A comparison of interpretable XGBoost and artificial neural network model for the prediction of severe acute pancreatitis

INTRODUCTION

Acute pancreatitis (AP) that progresses to persistent organ failure is defined as severe acute pancreatitis (SAP) which has a relatively high mortality. Early establishment of a prediction model is crucial for the improvement of disease prognosis.

OBJECTIVES

The aim of this study was to evaluate the accuracy of Extreme Gradient Boosting (XGBoost) and artificial neural network model (ANN) for predicting SAP.

PATIENTS AND METHODS

A total of 648 patients with AP were enrolled. XGBoost and ANN models were developed and valuated in the training set (519 patients) and test set (129 patients), respectively. The accuracy and results of XGBoost and ANN models were evaluated both by area under the receiver operating characteristic curves (AUC) and the area under precision recall curve.

RESULTS

15 variables were selected for model construction through univariable analysis. The AUCs of XGBoost model and ANN model in five-fold cross-validation of the training set were 0.92 (95%CI, 0.87-0.97) and 0.86 (95%CI, 0.78-0.92), respectively. AUCs of XGBoost model and ANN model for the test set were 0.93 (95%CI, 0.85-1.00) and 0.87 (95%CI, 0.79-0.96). XGBoost outperformed ANN in terms of both diagnostic accuracy and the area under the precision recall curve. Individualized prediction by XGBoost model was explained by local interpretable model-agnostic explanations (LIME) plot.

CONCLUSIONS

An interpretable XGBoost model showed higher discriminatory efficiency in predicting SAP compared to ANN.

Long COVID-19 gastrointestinal related disorders and traditional Chinese medicine: A network target-based approach

The significant number of individuals impacted by the pandemic makes prolonged symptoms after COVID-19 a matter of considerable concern. These are numerous and affect multiple organ systems. According to the World Health Organization (WHO), prolonged gastrointestinal issues are a crucial part of post-COVID-19 syndrome. The resulting disruption of homeostasis underscores the need for a therapeutic approach based on compounds that can simultaneously affect more than one target/node. The present review aimed to check for nutraceuticals possessing multiple molecular mechanisms helpful in relieving Long COVID-19-specific gastrointestinal symptoms. Specific plants used in Keywords Chinese Medicine (TCM) expected to be included in the WHO Global Medical Compendium were selected based on the following criteria: (1) they are widely used in the Western world as natural remedies and complementary medicine adjuvants; (2) their import and trade are regulated by specific laws that ensure quality and safety (3) have the potential to be beneficial in alleviating intestinal issues associated with Long COVID-19. Searches were performed in PubMed, Elsevier, Google Scholar, Scopus, Science Direct, and ResearchGate up to 2023. Cinnamomum cassia, Glycyrrhiza uralensis, Magnolia officinalis, Poria cocos, Salvia miltiorrhiza, Scutellaria baicalensis, and Zingiber officinalis were identified as the most promising for their potential impact on inflammation and oxidative stress. Based on the molecular mechanisms of the phytocomplexes and isolated compounds of the considered plants, their clinical use may lead to benefits in gastrointestinal diseases associated with Long COVID-19, thanks to a multiorgan and multitarget approach.

Fabp5 is a common gene between a high-cholesterol diet and acute pancreatitis

Background and aims

Hypercholesterolemia has been identified as risk factor for severe acute pancreatitis (AP). We aimed to identify the common differentially expressed genes (DEGs) between a high-cholesterol diet and AP.

Methods

We retrived gene expression profiles from the GEO database. DEGs were assessed using GEO2R. For AP hub genes, we conducted functional enrichment analysis and protein-protein interaction (PPI) analysis. GeneMANIA and correlation analysis were employed to predict potential DEG mechanisms. Validation was done across various healthy human tissues, pancreatic adenocarcinoma, peripheral blood in AP patients, and Sprague-Dawley rats with AP.

Results

The gene "Fabp5" emerged as the sole common DEG shared by a high-cholesterol diet and AP. Using the 12 topological analysis methods in PPI network analysis, Rela, Actb, Cdh1, and Vcl were identified as hub DEGs. GeneMANIA revealed 77.6% physical interactions among Fabp5, TLR4, and Rela, while genetic correlation analysis indicated moderate associations among them. Peripheral blood analysis yielded area under the ROC curve (AUC) values of 0.71, 0.63, 0.74, 0.64, and 0.91 for Fabp5, TLR4, Actb, Cdh1 genes, and artificial neural network (ANN) model respectively, in predicting severe AP. In vivo immunohistochemical analysis demonstrated higher Fabp5 expression in the hyperlipidemia-associated AP group compared to the AP and control groups.

Conclusion

Fabp5 emerged as the common DEG connecting a high-cholesterol diet and AP. Rela was highlighted as a crucial hub gene in AP. Genetic interactions were observed among Fabp5, TLR4, and Rela. An ANN model consisting of Fabp5, TLR4, Actb, and Cdh1 was helpful in predicting severe AP.

Comprehensive review on the pathogenesis of hypertriglyceridaemia-associated acute pancreatitis

It is well known, that the inflammatory process that characterizes acute pancreatitis (AP) can lead to both pancreatic damage and systemic inflammatory response syndrome (SIRS). During the last 20 years, there has been a growing incidence of episodes of acute pancreatitis associated with hypertriglyceridaemia (HTAP). This review provides an overview of triglyceride metabolism and the potential mechanisms that may contribute to developing or exacerbating HTAP. The article comprehensively discusses the various pathological roles of free fatty acid, inflammatory response mechanisms, the involvement of microcirculation, serum calcium overload, oxidative stress and the endoplasmic reticulum, genetic polymorphism, and gut microbiota, which are known to trigger or escalate this condition. Future perspectives on HTAP appear promising, with ongoing research focused on developing more specific and effective treatment strategies.

Use of tofacitinib as first or second-line therapy is associated with better outcomes in patients with ulcerative colitis: data from a real-world study

BACKGROUND

Data regarding the real-world (RW) use of tofacitinib (TOF) in patients with ulcerative colitis (UC) are limited. We aimed to investigate TOF's RW efficacy and safety in Italian UC patients.

RESEARCH DESIGN AND METHODS

A retrospective assessment of clinical and endoscopic activity was performed according to the Mayo score. The primary endpoints were to evaluate the effectiveness and safety of TOF.

RESULTS

We enrolled 166 patients with a median follow-up of 24 (IQR 8-36) weeks. Clinical remission was achieved in 61/166 (36.7%) and 75/166 (45.2%) patients at 8-week and 24-week follow-ups, respectively. The optimization was requested in 27 (16.3%) patients. Clinical remission was achieved more frequently when TOF was used as a first/second line rather than a third/fourth line treatment (p = 0.007). Mucosal healing was reported in 46% of patients at the median follow-up time. Colectomy occurred in 8 (4.8%) patients. Adverse events occurred in 12 (5.4%) patients and severe in 3 (1.8%). One case of simple Herpes Zoster and one of renal vein thrombosis were recorded.

CONCLUSIONS

Our RW data confirm that TOF is effective and safe in UC patients. It performs remarkably better when used as the first/second line of treatment.

Post-COVID-19 cholangiopathy: A systematic review

BACKGROUND

The recent and still ongoing pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) entailed various long-term complications, including post-infectious cholangiopathy.

AIM

To identify the available studies concerning post-coronavirus disease 2019 (COVID-19) cholangiopathy.

METHODS

An extensive bibliographical search was carried out in PubMed and in Cochrane Library to identify the articles (retrospective and prospective studies, cohort studies, case series and case reports) published between January 1, 2020 and August 22, 2022, using both MeSH terms and free-language keywords: cholangiopathy; COVID-19; post-COVID-19 cholangiopathy; SARS-CoV-2.

RESULTS

Thirteen studies fulfilled the inclusion criteria, which included 64 patients suffering from this condition. The patients were male in 82.8% of cases. Liver transplant was executed in 6 patients and scheduled in 7 patients, while 2 patients refused the surgical approach. Therefore in 23.4% of the cases, performing this procedure appeared to be necessary.

CONCLUSION

This review has revealed that generally the involvement of the liver in the course of SARS-CoV-2 infection is mild and transient, inducing cholestasis of cholangiocytes but can also be severe enough to cause organ failure in some cases.

Real-world efficacy and safety of vedolizumab in managing ulcerative colitis versus Crohn's disease: results from an Italian multicenter study

BACKGROUND

Vedolizumab (VDZ) can be used to treat refractory ulcerative colitis (UC) and Crohn's disease (CD). We assessed whether there are differences in treating UC vs CD with VDZ.

RESEARCH DESIGN AND METHODS

 Mayo score in UC and the Harvey-Bradshaw Index (HBI) in CD scored the clinical activity. Achievement and maintenance of clinical remission during the follow-up, and safety were the primary endpoints.

RESULTS

729 patients (475 with UC and 254 with CD), median follow-up of 18 (IQR 6-36) months, were enrolled. Clinical remission at the 6^th month of treatment was achieved in 488 (66.9%) patients (74.4% in CD vs 62.9% in UC, p<0.002) while, during the follow-up, no difference was found (81.5% in the UC group and 81.5% pts in the CD group; p=0.537). The clinical remission at the 6^th month of treatment (p=0.001) and being naïve to biologics (p<0.0001) were significantly associated with prolonged clinical remission. The clinical response was significantly higher in UC (90.1%) vs CD (84.3%) (p=0.023), and surgery occurred more frequently in CD (1.9% in UC vs 5.1% in CD, p=0.016).

CONCLUSION

We found differences when using VDZ in UC vs CD in real life. These parameters can help the physician predict this drug's longterm efficacy.

Post-COVID-19 cholangiopathy: A systematic review

BACKGROUND

The recent and still ongoing pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) entailed various long-term complications, including post-infectious cholangiopathy.

AIM

To identify the available studies concerning post-coronavirus disease 2019 (COVID-19) cholangiopathy.

METHODS

An extensive bibliographical search was carried out in PubMed and in Cochrane Library to identify the articles (retrospective and prospective studies, cohort studies, case series and case reports) published between January 1, 2020 and August 22, 2022, using both MeSH terms and free-language keywords: cholangiopathy; COVID-19; post-COVID-19 cholangiopathy; SARS-CoV-2.

RESULTS

Thirteen studies fulfilled the inclusion criteria, which included 64 patients suffering from this condition. The patients were male in 82.8% of cases. Liver transplant was executed in 6 patients and scheduled in 7 patients, while 2 patients refused the surgical approach. Therefore in 23.4% of the cases, performing this procedure appeared to be necessary.

CONCLUSION

This review has revealed that generally the involvement of the liver in the course of SARS-CoV-2 infection is mild and transient, inducing cholestasis of cholangiocytes but can also be severe enough to cause organ failure in some cases.

Non-linear correlation between amylase day 2 to day 1 ratio and incidence of severe acute pancreatitis

Background

This study aimed to assess whether the amylase day 2/amylase day 1 ratio was associated with severe acute pancreatitis (SAP).

Methods

We retrospectively enrolled 464 patients with acute pancreatitis. Serum amylase was measured on admission (day 1) and 24 h later (day 2). Univariable logistic regression with restricted cubic spline analysis, multivariable logistic analysis, and receiver operating characteristic curve analysis was used to evaluate the relationship between the amylase day 2/amylase day 1 ratio and SAP.

Results

A non-linear association between the amylase day 2/amylase day 1 ratio and SAP was observed. The multivariable logistic analysis confirmed that a high amylase day 2/amylase day 1 ratio (≥0.3) was independently associated with the development of SAP (OR: 6.62). The area under the receiver operating characteristic curve (AUC) of the amylase day 2/amylase day 1 ratio, as a predictive factor for SAP, was 0.65. When amylase ratio ≥0.3 was counted as 1 point and added to the BISAP score to build a new model named the BISAPA (BISAP plus Amylase ratio) score (AUC = 0.86), it improved the diagnostic power of the original BISAP score (AUC = 0.83) for SAP. With a cut-off value of 3, the BISAPA score achieved a sensitivity of 66.0%, a specificity of 86.7%, and diagnostic accuracy of 84.48%.

Conclusions

There is a non-linear correlation between the amylase day 2/amylase day 1 ratio and the incidence of SAP. BISAPA score might also be a useful tool for the same purpose.

SARS-CoV-2 vaccines: What we know, what we can do to improve them and what we could learn from other well-known viruses

In recent weeks, the rate of SARS-CoV-2 infections has been progressively increasing all over the globe, even in countries where vaccination programs have been strongly implemented. In these regions in 2021, a reduction in the number of hospitalizations and deaths compared to 2020 was observed. This decrease is certainly associated with the introduction of vaccination measures. The process of the development of effective vaccines represents an important challenge. Overall, the breakthrough infections occurring in vaccinated subjects are in most cases less severe than those observed in unvaccinated individuals. This review examines the factors affecting the immunogenicity of vaccines against SARS-CoV-2 and the possible role of nutrients in modulating the response of distinct immune cells to the vaccination.

Simultaneous laparoscopic removal of a Todani type II choledochal cyst and a microlithiasic cholecystitis

Diverticula of the choledochus, better known as Todani type II cysts, are very rare and represent a predominantly pediatric pathology. Their identification by radiological methods, even if occasional, requires clinical doctors to request a surgical consultation, even for asymptomatic subjects, to proceed with their removal, given the risk of associated neoplasms. The laparoscopic approach for surgical treatment of these cysts has been recently introduced with excellent results. Due to the poor clinical records, currently there are neither shared protocols about their management nor long-term follow-up of operated patients. We report a case of an adult female suffering for years from biliary colic due to the presence of a duodenal diverticulum associated with microlithiasis' cholecystitis, who was laparoscopically treated, with excellent results in terms of symptomatic regression, reduced hospitalization, and no surgery-related complications.

Effects of environmental parameters and their interactions on the spreading of SARS-CoV-2 in North Italy under different social restrictions. A new approach based on multivariate analysis

In 2020 North Italy suffered the SARS-CoV-2-related pandemic with a high number of deaths and hospitalization. The effect of atmospheric parameters on the amount of hospital admissions (temperature, solar radiation, particulate matter, relative humidity and wind speed) is studied through about 8 months (May-December). Two periods are considered depending on different conditions: a) low incidence of COVID-19 and very few regulations concerning personal mobility and protection ("free/summer period"); b) increasing incidence of disease, social restrictions and use of personal protections ("confined/autumn period"). The "hospitalized people in medical area wards/100000 residents" was used as a reliable measure of COVID-19 spreading and load on the sanitary system. We developed a chemometric approach (multiple linear regression analysis) using the daily incidence of hospitalizations as a function of the single independent variables and of their products (interactions). Eight administrative domains were considered (altogether 26 million inhabitants) to account for relatively homogeneous territorial and social conditions. The obtained models very significantly match the daily variation of hospitalizations, during the two periods. Under the confined/autumn period, the effect of non-pharmacologic measures (social distances, personal protection, etc.) possibly attenuates the virus diffusion despite environmental factors. On the contrary, in the free/summer conditions the effects of atmospheric parameters are very significant through all the areas. Particulate matter matches the growth of hospitalizations in areas with low chronic particulate pollution. Fewer hospitalizations strongly correspond to higher temperature and solar radiation. Relative humidity plays the same role, but with a lesser extent. The interaction between solar radiation and high temperature is also highly significant and represents surprising evidence. The solar radiation alone and combined with high temperature exert an anti-SARS-CoV-2 effect, via both the direct inactivation of virions and the stimulation of vitamin D synthesis, improving immune system function.

The function of specialized pro-resolving endogenous lipid mediators, vitamins, and other micronutrients in the control of the inflammatory processes: Possible role in patients with SARS-CoV-2 related infection

Inflammation is an essential protective response against harmful stimuli, such as invading pathogens, damaged cells, or irritants. Physiological inflammation eliminates pathogens and promotes tissue repair and healing. Effective immune response in humans depends on a tightly regulated balance among inflammatory and anti-inflammatory mechanisms involving both innate and adaptive arms of the immune system. Excessive inflammation can become pathological and induce detrimental effects. If this process is not self-limited, an inappropriate remodeling of the tissues and organs can occur and lead to the onset of chronic degenerative diseases. A wide spectrum of infectious and non-infectious agents may activate the inflammation, via the release of mediators and cytokines by distinct subtypes of lymphocytes and macrophages. Several molecular mechanisms regulate the onset, progression, and resolution of inflammation. All these steps, even the termination of this process, are active and not passive events. In particular, a complex interplay exists between mediators (belonging to the group of Eicosanoids), which induce the beginning of inflammation, such as Prostaglandins (PGE2), Leukotrienes (LT), and thromboxane A2 (TXA2), and molecules which display a key role in counteracting this process and in promoting its proper resolution. The latter group of mediators includes: ω-6 arachidonic acid (AA)-derived metabolites, such as Lipoxins (LXs), ω -3 eicosapentaenoic acid (EPA)-derived mediators, such as E-series Resolvins (RvEs), and ω -3 docosahexaenoic (DHA)-derived mediators, such as D-series Resolvins (RvDs), Protectins (PDs) and Maresins (MaRs). Overall, these mediators are defined as specialized pro-resolving mediators (SPMs). Reduced synthesis of these molecules may lead to uncontrolled inflammation with possible harmful effects. ω-3 fatty acids are widely used in clinical practice as rather inexpensive, safe, readily available supplemental therapy. Taking advantage of this evidence, several researchers are suggesting that SPMs may have beneficial effects in the complementary treatment of patients with severe forms of SARS-CoV-2 related infection, to counteract the "cytokine storm" observed in these individuals. Well-designed and sized trials in patients suffering from COVID-19 with different degrees of severity are needed to investigate the real impact in the clinical practice of this promising therapeutic approach.

Usefulness of Random Forest Algorithm in Predicting Severe Acute Pancreatitis

BACKGROUND AND AIMS

This study aimed to develop an interpretable random forest model for predicting severe acute pancreatitis (SAP).

METHODS

Clinical and laboratory data of 648 patients with acute pancreatitis were retrospectively reviewed and randomly assigned to the training set and test set in a 3:1 ratio. Univariate analysis was used to select candidate predictors for the SAP. Random forest (RF) and logistic regression (LR) models were developed on the training sample. The prediction models were then applied to the test sample. The performance of the risk models was measured by calculating the area under the receiver operating characteristic (ROC) curves (AUC) and area under precision recall curve. We provide visualized interpretation by using local interpretable model-agnostic explanations (LIME).

RESULTS

The LR model was developed to predict SAP as the following function: -1.10-0.13×albumin (g/L) + 0.016 × serum creatinine (μmol/L) + 0.14 × glucose (mmol/L) + 1.63 × pleural effusion (0/1)(No/Yes). The coefficients of this formula were utilized to build a nomogram. The RF model consists of 16 variables identified by univariate analysis. It was developed and validated by a tenfold cross-validation on the training sample. Variables importance analysis suggested that blood urea nitrogen, serum creatinine, albumin, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, calcium, and glucose were the most important seven predictors of SAP. The AUCs of RF model in tenfold cross-validation of the training set and the test set was 0.89 and 0.96, respectively. Both the area under precision recall curve and the diagnostic accuracy of the RF model were higher than that of both the LR model and the BISAP score. LIME plots were used to explain individualized prediction of the RF model.

CONCLUSIONS

An interpretable RF model exhibited the highest discriminatory performance in predicting SAP. Interpretation with LIME plots could be useful for individualized prediction in a clinical setting. A nomogram consisting of albumin, serum creatinine, glucose, and pleural effusion was useful for prediction of SAP.

A Comparison of XGBoost, Random Forest, and Nomograph for the Prediction of Disease Severity in Patients With COVID-19 Pneumonia: Implications of Cytokine and Immune Cell Profile

BACKGROUND AND AIMS

The aim of this study was to apply machine learning models and a nomogram to differentiate critically ill from non-critically ill COVID-19 pneumonia patients.

METHODS

Clinical symptoms and signs, laboratory parameters, cytokine profile, and immune cellular data of 63 COVID-19 pneumonia patients were retrospectively reviewed. Outcomes were followed up until Mar 12, 2020. A logistic regression function (LR model), Random Forest, and XGBoost models were developed. The performance of these models was measured by area under receiver operating characteristic curve (AUC) analysis.

RESULTS

Univariate analysis revealed that there was a difference between critically and non-critically ill patients with respect to levels of interleukin-6, interleukin-10, T cells, CD4⁺ T, and CD8⁺ T cells. Interleukin-10 with an AUC of 0.86 was most useful predictor of critically ill patients with COVID-19 pneumonia. Ten variables (respiratory rate, neutrophil counts, aspartate transaminase, albumin, serum procalcitonin, D-dimer and B-type natriuretic peptide, CD4⁺ T cells, interleukin-6 and interleukin-10) were used as candidate predictors for LR model, Random Forest (RF) and XGBoost model application. The coefficients from LR model were utilized to build a nomogram. RF and XGBoost methods suggested that Interleukin-10 and interleukin-6 were the most important variables for severity of illness prediction. The mean AUC for LR, RF, and XGBoost model were 0.91, 0.89, and 0.93 respectively (in two-fold cross-validation). Individualized prediction by XGBoost model was explained by local interpretable model-agnostic explanations (LIME) plot.

CONCLUSIONS

XGBoost exhibited the highest discriminatory performance for prediction of critically ill patients with COVID-19 pneumonia. It is inferred that the nomogram and visualized interpretation with LIME plot could be useful in the clinical setting. Additionally, interleukin-10 could serve as a useful predictor of critically ill patients with COVID-19 pneumonia.

Evaluation of the risk factors for severe complications and surgery of intestinal foreign bodies in adults: a single-center experience with 180 cases

BACKGROUND

Foreign bodies (FBs) lodged in the intestine or causing intestinal complications are uncommon in clinical practice but may pose diagnostic difficulties and prove life-threatening. This study aimed to evaluate the risk factors for severe complications and surgery to aid clinicians in the diagnosis and management of intestinal FBs.

METHODS

We performed a retrospective analysis of patients in whom FBs were lodged in the intestine or caused complications from 2010 to 2020 in the First Affiliated Hospital of Wenzhou Medical University (Zhejiang, China). The characteristics of the patients and FBs, symptoms, imaging findings, diagnostics, treatment strategies, and clinical outcomes were analysed. Furthermore, the risk factors for complications and surgery were investigated.

RESULTS

In total, 180 patients were included in our study. Most patients (76.1%) were unable to provide a history of ingestion. Bezoars were the most common FBs (35.6%). The FBs were mainly located in the duodenum (32.8%) and the ileum (27.8%). Surgical removal of FBs was successful in 89 (49.4%) patients and endoscopic removal in 54 (30.0%) patients. Eleven with perforations were treated conservatively. FBs located in the jejunum or ileum were more likely to cause severe complications than those located in the duodenum. FBs located in the jejunum, ileum, or sigmoid colon were more likely to undergo surgery, and severe complications were an independent risk factor for surgery.

CONCLUSION

Intestinal FBs, often localized in angulation, are likely to be misdiagnosed because most patients do not provide a history of FB ingestion. Surgery and endoscopic therapy are the most commonly used treatment modalities. Surgery is not mandatory in clinically stable patients with small and contained perforations. FBs located in the jejunum or ileum are risk factors for both complications and surgery.

COVID-19, what could sepsis, severe acute pancreatitis, gender differences, and aging teach us?

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes a potentially life-threatening disease, defined as Coronavirus Disease 19 (COVID-19). The most common signs and symptoms of this pathological condition include cough, fever, shortness of breath, and sudden onset of anosmia, ageusia, or dysgeusia. The course of COVID-19 is mild or moderate in more than 80% of cases, but it is severe or critical in about 14% and 5% of infected subjects respectively, with a significant risk of mortality. SARS-CoV-2 related infection is characterized by some pathogenetic events, resembling those detectable in other pathological conditions, such as sepsis and severe acute pancreatitis. All these syndromes are characterized by some similar features, including the coexistence of an exuberant inflammatory- as well as an anti-inflammatory-response with immune depression. Based on current knowledge concerning the onset and the development of acute pancreatitis and sepsis, we have considered these syndromes as a very interesting paradigm for improving our understanding of pathogenetic events detectable in patients with COVID-19. The aim of our review is: 1)to examine the pathogenetic mechanisms acting during the emergence of inflammatory and anti-inflammatory processes in human pathology; 2)to examine inflammatory and anti-inflammatory events in sepsis, acute pancreatitis, and SARS-CoV-2 infection and clinical manifestations detectable in patients suffering from these syndromes also according to the age and gender of these individuals; as well as to analyze the possible common and different features among these pathological conditions; 3)to obtain insights into our knowledge concerning COVID-19 pathogenesis. This approach may improve the management of patients suffering from this disease and it may suggest more effective diagnostic approaches and schedules of therapy, depending on the different phases and/or on the severity of SARS-CoV-2 infection.

SARS-CoV-2: lessons from both the history of medicine and from the biological behavior of other well-known viruses

SARS-CoV-2 is the etiological agent of the current pandemic worldwide and its associated disease COVID-19. In this review, we have analyzed SARS-CoV-2 characteristics and those ones of other well-known RNA viruses viz. HIV, HCV and Influenza viruses, collecting their historical data, clinical manifestations and pathogenetic mechanisms. The aim of the work is obtaining useful insights and lessons for a better understanding of SARS-CoV-2. These pathogens present a distinct mode of transmission, as SARS-CoV-2 and Influenza viruses are airborne, whereas HIV and HCV are bloodborne. However, these viruses exhibit some potential similar clinical manifestations and pathogenetic mechanisms and their understanding may contribute to establishing preventive measures and new therapies against SARS-CoV-2.

Paradoxical relationship between proton pump inhibitors and COVID-19: A systematic review and meta-analysis

BACKGROUND

The proton pump inhibitors (PPIs), used to reduce gastric acid secretion, represent one of the most widely used pharmaceutical classes in the world. Their consumption as a risk factor for the evolution of severe forms of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been investigated as well as the mortality of these patients. These risks also appear to be linked to the duration and the dosage. On the other hand, several studies have emerged with regard to the protective or therapeutic effects of these drugs. More and more evidence underlines the immunomodulatory and anti-fibrotic role of PPIs. In addition, their ability to alkalize the contents of endosomes and lysosomes serves as an obstacle to the entry of the virus into the host cells.

AIM

To identify studies on the relationship between the intake of PPIs and coronavirus disease 2019 (COVID-19) in patients affected by SARS-CoV-2 infection, with the main objective of evaluating the outcomes related to severity and mortality.

METHODS

A literature review was performed in November 2020. The MEDLINE/PubMed, Cochrane Library, EMBASE and Google Scholar databases were searched for all relevant articles published in English on this topic. The search terms were identified by means of controlled vocabularies, such as the National Library of Medicine's MESH (Medical Subject Headings) and keywords. The MESH terms and keywords used were as follows: "COVID-19", "proton pump inhibitors", "PPIs", "SARS-CoV-2", "outcomes", "severity" and "mortality". The inclusion criteria regarding the studies considered in our analysis were: meta-analysis, case-control, hospital-based case-control, population-based case-control, retrospective studies, online survey, as well as cohort-studies, while articles not published as full reports, such as conference abstracts, case reports and editorials were excluded. We tried to summarize and pool all the data if available.

RESULTS

A total of 9 studies were found that described the use of PPIs, of which only 5 clearly reported the severity and mortality data in SARS-CoV-2 patients. Our pooled incidence analysis of severe events did not differ between patients with and without PPIs (odds ratio 1.65, 95% confidence interval: 0.62-4.35) (P = 0.314), or for mortality (odds ratio 1.77, 95% confidence interval: 0.62-5.03) (P = 0.286).

CONCLUSION

Detailed and larger case studies are needed to accurately understand the role of PPIs in this viral infection.

An Ulcerated Large Colic Lipoma Causing Rectorrhagia Treated With Endoscopic Loop-Assisted Resection

Colonic lipomatous polyps are often an incidental finding during colonoscopy. Generally, these types of polyps can cause gastrointestinal bleeding when they are larger than 4 cm in size. Some case reports have documented the occurrence of overlying adenomatous formations in the apical portion, as well as ulcerated mucosa. There is currently no standardized endoscopic removal technique for their treatment. In this report, we present a case of a large and ulcerated lipoma causing rectorrhagia, which was successfully treated with endoscopic en-bloc resection and endoloop placement.

An Unexpected Gastric Subepithelial Mass

A63-year-old man came to our observation complaining of symptoms referable to gastroesophageal reflux disease. No epigastric pain, postprandial fullness, or vomiting were present during clinical examination. His history did not show noteworthy pathologies. The patient did not follow any pharmacological therapy, and there was no family history for neoplasia of the digestive system.

The rationale for a multi-step therapeutic approach based on antivirals, drugs and nutrients with immunomodulatory activity in patients with coronavirus-SARS2-induced disease of different severities

In December 2019, a novel human-infecting coronavirus, named Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2), was recognised to cause a pneumonia epidemic outbreak with different degrees of severity in Wuhan, Hubei Province in China. Since then, this epidemic has spread worldwide; in Europe, Italy has been involved. Effective preventive and therapeutic strategies are absolutely required to block this serious public health concern. Unfortunately, few studies about SARS-CoV-2 concerning its immunopathogenesis and treatment are available. On the basis of the assumption that the SARS-CoV-2 is genetically related to SARS-CoV (about 82 % of genome homology) and that its characteristics, like the modality of transmission or the type of the immune response it may stimulate, are still poorly known, a literature search was performed to identify the reports assessing these elements in patients with SARS-CoV-induced infection. Therefore, we have analysed: (1) the structure of SARS-CoV-2 and SARS-CoV; (2) the clinical signs and symptoms and pathogenic mechanisms observed during the development of acute respiratory syndrome and the cytokine release syndrome; (3) the modification of the cell microRNome and of the immune response in patients with SARS infection; and (4) the possible role of some fat-soluble compounds (such as vitamins A, D and E) in modulating directly or indirectly the replication ability of SARS-CoV-2 and host immune response.

Candida Albicans Lung Abscess in an Illicit Drugs User With Hepatitis C Virus Chronic Infection

Illicit substances are widely used all over the world. Among them, crack cocaine results to be the most used drug for the fact that it can be taken in different ways, such as inhaled or intravenous. Pulmonary complications are well known in people snorting it, mostly due to contamination with other substances contained in the objects able to infuse the drug. Herein, we present a case of lung candida abscess related to nasal insufflation of cocaine in an abuser patient suffering from hepatitis C virus (HCV) and not immunocompromised.

Critically Ill vs. Non-Critically Ill Patients With COVID-19 Pneumonia: Clinical Features, Laboratory Findings, and Prediction

OBJECTIVES

The objective of this study was to investigate the clinical features and laboratory findings of patients with and without critical COVID-19 pneumonia and identify predictors for the critical form of the disease.

METHODS

Demographic, clinical, and laboratory data of 63 COVID-19 pneumonia patients were retrospectively reviewed. Laboratory parameters were also collected within 3-5 days, 7-9 days, and 11-14 days of hospitalization. Outcomes were followed up until March 12, 2020.

RESULTS

Twenty-two patients developed critically ill pneumonia; one of them died. Upon admission, older patients with critical illness were more likely to report cough and dyspnoea with higher respiration rates and had a greater possibility of abnormal laboratory parameters than patients without critical illness. When compared with the non-critically ill patients, patients with serious illness had a lower discharge rate and longer hospital stays, with a trend towards higher mortality. The interleukin-6 level in patients upon hospital admission was important in predicting disease severity and was associated with the length of hospitalization.

CONCLUSIONS

Many differences in clinical features and laboratory findings were observed between patients exhibiting non-critically ill and critically ill COVID-19 pneumonia. Non-critically ill COVID-19 pneumonia also needs aggressive treatments. Interleukin-6 was a superior predictor of disease severity.

Involvement of the exocrine pancreas during COVID-19 infection and possible pathogenetic hypothesis: a concise review

The gastrointestinal system may be affected by COVID-19 infection with an incidence variable from 3% up to 79%. Several works show that the pancreas, both in its exocrine and endocrine function, can be affected by this viral infection, although this organ has been poorly analyzed in this current epidemic context. This mini-review aims to provide a summary of available studies on exocrine pancreas involvement during COVID-19 infection. A search through MEDLINE/PubMed was conducted on the topic in hand. With regard to exocrine function, some studies highlight the presence of an associated hyperenzymemia (hyperamylasemia, hyperlipasemia), while others describe isolated and rare cases of acute pancreatitis. More attention should be paid to pancreatic impairment in subjects with COVID-19, as this may prove to be one of the elements aggravating its clinical course. Indeed, acute pancreatitis, especially when presenting in severe forms with hyperstimulation of the pro-inflammatory response, may represent a crucial factor in the progression of COVID-19, entailing both an increase in hospitalization days and in mortality rate.

Cytokine storm in aged people with CoV-2: possible role of vitamins as therapy or preventive strategy

BACKGROUND

In December 2019, a novel human-infecting coronavirus, SARS-CoV-2, had emerged. The WHO has classified the epidemic as a "public health emergency of international concern". A dramatic situation has unfolded with thousands of deaths, occurring mainly in the aged and very ill people. Epidemiological studies suggest that immune system function is impaired in elderly individuals and these subjects often present a deficiency in fat-soluble and hydrosoluble vitamins.

METHODS

We searched for reviews describing the characteristics of autoimmune diseases and the available therapeutic protocols for their treatment. We set them as a paradigm with the purpose to uncover common pathogenetic mechanisms between these pathological conditions and SARS-CoV-2 infection. Furthermore, we searched for studies describing the possible efficacy of vitamins A, D, E, and C in improving the immune system function.

RESULTS

SARS-CoV-2 infection induces strong immune system dysfunction characterized by the development of an intense proinflammatory response in the host, and the development of a life-threatening condition defined as cytokine release syndrome (CRS). This leads to acute respiratory syndrome (ARDS), mainly in aged people. High mortality and lethality rates have been observed in elderly subjects with CoV-2-related infection.

CONCLUSIONS

Vitamins may shift the proinflammatory Th17-mediated immune response arising in autoimmune diseases towards a T-cell regulatory phenotype. This review discusses the possible activity of vitamins A, D, E, and C in restoring normal antiviral immune system function and the potential therapeutic role of these micronutrients as part of a therapeutic strategy against SARS-CoV-2 infection.

Azathioprine in the maintainance remission in inflammatory bowel disease patients: 7-year follow up

Background

Azathioprine (AZA) and thiopurine are widely used for induction and maintenance of remission in steroid dependent patients with inflammatory bowel disease (IBD).

Methods

Aim of this study has been to investigate its efficacy and safety in maintaining steroid-free remission in steroid dependent IBD patients seven year after the institution of treatment. Data from consecutive IBD outpatients referred in our Institution, between 1985-2016, were reviewed and all patients treated with AZA were included in this retrospective study. AZA was administered at the recommended dose of 2-2.5 mg/kg.

Results

Out of 2802 consecutive IBD outpatients visited in the index period, AZA was prescribed to 433 patients, 236 (54.5%) were affected by Crohn's disease (CD) and 197 (45.5%) by ulcerative colitis (UC). One hundred and seventy-nine patients with a follow-up &lt; 84 months were excluded from the study. Two hundred and fifty-four patients were evaluated, 141 (55.5%) with CD and 113 (44.5%) with UC. One hundred and thirty-nine (54.7%) were male and 115 (45.3%) female (average age of 35.62 ± 14.20 SD years, range 14-74 y.). Seven year after the institution of treatment, 127 (50%) patients still were in steroid-free remission (83 CD vs 44 UC, 58.8% and 38.9%, respectively, p = 0.0024), 71 (27.9%) had a relapse requiring retreatment with steroids (29 CD vs 42 UC, 20.6% and 37.2%, respectively, p = 0.0047), 56 (22.1%) discontinued the treatment due to side effects (29 CD vs 27 UC, 20.6% and 23.9%, respectively). Loss of response from 1st to 7th year of follow-up was low, about 20%.

Conclusions

Seven year after the onset of treatment 50% of patients did not require further steroid courses. After the first year loss of response was low in six subsequent years. In the present series the maintenance of steroid-free remission was significantly higher in CD than in UC patients. The occurrence of side effects leading to the withdrawal of AZA treatment has been low.

Key messages

An important therapeutic moment of IBD is mantaining remission in steroid dipendent patients. AZA can be a viable and inexpensive alternative to treath these patients.

Hypertransaminasemia in the course of infection with SARS-CoV-2: Incidence and pathogenetic hypothesis

In patients infected with severe acute respiratory syndrome coronavirus 2, the respiratory symptoms, such as fever, cough and dyspnea, are the most frequent clinical manifestations. These patients may also present with less well-defined symptoms like diarrhea, nausea, vomiting and/or abdominal discomfort both at the time of diagnosis and during the clinical course. In a few cases, these symptoms may also present before the appearance of respiratory symptoms. To penetrate the body, Severe acute respiratory syndrome coronavirus 2 uses ACE2 receptors, which are present not only in respiratory epithelium but also in gastrointestinal mucosa and liver cholangiocytes. In several cases, viral RNA is detectable in the stool of patients with coronavirus disease 2019 (COVID-19). The liver damage seems to show a multifactorial origin. About 2%-11% of patients with COVID-19 have known underlying hepatic pathologies. In 14%-53% of COVID-19 cases, there is an alteration of the indices of liver cytolysis and is more frequently observed in severe forms of COVID-19, especially during hospitalization.

Association of total cholesterol with severe acute pancreatitis: A U-shaped relationship

BACKGROUND & AIMS

There is no consensus on relationship between total cholesterol levels and incidence of severe acute pancreatitis (SAP). The aim of this study was to investigate the relation between total cholesterol (TC) and the disease severity of acute pancreatitis.

METHODS

We conducted a cross-sectional study on patients with acute pancreatitis between April 2012 and December 2015 in a university hospital. Fasting blood total cholesterol (TC) was assayed within 24 h of admission, as well as 3-5 days, 7-9 days and 13-15 days during hospitalization. Time interval before admission, age, gender, Body Mass Index, hypertension, diabetes mellitus, alcohol consumption, smoking, etiology and albumin were recorded as potential confounding factors. To assess the pattern of relationship of TC and SAP, we used restricted cubic spline analysis with multivariable logistic regression analysis. We also compared total cholesterol concentrations between patients with or without SAP at different time points.

RESULTS

648 patients (median age: 47.5 years; 62.4% man) were enrolled. The incidence of SAP was 10%. A U-shaped association of TC level within 24 h of admission with severity was observed in acute pancreatitis. Patients with low TC levels (<160 mg/dL) and high TC levels (>240 mg/dL) had a significantly higher incidence of SAP and protracted hospital stays when compared to moderate TC levels (160-240 mg/dL). Low total cholesterol levels (OR 2.72; 95 %eCI 1.27-5.83; P = 0.01) and high total cholesterol levels (OR 2.54; 95 %eCI 1.09-5.89; P = 0.03), were still independently associated with development of SAP after adjusting for potential confounding factors. Longitudinal cohort study indicated that patients with SAP had lower total cholesterol concentrations among 3-15 days after admission compared to patients without SAP (P < 0.001).

CONCLUSIONS

Both low TC level (<160 mg/dL) and high TC (>240 mg/dL) within 24 h of admission is independently associated with an increased risk of SAP.

Splenic Hematoma as a Rare Complication of Colonoscopy; a Case Report

Splenic injuries after colonoscopy are an uncommon complication, which can lead to potentially unfortunate outcomes. Their management depends on the type of the splenic damage (hematomas, lacerations, rupture). We describe the case of a woman who visited the Emergency Department due to abdominal pain and pre-syncopal condition, which had occurred 12 hours after she underwent a colonoscopy. An abdominal computed tomography scan showed a splenic hematoma and a hemoperitoneum. An emergency splenectomy was performed successfully. Emergency physicians, who are at the forefront of diagnosing and treating patients, should consider this post-endoscopic complication in order to implement a prompt treatment.

Development and validation of a risk prediction score for severe acute pancreatitis

INTRODUCTION

The available prognostic scoring systems for severe acute pancreatitis (SAP) have limitations that restrict their clinical value. The aim of this study was to develop a simple model (score) that could rapidly identify those at risk for SAP.

METHODS

We derived a risk model using a retrospective cohort of 700 patients by logistic regression and bootstrapping methods. The discriminative power of the risk model was assessed by calculating the area under the receiver operating characteristic curves (AUC). The classification and regression tree (CART) analysis was used to create risk categories. The model was internally validated by a tenfold cross-validation and externally validated in a separate prospective cohort of 194 patients.

RESULTS

The incidence of SAP was 9.7% in the derivation cohort and 9.3% in the validation cohort. A prognostic score (We denoted it as the SABP score), ranging from 0 to 10, consisting of systemic inflammatory response syndrome, serum albumin, blood urea nitrogen and pleural effusion, was developed by logistic regression and bootstrapping analysis. Patients could be divided into three risk categories according to total SABP score based on CART analysis. The mean probability of developing SAP was 1.9%, 12.8% and 41.6% in patients with low (0-3), moderate (4-6) and high (7-10) SABP score, respectively. The AUCs of prognostic score in tenfold cross-validation was 0.873 and 0.872 in the external validation.

CONCLUSION

Our risk prediction score may assist physicians in predicting the development of SAP.

A prediction model for hypoxemia during routine sedation for gastrointestinal endoscopy

OBJECTIVES

The current study was designed to assess the clinical predictors of hypoxemia and to develop a multivariable, predictive model for hypoxemia during routine gastrointestinal endoscopy.

METHODS

In total, 308 patients were enrolled in the analysis. Demographic data, concurrent chronic disease information, anesthetic dose and Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scores were collected and analyzed statistically.

RESULTS

Multivariate logistic regression indicated that age (OR: 1.04; 95%CI 1.01-1.08), body mass index (BMI) (OR: 1.12; 95%CI: 1.02-1.21) and habitual snoring (OR: 3.71; 95%CI: 1.62-8.48) were independently associated with hypoxemia. A logistic regression function (LR model) was developed to predict hypoxemia considering the parameters of -7.73+0.04 age (years), +0.11 BMI, and +1.31 habitual snoring (yes or no). The area under the receiver operating characteristic (ROC) curve for the LR model was 0.76.

CONCLUSIONS

The LR model, consisting of age, BMI and habitual snoring, was a useful predictor of hypoxemia during routine sedation for gastrointestinal endoscopy.

Prevalence and characteristics of colonic adenoma in mainland China

BACKGROUND AND AIM

To investigate the prevalence and characteristics of colonic adenoma and advanced colonic adenoma in a large group of patients in mainland China.

MATERIALS AND METHODS

We conducted a cross-sectional study on patients who had undergone colonoscopy examination in a university hospital in mainland China. Colonic adenomas and advanced adenomas were recorded.

RESULTS

The prevalence of polyps, adenoma, and advanced adenoma was 23.9%, 13.3%, and 3.5%, respectively. Age and sex were independent risk factors for the prevalence of adenoma and advanced adenoma. Polyp size was associated with an increased risk of both colonic adenoma (OR 1.50, 95% CI 1.44-1.56) and advanced adenoma (OR 2.78, 95% CI 2.55-3.03) after sex and age adjustment. Proximal colon polyps were a risk factor for adenoma (OR 1.41, 95% CI 1.20-1.66) and also associated with a significant reduction (44%) in risk of advanced adenoma (OR 0.56, 95% CI 0.36-0.86) compared to distal colon adenoma after sex and age adjustment. A screening indication was associated with a statistically significant decrease in the odds of prevalence of adenoma (OR 0.90, 95% CI 0.81-0.99) and advanced adenoma (OR 0.72, 95% CI 0.59-0.88) compared to a no-screening indication.

CONCLUSION

The overall prevalence of adenoma was low in mainland China. It exhibited a varied pattern with respect to age and sex. Polyp size was a risk factor for both colonic adenoma and its transition to advanced adenoma. Proximal colon polyps were a risk factor for adenoma, but a protective factor for advanced adenoma compared to distal colon adenoma.

Relationship between low-density lipoprotein cholesterol and severe acute pancreatitis ("the lipid paradox")

BACKGROUND AND AIM

The aim of this study was to investigate the association between low-density lipoprotein cholesterol (LDL-C) and the development of severe acute pancreatitis (SAP).

PATIENTS AND METHODS

A total of 674 patients with acute pancreatitis were enrolled. Non-linearity in the relationship between LDL-C and SAP was assessed by restricted cubic spline analysis. Univariable and multivariable regression analyses were used to identify independent risk factors of SAP.

RESULTS

The restricted cubic spline analysis suggested a nonlinear association between high-density lipoprotein cholesterol (HDL-C), LDL-C and triglyceride levels and incidence of SAP. The incidence of SAP in patients with low LDL-C (<90 mg/dL), moderate LDL-C (90-150 mg/dL) and high LDL-C (>150 mg/dL) levels was 15.1%, 3.7% and 9.8%, respectively. Multivariable analysis confirmed that low LDL-C levels (odds ratio [OR] 3.05; 95% confidence interval [CI] 1.35-6.90), high LDL-C levels (OR 4.42; 95% CI 1.41-13.87) and low HDL-C levels (OR 6.90; 95% CI 2.61-18.23) but not high triglyceride levels (OR 1.05; 95% CI 0.40-2.72) were associated with the development of SAP.

CONCLUSION

Both low LDL-C (<90 mg/dL) and high LDL-C (>150 mg/dL) levels within 24 hours from admission are independently associated with an increased risk of SAP.

Colonic diverticulosis is not a risk factor for colonic adenoma

BACKGROUND AND AIMS

Colonic diverticulosis may represent a risk factor for colonic adenomas by virtue of the fact that evolving data suggest that these 2 conditions may share common risk factors such as Western dietary pattern and physical inactivity. This study aims to investigate the association between colonic diverticulosis and colonic adenomas in mainland China.

METHODS

We conducted a cross-sectional study on patients who underwent colonoscopic examination between October 2013 and December 2014 in a university hospital in mainland China. Age, gender, colonic adenomas, advanced adenomas, and distribution of diverticulosis were recorded during the procedures. Multivariate logistic regression and stratified analysis were used to evaluate the associations between the prevalence of diverticulosis and age, sex, and presence of colonic adenomas and advanced adenomas.

RESULTS

A total of 17,456 subjects were enrolled. The prevalence of colonic diverticulosis and adenoma was 2.4% and 13.2%, respectively. With regard to distribution of diverticula, most (365/424, 86.1%) were right-sided. Multiple logistic regression analysis suggested that age and male gender were independent risk factors for adenoma and advanced adenoma. There was no relationship between diverticulosis or location of diverticulosis and presence of adenoma and advanced adenoma adjusting by age and gender. In a stratified analysis according to age and gender, similar results were also noted.

CONCLUSION

There was no statistical relationship between diverticulosis and the risk of adenoma and advanced adenoma. Our results may not be generalized to the Western population due to the fact that left-sided diverticular cases were very small in our study.

New device to implement the adenoma detection rate

It is well-known that colonoscopy is considered the gold standard for colon cancer prevention. Although performed by experienced endoscopists, the matter remains of polyps missed during this examination. The reasons may include the size, shape and location of the lesions. Many colorectal cancer screening programs have been proposed to increase the adenoma detection rate. The substantial difference between these methods is whether the improvement in vision, particularly the detection of irregularities of the mucosa, is inside the endoscope electronic components (magnification, wide-angle vision, narrow band imaging, flexible spectral imaging colour enhancement, i-Scan) or outside the same, by the use of specific caps (EndoCuff, EndoVision, EndoRings). Endocuff is a plastic device mounted at the end of the scope with a constant vision field of the entire colon. The aim of this study is to explore the potential clinical and technical benefits of Endocuff.

Massive perineal defect after radio-chemotherapy

Herein, we present a rare complication of radio-chemotherapy. A young man presented with loss of urine from the posterior perineum that showed a massive disappearance. He underwent Hartmann procedure for rectal neoplasia, afterwards treated with intensity-modulated radiotherapy (IMRT) (until 67 Gy) and chemotherapy with FOLFOX protocol (Leucoverin calcium, Fluorouracil, Oxaliplatin).

Desmoplasia influenced recurrence of disease and mortality in stage III colorectal cancer within five years after surgery and adjuvant therapy

BACKGROUND/AIMS

In patients with colon cancer who undergo resection for potential cure, 40-60% have advanced locoregional disease (stage III). Those who are suitable for adjuvant treatment had a definite disease-free-survival benefit. The aim of the present study was to demonstrate whether the presence of desmoplasia influenced the mortality rate of stage III colorectal cancer (CRC) within 5 years from the surgery and adjuvant therapy.

PATIENTS AND METHODS

Sixty-five patients with stage III CRC underwent resection and adjuvant therapy. Qualitative categorization of desmoplasia was obtained using Ueno's stromal CRC classification. Desmoplasia was related to mortality using Spearman correlation and stratified with other histological variables (inflammation, grading) that concurred to the major determinant of malignancy (venous invasion and lymph nodes) using the Chi-square test.

RESULT

The 5-year survival rate was 65% and the relapse rate was 37%. The mortality rate in patients with immature desmoplasia was 86%, 27% in intermediate desmoplasia, and 0% in mature desmoplasia (Spearman correlation coefficient: -0.572,P= 0.05).

CONCLUSION

Immature desmoplasia appears to be associated with disease recurrence and mortality in stage III CRC patients.

High-Density Lipoprotein Cholesterol, Blood Urea Nitrogen, and Serum Creatinine Can Predict Severe Acute Pancreatitis

BACKGROUND AND AIMS

Early prediction of disease severity of acute pancreatitis (AP) would be helpful for triaging patients to the appropriate level of care and intervention. The aim of the study was to develop a model able to predict Severe Acute Pancreatitis (SAP).

METHODS

A total of 647 patients with AP were enrolled. The demographic data, hematocrit, High-Density Lipoprotein Cholesterol (HDL-C) determinant at time of admission, Blood Urea Nitrogen (BUN), and serum creatinine (Scr) determinant at time of admission and 24 hrs after hospitalization were collected and analyzed statistically.

RESULTS

Multivariate logistic regression indicated that HDL-C at admission and BUN and Scr at 24 hours (hrs) were independently associated with SAP. A logistic regression function (LR model) was developed to predict SAP as follows: -2.25-0.06 HDL-C (mg/dl) at admission + 0.06 BUN (mg/dl) at 24 hours + 0.66 Scr (mg/dl) at 24 hours. The optimism-corrected c-index for LR model was 0.832 after bootstrap validation. The area under the receiver operating characteristic curve for LR model for the prediction of SAP was 0.84.

CONCLUSIONS

The LR model consists of HDL-C at admission and BUN and Scr at 24 hours, representing an additional tool to stratify patients at risk of SAP.

Serum Albumin Is Independently Associated with Persistent Organ Failure in Acute Pancreatitis

BACKGROUND AND AIMS

To investigate the association between serum albumin levels within 24 hrs of patient admission and the development of persistent organ failure in acute pancreatitis.

METHODS

A total of 700 patients with acute pancreatitis were enrolled. Multivariate logistic regression and subgroup analysis determined whether decreased albumin was independently associated with persistent organ failure and mortality. The diagnostic performance of serum albumin was evaluated by the area under Receiver Operating Characteristic (ROC) curves.

RESULTS

As levels of serum albumin decrease, the risk of persistent organ failure significantly increases (P_trend < 0.001). The incidence of organ failure was 3.5%, 10.6%, and 41.6% in patients with normal albumin and mild and severe hypoalbuminaemia, respectively. Decreased albumin levels were also proportionally associated with prolonged hospital stay (P_trend < 0.001) and the risk of death (P_trend < 0.001). Multivariate analysis suggested that biliary etiology, chronic concomitant diseases, hematocrit, blood urea nitrogen, and the serum albumin level were independently associated with persistent organ failure. Blood urea nitrogen and the serum albumin level were also independently associated with mortality. The area under ROC curves of albumin for predicting organ failure and mortality were 0.78 and 0.87, respectively.

CONCLUSION

A low serum albumin is independently associated with an increased risk of developing of persistent organ failure and death in acute pancreatitis. It may also be useful for the prediction of the severity of acute pancreatitis.

The management of the patient with non-variceal upper gastrointestinal bleeding: from evidence to clinical practice

A multidisciplinary group of 7 experts developed this update and expansion of the recommendations on the management of acute non-variceal upper gastrointestinal bleeding (NVUGIH) from guidelines published from 2013. The Appraisal of Guidelines for Research and Evaluation (AGREE) process and independent ethics protocols were used. Sources of data included original and published systematic reviews. Recommendations emphasize early risk stratification, by using validated prognostic scales, and early endoscopy (within 24 hours). Endoscopic hemostasis remains indicated for high-risk lesions, whereas data support attempts to dislodge clots with hemostatic, pharmacologic, or combination treatment of the underlying stigmata. Clips or thermo-coagulation, alone or with epinephrine injection, are effective methods. Second-look endoscopy may be useful in selected high-risk patients, but is not routinely recommended. Intravenous high-dose PPI therapy after successful endoscopic hemostasis decreases both rebleeding and mortality in patients with high-risk stigmata. Although selected patients can be discharged promptly after endoscopy, high-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis. For patients with UGIH who require a nonsteroidal anti-inflammatory drug, a PPI is preferred to reduce the rebleeding. Patients with NVUGIH needing secondary cardiovascular prophylaxis should start receiving acetylsalicylic acid (ASA) again as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days).

Prevalence of Colonic Diverticulosis in Patients Affected by Ulcerative Colitis: A Prospective Study

BACKGROUND

Diverticulosis of the colon is an acquired condition that results from herniation of the mucosa and submucosa through defects in the muscular layer. The true prevalence of colonic diverticulosis is difficult to measure because most individuals are asymptomatic. In particularly, in literature, there are few studies about the prevalence of colonic diverticulosis in patients affected by ulcerative colitis (UC).

GOALS

To investigate the prevalence of colonic diverticulosis in UC and in adult patients referred in a single center.

STUDY

Consecutive patients, referred to our institution to undergo a colonoscopy for colorectal cancer screening and/or for UC assessment, between January 1, 2014 and December 31, 2014, were studied.

RESULTS

Six hundred five consecutive patients were studied: 438 (72.4%) due to colorectal cancer screening (group A) and 167 (27.6%) for UC assessment (group B). Prevalence of colonic diverticulosis was higher in group A than group B (27.8% vs. 10.8%, P<0.0001). Female gender in patients with colonic diverticulosis was higher in group A than group B (55.7% vs. 22.2%, P=0.0106). Sigma and left colon was mainly involved in group A than group B (97.6% vs. 66.7%, P=0.0001), whereas in group B the right colon was mainly involved in group B versus group A (22.2% vs. 0.8%, P=0.0009).

CONCLUSIONS

Prevalence of colonic diverticulosis was significantly lower in patients with UC than in control group. UC may, therefore, be a protective factor for colonic diverticulosis occurrence.

Severe gastrointestinal bleeding due to erlotinib and celecoxib therapy: additional effect?

Non-small cell lung cancer (NSCLC) is the leading cause of cancer related dead worldwide and account for over 85% of all lung cancers. Furthermore, the majority of patients with NSCLC present with advanced, metastatic disease at the time of diagnosis. For most patients with non-small cell lung cancer, current treatments do not cure the cancer. Therefore, there is a great need for development of more effective therapies. The epidermal growth factor receptor tyrosine kinase inhibitors (EGFR TKIs) like erlotinib and gefitinib have been recognized as an important molecular target in cancer therapy and they are approved for the treatment of refractory advanced NSCLC patients. EGFR TKIs are generally well tolerated. The two most common toxicities include dermatologic and gastrointestinal side effects. Cases of gastrointestinal perforation, some of which were fatal, have also been reported in patients receiving erlotinib. Those at increased risk include those taking concomitant anti-angiogenic agents, corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), and/or taxane-based chemotherapy, or who have prior history of peptic ulceration or diverticular disease.

Prevalence of colonic diverticulosis in mainland China from 2004 to 2014

The aim of this study was to determine the prevalence of colonic diverticulosis in mainland China. Sixty two thousand and thirty-four colonoscopies performed between Jan 2004 and Dec 2014 were reviewed retrospectively. The overall diverticulosis prevalence was 1.97% and out of this, 85.3% was right-sided. Prevalence does not change, significantly, on trends between the period 2004-2014. The peak of prevalence of diverticulosis was compared between the female group aged >70 years to the male one of 41-50 years. The other peak, otherwise, was compared between the group of 51-60 years with the right-sided diverticulosis to the one of >70 years with left-sided disease. Multivariate analysis suggested that the male gender could be a risk factor for diverticulosis in the group aged ≤70 years, but not for the older patients. In addition, among men was registered an increased risk factor for right-sided diverticulosis and, at the same time, a protective one for left-sided localization. In conclusion, the prevalence of colonic diverticulosis is very low in mainland China and it does not change significantly on trends over the time. Both the prevalence of this condition and its distribution changes according to the age and the genders. These findings may lead the researchers to investigate the mechanisms causing this kind of disease and its distribution in regard of the age and the gender.

A randomized trial comparing 4.8 vs. 2.4 g/day of oral mesalazine for maintenance of remission in ulcerative colitis

BACKGROUND

Mesalazine is used as maintenance therapy in ulcerative colitis but the optimal dosage is still controversial.

AIM

To compare the remission-maintenance efficacy and tolerability of two daily doses of oral mesalazine (4.8 g and 2.4 g) in patients with ulcerative colitis with frequent relapses in a randomized controlled trial.

METHODS

112 ulcerative colitis patients in remission were enrolled and randomly allocated to treatment for 1 year with oral mesalazine at a daily dose of 4.8 g (n=56, Group A) or 2.4 g (n=56, Group B).

RESULTS

At the end of the 12 months, intention to treat analysis revealed persistent remission in 42 (75%) in Group A and 36 (64.2%) in Group B (p=0.3). The higher daily dose (4.8 g) proved to be significantly more effective for maintaining remission in patients under 40 years of age (90.5% Group A vs. 50% Group B; Fisher's exact test, p=0.0095) and in those with extensive disease (90.9% Group A vs. 46.7% Group B; Fisher's exact test, p=0.0064).

CONCLUSIONS

In ulcerative colitis patients younger than 40 years and/or with extensive disease, a daily dose of 4.8 g oral mesalazine results in increased rates and duration of remission compared to 2.4 g.

Efficacy of mesalazine or beclomethasone dipropionate enema or their combination in patients with distal active ulcerative colitis

OBJECTIVE

Mesalazine or Beclomethasone dipropionate (BDP) enema have been shown effective in treatment of distal active ulcerative colitis (UC). This study was aimed to determine whether the combination of topical mesalazine and BDP is superior to topical mesalazine or BDP used alone in patients with distal active UC. PATIENTS AND METHODS: One-hundred and twenty patients with clinical, endoscopic and histological diagnosis of distal active UC were randomly assigned to a regimen with mesalazine tablets 2.4 g/day associated to either mesalazine enema 4 g/day (group A, n=40), BDP 3 mg/60 ml every day (group B, n=40) or the combination treatment with the two compounds in a single administration (group C, n=40) for eight weeks. After four weeks of treatment all patients underwent clinical controls but only 109 patients returned back for clinical, endoscopic and histological controls at the end of the treatment period.

RESULTS

After eight weeks, complete remission rates were of 52%, 47% and 65% respectively, in group A, B and C. From baseline to 4 and 8 weeks the CAI score decreased significantly in all the three groups (p < 0.0001).

CONCLUSIONS

All the three combinations achieved equivalent results in terms of symptoms in inducing symptoms relief and mucosa healing in distally active UC.