Clinical course of severe colitis: a comparison between Crohn’s Disease and ulcerative colitis.

Few data are available about the clinical course of severe colonic Crohn’s disease (CD). The aim of this study is to describe the clinical course of severe Crohn’s colitis in a patient cohort with isolated colonic or ileocolonic CD, and to compare it with the clinical course of patients with severe ulcerative colitis (UC). Thirty-four patients with severe Crohn’s colitis were prospectively identified in our cohort of 593 consecutive hospitalized patients through evaluation of the Crohn’s Disease Activity Index score and the Harvey-Bradshaw Index. One hundred sixty-nine patients with severe ulcerative colitis were prospectively identified in our cohort of 449 consecutive hospitalized patients through evaluation of the Lichtiger score and the Truelove-Witts score. We evaluated the following data/aspects: response to steroids, response to biologics, colectomy rate in acute, colectomy rate during follow-up, megacolon and cytomegalovirus infection rate. We did not find significant differences in the response to steroids and to biologics, in the percentage of cytomegalovirus infection and of megacolon, while the rate of colectomy in acute turned out to be greater in patients with severe Crohn’s colitis compared to patients with severe UC, and this difference appeared to be the limit of statistical significance (Chi-squared 3.31, p = 0.069, OR 0.39); the difference between the colectomy rates at the end of the follow-up was also not significant. In the whole population, by univariate analysis, according to the linear regression model, a young age at diagnosis is associated with a higher overall colectomy rate (p = 0.024) and a higher elective colectomy rate (p = 0.022), but not with a higher acute colectomy rate, and an elevated ESR is correlated with a higher overall colectomy rate (p = 0.014) and a higher acute colectomy rate (p = 0.032), but not with a higher elective colectomy rate. This correlation was significant on multivariate analysis. The overall rate of colectomy in the cohort of patients with severe Crohn’s colitis was greater than that of the cohort of patients with severe UC, but this figure is not supported by a different clinical response to steroid therapy or rescue therapy with biologics. The clinical course of severe Crohn’s colitis requires to be clarified by prospective studies that include a larger number of patients in this subgroup of disease.

Incidence of Crohn's disease and CARD15 mutation in a small township in Sicily.

BACKGROUND: The incidence of Crohn's disease (CD) has been shown to be lower in Southern than in Northern Europe. Data on the frequency of the NOD2/CARD15 mutations for Mediterranean area are very scant. AIM: To determine the incidence of CD from 1979 to 2002 in a township in Sicily together with the allele frequency of NOD2/CARD15 mutations in patients, family members and controls, and to determine the allele frequency of these mutations in sporadic CD from other areas of Sicily in comparison with a control population. METHODS: Casteltermini is a small town close to Agrigento (Sicily) with a population of 9,130 inhabitants. All the diagnoses of inflammatory bowel disease (IBD) made from 1979 to 2002 were obtained through the local health authority. NOD2/CARD15 mutations were studied in 23 out of the 29 patients with CD in Casteltermini, in 60 family members and in 64 controls. NOD2/CARD15 was also studied in 80 sporadic cases of CD disease among Sicilians outside Casteltermini and 118 healthy controls. RESULTS: From 1979 to 2002, 29 patients with CD and 13 patients with ulcerative colitis (UC) were registered. The 6-year mean incidence of CD ranged from 8.0 to 17 new cases for every 100,000 inhabitants, whereas the mean incidence of UC ranged from five new cases to 7.8 for every 100,000 inhabitants. The allele frequencies of NOD2/CARD15 mutations (L1007finsC, G908R, R702W) were 8.7, 4.3 and 8.7%, respectively, in CD cases; 5.0, 4.2 and 3.1% in family members; 1.6, 2.3 and 3.1% in controls. In sporadic Sicilian CD patients outside Casteltermini the allele frequency was 7.5, 8.1, 6.2% whereas in control population it was 3.3, 1.6, 1.6%. CONCLUSIONS: A high incidence of CD compared with UC was observed in this small town in Southern Italy. The frequency of NOD2/CARD15 mutations in CD is similar to other Caucasian population studied so far.

The role of calprotectin in predicting endoscopic post-surgical recurrence in asymptomatic Crohn's disease: a comparison with ultrasound.

BACKGROUND AND OBJECTIVES: Faecal calprotectin is predictive of clinical relapse in inflammatory bowel disease and ultrasound is sensitive in detecting its post-surgical recurrence. However, no data regarding the role of calprotectin in predicting post-surgical recurrence in asymptomatic Crohn's disease are available. The aim of this study was to prospectively evaluate the role of calprotectin as a predictive marker for one year post-surgical endoscopic recurrence in comparison with ultrasound in patients with asymptomatic Crohn's disease. MATERIAL AND METHODS: We consecutively enlisted 50 patients who had undergone a resection for Crohn's disease. Faecal calprotectin was analysed and ultrasound were performed at the third month, and a colonoscopy after one year. The sensitivity and specificity of these two techniques were evaluated using endoscopic findings as a golden standard. A Receiver Operator Curve (ROC) curve was plotted, in order to identify the best-cut off value for calprotectin. RESULTS: 39 out of 50 patients were evaluated by performing a colonoscopy after one year; 19 patients had an endoscopic recurrence after one year. Calprotectin sensitivity and specificity were calculated for 5 different cut-off values; the best cut-off value for calprotectin sensitivity (63%) and specificity (75%) was > 200 mg/L. The US sensitivity and specificity at the third month were 26% and 90% respectively. CONCLUSIONS: When performed three months after surgery ultrasound is more specific than calprotectin in predicting endoscopic recurrence. Faecal calprotectin at a dosage > 200 mg/L seems to have a better sensitivity than ultrasound. Values of calprotectin > 200 mg can be an indication to colonoscopy in the group of patients with negative ultrasound in order to detect early recurrence.

Intravenous versus oral initial load of propafenone for conversion of recent-onset atrial fibrillation in the emergency room: a randomized trial.

BACKGROUND: Non-valvular paroxysmal atrial fibrillation is a common clinical condition associated with a high risk of thromboembolism and hemodynamic problems which increase with the duration of arrhythmia. Therefore, even if arrhythmia ceases spontaneously within 24 hours in about half of the patients, a higher early conversion rate is desirable. Propafenone either by intravenous or oral load has been shown effective in conversion to sinus rhythm. METHODS: We consecutively randomized all emergency patients with non-valvular atrial fibrillation lasting no more than 48 hours to either intravenous or oral initial load of propafenone. They all received further oral doses if still on atrial fibrillation after the initial load. Exclusion criteria were: mean ventricular rate < 65 b/min, age > 75 years, recent acute myocardial infarction, overt heart failure, conduction defects, ventricular preexcitation, thyroid dysfunction, renal or hepatic insufficiency, pregnancy, current treatment with propafenone or other antiarrhythmic drugs, and intolerance to propafenone. Primary and secondary end-points were the conversion to sinus rhythm within 12 and 48 hours of randomization respectively. RESULTS: Ninety-seven patients were randomized to intravenous (n = 49) or oral (n = 48) treatment. Overall, sinus rhythm restoration occurred in 83.3% of patients within 12 hours and in 98.9% at 24 hours. Recovery rate resulted significantly greater for intravenous treatment at 1 and 3 hours (p < 0.001 and p = 0.001, respectively). At 6, 12 and 24 hours no significant difference between the two groups was observed (p = 0.77, p = 0.81 and p = 0.99, respectively). No patient needed treatment suspension. CONCLUSIONS: In patients with recent-onset non-valvular atrial fibrillation treated with propafenone within 48 hours, conversion to sinus rhythm occurred in more than 80% within 12 hours. Even if intravenous initial load appears to be slightly more rapid, the oral way is easier to administer and cheaper. The choice may depend on the specific organization of the single emergency room.

Failure in intrauterine contraception. Analysis of 137 cases of unfavourable outcome.

137 cases of unfavourable outcome in IUD insertion (i.e. early removal or expulsion because of complications) were investigated as regards age, parity, previous intrauterine contraception, previous induced abortion, type of device inserted, and type of complications observed. Moreover, this group was compared for each feature mentioned with a control group of 454 women who successfully concluded the prescribed period from the insertion. All the devices were inserted with a significantly higher rate of favourable outcome in pluriparous versus nulliparous patients; age probably didn't affect the outcome, but strongly conditioned the prevalence of particular complications such as PID and abnormal bleeding. Progesterone-loaded IUD didn't show a more favourable outcome than copper devices.

PIP: The factors associated with 137 cases of IUD expulsion or early removal due to complications were investigated in a case-control study conducted at an Italian family planning clinic. The 454 controls were women who did not experience adverse IUD outcomes. Complications in the study group included: bleeding (35%), expulsion (13%), pregnancy (13%), pelvic pain (15%), and pelvic inflammatory disease (24%). The majority of complications occurred 6-12 months after IUD insertion. Previous IUD use and the type of IUD inserted were unrelated to outcome. Most significant in terms of outcome was parity. There was a statistically significant (p .001) difference between the percentage of nulliparae in the study group (34%) compared with the control group (17%). Although most of the nulliparae in the study group were under 20 years of age, age did not have a significant correlation with IUD outcome. Pelvic inflammatory disease was significantly more prevalent in women under 30 years of age, while excessive bleeding was more common in cases above this age.