PuraStat in gastrointestinal bleeding: results of a prospective multicentre observational pilot study

Background: A recently developed haemostatic peptide gel for endoscopic application has been introduced to improve the management of gastrointestinal bleeding. The aim of this pilot study was to evaluate the feasibility, safety, efficacy and indication profiles of PuraStat in a clinical setting. Methods: In this prospective observational multicentre pilot study, patients with acute non-variceal gastrointestinal bleeding (upper and lower) were included. Primary and secondary application of PuraStat was evaluated. Haemoglobin, prothrombin time, platelets and transfusion behaviour were documented before and after haemostasis. The efficacy of PuraStat was assessed during the procedure, at 3 days and 1 week after application. Results: 111 patients with acute gastrointestinal bleeding were recruited into the study. 70 percent (78/111) of the patients had upper gastrointestinal bleeding and 30% (33/111) had lower gastrointestinal bleeding. After primary application of PuraStat, initial haemostatic success was achieved in 94% of patients (74/79, 95% CI 88-99%), and in 75% of the patients when used as a secondary haemostatic product, following failure of established techniques (24/32, 95% CI 59-91%). The therapeutic success rates (absence of rebleeding) after 3 and 7 days were 91% and 87% after primary use, and 87% and 81% in all study patients. Overall rebleeding rate at 30 day follow-up was 16% (18/111). In the 5 patients who finally required surgery (4.5%), PuraStat allowed temporary haemostasis and stabilisation. Conclusions: PuraStat expanded the therapeutic toolbox available for an effective treatment of gastrointestinal bleeding sources. It could be safely applied and administered without complications as a primary or secondary therapy. PuraStat may additionally serve as a bridge to surgery in order to achieve temporary haemostasis in case of refractory severe bleeding, possibly playing a role in preventing immediate emergency surgery

Histone deacetylase-specific modification of inflammatory mediators

Einleitung Histon-Deazetylase (HDAC)-Inhibitoren sind für ihre anti- proliferativen und pro-apoptotischen Eigenschaften bekannt. Darüber hinaus sind ihre anti-inflammatorischen Eigenschaften in den Fokus gerückt. Der Einsatz von HDAC-Inhibitoren führt zu einer Verbesserung der experimentellen Kolitis in Mausmodellen, wobei Mechanismen die diese Effekte vermitteln unklar sind. Bekannt ist, dass für Modelle der experimentellen Kolitis T-Zellsubpopulationen entscheidend sind. Um mögliche Mechanismen der HDAC- Inhibitoren in Bezug auf T-Zellen aufzuklären, wurde der Effekt auf die Zytokinfreisetzung untersucht. Da die T-Zellpolarisierung und damit Entstehung inflammatorischer und regulatorischer Subpopulationen eine zentrale Schaltstelle für die mukosale Homöostase darstellt, wurde die Auswirkung des Pan-HDAC-Inhibitors ITF2357 auf die Polarisierung von naiven T-Zellen untersucht. Diesen Gedanken verfolgend wurde der Einfluss des Inhibitors auf den IL-6R untersucht, da IL-6 das entscheidende Zytokin für die Polarisierung pro-inflammatorischer Th17-Zellen darstellt. Um die Relevanz einzelner HDAC auf die anti-inflammatorischen Effekte definieren zu können, wurden diese HDAC durch siRNA-Technologie spezifisch supprimiert, die potentiell für die Vermittlung inflammatorischer Prozesse verantwortlich sind. Methoden Murine CD4+-T-Zellen wurden aus Milzen und Lymphknoten isoliert, mit ITF2357 behandelt und mittels Concanvalin A oder anti-CD3/anti-CD28 stimuliert. Anschließend wurde die IFNɣ-Produktion mittels ELISA analysiert. Ebenso gewonnene naive T-Zellen (CD4+/CD62L+) wurden in An- oder Abwesenheit von ITF2357 unter Th1-polarisierenden Bedingungen stimuliert und nach 48 h die IFNɣ-Konzentration mittels ELISA bestimmt. Die Interleukin-6 Rezeptor (IL-6R) mRNA Expression wurde in unterschiedlich behandelten T-Lymphozyten mittels quantitativer PCR bestimmt. Mittels Chromatinimmunpräzipitation (ChIP) und anschließender quantitativer PCR wurde die Histon 3-Azetylierung am Il6r- Genlocus bei naiven T-Lymphozyten nach Inkubation mit ITF2357 untersucht. Mittels siRNA-Technologie wurden einzelne HDAC spezifisch gehemmt und exemplarisch der Effekt auf die IFNɣ-Produktion auf mRNA-Ebene analysiert. Ergebnisse ITF2357 inhibiert die IFNɣ-Produktion von naiven CD4+-T-Zellen. Für diesen Effekt ist entscheidend, ob mit Concanvalin A oder anti-CD3/anti-CD28 stimuliert wurde. Auch führt die Zugabe des Inhibitors zu naiven CD4+-T-Zellen unter Th1 polarisierenden Bedingungen zu einer Zunahme der IFNɣ produzierenden Zellen. Als eine mechanistische Erklärung für den anti-inflammatorischen Effekt des HDAC-Inhibitors konnte eine Abnahme der IL-6R-Expression auf naiven T-Zellen nach Behandlung mit ITF2357 gezeigt werden. Der IL 6/IL-6R-Signalweg ist für die Polarisierung von Th17 Zellen entscheidend. Unter Einsatz der siRNA-Technologie konnten die HDAC 5, 7 sowie 9 als kritische HDAC für die Vermittlung inflammatorischer Prozesse identifiziert werden. Schlussfolgerungen Die hier vorliegende Arbeit konnte den anti- inflammatorischen Effekt von ITF2357 auf CD4+-T-Zellen zeigen. Entscheidend für die Vermittlung dieses Effektes ist die Wirkung des Inhibitors auf den IL-6/IL-6R-Signalweg der naiven T-Zellen und somit auf die Polarisierung von Th17-Zellen. Die HDAC 5, 7 und 9 konnten als mögliche therapeutische Zielstrukturen identifiziert werden.Introduction Histone deacetylase (HDAC) inhibitors have been known for their pro-apoptotic and anti-proliferative capacities. Recent studies also described anti-inflammatoriy effects in vitro and in vivo. The present study investigated the effect of the HDAC inhibitor ITF2357 on cytokine release of naive CD4+-T-cells. Additionally the effect of ITF2357 on T cell polarization towards Th1-cells was studied. To furthermore investigate the mechanisms behind the anti-inflammatory potency of HDAC inhibitors, the effect on the interleukin-6 receptor (IL-6R) mRNA expression of naϊve CD4+ T cells was evaluated. IL 6 is one of the key cytokines mediating the polarization of the pro-inflammatory T helper 17 (Th17) cells that are known for their ability in maintaining inflammation and autoimmune diseases. In the second part the aim was to define the specific impact of single HDAC in mediating these anti- inflammatory effects. Methods After isolation from spleens and lymph nodes, murine CD4+ T cells were treated with the HDAC inhibitor ITF2357. The interferon-ɣ (IFNɣ) release was determined by ELISA. In addition, the expression of the IL 6R mRNA in CD4+ T cells in the presence or absence of the pan-HDAC inhibitor ITF2357 was evaluated via quantitative PCR. In order to assess histone 3 acetylation at the site of the Il6r locus in naïve T cells, chromatin immunoprecipitation (ChIP) was performed. siRNA technology served to inhibit specific HDAC and IFNɣ-production was analyzed on the mRNA level as readout. Results The HDAC inhibitor ITF2357 showed an anti-inflammatory effect on naϊve CD4+ T cells. Here the mode of stimulation either with Concanvalin A or anti-CD3/ -CD28 played a critical role with regard to the effect of the inhibitor. Adding the inhibitor to CD4+ T cells under Th1 polarizing conditions leads to an increase of IFNɣ-producing cells. In the presence of ITF2357 a decrease of the IL-6R mRNA expression on naϊve CD4+ T cells was observed, serving as a possible mechanistic explanation for the anti- inflammatory effects, since the IL 6/IL-6R pathway is crucial for polarizing Th17 cells. By applying siRNA technology, HDAC5, 7 and 9 were identified as key HDAC in mediating the anti-inflammatory effects. Conclusion The present study was able to demonstrate an anti-inflammatory effect of HDAC inhibitors on naϊve CD4+ T cells. Down-regulation of the IL 6R mRNA expression could be revealed as one potential mechanism in naïve CD4+ T cells. Furthermore, HDAC5, 7 and 9 were identified as key HDAC in mediating the observed effects and hence might serve as target structures for future therapeutic approached

European Crohn's and Colitis Guidelines on Sexuality, Fertility, Pregnancy, and Lactation

Inflammatory bowel disease has a high incidence and prevalence especially in young individuals in their reproductive years. Trying to conceive and being pregnant is an emotional period for those involved. In the majority of patients suffering from inflammatory bowel disease, maintenance therapy is required during pregnancy to control the disease, and disease control might necessitate introduction of new drugs during a vulnerable period. Therefore, the management of patients with a wish to conceive and during pregnancy requires specialized counselling and appropriate management including a multidisciplinary approach and close involvement of the prospective parents under a shared decision-making model. This updated consensus paper addresses these issues and is aimed to optimize pre-conceptional, pregnancy and post pregnancy counselling, including the monitoring and therapeutic management of patients with IBD patients with a wish to conceive