SIED-GISCOR recommendations for colonoscopy in screening programs: Part I - Diagnostic

The implementation of FIT programs reduces incidence and mortality from CRC in the screened subjects. The ultimate efficacy for CRC morbidity and mortality prevention in a FIT program depends on the colonoscopy in FIT+ subjects that has the task of detecting and removing these advanced lesions. Recently, there has been growing evidence on factors that influence the quality of colonoscopy specifically withing organized FIT programs, prompting to dedicated interventions in order to maximize the benefit/harm ratio of post-FIT colonoscopy. This document focuses on the diagnostic phase of colonoscopy, providing indications on how to standardise colonoscopy in FIT+ subjects, regarding timing of examination, management of antithrombotic therapy, bowel preparation, competence and sedation.

Dasatinib-induced Crohn's-like colitis

Dasatinib is a second-generation multityrosine kinase inhibitor used in the first-line and second-line treatment of Philadelphia chromosome-positive leukaemia. The most frequent type of Dasatinib-induced intestinal injury is haemorrhagic colitis; other morphologic patterns include apoptotic colopathy, CD8+ T-cell-mediated colitis and non-specific colitis. Aim of this study is to describe a novel Crohn's-like histopathologic pattern of Dasatinib-induced colitis. Four patients developed diarrhoea during Dasatinib treatment; colonoscopy was performed and biopsy sets were taken for histological analysis. All patients showed patchy, chronic active inflammation with cryptitis and microgranulomas (two patients). Ileal and rectal biopsies showed either no or mild, focal inflammation. An increase in lamina propria eosinophils was seen (two patients) and apoptoses were seen (three patients). Complete remission was observed after interruption of treatment. Dasatinib-induced colitis and Crohn's disease may share histologic features including microgranulomas, which can potentially lead to misdiagnosis if no information on treatment is provided.

The PROSIT Cohort of Infliximab Biosimilar in IBD: A Prolonged Follow-up on the Effectiveness and Safety Across Italy

BACKGROUND

We report a prospective, nationwide cohort evaluating the safety and effectiveness of CT-P13.

METHODS

A structured database was used to record serious adverse events (SAEs), clinical remission/response, inflammatory biomarkers (CRP and calprotectin), and endoscopic findings.

RESULTS

Eight hundred ten patients with inflammatory bowel disease (IBD) (452 Crohn's disease [CD]) were enrolled. Four hundred fifty-nine patients were naïve to anti-TNFα (group A), 196 had a previous exposure (group B), and the remaining 155 were switched to CT-P13 (group C). All patients were included in the safety evaluation with a mean follow-up of 345 ± 215 days and a total number of 6501 infusions. One hundred fifty-four SAEs were reported (19%), leading to cessation of the biosimilar in 103 subjects (12.7%). Infusion reactions were 71, leading to cessation of the biosimilar in 53 subjects (6.5%), being significantly more frequent in patients pre-exposed to anti-TNFα (P = 0.017). The efficacy of therapy was calculated in 754 IBD patients, with a mean follow-up of 329 ± 202 days. Forty-eight patients had a primary failure (6.4%), and 188 (25.6%) lost response during follow-up. Six hundred twenty-eight (364 CD) and 360 IBD patients (222 CD) completed the follow-up at 6 and 12 months, respectively. At 12 months, patients without loss of response were 71%, 64%. and 82% in groups A, B, and C, respectively (log rank P = 0.01). Clinical/endoscopic scores and inflammatory biomarkers dropped significantly in CD and UC patients (P = 0.01 and P < 0.0001) compared with baseline.

CONCLUSIONS

In this large prospective cohort, no further signals of difference in safety and effectiveness of CT-P13 in IBD has been observed.

A simplified clinical risk score predicts the need for early endoscopy in non-variceal upper gastrointestinal bleeding

BACKGROUND

Pre-endoscopic triage of patients who require an early upper endoscopy can improve management of patients with non-variceal upper gastrointestinal bleeding.

AIMS

To validate a new simplified clinical score (T-score) to assess the need of an early upper endoscopy in non variceal bleeding patients. Secondary outcomes were re-bleeding rate, 30-day bleeding-related mortality.

METHODS

In this prospective, multicentre study patients with bleeding who underwent upper endoscopy were enrolled. The accuracy for high risk endoscopic stigmata of the T-score was compared with that of the Glasgow Blatchford risk score.

RESULTS

Overall, 602 patients underwent early upper endoscopy, and 472 presented with non-variceal bleeding. High risk endoscopic stigmata were detected in 145 (30.7%) cases. T-score sensitivity and specificity for high risk endoscopic stigmata and bleeding-related mortality was 96% and 30%, and 80% and 71%, respectively. No statistically difference in predicting high risk endoscopic stigmata between T-score and Glasgow Blatchford risk score was observed (ROC curve: 0.72 vs. 0.69, p=0.11). The two scores were also similar in predicting re-bleeding (ROC curve: 0.64 vs. 0.63, p=0.4) and 30-day bleeding-related mortality (ROC curve: 0.78 vs. 0.76, p=0.3).

CONCLUSIONS

The T-score appeared to predict high risk endoscopic stigmata, re-bleeding and mortality with similar accuracy to Glasgow Blatchford risk score. Such a score may be helpful for the prediction of high-risk patients who need a very early therapeutic endoscopy.

Two Case Reports of Biliary Tract Injuries during Laparoscopic Cholecystectomy

Background and Study Aims. Biliary tract injuries (BTI) represent the most serious and potentially life-threatening complication of cholecystectomy occurring also during laparoscopic approaches. Patients and Methods. We describe and discuss two different cases of BTI occurring during laparoscopic cholecystectomy (LC). Results. Two patients developed BTI during LC and one evidenced the complication during the LC itself and was treated during the same LC in real time. The other patient evidenced BTI only after the primary intervention and was successfully reoperated in laparotomy after 10 days from the LC. Conclusions. The factors that predispose to the occurrence of BTI during cholecystectomy and the cautions to be used to prevent BTI are discussed.

Two-dimensional fetal echocardiography: where we are

Congenital Heart Disease (CHD) is the most common severe congenital abnormality in the newborn and the cause of over half the deaths from congenital anomalies in childhood. Prenatal diagnosis, possible as early as 15 weeks of gestation, allows physicians and families the greatest number of therapeutic options, and can improve the postnatal outcome. There are several potential indications for performing such examination. Evaluation of the heart in the setting of restricted fetal growth or fetal distress is often recommended. Whenever extracardiac anomalies are detected during fetal ultrasound examination or in presence of chromosomal abnormalities detected with amniocentesis, cardiac assessment is mandatory. The test should also be performed as part of the assessment of fetal arrhythmias. Finally, whenever congenital heart disease is suspected for other reasons, such as maternal exposure to teratogenic substances or a parental history of previous children with congenital lesions, the examination should be considered. The performance of a fetal echocardiogram requires experience and a systematic approach. Guidelines for training have been formulated, and only qualified individuals should perform this highly specialized examination. A description of the techniques of heart examination is presented below.

[The use of transvaginal ultrasound following voluntary interruption of pregnancy to reduce complications due to incomplete curettage]

AIM

The aim of the study was to assess by what percentage the use of transvaginal ultrasound (TV, curettage) following voluntary interruption of pregnancy (IVG) reduces the incidence of haemorrhagic events resulting from incomplete drainage of the cavity during the first trimester of gestation.

METHODS

The present is a randomized prospective study involving 720 women who in the period between January 2005 and January 2007 underwent drainage of the cavity during the first trimester of gestation. The study group involved 360 women who were submitted to TV ultrasound using the Toshiba JustVision 400 system at the end of the surgical procedure. The control group also numbered 360 women; they, by contrast, did not undergo ultrasound examination at the end of surgery. In the study group, in those cases in which the ultrasound examination carried out with a TV probe highlighted an endometrial rima of thickness 8 mm, recurettage was carried out. Patients then underwent further gynecological and ultrasound control examination, 5-8 days after the surgical procedure.

RESULTS

The index of complications overall was 3.2%. Retained products of conception were encountered in 2 women in the study group (0.5%) and in 13 women from the control group (3.6%, P<0.05). Vaginal bleeding requiring hospitalization was observed in 2 women in the study group (0,5%) against 6 in the control group (1.6%, P=0.2). Cases of endometritis were diagnosed in only one woman in the study group (0.3%) against 5 in the control group (1.4%) and uterine perforation occurred in only one woman in the control group versus no case in the study group. There were no cases of retained products of conception in women presenting endometrial thickness <8 mm, a dimension obtained with the aid of ultrasound at the end of the surgical procedure.

CONCLUSION

The use of ultrasound examination, carried out with the aid of a TV probe immediately following uterine drainage during the first trimester of pregnancy, may considerably reduce the incidence both of post-IVG haemorrhages due to incomplete curettage and of the total number of complications. Evaluation of endometrial thickness is of crucial importance. If this turns out to be =8 mm at the end of the surgical procedure, recurettage of the uterine cavity is indicated.

Endoscopic management of symptomatic choledocholithiasis in pregnancy without the use of radiations

We report a case of 26-year-old woman at 10th week of gestation with cholestatic jaundice due to a common bile duct (CBD) stone managed by endoscopical retrograde cholangiopancreatography (ERCP). The procedure was successfully carried out without the use of ionizing radiations and under trans-abdominal ultrasonographical (US) control. A few cases are reported in literature in which ERCP was performed without fluoroscopy examination. We believe that ERCP with US guidance is an effective and safe procedure to treat symptomatic choledocholithiasis in pregnant women.

p53 codon 72 polymorphism in patients affected with ulcerative colitis

BACKGROUND

The p53 tumor suppressor protein plays a fundamental role in maintaining genomic integrity through its ability to arrest the cell cycle in G1 and induce apoptosis. The proapoptotic activity of p53 seems to be strictly related to proline-rich regions, homologous to the SH3 binding domain. In the literature, reported data suggest a role for polymorphism at codon 72 of p53 in the predisposition to neoplastic transformation, although the results are still controversial. In this study, we investigated Arg72Pro polymorphism of p53 and related this polymorphism to clinical parameters in patients affected with ulcerative colitis (UC).

METHODS

We studied 243 consecutive outpatients affected with well-established UC. The control group comprised 142 healthy blood donors, with age and sex comparable to those of the patients.

RESULTS

p53 Pro/Pro was significantly related to the clinical course and duration of disease (odds ratio, 55.8 and 8.8, respectively). Nineteen of 24 patients with Pro homozygosity had a duration of disease >7 years. In contrast, 87 of 123 patients with Arg/Arg had short-standing UC (< or =7 yrs) and 66 of 96 with Arg/Pro had short-standing UC (chi-squared, 22.86; P < 0.0001). Thirty-four of 243 patients affected with UC had a positive family history for colorectal carcinoma (CRC). In those patients p53, Pro/Pro was significantly related to a family history of CRC (odds ratio, 38.1).

CONCLUSIONS

These preliminary data suggest that polymorphism at codon 72 of the p53 gene influences the clinical course of UC, with continuous disease associated with p53 Pro homozygosity.

Concomitant treatment of brain metastasis with whole brain radiotherapy [WBRT] and temozolomide [TMZ] is active and improves quality of life

BACKGROUND

Brain metastases (BM) represent one of the most frequent complications related to cancer, and their treatment continues to evolve. We have evaluated the activity, toxicity and the impact on Quality of Life (QoL) of a concomitant treatment with whole brain radiotherapy (WBRT) and Temozolomide (TMZ) in patients with brain metastases from solid tumors in a prospective Simon two stage study.

METHODS

Fifty-nine patients were enrolled and received 30 Gy WBRT with concomitant TMZ (75 mg/m2/day) for ten days, and subsequently TMZ (150 mg/m2/day) for up to six cycles. The primary end points were clinical symptoms and radiologic response.

RESULTS

Five patients had a complete response, 21 patients had a partial response, while 18 patients had stable disease. The overall response rate (45%) exceeded the target activity per study design. The median time to progression was 9 months. Median overall survival was 13 months. The most frequent toxicities included grade 3 neutropenia (15%) and anemia (13%), and only one patient developed a grade 4 thrombocytopenia. Age, Karnofsky performance status, presence of extracranial metastases and the recursive partitioning analysis (RPA) were found to be predictive factors for response in patients. Overall survival (OS) and progression-free survival (PFS) were dependent on age and on the RPA class.

CONCLUSION

We conclude that this treatment is well tolerated, with an encouraging objective response rate, and a significant improvement in quality of life (p < 0.0001) demonstrated by FACT-G analysis. All patients answered the questionnaires and described themselves as 'independent' and able to act on their own initiatives. Our study found a high level of satisfaction for QoL, this provides useful information to share with patients in discussions regarding chemotherapy treatment of these lesions.

[Hypercoagulability during pregnancy: evidences for a thrombophilic state]

AIM

The development of thrombotic disorders is a major threat for young women during pregnancy. It is one of the main causes of pregnancy-related disorders, which may also result in harm for the conceptus. Successful pregnancies require an even balance of coagulation and fibrinolysis, in order to secure stabilization of the basal plate as well as adequate placental perfusion. Broad spectrum assays which measure a range of thrombin/fibrin formation in serum have become an established means of identifying activation of blood coagulation and/or fibrinolysis. There is considerable interest in the application of these assays to the diagnosis of other hypercoagulable states, such as thrombophilia during pregnancy. We investigated coagulation/fibrinolysis parameters for significant differences between pregnant women during their gestation (first, second and third trimester) with or without pregnancy loss and healthy nonpregnant women.

METHODS

Thirty-nine pregnant women, aged 24-39 years, were studied. They were subdivided according to pregnancy trimester: 15 patients in the first trimester; 13 in the second and 11 in the third. The selection of patients was carried out in cooperation with the Transfusion Center of the Second University of Naples in order to obtain a homogeneous sample group. The control group included 400 healthy patients. Biochemical and blood coagulation tests were performed for each patient and the results obtained were compared with the control group.

RESULTS

A decrease in free protein S (PS) and fibrinolysis (t-PA/PAI-1) activities and an increase in Factor VII, Factor VIII, prothrombin fragment 1+2 (F1+2), D-dimer (D-dimer) were observed in pregnant women during the follow-up of gestation. However, there were statistical differences between the groups of women with one or more pregnancy loss where it was found the lowest values in t-PA and PAI and the highest values in FVII and F1+2. Among subjects with more than one abortion, coagulation/fibrinolysis derangements before the partum were more prominent. A significant association exists between consecutive recurrent abortions and pregnancy complications such as placental abruption, hypertensive disorders and CS. This association persists after controlling for variables considered to coexist with recurrent abortions.

CONCLUSIONS

These findings suggest that an excessive hypercoagulable state is associated with the termination of pregnancy resulting into a moderate risk for thrombosis during the different trimesters of pregnancy. The follow-up of fibrinolytic markers could represent a useful diagnostic tool for termination of pregnancy.

Increased risk of breast cancer in first-degree relatives of Crohn's disease patients. An IG-IBD study

BACKGROUND

Increased rates of colorectal cancer have been reported in patients with ulcerative colitis as well as with Crohn's colitis. This risk could be the result of shared genetic susceptibility and could be co-inherited rather than being just secondary to a long-standing, extensive mucosal inflammation.

AIM

To assess the prevalence of all malignancies in first-degree relatives of Crohn's disease patients in order to establish whether any association exists.

PATIENTS AND METHODS

A total of 632 outpatients with a diagnosis of Crohn's disease and 632 control subjects were recruited. Information concerning the presence of malignancies was collected in 3,292 first-degree relatives of Crohn's disease patients and in 3,303 first-degree relatives of controls.

RESULTS

Two hundred and fourteen (6.5%) subjects were found to be affected by malignancy in the first-degree relatives of Crohn's disease patients and 180 (5.5%) in the first-degree relatives of controls. Forty-seven (7.4%) of Crohn's disease patients had a first-degree relative with IBD, but none of them had cancer. The frequency of extra-intestinal malignancies was higher in first-degree relatives of Crohn's disease patients than in those of controls (p=0.011). Frequency of breast cancer in female relatives of Crohn's disease patients, mainly in mothers, was two-fold higher than that in controls (0.91% versus 0.42%; odds ratio=2.16; 95% confidence interval=1.14-4.08; p=0.015). The presence of breast cancer showed no association with any specific phenotype of disease in Crohn's patients.

CONCLUSIONS

These results did not corroborate the hypothesis about a common genetic susceptibility between Crohn's disease and colorectal cancer. An unexpected finding was the more frequent occurrence of extra-digestive malignancies. The prevalence of breast cancer in first-degree relatives of Crohn's disease patients, in particular the mothers, was more than double than in those of controls. This association, if confirmed, would suggest that there may exist common genetic and/or environmental factors for Crohn's disease and breast cancer.

[The effects of phytoestrogen therapy on the endometrium in postmenopausal women]

AIM

The purpose of the present study was to carry out a comparative histological analysis of the endometrium in postmenopausal women who made use of phytoestrogens in order to assess the efficacy and possible side effects of this therapy.

METHODS

This study was carried out by forming 2 groups in order to compare the results. One group was given a dietary supplement of phytoestrogens for 24 months, whereas the other was given a placebo for the same period of time. At the beginning of this study endometrial bioptical samples were taken from those patients who had been previously selected at our University Centre. This study was started only with those postmenopausal patients whose bioptical sample was histologically suitable, and it was neither hyperplastic, nor cancerous and nor secretive. During these 24 months there have been frequent contacts aimed at verifying the standard therapeutic behaviour, symptoms and appearance of side effects. At the end of the study new and final bioptical samples of endometrium were taken from both groups.

RESULTS

One-hundred and forty-one patients completed the study. Five patients (3.4%) who were submitted to phytoestrogens therapy showed a weak proliferative endometrium bioptical sample. All the other biopsies at the beginning and at the end of the study showed an atrophic and inactive sample. Hot flushes, night sweats, vaginal dryness and dyspareunia improved at the end of the study for the group treated with phytoestrogens as compared to the one treated with a placebo. Although there have not been very significant differences ias to symptoms and side effects, it was noted that insomnia was the most common symptom in the group treated with non-hormonal therapy based on phytoestrogens.

CONCLUSIONS

Phytoestrogens did not cause any sensitive and worrisome stimulation of the endometrial mucosa. Insomnia was more frequent in the group treated pharmacologically in the 24 months of the study, whereas hot flushes, night sweats, vaginal dryness and dyspareunia persisted or increased as compared to the beginning of the study in the group treated with a placebo, but this did not occur for the group treated with phytoestrogens.

Worse clinical course of disease in Crohn's patients with previous appendectomy

OBJECTIVES

The aim of the present study was to assess the effect of previous appendectomy in a series of Crohn's disease (CD) patients on the clinical characteristics and course of disease.

METHODS

Demographic and clinical data were retrospectively analysed for 129 consecutive outpatients (68 men and 61 women, median age 38 years) with CD. For each patient, information concerning appendectomy, indication for surgery (acute/chronic) and the date of surgery were recorded. The date of the appendectomy in relation to the date of CD diagnosis was carefully assessed in order to evaluate the precise relationship between the two events. A total of 129 CD patients who had not undergone previous appendectomy served as controls. The severity of disease was assessed retrospectively by evaluating the need for systemic steroids, immunosuppressants and surgical treatment for CD, particularly resective procedures.

RESULTS

Forty-one CD patients (31.8%) underwent appendectomy before the diagnosis of disease. Appendectomy before diagnosis showed a negative association with colonic disease localization and with articular manifestations. In addition, the 41 patients with previous appendectomy had a significantly greater risk of surgery, particularly resective. Multivariate analysis confirmed appendectomy performed before diagnosis as an independent risk factor for surgery; on the contrary, colonic site and inflammatory type of disease were independent factors protecting against surgery. Although current smokers were at an increased risk of surgical treatment, a smoking habit alone did not seem to be relevant at the multivariate analysis.

CONCLUSION

The results of this study indicate a worse clinical course of CD in patients appendicectomized before diagnosis.

Serum p53 antibodies in patients affected with ulcerative colitis

During tumor progression, the accumulation in genetic alterations is a fundamental characteristic of malignant cells. p53 gene is frequently mutated in human tumor. Cellular accumulation of p53 protein can initiate an immune response with generation of circulating anti-p53 antibodies. Patients with ulcerative colitis have an increased risk of developing colorectal neoplasm and, among the different genes involved in carcinogenesis, p53 may play a key role. Sera and tissues from 97 patients (M = 53, F = 44) affected with ulcerative colitis (UC) were collected. Serum anti-p53 antibodies (p53Abs) were detected in duplicate with ELISA method. Serum p53Abs were detectable in 9.3% (9/97) of patients affected with UC. In these patients, the titer of p53Ab ranged between 3.1 and 14.9 U/mL (mean, 6.6 U/mL; SD, 4.64). Serum p53Abs were undetectable in control group. With an immunoluminometric assay for the quantitative determination of p53, we found 9/97 positive samples (> or = 0.69 mg/mg of total proteins). In contrast, the samples of the remaining 89 patients were found negative (< or = 0.30 mg/mg of total proteins). All patients that were positive for anti-p53 antibodies were also positive with p53 protein accumulation in the tissue of colonic biopsies. In UC, follow-up with colonoscopy has several advantages. The colonoscopy is not well accepted by patients, and poor patient observance has the potential to seriously devalue the technique as a screening tool, despite practical considerations of competence within endoscopy service. Serological detection of p53Abs by enzyme-linked immunosorbent assay (ELISA) is easy to perform, does not require tumor specimen, can be performed in a routine diagnostic procedure, may be used in clinical practice, and could facilitate physicians in patient monitoring. We suggest that serum p53Abs assessment, indirect marker for p53 gene mutations, and abnormally high p53 protein levels could be considered to have a potential for use as a complementary test to improve surveillance program performance.

Intestinal permeability assessment before and after ileal pouch-anal anastomosis

AIM

Intestinal permeability is considered an index of anatomic and functional integrity of the small intestine mucosa. Altered intestinal permeability has been suggested to be a possible cause of pouchitis. Aim of this paper was to assess variations in intestinal permeability during the first year of a pouch reconstruction.

METHODS

Intestinal permeability (IP) was investigated in 8 ulcerative colitis patients before and after total proctocolectomy, with ileal pouch-anal anastomosis (IPAA), by means of the cellobiose/mannitol test. To each patient a basal test (before surgery) and 3 more tests during a 1 year follow-up were administered.

RESULTS

Individual data were altered despite clinical findings in 9 of 30 IP measured values. An overall pattern of unaffected permeability was however shown and none of our patients, during the first year follow-up, has developed pouchitis.

CONCLUSIONS

Six of the 8 investigated patients presented at least 1 altered IP value. A longer follow-up aimed to further investigate patients beyond the first year after IPAA confection as to the occurrence of pouchitis and its possible correlation with a previous permeability alteration of the pouch mucosa is in progress.

[Thrombophilic syndrome associated to phenotypic resistance to activated protein C in postmenopausal women]

AIM

Hormone replacement therapy (HRT) may reduce the risk of cardiovascular events in healthy postmenopausal women. However recent studies suggest a 2-4 fold increased risk of idiopathic venous thromboembolism (VTE) among users of HRT. Our aim was to evaluate the overall effect of HRT on hemostatic variables probably related to increased VTE risk reported in epidemiological studies.

METHODS

Therefore, 100 healthy postmenopausal women aged 45-60 years divided into 50 HRT non-users and 50 HRT users were examined. The authors assayed on the automated coagulometer ACL7000 (Instrumentation Laboratory, Milan) the procoagulant proteins: factor VIII (VIII:C) and factor VII (VII:C); the natural anticoagulant proteins: antithrombin (ATIII), protein C (PC), protein S (PS) and the resistance to anticoagulant action of activated protein C (APC-Resistance). The free tissue factor pathway inhibitor (TFPI) was measured with an ELISA method (Diagnostica Stagò; France, Roche). The in vivo coagulation and fibrinolysis activation was evaluated by the assays of prothrombin fragment 1+2 (F1+2) and plasmin- antiplasmin complexes (PAP) using ELISA techniques.

RESULTS

Increased levels of FVIII:C and FVII:C were observed in HRT users and HRT non-users women compared to controls (FVIII:C= 126+/-58%, 120+/-59% vs 85+/-15% p=0.0001; FVII: C 113+/-23%, 103+/-19% vs 90+/-16% p=0.0001). The activation peptides were significantly different compared to those found in control subjects; higher values were observed in HRT users compared to HRT non-users (F1+2=1.11+/-0.44 nM, 077+/-0.31 nM vs 0.45+/-0.35 p=0.00001; P-AP= 606+/-406 ng/ml, 514+/-205 ng/ml vs 235+/-59 p=0.0001). The ATIII and the PC were similar among the 3 different groups of subjects, but reduced levels of PS were observed in HRT users (PS 93+/-23%, 105+/-22% vs 109+/-12 p=0.0001). The mean normalized APC sensitivity ratio (APC-SR) was lower in the two populations of women as compared with that of controls (nAPC-SR 1.02+/-0.7, 1.02+/-0.8 vs 1.1+/-25 p=0.02). The values of free TFPI were reduced in HRT users compared to HRT non-users (9.1+/-1.9 ng/ml, 10.1+/-2.3 ng/ml vs 4.6+/-1.5 ng/ml p<0.0001).

CONCLUSION

HRT appears to be associated to a shift in the procoagulant-anticoagulant balance towards a procoagulant state. The changes in hemostatic system could explain the increased risk of VTE in healthy postmenopausal women during HRT, nevertheless this risk could be higher in women known to have a congenital or acquired thrombophilic state.

Colorectal cancer and high grade dysplasia complicating ulcerative colitis in Italy. A retrospective co-operative IG-IBD study

BACKGROUND

Ulcerative colitis is a well-known risk factor for colorectal cancer.

AIM

To take a census of the cases of colorectal cancer in ulcerative colitis patients observed in Italy and to evaluate the clinical presentation of neoplastic complication.

PATIENTS AND METHODS

Experts from 28 Italian centres specialised in the management of inflammatory bowel disease or malignancies participated to the study. They were invited to send clinical data of patients with ulcerative colitis complicated by colorectal cancer or high-grade dysplasia consecutively observed between 1985 and 2000. One hundred and twelve patients (92 with cancer and 20 with high-grade dysplasia) were collected. Fourteen of them had undergone colectomy and ileo-rectal anastomosis for ulcerative colitis. Data of surgical patients were analysed separately.

RESULTS

The mean age at diagnosis of ulcerative colitis and colorectal cancer patients was 39.3 and 53.2 years, respectively, and the mean duration between diagnosis of ulcerative colitis and cancer was 13.9 years (range 0-53). Inflammation was proximal to the splenic flexure in 71 cases (76.3%). One hundred and three colorectal cancers were registered (93 patients with single lesion and five patients with two synchronous cancers), with 76.7% of cancers being located in the left colon. As to the surgical patients, the mean age at diagnosis of ulcerative colitis and cancer was 28.9 and 47.0 years, respectively, and the mean diagnostic interval for ulcerative colitis and cancer was 18.1 years. Only 51 out of 112 patients were in follow-up. An early diagnosis of neoplasia (high grade dysplasia, stage A or B sec. Dukes) occurred in 72.5% of patients who were subjected to endoscopic surveillance and in 48.0% of patients who did not undergo endoscopic surveillance (p=0.02).

CONCLUSIONS

These data show an earlier diagnosis of cancer in patients who had undergone endoscopic surveillance. The poor compliance to the follow-up program, however, reduces its effectiveness. Moreover, total colectomy allows an easier follow-up, with only the rectum being controlled. Colectomy with ileo-rectal anastomosis or proctocolectomy with ileo-anal anastomosis, could represent a valid alternative in patients at high risk of cancer who refuse endoscopic surveillance.

Assessment of intestinal permeability and orocecal transit time in patients with systemic sclerosis: analysis of relationships with epidemiologic and clinical parameters

OBJECTIVE

The aim of this study was to assess intestinal permeability (IP) in patients with systemic sclerosis (SSc) and to relate the results with general disease activity and gastrointestinal involvement.

METHODS

Twenty-eight females and four males were studied. Patients with severe gastrointestinal involvement were excluded. Thirty-three healthy volunteers served as controls. Intestinal permeability was assessed by means of the orally administered cellobiose/mannitol sugar (Ce/Ma) test. Intestinal transit time (ITT) was investigated with the H2-lactulose breath test.

RESULTS

The mean value of IP in 32 SSc patients was significantly higher than in 33 controls ( P<0.05), although it fell within the normal range. Eleven patients showed abnormally high individual IP values (>0.028) that significantly correlated to disease duration ( r=0.73). Altered IP was associated with the higher but not statistically relevant presence of anti-Scl70 antibodies (9/11) and to more severe gastrointestinal involvement. More than half of the SSc patients showed slower orocecal transit times on the H2 breath test. In particular, delayed ITT was observed in 60% of patients with increased IP and in all patients with moderate gastrointestinal involvement according to the scleroderma severity scale.

CONCLUSION

Intestinal permeability was altered in 11/32 SSc patients. Correlations between increased IP and duration of disease and degree of gastrointestinal involvement appear to support the hypothesis of secondary involvement of the intestinal barrier, and the presence of anti-Scl70 antibodies in 82% of the patients with higher IP clearly reinforces the hypothesis of an altered immune response in these subjects.

Procaine into the VMH inhibits IBAT activation caused by frontal cortex stimulation in urethane-anesthetized rats

This experiment tested the effect of procaine injection into the ventromedial hypothalamus on the sympathetic and thermogenic activation induced by frontal cortex stimulation. Oxygen consumption, firing rate of the sympathetic nerves to interscapular brown adipose tissue (IBAT), along with IBAT and colonic temperatures were monitored in fasted male Sprague-Dawley rats before and during 25 min after an electrical stimulation of the frontal cortex. The same variables were monitored in rats with administration of procaine into the ventromedial hypothalamus. The results show that cortical stimulation increases oxygen consumption, sympathetic firing rate, IBAT and colonic temperatures. The increase in sympathetic firing rate was reduced by procaine injection, and the increase in IBAT and colonic temperatures as well as oxygen consumption was fully inhibited by procaine. These findings suggest that the ventromedial nucleus plays an important role in the sympathetic and thermogenic changes induced by cortical stimulation.

Intestinal permeability in Crohn's disease patients and their first degree relatives

BACKGROUND

Family studies suggested that an altered intestinal permeability plays a role in the genesis of Crohn's disease.

AIM

Aim of the present study was to investigate a possible genetic alteration of the mucosal barrier in Crohn's disease.

SUBJECTS

16 Crohn's disease patients and 26 of their cohabiting first degree relatives were studied.

METHODS

To investigate intestinal permeability, Cellobiose/Mannitol test was administered to both groups.

RESULTS

In the two groups, we found that the median intestinal permeability values were higher and statistically different from those obtained in 32 healthy control subjects as well as in five healthy control families. Six (37.5%) Crohn's disease patients and three (11.5%) of their first degree relatives showed increased individual intestinal permeability values. Intestinal permeability alteration in Crohn's disease patients was unrelated to sex, age, disease activity, localisation, duration, treatment schedule, as well as to serum anti-Saccharomyces cervisiae antibody positivity in a pilot study conducted in 7 Crohn's disease patients; anti-Saccharomyces cervisiae antibody values were negative in all 10 first degree relatives investigated.

CONCLUSIONS

These findings demonstrate the increase in IP in 37% of the patients and in 11% of their relatives. More extensive investigation of the correlation between ASCA alterations and IP will be needed in both patients with Crohn's disease and their relatives.

[Small ovarian cysts in postmenopause: assessment of their malignant potential with vaginal ultrasonography and tumor marker Ca125 titration]

BACKGROUND

The aim of this study was to determine the risk of malignancy in cystic ovarian tumors < 10 cm in diameter in asymptomatic postmenopausal women.

METHODS

All cystic ovarian tumors, detected by abdominal and transvaginal sonography screening, in asymptomatic postmenopausal women were evaluated with respect to size and morphology. Follow-up data were available both on patients undergoing surgery and on those who elected to be followed without operative intervention. Titration of the tumoral marker Ca125 was carried out, too.

RESULTS

Unilocular cystic tumors were detected in 32 of 352 postmenopausal patients (9%), of 45-65 years of age arrived at the "Centre for diagnosis and therapy of menopausal diseases" of the III Divisione di Ginecologia e Ostetricia della Seconda Università degli Studi di Napoli from the 1st January to the 31st December 1999. All tumors were < 10 cm in diameter and 98% were < 5 cm in diameter; just one tumor was hardly > 5 cm in diameter (5.8), 14 of these cystic ovarian tumors (49%) resolved spontaneously within 60 days while 18 (51%) persisted. Seven patients with persistent cystic ovarian tumors underwent operative tumor removal. Five of these patients had serous cystadenoma and 2 other women had cystoadenofibroma. Not even one case of ovarian carcinoma was found in this group. The remaining 11 patients with unilocular cystic ovarian tumors underwent sonography control every 3 months for one year and no one of these patients developed ovarian carcinoma. In all these patients the dosage of the tumoral marker Ca125 remained under the suspicious threshold of malignant ovaric tumor (Ca125 = 35 U/ml).

CONCLUSIONS

Unilocular cystic ovarian tumors < 5 cm in diameter in asymptomatic postmenopausal women were associated with minimal risk for ovarian cancer. In contrast, complex ovarian cysts wall abnormalities or solid areas are associated with a significant risk for malignancy. These date are important in determining therapeutic optimal strategies in these patients.

Cellular expression of the Drosophila melanogaster FMRFamide neuropeptide gene product DPKQDFMRFamide. Evidence for differential processing of the FMRFamide polypeptide precursor

DPKQDFMRFamide is one of five different FMRFamide-containing peptides encoded in the Drosophila FMRFamide gene. To study the cellular expression of DPKQDFMRFamide, we have generated antisera to DPKQD, the N-terminal sequence of the peptide, to avoid crossreactivity with other -FMRFamide-containing peptides. The antisera were purified and the specificity characterized. DPKQDFMRFamide immunoreactive material is first observed in the embryonic central nervous system (CNS) in one cell of the subesophageal ganglion and one cell in each of the three thoracic ganglia. This pattern of expression is observed in larval, pupal, and adult neural tissue, albeit with increased signal intensity. In larva, pupa, and adult, additional cells in the superior protocerebrum, a thoracic ganglion, and an abdominal ganglion express DPKQDFMRFamide immunoreactive material. Immunoreactivity is observed in a cell in the lateral protocerebrum of pupa and adult and cells in the optic lobe of adult. No immunoreactive material was observed in gut tissue. DPKQDFMRFamide antisera stain a subset of cells previously identified by in situ hybridization and immunocytochemistry to express the FMRFamide transcript and polypeptide precursor. These data suggest that the Drosophila FMRFamide polypeptide precursor undergoes differential processing to produce DPKQDFMRFamide immunoreactive material in a limited number of cells expressing the FMRFamide precursor.