Agreement between patients and physicians on scores of inflammatory bowel disease activity and burden assessed on a telemonitoring platform

BACKGROUND AND AIMS

Telemonitoring is increasingly used in the management of IBD patients. We investigated the agreement between patients and physicians on scores of disease activity and burden.

METHODS

Consecutive outpatients at one IBD clinic were recruited between February and December 2021. Enrolled patients completed a questionnaire for disease activity (Harvey-Bradshaw Index [HBI] for Crohn's disease or Simple Clinical Colitis Activity Index [SCCAI] for ulcerative colitis) and a test of disease burden (Pictorial Representation of Illness and Self Measure [PRISM]). They did the tests within 5 days of an outpatient visit, working independently on IBD Tool, a new web-based telemonitoring application. Concomitantly, the senior and junior physicians who examined them completed the same tests. The agreement was tested for every pair of scores.

RESULTS

Five hundred and sixty patients (289 Crohn's disease; 271 ulcerative colitis) completed disease questionnaires on IBD Tool (in total, 742 times). By Spearman's correlation, the agreement was substantial both for HBI (rho 0.685-0.837) and SCCAI (rho 0.694-0.888) for comparisons between patients, junior and senior physicians. The agreement was moderate-to-substantial for PRISM (rho 0.406-0.725) for the same comparisons. The correlation between disease activity (HBI/SCCAI) and PRISM scores was substantial for senior (rho 0.757-0.788) or junior (rho 0.746-0.753) physicians and moderate for patients (rho 0.458-0.486). The median PRISM score difference was 2.3-1.6 points lower between patients and senior-junior physicians.

CONCLUSION

Agreement between IBD patients and physicians was substantial for disease activity and moderate for disease impact. The inclusion of disease burden scoring in telemonitoring platforms provides important information for the management of IBD patients.Study highlightsWhat IS known•Continuous response to treatments and patient-reported outcomes became an essential goal for IBD patient management.•The use of tele-monitoring and eHealth technologies allows for regular disease assessments and for managing more efficiently IBD patients; disease questionnaires and tests are key to support eHealth tools.What is new here•Agreement between IBD patients and physicians was substantial for disease activity and moderate for disease burden, while agreement among junior and senior physicians was substantial for both.•PRISM performs as well for ulcerative colitis as for Crohn's patients.•The inclusion of disease burden tests might add to eHealth platforms valuable information, complemental to disease activity questionnaires.

Effectiveness of adalimumab for ulcerative colitis: A multicentre, retrospective study of clinical practice in Italy

BACKGROUND

Adalimumab is used to treat ulcerative colitis, but additional effectiveness and safety data are needed.

PATIENTS AND METHODS

This retrospective study considered adults with ulcerative colitis treated with adalimumab at 19 hospitals. Clinical data were collected from the start of treatment, after 2, 6 and 12 months, and at the last visit. Outcome measures of effectiveness were treatment duration, reasons for discontinuation and colectomy.

RESULTS

We studied 381 patients treated with adalimumab for a median of 12.1 months. Disease activity at the start of treatment was moderate to severe in 262 cases (68.8%) and endoscopic activity was moderate to severe in 339 cases (89.0%). At week 8, clinical responses were observed in 177 cases (46.5%) and clinical remission in 136 cases (35.7%). At 12 months, remission was observed in 128 cases (33.6%). Overall, 44 patients required colectomy, and 170 patients (44.6%) were still taking adalimumab when data were collected. Variables associated with adalimumab discontinuation were concomitant steroid treatment, severe clinical-endoscopic activity at baseline, need for adalimumab intensification and drug-related adverse events. Variables associated with colectomy were concomitant steroid treatment and high baseline C-reactive protein.

CONCLUSION

Adalimumab is safe and effective for the treatment of ulcerative colitis.

Predictivity of early and late assessment for post-surgical recurrence of Crohn's disease: Data from a single-center retrospective series

BACKGROUND AND AIMS

Post-surgical recurrence of Crohn's disease (CD) after ileocolonic resection is common. Early identification of features associated with recurrence is a standard procedure of postoperative management, but the prognostic role of such features when detected at later time points is unclear. We compared the predictivity for Crohn's disease recurrence of common clinical-instrumental variables when assessed early (<12 months) or late (>36 months) after surgery.

METHODS

This retrospective study considered CD patients who had ileocolonic resection and were followed for a median of 7.6 years. Clinical characteristics, post-surgical therapy, endoscopy recurrence (Rutgeerts' score ≥i2) and ultrasound features were compared between subgroups who had a early or late post-surgical assessment. Univariate and multivariate analyses were done to identify variables associated with recurrence (clinical and surgical).

RESULTS

Of 201 patients, 70 (32%) had a early and 39 (19%) had a late post-surgical assessment. The Early and Late subgroups had similar clinical characteristics. Overall, clinical relapse was observed in 131 patients (66%), surgical relapse in 31 (16%), endoscopic recurrence in 149 (75%) and ultrasonographic recurrence in 132 (66%), without significant differences in frequencies between subgroups. By Cox proportional hazard regression, endoscopic recurrence was a significant predictor of clinical recurrence overall (HR=2.31, P = 0.002) and in the Early (HR=3.85, P = 0.002) but not Late subgroup.

DISCUSSION

The most informative postoperative CD assessment is the one done within the first year of surgery. Later endoscopic evaluations have no prognostic value and should be done only for clinical needs or for research purposes.

A multicenter survey on endoscopic retrograde cholangiopancreatography during the COVID-19 pandemic in northern and central Italy

Background and study aims  COVID-19 has dramatically impacted endoscopy practice because upper endoscopy procedures can be aerosol-generating. Most elective procedures have been rescheduled. Endoscopic retrograde cholangiopancreatography (ERCP) is frequently performed in emergency or urgent settings in which rescheduling is not possible. We evaluated the impact of the COVID-19 pandemic on ERCP in Italy during the SARS-CoV-2 lockdown, in areas with high incidence of COVID-19. Patients and methods  We performed a retrospective survey of centers performing ERCP in high COVID-19 prevalence areas in Italy to collect information regarding clinical data from patients undergoing ERCP, staff, case-volume and organization of endoscopy units from March 8, 2020 to April 30, 2020. Results  We collected data from 31 centers and 804 patients. All centers adopted a triage and/or screening protocol for SARS-CoV-2 and performed follow-up of patients 2 weeks after the procedure. ERCP case-volume was reduced by 44.1 % compared to the respective 2019 timeframe. Of the 804 patients undergoing ERCP, 22 (2.7 %) were positive for COVID-19. Adverse events occurred at a similar rate to previously published data. Of the patients, endoscopists, and nurses, 1.6 %, 11.7 %, and 4.9 %, respectively, tested positive for SARS-CoV-2 at follow up. Only 38.7 % of centers had access to a negative-pressure room for ERCP. Conclusion  The case-volume reduction for ERCP during lockdown was lower than for other gastrointestinal endoscopy procedures. No definitive conclusions can be drawn about the percentage of SARS-CoV-2-positive patients and healthcare workers observed after ERCP. Appropriate triage and screening of patients and adherence to society recommendations are paramount.

Risk of Colorectal Cancer in Inflammatory Bowel Disease: Prevention and Monitoring Strategies According With Risk Factors

Colorectal cancer (CRC) is slightly increased in inflammatory bowel disease (IBD) patients, with roughly a 2.5-fold increase compared to the general population. Clinical features associated to CRC risks are extent and severity of colonic involvement, disease duration, concomitant primary sclerosing cholangitis (PSC) and/or familial history of CRC in first-degree relatives. Colonic Crohn’s disease (CD) and ulcerative colitis (UC) share similar risks when similar colonic extent is affected. Risk stratification affects outcomes and surveillance programs.Newer endoscopic techniques substantially ameliorated diagnostic performance of endoscopy, and nowadays the standard for CRC surveillance in IBD patients is high-definition endoscopy, with dye-spray or virtual colonoscopy, oriented at targeted (+ random) colonic biopsies.Visible dysplastic lesions should be considered for endoscopic resection, while invisible dysplasia is still a mandatory proctocolectomy indication.Newer endoscopic interventional techniques (endoscopic mucosa resection, EMR, and endoscopic submucosal dissection, ESD) are appropriate therapeutic techniques to be delivered, but long-term risks of cancer should be balanced towards proctocolectomy.

Cytomegalovirus myocarditis in a patient with systemic lupus erythematosus (SLE) successfully treated with ganciclovir

Myocarditis is an inflammatory disease of the myocardium. Viruses, such as enterovirus, adenovirus, parvovirus B19, HHV6 or cytomegalovirus (CMV) and autoimmune diseases are recognized causes of myocarditis. We describe the clinical case of a young Indian woman with SLE and a concomitant acute CMV related myocarditis with favourable outcome after ganciclovir therapy. CMV myocarditis may range from being a subclinical infection with incidental findings on ECG to a life threating presentation. There are no trials demonstrating the efficacy of antiviral therapy in myocarditis. Case series of patients with CMV myocarditis have reported an excellent clinical outcome after antiviral agents. Lupus Myocarditis (LM) is more prevalent in young females. There are no specific ECG or echocardiographic signs. Treatment strategies of LM are based on corticosteroids, immunosuppressive agents and cardiovascular support, usually with a favorable prognosis, but LM often lead to a severe clinical picture, with mortality of 10.3%. Endomyocardial biopsy (EBM) is recommended as the gold standard but it is very underused in clinical practice, It should be performed in a specialized center but there are concerns on lack of specificity, low negative predictive value, risk of complication, and sampling errors due to the focal nature of myocarditis. Both SLE and CMV are potentially responsible of acute myocarditis. In our knowledge, CMV myocarditis with SLE was described in only one other patient. The initiation of antiviral therapy improved the clinical picture and, in our opinion, it is mandatory when CMV related life threating conditions develop.

Management of Helicobacter pylori in Piedmont, Italy

Helicobacter pylori (H. pylori) is a Gram-negative bacterium, usually acquired during childhood, whose natural habitat is the gastric lumen. H. pylori is accepted as the most important cause of gastritis and peptic ulcer in humans. Nevertheless, its important role in the pathogenesis of gastric cancer as well as in several extra-gastroduodenal diseases has been confirmed. The aim of this work is to discuss, for the first time in a single article, all publications concerning H. pylori infection arising from Piedmont region, Italy, where in 1893 Giulio Bizzozero was the first who observed and described spiral organisms in the stomach of animal models. A systematic review of all publications on the management of H. pylori in adults in Piedmont, based on a PubMed and a Scopus research from 1965 to 2017 was performed. The discussed aspects are the epidemiology, the study on gastric and extragastric diseases related to H. pylori, the diagnostic methods, the treatment of H. pylori infection, and the possibility of reinfection. In conclusions, with almost 70 publications, Piedmont has proudly maintained the tradition of the father of the H. pylori.

Application of multiple laboratory tests for Mycobacterium avium ssp. paratuberculosis detection in Crohn's disease patient specimens

The difficulties involved in detecting and enumerating Mycobacterium avium subsp. paratuberculosis (MAP) as a pathogen potentially involved in Crohn's disease (CD) are well known. This study aimed to improve this situation through the application of multiple laboratory diagnostic tests to detect and isolate this bacterium from different specimens collected from CD-patients and non-CD subjects as controls. A total of 120 samples (terminal ileum and colon biopsies, blood and stool) were obtained from 19 CD-patients and from 11 individuals who did not have a clinicopathological diagnosis of CD (non-CD controls) attending for ileocolonoscopy. All samples were processed by staining techniques, culture on both solid and liquid media, and Insertion Sequence 900/F57 real-time PCR. The MAP frequency in CD-patients was found in a significantly greater proportion than in non-CD subjects; the most positive samples were biopsies from CD-patients tested by real-time PCR. MAP detection in biopsies, and in the other samples, by applying multiple and validated laboratory diagnostic tests, could be a marker of active infection, supporting MAP involvement in CD.

Infliximab three-dose induction regimen in severe corticosteroid-refractory ulcerative colitis: early and late outcome and predictors of colectomy

BACKGROUND

Infliximab is effective as rescue therapy in severe corticosteroid-refractory ulcerative colitis. The optimal dose regimen and the long term benefits are not well defined. The aim of the present study was to evaluate short- and long-term colectomy rate in a cohort of patients with severe corticosteroid-refractory ulcerative colitis who received a three-dose infliximab induction regimen.

METHODS

One hundred and thirteen patients admitted to 11 Italian IBD referral centres and treated with infliximab according to an intention to treat three-dose regimen were included. The co-primary endpoints were 3- and 12-month colectomy rate. The secondary end-points were the overall colectomy-free survival and the identification of predictors of colectomy.

RESULTS

The 3- and 12-month colectomy rates were 18.6% (95%CI 11.8%-26.9%) and 25.6% (95%CI 17.9%-34.7%) respectively. High CRP values and severe endoscopic lesions were associated with the risk of colectomy: Risk Ratio (RR)=2.15 (95%CI 1.05-4.36), and RR=5.13 (95%CI 1.55-16.96), respectively. In patients escaping early colectomy, the probability of a colectomy-free course at 12, 24, 36 and 60months was 91%, 85%, 81% and 73%, respectively. Endoscopic severity was the only predictor of long term colectomy (RR=7.0; 95%CI 1.09-44.7). Adverse events occurred in 16 patients (14%); there was one death (0.88%) due to pulmonary abscess.

CONCLUSIONS

Infliximab is an effective and safe rescue therapy for severe corticosteroid-refractory ulcerative colitis. A three-dose induction regimen seems to be the treatment of choice for preventing early colectomy. Severe endoscopic lesions appear to be predictor of short- and long-term colectomy.

Prospective study of the effects of concomitant medications on thiopurine metabolism in inflammatory bowel disease

BACKGROUND

Thiopurines are increasingly used in the treatment of inflammatory bowel disease (IBD), being the most common immunosuppressive therapy; however, potentially harmful interactions between thiopurines and other drugs (especially 5-aminosalicylic acid, 5-ASA) were described.

AIM

To explore potential interactions between thiopurines and concomitant medications.

METHODS

A total of 183 consecutive IBD patients were enrolled. Clinical characteristics and concomitant medications were recorded. Thiopurine metabolism was analysed with thiopurine S-methyl transferase (TPMT) genetic variants and enzyme activity assays. Comparisons were carried out with stratification of patients according to clinical characteristics and active treatments.

RESULTS

Based on TPMT genetics, 95% IBD patients were wild-type homozygous, the remaining being heterozygous. Median TPMT activity was 24.9 U/Hgb g (IQR 20.7-29.5). No difference in TPMT activity was noted according to 5-ASA exposure. IBD patients on thiopurines had higher TPMT activity levels, but no dose-effect was evident. No difference in TPMT activity was observed in 41 (63%) patients co-treated with 5-ASA. In patients on active thiopurines also, 6-TGN and 6-MMP levels were evaluated and no significant difference was observed based on co-medication. TPMT activity was independently associated only with thiopurines dose (P = 0.016).

CONCLUSIONS

Our data suggest the absence of significant interactions between thiopurines and 5-ASA.

Abdominal bowel ultrasound can predict the risk of surgery in Crohn's disease: proposal of an ultrasonographic score

OBJECTIVE

Abdominal bowel ultrasound (US) is widely used in the management of Crohn's disease (CD). The aim of this study was to evaluate the prognostic role of bowel-wall US morphology on the short-term risk of surgery.

MATERIAL AND METHODS

The 147 CD patients recruited in a case-control study comprised 49 cases operated on within 30 days after US examination and 98 matched non-operated controls. Clinical and US characteristics were analysed. Bowel-wall thickness was recorded, bowel-wall patterns were grouped into five types, but for final analysis they were grouped as "preserved" or "disrupted stratification".

RESULTS

Wall thickness and US patterns were significantly different between cases and controls (p<0.0001). A wall thickness >4.5 mm was observed in 45/49 cases and 47/98 controls (OR = 12.21), while "disrupted stratification" was observed in 34/49 cases and 12/98 controls (OR = 16.24). Among the clinical and US characteristics recorded, only 4 US variables were independently associated with surgery (pattern, thickness, presence of fistulae/abscesses and stenoses) and considered for the US score=(2.5*US pattern)+(1.5*Bowel thickness)+(3*Presence of fistulae/abscesses)+(1.5*Presence of stenoses). Based on this score, up to 84% of patients were correctly classified according to actual status (operated/non-operated).

CONCLUSIONS

Although it needs further prospective validation, the score we propose seems to be a reliable prognostic marker for the short-term risk of surgery in CD. In particular, the score points out those patients with an impending risk of surgery who need careful and frequent control in order to decide on the right time for surgery.

Study of bone metabolism in patients with chronic HIV infection

AIMS

Various studies have confirmed the high incidence of skeletal homeostasis modifications in subjects who are carriers of chronic HIV infections, and specific pharmacological treatments, which modify the metabolism and condition both the weight loss and the reshaping of the bones. The presence of a reduction in body mass index seems to contribute to the progressive deterioration of the skeletal framework. The aim of this study was to see whether the presence of HIV-seropositivity could constitute a risk factor for the development of osteoporosis/osteopenia, even in the light of the fact that our group was composed of patients with a concentrated age span well under the limit for both post-menopausal and senile osteoporosis, and with a median age superimposable for both sexes.

MATERIALS AND METHODS

Our study involved 26 HIV+ patients with an average duration of infection equal to 6.7 +/- 4.8 years, and a range of seropositive duration between 6 months to 16 years. The prominent ultrasonometrical parameters are as follows: Broadband Ultrasound Attenuation, Speed of Sound, Stiffness Index or Quantitative Ultra-sound Index, Bone Mineral Density, and T-score. The biochemical study was carried out by assessing a marker of neoformation such as seric osteocalcine, and uninary pyridinoline and deoxipyridonoline as resorption markers.

RESULTS

The results confirmed the presence of osteoporosis/osteopenia in 46% of the samples (11%, and 35%, respectively), with a progressive reduction in bone mineral density in relation to the duration of HIV infection. Assessment of the marker for bone metabolism showed a significant increase in osteocalcine in the female population compared to the males, without any significant variations in the normal values.

CONCLUSIONS

Extreme variability in the morphological appearance at bone level during the course of HIV infection would lead us to believe that in the genesis of various forms, depending on the mechanisms and the time involved only in the parts defined, other attributable factors are responsible, not only for the progression of the core pathology and the possible interference of hormonal factors (behavioural and/or nutritional) directly correlated with the state of infection, but also for the dismetabolic effects of the antiretroviral drugs.

The role of endoscopic assessment in ulcerative colitis in the era of infliximab

Endoscopic evaluation of mucosal appearance is important for the clinical management of ulcerative colitis patients, as it offers valuable prognostic tools and data useful to change the management and treatment strategies. In the field of severe ulcerative colitis, partial endoscopy and bioptic sampling allows to obtain additional and relevant prognostic information: if severe endoscopic lesions are present, response to standard treatment is less likely, and if CMV superinfection is detected, anti-viral treatment should be added to conventional treatments. When clinical remission is obtained with conventional treatments, distal colonoscopy may add valuable data: the occurrence of complete endoscopic healing is a major predictor of long-term remission with no clinical activity. Finally, biologic treatments, and mainly infliximab, were shown to induce remarkable and significant mucosal healing also in ulcerative colitis, and patients with complete endoscopic healing in response to infliximab were shown to be more likely to experience fewer clinical relapses during the follow-up. Therefore endoscopic evaluation has to be considered a major prognostic marker in ulcerative colitis. In this review data from the Literature supporting this role will be reviewed.

[Endoscopic ultrasound-fine needle aspiration (EUS-FNA) for pancreatic lesions: effectiveness in clinical practice]

Endoscopic ultrasound-fine needle aspiration (EUS-FNA) was shown to be a highly reliable and a very effective diagnostic technique, both based on data from clinical trials and from large clinical practice studies. EUS-FNA results are reported to be in good-to-very good agreement with the final diagnosis, and the agreement significantly exceeded the chance agreement. The overall sensitivity and specificity of EUS and of EUS-FNA are very good. EUS-FNA is an effective diagnostic technique for the evaluation of pancreatic lesions, either reported with other imaging tests or suspected on the basis of clinical and biochemical features. EUS-FNA may be performed in most cases, and the results of EUS-FNA are particularly important for their excellent positive predictive value. Nonetheless, in a few cases EUS-FNA can not be feasible, or can give false negative or inconclusive

RESULTS

The main practical consequence is that before referring patients to surgeons or oncologists, EUS-FNA should be considered as the best diagnostic strategy, since tissue is still the issue' . In a prospective two-centers consecutive series from Italy, FNA did not give any false positive diagnoses of malignancy, and reduced the number of indeterminate diagnoses; moreover, FNA significantly increased the specificity of diagnosis, while sensitivity was unchanged.

Endoscopic ultrasound-fine needle aspiration (EUS-FNA) for pancreatic lesions: effectiveness in clinical practice

BACKGROUND

Diagnosis of pancreatic masses is often difficult. Endoscopic ultrasound-fine needle aspiration has been proposed as the best single-step strategy.

AIMS

To prospectively evaluate feasibility, effectiveness and safety of endoscopic ultrasound-fine needle aspiration of pancreatic masses in a consecutive study of unselected patients.

METHODS

Two hundred ninety-three patients were enrolled in two referral Hospitals in Northern Italy. All patients were referred either due to the presence of imaging test abnormalities (suspected or evident masses, or features indirectly suggesting the presence of a mass) or due to clinical or biochemical findings suggesting pancreatic cancer in the absence of positive imaging. All patients underwent linear array endoscopic ultrasound and, when indicated, fine needle aspiration. All procedures were recorded prospectively. The final diagnosis was established at the end of follow-up or when the patients underwent surgery or died.

RESULTS

Fine needle aspiration was indicated in 246 of 293 cases (84%), considered technically feasible in 232 of 246 cases (94%) and gave adequate samples for histopathological diagnosis in 204 of 232 cases (88%). Endoscopic ultrasound sensitivity, specificity and accuracy were 79, 60 and 72%, respectively; the corresponding figures for endoscopic ultrasound-fine needle aspiration were 80, 86 and 82%. There was good agreement with final diagnosis for endoscopic ultrasound-fine needle aspiration (kappa 0.673, 95%CI 0.592-0.753), greater than that for endoscopic ultrasound alone (kappa 0.515, 95%CI 0.425-0.605). There was one case of intracystic haemorrhage and one case of transient hyperthermia (0.3%).

CONCLUSIONS

Endoscopic ultrasound-fine needle aspiration of pancreatic masses seems to be feasible, effective and safe in this consecutive study of patients.

Infliximab and the risk of latent viruses reactivation in active Crohn's disease

BACKGROUND

Infliximab is used for refractory Crohn's disease but there are concerns regarding long-term safety. Recently, JC-polyomavirus (JCV) was studied after 3 cases of progressive multifocal leukoencephalopathy (PML) were found after treatment with natalizumab. The aim of this study was to investigate the short-term effect of infliximab on reactivation of several harmful latent viruses.

METHODS

Sixty consecutive patients scheduled for infliximab induction course were prospectively enrolled. Blood samples were taken before each infliximab infusion at 0, 2, 6, and 14 weeks. Specific polymerase chain reaction (PCR) analyses were performed to detect JCV, Epstein-Barr virus (EBV), human herpes virus-6, (HHV-6), -7, -8, and cytomegalovirus (CMV).

RESULTS

Indications to infliximab were luminal and fistulizing disease in 49 and 15 cases, respectively. Clinical improvement and remission were achieved in 54 (90%) and 39 (65%) of patients, respectively, at 6 weeks. No patient was JCV-positive at any timepoint. EBV serology was positive for 59/60 patients (98%); EBV-PCR tests were transiently positive (>40 copies/10(5) Peripheral blood mononuclear cells, PBMC) in 4 (7%) patients after infliximab, but in each case were negative at subsequent timepoints. All patients were negative for HHV-6, -7, and -8 at all timepoints. CMV serology was positive in 42 patients (70%), but no CMV-PCR-positive patient was observed. There was no association between concomitant treatments or clinical characteristics and viral status.

CONCLUSIONS

Our results support the safety of short-term infliximab treatment with respect to latent virus reactivation. The long-term effects of infliximab, particularly for the issue of lymphoproliferative disorders, warrants further studies with larger populations, but so far data are reassuring.

The hazardous burden of Herpesviridae in inflammatory bowel disease: the case of refractory severe ulcerative colitis

BACKGROUND

Herpesviridae infection or spread may be a hazard in immunodepressed patients. In the field of inflammatory bowel disease, refractory severe ulcerative colitis is a challenging condition, closely associated to immunosuppression both for inanition due to the disease activity and for immunosuppressive treatments. Cytomegalovirus (CMV) has been proposed as a major cause of refractoriness, while other Herpesviridae may be a risk factor in the long-term follow-up.

AIM OF THE STUDY

To evaluate the positivity rates of CMV, Epstein-Barr (EBV) and Human herpes virus-8 (HHV8) in a consecutive group of ulcerative colitis patients who underwent colectomy for refractoriness to medical treatment compared to a control group, using state of the art methods.

PATIENTS AND METHODS

Colonic specimens from 24 consecutive patients with ulcerative colitis submitted to colectomy for refractoriness and from 20 controls (submitted to colectomy for colorectal cancer) were studied. Standard histology and immunohistochemistry (IHC) for CMV and specific polymerase chain-reaction (PCR) for CMV, EBV and HHV8 were carried out.

RESULTS

Regarding CMV, 1 case (4%) was positive at histology and IHC, whereas 3 cases (13%) were positive at PCR, compared to none in the control group (p=0.239). For EBV 2 cases (8%) and 2 controls (10%) were positive at PCR. None of the cases or of controls was positive for HHV8. The only clinical characteristic independently associated to CMV positivity was the white blood cell count at admission, higher among CMV positive patients (p<0.001). At the end of the post-surgery follow-up (median 7.3 years) none of the CMV positive cases experienced pouchitis, compared to 3/21 (14%) of the CMV negative cases (p=1.000).

DISCUSSION

Our data suggest that CMV is uncommon (13%), even though PCR techniques, considered to be the most sensitive tools, were used for virus detection and the study population is made by highly selected patients with definite refractoriness. EBV and HHV8 may represent a theoretical risk of immunosuppressive therapy because of their potential role as cancer triggers; however in our study, results seem to be reassuring that UC patients undergoing immunosuppressive therapy are not exposed to an excessive risk of viral infection.

EUS diagnosis and simultaneous endoscopic retrograde cholangiography treatment of common bile duct stones by using an oblique-viewing echoendoscope

BACKGROUND

MRCP and EUS have replaced ERCP in the diagnosis of biliary diseases, but the latter is needed for treatment. This study evaluates a new approach in the management of common bile duct stones, by using an oblique-viewing echoendoscope.

METHODS

Nineteen patients with acute abdominal pain associated with increased liver tests entered the study. Evaluation of the biliary tree was performed by using an oblique-viewing echoendoscope (JF-UM20; Olympus Europe GmbH, Hamburg, Germany). When biliary stones or sludge were found, bile duct cannulation and sphincterotomy were performed in the same session.

RESULTS

Bile duct stones were diagnosed by EUS in 4 patients and biliary sludge in 12; the subsequent cholangiography and sphincterotomy with stone extraction confirmed the diagnosis in all patients. Bile duct cannulation failed in 1 patient. EUS showed features of chronic pancreatitis in 3 cases. The mean time for the whole procedure (EUS plus endoscopic retrograde cholangiography with biliary treatment) was 27 minutes. No procedure-related complications were observed.

CONCLUSION

This new approach appears to be feasible and safe, providing an accurate diagnosis and, at the same time, an appropriate treatment of common bile duct stones when needed. With technical improvements, this extended EUS technique could be used as the first-line procedure in patients with biliopancreatic diseases.

An outbreak of hepatitis A virus infection with a high case-fatality rate among injecting drug users

BACKGROUND/AIMS

In 2002, the first reported outbreak of hepatitis A virus (HAV) infection involving mostly intravenous drug users (IDU) occurred in Italy. We attempted a thorough evaluation of the outbreak, including epidemiological, clinical and virological analyses.

METHODS

We conducted an epidemiological investigation, including a case-control study, to identify the source and the modes of HAV transmission. Hepatitis B and C (HCV) viruses and human immunodeficiency virus (HIV) coinfections were clinically analysed. Sequence analysis of the VP1/2A junction of the HAV isolates was also performed.

RESULTS

Of the 47 symptomatic cases, 35 were IDUs. The only associated risk factor was contact (not related to injecting practices) with a jaundiced person (odds ratio: 5.8; 95% confidence interval: 1.3-29.9). Of the cases, 58% were anti-HCV positive and 4.7% anti-HIV positive. Three individuals died of acute liver failure: 2 were HCV-coinfected alcohol abusers, with underlying liver cirrhosis; 1 was HCV/HIV-coinfected. HAV-RNA was found in 15 of the 24 tested patients: genotype IB (8 cases) and IIIA (7 cases) were detected.

CONCLUSIONS

HAV was probably transmitted through the fecal-oral route, although parenteral transmission cannot be excluded. The high fatality rate was probably due to severe underlying liver damage. The occurrence of this outbreak highlights the need for routine HAV vaccination for IDUs.

Infliximab in the treatment of Crohn's disease: predictors of response in an Italian multicentric open study

BACKGROUND

Almost 20% of patients with active Crohn's disease are refractory to conventional therapy. Infliximab is a treatment of proven efficacy in this group of patients and it is not clear which variables predict a good response. AIMS.: To evaluate the role of infliximab looking at the predictors of response in a large series of patients with Crohn's disease.

PATIENTS AND METHODS

Five hundred and seventy-three patients with luminal refractory Crohn's disease (Crohn's Disease Activity Index (CDAI)>220-400) (312 patients) or with fistulising disease (190 patients) or both of them (71 patients) were treated with a dose of 5 mg/kg in 12 Italian referral centres. The primary endpoints of the study were clinical response and clinical remission for luminal refractory and fistulising disease. We evaluated at univariable and multivariable analysis the following variables: number of infusions, sex, age at diagnosis, smoking habit, site of disease, previous surgery, extraintestinal manifestations and concomitant therapies, and type of fistulas.

RESULTS

Patients with luminal refractory disease: 322 patients (84.1%) had a clinical response and 228 (59.5%) reached clinical remission. Patients with fistulising disease: 187 patients (72%) had a reduction of 50% of the number of fistulas and in 107 (41%) a total closure of fistulas was observed. For luminal disease, single infusion (OR 0.49, 95% CI 0.28-0.86) and previous surgery (OR 0.53, 95% CI 0.30-0.93) predicted a worse response for fistulising disease. Other fistulas responded worse than perianal fistulas (OR 0.57, 95% CI 0.303-1.097).

CONCLUSION

In Crohn's disease infliximab is effective in luminal refractory and in fistulising disease. A single infusion and previous surgery predicted a worse response in luminal disease whereas perianal fistulas predicted a better response than other type of fistulas.

Therapeutic ERCP in paediatric patients

BACKGROUND

Major limitations of endoscopic retrograde cholangiopancreatography in paediatric populations are a low incidence of biliopancreatic disease among children, the equipment dimensions (size of endoscopes and devices) and the increasing role of MR-cholangiopancreatography in the field of diagnostic indications. Aim of this study was to evaluate the diagnostic and therapeutic yields of endoscopic retrograde cholangiopancreatography for biliopancreatic diseases in a paediatric population.

METHODS

Between 1996 and 2002, 48 endoscopic retrograde cholangiopancreatographies were performed in 38 children aged 4 weeks to 17 years as part of the diagnostic evaluation for suspected pancreatic or biliary tract disease. Endoscopic retrograde cholangiopancreatography was carried out under general anaesthesia, using prototype paediatric duodenoscopes or standard duodenoscopes in children younger or older than 18 months, respectively.

RESULTS

The indications to perform endoscopic retrograde cholangiopancreatography were common bile duct stones (14 children), biliopancreatic abnormalities (8), primary sclerosing cholangitis (2), Wirsung disruption (1), biliary leakage (1), cholestasis (4) and pancreatitis (8). Cannulation was successful in all patients but one. Sphincterotomy together with stone extraction or stent insertion was performed in 30/38 patients. Immediate complications were mild and treated conservatively.

CONCLUSIONS

Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography can be used safely and effectively in the management of biliopancreatic diseases in childhood as well. Indications, endoscopic techniques and complications are similar to those reported for adult patients.

The role of endoscopy in inflammatory bowel disease

Endoscopy is an essential tool for diagnosis, management and prognostic evaluation of inflammatory bowel disease. However dyscomfort, potential risks and costs associated to endoscopic examinations should contribute to the narrowing of indications to those cases in which the result of endoscopy is essential to determine a variation in the management strategy. Ileocolonoscopy performed by an expert endoscopist allows accurate diagnosis of Crohn's disease or ulcerative colitis in up to almost 90% of cases. Colonoscopy has a prognostic role during a severe flare of disease (the occurrence of severe endoscopic lesions have a negative prognostic value with significantly higher risk not to respond to medical treatment) both in ulcerative colitis and in Crohn's disease; moreover in Crohn's disease the evaluation of recurrent lesions at anastomosis after curative surgery has a strong prognostic role (endoscopic recurrence closely correlates with clinical/surgical recurrence) and preliminary data suggest that mucosal healing assessed with endoscopy after biologic treatments could be associated with a better prognosis. Finally colonoscopy is essential for cancer surveillance during the long-term follow-up. Furthermore there are new endoscopic techniques under evaluation in inflammatory bowel disease, like wireless capsule endoscopy or double balloon enteroscopy for the imaging of small bowel, or endoscopic ultrasound for evaluation of strictures or of perianal disease. Finally some operative techniques like balloon dilation could possibly be employed more frequently in the future in the management of Crohn's disease. Future perspectives in endoscopy for IBD are chromoendoscopy and newer endoscopic imaging techniques, possibly leading to an "in-vivo histology".

Review article: Crohn's disease: monitoring disease activity

A global measurement of Crohn's disease activity, comprising clinical, endoscopic, biochemical and pathological features is not available yet and perhaps is unobtainable. In this review we analyse the most used and validated clinical indices (Crohn's Disease Activity Index [CDAI], Perianal Disease Activity Index [PDAI], fistula drainage assessment), quality of life scores (Inflammatory Bowel Disease Questionnaire [IBDQ]), sub-clinical markers (C-reactive protein, faecal calprotectin, intestinal permeability) and endoscopic indices (Crohn's Disease Endoscopic Index of Severity [CDEIS]/Simple Endoscopic Score for Crohn's Disease [SES-CD], Rutgeeerts' score for postsurgical recurrence). We also review the main advantages and disadvantages of each of these scoring systems. All these indices are rather complex and time-consuming, therefore their use is limited to clinical trials. In everyday clinical practice most gastroenterologists rely on their global clinical judgement, which is less reproducible, but simpler for decision-making.

[Cerebral hemorrhagic infarction caused by tubercular arteritis in HIV positive patient: a case report]

A case of cerebral hemorrhagic infarction caused by tubercular arteritis complicating the course of a tubercular meningitis in an HIV-positive patient is described. The atypical clinical course and histopathologic findings of this rare deadly complication of specific meningeal infection are underlined.

Effectiveness of Helicobacter pylori eradication treatments in a primary care setting in Italy

AIM

To evaluate the choice and relative effectiveness of Helicobacter pylori eradication regimens in a primary care setting.

PATIENTS AND METHODS

Patients referred to our department, who had been treated for H. pylori infection during the preceding 6 months, were enrolled between September 1998 and July 1999. H. pylori status was assessed by urea breath test. Information on the drugs administered, compliance and side-effects was recorded.

RESULTS

The mean eradication rate was 72% in patients receiving their first course of treatment (1863 cases; 45% male; mean age, 53 +/- 14 years); a double therapy regimen was prescribed to 14% of patients, triple therapy to 85% and quadruple therapy to 1%. Maastricht Consensus proton pump inhibitor-based regimens were prescribed in 80% of cases, with a mean eradication rate of 73%. No statistically significant correlation was found between eradication failure and sex, age, endoscopic findings or administered treatment.

CONCLUSIONS

In Italy, in a primary care setting, first-line H. pylori eradication therapies reflect international guidelines. The efficacy of such regimens is lower than that reported by controlled trials. These results are relevant when making pharmacoeconomic evaluations of H. pylori management.

Modality of treatment and outcome of Helicobacter pylori infection in primary care. An Italian experience

BACKGROUND

Aim of the present study was to evaluate the selection and the relative efficacy of H. pylori eradication regimens in primary care setting.

METHODS

Patients referred to our Department, treated for H. pylori infection during the last 6 months, were enrolled during September 1998-July 1999. H. pylori status was assessed by urea breath test and recorded together with information about administered drugs, compliance, side effects.

RESULTS

In patients undergone the first treatment course (1863 cases, 45% M, mean age 53+/-14 yrs) the mean eradication rate (ER) was 72%: a double therapy was prescribed in 14% of cases, a triple therapy in 85% and a quadruple in 1%. Maastricht Consensus PPI-based regimens were prescribed in 80% of total cases with a mean ER of 73%. No statistical significant correlation was found between eradication failure and sex, age or administered treatment.

CONCLUSIONS

In Italy, in primary care setting: 1) first line H. pylori eradication therapies reflect international guidelines; 2) the efficacy of such regimens is lower than the one reported by controlled trials: such data should be kept in mind when pharmacoeconomic evaluations of H. pylori management are drawn.

Impact of urea breath test (UBT) in the management of H. pylori infection in a primary care setting

BACKGROUND

Aim of the present study was to evaluate the use of UBT in a primary care setting.

METHODS

From September 1998 to July 1999 we studied 2810 consecutive patients, referred to the Department of Gastroenterology, Mauriziano Hospital, Torino. A structured questionnaire was used to record information on demographic characteristics and clinical history. 13C-UBT was performed by means of isotope ratio mass spectrometer.

RESULTS

The results shown that: 1) the main indication to perform UBT was the evaluation of treatment success (72% of cases); 2) in patients aged less than 45 years and never assessed before for H. pylori infection, UBT was used as first line procedure in 68% of cases: this finding stand for an initial adoption of the ''test and treat'' strategy; 3) first line H. pylori eradication therapies reflect international guidelines.

CONCLUSIONS

The effectiveness of therapeutic regimens results to be decreased when translated into routine clinical practice.