The degree of bowel remission predicts phenotype progression in Crohn's disease

BACKGROUND

Patients with Crohn's disease (CD) are at risk of progressing from inflammatory to stricturing and penetrating phenotypes. The influence of the depth of remission on the risk of progression has not been adequately evaluated.

METHODS

A retrospective cohort study including surgically naïve CD patients with inflammatory phenotype evaluated concomitantly by magnetic resonance enterography and colonoscopy. The degree of remission was correlated with the risk of progressing to stricturing and penetrating phenotypes.

RESULTS

Three hundred nineteen CD patients were included: 27.0% with transmural remission, 16.0% with isolated endoscopic remission, 14.4% with isolated radiologic remission, and 42.6% without remission. Patients with transmural remission presented the lowest rates of phenotype progression (1.2%), with a significant difference compared to isolated radiologic remission (10.9%, p = 0.019), to isolated endoscopic remission (19.6%, p ≤ 0.001), and to no remission (46.3%, p ≤ 0.001). In multivariate regression analysis, transmural remission (OR 0.017 95% CI 0.002-0.135, p < 0.001), isolated radiologic remission (OR 0.139 95% CI 0.049-0.396, p < 0.001), and isolated endoscopic remission (OR 0.301 95% CI 0.123-0.736, p = 0.008) resulted in lower rates of phenotype progression compared to no remission. No patient with transmural or isolated radiologic remission progressed to penetrating phenotypes.

CONCLUSION

The degree of bowel remission correlates with the risk of phenotype progression. Patients with transmural remission are at the lowest risk of progressing to stricturing and penetrating phenotypes.

Tight control using fecal calprotectin and early disease intervention increase the rates of transmural remission in Crohn's disease

BACKGROUND

Increasing evidence supports the use of transmural remission as a treatment target in Crohn's disease (CD), but it is seldom achieved in clinical practice. Tight monitoring of inflammation using fecal calprotectin with reactive treatment escalation may potentially improve these results.

AIMS

To evaluate if treatment escalation based on fecal calprotectin can improve the rates of transmural remission in CD. The influence of the timing of intervention on this strategy was also evaluated.

METHODS

Retrospective cohort study including 256 CD patients with 2 consecutive assessments by MRI-enterography and colonoscopy and with regular monitoring using fecal calprotectin. For each occurrence of an elevated fecal calprotectin (≥250 μg/g), we evaluated whether a reactive adjustment of medical treatment was performed. The ratio of treatment escalation/elevated fecal calprotectin was correlated with the chances of reaching transmural remission. Early disease was defined as disease duration <18 months without previous exposure to immunomodulators and biologics.

RESULTS

After a median follow-up of 2 years (IQR 1-4), 61 patients (23.8%) reached transmural remission. Ratios of escalation ≥50% resulted in higher rates of transmural remission (34.2% vs. 15.1%, p < 0.001). The effect was more pronounced in patients with early disease (50.0% vs. 12.0%, p = 0.003). In multivariate analysis, a treatment escalation ratio ≥50% (OR 3.46, 95% CI 1.67-7.17, p = 0.001) and early disease intervention (OR 3.24, 95% CI 1.12-9.34, p = 0.030) were independent predictors of achieving transmural remission.

CONCLUSION

Tight-monitoring and reactive treatment escalation increase the rates of transmural remission in CD. Intervention in early disease further improves these results.

Proactive Infliximab Monitoring Improves the Rates of Transmural Remission in Crohn's Disease: A Propensity Score-Matched Analysis

BACKGROUND

Few patients can reach transmural remission in Crohn's disease (CD) with currently available therapies. Proactive optimization of infliximab (IFX) based on trough levels may potentially improve these results.

METHODS

Retrospective cohort study including consecutive CD patients starting treatment with IFX. Rates of transmural remission were compared between patients with and without therapeutic drug monitoring (target level: 5-7 µg/mL). A propensity score-matched analysis was performed to adjust for potential confounders.

RESULTS

A total of 195 CD patients were included, 57.9% receiving proactive therapeutic drug monitoring. The rates of transmural remission were higher in patients under proactive therapeutic drug monitoring (37.2% vs 18.3%; P = .004) with similar results in the propensity score-matched analysis (34.2% vs 17.1%; P = .025). In multivariate analysis, proactive therapeutic drug monitoring was independently associated with transmural remission (odds ratio, 2.95; 95% confidence interval, 1.44-6.06; P = .003).

CONCLUSIONS

Proactive optimization of IFX based on trough levels increases the rates of transmural remission in CD.

Primary Diffuse Large B-Cell Lymphoma of the Rectum in a Non-Immunosuppressed Patient with Ulcerative Colitis

Introduction

The incidence of primary colorectal lymphoma in the gastrointestinal tract is very low, the rectum being infrequently affected. The development of this entity in inflammatory bowel disease patients usually occurs in a context of immunosuppression-based therapy, with only a few case reports describing its development in patients presenting no known risk factors. Moreover, the clinical presentation of primary colorectal lymphomas may be difficult to distinguish from an acute flare of ulcerative colitis (UC).

Case Presentation

We present a case of non-Hodgkin lymphoma of the rectum in a 42-year-old male with a 7-year history of UC and no previous exposure to immunomodulatory agents. He presented with a history of mucous diarrhoea, tenesmus, proctalgia and weight loss, refractory to optimized therapy. A lower gastrointestinal endoscopy was performed revealing a circumferential ulcerated lesion of the rectum, from which histopathological analysis established the diagnosis of a non-Hodgkin diffuse large B-cell lymphoma (DLBCL).

Discussion/Conclusion

The present case suggests the existence of alternative mechanisms for the development of DLBCL in UC patients. The clinical presentation mimicking an acute flare of UC posed a diagnostic challenge, highlighting the complexity behind the management of UC patients.

Proactive infliximab is more effective than vedolizumab in inducing fecal calprotectin remission in inflammatory bowel disease

BACKGROUND

Current evidence suggests vedolizumab (VDZ) may be as effective as Infliximab (IFX) in inflammatory bowel disease. It is unknown if proactive therapeutic drug monitoring (PTDM) of IFX may improve these results.

METHODS

Case-control study including consecutive patients with primary response to conventional IFX (n = 70), proactive IFX (n = 148), and VDZ (n = 95). PTDM was performed at week 14 and every other infusion, aiming at a trough level between 5 and 10 µg/ml. The primary outcome was fecal calprotectin (Fc) remission (<250 µg/g) at 1 year of treatment. Secondary outcomes included Fc remission at week 14 (proactive IFX/VDZ), clinical remission, treatment discontinuation, hospitalization, and surgery at 1-year of follow-up.

RESULTS

Proactive IFX was superior to conventional IFX and VDZ in inducing Fc remission at 1-year (69.4% vs 47.1% vs 37.9%, p = .003 and p < .001). Results remained significant in biologic naïve patients (70.8% vs 44.4% vs 51.4%, p = .001 and p = .043) but comparisons between conventional IFX and VDZ were not significant (p = .265 and p = .664). In multivariate analysis correcting for prior biologic exposure, proactive IFX was more effective than conventional IFX (OR 2.480 95%CI [1.367-4.499], p = .003) and VDZ (OR 3.467 95%CI [1.578-7.617], p = .002) in inducing Fc remission. Amongst secondary outcomes, only clinical remission was significant between proactive IFX and VDZ in the overall cohort (80.4% vs 55.8%, p < .001) and in biologic naïve patients (80.2% vs 62.9%, p = .043). Fc remission at 1-year was associated with better results in most secondary outcomes.

CONCLUSION

Proactive IFX was superior to VDZ in inducing Fc remission at 1-year, which was associated with improved clinical outcomes.SUMMARYCurrent evidence suggests that vedolizumab may be as effective as Infliximab in the treatment of patients with inflammatory bowel disease.There have been no studies comparing vedolizumab with proactively optimized Infliximab based on trough levels.We confirm that conventional IFX is as effective as vedolizumab but proactive IFX appears superior to vedolizumab in inducing fecal calprotectin remission.Fecal calprotectin remission associates with better clinical outcomes.

Proactive therapeutic drug monitoring is more effective than conventional management in inducing fecal calprotectin remission in inflammatory bowel disease

BACKGROUND

Proactive therapeutic drug monitoring (pTDM) may improve treatment outcomes in inflammatory bowel disease.

AIMS AND METHODS

We compared 135 patients following a prospective pTDM protocol aiming at an infliximab trough level (IFXTL) between 5 and 10 μg/ml with sequential measurements of Fc, with 108 patients from a retrospective group under conventional management. We evaluated the rates of Fc remission (<250 μg/g) and other clinical outcomes at 2-year of follow-up.

RESULTS

pTDM associated with higher rates of Fc remission (69.6% vs. 50.0%; P = 0.002), and steroid-free clinical remission (78.4% vs. 55.2%, P = 0.028) with a trend for clinical remission (79.3% vs. 68.5%, P = 0.075). There was no difference in treatment discontinuation (P = 0.195), hospitalization (P = 0.156), and surgery (P = 0.110). Higher IFXTL associated with Fc remission at week 14 (6.59 vs. 2.96 μg/ml, P < 0.001), and at the end of follow-up (8.10 vs. 5.03 μg/ml, P = 0.001). In patients reaching Fc remission after week 14, IFXTL increased from week 14 to the end of follow-up (2.71 vs. 8.54 μg/ml, P < 0.001). Fc remission associated with higher rates of clinical (85.8% vs. 56.8% P < 0.001) and steroid-free clinical remission (86.9% vs. 50.0% P < 0.001), lower IFX discontinuation (8.8% vs. 36.8%, P < 0.001), and hospitalization (13.5% vs. 33.7%, P < 0.001), without significance for surgery (6.1% vs. 12.6%, P = 0.101).

CONCLUSION

pTDM was more effective than conventional management in inducing Fc remission which was associated with improved outcomes.

Outcomes of excessive alcohol drinkers without baseline evidence of chronic liver disease after 15 years follow-up: Heavy burden of cancer and liver disease mortality

Background

Most long-term heavy drinkers do not have clinically evident chronic liver disease (CLD). However, at any time-point, their risk of developing CLD remains unknown. We aimed to evaluate the long-term outcomes of a group of heavy drinkers, without evidence of CLD at baseline.

Methods

A cohort of 123 long-term heavy drinkers without CLD were prospectively recruited in 2002 and retrospectively followed until 2018.

Results

At baseline (2002), median alcohol consumption was 271±203g/day during 21.5±20 years, 65% being abstinent during the previous 1.75±5 months. Patients were followed for 14±3 years. During follow-up, 53% reported any alcohol intake. Alcohol consumption during follow-up associated weakly with either 1- or 6-months previous abstinence at baseline. Until 2018, progression to CLD occurred in 6%, associating with years of alcohol intake during follow-up (OR 1.15 [1.01–1.31]) and baseline alkaline-phosphatase (OR 1.05 [1.01–1.10]). During follow-up, being abstinent for at least 1 year positively associated with CLD-free survival. 27% died (55% of cancer–mostly oropharyngeal cancer, 27% of cardiovascular disease, and 9% of liver disease), with a mean age of 71 years [69–74] (10 years less than the expected in the Portuguese population). Achieving abstinence for at least 1 year positively associated with overall survival, while smoking, and hepatic steatosis at baseline associated negatively.

Conclusion

Long-term heavy drinkers seemed to have a decreased life expectancy compared with the overall Portuguese population. Cancer was the main cause of death. Our results suggest that progression to CLD depends mostly on continued alcohol intake. Alcohol abstinence, even if temporary, seems to decrease the risks of CLD and mortality.

Age at Diagnosis Is Determinant for the Outcome of Inflammatory Bowel Disease: Is It a Myth?

INTRODUCTION

Patients with elderly-onset inflammatory bowel disease were previously associated with a less aggressive course of the disease. However, there are conflicting data that need further validation. We aimed to determine the association between age at diagnosis and the development of progressive disease in patients with Crohn's disease (CD) and ulcerative colitis (UC).

METHODS

This cohort study included patients with CD and UC followed in 6 secondary and tertiary care centers in mainland Portugal. Patients were divided into a derivation (80%) cohort and a validation (20%) cohort. The primary outcome was progressive disease. Logistic regression analysis, receiver operating characteristic curves, and the areas under the curve (AUC) were performed. Odds ratios with 95% confidence intervals (CIs) were estimated.

RESULTS

The derivation cohorts included 1245 patients with CD (68% with progressive disease) and 1210 patients with UC (37% with progressive disease), whereas the validation cohorts included 302 patients with CD and 271 patients with UC, respectively, with similar outcome proportions. In our final model, age at diagnosis older than 60 years was significantly associated with a lower risk of developing progressive disease (odds ratio 0.390, 95% CI 0.164-0.923, P = 0.032), with a high discriminative power (AUC 0.724, 95% CI 0.693-754) in patients with CD. However, according to this model, no significant associations were found between age at diagnosis and the risk of developing progressive disease in patients with UC. No differences were observed in the AUC values between the validation and the derivation cohorts.

DISCUSSION

Patients with elderly-onset CD, but not patients with UC, were associated with a less progressive course of the disease.

Proactive Infliximab Drug Monitoring Is Superior to Conventional Management in Inflammatory Bowel Disease

BACKGROUND

Increasing evidence supports the use of reactive therapeutic drug monitoring (TDM) in Crohn's disease (CD) and ulcerative colitis (UC) following secondary loss of response. It is still unknown if proactive TDM can improve clinical outcomes.

METHODS

Consecutive patients completing infliximab (IFX) induction therapy were prospectively allocated into a proactive TDM protocol (pTDM). Before the fourth infusion and every 2 infusions, IFX trough levels and antidrug antibodies were measured using a drug-sensitive assay (Theradiag, Lisa Tracker). Treatment was proactively escalated aiming at an IFX trough level between 3 and 7 ug/mL (CD) and 5 and 10 ug/mL (UC). A retrospective cohort treated with IFX but without TDM served as the reference group. End points included the need for surgery, hospitalization, treatment discontinuation, and mucosal healing at 2 years of follow-up.

RESULTS

Two hundred five patients were included, 56 in the proactive regimen. Treatment escalation was more common in pTDM patients (76.8% vs 25.5%; P < 0.001), who also required less surgery (8.9% vs 20.8%; P = 0.032) and presented higher rates of mucosal healing (73.2% vs 38.9%; P < 0.0001). Proactive TDM significantly decreased the odds of reaching any unfavorable outcome (odds ratio, 0.358; 95% confidence interval, 0.188-0.683; P = 0.002).

CONCLUSIONS

Proactive TDM is associated with fewer surgeries and higher rates of mucosal healing than conventional non-TDM-based management.

Androgen insensitivity syndrome

OBJECTIVE

We provide a review of the literature about the Androgen Insensitivity Syndrome (AIS), its onset and associated developmental anomalies and the genetic alterations causing it.

MATERIALS AND METHODS

We searched PubMed with a larger emphasis on the physiology, genetics and current management of AIS.

RESULTS

AIS is an X-linked recessive Disorder of Sex Development (DSD). It is caused by mutations of the Androgen Receptor, and their large amount and heterogeneity (missense and nonsense mutations, splicing variants, deletions, and insertions) are responsible for the wide spectrum of possible phenotypes of patients, divided into Partial AIS (PAIS) and Complete AIS (CAIS). Once the clinical and laboratory investigations have laid the foundation for a diagnostic hypothesis, it is important to identify the actual karyotype of the individual and search for the mutation in the Androgen Receptor to diagnose with certainty the syndrome. Alternatively, in the absence of such evidence, the diagnosis should more properly be an AIS-like condition, which we describe as well in our report.

CONCLUSIONS

The management of this DSD is based on pharmacotherapies, surgery and psychological support: all of them must be directed to facilitate the patient's life, considering his/her sexual identity.

Treat to target in inflammatory bowel disease: a survey of treatment strategies amongst Portuguese doctors

BACKGROUND

treatment goals in inflammatory bowel disease have changed over the last few years and have shifted from a mainly symptom-based management to objective endpoints, such as mucosal healing and deep remission. A treat-to-target strategy to achieve these goals has been proposed by several experts, although the real-life clinical data is still lacking. This study aimed to investigate the current practices among Portuguese gastroenterologists who treat inflammatory bowel disease patients.

METHODS

Portuguese gastroenterologists were asked to participate in an anonymous online survey. The questions focused on opinions and current practice with regard to treatment targets in inflammatory bowel disease.

RESULTS

sixty-two physicians agreed to participate in the survey, 40 were gastroenterology specialists and 22 (35.5%) were fellows. Deep remission was considered as the main treatment goal for Crohn's disease and ulcerative colitis by 82% and 83.9% of the participants, respectively. Mucosal healing as a treatment target was used by 95% and 80% of participants in ulcerative colitis and Crohn's disease, respectively; 71% intensified the treatment to achieve mucosal healing after clinical remission. The most common definition of mucosal healing in Crohn's disease and ulcerative colitis was the absence of mucosal ulceration (32.3%) and a Mayo endoscopic sub-score of 0 (41.9%). Only 3.2% escalated treatment with the aim to achieve histologic remission in ulcerative colitis.

CONCLUSION

a treat-to-target strategy to achieve mucosal healing and deep remission is currently accepted by a substantial number of Portuguese gastroenterologists.

Miniprobe endoscopic ultrasonography for the diagnosis of colon hemangiolymphangioma

Hemangiolymphangioma is a very rare benign vascular tumor that affects the gastrointestinal tract in less than 1% of cases. We present the case of an asymptomatic 52-year-old female referred for endoscopic colorectal cancer screening. A sub-epithelial pediculated polypoid lesion in the splenic angle of the colon was identified. An endoscopic ultrasonography with a miniprobe was performed, which identified an anechoic lesion in the submucosal layer. Surgery was performed and the histologic findings were compatible with two hemangiolymphangioma lesions. This is one of the few cases reported in the literature of hemangiolymphangioma diagnosed by miniprobe endoscopic ultrasonography and the first to describe two lesions in the same patient.

Predicting the Course of Disease in Hospitalized Patients With Acute Severe Ulcerative Colitis

BACKGROUND

Up to one-third of patients with acute severe ulcerative colitis (ASUC) will fail intravenous steroid (IVS) treatment, requiring rescue therapy with cyclosporin (Cys), infliximab (IFX), or colectomy. Although several scores for predicting response to IVS exist, formal comparison is lacking.

METHODS

We performed a single-center retrospective analysis including 489 patients with ulcerative colitis. In patients with ASUC, the Mayo endoscopic subscore and the Oxford, Edinburgh, and Lindgren scores were assessed. Outcomes included IVS failure, need for rescue medical therapy, and surgery.

RESULTS

One hundred twelve patients presented with ASUC. Forty-two percent showed an incomplete or absent response to IVS, 28.6% received rescue therapy (22 with IFX, 10 with Cys, and 1 with sequential treatment), and 26.8% required surgery. The Lindgren score showed the highest performance in predicting IVS failure (are under the curve [AUC], 0.856; 95% confidence interval [CI], 0.784-0.928), need for medical rescue therapy (AUC, 0.826; 95% CI, 0.749-0.902), and surgery (AUC, 0.836; 95% CI, 0.712-0.960; all P < 0.01).

CONCLUSIONS

In our series, the Lindgren score was superior to the Mayo, Oxford, and Edinburgh scores in predicting major clinical outcomes in ASUC.

Systemic sclerosis and sarcoidosis: a rare case of chronic intestinal pseudo-obstruction

The coexistence of systemic sclerosis (SSc) and sarcoidosis is an extremely rare phenomenon; some studies question its existence. We report the case of a male with a diagnosis of sarcoidosis that was admitted due to abdominal distension and pain. After a thorough investigation, he was diagnosed with severe chronic intestinal pseudo-obstruction as a manifestation of SSc.

Kaolin modulates ABA and IAA dynamics and physiology of grapevine under Mediterranean summer stress

The foliar exogenous application of kaolin, a radiation-reflecting inert mineral, has proven to be an effective short-term climate change mitigation strategy for Mediterranean vineyards. In this work, we address the hypothesis that kaolin could improve both the hormonal dynamics and physiological responses of grapevines growing in Douro Region, northern Portugal. For this purpose, the leaf water potential, gas exchange and chlorophyll a fluorescence parameters were monitored, as well as the abscisic acid (ABA) and indole-3-acetic acid (IAA) quantification and immunolocalization were assessed. The study revealed a slight decrease in ABA and an increase in IAA in the kaolin treatment, which in turn were associated with the improvement of physiological performance. A month after spraying, kaolin improves the water potential respectively, 30% and 17% in the predawn and midday periods. Besides, plants treated with kaolin showed higher values of stomatal conductance, net CO₂ assimilation rate and intrinsic water use efficiency. Kaolin also ameliorates the effective PSII efficiency (67%), as well as the maximum quantum efficiency of photosystem II and the photosynthetic electron transport rate (>73%). These results were consistent with the higher photochemical quenching and the lower non-photochemical quenching observed in treated leaves and with the better performance obtained by the JIP test parameters. Physiological and hormonal analysis confirmed that kaolin effectively enhance grapevine summer stress tolerance.

A rare cause of acute liver failure- a case report

Background

Acute liver failure (ALF) induced by diffuse metastatic disease has rarely been reported.

Case presentation

We present a 51-years-old woman with relevant clinical history for breast cancer. The patient was admitted in the emergency department with jaundice, dark urine and pale stools. She was on the 10th day of hormonotherapy for recurrence of breast cancer, diagnosed 7 years previously. Usual causes of acute liver failure were excluded, all drugs were stopped and the imaging studies performed were positive only for steatosis. Nonetheless, ALF progressed and the patient died 4 days later. Autopsy demonstrated a massive intrasinusoidal infiltration of the liver by breast cancer cells.

Conclusion

We highlight a rare cause of ALF. Although uncommon, physicians should be alert for this situation as the diagnosis can be challenging and the imaging studies can remain normal.

MRI and US in the evaluation of fetal anomalies: The need to work together

PURPOSE

Real-time virtual sonography (RVS) is a new technique that synchronizes real-time ultrasonography (US) and multiplanar reconstructed magnetic resonance imaging (MRI). The purpose of this study was to evaluate the feasibility and ability of RVS to assess the main pathologies in fetuses with suspected US anomalies.

METHOD AND MATERIALS

Real-time virtual sonography (Hitachi, HI VISION Ascendus) was offered to 30 patients who had undergone fetal MRI. The acquired MRI image dataset was loaded into the fusion system and displayed together with the real-time US image. The ability of RVS to assess the main anatomical sites and fetal anomalies was evaluated.

RESULTS

Real-time virtual sonography was technically possible in all cases. From a total of 30 patients, RVS helped the diagnosis in 10 cases. In 15 cases of encephalic pathology, fusion imaging improved the accuracy of the diagnosis; in the other 5 cases, MRI was superior to US even when using the RVS.

CONCLUSION

This is a study on the feasibility and practical use of RVS. Thanks to information from both US and MRI, RVS allowed better identification of the fetal pathologies and improved the performance of the ultrasound examination. In our experience, it was really helpful in pathologies that would benefit from US follow-up.

Parents' early healthcare transition experiences with preterm and acutely ill infants: a scoping review

BACKGROUND

Parents undergo multiple transitions following the birth of an ill infant: their infant's illness-health trajectory, neonatal intensive care unit hospitalization and transfers from one healthcare setting to another, while also transitioning to parenthood. The objective of this review was to map and synthesize evidence on the experiences and needs of parents of preterm or ill infants as they transition within and between healthcare settings following birth.

METHODS

The scoping review followed Arskey and O'Malley's () framework, enhanced by Levac et al. (). Relevant studies were identified through a comprehensive search strategy of scientific and grey literature databases, online networks, Web of Science and citation lists of relevant articles. Inclusion criteria encompassed a focus on infants undergoing a healthcare transition, and the experiences and needs of parents during transition. Studies were appraised for design quality, and data relevant to parent experiences were extracted and underwent thematic analysis.

RESULTS

A total of 7773 records were retrieved, 90 full texts reviewed and 11 articles synthesized that represented a total sample of 435 parents of preterm or ill infants. Parents reported on their experiences in response to their infant's transition within and between hospitals and across levels of neonatal intensive care unit, intermediate and community hospital care. Ten studies used qualitative research methods, while one employed quantitative survey methods. Four key themes were identified: that of parent distress throughout transition, parenting at a distance, sources of stress and sources of support. Parents' stress resulted from not being informed or involved in the transition decision, inadequate communication and perceived differences in cultures of care across healthcare settings.

CONCLUSIONS

Opportunities to improve parents' early transition experiences include enhanced engagement, communication, information-sharing and shared decision-making between health care providers and parents. Future areas of research should focus on early transition interventions to advance parent capacity, confidence and closeness as the primary nurturer.

Mesalamine-induced myopericarditis - A case report

Myopericarditis has occasionally been reported as a side effect of mesalamine in patients with inflammatory bowel disease. We present a 20-year-old woman with ulcerative colitis admitted with chest pain. After thorough investigation she was diagnosed with myopericarditis potentially related to mesalamine. There was complete clinical and laboratorial recovery following drug withdrawal. Although uncommon, the possibility of myopericarditis should be considered in patients with inflammatory bowel disease presenting with cardiac complaints. Early recognition can avoid potential life-threatening complications.

Improving Transition Practices: Understanding Family Experiences and Needs in Transitioning Their Child to Developmental/Rehabilitation Services

BACKGROUND: Children born preterm (&lt;37 weeks) with cerebral palsy (CP) have long-term complex medical needs that require transitions between multiple healthcare services, necessitating parental support. The experiences of parents undergoing early transitions from the neonatal intensive care unit (NICU) to neonatal follow-up clinics (NFUC) to home are well-documented. Our prior research conducted found parents described positive transitions as: access to information, feeling involved in care and witnessing improvement in their child’s health outcomes post-transition. Negative experiences entail: unanticipated differences between healthcare services, feeling separated from their child and having inadequate information. Unfortunately, the next transition from children with CP born preterm (&lt;37 weeks) to developmental/rehabilitation services (DRS) is grossly under-studied and knowledge from well-studied healthcare transitions has yet to be applied to this population.

OBJECTIVES: To identify and describe the experience and needs of parents of children with CP born preterm, as they transition from NFUC to DRS. Additionally, to make recommendations building upon characteristics of supportive/positive transition experiences to meet the emotional, informational, and instrumental needs of parents during transition to DRS.

DESIGN/METHODS: A descriptive qualitative study was conducted recruiting English-speaking parents of children born preterm with CP that required NICU hospitalization, and DRS post CP diagnosis. Purposeful and maximum variation strategies were used to recruit a sample of 15 parents. To ensure rigor, sampling continued until data saturation was reached. Interviews were audio-recorded, transcribed verbatim, coded using NVivo 10 software and underwent thematic analysis. Data collection and analyses were performed concurrently, with themes from early interviews incorporated, collapsed and used to inform later interviews.

RESULTS: A majority of participants were mothers, whose child had received DRS for the past one to 12 years. Preliminary themes iterated by parents’ transition experiences included: Poor communication of diagnosis caused anxiety surrounding transition of care; a lack of timely access to appropriate care and resources negatively affected parents’ experiences; continuity and consistency of healthcare providers improved families’ perception of accessibility to care; and social support was desired throughout the transition period.

CONCLUSION: The transition between NFUC and DRS for families with CP is significant, but lacks best practice research to advise care. Preliminary recommendations derived from data reveal the need to better support families earlier on in the transition process, beginning at the NFUC. Further research is required to identify best practices to strengthen communication, family involvement, continuity of care, and timely access to informational supports for parents.

Kaolin exogenous application boosts antioxidant capacity and phenolic content in berries and leaves of grapevine under summer stress

Heat waves, high light intensities and water deficit are becoming important threats in many important viticultural areas worldwide, so the implementation of efficient and cost-effective mitigation strategies is crucial for the production of premium wines while maintaining productivity. In this context, the foliar application of kaolin, a chemically inert mineral with excellent reflective properties, is being developed and experimented as a strategy to reduce the impact of heat and drought in Douro vineyards (Northern Portugal), already revealing promising results. In the present study we investigated if an improved antioxidant capacity is part of the beneficial effects of kaolin, by studying changes in the enzymatic and nonenzymatic antioxidant system in leaves and berries (cv Touriga Nacional). Results showed that mature grape berries contained higher amounts of total phenols (40%), flavonoids (24%), anthocyanins (32%) and vitamin C (12%) than fruits from control vines, and important changes were also measured in leaves. In parallel, kaolin application improved the antioxidant capacity in berries, which was correlated with the observed increased content in secondary metabolites. Kaolin application also regulated secondary metabolism at the transcriptional level through the increase in the transcript abundance of genes encoding phenylalanine ammonia lyase and chalcone synthase.

Comparison of ultrasound and magnetic resonance imaging in the prenatal diagnosis of Apert syndrome: report of a case

BACKGROUND

The birth prevalence of Apert syndrome is estimated at 1:64,500 and accounts for about 4.5 % of all craniosynostosis with a male/female ratio equal to 1:1. It is associated to allelic mutations in the fibroblast growth factor receptor 2 (FGFR2) gene. Majority cases are sporadic. Prenatal ultrasound diagnosis is based on the detection of abnormal cranial shape, midfacial hypoplasia and bilateral syndactyly of hands and feet, hypertelorism, and exorbitism. Other abnormalities includes central nervous system anomalies, congenital heart diseases, cleft palate, and urogenital diseases.

CASE REPORT

A 37-year-old Caucasian woman, gravida 2, para 1, was referred to our center of Prenatal Diagnosis for routine ultrasound at 21 weeks of gestation. We detected irregular head shape, dolicocephaly, prominent forehead, bilateral mild ventriculomegaly, suspicion of partial agenesis of the corpus callosum, hypertelorism, and midfacial hypoplasia, with a depressed nasal bridge and syndactyly, prompting a suspicion for Apert syndrome. Magnetic resonance excluded agenesis of corpus callosum and confirmed bilateral mild ventriculomegaly. A follow-up ultrasound, performed at 23 weeks, confirmed the anomalies showed in the previous scan. An amniocentesis was performed. The results showed a normal male karyotype, while the molecular genetic test confirmed a mutation in FGFR2 gene. Fetus macroscopic analysis showed compatible features.

CONCLUSIONS

Our case underlines the complementary role of ultrasound and magnetic resonance imaging in the early prenatal diagnosis of Apert syndrome.

Magnetic resonance imaging of fetal heart: anatomical and pathological findings

Congenital heart disease is one of the most frequent prenatal malformation representing an incidence of 5/1000 live births; moreover, it represents the first cause of death in the first year of life. There is a wide range of severity in congenital heart malformations from lesions which require no treatment such as small ventricular septal defects, to lesions which can only be treated with palliative surgery such as hypoplastic left heart syndrome. A good prenatal examination acquires great importance in order to formulate an early diagnosis and improve pregnancy management. Nowadays, echocardiography still represents the gold standard examination for fetal heart disease. However, especially when preliminary ultrasound is inconclusive, fetal MRI is considered as a third-level imaging modality. Preliminary experiences have demonstrated the validity of this reporting a diagnostic accuracy of 79%. Our article aims to outline feasibility of fetal MRI in the anatomic evaluation, the common indication to fetal MRI, its role in the characterization of congenital heart defects, and at last its main limitations.

Benefits of the simplified edentulous treatment (SET) method in communicating with the laboratory

AIM

According to the literature, a high quality prosthetic rehabilitation consists of physical and psychological acceptance of the denture by the patient, an empathic relationship between the clinician and the patient and correct application of complete denture construction principles. To apply these principles correctly, it is important to establish excellent communication with the technician. Interactions between dentists and technical laboratories is typically characterised by minimal communication, which is considered to be the most significant problem for achieving a qualitatively elevated prosthetic manufacture. The aim of the simplified edentulous treatment (SET) method is to correctly transmit clinical data to the laboratory and maintain these data throughout the entire treatment period.

METHODS

One hundred twenty-three completely edentulous, Caucasian patients (71 men and 52 women; medium age: 66 years; range 27 to 85 years) were recruited for this study. The inclusion criteria were total edentulism, both maxillary and mandibular, both in patients wearing and not wearing a complete denture. To complete the denture, the patients were entrusted to 65 teams of two students each, attending the fifth year of their degree course in dentistry and performing their first rehabilitation of an edentulous patient, under the supervision of six skilled tutors. The denture manufacturing was performed by 12 technical laboratories.

RESULTS

In the rehabilitation of an edentulous patient, transmission of clinical data to the technical laboratory is effective and reliable.

CONCLUSION

The data transfer block allows one to transfer all of the necessary information to the laboratory at one time.

Morpho-functional patterns of physiologic oropharyngeal swallowing evaluated with dynamic fast MRI

With the advent of dynamic fast MRI sequences the act of deglutition can be dynamically visualized in cine-mode. Twenty-three healthy volunteers were enrolled in this study to define the morpho-functional patterns of oral and pharyngeal deglutition using new dynamic MRI techniques. All subjects were previously submitted to video endoscopic assessment, to exclude swallowing abnormalities. As contrast material a combination of yogurt mixed with gadolinium-diethylene diamine pentaacetic acid was used. The protocol was divided into three parts: (a) preliminary assessment of the oral cavity, pharynx and laryngeal structures; (b) morphologic assessment of tongue, soft palate, pharynx, epiglottis and larynx-hyoid bone; (c) dynamic assessment of swallowing without administrating any contrast media and, in subsequent phase, by injecting 5 ml of yogurt-based contrast medium in the patient's mouth. The time resolution was 3-4 images/s. The MR protocol revealed to be effective in the evaluation of normal motility patterns of the structures involved in swallowing. Moreover, the evaluation of the bolus progression, slowdown or stagnation, was possible. On the contrary problems were encountered in calculating precisely the bolus progression time, because of the insufficient temporal resolution. However, more energy should be invested to optimize the spatial and temporal resolution of turbo-FLASH sequences, to obtain a better dynamic representation of a complex function such as deglutition.