The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Transforming growth factor-β1-mediated cardiac fibrosis: potential role in HIV and HIV/antiretroviral therapy-linked cardiovascular disease

HIV infection elevates the incidence of cardiovascular disease (CVD) independent of traditional risk factors. Autopsy series document cardiac inflammation and endomyocardial fibrosis in the HIV+ treatment naïve, and gadolinium enhancement magnetic resonance imaging has identified prominent myocardial fibrosis in the majority of HIV+ individuals despite use of suppressive antiretroviral therapies (ART). The extent of such disease may correlate with specific ART regimens. For example, HIV-infected patients receiving ritonavir (RTV)-boosted protease inhibitors have the highest prevalence of CVD, and RTV-exposed rodents exhibit cardiac dysfunction coupled with cardiac and vascular fibrosis, independent of RTV-mediated lipid alterations. We recently showed that platelet transforming growth factor (TGF)-β1 is a key contributor to cardiac fibrosis in murine models. We hypothesize that in the HIV+/ART naïve, cardiac fibrosis is a consequence of proinflammatory cytokine and/or ART-linked platelet activation with release of TGF-β1. Resultant TGF-β1/Smad signaling would promote collagen synthesis and organ fibrosis. We document these changes in a pilot immunohistochemical evaluation of cardiac tissue from two ART-naive pediatric AIDS patients. In terms of ART, we showed that RTV inhibits immunoproteasome degradation of TRAF6, a nuclear adapter signaling molecule critical to the regulation of proinflammatory cytokine signaling pathways involved in osteoclast differentiation and accelerated osteoporosis. We now present a model illustrating how RTV could similarly amplify TGF-β1 signaling in the promotion of cardiac fibrosis and accelerated CVD. Supportive clinical data correlate RTV use with elevation of NT-proBNP, a biomarker for CVD. We discuss potential interventions involving intrinsic modulators of inflammation and collagen degradation, including carbon monoxide-based therapeutics.

Assessing fatigue in inflammatory bowel disease: comparison of three fatigue scales

BACKGROUND

Fatigue is commonly reported by patients with inflammatory bowel disease (IBD), both in quiescent and active disease. Few fatigue scales have been tested in IBD.

AIM

To assess three fatigue assessment scales in IBD and to determine correlates of fatigue.

METHODS

Potential participants (n = 2131) were randomly selected from an IBD organisation's members' database; 605 volunteered and were posted three fatigue scales: Inflammatory Bowel Disease Fatigue scale, Multidimensional Fatigue Inventory and Multidimensional Assessment Fatigue scale and questionnaires assessing anxiety, depression, quality of life (QoL) and IBD activity. The questionnaires were tested for stability over time with another group (n = 70) of invited participants. Internal consistency was measured by Cronbach's alpha and test-retest reliability by the intraclass correlation coefficient (ICC).

RESULTS

Four hundred and sixty-five of 605 (77%) questionnaires were returned; of 70 invited, 48/70 returned test (68.6%) and 41/70 (58.6%) returned retest. The three scales are highly correlated (P < 0.001). Test-retest suggests reasonable agreement with ICC values between 0.65 and 0.84. Lower age, female gender, IBD diagnosis, anxiety, depression and QoL were associated with fatigue (P < 0.001) on univariable analysis. However, on multivariable analysis only depression and low QoL were consistently associated with fatigue, while female gender was associated on most scales. IBD diagnosis, age and other factors were not consistently associated with severity or impact of fatigue once other variables were controlled for.

CONCLUSIONS

All three fatigue scales are likely to measure IBD fatigue adequately. Responsiveness to change has not been tested. Depression, poorer QoL and probably female gender are the major associations of fatigue in IBD.

Effects of different forms and origins of oilseeds on dynamics of ruminal biohydrogenation of long-chain fatty acids in vitro

Dietary unsaturated fatty acids (FA) are intensively hydrogenated in the rumen, resulting in reduced amount of poly-unsaturated fatty acids (PUFA) and accumulation of several biohydrogenation (BH) products. In this study, BH of PUFA originating from different oilseeds (linseed, soya beans, sunflower seed and rapeseed) present in crushed oilseeds or their free oils were assessed in vitro. The assay substrates were incubated in buffered rumen fluid for 0, 6, 12 and 24 h. After incubation, the FA pattern of the incubated samples was analysed using gas chromatography. Biohydrogenation is defined as disappearance of double bonds (DB) calculated from the contents of unsaturated FA. After 24-h incubation, the DB contents of all oilseeds were reduced (p < 0.001) by 40-60%. The reduction was higher (p < 0.001) for the crushed form compared with the oil form. In addition, linseed and sunflower seed known as oilseeds with high contents of linolenic acid C18:3 c9,12,15 (LNA) and linoleic acid C18:2 c9,12 (LA), respectively, showed a higher (p < 0.001) accumulation of the BH intermediates conjugated linoleic acid (CLA, isomer C18:2 c9t11) and vaccenic acid (C18:1 t11) for the crushed form, when compared with the oil. These results suggest an inherent effect of the physical form of the assay oilseeds on in vitro BH. Changes in FA pattern during BH in vitro can be attributed to both source and physical form of the assay oilseeds. However, further investigations are warranted to ensure whether the observed in vitro effects on ruminal BH can be confirmed in vivo.

The polypeptide chain fold in tyrosine phenol-lyase, a pyridoxal-5'-phosphate-dependent enzyme

The tyrosine phenol lyase (EC 4.1.99.2) from Citrobacter intermedius has been crystallised in the apo form by vapour diffusion. The space group is P2(1)2(1)2. The unit cell has dimensions a = 76.0 A, b = 138.3 A, c = 93.5 A and it contains two subunits of the tetrameric molecule in the asymmetric unit. Diffraction data for the native enzyme and two heavy atom derivatives have been collected with synchrotron radiation and an image plate scanner. The structure has been solved at 2.7 A resolution by isomorphous replacement with subsequent modification of the phases by averaging the density around the non-crystallographic symmetry axis. The electron density maps clearly show the relative orientation of the subunits and most of the trace of the polypeptide chain. Each subunit consists of two domains. The topology of the large domain appears to be similar to that of the aminotransferases.

Refinement of glucose isomerase from Streptomyces albus at 1.65 A with data from an imaging plate

The structure of 'metal-free' glucose isomerase of Streptomyces albus strain number YT ATCC 21132 has been analysed and refined at 1.65 A. The space group is I222, with cell dimensions a = 93.9 (1), b = 99.7 (1) and c = 102.9 (1) A, and there is one monomer of the tetrameric molecule per asymmetric unit. The data were recorded from two crystals of the protein using synchrotron radiation from the EMBL beamline X11 at DESY, Hamburg. Data were recorded with an imaging plate scanner designed and built in the EMBL Hamburg outstation. The total data-collection time was less than 12 h and the processing of all data took less than 2 days. The coordinates of the Arthrobacter glucose isomerase refined at a resolution of 2.5 A were used as a starting model. The structure of the protein and of 445 associated water molecules in the asymmetric unit were refined by restrained least-squares minimization using all data between 8 and 1.65 A to a final R factor of 14.1%.

Leptospirosis presenting as a flaccid paraplegia

A fatal case of leptospirosis in a 64 year old farm worker is described. The dramatic neurological presentation with a rapidly evolving flaccid paraplegia associated with biochemical evidence of renal and hepatic dysfunction is discussed. Attention is drawn to the wide range of neurological symptoms reported in leptospirosis, and to the possibility that this infectious disease may present neurologically.

Change and stability in adult intellectual functioning assessed by Wechsler item responses

Change in adult intellectual performance was assessed with longitudinal data from the Intergenerational Studies at the Institute of Human Development. Wechsler Intelligence data from two age cohorts spanning ages 18 to 61 were analyzed at the subtest and item level. Hotelling T2 analyses on sets of equivalent items from Wechsler subtests were studied to determine if change in response occurred between pairwise combinations of occasions of test administrations. We used Bowker's test to analyze data at the item level to determine the direction of change in performance. Consistent improvement in performance occurred between the ages of 18-40 and 18-54. Between the ages of 40 and 61, results showed mostly improved performance on the Information, Comprehension, and Vocabulary subtests, mixed change on the Picture Completion subtest, and decline on the Digit Symbol and Block Design subtests. The pattern of mixed change on the Picture Completion subtest indicated improvement on the easy items and decline on the difficult items. Decline in performance on the Block Design test occurred only for the most difficult items.

Change and stability in adult intellectual functioning assessed by Wechsler item responses

Change in adult intellectual performance was assessed with longitudinal data from the Intergenerational Studies at the Institute of Human Development. Wechsler Intelligence data from two age cohorts spanning ages 18 to 61 were analyzed at the subtest and item level. Hotelling T2 analyses on sets of equivalent items from Wechsler subtests were studied to determine if change in response occurred between pairwise combinations of occasions of test administrations. We used Bowker's test to analyze data at the item level to determine the direction of change in performance. Consistent improvement in performance occurred between the ages of 18-40 and 18-54. Between the ages of 40 and 61, results showed mostly improved performance on the Information, Comprehension, and Vocabulary subtests, mixed change on the Picture Completion subtest, and decline on the Digit Symbol and Block Design subtests. The pattern of mixed change on the Picture Completion subtest indicated improvement on the easy items and decline on the difficult items. Decline in performance on the Block Design test occurred only for the most difficult items.

A principal-components analysis of the Narcissistic Personality Inventory and further evidence of its construct validity

We examined the internal and external validity of the Narcissistic Personality Inventory (NPI). Study 1 explored the internal structure of the NPI responses of 1,018 subjects. Using principal-components analysis, we analyzed the tetrachoric correlations among the NPI item responses and found evidence for a general construct of narcissism as well as seven first-order components, identified as Authority, Exhibitionism, Superiority, Vanity, Exploitativeness, Entitlement, and Self-Sufficiency. Study 2 explored the NPI's construct validity with respect to a variety of indexes derived from observational and self-report data in a sample of 57 subjects. Study 3 investigated the NPI's construct validity with respect to 128 subject's self and ideal self-descriptions, and their congruency, on the Leary Interpersonal Check List. The results from Studies 2 and 3 tend to support the construct validity of the full-scale NPI and its component scales.

A principal-components analysis of the Narcissistic Personality Inventory and further evidence of its construct validity

We examined the internal and external validity of the Narcissistic Personality Inventory (NPI). Study 1 explored the internal structure of the NPI responses of 1,018 subjects. Using principal-components analysis, we analyzed the tetrachoric correlations among the NPI item responses and found evidence for a general construct of narcissism as well as seven first-order components, identified as Authority, Exhibitionism, Superiority, Vanity, Exploitativeness, Entitlement, and Self-Sufficiency. Study 2 explored the NPI's construct validity with respect to a variety of indexes derived from observational and self-report data in a sample of 57 subjects. Study 3 investigated the NPI's construct validity with respect to 128 subject's self and ideal self-descriptions, and their congruency, on the Leary Interpersonal Check List. The results from Studies 2 and 3 tend to support the construct validity of the full-scale NPI and its component scales.

Changes in thick filament length in Limulus striated muscle

Here we describe the change in thick filament length in striated muscle of Limulus, the horseshoe crab. Long thick filaments (4.0 microns) are isolated from living, unstimulated Limulus striated muscle while those isolated from either electrically or K+-stimulated fibers are significantly shorter (3.1 microns) (P less than 0.001). Filaments isolated from muscle glycerinated at long sarcomere lengths are long (4.4 microns) while those isolated from muscle glycerinated at short sarcomere lengths are short (2.9 microns) and the difference is significant (P less than 0.001). Thin filaments are 2.4 microns in length. The shortening of thick filaments is related to the wide range of sarcomere lengths exhibited by Limulus telson striated muscle.