Appropriate maintenance treatment for Crohn's disease: results of a multidisciplinary international expert panel - EPACT II

Introduction: Biological. therapy has dramatically changed management of Crohn's disease (CD). New data have confirmed the benefit and relative long-term safety of anti-TNF alpha inhibition as part of a regular scheduled administration programme. The EPACT appropriateness criteria for maintenance treatment after medically-induced remission (MIR) or surgically-induced remission (SIR) of CD thus required updating. Methods: A multidisciplinary international expert panel (EPACT II, Geneva, Switzerland) discussed and anonymously rated detailed, explicit clinical indications based on evidence in the literature and personal expertise. Median ratings (on a 9-point scale) were stratified into three assessment categories: appropriate (7-9), uncertain (4-6 and/or disagreement) and inappropriate (1-3). Experts ranked appropriate medication according to their own clinical practice, without any consideration of cost. Results: Three hundred and ninety-two specific indications for maintenance treatment of CD were rated (200 for MIR and 192 for SIR). Azathioprine, methotrexate and/or anti-TNF alpha antibodies were considered appropriate in 42 indications, corresponding to 68% of all appropriate interventions (97% of MIR and 39% of SIR). The remaining appropriate interventions consisted of mesalazine and a "wait-and-see" strategy. Factors that influenced the panel's voting were patient characteristics and outcome of previous treatment. Results favour use of anti-TNF alpha agents after failure of any immunosuppressive therapy, while earlier primary use remains controversial. Conclusion: Detailed explicit appropriateness criteria (EPACT) have been updated for maintenance treatment of CD. New expert recommendations for use of the classic immunosuppressors as well as anti-TNF alpha agents are now freely available online (www.epact.ch). The validity of these criteria should now be tested by prospective evaluation. (C) 2009 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.

T-dependent B cell activation and differentiation in Lat Y136F mice : polyclonal response leading to autoimmune disease

SUMMARY LatY136F knock-in mice harbor a point mutation in tyrosine 136 of the linker for activation of T cells (LAT), and show accumulation of TH2 effector cells leading to IgG1 and IgE hypergammaglobulinemia. The observed polyclonal. B cell activation was not a direct effect of the mutation on B cells since in the absence of T cells mutant B cells did not show an activated phenotype. After adoptive transfer of LAT mutant T cells into wild type (WT) Tcell-deficient recipients, recipient B cells became activated. We show in vivo and in vitro that the LatY136F mutation promotes Tcell-dependent B cell activation leading to germinal center, memory and plasma cell formation even in the absence of MHC class II. This effect was, however, dependant on CD40 and CD80/CD86. All the plasma and memory B cell populations found in physiological T cell-dependent B cell responses were found. Characterization of the abundant plasmablasts observed in. secondary lymphoid organs of LatY136F mice revealed the presence of a previously uncharacterized CD93expressing subpopulation, whose existence was confirmed in WT mice after immunization. In LatY136F mice, B cell activation was polyclonal and not antigen-driven, since the increase in serum IgG1 and IgE concentrations involved antibodies and autoantibodies with different specificities equally. Although the non-complement-fixing IgG1 and IgE were the only isotypes significantly increased in LatY136F serum, we observed early onset of systemic autoimmunity with nephritis showing IgE autoantibody deposits and severe proteinuria. These results show that TH2 cells developing in LatY136F mice can trigger polyclonal B cell activation and thereby lead to systemic autoimmune disease. RESUME Les souris présentent une mutation ponctuelle au niveau de la tyrosine 136 de l'adaptateur requis pour l'activation des cellules T (LAT) et développent, de ce fait, une accumulation de cellules T effectrices de type TH2 ainsi qu'une hypergammaglobulémie des isotypes IgG1 et IgE. Dans ce modèle murin, l'activation des cellules B et la production d'anticorps qui y est associée ne sont pas dues à un effet direct de la mutation. Nous avons mis en évidence que l'interaction physique entre cellules T activées et cellules B est indispensable au développement de ce phenotype. D'un point de vue moléculaire, cette interaction ne requiert pas l'intervention des complexes majeurs d'histocompatibilité de classe II, garant de la spécificité d'une réponse immunitaire. Cependant, les molécules de costimulation CD40 et CD80/CD86 sont indispensables à une réponse complète des cellules B. Les souris LatY136F développent d'importantes populations de cellules B des centres germinatifs, de cellules B mémoires ainsi que de cellules sécrétant des anticorps, qui présentent les mêmes caractéristiques que lors d'une réponse immunitaire à un antigène classique. En observant plus précisément les plasmablastes présents dans les ganglions des souris LatY13sF, nous avons détecté une sous-population exprimant CD93; l'expression de ce marqueur par les cellules B n'a jamais été mise en évidence durant une réponse immunitaire. Cependant, notre étude a permis de confirmer sa présence, dans les ganglions de souris de type sauvage, lors d'immunisation avec différents antigènes. Nous avons montré que l'activation des cellules B des souris LatY136F est polyclonale et n'est pas dirigée par un antigène; les taux d'autoanticorps augmentent de manière proportionnelle à ceux des anticorps totaux. Bien que les IgG1 et les IgE ne soient pas des isotypes connus pour leurs propriétés pathogéniques, nous avons observé le développement d'une autoimmunité systémique caractérisée par une néphrite impliquant des dépôts d'autoanticorps du type IgE ainsi que par une sévère proteinurée.

Overlap Between Common Genetic Polymorphisms Underpinning Kidney Traits and Cardiovascular Disease Phenotypes: The CKDGen Consortium.

BACKGROUND: Chronic kidney disease is associated with cardiovascular disease. We tested for evidence of a shared genetic basis to these traits. STUDY DESIGN: We conducted 2 targeted analyses. First, we examined whether known single-nucleotide polymorphisms (SNPs) underpinning kidney traits were associated with a series of vascular phenotypes. Additionally, we tested whether vascular SNPs were associated with markers of kidney damage. Significance was set to 1.5×10(-4) (0.05/325 tests). SETTING & PARTICIPANTS: Vascular outcomes were analyzed in participants from the AortaGen (20,634), CARDIoGRAM (86,995), CHARGE Eye (15,358), CHARGE IMT (31,181), ICBP (69,395), and NeuroCHARGE (12,385) consortia. Tests for kidney outcomes were conducted in up to 67,093 participants from the CKDGen consortium. PREDICTOR: We used 19 kidney SNPs and 64 vascular SNPs. OUTCOMES & MEASUREMENTS: Vascular outcomes tested were blood pressure, coronary artery disease, carotid intima-media thickness, pulse wave velocity, retinal venular caliber, and brain white matter lesions. Kidney outcomes were estimated glomerular filtration rate and albuminuria. RESULTS: In general, we found that kidney disease variants were not associated with vascular phenotypes (127 of 133 tests were nonsignificant). The one exception was rs653178 near SH2B3 (SH2B adaptor protein 3), which showed direction-consistent association with systolic (P = 9.3 ×10(-10)) and diastolic (P = 1.6 ×10(-14)) blood pressure and coronary artery disease (P = 2.2 ×10(-6)), all previously reported. Similarly, the 64 SNPs associated with vascular phenotypes were not associated with kidney phenotypes (187 of 192 tests were nonsignificant), with the exception of 2 high-correlated SNPs at the SH2B3 locus (P = 1.06 ×10(-07) and P = 7.05 ×10(-08)). LIMITATIONS: The combined effect size of the SNPs for kidney and vascular outcomes may be too low to detect shared genetic associations. CONCLUSIONS: Overall, although we confirmed one locus (SH2B3) as associated with both kidney and cardiovascular disease, our primary findings suggest that there is little overlap between kidney and cardiovascular disease risk variants in the overall population. The reciprocal risks of kidney and cardiovascular disease may not be genetically mediated, but rather a function of the disease milieu itself.

Urinary and plasma catecholamines and metanephrines in dogs with pheochromocytoma, hypercortisolism, nonadrenal disease and in healthy dogs.

BACKGROUND: Diagnosis of pheochromocytoma (PC) is based on a combination of clinical suspicion, finding an adrenal mass, increased plasma, and urine concentrations of catecholamine metabolites and is finally confirmed with histopathology. In human medicine, it is controversial whether biochemically testing plasma is superior to testing urine. OBJECTIVES: To measure urinary and plasma catecholamines and metanephrines in healthy dogs, dogs with PC, hypercortisolism (HC), and nonadrenal diseases (NAD) and to determine the test with the best diagnostic performance for dogs with PC. ANIMALS: Seven PC dogs, 10 dogs with HC, 14 dogs with NAD, 10 healthy dogs. METHODS: Prospective diagnostic clinical study. Urine and heparin plasma samples were collected and stored at -80°C before analysis using high-pressure liquid chromatography (HPLC) coupled to electrochemical detection or tandem mass spectrometry were performed. Urinary variables were expressed as ratios to urinary creatinine concentration. RESULTS: Dogs with PC had significantly higher urinary normetanephrine and metanephrine : creatinine ratios and significantly higher plasma-total and free normetanephrine and plasma-free metanephrine concentrations compared to the 3 other groups. There were no overlapping results of urinary normetanephrine concentrations between PC and all other groups, and only one PC dog with a plasma normetanephrine concentration in the range of the dogs with HC and NAD disease. Performances of total and free plasma variables were similar. Overlap of epinephrine and norepinephrine results between the groups was large with both urine and plasma. CONCLUSION AND CLINICAL IMPORTANCE: Measurement of normetanephrine is the preferred biochemical test for PC and urine was superior to plasma.

An unusual Association Between Parkinson's Disease (PD) and Essential Tremor (ET) Characterized by opposite Lateral Predominance.

The occurrence of disabling postural and action tremor, which is repotted in less than 15 % of cases of PD. may be due to a combination of ET and PD, We report the case of a patient suffering bilaterally from postural tremor of different etiology on either side. A 69 year-old, right-handed woman with a family history of ET, was referred for bilateral hand tremor which was disabling on the right side. At the age of 61 she noticed a right hand postural tremor. not responsive to $- blockers, followed. two years later, by the onset of postural and action tremor on the opposite side. In the following two years. the patient developed asymmetric right-sided parkinsonism, while the postural and action tremor on the left remained unchanged. At time of evaluation, the patient had asymmetric parkinsonism with a 5 Hz rest and postural tremor on the right side and a postural-action tremor of the left hand. Dopaminergic acute challenge tests were performed. The administration of levodopalcarbidopa (ZOO/SO mg) improved the tremor on the right but not on the left. A progressive and more significant improvement was observed after the administration of increasing doses of apomorphine ( 1.6-3-4.5-6 mg). At the dose of 6 mg, apomorphine nearly completely abolished tremor on the right. The tremor of the left hand remained unchanged. The distinction between the two types of tremor was confirmed by the chronic treatment (using levodopa and dopaminergic agonists). Which improved only the right-sided tremor. Primidone was later introduced and improved selectively the tremor on the left. Conclusions: This patient developed both PD and ET with an unusual opposite prevalence. Drug challenge permitted the differentiation the clinically similar tremor types, which have a different pathophysiology.

Information Needs and Concerns of Patients with Inflammatory Bowel Disease: What Can We Learn from Participants in a Bilingual Clinical Cohort?

BACKGROUND: Inflammatory Bowel Disease (IBD) patients are confronted with needs and concerns related to their disease. AIM: To explore information expectations of patients included in a national bilingual IBD cohort in Switzerland (SIBDC). METHODS: This is a mixed-methods study, comprising 1) a semi-narrative survey sent to 1506 patients from the SIBDC and 2) two focus groups conducted with 14 patients to explore and assess the relevance of the survey's findings. Data collected within the framework of the SIBDC was used to characterize survey's responders. RESULTS: 728 patients (48%) replied to the survey: 52.5% females, 56% Crohn's disease (CD), 87% secondary/tertiary level educated, 70% full/part-time employed. On average, 47% of patients sought for information, regardless of the disease stage; 27% of them were dissatisfied with information received at the time of first symptoms. During flares, 43% were concerned about drugs and therapies; in remission, 57% had concerns on research and developments; 27% searched for information linked to daily disease management. Information-seeking increased when active disease, for CD with high levels of perceived stress (OR = 2.47; p = 0.003), and for all with higher posttraumatic stress symptoms. The focus groups confirmed a perceived lack of information about general functioning, disease course, treatments and their risks, extra-intestinal symptoms and manifestations. CONCLUSIONS: Information remains insufficient for IBD patients. Lack of information in specific domains can potentially cause stress and hinder detection of symptoms. Better information should be considered as a potentially important component in improving patients' outcomes in IBD.