Henoch-Schönlein purpura masquerading as Crohn's disease flare.

We describe the case of a 69-year-old male with Crohn's disease (CD), treated with infliximab and undergoing intestinal resection. The surgery and postoperative period were unremarkable, with no CD-related symptoms. Two months after surgery and two weeks after the introduction of infliximab, he was admitted due to acute onset diffuse abdominal pain, hematochezia and arthralgia. On physical observation on admission, he showed signs of arthritis of the left knee. Laboratory tests revealed renal failure with nephrotic proteinuria, slightly low complement (C3) and IgA elevation. Remaining autoimmunity and viral panel were negative. Abdominal examination showed duodenum and thickening of the proximal wall of the jejunum. Biopsies excluded active CD. Colon and ileum mucosa were normal. The patient met EULAR criteria for Henoch-Schönlein purpura and was started on prednisolone with response. Although no clear trigger was pointed out, we switched anti-TNF to ustekinumab. We present this case given its endoscopic exuberance, and because of the high index of suspicion to make the diagnosis in adult patients with previous inflammatory bowel disease. The distinction between this vasculitis and CD is of utmost importance, given the therapeutic implications.

Isolated Jejunal Crohn's Disease: a challenging diagnosis.

A 27-year-old Nepalese male presented with recurrent abdominal pain accompanied by a lower stool consistency over the past 2 years. These episodes occurred several times a year, lasting 1 to 2 weeks, and resolved spontaneously, after adjustment of diet and/or medication for symptomatic control (e.g., antispasmodics, probiotics). Over the last year, the patient had undergone an extensive diagnostic investigation, which revealed no alterations in the laboratory workup, abdominal scan, esophagogastroduodenoscopy, and colonoscopy, including biopsies of the duodenum, and colon, so the symptoms have been attributed to irritable bowel syndrome. However, the symptoms had become more frequent, so the patient was referred to our gastroenterology department. We repeated and extended the work-up. Laboratory investigations showed an elevated erythrocyte sedimentation rate and faecal calprotectin. The remaining laboratory as well an extensive stool workup for infection were unremarkable. Esophagogastroduodenoscopy and ileocolonoscopy were normal. Small bowel capsule endoscopy revealed jejunal mucosa with lymphangiectasias, pseudopolypoids formations and superficial longitudinal ulcers, these findings were corroborated by the double-balloon enteroscopy, and biopsies showed marked architectural distortion, chronic inflammatory infiltrate, and an epithelioid granuloma. The clinical, endoscopic, biochemical, and histological findings were consistent with isolated jejunal Crohn's disease. The patient started adalimumab with complete remission after one year. We present this case given its exuberant endoscopic findings and due to the difficulty in making the diagnosis due to its rarity, location, and unspecific presentation.

Time trends in episiotomy and severe perineal tears in Portugal: a nationwide register-based study.

INTRODUCTION: Rates of episiotomy and severe perineal tears (SPT) are indicators of the quality of obstetric care. Time-trends in the reported occurrence of episiotomy and SPT can contribute to understand both, changes in care and in the frequency of risk factors. Therefore, we aimed to estimate time trends in the frequency of SPT in Portugal and its relationship with episiotomy. METHODS: We conducted a nationwide register-based study using data from the national inpatient database of all Portuguese public hospitals between 2000 and 2015. Time-trend analysis using joinpoint regression models was performed to identify trends (joinpoints) and compare time changes in the prevalence of SPT and risk factors expressed as annual percentage changes (APC) with 95% Confidence Intervals (95% CI). Poisson regression models were fitted to estimate whether time-trends in SPT rates were explained by changes in risk factors and to assess the association between episiotomy and SPT. Adjusted relative risk (aRR) and their respective 95% CI were obtained. RESULTS: From 908,999 singleton vaginal deliveries, 20.6% were instrumental deliveries, 76.7% with episiotomy and 0.56% were complicated by SPT. Among women with non-instrumental deliveries and no episiotomy SPT decreased from 2009 onwards (1.3% to 0.7%), whereas SPT kept increasing in women with episiotomy for both non-instrumental (0.1% in 2000 to 0.4% in 2015) and instrumental deliveries (0.7% in 2005 to 2.3% in 2015). Time-trends in potential risk factors did not explain the observed increase in SPT. Episiotomy was associated with a decrease in SPT with adjusted RR varying between 2000 and 2015 from 0.18 (95%CI:0.13-0.25) to 0.59 (95%CI:0.44-0.79) for non-instrumental deliveries and from 0.45 (95%CI:0.25-0.81) to 0.50 (95%CI:0.40-0.72) for instrumental deliveries. CONCLUSIONS: Our findings suggest that episiotomy rate could safely further decrease as the main factor driving SPT rates seems to be an increase in awareness and reporting of SPT particularly among women who underwent an episiotomy.

Novel xylan-degrading enzymes from polysaccharide utilizing loci of Prevotella copri DSM18205.

Prevotella copri is a bacterium that can be found in the human gastrointestinal tract (GIT). The role of P. copri in the GIT is unclear, and elevated numbers of the microbe have been reported both in dietary fiber-induced improvement in glucose metabolism but also in conjunction with certain inflammatory conditions. These findings raised our interest in investigating the possibility of P. copri to grow on xylan, and identify the enzyme systems playing a role in digestion of xylan-based dietary fibers. Two xylan degrading polysaccharide utilizing loci (PUL10 and 15) were found in the genome, with three and eight glycoside hydrolase (GH) -encoding genes, respectively. Three of them were successfully produced in Escherichia coli: One extracellular enzyme from GH43 (subfamily 12, in PUL10, 60 kDa) and two enzymes from PUL15, one extracellular GH10 (41 kDa), and one intracellular GH43 (subfamily 137 kDa). Based on our results, we propose that in PUL15, GH10 (1) is an extracellular endo-1,4-ß-xylanase, that hydrolazes mainly glucuronosylated xylan polymers to xylooligosaccharides (XOS); while, GH43_1 in the same PUL, is an intracellular ß-xylosidase, catalyzing complete hydrolysis of the XOS to xylose. In PUL10, the characterized GH43_12 is an arabinofuranosidase, with a role in degradation of arabinoxylan, catalyzing removal of arabinose-residues on xylan.

Equitable migrant-friendly perinatal healthcare access and quality in public maternity units in Portugal.

BACKGROUND: Migrant women are at higher risk to face access barriers to perinatal care services and to experience worse pregnancy outcomes compared to native. Assessing the perception of migrant women and health providers discloses a multifaceted view on migrant-friendly care, a multidimensional concept in itself. This study aims to compare self-perceived assessments of migrant women and directors of obstetrics and gynaecology (GYN/OBS) departments on equitable migrant-friendly perinatal healthcare quality and access during the intrapartum and postpartum period at public maternities in Portugal. METHODS: In this cross-sectional study, two indicators on Healthcare access and Quality of care were developed to compare how adult migrant women who gave birth between April 2017 and March 2019 and GYN/OBS department directors assessed offered care. The one-sample Wilcoxon test was used to compare directors' with migrants' assessments and the Kruskal-Wallis one-way analysis of variance to test for country regional differences. A stratified analysis by sex, spoken language, and country of birth tested for potential effect modifiers. RESULTS: Migrants rated Healthcare access significantly better (P<0.05), but perceived Quality of care worse (P<0.01) than GYN/OBS department directors. Migrants' and directors' perceptions differed significantly according to directors' gender (P<0.05). Migrants' and directors' assessments on Healthcare access (P<0.05) and Quality (P<0.01) changed significantly across regions. CONCLUSIONS: Migrants' and directors' self-perceived appraisal of Healthcare access and Quality of care significantly varied. Identifying these discordances allows to deliver insights into existing barriers in access and provision of care and raises awareness to improve quality assurance, essential to inform practice and policies.

Monitoring severe acute maternal morbidity across Europe: A feasibility study.

BACKGROUND: Monitoring severe acute maternal morbidity (SAMM) appears essential for optimising care and informing health care policies, especially given changes in obstetric practices and mother profiles. International comparisons can identify areas where improvement is needed, but the comparability of indicators must be evaluated. OBJECTIVE: To assess the feasibility of monitoring SAMM using common definitions from hospital discharge databases across Europe. METHODS: We used hospital discharge data in eight countries (2 826 868 deliveries) to identify women with SAMM among all hospitalisations of women of reproductive age admitted for antenatal or delivery care. Five SAMM indicators were investigated: eclampsia, septicaemia, hysterectomy, hysterectomy associated with a diagnosis of obstetric haemorrhage, and red blood cell (RBC) transfusion associated with a diagnosis of obstetric haemorrhage. Between-country variation was described, by the ratio of the highest to lowest rates, while external validation was assessed by comparing with population-based studies on maternal morbidity. RESULTS: Ratios for hysterectomy and red blood cell (RBC) transfusion in the context of obstetric haemorrhage were 1:2.1 and 1:3.5, respectively. High values of hysterectomy and low values of transfusion were both consistent with high maternal mortality from haemorrhage (France, Italy, Portugal). Ratios across countries were relatively low for eclampsia (1:3.4) but very high for septicaemia (1:22.5). Compared to population-based morbidity estimates, eclampsia was over-reported in hospital databases whereas the two indicators of severe haemorrhage had good external validity. CONCLUSIONS: In association with diagnosis codes indicating obstetric haemorrhage, hysterectomy and RBC transfusion appear to be good candidates for surveillance of maternal morbidity in Europe.

Correction to: Evaluation of the efficacy of Lactobacillus plantarum HEAL9 and Lactobacillus paracasei 8700:2 on aspects of common cold infections in children attending day care: a randomised, double-blind, placebo-controlled clinical study.

The original version of this article unfortunately contained a mistake. A number in Table 6 has been corrected.

Evaluation of the efficacy of Lactobacillus plantarum HEAL9 and Lactobacillus paracasei 8700:2 on aspects of common cold infections in children attending day care: a randomised, double-blind, placebo-controlled clinical study.

BACKGROUND: The combination of Lactobacillus plantarum HEAL9 and Lactobacillus paracasei 8700:2 (commercially available as Probi Defendum®) has previously been reported to reduce the incidence, duration and severity of naturally acquired common colds in adults. The aim of the present study was to evaluate the impact of Probi Defendum® on aspects of common cold in healthy children 1-6 years of age attending day care. METHODS: A total of 131 children, out of the planned 320, were recruited into the study during 1 common cold season and randomised to consume once daily either 109 CFU (colony forming units) of the probiotic product or placebo. Due to unforeseen reasons, the recruitment of more children did not continue beyond the first cold season. RESULTS: There were 106 children that completed the study out of the 131 randomised. Daily consumption of the probiotic product for a period of 3 months significantly reduced the severity of the symptom "nasal congestion/runny nose" with a mean severity score for the whole study period of 7.5 ± 9.7 in the probiotic group and 13.9 ± 15.2 in the placebo (p < 0.05). Moreover, significantly less concomitant medication was used in the probiotic group. When the data were projected to a larger population corresponding to the originally estimated sample size, the results were in favour of the probiotic group regarding the reduced absence from day care (p < 0.05), reduced mean total severity per day in the reported episodes (p < 0.05) and reduced severity of the symptom "crying more than usual" (p < 0.05). CONCLUSION: Intake of Probi Defendum® once daily for a period of 3 months was beneficial to children and reduced the severity of common colds.

Motivations and attitudes towards the act of blood donation among undergraduate health science students.

BACKGROUND: Undergraduate students are a target for blood donation, as they constitute a young healthy and well-informed group. AIM: To understand motivations and attitudes underpinning the act of blood donation among undergraduate health science students. MATERIALS AND METHODS: Cross-sectional study enrolling undergraduate students of a College of Health Sciences in the Northeast of Portugal (January/February, 2017). Data collection tool was a self-administered questionnaire covering questions about motivations (n = 8) and attitudes (n = 5) towards the act of blood donation. Participants were classified by donation status into donors (one previous donation) and non-donors (never donated). Multiple logistic regression models were used to assess the association between each attitude and motivation on donation status. Odds-ratio (OR) and respective 95% confidence intervals (95%CI) adjusted for potential confounders, were obtained. RESULTS: Out of 362 participants, 12.7% (n = 46) had ever donated blood and 56.5% (n = 26) of them were regular donors. Out of 316 non-donors, 88.0% (n = 278) will donate blood under request. There were no differences between donors and non-donors regarding the attitudes towards blood donation. From all motivations only "be a civic duty" had a significant impact on donor status, such that participants reporting this motivation are more likely to be blood donors (OR = 2.58; IC95%:1.34-4.99) than their counterparts. CONCLUSION: This study revealed that 80.0% of undergraduate health science students are non-donors, but they are available to donate blood under request. Campaigns and advertising methods focused on the emergent needs for blood donation could play an important role in the recruitment of new donors among undergraduate students.

Age-dependent biologic response to orthodontic forces.

INTRODUCTION: Orthodontic tooth movement results from increased inflammation and osteoclast activation. Since patients of all ages now routinely seek orthodontics treatment, we investigated whether age-dependent biologic responses to orthodontic force correlate with the rate of tooth movement. METHODS: We studied 18 healthy subjects, adolescents (11-14 years) and adults (21-45 years), with Class II Division 1 malocclusion requiring 4 first premolar extractions. Canines were retracted with a constant force of 50 cN. Gingival crevicular fluid was collected before orthodontic treatment and at days 1, 7, 14, and 28 after the canine retraction. Cytokine (IL-1ß, CCL2, TNF-α) and osteoclast markers (RANKL and MMP-9) were measured using antibody-based protein assays. Pain and discomfort were monitored with a numeric rating scale. The canine retraction rate was measured from study models taken at days 28 and 56. RESULTS: Although the cytokine and osteoclast markers increased significantly in both age groups at days 1, 7, and 14, the increases were greater in adults than in adolescents. Interestingly, the rate of tooth movement in adults was significantly slower than in adolescents over the 56-day study period. Adults also reported significantly more discomfort and pain. CONCLUSIONS: Age is a significant variable contributing to the biologic response to orthodontic tooth movement. Adults exhibited a significantly higher level of cytokine and osteoclasts activity but, counterintuitively, had a significantly slower rate of tooth movement.

Esophageal lichen planus: a rare case.

Lichen planus is a rare, idiopathic disease that usually involves the skin and mucosae. Oral lesions occur in two thirds of cases and may occur without skin involvement. Esophageal lichen planus occur more frequently in middle-age women, it is frequently asymptomatic but may cause odynophagia and dysphagia. Esophageal lichen planus has been associated with squamous cell carcinoma. The most effective treatment is systemic corticotherapy, but relapse is expected in 85% with steroid withdrawal. We present the case of esophageal lichen planus in a 50-year-old man.

Colonic diverticulosis and the metabolic syndrome: an association?

BACKGROUND AND OBJECTIVES: Colonic diverticulosis (CD) is related to advanced age and a lack of dietary fiber. Recently, several studies have shown that metabolic syndrome (MS) is also implicated in the etiopathogenesis of CD. This study aimed to assess the association between MS, obesity and CD. METHODS: This was a prospective study of a one-year duration. The MS was defined according to the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III). Demographic data, risk factors for MS and endoscopic findings of patients who underwent a total colonoscopy in the department were collected. Obesity was defined as a body mass index ≥ 30 kg/m2. Informed consent was obtained. The local Ethics Committee and National Data Protection Committee approved the study. Statistical analysis was performed with SPSS 21 and statistical significance was defined as p < 0.05. RESULTS: The study included 203 patients, 95 males with a mean age of 65.5 years. CD was diagnosed in 30.5% of patients. Univariate analysis showed that age, hypertension, increased waist circumference and hyperlipidemia were associated with colonic diverticulosis. There was no association with gender, obesity or type 2 diabetes mellitus. Multivariate analysis showed that age and a greater waist circumference increased the risk of diverticulosis. Age-adjusted analysis showed that MS was associated with diverticulosis. The prevalence of adenoma in patients with CD was similar to that in patients without CD. CONCLUSION: In this series, MS was significantly associated with CD. The identification of risk groups is important since diverticulosis can have serious and potentially fatal complications. To our knowledge, this is the first Southern European prospective study evaluating the association between MS and CD.

Comparison of the prognostic value of Chronic Liver Failure Consortium scores and traditional models for predicting mortality in patients with cirrhosis.

BACKGROUND AND AIM: Recently, the European Association for the Study of the Liver - Chronic Liver Failure (CLIF) Consortium defined two new prognostic scores, according to the presence or absence of acute-on-chronic liver failure (ACLF): the CLIF Consortium ACLF score (CLIF-C ACLFs) and the CLIF-C Acute Decompensation score (CLIF-C ADs). We sought to compare their accuracy in predicting 30- and 90-day mortality with some of the existing models: Child-Turcotte-Pugh (CTP), Model for End-Stage Liver Disease (MELD), MELD-Na, integrated MELD (iMELD), MELD to serum sodium ratio index (MESO), Refit MELD and Refit MELD-Na. METHODS: Retrospective cohort study that evaluated all admissions due to decompensated cirrhosis in 2 centers between 2011 and 2014. At admission each score was assessed, and the discrimination ability was compared by measuring the area under the ROC curve (AUROC). RESULTS: A total of 779 hospitalizations were evaluated. Two hundred and twenty-two patients met criteria for ACLF (25.9%). The 30- and 90-day mortality were respectively 17.7 and 37.3%. CLIF-C ACLFs presented an AUROC for predicting 30- and 90-day mortality of 0.684 (95% CI: 0.599-0.770) and 0.666 (95% CI: 0.588-0.744) respectively. No statistically significant differences were found when compared to traditional models. For patients without ACLF, CLIF-C ADs had an AUROC for predicting 30- and 90-day mortality of 0.689 (95% CI: 0.614-0.763) and 0.672 (95% CI: 0.624-0.720) respectively. When compared to other scores, it was only statistically superior to MELD for predicting 30-day mortality (p=0.0296). CONCLUSIONS: The new CLIF-C scores were not statistically superior to the traditional models, with the exception of CLIF-C ADs for predicting 30-day mortality.

Impairment of autophagy by TTR V30M aggregates: in vivo reversal by TUDCA and curcumin.

Transthyretin (TTR)-related amyloidoses are diseases characterized by extracellular deposition of amyloid fibrils and aggregates in tissues composed of insoluble misfolded TTR that becomes toxic. Previous studies have demonstrated the ability of small compounds in preventing and reversing TTR V30M deposition in transgenic mice gastrointestinal (GI) tract as well as lowering biomarkers associated with cellular stress and apoptotic mechanisms. In the present study we aimed to study TTR V30M aggregates effect in autophagy, a cellular mechanism crucial for cell survival that has been implicated in the development of several neurodegenerative diseases. We were able to demonstrate in cell culture that TTR V30M aggregates cause a partial impairment of the autophagic machinery as shown by p62 accumulation, whereas early steps of the autophagic flux remain unaffected as shown by autophagosome number evaluation and LC3 turnover assay. Our studies performed in TTR V30M transgenic animals demonstrated that tauroursodeoxycholic acid (TUDCA) and curcumin effectively reverse p62 accumulation in the GI tract pointing to the ability of both compounds to modulate autophagy additionally to mitigate apoptosis. Overall, our in vitro and in vivo studies establish an association between TTR V30M aggregates and autophagy impairment and suggest the use of autophagy modulators as an additional and alternative therapeutic approach for the treatment of TTR V30M-related amyloidosis.

Effects of variety and steeping conditions on some barley components associated with colonic health.

BACKGROUND: Butyric acid is produced by degradation of dietary fibre by microbiota and is crucial for maintaining a healthy colon. The physicochemical properties are important for butyric acid formation, and this study aimed to evaluate the use of malting to tailor the functional characteristics of barley dietary fibre. The effect of different steeping conditions was evaluated in laboratory-scale malting experiments with three different barley varieties. RESULTS: Steeping at 35°C and with 0.4 % (v/v) lactic acid resulted in a higher content of ß-glucan and soluble fibre in malts than in those steeped at lower temperature and lower lactic acid concentration. Resistant starch increased, whereas the content of soluble arabinoxylan was lower. Dietary fibre components in Tipple were more affected by steeping conditions than the other varieties. The total contents of iron, phytate and amylose were little influenced by steeping conditions. CONCLUSION: The selection of steeping conditions during malting influences composition and the characteristics of dietary fibre in barley. However, the choice of barley variety is also important for tailoring of functional ingredients beneficial for colonic health. © 2016 The Authors. Journal of the Science of Food and Agriculture published by JohnWiley & Sons Ltd on behalf of Society of Chemical Industry.

Therapy-induced enrichment of putative lung cancer stem-like cells.

Tumour drug resistance is a major issue in the management of lung cancer patients as almost all lung tumours are either intrinsically resistant or quickly develop acquired resistance to chemotherapeutic drugs. Cancer drug resistance has recently been linked, at least in part, to the existence of cancer stem-like cells (CSLCs), a small sub-population of cells within the tumour that possess stem-like properties. CSLCs are often isolated by fluorescence activated cell sorting (FACS) according to the expression of certain stem-like cell membrane markers. Conflicting results regarding the specificity of particular stem cell surface markers for isolating CSLCs have, however, been recently reported. Therefore, alternative strategies enabling the identification and study of CSLCs should be considered, particularly in tumour types where appropriate stem cell markers are not well established and validated, like in lung cancer. In this article, we review data indicating therapy-selection as a valid approach for putative lung CSLCs enrichment. We believe that this strategy would be determinant for correctly assessing and characterising the sub-populations of CSLCs that are able to survive chemo or radiotherapy regimens and, at the same time, also have the ability to recapitulate and sustain tumour growth. Using therapy-induced enrichment of CSLCs may, therefore, prove to be an extremely useful method for studying CSLCs and provide new clues regarding potential therapeutic targets for their efficient elimination, which will undoubtedly play a decisive role in improving lung cancer patients' survival.

Obstetric Interventions Among Native and Migrant Women: The (Over)use of Episiotomy in Portugal.

Objective: Episiotomy, defined as the incision of the perineum to enlarge the vaginal opening during childbirth, is one of the most commonly performed surgical interventions in the world. We aimed to determine if migrant status is associated with episiotomy, and if individual characteristics mediate this association. Methods: We analyzed data from the Bambino study, a national, prospective cohort of migrant and native women giving birth at a public hospital in mainland Portugal between 2017 and 2019. We included all women with vaginal delivery. The association between migrant status and episiotomy was assessed using multivariable multilevel random-effect logistic regression models. We used path analysis to quantify the direct, indirect and total effects of migrant status on episiotomy. Results: Among 3,583 women with spontaneous delivery, migrant parturients had decreased odds of episiotomy, especially those born in Africa, compared to native Portuguese women. Conversely, with instrumental delivery, migrant women had higher odds of episiotomy. Disparities in episiotomy were largely explained by maternity units' factors, and little by maternal and fetal characteristics. Conclusion: Our results suggest non-medically justified differential episiotomy use during childbirth and highlight the importance of developing evidence-based recommendations for episiotomy use in a country with a high frequency of medical interventions during delivery.