Prevalence and Natural History of Segmental Colitis Associated With Diverticulosis

INTRODUCTION

We assessed the prevalence and clinical outcomes of segmental colitis associated with diverticulosis (SCAD) in patients with newly diagnosed diverticulosis.

METHODS

A 3-year international, multicenter, prospective cohort study was conducted involving 2,215 patients.

RESULTS

SCAD diagnosis was posed in 44 patients (30 male patients; median age: 64.5 years; prevalence of 1.99%, 95% confidence interval, 1.45%-2.66%). Patients with SCAD types D and B showed worse symptoms, higher fecal calprotectin values, needed more steroids, and reached less likely complete remission.

DISCUSSION

Although SCAD generally had a benign outcome, types B and D were associated with more severe symptoms and worse clinical course.

Diverticular Inflammation and Complication Assessment classification, CODA score and fecal calprotectin in clinical assessment of patients with diverticular disease: A decision curve analysis

BACKGROUND AND AIMS

The Diverticular Inflammation and Complication Assessment (DICA) classification and the Combined Overview on Diverticular Assessment (CODA) were found to be effective in predicting the outcomes of Diverticular Disease (DD). We ascertain whether fecal calprotectin (FC) can further aid in improving risk stratification.

METHODS

A three-year international, multicentre, prospective cohort study was conducted involving 43 Gastroenterology and Endoscopy centres. Survival methods for censored observations were used to estimate the risk of acute diverticulitis (AD) in newly diagnosed DD patients according to basal FC, DICA, and CODA. The net benefit of management strategies based on DICA, CODA and FC in addition to CODA was assessed with decision curve analysis, which incorporates the harms and benefits of using a prognostic model for clinical decisions.

RESULTS

At the first diagnosis of diverticulosis/DD, 871 participants underwent FC measurement. FC was associated with the risk of AD at 3 years (HR per each base 10 logarithm increase: 3.29; 95% confidence interval, 2.13-5.10) and showed moderate discrimination (c-statistic: 0.685; 0.614-0.756). DICA and CODA were more accurate predictors of AD than FC. However, FC showed high discrimination capacity to predict AD at 3 months, which was not maintained at longer follow-up times. The decision curve analysis comparing the combination of FC and CODA with CODA alone did not clearly indicate a larger net benefit of one strategy over the other.

CONCLUSIONS

FC measurement could be used as a complementary tool to assess the immediate risk of AD. In all other cases, treatment strategies based on the CODA score alone should be recommended.

A comparison of different symptomatic reflux esophagitis treatments: A real-world study

BACKGROUND

Proton pump inhibitors (PPIs) are currently the reference drugs for gastroesophageal reflux disease (GERD), but symptoms often recur after their withdrawal. Moreover, whether prokinetics or barrier drugs used alongside PPIs are more effective remains under debate.

OBJECTIVES

The aim of the study was to assess the efficacy of different therapeutic approaches to GERD treatment.

MATERIAL AND METHODS

We enrolled 211 grade A reflux esophagitis patients who consented to participate in this non-randomized, open-label trial. The study consisted of 6 sequentially administered medical treatments for GERD, lasting 2 months, with a 3-week washout period between each drug schedule: Group A: PPI (esomeprazole 40 mg/day before breakfast); Group B: mucosal protective drugs (a combination of hyaluronic acid, chondroitin sulfate and poloxamer 407, or a combination of hyaluronic acid, chondroitin sulfate and aluminum, 3 times daily after a meal); Group C: prokinetics (levosulpiride 25 mg or domperidone 10 mg, 3 times daily before a meal); Group D: barrier drug (alginate 3 times daily after a meal); Group E: PPI (esomeprazole 40 mg/day before breakfast) and mucosal protective drugs (a combination of hyaluronic acid, chondroitin sulfate and poloxamer 407, or a combination of hyaluronic acid, chondroitin sulfate and aluminum, before sleep); Group F: PPI (esomeprazole 40 mg/day before breakfast) and prokinetics (levosulpiride 25 mg or domperidone 10 mg before lunch and dinner). Symptoms were evaluated using the visual analogue scale (VAS) and global symptomatic score (GSS), as follows: heartburn: 0-3; retrosternal chest pain: 0-3; regurgitation: 0-3.

RESULTS

All but 2 treatments (groups C and D) significantly improved VAS and GSS, with group E showing the most significant GSS improvement. Group C had the highest number of dropouts due to treatment failure and reported more side effects.

CONCLUSION

Using PPIs and mucosal protective drugs resulted in significant symptom alleviation. However, the administration of prokinetics caused higher dropouts due to treatment failure.

PPIs and gastric cancer: any causal relationship?

Hydrochloric acid is crucial in gastric physiology. In 1978 cimetidine, the first H2 antagonist of histamine receptors on the gastric parietal cell was introduced into therapy, inducing acid. Lasting the years, several studies focused on the potential relationship between inducing hypo-achlorhydria and risk of developing gastric cancer. In 1988 omeprazole, the first proton pump inhibitor, entered therapy. In 1996, Kuipers underlined the danger of progression of chronic atrophic gastritis in subjects taking PPIs. In 2018, one paper from Korea and an another on from Sweden suggested a possible relationship between long-term PPI therapy and the development of gastric cancer. Over the years, several articles, meta-analyzes and population based  focused on relationship between long-term of PPI use and the onset of gastric cancer, with conflicting results. As reported, the presence of bias in the collection of cases, in particular concerning the evaluation of the H.p. status and presence of atrophic gastritis and intestinal metaplasia in subjects treated with PPI, can lead to noticeable errors in the results and conclusions, as demonstrated in the literature by exhaustive methodological studies of pharmacoepidemiology. A possible bias in the collection of case histories is due to the fact that PPIs are often administered to dyspeptic patients, among which there are patients already carriers of gastric neoplasia: the so-called inverse causality.  Literature data, amended by methodological bias (sampling errors, lack of comparative assessment of Hp status and atrophic gastritis) NOT support a causal relationship between long-term PPIs therapy and the onset of gastric cancer.

Appropriateness of Proton Pump Inhibitor Prescription Evaluated by Using Serological Markers

Inappropriate prescription of proton pump inhibitors (PPI) has been widely reported, often lacking initial exclusion of Helicobacter pylori (HP) infection and evaluation of gastric functional status. The aim of this study was to evaluate the utility of gastric functional tests to define the acid output, as well as HP status, in order to better direct PPI therapy prescription. Dyspeptic patients without alarm symptoms from a primary care population were evaluated. For each patient, serum Pepsinogen I (PGI) and II (PGII), gastrin 17 (G17) and anti-HP IgG antibodies (Biohit, Oyj, Finland) were determined. For each subject, data were collected regarding symptoms, past medical history of HP infection, and PPI use. Therapeutic response to PPIs was determined according to PGI and G17 values, where G17 > 7 in the presence of elevated PGI and absence of chronic atrophic gastritis (CAG) was considered an adequate response. Among 2583 dyspeptic patients, 1015/2583 (39.3%) were on PPI therapy for at least 3 months before serum sampling, and were therefore included in the study. Active HP infection and CAG were diagnosed in 206 (20.2%) and 37 (3.6%) patients, respectively. Overall, an adequate therapeutic response to PPIs was observed in 34.9%, reaching 66.7% at the highest dose. However, 41.1% and 20.4% of patients showed low (G17 1-7) or absent (G17 < 1) response to PPI, regardless of the dosage used. According to gastric functional response, most patients currently on PPI maintenance therapy lack a proper indication for continuing this medication, either because acid output is absent (as in CAG) or because gastrin levels fail to rise, indicating absence of gastric acid negative feedback. Lastly, HP eradication is warranted in all patients, and gastric function testing ensures this pathogen is sought for and adequately treated prior to initiating long-term PPI therapy.

Prognostic performance of the 'DICA' endoscopic classification and the 'CODA' score in predicting clinical outcomes of diverticular disease: an international, multicentre, prospective cohort study

OBJECTIVE

To investigate the predictive value of the Diverticular Inflammation and Complication Assessment (DICA) classification and to develop and validate a combined endoscopic-clinical score predicting clinical outcomes of diverticulosis, named Combined Overview on Diverticular Assessment (CODA).

DESIGN

A multicentre, prospective, international cohort study.

SETTING

43 gastroenterology and endoscopy centres located in Europe and South America.

PARTICIPANTS

2215 patients (2198 completing the study) at the first diagnosis of diverticulosis/diverticular disease were enrolled. Patients were scored according to DICA classifications.

INTERVENTIONS

A 3-year follow-up was performed.

MAIN OUTCOME MEASURES

To predict the acute diverticulitis and the surgery according to DICA classification. Survival methods for censored observation were used to develop and validate a novel combined endoscopic-clinical score for predicting diverticulitis and surgery (CODA score).

RESULTS

The 3-year cumulative probability of diverticulitis and surgery was of 3.3% (95% CI 2.5% to 4.5%) in DICA 1, 11.6% (95% CI 9.2% to 14.5%) in DICA 2 and 22.0% (95% CI 17.2% to 28.0%) in DICA 3 (p<0.001), and 0.15% (95% CI 0.04% to 0.59%) in DICA 1, 3.0% (95% CI 1.9% to 4.7%) in DICA 2 and 11.0% (95% CI 7.5% to 16.0%) in DICA 3 (p<0.001), respectively. The 3-year cumulative probability of diverticulitis and surgery was ≤4%, and ≤0.7% in CODA A; <10% and <2.5% in CODA B; >10% and >2.5% in CODA C, respectively. The CODA score showed optimal discrimination capacity in predicting the risk of surgery in the development (c-statistic: 0.829; 95% CI 0.811 to 0.846) and validation cohort (c-statistic: 0.943; 95% CI 0.905 to 0.981).

CONCLUSIONS

DICA classification has a significant role in predicting the risk of diverticulitis and surgery in patients with diverticulosis, which is significantly enhanced by the CODA score.

TRIAL REGISTRATION NUMBER

NCT02758860.

Pepsinogen II in gastritis and Helicobacter pylori infection

BACKGROUND AND AIM

In the gastric mucosa, pepsinogen II (PgII) is produced/secreted by glands in the mucus-secreting antral and cardia compartments, but also by the chief cells and the oxyntic glands. Increasing PgII serum levels are associated with the whole spectrum of gastric inflammatory diseases, including gastritis induced by Helicobacter pylori (H. pylori). This review critically addresses the clinical value of PgII serology for assessing gastric mucosal inflammation, and as a marker of H. pylori status, in both H. pylori-positive patients and after eradication therapy.

RESULTS

A search in PubMed/Scopus records yielded 39 out of 1190 published scientific studies meeting the selection criteria for this study. In the studies considered, PgII levels were significantly associated with non-atrophic gastric inflammatory lesions (p-values: 0.025-0.0001). H. pylori-positive patients had significantly higher PgII levels than H. pylori-negative individuals (p-values: 0.o5-0.0001). While a significant drop in serum PgII levels is consistently reported in H. pylori-eradicated patients (p-values: from 0.05 to 0.0001), inconsistencies in the related negative and positive predictive values significantly lower the clinical reliability of PgII testing by comparison with other available non-invasive tests.

CONCLUSIONS

PgII serology may provide clinically useful information on gastric inflammatory diseases, particularly if they are non-atrophic. PgII serology is inconsistent, however, for the purposes of distinguishing patients whose H. pylori eradication therapy is successful from those who remain infected.

Burning mouth syndrome and Reflux Disease: relationship and clinical implications

BACKGROUND AND AIM

An association between reflux and burning mouth syndrome (BMS) has been proposed. Aims of this study were: 1) to investigate the frequency of BMS in a sample of GERD patients; 2) to measure G17, in a sample of BMS patients; 3) to assess the efficacy of different therapeutical schedules for GERD in BMS patients.

METHODS

We divided the study in 3 main steps. In step one, we analyzed 500 consecutive GERD patients' type and frequency of extraesophageal manifestations including BMS. In step two, we collected 124 consecutive BMS patients' symptoms and  G17.  In step three, we evaluate the efficacy of 3 different drugs on BMS.

RESULTS

In step one, 204 patients complained heartburn; 31 globus pharyngeus; 52 chronic cough; 54 pharyngitis; 31 postnasal drip; 56 burning mouth symptoms; 34 noncardiac chest pain; 17 asthma and 21 sleep apnea. In step two, 29 patients had G17 ≤ 1 pg/L; 64 patients between 1 and 3; and 31 patients ≥ 3. In step three, 49 patients reported slight benefit with PPI, 75 no benefit. 61 patients reported slight benefit with sodium alginate and sodium bicarbonate, 63 no benefit. 23 reported an almost complete remission with HYCHSA, 26 slight benefit, 33 no benefit.

CONCLUSIONS

Prevalence of BMS in GERD patients was similar to that reported for chronic chough and pharyngitis. Low levels of G17 were found in the majority of BMS patients. Finally, we observed a greater benefit from barrier drugs therapy than from PPI therapy in BMS patients. (www.actabiomedica.it).

Recovery of gastric function in patients affected by chronic atrophic gastritis using l-cysteine (Acetium®): one year survey in comparison with a control group

BACKGROUND AND AIM

Chronic Atrophic Gastritis (CAG) is a precancerous condition for gastric cancer (GC) as single risk factor, being a consequence of a previous Helicobacter pylori (Hp) infection or based on autoimmune mechanisms. Achlorhydria plays an important role towards the formation of a class I carcinogen, acetaldehyde, after food intake. L-cysteine has been claimed to be able to bind in a covalent way acetaldehyde when administered at means.

METHODS

In this study we enrolled two CAG groups of patients, one treated whit 300 mg/daily of L-cysteine for one year, the other one untreated. We assessed gastric function lasting the one year follow-up by using non invasive surrogates, i.e. Pepsinogen I (PGI) and gastrin 17 (G17).

RESULTS

In the group of 77 CAG on therapy we found a statistically significative increase in PGI values and a decrease in G17 levels, in comparison with unchanged values in control group.

CONCLUSIONS

L-cysteine seems able to provide a recovery in gastric function when administered in CAG patients and could be proposed as a possible therapy in such patients.

A non-invasive combined strategy to improve the appropriateness of upper gastrointestinal endoscopy

Background and aim Increasing the appropriateness of upper gastrointestinal endoscopy (UGIE) improves the quality of care while containing costs. The aim of this study was to improve the appropriateness of UGIE through a process involving evaluation of prescriptions and the use of a non-invasive alternative. Materials and methods A senior endoscopist evaluated the appropriateness of all outpatient referrals for UGIE and established the proper timing. Referrals were either accepted and programmed, canceled, or substituted by a non-invasive evaluation of gastric function, determining serum levels of gastrin-17 (G17), Pepsinogen I (PGI) and II (PGII), and antibodies against Helicobacter pylori. Results A total of 5102 requests for UGIE examinations were evaluated; 540 (10.4%) were inappropriate and had been prescribed for: gastroesophageal reflux disease (n=307), surveillance with erroneous timing (n=113), dyspepsia (n=66), other indications (n=20), and absence of written indication (n=34). Gastric function was evaluated in 282/540 patients; findings included normal values in 94 patients without proton-pump inhibitor therapy (PPI) and in 48 on PPI, active H pylori infection in 56, previous H pylori infection in 30, GERD in n=50, and atrophic gastritis in n=4. UGIE was performed in the latter 4 cases.  Within 2 years (range 1-22 months) of the initial refusal, 105/504 patients underwent UGIE, with normal endoscopic findings in 71/105 (67.5%), and with no cases of cancer. Conclusions This strategy, based on a strict control of prescriptions, is effective to increase the appropriateness while containing public health costs. The use of gastric function testing improves patient selection for UGIE endoscopy.

Barrett's esophagus: results from an Italian cohort with tight endoscopic surveillance

BACKGROUND AND AIM

Barrett's Esophagus represents a condition that predisposes to the development of esophageal adenocarcinoma. The aim of the present study was to analyze the demographic and clinical characteristics of patients with BE, to establish the presence of risk factors for this condition, and to determine the frequency of dysplastic lesions as well as the evolution towards adenocarcinoma under tight endoscopic control.

METHODS

In this study, we retrospectively collected and analyzed data from a cohort of patients with Barrett's Esophagus identified through endoscopic records of ULSS7 in Northern Italy, who underwent upper esophagogastroduodenoscopy over a 10-year period from July 2008 to December 2020.

RESULTS

A total of 264 patients were identified as having BE and included in the study. Mean follow-up was 6.7 years (range: 3 months-13 years). Demographic characteristics of the study population included mean age of 62.7 years (range 33-90 years), with 62.5% of the study population being aged 60 or older, and a male predominance. Females were significantly older than males (65.7 years, range 37-90 vs 61.9 years, range 33-87, p=0.043, respectively).

CONCLUSIONS

The present study confirms the importance of tight endoscopic control in the management of BE, favoring early detection of BE degeneration towards high-grade dysplasia or adenocarcinoma. In a subset of patients with high-risk factors including male sex, cigarette smoking and heavy alcohol intake, it may be worthwhile to consider endoscopic control over time in order to detect the development of BE.

Abnormal Levels of Pepsinogen I and Gastrin 17 in a case of Ménétrier Disease

BACKGROUND AND AIM

We describe a case of Ménétrier disease, occurred in female patient.

METHODS

We decide to assess by non-invasive way (serum pepsinogens and gastrin 17) the secretory status of gastric mucosa, to confirm previous data of the literature, claiming high levels of both acid secretion and hypergastrinemia in this rare pathological condition.

RESULTS AND CONCLUSION

We find in the subject the highest values of pepsinogen 1 - a marker of acid secretion - never described in the literature to our knowledge: 1940 mcg/L, being normal values ranging from 30-160 mcg/L. Similarly, gastrin 17, produced 90% in the antrum and responsible for negative acid feedback, was very high: 139 pg/L, ranging normal values between 1-10 pg/L. (www.actabiomedica.it).

Low Levels of Gastrin 17 are Related with Endoscopic Findings of Esophagitis and Typical Symptoms of GERD

BACKGROUND AND AIMS

In clinical practice, most patients with symptoms suggestive of gastroesophageal reflux disease (GERD) undergo esophago-gastro-duodenoscopy (EGD), despite its low sensitivity in detecting reflux stigmata. Gastrin 17 (G-17) has been proposed to be related with GERD, due to the negative feedback between acid secretion and this hormone. We assessed the clinical usefulness of fasting G-17 serum determination for a non-invasive diagnosis of GERD in patients with typical symptoms.

METHODS

We consecutively enrolled patients complaining of typical GERD symptoms in two different settings: a single referral center and a primary care setting. Control groups consisted of dyspeptic patients. All subjects underwent assessment of serum levels of G-17 and EGD.

RESULTS

At the academic hospital, 100 GERD patients (n=89 with erosive esophagitis and 11 with Barrett's esophagus) had statistically significant low levels of G-17 as compared with 184 dyspeptic patients (1.7±1.2 pg/L vs 8.9±5.7 pg/L p<0.0001). Similarly, in the primary care setting, 163 GERD patients had statistically significant low levels of G-17 as compared with 132 dyspeptic patients (0.5±0.2 pg/L vs. 4.0±2.6 pg/L, p<0.0001). Moreover, in the primary care setting, no statistically significant differences were found for G-17 levels between patients with erosive and non-erosive reflux pattern (0.4±0.2 vs 0.7±0.3; p=0.08). In primary care, the accuracy of G-17 less than 1 pg/L to diagnose non-invasively GERD was 94.3%.

CONCLUSIONS

Low levels of G-17 were detected in patients with erosive esophagitis and Barrett's esophagus in a referral center and in patients with typical GERD symptoms in a sample of patients from a primary care setting.

The natural history of symptomatic uncomplicated diverticular disease: a long-term follow-up study

Background

Symptomatic uncomplicated diverticular disease (SUDD) affects about 20% of patients who have diverticulosis. However, the natural history of SUDD is not yet completely understood. Our aim was to assess the outcomes of a cohort of SUDD patients during a long-term follow up.

Methods

One hundred eighty-five patients suffering from SUDD were identified from a large electronic database. Symptoms assessed were abdominal pain, bloating, bowel movement/day, each of which was scored using a visual analogic scale (VAS); the symptom score was calculated by considering the value of the worst symptom present during assessment. Another VAS was used to assess patients' quality of life (QoL). Patients were treated at the physician's discretion (with rifaximin, mesalazine, probiotics, spasmolytics) only when symptoms occurred during the follow up. Follow-up visit was performed every year or whenever patients consider it necessary.

Results

During the follow up (156 months, interquartile range 9-171), 47 patients were lost to follow up. Among these, 9 died from causes not related to SUDD. Acute diverticulitis occurred in 14 patients (7.6% of the overall population): 6 patients (3.2% of the overall population) underwent surgery, and 2 patients (1.1% of the overall population) died because of peritonitis. Both the symptom score and the QoL score were substantially unmodified during the study period.

Conclusions

SUDD is an important disease able to affect patients significantly in the long term. Acute diverticulitis may sometimes occur in these patients, often leading to surgery with possible severe complications.

Risk factors for endoscopic severity of diverticular disease of the colon and its outcome: a real-life case-control study

BACKGROUND

Diverticular disease is an increasing global problem.

AIMS

To assess the factors associated with the severity of diverticular disease and its outcome, analyzing a real-life population.

METHODS

A cohort of patients, submitted to colonoscopy from 1 January 2012 to 30 April 2018 was revised. The endoscopic severity of diverticular disease was scored according to the Diverticular Inflammation and Complications Assessment (DICA) classification.

RESULTS

A cohort of 11 086 patients was identified during the study period, 5635 with diverticulitis and 5451 without diverticulosis. Blood hypertension, diabetes and angiotensin receptor blocker users occurred more frequently in the study group, while the prevalence of colorectal cancer (CRC) was significantly lower. Age >70 years, BMI >30 and blood hypertension were factors independently related to the presence of diverticulosis, while diabetes and CRC were significantly associated with the absence of diverticulosis. Female sex, age, smoke, appendectomy, proton-pump inhibitors and acetyl-salicylic acid use were directly related to the severity of diverticular disease, while CRC and colonic polyp occurrence were inversely related to the severity of diverticular disease, significantly. Female sex, age >70 years and smoke were significantly related to the severity of diverticular disease. CRC and colonic polyps were significantly less in DICA 3 patients. DICA 3 patients were more often symptomatic, at higher risk of hospital admission, longer hospital stay and higher mean costs.

CONCLUSIONS

Several factors are associated with the severity of diverticular disease according to the DICA classification. The DICA classification is also predictive of the outcome of the disease in terms of hospital admission, stay and costs.

Functional Dyspesia

Dyspepsia is a functional GI disorder consisting in a wide range of symptoms. The main diagnostic challenge has been whether to perform an EGD or an abdominal US in order not to miss organic lesions, but to avoid unnecessary and sometimes invasive tests. Pepsinogen serology has been proposed as an useful non-invasive test to explore the status of the gastric mucosa, suggesting this strategy as an adequate approach in management of dyspepsia. In a primary care setting, 266 dyspeptic patients were investigated to establish the proper diagnosis. The workup included upper GI endoscopy with biopsies, a structured questionnaire including type and severity of symptoms, serological determination of serum pepsinogens, gastrin 17 and IgG against Hp. Inclusion criteria were dyspeptic symptoms (epigastric pain, nausea and/or vomiting, post prandial fullness, early satiation) lasting more than 1 year and the association between symptoms and food ingestion.. Helicobacter pylori infection was present in 114 subjects, characterized by high levels of pepsinogen II and IgG against Hp. Twenty subjects were classified according with the diagnosis of chronic body atrophic gastritis. Nausea and post prandial fullness were the most frequent symptoms (48% and 41%, respectively) in the studied population, followed by epigastric pain and early satiation (37% and 26% respectively). A diagnosis of normality by serological diagnosis was found in half of patients experiencing epigastric pain and in about 60% of subjects with the three other symptoms (nausea, post prandial fullness, and early satiation). In conclusion, this experience confirms the clinical usefulness of serology in dyspepsia, contributing to correctly diagnosing CAG and H.p. infection in such patients and providing a good correlation with the clinical picture.

Inflammatory bowel disease (IBD) position statement of the Italian Society of Colorectal Surgery (SICCR): general principles of IBD management

The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of inflammatory bowel disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the general principles of surgical treatment of inflammatory bowel disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.

Prognostic value of the Diverticular Inflammation and Complication Assessment (DICA) classification

Key messages

DICA classification was able to discriminate, based on endoscopic records, the patients that could develop complications for Diverticular Disease. DICA classification is a valid parameter to predict the outcome of the disease, with great impact on public health improving the effectiveness of treatment.

Vedolizumab is effective and safe in real-life treatment of inflammatory bowel diseases outpatients: A multicenter, observational study in primary inflammatory bowel disease centers

BACKGROUND

Italian data currently available in managing ulcerative colitis (UC) and Crohn's disease (CD) patients with vedolizumab (VDZ) are coming just from secondary and tertiary centers. The present study aimed to assess the real-life efficacy and safety of VDZ to achieve remission in inflammatory bowel diseases (IBD) outpatients in primary gastroenterology centers.

METHODS

Clinical activity was scored according to the Mayo score in UC and to the Harvey-Bradshaw Index (HBI) in CD. The primary endpoints were the achievement of clinical remission and safety. Secondary endpoints were clinical response to treatment, achievement of mucosal healing (MH), and steroid discontinuation.

RESULTS

One hundred and thirty-six pts. were enrolled (91 UC and 45 CD pts). During an 18-month median follow-up, clinical remission was present in 63 (46.3%) pts.: in particular, it occurred in 48 (52.7%) patients in UC group and in 15 (33.3%) patients in CD group (p = 0.003). more in UC group. Fecal calprotectin ≥400 μg/g and presence of comorbidities were factors significantly related to the failure of remission in UC and CD, respectively. Ten (7.3%) cases of adverse events were recorded (2 required suspension of treatment). Clinical response was present in 105 (72.2%) pts.: 71 (78.0%) in UC and 34 (75.5%) in CD group. MH occurred in 47 (62.7%) UC and in 9 (50.0%) CD patients. Steroids discontinuation occurred in 92 (67.6%) pts.; 61 (67.0%) UC and 31 (68.9%) CD pts.

CONCLUSION

VDZ is effective and safe in IBD outpatients, especially in UC patients.

Infliximab biosimilar CT-P13 is effective and safe in treating inflammatory bowel diseases: a real-life multicenter, observational study in Italian primary inflammatory bowel disease centers

Background

The purpose of this study was to assess the efficacy and safety of biosimilar infliximab (IFX) CT-P13 in treating outpatients with inflammatory bowel disease (IBD) in Italian primary gastroenterology centers.

Methods

Consecutive IBD outpatients who completed the induction treatment were evaluated retrospectively. Clinical activity was scored according to the Mayo score for ulcerative colitis (UC) and to the Harvey-Bradshaw Index (HBI) for Crohn’s disease (CD). The primary endpoint was the achievement of clinical remission (Mayo score ≤2 in UC and HBI ≤5 in CD). Secondary endpoints were clinical response to treatment, achievement of mucosal healing, and safety.

Results

One hundred forty-one patients (96 UC and 45 CD) were enrolled. Previous treatment with anti-tumor necrosis factor (TNF)α had been provided to 26% of UC patients and 28.9% of CD patients. Remission was achieved in 57.3% UC patients and in 75.6% CD patients during a median (interquartile range) follow up of 24 (6-24) months. Clinical response and mucosal healing were achieved in 87.5% and 75.0% of UC patients and in 84.4% and 84.2% of CD patients, respectively. By both univariate and multivariate analysis, age >40 years, presence of comorbidities, and naivety to anti-TNFα were significantly related to remission. Only one (0.7%) adverse event was reported in the CD group. Surgery was performed in 2.1% of UC patients and 6.7% of CD patients. Switching from IFX originator to biosimilar did not influence the maintenance of the clinical remission.

Conclusion

This study confirmed the long-term efficacy and safety of CT-P13 therapy in IBD, in both naïve patients and those switching from IFX originator.

Long-term efficacy of rifaximin to manage the symptomatic uncomplicated diverticular disease of the colon

Although rifaximin is currently advised in managing symptomatic uncomplicated diverticular disease (SUDD) of the colon, no long-term data are available. This retrospective study assessed the outcome of a large cohort of patients with SUDD, treated with rifaximin, during an 8-year follow-up. The study group (group A) included 346 patients with SUDD (median age 64 years, IQR 58-69, 62.4% females), treated with rifaximin 800 mg/d for 7 days every month. The control group (group B) included 470 patients with SUDD (median age 65 years, IQR 59-74 years, 60.8% females), taking any other treatment on demand. Two symptoms (left lower abdominal pain and bloating) were assessed by a visual analog scale (VAS), graded from 0=no symptom to 10=the most severe symptom. Daily bowel movements were also reported. Median (IQR) VAS score for pain was 6 (5-7) in group A and 6 (6-7) in group B at baseline (p=0.109); at 8-year follow-up it was 3 (3-4) and 6 (5-7), respectively (p<0.000). Both bloating and daily bowel movements were significantly reduced in group A. Acute diverticulitis occurred in 9 (2.6%) patients in group A and in 21 (4.5%) patients in group B (p=0.155). Surgery occurred in 4 (1.2%) patients in group A and 9 (1.9%) in group B (p=0.432). Disease-related mortality occurred in no patient in group A and 2 (0.4%) patients in group B (p=0.239). No side effects were recorded during the entire study period. Rifaximin is effective to relieve symptoms and reduce the risk of disease-related complications in patients with SUDD.

Non-invasive method for the assessment of gastric acid secretion

Methods for the measure of gastric acid secretion include invasive and non-invasive tests. The gold-standard to measure the acid output is the collection of gastric after in basal condition (Basal Acid Output, B.A.O.) and after an i.m. injection of pentagastrin (Maximal Acid Output, M.A.O.). However, direct measurement of gastric acid production is out of order in clinical practice, but many GI symptoms are claimed to be related with acid disorders and empirically cured. Hypochlorhydria is associated with precancerous conditions such as chronic atrophic gastritis (CAG). Acid measurement with non-invasive methods (pepsinogens) is supported by international guidelines. (www.actabiomedica.it)

Epidemiology and risk factors of pancreatic cancer

The most frequent pancreatic cancer is pancreatic adenocarcinoma. It has high and early locally and distant invasiveness; this is the reason why it often shows little sign or symptoms in early stage and poor prognosis after the diagnosis, frequently in advanced stage. Although it is possible to detect this tumor in early stage because of its neoplastic precursor (PanINs). Epidemiological data shows that pancreatic cancer is not very common but obvious it is one of the most neoplastic death-cause in the world. The trend of incidence is quite increasing through years, proportionally to the increase of risk factors. About risk factors, it is not easy to detect in all the cases but it is known the role of some of that: there are hereditary risk factors, such as genetic pattern like HBOC, HNPCC, FAP, PJS, FAMMM, HP and CF and environmental ones (modifiable) such as smoke, alcohol consumption, chronic pancreatitis, obesity and diabetes mellitus. This narrative review aims to analyze the epidemiological data of pancreatic cancer and associated risk factors. (www.actabiomedica.it)

Clinical manifestations of chronic atrophic gastritis

Although the actual prevalence of chronic atrophic gastritis is unknown and it is probable that this entity goes largely underdiagnosed, patients in whom diagnosis is established usually present advanced stages of disease. Destruction of parietal cells, either autoimmune-driven or as a consequence of Helicobacter pylori infection, determines reduction or abolition of acid secretion. Hypo/achloridia causes an increase in serum gastrin levels, with an increased risk of the development of neuroendocrine tumors. Microcytic, hypochromic anemia frequently precedes the development of megaloblastic, vitamin B12-associated anemia. Moreover, vitamin B12 deficiency,may cause elevation of homocysteine, with an increase in the cardiovascular risk, and may be associated with neurological manifestations, mainly characterized by spinal cord demyelination and atrophy, with ensuing sensory-motor abnormalities. Gastrointestinal manifestations seem to be associated with non-acid reflux and tend to be non-specific.

Autoimmune diseases in autoimmune atrophic gastritis

Autoimmune diseases, characterized by an alteration of the immune system which results in a loss of tolerance to self antigens often coexist in the same patient. Autoimmune atrophic gastritis, characterized by the development of antibodies agains parietal cells and against intrinsic factor, leads to mucosal destruction that affects primarily the corpus and fundus of the stomach. Autoimmune atrophic gastritis is frequently found in association with thyroid disease, including Hashimoto's thyroiditis, and with type 1 diabetes mellitus, Other autoimmune conditions that have been described in association with autoimmune atrophic gastritis are Addison's disease, chronic spontaneous urticaria, myasthenia gravis, vitiligo, and perioral cutaneous autoimmune conditions, especially erosive oral lichen planus. Interestingly, however, celiac disease, another frequent autoimmune condition, seems to play a protective role for autoimmune atrophic gastritis. The elevated prevalence of autoimmune disease clustering should prompt the clinicial to exclude concomitant autoimmune conditions upon diagnosis of any autoimmune disease.

Effectiveness and safety of adalimumab to treat outpatient ulcerative colitis: A real-life multicenter, observational study in primary inflammatory bowel disease centers

Adalimumab (ADA) was approved in Italy for the treatment of ulcerative colitis (UC) unresponsive to standard treatments in 2014, but no data from real life are currently available. The aim of the present study was to assess the real-life efficacy and safety of ADA in managing UC outpatients in some Italian primary inflammatory bowel disease (IBD) centers after approval of ADA reimbursement.Consecutive UC outpatients with at least 3-month follow-up were retrospectively evaluated. The primary end point was the induction and maintenance of remission in UC, defined as Mayo score ≤2.One hundred seven patients were included. At 3-month follow-up, obtained in 102 (95.3%) patients, 56 (54.9%) patients achieved a clinical remission. At univariate analysis, both Mayo partial score >7 and Mayo subscore for endoscopy = 3 at entry showed to be significantly associated with the lack of remission induction.During a median (95% confidence interval [CI]) follow-up of 18 (12-24) months, 56.6% of patients were under clinical remission; clinical response was achieved in 89.2% of cases. Mucosal healing was achieved in 66 (76.7%) patients, and colectomy occurred in 3 (2.8%) patients. Both C-reactive protein and fecal calprotectin values significantly decreased during follow-up. Steroids discontinuation occurred in 67 (66.7%) patients, and ADA dose escalation was adopted in 9 (16.1%) patients under remission. No factor was significantly related to the maintenance of clinical remission.This first Italian experience found ADA safe and effective to induce and maintain remission in real-life UC outpatients.

Formation of stromatolite lamina at the interface of oxygenic-anoxygenic photosynthesis

In modern stromatolites, mineralization results from a complex interplay between microbial metabolisms, the organic matrix, and environmental parameters. Here, we combined biogeochemical, mineralogical, and microscopic analyses with measurements of metabolic activity to characterize the mineralization processes and products in an emergent (<18 months) hypersaline microbial mat. While the nucleation of Mg silicates is ubiquitous in the mat, the initial formation of a Ca-Mg carbonate lamina depends on (i) the creation of a high-pH interface combined with a major change in properties of the exopolymeric substances at the interface of the oxygenic and anoxygenic photoautotrophic layers and (ii) the synergy between two major players of sulfur cycle, purple sulfur bacteria, and sulfate-reducing bacteria. The repetition of this process over time combined with upward growth of the mat is a possible pathway leading to the formation of a stromatolite.

Effectiveness and Safety of Pylera® in Patients Infected by Helicobacter Pylori: A Multicenter, Retrospective, Real Life Study

BACKGROUND

Our aims were to assess the real life effectiveness and safety of the new bismuth-containing quadruple therapy in a large population of patients infected by Helicobacter pylori.

METHODS

Consecutive dyspeptic H. pylori-positive patients were enrolled, both naïve for treatment and already unsuccessfully treated. Patients were treated with Pylera® 3 capsules 4 times/daily plus omeprazole 20 mg or esomeprazole 40 mg 2 times/daily for 10 days. Eradication was confirmed using a urea-breath test (at least 30 days after the end of the treatment). Efficacy and safety were assessed.

RESULTS

A total of 349 patients were treated. H. pylori eradication was achieved in 316 (90.5%, 95% CIs 80.8-1.0) patients in the intention-to-treat population, and in 93.5% (95% CIs 83.5-1.0) in the per-protocol population. No difference in the eradication rate was found between naïve and previously treated patients (91.3 vs. 90.0%, p = 0.901). Adverse events occurred in 55 patients (15.8%, 95% CIs 11.9-20.1). Five patients discontinued treatment: 2 patients suffered from severe abdominal pain, one patient from headache, one patient from diarrhea, and one patient from diffuse urticarial rush.

CONCLUSIONS

Pylera® achieved a remarkable eradication rate in real life both as first treatment and as a rescue therapy, with a good safety profile.

New bismuth-containing quadruple therapy in patients infected with Helicobacter pylori: A first Italian experience in clinical practice

BACKGROUND

Rising antibiotic resistance requires the evaluation of new and effective therapies.

AIMS

To test the efficacy and safety of the new bismuth-containing quadruple therapy in patients infected with Helicobacter pylori.

MATERIAL AND METHODS

Consecutive H. pylori-positive dyspeptic patients were enrolled, either naïve or with previous failure treatment. Patients were treated with Pylera^® (three-in-one capsules containing bismuth subcitrate potassium 140 mg, metronidazole 125 mg, and tetracycline 125 mg) three capsules q.i.d. plus omeprazole 20 mg or esomeprazole 40 mg b.i.d. for 10 days. Eradication was confirmed using an urea breath test (at least 30 days after the end of treatment). Efficacy was assessed by UBT and safety by means of treatment-emergent adverse events.

RESULTS

One hundred and thirty-one patients were included in the study: 42% of patients were naïve, and 58%, with previous failure treatment. H. pylori eradication was achieved in 124 patients (94.7%, 95% confidence intervals (CIs) 89.3-97.8) in ITT population. In the PP population, the percentage was 97.6% (95%, CIs 93.3-99.2). No difference in eradication rate was found either between naïve and previously treated patients (92.7% vs 96.0%, P=.383), or smoking and nonsmoking ones, or in patients taking omeprazole or esomeprazole. Treatment-emergent adverse events occurred in 35 patients (26.7%, 95% CIs 19.9-34.9). They were mild in all cases except in four, who discontinued the study due to diarrhea (three patients) and diffuse urticarial rush (one patient).

CONCLUSIONS

Pylera^® achieved a remarkable eradication rate in clinical practice, irrespective if it was used as first treatment or as a rescue therapy. Treatment-emergent adverse events were uncommon generally mild.

Non-invasive assessment of gastric secretory function in centenarians

Gastric acid secretion is believed to decrease in the aging stomach, but the number of elderly patients on proton pump inhibitor (PPI) therapy is increasing. The aim was to assess gastric function by means of serology (PGI, PGII, G17 and IgG antibodies against <em>Helicobacter pylori</em>) in centenarians. Twenty-five centenarians (2 males, 23 females, mean age 101.3 years, range 100- 106 years) underwent to serological gastric markers assessment by means of Gastropanel^®. Patients with laboratory signs of severe oxyntic gastric atrophy (OGA) underwent gastroscopy with biopsy samples. Twelve patients (48.0%) had serological values according to normal gastric secretion; 3 patients (12%) had serological values according to severe OGA, confirmed by histology; 21 patients (84.0%) had serological values according to <em>H. pylori</em> infection. Acid secretion seems to be preserved in a large part of centenarians. Serological markers may be helpful to identify patients affected by OGA, in whom the administration of PPI is inappropriate.

Preliminary evaluation of the tactile feedback system based on artificial skin and electrotactile stimulation

This research is motivated by the need of integrating cutaneous sensing into a prosthetic device, enabling a bidirectional communication between the amputee and the prosthetic limb. An electronic skin based on piezoelectric polymer sensors transduces mechanical contact into electrical response which is conveyed to the human subject by electrotactile stimulation. Rectangular electrode arrays are placed on each patient's forearm and experiments are conducted on five different subjects to determine how well the orientation, position and direction of single lines are recognized. Overall, subjects discriminate the different touch modalities with acceptable success rates. In particular, the direction is identified at best and longitudinal lines on the patient's skin are recognized with the highest success rates. These preliminary results assess the feasibility of the artificial skin - electrostimulation system for prosthetic applications.

On the role of low-permeability beds in the acquisition of F and SO4 concentrations in a multi-layer aquifer, South-West France

Fluoride (F(-)) commonly threatens groundwater quality. This is the case around the city of Bordeaux (France), where numerous wells tapping the thick and complex Eocene aquifer are contaminated by fluoride, which presents an issue for drinking water supply. The joint analysis of the spatial distribution of fluoride with other species like sulfate suggests that concentrations are mainly related to the occurrence of low-permeability layers containing evaporites or fluorite deposits. In order to identify the origin of the observed concentrations, a radial flow and transport model is implemented at the borehole scale. The hydraulic conductivity of the low-permeability layers and the vertical dispersivity of the aquifer were optimized to match the observed values of sulfate and fluoride concentrations. Interestingly, each of these parameters influences differently the simulated concentrations. This model has been successfully implemented to a neighboring well with the same parameter values, which tests the approach. The major conclusions drawn are: (i) the contamination in fluoride originates from the low-permeability layers, (ii) every low-permeability layer intercepted by the well releases fluoride (iii) Contamination not only originates from pore water of low-permeability layers, but may persist with long-term pumping due to mineral dissolution. As a consequence, fluoride contamination is likely to persist for a long time and the only solution to reduce fluoride concentration in abstracted water is to seal well screens facing low-permeability layers.

Helicobacter pylori infection in older people

Since the discovery of Helicobacter pylori (H. pylori) infection as the major cause of gastroduodenal disorders three decades ago, H. pylori has been the focus of active research and debate in the scientific community. Its linkage to several diseases, such as peptic ulcer disease, gastritis and gastric malignancy is incontestable. In particular, it has been noticed that, as the aged population is increasing worldwide, older people are at increased risk of developing several gastroduodenal diseases and related complications. At the same time, gastric cancer is definitely more frequent in elderly than in adult and young people. In addition, it has been showed that peptic ulcer and related complications occur much more commonly in aged individuals than in young people, resulting in a significantly higher mortality. Although this infection plays a crucial role in gastrointestinal disorders affecting all age groups and in particular older people, only a few studies have been published regarding the latter. This article presents an overview of the epidemiology, diagnosis, clinical manifestations and therapy of H. pylori infection in elderly people.

CHF5074 Reduces Biomarkers of Neuroinflammation in Patients with Mild Cognitive Impairment: A 12-Week, Double-Blind, Placebo-Controlled Study

As neuroinflammation is an early event in the pathogenesis of Alzheimer's disease, new selective anti-inflammatory drugs could lead to promising preventive strategies. We evaluated the safety, tolerability, pharmacokinetics and pharmacodynamics of CHF5074, a new microglial modulator, in a 12-week, double-blind, placebo-controlled, parallel groups, ascending dose study involving 96 MCI patients. Subjects were allocated into three successive study cohorts to receive ascending, titrated doses of CHF5074 (200, 400 or 600 mg/day) or placebo. Vital signs, cardiac safety, neuropsychological performance and safety clinical laboratory parameters were assessed on all subjects. Plasma samples were collected throughout the study for measuring drug concentrations, soluble CD40 ligand (sCD40L) and TNF-α. At the end of treatment, cerebrospinal fluid (CSF) samples were optionally collected after the last dose to measure drug levels, β-amyloid1-42 (Aβ42), tau, phospho-tau181, sCD40L and TNF-α. Ten patients did not complete the study: one in the placebo group (consent withdrawn), two in the 200-mg/day treatment group (consent withdrawn and unable to comply) and seven in the 400-mg/day treatment group (five AEs, one consent withdrawn and one unable to comply). The most frequent treatment-emergent adverse events were diarrhea, dizziness and back pain. There were no clinically significant treatment-related clinical laboratory, vital sign or ECG abnormalities. CHF5074 total body clearance depended by gender, age and glomerular filtration rate. CHF5074 CSF concentrations increased in a dose-dependent manner. At the end of treatment, mean sCD40L and TNF-α levels in CSF were found to be inversely related to the CHF5074 dose (p=0.037 and p=0.001, respectively). Plasma levels of sCD40L in the 600-mg/day group were significantly lower than those measured in the placebo group (p=0.010). No significant differences between treatment groups were found in neuropsychological tests but a positive dose-response trend was found on executive function in APOE4 carriers. This study shows that CHF5074 is well tolerated in MCI patients after a 12-week titrated treatment up to 600 mg/day and dose-dependently affects central nervous system biomarkers of neuroinflammation.

Association of upper gastrointestinal symptoms with functional and clinical characteristics in the elderly

AIM: To evaluate the prevalence of upper gastrointestinal symptoms and their association with clinical and functional characteristics in elderly outpatients.

METHODS: The study involved 3238 outpatients ≥ 60 years consecutively enrolled by 107 general practitioners. Information on social, behavioral and demographic characteristics, function in the activities of daily living (ADL), co-morbidities and drug use were collected by a structured interview. Upper gastrointestinal symptom data were collected by the 15-items upper gastro-intestinal symptom questionnaire for the elderly, a validated diagnostic tool which includes the following five symptom clusters: (1) abdominal pain syndrome; (2) reflux syndrome; (3) indigestion syndrome; (4) bleeding; and (5) non-specific symptoms. Presence and severity of gastrointestinal symptoms were analyzed through a logistic regression model.

RESULTS: 3100 subjects were included in the final analysis. The overall prevalence of upper gastrointestinal symptoms was 43.0%, i.e. cluster (1) 13.9%, (2) 21.9%, (3) 30.2%, (4) 1.2%, and (5) 4.5%. Upper gastrointestinal symptoms were more frequently reported by females (P < 0.0001), with high number of co-morbidities (P < 0.0001), who were taking higher number of drugs (P < 0.0001) and needed assistance in the ADL. Logistic regression analysis demonstrated that female sex (OR = 1.39, 95% CI: 1.17-1.64), disability in the ADL (OR = 1.47, 95% CI: 1.12-1.93), smoking habit (OR = 1.29, 95% CI: 1.00-1.65), and body mass index (OR = 1.06, 95% CI: 1.04-1.08), as well as the presence of upper (OR = 3.01, 95% CI: 2.52-3.60) and lower gastroenterological diseases (OR = 2.25, 95%CI: 1.70-2.97), psychiatric (OR = 1.60, 95% CI: 1.28-2.01) and respiratory diseases (OR = 1.25, 95% CI: 1.01-1.54) were significantly associated with the presence of upper gastrointestinal symptoms.

CONCLUSION: Functional and clinical characteristics are associated with upper gastrointestinal symptoms. A multidimensional comprehensive evaluation may be useful when approaching upper gastrointestinal symptoms in older subjects.

Validation of a Modified-Multidimensional Prognostic Index (m-MPI) including the Mini Nutritional Assessment Short-Form (MNA-SF) for the prediction of one-year mortality in hospitalized elderly patients

BACKGROUND

The mortality prediction represents a key factor in the managing of elderly hospitalized patients. Since in older subjects mortality results from a combination of biological, functional, nutritional, psychological and environmental factors, a Multidimensional Prognostic Index (MPI) that predict short- and long-term mortality based on a standardized comprehensive geriatric assessment (CGA) has recently been developed and validated.

OBJECTIVE

This study compares the accuracy in predicting the mortality of the MPI with a modified version of the MPI (m-MPI) that included the Mini Nutritional Assessment-Short Form (MNA-SF) instead of the standard MNA.

DESIGN

This prospective study with a one-year follow-up included 4088 hospitalized patients aged 65 years and older. A standardized CGA that included information on functional (Activities of Daily Living, ADL and Instrumental-ADL), cognitive (Short Portable Mental Status Questionnaire), risk of pressure sore (Exton-Smith Scale), comorbidities (CIRS Index), medications, living status and nutritional status (MNA and MNA-SF) was used to calculate the MPI using a previously validated algorithm.

RESULTS

Higher MPI values were significantly associated with higher mortality rates with a close agreement between the estimated and the observed mortality both after 1-month (MPI1=2.8% versus m-MPI1=2.8%,p=0.946; MPI2=8.9% versus m-MPI2=9%,p=0.904; MPI3=21.9% versus m-MPI3=21.9,p=0.978) and 1-year of follow-up (MPI1=10.8% versus m-MPI1=10.5%,p=0.686; MPI2=27.3% versus m-MPI2=28%, p=0.495; MPI3=52.8% versus m-MPI3=52.7%,p=0.945). The estimated areas under the receiver operating characteristics (ROC) curves suggested a clinically negligible difference between the two indices.

CONCLUSION

The m-MPI is as sensitive as the MPI in stratifying hospitalized elderly patients into groups at varying risk of short- and long-term mortality, but with fewer items.

Optimal management of peptic ulcer disease in the elderly

Recent data report that the incidence of peptic ulcer is decreasing in the general population; conversely, the rates of gastric and duodenal ulcer hospitalization and mortality remain very high in older patients. Two major factors that might explain this epidemiological feature in the elderly population are the high prevalence of Helicobacter pylori infection and the increasing prescriptions of gastroduodenal damaging drugs, including NSAIDs and/or aspirin (acetylsalicylic acid). The main goals for treating peptic ulcer disease in old age are to reduce recurrence of the disease and to prevent complications, especially bleeding and perforation. The available treatments for peptic ulcer are essentially based on gastric acid suppression with antisecretory drugs and the eradication of H. pylori infection. The aim of this article is to report the available data on clinical efficacy and tolerability of peptic ulcer treatments in elderly patients and provide recommendations for their optimal use in this special population. Proton pump inhibitor (PPI)-based triple therapies for 7 days are highly effective for the cure of H. pylori-positive peptic ulcers as well as for reducing ulcer recurrence. Antisecretory drugs are also the treatment of choice for NSAID- or aspirin-related peptic ulcers and are useful as preventive therapy in chronic users of NSAIDs and low-dose aspirin as antiplatelet therapy. Antisecretory PPI therapy has a favourable tolerability profile in geriatric patients; however, monitoring is suggested in older patients with frequent pulmonary infections, gastrointestinal malabsorption, unexplained chronic diarrhoea, osteoporosis or those taking concomitant cytochrome P450 2C19-metabolized medications. The overall approach to the geriatric patient should include a comprehensive geriatric assessment that ensures multidimensional evaluation of the patient in order to better define the clinical risk of adverse outcomes in the older patient with peptic ulcer and its complications.

A multidimensional approach to the geriatric patient with chronic kidney disease

The prognostic evaluation of elderly patients with chronic kidney disease (CKD) plays a key role in the decision analyses of care processes. It is increasingly evident that the prognosis of older patients with CKD is strongly affected by functional and cognitive status, body composition and nutrition, comorbidity and treatments and other factors that are not directly related to the index disease. The comprehensive geriatric assessment (CGA) is a multidimensional diagnostic process intended to determine an elderly person?s medical, functional and psychosocial capacity and problems, with the objective of developing an overall plan for treatment and follow-up. The potential usefulness of the CGA in evaluating treatment and follow-up of older patients with CKD is unknown. In this paper we reported the efficacy of the Multidimensional Prognostic Index (MPI), calculated from information collected by a standardized CGA, in predicting mortality risk in older patients hospitalized with CKD. The CGA included 6 standardized scales: Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), Short Portable Mental Status Questionnaire (SPMSQ), Mini Nutritional Assessment (MNA), Exton-Smith score (ESS) and Cumulative Index Rating Scale (CIRS), as well as information on medication history and cohabitation, for a total of 63 items. The MPI was calculated from the integrated total scores and expressed as MPI 1 = low risk, MPI 2 = moderate risk and MPI 3 = severe risk of mortality. Higher MPI values were significantly associated with higher 1-year mortality in older patients with CKD. Moreover, MPI showed a greater discriminatory power than organ-specific prognostic indexes such as the estimated glomerular filtration rate. All of these findings support the concept that a multidimensional approach may be appropriate for the evaluation of older patients with CKD, as has been reported for patients with other pathological conditions.

HLA-A*01 is associated with late onset of Alzheimer's disease in Italian patients

In this study, the distribution of HLA-A alleles was analyzed in Italian Alzheimer's Disease (AD)patients. Interaction between HLA alleles, APOE genotypes, age of onset, and gender were also analyzed. The results were compared to those obtained in healthy controls (HC). One hundred-seventy-three AD patients and 258 age-and-sex-matched healthy controls were enrolled in the study. AD patients were classified according to age at the onset of disease using quartiles of the distribution. HLA-A genotyping was performed by PCR-SSP; APOE genotyping was performed by RFLP. A correlation between late disease onset and HLA-A*01 was observed. Thus, HLA-A*01, calculated as number of alleles, was significantly more present in patients with age of onset > 74.0 years than in HC (20% vs 10.5%; p=0.014); the distribution of this allele was skewed also in patients 68.1-74 years of age (16.3%), even if the difference did not reach statistical significance. The relative risk ratio (RRR) of AD onset calculated by a multinomial logistic regression adjusted for sex and presence of APOE-4 confirmed a significant association of HLA-A*01 with AD onset > 74.0 years of age (RRR=2.2; 95%CI: 1.1-4.6; p=0.033). A high RRR (2.04) was also present in patients 68.1-74 years (p=0.064). Lower age of disease onset did not correlate with HLA-A*01. Data herein suggest that the presence of HLA-A*01 results in delayed AD development, even in patients carrying APOE-4. These results could offer new insights into the etiopathogenesis of Alzheimer's disease.