Application of clinical indexes in ulcerative colitis patients in regular follow-up visit. correlation with endoscopic 'mucosal healing' and implication for management

OBJECTIVE: Ulcerative Colitis (UC) is a chronic inflammatory disease of the colon of unknown etiology. Several clinical indexes have been proposed for UC disease activity evaluation, but none have been properly validated. Moreover, the reference parameter for the scores and their prognostic value is not clear. Mucosal healing has been recently proposed as an important end-point. Aim of the present study was to evaluate the correlation of four clinical indexes with objective diagnostic tools for UC evaluation, the discriminative ability in identifying patients with endoscopic mucosal healing, and to analyze the possible prognostic indication for disease course in 1 year of follow-up. PATIENTS AND METHODS: We analyzed data of 75 patients recorded in regular follow-up visit in IBD clinic at S. Andrea Hospital, Rome, between 2007-2011. We recorded clinical data and lab tests at the time of the visit, and endoscopic/ histological repor ts performed within 1 month. Clinical indexes (Seo' activity index, Simple Clinical Colitis Activity Index, partial Mayo score and Endoscopic-Clinical Correlation Index) were calculated and correlation to endoscopic and histologic activity, and to C-reactive protein increment, was assessed by mean of Spearman's rank correlation. Discriminative ability of the indexes for patients with and without endoscopic mucosal healing was tested by calculation of area under ROC curve (AUC). Patients with low and high clinical scores were compared for number of flares and increment of therapy during 1 year of follow-up. RESULTS: Clinical indexes had a good correlation with endoscopic activity (mean r = 0.73 ± 0.06), a fair correlation with CRP-increment (mean r = 0.55 ± 0.01) and a poor one with histologic activity (mean r = 0.35 ± 0.01). The discriminatory ability of the indexes for endoscopic mucosal healing was good for all the indexes (mean AUC = 0.87 ± 0.05). Patients with high clinical score had more flares and required more frequently increase of therapy at 1 year of follow up compared with patients with low score. CONCLUSIONS: Clinical indexes have a good correlation with endoscopic activity and can discriminate patients with and without mucosal healing. Patients with low and high score have different risk of disease flare and of need to increase therapy at 1 year. Clinical indexes may represent a useful tool for disease assessment in clinical practice in UC outpatients with mildmoderate disease

Hypergastrinemia and enterochromaffin-like cell hyperplasia.

The enterochromaffin-like (ECL) cells, the most frequent endocrine cells of the oxyntic mucosa of the stomach, are under the trophic stimulus of gastrin. These cells undergo a hyperplastic increase in variety of hypergastrinemic diseases. The most widely accepted nomenclature for the description of hyperplastic proliferation has been retrospectively arranged in a sequence presumed to reflect a temporal evolution of the proliferative process. A comparative, prospective study aimed to verify, in human hypergastrinemic diseases such as atrophic body gastritis (ABG), Zollinger-Ellison syndrome (ZES) and antral gastrin cell hyperfunction (AGCH), the effect of exposure of ECL cells to different pattern of gastrin hypersecretion, is lacking. To this purpose, we studied a series of consecutive patients with ABG, ZES and AGCH at the time of first diagnosis. Material and Methods: The patients included in this study (124 ABG, 18 ZES and 10 AGCH) were selected on the basis of two previously performed screening studies aimed to diagnose these diseases. All patients at the time of diagnosis underwent gastroscopy, with multiple biopsies of the gastric body mucosa for the evaluation of qualitative pattern of ECL cells hyperplasia, and basal fasting gastrin determination. A sample of hypergastrinemic patients from each group was further investigated by meal-stimulation of gastrin secretion and quantitative morphometry for CgA positive gastric body endocrine cells. Results: AGCH patients showed only the normal or simple hyperplasia pattern. In the ZES group, simple and linear grades accounted for 38.4 percent and 46.1 percent, respectively. MEN-I patients showed only these two patterns. The majority of ABG patients showed the presence of micronodular pattern (59.7 percent). A correlation analysis between fasting gastrin levels and grade of hyperplasia (r = 0.5580, p < 0.0001), indicates that the greater the gastrin levels, the higher is the degree of severity of ECL hyperplasia pattern. In conclusion, our data support the role of gastrin as the selective contributor to the progression of ECL cell hyperplasia in humans

Slow Diffeomorphisms of a Manifold with Two Dimensions Torus Action

The uniform norm of the differential of the n-th iteration of a diffeomorphism is called the growth sequence of the diffeomorphism. In this paper we show that there is no lower universal growth bound for volume preserving diffeomorphisms on manifolds with an effective two dimensions torus action by constructing a set of volume-preserving diffeomorphisms with arbitrarily slow growth.Comment: 12 p

Laparoscopic distal pancreatectomy in Italy: A systematic review and meta-analysis

Background The use of laparoscopic distal pancreatectomy (LDP) increased in the past twenty years but the real diffusion of this technique is still unknown as well as the type of centers (high or low volume) in which this procedure is more frequently performed. Data Source A systematic review was performed to evaluate the frequency of LDP in Italy and to compare indications and results in high volume centers (HVCs) and in low volume centers (LVCs). Results From 95 potentially relevant citations identified, only 5 studies were included. A total of 125 subjects were analyzed, of whom 95 (76.0%) were from HVCs and 30 (24.0%) from LVCs. The mean number of LDPs performed per year was 6.5. The mean number of patients who underwent LDP per year was 8.8 in HVCs and 3.0 in LVCs (P<0.001). The most frequent lesions operated on in HVCs were cystic tumors (62.1%, P<0.001) while, in LVCs, solid neoplasms (76.7%, P<0.001). In HVCs, malignant neoplasms were treated with LDP less frequently than in LVCs (17.9% vs 50.0%, P<0.001). Splenectomy was performed for non-oncologic reason frequenter in HVCs than in LVCs (70.2% vs 25.0%, P=0.004). The length of stay was shorter in HVCs than in LVCs (7.5 vs 11.3, P<0.001). No differences were found regarding age, gender, ductal adenocarcinoma treated, operative time, conversion, morbidity, postoperative pancreatic fistula, reoperation and margin status. Conclusions LDPs were frequently performed in Italy. The "HVC approach" is characterized by a careful selection of patients undergoing LDP. The "LVC approach" is based on the hypothesis that LDPs are equivalent both in short-term and long-term results to laparotomic approach. These data are not conclusive and they point out the need for a national register of laparoscopic pancreatectomy

Is the United States Claims Court Constitutional?

This article will deal with two major constitutional problems that have resulted from the creation of the Claims Court. The first issue is the constitutionality of the appointment of existing Court of Claims Commissioners to be judges on the Claims Court during a four-year transition period. By legislatively designating the persons who are to serve as judges on the new court, Congress has usurped the presidential appointment power. The second issue relates to the constitutional status of the Claims Court. The Court of Claims which it replaces was created under article III of the Constitution, and the judges on it were therefore entitled to life tenure and salaries that could not be reduced during their terms in office. The new Claims Court, on the other hand, is designated by Congress as an article I court; the judges are to be appointed for only fifteen year terms, and their salaries are subject to control by Congress. The new court exercises full judicial authority, however, and has jurisdiction over cases of national importance in which the government of the United States has a great financial stake. Although the analysis of this issue is far from simple, this author concludes that Congress has exceeded its constitutional authority by failing to comply with the requirements of article III of the Constitution in establishing the Claims Court

Surgical stress and metabolic response after totally laparoscopic right colectomy

No clear consensus on the need to perform an intracorporeal anastomosis (IA) after laparoscopic right colectomy is currently available. One of the potential benefits of intracorporeal anastomosis may be a reduction in surgical stress. Herein, we evaluated the surgical stress response and the metabolic response in patients who underwent right colonic resection for colon cancer. Fifty-nine patients who underwent laparoscopic resection for right colon cancer were randomized to receive an intracorporeal or an extracorporeal anastomosis (EA). Data including demographics (age, sex, BMI and ASA score), pathological (AJCC tumour stage and tumour localization) and surgical results were recorded. Moreover, to determine the levels of the inflammatory response, mediators, such as C-reactive protein (CRP), tumour necrosis factor (TNF), interleukin 1β (IL-1β), IL-6, IL-10, and IL-13, were evaluated. Similarly, cortisol and insulin levels were evaluated as hormonal responses to surgical stress. We found that the proinflammatory mediator IL-6, CRP, TNF and IL-1β levels, were significantly reduced in IA compared to EA. Concurrently, an improved profile of the anti-inflammatory cytokines IL-10 and IL-13 was observed in the IA group. Relative to the hormone response to surgical stress, cortisol was increased in patients who underwent EA, while insulin was reduced in the EA group. Based on these results, surgical stress and metabolic response to IA justify advocating the adoption of a totally laparoscopic approach when performing a right colectomy for cancer. This trial is registered on ClinicalTrials.gov (ID: NCT03422588)

Tackling the jelly web: Trophic ecology of gelatinous zooplankton in oceanic food webs of the eastern tropical Atlantic assessed by stable isotope analysis

Gelatinous zooplankton can be present in high biomass and taxonomic diversity in planktonic oceanic food webs, yet the trophic structuring and importance of this “jelly web” remain incompletely understood. To address this knowledge gap, we provide a holistic trophic characterization of a jelly web in the eastern tropical Atlantic, based on δ13C and δ15N stable isotope analysis of a unique gelatinous zooplankton sample set. The jelly web covered most of the isotopic niche space of the entire planktonic oceanic food web, spanning > 3 trophic levels, ranging from herbivores (e.g., pyrosomes) to higher predators (e.g., ctenophores), highlighting the diverse functional roles and broad possible food web relevance of gelatinous zooplankton. Among gelatinous zooplankton taxa, comparisons of isotopic niches pointed to the presence of differentiation and resource partitioning, but also highlighted the potential for competition, e.g., between hydromedusae and siphonophores. Significant differences in spatial (seamount vs. open ocean) and depth‐resolved patterns (0–400 m vs. 400–1000 m) pointed to additional complexity, and raise questions about the extent of connectivity between locations and differential patterns in vertical coupling between gelatinous zooplankton groups. Added complexity also resulted from inconsistent patterns in trophic ontogenetic shifts among groups. We conclude that the broad trophic niche covered by the jelly web, patterns in niche differentiation within this web, and substantial complexity at the spatial, depth, and taxon level call for a more careful consideration of gelatinous zooplankton in oceanic food web models. In light of climate change and fishing pressure, the data presented here also provide a valuable baseline against which to measure future trophic observations of gelatinous zooplankton communities in the eastern tropical Atlantic