Cost-effectiveness analysis of immune-modulating nutritional support for gastrointestinal cancer patients.

BACKGROUND & AIM: Immune-modulating nutritional formula containing arginine, omega-3 fatty acids and nucleotides has been demonstrated to decrease complications and length of stay in surgical patients. This study aims at assessing the impact of immune-modulating formula on hospital costs in gastrointestinal cancer surgical patients in Switzerland. METHOD: Based on a previously published meta-analysis, the relative risks of overall and infectious complications with immune-modulating versus standard nutrition formula were computed. Swiss hospital costs of patients undergoing gastrointestinal cancer surgery were retrieved. A method was developed to compute the patients' severity level, not taking into account the complications from the surgery. Incremental costs of complications were computed for both treatment groups, and sensitivity analyses were carried out. RESULTS: Relative risk of complications with pre-, peri- and post-operative use of immune-modulating formula was 0.69 (95%CI 0.58-0.83), 0.62 (95%CI 0.53-0.73) and 0.73 (95%CI 0.35-0.96) respectively. The estimated average contribution of complications to the cost of stay was CHF 14,949 (euro10,901) per patient (95%CI 10,712-19,186), independently of case's severity. Based on this cost, immune-modulating nutritional support decreased costs of hospital stay by CHF 1638 to CHF 2488 per patient (euro1195-euro1814). Net hospital savings were present for baseline complications rates as low as 5%. CONCLUSION: Immune-modulating nutritional solution is a cost-saving intervention in gastrointestinal cancer patients. The additional cost of immune-modulating formula are more than offset by savings associated with decreased treatment of complications.

Thrombin-sensitive dual fluorescence imaging and therapeutic agent for detection and treatment of synovial inflammation in murine rheumatoid arthritis.

We have developed a thrombin-sensitive polymeric photosensitizer prodrug (T-PS) to selectively image and eradicate inflammatory lesions in rheumatoid arthritis (RA). Thrombin is a serine protease up-regulated in synovial tissues of rheumatoid arthritis (RA) patients. T-PS consists of a polymeric backbone, to which multiple photosensitizer (PS) units are tethered via short thrombin-cleavable peptide linkers. Fluorescence emission and phototoxicity of the prodrug are efficiently quenched due to the interaction of neighboring photosensitizer units. The prodrug is passively delivered to the inflammation site via the enhanced permeability and retention (EPR) effect. Subsequent site-selective proteolytic cleavage of the peptide linkers restores its photoactivity by increasing the mutual distance between PS. Whole animal imaging in murine collagen-induced arthritis, an experimental model of RA revealed a dose-dependent fluorescence increase in arthritic paws after systemic prodrug injection. In addition, administration of T-PS resulted in much higher fluorescence selectivity for arthritic joints as compared to the free PS. Irradiation of the arthritic joints induced light dose dependent phototoxic effects such as apoptosis, vascular damage and local hemorrhage. Long-term observations showed complete regression of the latter. Irradiated non-arthritic tissues or non-irradiated arthritic tissues showed no histological effects after photodynamic therapy with T-PS. This illustrates that T-PS can localize inflammatory lesions with excellent selectivity and induce apoptosis and vascular shut down after irradiation.

Secretory IgA and intestinal epithelial cells at the interface between homeostasis regulation and protection against infection

RESUME DESTINE A UN LARGE PUBLICL'intestin est le siège d'intenses agressions de la part de l'ensemble des aliments ingérés, de bactéries agressives dites pathogènes mais également de bactéries dites commensales peuplant naturellement les surfaces intestinales muqueuses. Pour faire face, notre organisme arbore de nombreux niveaux de protections tant physiques, chimiques, mécaniques mais aussi immunitaires. La présence d'un type particulier de cellules, les cellules épithéliales (IEC) assurant une protection physique, ainsi que la production d'anticorps spécialisés par le système immunitaire appelés immunoglobulines sécrétoires A (SlgA) servent conjointement de première ligne de défense contre ces agressions externes. Néanmoins, comment le dialogue s'articule entre ces deux partenaires reste incomplet.Nous avons donc décidé de mimer ces interactions en modélisant les surfaces muqueuses par une monocouche de cellules différenciées en laboratoire. Des souches bactériennes isolées de l'intestin humain seules ou associées à des SlgA non-spécifiques ont été mises au contact de ce modèle cellulaire nous permettant de conclure quant à la présence effective d'une modulation du dialogue bactérie/lEC impliquant une activation de la réponse cellulaire vers un état de tolérance mutuelle. De façon surprenante, nous avons par ailleurs mis en évidence un type d'interaction nouveau entre ces anticorps et ces bactéries. Une étude biochimique nous a permis de détailler un nouveau rôle des SlgA médié par les sucres présents à leur surface dans le maintien d'une relation pacifique avec les commensaux perpétuellement présents, relations qualifiées d'homésostase intestinale.Le rôle protecteur des SlgA a par ailleurs été abordé pour avoir une meilleure appréhension de leur impact au niveau cellulaire lors d'infection par Shigella flexneri, bactérie causant la Shigellose, diarrhée sanglante responsable de la mort de plus d'un million de personnes chaque année. Basée sur le même modèle cellulaire, cette étude nous a permis de démontrer une nouvelle entrée de ce pathogène directement via les IEC. La présence d'anticorps spécifiques à la surface des bactéries restreint leur champs d'action contre les cibles intracellulaires identifiées que sont les filaments soutenant le squelette de la cellule, les fibres d'actine ainsi que les jonctions serrées, réseaux de protéines clés des interactions entre cellules. Cette ouverture au niveau cellulaire apporte un nouvel élan quant à la compréhension du rôle protecteur des SlgA lors d'attaques de l'intestin, protection semblant dépendante d'une agrégation des bactéries.Pour finir, nous avons mis en évidence la détection directe par les cellules de la présence d'anticorps libres dans l'intestin ajoutant une nouvelle réplique dans le dialogue complexe entre ces deux piliers de l'équilibre intestinal que sont les SlgA et les cellules épithéliales.RESUMELa muqueuse intestinale est dotée d'un réseau complexe de protections physico-chimiques, mécaniques ou immunologiques. Associées à un système immunitaire omniprésent, les cellules épithéliales intestinales {IEC) bordant la lumière intestinale ont la double tâche de protéger l'intérieur de l'organisme stérile contre l'invasion et la dissémination d'agents pathogènes, et de maintenir une relation pacifique avec la flore intestinale, rôles également joués par les immunoglobulines sécrétoires A (SlgA), anticorps les plus abondamment présents à la surface des muqueuses. Tant les IEC que les SlgA sont ainsi décrites comme convergeant vers le même objectif ; néanmoins, les rouages de leurs interactions restent largement inconnus.Pour répondre à cette question, des monocouches épithéliales reconstituées in vitro ont été incubées avec des souches commensales telles que des Lactobacillus ou des Bifodobacteria, seules ou complexées avec des SlgA non-spécifiques, nous permettant de décrypter l'influence des SlgA sur la détection des bactéries par les IEC, favorisant l'adhésion bactérienne et la cohésion cellulaire, augmentant l'activation de la voie NF-κΒ ainsi que la sécrétion de la cytokine thymic stromal lymphopoietin contrairement à celle de médiateurs pro-inflammatoires qui reste inchangée. Par ailleurs, une interaction Fab-indépendante est suggérée dans l'interaction SlgA/bactéries. Comme une interaction de faible affinité a été décrite comme prenant naturellement place au niveau de l'intestin, nous avons donc disséqué les mécanismes sous- jacents en utilisant un large spectre de bactérie associés à des protéines soit recombinantes soit isolées à partir de colostrum, mettant en évidence un rôle crucial des N-glycanes présents sur la pièce sécrétoire et soulignant une nouvelle propriété des SlgA dans l'homéostase intestinale.Intrinsèquement liés aux caractéristiques des SlgA, nous nous sommes également focalisés sur leur rôle protecteur lors d'infection par l'enteropathogène Shigella flexneri reproduites in vitro sur des monocouches polarisées. Nous avons tout d'abord démontré une nouvelle porte d'entrée pour ce pathogène directement via les IEC. L'agrégation des bactéries par les SlgA confère aux cellules une meilleure résistance à l'infection, retardant croissance bactérienne et entrée cellulaire, affectant par ailleurs leur capacité à cibler le cytosquelette et les jonctions serrées. La formation de tels cargos détectés de façon biaisée par les IEC apparaît comme une explication plausible au maintien de la cohésion cellulaire médiée par les SlgA.Enfin, le retrotransport des SlgA à travers les IEC a été abordé soulignant une participation active de ces cellules dans la détection de l'environnement extérieur, les impliquant possiblement dans l'activation d'un état muqueux stable.Conjointement, ces résultats indiquent que les SlgA représentent l'un des éléments-clés à la surface de la muqueuse et soulignent la complexité du dialogue établi avec l'épithélium en vue du maintien d'un fragile équilibre intestinal.ABSTRACTThe intestinal mucosa is endowed with a complex protective network melting physiochemical, mechanical and immunological features. Beyond the ubiquitous intestinal immune system, intestinal epithelial cells (IEC) lying the mucosal surfaces have also the dual task to protect the sterile core against invasion and dissemination of pathogens, and maintain a peaceful relationship with commensal microorganisms, aims also achieved by the presence of high amounts of secretory immunoglobulins A (SlgA), the most abundant immunoglobulin present at mucosal surfaces. Both IEC and SlgA are thus described to converge toward the same goal but how their interplay is orchestrated is largely unknown.To address this question, in vitro reconstituted IEC monolayers were first apically incubated with commensal bacteria such as Lactobacillus or Bifodobacteria strains either alone or in complexes with non-specific SlgA. Favoring the bacterial adhesion and cellular cohesion, SlgA impacts on the cellular sensing of bacteria, increasing NF-κΒ activation, and leading to cytokine releases restricted to the thymic stromal lymphopoietin and unaffected expression of pro-inflammatory mediators. Of main interest, bacterial recognition by SlgA suggested a Fab-independent interaction. As this low affinity, called natural coating occurs in the intestine, we further dissected the underlying mechanisms using a larger spectrum of commensal strains associated with recombinant as well as colostrum-derived proteins and pinpointed a crucial role of N-glycans of the secretory component, emphasizing an underestimated role of carbohydrates and another properties of SlgA in mediating intestinal homeostasis.As mucosal protection is also anchored in SlgA and IEC features, we focused on the cellular role of SlgA. Using IEC apical infection by the enteropathogen Shigella flexneri, we have first demonstrated a new gate of entry for this pathogen directly via IEC. Specific SlgA bacterial aggregation conferred to the cells a better resistance to infection, delaying bacterial growth and cellular entry, affecting their ability to damage both the cytoskeleton and the tight junctions. Formation of such big cargos differentially detected by IEC appears as a plausible explanation sustaining at the cellular level the antibody-mediated mucosal protection.Finally, SlgA retrotransport across IEC has been tackled stressing an active IEC sensing of the external environment possibly involved in the steady-state mucosal activation.All together, these results indicate that SlgA represents one of the pivotal elements at mucosal surfaces highlighting the complexity of the dialogue established with the epithelium sustaining the fragile intestinal balance.The Intestinal mucosa is endowed with a complex protective network melting physiochemical, mechanical and immunological features. Beyond the ubiquitous intestinal immune system, intestinal epithelial cells (IEC) lying the mucosal surfaces have also the dual task to protect the sterile core against invasion and dissemination of pathogens, and maintain a peaceful relationship with commensal microorganisms, aims also achieved by the presence of high amounts of secretory immunoglobulins A (SlgA), the most abundant immunoglobulin present at mucosal surfaces. Both IEC and SlgA are thus described to converge toward the same goal but how their interplay is orchestrated is largely unknown.To address this question, in vitro reconstituted IEC monolayers were first apically incubated with commensal bacteria such as Lactobacillus or Bifodobacteria strains either alone or in complexes with non-specific SlgA. Favoring the bacterial adhesion and cellular cohesion, SlgA impacts on the cellular sensing of bacteria, increasing NF-κΒ activation, and leading to cytokine releases restricted to the thymic stromal lymphopoietin and unaffected expression of pro-inflammatory mediators. Of main interest, bacterial recognition by SlgA suggested a Fab-independent interaction. As this low affinity, called natural coating occurs in the intestine, we further dissected the underlying mechanisms using a larger spectrum of commensal strains associated with recombinant as well as colostrum-derived proteins and pinpointed a crucial role of N-glycans of the secretory component, emphasizing an underestimated role of carbohydrates and another properties of SlgA in mediating intestinal homeostasis.As mucosal protection is also anchored in SlgA and IEC features, we focused on the cellular role of SlgA. Using IEC apical infection by the enteropathogen Shigella flexneri, we have first demonstrated a new gate of entry for this pathogen directly via IEC. Specific SlgA bacterial aggregation conferred to the cells a better resistance to infection, delaying bacterial growth and cellular entry, affecting their ability to damage both the cytoskeleton and the tight junctions. Formation of such big cargos differentially detected by IEC appears as a plausible explanation sustaining at the cellular level the antibody-mediated mucosal protection.Finally, SlgA retrotransport across IEC has been tackled stressing an active IEC sensing of the external environment possibly involved in the steady-state mucosal activation.All together, these results indicate that SlgA represents one of the pivotal elements at mucosal surfaces highlighting the complexity of the dialogue established with the epithelium sustaining the fragile intestinal balance.

Rôle du pathologiste dans la prise en charge des tumeurs stromales gastro-intestinales (GIST) [The role of the pathologist in the management of gastrointestinal stromal tumors (GIST)]

Considerable progress was realized these last years in the understanding of the molecular mechanisms and the treatment of the GIST. Their diagnosis remains based on the morphology and immunohistochemistry. The evaluation of GIST prognosis was till know difficult to establish but a new histopronostic classification currently used allows a better therapeutic approach. The search for KIT and PDGFRA mutations is recommended to adapt a targeted therapy by KIT inhibitors. The pathologist plays a crucial role in the management of the GIST because it is on him that is based the diagnosis, the evaluation of the prognosis and the treatment (surgery and kit inhibitors).

Protective effects of maternal nutritional supplementation with lactoferrin on growth and brain metabolism.

Background:Intrauterine growth restriction (IUGR) is a major risk factor for both perinatal and long-term morbidity. Bovine lactoferrin (bLf) is a major milk glycoprotein considered as a pleiotropic functional nutrient. The impact of maternal supplementation with bLf on IUGR-induced sequelae, including inadequate growth and altered cerebral development, remains unknown.Methods:IUGR was induced through maternal dexamethasone infusion (100 μg/kg during last gestational week) in rats. Maternal supplementation with bLf (0.85% in food pellet) was provided during both gestation and lactation. Pup growth was monitored, and Pup brain metabolism and gene expression were studied using in vivo (1)H NMR spectroscopy, quantitative PCR, and microarray in the hippocampus at postnatal day (PND)7.Results:Maternal bLf supplementation did not change gestational weight but increased the birth body weight of control pups (4%) with no effect on the IUGR pups. Maternal bLf supplementation allowed IUGR pups to recover a normalized weight at PND21 (weaning) improving catch-up growth. Significantly altered levels of brain metabolites (γ-aminobutyric acid, glutamate, N-acetylaspartate, and N-acetylaspartylglutamate) and transcripts (brain-derived neurotrophic factor (BDNF), divalent metal transporter 1 (DMT-1), and glutamate receptors) in IUGR pups were normalized with maternal bLf supplementation.Conclusion:Our data suggest that maternal bLf supplementation is a beneficial nutritional intervention able to revert some of the IUGR-induced sequelae, including brain hippocampal changes.

Autophagic cell death exists.

The term autophagic cell death (ACD) initially referred to cell death with greatly enhanced autophagy, but is increasingly used to imply a death-mediating role of autophagy, as shown by a protective effect of autophagy inhibition. In addition, many authors require that autophagic cell death must not involve apoptosis or necrosis. Adopting these new and restrictive criteria, and emphasizing their own failure to protect human osteosarcoma cells by autophagy inhibition, the authors of a recent Editor's Corner article in this journal argued for the extreme rarity or nonexistence of autophagic cell death. We here maintain that, even with the more stringent recent criteria, autophagic cell death exists in several situations, some of which were ignored by the Editor's Corner authors. We reject their additional criterion that the autophagy in ACD must be the agent of ultimate cell dismantlement. And we argue that rapidly dividing mammalian cells such as cancer cells are not the most likely situation for finding pure ACD.

Liver, gastrointestinal and cardiac toxicity in intermediate hepatocellular carcinoma treated with PRECISION TACE with drug-eluting beads: Results from the PRECISION V randomized trial : B-240

Purpose: To evaluate the toxicity focussing on hepatic, gastrointestinal and cardiac parameters following PRECISION TACE with DC Bead? versus conventional transarterial chemoembolization (cTACE) in the treatment of intermediate-stage hepatocellular carcinoma (HCC). Methods and Materials: This prospective, randomized, multicentre study was conducted under best practice trial management and authorized by local institutional review boards. Informed consent was obtained. 212 patients (185 men/27 women; mean: 67 years) were randomized to be treated with DC Beads? or cTACE. The majority of both groups presented in a more advanced stage. Safety was measured by rate of adverse events (South West Oncology Group criteria) and changes in laboratory parameters. Cardiotoxicity was assessed by means of left ventricular ejection fraction (LVEF) in MRI or echocardiography. The results of the two groups were compared using the chi-square test and Student`s t-test. Results: Mean maximum alanine transaminase increase in the DC Bead group was 50% in the cTACE group (p < 0.001) and 59% for aspartate transaminase (p < 0.001). For bilirubin, mean increase was 5.30±15.13 vs. 13.53±73.89 µmol/L. Concerning gastrointestinal disorders, 120 adverse events (AEs) occurred in 57/93 (61.3%) patients in the DC Bead group vs. 114 in 49/108 (45.4%) in cTACE. Concerning hepatobiliary disorders, serious AEs occurred in 8/93 (8.6%) vs. 11/108 (10.2%) patients. LVEF showed an increase in the DC Bead group by +2.7±10.1 percentage points and a small decrease by -1.5±7.6 in the cTACE group, p=0.018. Conclusion: PRECISION TACE is safe, even in more advanced HCC patients. Serious liver and cardiac toxicity were significantly lower in the DC Bead group.

Having a good relationship with their mother: a protective factor against sexual risk behavior among adolescent females?

STUDY OBJECTIVE: To assess whether having a good relationship with their mother was a protective factor against risky sexual behavior for female adolescents and whether it was independent of family structure. DESIGN: Cross-sectional survey of in-school adolescents aged 14-19 years. SETTING: Catalonia, in northeast Spain. PARTICIPANTS: A total of 3677 females divided according on whether they had a good (n=3335) or a bad (n=342) relationship with their mother. MAIN OUTCOME MEASURES: Rates of sexual activity and sexual behavior. RESULTS: Adolescents in the good relationship group were significantly younger, more likely to live in an intact family, to have a good relationship with their father and siblings, and to talk about sexuality and their partner with their mother. They were also less likely to have ever had sexual intercourse. Among those sexually experienced, they were significantly older at first intercourse and less likely to have multiple partners or a history of STI. After adjusting for potential confounders, females in the good relationship group were less likely to be sexually active and to have had multiple partners, independently of family structure. CONCLUSIONS: Having a good relationship with their mother is a protective factor against sexual intercourse and having multiple sexual partners independently of family structure. Communication between generations and having a good relationship with their father and siblings also play an important role.

Antigen binding to secretory immunoglobulin A results in decreased sensitivity to intestinal proteases and increased binding to cellular Fc receptors.

In intestinal secretions, secretory IgA (SIgA) plays an important sentinel and protective role in the recognition and clearance of enteric pathogens. In addition to serving as a first line of defense, SIgA and SIgA x antigen immune complexes are selectively transported across Peyer's patches to underlying dendritic cells in the mucosa-associated lymphoid tissue, contributing to immune surveillance and immunomodulation. To explain the unexpected transport of immune complexes in face of the large excess of free SIgA in secretions, we postulated that SIgA experiences structural modifications upon antigen binding. To address this issue, we associated specific polymeric IgA and SIgA with antigens of various sizes and complexity (protein toxin, virus, bacterium). Compared with free antibody, we found modified sensitivity of the three antigens assayed after exposure to proteases from intestinal washes. Antigen binding further impacted on the immunoreactivity toward polyclonal antisera specific for the heavy and light chains of the antibody, as a function of the antigen size. These conformational changes promoted binding of the SIgA-based immune complex compared with the free antibody to cellular receptors (Fc alphaRI and polymeric immunoglobulin receptor) expressed on the surface of premyelocytic and epithelial cell lines. These data reveal that antigen recognition by SIgA triggers structural changes that confer to the antibody enhanced receptor binding properties. This identifies immune complexes as particular structural entities integrating the presence of bound antigens and adds to the known function of immune exclusion and mucus anchoring by SIgA.

Valganciclovir in adult solid organ transplant recipients: pharmacokinetic and pharmacodynamic characteristics and clinical interpretation of plasma concentration measurements.

Valganciclovir and ganciclovir are widely used for the prevention of cytomegalovirus (CMV) infection in solid organ transplant recipients, with a major impact on patients' morbidity and mortality. Oral valganciclovir, the ester prodrug of ganciclovir, has been developed to enhance the oral bioavailability of ganciclovir. It crosses the gastrointestinal barrier through peptide transporters and is then hydrolysed into ganciclovir. This review aims to describe the current knowledge of the pharmacokinetic and pharmacodynamic characteristics of this agent, and to address the issue of therapeutic drug monitoring. Based on currently available literature, ganciclovir pharmacokinetics in adult solid organ transplant recipients receiving oral valganciclovir are characterized by bioavailability of 66 +/- 10% (mean +/- SD), a maximum plasma concentration of 3.1 +/- 0.8 mg/L after a dose of 450 mg and of 6.6 +/- 1.9 mg/L after a dose of 900 mg, a time to reach the maximum plasma concentration of 3.0 +/- 1.0 hours, area under the plasma concentration-time curve values of 29.1 +/- 5.3 mg.h/L and 51.9 +/- 18.3 mg.h/L (after 450 mg and 900 mg, respectively), apparent clearance of 12.4 +/- 3.8 L/h, an elimination half-life of 5.3 +/- 1.5 hours and an apparent terminal volume of distribution of 101 +/- 36 L. The apparent clearance is highly correlated with renal function, hence the dosage needs to be adjusted in proportion to the glomerular filtration rate. Unexplained interpatient variability is limited (18% in apparent clearance and 28% in the apparent central volume of distribution). There is no indication of erratic or limited absorption in given subgroups of patients; however, this may be of concern in patients with severe malabsorption. The in vitro pharmacodynamics of ganciclovir reveal a mean concentration producing 50% inhibition (IC(50)) among CMV clinical strains of 0.7 mg/L (range 0.2-1.9 mg/L). Systemic exposure of ganciclovir appears to be moderately correlated with clinical antiviral activity and haematotoxicity during CMV prophylaxis in high-risk transplant recipients. Low ganciclovir plasma concentrations have been associated with treatment failure and high concentrations with haematotoxicity and neurotoxicity, but no formal therapeutic or toxic ranges have been validated. The pharmacokinetic parameters of ganciclovir after valganciclovir administration (bioavailability, apparent clearance and volume of distribution) are fairly predictable in adult transplant patients, with little interpatient variability beyond the effect of renal function and bodyweight. Thus ganciclovir exposure can probably be controlled with sufficient accuracy by thorough valganciclovir dosage adjustment according to patient characteristics. In addition, the therapeutic margin of ganciclovir is loosely defined. The usefulness of systematic therapeutic drug monitoring in adult transplant patients therefore appears questionable; however, studies are still needed to extend knowledge to particular subgroups of patients or dosage regimens.

Regulation of protective immunity against Leishmania major in mice.

Resolution of lesions induced by Leishmania major in mice results from the development of Th1 responses. Cytokines produced by Th1 cells activate macrophages to a parasiticidal state. The development of Th2 responses in mice from a few strains underlies susceptibility to infection. Cytokines produced by Th2 cells exacerbate the development of lesions because of their deactivating properties for macrophages. This murine model of infection has provided significant insight into the mechanisms intrinsic to the differentiation of disparate CD4+ T cell subsets in vivo in animals from different genetic backgrounds.