Proliferative and Osteogenic Differentiation Potentials of Human Fetal Bone Cells

BACKGROUND. Human primary fetal bone cells (hFBC) are being characterized for use in bone tissue regeneration. Unlike human mesenchymal stem cells (hMSC), hFBC are partially differentiated with high expansion and regeneration potential. To date, proliferative and osteoblastic differentiation capacities of fetal bone cells remain poorly examined. The goal of this study was to define an environmental culture conditions for optimal proliferation and production of extracellular bone matrix leading to efficient bone repair. METHODS. Human primary FBC derived from our dedicated, consistent banks of bone cells comprising several fetal donors. For proliferation study, monolayer cultures of both cell types were expanded in DMEM or α- MEM media. Osteoblastic differentiation potentials of both hFBC and hMSC were evaluated through RT-PCR. Regulation of osteogenic differentiation by protein ligands Wnt3a and Wnt5a was studied by ALP enzymatic activity measurement. RESULTS. Evaluation of the proliferation rate demonstrated that hFBC proliferated more rapidly in α-MEM medium. Regarding growth factors that could stimulate cell proliferation rate, we observed that PDGF, FGF2 and Wnt3a had positive effects on proliferation of hFBC. Gene expression analysis demonstrated a higher expression of runx2 in hFBC cultured in basal conditions, which was was similar than that was observed in hMSC in osteoinductive culture conditions. Expression of sox9 was very low in hBFC and hMSC, compared to expression observed in fetal cartilage cells. Looking at osteogenic differentiation capacity, ALP activity was positively regulated byWnt5awhen hFBCwere cultured inα-MEM, but not in DMEM. Conversely, Wnt3a was shown to block the effect of osteogenic inductors on differentiation of both cell types. CONCLUSION. Data presented in this study indicate that the proliferation and differentiation of fetal and mesenchymal stem cells is optimal in α- MEM. Evidence for a pre-differentiated state of hBFC was given by extracellular matrix spontaneous mineralization as well as by higher ALP activity levels observed for these cells in baseline culture conditions, in comparison with hMSC. As we showed that, in vitro, hFBC express a higher capacity to differentiate in osteoblasts, they represent an attractive and promising prospect for fundamental research, and specifically for a new generation of skeletal tissue engineering.

Role of CLOCK and circadian rhythms in calcium homeostasis

Le maintien d'une concentration sanguine constante de calcium est d'une importance cruciale et trois organes participent à la balance calcique normale : les reins, les intestins et les os. La concentration plasmatique de calcium est strictement régulée par l'hormone parathyroïdienne (PTH) et par la vitamine D. Des variations circadiennes de la PTH, de la vitamine D ainsi que du calcium plasmatique ont été décrites précédemment chez l'humain ainsi que chez le rat. Ces rythmes de PTH dans le sérum sont importants pour la régulation du remodelage de l'os. En effet, il a été montré chez les souris C57BL/6J que des injections de PTH une fois par jour mènent à une augmentation de la densité minérale de l'os alors que l'infusion en continu de PTH est associée à une diminution de cette densité. La vitamine D joue également un rôle fondamental dans la physiologie osseuse, car un déficit en vitamine D peut conduire à une ostéomalacie. Cependant la fonction des oscillations de vitamine D au niveau de l'homéostasie osseuse reste inconnue. L'horloge circadienne est un système interne de contrôle biologique du temps générant des rythmes de 24 heures dans l'expression des gènes, ainsi que dans la physiologie et le comportement. Ce contrôle s'opère par des boucles rétroactives positives et négatives de l'expression de gènes circadiens tels que CLOCK, BMAL1, CRY1 et 2 ou PERI et 2. Dans ce travail, nous avons émis l'hypothèse que l'homéostasie calcique est sous le contrôle de l'horloge circadienne. Dans un premier temps, nous avons montré chez les souris C57BL/6J des variations journalières des concentrations de calcium, de PTH et de vitamine D dans le sang, ainsi que de calcium dans les urines. Nous avons également démontré des changements au niveau de l'expression rénale des gènes importants dans l'homéostasie du calcium, tant au niveau de l'ARN messager que des protéines. Ensuite, pour analyser le rôle du système de l'horloge circadienne dans l'homéostasie du calcium, nous avons étudié des souris dans lesquelles a été supprimé le gène CLOCK crucial pour la fonction de l'horloge et nous avons comparé ces souris à des souris de type sauvage de même portée. Les souris CLOCK-I- étaient hypercalciuriques à chaque moment de la journée. Cependant le rythme circadien de l'excrétion de calcium était préservé. Le taux de calcium plasmatique ne différait pas entre les génotypes, mais les souris CLOCK -/- ne montraient pas de variations journalières de ce paramètre. Une perte du rythme journalier était également observée pour les niveaux de vitamine D, perte qui pourrait être une cause de l'altération de la micro-architecture osseuse révélée chez les souris CLOCK-/-. En effet, ces souris montrent une diminution du nombre de trabécules, de leur volume ainsi que de leur surface, ce qui suggère la présence d'ostéoporose. Nous avons également trouvé que le rythme de l'expression de l'ARN messager de CYP27B1 était aboli dans les reins des souris CLOCK -/-, ce qui peut expliquer l'altération du rythme de la vitamine D. Les taux sanguins de PTH étaient comparables entre les souris CLOCK -/- et de type sauvage. Dans les reins, une augmentation de l'expression de l'ARN messager de TRPV5 et NCX1 a été constatée, ce qui suggérerait une augmentation de la réabsorption de calcium dans le tubule convoluté distal et dans le tubule connecteur. Dans les intestins, la réabsorption calcique était diminuée, chez les souris CLOCK-I-, fait confirmé par une diminution des niveaux d'ARN messager de TRPV6 et PMCAL. En résumé, la suppression du gène CLOCK chez les souris a conduit à une hypercalciurie, une altération du rythme des taux plasmatiques de calcium et de vitamine D et à une détérioration de l'architecture osseuse. Pour conclure, ces résultats montrent que l'horloge circadienne est essentielle à l'homéostasie calcique ainsi qu'à la physiologie des os. - L'ostéoporose affecte environ 22 millions de femmes et 5.5 millions d'hommes en Europe, réduisant significativement leur qualité de vie et a causé 3.5 millions de nouvelles fractures en 2010. Les dépenses totales liées à ces fractures ont atteint 37 milliards d'euro et ce coût devrait augmenter de 25% d'ici à 2025. Le nombre de nouvelles fractures dues à l'ostéoporose à travers le monde est estimé à environ 1000 par heure. Parmi les causes de l'ostéoporose, le déficit én calcium et/ou en vitamine D joue un rôle important, mais il existe également des causes génétiques ou liées à des facteurs comme les hormones sexuelles (estrogènes, testostérone), l'âge, le tabac, le poids corporel, certains médicaments,... La vie est rythmique : ceci est dû à l'alternance naturelle du jour et de la nuit et de ses effets sur le corps. La prise alimentaire, par exemple, est un processus qui a lieu pendant la phase active, qui est prévisible (il se produit toujours au même moment) et qui peut être anticipé par le corps. Pour cela, une horloge interne est présente dans chaque cellule du corps et est synchronisée par la lumière du jour, entre autres stimuli. Cette horloge indique la phase du jour et régule l'expression de gènes impliqués dans les différents processus qui nécessitent une anticipation. Pendant mon travail de thèse, je me suis demandé si des îythmes circadiens (c'est-à-dire d'une durée d'environ 24 heures et indépendants des stimuli externes) étaient observables'pour les gènes régulant les flux de calcium dans le corps et si l'interruption de ces rythmes pouvait mener à des altérations de la qualité de l'os. J'ai d'abord travaillé avec des souris normales et j'ai pu montrer la présence de rythmes au niveau du calcium sanguin et urinaire, mais également au niveau des hormones et gènes qui contrôlent le métabolisme du calcium dans le corps, comme la vitamine D et l'hormone parathyroidienne. De manière intéressante, j'ai observé que la plupart de ces gènes ont un rythme synchronisé. J'ai ensuite utilisé un modèle de souris dans lequel l'horloge interne a été génétiquement invalidée et j'ai montré que ces souris présentent une augmentation de leur excrétion urinaire de calcium et un rythme circadien altéré de la vitamine D dans le sang. Ces souris absorbent aussi moins bien le calcium intestinal et présentent une ostéoporose marquée. Ce travail montre donc que l'horloge interne est nécessaire pour établir un rythme circadiens de certains facteurs influant les flux de calcium dans l'organisme, comme la vitamine D, et que la perturbation de ces rythmes mène à une dérégulation du métabolisme osseux. Ainsi, la perturbation de l'horloge interne peut causer une ostéoporose et une hypercalciurie qui pourraient aboutir à la formation de fractures et de calculs rénaux. L'extrapolation de ces observations chez l'homme ou à des changements plus subtiles des rythmes circadiens, comme le décalage horaire, restent à montrer. Cette recherche a démontré que les rythmes circadiens des mécanismes de régulation des flux de calcium dans l'organisme sont essentiels au maintien d'un squelette normal et suggère que les perturbations des rythmes circadiens pourraient être une nouvelle cause de l'ostéoporose. - Maintaining constant calcium concentration in the plasma is of a crucial importance and three organs participate in normal calcium balance - kidney, gut and bone. Plasma calcium concentration is strictly regulated by parathyroid hormone (PTH) and vitamin D. Circadian variations of PTH, vitamin D and plasma calcium were previously described in humans, as well as in rats. Rhythms in serum PTH are important for balanced bone remodelling. Indeed in C57BL/6J mice, PTH injection once per day leads to an increase in bone mineral density (BMD), whilst continuous infusion is associated with decreased BMD. Vitamin D also plays a crucial role in bone physiology, since the deficiency in vitamin D can lead to rickets/osteomalacia. However, the role of vitamin D rhythms in bone homeostasis remains unknown. The circadian clock is an. internal time-keeping system generating rhythms in gene expression with 24h periodicity, in physiology and in behaviour. It is operated by positive- and negative-feedback loops of circadian genes, such as CLOCK, BMAL1, CRY1 and 2 or PERI and 2. In this work, we hypothesized, that calcium homeostasis is under the control of the circadian clock. First, we showed daily variations in urinary calcium and serum calcium, PTH and l,25(OH)2 vitamin D, together with renal mRNA and protein levels of genes involved in calcium homeostasis in C57BL/6J mice. Second, and to investigate the role of the circadian clock system in calcium handling, we studied mice lacking the gene CLOCK crucial for fonction of the clock system and compared them to the WT littermates. CLOCK-/- mice were hypercalciuric at all timepoints of the day. However, the circadian rhythm of calcium excretion was preserved. Serum calcium levels did not differ between the genotypes, but CLOCK-/- mice did not exhibit daily variation for this parameter. Loss of rhythm was observed also for serum l,25(OH)2 vitamin D levels, which may be one of the causes of altered bone microarchitecture that was revealed in CLOCK-/- mice. They displayed increased trabecular separation and decreased trabecular number, trabecular bone volume and trabecular bone surface, suggestive of osteoporosis. We found that the rhythm of the mRNA expression of CYP27B1 was abolished in the kidney of CLOCK-/- mice, which could induce the altered rhythm of l,25(OH)2 vitamin. Serum PTH levels were comparable between CLOCK-/- and WT mice. In the kidney, increased mRNA expression of TRPV5 and NCX1 suggests increased calcium reabsorption in the distal convoluted and connecting tubule. In the gut, intestinal calcium absorption was decreased in CLOCK¬/- mice, confirmed by decreased mRNA levels of TRPV6 and PMCA1. In summary, deletion of the CLOCK gene in mice conducts to hypercalciuria, alteration of the rhythm in serum calcium and l,25(OH)2D levels, and impainnent of their bone microarchitecture. In conclusion, these data show that the circadian clock system is essential in calcium homeostasis and bone physiology.

Eosinophilic oesophagitis and proton pump inhibitor-responsive oesophageal eosinophilia have similar clinical, endoscopic and histological findings.

BACKGROUND: Some patients with a phenotypic appearance of eosinophilic oesophagitis (EoE) respond histologically to PPI, and are described as having PPI-responsive oesophageal eosinophilia (PPI-REE). It is unclear if PPI-REE is a GERD-related phenomenon, a subtype of EoE, or a completely unique entity. AIM: To compare demographic, clinical and histological features of EoE and PPI-REE. METHODS: Two databases were reviewed from the Walter Reed and Swiss EoE databases. Patients were stratified into two groups, EoE and PPI-REE, based on recent EoE consensus guidelines. Response to PPI was defined as achieving less than 15 eos/hpf and a 50% decrease from baseline following at least a 6-week course of treatment. RESULTS: One hundred and three patients were identified (63 EoE and 40 PPI-REE; mean age 40.2 years, 75% male and 89% Caucasian). The two cohorts had similar dysphagia (97% vs. 100%, P = 0.520), food impaction (43% vs. 35%, P = 0.536), and heartburn (33% vs. 32%, P = 1.000) and a similar duration of symptoms (6.0 years vs. 5.8 years, P = 0.850). Endoscopic features were also similar between EoE and PPI-REE; rings (68% vs. 68%, P = 1.000), furrows (70% vs. 70%, P = 1.000), plaques (19% vs. 10%, P = 0.272), strictures (49% vs. 30%, P = 0.066). EoE and PPI-REE were similar in the number of proximal (39 eos/hpf vs. 38 eos/hpf, P = 0.919) and distal eosinophils (50 vs. 43 eos/hpf, P = 0.285). CONCLUSIONS: EoE and PPI-responsive oesophageal eosinophilia are similar in clinical, histological and endoscopic features and therefore are indistinguishable without a PPI trial. Further studies are needed to determine why a subset of patients with oesophageal eosinophilia respond to PPI.

Primary γδ T cell lymphoma of the lung: report of a case with features suggesting derivation from intraepithelial γδ T lymphocytes [Primary gammadelta T cell lymphoma of the lung: report of a case with features suggesting derivation from intraepithelial gammadelta T lymphocytes].

T cell lymphoma of γδ T cell origin is a rare disease that mainly involves extranodal sites and shows aggressive clinical behavior. Here, we report a case of primary γδ T cell lymphoma of the lungs with epitheliotropism in the respiratory epithelium, a feature somewhat reminiscent of what is observed in enteropathy-associated T cell lymphoma. A 63-year-old man presented with chest pain and dyspnea on exertion, weight loss, and general weakness. On a positron emission tomography (PET) scan, multiple hypermetabolic lesions were found in both lungs. Microscopic examination of the wedge lung biopsy revealed nodular infiltration of monomorphic, medium- to large-sized atypical lymphocytes with round nuclei, coarse chromatin, and a variable amount of clear to eosinophilic cytoplasm. Of note, intraepithelial lymphocytosis by atypical lymphoid cells was observed in the respiratory epithelium within and around the nodule. Immunohistochemically, the tumor cells were CD3+, TCRβF1-, TCRγ+, CD5-, CD7+, CD20-, CD79a-, CD30-, CD4-, CD8-, CD10-, BCL6-, CD21-, CD56+, CD57-, and CD138-, and expressed cytotoxic molecules. Epstein-Barr virus (EBV) was not detected by an in situ hybridization assay for EBV-encoded RNA. Interestingly, CD103 was expressed by a subset of tumor cells, especially those infiltrating the epithelium. T cell clonality was detected by multiplex PCR analysis of TRG and TRD gene rearrangements. After 2 months of systemic chemotherapy, PET scan showed regression of the size and metabolic activity of the lesions. This case represents a unique γδ T cell lymphoma of the lungs showing epitheliotropism by CD103+ γδ T cells that is suggestive of tissue-resident γδ T cells as the cell of origin.

Mapping genetic variants associated with beta-adrenergic responses in inbred mice.

β-blockers and β-agonists are primarily used to treat cardiovascular diseases. Inter-individual variability in response to both drug classes is well recognized, yet the identity and relative contribution of the genetic players involved are poorly understood. This work is the first genome-wide association study (GWAS) addressing the values and susceptibility of cardiovascular-related traits to a selective β(1)-blocker, Atenolol (ate), and a β-agonist, Isoproterenol (iso). The phenotypic dataset consisted of 27 highly heritable traits, each measured across 22 inbred mouse strains and four pharmacological conditions. The genotypic panel comprised 79922 informative SNPs of the mouse HapMap resource. Associations were mapped by Efficient Mixed Model Association (EMMA), a method that corrects for the population structure and genetic relatedness of the various strains. A total of 205 separate genome-wide scans were analyzed. The most significant hits include three candidate loci related to cardiac and body weight, three loci for electrocardiographic (ECG) values, two loci for the susceptibility of atrial weight index to iso, four loci for the susceptibility of systolic blood pressure (SBP) to perturbations of the β-adrenergic system, and one locus for the responsiveness of QTc (p<10(-8)). An additional 60 loci were suggestive for one or the other of the 27 traits, while 46 others were suggestive for one or the other drug effects (p<10(-6)). Most hits tagged unexpected regions, yet at least two loci for the susceptibility of SBP to β-adrenergic drugs pointed at members of the hypothalamic-pituitary-thyroid axis. Loci for cardiac-related traits were preferentially enriched in genes expressed in the heart, while 23% of the testable loci were replicated with datasets of the Mouse Phenome Database (MPD). Altogether these data and validation tests indicate that the mapped loci are relevant to the traits and responses studied.

Biases on the administered parenteral doses of an experimental drug during phase I clinical trials

Introduction: The pharmaceutical aspects of drug administration in clinical trials receive poor consideration compared with the important attention devoted to the analytical and mathematical aspects of biological sample exploitation. During PK calculations, many researchers merely use for dose the nominal amount declared, overlooking the noticeable biases that may result in the assessment of PK parameters. The aim of this work was to evaluate the biases related to doses injected of a biosimilar drug in 2 Phase I clinical trials. Patients (or Materials) and Methods: In trial A, 12 healthy volunteers received different doses of a biosimilar of interferon beta-1a by either subcutaneous (SC) or intravenous (IV) injection. The doses were prepared by partially emptying 0.5-mL syringes supplied by the manufacturer (drop count procedure). In trial B, 12 healthy volunteers received 3 different formulations of the drug by IV injection (biosimilar without albumin [HSA], biosimilar with HSA and original brand [Rebif®]) and 2 different formulations as multiple SC injections (biosimilar HSA-free and original brand). In both trials, the actual dose administered was calculated as: D = C·V - losses. The product titer C was assessed by ELISA. The volume administered IV was assessed by weighting. Losses were evaluated by in vitro experiments. Finally, the binding of 125I-interferon to HSA was evaluated by counting the free and HSA complexed molecule fractions separated by gel filtration. Results: Interferon was not significantly adsorbed onto the lines used for its IV administration. In trial A, the titer was very close to the one declared (96 ± 7%). In trial B, it differed significantly (156 ± 10% for biosimilar with/without HSA and 123 ± 5% for original formulation). In trial A, the dose actually administered showed a large variability. The real injected volume could be biased up to 75% compared with the theoretical volume (for the lower dose administered [ie, 0.03 mL]). This was mainly attributed to a partial re-aspiration of the drug solution before withdrawing the syringe needle. A strict procedure was therefore applied in trial B to avoid these inaccuracies. Finally, in trial B, 125I-Interferon beta-1a binding to HSA appeared time dependent and slow, reaching 50% after 16-hour incubation, which is close to steady state reported for the comparator Rebif®. Conclusion: These practical examples (especially biases on actual titer and volume injected) illustrate that actual dose assessment deserves attention to ensure accuracy for estimates of clearance and distribution volume in the scientific literature and for registration purposes, especially for bioequivalence studies.

Prognostic significance of nailfold capillary microscopy in patients with Raynaud's phenomenon and scleroderma-pattern abnormalities. A six-year follow-up study.

The aim of this study was to assess the prognostic significance of scleroderma capillary pattern (SD-pattern) in patients with Raynaud's phenomenon. Thirty patients with a capillaroscopy examination suggestive of scleroderma (megacapillaries and/or avascularity) but without clinical criteria of scleroderma (ARA criteria) were reevaluated 6 years after the initial clinical and capillaroscopy examinations. SD-pattern abnormalities were classified according to a semiquantitative method. Eight out of the 28 evaluated patients (28%) developed a scleroderma spectrum disorder (SDS). The presence of avascularity and/or a mean of more than two megacapillaries digit greatly enhanced the percentage of evolution toward SDS (70%/88% respectively). Most of the patients with few enlarged capillaries and no capillary rarefaction at entry had primary acrocyanosis (11/15). None of them developed SDS. The microangiopathy disappeared during the follow-up period in most of these patients (14/15). These results confirm the prognostic value of SD-pattern capillary abnormalities for SDS. Primary acrocyanosis, a benign clinical entity should be considered in presence of few megacapillaries and without capillary rarefaction.

Altered processing of contextual information during fear extinction in PTSD: an fMRI study.

Medial prefrontal cortical areas have been hypothesized to underlie altered contextual processing in posttraumatic stress disorder (PTSD). We investigated brain signaling of contextual information in this disorder. Eighteen PTSD subjects and 16 healthy trauma-exposed subjects underwent a two-day fear conditioning and extinction paradigm. On day 1, within visual context A, a conditioned stimulus (CS) was followed 60% of the time by an electric shock (conditioning). The conditioned response was then extinguished (extinction learning) in context B. On day 2, recall of the extinction memory was tested in context B. Skin conductance response (SCR) and functional magnetic resonance imaging (fMRI) data were collected during context presentations. There were no SCR group differences in any context presentation. Concerning fMRI data, during late conditioning, when context A signaled danger, PTSD subjects showed dorsal anterior cingulate cortical (dACC) hyperactivation. During early extinction, when context B had not yet fully acquired signal value for safety, PTSD subjects still showed dACC hyperactivation. During late extinction, when context B had come to signal safety, they showed ventromedial prefrontal cortex (vmPFC) hypoactivation. During early extinction recall, when context B signaled safety, they showed both vmPFC hypoactivation and dACC hyperactivation. These findings suggest that PTSD subjects show alterations in the processing of contextual information related to danger and safety. This impairment is manifest even prior to a physiologically-measured, cue-elicited fear response, and characterized by hypoactivation in vmPFC and hyperactivation in dACC.

Spectrum of ocular digoxin toxicity in the elderly: A case report

Introduction: We report a case of digoxin intoxication with severe visual symptoms. Patients (or Materials) and Methods: Digoxin 0.25 mg QD for atrial fibrillation was prescribed to a 91-year-old woman with an estimated creatinine clearance of 18 mL/min. Within 2 to 3 weeks, she developed nausea, vomiting, and dysphagia, and began complaining of snowy and blurry vision, photopsia, dyschromatopsia, aggravated bedtime visual and proprioceptive illusions (she felt as being on a boat), and colored hallucinations. She consulted her family doctor twice and visited the eye clinic once until, 1 month after starting digoxin, impaired autonomy led her to be admitted to the emergency department. Results: Digoxin intoxication was confirmed by a high plasma level measured on admission (5.7 μg/L; reference range, 0.8-2 μg/L). After stopping digoxin, general symptoms resolved in a few days, but visual symptoms persisted. Ophtalmologic care and follow-up diagnosed digoxin intoxication superimposed on pre-existing left eye (LE) cataract, dry age-related macular degeneration (DMLA), and Charles Bonnet syndrome. Visual acuity was 0.4 (right eye, RE) and 0.5 (LE). Ocular fundus was physiologic except for bilateral dry DMLA. Dyschromatopsia was confirmed by poor results on Ishihara test (1/13 OU). Computerized visual field results revealed nonspecific diffuse alterations. Full-field electroretinogram (ERG) showed moderate diffuse rod and cone dysfunction. Visual symptoms progressively improved over the next 2 months, but ERG did not. Complete resolution was not expected due to the pre-existing eye disease. The patient was finally discharged home after a 5-week hospital stay. Conclusion: Digoxin intoxication can go unrecognized by clinicians, even in a typical presentation. The range of potential visual symptoms is far greater than isolated xanthopsia (yellow vision) classically described in textbooks. Newly introduced drugs and all symptoms must be actively sought after, because they significantly affect quality of life and global functioning, especially in the elderly population, most liable not to mention them.

Rifaximin treatment for the irritable bowel syndrome with a positive lactulose hydrogen breath test improves symptoms for at least 3 months.

BACKGROUND: While rifaximin was able to improve symptoms in patients with irritable bowel syndrome (IBS) in phase III trials, these results are yet to be repeated in phase IV studies. AIM: To evaluate the treatment response to rifaximin in IBS patients in a phase IV trial. METHODS: IBS patients underwent lactulose hydrogen breath testing (LHBT). LHBT-positive patients were treated with rifaximin for 14 days. Prior to treatment as well as at week 4 and 14 following the start of rifaximin treatment, patients completed a questionnaire assessing symptom severity on a Likert scale from 0 to 10. RESULTS: One hundred and six of 150 IBS patients (71%) were LHBT-positive and treated with rifaximin. As assessed at week 4 following commencement of the therapy, rifaximin provided significant improvement of the following IBS-associated symptoms: bloating (5.5±2.6 before the start of the treatment vs. 3.6±2.7 at week 4, P<0.001), flatulence (5.0±2.7 vs. 4.0±2.7, P=0.015), diarrhoea (2.9±2.4 vs. 2.0±2.4, P=0.005) and abdominal pain (4.8±2.7 vs. 3.3±2.5, P<0.001). Overall well-being also significantly improved (3.9 ± 2.4 vs. 2.7 ± 2.3, P < 0.001). Similar improvements in IBS symptoms were obtained at week 14. Eighty-six per cent of patients undergoing repetitive LHBT (55/64) tested negative at week 4. CONCLUSIONS: We found a high percentage of LHBT-positive IBS patients. IBS-associated symptoms (bloating, flatulence, diarrhoea, pain) were improved for a period of 3 months following 2 weeks of treatment with rifaximin. We conclude that rifaximin treatment alleviates symptoms in LHBT-positive IBS patients.

Lipoxin A₄ prevents the progression of de novo and established endometriosis in a mouse model by attenuating prostaglandin E₂ production and estrogen signaling.

Endometriosis, a leading cause of pelvic pain and infertility, is characterized by ectopic growth of endometrial-like tissue and affects approximately 176 million women worldwide. The pathophysiology involves inflammatory and angiogenic mediators as well as estrogen-mediated signaling and novel, improved therapeutics targeting these pathways are necessary. The aim of this study was to investigate mechanisms leading to the establishment and progression of endometriosis as well as the effect of local treatment with Lipoxin A4 (LXA₄), an anti-inflammatory and pro-resolving lipid mediator that we have recently characterized as an estrogen receptor agonist. LXA₄ treatment significantly reduced endometriotic lesion size and downregulated the pro-inflammatory cytokines IL-1β and IL-6, as well as the angiogenic factor VEGF. LXA₄ also inhibited COX-2 expression in both endometriotic lesions and peritoneal fluid cells, resulting in attenuated peritoneal fluid Prostaglandin E₂ (PGE₂) levels. Besides its anti-inflammatory effects, LXA₄ differentially regulated the expression and activity of the matrix remodeling enzyme matrix metalloproteinase (MMP)-9 as well as modulating transforming growth factor (TGF)-β isoform expression within endometriotic lesions and in peritoneal fluid cells. We also report for first time that LXA₄ attenuated aromatase expression, estrogen signaling and estrogen-regulated genes implicated in cellular proliferation in a mouse model of disease. These effects were observed both when LXA₄ was administered prior to disease induction and during established disease. Collectively, our findings highlight potential targets for the treatment of endometriosis and suggest a pleotropic effect of LXA₄ on disease progression, by attenuating pro-inflammatory and angiogenic mediators, matrix remodeling enzymes, estrogen metabolism and signaling, as well as downstream proliferative pathways.

Team Effectiveness in Patient Health Management: An Overview of Reviews

Background: The desire to improve the quality of health care for an aging population with multiple chronic diseases is fostering a rapid growth in inter-professional team care, supported by health professionals, governments, businesses and public institutions. However, the weight of evidence measuring the impact of team care on patient and health system outcomes has not, heretofore, been clear. To address this deficiency, we evaluated published evidence for the clinical effectiveness of team care within a chronic disease management context in a systematic overview. Methods: A search strategy was built for Medline using medical subject headings and other relevant keywords. After testing for perform- ance, the search strategy was adapted to other databases (Cinhal, Cochrane, Embase, PsychInfo) using their specific descriptors. The searches were limited to reviews published between 1996 and 2011, in English and French languages. The results were analyzed by the number of studies favouring team intervention, based on the direction of effect and statistical significance for all reported outcomes. Results: Sixteen systematic and 7 narrative reviews were included. Diseases most frequently targeted were depression, followed by heart failure, diabetes and mental disorders. Effective- ness outcome measures most commonly used were clinical endpoints, resource utilization (e.g., emergency room visits, hospital admissions), costs, quality of life and medication adherence. Briefly, while improved clinical and resource utilization endpoints were commonly reported as positive outcomes, mixed directional results were often found among costs, medication adherence, mortality and patient satisfaction outcomes. Conclusions: We conclude that, although suggestive of some specific benefits, the overall weight of evidence for team care efficacy remains equivocal. Further studies that examine the causal interactions between multidisciplinary team care and clinical and economic outcomes of disease management are needed to more accurately assess its net program efficacy and population effectiveness.

Malignancy transformation of chronic osteomyelitis: description of 6 cases of Marjolin's ulcers

Marjolin's ulcer describes any malignant transformation of a chronic inflammatory lesion. In the majority of cases, a squamous cell carcinoma is diagnosed. Malignant transformation occurs usually after a long period of latency of chronic infection; it takes approximately 35 years on average. There are no typical clinical presentations, but several indirect signs may suggest the malignant transformation, such as increased or changed discharge, pathologic fracture, a slow-growing exophytic mass, or other suggestive signs of malignant transformation, which should prompt to biopsy for histological exam. The diagnosis of chronic osteomyelitis should not prevent to search for carcinoma. We present six patients with chronic osteomyelitis that developed well-differentiated squamous cell carcinoma. All patients were older than 50 years (mean 60 years, range 52-77 years). Five Marjolin's ulcers were located on the lower limb and one on the arm. The average time of the chronic discharging osteomyelitis before diagnosis of carcinoma ranged between 12 and 40 years. All patients were treated by amputation of the affected limb. None had metastasis, and one patient developed local recurrence and received palliative treatment. Our study emphasizes that Marjolin's ulcer should be considered as a rare but significant long-term complication of chronic osteomyelitis. The finding of microorganisms should not prevent from further diagnostic procedures by histopathological examination so that the correct surgical treatment can be performed.

How to Improve the Use of Proton Pump Inhibitors

Introduction: Proton pump inhibitors (PPI) are one of the most prescribed medications in the world with proven efficacy. However, several studies showed that their use often doesn't respect indications, leading to over-consumption, thus exposing patients to drug interactions and adverse events (for example pneumonias). Interruption of PPIs can induce a rebound phenomenon. This generates costs for health systems.Methods: This is a prospective interventional study performed in two hospitals: La Chaux-de-Fonds (CDF, cases) and Neucha^tel (NE, control) during two six-month periods, comparing use of PPIs before and after intervention. We elaborated recommendations (PPI doses and treatment duration) based on recent medical literature that we summarized on A6 cards and gave out to all prescribing doctors in the hospital of CDF and held a 30-minute information session for the departments of surgery, medicine and anesthesiology in March 2010. Doctors were asked to apply our recommendations as often as possible, leaving space for their own assessment. No information was given to the doctors of the control hospital. The number of PPI tablets that the pharmacy sent to each careunit in both hospitals was counted and adjusted to the number of patientdays from April to September 2009 (before intervention) and April to September 2010 (after intervention). The number of other antacids that were used in both hospitals was counted during the same periods. General practitioners (GP) in the region around CDF received an explanation letter to avoid re-introduction, after discharge from the hospital, of PPI treatment stopped during the stay. The number of gastro-duodenal ulcers and upper digestive hemorrhages was counted from April to December 2009 and the same period in 2010 in both hospitals.Results: In 2010, in the hospital of CDF, the use of PPIs per 100 patient-days decreased by 36% in the surgical and medical departments compared to 2009. In the control hospital the use of PPIs per 100 patient-days increased by 10% in the surgical department and decreased by 5% in the medical department during the same periods. The decrease from 2009 to 2010 of PPI utilization in CDF comparing to NE is statistically significant: p<0.0001. Use of other antacids didn't change, ulcers or digestive hemorrhages decreased slightly from 2009 to 2010 in both hospitals. Conclusions: The study showed that with a very low-cost intervention, it is possible to decrease considerably the use of PPIs in a hospital, without taking any risk for gastro-intestinal complications.