Clinical outcomes of diverticular disease in young adults: results from a tertiary referral center

Introduction

Diverticular disease (DD), commonly associated with the elderly, is becoming more prevalent among younger individuals. This retrospective study aimed to evaluate the differences in the natural history and outcomes between young and old patients with DD.

Methods

Adult patients with DD diagnosed between 2010 and 2022 at an Italian tertiary referral center were enrolled, and their demographic and clinical data were retrieved. The patients were categorized as young or old based on the 25th percentile of the population's age at diagnosis. Univariate and multivariate analyses were performed to assess the association between the collected variables and the age of disease presentation. Additionally, survival analyses were conducted to evaluate the association between the age of diagnosis and clinical outcomes at follow-up, including disease recurrence, hospital access, surgery, and death.

Results

A total of 220 DD patients (with a median age of 66 years, IQR 55-74, and a female-to-male ratio of 1.4:1) were included in the study, comprising 54 patients receiving a diagnosis before the age of 49 years (young DD patients) and 166 patients diagnosed after the age of 49 years (old DD patients). Male sex (57 vs. 36%, p < 0.01), smoking (38 vs. 14%, p < 0.01), and alcohol consumption (54 vs. 38%) were highly prevalent in young patients. The complications at the time of diagnosis, particularly abscesses and free perforations, occurred more frequently in younger patients (p = 0.04). Moreover, young DD patients experienced a higher rate of hospitalization and surgical intervention (p = 0.01 and p = 0.04, respectively) over a median follow-up period of 5 years.

Conclusion

Preventive strategies and prompt diagnosis are crucial in young patients with DD for achieving better disease outcomes and preventing complications.

Diagnostic Delay of Celiac Disease in Childhood

Importance

The extent and factors associated with risk of diagnostic delay in pediatric celiac disease (CD) are poorly understood.

Objectives

To investigate the diagnostic delay of CD in childhood, and to assess factors associated with this delay.

Design, Setting, and Participants

Multicenter, retrospective, cross-sectional study (2010-2019) of pediatric (aged 0-18 years) patients with CD from 13 pediatric tertiary referral centers in Italy. Data were analyzed from January to June 2023.

Main Outcomes and Measures

The overall diagnostic delay (ie, the time lapse occurring from the first symptoms or clinical data indicative of CD and the definitive diagnosis), further split into preconsultation and postconsultation diagnostic delay, were described. Univariable and multivariable linear regression models for factors associated with diagnostic delay were fitted. Factors associated with extreme diagnostic delay (ie, 1.5 × 75th percentile) and misdiagnosis were assessed.

Results

A total of 3171 patients with CD were included. The mean (SD) age was 6.2 (3.9) years; 2010 patients (63.4%) were female; and 10 patients (0.3%) were Asian, 41 (1.3%) were Northern African, and 3115 (98.3%) were White. The median (IQR) overall diagnostic delay was 5 (2-11) months, and preconsultation and postconsultation diagnostic delay were 2 (0-6) months and 1 (0-3) month, respectively. The median (IQR) extreme overall diagnostic delay (586 cases [18.5%]) was 11 (5-131) months, and the preconsultation and postconsultation delays were 6 (2-120) and 3 (1-131) months, respectively. Patients who had a first diagnosis when aged less than 3 years (650 patients [20.5%]) showed a shorter diagnostic delay, both overall (median [IQR], 4 [1-7] months for patients aged less than 3 years vs 5 [2-12] months for others) and postconsultation (median [IQR], 1 [0-2] month for patients aged less than 3 years vs 2 [0-4] months for others). A shorter delay was registered in male patients, both overall (median [IQR], 4 [1-10] months for male patients vs 5 [2-12] months for female patients) and preconsultation (median [IQR], 1 [0-6] month for male patients vs 2 [0-6] months for female patients). Family history of CD was associated with lower preconsultation delay (odds ratio [OR], 0.59; 95% CI, 0.47-0.74) and lower overall extreme diagnostic delay (OR, 0.75; 95% CI, 0.56-0.99). Neurological symptoms (78 patients [21.5%]; OR, 1.35; 95% CI, 1.03-1.78), gastroesophageal reflux (9 patients [28.1%]; OR, 1.87; 95% CI, 1.02-3.42), and failure to thrive (215 patients [22.6%]; OR, 1.62; 95% CI, 1.31-2.00) showed a more frequent extreme diagnostic delay. A previous misdiagnosis (124 patients [4.0%]) was more frequently associated with gastroesophageal reflux disease, diarrhea, bloating, abdominal pain, constipation, fatigue, osteopenia, and villous atrophy (Marsh 3 classification).

Conclusions and Relevance

In this cross-sectional study of pediatric CD, the diagnostic delay was rather short. Some factors associated with risk for longer diagnostic delay and misdiagnosis emerged, and these should be addressed in future studies.

Diagnostic delay in symptomatic uncomplicated diverticular disease: an Italian tertiary referral centre study

The magnitude of the diagnostic delay of symptomatic uncomplicated diverticular disease (SUDD) is unknown; we aimed to evaluate SUDD diagnostic delay and its risk factors. SUDD patients diagnosed at a tertiary referral centre were retrospectively enrolled (2010-2022). Demographic and clinical data were retrieved. Overall, patient-, and physician-dependant diagnostic delays were assessed. Univariate and multivariate analyses were fitted to identify risk factors for diagnostic delay. Overall, 70 SUDD patients (median age 65 years, IQR 52-74; F:M ratio = 1.6:1) were assessed. The median overall diagnostic delay was 7 months (IQR 2-24), patient-dependant delay was 3 months (IQR 0-15), and physician-dependant delay was 1 month (IQR 0-6). Further, 25% of patients were misdiagnosed with irritable bowel syndrome (IBS). At multivariate analysis, previous misdiagnosis was a significant risk factor for overall and physician-dependant diagnostic delay (OR 9.99, p = 0.01, and OR 6.46, p = 0.02, respectively). Also, a high educational level (> 13 years) was associated with a greater overall diagnostic delay (OR 8.74 p = 0.02), while previous abdominal surgery was significantly associated to reduced physician-dependant diagnostic delay (OR 0.19 p = 0.04). To conclude, SUDD may be diagnosed late, IBS being the most frequent misdiagnosis. Timely diagnosis is crucial to tackle the burden of SUDD on patients and healthcare.

Diagnostic delay in adult coeliac disease: An Italian multicentre study

BACKGROUND

There are few data regarding the diagnostic delay and its predisposing factors in coeliac disease (CD).

AIMS

To investigate the overall, the patient-dependant, and the physician-dependant diagnostic delays in CD.

METHODS

CD adult patients were retrospectively enroled at 19 Italian CD outpatient clinics (2011-2021). Overall, patient-dependant, and physician-dependant diagnostic delays were assessed. Extreme diagnostic, i.e., lying above the third quartile of our population, was also analysed. Multivariable regression models for factors affecting the delay were fitted.

RESULTS

Overall, 2362 CD patients (median age at diagnosis 38 years, IQR 27-46; M:F ratio=1:3) were included. The median overall diagnostic delay was 8 months (IQR 5-14), while patient- and physician-dependant delays were 3 (IQR 2-6) and 4 (IQR 2-6) months, respectively. Previous misdiagnosis was associated with greater physician-dependant (1.076, p = 0.005) and overall (0.659, p = 0.001) diagnostic delays. Neurological symptoms (odds ratio 2.311, p = 0.005) and a previous misdiagnosis (coefficient 9.807, p = 0.000) were associated with a greater extreme physician-dependant delay. Gastrointestinal symptoms (OR 1.880, p = 0.004), neurological symptoms (OR 2.313, p = 0.042), and previous misdiagnosis (OR 4.265, p = 0.000) were associated with increased extreme overall diagnostic delay.

CONCLUSION

We identified some factors that hamper CD diagnosis. A proper screening strategy for CD should be implemented.

Case Report: A rare case of small bowel obstruction secondary to plasma cell myeloma

Gastrointestinal (GI) involvement of plasma cell neoplasms is extremely rare. Herein, we describe the case of a 74-year-old Caucasian woman who came to our attention with abdominal pain, food vomiting, and weight loss of 10 kg over 1 year. A computed tomography scan of the abdomen revealed circumferential thickening of terminal ileum, for which the patient underwent an urgent 20-cm-long ileal resection. Histopathological and immunophenotypic analysis revealed a plasma cell neoplasm of the ileum. Subsequent investigations found a serum monoclonal immunoglobulin A component, an osteolytic lesion of the left jaw, and a clonal bone marrow plasma cell infiltrate carrying 1q21 amplification. Given the final diagnosis of plasma cell myeloma (PCM), the patient underwent a VMD (bortezomib, melphalan, and dexamethasone) chemotherapy regimen, achieving a complete remission after a 12-month treatment. For disease relapse, two further chemotherapy regimens were later attempted. At the last follow-up 4 years after the diagnosis, the patient is still alive. This case draws attention to the extramedullary presentation of plasma cell neoplasms, even if rare, as a prompt diagnosis seems to result in a better prognosis. In addition, it highlights the relevance of a multidisciplinary approach, involving gastroenterologists, hematologists, and pathologists, to the diagnosis and management of these neoplasms.

Impact of COVID-19 in immunosuppressive drug-naïve autoimmune disorders: Autoimmune gastritis, celiac disease, type 1 diabetes, and autoimmune thyroid disease

Few conflicting data are currently available on the risk of SARS-CoV-2 infection in patients with autoimmune disorders. The studies performed so far are influenced, in most cases, by the treatment with immunosuppressive drugs, making it difficult to ascertain the burden of autoimmunity per se. For this reason, herein we assessed the susceptibility to COVID-19 in immunosuppressive drug-naïve patients with autoimmune diseases, such as autoimmune gastritis (AIG), celiac disease (CD), type 1 diabetes (T1D), and autoimmune thyroid disease (AITD). Telephone interviews were conducted on 400 patients-100 for each group-in May 2021 by looking at the positivity of molecular nasopharyngeal swabs and/or serology for SARS-CoV-2, the need for hospitalization, the outcome, and the vaccination status. Overall, a positive COVID-19 test was reported in 33 patients (8.2%), comparable with that of the Lombardy general population (8.2%). In particular, seven patients with AIG, 9 with CD, 8 with T1D, and 9 with AITD experienced COVID-19. Only three patients required hospitalization, none died, and 235 (58.7%) were vaccinated, 43 with AIG, 47 with CD, 91 with T1D, and 54 with AITD. These results seem to suggest that autoimmunity per se does not increase the susceptibility to COVID-19. Also, COVID-19 seems to be mild in these patients, as indicated by the low hospitalization rates and adverse outcomes, although further studies are needed to better clarify this issue.

The effect of protein restriction during the growing period on carcass, meat and fat quality of heavy barrows and gilts

Nutritional strategies are being researched in pigs to increase fatness and then to improve quality of dry-cured products. A total of 160 Duroc×(Landrace×Large White) pigs, 50% barrows and 50% gilts, were used in a trial. During the growing period (73-118d of age), four feeds were formulated with decreasing levels of crude protein (CP; 21.6, 17.7, 14.7 and 13.5%) to achieve 1.10, 0.91, 0.78 and 0.52% of total Lysine, respectively. From 118d until slaughter, at 123kg (183, 181, 178 or 192d of age, respectively), a common diet was provided (17.7% CP and 0.91% Lysine). Barrows had fatter carcasses than gilts but intramuscular fat (IMF) proportion was similar for both. Dietary CP restriction promoted wider backfat depth and pork with higher IMF percentage which was more monounsaturated and less polyunsaturated. We conclude that CP restriction during the grower period improves desirable carcass and meat traits in barrows and gilts intended for dry-cured products.

The increase of slaughter weight in gilts as a strategy to optimize the production of Spanish high quality dry-cured ham

Crossbred pigs (n=120) from Duroc sires mated to Landrace x Large White dams, with a mean BW of 110.5+/-2.3 kg, were used to investigate the effect of increasing the slaughter weight of gilts with regard to that of the barrows on the production of high quality dry-cured hams from Spain (Teruel ham). There were 3 treatments: barrows slaughtered at 130 kg of BW (B), gilts slaughtered at 130 kg of BW (G1), and gilts slaughtered at 134 kg of BW (G2). Growth performance was similar for G1 and G2, and both consumed less feed (P<0.001) and had less BW gain (P<0.05) and better G:F (P<0.01) than B. Also, the B treatment showed thicker backfat (P<0.001) and covering fat over the gluteus medius (GM) muscle (P<0.05) than G1 or G2, but no differences in carcass fat were detected between G1 and G2. Loin and ham yields were similar for B and G2, and both were less than those for G1 (P<0.01). Treatment did not affect the proportion of carcasses with a minimum weight of 84 kg, but the percentage of carcasses with a minimum fat depth over the GM muscle of 18 mm and the percentage of carcasses that fulfill both requirements (as required for the Teruel ham trademark) were less for G1 than for B or G2 (P<0.001). Meat from B had greater (P<0.05) intramuscular fat content than meat from G1 with loin from G2 being intermediate. Thawing losses of the loins were greater (P<0.05) for B than for G2 with loins from G1 being intermediate. Shear force value was greater for meat from G1 than for that from G2 with meat from B being intermediate (P<0.05). Fat over the GM muscle from the B treatment was more saturated and had decreased PUFA/SFA ratio than that from G1 with fat from G2 being intermediate (P<0.001). Also, backfat from the B treatment showed decreased (P<0.01) PUFA proportion than backfat from G1 or G2. We conclude that increasing the slaughter weight of gilts by 4 kg with respect to that of barrows optimized the 2 criteria used for the selection of carcasses destined for the production of Teruel ham.

Feeding regimen and enzyme supplementation to rye-based diets for broilers

A trial was conducted to study the influence of feeding regimen [ad libitum, (AL) vs. feed restriction, (FR)] and supplementation of the diet with a combination of xylanase and beta-glucanase on physiological parameters and performance of broilers fed rye-based diets. There were 4 dietary treatments arranged factorially with 2 feeding regimens (0 vs. 30% FR from 4 to 14 d), 2 enzyme doses (0 vs. 500 ppm), and an additional corn control diet. Each treatment was replicated 9 times from 4 to 25 d (15 chicks caged together) and 6 times from 25 to 46 d. From 4 to 46 d of age, FR did not affect weight gain and improved feed conversion of broilers (P < 0.05). Also, FR reduced the incidence of leg disorders, digesta viscosity, and pasted vents (P < 0.01) and increased relative weight of gizzard (P < 0.001). Enzyme supplementation (ES) improved average daily gain and feed conversion at all ages (P < 0.01), and the beneficial effects were greater for AL than for FR birds (P < 0.10). Also, ES reduced digesta viscosity (P < 0.001), relative weights of gizzard (P < 0.05) and crop (P < 0.01), and jejunum length (P < 0.05). Compared with feeding corn, feeding rye AL with or without ES impaired growth and feed conversion from 4 to 46 d (P < 0.01) and increased incidence of leg disorders (P < 0.05), viscosity of jejunum content (P < 0.01), and jejunum length (P < 0.05). We concluded that rye in feed impaired broiler performance and increased digesta viscosity and incidence of leg disorders and that FR and ES reduced the magnitude of the problem. The beneficial effects of ES on bird performance were more evident when birds were fed AL.

The effects of gender and slaughter weight on the growth performance, carcass traits, and meat quality characteristics of heavy pigs1

Crossbred pigs (n = 192) from Piétrain x Large White sires mated to Landrace x Large White dams, with a mean BW of 75 +/- 1.3 kg, were used to investigate the effects of gender and slaughter weight (SW) on growth performance, carcass characteristics, and meat quality. Pens of pigs (eight pigs/pen) were assigned randomly to one of six treatments arranged in a 2 x 3 factorial design with two genders (barrows or gilts) and three SW (116, 124, or 133 kg). Each treatment was replicated four times. Over the entire trial, barrows had higher (P < 0.001) ADFI (as-fed basis) and ADG than gilts; however, gilts had higher (P < 0.05) gain-to-feed ratios (G:F) than barrows. Barrows had lower (P < 0.01) dressing percents than gilts and produced fatter (P < 0.001) carcasses that had lower trimmed shoulder (P < 0.10) and ham (P < 0.001) yields than gilts. There was a trend for the semimembranosus muscle (SM) from barrows to have a higher (P < 0.10) 45-min pH than that of gilts, but 24-h pH was 0.11 pH unit higher (P < 0.01) in the SM of barrows than gilts. Gender had no (P > 0.10) effect on the moisture and lipid content of the longissimus muscle (LM), nor did gender affect (P > 0.10) LM color, myoglobin content, or thaw loss percentage. However, the LM from barrows had lower (P < 0.05) cooking loss percentages and tended to have lower (P < 0.10) shear force values than the LM from gilts. Pigs slaughtered at 116 kg had higher (P < 0.05) ADG than pigs slaughtered at 124 and 133 kg. Daily feed intake (as-fed basis) was not (P > 0.10) different among SW; however, pigs slaughtered at 116 and 124 kg had higher (P < 0.001) G:F than those slaughtered at 133 kg. Dressing percent, backfat depth, carcass length, and ham and shoulder weights increased (P < 0.001) as SW increased from 116 to 133 kg. The initial (45-min) pH of the SM from pigs slaughtered at 133 kg was higher (P < 0.05) than from pigs slaughtered at 116 or 124 kg; however, 24-h pH was not (P > 0.10) affected by SW. The LM from pigs slaughtered at 133 kg was darker (lower L* values; P < 0.001), redder (higher a* value; P < 0.01), and had more (P < 0.001) myoglobin than the LM of pigs slaughtered at 116 and 124 kg. Barrows and gilts of this particular crossbreed can be used to produce acceptable quality fresh pork when slaughtered at 116 kg; however, increasing SW to 124 kg, or more, decreased live pig performance and carcass leanness without any additional benefits to pork quality attributes.

Heat processing of barley and enzyme supplementation of diets for broilers

The influence of heat processing (HP) of barley and enzyme supplementation (ES) of the diet on digestive and performance traits of broilers to 21 d was studied. There were four treatments arranged factorially with two barley-processing treatments (raw or heated), two levels of ES (0 or 500 ppm), and five replicates per treatment. Chicks fed HP barley grew faster than broilers fed raw barley until 8 d of age, but the effect disappeared thereafter. In general, ES improved broiler performance at all ages. Intestinal viscosity was increased by HP of barley (P < or = 0.05) and reduced by ES (P < or = 0.001), and the decrease in viscosity caused by ES was greater for HP than for raw barley diets (HP x ES; P < or = 0.05). Heat processing of barley and ES of the diet improved apparent retention of nutrients (P < or = 0.001). Age affected apparent retention of nutrients differently. For starch and neutral detergent fiber, retention increased linearly with age (P < or = 0.01), but for the remaining nutrients the retention decreased from d 4 to 8 and then increased until d 21 (P < or = 0.001). Also, the beneficial effects of HP on retention of nutrients were more pronounced at younger ages (HP x age; P < or = 0.05). Both HP (P < or = 0.001) and ES (P < or = 0.01) increased liver weight, and enzymes reduced the weights of pancreas (P < or = 0.05) and small intestine (P < or = 0.001). Villus height was improved by HP (P < or = 0.001) and ES (P < or = 0.01), but villus surface area was only improved by enzymes (P < or = 0.01). It was concluded that broiler performance is improved by HP of barley at early ages and by ES of the diet throughout the trial. Also, HP and ES increased apparent retention of nutrients, AMEn of the diet, and villus height.

Prevalence of multiple sclerosis in the province of Teruel, Spain

There have been few reports about the frequency of multiple sclerosis (MS) in Spain. We undertook a prevalence study in the province of Teruel, which is served by two hospitals as referral centres for a population of 143,680. We found a total of 46 patients who fulfilled Poser's criteria for clinically definite or probable MS with a prevalence rate of 32/100,000 [95% confidence interval (CI): 22.8-41.3]. The prevalence rates for males and females were 23.5 (95% CI: 12.3-34.7) and 40.6 (95% CI: 25.8-55.4) respectively. We found an incidence rate of 2.2/year per 100,000 in the last 5 years. The sex ratio (females/males) was 1.7. The mean age on prevalence day was 40.6 years (range: 15-76). The clinical course was relapsing-remitting in 82% of patients, progressive in 9% and secondary progressive in the other 9%. The mean EDSS score was 3.73 (range: 1-8.5). Our results confirm the hypothesis that Spain is an area at high risk for MS.