Clinical and epidemiological features of ulcerative colitis patients in Sardinia,Italy:Results from a multicenter study

BACKGROUND There are little data on the epidemiological and clinical features of adult patients with ulcerative colitis(UC) in the different Italian regions,mainly derived from the absence of a national registry.This prevents correct interpretation of the disease burden.AIM To assess the main clinical and epidemiological features of adult patients diagnosed with UC in Sardinia,Italy.METHODS We performed a multicenter,observational,cross-sectional study that included adult patients with UC enrolled in seven gastroenterology unit centers in Sardinia.Data were obtained from the patients’ medical records and from a questionnaire administered at the inclusion visit.RESULTS Four hundred and forty-two patients with UC were included.The median age at diagnosis was 39years(interquartile range 28-48).After a median disease duration of 10 years,53 patients experienced proximal extension of proctitis or left-sided colitis.Seventy-five patients developed extraintestinal manifestations.Nineteen patients(4.3%) developed cancer:two with colorectal cancer and seventeen with extracolonic cancers.Mesalazine(5-ASA) remains the mainstay of treatment for UC.Overall,95 patients(21.5%) were treated with one or more biologic agents,whereas 15 patients(3.4%) underwent surgery,mostly colectomy.CONCLUSION Our results provide important insights into the clinical and epidemiological features of patients with UC,and while waiting for a national Italian registry,present eligible data on the UC population in Sardinia.

Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy

Biliary lithiasis is an endemic condition in both Western and Eastern countries, in some studies affecting 20% of the general population. In up to 20% of cases, gallbladder stones are associated with common bile duct stones (CBDS), which are asymptomatic in up to one half of cases. Despite the wide variety of examinations and techniques available nowadays, two main open issues remain without a clear answer: how to cost-effectively diagnose CBDS and, when they are finally found, how to deal with them. CBDS diagnosis and management has radically changed over the last 30 years, following the dramatic diffusion of imaging, including endoscopic ultrasound (EUS) and magnetic resonance cholangiography (MRC), endoscopy and laparoscopy. Since accuracy, invasiveness, potential therapeutic use and cost-effectiveness of imaging techniques used to identify CBDS increase together in a parallel way, the concept of “risk of carrying CBDS” has become pivotal to identifying the most appropriate management of a specific patient in order to avoid the risk of “under-studying” by poor diagnostic work up or “over-studying” by excessively invasive examinations. The risk of carrying CBDS is deduced by symptoms, liver/pancreas serology and ultrasound. “Low risk” patients do not require further examination before laparoscopic cholecystectomy. Two main “philosophical approaches” face each other for patients with an “intermediate to high risk” of carrying CBDS: on one hand, the “laparoscopy-first” approach, which mainly relies on intraoperative cholangiography for diagnosis and laparoscopic common bile duct exploration for treatment, and, on the other hand, the “endoscopy-first” attitude, variously referring to MRC, EUS and/or endoscopic retrograde cholangiography for diagnosis and endoscopic sphincterotomy for management. Concerning CBDS diagnosis, intraoperative cholangiography, EUS and MRC are reported to have similar results. Regarding management, the recent literature seems to show better short and long term outcome of surgery in terms of retained stones and need for further procedures. Nevertheless, open surgery is invasive, whereas the laparoscopic common bile duct clearance is time consuming, technically demanding and involves dedicated instruments. Thus, although no consensus has been achieved and CBDS management seems more conditioned by the availability of instrumentation, personnel and skills than cost-effectiveness, endoscopic treatment is largely preferred worldwide.

Food allergy in gastroenterologic diseases:Review of literature

Food allergy is a common and increasing problem worldwide. The newly-found knowledge might provide novel experimental strategies, especially for laboratory diagnosis. Approximately 20% of the population alters their diet for a perceived adverse reaction to food, but the application of double-blind placebo-controlled oral food challenge, the ＂gold standard＂ for diagnosis of food allergy, shows that questionnaire-based studies overestimate the prevalence of food allergies. The clinical disorders determined by adverse reactions to food can be dassified on the basis of immunologic or nonimmunologic mechanisms and the organ system or systems affected. Diagnosis of food allergy is based on clinical history, skin prick tests, and laboratory tests to detect serum-food specific IgE, elimination diets and challenges. The primary therapy for food allergy is to avoid the responsible food. Antihistamines might partially relieve oral allergy syndrome and IgE-mediated skin symptoms, but they do not block systemic reactions. Systemic corticosteroids are generally effective in treating chronic IgE-mediated disorders. Epinephrine is the mainstay of treatment for anaphylaxis. Experimental therapies for IgE-mediated food allergy have been evaluated, such as humanized IgG anti-IgE antibodies and allergen specific immunotherapy.

Stem cells for end stage liver disease: How far have we got?

End stage liver disease (ESLD) is a health problem worldwide. Liver transplantation is currently the only effective therapy, but its many drawbacks include a shortage of donors, operative damage, risk of rejection and in some cases recidivism of the pre-transplant disease. These factors account for the recent growing interest in regenerative medicine. Experiments have sought to identify an optimal source of stem cells, sufficient to generate large amounts of hepatocytes to be used in bioartificial livers or injected in vivo to repair the diseased organ. This update aims to give non-stem cell specialists an overview of the results obtained to date in this fascinating field of biomedical research.

Pathophysiological aspects of diverticular disease of colon and role of large bowel motility

Colonic diverticular disease (diverticulosis) is one of the most common gastrointestinal disorders in Western countries. This disorder is strictly related to aging and fibre intake, and still bears a discrete amount of morbidity. Numerous etiological co-factors have to date been implicated in the pathogenesis of the disease, yet the supporting evidence is still far from absolute. The present review considers the pathophysiology of colonic diverticular disease, with a special emphasis on factors related to abnormal colonic motility.

Problematic Internet use in drug addicts under treatment in public rehab centers

BACKGROUND Problematic Internet use(PIU)or Internet addiction has been recognized to be a behavioral addiction characterized by excessive or poorly controlled preoccupations,urges,or behaviors regarding computer use and Internet access that leads to impairment or distress resembling substance abuse.AIM To investigate the prevalence and characteristics of Internet use and abuse in a group of drug addicts from Southern Italy,by means of a specific questionnaire[“Questionario sull’Utilizzo delle Nuove Tecnologie”(QUNT)].METHODS All subjects(183)were heavy smokers,almost 50%of them used heroin and/or opioid compounds,30%alcohol,10%cannabis,8%cocaine,and 5%were polydrug users.Almost 10%of the individuals were also suffering from gambling disorder.RESULTS The time spent online was more than 4 hours a day in the total sample,with a slight prevalence in male subjects.Cocaine and cannabis users spent more than 6 hours online,significantly more than opioid and alcohol abusers.Distribution of the QUNT factors was not different in both sexes.Cocaine users showed higher scores at the“loss of control”,“pornography addiction”,and“addiction to social networks”factors,for the stimulant effect of this substance.Moreover,15 out of the total 17 cocaine users were pathological gamblers.Positive and statistically significant relationships were observed between some QUNT factors and body mass index.CONCLUSION These findings indicate that PIU is less severe in subjects taking sedative substances,such as heroin/opioids and alcohol,than in subjects taking stimulants.Alternatively,it may be used as a“stimulant”trigger in cocaine and cannabis users.Flattening effect of abuse drugs was noted on possible sex-related differences in QUNT items.We observed a sort of“protective”effect of a love relationship and/or living together with a partner,as those engaged subjects showed lower scores on different items than single subjects or those living alone.The relationship between time spent online(and related sedentary lifestyle)and body mass index would suggest that Internet use might be a contributing factor to increasing weight gain and obesity amongst adolescents and young adults worldwide.Our findings also highlighted the specific vulnerability of drug addicts who use stimulants,rather than sedative compounds,to other kinds of behavioral addictions,such as gambling disorder.

Serum SCCA-IgM as a predictor of hepatocellular carcinoma in patients with liver cirrhosis

Aberrant Squamous Cell Carcinoma Antigen (SCCA) expression is an early hepatocarcinogenetic event and circulating SCCA-IgM complexes are elevated in most HCC patients. We evaluated whether serum SCCA-IgM levels can identify HCV +ve cirrhotic patients at low HCC risk. In this retrospective study we enrolled 29 cirrhotic patients in whom serum SCCA-IgM was measured 8 - 69 months (median 31) before HCC diagnosis, and 28 cirrhotic patients who remained HCC- free, with SCCA-IgM measured 15 - 68 months (median 48) before the study end. The best discriminating value of SCCA-IgM was calculated and tested in predicting HCC diagnosis within 12, 24 and 36 months. Sensitivity analysis, considering different HCC incidence, was conducted to identify the patient subgroup with an annual cancer risk below the threshold of a cost-effective semiannual surveillance with ultrasound. Cumulative HCC incidence at 12, 24 and 36 months was 7.0%, 15.7% and 26.3%, respectively. SCCA-IgM levels were higher in HCC than in cirrhotic patients [median: 381 (95% C.I.: 50 - 5289) vs. 100 (70 - 493) AU/mL, P = 0.005]. The SCCA-IgM value ≤ 200 AU/mL accurately identified patients at low risk of HCC development in the subsequent year (sensitivity 75%, specificity 62%, positive predictive value 13% and negative predictive value 97%). Considering an annual HCC incidence ≤ 3%, patients with SCCA-IgM ≤ 200 AU/mL (60% of the whole patients) had an HCC risk below the accepted threshold of a cost-effective surveillance (1.5%). In conclusion, provided that our provocative results are confirmed in larger studies, SCCA-IgM serum measurement could permit implementation of a two step (with different costs) surveillance: an initial serological surveillance, based on the annual monitoring of this biomarker, and the conventional surveillance by semiannual US when SCCA-IgM becomes >200 AU/mL. This could improve the cost/effectiveness of surveillance of HCV infected patients at risk of HCC.

Coronary artery bypass grafting in diabetic patients: Should we still use the saphenous vein graft? A review of literature in the past 15 years

The burden of diseases associated with diabetes mellitus is dramatic: adults with diabetes mellitus are 2 to 4 times more likely to have cardiovascular diseases than those without it, and at least 65% will die because of diabetes complications. The revascularization strategy in these types of patients included percutaneous coronary interventions with bare metal stents or medicated stents and surgical coronary artery bypass grafting (CABG), but it is well known that in the diabetic patient with two or more vessel disease, the surgical strategy allows the best mid- and long- term results. Moreover, benefits of CABG surgery are limited by life expectancy of the most common type of graft, the saphenous vein (SV). Nearly 40 years after the introduction of bypass surgery, the rate of vein graft failure remains at high levels. Several arterial conduits had been studied as alternative conduits to SV: the Right Internal Thoracic Artery (RITA), the Radial Artery (RA), the Gastroepiploic Artery (GEA) and the Inferior Epigastric Artery (IEA), 40 years ago. The aim of our article is to review the scientific literature of the past 15 years to answer this question: are we ready to treat the diabetic patient, with a completely arterial revascularization, avoiding the use of the great saphenous vein grafts?

Treatment of gastric cancer

The authors focused on the current surgical treatment of resectable gastric cancer, and significance of peri- and post-operative chemo or chemoradiation. Gastric cancer is the 4th most commonly diagnosed cancer and the second leading cause of cancer death worldwide. Surgery remains the only curative therapy, while perioperative and adjuvant chemotherapy, as well as chemoradiation, can improve outcome of resectable gastric cancer with extended lymph node dissection. More than half of radically resected gastric cancer patients relapse locally or with distant metastases, or receive the diagnosis of gastric cancer when tumor is disseminated; therefore, median survival rarely exceeds 12 mo, and 5-years survival is less than 10%. Cisplatin and fluoropyrimidine-based chemotherapy, with addition of trastuzumab in human epidermal growth factor receptor 2 positive patients, is the widely used treatment in stage IV patients fit for chemotherapy. Recent evidence supports the use of second-line chemotherapy after progression in patients with good performance status

Interleukin-6 and its soluble receptor in patients with liver cirrhosis and hepatocellular carcinoma

AIM： To evaluate the immunohistochemical localization of interleukin-6 （IL-6） and IL-6 receptor （IL-6R） on tumor tissue specimens from patients with hepatocellular carcinoma （HCC） and the serum levels of IL-6 and sIL-6R in a group of patients with HCC as well as liver cirrhosis （LC） in a group of patients with LC alone and in a control group. METHODS： Three groups of subjects were studied： group Ⅰ （n =83） suffering from HCC and LC, group Ⅱ （n = 72） suffering from LC alone and group Ⅲ （n =42） as healthy controls. All patients had hepatitis C virus infection. Serum IL-6 and IL-6R levels were determined using a commercially available ELISA kit. Immunohistochemistry was performed using the streptavidin-biotin complex and rabbit polyclonal antibodies against IL-6 and IL-6R. RESULTS： Immunohistochemistry analysis showed a medium to strong cytoplasmic and membrane reactivity for IL-6 and IL-6R respectively, in at least 40% of cases of HCC, whereas liver cirrhosis patients and controls were negative for IL-6 or showed a very mild and focal dot-like cytoplasmic reaction for IL-6R. Serum IL-6 levels in HCC group were significantly higher than those in LC and control groups （P〈 0.0001）. There was no significant difference in sIL-6R concentrations among 3 groups. When the patients with HCC were divided into groups according to Okuda＇s classification, a significant serum increase of IL-6 and slL-6R level was observed from stage Ⅰ to stage Ⅲ （P〈0.02, P〈0.0005）. When HCC and LC patients were divided into 3 classes of cirrhosis severity according to Child-Pugh, values in HCC patients were significantly higher than those in LC patients for each corresponding class （P〈 0.01）. CONCLUSION： IL-6 serum levels in HCC patients are higher than those in LC patients and controls, suggesting an increased production of this cytokine by neoplastic cells, sIL-6R values are similar in all groups, increasing only in stage III HCC patients. These data suggest that they have a closer relationship with the neoplastic mass rather than with the residual functioning hepatic mass.

Non-surgical treatment of esophageal achalasia

Esophageal achalasia is an infrequent motility disorder characterized by a progressive stasis and dilation of the oesophagus; with subsequent risk of aspiration, weight loss, and malnutrition. Although the treatment of achalasia has been traditionally based on a surgical approach, especially with the introduction of laparoscopic techniques, there is still some space for a medical approach. The present article reviews the non-surgical therapeutic options for achalasia.

Changes in nutritional status after liver transplantation

Chronic liver disease has an important effect on nutritional status, and malnourishment is almost universally present in patients with end-stage liver disease who undergo liver transplantation. During recent decades,a trend has been reported that shows an increase in number of patients with end-stage liver disease and obesity in developed countries. The importance of carefully assessing the nutritional status during the workup of patients who are candidates for liver replacement is widely recognised. Cirrhotic patients with depleted lean body mass(sarcopenia) and fat deposits have an increased surgical risk; malnutrition may further impact morbidity, mortality and costs in the post-transplantation setting. After transplantation and liver function is restored, many metabolic alterations are corrected,dietary intake is progressively normalised, and lifestyle changes may improve physical activity. Few studies have examined the modifications in body composition that occur in liver recipients. During the first 12 mo, the fat mass progressively increases in those patients who had previously depleted body mass, and the muscle mass recovery is subtle and non-significant by the end of the first year. In some patients, unregulated weight gain may lead to obesity and may promote metabolicdisorders in the long term. Careful monitoring of nutritional changes will help identify the patients who are at risk for malnutrition or over-weight after liver transplantation. Physical and nutritional interventions must be investigated to evaluate their potential beneficial effect on body composition and muscle function after liver transplantation.

Mechanisms of resistance to anti-epidermal growth factor receptor inhibitors in metastatic colorectal cancer

The prognosis of patients with metastatic colorectal cancer (mCRC) remain poor despite the impressive improvement of treatments observed over the last 20 years that led to an increase in median overall survival from 6 mo, with the only best supportive care, to approximately 30 mo with the introduction of active chemotherapy drugs and targeted agents. The monoclonal antibodies (moAbs) cetuximab and panitumumab, directed against the epidermal growth factor receptor (EGFR), undoubtedly represent a major step forward in the treatment of mCRC, given the relevant efficacy in terms of progression-free survival, overall survival, response rate, and quality of life observed in several phase III clinical trials among different lines of treatment. However, the anti-EGFR moAbs were shown only to be effective in a subset of patients. For instance, KRAS and NRAS mutations have been identified as biomarkers of resistance to these drugs, improving the selection of patients who might derive a benefit from these treatments. Nevertheless, several other alterations might affect the response to these drugs, and unfortunately, even the responders eventually become resistant by developing secondary (or acquired) resistance in approximately 13-18 mo. Several studies highlighted that the landscape of responsible alterations of both primary and acquired resistance to anti-EGFR drugs biochemically converge into MEK-ERK and PIK3CA-AKT pathways. In this review, we describe the currently known mechanisms of primary and acquired resistance to anti-EGFR moAbs together with the various strategies evaluated to prevent, overcame or revert them.

Sustained virological response: A milestone in the treatment of chronic hepatitis C

AIM: To evaluate the long-term eradication of hepatitis C virus (HCV) infection and liver-related complications in chronically infected patients that have achieved sustained virological response. METHODS: One hundred and fifty subjects with chronic hepatitis C (CHC) or cirrhosis and sustained virological response (SVR) between the years of 1989 and 2008 were enrolled in a long-term clinical follow-up study at the Gastrointestinal and Liver Unit of the University Hospital of Naples "Federico Ⅱ". At the beginning of the study, the diagnosis of HCV infection was made on the basis of serum positivity for antibodies to HCV and detection of HCV RNA transcripts, while a diagnosis of chronic hepatitis was formulated using imaging techniques and/or a liver biopsy. SVR was achieved by interferon-based therapy, both conventional and pegylated, with and without ribavirin treatment. The patients were evaluated for follow-up at a median length of 8.6 years, but ranged from 2-19.9 years. Among them, 137 patients had pre-treatment CHC and 13 had cirrhosis. The patients were followed with clinical, biochemical, virological, and ultrasound assessments on a given schedule. Finally, a group of 27 patients underwent a liver biopsy at the beginning of the study and transient elastography at their final visit to evaluate changes in liver fibrosis. RESULTS: The median follow-up was 8.6 years (range 2-19.9 years). HCV RNA remained undetectable in all patients, even in patients who eventually developed liver-related complications, indicating no risk of HCV recurrence. Three liver-related complications were observed: two cases of hepatocellular carcinoma and one case of bleeding from esophageal varices resulting in an incidence rate of 0.23%/person per year. Further, all three complications took place in patients diagnosed with cirrhosis before treatment began. Only one death due to liver-related causes occurred, resulting in a mortality rate of 0.077% person per year. This amounts to a 99.33% survival rate in our cohort of patients after therapy for HCV infection. Finally, of the 27 patients who underwent a liver biopsy at the beginning of the study, a reduction in liver fibrosis was observed in 70.3% of the cases; only three cases registering values of liver stiffness indicative of significant fibrosis. CONCLUSION: Patients with CHC and SVR show an excellent prognosis with no risk of recurrence and a very low rate of mortality. Our data indicate that viruseradication following interferon treatment can last up to 20 years.

Challenges of liver cancer:Future emerging tools in imaging and urinary biomarkers

Chronic liver disease has become a global health problem as a result of the increasing incidence of viral hepatitis, obesity and alcohol misuse. Over the past three decades, in the United Kingdom alone, deaths from chronic liver disease have increased both in men and in women. Currently, 2.5% of deaths worldwide are attributed to liver disease and projected figures suggest a doubling in hospitalisation and associated mortality by 2020. Chronic liver diseases vary for clinical manifestations and natural history, with some individuals having relatively indolent disease and others with a rapidly progressive course. About 30% of patients affected by hepatitis C has a progressive disease and develop cirrhosis over a 20 years period from the infection, usually 5-10 years after initial medical presentation. The aim of the current therapeutic strategies is preventing the progression from hepatitis to fibrosis and subsequently, cirrhosis. Hepatic steatosis is a risk factor for chronic liver disease and is affecting about the half of patients who abuse alcohol. Moreover non-alcoholic fatty liver disease is part of the metabolic syndrome, associated with obesity, hypertension, type Ⅱ diabetes mellitus and dyslipidaemia, and a subgroup of patients develops non-alcoholic steatohepatitis and fibrosis with subsequent cirrhosis. The strengths and pitfalls of liver biopsy are discussed and a variety of new techniques to assess liver damage from transient elastography to experimental techniques, such as in vitro urinary nuclear magnetic resonance spectroscopy. Some of the techniques and tests described are already suitable for more widespread clinical application, as is the case with ultrasound-based liver diagnostics, but others, such as urinary metabonomics, requires a period of critical evaluation or development to take them from the research arena to clinical practice.

Total plasma homocysteine and methylenetetrahydrofolate reductase C677T polymorphism in patients with colorectal carcinoma

AIM: To investigate the behaviour of total plasma homocysteine (tHcy) and its most common genetic determinant defect, the methylenetetrahydrofolate reductase C677T (C677TMTHFR) polymorphism in patients with early stage colorectal carcinoma. METHODS: tHcy was quantified by Abbott IMx immunoassay; screening for C677TMTHFR substitution was performed by PCR and restriction analysis. RESULTS: The frequency of the C/T and T/T genotypes of the C677TMTHFR gene polymorphism did not differ between the groups. The mean tHcy was statistically higher in cancer patients than in control subjects carrying the same C/C or C/T genotype, whereas there was no difference in the T/T homozygous carriers of the two groups. tHcy was significantly higher in the T/T homozygous carriers than in C/C and C/T genotype carriers. CONCLUSION: The statistically significant increase of tHcy observed in C/C and C/T genotype carriers among our cancer patients is related to substrate consumption dependent on the tumor cell proliferation rate, whereas the tHcy increase observed in T/T genotype carriers of both groups probably depends on the enzymatic deficit of the homocysteine conversion to methionine and/or on the folate deficiency.

Tissue resonance interaction accurately detects colon lesions: A double-blind pilot study

AIM: To investigated the performance of the tissue resonance interaction method(TRIM) for the noninvasive detection of colon lesions.METHODS: We performed a prospective single-center blinded pilot study of consecutive adults undergoing colonoscopy at the University Hospital in Sassari, Italy. Before patients underwent colonoscopy, they were examined by the TRIMprobe which detects differences in electromagnetic properties between pathological and normal tissues. All patients had completed the polyethylene glycol-containing bowel prep for the colonoscopy procedure before being screened. During the procedure the subjects remained fully dressed. A hand-held probe was moved over the abdomen and variations in electromagnetic signals were recorded for 3 spectral lines(462-465 MHz, 930 MHz, and 1395 MHz). A single investigator, blind to any clinical information, performed the test using the TRIMprob system. Abnormal signals were identified and recordedas malignant or benign(adenoma or hyperplastic polyps). Findings were compared with those from colonoscopy with histologic confirmation. Statistical analysis was performed by χ2 test.RESULTS: A total of 305 consecutive patients fulfilling the inclusion criteria were enrolled over a period of 12 months. The most frequent indication for colonoscopy w a s a b d o m i n a l p a i n( 3 3 %). T h e T R I M p r o b w a s well accepted by all patients; none spontaneously complained about the procedure, and no adverse effects were observed. TRIM proved inaccurate for polyp detection in patients with inflammatory bowel disease(IBD) and they were excluded leaving 281 subjects(mean age 59 ± 13 years; 107 males). The TRIM detected and accurately characterized all 12 adenocarcinomas and 135/137 polyps(98.5%) including 64 adenomatous(100%) found. The method identified cancers and polyps with 98.7% sensitivity, 96.2% specificity, and 97.5% diagnostic accuracy, compared to colonoscopy and histology analyses. The positive predictive value was 96.7% and the negative predictive value 98.4%. Among the 281 non-IBD subjects, there were 7 cases with discordant results(2.5%) between TRIMprob and the reference standard including 5 false positive results(1.8%) and 2 false negative(0.7%) results. The main limitation of the TRIMprob system is the need for trained operators.CONCLUSION: The study confirmed that TRIM provides rapid, accurate, convenient and noninvasive means to identify individuals most likely to benefit from colonoscopy.

An extended assessment of bowel habits in a general population

AIM:Bowel habits are difficult to study, and most data on defecatory behaviour in the general population have been obtained on the basis of recalled interview. The objective assessment of this physiological function and its pathological aspects continues to pose a difficult challenge. The aim of this prospective study was to objectively assess the bowel habits and related aspects in a large sample drawn from thegeneral population.METHODS: Over a two-month period 488 subjects were prospectively recruited from the general population and asked to compile a daily diary on their bowel habits and associated signs and symptoms (the latter according to Rome Ⅱ criteria). A total of 298 (61%) participants returned a correctly compiled record, so that data for more than 8000 patient-days were available for statistical analysis.RESULTS:The average defecatory frequency was once per day (range of 0.25-3.25) and was similar between males and females.However, higher frequencies of straining at stool (P=0.001), a feeling of incomplete emptying and/or difficult evacuation (P=0.0001), and manual manoeuvres to facilitate defecation (P=0.046) were reported by females as compared to males.CONCLUSION:This study represents one of the first attempts to objectively and prospectively assess bowel habits in a sample of the general population over a relatively long period of time. The variables we analyzed are coherent with the criteria commonly used for the clinical assessment of functional constipation, and can provide a useful adjunt for a better evaluation of constipated patients.

Prevalence of factor V Leiden and prothrombin G20210A in patients with gastric cancer

AIM： To analyze the prevalence of the two commonest thrombophilic mutations, factor V Leiden and prothrombin G20210A, in patients with gastric cancer. METHODS： One hundred and twenty-one patients with primary gastric carcinoma and 130 healthy subjects, comparable for age and sex, were investigated. Factor V Leiden was detected by using polymerase chain reaction and restriction enzyme digestion, and prothrombin G20210A gene mutation by allele-specific PCR. RESULTS： Among the 121 cancer patients, factor V Leiden was found in 4 cases （GA genotype： 3.3%） and prothrombin G20210A in 10 cases （GA genotype： 8.3%）. Of the 130 control subjects, factor V Leiden was detected in 6 cases （GA genotype： 4.6%） and prothrombin G20210A in 8 cases （GA genotype： 6.1%）. No double heterozygous carriers of both mutations were found in either group. The prevalence of both factor V Leiden and prothrombin G20210A variant was not statistically different between the cancer patients and the healthy subjects. CONCLUSION： Our study suggests that, in gastric cancer, the risk factors of thrombophilic cancer state are on acquired rather than on a genetic basis and that prothrombin G20210A does not seem to be a cofactor in gastric cancer pathogenesis.

A Pilot Experience in the training of healthcare professionals to face the childhood obesity epidemic through family therapeutic education

Background: Obesity is a high-cost social disease, the management of which, usually assigned to general practice, is less supported by evidence-based medicine. Most general practitioners feel unprepared to face the problem. Objectives: In 2000, at the Pediatric Department of Ferrara, we started a Family Group Therapeutic Education Program for the treatment of childhood obesity. More than 300 families have attended the program. Following our positive results, we created a professional training course on therapeutic education, addressed to healthcare personnel involved in the treatment of childhood obesity. The purpose of the present study is to discover if it is possible to promote the development of a shared therapeutic education strategy for obesity, involving primary care physiccians/pediatricians, specialists and dietitians. Methods: The integrated professional training course consists of a four-day seminar along with an on-line course for distance learning. The assessment of the project takes into account the following criteria: a multidimensional questionnaire (a pre- and post-test which explores: knowledge, motivation, self-efficacy, methodology, communication, modeling, etc.), an appreciation questionnaire with responses collected over the course of 2 years. Moreover, the nine participants of our 2008 training course began to use the new therapeutic tools in their practice and six of them sent us the anthropometric measurements of patients whom they have treated over the past two years using this approach allows us to present outcomes in terms of implementation of this therapeutic education program in everyday professional practice. Results and Conclusions: The course was attended by 15 healthcare professionals: ten in 2008 and five in 2009, from different Italian centers. Results seem to indicate a great interest and appreciation by the participants. Results based on BMI z-score reduction of the children cared for by our trainees seem to support the efficacy of our educational method in clinical practice. If these preliminary results are confirmed, new training projects for the management of childhood obesity can be planned and addressed to a wider healthcare professional public.