An algorithm to generate 2D bathymetry of an Alpine river for habitat suitability assessment

Here we present an original approach to generate 2D high detail riverbed based on a drone photogrammetric survey, and RTK bathymetry measurements for Mera river in the Italian Alps. The aim is to better represent macro-roughness and riverbed structure of the river, also extending it to an ungauged area. Specifically, we apply a step-by-step approach. I) Depth and average slope of the riverbed were calculated from bathymetry data. II) Thus, a trapezoidal channel with constant slope and variable width was defined using the drone images. III) Riffle-pool sequence was assessed as a function of river width and applied to the generated channel. IV) Finally, the semi-random Perlin Noise was added to recreate riverbed irregularities in the natural stream. HEC-RAS 2D hydraulic software was then implemented to assess spatialized water depth and velocity. The proposed methodology could be quite relevant in river hydraulics to decouple roughness coefficient from water submergence, and in Physical Habitat Simulation Model (PHABSIM), where the dependency of the output is not linear with hydraulic parameters (i.e. water depth and velocity). Indeed, we apply PHABSIM for a case study of a stretch of the river and results are compared with a previous environmental study for Mera river.

Community use of antibiotics and development of bacterial resistance: a case-control study in Italy

Background

Antibiotic resistance is now a global emergency. An increasing number of infections are becoming difficult to treat and lead to longer hospitalizations, higher medical costs and increased mortality. The aim of this study is to assess, in a population at low prevalence of use of antibiotics, whether a previous use of these drugs is associated with the occurrence of clinically relevant resistance of E.coli to fluoroquinolones (FQs), one of the most widespread and critical bacteria resistance in Italy.

Methods

Through a data linkage of databases of the health information systems of the Province of Bolzano (Italy) a case-control study was carried out using 2016 data. All subjects for which the resistance of E. coli to FQs was tested by the regional microbiology reference laboratory were included in the study. Those with a positive FQs-resistant E.coli isolate were defined as cases (n = 409), while the others were considered controls (n = 933). For each subject the total number of prescriptions of any antibiotics and the total number of prescriptions of FQs in the previous year were detected through a record linkage with the drug prescription database. Information on potential confounding factors (age, gender, number of hospital admissions, days of hospitalization, number of surgeries, diagnosis of chronic diseases) were obtained from the database of hospital admissions. Multivariate logistic regression analysis was used to study the association between previous use of antibiotics (any and FQs only) and development of E.coli resistance to FQs.

Results

It was observed that for each unit increase in the number of prescriptions of any antibiotic, the probability for E.coli to develop FQs resistance significantly rises by 16%. This probability is much higher (45%) if the prescribed antibiotic is a FQ.

Conclusions

This study confirms the association between previous consumption of antibiotics and the onset of resistance even in an area with a low prevalence of use.

Key messages

The results of this study reiterate the need to prescribe and dispense antibiotics only when they are really needed. Health information systems allows to study the role of antibiotic use in the development of bacterial resistance, providing useful information for audit interventions among healthcare professionals.

Retrospective comparison of long-term ten-day/month rifaximin or mesalazine in prevention of relapse in acute diverticulitis

OBJECTIVE

Diverticular disease (DD) of the colon has an increasing burden on health services. The effectiveness of rifaximin for the treatment of DD, is not yet established. The aim of this study is to assess the impact of long-term treatment with rifaximin or mesalazine in a 10-day schedule for the prevention of recurrent diverticulitis.

PATIENTS AND METHODS

This is a retrospective study. We identified all consecutive patients with DD and previous acute diverticulitis (AD) in our outpatients' database; 124 patients, were included. The recommended therapy consisted of a ten-day/month treatment with either rifaximin (400 mg bid), or mesalazine (2.4 g/daily). Primary end point was AD recurrence.

RESULTS

Between 2010 and 2014, 72 patients were treated with rifaximin and 52 with mesalazine. During a median follow-up of 15 months (range 1-50), we observed 21 episodes of AD among users of either rifaximin (n=7; 0.54 per 100 person-months), or mesalazine group (n=14; 1.46 per 100 person-months). Kaplan-Meier survival estimates of recurrent AD significantly differed between rifaximin and mesalazine groups (p=0.015). The multivariate Cox regression analysis showed that AD recurrence was significantly associated with therapy (rifaximin vs. mesalazine, adjusted HR 0.27; 95% CI: 0.10 to 0.72), age and gender.

CONCLUSIONS

Long-term treatment with rifaximin in a 10-day schedule appears more effective than mesalazine in preventing recurrent AD.

Benign pneumoperitoneum after percutaneous endoscopic gastrostomy (PEG) feeding tube placement: do not be afraid!

In order to ensure enteral feeding, placement of a percutaneous endoscopic gastrostomy (PEG) is considered a standard care for patients with oropharyngeal malignancies. Benign pneumoperitoneum is a complication of PEG feeding tube placement and it is usually an incidental finding that arises, generally, immediately following the procedure. We report a case of a benign pneumoperitoneum, developed 48 hours after the procedure, which was treated conservatively.

Efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) performed in patients with Periampullary duodenal diverticula (PAD)

BACKGROUND AND AIM

Periampullary diverticula (PAD) are found in 9-32% of patients who undergo endoscopic retrograde cholangiopancreatography (ERCP). PAD are acquired lesions which are rare in patients <40 years, but increasing with age. Several endoscopic studies have revealed an association between PAD and common bile duct (CBD) stones. The presence of a papilla located in the diverticula is also frequent (6.8-54.9%) and represents a restrictive factor for successful cannulation.

MATERIALS AND METHODS

A retrospective analysis has been made of data related to the patients with PAD treated at our GI Unit (small center with low case volume), who underwent ERCP in the period 1st January 2010 to 31st March 2014. For each patient were analyzed data regarding sex, age at diagnosis, indication to ERCP, cannulation rate, endoscopic treatment and complications. PAD were classified in 3 different types according to the position of the major papilla.

RESULTS

A total of 647 ERCPs have been performed of which 77 (16.5%) in pts with PAD (48 F, 29 M, mean age: 78.3 years; range: 48-95). PAD type I (inside the diverticulum) were found in 22 pts (28.6 %), Type II (in the margin of the diverticulum or between two PADs) in 36 pts (46.7 %) of which 12 cases between two PADs, type III (near the diverticulm) in 19 pts (24.7 %). The indication for ERCP were: 72 CBD stones (93.5%), 3 cholangiocarcinoma (3.9%) and 2 pancreatic head cancer (2.6%). In cases of difficult cannulation, precut was performed in 12 pts (15.6%). Deep CBD cannulation and endoscopic sphincterotomy (ES) was achieved in 70 cases (90.9%). The other 7 case of failure were all in patients with CBD stones. Complete clearance of CBD stones was achieved in 57 patients (87.7%) (57/65 ERCP/ES). Stent placement was necessary in 8 cases (12.3%) (8/65 ERCP/ES), due to multiple large stones. The adverse events related to ERCP/ES included 4 intraprocedural bleeding (5.7%) (4/70 ERCP/ES) and 1 mild pancreatitis (1.4%) (1/70 ERCP/ES), all managed conservatively.

CONCLUSIONS

Our data show that ERCP is a safe procedure also in patients with PAD, with a good success rate and low complications.

Role of endoscopic sphincterotomy of the minor papilla in pancreas divisum

BACKGROUND

Pancreas divisum (PD) is a common anatomical variant of the pancreatic duct system. Only a little percentage of patients with this altered anatomy develop symptoms: acute recurrent pancreatitis (ARP), chronic pancreatitis (CP) and pancreatic-type pain alone. These have been supposed to arise from an obstruction to outflow of the pancreatic dorsal duct due to a stenosis of the minor papilla. Endoscopic sphincterotomy of the minor papilla (MiES) can be considered an effective treatment for patients with PD and ARP supported by stenosis or obstruction of the minor papilla. On the other hand, the access through the minor papilla is essential for therapeutic pancreatic endoscopy in patients with PD and CP, but the effectiveness of MiES in these patients is extremely controversial.

MATERIALS AND METHODS

Aim of this brief review has been to evaluate the short and long-term effects of endoscopic pancreatic interventions in patients affected by symptomatic PD who underwent therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic sphincterotomy of the minor papilla (MiES). The main literature database was Medline (1966-2013).

RESULTS

Data come from a personal overview of articles emerging from the same search strategy.

CONCLUSIONS

Nowadays, when endoscopic pancreatic drainage is indicated in patient with symptomatic PD, access through the minor papilla (MiP) is required. Therapeutic endoscopic interventions provide less invasive alternatives to the surgical approach.

Comparison of endoscopic retrograde cholangiopancreatography between elderly and younger patients for common bile duct stones

BACKGROUND

Choledocholithiasis is increasing in elderly subjects. The introduction of endoscopic retrograde cholangiopancreatography with biliary sphincterotomy has almost replaced surgery in the treatment of this condition. The aim of the present study was to evaluate the rates of successful clearance of common bile duct stones and the endoscopic techniques used in a population aged 75 years or older compared with those in a younger age group.

MATERIALS AND METHODS

A retrospective analysis was made of data related patients who underwent endoscopic retrograde cholangiopancreatography for choledocolithiasis in the period 2010-2011. For all patients, factors such as sex, age at diagnosis, endoscopic treatment (stone extraction using baskets and balloon, mechanical lithotripsy and balloon dilatation of the ampulla, placement of a stent or a naso-biliary tube) and need of surgery were analysed. Two groups of patients were identified: patients aged <75 years (Group A) and patients aged ≥75 years (Group B). For the statistical analysis Mann-Whitney test and Fischer's Exact test were used.

RESULTS

A total of 234 patients were enrolled in the study (94 in Group A, 140 in Group B). No statistically significant differences were observed as far concerns sex, previous cholecystectomy, gallbladder stones and periampullary diverticula, but only for common bile duct dilatation. Complete clearance of common bile duct stones was achieved in 230 patients (97.5%).

CONCLUSIONS

The present data are in keeping with those presented in the literature, which confirm that endoscopic retrograde cholangiopancreatography is a safe and effective procedure also in older patients.

Self-expandable metal stent placement for treatment of severe sphincterotomy bleeding

One of the most frequent complications of endoscopic sphincterotomy (ES) is bleeding. When post-ES bleeding does not respond to the use of typical endoscopic therapy, the only alternative is angiography or surgery. A 82-year-old female was admitted for jaundice. A RMN-cholangiography revealed multiple stones in the common bile duct (CBD). She underwent endoscopic retrograde cholangiopancreatography (ERCP). The papilla major was located between two large periampullary diverticula. During the ES, a severe bleeding was observed from the upper part of the biliary cut. Several methods of hemostasis (injection of adrenaline, thermal methods and balloon tamponate) were performed without efficacy. A partially covered metallic stent was placed across the biliary orifice, in order to compress mechanically the bleeding site archiving the hemostasis.

Gastric Dieulafoy's lesion successfully treated by "adjuvant" arterial embolization and endoscopic clipping

While it is well recognized that peptic ulcer disease is the most common cause of nonvariceal upper gastrointestinal bleeding, other lesions cause of haemorrhage, even if rare, may potentially life-threatening. These include arteriovenous malformations such as Dieulafoy's lesion, defined as caliber-persistent submucosal vessel. The endoscopy with its hemostatic techniques is usually the treatment of choice for such patients. In those cases, in which these techniques fail due to the difficult in the correct localization, angiography with embolization may be a good alternative. The use of microcatheters and new embolic agents have improved this procedure. In fact, transcatheter arterial embolization represents a minimally invasive alternative to surgery when endoscopic treatment fails to control gastrointestinal bleeding, especially for the upper tract. This technique proved to be safe, fast and effective. According to our knowledge, only one case of a Dieulafoy's lesion of the duodenum treated with "adjuvant" embolization followed by laser coagulation has been reported in literature. Herein, we report a case of a Dieulafoy's lesion of the stomach, in which "adjuvant" transcatheter arterial embolization has permitted a more easier endoscopic diagnosis and treatment.

[Use of argon plasma coagulation in digestive endoscopy: a concise review]

Argon plasma coagulation (APC) is a non-contact thermal method of hemostasis that has generated much attention in recent years. This endoscopic procedure is used primarily to control bleeding from lesions in the gastrointestinal tract, and also sometimes to debulk tumours in the case of patients for whom surgery is not recommended. APC involves the use of a jet of ionized argon gas (plasma) that is directed through a probe passed through the endoscope. The probe is placed at some distance from the lesion, and tissue damage is limited to superficial layers. The depth of coagulation is usually only a few millimetres. Theoretical advantages of APC include facility application, speedy treatment of multiple lesions in the case of angiodysplasias or wide areas (the base of resected polyps or tumor bleeding), safety due to reduced depth of penetration, and lower cost compared to laser.

Hematemesis from esophageal varices associated with esophageal perforation: sclerotherapy and endoscopic clipping

A 46-year-old man was referred to our Unit for hematemesis. The medical history of the patient revealed an HCV-related cirrhosis, a human immunodeficiency virus (HIV) infection and recent and persistent episodes of emesis. An urgent gastroscopy disclosed evidence of active bleeding from varices of the lower third of the esophagus and a concomitant laceration of the esophageal wall due to the emesis. These two conditions have been endoscopically diagnosed and successfully treated by sclerotherapy and endoscopic clipping.

[Endoscopic therapy with balloon dilatation in patients with colonic post anastomotic strictures. Personal experience]

BACKGROUND AND AIM

Colorectal post anastomotic benign strictures are not uncommon. The purpose of this study was to investigate the results of endoscopic balloon dilatation of anastomotic strictures.

MATERIALS AND METHODS

The study was on a retrospective survey. Records of 14 consecutive patients with anastomotic strictures (5 F, 9 M; median age 64 years; range: 50-87 years), attending our GI Unit from February 1st 2008 to December 31st 2009, were analyzed. All patients had been operated for colon carcinoma. All of them were treated with balloon dilatation.

RESULTS

All the patients presented symptoms of obstruction. The total number of dilatation sessions was 37 and the median number of sessions by patient was 1,5 (range: 1-7). After the procedures, all patients had an improvement of symptoms. No complications were observed.

CONCLUSIONS

Our experience underlines that endoscopic ballon dilatation, in patients with post anastomotic benign strictures, is a safe technique with a low rate of complications.

Percutaneous endoscopic gastrostomy (PEG) in critically ill patients performed at bed in Intensive Care Unit: report of our experience

BACKGROUND AND AIM

Patients with severe brain injures and severe neurological diseases frequently require prolonged nutritional support during their hospitalization as well as during their rehabilitation period. Since 1980, the percutaneous endoscopic gastrostomy (PEG) has become the method of choice for long term feeding. The aim of the present study was to present our experience concerning the placement of PEG in critically ill patients, recovered in Intensive Care Unit (ICU).

MATERIALS AND METHODS

From 3-05-2001 to 28-09-2005, 36 patients (13 female, 23 male) with a median age of 63 years [range: 18-86 years], recovered in ICU of the Sandro Pertini Hospital, underwent PEG. These patients were retrospectively evaluated in terms of complications, indications to the procedures, durability of gastrostomy and mortality. Intravenous antibiotic prophylaxis was administered 1 h before the procedure (ceftriaxone 2gr). The entire PEG was placed in ICU at patient's bed, with the assistance of the anaesthetist. Propofol was used e.v. for sedation and fentanest for analgesia while lidocaine was used for local anesthesia. A 16-Fr or 20-Fr tube was inserted by the "pull method", after a complete upper gastroduodenoscopy.

RESULTS

PEG was performed mainly for neurological disorders including cerebrovascular accidents (13), SLA (8), post-traumatic coma (7), post-cardiac arrest coma (7) and dementia (1). Procedure related mortality was 0%. The tube was changed in 4 patients due to clogging. The durability of the tube was a median of 2 months (range: 1-12 months). In 23 patients the placement of the PEG was definitive.

CONCLUSIONS

Our experience underlines that PEG, in selected critically ill patients, is a safe technique easy to perform even in ICU.

Bouveret's syndrome: description of a case

Bouveret's syndrome is a rare condition usually caused by a single large stone impacted in the duodenum. This is a cause of gastric outlet. Even if endoscopy is the mainstay of diagnosis, the radiographic examinations are also important too. Generally, the stones are too large to be removed endoscopically. Conservative endoscopic treatment should be attempted initially, and if it fails, surgical approach should be performed.

[Diagnosis and treatment of bleeding peptic ulcer: our experience]

BACKGROUND

Bleeding peptic ulcer (PU) is the commonest cause of an acute upper gastrointestinal bleed. Aim of this study was to present our data regard the management of acute bleeding from PU during urgent endoscopy (examination performed in 2-6 h by the call).

MATERIALS AND METHODS

This study is based on an observational retrospective protocol. Records of 259 consecutive patients with PU (92 F, 167 M; median age 71.5 years; range: 19-100 years), attending our GI Unit from February 1st 2004 to July 31st 2007, were analyzed.

RESULTS

Out of 259 patients with PU, 170 (65.6%) were treated with endoscopic hemostasis followed by medical therapy (PPI 80 mg bolus within 12 h of endoscopy followed by 8 mg/for 72 h and then an oral PPI , 40 mg once daily for 30 days), while 89 (34.4%) patients received only medical therapy (PPI, 40 mg once daily for 30 days). All ulcerative lesions with endoscopic stigmata of acute bleeding, visible vessels or adherent clot (Forrest Ia-IIb) were treated during the gastroscopy. The endoscopic procedures used were: injection of 1:10000 adrenaline (about 10 mL) around the bleeding lesion in 93 cases (55%); injection therapy and thermal method (argon plasma coagulation) in 53 cases (31%); injection therapy and mechanical method (metallic clips) in 20 cases (12%); only mechanical method (metallic clips) in 4 cases (2%). Endoscopic hemostasis was achieved in 251 pts (97%), while 17 pts (6.5%) required second endoscopy for rebleeding. Three patients (1.16%) required immediate surgery for failure of primary endoscopic hemostasis. The mortality within 30 days from the bleeding episode was 3.9% (10 pts).

CONCLUSIONS

The treatment of this condition has made important progress since the introduction of emergency endoscopy and endoscopic techniques for hemostasis. The application of specific protocols, significantly decreases rebleeding and the need for surgery, whereas mortality is still high. Our data are in keeping with previous studies of the literature.

[Sedation with propofol in endoscopic retrograde cholangiopancreatography: personal experience]

AIM

Adequate sedation is fundamental for the execution of the endoscopic retrograde cholangiopancreatography (ERCP). Propofol is widely used for gastrointestinal endoscopy because of its rapid recovery profile. The aim of this study was to determine, retrospectively, whether the administration of propofol was safe in patients undergoing ERCP, both diagnostic and therapeutic.

MATERIALS AND METHODS

In our GI Unit, from 1st February 2006 to 23 November 2006, we performed 100 ERCP. All the patients were sedated by using midazolam e.v., as pre-anaesthetic agent, and propofol e.v. During the procedure, vital signs were continuously monitored (oxygen saturation, blood pressure, heart rate). Patients were also divided into two groups: less than 80 years of age (group I) and 80 years of age and older (group II). Cardiorespiratory complications were recorded.

RESULTS

Patients were 51 females and 49 males, with a median age of 74 years (range: 23-94 years). Group I was composed by 72 patients (35 F, 37 M) and Group II by 28 patients (16 F, 12 M). There were no episodes of hemodynamic instability or airway obstruction. New ECG changes (1 ischemia, 3 arrhythmias) and 1 significant oxygen desaturation episode (SpO2<90%) occurred in 5% of procedures. If we considered the two groups, the rates of cardiopulmonary complications were 4.1% and 7.1%, respectively in group I and in group II.

CONCLUSIONS

Propofol seems to be safe and effective sedation for ERCP, with a low complication rate, also in patients aged 80 years or older.

[Distal hyperplastic polyps as a marker for advanced neoplasm of the proximal colon. Our experience]

BACKGROUND AND AIM

While, several studies indicate that there is an association between proximal and distal colorectal adenomas, no agreement seems to be between the presence of distal hyperplastic polyps and proximal neoplasia. The aim of this study was to investigate, retrospectively, the possible correlation between the distal hyperplastic polyps and proximal colorectal neoplasia.

MATERIALS AND METHODS

In our GI Unit, from 1st February 2006 to 24 November 2006, we performed 142 polypectomy. Patients were 36 females and 80 males, with a median age of 66 years [range: 38-87 years]. All of the polpys were resected during colonoscopy and sent for histological study. Chi-square test was used for statistical analysis. A probability value of P< or =0.05 was considered to be statistically significant.

RESULTS

Histological study showed the following results: 33 hyperplastic polyps (8 F, 21 M; median age 63 years), 100 adenomas (26 F, 61 M; median age 67 years) and 2 inflammatory polpys (2 F, 0 M; median age 71 years). The rectal localization was associated with a significantly higher frequency of hyperplastic polyps (63.6% vs 23.5%), OR: 5.688 (95% C.I. 2.445-13.230) (p<0.0001). Five hyperplastic polyps of the rectum were associated with 5 adenomas located 1 in the rectum, 2 in the sigmoid colon, and 1 in the descendens colon and 1 in the ascendens colon. While, 5 adenomas were associated with 5 adenocarcinoma.

CONCLUSIONS

Guidelines from the American College of Gastroenterology and the American Society of Gastrointestinal Endoscopy do not recommend colonoscopy for patients with distal hyperplastic polyps. Also our study is in keeping with the data of the literature and it confirmed that rectal localization is associated with a higher prevalence of hyperplastic polyps.

[Foreign bodies in the upper gastrointestinal tract. Personal experience]

OBJECTIVE

Foreign bodies ingestion is a potentially serious problem. The majority of ingested foreign bodies pass spontaneously, but serious complications, such as bowel perforation and obstruction, can occur. In the present work, we report our experience in the management of ingested foreign bodies.

MATERIALS AND METHODS

The study was observational and retrospective. We included in the study the foreign bodies ingestions occurred during urgent endoscopy (examination performed from 1 to 6 h by the call).

RESULTS

Records of 696 consecutive EGDS performed in urgency at the Unit of Gastroenterology and Digestive Endoscopy of the Hospital Sandro Pertini of Rome, from 01-02-'04 to 18-01-2006, were analyzed retrospectively. Out of these procedures, 21 (3.01%) were performed for suspected foreign bodies ingestion.

CONCLUSIONS

We present the initial report of our working experience. Objects that have passed the duodenum should be managed conservatively by radiographic surveillance and inspection of stool. Endoscopic or surgical approach is indicated when significant symptoms develop or if the object fails to progress through the gastrointestinal tract. The present data are in keeping with previous studies of the literature.

[Use of expandable metal stents for gastroduodenal outlet obstruction]

Gastroduodenal obstruction is a preterminal event in patients with advanced malignancies of the stomach, pancreas and duodenum. Surgical gastrojejunostomy has been considered the traditional palliative treatment. The use of metallic stents is intended not to be curative but to provide nonsurgical palliation for the symptoms of obstruction. The advantages of this technique are the minor invasivity, the decrease in morbidity and mortality respect the surgical approach, the patient that can be discharged the day of or the day after the procedure and the better life expectation.

Placement of two overlapping uncovered metallic stents for malignant gastric outlet and duodenal obstruction due to colon cancer

Malignant obstruction of the gastric outlet and duodenum is frequently due to extrinsic involvement by tumors from contiguous organs, in particular from pancreas and gallbladder. The treatment of malignant gastroduodenal stenoses is difficult. Many patients have advanced malignant disease and are too ill to undergo surgical approach. Surgical gastrojejunostomy has been considered the palliative treatment of choice. Metallic stents can be useful in this condition with adequate palliation obtained in most cases. We report a case in which self-expanding metallic stents were placed for stenoses of the gastric outlet and duodenum due to a colon cancer.

Drug use and acute leukemia

OBJECTIVE

To study the occurrence of acute leukemia in relation to preceding use of drugs a case-control study has been carried out in Rome, Italy.

PATIENTS AND METHODS

Two hundred and two patients (age >15 years) with a diagnosis of acute leukemia during the period July 1992-June 1994 were enrolled. For each patient, 10 controls matched by age and gender were randomly drawn from the source population. Through the individual beneficiary code the information relevant to the drugs received within the National Health Service during the period January 1989-December 1992 was retrieved. The use of drugs was considered etiologically related to leukemia if the prescription occurred before the 12 months preceding the diagnosis. Exposure was categorized as 'any use' (at least one prescription during the etiologic period), 'high use' (duration of use greater than the median in the control group) and, for NSAIDs, 'very high use' (duration of use greater than 180 days).

RESULTS

Among drugs suspected to cause leukemia, users of high doses of chloramphenicol presented an OR of 1.8 (95% CI: 0.6-5.3). Among other categories of drugs with an increase in the ORs, though not statistically significant, we found tricyclic antidepressants (OR=1.7; 0.8-3.4) and oral contraceptives (OR=1.8; 0.8-4.0). No excess risk was observed for users of calcium-channel blockers (OR=0.9; 0.5-1.7). Use of very high doses of NSAIDs appeared to decrease the occurrence of acute leukemia (OR=0.4; 0.1-1.5).

CONCLUSION

Even with several limitations, this study provides an initial frame of reference for the potential causal role of drugs in acute leukemia.

The geographic relationship between the use of antimicrobial drugs and the pattern of resistance for Streptococcus pneumoniae in Italy

OBJECTIVES

A temporal relationship between the increasing use of antibiotics and the increasing levels of antibiotic resistance has been established for Streptococcus pneumoniae. There are also data that support the presence of a geographic correlation between the level of resistance and the pattern of use among different countries and even within the same country. The aim of this study was to evaluate the potential geographic correlation between the use of beta-lactams and erythromycin in different Italian regions and the resistance of these antibiotics to invasive strains of S. pneumoniae during the period 1999-2000.

METHODS

Ecological study.

RESULTS

In Italy the mean level of resistance for penicillin and erythromycin was 11.4% and 28.9%, respectively. The highest level of resistance for both antibiotics was observed in central and southern regions (i.e. Campania, Lazio and the combined regions of Calabria, Puglia and Sicilia). These regions were also those with the highest consumption of antibiotics. A strong correlation was found between the prevalence of resistance to erythromycin and the regional use of macrolides (r=0.93, P=0.001) and beta-lactams (r=0.84, P=0.002). With regard to penicillin resistance, the greatest correlation was observed for oral penicillin (r=0.85, P=0.002).

CONCLUSION

Our study provides further evidence of the association between regional level of antibiotic use and prevalence of antibiotic resistance.

[Study of the facial nerve in parotid surgery]

The Authors, basing on cadaveric dissections and 40 parotidectomies performed, accurately describe relations between facial nerve and surrounding tissues in its extracranial tract, with particular reference to parotid surgery. They underline Schwalbe's apophysis as the sole safe and constant anatomic landmark in the dissection of the facial nerve trunk.

Risk management of HBsAg or anti-HCV positive healthcare workers in hospital

Recommendations are made for controlling the transmission of the hepatitis B and hepatitis C viruses from healthcare workers to patients. These recommendations were based both on the literature and on experts' opinions, obtained during a Consensus Conference. The quality of the published information and of the experts' opinions was classified into 6 levels, based on the source of the information. The recommendations can be summarised as follows: all healthcare workers must undergo hepatitis B virus vaccination and adopt the standard measures for infection control in hospitals; healthcare workers who directly perform invasive procedures must undergo serological testing and the evaluation of markers of viral infection. Those found to be positive for: 1) HBsAg and HBeAg, 2) HBsAg and hepatitis B virus DNA, or 3) anti-hepatitis C virus and hepatitis C virus RNA must abstain from directly performing invasive procedures; no other limitations in their activities are necessary. Infected healthcare workers are urged to inform their patients of their infectious status, although this is left to the discretion of the healthcare worker; whose privacy is guaranteed by law. If exposure to hepatitis B virus occurs, the healthcare worker must undergo prophylaxis with specific immunoglobulins, in addition to vaccination.

[The issue of authorship and proliferation of scientific research]

In conducting scientific research, certain ethical standards must be applied, not only in the actual performance of the research, in particular the choice of appropriate methodology, but also in writing about science. Authorship is an important aspect of ethical standards in scientific writing. In this article, we discuss the benefits and drawbacks of the most universally recognised guidelines for scientific authorship (i.e., those of the Vancouver Convention), in an attempt to contribute to resolving the recent debate on their presumed inapplicability. In addition to possible solutions to this problem, we provide indications regarding the closely related problem of the proliferation of scientific publications, which affects publication bias and contributes to the confusion surrounding the Impact Factor. Regardless of the specific solution adopted, it must be stressed that writing about science is an ethical decision.

[Pharmaco-epidemiologic indicators for the analysis of drug consumption at the regional level]

The analysis of drug use is often limited to the description of per capita pharmaceutical expenditure. Differences that are observed in the comparison are attributable to the specific age and gender distribution of the compared populations, and to prescriptive behaviors of general practitioners. Aim of this paper is to analyze drug prescription in a local health unit of the Friuli-Venezia Giulia region. In order to take into account differences in age distribution among health districts we used "weighted" populations. An in depth analysis has been carried out on antihypertensive drugs to evaluate differences in GPs' prescriptive behavior. Both the differences among districts in the level of drug use, and variability observed in antihypertensive use in the population, suggest that drug prescription might be partly inappropriate.

Niflumic acid and cutaneous reactions in children

In a case control study of adverse drug reactions in children, the odds ratio of developing a serious mucocutaneous event among users of niflumic acid, adjusted for concomitant use of all other drugs, was 4.9 (95% CI 1.9 to 12.8). Given the availability of safer analgesics and antipyretics, there is no indication, in our opinion, that requires the prescription of substances which bear an increased risk.

Preprogramming and control activity of bimanual self-paced motor task in Parkinson's disease

OBJECTIVE

The authors investigated programming (Bereitschaftspotential or BP) and control activity (Skilled Performance Positivity or SPP) of a bimanual, sequential, skilled motor act in off-therapy Parkinson's disease (PD) patients.

METHODS

We recorded Movement Related Potentials (MRPs) in 12, non-demented, off-therapy parkinsonian patients and in 17 control subjects who were performing a skilled, time-locked motor act, which was not routine in their everyday life but had to be learned: the Skilled Performance Task (SPT). BP, SPP and correct performances were evaluated in grand average waveforms and in sequential blocks.

RESULTS

The analysis of correct performances showed that accuracy in PD patients was significantly lower than in the control group and this accuracy did not improve throughout the blocks. A significantly low level of performances was associated with an increased BP amplitude (P<0.05) and decreased SPP amplitude (P<0.05) in PD patients.

CONCLUSION

Our findings suggest that skill motor learning is impaired in non-demented unmedicated PD patients. We discuss the view that PD patients may allocate more attentional resources, as suggested by the increased BP amplitude, the decreased SPP amplitude and the low correct performances, in order to perform a new skilled motor act.

Multiple sclerosis and vaccination against hepatitis B: analysis of risk benefit profile

BACKGROUND

Since 1994, the hypothesis of a potential causal relationship between vaccination against hepatitis B and multiple sclerosis (and other demyelinating diseases) was brought to the attention of the French health authority, and to public debate. In Italy, since 1991, vaccination against hepatitis B has been mandatory for newborns and 12-year-old children, and also recommended for high-risk groups.

AIM

To re-evaluate the risk/benefit profile of the Italian strategy of hepatitis B vaccination.

SUBJECTS

The study population is a hypothetical cohort of 100,000 newborns.

METHODS

We present a simulation of the hepatitis B cases that could be prevented with the vaccination and of the potential excess of multiple sclerosis cases which would occur, assuming different odds ratios of multiple sclerosis among vaccinees, and by effecting the vaccination at different ages.

RESULTS

In the cohort, we would expect 1,099 hepatitis B cases, that would be prevented with vaccination. Assuming that the highest odds ratio of 1.7 reported is true, the excess of "life-time" multiple sclerosis incidence would be 0.3% for 12-year-old subjects, and 2.9% for adults.

CONCLUSIONS

On the basis of these data, our opinion is that the hepatitis B vaccination strategy presently adopted in Italy for newborns, teen-agers and high risk groups should not be modified.

Prescription of neuroleptics for children and adolescents in Italy

The objective of this study was to describe the use of neuroleptics among children and adolescents in the province of Rome. Subjects 5 to 19 years of age who received neuroleptic prescriptions within the National Health Service between 1986 and 1991 were identified. Prevalence and incidence of use were estimated. The yearly prevalence of use during the study period ranged from 1.3 to 1.7 per 1000 inhabitants. The incidence during 1989 was 1.1 per 1000, with a marked increase with age. Haloperidol was the drug most frequently prescribed; 59.2% of the subjects received only one prescription during the year. Among subjects with more than one prescription, 42.3% received neuroleptics in combination. The observed pattern of use suggests that in current practice neuroleptics are also used for the treatment of nonpsychotic conditions. The analysis of data derived from a prescription monitoring system may provide an important contribution to the description of neuroleptic use among children and adolescents.

[Ethics problems in phase IV of drug studies]

Phase IV clinical studies include all investigations carried out after the approval of drugs. The objective of these studies is well defined: to gain additional knowledge on efficacy and safety of drugs. There are uncertainties however with regard to which kind of study design is appropriate to provide scientifically valid contributions. In the present article we will clarify why an experimental design (e.g. randomized clinical trial) is ordinarily required, on the basis of scientific and ethical concerns, to answer questions concerning efficacy even after drug commercialization. Viceversa, non experimental designs (from case series analysis to cohort and case control studies) are indicated to investigate drug effects in current practice if the objective is to evaluate safety.

Ketorolac use in outpatients and gastrointestinal hospitalization: a comparison with other non-steroidal anti-inflammatory drugs in Italy

OBJECTIVE

To compare the risk of hospitalization for gastroduodenal ulcer associated with the use of ketorolac and other non-steroidal anti-inflammatory drugs (NSAIDs).

METHODS

A cohort and a nested case-control study were carried out. All residents in the region of Umbria (Italy), aged 35-84 years, who had been given at least one NSAID prescription in 1993 and 1994 were identified. Exposure to drugs was ascertained through a drug prescription database. We estimated rate ratios of hospitalization for gastroduodenal ulcer with or without complications in the current, recent or past period according to exposure to different NSAIDs.

RESULTS

Rate ratio estimates, adjusted for age and sex, were 2.8 for any current NSAID and 1.4 for any recent NSAID. The highest rate ratios of lesions of any severity for current NSAID use were observed for piroxicam (RR: 4.6) and ketorolac (RR: 3.4). For gastrointestinal haemorrhage or perforation the highest rate ratios were those for ketorolac (RR: 5.9) and piroxicam (RR: 4.8). Rate ratio estimates did not change after adjustment for concomitant use of gastrotoxic drugs, use of gastroprotective agents not associated with NSAIDs and prior use of NSAIDs.

CONCLUSION

Our study demonstrates the need to adhere to the restrictions relating to the indications and duration of use of ketorolac. At present piroxicam represents a greater public health concern since it is confirmed to be among the most gastrotoxic NSAIDs and is one of the most commonly prescribed NSAIDs in Italy.

Prescriptions for mesalazine and sulphasalazine: a prevalence estimate of patients treated for inflammatory bowel disease in Rome

BACKGROUND

Sulphasalazine and 5-amino salicyclic acid drugs are specifically indicated for the treatment of inflammatory bowel disease.

AIM

To use drug consumption by a given population as a marker to estimate the number of patients with inflammatory bowel disease.

METHODS

Prescriptions for sulphasalazine and mesalazine were identified for the 133000 inhabitants of a local health unit in Rome. Other prescriptions received by the patients, who were users of sulphasalazine or mesalazine, were also studied.

RESULTS

99465 patients received at least one prescription for any drug in 1991. Three hundred and seventy-six patients were prescribed sulphasalazine and/or mesalazine, an average of 3.8 prescriptions per patient. These patients were exposed more frequently than the general population to other drugs often used in inflammatory bowel disease treatment, for example, corticosteroids, anti-diarrhoeal drugs and intestinal anti-infectives. We identified that 258 of 100000 inhabitants were prescribed either sulphasalazine or mesalazine; 127 of 100000 inhabitants received full-dose treatment for at least 30 days, and 42.8 of 100000 inhabitants received prescriptions of either drug, also associated with systemic corticosteroids.

CONCLUSION

The consumption of drugs used specifically for inflammatory bowel disease may act as a marker for the prevalence of the condition in a community.

Drug prescription in Italy

Drug use in Italy in the period 1983-1991 has been analysed. The twenty most used substances accounted for about 20% of the sold packages. The effect of marketing of new drugs is worth noting: new and more expensive drugs are preferred even when effective, safe and less expensive alternatives are available. Prescribers have to face a highly dynamic pharmaceutical market in which 30% of substances (among the 300 most sold) changes every five years. Other than a more rational formulary, independent information and continuing education have to be considered as tools to improve a more rational prescribing.

Gangliosides and Guillain-Barré syndrome

Cases of Guillain-Barré syndrome (GBS) associated with parenteral use of gangliosides have been reported in several European countries. To evaluate the hypothesis of association between ganglioside exposure and occurrence of GBS, a case-control study was conducted. GBS cases discharged during 1989 from public and private hospitals in three Italian provinces were identified: 42 GBS cases and 420 controls matched on age and gender were enrolled. Data of onset of symptoms of GBS was taken from clinical records. Exposure status of subjects was ascertained through the regional computerized drug prescription monitoring system. The odds ratio of association between ganglioside use, in the 30 days prior to onset of symptoms, and GBS was 9.1 (95% confidence interval 2.8-29.4). Although there are formidable difficulties in distinguishing prodromal therapy of GBS from drug causation, the association with ganglioside therapy is strong and supportive of the hypothesis of a role of ganglioside preparations in the occurrence of GBS.

Use and misuse of antidepressant drugs in a random sample of the population of Rome, Italy

Prescribing patterns of antidepressant drugs were studied, over a period of 30 months, in a random sample of 8743 residents of the area of Rome, Italy. Data from the regional outpatient drug monitoring system were used. The proportion of subjects receiving, during the study period, at least one prescription of antidepressant drugs, was 5.4%; the female-to-male ratio was 2.1. Consumption prevalence increased with age. The single most prescribed drug was fluoxetine followed by amitriptyline and ademetionine. For a surprisingly high proportion of subjects, the observed length of treatment was shorter than expected on the basis of current knowledge in clinical pharmacology. Inappropriate diagnostic and therapeutic procedures are likely explanations.

Gastroduodenal toxicity of different nonsteroidal antiinflammatory drugs

Although the etiologic relation between nonsteroidal antiinflammatory drug (NSAID) use and gastrointestinal lesions is well documented, newly introduced NSAIDs deserve a fresh examination for their risk/benefit ratio. To estimate the association between consumption of ketorolac and the occurrence of gastroduodenal lesions, we conducted a case-control study. The study population comprised 600 outpatients with a confirmed endoscopic diagnosis of ulcer and erosion in 1991 and 1992 and 6,000 community controls matched by age and sex. We retrieved the prescription history through a computerized prescription monitoring system. We defined exposure to each study drug as "current" (month of endoscopy and preceding month), "recent" (second or third month preceding endoscopy). and "past" (fourth to sixth month preceding endoscopy). Current users of NSAIDs showed a 30% increase in the incidence of gastroduodenal lesions [odds ratio (OR) = 1.3; 95% confidence interval (CI) = 0.98 - 1.8] after adjustment for recent or past use of any NSAID, recent or past gastrotoxic therapy, recent or past use of gastroprotective drugs, and recent or past use of any other drug. Among NSAIDs, ketorolac was the only one showing a distinctly elevated risk of gastroduodenal lesions (OR = 4.2; 95% CI = 1.9-9.4). Current use of any NSAID was associated with almost a doubling of risk for ulcer alone (OR = 1.9; 95% CI = 1.3-3.0); no elevation in risk was found for erosions. The adjusted relative risk for ulcer associated with current use of ketorolac was 9.8 (95% CI = 3.4-28.10. Recent and past use of NSAIDs does not increase the risk of ulcer.(ABSTRACT TRUNCATED AT 250 WORDS)

Antipsychotic drug prescription in general practice in Italy

Prescribing patterns of neuroleptic drugs in a population of about 3,700,000 inhabitants were analysed using all individual prescriptions delivered by the Italian National Health Service during 4 years (1986-1989). Data contained in a regional prescription database were analysed using an outpatient drug monitoring system (VIDEOFAR). The proportion of subjects receiving neuroleptics was about 1.3% of the entire population. During 1989, 20.2% of 52,716 observed subjects received multiple neuroleptic therapy. Haloperidol, the most frequently prescribed antipsychotic, was dispensed to 21.3% of the individuals as the only neuroleptic treatment. Consumption sharply increased with age and about 60% of patients receiving a prescription were women. Nonetheless, among the heavy users in the younger ages, the male-to-female ratio is significantly greater than one. Although the principal indications for neuroleptics are subacute or chronic clinical conditions, a surprisingly high proportion of subjects (ranging from 48% to 76% depending on the type of neuroleptic) received only one single prescription during 1989.

The nature content and interpractice variation of general practice: a regional study in Italy

The activity of 34 general practitioners (GP) working in solo practices in six Local Health Units were assessed, as a preliminary step of a main study, to evaluate and possibly improve the quality of GP professional performance using peer review and feed-back information. A wide interpractice variation was observed in patient visit and patient visiting rates, drug and test prescribing, in- and out-patient referrals, as well as in the composition of the practice case-mix. The extent of interpractice variation for relevant actions in the process of care was unchanged after adjusting for case-mix, suggesting that case-mix differences have little effect in explaining differences among physicians' overall pattern of care and health care resource consumptions.