Ioannis G. Vlachonikolis

Role of appendicitis and appendectomy in the pathogenesis of ulcerative colitis: a critical review.

Besides a genetic predisposition, a causal role of various environmental factors has been considered in the etiology of ulcerative colitis (UC). The association between appendectomy and UC has recently been the subject of intense scrutiny in the hope that it may lead to the identification of important pathogenetic mechanisms. Published data from animal models of colitis demonstrated reduction in experimental colitis after appendectomy, especially if performed at an early age. Several epidemiological case control and cohort studies have shown a strong and consistent relationship. The metaanalysis of 17 case-controlled studies showed an overall odds ratio 0.312 (95% confidence intervals = 0.261–0.373) in favor of appendectomy (p < 0.0001). One of the two recent large cohort studies is in agreement with these results, but the other failed to confirm them. All these studies have suggested that alterations in mucosal immune responses leading to appendicitis or resulting from appendectomy may negatively affect the pathogenetic mechanisms of UC. Further investigation of the role of appendectomy in UC is expected to open new fields for basic scientific research and may lead to the improvement of our understanding for the disease pathogenesis.

Application of a ketogenic diet in children with autistic behavior: pilot study.

A pilot prospective follow-up study of the role of the ketogenic diet was carried out on 30 children, aged between 4 and 10 years, with autistic behavior. The diet was applied for 6 months, with continuous administration for 4 weeks, interrupted by 2-week diet-free intervals. Seven patients could not tolerate the diet, whereas five other patients adhered to the diet for 1 to 2 months and then discontinued it. Of the remaining group who adhered to the diet, 18 of 30 children (60%), improvement was recorded in several parameters and in accordance with the Childhood Autism Rating Scale. Significant improvement (> 12 units of the Childhood Autism Rating Scale) was recorded in two patients (pre-Scale: 35.00 ± 1.41 [mean ± SD]), average improvement (> 8—12 units) in eight patients (pre-Scale: 41.88 ± 3.14[mean ± SD]), and minor improvement (2—8 units) in eight patients (pre-Scale: 45.25 ± 2.76 [mean ± SD]). Although these data are very preliminary, there is some evidence that the ketogenic diet may be used in autistic behavior as an additional or alternative therapy. ( J Child Neurol 2003; 18: 113—118).

Appendectomy and the Development of Ulcerative Colitis: Results of a Metaanalysis of Published Case-Control Studies

OBJECTIVE:Numerous epidemiological studies have been performed to determine risk factors that might contribute to the development of ulcerative colitis (UC). Recent studies have focused on the role of appendectomy in the diseases pathogenesis. This report aims to review and analyze the degree of evidence from recent published studies.METHODS:Medline and Embase databases were scrutinized for studies published between 1987 and January 1999. Reference lists from published articles, reviews, and abstracts from major gastrointestinal (GI) meetings were also reviewed. All studies specifically designed to evaluate the association between appendectomy and UC were selected. Thirteen studies that satisfied our selection criteria were evaluated by metaanalysis.RESULTS:The 13 case-control studies collectively gathered evidence from 2770 patients with UC and 3352 controls. Combining the results of the individual studies gave an overall odds ratio of 0.307 (95% confidence interval [CI] = 0.249–0.377) in favor of appendectomy (p < 0.0001). This suggests that appendectomy gives a 69% reduction in the risk of developing UC (95% CI = 62%–75%). The test for heterogeneity (of all 13 studies) was not significant (χ2= 16.213, d.f. = 12, p > 0.10). The influence of potential confounding factors (mainly smoking) on these results could be excluded.CONCLUSIONS:The review of the literature and the metaanalysis of the selected studies suggest that the inverse association between appendectomy and UC is strong and consistent. Further studies are needed to establish whether a causal relationship exists.

Anti–saccharomyces cerevisiae mannan antibodies and antineutrophil cytoplasmic autoantibodies in Greek patients with inflammatory bowel disease

OBJECTIVES:The combined measurement of perinuclear antineutrophil cytoplasmic autoantibodies (pANCA) and anti–Saccharomyces cerevisiae mannan antibodies (ASCA) has recently been suggested as a valuable diagnostic approach in inflammatory bowel disease (IBD). The aim of this study was to assess the value of detecting pANCA and ASCA in the differentiation between ulcerative colitis (UC) and Crohns disease (CD) in a Greek population with IBD.METHODS:Sera were collected from 157 patients with IBD (97 with UC, 56 with CD, and four with indeterminate colitis) and 150 healthy controls. Determination of pANCA was performed by a standard indirect immunofluorescence technique on ethanol-fixed granulocytes and ASCA by an ELISA assay.RESULTS:In patients with UC, sensitivity, specificity, positive predictive value, and negative predictive value of the pANCA test was 67%, 84%, 93%, and 46% respectively. These values did not change significantly when the combination of positive pANCA and negative ASCA was used. ASCA test in diagnosing CD yielded a sensitivity, specificity, positive predictive value, and negative predictive value of 39%, 89%, 54%, and 81%. The combination of pANCA negative and ASCA positive increased the positive predictive value to 77% and it was associated with small bowel disease.CONCLUSIONS:A positive pANCA test in Greek patients has a diagnostic value in confirming a diagnosis of UC. Measurement of pANCA and ASCA together has a rather limited value in the differential diagnosis between UC and CD but may be of help in studying disease heterogeneity.

Comparison of Ranson, APACHE II and APACHE III Scoring Systems in Acute Pancreatitis

Introduction Acute pancreatitis runs an unpredictable course. The early prediction of the severity of an acute attack has important implications for management and timely intervention. Aim To assess the prognostic accuracy of Ranson and APACHE II and III scoring systems in predicting the severity of acute pancreatitis. Methods One hundred fifty-three patients with acute pancreatitis (67.3% gallstone-related, 9.2% alcoholic, 17% idiopathic, and 6.5% of miscellaneous causes) were studied prospectively. Data conforming to the scoring systems were recorded 24 (the APACHE scores) and 48 hours (the Ranson score) after admission. Analysis was performed by using receiver operating characteristic curves (ROC), area under a curve (AUC), and by comparing likelihood ratios of positive test (LRPT). Results One hundred nineteen cases of pancreatitis were classified as mild, and 34 were classified as severe. The mortality rate was 3.2%. All three scores correlated with length of stay and disease severity. AUC for Ranson was found to be significantly larger than AUC for APACHE II and APACHE III score (0.817, cut-off ≥3; 0.618, cut-off, ≥10; and 0,676, cut-off ≥42 respectively). The Ranson score achieved the highest sensitivity and the lowest false-negative rate, but the positive and negative predictive values and LRPT were of similar extent for all three scores. Conclusion The APACHE III offers little, if any, advantage over the APACHE II score. Ranson criteria proved to be as powerful a prognostic model as the more complicated APACHE II and III scoring systems, but with the disadvantage of a 24-hour delay.

The Role of Quality of Care in Health-related Quality of Life in Patients with IBD

In the literature there are indications of associations between health-related quality of life (HRQoL) in inflammatory bowel disease and disease activity, psychological status, coping, stressful life events, and social support. The aim of this study was to examine whether a relation exists between quality of health care and HRQoL, taking possible confounding variables into account.For this purpose, one single questionnaire was compiled from existing validated questionnaires. A population-based inception cohort of 1056 patients with inflammatory bowel disease in eight countries, diagnosed 6 to 8 years prior to the study, was approached to participate.In total, 824 patients responded (78%), and 517 could be included in statistical analyses. It was shown that in inflammatory bowel disease HRQoL was indeed influenced by quality of care (particularly with regard to the parameters of “providing information,” “costs,” and “courtesy”), as well as by disease activity, psychological status, type of hospital, social support, stressful life events, and way of administration of the questionnaire. Patients with active disease had lower psychological status and HRQoL scores at the time of the survey than patients without active disease. However, quality of care scores did not differ between these groups. The care aspect “costs” was scored worse by CD compared with UC patients, probably caused by a potentially more expensive treatment.In conclusion, it is shown in a large exploratory study, for the first time, that in inflammatory bowel disease, quality of care has a significant role in determining health-related quality of life.

The inflammatory bowel disease questionnaire. A review of its national validation studies

Health-related quality of life (HRQoL) is an important measure of illness perception on the part of the patient. The Inflammatory Bowel Disease Questionnaire (IBDQ) is a widely used questionnaire for HRQoL assessment in patients with inflammatory bowel diseases (IBDs). This questionnaire has been adapted and validated into several languages and cultural milieus. The aim of this study is to review the methods used by several adaptation studies for assessing the validity and reliability of the adapted IBDQ. A search was made of the Medline database for relevant articles since 1989. Standard validation criteria were used for including studies for further evaluation. The following aspects of the validation procedure were examined: translation, construct validity, reliability, sensitivity to change, and used statistical methods. Nine validation studies of the IBDQ, in England and in non–English-speaking countries (Holland, Spain, Korea, Sweden, Greece, and China) were selected. All studies concluded that the adapted instrument was valid and reliable. Only few modifications were proposed. Two studies recommended the split of the four dimensions of the original questionnaire in five. Assessing HRQoL in patients with IBD is an ever-increasing practice, especially in clinical trials. IBDQ was proven to be valid and reliable in several cultural and linguistic milieus when appropriate validation procedures were applied.

A Prospective Epidemiologic Study of Crohn's Disease in Heraklion, Crete Incidence over a 5-Year Period

BACKGROUND There has been an impression from published work that Crohns disease is less common in southern than in northern Europe. A low incidence of Crohns disease has been observed in Greece, but conclusive data are still lacking. METHOD A 5-year prospective and population-based epidemiologic study of Crohns disease was carried out in a well-defined area of Crete. RESULTS The mean annual incidence of the disease for the years 1990-94 was 3.0 per 10(5) inhabitants. During the study period the incidence increased from 1.9/10(5) in 1990 to 3.8/10(5) in 1994. The male to female ratio was 2.4:1. The age group 25-34 years had the highest age-adjusted incidence (6.3/10(5)). The incidence of Crohns disease was also found to be higher in smokers, in urban areas, and in people with high educational level. CONCLUSION Crohns disease is common in Heraklion, Crete. The findings of the study are discussed in relation to those of other European countries.

Quality of life of Greek patients with inflammatory bowel disease: Validation of the Greek translation of the Inflammatory Bowel Disease Questionnaire

Background/Aims: Health-related quality of life (HRQOL) is an important outcome measure in inflammatory bowel disease (IBD). The aim of our study is to validate the Greek translation of the Inflammatory Bowel Disease Questionnaire (IBDQ). For this we assessed its construct validity, discriminant ability, reliability and sensitivity to change. Methods: One hundred and fourteen patients with IBD (69 UC, 45 CD) completed the Greek version of the IBDQ, and a Visual Analogue Scale (VAS) for general well-being. Fifty-two patients also completed the SF-36. A subgroup of 46 patients completed the Greek IBDQ for a second time. Clinical activity was assessed by Harvey-Bradshaw Index and Colitis Activity Index. Results: Correlation coefficients between the four dimensional scores of the Greek IBDQ and the clinical activity indexes, VAS and the SF-36 were all reasonably high and statistically significant. The Greek IBDQ was able to discriminate well between groups of patients with either different clinical disease activity or subjective assessment of well-being. It also showed high reliability when it was repeated in patients who reported no change in their general well-being (intraclass correlation coefficient 0.940–0.998). In contrast, there was a significant difference between the baseline and the follow-up measurement in patients who reported change in their general well-being. Conclusions: The Greek IBDQ proved to be a valid and reliable instrument for assessing HRQOL, useful in the evaluation of clinical trials or health surveys as well as in the therapeutic management of IBD patients.

In what extent anemia coexists with cognitive impairment in elderly: a cross-sectional study in Greece

BackgroundA project aimed at studying the frequency of dementia and depression in the catchment area of the Health Centre of Chrissoupolis (HCCh), Northern Greece, was carried out. This paper reports the association between AD and anemia among the elderly participants in this Greek study.MethodsEligible participants were people 65 years or over who were (a) living in the Elderly Peoples Home (all 48 subjects included); (b) visiting the Open Center for Elderly People during a 20 workday period (75 subjects) and (c) visiting the HCCh for routine medical care. The Mini Mental State Examination (MMSE) was used in assessing the cognitive capacity of the participants. Blood was drawn for serum hematocrit, vitamin B12 and folate determination.ResultsThe prevalence proportions of possible cognitive impairment among anemic and non-anemic males were 55.6% and 34.4%, respectively (X2 = 5.8, d.f. = 1, p = 0.016). The corresponding proportions in females were 47.5% and 40.1 % (X2 = 1.1, d.f. = 1, p = 0.305). Using logistic regression analysis, age-group (≥ 80 yrs), type of Institute, vitamin B12 and anemia had significant independent associations with possible cognitive impairment.ConclusionsAnemia is a frequent finding in elderly and it may be a risk factor for dementia, but the extent of the associated deterioration of cognitive impairment or the relation with AD is not known. GPs should be aware of this coexistence and recommend for screening, assaying and treating elderly people.