Ustekinumab safety and effectiveness in patients with ulcerative colitis: results from a large real-life study

BACKGROUND

Ustekinumab (UST) is an interleukin-12/interleukin-23 receptor antagonist recently approved for treating ulcerative colitis (UC) but with limited real-world data. Therefore, we evaluated the effectiveness and safety of UST in patients with UC in a real-world setting.

RESEARCH DESIGN AND METHODS

This is a multicenter, retrospective, observational cohort study. The primary endpoints were the clinical remission rate (partial Mayo score, PMS, ≤1) and the safety of UST. Other endpoints were corticosteroid-free remission (CSFR) rate, clinical response rate (PMS reduction of at least 2 points), and fecal calprotectin (FC) reduction at week 24.

RESULTS

We included 256 consecutive patients with UC (M/F 139/117, median age 52). The clinical remission and clinical response rates at eight weeks were 18.7% (44/235) and 53.2% (125/235), respectively, and 27.6% (42/152) and 61.8% (94/152) at 24 weeks, respectively. At 24 weeks, CSFR was 20.3% (31/152), and FC significantly dropped at week 12 (p = 0.0004) and 24 (p = 0.038). At eight weeks, patients naïve or with one previous biologic treatment showed higher remission (p = 0.002) and clinical >response rates (p = 0.018) than patients previously treated with ≥ 2. Adverse events occurred in six patients (2.3%), whereas four patients (1.6%) underwent colectomy.

CONCLUSION

This real-world study shows that UST effectively and safely treats patients with UC.

Efficacy of a new nutraceutical formulation: L-tryptophan, probiotics, charcoal, chamomile, mint, and licorice (COLONIR®) in the improvement of gastrointestinal symptoms in subjects with irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders. IBS is characterized by recurrent chronic abdominal pain and altered bowel habits in the absence of organic damage. Although there are reviews and guidelines for treating IBS, the complexity and diversity of IBS presentation make treatment difficult. Treatment of IBS focuses on relieving symptoms as mild signs and symptoms can often be controlled by managing stress and by making changes in diet and lifestyle. The use of nutraceutical compounds has been advocated as a possible alternative treatment in patients with IBS. COLONIR^® (Omega Pharma Srl, Milan, Italy) may be an alternative or adjuvant treatment in patients with gastrointestinal symptoms. This study aimed to evaluate the effect of this new nutraceutical formulation in inducing symptoms remission and improve gastrointestinal habits.

METHODS

An initial cohort of 1004 consecutive patients referred to 25 different Units of Internal Medicine a/o Gastroenterology in Italy to perform colonoscopy for intestinal symptoms was asked to participate. Patients were treated for 2 months with three doses of nutraceuticals/day after meals namely COLONIR^®. Patients were assessed at baseline and after 2 months to evaluate the frequency and severity of gastrointestinal symptoms in the past seven days with a questionnaire based on ROMA IV criteria.

RESULTS

After 2 months, 899 patients completed the follow-up. COLONIR^® achieved a statistically significant reduction of severity of symptoms in the study population without any documented side effects.

CONCLUSIONS

These promising results, here reported, need to be confirmed, valuating the efficacy of COLONIR^® in relieving gastrointestinal symptoms in IBS patients in further studies.

EUS-guided tissue acquisition in chronic pancreatitis: Differential diagnosis between pancreatic cancer and pseudotumoral masses using EUS-FNA or core biopsy

Background and Objective:

EUS-FNA sensitivity for malignancy in parenchymal masses of patients with concurrent chronic pancreatitis (CP) has been reported to be unsatisfactory. The aim of the present study was to directly compare the diagnostic accuracy of EUS-FNA and EUS-fine-needle biopsy (FNB) in differentiating between inflammatory masses and malignancies in the setting of CP.

Methods:

We performed a retrospective analysis of prospective, multicentric databases of all patients with pancreatic masses and clinico-radiological-endosonographic features of CP who underwent EUS-FNA or FNB.

Results:

Among 1124 patients with CP, 210 patients (60% males, mean age: 62.7 years) with CP and pancreatic masses met the inclusion criteria and were enrolled. In the FNA group (110 patients), a correct diagnosis was obtained in all but 18 cases (diagnostic accuracy 83.6%, sensitivity 69.5%, specificity 100%, positive predictive value [PPV] 100%, and negative predictive value [NPV] 73.9%); by contrast, among 100 patients undergoing FNB, a correct diagnosis was obtained in all but seven cases (diagnostic accuracy 93%, sensitivity 86.8%, specificity 100%, PPV 100%, and NPV 87%) (P = 0.03, 0.03, 1, 1, and 0.07, respectively). At binary logistic regression, focal pancreatitis (odds of event occurrence [OR]: 4.9; P < 0.001), higher Ca19-9 (OR: 2.3; P = 0.02), and FNB (OR: 2.5; P < 0.01) were the only independent factors associated with a correct diagnosis.

Conclusion:

EUS-FNB is effective in the differential diagnosis between pseudotumoral masses and solid neoplasms in CP, showing higher diagnostic accuracy and sensitivity than EUS-FNA. EUS-FNB should be considered the preferred diagnostic technique for diagnosing cancer in the setting of CP.

FRAX Score Can Be Used to Avoid Superfluous DXA Scans in Detecting Osteoporosis in Celiac Disease: Accuracy of the FRAX Score in Celiac Patients

The Fracture Risk Assessment (FRAX) tool has been developed to estimate patients' 10-yr probability of fracture, thus establishing which patients should undergo dual-energy X-ray Absorptiometry (DXA) scan. This study aimed to evaluate if the FRAX tool can replace or optimize the use of DXA scan in celiac disease (CD). We prospectively enrolled all CD patients aged over 40 yr diagnosed at our third-level unit. At time of CD diagnosis, all patients underwent FRAX score calculation for risk of major osteoporotic and hip fractures and DXA scan (used as gold standard) to assess the accuracy of the FRAX score. The FRAX score calculation was based on the following 10 variables: age (>40 yr), sex (M/F), body mass index, history of previous fracture (yes/no), parent fractured hip (yes/no), current smoking (yes/no), use of steroids (yes/no), rheumatoid arthritis (yes/no), secondary osteoporosis (yes/no), and alcohol ≥3 units/d (yes/no). DXA assessment was performed within 1 week from FRAX calculation. The FRAX score was dichotomized as normal or pathologic in accordance with the National Osteoporosis Guideline Group. A total of 160 CD patients were enrolled (M/F = 20/140; mean age 48.7 yr). A pathologic FRAX score was evident in 14 out of 160 patients (8.7%), whereas osteoporosis based on DXA scan was found in 10 patients (6%) (κ = 0.6); 3 patients with osteoporosis (1.9%) showed a 10-yr risk of major fracture >10% according to the National Osteoporosis Guideline Group criteria. With regard to diagnostic accuracy, the FRAX score showed sensitivity of 0%, specificity of 91%, positive predictive value of 0%, and negative predictive value of 94%. The prevalence of osteoporosis in adult CD appears to be quite low and only a small proportion of patients would require a DXA investigation. The FRAX score could be an effective tool to avoid useless DXA scans in CD patients in view of its high negative predictive value.

Beneficial effects of gluten free diet in potential coeliac disease in adult population

BACKGROUND

To date, potential coeliac disease (PCD) occurring in adults remains an almost unexplored condition.

AIMS

To explore the prognostic role of Marsh grade in adult PCD patients, and to evaluate the effects of gluten-containing diet (GCD) in asymptomatic PCD patients.

METHODS

We retrospectively evaluated all consecutive adult PCD patients followed-up for at least 6 years. Patients were divided into: Group A (patients with Marsh 0 histology) and Group B (Marsh 1 patients). Symptomatic patients were started gluten-free diet (GFD), while asymptomatic subjects were kept on GCD and were followed-up.

RESULTS

56 PCD patients were enrolled (21 in Group A and 35 in Group B). Forty-three patients were symptomatic and started GFD. Of these, none of 15 patients in Group A and 8 of 28 patients in Group B developed immune-mediated disorders (IMD) during follow-up (P=0.03; OR=4.2). The 13 asymptomatic PCD patients were kept on GCD. During the follow-up, 9 patients developed CD-related symptoms, 6 villous atrophy and 8 IMD. At the end, patients kept on GCD were at higher risk of developing IMD than those following a GFD (61% vs 18%, P=0.03, OR=3.3).

CONCLUSIONS

Although PCD with normal mucosa seems to be a milder disease, the continuation of GCD places patients at a high risk of developing villous atrophy and IMD compared to commencement of GFD. Adult PCD patients should start GFD even if not symptomatic.

Non-variceal upper gastrointestinal bleeding: Rescue treatment with a modified cyanoacrylate

AIM

To evaluate the safety and efficacy of a modified cyanoacrylate [N-butyl-2-cyanoacrylate associated with methacryloxysulfolane (NBCA + MS)] to treat non-variceal upper gastrointestinal bleeding (NV-UGIB).

METHODS

In our retrospective study we took into account 579 out of 1177 patients receiving endoscopic treatment for NV-UGIB admitted to our institution from 2008 to 2015; the remaining 598 patients were treated with other treatments. Initial hemostasis was not achieved in 45 of 579 patients; early rebleeding occurred in 12 of 579 patients. Thirty-three patients were treated with modified cyanoacrylate: 27 patients had duodenal, gastric or anastomotic ulcers, 3 had post-mucosectomy bleeding, 2 had Dieulafoy’s lesions, and 1 had duodenal diverticular bleeding.

RESULTS

Of the 45 patients treated endoscopically without initial hemostasis or with early rebleeding, 33 (76.7%) were treated with modified cyanoacrylate glue, 16 (37.2%) underwent surgery, and 3 (7.0%) were treated with selective transarterial embolization. The mean age of patients treated with NBCA + MS (23 males and 10 females) was 74.5 years. Modified cyanoacrylate was used in 24 patients during the first endoscopy and in 9 patients experiencing rebleeding. Overall, hemostasis was achieved in 26 of 33 patients (78.8%): 19 out of 24 (79.2%) during the first endoscopy and in 7 out of 9 (77.8%) among early rebleeders. Two patients (22.2%) not responding to cyanoacrylate treatment were treated with surgery or transarterial embolization. One patient had early rebleeding after treatment with cyanoacrylate. No late rebleeding during the follow-up or complications related to the glue injection were recorded.

CONCLUSION

Modified cyanoacrylate solved definitively NV-UGIB after failure of conventional treatment. Some reported life-threatening adverse events with other formulations, advise to use it as last option.

Coeliac disease in the elderly in a tertiary centre

INTRODUCTION AND AIMS

Coeliac disease (CD) was believed to be a childhood disease while it can affect any age.

AIM

to evaluate the prevalence of CD in elderly population, recording the main clinical features of this group respect to young patients.

METHODS

We retrospectively analysed the prevalence of CD in an elderly population from 1970 to 2015. We divided patients into three age-groups (group A: 18-34 years; group B: 35-64 years; group C: ≥65 years) and compared them regarding baseline anthropometric and serological variables, clinical features at diagnosis, diagnostic mode, associated autoimmune diseases, and CD-related neoplastic complications.

RESULTS

We made 2812 CD diagnoses in adults: 2.5% of them were ≥65 years at diagnosis. When comparing the three groups, we found no differences in sex, haemoglobin, serum iron, albumin, and anti-tissue transglutaminase (anti-tTG) (p = NS) while as expected, we found higher values of cholesterol, glycaemia, and triglycerides in older patients (p < 0.0001). Elderly had a higher risk of being diagnosed with malabsorption symptoms compared to younger patients (OR 2.20, 95%CI 1.3-3.74). No difference in the risk of autoimmune CD-related diseases was seen among groups. Furthermore, we observed 16 neoplastic complications, 13 of them happened in the patients diagnosed with CD aged 35-64 years. The number of CD diagnoses increased over time, particularly in elderly.

CONCLUSION

CD diagnosis in elderly population is quite uncommon although not rare. Elderly CD patients have a higher risk of being diagnosed with malabsorption symptoms than younger patients but without increased risk of autoimmune and neoplastic complications.

Gluten-free diet does not influence the occurrence and the Th1/Th17-Th2 nature of immune-mediated diseases in patients with coeliac disease

INTRODUCTION

Coeliac disease (CD) is the most common Th1-mediated enteropathy, frequently associated with other immune-mediated disorders (IMD).

AIMS

To evaluate: (1) the prevalence of IMD at the time of and after CD diagnosis; (2) a possible change in immune response to gluten free diet (GFD); (3) the potential role of GFD in reducing and/or preventing IMD in CD.

METHODS

Prospective study including all consecutive adult CD patients who underwent investigations for Th1-Th17/Th2-IMD at the time of CD diagnosis and after a 5-year follow-up period.

RESULTS

1255 CD were enrolled. Of these, 257 patients (20.5%) showed IMD at the time of CD diagnosis, with 58.4% presenting a Th1/Th17-IMD. After a 5-year follow-up period, 682 patients (54.3%) showed new IMD despite GFD. Of these, 57.3% presented a Th1/Th17-IMD and 42.7% a Th2-IMD (p=0.8). When compared the prevalence of each type of IMD before and after CD diagnosis, we did not identify any significant "switch" from Th1/Th17- to Th2-IMD or vice versa. The number of patients with Th1/Th17- and/or Th2-IMD increased during the GFD period (20.5% vs 54.3%; p<0.01; OR 1.9).

CONCLUSIONS

The prevalence of IMD at the time of CD diagnosis is high and it seems to increase in the follow-up period despite GFD.

High prevalence of post-partum depression in women with coeliac disease

AIM: To explore the prevalence of post-partum depression (PPD) in coeliac disease (CD).

METHODS: We performed a case-control study evaluating the prevalence of PPD in CD patients on gluten-free diet (GFD) compared to that of healthy subjects experiencing a recent delivery. All participants were interviewed about menstrual features, modality and outcome of delivery and were evaluated for PPD by Edinburgh Postnatal Depression Scale (EPDS).

RESULTS: The study included 70 CD patients on GFD (group A) and 70 controls (group B). PPD was present in 47.1% of CD women and in 14.3% of controls (P < 0.01; OR = 3.3). Mean EPDS score was higher in CD compared to the controls (mean score: group A 9.9 ± 5.9; group B 6.7 ± 3.7; P < 0.01). A significant association was observed between PPD and menstrual disorders in CD (69.7% vs 18.9%; P < 0.001; OR = 3.6).

CONCLUSION: PPD is frequent in CD women on GFD, particularly in those with previous menstrual disorders. We suggest screening for PPD in CD for early detection and treatment of this condition.

Metabolic syndrome in patients with coeliac disease on a gluten-free diet

BACKGROUND

Several studies have shown that weight changes are common in patients with coeliac disease after starting a gluten-free diet (GFD), but data on the prevalence of metabolic syndrome in this population are still scarce.

AIMS

To assess the prevalence of metabolic syndrome in patients with CD at diagnosis and 1 year after starting GFD.

METHODS

We enrolled all consecutive patients with newly diagnosed coeliac disease (CD) who were referred to our third-level CD Unit. For all patients we collected: waist circumference, BMI, blood pressure, lipid profile (HDL cholesterol, triglycerides) and levels of blood glucose. Diagnosis of metabolic syndrome was made according to the International Diabetes Federation (IDF) criteria for European countries. The prevalence of metabolic syndrome was re-assessed after 12 months of GFD.

RESULTS

Ninety-eight patients with CD were assessed, two patients with CD (2%) fulfilled the diagnostic criteria for metabolic syndrome at diagnosis and 29 patients (29.5%) after 12 months of GFD (P < 0.01; OR: 20). With regard to metabolic syndrome sub-categories 1 year after GFD compared to baseline respectively: 72 vs. 48 patients exceeded waist circumference cut-off (P < 0.01; OR: 2.8); 18 vs. 4 patients had high blood pressure (P < 0.01; OR: 5.2); 25 vs. 7 patients exceeded glycemic threshold (P = 0.01; OR: 4.4); 34 vs. 32 patients with CD had reduced levels of HDL cholesterol (P = 0.7); and 16 vs. 7 patients had high levels of triglycerides (P = 0.05).

CONCLUSIONS

Patients with coeliac disease show a high risk of metabolic syndrome 1 year after starting a gluten-free diet. We suggest that an in-depth nutritional assessment is undertaken for all patients with coeliac disease.

The presence of anti-endomysial antibodies and the level of anti-tissue transglutaminases can be used to diagnose adult coeliac disease without duodenal biopsy

BACKGROUND

The new ESPGHAN guidelines for diagnosis of paediatric coeliac disease suggest to avoid biopsy in genetically pre-disposed and symptomatic individuals with positive anti-endomysial antibodies (EMA) and anti-tissue transglutaminases (a-tTG). However, duodenal biopsy remains the gold standard in adult coeliac disease.

AIMS

To establish the cut-off values of a-tTG, which would: predict the presence of duodenal histology (Marsh ≥2) diagnostic for coeliac disease; and predict the presence of villous atrophy (Marsh 3) in adults.

METHODS

We performed an observational prospective study including all consecutive adult patients with suspected coeliac disease. All subjects were tested for EMA and a-tTG. Coeliac disease diagnosis was made in presence of Marsh ≥2, a-tTG >7 U/mL and positive EMA. A ROC curve was constructed to establish the best specificity cut-off of a-tTG levels, which would predict the presence of Marsh ≥2 and Marsh 3 at histology.

RESULTS

The study included 310 patients with positive antibodies. Histology showed Marsh 1 in 8.7%, Marsh 2 in 3.5%, Marsh 3 in 87.7%. The best cut-off value of a-tTG for predicting Marsh ≥2 was 45 U/mL (sensitivity 70%; specificity 100%; PPV 100%; NPV 24.1%); the best cut-off for predicting villous atrophy was 62.4 U/mL (sensitivity 69%, specificity 100%; PPV 100%; NPV 31%).

CONCLUSIONS

The diagnosis of coeliac disease can be reached without histology in adult patients with positive EMA and a-tTG levels >45 U/mL. An a-tTG level >62.4 was diagnostic for villous atrophy. These results could contribute to improving the diagnosis of coeliac disease by allowing for a significant reduction in diagnosis-related costs.

Fluoroquinolone-based protocols for eradication of Helicobacter pylori

Helicobacter pylori (H. pylori) is a widespread pathogen infecting about 40% of people living in urban areas and over 90% of people living in the developing regions of the world. H. pylori is well-documented as the main factor in the pathogenesis of peptic ulcer disease, chronic gastritis, and gastric malignancies such as cancer and mucosa-associated lymphoid tissue-lymphoma; hence, its eradication is strongly recommended. The Maastricht IV consensus, which focused on the management of H. pylori infection, set important new strategies in terms of treatment approaches, particularly with regards to first- and second-line treatment protocols and led to improved knowledge and understanding of H. pylori resistance to antibiotics. In recent years, various fluoroquinolone-based protocols, mainly including levofloxacin, have been proposed and effectively tested at all therapeutic lines for H. pylori eradication. The aim of the present paper is to review the scientific literature focused on the use of fluoroquinolones in eradicating H. pylori.

Predictive value of "Marsh 1" type histology in subjects with suspected cealic disease

INTRODUCTION

The diagnosis of celiac disease (CD) is based on histology in combination with anti-tissue transglutaminase (a-tTG) and anti-endomysial antibodies (EMAs). The increase of intraepithelial lymphocytes defines the Marsh 1 histology that appears not to be specific for CD.

AIM

To explore the positive predictive value (PPV) and clinical relevance of Marsh 1 histology in suspected CD.

METHODS

We carried out an observational prospective study including all consecutive subjects with a Marsh 1 histology. All patients were tested for a-tTG and EMAs. Diagnosis of potential CD was defined in the presence of Marsh 1 with positive a-tTG and EMAs. Patients were investigated for symptoms, CD familial aggregation, other diseases, and current medication.

RESULTS

Sixty-three patients with Marsh 1 were included. Diagnosis of potential CD was made in 23 subjects (36%), so that Marsh 1 histology showed a PPV of 36%. With regard to familial aggregation, patients with potential CD showed a higher frequency of familiarity for CD (60.8% vs. 15.0%; p < 0.01). No significant difference was detected between CD and non-CD in terms of intestinal and extra-intestinal symptoms. We also documented the presence of conditions other than CD in the remaining population: 7 patients (17.5%) with immuno-mediated diseases while 5 patients (12.5%) showed Helicobacter pylori (HP) infection. About medication, 3 patients (7.5%) were on non-steroidal anti-inflammatory drugs, while another 4 (10%) patients were being treated with other drugs.

CONCLUSION

The Marsh 1 type histology is not specific for CD and it can also be associated with immuno-mediated disorders, HP infection, and drugs.

Fecal calprotectin in coeliac disease

We would like to share with the readers the results of our experience in 50 celiac disease (CD) patients, enrolled between September 2012 and April 2013, who were referred to our third-level CD Unit. The fecal calprotectin (FC) concentration of 50 adults with newly diagnosed CD was compared to that of a control group of 50 healthy subjects. FC level was determined by enzyme linked immunosorbent assay with diagnostic cut-off of 75 μg/g. In addition, we tried to correlate the FC level with symptoms, histological severity of CD (Marsh grade) and level of tissue transglutaminase antibodies (aTg) in CD patients. Finally, FC level was increased in five CD patients and in four controls (10% vs 8%, P = NS); mean FC concentration of patients and controls were 57.7 (SD ± 29.1) and 45.1 (SD ± 38.4) respectively. Furthermore, no significant correlation was seen between FC levels and symptoms/Marsh grade/aTg. The five CD patients did not show inflammatory lesions (e.g., ulcers, erosions) at upper endoscopy. The four healthy controls with positive FC were followed-up for further six months; in this observational period they did not show clinical signs of any underlying disease. On these bases, we think that FC is not able to investigate the subclinical inflammatory changes of active CD and FC should be considered a useless tool in the diagnostic work-up of uncomplicated CD but it should be accompanied by aTg when ruling out organic disease in patients with irritable bowel syndrome.

Role of gluten intake at the time of hepatitis B virus vaccination in the immune response of celiac patients

Some reports have demonstrated an inadequate response to hepatitis B vaccination in patients affected by celiac disease. The aim of our study was to evaluate hepatitis B vaccination response in relation to gluten exposure status in patients with celiac disease. To measure the gluten exposure status at the time of vaccination, we considered three groups: group A (exposed to gluten), including patients vaccinated as 12-year-old adolescents (the celiac disease diagnosis was established after vaccination); group B (not exposed to gluten), including patients vaccinated as 12-year-old adolescents on a gluten-free diet at the time of vaccination; and group C (infants), including patients vaccinated at birth. The response of celiac patients to hepatitis B vaccination was compared to that of healthy subjects, i.e., those in the control group (group D). This study included 163 celiac patients (group A, 57 patients; group B, 46 patients; and group C, 60 patients) and 48 controls (group D). An inadequate response to hepatitis B immunization was present in 43.9% of patients in group A, 34.8% of patients in group B, 58.3% of patients in group C, and 8.3% of patients in group D (group A versus group D, P < 0.001; group B versus group D, P = 0.002; group C versus group D, P = 0.001) (no significant difference for group A versus group B and group A versus group C was evident). Our data suggest that gluten exposure does not influence the response to hepatitis B immunization and that the human leukocyte antigen probably plays the main immunological role in poor responses to hepatitis B-vaccinated celiac patients.

Prevalence of functional dyspepsia and its subgroups in patients with eating disorders

AIM: To study the prevalence of functional dyspepsia (FD) (Rome III criteria) across eating disorders (ED), obese patients, constitutional thinner and healthy volunteers.

METHODS: Twenty patients affected by anorexia nervosa, 6 affected by bulimia nervosa, 10 affected by ED not otherwise specified according to diagnostic and statistical manual of mental disorders, 4th edition, nine constitutional thinner subjects and, thirty-two obese patients were recruited from an outpatients clinic devoted to eating behavior disorders. Twenty-two healthy volunteers matched for age and gender were enrolled as healthy controls. All participants underwent a careful clinical examination. Demographic and anthropometric characteristics were obtained from a structured questionnaires. The presence of FD and, its subgroups, epigastric pain syndrome and postprandial distress syndrome (PDS) were diagnosed according to Rome III criteria. The intensity-frequency score of broader dyspeptic symptoms such as early satiety, epigastric fullness, epigastric pain, epigastric burning, epigastric pressure, belching, nausea and vomiting were studied by a standardized questionnaire (0-6). Analysis of variance and post-hoc Sheffè tests were used for comparisons.

RESULTS: 90% of patients affected by anorexia nervosa, 83.3% of patients affected by bulimia nervosa, 90% of patients affected by ED not otherwise specified, 55.6% of constitutionally thin subjects and 18.2% healthy volunteers met the Postprandial Distress Syndrome Criteria (χ², P < 0.001). Only one bulimic patient met the epigastric pain syndrome diagnosis. Postprandial fullness intensity-frequency score was significantly higher in anorexia nervosa, bulimia nervosa and ED not otherwise specified groups compared to the score calculated in the constitutional thinner group (4.15 ± 2.08 vs 1.44 ± 2.35, P = 0.003; 5.00 ± 2.45 vs 1.44 ± 2.35, P = 0.003; 4.10 ± 2.23 vs 1.44 ± 2.35, P = 0.002, respectively), the obese group (4.15 ± 2.08 vs 0.00 ± 0.00, P < 0.001; 5.00 ± 2.45 vs 0.00 ± 0.00, P < 0.001; 4.10 ± 2.23 vs 0.00 ± 0.00, P < 0.001, respectively) and healthy volunteers (4.15 ± 2.08 vs 0.36 ± 0.79, P < 0.001; 5.00 ± 2.45 vs 0.36 ± 0.79, P < 0.001; 4.10 ± 2.23 vs 0.36 ± 0.79, P < 0.001, respectively). Early satiety intensity-frequency score was prominent in anorectic patients compared to bulimic patients (3.85 ± 2.23 vs 1.17 ± 1.83, P = 0.015), obese patients (3.85 ± 2.23 vs 0.00 ± 0.00, P < 0.001) and healthy volunteers (3.85 ± 2.23 vs 0.05 ± 0.21, P < 0.001). Nausea and epigastric pressure were increased in bulimic and ED not otherwise specified patients. Specifically, nausea intensity-frequency-score was significantly higher in bulimia nervosa and ED not otherwise specified patients compared to anorectic patients (3.17 ± 2.56 vs 0.89 ± 1.66, P = 0.04; 2.70 ± 2.91 vs 0.89 ± 1.66, P = 0.05, respectively), constitutional thinner subjects (3.17 ± 2.56 vs 0.00 ± 0.00, P = 0.004; 2.70 ± 2.91 vs 0.00 ± 0.00, P = 0.005, respectively), obese patients (3.17 ± 2.56 vs 0.00 ± 0.00, P < 0.001; 3.17 ± 2.56 vs 0.00 ± 0.00, P < 0.001 respectively) and, healthy volunteers (3.17 ± 2.56 vs 0.17 ± 0.71, P = 0.002; 3.17 ± 2.56 vs 0.17 ± 0.71, P = 0.001, respectively). Epigastric pressure intensity-frequency score was significantly higher in bulimic and ED not otherwise specified patients compared to constitutional thin subjects (4.67 ± 2.42 vs 1.22 ± 1.72, P = 0.03; 4.20 ± 2.21 vs 1.22 ± 1.72, P = 0.03, respectively), obese patients (4.67 ± 2.42 vs 0.75 ± 1.32, P = 0.001; 4.20 ± 2.21 vs 0.75 ± 1.32, P < 0.001, respectively) and, healthy volunteers (4.67 ± 2.42 vs 0.67 ± 1.46, P = 0.001; 4.20 ± 2.21 vs 0.67 ± 1.46, P = 0.001, respectively). Vomiting was referred in 100% of bulimia nervosa patients, in 20% of ED not otherwise specified patients, in 15% of anorexia nervosa patients, in 22% of constitutional thinner subjects, and, in 5.6% healthy volunteers (χ², P < 0.001).

CONCLUSION: PDS is common in eating disorders. Is it mandatory in outpatient gastroenterological clinics to investigate eating disorders in patients with PDS?

In vitro gliadin challenge: diagnostic accuracy and utility for the difficult diagnosis of celiac disease

OBJECTIVES

Diagnosis of celiac disease is difficult when treatment with gluten-free diet (GFD) is started before diagnosis and/or when the results of tests are inconsistent. The objective of this study was to evaluate the in vitro gliadin challenge.

METHODS

The study cohort included patients without celiac disease (negative controls, n=57), patients with celiac disease (positive controls, n=166 untreated and n=55 on GFD), and patients with difficult diagnosis (n=59). All patients underwent endoscopy for collection of duodenal samples, which served for the diagnosis of celiac disease and for the in vitro evaluation of the gliadin-induced mucosal expression of seven inflammatory markers: PY99, ICAM-1 (intercellular cell adhesion molecule), HLA-DR, CD3, CD25, CD69, and transglutaminase 2 IgA. Diagnostic work-up for celiac disease included the search of specific serum antibodies. Patients of the difficult diagnosis group were asked to stop GFD for repeated search of these antibodies under untreated conditions. The area under the receptor-operated curve (ROC) was used for statistical analyses on accuracy.

RESULTS

HLA-DR had the highest accuracy for celiac disease diagnosis in analyses on negative controls and positive controls also excluding patients on GFD (area under ROC=0.99). Accuracy of test did not increase combining data of HLA-DR with data of other markers. Findings were similar in the 39 patients of the difficult diagnosis group undergoing the search celiac disease-specific antibodies under untreated conditions.

CONCLUSIONS

The in vitro response of mucosal HLA-DR to gliadin is an accurate tool for the diagnosis of celiac disease also in patients with difficult diagnosis.

From menarche to menopause: the fertile life span of celiac women

OBJECTIVE

We evaluated menopause-associated disorders and fertile life span in women with celiac disease (CD) under untreated conditions and after long-term treatment with a gluten-free diet.

METHODS

The participants were 33 women with CD after menopause (untreated CD group), 25 celiac women consuming a gluten-free diet at least 10 years before menopause (treated CD group), and 45 healthy volunteers (control group). The Menopause Rating Scale questionnaire was used to gather information on menopause-associated disorders. The International Physical Activity Questionnaire was used to acquire information on physical activity.

RESULTS

Untreated celiac women had a shorter duration of fertile life span than did the control women because of an older age of menarche and a younger age of menopause (P < 0.01). The scores for hot flushes, muscle/joint problems, and irritability were higher in untreated celiac women than in the control women (higher by 49.4%, 121.4%, and 58.6%, respectively; P < 0.05). In comparison with untreated CD, long-lasting treatment of CD was not associated with a significant difference in the duration of fertile life span, but was only associated with a significant reduction in muscle/joint problems (a reduction of 47.1%; P < 0.05).

CONCLUSIONS

Late menarche and early menopause causes a shorter fertile period in untreated celiac women compared with control women. A gluten-free diet that started at least 10 years before menopause prolongs the fertile life span of celiac women. The perception of intensity of hot flushes and irritability is more severe in untreated celiac women than in controls. Low physical exercise and/or poorer quality of life frequently reported by untreated celiac women might be the cause of reduced discomfort tolerance, thus increasing the subjective perception of menopausal symptoms.

Effect of beta-glucan, inositol and digestive enzymes in GI symptoms of patients with IBS

BACKGROUND

Irritable bowel syndrome (IBS) is a very common functional gastrointestinal (GI). Diagnosis of IBS is based on the fulfilment of the Rome III criteria. Common GI symptoms are lower abdominal pain, bloating and disturbed defecation, such as urgent diarrhoea and/or episodes of chronic constipation. Many agents have been employed in the management of IBS, although only few have been demonstrated to show a relevant efficacy.

AIM

To evaluate the effectiveness of the administration of a mixture of beta-glucan, inositol and digestive enzymes (Biointo) in improving GI symptoms in patients affected by IBS.

PATIENTS AND METHODS

50 IBS patients (20 males, 30 females; mean age 51 +/- 19) were treated with Biointo (group A) while another group consisting of 40 IBS patients (15 males, 25 females; mean age 50 +/- 18) did not receive any therapy (group B).

RESULTS

Biointol administration improved significantly bloating, flatulence and abdominal pain, with a slight increasing of urgency for bowel movements. On the contrary, Biointol did not show any significant effect on the other IBS symptoms.

CONCLUSIONS

Currently, only few agents used in the management of IBS have been proven to be effective. Biointol administration has shown to improve some IBS symptoms, such as bloating, flatulence and abdominal pain, all connected to the presence of gas inside the intestinal lumen.

Long-term antibody persistence and immune memory to hepatitis B virus in adult celiac patients vaccinated as adolescents

Aim of this study was to investigate the anti-HBs antibody persistence and immune memory to hepatitis B virus in adult celiacs vaccinated as adolescents and the effect of a booster administration in non-protected individuals. Eleven years after primary vaccination, the proportion of vaccinees with titres ≥ 10 mIU/ml and antibody geometric mean concentrations (GMCs) were lower among celiac patients than among controls (68.6% vs 91.7%, p<0.01; GMCs 29.38 mIU/ml vs 250.6 mIU/ml, p<0.001). Participants with anti-HBs below 10 mIU/ml received a booster dose and were retested 2 weeks later to assess the anamnestic response. Post-booster anti-HBs levels were still <10 mIU/ml in 71.4% celiacs and 25% controls (p<0.01). Our findings indicate that the prevalence of seroprotective levels of anti-HBs detected eleven years after primary immunization as well as the frequency of response to a booster dose of vaccine are lower in celiac patients compared to healthy controls.

The quality of sleep in patients with coeliac disease

BACKGROUND

Coeliac disease is a chronic disease with a various clinical presentation, including anxiety and depression.

AIM

To investigate the quality of sleep in coeliac disease.

METHODS

The participants were coeliacs at diagnosis; coeliacs on a gluten-free diet at follow-up and healthy volunteers. Participants completed the Pittsburgh Sleep Quality Index (PSQI), SF36, Zung and Fatigue scales and State-Trait Anxiety Inventory (STAI).

RESULTS

The PSQI score was higher in coeliacs at diagnosis and in a gluten-free diet than in healthy volunteers (P < 0.001). A gluten-free diet did not improve the PSQI score (P = 0.245) in coeliac disease. The other test scores were similar between coeliacs at diagnosis and those on a gluten-free diet, whereas significant differences were found between coeliacs and volunteers. PSQI score was inversely associated with the quality of the physical (r = -0.327, P = 0.002) and mental (r = -0.455, P < 0.001) component scores. The sleep quality scores were related to depression (r = 0.633, P < 0.001), fatigue (r = 0.377, P < 0.001), state anxiety (r = 0.484, P < 0.001) and trait anxiety (r = 0.467, P < 0.001).

CONCLUSIONS

Sleep disorders are common in coeliac disease not only at diagnosis but also during treatment with a gluten-free diet. Sleep disorders are related to depression, anxiety and fatigue, and inversely related to quality of life scale scores.

Celiac disease: Alternatives to a gluten free diet

Celiac disease is a chronic inflammatory disorder of the small intestine caused by the ingestion of gluten or related rye and barley proteins. At present, the only available treatment is a strict gluten-exclusion diet. However, recent understanding of the molecular basis for this disorder has improved and enabled the identification of targets for new therapies. This article aims to critically summarize these recent studies.

Atypical pathogens and asthma: can they influence the natural history of the disease?

The association between respiratory infections and asthma exacerbations was first observed in the early '70s. In particular, the role of viral upper respiratory tract infections has been evaluated both in pediatric and adult populations. More recently, evidence of Mycoplasma and Chlamydia pneumoniae involvement in asthma attacks has been reported. These pathogens are also involved in chronic asthma, and both in vitro and animal model studies indicate that atypical agents may play a role in the pathogenesis of the disease. Further research is required to determine whether specific antibiotic treatment may alter the natural history of asthma.

[Right atrial thrombosis and pulmonary embolism: role of echocardiography]

The echocardiographic detection of a right thromboembolus, although rare, should be considered as a cardiological emergency that could lead to death for massive pulmonary embolism. The case of a 70 year-old man admitted to our Institution with the suspicion of pulmonary embolism is described. The echocardiogram performed showed a large mobile thrombus in the right atrium prolapsing through the tricuspid valve during diastole. After thrombolytic therapy with r-TPA, the patient faced a progressive hemodynamic deterioration and died of electromechanical dissociation.

Clinical and hormonal effects of the new angiotensin II receptor antagonist LRB081

The renin-angiotensin system is a major contributor to the pathophysiology of cardiovascular diseases such as congestive heart failure and hypertension. Antagonizing angiotensin (Ang) II at the receptor site may produce fewer side effects than inhibition of the promiscuous converting enzyme. The present study was designed to assess in healthy human subjects the effect of LRB081, a new orally active AT1-receptor antagonist, on the pressor action of exogenous Ang II. At the same time, plasma hormones and drug levels were monitored. At 1-week intervals and in a double-blind randomized fashion, 8 male volunteers received three doses of LRB081 (10, 40, and 80 mg) and placebo. Blood pressure (BP) was measured at a finger by photoplethysmograph. The peak BP response to intravenous injection of a standard dose of Ang II was determined before and for < or = 24 h after administration of an oral dose of LRB081 or placebo. After drug administration, the blood BP response to Ang II was expressed in percent of the response before drug administration. At the same time, plasma renin activity (PRA), Ang II, aldosterone, catecholamine (radioassays), and drug levels (by high-performance liquid chromatography) were monitored. After LRB081 administration, a dose dependent inhibition of the BP response to Ang II was observed. Maximal inhibition of the systolic BP response was 54 +/- 3 (mean +/- SEM), 63 +/- 2, and 93 +/- 1% with 10, 40, and 80 mg LRB081, respectively. The time to peak was 3 h for 6 subjects and 4 and 6 h for 2 others. Preliminary plasma half-life (t1/2) was calculated at 2 h. With the highest dose, the inhibition remained significant for 24 h (31 +/- 5%, p < 0.05). Maximal BP-blocking effect and maximal plasma drug level coincided, suggesting that the unmetabolized LRB081 is responsible for the antagonistic effect. PRA and Ang II increased dose dependently after LRB081 intake. Aldosterone, epinephrine, and norepinephrine concentrations remained unchanged. No clinically significant adverse reaction was observed during the study. LRB081 is a well-tolerated, orally active, potent, and long-acting Ang II receptor antagonist. Unlike in the case of losartan, no active metabolite of LRB081 has been shown to be responsible for the main effects.

[Arrhythmogenic right ventricular dysplasia. Report of a familial case]

Arrhythmogenic right ventricular dysplasia is a pathologic condition of unknown origin that primarily affects the right ventricle free wall characterized by progressive atrophy with fibrous-fatty substitution of the myocardium. The patient affected may present in childhood or as an adult with cardiomegaly or/and ventricular arrhythmias with a left bundle branch block configuration. The reports of familial occurrence suggest the etiologic role of a genetic defect with autosomal dominance and variable expression and penetrance, an alternative, myocarditis (toxic or infectious) is a possible cause. The aim of the present study is an non-invasive instrumental evaluation of the family of a young patient affected by arrhythmogenic right ventricle dysplasia. The authors evaluated 10 patients, 7 women and 3 men, all asymptomatic, with electrocardiography, exercise stress test on a bicycle ergometer, 24-hour Holter monitoring and two-dimensional echocardiography. A patient had certain ARVD diagnosis, while in the other 9 patients all the instrumental investigations were normal. This observation seem to confirm that ARVD may be familial and justify a systematic in-depth familial study in all demonstrated cases of ARVD and the follow-up of all patients identified who had arrhythmias or isolated right ventricular morphologic anomalies.

[Atrial fibrillation induced by massage of the carotid sinus in patients with orthodromic reciprocal supraventricular tachycardia and Wolff-Parkinson-White syndrome]

A 46 years old man with WPW syndrome, due to a posteroseptal accessory pathway, was admitted because of orthodromic reciprocating tachycardia, 210/m'in frequency. At the end of the carotid sinus massage, for accomplish the conversion of tachycardia to sinus rhythm, the orthodromic reciprocating supraventricular tachycardia degenerated into atrial fibrillation associated with high ventricular rate and the presence of hemodynamic instability, reverted to sinus rhythm by intravenous propafenone. Vagal stimulation, induced by carotid sinus massage, probably caused dispersion of atrial refractorines and intraatrial reentry, converting the orthodromic tachycardia into atrial fibrillation. The transesophageal electrophysiologic study, executed in treatment with propafenone, not documented the accessory connection and atrial fibrillation or reciprocating tachycardia were not inducible.

Angiotensin-converting enzyme inhibition by hydroxamic zinc-binding idrapril in humans

The new angiotensin-converting enzyme (ACE) inhibitor idrapril acts by binding the catalytically important zinc ion to a hydroxamic group. We investigated its pharmacodynamic and pharmacokinetic properties in 8 healthy men: Increasing doses of 1, 5, and 25 mg idrapril as well as placebo or 5 mg captopril were administered intravenously (i.v.) at 1-week intervals. Six of the subjects received 100 mg idrapril orally (p.o.) last, and two ingested oral placebo as a double-blind control. Blood pressure (BP) and heart rate (HR) remained unchanged. No serious side effects were observed. ACE inhibition in vivo was evaluated by changes in the ratio of specifically measured plasma angiotensin II (AngII) and AngI concentrations determined by high-performance liquid chromatography/radioimmunoassay (HPLC/RIA) techniques. Plasma ACE activity in vitro was estimated by radioenzymatic assay; it was suppressed by > or = 93% at 15 min after injection of 25 mg idrapril or 5 mg captopril and by 96% 2 h after idrapril intake. Mean AngII levels were decreased dose dependently at 15 min after idrapril injections. At the same time, plasma renin activity (PRA) and AngI increased according to the doses. The AngII/AngI ratio was clearly related to plasma idrapril levels (r = -0.88, n = 60). Oral idrapril inhibited ACE maximally at 1-4 h after dosing, when < 7% of initial ACE activity was observed in vitro and in vivo. Idrapril is a safe and efficient ACE inhibitor in human subjects. It is well absorbed orally. Besides having a slightly slower onset of action, idrapril has pharmacodynamic effects comparable to those of captopril.

[Iatrogenic torsade de pointes induced by thioridazine]

Torsade de pointes is a form of polymorphous ventricular tachycardia in which the polarity of the QRS complex exhibits phasic alterations in both axis. Traditionally, torsade de pointes has been described in association with a congenital or acquired (including drug and metabolic) causes of QT prolongation. Clinical outcomes range from asymptomatic, self-terminating arrhythmias to ventricular fibrillation resulting in cardiac arrest. For the treatment of torsade de pointes, the conventional antiarrhythmic drugs cannot be relied on, cardiac pacing should be instituted as soon as possible; however, as this technique may not always be immediately available, isoproterenol infusion may be the first-choice treatment. Potassium and magnesium repletion appear to be essential in abolishing drug-induced torsade de pointes. This report describes a case of thioridazine-induced torsade de pointes treated efficaciously with magnesium sulphate and overdrive right ventricular pacing.

A placebo-controlled double-blind multicenter study of celiprolol in the treatment of mild and moderate hypertension

This study evaluated the 24-h antihypertensive effect of single daily doses of celiprolol, a beta-1 adrenoceptor antagonist. Patients with supine diastolic BP between 95 and 114 mm Hg started on placebo or celiprolol 200 mg daily for 2 weeks; non-responders received 400 mg daily for 2 weeks and then 600 mg daily for another 2 weeks. Response was defined as a reduction of diastolic BP to 90 mm Hg or below. One hundred ninety patients were evaluated for efficacy, 114 in the celiprolol group and 76 in the placebo group, 84 men and 106 women, mean age 52 years. Blood pressure after 6 weeks fell from 165/103 to 149/92 on celiprolol and from 162/103 to 157/97 on placebo. The fall in systolic and diastolic BP after celiprolol is statistically different (p less than 0.001) from that after placebo. The pulse rate was reduced to a similar extent by the two treatments. The percent of patients with supine diastolic BP either reduced by at least 10 mm Hg or to 90 mm Hg or below, was 66% after celiprolol and 38% after placebo (p less than 0.001). The incidence of adverse reactions was comparable in the two groups: 31% during celiprolol, 25% during placebo. The most frequent reactions observed in both groups were gastrointestinal symptoms, dizziness, fatigue, headache. In conclusion, celiprolol proved to be a safe and effective beta-blocker in the treatment of mild and moderate hypertension.

Celiprolol in the treatment of exercise induced angina pectoris

A multicenter, double-blind placebo controlled study was designed to examine the efficacy of celiprolol in exercise induced angina pectoris. The study consisted of a 4-week placebo run-in period, 6-week titration, 4-week maintenance, 2-week tapering and a 2-week placebo run-out period. Entry criteria were a history of stable angina with chest pain and 1 mm ST segment depression between 3 and 12 min after start of treadmill exercise stress test. Patients started with celiprolol 200 mg daily for 2 weeks; non-responders received 400 mg daily for 2 weeks and then if necessary 600 mg daily for another 2 weeks. A 20% increase over baseline in exercise stress test to onset of angina was considered a response. Ninety-two patients were evaluated, 54 in the celiprolol group and 38 in the placebo group; 63 men and 29 women, mean age 57 years. The celiprolol group was significantly different from placebo after 6 weeks. In particular, exercise time increased by 4.3 min (placebo increased by 0.3 min), ST segment depression reduced by 0.4 mm, notwithstanding the increase in exercise time (placebo increased by 0.2 mm), maximum exercise heart rate reduced by 6 beats per min (placebo increased by 3 beats per min), maximum exercise systolic BP reduced by 14 mm Hg (placebo decreased by 1 mm Hg). The therapeutic success rate based on a 20% increase of exercise time was 85% after celiprolol and zero after placebo. Reduction in weekly angina attacks and nitroglycerin consumption was from 8 to 3 after celiprolol and from 9 to 6 after placebo.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of celiprolol and chlorthalidone in hypertensive patients with reversible bronchial obstruction

The objective of this study was to evaluate the effects of celiprolol, a new beta-blocking drug, on the clinical condition and pulmonary function of hypertensive patients with reversible bronchial obstruction. Celiprolol was compared with chlorthalidone, an antihypertensive drug without known effect on bronchial tone. The study consisted of a 4-week placebo run-in period and a 12-week titration period in which the dose of both drugs was increased at 4-week intervals if blood pressure was not reduced adequately. The doses of celiprolol were 200, 400, or 600 mg once daily; those for chlorthalidone 12.5, 25, or 37.5 mg once daily. Entry criteria were a diastolic blood pressure between 90 and 115 mg Hg, and FEV-1 between 40% and 80% of predicted value, increasing by 15% or more after salbutamol, and a need for occasional bronchodilator therapy. Prophylactic medication for asthma was given in constant dosage for a month before the study and throughout the study. Preliminary results on 66 patients demonstrate that neither drug had a clinically significant effect on FEV-1, FEF 25-75, or FVC. Clinical variables were not significantly changed by either drug: the average monthly asthma attacks fell from 18 to 13 with celiprolol and from 11 to 7 with chlorthalidone. FEF was reduced by more than 50% in two patients on celiprolol and three on chlorthalidone. Monthly asthma attacks increased by more than 100% in five patients on celiprolol and four on chlorthalidone. Thus, preliminary results are unable to demonstrate adverse effects from celiprolol in patients with asthma and hypertension.

Celiprolol in angina pectoris: a controlled study

This double-blind, placebo-controlled, parallel, multicenter study was designed to evaluate the anti-anginal and anti-ischemic effects of celiprolol in patients with stable, exercise-induced angina pectoris. The study began with a 4-week single-blind, placebo run-in, followed by 4 weeks of double-blind active treatment with celiprolol 200, 400, or 600 mg once daily or placebo, and 1 week of a placebo run-out. Patients studied had a history of chronic, stable angina pectoris and myocardial ischemia (greater than or equal to 1.0 mm ST segment depression) within 3-12 min of treadmill exercise (modified Bruce) after 3 and 4 weeks of placebo. After 2 weeks treatment, treadmill testing results indicated a mean time to myocardial ischemia for patients receiving placebo increased by 0.5 min (8%), whereas the increases for celiprolol 200, 400, and 600 mg were 0.8 min (11%), 2.1 min (33%), and 1.1 min (16%) respectively. Mean time to anginal symptoms for placebo patients was increased by 0.6 min (10%), and for celiprolol patients by 1.8 min (27%), 1.5 min (19%), and 1.0 min (14%) respectively at the 3 dose levels. The maximum exercise double product (heart rate X systolic BP) 24 h after medication, was increased by a mean of 373 (2%) after placebo, but decreased by 3301 (-15%), 3400 (-17%), and 3549 (-16%) for celiprolol 200, 400, and 600 mg respectively.(ABSTRACT TRUNCATED AT 250 WORDS)