Extraintestinal Manifestations of Inflammatory Bowel Disease in SPARC-IBD

BACKGROUND

Extraintestinal manifestations (EIMs) of inflammatory bowel diseases (IBDs) are a common and debilitating feature of disease, occurring in up to 40% of patients with IBD, yet predicting who may develop them is difficult. The goal of our study was to better characterize which patients may be at highest risk of developing not only 1 EIM, but also multiple EIMs, across both diseases.

METHODS

A retrospective study of participants enrolled in the SPARC IBD (Study of Prospective Adult Research Cohort with IBD) registry was performed, and demographic and clinical data were analyzed. A total of 1211 patients with data available on EIMs were included, and differences among variables with vs without EIMs were assessed.

RESULTS

A total of 329 participants with at least 1 EIM were identified, compared with 882 participants without any EIMs. Crohn's disease patients and women were more likely to have 2 or more EIMs (P = .005 and P ≤ .001, respectively). Participants with ocular manifestations were likeliest to have at least 2 EIMs (P ≤ .001). Even when diagnosis was controlled for, involvement of the right colon (P = .021) was predictive of IBD-associated arthritis across both diseases in a multivariate generalized linear model.

CONCLUSIONS

This is the first comprehensive large-cohort assessment of how EIMs relate to one another at the individual vs systems levels. Further, our analysis is the first to recognize specific locations of colon involvement associated with EIMs of IBD, regardless of IBD type. These results are important in identifying patients at risk of developing future EIMs and may help with risk stratification when choosing treatments.

Muscarinic receptor agonist-induced βPix binding to β-catenin promotes colon neoplasia

M3 muscarinic receptors (M3R) modulate β-catenin signaling and colon neoplasia. CDC42/RAC guanine nucleotide exchange factor, βPix, binds to β-catenin in colon cancer cells, augmenting β-catenin transcriptional activity. Using in silico, in vitro, and in vivo approaches, we explored whether these actions are regulated by M3R. At the invasive fronts of murine and human colon cancers, we detected co-localized nuclear expression of βPix and β-catenin in stem cells overexpressing M3R. Using immunohistochemistry, immunoprecipitation, proximity ligand, and fluorescent cell sorting assays in human tissues and established and primary human colon cancer cell cultures, we detected time-dependent M3R agonist-induced cytoplasmic and nuclear association of βPix with β-catenin. βPix knockdown attenuated M3R agonist-induced human colon cancer cell proliferation, migration, invasion, and expression of PTGS2, the gene encoding cyclooxygenase-2, a key player in colon neoplasia. Overexpressing βPix dose-dependently augmented β-catenin binding to the transcription factor TCF4. In a murine model of sporadic colon cancer, advanced neoplasia was attenuated in conditional knockout mice with intestinal epithelial cell deficiency of βPix. Expression levels of β-catenin target genes and proteins relevant to colon neoplasia, including c-Myc and Ptgs2, were reduced in colon tumors from βPix-deficient conditional knockout mice. Targeting the M3R/βPix/β-catenin axis may have therapeutic potential.

Extraintestinal Manifestations of Inflammatory Bowel Disease Are Associated With Increased Biologic Cycling

Background

Extraintestinal manifestations (EIMs) of inflammatory bowel disease (IBD) are a common, frequently debilitating complication of the disease. Biologics are indicated and often required in patients with EIMs to control disease; however, little is known about whether patients with EIMs cycle through more therapies than their counterparts without EIMs.

Methods

To address this question, we performed a retrospective analysis of patients enrolled in the Study of Prospective Adult Research Cohort with IBD registry seen at our University Medical Center, on data from December 2016 to January 2021. Four hundred fifty-six participants with information on EIMs and biologic use available were included, and demographic and clinical characteristics were analyzed.

Results

Three hundred thirty-eight and 118 participants without and with EIMs were identified, respectively. Those with EIMs were likelier to have biologic exposure, and cycle through more biologics, both in univariate and multivariate analyses controlling for age, disease duration, sex, corticosteroid use, and IBD type (P-value = .006). In a subanalysis of patients with Crohn's disease (CD), EIMs were associated with increased biologic cycling in ileocolonic disease (P-value = .050).

Conclusions

To our knowledge, this is the first study assessing biologic cycling in patients with EIMs. Our findings that patients with EIMs are likelier to cycle through biologics, particularly CD patients with ileocolonic disease, highlights the need for more research on which biologics may be most effective for specific subsets of IBD patients, including those with concurrent EIMs. The presence of EIMs is a marker of harder-to-treat IBD and may indicate earlier initiation of advanced therapies.

Histologic Inflammation can Predict Future Clinical Relapse in Ulcerative Colitis Patients in Endoscopic Remission

Background

In ulcerative colitis (UC), endoscopic improvement, defined as a Mayo Endoscopic Score (MES) of 0 or 1, is a target of treatment. The aim of our study was to evaluate the risk of clinical relapse between patients with an MES of 0 or 1 and determine if histologic activity using the Robarts Histopathologic Index (RHI) was predictive of clinical relapse.

Methods

UC patients with an MES score of 0 or 1, no prior colectomy, and at least 1 year of outpatient follow-up after colonoscopy were included. Demographic, clinical characteristics, and clinical relapse were retrospectively collected. Biopsy specimens were read by a gastrointestinal pathologist. Primary outcome was defined as a composite of relapse requiring change in medical therapy, new steroid use, UC-related hospitalization, and/or colectomy.

Results

Four hundred and forty-five UC patients were identified. Ninety-five percent of patients with MES 0 were in histologic remission by the RHI whereas only 35% of patients with MES 1 were in histologic remission. Twenty-six percent of patients experienced a clinical relapse; patients with MES 1 or RHI > 3 were significantly more likely to relapse (P < .01) compared to patients with MES 0 or RHI ≤ 3. When patients were stratified into 4 groups (MES 0, RHI ≤ 3; MES 0, RHI > 3; MES 1, RHI ≤ 3; MES 1, RHI > 3) and adjusted for age and sex, RHI > 3 was predictive of relapse (P = .008).

Conclusions

UC patients with endoscopic improvement have a high rate of clinical relapse over time. Histologic activity is a predictor of clinical relapse.

Factors influencing social prescribing initiatives: a systematic review of qualitative evidence

AIMS

Social prescribing is a growing health policy agenda to improve the quality and effectiveness of health systems. However, systematically collected knowledge on factors influencing the effective implementation of SP is scarce. A systematic review was conducted to identify and categorize factors influencing social prescribing initiatives.

METHODS

A search of three electronic databases (PubMed, Scopus, and ISI Web of Knowledge) was carried out to retrieve studies from inception to May 2022, supplemented by grey literature searching and snowballing of the relevant references. The inclusion criteria were original empirical research, qualitative data collection, and a description of factors affecting social prescribing initiatives. Study quality was evaluated using the Critical Appraisal Skills Programme tool. We categorized the results of individual studies using a narrative approach.

RESULTS

A total of 23 studies were included for analysis. Along with patient-related factors (patient-centeredness, clinical complexity, perception, knowledge), three main settings of social prescribing initiatives (including healthcare providers, link workers, and voluntary and community sectors) are affected by (1) individual characteristics (knowledge, perception, skill mix); (2) interpersonal relations (collaboration, trust, feedback, supportive climate, follow-up, sustained connection, peer support within and across sectors); (3) organizational contingencies (resource adequacy, staffing, training, role description, continuity of support, caseload management, monitoring, affordability, accessibility, referral criteria, and tailored support); and (4) political context (national policy and guidance, stewardship, planning, cocreation, bureaucracy, economic condition, and the number of support organizations).

CONCLUSION

Many factors influencing social prescribing initiatives were identified. The results of this review can be applied by different stakeholders of social prescribing to guide development, implementation, description, and evaluation.

Assessing Progression of Biologic Therapies Based on Smoking Status in Patients With Crohn's Disease

BACKGROUND

Active smoking is a well-established risk factor for developing Crohn's disease (CD) and negatively impacts overall disease progression. Patients who start or continue smoking after CD diagnosis are at risk for poor outcomes, higher therapeutic requirements, and have higher rates of relapse. However, it remains unclear if the exposure to smoking leads to increased sequencing through treatment therapies, especially biologics.

METHODS

The Study of Prospective Adult Research Cohort with IBD (SPARC IBD) registry has been collecting patient-reported outcomes data in real-time, as well as laboratory, endoscopic, and pathologic samples from 17 tertiary referral centers since 2016. In this study, we conducted a retrospective review of the SPARC clinical registry collected between December 2016 and January 2021 from 1 participating site, the University of Maryland School of Medicine's Inflammatory Bowel Disease Program. A total of 619 patients were enrolled in the SPARC IBD database. Four hundred twenty-five patients with CD were included for initial review of completeness of data; of these, 144 patients were excluded due to missing data on smoking status and/or biologic treatment, resulting in a final cohort of 281 patients. We collected and analyzed baseline demographic and clinical characteristics. The final cohort was categorized into 3 exposure groups: current, former, and never smokers. Our outcome of interest was number biologics used, categorized into 3 groups: 0, 1, or ≥2 biologics.

RESULTS

One hundred seventy-two never smokers, 70 former smokers, and 39 current smokers were identified. Current, former, and never smokers had no statistically significant differences in number of biologics used (ie, biologic sequencing). However, statistically significant independent risk factors for increased sequencing of biologics were identified. These risk factors included female sex, ileocolonic disease location, younger age at diagnosis, and prolonged disease duration; none of these factors remained significant in adjusted analyses.

CONCLUSION

To date, this is the first study assessing the association of smoking and sequencing of biologics. Although current or former smokers were not found to sequence through more biologics when compared with never smokers, smoking is a well-established risk factor for poor health outcomes, and efforts should be made to counsel patients to quit. Further, additional research must be done to stratify risk to patients based on amount of tobacco exposure.

Primary sclerosing cholangitis and pancreatic cancer: A retrospective cohort study of United States veterans

Primary sclerosing cholangitis (PSC) is associated with hepatobiliary and colorectal cancers, but it remains uncertain if PSC increases the risk for pancreatic cancer. While some European studies have suggested an increased risk of pancreatic cancer in PSC patients, other studies have not. And these studies did not well account for presence or absence of concomitant inflammatory bowel disease (IBD). The purpose of this study is to investigate the prevalence of pancreatic cancer in United States veterans with PSC both with and without IBD.

Methods

This retrospective study used International Classification of Diseases, Tenth Revision (ICD-10) codes to identify patients with PSC, IBD, and pancreatic cancer from the Veterans Affairs (VA) Corporate Data Warehouse. The prevalence of pancreatic cancer in patients with PSC only, IBD only, PSC with IBD, and neither PSC nor IBD were compared. Logistic regression was used to control for age, gender, chronic pancreatitis, diabetes mellitus, and tobacco and alcohol use.

Results

A total of 946 patients with PSC were identified from a population of over 9 million veterans. 486 (51.4%) of these had concurrent IBD. Additionally 112,653 patients with IBD without PSC were identified. When adjusted for confounding factors, patients with PSC had a significantly higher prevalence of pancreatic cancer compared to the general population and those with IBD without PSC (2.4% vs. 0.2% and 0.5%, respectively).

Conclusions

Veterans with PSC, particularly those without concomitant IBD, have a high prevalence of pancreatic cancer compared to the general veteran population. Our findings support the need for multicenter prospective studies investigating the benefits of screening for pancreatic cancer in patients with PSC.

Patients with inflammatory bowel disease are more hesitant about Coronavirus disease 2019 vaccination

Despite the impact of the Coronavirus Disease 2019 (COVID-19) pandemic, vaccine hesitancy remains common in the general public and patients with Inflammatory Bowel Diseases (IBD). We sought to examine the reasons for vaccine hesitancy in patients with IBD. In this case-control study, we performed a retrospective chart review of 1,349 IBD patients and 215 non-IBD patients seen at University of Maryland Medical Center, a tertiary referral medical center, between March 2020 and October 2021. Data obtained included demographics, vaccination records, disease history, number of IBD-related surgeries, and IBD medications. 813/1,349 (60.3%) IBD patients received at least one dose of either the Pfizer/BioNTech, Moderna, or Johnson & Johnson vaccines. In a multivariate logistic regression, COVID vaccination was found to be positively associated with older age (p-value = 1.65e-5), female sex (p = 0.00194), Asian and White races (p = 0.02330, 0.00169), number of clinic visits (p = 1.11e-08), and biologic use (p = 7.82e-5). There was no association between vaccination and other types of vaccination nor with the use of other IBD medications. There was a negative association between vaccination status and the total number of IBD related surgeries (p = 0.02857). In non-IBD patients, only the number of clinic visits was positively associated with COVID-19 vaccination. Although the majority of IBD patients are immunosuppressed, COVID-19 vaccination rate was only 60.3%. Younger adults, males, African Americans, and those requiring IBD-related surgeries were less likely to receive COVID-19 vaccine. Healthcare providers need to recognize these potential risk factors for COVID-19 vaccine hesitancy.

Closure of Mucosal Defects Using Endoscopic Suturing Following Endoscopic Submucosal Dissection: A Single-Center Experience

Background and Aims

Endoscopic submucosal dissection (ESD) is a therapeutic technique for en-bloc resection of both large (>20 mm) and smaller, complex gastrointestinal neoplasms. ESD has a higher success rate of en-bloc resection and a lower rate of local recurrence compared to endoscopic mucosal resection (EMR). Removal of lesions via ESD can leave large mucosal defects, raising unique challenges leading to adverse events. We aimed to determine clinical outcomes including delayed bleeding, perforation and hospitalization in patients undergoing endoscopic suturing following ESD.

Methods

Single-center retrospective study of a prospectively collected database of consecutive adult patients who underwent ESD with mucosal defect closure using endoscopic suturing. Primary outcomes were adverse events, specifically, delayed bleeding or perforation. Secondary outcomes included need for hospitalization and suturing complications.

Results

55 patients (mean age: 67 years) were included with a mean lesion size of 27.4 mm ± 15. Defect closure occurred in the esophagus (6), gastroesophageal junction (2), stomach (30), cecum (2), sigmoid colon (2) and rectum (13). A mean of 1.8 ± 1.0 sutures were required for defect closure. Hospital admission rates were 14% (8/55) with an average length of stay 2 days (range: 1-3 days). Intra-procedure perforation occurred in two patients and both were successfully treated with endoscopic suturing. There was one case of delayed bleeding and no cases of delayed perforation or suturing complications.

Conclusion

The use of endoscopic suturing following ESD is a safe and clinically reliable method to close mucosal defects. This approach is associated with minimal adverse events and need for hospitalization. Larger studies are needed to further validate these findings.

Gastrointestinal neoplasia: carcinogenic interaction between bile acids and Helicobacter pylori in the stomach

Bile acids modulate cell functions in health and disease, however, the mechanisms underlying their actions on neoplastic cells in the gastrointestinal (GI) tract remain largely unknown. In this issue of the JCI, Noto et al. comprehensively analyzed how interactions between Helicobacter pylori infection, iron deficiency, and bile acids modulate gastric inflammation and carcinogenesis. The investigators used sophisticated models, including INS-GAS mice with elevated serum gastrin and gastric acid secretion, in which H. pylori infection mimics human disease progression, to show that selected bile acids potentiated the carcinogenic effects of H. pylori infection and iron depletion. This elegant work has broad translational implications for microbe-associated GI neoplasia. Importantly, bile acid sequestration robustly attenuated the combined effects of H. pylori infection and iron depletion on gastric inflammation and cancer.

Mechanistic Clues Provided by Concurrent Changes in the Expression of Genes Encoding the M1 Muscarinic Receptor, β-Catenin Signaling Proteins, and Downstream Targets in Adenocarcinomas of the Colon

Muscarinic receptors (MRs) in the G protein-coupled receptor superfamily are recipients and mediators of parasympathetic neural transmission within the central and enteric nervous systems. MR subtypes, M₁R-M₅R, encoded by CHRM1-CHRM5, expressed widely throughout the gastrointestinal (GI) tract, modulate a range of critical, highly regulated activities in healthy tissue, including secretion, motility, and cellular renewal. CHRM3/M₃R overexpression in colon cancer is associated with increased cell proliferation, metastasis, and a worse outcome, but little is known about the role of the other four muscarinic receptor subtypes. To address this gap in knowledge, we queried the NCI Genomic Data Commons for publicly available TCGA-COAD samples collected from colon tissue. RNA-seq data were collected and processed for all available primary adenocarcinomas paired with adjacent normal colon. In this unbiased analysis, 78 paired samples were assessed using correlation coefficients and univariate linear regressions; gene ontologies were performed on a subset of correlated genes. We detected a consistent pattern of CHRM1 downregulation across colorectal adenocarcinomas. CHRM1 expression levels were positively associated with those for APC and SMAD4, and negatively associated with CTNNB1, the gene for β-catenin, and with coordinate changes in the expression of β-catenin target genes. These findings implicating CHRM1/M₁R as an important deterrent of colon cancer development and progression warrant further exploration.

Differential Actions of Muscarinic Receptor Subtypes in Gastric, Pancreatic, and Colon Cancer

Cancers arising from gastrointestinal epithelial cells are common, aggressive, and difficult to treat. Progress in this area resulted from recognizing that the biological behavior of these cancers is highly dependent on bioactive molecules released by neurocrine, paracrine, and autocrine mechanisms within the tumor microenvironment. For many decades after its discovery as a neurotransmitter, acetylcholine was thought to be synthesized and released uniquely from neurons and considered the sole physiological ligand for muscarinic receptor subtypes, which were believed to have similar or redundant actions. In the intervening years, we learned this former dogma is not tenable. (1) Acetylcholine is not produced and released only by neurons. The cellular machinery required to synthesize and release acetylcholine is present in immune, cancer, and other cells, as well as in lower organisms (e.g., bacteria) that inhabit the gut. (2) Acetylcholine is not the sole physiological activator of muscarinic receptors. For example, selected bile acids can modulate muscarinic receptor function. (3) Muscarinic receptor subtypes anticipated to have overlapping functions based on similar G protein coupling and downstream signaling may have unexpectedly diverse actions. Here, we review the relevant research findings supporting these conclusions and discuss how the complexity of muscarinic receptor biology impacts health and disease, focusing on their role in the initiation and progression of gastric, pancreatic, and colon cancers.

Potential Role for Combined Subtype-Selective Targeting of M1 and M3 Muscarinic Receptors in Gastrointestinal and Liver Diseases

Despite structural similarity, the five subtypes comprising the cholinergic muscarinic family of G protein-coupled receptors regulate remarkably diverse biological functions. This mini review focuses on the closely related and commonly co-expressed M₁R and M₃R muscarinic acetylcholine receptor subtypes encoded respectively by CHRM1 and CHRM3. Activated M₁R and M₃R signal via G_q and downstream initiate phospholipid turnover, changes in cell calcium levels, and activation of protein kinases that alter gene transcription and ultimately cell function. The unexpectedly divergent effects of M₁R and M₃R activation, despite similar receptor structure, distribution, and signaling, are puzzling. To explore this conundrum, we focus on the gastrointestinal (GI) tract and liver because abundant data identify opposing effects of M₁R and M₃R activation on the progression of gastric, pancreatic, and colon cancer, and liver injury and fibrosis. Whereas M₃R activation promotes GI neoplasia, M₁R activation appears protective. In contrast, in murine liver injury models, M₃R activation promotes and M₁R activation mitigates liver fibrosis. We analyze these findings critically, consider their therapeutic implications, and review the pharmacology and availability for research and therapeutics of M₁R and M₃R-selective agonists and antagonists. We conclude by considering gaps in knowledge and other factors that hinder the application of these drugs and the development of new agents to treat GI and liver diseases.

Atlas-Based Quantification of DTI Measures in a Typically Developing Pediatric Spinal Cord

BACKGROUND AND PURPOSE

Multi-parametric MRI, provides a variety of biomarkers sensitive to white matter integrity, However, spinal cord MRI data in pediatrics is rare compared to adults. The purpose of this work was 3-fold: 1) to develop a processing pipeline for atlas-based generation of the typically developing pediatric spinal cord WM tracts, 2) to derive atlas-based normative values of the DTI indices for various WM pathways, and 3) to investigate age-related changes in the obtained normative DTI indices along the extracted tracts.

MATERIALS AND METHODS

DTI scans of 30 typically developing subjects (age range, 6-16 years) were acquired on a 3T MR imaging scanner. The data were registered to the PAM50 template in the Spinal Cord Toolbox. Next, the DTI indices for various WM regions were extracted at a single section centered at the C3 vertebral body in all the 30 subjects. Finally, an ANOVA test was performed to examine the effects of the following: 1) laterality, 2) functionality, and 3) age, with DTI-derived indices in 34 extracted WM regions.

RESULTS

A postprocessing pipeline was developed and validated to delineate pediatric spinal cord WM tracts. The results of ANOVA on fractional anisotropy values showed no effect for laterality (P = .72) but an effect for functionality (P < .001) when comparing the 30 primary WM labels. There was a significant (P < .05) effect of age and maturity of the left spinothalamic tract on mean diffusivity, radial diffusivity, and axial diffusivity values.

CONCLUSIONS

The proposed automated pipeline in this study incorporates unique postprocessing steps followed by template registration and quantification of DTI metrics using atlas-based regions. This method eliminates the need for manual ROI analysis of WM tracts and, therefore, increases the accuracy and speed of the measurements.

Yeast cell wall polysaccharides enhanced expression of T helper type 1 and 2 cytokines profile in chicken B lymphocytes exposed to LPS challenge and enzyme treatment

1. The objective of this study was to investigate the potential immunomodulatory effects of yeast (Saccharomyces cerevisiae) and yeast-derived products treated with a cell wall lytic enzyme mixture on the gene expression of toll-like receptors and cytokines of chicken B cell line (DT 40) stimulated with lipopolysaccharide. 2. The effect of brewer's yeast (Y), yeast cell wall (YCW), distilled dried grains with solubles (DDGS) and a processed yeast + nucleotide-rich product (PY/N) treated with a yeast cell wall lytic enzyme (E) was assessed using a chicken B cells and LPS challenge model. 3. Relative gene expression of toll-like receptors (TLRs) and cytokines was investigated. Treatment of cells with Y, YCW, YCW + E and PY/N upregulated the expression of TLR2b following LPS challenge. Gene expression of TLR4 was downregulated in E, YCW and YCW + E treatments compared to control, while adding DDGS and PY/N upregulated the expression of TLR4 either before or after enzyme treatment. Following LPS challenge, expression of IL-4 and IL-10 was upregulated in cells treated with YCW and PY/N, both pre and post enzyme incubation. Adding YCW and PY/N to the cells challenged with LPS upregulated the expression of IFN-γ and IL-12 before and after enzyme treatment. Treatment of cells with YCW, DDGS and PY/N increased the expression of IL-6 prior to LPS challenge. 4. In conclusion, the results suggested that yeast-derived products affected immunomodulatory activities by changing the expression of cytokines involved in the innate immune response.

Correlation Between Resilience with Aggression and Hostility in University Students

Resilience as a capacity to withstand stress and calamity is one of the important components of mental health and aggressive is a negative behaviour that can threaten human health. So, the purpose of this study was to investigate the correlation between resilience with aggression and hostility in university students. The research method is correlation, 155 university students were selected by convenience sampling method and responded to Corner & Davidson resilience questionnaires and Boos & Perry aggression and hostility questionnaire. The data were analysed by correlation formula. The results showed that there is a significant and negative correlation between resilience with aggression and hostility, which means when the score of resilience is high, people's aggression and hostility decreases. Therefore, it is recommended to increase the resilience of people by specific teaching programs to reduce the basis of aggression and hostility.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Feasibility of diffusion and probabilistic white matter analysis in patients implanted with a deep brain stimulator

Deep brain stimulation (DBS) for Parkinson's disease (PD) is an established advanced therapy that produces therapeutic effects through high frequency stimulation. Although this therapeutic option leads to improved clinical outcomes, the mechanisms of the underlying efficacy of this treatment are not well understood. Therefore, investigation of DBS and its postoperative effects on brain architecture is of great interest. Diffusion weighted imaging (DWI) is an advanced imaging technique, which has the ability to estimate the structure of white matter fibers; however, clinical application of DWI after DBS implantation is challenging due to the strong susceptibility artifacts caused by implanted devices. This study aims to evaluate the feasibility of generating meaningful white matter reconstructions after DBS implantation; and to subsequently quantify the degree to which these tracts are affected by post-operative device-related artifacts. DWI was safely performed before and after implanting electrodes for DBS in 9 PD patients. Differences within each subject between pre- and post-implantation FA, MD, and RD values for 123 regions of interest (ROIs) were calculated. While differences were noted globally, they were larger in regions directly affected by the artifact. White matter tracts were generated from each ROI with probabilistic tractography, revealing significant differences in the reconstruction of several white matter structures after DBS. Tracts pertinent to PD, such as regions of the substantia nigra and nigrostriatal tracts, were largely unaffected. The aim of this study was to demonstrate the feasibility and clinical applicability of acquiring and processing DWI post-operatively in PD patients after DBS implantation. The presence of global differences provides an impetus for acquiring DWI shortly after implantation to establish a new baseline against which longitudinal changes in brain connectivity in DBS patients can be compared. Understanding that post-operative fiber tracking in patients is feasible on a clinically-relevant scale has significant implications for increasing our current understanding of the pathophysiology of movement disorders, and may provide insights into better defining the pathophysiology and therapeutic effects of DBS.

P6426The use of direct oral anti-coagulations (DOACs) compared to vitamin k antagonist in patients with left ventricular thrombus after acute myocardial infarction

Aim

Current guidelines recommend the use of Vitamin K Antagonist (VKA) for up to 3–6 months for the treatment of LV thrombus post- acute myocardial infarction (AMI). However based on evidence supporting the non-inferiority and potential superiority of Direct Oral Anti-Coagulation's (DOAC) compared to VKA for other indications such as atrial fibrillation, DOACs are being increasingly used off licence for the treatment of left ventricular (LV) thrombus post AMI. In this study we investigated the effect of DOACs compared to VKA on LV thrombus resolution and their safety profile in patients presenting with AMI.

Methods and results

This was a prospective observational study of 2,328 consecutive patients undergoing Percutaneous Coronary Intervention (PCI) for AMI between 2015- 2018, at a UK cardiac centre. Patients' details were collected from the hospital electronic database. The primary end-point was the rate of resolution of LV thrombus with bleeding rates as a secondary outcome.

Left ventricular (LV) thrombus was diagnosed by echocardiography, or cardiac magnetic resonance imaging in 98 (5.1%) patients. Sixty patients (61.2%) were started on VKA and 38 patients (38.8%) on DOAC therapy (Rivaroxaban: 57.9%, Apixaban, 36.8% and Edoxaban: 5.3%). Both groups were well matched in terms of baseline characteristics including age, previous cardiac history (previous MI, PCI, CABG), and cardiovascular risk factors (Hypertension, Diabetes, Hypercholesterolaemia).

Over the follow up period (median 1.8 years), overall rates of LV thrombus resolution were 86%. There was greater and earlier LV thrombus resolution in the DOAC group compared to patients treated with warfarin (75% vs 53%, p=0.0018, at 1 year), which persisted after adjusting for baseline variables (OR 1.8 95% CI 1.2–2.9). Major bleeding such as intracranial bleed, major GI bleed and bleed requiring hospital admission were lower in DOAC group, compared with VKA group (0% vs 5%, p=0.030) with no difference in rates of systemic thromboembolism (p=0.388).

Conclusion

This data suggests improved thrombus resolution in post ACS LV thrombosis in patient treated with DOACs compared to vitamin K antagonists. This improvement in thrombus resolution was accompanied with a better safety profile for the DOAC patients' vs VKA treated patients. This supports the need for randomised controlled trials to confirm this observational data.

Acknowledgement/Funding

None

Identifying crossing collagen fibers in human corneal tissues using pSHG images

Polarization sensitive second harmonic generation (pSHG) microscopy has been used previously to characterize the structure of collagen fibers in corneal samples. Due to the typical organization of the corneal stroma, the information that pSHG provides may be misleading in points where two different collagen fiber bundles orient along different direction crossings. Here, a simulation that illustrates the problem is presented, along with a novel method that is capable of identifying these crossing points. These results can be used to improve the evaluation of corneal collagen structure, and it has been applied to analyze pSHG data acquired from healthy and keratoconic human corneal samples.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Isolation of probiotic bacteria from raw camel's milk and their antagonistic effects on two bacteria causing food poisoning

Lactic acid bacteria (LAB) is one of the main classes of acid-producing organisms in the food industry, and they play a vital part in many food and feed fermentations. We isolated and performed molecular identification of LAB from raw camel's milk and assessed their protective effects against pathogenicity induced by Staphylococcus aureus and Escherichia coli. Fourteen samples of camel's milk were obtained from several districts under aseptic conditions. Bacteria isolation was performed by plating the samples on selective media. Isolates were identified by amplification of the 16S ribosomal RNA by PCR and sequencing. A total of 32 isolates were randomly picked, eight of which were analysed in this study. On the basis of phenotypic and genotypic methods, isolated LAB was included Leuconostoc mesenteroides, Lactobacillus plantarum, Weissella paramesenteroides and Weissella confuse. Antagonistic activity of isolated LAB against two pathogenic bacteria showed that they had more inhibitory activity against S. aureus subsp. aureus PTCC 1431 than E. coli ATCC 25922. This study discovered that raw camel's milk obtained from three districts of Kerman province contain LAB bacteria that have antagonistic properties on S. aureus.

Zonally Magnified Oblique Multislice and Non-Zonally Magnified Oblique Multislice DWI of the Cervical Spinal Cord

BACKGROUND AND PURPOSE

The zonally magnified oblique multislice EPI (ZOOM-EPI) diffusion-weighted sequence has been visually shown to provide superior MR diffusion image quality compared with the full-FOV single-shot EPI sequence (non-ZOOM-EPI) in the adult cervical spinal cord. The purpose of this study was to examine the diffusion tensor imaging indices in the normal human cervical spinal cord between ZOOMED and non-ZOOMED DTI acquisitions and determine whether DTI values are comparable between direct and indirect age-matched groups.

MATERIALS AND METHODS

Fifty-four subjects 23-58 years of age (9 direct age-matched and 45 indirect age-matched) were scanned using a 1.5T scanner. Diffusion tensor indices including fractional anisotropy, mean diffusivity, axial diffusivity, and radial diffusivity were generated from the DTI dataset. These DTI values were calculated for both ZOOM and non-ZOOM acquisitions and compared at each intervertebral disc level. The variability of the DTI values for ZOOM and non-ZOOM sequences was measured using a coefficient of variation within direct and indirect age-matched controls.

RESULTS

The mean diffusivity, axial diffusivity, and radial diffusivity values obtained along the cervical spinal cord in the age-matched controls showed a significant decrease using the ZOOM sequence (P = .05, P = .002, and P < .001). Mean fractional anisotropy showed a significant increase (P = .04) using the ZOOM sequence. The indirect age-matched controls showed a statistically significant increase in fractional anisotropy (P = .03) and a decrease in mean diffusivity (P = .002), axial diffusivity (P < .001), and radial diffusivity (P = .002) using the ZOOM sequence. Less variability has been shown in DTI using the ZOOM sequence compared with the non-ZOOM sequence in both direct and indirect age groups. The ZOOM sequence exhibited higher SNR (SNR_ZOOM = 22.84 ± 7.59) compared with the non-ZOOM sequence (SNR_non-ZOOM = 19.7 ± 7.05). However, when we used a 2-tailed t test assuming unequal variances, the ZOOM sequence did not demonstrate a statistically significant increase.

CONCLUSIONS

ZOOM DTI acquisition methods provide superior image quality and precision over non-ZOOM techniques and are recommended over conventional full-FOV single-shot EPI DTI for clinical applications in cervical spinal cord imaging.

Effect of yeast-derived products and distillers dried grains with solubles (DDGS) on growth performance and local innate immune response of broiler chickens challenged with Clostridium perfringens

This study evaluated the effect of yeast-derived products on growth performance, gut lesion score, intestinal population of Clostridium perfringens, and local innate immunity of broiler chickens challenged with C. perfringens. One-day-old broiler chickens were randomly assigned to eight dietary treatments providing six replicate pens of 55 birds each per treatment. Dietary treatments consisted of Control diets without and with C. perfringens challenge, and diets containing bacitracin methylene disalicylate (BMD, 55 g/tonne), nucleotides (150 g/tonne), yeast cell wall (YCW, 300 g/tonne), and a commercial product Maxi-Gen Plus (1 kg/tonne) fed to chickens challenged with C. perfringens. Diets containing 10% distillers dried grains with solubles without and with C. perfringens challenge were also used. Birds were orally challenged with C. perfringens (10(8) colony-forming units (cfu)/bird) on day 14. On day 21, intestinal samples were collected for gene expression analysis. Pathogen challenge significantly (P < 0.05) impaired feed intake, body weight gain, and feed conversion ratio (FCR) shortly after the challenge (14-21 days). Increased C. perfringens counts and intestinal lesion scores were observed for challenged birds except the BMD-containing diet. Over the entire trial (1-35 days), no difference in growth performance was observed except the BMD diet which improved FCR over the Control, challenged group. Birds receiving nucleotides showed increased expression of toll-like receptors and cytokines interleukin (IL)-4 and IL-18 compared to the Control, challenged group. Expression of macrophage mannose receptor and IL-18 was upregulated in birds receiving YCW. Increased expression of cytokines and receptors involved in innate immunity in broilers receiving nucleotides and YCW suggests the immunomodulatory properties of these products under pathogen challenge conditions.

An EMG-driven biomechanical model of the canine cervical spine

Due to the frequency of cervical spine injuries in canines, the purpose of this effort was to develop an EMG-driven dynamic model of the canine cervical spine to assess a biomechanical understanding that enables one to investigate the risk of neck disorders. A canine subject was recruited in this investigation in order to collect subject specific data. Reflective markers and a motion capture system were used for kinematic measurement; surface electrodes were used to record electromyography signals, and with the aid of force plate kinetics were recorded. A 3D model of the canine subject was reconstructed from an MRI dataset. Muscles lines of action were defined through a new technique with the aid of 3D white light scanner. The model performed well with a 0.73 weighted R² value in all three planes. The weighted average absolute error of the predicted moment was less than 10% of the external moment. The proposed model is a canine specific forward-dynamics model that precisely tracks the canine subject head and neck motion, calculates the muscle force generated from the twelve major moment producing muscles, and estimates resulting loads on specific spinal tissues.

MRI cross sectional atlas of normal canine cervical musculoskeletal structure

Although magnetic resonance imaging (MRI) has been increasingly used as a diagnostic tool for cervical spine injuries in canines, a comprehensive normal MRI anatomy of the canine cervical spine muscles is lacking. Therefore, the purpose of this study was to build a magnetic resonance imaging atlas of the normal cross sectional anatomy of the muscles of the canine cervical spine. MRI scans were performed on a canine cadaver using a combination of T1 and T2-weighted images in the transverse, sagittal and dorsal planes acquired at a slice thickness of 1mm. Muscle contours were traced manually in each slice, using local osseous structures as reference points for muscle identification. Twenty-two muscles were traced in 401 slices in the cervical region. A three dimensional surface model of all the contoured muscles was created to illustrate the complex geometrical arrangement of canine neck muscles. The cross-sectional area of the muscles was measured at the mid-level of each vertebra. The accuracy of the location of the mapped muscles was verified by comparing the sagittal view of the 3D model of muscles with still photographs obtained from anatomic canine cadaver dissection. We believe that this information will provide a unique and valuable resource for veterinary researchers, clinicians and surgeons who wish to evaluate MRI images of the cervical spine. It will also serve as the foundation for ongoing work to develop a computational model of the canine cervical spine in which anatomical information is combined with electromyographic, kinematic and kinetic data.