Upper Gastrointestinal Endoscopy Quality in Italy: A Nationwide Study

BACKGROUND AND AIMS

International guidelines advise improving esophagogastroduodenoscopy (EGD) quality in Western countries, where gastric cancer is still diagnosed in advanced stages. This nationwide study investigated some indicators for the quality of EGD performed in endoscopic centers in Italy.

METHODS

Clinical, endoscopic, and procedural data of consecutive EGDs performed in one month in the participating centers were reviewed and collected in a specific database. Some quality indicators before and during endoscopic procedures were evaluated.

RESULTS

A total of 3,219 EGDs performed by 172 endoscopists in 28 centers were reviewed. Data found that some relevant information (family history for GI cancer, smoking habit, use of proton pump inhibitors) were not collected before endoscopy in 58.5-80.7% of patients. Pre-endoscopic preparation for gastric cleaning was routinely performed in only 2 (7.1%) centers. Regarding the procedure, sedation was not performed in 17.6% of patients, and virtual chromoendoscopy was frequently (>75%) used in only one (3.6%) center. An adequate sampling of the gastric mucosa (i.e., antral and gastric body specimens) was heterogeneously performed, and it was routinely performed only by 23% of endoscopists, and in 14.3% centers.

CONCLUSIONS

Our analysis showed that the quality of EGD performed in clinical practice in Italy deserves to be urgently improved in different aspects.

Endoscopic characterization of neoplastic and non-neoplastic lesions in inflammatory bowel disease: systematic review in the era of advanced endoscopic imaging

Background

Current guidelines strongly recommend the use of validated classifications to support optical diagnosis of lesions with advanced endoscopic imaging in the lower gastrointestinal tract. However, the optimal strategy in inflammatory bowel disease (IBD) is still a matter of debate.

Objectives

To analyze the accuracy of endoscopic classifications or single predictors for in vivo lesion characterization during endoscopic surveillance of IBD with advanced endoscopic imaging.

Design

Systematic review.

Data sources and methods

Medline and PubMed were used to extract all studies which focused on lesion characterization of neoplastic and non-neoplastic lesions in IBD. The diagnostic accuracy of endoscopic classifications and single endoscopic predictors for lesion characterization were analyzed according to type of patients, lesions, and technology used. When available, the rates of true and false positives or negatives for neoplasia were pooled and the sensitivity (SE), specificity (SP), positive predictive value, and negative predictive value (NPV) were calculated.

Results

We included 35 studies (2789 patients; 5925 lesions - 1149 neoplastic). Advanced endoscopic imaging included dye-based chromoendoscopy, virtual chromoendoscopy (VCE), magnification and high-definition endoscopy, confocal laser endomicroscopy (CLE), endocytoscopy, and autofluorescence imaging. The Kudo classification of pit patterns was most frequently used, with pooled SE 83%, SP 83%, and NPV 95%. The endoscopic criteria with the highest accuracy, with minimum SE ⩾ 90%, SP ⩾ 80%, and NPV ⩾ 90% were: the Kudo-IBD classification used with VCE (Fuji Intelligent Color Enhancement and i-SCAN); combined irregular surface and vascular patterns used with narrow band imaging; the Mainz classification used with CLE. Multiple clinical and technical factors were found to influence the accuracy of optical diagnosis in IBD.

Conclusion

No single endoscopic factor has yet shown sufficient accuracy for lesion characterization in IBD surveillance. Conventional classifications developed in the non-IBD setting have lower accuracy in IBD. The use of new classifications adapted for IBD (Kudo-IBD), and new technologies based on in vivo microscopic analysis show promise.

A multicenter survey on endoscopic retrograde cholangiopancreatography during the COVID-19 pandemic in northern and central Italy

Background and study aims  COVID-19 has dramatically impacted endoscopy practice because upper endoscopy procedures can be aerosol-generating. Most elective procedures have been rescheduled. Endoscopic retrograde cholangiopancreatography (ERCP) is frequently performed in emergency or urgent settings in which rescheduling is not possible. We evaluated the impact of the COVID-19 pandemic on ERCP in Italy during the SARS-CoV-2 lockdown, in areas with high incidence of COVID-19. Patients and methods  We performed a retrospective survey of centers performing ERCP in high COVID-19 prevalence areas in Italy to collect information regarding clinical data from patients undergoing ERCP, staff, case-volume and organization of endoscopy units from March 8, 2020 to April 30, 2020. Results  We collected data from 31 centers and 804 patients. All centers adopted a triage and/or screening protocol for SARS-CoV-2 and performed follow-up of patients 2 weeks after the procedure. ERCP case-volume was reduced by 44.1 % compared to the respective 2019 timeframe. Of the 804 patients undergoing ERCP, 22 (2.7 %) were positive for COVID-19. Adverse events occurred at a similar rate to previously published data. Of the patients, endoscopists, and nurses, 1.6 %, 11.7 %, and 4.9 %, respectively, tested positive for SARS-CoV-2 at follow up. Only 38.7 % of centers had access to a negative-pressure room for ERCP. Conclusion  The case-volume reduction for ERCP during lockdown was lower than for other gastrointestinal endoscopy procedures. No definitive conclusions can be drawn about the percentage of SARS-CoV-2-positive patients and healthcare workers observed after ERCP. Appropriate triage and screening of patients and adherence to society recommendations are paramount.

E-Coaching: the DianaWeb study to prevent breast cancer recurrences

INTRODUCTION

Breast cancer is the most common cancer in women worldwide, for which the survival rate is increasing over time. Growing evidence are showing that the effect of lifestyle could have the same weight of the effect of the usual clinical-pathological risk factors on survival rate. The DianaWeb study responds to the pressing request of patients diagnosed with breast cancer to know the most advanced point of scientific research on the prevention of recurrences, to have a virtual space to meet, where to receive advice and practical information for the daily management the lifestyle change. DianaWeb is a community-based participatory research, dedicated to breast cancer patients, aimed to monitor lifestyle, provide them tips to encourage sustainable lifestyle changes, and to analyze clinical outcomes. In order to achieve these aims, DianaWeb uses a specific interactive website (http://www.dianaweb.org/).

METHODS

The web architecture has been designed essential and light, with a rigorous implantation that brings the figure of the woman to the center. In order to humanized the project the acronym used to identify the study was Diana (Diet and Androgens), a classical female name, who was illustrated as a female avatar, aimed to symbolize all women. The graphical interface was developed using seven pastel tones colors, which become a fundamental elements of the layout, such as frame, navigation menu, and separation interspaces.

RESULTS

The project started in 2015, and in 4 days the web site was visited by more than 1000 people. A total of 2823 persons enrolled in the study, but 2182 did not send the full documentations, 61 persons abandoned the study, 641 timely answered to the questionnaires.

CONCLUSIONS

The high number of participants' interaction within the web page, confirmed the high usability of the web page and the great interest of patients. Prevention of breast cancer recurrences with low cost technologies, easily available to everybody, is a priority for both public health and public finances.

Plastic Biliary Stent Migration During Multiple Stents Placement and Successful Endoscopic Removal Using Intra-Stent Balloon Inflation Technique: A Case Report and Literature Review

Patient: Male, 77

Final Diagnosis: Biliary neoplasm

Symptoms: —

Medication: —

Clinical Procedure: Biliary stent removal using intra-stent balloon inflation techniqueextraction

Specialty: Gastroenterology and Hepatology

Effect of puerperal metritis on reproductive and productive performance in dairy cows in Argentina

The objectives of this study were to evaluate the reproductive and productive performance of dairy cows with and without puerperal metritis and to evaluate the effectiveness of using a long-acting ceftiofur preparation. Dairy cows in one dairy farm, calving from July 2009 to January 2010, were examined between 3 and 14 days postpartum and classified on the basis of vaginal discharge into three groups: cows with normal discharge (control; C); cows with a bloody mucus purulent or pathologic nonfetid discharge (PnFD), and cows with bloody mucopurulent or purulent fetid discharge (PFD). Cows in C and PnFD groups were not treated, whereas those in the PFD group were randomly allocated to receive 2.2 mg/kg of ceftiofur subcutaneously behind the ear (PFD-T) or remain untreated (PFD-No T). From the 640 cows examined, 58.2% formed the C group, 13.4% formed the PnFD group, and 28.4% formed the PFD group. Survival curves differed between cows in the C group and PFD-No T group (P = 0.0013) and between PFD-No T versus PFD-T group (P = 0.0006). Survival curves of PnFD were intermediate and did not differ from those in the C group (P = 0.2) and PFD-T group (P = 0.1) but tended to be different from the PFD-No T group (P = 0.056). The postpartum interval to achieve a 25% pregnancy rate was 72 days for cows in the C group, 73 days for the PFD-T group, 83 days for PnFD group, and 95 days for the PFD-No T group. The chance of pregnancy in a cow in the C group was 1.98 times higher (95% confidence interval = 1.33, 3.08) and in cows in the PFD-T group was 2.16 times higher (95% confidence interval = 1.37, 3.50) than that in the PFD-No T group. Finally, the chance of pregnancy in cows in the PnFD group tended to be higher (P = 0.08) than that in the PFD-No T group but did not differ from the other two groups. Cumulative 305-day milk production was higher (P < 0.0001) in C group than those with vaginal discharge, regardless of fetidness and regardless of treatment. It is concluded that puerperal metritis affects the reproductive and productive performance of dairy cows and the treatment with ceftiofur was effective in reducing the adverse effects on reproductive performance but not on milk production.

Is microencapsulation the future of probiotic preparations? The increased efficacy of gastro-protected probiotics

In a recent publication we assessed the kinetics of intestinal colonization by microencapsulated probiotic bacteria in comparison with the same strains given in an uncoated form. It's well known, in fact, that microencapsulation of probiotics with specific materials is able to confer a significant resistance to gastric juice, thus protecting the cells during the gastric and duodenal transit and enhancing the probiotic efficacy of any supplementation. In any case, this was the first study reporting the fecal amounts of probiotics administered in a coated, protected form compared with traditional, uncoated ones. Here we discuss additional in vitro data of resistance of the same bacteria to gastric juice, human bile and pancreatic secretion and correlate them with the results of in vivo gut colonization.

Reduced brachial flow-mediated vasodilation in young adult ex extremely low birth weight preterm: a condition predictive of increased cardiovascular risk?

BACKGROUND

Sporadic data present in literature report how preterm birth and low birth weight constitute the risk factors for the development of cardiovascular diseases in later life.

AIM

To assess the presence of potential alterations to endothelial function in young adults born preterm at extremely low birth weight (<1000 g; ex ELBW).

METHOD

Thirty-two ex-ELBW subjects (10 males [M] and 22 females [F], aged 17-28 years, mean [+/- DS] 20.1 +/- 2.5 years) were compared with 32 healthy, age-matched subjects born at term (C, 9 M and 23 F).

EXCLUSION CRITERIA

1) pathological conditions known to affect endothelial function; 2) administration of drugs known to affect endothelial function. Endothelial function was assessed by non-invasive finger plethysmography, previously validated by the US Food and Drug Administration (Endopath; Itamar Medical Ltd., Cesarea, Israel).

RESULTS

Endothelial function was significantly reduced in ex-ELBW subjects compared to C (1.94 +/- 0.37 vs. 2.68 +/- 0.41, p < 0.0001). Moreover, this function correlated significantly with gestational age (r = 0.56, p < 0.0009) and birth weight (r = 0.63, p < 0.0001).

CONCLUSIONS

The results obtained reveal a significant decrease in endothelial function of ex-ELBW subjects compared to controls, underlining a probable correlation with preterm birth and low birth weight. Taken together, these results suggest that an ELBW may underlie the onset of early circulatory dysfunction predictive of increased cardiovascular risk.

Assessing erectile neurogenic dysfunction from heart rate variability through a Generalized Linear Mixed Model framework

BACKGROUND

The low (LF) vs. high (HF) frequency energy ratio, computed from the spectral decomposition of heart beat intervals, has become a major tool in cardiac autonomic system control and sympatho-vagal balance studies. The (statistical) distributions of response variables designed from ratios of two quantities, such as the LF/HF ratio, are likely to non-normal, hence preventing e.g., from a relevant use of the t-test. Even using a non-parametric formulation, the solution may be not appropriate as the test statistics do not account for correlation and heteroskedasticity, such as those that can be observed when several measures are taken from the same patient.

OBJECTIVES

The analyses for such type of data require the application of statistical models which do not assume a priori independence. In this spirit, the present contribution proposes the use of the Generalized Linear Mixed Models (GLMMs) framework to assess differences between groups of measures performed over classes of patients.

METHODS

Statistical linear mixed models allow the inclusion of at least one random effect, besides the error term, which induces correlation between observations from the same subject. Moreover, by using GLMM, practitioners could assume any probability distribution, within the exponential family, for the data, and naturally model heteroskedasticity. Here, the sympatho-vagal balance expressed as LF/HF ratio of patients suffering neurogenic erectile dysfunction under three different body positions was analyzed in a case-control protocol by means of a GLMM under gamma and Gaussian distributed responses assumptions.

RESULTS

The gamma GLMM model was compared with the normal linear mixed model (LMM) approach conducted using raw and log transformed data. Both raw GLMM gamma and log transformed LMM allow better inference for factor effects, including correlations between observations from the same patient under different body position compared to the raw LMM. The gamma GLMM provides a more natural distribution assumption of a response expressed as a ratio.

CONCLUSIONS

A gamma distribution assumption intrinsically models quadratic relationships between the expected value and the variance of the data avoiding prior data transformation. SAS and R source code are available on request.

Non-parametric smoothing of multivariate genetic distances in the analysis of spatial population structure at fine scale

Species dispersal studies provide valuable information in biological research. Restricted dispersal may give rise to a non-random distribution of genotypes in space. Detection of spatial genetic structure may therefore provide valuable insight into dispersal. Spatial structure has been treated via autocorrelation analysis with several univariate statistics for which results could dependent on sampling designs. New geostatistical approaches (variogram-based analysis) have been proposed to overcome this problem. However, modelling parametric variograms could be difficult in practice. We introduce a non-parametric variogram-based method for autocorrelation analysis between DNA samples that have been genotyped by means of multilocus-multiallele molecular markers. The method addresses two important aspects of fine-scale spatial genetic analyses: the identification of a non-random distribution of genotypes in space, and the estimation of the magnitude of any non-random structure. The method uses a plot of the squared Euclidean genetic distances vs. spatial distances between pairs of DNA-samples as empirical variogram. The underlying spatial trend in the plot is fitted by a non-parametric smoothing (LOESS, Local Regression). Finally, the predicted LOESS values are explained by segmented regressions (SR) to obtain classical spatial values such as the extent of autocorrelation. For illustration we use multivariate and single-locus genetic distances calculated from a microsatellite data set for which autocorrelation was previously reported. The LOESS/SR method produced a good fit providing similar value of published autocorrelation for this data. The fit by LOESS/SR was simpler to obtain than the parametric analysis since initial parameter values are not required during the trend estimation process. The LOESS/SR method offers a new alternative for spatial analysis.

Partial least squares regression: a valuable method for modeling molecular behavior in hemodialysis

The aim of this work was to use the Partial Least Squares Regression (PLS) technique to fit simple models for the interpretation of an underlying complex process. In this study, the technique was used to build a statistical model for molecular kinetic data obtained from hemodialyzed patients. By using PLS we derived statistical linear models for the prediction of the equilibrated urea concentration which would be reached 30-60 min after the end of the dialysis session. Models with an average relative prediction error (RPE) of less than 0.05% were achieved. The model predictive accuracy was evaluated in a cross-center study yielding an RPE < 3%. The chosen model was robust to variations such as sampling extraction time demonstrating a high capacity for modeling kinetics. It also was found to be useful for bedside monitoring. Finally, the PLS technique allowed identification of the most important co-variables in the model and of those patients with outlier patterns in their molecular dynamics.

Quantification and description of fracture network by MRI image analysis

The contribution of fractures to total porosity and their geometrical descriptions have been studied by Image Analysis applied to 1H Magnetic Resonance Imaging (MRI). Reservoirs of different lithology were acquired with MSME 2D quantitative and 3D sequences. An image analysis procedure, developed ad hoc, was then applied to these acquisitions and the petrophysical parameters computed. These parameters range from fracture porosity to fracture density.

An overview of cerebral aneurysms. Which factors affect the outcome of microsurgical treatment

There is a higher incidence of subarachnoid hemorrhage (SAH) with advancing age. Considerable controversy exists as to whether aggressive therapy is indicated in the elderly. With increased life expectancy, a greater number of elderly patients with SAH will require treatment in the future. This study was undertaken to evaluate the effect of age, aneurysm characteristics, Hunt-Hess grade on admission, race, and smoking status to the eventual outcome. The results of 76 consecutive aneurysms clipped in 67 patients by a single surgeon (B.B.) were analyzed. Among the variables, Hunt-Hess grade at admission seemed to be the only significant factor influencing the outcome in this series (X2MH = 17.136, p < 0.001). Advancing age did not worsen the prognosis after SAH and therefore age should not be a contraindication for aggressive management.

Permeability estimation from NMR diffusion measurements in reservoir rocks

It is well known that in restricted geometries, such as in porous media, the apparent diffusion coefficient (D) of the fluid depends on the observation time. From the time dependence of D, interesting information can be derived to characterise geometrical features of the porous media that are relevant in oil industry applications. In particular, the permeability can be related to the surface-to-volume ratio (S/V), estimated from the short time behaviour of D(t), and to the connectivity of the pore space, which is probed by the long time behaviour of D(t). The stimulated spin-echo pulse sequence, with pulsed magnetic field gradients, has been used to measure the diffusion coefficients on various homogeneous and heterogeneous sandstone samples. It is shown that the petrophysical parameters obtained by our measurements are in good agreement with those yielded by conventional laboratory techniques (gas permeability and electrical conductivity). Although the diffusing time is limited by T1, eventually preventing an observation of the real asymptotic behaviour, and the surface-to-volume ratio measured by nuclear magnetic resonance is different from the value obtained by BET because of the different length scales probed, the measurement remains reliable and low-time consuming.

NMR study of the diffusion processes in gels

Stimulated spin-echo and Carr-Purcell pulse sequences, with pulsed magnetic field gradients, have been used to study the self-diffusion processes of the water in swollen and in supercoiled polyacrylamide gels and in polysaccharides agarose gels, for different polymer concentrations. Restricted diffusion effects are evidenced in both types of gels through the time dependence of the diffusion constant. The results can be interpreted in the framework of diffusion model through permeable walls.