Julián Panés

Hospital Clínic de Barcelona, Barcino, Catalonia, Spain

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Publications (455)3828.94 Total impact

  • [Show abstract] [Hide abstract] ABSTRACT: Aim: The objective of the current study was to compare two patient assessment strategies using colonoscopy and MRI alternatively as first or second line examinations. Methods: Clinical data, endoscopy and MRI examinations of 100 patients diagnosed with ileocolonic Crohn's disease performed within one week were blindly reviewed by 4 clinical investigators. Two investigators evaluated MRI followed by colonoscopy for 50 cases and reverse order for other 50 cases, the other 2 investigators evaluated the same cases switching the order of examinations. The assessments included a likelihood of the presence of inflammation, stenosis, fistula and abscess, and therapeutic recommendations. Results: Information of the first examination was considered sufficient for management in 80% of cases for MRI and only 34% of cases for colonoscopy (p<0.001). Adding MRI to the information of colonoscopy changed the clinicians' confidence grade in a higher proportion of patients than adding colonoscopy to the information of MRI for the diagnosis of disease activity (10% vs 4%, p=0.03), stenosis (25% vs 9%, p<0.001), fistula (31% vs 0%, p<0.001), and internal abscess (27% vs 0%, p<0.001). Indications for anti-TNF therapy (51% vs 37%, F=0.006), and surgery (12 vs 5%, F=0.019) were more frequent after MRI than after colonoscopy as first examination. As a second examination, MRI led to change in therapy in a higher proportion of patients than colonoscopy (28% vs 8%, p<0.001). Conclusion: In CD, information provided by MRI has a higher impact on patient management than colonoscopy and may be considered as a first line examination for CD assessment.
    No preview · Article · Jan 2016 · Journal of Crohn s and Colitis
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    [Show abstract] [Hide abstract] ABSTRACT: Objectives: New e-health technologies can improve patient-physician communication and contribute to optimal patient care. We compared the diagnostic performance of the Simple Clinical Colitis Activity Index (SCCAI) self-administered by patients with ulcerative colitis (UC) at home (through a website) with the in-clinic gastroenterologist-assessed SCCAI. Methods: Patients were followed-up over 6 months. At months 3 and 6, patients completed the SCCAI online at home; within 48 h, gastroenterologists (blinded to patients' scores) completed the in-clinic SCCAI (reference). SCCAI scores were dichotomized to remission or active disease, and SCCAI changes in disease activity from month 3 to 6 were classed as worsening, stability, or improvement. Results: A total of 199 patients (median age: 38 years; 56% female) contributed with 340 pairs of questionnaires. Correlation of SCCAI scores by patients and physicians was good (Spearman's ρ=0.79), with 85% agreement for remission or activity (95% CI: 80.8-88.6, κ=0.66). The negative predictive value for active disease was 94.5% (91.4-96.6); the positive predictive value was 68.0% (58.8-69.2). Agreement between patient and physician was higher in the 168 month 6 pairs than in the 172 month 3 pairs of questionnaires (89.3% (83.6-93.1) vs. 80.8% (74.2-86.0), P=0.027). Conclusions: In patients with UC, SCCAI self-administration via an online tool resulted in a high percentage of agreement with evaluation by gastroenterologists, with a remarkably high negative predictive value for disease activity. Remote monitoring of UC patients is possible and might reduce hospital visits.Am J Gastroenterol advance online publication, 12 January 2016; doi:10.1038/ajg.2015.403.
    Full-text · Article · Jan 2016 · The American Journal of Gastroenterology
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    [Show abstract] [Hide abstract] ABSTRACT: Objective: To evaluate the feasibility and toxicity of autologous haematopoietic stem cell transplantation (HSCT) for the treatment of refractory Crohn's disease (CD). Design: In this prospective study, patients with refractory CD suffering an aggressive disease course despite medical treatment, impaired quality of life and in whom surgery was not an acceptable option underwent HSCT. Toxicity and complications during the procedure and within the first year following transplantation were evaluated, along with the impact of the introduction of supportive measures on safety outcomes. Results: 26 patients were enrolled. During mobilisation, 16 patients (62%) presented febrile neutropaenia, including one bacteraemia and two septic shocks. Neutropaenia median time after mobilisation was 5 days. 5 patients withdrew from the study after mobilisation and 21 patients entered the conditioning phase. Haematopoietic recovery median time for neutrophils (>0.5×10(9)/L) was 11 days and for platelets (>20×10(9)/L) 4 days. Twenty patients (95%) suffered febrile neutropaenia and three patients (27%) presented worsening of the perianal CD activity during conditioning. Among non-infectious complications, 6 patients (28.5%) presented antithymocyte globulin reaction, 12 patients (57%) developed mucositis and 2 patients (9.5%) had haemorrhagic complications. Changes in supportive measures over the study, particularly antibiotic prophylaxis regimes during mobilisation and conditioning, markedly diminished the incidence of severe complications. During the first 12-month follow-up, viral infections were the most commonly observed complications, and one patient died due to systemic cytomegalovirus infection. Conclusions: Autologous HSCT for patients with refractory CD is feasible, but extraordinary supportive measures need to be implemented. We suggest that this procedure should only be performed in highly experienced centres.
    Full-text · Article · Nov 2015 · Gut
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    [Show abstract] [Hide abstract] ABSTRACT: Background: Reliable tools for patient selection are critical for clinical drug trials. Aim: To evaluate a consensus-based, standardised magnetic resonance enterography (MRE) protocol for selecting patients for inclusion in Crohn's disease (CD) multicenter clinical trials. Methods: This study recruited 20 patients [Crohn's Disease Activity Index (CDAI) scores: <150 (n = 8); 150-220 (n = 4); 220-450 (n = 8)], to undergo ileocolonoscopy and two MREs (with and without colonic contrast) within a 14-day period. Procedures were scored centrally using, Magnetic Resonance Index of Activity (MaRIA), and both Crohn's Disease Endoscopic Index of Severity (CDEIS) and Simplified Endoscopic Score (SES-CD). Results: 37 MREs were acquired. Both MREs were evaluable in 16 patients for calculation of test-retest and inter-reader reliability scores. The MaRIA scores for the terminal ileum had excellent test-retest and inter-reader reliability, with correlations >0.9. The proximal ileum showed strong within-reader agreement (0.90-0.96), and fair between-reader agreement (0.59-0.72). MRE procedures were tolerable. MaRIA scores correlated with CDEIS and SES-CD (0.63 and 0.71), but not with CDAI (0.34). MRE identified 3 patients with intra-abdominal complications, who would otherwise have been included in clinical trials. Furthermore, both MRE and ileocolonoscopy identified active bowel wall inflammation in 2 patients with CDAI <150, and none in 1 patient with CDAI > 220. Data quality was good/excellent in 85% of scans, and fair or better in 96%. Conclusions: Magnetic resonance enterography of high-quality and reproducibility was feasible in a global multi- centre setting, with evidence for improved selectivity over CDAI and ileocolonoscopy in identifying appropriate CD patients for inclusion in therapeutic intervention trials.
    Full-text · Article · Nov 2015 · Alimentary Pharmacology & Therapeutics
  • [Show abstract] [Hide abstract] ABSTRACT: Ulcerative colitis (UC) is a chronic intestinal inflammatory disease that may undergo periods of activity followed by remission. We aimed to identify the endogenous regulatory mechanisms that may promote disease remission. Transcriptional and protein analysis of the intestinal mucosa revealed that the IL-1 decoy receptor, interleukin-1 receptor type 2 (IL1R2), was upregulated in remission compared with active UC and controls. We identified epithelial cells as being responsible for increased IL-1R2 production during remission. Expression of IL1R2 was negatively regulated by Wnt/beta-catenin signals in colonic crypts or epithelial stem cell cultures; accordingly, epithelial stem cells upregulated IL-1R2 upon differentiation. Blocking IL-1R2 in isolated colonic crypt cultures of UC patients in remission and T-cell cultures stimulated with biopsy supernatant from UC patients in remission boosted IL-1β-dependent production of inflammation-related cytokines. Finally, IL1R2 transcription was significantly lower in patients that relapsed during a 1-year follow-up period compared with those in endoscopic remission. Collectively, our results reveal that the IL-1/IL-1R2 axis is differentially regulated in the remitting intestinal mucosa of UC patients. We hypothesize that IL-1R2 in the presence of low concentrations of IL-1β may act locally as a regulator of intestinal homeostasis.Mucosal Immunology advance online publication 4 November 2015. doi:10.1038/mi.2015.108.
    No preview · Article · Nov 2015 · Mucosal Immunology
  • [Show abstract] [Hide abstract] ABSTRACT: Background & aims: Endoscopy limited to the rectosigmoid colon is the standard technique used to measure endoscopic healing in ulcerative colitis (UC) clinical trials. We evaluated whether rectosigmoidoscopy adequately measures UC activity in the more proximal colon. Methods: We analyzed data from a phase 2 placebo-controlled study that evaluated the efficacy and safety of etrolizumab in patients with moderate to severely active UC who had not responded to standard therapy. Central readers determined Mayo Clinic endoscopic subscores (MCSe) and ulcerative colitis endoscopic index of severity (UCEIS) scores from the rectosigmoid and proximal colon in videos of 331 examinations performed at baseline, week 6, and week 10. Rates of endoscopic healing (MCSe≤1, MCSe=0) and scores from rectosigmoidoscopy and colonoscopy analyses were compared among 239 examinations with endoscopic assessment proximal to the rectosigmoid colon. Results: There was a high degree of correlation between findings from rectosigmoidoscopy vs colonoscopy in assessment of disease activity based on MCSe≥2 (r=0.84) or MCSe≥1 (r=0.96), or the UCEIS (r=0.92). In 230/239 videos, findings from rectosigmoidoscopy agreed with those from colonoscopy in detection of active disease (MCSe≥2; n=205) or healing (MCSe≤1; n=25). In 9 videos (2 taken at baseline, 7 after treatment), colonoscopy found proximal disease activity not detected by rectosigmoidoscopy. Post-treatment discordance was more frequent in the placebo group, affecting assessment of efficacy at week 10. When endoscopic healing was defined as MCSe=0, there were discordant findings from only 1 video. Conclusions: There is a high degree of correlation in assessments of UC activity made by rectosigmoidoscopy vs colonoscopy. For detection of endoscopic healing (MCSe≤1), colonoscopy found persistent proximal lesions in the placebo group, which affected efficacy analyses. When endoscopic healing was defined as MCSe=0, the concordance between rectosigmoidoscopy and colonoscopy was nearly perfect.
    No preview · Article · Nov 2015 · Gastroenterology
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    [Show abstract] [Hide abstract] ABSTRACT: Background & aims: Etrolizumab is a humanized monoclonal antibody against the β7 integrin subunit that has shown efficacy vs placebo in patients with moderate-to-severely active ulcerative colitis (UC). Patients with colon tissues that expressed high levels of the integrin alpha E gene (ITGAE) appeared to have the best response. We compared differences in colonic expression of ITGAE and other genes between patients who achieved clinical remission with etrolizumab vs those who did. Methods: We performed a retrospective analysis of data collected from 110 patients with UC who participated in a phase 2 placebo-controlled trial of etrolizumab, as well as from 21 patients with UC or without inflammatory bowel disease (controls) enrolled in an observational study at a separate site. Colon biopsies were collected from patients in both studies and analyzed by immunohistochemistry and gene expression profiling. Mononuclear cells were isolated and analyzed by flow cytometry. We identified biomarkers associated with response to etrolizumab. In the placebo-controlled trial, clinical remission was defined as total Mayo Clinic Score≤2, with no individual subscore >1, and mucosal healing was defined as endoscopic score ≤1. Results: Colon tissues collected at baseline from patients who had a clinical response to etrolizumab expressed higher levels of T-cell-associated genes than patients who did not respond (P<.05). Colonic CD4+ integrin αE+ cells from patients with UC expressed higher levels of granzyme A mRNA (GZMA mRNA) than CD4+ αE- cells (P<.0001); granzyme A and integrin αE protein were detected in the same cells. Of patients receiving 100 mg etrolizumab, a higher proportion of those with high levels of GZMA mRNA (41%) or ITGAE mRNA (38%) than low levels of GZMA (6%) or ITGAE mRNA (13%) achieved clinical remission (P<.05) and mucosal healing (41% GZMAhigh vs 19% GZMAlow and 44% ITGAEhigh vs 19% ITGAElow). Compared to ITGAElow and GZMAlow patients, patients with ITGAEhigh and GZMAhigh had higher baseline numbers of epithelial crypt-associated integrin αE+ cells (P<.01 for both), but a smaller number of crypt-associated integrin αE+ cells after etrolizumab treatment (P<.05 for both). After 10 weeks of etrolizumab treatment, expression of genes associated with T-cell activation and genes encoding inflammatory cytokines decreased by 40%-80% from baseline (P<.05) in patients with colon tissues expressing high levels of GZMA at baseline. Conclusions: Levels of GZMA and ITGAE mRNAs in colon tissues can identify patients with UC who have appear to have activated T cells and are most likely to benefit from etrolizumab; expression levels decrease with etrolizumab administration. Larger, prospective studies of markers are needed to assess their clinical value.
    Full-text · Article · Nov 2015 · Gastroenterology
  • J. Panés
    No preview · Article · Oct 2015
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    [Show abstract] [Hide abstract] ABSTRACT: The introduction of biologic drugs represents the most significant advance in the management of immune-mediated inflammatory diseases for a decade. However, complex proteins are expensive to produce and manufacture. Biosimilar versions of established biologics are becoming available as another version of the reference medicinal product and are expected to provide substantial cost savings. However, because of their complexity, the approval of biosimilars requires strict controls to ensure that all therapeutically relevant characteristics are comparable to the reference medicinal product. This review summarizes the scientific principles and data requirements underpinning regulatory approval of biosimilars and the assumptions that enable extrapolation of data between indications. These important concepts are exemplified by CT-P13 (Remsima(®), Inflectra(®)), the first biosimilar monoclonal antibody approved in Europe.
    Preview · Article · Sep 2015 · Expert review of gastroenterology & hepatology
  • [Show abstract] [Hide abstract] ABSTRACT: Background & aims: Accurate biomarkers of disease activity and therapeutic response can be valuable for clinical trials. We performed a post-hoc analysis of data from a Phase 2 trial to assess the relationship between concentration of fecal calprotectin (FCP) and clinical and endoscopic outcomes of patients with moderate to severe ulcerative colitis receiving tofacitinib. Methods: In a double-blind, placebo-controlled, phase 2 trial, 194 patients were randomly assigned to groups given tofacitinib (0.5, 3, 10, or 15 mg twice daily) or placebo. Clinical and endoscopic outcomes were assessed at week 8 using the Mayo scoring system. Receiver operating characteristics (ROC) were used to evaluate the relationships between FCP concentration and clinical and endoscopic outcomes, and to determine the FCP cutoff concentration that correlated with patient outcome. Results: Week 8 median concentrations of FCP were significantly lower in responders than non-responders (P<.001): clinical response, 156 mg/kg vs 725 mg/kg; clinical remission, 64 mg/kg vs 617 mg/kg; endoscopic remission, 44 mg/kg vs 489 mg/kg; and mucosal healing, 127 mg/kg vs 753 mg/kg. Area-under-the-curve values for FCP ROC models were 0.80 for clinical remission, 0.81 for endoscopic remission, and 0.78 for mucosal healing. An FCP cutoff of 150 mg/kg achieved the highest summation of sensitivity and specificity for clinical remission (0.68 and 0.79; κ coefficient, 0.44) and endoscopic remission (0.79 and 0.75; κ coefficient, 0.38). Conclusions: Concentrations of FCP correlate with clinical and endoscopic outcomes of patients with moderate to severe ulcerative colitis receiving tofacitinib, although at an individual level, agreement was moderate. FCP concentration with a cutoff of 150 mg/kg had only fair to good accuracy in classifying clinical and endoscopic outcomes in a clinical trial. (ClinicalTrials.gov no: NCT00787202.).
    No preview · Article · Sep 2015 · Gastroenterology
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    [Show abstract] [Hide abstract] ABSTRACT: The Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) program was initiated by the International Organization for the Study of Inflammatory Bowel Diseases (IOIBD). It examined potential treatment targets for inflammatory bowel disease (IBD) to be used for a "treat-to-target" clinical management strategy using an evidence-based expert consensus process. A Steering Committee of 28 IBD specialists developed recommendations based on a systematic literature review and expert opinion. Consensus was gained if ≥75% of participants scored the recommendation as 7-10 on a 10-point rating scale (where 10=agree completely). The group agreed upon 12 recommendations for ulcerative colitis (UC) and Crohn's disease (CD). The agreed target for UC was clinical/patient-reported outcome (PRO) remission (defined as resolution of rectal bleeding and diarrhea/altered bowel habit) and endoscopic remission (defined as a Mayo endoscopic subscore of 0-1). Histological remission was considered as an adjunctive goal. Clinical/PRO remission was also agreed upon as a target for CD and defined as resolution of abdominal pain and diarrhea/altered bowel habit; and endoscopic remission, defined as resolution of ulceration at ileocolonoscopy, or resolution of findings of inflammation on cross-sectional imaging in patients who cannot be adequately assessed with ileocolonoscopy. Biomarker remission (normal C-reactive protein (CRP) and calprotectin) was considered as an adjunctive target. Evidence- and consensus-based recommendations for selecting the goals for treat-to-target strategies in patients with IBD are made available. Prospective studies are needed to determine how these targets will change disease course and patients' quality of life.Am J Gastroenterol advance online publication, 25 August 2015; doi:10.1038/ajg.2015.233.
    Full-text · Article · Aug 2015 · The American Journal of Gastroenterology
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    [Show abstract] [Hide abstract] ABSTRACT: Background and aims: Ex-vivo generated autologous tolerogenic dendritic cells (tolDCs) can restore immune tolerance in experimental colitis. The aim of this study was to determine the safety and tolerability of administration of autologous tolDCs in refratory Crohn's disease (CD) patients. Methods: A phase-I, single-center, sequential-cohorts, dose-range study was designed. Stable tolDCs were generated ex-vivo from monocytes following a previously developed protocol and administered by sonography-guided intraperitoneal injection. Six sequential refractory-CD-cohorts were established: the first 3 cohorts received a single intraperitoneal injection of tolDCs at escalating doses (2x10(6)/5x10(6)/10x10(6)) and the last 3 cohorts, three biweekly intraperitoneal injections at same escalating doses. Safety was sequentially evaluated. Patients were assessed from week 0 to 12 and followed up for 1-year period for safety. Results: Nine patients were included. No adverse effects were detected during tolDCs injection and follow-up. Three patients withdrew the study due to CD worsening. Clinical activity (CDAI) decreased from 274(60) (mean[SD]) to 222(113) (p=0.3): 1 (11%) patient reached clinical remission (CDAI<150) and 2 (22%) clinical response (CDAI decrease≥100). Endoscopic activity (CDEIS) decreased from 18(5) to 13(8) (p=0.4): lesions improved markedly in 3 patients (33%). Quality of life (IBDQ) changed from 125(27) to 131(38) (p=0.7): remission (IBDQ at week 12≥170) was reached in 1 (11%) case and response (IBDQ score increase≥16) in 2 (22%). Conclusions: Intraperitoneal administration of autologous tolDCs appears safe and feasible in refractory CD patients. Further studies should be developed to test clinical benefit, determine the optimal administration route and dose, and monitor the immune responses. www.eudract.ema.europa.eu, EudraCT number 2007-003469-42; www.aemps.gob.es, number PEI 08-049.
    Full-text · Article · Aug 2015 · Journal of Crohn s and Colitis
  • [Show abstract] [Hide abstract] ABSTRACT: Background: The response to thiopurine treatment in inflammatory bowel disease patients differs greatly among individuals and nearly 50% of patients experience no benefit. Several factors have been implicated in determining this response, including individual genetic variation. Methods: Aiming to identify genes involved in the response to thiopurine drugs, a two-stage investigation of 20,000 coding single-nucleotide polymorphisms (cSNPs) in 10,000 genes was performed in a Spanish cohort of 257 individuals, 193 showing steroid free remission versus 64 non responder individuals 12 months after initial dose of the drug. The 20 top cSNPs with lower p-values for the association test identified at the first stage (133 responders/ 34 non responders), were replicated in a second cohort (60 responders/ 30 non responders). Results: Whereas not statistically significant in all of the two analyzed cohorts, the consistent across samples direction of the observed associations and the allelic joined analysis suggest a significant risk for lack of response related to two genes, PION and ZNF673. With a CMH p-value= 4.26x-06, the associated PION cSNP (rs17151692) minor A allele increases risk for treatment failure 4.5 times when all data is combined. Conclusion: These findings might help to understand the biological mechanisms behind thiopurine treatment failure and to tailor treatment for individual inflammatory bowel disease patients.
    No preview · Article · Aug 2015
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    [Show abstract] [Hide abstract] ABSTRACT: Although most treatment algorithms in inflammatory bowel disease (IBD) begin with classifying patients according to disease severity, no formal validated or consensus definitions of mild, moderate, or severe IBD currently exist. There are 3 main domains relevant to the evaluation of disease severity in IBD: impact of the disease on the patient, disease burden, and disease course. These measures are not mutually exclusive and the correlations and interactions between them are not necessarily proportionate. A comprehensive literature search was performed regarding current definitions of disease severity in both Crohn's disease and ulcerative colitis, and the ability to categorize disease severity in a particular patient. Although numerous assessment tools for symptoms, quality of life, patient-reported outcomes, fatigue, endoscopy, cross-sectional imaging, and histology (in ulcerative colitis) were identified, few have validated thresholds for categorizing disease activity or severity. Moving forward, we propose a preliminary set of criteria that could be used to classify IBD disease severity. These are grouped by the 3 domains of disease severity: impact of the disease on the patient (clinical symptoms, quality of life, fatigue, and disability); measurable inflammatory burden (C-reactive protein, mucosal lesions, upper gastrointestinal involvement, and disease extent), and disease course (including structural damage, history/extension of intestinal resection, perianal disease, number of flares, and extraintestinal manifestations). We further suggest that a disease severity classification should be developed and validated by an international group to develop a pragmatic means of identifying patients with severe disease. This is increasingly important to guide current therapeutic strategies for IBD and to develop treatment algorithms for clinical practice.
    Preview · Article · Jun 2015 · Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association
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    Julián Panés
    Preview · Article · May 2015 · Journal of Crohn s and Colitis
  • [Show abstract] [Hide abstract] ABSTRACT: Diagnostic delay is frequent in patients with Crohn's disease (CD), We developed a tool to predict early diagnosis. A systematic literature review and twelve CD specialists identified "Red Flags" symptoms or signs suggestive of CD. A 21-item questionnaire was administered to 36 healthy subjects and 80 patients with irritable bowel syndrome (non-CD group), and 85 patients with recently diagnosed CD (<18 months). Patients with CD were asked to recall symptoms and signs they experienced during the 12 months before diagnosis. Multiple logistic regression analyses selected and weighted independent items to construct the "Red Flags" index. ROC curve was used to assess the threshold that discriminated CD from non-CD. Association of the "Red Flags" index relative to this threshold was expressed through the odds-ratios (OR). 201 subjects, CD and non-CD, answered the questionnaire. The multivariate analysis identified 8 items independently associated with a diagnosis of CD. A minimum "Red Flags" index value of 8 was highly predictive of CD diagnosis with sensitivity and specificity bootstrap estimates of 0.94 (95% confidence interval: 0.88-0.99) and 0.94 (0.90-0.97), respectively. Positive and negative likelihood ratios were 15.1 (9.3-33.6) and 0.066 (0.013-0.125). The association between CD diagnosis and a "Red Flags" index value of 8 or more corresponds to an OR of 290 (p<0.0001). A "Red Flags" index, using early symptoms and signs, has a high predictive value for the diagnosis of CD. These results need prospective validation prior to introduction into clinical practice. Copyright © 2015 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.
    No preview · Article · Apr 2015 · Journal of Crohn s and Colitis
  • Azucena Salas · Julián Panés
    [Show abstract] [Hide abstract] ABSTRACT: The suppression of excessive immune responses by infusion of regulatory T cells would require a product of high purity, adequate ex vivo expansion and functional stability. A description of the process to obtain an autologous cell product fulfilling these characteristics paves the way to develop clinical trials in humans.
    No preview · Article · Apr 2015 · Nature Reviews Gastroenterology &#38 Hepatology
  • No preview · Article · Apr 2015 · Gastroenterology
  • No preview · Article · Apr 2015 · Gastroenterology
  • No preview · Article · Apr 2015 · Gastroenterology

Publication Stats

13k Citations
3,828.94 Total Impact Points

Institutions

  • 2015
    • Hospital Clínic de Barcelona
      • Servicio de Gastroenterología
      Barcino, Catalonia, Spain
  • 1998-2015
    • Institut Marqués, Spain, Barcelona
      Barcino, Catalonia, Spain
  • 2000-2014
    • IDIBAPS August Pi i Sunyer Biomedical Research Institute
      Barcino, Catalonia, Spain
  • 2012
    • Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas
      Barcino, Catalonia, Spain
  • 2007
    • University of Chicago
      Chicago, Illinois, United States
    • Universität Regensburg
      Ratisbon, Bavaria, Germany
  • 2003
    • University of Zaragoza
      Caesaraugusta, Aragon, Spain
    • Hospital Clínico Universitario Lozano Blesa, Zaragoza
      Caesaraugusta, Aragon, Spain
  • 2001
    • Louisiana State University Health Sciences Center Shreveport
      Shreveport, Louisiana, United States
  • 1999
    • Hospital Universitario de Canarias
      San Cristóbal de La Laguna, Canary Islands, Spain
  • 1994-1998
    • University of Barcelona
      • Department of Medicine
      Barcino, Catalonia, Spain
  • 1997
    • Louisiana State University in Shreveport
      Shreveport, Louisiana, United States
  • 1995
    • University of New South Wales
      Kensington, New South Wales, Australia