Ana Maria Oliveira

Improving the Quality of Web-GIS Modularity Using Aspects

Spatial concerns of Web Geographical Information Systems (Web-GIS) are inherently crosscutting and volatile: crosscutting because they affect multiple functionalities of Web-GIS systems, such as visualization of a route in a map, volatile because their status may change often (e.g., in a map, a route can be obstructed temporarily due to a car accident or festivity, so alternative routes should be provided dynamically). The quality of Web-GIS services, in particular the efficiency required for their adaptation and evolution, can be compromised if volatility and the crosscutting nature of spatial concerns are not taken into consideration during modularization. This paper presents an aspect-oriented approach for Web-GIS applications. This approach models crosscutting spatial concerns and handles the volatile nature of some spatial concerns as if these were crosscutting. Thus, both types of concerns, crosscutting and volatile, are modeled as candidate aspects. By modularizing volatile concerns as aspects, it is simple to add and remove them at runtime from an application by using dynamic weaving. The approach starts with the identification and specification of crosscutting concerns and follows by composing them using MATA, an aspect-oriented modeling technique. GIS crosscutting concerns are stored and documented in a concern catalogue for promoting their reuse. Conflicts regarding the ordering of composition are also taken into account.

Can Red Cell Distribution Width Be Used as a Marker of Crohn's Disease Activity?

Introduction Recently, it has been suggested an association between red cell distribution width (RDW) and Crohns disease activity index (CDAI), but its use is not yet performed in daily clinical practice. Objectives To determine whether RDW can be used as a marker of Crohns disease (CD) activity. Methods This was a cross-sectional study including patients with CD, observed consecutively in an outpatient setting between January 1st and September 30th 2013. Blood cell indices, erythrocyte sedimentation rate (ESR), and C-reactive protein were measured. CD activity was determined by CDAI (active disease if CDAI ≥ 150). Associations were analyzed using logistic regression (SPSS version 20). Results 119 patients (56% female) were included in the study with a mean age of 47 years (SD 15.2). Twenty patients (17%) had active disease. The median RDW was 14.0 (13–15). There was an association between RDW and disease activity (p = 0.044). After adjustment for age and gender, this association remained consistent (OR 1.20, 95% CI 1.03–1.39, p = 0.016). It was also found that the association between RDW and disease activity was independent of hemoglobin and ESR (OR 1.36, 95% CI 1.08–1.72, p = 0.01) and of biologic therapy (OR 1.19, 95% CI 1.03–1.37, p = 0.017). A RDW cutoff of 16% had a specificity and negative predictive value for CDAI ≥ 150 of 88% and 86%, respectively. Conclusion In this study, RDW proved to be an independent and relatively specific marker of CD activity. These results may contribute to the implementation of this simple parameter, in clinical practice, aiming to help therapeutic decisions.

Is there a proximal shift in the distribution of colorectal adenomas

Introduction Several studies have shown a proximal shift of colorectal cancer (CRC) during the last decades. However, few have analyzed the changing distribution of adenomas over time. Aim The aim of this study was to compare the site and the characteristics of colorectal adenomas, in a single center, during two periods. Methods We conducted a retrospective, observational study in a single hospital of adenomas removed during a total colonoscopy in two one-year periods: 2003 (period 1) and 2012 (period 2). Patients with inflammatory bowel disease, familial adenomatous polyposis, hereditary non-polyposis colorectal cancer syndrome, or history of CRC were excluded from the study. The χ2 statistical test was performed. P values less than 0.05 were considered statistically significant. Results During the two considered periods, a total of 864 adenomas from 2394 complete colonoscopies were analyzed: 333 adenomas from 998 colonoscopies during period 1 and 531 adenomas from 1396 colonoscopies during period 2. There was a significant increase in the proportion of adenomatous polyps in the proximal colon from period 1 to 2 (30.6% to 38.8% (p = 0.015)). Comparing the advanced features of adenomas between the two periods, it was noted that in period 2, the number of adenomas with size ≥1 cm (p = 0.001), high-grade dysplasia (p = 0.001), and villous features (p < 0.0001) had a significant increase compared to period 1. Conclusion Incidence of adenomatous polyps in the proximal colon as well as adenomas with advanced features has increased in the last years. This finding may have important implications regarding methods of CRC screening.

MODELLING LOCATION-AWARE BEHAVIOUR IN WEB-GIS USING ASPECTS

Web-GIS applications evolve fast as new requirements emerge constantly. Some of these requirements, particularly those related with spatial behaviours, might crosscut previous core application requirements. Conventional modelling techniques, which ignore the effect of crosscutting concerns (such as tangling and scattered behaviours) affect negatively the modularity and thus compromise application maintenance. In this paper we present and aspect-oriented approach to model crosscutting concerns in Web-GIS applications, particularly those related with spatial features. The process introduced in this paper starts with the identification and specification of crosscutting concerns, followed by the composition of these concerns, using the MATA language.

Isolated Visceral Angioedema Induced by Angiotensin-Converting Enzyme Inhibitor

Visceral angioedema is a rare complication of therapy with angiotensin-converting enzyme (ACE) inhibitors. Clinical presentation includes nausea, vomiting, abdominal pain and diarrhea. Early detection of this entity can prevent recurrent episodes and unnecessary invasive procedures, including surgery. This article describes a 46-year-old-woman who presented to the emergency department with abdominal pain, associated with nausea and vomiting. She had been taking ramipril for 15 days. A computed tomography was performed which revealed thickening of a jejunal segment, with submucosal edema. ACE inhibitor-associated angioedema was suspected and the medication was discontinued, with resolution of symptoms in 48 h. After 7 months of follow-up, the patient is asymptomatic. Despite of its rarity, ACE inhibitor-induced small-bowel angioedema should be included in the differential diagnosis when patients receiving ACE inhibitor therapy present with abdominal complaints.

Acute Hepatitis in the DRESS Syndrome

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe, idiosyncratic reaction characterized by diffuse maculopapular rash, facial edema, lymphadenopathy, fever, eosinophilia and/or other leukocyte abnormalities, and involvement of internal organs as liver, kidney, heart and lung. Diagnosing this entity is specifically complicated due to the multiplicity of organs involved. DRESS syndrome must be recognized promptly and the causative drug withdrawn in order to improve patient outcomes. Indeed, it is a potentially life-threatening condition, with a reported mortality between 5 and 20%. We describe a case of a 22-year old woman admitted to our hospital with acute diffuse, pruritic rash associated with crampy abdominal pain, vomiting, diarrhea and fever three weeks after starting sulfasalazine therapy. Initially, laboratory parameters revealed normal white blood cell count and normal liver enzymes, but during hospitalization, eosinophilia developed and liver enzymes, including transaminases and cholestatic parameters, dramatically increased. The diagnostic of DRESS syndrome was made and sulfasalazine was withdrawn and as there were signs of disease severity, systemic corticotherapy was initiated, with gradually improvement of the rash and symptoms resolution. The patient was discharged home after thirty days of hospitalization.

Vitamin D Deficiency in a Portuguese Cohort of Patients with Inflammatory Bowel Disease: Prevalence and Relation to Disease Activity

Background and Aims: Vitamin D deficiency is more common in inflammatory bowel disease (IBD) patients than in the general population. However, there are conflicting data about predictive factors of vitamin D deficiency and its potential association with disease activity. The aims of this study were to determine the prevalence and predictive factors of vitamin D deficiency and to evaluate a possible association with disease activity. Methods: A prospective observational study was conducted, including patients with IBD from January to July 2016. The Endocrine Society guidelines were considered for defining levels of serum 25-hydroxyvitamin D (25-OH-D) as follows: deficient (< 20 ng/mL, < 10 ng/mL being severe deficiency), insufficient (21–29 ng/mL), and adequate (> 30 ng/mL). Results: A total of 152 patients (52% men; 47.2 ± 17.3 years) were included, of whom 70% had Crohn’s disease (CD). Thirty-seven percent of patients were on immunosuppressors and 17% were on biologics. The majority were outpatients (88.2%). Mean 25-OH-D levels were 17.1 ± 8 ng/mL (CD: 16.7 ± 8 ng/mL vs. ulcerative colitis: 17.6 ± 7 ng/mL, p = 0.1). Inadequate levels were present in 90.8% of patients (deficiency: 68.4%; insufficiency: 22.4%). A significant negative correlation between 25-OH-D levels and age (r = –0.2, p = 0.04), C-reactive protein (CRP) levels (r = –0.22, p = 0.004), and Harvey-Bradshaw index (HBi) (r = –0.32, p = 0.001) was found. Patients with severe deficiency showed a higher CRP (0.6 vs. 1.4 mg/dL, p = 0.03), erythrocyte sedimentation rate (ESR) (22 vs. 31 mm/h, p = 0.03), and HBi (2 vs. 5, p < 0.001) and lower hemoglobin (13.6 vs. 12.7 g/dL, p = 0.02). There was no association between vitamin D deficiency and gender, type, extent, and duration of disease, surgery, and other measures of disease activity, such as ESR, hemoglobin (these 2 items except for severe deficiency), fecal calprotectin, or Truelove and Witts classification. Conclusions: There is a high prevalence of inadequate levels of vitamin D in IBD patients, particularly deficiency (68.4%). There seems to exist an association between lower levels of vitamin D and higher disease activity, especially in CD.

Wilkie Syndrome behind Crohn Disease? Superior Mesenteric Artery Syndrome Mimicking and Complicating Crohn Disease of the Upper Gastrointestinal Tract.

loss (22% in the previous 6 months; body mass index 17). She had a history of gastric and duodenal peptic ulcers associated with Helicobacter pylori (Hp) infection, which led to Hp eradication in 2007. An upper endoscopy was performed, revealing an ulcerated pyloric stenosis, 4 duodenal ulcers (5–12 mm in diameter), a dilated duodenal bulb with cobblestone appearance, and a stricture in the third portion of the duodenum (D3) that could not be passed through ( Fig. 1 ). Gastric biopsies revealed chronic non-atrophic gastritis, and duodenal biopsies showed an intense chronic lymphoplasmacytic infiltrate of the mucosa and submucosa. No microorganisms (including Hp) or granulomas were identified. Biopsies of the stricture showed mucosal edema but no significant inflammatory infiltrate. Total colonoscopy with ileoscopy was normal. AntiSaccharomyces cerevisae antibodies (IgG-IgA) were positive (titer 1: 1,000). Given the persistence of gastroduodenal ulcers after previous optimal therapy for peptic disease as well as other endoscopic changes, chronic inflammation in the duodenal mucosa and submucosa, positive antiS. cerevisae antibodies, and a duodenal stenosis after ruling out other relevant conditions, we established the diagnosis of Crohn disease (CD) involving the upper gastrointestinal tract.

Pseudomyxoma peritonei: a clinical case of this poorly understood condition.

Background Pseudomyxoma peritonei is an uncommon condition with an estimated incidence of one to two per million (worldwide) per year. It is characterized by the peritoneal deposition of mucinous tumors, most commonly of the appendix, and occasionally from the ovary, coupled by mucinous ascites. Case presentation We report the case of a 76-year-old woman who presented with increased abdominal girth and dyspnea for 2 weeks. She was diagnosed as a case of pseudomyxoma peritonei. She was submitted to right oophorectomy, omentectomy, and pseudomyxoma debulking. The histology was compatible with a mucinous tumor of colorectal/appendicular origin. Chemotherapy was not administered because of her functional status. Two years and 8 months later, she refers with postprandial fullness and has moderate ascites.

Severe Odynophagia and Rapidly Progressive Dysphagia as an Unusual Presentation of Eosinophilic Gastroenteritis

A50-year-old asthmatic woman presented to the emergency department with a 2-week history of severe odynophagia, rapidly progressive dysphagia for solids, and abdominal distention, without fever, abdominal pain, or weight loss. The patient experienced several episodes of mild and self-limited odynophagia in the past year. She denied caustic ingestion, alcohol consumption, or taking any medications other than inhaled steroids and desloratadine. Physical examination was unremarkable except for slightly distended abdomen. Blood tests showed leukocytosis (15,400/mL), eosinophilia (5800/mL), mild elevation of C-reactive protein (4.85 mg/dL), and normal albumin. Computed tomography scan revealed marked circumferential wall thickening of the lower two-thirds of the esophagus and jejunum, minimal right-sided pleural effusion, and mesenteric lymphadenopathy (Figures A and B). Endoscopic findings were normal, but histologic examination demonstrated an intense eosinophilic infiltration (>20 eosinophils/high-power field) in mucosal biopsies from the esophagus (Figure C), stomach, and duodenum (Figure D). Levels of serum immunoglobulin E and erythrocyte sedimentation rate were normal. The symptoms got progressively worse, and the peripheral eosinophil count rose above 8900/mL. Because of the lack of evidence of extragastrointestinal disease and after exclusion of parasitic disease (absence of epidemiologic context, negative stool ova and parasites test, negative serologies for Strongyloides stercoralis and Toxocara canis), we established the diagnosis of eosinophilic gastroenteritis (EG) and started a course of oral