Diagnostic accuracy of a velcro sound detector (VECTOR) for interstitial lung disease in rheumatoid arthritis patients: the InSPIRAtE validation study (INterStitial pneumonia in rheumatoid ArThritis with an electronic device).

BACKGROUND: Interstitial lung disease (ILD) is a severe systemic manifestation of rheumatoid arthritis (RA). High-resolution computed tomography (HRCT) represents the gold standard for the diagnosis of ILD, but its routine use for screening programs is not advisable because of both high cost and X-ray exposure. Velcro crackles at lung auscultation occur very early in the course of interstitial pneumonia, and their detection is an indication for HRCT. Recently, we developed an algorithm (VECTOR) to detect the presence of Velcro crackles in pulmonary sounds and showed good results in a small sample of RA patients. The aim of the present investigation was to validate the diagnostic accuracy of VECTOR in a larger population of RA patients, compared with that of the reference standard of HRCT, from a multicentre study. METHODS: To avoid X-ray exposure, we enrolled 137 consecutive RA patients who had recently undergone HRCT. Lung sounds of all patients were recorded in 4 pulmonary fields bilaterally with a commercial electronic stethoscope (ES); subsequently, all HRCT images were blindly evaluated by a radiologist, and audio data were analysed by means of VECTOR. RESULTS: Fifty-nine of 137 patients showed ILD (43.1%). VECTOR correctly classified 115/137 patients, showing a diagnostic accuracy of 83.9% and a sensitivity and specificity of 93.2 and 76.9%, respectively. CONCLUSIONS: VECTOR may represent the first validated tool for the screening of RA patients who are suspected for ILD and who should be directed to HRCT for the diagnosis. Moreover, early identification of RA-ILD could contribute to the design of prospective studies aimed at elucidating unclear aspects of the disease.

Automated computer-based CT stratification as a predictor of outcome in hypersensitivity pneumonitis.

BACKGROUND: Hypersensitivity pneumonitis (HP) has a variable clinical course. Modelling of quantitative CALIPER-derived CT data can identify distinct disease phenotypes. Mortality prediction using CALIPER analysis was compared to the interstitial lung disease gender, age, physiology (ILD-GAP) outcome model. METHODS: CALIPER CT analysis of parenchymal patterns in 98 consecutive HP patients was compared to visual CT scoring by two radiologists. Functional indices including forced vital capacity (FVC) and diffusion capacity for carbon monoxide (DLco) in univariate and multivariate Cox mortality models. Automated stratification of CALIPER scores was evaluated against outcome models. RESULTS: Univariate predictors of mortality included visual and CALIPER CT fibrotic patterns, and all functional indices. Multivariate analyses identified only two independent predictors of mortality: CALIPER reticular pattern (p = 0.001) and DLco (p < 0.0001). Automated stratification distinguished three distinct HP groups (log-rank test p < 0.0001). Substitution of automated stratified groups for FVC and DLco in the ILD-GAP model demonstrated no loss of model strength (C-Index = 0.73 for both models). Model strength improved when automated stratified groups were combined with the ILD-GAP model (C-Index = 0.77). CONCLUSIONS: CALIPER-derived variables are the strongest CT predictors of mortality in HP. Automated CT stratification is equivalent to functional indices in the ILD-GAP model for predicting outcome in HP. KEY POINTS: • Computer CT analysis better predicts mortality than visual CT analysis in HP. • Quantitative CT analysis is equivalent to functional indices for prognostication in HP. • Prognostication using the ILD-GAP model improves when combined with quantitative CT analysis.

Characterization of protected designation of origin Italian meat products obtained from heavy pigs fed barley-based diets.

A study was conducted to evaluate the quality and sensory properties of protected designation of origin (PDO) Parma ham and Piacentina neck obtained from heavy pigs (Italian Duroc × Italian Large White) fed barley-based diets. Four diets were tested: 1) a corn-based diet (control), 2) the control diet with 80% of a normal-amylose hulled barley variety (Cometa), 3) the control diet with 80% of a normal-amylose hulless barley variety (Astartis), and 4) the control diet with 80% of a low-amylose hulless barley variety (Alamo). All the meat products were analyzed for physicochemical and color parameters. The dry-cured hams and necks were also evaluated for sensory properties. The data of physicochemical, color, and sensory parameters were separately analyzed by multivariate factor analysis, and interpretation of each extracted factor was based on specific original variables loading on each one. The meat products obtained from pigs fed the barley-based diets differed from those obtained from the control pigs on the PUFA factors characterized by C18:2-6 and omega-3:omega-6 ratio. In particular, the meat products obtained from pigs fed the barley-based diets had a lower content of C18:2-6 and a higher omega-3:omega-6 ratio ( < 0.05) than the control. In fresh hams, iodine number and SFA (C16:0 and C18:0) in addition to PUFA and omega-3:omega-6 ratio loaded on the PUFA/SFA factor. The fresh hams produced from pigs fed the barley-based diets had subcutaneous fat (SC) with a lower iodine number and a higher SFA level compared with those produced from the control pigs ( < 0.05). A sex effect was measured for PUFA/SFA and oleic acid factors. In particular, the barrow SC had a lower SFA content, higher PUFA and C18:1-9 levels, and a higher iodine number ( < 0.05) than the gilt SC. There were no appreciable differences in the color and sensory properties of meat products obtained from pigs fed the different diets. The hams from barrows differed from those obtained from gilts on the lean properties factor describing properties related to aspect and odor of dry-cured hams. Indeed, the hams from barrows were depreciated compared with the hams from gilts for minor intensity, brightness, and uniformity of the lean, pinkish intermuscular fat and cured odor. In conclusion, barley could be used as a replacement for corn in heavy pig diets for the production of PDO Italian products without negative effects on the physicochemical, color, or sensory characteristics of meat products.

Selective mobilization of fatty acids in adipose tissue of heavy pigs.

The mobilization of fatty acids during food deprivation is a selective process studied in different species (humans, rodents, birds, viverrids). The aim of this work was to study the effect of fasting on selective mobilization in commercial pigs. A total of 16 barrows (Large White×Landrace (167 kg±12.5 kg live weight) were subdivided into two homogeneous groups, one subjected to 12 h and the other to 60 h of fasting (fasting time) before slaughtering. For each pig inner and outer backfat layer were sampled at slaughter and at ham trimming 24 h later (sampling time). Increasing the fasting time and the sampling time after slaughter caused an increase in the amount of free fatty acids in both layers. Therefore it can be argued that during fasting lipolysis is stimulated and remains active also after slaughtering. The factors that stimulate lipolysis determine a greater mobilization of unsaturated fatty acids than saturated ones. Thus fasting time may influence the suitability of pork for processing and conservation, since free fatty acids are more suitable for oxidation than the esterified ones.

Effect of replacing corn with hulled and hulless or low-amylose hulless barley varieties on growth performance and carcass quality of Italian growing-finishing pig.

A study was conducted to evaluate the effect of diets based on hulled or hulless (normal- and low-amylose) barley varieties on growth performance and carcass characteristics in heavy growing-finishing pigs for the production of protected designation of origin (PDO) Italian products. The study was performed with 40 gilts and 40 barrows (Italian Duroc × Italian Large White). Four diets were formulated: 1) corn-based diet (control), 2) control diet with 80% of a normal-amylose hulled barley variety named Cometa (Cometa), 3) control diet with 80% of a normal-amylose hulless barley variety named Astartis (Astartis), and 4) control diet with 80% of a low-amylose hulless barley variety named Alamo (Alamo). The diets were formulated according to 3 growth phases (P1, 40 to 80 kg BW; P2, 80 to 120 kg BW; and P3, 120 to 170 kg BW), with the same Lys:DE ratio (2.60, 2.20, and 1.80, respectively in P1, P2, and P3) according to the NRC requirements for P1 and P2 and according to requirements for high-performing pigs for P3. The diets were analyzed for their in vitro starch digestion potentials (predicted glycemic index, pGI) and for their resistant starch (RS) contents. In P1, P2, and P3, the Alamo diet had the numerically lowest RS contents and greatest pGI values, whereas the control diet had the numerically greatest RS contents and the lowest pGI values. Throughout the study, the pigs fed Cometa and Alamo diets grew faster (P < 0.01) than those fed the control diet, whereas pigs receiving Astartis diet grew in a similar manner to those receiving all the other diets. Pigs fed Cometa and Alamo achieved greater final BW (P < 0.01) compared with those fed the control diet. The pigs receiving the Astartis diet had a mean final BW similar to that of the pigs fed other diets. Throughout the study, the control group had a lower grams per megacalorie DE (P < 0.01) compared with the pigs fed diets with barley, whereas the gain per megacalorie of DE (G/Mcal DE) was greater (P < 0.01) for the pigs fed hulled barley compared with the pig fed hulless barleys. No difference in carcass characteristics was found among treatments (P > 0.05). This study showed that diets based both on hulled and hulless barley might be suitable for the heavy pig breeding intended to the production of Italian PDO products. In addition, hulled or low-amylose hulless barley could be valuable to support maximum pig growth performance without affecting carcass composition.

Addition of nonstarch polysaccharides degrading enzymes to two hulless barley varieties fed in diets for weaned pigs.

A study was conducted to evaluate the effect of 2 hulless barley varieties, with or without the addition of a nonstarch polysaccharide (NSP) enzyme complex (ß-glucanase and xylanase), on growth performance of weaned piglets in a 42-d feeding study. The study was conducted with 140 piglets (PIC × Duroc). Pigs were allocated to pens (4 castrated males or 4 females per pen) based on BW and sex, and pens were assigned to 5 experimental diets with 4 pens of castrated males and 3 pens of females per treatment. Five isonitrogenous and isoenergetic diets were compared: 1) control corn-based diet (CTR), 2) diet with corn and wheat bran replaced by the Astartis hulless barley variety (AS), 3) diet with corn and wheat bran replaced by the AS supplemented with the NSP enzyme complex (ASE), 4) diet with corn and wheat bran replaced by the Alamo hulless barley variety (AL), and 5) diet with corn and wheat bran replaced by the AL supplemented with the NSP enzyme complex (ALE). The diets were formulated to meet or exceed nutrient requirements and offered in 2 phases: d 0 to 14 and d 14 to 42. At the end of the study, pigs fed AS and AL had equal weights as pigs fed CTR. Pigs fed the hulless barley diets had greater (P < 0.05) ADG during the second phase (P2) and overall phase, BW at d 42, and G:F during the P2 than those fed the CTR. Pigs fed the ASE and ALE had greater (P < 0.05) ADFI during the P2 and overall ADG than those fed the AS and AL. The increases in ADG during the P2 and final BW obtained with NSP enzyme supplementation were greater in pigs fed the AS than those fed the AL (barley × enzyme, P < 0.05). On the other hand, the NSP enzyme complex increased G:F in pigs fed the AS during the P2 and overall phase, but it had no effect on those fed the AL (barley × enzyme, P < 0.05). In conclusion, hulless barley with or without the NSP enzyme complex can be a replacement ingredient for corn and wheat bran in weaned pig diets. Addition of the NSP enzyme complex to AS variety, but not AL variety, improved growth performance of weanling pigs.

Performance and fat quality of heavy pigs fed maize differing in linoleic acid content.

Maize shows wide differences in linoleic acid due both to total lipid content and to fatty acid profile. Therefore, diets containing the same high maize percentage (up to 55%) can differ in linoleic acid content and lead to subcutaneous fats of differing suitability for raw ham curing. Two trials were performed on heavy pigs; in the first, 60 pigs (body weight 48.7+/-5.1 kg) were fed three diets made using three maize batches differing in linoleic acid due to different total lipid content, in the second trial, 40 pigs (live weight 70.4+/-3.4 kg) were fed two diets made using two maize batches differing in linoleic acid due to their fatty acid profile. Pigs were slaughtered at 170 kg of live weight. In both trials, the growth and slaughtering performance did not differ. In the first trial the three diets lead to a different content of linoleic acid both in subcutaneous (low linoleic vs medium linoleic vs high linoleic P0.01) and intramuscular fat (low linoleic vs high linoleic P0.05). In the second trial different linoleic acid content was observed for subcutaneous fat (P0.01) but not for intramuscular fat. To formulate diets for heavy pigs, it is crucial to know the linoleic acid content of the maize used, because differences of only 0.3% can lead to significant differences in fatty acids composition of depot fats.

Use of pure glycerol in fattening heavy pigs.

Eighty Italian Duroc×Italian Large White pigs (BW 42.6±3.37kg) were used to determine the effects of pure glycerol on growth performance and meat quality of heavy pigs. Pigs were divided into five groups receiving 0% (control), 5% or 10% during the growing and finishing phases (42.6-160kg BW) (G+F5,G+F10) or 5% or 10% during the finishing period (100-160kg BW) (FIN5,FIN10) of pure glycerol in substitution for maize meal (on a dry matter basis). The pigs were slaughtered at approximately 160kg BW. The growth performance of pigs fed 5% glycerol did not differ from controls regardless of feeding duration, whereas those fed 10% glycerol showed reduced growth and poorer feed:gain ratio. Fat quality and meat suitability for raw ham curing were not affected by dietary treatment. Differences were not consistent enough to draw any conclusion about the effects of feeding glycerol on sensory characteristics.

Effect of feeding partially hydrogenated lard on trans-fatty acid content of muscle and backfat of heavy pigs.

The incorporation of fat in diets for heavy pigs may be necessary in order to increase their energy intake in the finishing period. Lard may be a good lipid source but it contains 10-13% of linoleic acid, which makes the subcutaneous fat less suitable for long term curing of raw ham. Partial hydrogenation of lard decreases linoleic acid content, but increases trans-fatty acid content. This trial involved two groups of pigs of 114kg live weight, fed for the last two months before slaughter with diets containing 3% lard (L) or 3% partially hydrogenated lard (PHL). The PHL contained about 10% trans-fatty acids and 2.5% linoleic acid. Rearing performance and carcass characteristics were unaffected by treatment. The group fed PHL showed a lower percentage of linoleic acid in the backfat (PHL 12.28% vs. L 13.04%) and a higher percentage of C18:1 trans-fatty acids both in backfat (0.5% vs. 0.06%) and in intramuscular fat (0.2% vs. 0.04%).

Isolated jejunal Crohn's disease in a young adult presenting as fever of unknown origin.

A 27-yr-old man was referred for fever, weight loss, fatigue, and occasional mild epimesogastric pain without diarrhea or vomiting. Laboratory tests were suggestive of an active inflammatory disease but serological, bacteriological, viral searches, markers of autoimmunity, and neoplasia were all negative. The following were also negative: ultrasonography; conventional x-rays; CT scans; esophagogastroduodenoscopy, pancolonoscopy with ileoscopy; cytohistology including duodenum and ileocolon. Empiric antibiotic regimens failed to control the temperature. Small bowel enema disclosed multiple proximal jejunal strictures. Jejunoscopy revealed erythema, friability, linear ulcerations, stenosis, and dilation in the proximal jejunum. Multiple directed biopsies showed inflammatory changes devoid of any specific features. The patient received steroid treatment and his temperature normalized. Six months later, he was readmitted on account of intestinal subocclusion that was managed conservatively. A few days later urgent laparotomy was performed with peritoneal lavage, repair of double perforated proximal jejunal ulcers, and stricturoplasty. Surgical jejunal biopsy confirmed the results of enteroscopic biopsies. The patient is presently without fever, in the absence of steroid treatment. There have been no reports of cryptogenic fever due to isolated jejunal Crohn's disease in the recent literature. Our patient's clinical picture resembled disease as seen in older children and adolescents, in whom it is a difficult diagnosis owing to the absence of diarrhea. In adults with Crohn's disease isolated jejunal involvement represents approximately 1% of cases. A thorough small bowel investigation is warranted in young adults with cryptogenic fever and low serum protein levels, even in the absence of major gastrointestinal complaints.

Frequency and type of colorectal tumors in asymptomatic high-risk individuals in families with hereditary nonpolyposis colorectal cancer.

In hereditary nonpolyposis colorectal cancer (HNPCC, or Lynch syndrome) a close surveillance is usually proposed to high-risk family members with the ultimate goal of reducing cancer incidence and mortality. Through a specialized registry, between 1984 and 1996, we identified 31 families with clinical features of HNPCC. A total of 390 first-degree relatives of affected patients were considered at high risk for colorectal cancer. The main purposes of this study were: (a) to assess overall compliance; and (b) to evaluate the frequency and morphological features of tumors detected at endoscopy. Two hundred twenty-three subjects could be directly interviewed and colonoscopy strongly recommended. Each of the 86 individuals who underwent colonoscopy was matched to a control of the same age (+/-3 years) and sex (control subjects were seeking endoscopy for constipation, rectal bleeding or abdominal discomfort). Of the 390 individuals traced as "at risk," 223 (57.2%) could be contacted, and, of these, 86 (38.6%, or 22.0% of the total) underwent colonoscopy. One or more colorectal lesions were found in 35 of 86 (40.7%) HNPCC asymptomatic family members and in 15 (17.4%; P < 0.001) controls. In the former group, 29 adenomas were detected in 20 individuals as opposed to 11 adenomas in 9 subjects among controls (P < 0.03). Moreover, adenomas in family members were significantly larger [9.1 +/- 5.9 mm (mean +/- SD) versus 5.8 +/- 3.7 mm; P < 0.02] and more frequently showed a tubulovillous histological type and a high degree of dysplasia. Five colorectal carcinomas (in four patients) were detected among cases (four of which were located between the cecum and the hepatic flexure); only one was detected among controls. Surveillance of high-risk subjects in HNPCC families can be carried out only in a fraction of them, because the majority cannot be reached or refuse to collaborate. On the other hand, the frequency of newly detected lesions among family members and the possible aggressive behavior of the lesions render pancolonoscopy necessary at regular intervals of time.

Triple therapy with azithromycin, omeprazole, and amoxicillin is highly effective in the eradication of Helicobacter pylori: a controlled trial versus omeprazole plus amoxicillin.

BACKGROUND: Azithromycin is a new-generation, acid-stable macrolide antibiotic that achieves remarkably high concentrations in gastric tissue, persisting above the MIC90 for Helicobacter pylori over a 5-day period after a single 500-mg oral dose. METHODS: We evaluated a new metronidazole-free triple therapy with omeprazole 20 mg b.i.d. plus amoxicillin 1 g b.i.d. (both for 14 days) and azithromycin 500 mg mane (for the first 3 days only) (group I) versus double therapy with omeprazole 20 mg b.i.d. plus amoxicillin 1 g t.i.d., both for 14 days (group II). H. pylori status was determined by urease test and histology before and 6 wk after completion of therapy. RESULTS: Ninety-two patients with peptic ulcer disease or nonulcer dyspepsia completed the study. H. pylori infection was eradicated in 44 (91.6%) of 48 patients randomized to receive triple therapy versus 26 (59.1%) of 44 who received double therapy (p < 0.001). Smoking, but not omeprazole pretreatment, proved to be a risk factor for treatment failure only in the double-therapy group (p = 0.05). All ulcers healed by the time of the 8-wk endoscopic control. Side effects, usually minor, were recorded in 12.5% and 9.1% of patients, respectively (NS), but therapy had to be discontinued in one patient in group I and in three in group II (NS). CONCLUSIONS: Two-week triple therapy with omeprazole, amoxicillin, and (for the first 3 days) low-dose azithromycin is highly effective in eradicating H. pylori. This regimen is safe and well-tolerated, and we recommend that it be used as first-line treatment, as an alternative to less-effective omeprazole-amoxicillin double therapy. Moreover, azithromycin appears to be a new, promising antibiotic for future innovative anti-H. pylori combinations.

Combined endoscopic and surgical management of Dieulafoy vascular malformation.

BACKGROUND: Dieulafoy's disease (exulceratio simplex) is an uncommon cause of gastric hemorrhage as a result of an abnormally large, submucosal, eroded gastric artery, often located in the upper part of the stomach. It represents a clinical challenge because of the intermittent nature of massive bleeding accounting for a constantly fatal course in conservatively (nonsurgically or nonendoscopically) treated patients. Published therapeutic options include techniques of endoscopic hemostasis or operative procedures. STUDY DESIGN: Herein we report two patients in whom a combined endoscopic and operative approach was performed to obtain a definitive prevention of rebleeding and an undoubted anatomopathologic diagnosis. RESULTS: Our innovative combined endoscopic and operative approach has offered three significant advantages: endoscopic preoperative diagnosis and control of the bleeding; valid aid in the intraoperative localization of hemorrhagic lesions, which is erratic intraoperatively, requires gastrotomy, and prolongs the duration of operation; and endoscopy-guided limited wedge resection as opposed to standard techniques involving gastrotomy for simple ligation or oversewing of the involved vessel, local excision, or wide wedge resections that used to be recommended until the recent past. CONCLUSIONS: We confirm that seemingly obscure origins of massive recurring hemorrhage of the upper part of the gastrointestinal tract should increase the suspicion of Dieulafoy's disease, prompting careful examination of the gastric fundic area and greater curvature. Endoscopic hemostasis is the first choice; whenever operative treatment is indicated (because of the endoscopic or clinical situation), it should be as conservative as possible because of intraoperative endoscopic localization of the bleeding source.

Are routine duodenal and antral biopsies useful in the management of "functional" dyspepsia? A diagnostic and therapeutic study.

Fifty-three patients with previously uninvestigated chronic dyspepsia symptoms in the absence of gastrointestinal or extra-gastrointestinal disease (functional dyspepsia) underwent antral and duodenal mucosal biopsies to detect the role of such samplings in the presence of normal endoscopic findings. Patients were enrolled in a randomized, placebo-controlled, double-blind trial, receiving either eradicating treatment (colloidal bismuth subcitrate plus metronidazole) or placebo if they had Helicobacter pylori-associated gastritis (20 patients), or cisapride or placebo if they had normal antral mucosa (28 cases). Unsuspected celiac sprue was found in one patient. Eradicating treatment ameliorated histological gastritis (p = 0.01). However, owing to great placebo efficacy, symptom remission rates following a 1-month wash-out period in both treatment groups were no higher than that in controls. Independent of the initial randomization, an extremely low symptom recurrence rate was observed during a drug-free follow-up study equivalent to the mean duration of symptoms before enrollment. We conclude that in functional dyspepsia, bulbar and antral biopsies are not useful in clinical management, equivalent symptom relief can be achieved in patients randomly assigned to both drugs and placebos, and such improvement can be long lasting in the absence of any maintenance treatment. We believe the prevalence of unsuspected villous atrophy and the therapeutic role of investigation-based reassurance deserve further assessment.