Thus, enhanced adiposity can either through the interaction betwe

Thus, enhanced adiposity can either through the interaction between adipocytes and immune cells, or the overloading of hepatocytes with fat, result in inflammation, IR, and steatosis. Transgenic strategies involving whole-body and tissue-specific gene modulation in elegant mouse models clearly illustrate the contribution of both adipocytes and hepatocytes. For example, genetic changes in adipocyte c-Jun NH2-terminal kinase (JNK1),9 or hepatocyte glycoprotein 130 (gp130)10 and IκB kinase-β11 can regulate IR and steatosis. However, in humans, adipocyte growth and liver steatosis occur over a protracted time frame. Thus, although the rodent studies are highly informative, it is likely that the combination of the two promotes IR and its consequences, including nonalcoholic fatty liver

disease increasingly seen GDC-0449 purchase by hepatologists. Fas (CD95), a member of the TNF family, is expressed by most tissues and plays an important role in mediating programmed cell death (apoptosis). The binding of Fas ligand (FasL) to Fas assists in the formation of the death-inducing signaling complex (DISC), leading to the activation of caspase-8 and caspase-3 and thereby apoptosis. However, as for TNF-α, evidence now suggests that Fas may be involved in nonapoptotic activities.12 For example, in terms of inflammation, Fas can promote the secretion of proinflammatory cyokines

such as IL-1α, IL-1β, IL-6, IL-8, and monocyte chemoattractant protein-1 (MCP-1).13, 14 Moreover, anti-CD95 antibodies can cause massive apoptosis of hepatocytes in vivo,15 ALOX15 but these antibodies can accelerate regeneration in partially hepatectomized livers,16 suggesting additional nonapoptotic functions of Fas. In humans, Fas is expressed in preadipocytes, adipocytes,17 and hepatocytes12 and the Fas receptor has been shown to mediate apoptosis in both adipocytes and the liver. However, adipocyte apoptosis during obesity and in human adipocytes in culture under reduced serum conditions is limited. This may be explained by adipocyte-produced insulin growth factor-1 inhibiting FasL-induced adipocyte apoptosis.17 In order to examine the role of Fas in adipocyte function and in regulating inflammation, Wueest et al.18 recently undertook a detailed in vitro and in vivo study. They observed up-regulation of Fas expression in the perigonadal fat pads of db/db, ob/ob, and high-fat diet (HFD)-fed wild-type mice and in the fat tissues of obese patients, and observed further elevated Fas expression in obese patients with type 2 diabetes. Based on these preliminary observations and in order to analyze the role of increased Fas expression, the authors then utilized total-body Fas knockout (FasKO) mice and determined the effects of high-fat feeding.

Most of this information is not available in the studies performe

Most of this information is not available in the studies performed see more to date. Regarding future investigations in the area of inhibitor development, EHTSB recommends that the studies be carried out on well characterized, large cohorts of severe (clotting activity <1%), infusion-naïve PUPs with consecutive enrolment. The only exception to this recommendation is the evaluation of immunogenicity of new factor concentrates which, according to the EMEA guidelines, should first be carried out in PTPs. Potentially confounding factors should be addressed and

genetic factors taken into account. Validated assays (e.g. Nijmegen) for inhibitor analysis should preferably be performed in a central laboratory with a pre-defined cut-off value and, in a case where an inhibitor is detected, confirmed with another test within the shortest possible interval. Patients who develop an inhibitor should be classified by clear criteria as high responders (≥5 BU), low responders (<5 BU) and whether the inhibitor is transient (disappearing within 3 months without a change in treatment regimen, or disappearing) or not. Enzyme linked immune sorbent assay (ELISA) should also be performed to detect all antibodies produced against the deficient factor. Well-conducted studies will contribute to our understanding of the pathophysiology AZD1208 of inhibitor development, thereby enabling

the use of treatment approaches with the potential to minimize inhibitor development in patients with haemophilia. The EHTSB is a collaborative independent network of European haemophilia centres sponsored by an unrestricted grant from Baxter. C. Altisent, Barcelona, Spain; J. Astermark, Malmö, Ribose-5-phosphate isomerase Sweden; A. Batorova, Bratislava, Slovakia; P. de Moerloose, Geneva, Switzerland; G. Dolan, Nottingham, UK; K. Fijnvandraat, Amsterdam, The Netherlands; K. Fischer, Utrecht, The Netherlands; A. Gringeri, Milan, Italy; C. Hermans, Brussels, Belgium; P. A. Holme, Oslo, Norway; K. Holstein, Hamburg, Germany; M. João

Diniz, Lisbon, Portugal; A. Karafoulidou, Athens, Greece; R. Klamroth, Berlin, Germany; T. Lambert, Paris, France; R. Lassila, Helsinki, Finland; G. Lavigne-Lissalde, Nîmes, France; F. Lopéz, La Coruňa, Spain; R. Pérez, Seville, Spain; M. Richards, Leeds, UK; A. Rocino, Naples, Italy; M. Schiavoni, Bari, Italy; M. von Depka, Hannover, Germany; J. Windyga, Warsaw, Poland. Dr Astermark has received research funds from Baxter, Bayer, Wyeth, Octapharma, CSL Behring and Grifols. He has also received honoraria for organising education sessions, for speaking at scientific meetings or for consultancy services from Baxter, Bayer, Wyeth, Octapharma, CSL Behring, Novo Nordisk, and Biovitrum. Dr Batorova has received honoraria for organizing educational session and speaking at scientific meetings from Bayer, Octapharma, Novo Nordisk, and consultancy fees from Baxter.

The baseline timepoint was considered

to be the date of t

The baseline timepoint was considered

to be the date of the first TE examination diagnostic of cirrhosis. The time-to-event was computed as the months elapsed from this timepoint to the different endpoints. Selumetinib cell line Kaplan-Meier estimates of the cumulative probability of survival were built and survival curves were compared using the log-rank test. For these analyses continuous variables were categorized according to the median value or cutoff points considered clinically relevant. Namely, the CTP score was divided into class A (5-6 points), B (7-9 points), or C (10-15 points) and MELD score was categorized using a cutoff value of 14. For LS and HCV viral load, the cutoff point with the best sensitivity and specificity as predictor of the emergence of decompensations was selected using receptor operating characteristic (ROC) curves. Additionally, LS was also categorized by other clinically relevant cutoff points. Those variables with a P ≤ 0.1 on univariate analyses were entered in Cox proportional hazard models. Also, age, sex, and

the achievement of sustained virological response (SVR) during follow-up were also included in these models. Finally, the presence of statistical interactions between LS, CTP, and MELD scores was evaluated by means of multivariate selleck products Cox regression analyses. Associations with P < 0.05 were considered significant. The hazard ratio (HR) and the respective 95% CIs were calculated. Comparisons between AUROC were performed using the Hanley and McNeil test. Also, the integrated discrimination improvement (IDI) was computed to compare the ability of the models to predict outcomes.32 Likewise, the sensitivity, specificity, PPV, and NPV were calculated. The statistical analysis was carried out using the SPSS 19 Statistical Software Package (Chicago, IL) and STATA v. 9 (StataCorp, College Station, TX). The study was designed and conducted following the Helsinki Declaration. The Ethics Committee of the Hospital ID-8 Universitario de Valme approved the study. All the participant subjects gave written consent to participate in the study. In

all, 239 patients were included in this study. The median (Q1-Q3) follow-up at the end of the study period was 20.7 (range: 9.5-34.5) months. Twelve (5%) patients were lost to the follow-up. Fifty-eight (24%) patients had previously undergone a liver biopsy, with a median (Q1-Q3) elapsed time before enrolment of 37 (range: 26-62) months. The median (Q1-Q3) elapsed time from last clinical visit with evidence of lack of cirrhosis before enrolment was 9 (range: 3-27) months. The main characteristics of the study population are summarized in Table 1. At baseline, 223 (93%) patients had clinical, ultrasound, or histological data supporting the diagnosis of cirrhosis established by TE. Thirty-nine (16%) patients had previously received therapy against HCV without achieving SVR.

It has been

It has been Palbociclib in vivo proposed that pretreatment with PPI decreases the efficacy of H. pylori eradication treatment. With so many patients being treated with PPI for a period prior to being investigated for dyspepsia, this could have obvious negative

clinical implications. Two studies published on this topic this year, however, failed to support this hypothesis nor does it appear to have any impact on symptom severity and quality of life [38,39]. There is a cohort of patients, however, for whom the use of a PPI for H. pylori eradication might be undesirable, for instance those on dual antiplatelet therapy with coronary stents or patients with allergies and intolerances. A trial was published this year on a new-generation histamine-2 click here receptor antagonist, lafutidine, that has antisecretory properties. This study suggested that as part of a standard

triple-therapy regimen, similar rates of eradication could be achieved with lafutidine as with lansoprazole with no increase in adverse events [40]. It may be possible to tailor the eradication regime offered to individual patients to maximize its efficacy. There are a number of options available to achieve this, which have been examined in the past such as examining bacterial virulence factors and pretesting for antibiotic susceptibility,

but in the last year, some new developments have been made. One of the more interesting targets for this aim lies in understanding the role of the cytochrome P450 2C19 (CYP2C19) genotype in H. pylori eradication. The effect here is exerted via the PPI component of therapy with polymorphisms of the CYP2C19 leading some individuals to metabolize more extensively than others. The studies carried Morin Hydrate out in the last year have mainly involved Chinese patients. One study divided subjects receiving a standard triple-therapy regime with omeprazole into extensive (EM), intermediate (IM), and poor (PM) metabolizers according to their CYP2C19 phenotype: 33% for the EM group, 92% for the IM group, and 100% for PM [41]. CYP2C19 polymorphisms can be overcome somewhat in EM by increasing PPI dose with one study showing significantly higher eradication rates in EM when 40 mg rather than 20 mg of omeprazole is used in a dual-therapy regime [42]. It may also be the case that not all PPIs are the same. In another Chinese study where esomeprazole was used, no significant difference was observed when 40 mg was used as opposed to 20 mg in either rate of eradication or side effects [43]. Similarly, in another study where rabeprazole and lansoprazole were used, a dose-dependent effect was not seen [44].

[32] There is also another interesting explanation, of relevance

[32] There is also another interesting explanation, of relevance for clinical practice, for these results. In the absence of an objective diagnostic marker, CM diagnosis is based on a clinical picture alone. There could be a group of patients with a phenotype mimicking that of CM who are actually suffering from other headaches, either primary or secondary. Even after being

assessed by an experienced headache neurologist and a magnetic resonance imaging has been performed with normal results, other diagnoses, such as tension-type headache in a previous migraineur or psychogenic headache expressing as CM, are still possibilities, which would explain in part the relevant response to placebo in trials with onabotA.[11] This could be an interesting point to be tested in future placebo-controlled clinical trials in CM and is a further example of the necessity of introducing objective markers, such Luminespib as CGRP levels, in CM research to try Ferrostatin-1 to avoid other diagnostic mimics. We still do not have a complete understanding of the pathophysiology of CM

or the real mechanism of action of onabotA in this entity. It is well established, however, that activation of the TVS has a crucial role and leads to afferent and efferent release of neuropeptides, especially CGRP. This facilitates a peripheral inflammatory response and vasodilatory response and causes activation of second-order neurons involved in pain transmission. In most vessels, the release of neuropeptides causes endothelium- and nitric oxide-independent vasodilation through a direct action on smooth muscle cells mediated both by cyclic adenosine monophosphate and by activation of adenosine triphosphate-dependent K + channels.[33, 34] Persistent release of CGRP and possibly other neuropeptides is thought to induce sensitization of central trigeminal neurons, and therefore migraine chronification, by triggering a signaling pathway mediated by brain-derived neurotrophic factor leading those to increased expression of the P2X

receptors. These peptidergic central neurons use L-glutamate as their primary neurotransmitter.[35, 36] CGRP, acting via a unique receptor complex, increases neurotransmitter release at these levels, which could lead to the central sensitization underlying chronic pain states such as CM.[7, 8] Our results, showing high CGRP and VIP levels in CM patients and a significant relationship between increased levels of these neuropeptides and response to onabotA, support, first, a crucial role of these neuropeptides in the pathophysiology of CM in humans, and second, that inhibition of local release of these neuropeptides is the likely mechanism of action of onabotA in CM, as previously had been hypothesized from experimental models.

Cylindrospermum licheniforme (Bory) Kütz ex Bornet et Flahault (

Cylindrospermum licheniforme (Bory) Kütz. ex Bornet et Flahault (Fig. 4, aj-at) Thallus compact leathery with star-like spreading bundles of filaments, blue-green in young cultures, becoming olive-green to brown-green or yellowish at the margins with age. Brown pigments released into the substrate. Filaments motile. Trichomes short or long, dispersed in a wide mucilage or tube-like sheaths including

several filaments, flexuous, strongly constricted at the cross walls, isopolar or heteropolar, 3.6–4.8 μm wide. Vegetative cells mostly cylindrical, typically shorter than wide, up to isodiametric, pale blue-green, selleck inhibitor 3.1–5.1 μm long. Heterocytes forming terminally after trichome fragmentation,

solitary, unipored, oval to elongated to bluntly conical, 5.4–9 μm long, 4.0–5.2 μm wide. Akinetes forming paraheterocytically, solitary, broadly oval to elongated, with smooth, colorless to dark brown exospores, sometimes with dark yellow to brown rough surface (precipitates?) and blue-green granulated content, 13–23 μm long, 7.0–12.4 μm wide. Rows of enlarged cells (proakinetes?) observed in paraheterocytic position. Reference strain CCALA 995. Herbarium voucher BRY37716, sequence KF052610. Isolated from prairie remnant soil in Pyramid State Recreational Area, Illinois, NVP-LDE225 ic50 USA. Cylindrospermum maius Kütz. ex Bornet et Flahault (Fig. 6, i–s) Thallus leather-like, dark green, olive-green to dark brown-green, releasing brown pigments into the substrate. Trichomes immotile or slightly motile. constricted at cross walls, 3.9–5.0 μm wide. Cells cylindrical, isodiametric, shorter than wide or longer than wide, with homogenous, nongranular blue-green cytoplasm, 3.7–6.5 μm

long. End cells cylindrical, rounded. Heterocytes unipolar, terminal, spherical to elongated, smooth, tan, or yellow-green, 4.0–10.0 μm long, 4.5–6.0 μm wide. Akinetes single, adjacent to heterocyte, with smooth C-X-C chemokine receptor type 7 (CXCR-7) surface, coarsely granulated content, cylindrical, oval to ellipsoid, (18)21–36 μm long, 10–15(16) μm wide. Exospore initially unstructured colorless, later turning brown and layered, 1–1.5 μm wide. Reference strain CCALA 998. Herbarium voucher BRY37719, sequence KF052614. Isolated from recultivated (top) soil after coal mining, with loblolly pine, Pyramid State Recreation Area, Illinois, USA. Cylindrospermum marchicum (Lemm.) Lemm. (Fig. 6, a–h) Thallus soft, with rough surface, air bubbles forming along the colony edge, green, dark-green to blackish-green, with nacreous, shiny surface. Trichomes heteropolar, long, constricted at the cross walls, (2)2.5–3(4) μm wide. Vegetative cells isodiametric to longer than wide, bright blue-green or green, 3–5.5(9) μm long. Heterocytes apical, mostly cylindrical, rarely spherical or slightly conical, 3.5–6 μm wide, 4–8(10) μm long.

5-fold versus patients with mild hepatitis C and healthy controls

5-fold versus patients with mild hepatitis C and healthy controls, respectively).

Furthermore, 80% of CD8+ MPs were additionally CD25+, a T cell activation marker.12 Levels of MPs derived from other cells,14 such as CD41+ MPs (from platelets) and CD15+ MPs (from neutrophils), were unchanged, whereas CD14+ MPs (from monocytes, macrophages, and dendritic cells) were reduced by nearly 50% in patients with active hepatitis C (P = 0.015) (Fig. 1C). When patients’ LBH589 liver histology was matched with MP plasma levels using linear regression analysis, both histological grade and stage showed a significant correlation with CD4+ and CD8+ MPs (Fig. 2). Due to the low numbers of circulating MPs, initial characterization and functional analyses were performed with T cell MPs released from the human Jurkat T cell line and from peripheral blood of healthy human donors. We stimulated MP release either by activation with PHA,15, 16 or by induction of apoptosis using the tyrosine kinase inhibitor ST.8 Whereas the Jurkat S10-MP fraction was Annexin Vlow and CD3low, the Jurkat S100-MP fraction was Annexin Vhigh and CD3high (Supporting Fig. 1A), which was confirmed by analysis of mean fluorescence Pirfenidone chemical structure intensity (Supporting Fig. 1B). This difference between S100-MPs and S10-MPs was found regardless of the mode of generation

(by way of PHA, ST, or PHA and ST combined) (Supporting Fig. 1B). Electron microscopic images from both fractions demonstrated that S10-MPs were heterogeneous in size and contained electron dense material, indicating

debris of intracellular organelles, whereas S100-MPs showed a more homogeneous structure, being surrounded by a double-layered cell membrane and being electron-lucent, Niclosamide with a variable diameter ranging from 30 nm to 700 nm (Fig. 3A). Fig. 3B shows a typical FACS scatter plot that characterizes the S-100 MPs along with 3-μm marker beads and intact T cells. The exclusive expression of transmembrane CD3 on T cells allowed us to monitor the transfer of CD3 from S100-MPs to human LX-2 HSCs. Six hours of incubation with S100-MPs, the transfer of CD3 from MPs to HSCs peaked, with 17% of the HSCs being positive for CD3 (Fig. 3C,D). In support of the FACS data, fluorescence microscopy demonstrated that S100-MPs labeled with the membrane-dye PKH26 began to attach to HSC membranes at 30 minutes, generating a punctate red-fluorescent membrane pattern, and a diffuse membrane staining, indicative of membrane fusion, from 60 minutes onward (Fig. 3E). Membrane fusion was not found with PKH26-labeled S10-MPs (Supporting Fig. 1C). Because MMPs, especially MMP-3, are up-regulated in cells undergoing apoptosis,17 and because our data show that S100-MPs derived from apoptotic T cells prominently up-regulated MMP-3 in HSCs, we evaluated apoptosis induction by S100-MPs using Annexin V and 7-amino-actinomycin D staining as a readout (Supporting Fig. 1D,E).

There is

limited evidence to guide albumin dosing in this

There is

limited evidence to guide albumin dosing in this clinical scenario. Current recommendations are to give 1gm/kg/day of albumin up to 100gm/day. Our goal in performing this retrospective chart review is to identify differences in outcomes among patients with cirrhosis who present with AKI and who receive differing daily doses of albumin. Using Vanderbilt University Hospitals EMR, 1,124 charts were reviewed from all patients admitted to the Hepatology service from 2010–2013 with 149 subjects identified. Patients with an admission diagnosis of AKI were included if their admission serum creatinine was >2.0mg/dL and had increased from their prior baseline by ≥0.3mg/dL, or KU-57788 in vivo their admission serum creatinine was 1.5 times their baseline value. Subjects who met these criteria were excluded if they were diagnosed APO866 chemical structure with spontaneous bacterial peritonitis during their

hospital stay. We then looked at the admission creatinine, and creatinine after a 48hour albumin challenge to assess for improvement in renal function. Our results show no evidence that increasing doses of albumin are associated with increasing degree of change in creatinine from pre-to-post intervention (p=0.49). In a multivariable model including MELD scores, PRBC administration and urine sodium; there is no evidence that MELD scores, PRBCs, urine sodium or albumin are associated with changes in creatinine. For subjects receiving less than or equal to 0.5 g/kg of albumin BID, creatinine decreased by 0.44 units from pre to post Tyrosine-protein kinase BLK intervention; in subjects receiving more than 0.5 g/kg of albumin,

creatinine decrease by 0.42 units. This is a difference of 0.02 units (95% CI: [−0.24 to 0.28]) due to albumin dosing. While we were unable to show that increasing albumin dose had a greater effect on improving renal function, in general there was an improvement. This study shows no association between albumin dose and effect on improving kidney function, glomerular filtration rate or hospital length of stay in patients with known cirrhosis. These results allowed us to develop a hypothesis that larger doses of albumin are no more effective than low dose albumin regimens in effecting change in overall kidney function. Moving forward it is our goal to create a prospective study with the aim of more effectively using albumin as a hospital resource given Vanderbilt University Hospital as a whole spent 4.6 million dollars on albumin from 2010–2013. Disclosures: The following people have nothing to disclose: Derek J. Feussner, Amy P. Myers, James C. Slaughter, Andrew Scanga Introduction: Hospital-acquired infections in cirrhosis patients are associated with significant morbidity and mortality.

9 Although a relatively small fraction of the total binding site

9. Although a relatively small fraction of the total binding sites, a peak of total or unique FXR-binding sites was observed within 1 kb of the transcription start site (TSS) in both groups (Fig. 1C; Supporting Fig. 10). The highest scored binding motif for the 250 top-scoring FXR-binding sites was an inverted repeat 1 (IR1) motif with similar

preferred sequences in both healthy Selleckchem TSA HDAC and obese mice (Fig. 1D). To identify possible biological functions regulated by FXR, potential FXR target genes were assigned to functional groups by GO analysis. Many potential FXR target genes represent previously unknown functions, such as cellular signaling, hypoxia, autophagy, apoptosis, RNA processing, and many transcriptional regulators. Notably, genes encoding components of diverse cellular signaling pathways, such as G-protein signaling, Wnt signaling, mitogen-activated protein kinase signaling, numerous kinases, and phosphatases, were identified (Fig. 1E). These results suggest that previously unknown functions of FXR, particularly in the regulation of cellular signaling pathways, are different in healthy and obese Ponatinib solubility dmso mice, which could underlie abnormal regulation in obesity. Overall, these GO studies, together with the analysis of genome-wide FXR binding, reveal novel potential FXR target genes, suggesting that FXR may have much broader biological functions than previously appreciated.

Examples of FXR-binding peaks detected near selected genes unique in either healthy or obese mice are shown in Fig. 2 and Supporting Fig. 11. These analyses reveal previously unrecognized genomic targets of FXR in liver with novel biological functions, suggesting that transcriptional patterns and biological pathways regulated by ligand-activated FXR are likely altered in obesity. To initially examine whether differences

in FXR-binding correlate with relative gene expression, ChIP and qRT-PCR studies were performed for randomly selected potential target genes. FXR binding was detected click here by ChIP analysis in 86% (13 of 15 genes) or 100% (5 of 5 genes) of these target genes unique to healthy or obese mice, which validated the accuracy of the ChIP-seq analysis (Fig. 3A,B). For 15 genes with FXR binding unique to healthy mice, mRNA levels of nearly all of the genes were changed, compared to obese mice (Fig. 3C), whereas only 5 of 14 genes with FXR binding unique in obese mice showed significant changes in mRNA levels (Fig. 3D). These results suggest either that FXR-binding sites are likely not functional for a large fraction of the genes in obese mice, or that factors other than FXR may contribute to the overall difference in expression of these genes in obesity. To correlate the binding of FXR at a gene with its expression, mRNA levels of randomly selected genes with FXR-binding sites were measured.

In a systematic review of 32 trials of steroid therapy for acute

In a systematic review of 32 trials of steroid therapy for acute severe colitis involving 1991 patients, the overall response

to corticosteroids was 67% (95% CI 65–69%).118 Higher doses are no more effective, but lower doses are less effective.5,117 Bolus injection is as effective as continuous infusion.122 Treatment is usually given for about 5 days, since extending therapy beyond 7–10 days carries no benefit but may delay definitive treatment.118,120,121,123 Other measures for the management of acute severe colitis in addition to IV corticosteroids are:4,5,124 Nil orally if impending surgery. Patients with acute severe UC, non-responsive this website to IV corticosteroids within 5–7 days are candidates for second line therapy cyclosporin [I,A], anti-TNF therapy [II-3,C] and surgery [III,C]. Level of agreement: a-81%, b-19%, c-0%, d-0%, e-0% Quality of evidence and Classification of recommendation: as above Cyclosporin (CsA).  CsA is an immunosuppressive macrolide that inhibits the production of interleukin 2 by activated T lymphocytes through

a calcineurin-dependent pathway. CsA has been used to induce clinical remission in acute severe colitis refractory to IV corticosteroids. CsA commenced initially selleckchem as intravenous therapy may be continued orally to bridge the gap needed for the full efficacy of azathioprine or 6-mercapropurine, especially if thiopurine agents have not been tried previously, to prevent disease relapse.117,125 In the only Avelestat (AZD9668) randomized controlled trial published, 82% of patients with severe steroid-refractory colitis responded to IV CsA (4 mg/kg daily) compared with 0% treated with

placebo.126 Low dose (2 mg/kg) intravenous induction therapy is as effective as standard dose (4 mg/kg), but has fewer adverse effects.127 The long-term outcome, however, indicates that colectomy was avoided in 12–42% patients at 7 years.128–130 In small open-label studies in Japan and India, CsA was effective in steroid-refractory UC patients.131,132 Cytomegalovirus colitis has been recognized as a complication in UC patients undergoing treatment with CsA and responds to treatment with ganciclovir.133 Infliximab (IFX).  IFX is an alternative option to CsA in treating steroid-refractory acute severe UC but no controlled data on comparative efficacy are currently available. The choice between using IFX and CsA remains controversial in this situation. A placebo controlled study demonstrated significant reduction in surgical colectomy after a single dose of IFX (7/24) compared to placebo (14/24).134 Acceptable response rates are seen in other recent retrospective uncontrolled case series.135 Data on the long-term outcome following IFX, bridging to a thiopurine and the eventual need for colectomy are not currently available. Third line salvage therapy after failure of CsA or IFX with the alternative agent is generally not recommended due to the high risk of serious septic complications.