Update of the PANCCO clinical practice guidelines for the treatment of ulcerative colitis in the adult population

Ulcerative colitis (US) is a chronic disease of unknown etiology. It is incurable and its clinical course is intermittent, characterized by periods of remission and relapse. The prevalence and incidence of the disease has been increasing worldwide. The update presented herein includes the participation of healthcare professionals, decision-makers, and a representative of the patients, all of whom declared their conflicts of interest. Answerable clinical questions were formulated, and the outcomes were graded. The information search was conducted on the Medline/PubMed, Embase, Epistemonikos, and LILACS databases, and covered grey literature sources, as well. The search was updated on November 30, 2020, with no restrictions regarding date or language. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification system was implemented to establish the strength of the recommendation and quality of evidence. A formal consensus was developed, based on the RAND/UCLA methodology and the document was peer reviewed. The short version of the Clinical Practice Guidelines for the Treatment of Ulcerative Colitis in the Adult Population is presented herein, together with the supporting evidence and respective recommendations. In mild-to-moderate UC, budesonide MMX is an option when treatment with 5-ASA fails, and before using systemic steroids. In moderate-to-severe UC, infliximab, adalimumab, vedolizumab, ustekinumab, and tofacitinib can be used as first-line therapy. If there is anti-TNF therapy failure, ustekinumab and tofacitinib provide the best results. In patients with antibiotic-refractory pouchitis, anti-TNFs are the treatment of choice.

Development of high-temperature strain instrumentation for in situ SEM evaluation of ductility dip cracking

Nowadays, the implementation of sophisticated in situ electron microscopy tests is providing new insights in several areas. In this work, an in situ high-temperature strain test into a scanning electron microscope was developed. This setup was used to study the grain boundary sliding mechanism and its effect on the ductility dip cracking. This methodology was applied to study the mechanical behaviour of Ni-base filler metal alloys ERNiCrFe-7 and ERNiCr-3, which were evaluated between 700°C and 1000°C. The ductility dip cracking susceptibility (threshold strain; εmin) for both alloys was quantified. The εmin of ERNiCrFe-7 and ERNiCr-3 alloys were 7.5% and 16.5%, respectively, confirming a better resistance of ERNiCr-3 to ductility dip cracking. Furthermore, two separate components of grain boundary sliding, pure sliding (Sp) and deformation sliding (Sd), were identified and quantified. A direct and quantitative link between grain boundary tortuosity, grain boundary sliding and ductility dip cracking resistance has been established for the ERNiCrFe-7 and ERNiCr-3 alloys.

Seroprevalence of Schistosoma mansoni in Puerto Ricans with inflammatory bowel disease

BACKGROUND

The etiology of Inflammatory Bowel Diseases, Crohn's disease (CD) and ulcerative colitis (UC), is unknown. These diseases have a higher incidence in industrialized countries and their pathogenesis involves an over-reaction of the immune system. A genetic factor is believed to predispose to the development of chronic inflammation in response to an unidentified stimulus. Exposure to infections in childhood may modulate future immune responses. Parasitosis, particularly Schistosomiasis, stimulate Th2 immune responses. It has been hypothesized that the absence of these parasitic infections, as seen in economically developed countries, favors a Th1 response that may result in the clinical appearance of Crohn's disease later in life.

OBJECTIVE

To determine the prevalence of Schistosoma mansoni antibodies in Puerto Ricans with Inflammatory Bowel Disease and controls.

METHODS

Serum from 92 Puerto Ricans with IBD and 106 controls was screened for S. mansoni adult microsomal antigens (MAMA) using the FAST:ELISA assay. Those positive were confirmed with an enzyme-linked immunoelectrotransfer blot test.

RESULTS

Seven serum samples (3 UC and 4 controls) were positive for S. mansoni antibodies. There was no significant difference between groups in gender, municipality of origin or seroprevalence of Schistosomiasis. The control group was slightly older than the IBD group.

CONCLUSIONS

Our study did not demonstrate an inverse relation between Schistosomiasis and IBD. However, the decreasing prevalence of Schistosomiasis in the general population of Puerto Rico may account for this result.

Ileal pouch-anal anastomosis for ulcerative colitis: the University of Puerto Rico experience

OBJECTIVE

To review the experience with ileal pouch-anal anastomosis surgery for ulcerative colitis at the University Hospital.

BACKGROUND

As many as 40% of patients with ulcerative colitis (UC) and 75% with Crohn's disease (CD) require some surgery for their disease. The number of patients referred to our clinics for evaluation and management of Inflammatory Bowel Disease (IBD) has risen in the past seven years. A multidisciplinary IBD service has been created at the University Hospital for the care of these patients, leading to a dramatic increase in the number of surgeries performed for IBD. Over the past decade the ileal pouch-anal anastomosis (IPAA) has emerged as the procedure of choice in most patients with ulcerative colitis requiring total colectomy for management of their disease. Even though the procedure is associated with a considerable morbidity rate, it has become very popular since it avoids the need for a permanent stoma and presumably rids the patient of disease and subsequent cancer risk.

RESULTS

Twenty-five patients were identified as having IPAA for ulcerative colitis between 1993-2000. Indications for surgery were intractability and toxic megacolon. Complications were pouchitis in 11/25 (44%), anastomotic stricture in 6/25 (24%), small bowel obstruction in 4/25 (16%), and pouch failure in 2/25 (8%). Other complications included wound abscess in 1/25 (4%), and sexual dysfunction in 1/25 (4%) patients. There was no mortality; the patients' quality of life was rated as greatly improved in 14 of 17 patients interviewed (82.4%) and 16 of 17 said they would recommend the surgery to others (94.1%).

CONCLUSIONS

The results of IPAA surgery, morbidity, mortality, and patient satisfaction in our series were similar to other centers around the world.

Profile of the inflammatory bowel disease patient with depressive disorders

OBJECTIVE

To describe the demographic and clinical characteristics of patients attending the Inflammatory Bowel Disease Clinic of the University of Puerto Rico School of Medicine and determine whether these characteristics are risk factors for the development of a depressive disorder.

METHOD

Sixty-seven patients attending the Inflammatory Bowel Disease Clinic of the University of Puerto Rico School of Medicine were assessed for the presence of depressive symptoms using a simple questionnaire (CES-D) and a detailed diagnostic evaluation (CIDI-DSM IV Module E). Age, gender, education, time of IBD diagnosis, duration of treatment, psychiatric history, treatment with corticosteroids, and activity of IBD were determined and correlated with the presence of depressive symptoms and depressive diagnosis. Study data was tabulated on Epi-Info 6.0 and it was analyzed using SPSS version 10. Univariate (includes means and frequencies), bivariate (t-student, Kruskal Wallis and Chi-square) and multivariate analyses (logistic regression) were performed.

RESULTS

Patients older than 34 years old had three times higher probability of developing a depressive disorder (p = 0.043, OR = 3.22). Patients with a psychiatric history had seven times higher probability of developing depressive disorder (p = 0.004, OR = 7).

CONCLUSION

The risk factors identified with an increased probability of developing a depressive disorder were age older than 34 years and psychiatric history.

Osteopenia in Puerto Ricans with Crohn's disease

BACKGROUND

Osteopenia has been reported in association to Inflammatory Bowel Disease, and in particular Crohn's disease. The use of corticosteroids, resection of the ileum, malabsorption, poor calcium intake, and the effect of inflammatory cytokines have all been considered as contributing factors. As Crohn's disease is more prevalent in young people, when peak bone mass is achieved, the presence of osteopenia is especially significant.

OBJECTIVES

The aim of this study was to evaluate the bone density of patients with Crohn's disease in the University of Puerto Rico IBD Clinic; to determine the prevalence of osteopenia in these patients and to correlate bone mineral density with risk factors for osteopenia.

METHODS

Sixty-six patients, 30 males and 36 females were included. After informed consent, demographic, clinical and metabolic data was obtained. Serum albumin, calcium, inorganic phosphorus and alkaline phosphatase were measured. Body mass index (BMI) was calculated. Bone density was determined by DEXA of the lumbar spine and femur and expressed as the Z score (standard deviations from normal correlated with sex and age). Severe osteopenia was a Z score > or = -2 and osteopenia was Z < or = -1.99 or > or = 1.01. Results were expressed in means. Pearson correlation coefficient was used for quantitative variables and Pearson chi-square for categorical values.

RESULTS

Osteopenia was present in the hip in 69% and in the lumbar spine in 68%. Most patients had received steroids; the difference between treated and not treated patients was not significant. Osteopenia did not correlate with ileal resection, gender, BMI, disease characteristics or biochemical parameters.

CONCLUSIONS

Low bone density was frequent in patients with Crohn's disease, but no specific risk factors could be identified. Bone density should be determined in patients with Crohn's disease in order to institute appropriate therapeutic measures.

Fine-needle aspiration diagnosis of hydatid cyst

The diagnosis of hydatid disease outside endemic areas is usually not suspected. Hydatid cysts in imaging studies can be confused with hepatic tumors, abscesses, cystadenomas, liver cysts or other lesions. Serology is the usual confirmatory test, but cytologic diagnosis has been described. Aspiration of the cysts has not been employed as a routine diagnostic method for fear of spillage and anaphylactic reactions. We report a case of unsuspected hepatic echinococcosis that was confirmed by fine-needle aspiration of the lesion and cytologic confirmation without complications.

Steroid therapy in fulminant hepatic failure secondary to autoimmune hepatitis

Autoimmune hepatitis is a chronic inflammatory liver disorder of unknown etiology associated with serum autoantibodies and hypergammaglobulinemia. This disease has a broad spectrum of presentations ranging from asymptomatic to fulminant hepatic failure. A 36 year old female with past history of hypothyroidism developed jaundice 2 months prior to admission. Outpatient evaluation revealed ANA and anti-SMA antibodies in high titers, negative viral markers for hepatitis, and hypergammaglobulinemia. A presumptive diagnosis of autoimmune hepatitis was made; steroids were recommended but the patient did not take them. She was admitted to the University Hospital due to increased jaundice, general malaise and ascites 5 weeks later. She deteriorated developing coagulopathy, encephalopathy and increasing hyperbilirubinemia. Intravenous corticosteroids were started. The patient improved and was discharged 3 weeks after admission. Fulminant hepatic failure has a high mortality and may require liver transplant. Our patient survived fulminant hepatic failure that resolved after corticosteroid therapy. It is important to identify and distinguish autoimmune hepatitis from other forms of liver disease because of the high percentage of response to immuno-suppressive therapy. Early diagnosis and treatment of this condition could improve survival, quality of life, and defer liver transplantation.

Chronic hepatitis C: treatment comparison between 3 and 5 million units of interferon alpha-2b

Interferon (IFN) is the only drug that has been approved by the FDA for therapy of chronic hepatitis C. However, optimal dose and duration of therapy are still controversial. This study compares the effectiveness of treatment of chronic hepatitis C patients with 3 vs. 5 million units (MU) of recombinant alpha-interferon 2-b three times per week. We also evaluated the relapse rate with a shorter 12 week-course of therapy in those patients who had normalization of aminotransferases by week 12. Seventy-five patients were randomized to receive either 3 vs. 5 MU of IFN; seventy-two completed the study. A complete response was seen in 11/35 (31%) of those treated with 5 MU vs. 13/37 (35%) in the 3 MU dose (p = 0.74). Patients were followed after IFN was withdrawn and only 2 had persistently normal aminotransferases. Analysis of multiple variables was done to predict response to IFN and only elevations of GGT, ferritin and alkaline phosphatase were found to be predictors of a poor response. Therefore, we recommend initial therapy with 3 MU of IFN for a longer period than 12 weeks in patients who show a response.

Cerebral thrombosis associated with active Crohn's disease

An increased incidence of cerebral thromboembolic events has been reported in young patients with inflammatory bowel disease (IBD). It has been suggested that a hypercoagulable state is associated with clinical activity of the disease, with elevation of factors V, VIII, fibrinogen and platelets and a lowering of anti-thrombin III. We present the case of a 35 y/o male with refractory Crohn's disease who complained of headaches, blurred vision and tonic-clonic seizures. The studies demonstrated an ischemic stroke of the left cerebral hemisphere, without vascular abnormalities. Elevation of factor VIII, platelets, and antithrombin III were found. The symptoms were relieved with medical treatment and the patient has continued in good health after resection of the diseased terminal ileum.

[Viral contamination of food products: a poorly understood public health problem]

Throughout the world there have been several epidemics of food-borne diseases (FBD) about which there is lack of sufficient information for public health institutions to take appropriate measures. This study was conducted for the purpose of contributing to the dissemination of information on these diseases and their etiologic agents, epidemiology, and control. The study was based on data from 61 sources, including review articles, reports of outbreaks, and databases. Results reveal considerable underregistration and lack of data on FBD throughout the various countries, with viruses being the second most important cause of FBD in the United States of America. Two agents, Norwalk virus and hepatitis A virus, were the fifth and sixth most frequent causes, respectively, although the former was the single most frequent cause of FBD in 1982 and the second most frequent cause of water-borne diseases during the period from 1986 to 1988. Despite the scarcity of information on the problem, rotavirus, poliovirus, hepatitis E virus, astrovirus, and small gastroenteric viruses are also important causes of FBD. We also discuss the importance of viral zoonoses, especially hemorrhagic fevers transmitted by contact with rodent feces and tick-borne viral encephalitides (Lassa fever). There is discussion of the controversial mad cow disease and its potential transmission through food products, as well as of dietary aspects of the management of AIDS and other viral infections. Finally, measures for the prevention and control of FBD are described.

Sustained response to interferon in a patient with common variable immunodeficiency and hepatitis C

Hepatitis C infection progresses faster in patients with hypogammaglobulinemia, often leading to death from liver failure within 10 yr of exposure. Response to interferon treatment has been poor in these patients. We report the case of a patient with common variable immunodeficiency and hepatitis C in whom a sustained biochemical and viral remission was obtained after treatment with interferon.

Both psoriasis and benign migratory glossitis are associated with HLA-Cw6

This study was undertaken to investigate human leucocyte antigen (HLA) associations with benign migratory glossitis and psoriasis in Brazilian patients and particularly to determine whether benign migratory glossitis is also associated with HLA-Cw6, the classical association observed in psoriasis. The results showed a highly significant association of Cw6 with both psoriasis and benign migratory glossitis, with this antigen being present in 59.1% of the patients with psoriasis, in 43.8% of the patients with benign migratory glossitis, and in only 12.6% of the controls. Other significant positive associations, although at a lower significance level, were with B13, both in psoriasis and in benign migratory glossitis, and with B17, only in psoriasis. To our knowledge, this is the first report on the association of Cw6 with benign migratory glossitis. We believe that this finding reinforces the concept of a pathogenetic relationship between benign migratory glossitis and psoriasis.

Prevention of recurrent esophageal bleeding and survival in patients with alcoholic cirrhosis: a randomized study

OBJECTIVES

To compare endoscopic sclerotherapy, propranolol and distal splenorenal shunt in the prevention of rebleeding esophageal varices and mortality in alcoholic cirrhotics.

METHODS

Forty-three alcoholic cirrhotics that had bled from esophageal varices were randomized to sclerotherapy (13), shunt (15) or propranolol(15). Outcomes measured were rebleeding from varices and death.

RESULTS

There was no significant difference between the three treatment groups in relation to rebleeding rate or death. Continued alcohol consumption did not influence outcome.

CONCLUSIONS

All three therapies were equally effective in preventing rebleeding from varices.

Esophageal motility patterns in a Puerto Rican population

One hundred consecutive patients underwent esophageal motility testing at the Gastroenterology Section of the University Hospital for symptoms of esophageal dysfunction. These were dysphagia (55), non cardiac chest pain (11), gastroesophageal reflux (32), and other (2). Fifty five studies were abnormal. The most frequent findings were achalasia in fourteen patients and nonspecific esophageal motility disorder in fourteen. When the clinical presentation was correlated with the results of the study, 35 of the 55 patients with dysphagia had an abnormal study, as compared with 5 of 11 with chest pain and only 12 of 32 with reflux symptoms. These findings compare with those reported elsewhere and suggest that esophageal motility studies are most useful in the diagnosis of patients presenting with dysphagia or non cardiac chest pain.

Idiopathic hemochromatosis: a study in a large Puerto Rican family

We studied 13 first-degree relatives in a large family with an index case of idiopathic hemochromatosis to detect the relatives with evidence of iron overloading. Serum iron, total iron binding capacity (TIBC), and serum ferritin levels were measured in all family members. We also performed HLA typing to identify the relatives who are homozygous with the proband and genetically predisposed to develop the disease. The family was composed of the parents and 12 siblings including the index case. The mean age of the siblings was 25 years. None presented with evidence of iron overload by the iron biochemical tests. HLA typing demonstrated six homozygous siblings with the proband. In separate analysis these siblings did not present abnormalities in any of the iron biochemical tests. These homozygous relatives were followed for one year after initial evaluation and none presented abnormalities in the iron studies during this period. These results are contradictory to other previous studies done in families with idiopathic hemochromatosis. The most feasible explanations for these findings are the young age of these siblings and the predominance of females among them. We consider that these homozygous relatives must be followed for their life-times with iron studies to detect a possible increase in iron stores as expected in later ages.

Idiopathic hemochromatosis in a young man presenting with palpitations

A 32-year-old male presented with palpitations and an elevated serum iron. Further evaluation revealed elevated serum ferritin, and a liver biopsy confirmed the diagnosis of hemochromatosis. Cardiovascular workup was normal except for sinus bradycardia alternating with sinus tachycardia in the 24-hour Holter study. Treatment with weekly phlebotomies was started and the family is being studied for early diagnosis of any other case of hemochromatosis. The manifestations, diagnostic workup, and the importance of early diagnosis of hemochromatosis is stressed.

Phenytoin induced fatal hepatic injury

A 61 year old female developed fatal hepatic failure after phenytoin administration. A typical multisystem clinical pattern precedes the manifestations of hepatic injury. The hematologic, biochemical and pathologic features indicate a mixed hepatocellular damage due to drug hypersensitivity. In a patient receiving phenytoin who presents a viral-like illness, early recognition and discontinuation of the drug are mandatory.

Immunological disturbance in West and Lennox-Gastaut syndromes

Cell-mediated and humoral immunity were investigated in 18 patients with West syndrome, 12 with Lennox-Gastaut syndrome and 19 healthy controls. The study included determination of T and B peripheral blood lymphocytes, serum levels of IgG, IgA and IgM, skin sensibilization with DNCB, intracutaneous PHA, leucocyte migration inhibition test and lymphocyte blastic transformation in the presence of PHA. Cell-mediated deficiency was detected in 28 children whereas low levels of immunoglobulins were observed only in 6 children. Immunological disturbances were more prominent in children with West syndrome.