The Role of Mesenteric Adipose Tissue in Crohn’s Disease

Inflammatory bowel disease (IBD) has become an increasingly frequent chronic health problem in the last few decades, particularly in developing countries. In young adults, one of the most common forms of IBD is Crohn’s disease (CD). CD is a multifactorial genetic disease characterized by a transmural granulomatous inflammation that especially affects the terminal ileum and the colon. As it involves defective inflammatory pathways, the immune adaptive complex, and environmental factors, this disease has periods of remission and recurrence followed by diarrhea, abdominal pain, and malnutrition, which often lead to lumen bowel stenosis associated to multiple fistulas. In addition, the growth of mesenteric adipose tissue (MAT) near the affected intestinal area is a hallmark of CD. Evidence linking the development of mesenteric and intestinal alterations in CD is increasing. The aim of this chapter is to address adipose tissue in general, the morphological and functional differences between its compartments, the main characteristics of MAT in CD, and its possible role in the etiopathology of this immune-mediated disease

Serum Levels of Infliximab and Anti-Infliximab Antibodies in Brazilian Patients with Crohn’s Disease

OBJECTIVES: The aim of this study was to evaluate the quantitative serum level of infliximab (IFX) as well as the detection of anti-infliximab antibodies (ATIs) in patients with Crohn’s disease (CD). METHOD: Forty patients with CD under treatment at a tertiary center in southeastern Brazil were evaluated. Their use of infliximab was continuous and regular. We analyzed and compared the differences in the IFX and ATI levels between the patients with active CD (CDA) and those with CD in remission (CDR). RESULTS: There was no difference in the IFX level between the CDA and CDR groups (p40.05). Eighty percent of all patients had IFX levels above the therapeutic concentration (6-10 mg/mL). Two (9%) of the 22 patients with active disease and four (22.2%) of the 18 patients in remission had undetectable levels of IFX. Four (66.6%) of the six patients with undetectable levels of IFX had positive ATI levels; three of these patients were in remission, and one had active disease. In addition, the other two patients with undetectable levels of IFX presented ATI levels close to positivity (2.7 and 2.8 AU/ml). None of the patients with therapeutic or supratherapeutic IFX levels had positive ATI levels. CONCLUSIONS: The undetectable levels of IFX correlated with the detection of ATIs, which was independent of disease activity. Immunogenicity was not the main factor for the loss of response to IFX in our study, and the majority of patients in both groups (CDA and CDR) had supratherapeutic levels of IFX

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

Whole transcriptional analysis identifies markers of B, T and plasm cells in the mesenteric adipose tissue of Crohn's disease patients

Orientadores: Raquel Franco Leal, Azucena SalasTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências MédicasResumo: Introdução: A doença de Cohn (DC) é uma doença multifatorial caracterizada por inflamação intestinal crônica. O aumento da adiposidade visceral próxima à área intestinal afetada, da qual o tecido adiposo mesentérico (TAM) é o principal componente, é uma característica da DC. Tanto um papel protetor como patológico tem sido atribuído a esse tecido associado à DC. Objetivo: Compreender a contribuição do TAM para a fisiopatologia da DC, fornecendo um perfil molecular e celular próprios desse tecido na DC. Casuística e Método: A análise transcricional total foi realizada por sequenciamento total de RNA (RNA-seq) do TAM e de mucosa ileal de pacientes com DC em atividade (grupo DC, n=8) e controles sem doença inflamatória intestinal (grupo CTR, n=8). A validação biológica de um painel de genes diferencialmente expressos foi conduzida por reação em cadeia polimerase em tempo real (qPCR) em 26 pacientes com DC e 17 controles. Imuno-histoquímica e imunofluorescência também foram realizadas para análise de validação. Resultados: RNA-seq identificou 17 genes significativamente regulados (|FC|>1,5; FDR1,5, p nominal1,5; FDR1.5; FDR1.5, nominal p?0.05) revealed a larger list of 651 genes in CD-MAT compared to controls. Ingenuity Pathway Analysis of this signature revealed a significant regulation of pathways related to T- and B-cell functionality. In contrast to MAT, transcriptional analysis of the ileum revealed a set of 849 genes significantly regulated in CD compared to non-IBD controls (|FC|>1.5; FDR<0.05), and 2,654 genes when applying the lower cutoff (nominal p value<0.05). Despite the differences between the MAT and ileal signatures of CD patients, we identified a subset of 204 genes significantly modulated in both tissues. This common signature included genes related to the plasma cell signature (MZB1, POU2AF1, IGLL5, JCHAIN, DERL3 and PIM2) that were significantly up-regulated both in CD-MAT and ileum. In contrast, other genes that are highly increased in CD ileum such as S100A8 / S100A9 (calprotectin), IL1B, CD14, CXCL1, CXCL8, MMP1, OSMR, all of which are related to an acute inflammatory response, were exclusively regulated in the ileal mucosa of CD, but not in the adjacent MAT. In contrast, some genes encoding for lymphocyte receptors were exclusively regulated in CD-MAT, (i.e., MS4A1, CD6, CTLA4, CD3D, CD3E, IL2RG, LAG3-2, CD24, CD79A, CD5 and CD69), showing a different pattern of immune cell activation in this tissue compared to the ileum. qPCR in a patient and control cohort confirmed the significant upregulation of CD79A, SM4A1 (CD20), CTLA4 and CD3D in CD-MAT compared to controls, with no significant differences in IL1B and S100A8. Finally, immunohistochemistry and immunofluorescence analysis confirmed the large infiltrates and localized follicular structures containing CD3+ and CD20+ lymphocytes and CD138+ plasma cells in CD-MAT compared to the controls. Conclusions: Our study reveals the marked accumulation of lymphocytes and plasma cells that form disseminated aggregates, as well as well-structured lymphoid follicles, in the MAT associated with CD inflamed ileum, but not in controls. Remarkably, acute inflammatory genes highly expressed in the ileum were not markedly upregulated in the adipose tissue. Our data strongly supports the role of CD-associated MAT as a site for T-, B- and plasma cell activation and suggests that it could also act as a reservoir of memory immune and antibody-mediated responses. To understand if these specific responses to antigens are harmful or protective in CD, further studies are necessaryDoutoradoFisiopatologia CirúrgicaDoutora em Ciências0012016/01638-7CAPESFAPES

Evaluation of plasma-rich in platelets use as an immunomodulator in patients whit Crohn's disease

Orientadores: Joyce Maria Annichino Bizzacchi, Raquel Franco LealDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências MédicasResumo: A doença de Crohn (DC) é uma patologia complexa e multifatorial. Tratamentos atuais disponíveis incluem medicamentos imunossupressores, corticosteroides e terapia biológica. Cerca de 40% dos pacientes deixam de responder após a administração destes medicamentos. Plasma rico em plaquetas (PRP) é uma terapia alternativa amplamente usada em ortopedia e odontologia. Mais recentemente, tem sido estudada em afecções dermatológicas e doenças autoimunes, com resultados promissores. Avaliamos os resultados do plasma pobre em plaquetas (P-PRP) durante 12 semanas em pacientes DC refratária. Métodos: Cinco pacientes diagnosticados com DC ileocolônica foram selecionados. Estes pacientes estavam sem medicação durante pelo menos dois meses e estavam resistentes à terapia biológica por pelo menos um ano. Os fatores de crescimento, interleucinas, proteína C-reativa, número de plaquetas e frequência das células T reguladoras foram quantificados em dois momentos diferentes: antes do tratamento e após 12 aplicações de P-PRP. A atividade da doença foi avaliada por índice clínico e endoscópico. Resultado: Os índices endoscópicos após P-PRP diminuíram em relação ao início do tratamento em quatro pacientes, mas não foi verificada remissão endoscópica completa. Quatro pacientes tiveram remissão clínica, incluindo o desaparecimento de artralgia. Dois pacientes com DC perianal mostraram uma diminuição da secreção das fístulas. Não foram observados efeitos adversos, tais como reações alérgicas, embora um paciente desenvolvesse displasia colônica durante o tratamento. Em conclusão, houve um benefício em curto prazo do P-PRP para a maioria dos pacientes nesta série, no entanto, a inclusão de mais pacientes neste protocolo e um maior tempo de seguimento são necessários, a fim de mostrar se esta terapia poderia ser uma opção para pacientes com DC refratáriosAbstract: Crohn¿s disease (CD) is a complex and multifactorial pathology. Available current treatments comprise immunosuppressive drugs, corticosteroids and biological therapy. About 40% of the patients cease to respond after taking these medications. Platelet rich plasma (PRP) is an alternative therapy widely used in orthopedics and dentistry fields. Most recently, it has been studied in dermatological affections and autoimmune diseases with promising results. Aim: To evaluate the results of P-PRP for 12 weeks in CD patients with refractory disease. Methods: Five patients diagnosed with ileocolic CD were selected. These patients were not taking any medication for at least two months and they were resistant to biological therapy for at least one year. Growth factors, interleukins, C-reactive protein, platelet and regulatory T cell frequency were measured at two different times: before treatment and after 12 injections of P-PRP. The activity of the disease was accessed by clinical and endoscopic indexes. Results: Endoscopic scores after P-PRP decreased compared to the baseline in four patients, but no complete endoscopic remission was verified. Four patients had clinical remission, including the absence of joint pain. Two patients with perianal CD showed a decrease of discharge. No adverse effects such as allergic reactions were observed, although one patient developed colonic adenomas throughout the treatment. In conclusion, there was a short-term benefit of P- PRP for most patients in this series, however, inclusion of more patients in this protocol and a longer follow-up are needed, in order to show whether this therapy could be an option for refractory CD patientsMestradoFisiopatologia MédicaMestra em CiênciasCAPE

Serum Levels of Infliximab and Anti-Infliximab Antibodies in Brazilian Patients with Crohn’s Disease

OBJECTIVES: The aim of this study was to evaluate the quantitative serum level of infliximab (IFX) as well as the detection of anti-infliximab antibodies (ATIs) in patients with Crohn’s disease (CD). METHOD: Forty patients with CD under treatment at a tertiary center in southeastern Brazil were evaluated. Their use of infliximab was continuous and regular. We analyzed and compared the differences in the IFX and ATI levels between the patients with active CD (CDA) and those with CD in remission (CDR). RESULTS: There was no difference in the IFX level between the CDA and CDR groups (p>0.05). Eighty percent of all patients had IFX levels above the therapeutic concentration (6-10 μg/mL). Two (9%) of the 22 patients with active disease and four (22.2%) of the 18 patients in remission had undetectable levels of IFX. Four (66.6%) of the six patients with undetectable levels of IFX had positive ATI levels; three of these patients were in remission, and one had active disease. In addition, the other two patients with undetectable levels of IFX presented ATI levels close to positivity (2.7 and 2.8 AU/ml). None of the patients with therapeutic or supratherapeutic IFX levels had positive ATI levels. CONCLUSIONS: The undetectable levels of IFX correlated with the detection of ATIs, which was independent of disease activity. Immunogenicity was not the main factor for the loss of response to IFX in our study, and the majority of patients in both groups (CDA and CDR) had supratherapeutic levels of IFX

Transcriptional and molecular pathways activated in mesenteric adipose tissue and intestinal mucosa of Crohn's disease patients

FAPESP - FUNDAÇÃO DE AMPARO À PESQUISA DO ESTADO DE SÃO PAULOCrohn’s disease (CD) is a chronic inflammatory disorder, characterized by cytokine imbalance and transcription signaling pathways activation. In addition, the increase of mesenteric adipose tissue (MAT) near the affected intestinal area is a hallmark of C20171110FAPESP - FUNDAÇÃO DE AMPARO À PESQUISA DO ESTADO DE SÃO PAULOFAPESP - FUNDAÇÃO DE AMPARO À PESQUISA DO ESTADO DE SÃO PAULOsem informaçã