Women in Gastroenterology: What Is the Current Situation? Results of an Italian National Survey

BACKGROUND

Many women grow up dreaming of becoming doctors, preferring specialties that allow more focus on time outside the hospital and on family life. Nowadays, specialties, like gastroenterology, have still a significant gender gap.

METHODS

Based on this known discrepancy, a web-based questionnaire was designed by the Young Component of the Scientific Committee of the Federation of Italian Scientific Societies of Digestive Diseases 2023 (FISMAD) to examine the current situation of female gastroenterologists in Italy. The survey, designed specifically for this study, was sent by email to all female gastroenterologists and residents gastroenterologists, members of the three major Italian societies of Gastroenterology.

RESULTS

A total of 423 female physicians responded to the survey: 325 (76.8%) had full-time employment, and only a few had an academic career (7.2%). The main occupations were outpatient clinics (n = 288, 68%) and diagnostic endoscopy (n = 289, 68.3%); only 175 (41.3%) performed interventional endoscopy. One hundred and forty-seven (34.7%) had the chance to attend a master in advanced or interventional endoscopy, while 133 (31.4%) faced disadvantages that enabled them to attend. Of the 244 (58%) who reported feeling underappreciated, 194 (79.5%) said it was due to gender bias. We found that women doctors considered themselves disadvantaged compared with men doctors due to career opportunities (n = 338), salary negotiations (n = 64), and training opportunities (n = 144).

CONCLUSIONS

In conclusion, gastroenterology still has a long way to go before approaching greater gender parity.

The carbon cost of inappropriate endoscopy

BACKGROUND AND AIMS

Digestive endoscopy is a resource-intensive activity with a conspicuous carbon footprint and an estimated rate of inappropriateness. However, the carbon costs of inappropriate endoscopic procedures still remain obscure. Here we evaluated the environmental impact of inappropriate endoscopic examinations.

METHODS

We calculated the carbon cost of a standard endoscopic procedure (EGD and colonoscopy [CLS]), taking into account the items (eg, disposable materials, personal protective equipment) and energy required for the endoscopy procedure itself and the cleaning process. The rates of inappropriateness and the mortality cost of carbon (MCC) of endoscopic examinations in different scenarios were calculated.

RESULTS

EGD and CLS presented a carbon cost of 5.43 kg and 6.71 kg of CO2, respectively. Different scenarios were evaluated, according to the number of endoscopic procedures performed in Italy per 1000 inhabitants and the reported data on their inappropriateness. The carbon cost of inappropriate EGD and CLS in Italy was 4133 CO2 metric tons per year (MCC, .93), ranging from 3527 to 4749, and equivalent to 1,760,446 L of gasoline consumed. Applying the same data to the European population, the estimated carbon footprint of inappropriate digestive endoscopy in Europe was 30,804 metric tons.

CONCLUSIONS

The environmental impact of inappropriate endoscopic procedures in Europe is remarkable. These results highlight the need to adopt novel strategies aimed at reducing both the carbon footprint of digestive endoscopy and the rate of inappropriate procedures.

The interaction of patients' physical status and time to endoscopy on mortality risk in patients with upper gastrointestinal bleeding: A national prospective cohort study

BACKGROUND AND AIM

The correct time to perform an upper endoscopy is decisive in acutely GI bleeding patients. However, patients' physical status may affect mortality. We speculated that the physical status and procedural time could be the principal factors accountable for death-risk. The primary aim was to verify the interaction between physical status and time to endoscopy on mortality; the secondary aim was to verify the interaction of the physical status and time to endoscopy on the length of stay (LOS).

METHODS

Consecutive patients admitted to 50 Italian hospitals were included. Clinical and endoscopic data were recorded. A multiple logistic regression analysis was performed and the interaction of adjusted clinical physical status and time to endoscopy on mortality was calculated.

RESULTS

Complete data were available for 3.190 patients. The time frames did not interfere with outcomes but influenced LOS. Conversely, the ASA score correlated with mortality, LOS, need for transfusions and rebleeding risk.

CONCLUSION

Endoscopy time should be tailored to the patient's physical. In our experience, ASA 1-2-3 patients can be safely submitted to endoscopy to reduce the LOS; on the contrary, keen attention should be paid to ASA4 patients, following the 'not too early-not too late' rule (12-24 h from admission).

Defining Time in Acute Upper Gastrointestinal Bleeding: When Should We Start the Clock?

Introduction: The execution of upper endoscopy at the proper time is key to correctly managing patients with upper gastrointestinal bleeding (UGIB). Nonetheless, the definition of “time” for endoscopic examinations in UGIB patients is imprecise. The primary aim of this study was to verify whether the different definitions of “time” (i.e., the symptoms-to-endoscopy and presentation-to-endoscopy timeframes) impact mortality. The secondary purpose of this study was to evaluate the similarity between the two timeframes. Methods: A post-hoc analysis was performed on a prospective multicenter cohort study, which included UGIB patients admitted to 50 Italian hospitals. We collected the timings from symptoms and presentation to endoscopy, together with other demographic, organizational and clinical data and outcomes. Results: Out of the 3324 patients in the cohort, complete time data were available for 3166 patients. A significant difference of 9.2 h (p < 0.001) was found between the symptoms-to-endoscopy vs. presentation-to-endoscopy timeframes. The symptoms-to-endoscopy timeframe demonstrated (1) a different death risk profile and (2) a statistically significant improvement in the prediction of mortality risk compared to the presentation-to-endoscopy timeframe (p < 0.0002). The similarity between the two different timeframes was moderate (K = 0.42 ± 0.01; p < 0.001). Conclusions: The symptoms-to-endoscopy and presentation-to-endoscopy timeframes referred to different timings during the management of upper endoscopy in bleeding patients, with the former being more accurate in correctly identifying the mortality risk of these patients. We suggest that further studies be conducted to validate our observations, and, if confirmed, a different definition of time should be adopted in endoscopy.

Improved Survival for Patients With Acute Upper Gastrointestinal Bleeding While on Antithrombotic Therapy: A Multicenter Prospective Cohort Study

GOALS

Aim of the study was to determine if patients with acute upper gastrointestinal bleeding (AUGIB) while on antithrombotic agents (ATs) are at higher risk for worse outcomes.

BACKGROUND

ATs are risk factors of AUGIB, but their impact on clinical outcomes is uncertain.

STUDY

Patients with AUGIB (nonvariceal, NV-AUGIB or variceal, V-AUGIB) in 50 Italian hospitals were prospectively enrolled from January 1, 2014 to December 31, 2015. Clinical data, laboratory tests, comorbidities, prognostic scores, received therapies, and outcomes (death, rebleeding, surgery/radiology, transfusions, length of hospitalization) were analyzed.

RESULTS

A total of 3324 patients (2764 NV-AUGIB, 83.2% and 560 V-AUGIB, 16.8%) were enrolled, 1399 (42.1%) on ATs. Patients taking ATs were older (75.4 vs. 62.8 y, P <0.001), had higher American Society of Anesthesiologists (ASA), Rockall and Glasgow-Blatchford scores ( P <0.001). At multivariate analysis considering comorbidities, ATs use resulted an independent protective factor against death [odds ratio (OR): 0.63, 95% confidence interval (CI): 0.45-0.87, P =0.006]. Rebleeding (5.5% vs. 5.8%, P =0.71) and need for salvage surgery/radiology (4.2% vs. 4.8%, P =0.41) were similar in the 2 groups. Considering specific ATs, low-dose aspirin was the most powerful factor lowering the death risk (OR: 0.51, 95% CI: 0.33-0.81, P =0.004). While the generic use of AT therapy did not emerge as a statistically significant independent protective factor considering separately NV-AUGIB (OR: 0.80, 95% CI: 0.56-1.13, P =0.21) and V-AUGIB (OR: 0.40, 95% CI: 0.15-1.07, P =0.068), the protective effect of low-dose aspirin was confirmed for NV-AUGIB (OR: 0.62, 95% CI: 0.41-0.94, P =0.025).

CONCLUSIONS

ATs use is an independent protective factor against death in AUGIB. The protective effect is mainly derived from low-dose aspirin.

Comparison of assessment tools in acute upper gastrointestinal bleeding: Which one at which time point?

BACKGROUND

Decisions on managing bleeders remain a critical issue due to the high death risk. The Glasgow-Blatchford score (GBS) correctly identifies low-risk patients but none of the existing scores precisely assess the high risk patients.

AIMS

To evaluate bleeding scores' prognostic performances in predicting mortality risk.

SECONDARY OUTCOMES

To compare the scores in low and high-risk patients and identify the "best performing cut-off" (if different from the standard one) in discriminating survivors from deceased.

METHODS

prospective multicenter cohort study including consecutive UGIB patients admitted to 50 Italian hospitals. We collected information to calculate Rockall, PNED, AIMS65, GB, and ABC scores, together with demographic and clinical data, and outcomes.

RESULTS

for low-risk patients, the GB and the ABC are the best performing scores; for high-risk patients, all scores showed weak results, with the PNED score having the higher PPV. Searching for the "best performing cut-off", we found different points that determined a relevant numerical gain in terms of patients correctly assessed.

CONCLUSIONS

we suggest using the GBS and the ABC score at admission, while the PNED appears to be more useful for high-risk. We also suggest using a new decisional cut-offs that, if validated, may increase the accuracy of current scores.

Enteroscopy in diagnosis and treatment of small bowel bleeding: A Delphi expert consensus

BACKGROUND

Enteroscopy plays an important role in the management of small bowel bleeding. However, current guidelines are not specifically designed for small bowel bleeding and recommendations from different international societies do not always align. Consequently, there is heterogeneity in the definitions of clinical entities, clinical practice policies, and adherence to guidelines among clinicians. This represents an obstacle to providing the best patient care and to obtain homogeneous data for clinical research.

AIMS

The aims of the study were to establish a consensus on the definitions of bleeding entities and on the role of enteroscopy in the management of small bowel bleeding using a Delphi process.

METHODS

A core group of eight experts in enteroscopy identified five main topics of small bowel bleeding management and drafted statements on each topic. An expert panel of nine gastroenterologists participated in three rounds of the Delphi process, together with the core group.

RESULTS

A total of 33 statements were approved after three rounds of Delphi voting.

CONCLUSION

This Delphi consensus proposes clear definitions and a unifying strategy to standardize the management of small bowel bleeding. Furthermore, it provides a useful guide in daily practice for both clinical and technical issues of enteroscopy.

An Italian prospective multicenter study on colonoscopy practice and quality: What has changed in the last 10 years

BACKGROUND

A relevant number of adenomas can be missed during colonoscopy.

AIMS

Assess the current status of colonoscopy procedures in Italian centers.

METHODS

A prospective observational study involving 17 hospitals (34 endoscopists) included consecutive patients undergoing standard colonoscopy. In the first phase, endoscopists performed consecutive colonoscopies. In the second phase, retraining via an online learning platform was planned, while in the third phase data were collected analogously to phase 1.

RESULTS

A total of 3,504 patients were enrolled. Overall, a BBPS score ≥6 was obtained in 95.6% of cases (94.8% and 96.9% in the pre- and post-training phases, respectively). 88.4% of colonoscopies had a withdrawal time ≥6 min (88.2% and 88.7% in the pre- and post-training phases). Median adenoma detection rate (ADR) was 39.1%, with no significant differences between the pre- and post-training phases (40.1% vs 36.9%; P = 0.83). In total, 81% of endoscopists had a ADR performance above the 25% threshold.

CONCLUSION

High colonoscopy quality standards are achieved by the Italian hospitals involved. Quality improvement initiatives and repeated module-based colonoscopy-training have been promoted in Italy during the last decade, which appear to have had a significant impact on quality colonoscopy metrics together with the activation of colorectal cancer screening programs.

Derivation and validation of Re.Co.De death score risk in patients with acute nonvariceal upper GI bleeding

BACKGROUND AND AIMS

Scores in upper GI bleeding (UGIB) are used to stratify death risk and need for hospitalization at admission, but a tool that incorporates dynamic changes during the hospital stay is lacking. We aimed to develop a death risk score that considers changes in clinical status during hospitalization and compare its performance with existing ones.

METHODS

A multicenter cohort study enrolling patients with UGIB in 50 Italian hospitals from January 2014 to December 2015 was conducted. Data were collected and used to develop a risk score using logistic regression analyses. Performance curves (area under the receiver-operating characteristic [AUROC] curves), sensitivities, specificities, positive and negative predictive values, and outcomes classified as low, intermediate, and high death risk were calculated. The score's performance was externally validated and then compared with other scores.

RESULTS

We included 1852 patients with nonvariceal UGIB in the development cohort and 912 in the validation cohorts. The new score, which we named the Re.Co.De (rebleeding-comorbidities-deteriorating) score, included 10 variables depicting the changes in clinical conditions while in the hospital. The mortality AUROC curves were .93 (95% confidence interval, .91-.96) in the derivation cohort and .94 (95% confidence interval, .91-.98) in validation cohort. In a comparison of AUROC curves with other scores, the new score showed a significant performance compared with pre- and postendoscopy scores. Patients with low and high scores had 30-day mortality rates of .001% and 48.2%, respectively.

CONCLUSIONS

The Re.Co.De score has a higher performance for predicting mortality in patients with UGIB compared with other scores, correctly identifying patients at low and high death risk while in the hospital through a dynamic re-evaluation of clinical status.

No evidence of "weekend effect" in upper gastrointestinal bleeding in Italy: data from a nationwide prospective registry

OBJECTIVES

The literature offers conflicting information about 'weekend effect' in acute upper gastrointestinal bleeding (AUGIB). Aim of our study was to compare clinical outcomes of patients admitted for AUGIB during the weekend or on weekdays in Italy.

METHODS

We analyzed data from a prospective registry of AUGIB (either nonvariceal, NV-AUGIB or variceal, V-AUGIB) from 50 Italian hospitals from January 2014 to December 2015. Mortality, rebleeding, need for salvage procedures and length of hospitalization were compared among patients admitted during the weekend or on weekdays.

RESULTS

In total 2599 patients (mean age 67.4 ± 15.0 years, 69.2% males) were included, 2119 (81.5%) with NV-AUGIB and 480 (18.5%) with V-AUGIB. Totally 494 patients with NV-AUGIB (23.3%) and 129 patients with V-AUGIB (20.7%) were admitted during the weekend. The two study groups were similar in terms of physical status (American Society of Anesthesiologists score, comorbidities) and bleeding-specific prognostic scores. We did not find differences in terms of mortality (5.6 vs. 4.9%; P = 0.48), rebleeding (5.9 vs. 5.1%; P = 0.39), need for salvage procedures (4.0 vs. 3.6%; P = 0.67) or duration of hospitalization (8.5 ± 6.9 vs. 8.3 ± 7.2 days; P = 0.58) between patients admitted during weekend or weekdays. Considering separately NV-AUGIB and V-AUGIB, the only difference found in clinical outcomes was a higher rebleeding risk in patients with V-AUGIB admitted during the weekend (13.2 vs. 7.4%; P = 0.05).

CONCLUSIONS

Data from our large, prospective multicenter registry shows that in Italy there is no significant 'weekend effect' for either NV- or V-AUGIB. Our results show that the Italian hospital network is efficient and able to provide adequate care and an effective therapeutic endoscopy even during the weekend.

Comparison of assessment tools in acute upper gastrointestinal bleeding: which one for which decision

BACKGROUND

Upper GI bleeding (UGIB) remains a common emergency with significant mortality. Scores help triage patients, but it is still unclear which score should be used in the different decision-making moments to identify patients at high or low death risk. We aimed to compare the overall performances of the most validated scores and their cut-off performance to identify patients at low and high death risk. The secondary outcome was to compare the scores' performance for predicting therapeutic endoscopy, the need for transfusion(s), rebleeding, and surgery/interventional radiology.

METHODS

We conducted a prospective multicenter cohort study, including consecutive UGIB patients admitted to 50 Italian hospitals. We collected information to calculate the Rockall, the Progetto Nazionale Endoscopia Digestiva (PNED), the AIMS65, the Glasgow-Blatchford (GBS), and the Age, Blood tests, Comorbidities (ABC) scores, together with demographic figures, clinical data, and outcomes.

RESULTS

We obtained complete data of 2307 outpatients, including 1887 non-variceal and 420 variceal bleeders. Our cohort's mean age was 67.5 years, with a prevalence of male gender (69%). The GBS has the best overall performance (ROC 0.74) compared to the other scores in identifying low-risk patients (p < .001). At the cut-off 0-1, both GBS and ABC scores provide the highest PPV (100%) for low-risk patients. ABC and PNED scores are the most useful ones (for AUC >80) to assess the high-risk patients for mortality.

CONCLUSIONS

At admission, GBS and ABC scores identify low-risk patients suitable for outpatient management, while PNED and ABC scores identify high-risk patients. During hospitalization, the PNED score should be used to re-assess the mortality risk if a modification of clinical status occurs.

Clinical outcomes in cirrhotics with variceal or nonvariceal gastrointestinal bleeding: A prospective, multicenter cohort study

BACKGROUND AND AIM

Upper gastrointestinal bleeding (UGIB) is associated with a distinct mortality in cirrhotics. We evaluated whether the rate of mortality and other outcomes differs between variceal and nonvariceal UGIB.

METHODS

This was a prospective, multicenter, cohort study on UGIB cirrhotics observed in 50 hospitals. Variceal or nonvariceal UGIB were diagnosed at endoscopy. The 6-week mortality rate, need of blood transfusion, intensive care unit (ICU) admission, radiologic or surgical intervention, rebleeding rate, and length of stay in hospital were the main clinical outcomes compared. Data were analyzed at univariate and multivariate analysis, and odds ratio (OR) with their 95% confidence interval (CI) was calculated.

RESULTS

The study enrolled 706 cirrhotics, including 516 (73%) variceal and 190 (27%) nonvariceal UGIB. There were 78 (11%; 95% CI = 8.7-13.4) deceases, without any difference between variceal (11.0%) and nonvariceal (11.0%) groups. Child-Pugh score C (OR: 6.99; 95% CI = 2.58-18.95), and development of either hepatorenal syndrome (OR: 16.5; 95% CI = 7.02-38.9) or hepatic encephalopathy (OR: 2.38; 95% CI = 1.25-4.5) were independent predictors of mortality. Transfusions and onset of hepatic encephalopathy were significantly more frequent in variceal, whereas ICU admission rate was higher in nonvariceal bleedings. Overall, antibiotic prophylaxis was eventually administered in only 392 (55.5%) patients.

CONCLUSIONS

Data found that the overall mortality rate in cirrhotics with UGIB seems to be reducing and that the value did not differ between variceal and nonvariceal types. Prevention of both hepatorenal syndrome and hepatic encephalopathy and implementation of antibiotic prophylaxis could improve survival in these patients.

Safety and protection in endoscopic services during phase II of COVID-19 pandemic: a national survey

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic requires appropriate measures for containing infection spreading. Endoscopic procedures are considered at increased risk of infection transmission. We evaluated organizational aspects and personal behaviours in Italian Endoscopic Units during phase II of the pandemic.

METHODS

A questionnaire on organizational aspects and use of personal protective equipment (PPE) were e-mailed to gastroenterologists working in Endoscopic Units. Data were analysed accordingly to the National Health Institute and Gastroenterology Societies recommendations.

RESULTS

Data of 117 centres were collected, and different shortcomings emerged. Specific protocols for containing infection and training programs for operators were lacking in 20 and 30% of centres, respectively, and telephone triage 24-72 h before the endoscopy was not implemented in 25% of hospitals. In 30% of centres, the slot time for endoscopies and between examinations was not prolonged. PPE, masks, shirts and gloves were universally adopted, although with some differences. In 20% of centres, a FFPE-FFP3 mask was not adopted during endoscopic examinations. Postendoscopy patient tracking/contact was completed in only one-third of centres.

CONCLUSIONS

Our survey provides information on organizational and medical behaviours during COVID-19 phase II in Italy, which could be useful for adopting appropriate measures for containing COVID-19 spread during phase II.

ABC score: a new risk score that accurately predicts mortality in acute upper and lower gastrointestinal bleeding: an international multicentre study

OBJECTIVES

Existing scores are not accurate at predicting mortality in upper (UGIB) and lower (LGIB) gastrointestinal bleeding. We aimed to develop and validate a new pre-endoscopy score for predicting mortality in both UGIB and LGIB.

DESIGN AND SETTING

International cohort study. Patients presenting to hospital with UGIB at six international centres were used to develop a risk score for predicting mortality using regression analyses. The score's performance in UGIB and LGIB was externally validated and compared with existing scores using four international datasets. We calculated areas under receiver operating characteristics curves (AUROCs), sensitivities, specificities and outcome among patients classified as low risk and high risk.

PARTICIPANTS AND RESULTS

We included 3012 UGIB patients in the development cohort, and 4019 UGIB and 2336 LGIB patients in the validation cohorts. Age, Blood tests and Comorbidities (ABC) score was closer associated with mortality in UGIB and LGIB (AUROCs: 0.81-84) than existing scores (AUROCs: 0.65-0.75; p≤0.02). In UGIB, patients with low ABC score (≤3), medium ABC score (4-7) and high ABC score (≥8) had 30-day mortality rates of 1.0%, 7.0% and 25%, respectively. Patients classified low risk using ABC score had lower mortality than those classified low risk with AIMS65 (threshold ≤1) (1.0 vs 4.5%; p<0.001). In LGIB, patients with low, medium and high ABC scores had in-hospital mortality rates of 0.6%, 6.3% and 18%, respectively.

CONCLUSIONS

In contrast to previous scores, ABC score has good performance for predicting mortality in both UGIB and LGIB, allowing early identification and targeted management of patients at high or low risk of death.

Gastroprotection in patients on antiplatelet and/or anticoagulant therapy: a position paper of National Association of Hospital Cardiologists (ANMCO) and the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO)

Aspirin and P2Y₁₂ receptor antagonists are widely used across the spectrum of cardiovascular and cerebrovascular diseases. Gastrointestinal complications, including ulcer and bleeding, are relatively common during antiplatelet treatment and, therefore, concomitant proton pump inhibitor (PPI) treatment is often prescribed. However, potential increased risk of cardiovascular events has been suggested for PPIs, and, in recent years, it has been discussed whether these drugs may reduce the cardiovascular protection by aspirin and, even more so, clopidogrel. Indeed, pharmacodynamic and pharmacokinetic studies suggested an interaction through hepatic CYP2C19 between PPIs and clopidogrel, which could translate into clinical inefficacy, leading to higher rates of cardiovascular events. The FDA and the EMA sent a warning in 2010 discouraging the concomitant use of clopidogrel with omeprazole or esomeprazole. In addition, whether the use of PPIs may affect the clinical efficacy of the new P2Y₁₂ receptor antagonists, ticagrelor and prasugrel, remains less known. According to current guidelines, PPIs in combination with antiplatelet treatment are recommended in patients with risk factors for gastrointestinal bleeding, including advanced age, concurrent use of anticoagulants, steroids or non-steroidal anti-inflammatory drugs, and Helicobacter pylori infection. Like vitamin K antagonists (VKAs), DOACs can determine gastrointestinal bleeding. Results from both randomized clinical trials and observational studies suggest that high-dose dabigatran (150 mg bid), rivaroxaban and high-dose edoxaban (60 mg daily) are associated with a higher risk of GI bleeding as compared with apixaban and warfarin. In patients taking oral anticoagulant with GI risk factor, PPI could be recommended, even if usefulness of PPIs in these patients deserves further data. Helicobacter pylori should always be searched, and treated, in patients with history of peptic ulcer disease (with or without complication). Given the large number of patients treated with antithrombotic drugs and PPIs, even a minor reduction of platelet inhibition or anticoagulant effect potentially carries a considerable clinical impact. The present joint statement by ANMCO and AIGO summarizes the current knowledge regarding the widespread use of platelet inhibitors, anticoagulants, and PPIs in combination. Moreover, it outlines evidence supporting or opposing drug interactions between these drugs and discusses consequent clinical implications.

IL-1 Receptor Antagonist Anakinra in the Treatment of COVID-19 Acute Respiratory Distress Syndrome: A Retrospective, Observational Study

The IL-1 receptor antagonist, anakinra, may represent a therapeutic option for acute respiratory distress syndrome (ARDS) associated with coronavirus disease 2019 (COVID-19). In this study, COVID-19 ARDS patients admitted to the Azienda Socio Sanitaria Territoriale of Lecco, Italy, between March 5th to April 15th, 2020, and who had received anakinra off-label were retrospectively evaluated and compared with a cohort of matched controls who did not receive immunomodulatory treatment. The primary end point was survival at day 28. The population consisted of 112 patients (56 treated with anakinra and 56 controls). Survival at day 28 was obtained in 69 patients (61.6%) and was significantly higher in anakinra-treated patients than in the controls (75.0 versus 48.2%, p = 0.007). When stratified by continuous positive airway pressure support at baseline, anakinra-treated patients' survival was also significant compared with the controls (p = 0.008). Univariate analysis identified anakinra usage (odds ratio, 3.2; 95% confidence interval, 1.47-7.17) as a significant survival predictor. This was not supported by multivariate modeling. The rate of infectious-related adverse events was similar between groups. In conclusion, anakinra improved overall survival and invasive ventilation-free survival and was well tolerated in patients with ARDS associated with COVID-19.

Quality performance measures for small capsule endoscopy: Are the ESGE quality standards met?

Background and study aims  The European Society of Gastrointestinal Endoscopy (ESGE) recently issued a quality performance measures document for small bowel capsule endoscopy (SBCE). The aim of this nationwide survey was to explore SBCE practice with ESGE quality measures as a benchmark. Patients and methods  A dedicated per-center semi-quantitative questionnaire based on ESGE performance measures for SBCE was created by a group of SBCE experts. One-hundred-eighty-one centers were invited to participate and were asked to calculate performance measures for SBCE performed in 2018. Data were compared with 10 ESGE quality standards for both key and minor performance measures. Results  Ninety-one centers (50.3 %) participated in the data collection. Overall in the last 5 years (2014-2018), 26,615 SBCEs were performed, 5917 of which were done in 2018. Eighty percent or more of the participating centers reached the minimum standard established by the ESGE Small Bowel Working Group (ESBWG) for four performance measures (indications for SBCE, complete small bowel evaluation, diagnostic yield and retention rate). Conversely, compliance with six minimum standards established by ESBWG concerning adequate bowel preparation, patient selection, timing of SBCE in overt bleeding, appropriate reporting, reading protocols and referral to device-assisted enteroscopy was met by only 15.5 %, 10.9 %, 31.1 %, 67.7 %, 53.4 %, and 32.2 % of centers, respectively. Conclusions  The present survey shows significant variability across SBCE centers; only four (4/10: 40 %) SBCE procedural minimum standards were met by a relevant proportion of the centers ( ≥ 80 %). Our data should help in identifying target areas for quality improvement programs in SBCE.

[ANMCO/AIGO Intersocietary consensus document: Gastroprotection in patients receiving antiplatelet and/or anticoagulant drugs]

Aspirin and P2Y12 receptor antagonists are widely used across the spectrum of cardiovascular and cerebrovascular diseases. Gastrointestinal complications, including ulcer and bleeding, are relatively common during antiplatelet treatment and, therefore, concomitant proton pump inhibitor (PPI) treatment is often prescribed. However, potential increased risk of cardiovascular events has been suggested for PPIs, and, in recent years, it has been discussed whether these drugs may reduce the cardiovascular protection by aspirin and, even more so, clopidogrel. Indeed, pharmacodynamic and pharmacokinetic studies suggested an interaction through CYP2C19 between PPIs and clopidogrel, which could translate into clinical inefficacy, leading to higher rates of cardiovascular events. The Food and Drug Administration and the European Medicines Agency sent a warning in 2010 discouraging the concomitant use of clopidogrel with omeprazole or esomeprazole. In addition, whether the use of PPIs may affect the clinical efficacy of the new P2Y12 receptor antagonists, ticagrelor and prasugrel, remains less known. According to current guidelines, PPIs in combination with antiplatelet treatment are recommended in patients with risk factors for gastrointestinal bleeding, including advanced age, concurrent use of anticoagulants, steroids or non-steroidal anti-inflammatory drugs, and Helicobacter pylori infection. Like traditional anticoagulants, novel oral anticoagulants may cause gastrointestinal bleeding. Results from both randomized clinical trials and observational studies suggest that high-dose dabigatran (150 mg bid), rivaroxaban and high-dose edoxaban (60 mg daily) are associated with a higher risk of gastrointestinal bleeding as compared with warfarin. However, the usefulness of PPIs in patients receiving these anticoagulants deserves to be further demonstrated. Given the large number of patients treated with antithrombotic drugs and PPIs, even a minor reduction of platelet inhibition or anticoagulant effect potentially carries a considerable clinical impact. The present joint statement by ANMCO and AIGO summarizes the current knowledge regarding the widespread use of platelet inhibitors, anticoagulants, and PPIs in combination. Moreover, it outlines evidence supporting or opposing drug interactions between these drugs and discusses consequent clinical implications.

Patient's performance status should dictate transfusion strategy in nonvariceal acute upper gastrointestinal bleeding (NV-AUGIB): A prospective multicenter cohort study: Transfusion strategy in NV-AUGIB

BACKGROUND

Non-variceal acute UGI bleeding (NV-AUGIB) is a frequent indication for transfusion, but the best hemoglobin threshold and target values for transfusion in relation to the patients' performance status are unknown.

OBJECTIVE

To identify threshold and target hemoglobin levels for transfusion favoring survival of patients with NV-AUGIB stratified by ASA score.

DESIGN

Prospective cohort study.

SETTING

50 hospitals of the Italian National Health Service.

PARTICIPANTS

2758 consecutive patients with NV-AUGIB admitted to 50 Italian hospitals from January 1st, 2014 to December 31st, 2015. Five hemoglobin cut-off values were evaluated.

RESULTS

30-days mortality: overall: 5.4%; ASA 1-2 patients: 2.5%; ASA 3-4 patients: 10.8%. Mortality was higher when hemoglobin at admission was ≤ 7 g/dL in ASA 1-2 patients, and when it was ≤ 8 g/dL in ASA 3-4 patients. The hemoglobin levels after transfusion favouring survival were ≥ 8 g/dL in ASA 1-2, p <0.0001 and 9-10 g/dL in ASA 3-4 patients; p = 0.0002.

CONCLUSIONS

In patients with NV-AUGIB the physical performance status should dictate the transfusion strategy. In ASA 1-2 patients, admission hemoglobin values ≤ 7 g/dL should prompt transfusion, aiming at a target value of 8-9 g/dL; the corresponding figures for ASA 3-4 patients are: admission hemoglobin level ≤ 8 g/dL and target value of 9-10 g/dL.

Medical care setting is associated with survival in acute upper gastro-intestinal bleeding: A cohort study

BACKGROUND

There are limited data on the effect of the medical care setting on survival in patients admitted with acute upper gastrointestinal bleeding.

AIMS

To identify the organisational and care setting which provides the optimal survival in patients with acute upper gastrointestinal bleeding.

METHODS

A retrospective observational study of administrative data from a cohort of patients admitted to a Regional or Local hospital, and cared for in a gastroenterology or general ward.

PRIMARY OUTCOME

30 day survival for non-variceal bleeding and 42 day survival for variceal bleeding.

RESULTS

Out of 3368 patients, the source of bleeding was non-variceal in 2980 (88.5%). Survival, adjusted for clinical and organisational factors, was higher in patients admitted to a gastroenterology ward vs other wards (OR = 2.02 p < 0.0006). Management in a gastroenterology ward in a Regional hospital provided a higher survival rate (95.6% ± 0.08) vs a non-gastroenterology ward in a Local hospital (92.9% ± 0.05 p < 0.01) or a non-gastroenterology ward in a Regional hospital (89.5% ± 0.01 p < 0.0001). Survival (94.0% ± 1.6) in a Local hospital with a gastroenterology ward was significantly higher than in a Regional hospital without (89.5% ± 1.1) p < 0.01.

CONCLUSION

Survival was optimal for patients treated in a gastroenterology ward independently of Regional or Local hospital setting.

Complications and early mortality in percutaneous endoscopic gastrostomy placement in lombardy: A multicenter prospective cohort study

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is the most common endoscopic procedure used to provide nutritional support.

AIM

To prospectively evaluate the mortality and complication incidences after PEG insertion or replacement.

METHODS

All patients who underwent PEG insertion or replacement were included. Details on patient characteristics, ongoing therapies, comorbidities, and indication for PEG placement/replacement were collected, along with informed consent form signatures. Early and late (30-day) complications and mortality were assessed.

RESULTS

950 patients (47.1% male) were enrolled in 25 centers in Lombardy, a region of Northern Italy. Patient mean age was 73 years. 69.5% of patients had ASA status 3 or 4. First PEG placement was performed in 594 patients. Complication and mortality incidences were 4.8% and 5.2%, respectively. The most frequent complication was infection (50%), followed by bleeding (32.1%), tube dislodgment (14.3%), and buried bumper syndrome (3.6%). At multivariable analysis, age (OR 1.08 per 1-year increase, 95% CI, 1.0-1.16, p = 0.010) and BMI (OR 0.86 per 1-point increase, 95% CI, 0.77-0.96, p = 0.014) were factors associated with mortality. PEG replacement was carried out in 356 patients. Thirty-day mortality was 1.8%, while complications occurred in 1.7% of patients.

CONCLUSIONS

Our data confirm that PEG placement is a safe procedure. Mortality was not related to the procedure itself, confirming that careful patient selection is warranted.

Mechanosensing at the Nuclear Envelope by Nuclear Pore Complex Stretch Activation and Its Effect in Physiology and Pathology

Cell fate is correlated to mechanotransduction, in which forces transmitted by the cytoskeleton filaments alter the nuclear shape, affecting transcription factor import/export, cells transcription activity and chromatin distribution. There is in fact evidence that stem cells cultured in 3D environments mimicking the native niche are able to maintain their stemness or modulate their cellular function. However, the molecular and biophysical mechanisms underlying cellular mechanosensing are still largely unclear. The propagation of mechanical stimuli via a direct pathway from cell membrane integrins to SUN proteins residing in the nuclear envelop has been demonstrated, but we suggest that the cells’ fate is mainly affected by the force distribution at the nuclear envelope level, where the SUN protein transmits the stimuli via its mechanical connection to several cell structures such as chromatin, lamina and the nuclear pore complex (NPC). In this review, we analyze the NPC structure and organization, which have not as yet been fully investigated, and its plausible involvement in cell fate. NPC is a multiprotein complex that spans the nuclear envelope, and is involved in several key cellular processes such as bidirectional nucleocytoplasmic exchange, cell cycle regulation, kinetochore organization, and regulation of gene expression. As several connections between the NPC and the nuclear envelope, chromatin and other transmembrane proteins have been identified, it is reasonable to suppose that nuclear deformations can alter the NPC structure. We provide evidence that the transmission of mechanical forces may significantly affects the basket conformation via the Nup153-SUN1 connection, both altering the passage of molecules through it and influencing the state of chromatin packing. Finally, we review the known correlations between a pathological NPC structure and diseases such as cancer, autoimmune disease, aging and laminopathies.

Diagnosis of chronic anaemia in gastrointestinal disorders: A guideline by the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) and the Italian Society of Paediatric Gastroenterology Hepatology and Nutrition (SIGENP)

Anaemia is a common pathologic condition, present in almost 5% of the adult population. Iron deficiency is the most common cause; other mechanisms can be involved, making anaemia a multi-factorial disorder in most cases. Anaemia being a frequent manifestation in the diseases of the gastrointestinal tract, patients are often referred to gastroenterologists. Furthermore, upper and lower endoscopy and enteroscopy are pivotal to the diagnostic roadmap of anaemia. In spite of its relevance in the daily clinical practice, there is a limited number of gastroenterological guidelines dedicated to the diagnosis of anaemia. For this reason, the Italian Association of Hospital Gastroenterologists and Endoscopists and the Italian Society of Paediatric Gastroenterology, Hepatology and Nutrition commissioned a panel of experts to prepare a specific guideline on anaemia and its diagnostic roadmap in the gastroenterological scenario. The panel also discussed about the potential involvement of gastroenterologists and endoscopists in the management of patients with anaemia, with particular attention to the correct use of investigations. The panel paid particular attention to practical issues with the aim to support gastroenterologists in their clinical practice when dealing with patients with anaemia.

Five common errors to avoid in clinical practice: the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) Choosing Wisely Campaign

Modern medicine provides almost infinite diagnostic and therapeutic possibilities if compared to the past. As a result, patients undergo a multiplication of tests and therapies, which in turn may trigger further tests, often based on physicians' attitudes or beliefs, which are not always evidence-based. The Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) adhered to the Choosing Wisely Campaign to promote an informed, evidence-based approach to gastroenterological problems. The aim of this article is to report the five recommendations of the AIGO Choosing Wisely Campaign, and the process used to develop them. The AIGO members' suggestions regarding inappropriate practices/interventions were collected. One hundred and twenty-one items were identified. Among these, five items were selected and five recommendations were developed. The five recommendations developed were: (1) Do not request a fecal occult blood test outside the colorectal cancer screening programme; (2) Do not repeat surveillance colonoscopy for polyps, after a quality colonoscopy, before the interval suggested by the gastroenterologist on the colonoscopy report, or based on the polyp histology report; (3) Do not repeat esophagogastroduodenoscopy in patients with reflux symptoms, with or without hiatal hernia, in the absence of different symptoms or alarm symptoms; (4) Do not repeat abdominal ultrasound in asymptomatic patients with small hepatic haemangiomas (diameter < 3 cm) once the diagnosis has been established conclusively; (5) Do not routinely prescribe proton pump inhibitors within the context of steroid use or long-term in patients with functional dyspepsia. AIGO adhered to the Choosing Wisely Campaign and developed five recommendations. Further studies are needed to assess the impact of these recommendations in clinical practice with regards to clinical outcome and cost-effectiveness.

Multi-Scale Analysis of the Toraymyxin Adsorption Cartridge Part II: Computational Fluid-Dynamic Study

Extracorporeal endotoxin removal by means of the Toraymyxin device is based on the ability of polymyxin B to bind endotoxins with a high specificity. The endotoxins/polymyxin molecular interactions were computationally analyzed in a parallel work (Part I). In this paper we investigate with a multi-scale approach the phenomena involving blood and plasma fluid dynamics inside the device. The macro- and mesoscale phenomena were studied by means of 3D models using computational fluid dynamics. The flow behavior in the sorbent material was focused, modeling the sorbent as a homogeneous porous medium at the macroscale level, or accounting for the realistic geometry of its knitted fibers at the mesoscale level. A microscale model was then developed to analyze the behavior of endotoxin molecules subjected to the competition of flow drag and molecular attraction by fibergrafted polymyxin B. The macroscale results showed that a very regular flow field develops in the sorbent, furthermore supplying the peak velocity to be input in the lower-scale model. The mesoscale analysis yielded the realistic range for wall shear stresses (WSSs) acting on fiber walls. With WSS values in the entire range, the results of the microscale analysis demonstrated that the capability of polymyxin B to capture endotoxin molecules from the flow extends at distances one order of magnitude greater than the characteristic distance of the stable intermolecular bond. We conclude that the use of an integrated, multi-scale analysis allows for a comprehensive understanding of the complex mechanisms involved in endotoxin sorption phenomena with immobilized polymyxin B.

Implications of small-bowel transit time in the detection rate of capsule endoscopy: A multivariable multicenter study of patients with obscure gastrointestinal bleeding

AIM

To define the role of small-bowel transit time in the detection rate of significant small-bowel lesions.

METHODS

Small-bowel capsule endoscopy records, prospectively collected from 30 participating centers in the Lombardy Registry from October 2011 to December 2013, were included in the study if the clinical indication was obscure gastrointestinal bleeding and the capsule reached the cecum. Based on capsule findings, we created two groups: P2 (significant findings) and P0-1 (normal/negligible findings). Groups were compared for age, gender, small-bowel transit time, type of instrument, modality of capsule performance (outpatients vs inpatients), bowel cleanliness, and center volume.

RESULTS

We retrieved and scrutinized 1,433 out of 2,295 capsule endoscopy records (62.4%) fulfilling the inclusion criteria. Patients were 67 ± 15 years old, and 815 (57%) were males. In comparison with patients in the P0-1 group, those in the P2 group (n = 776, 54%) were older (P < 0.0001), had a longer small-bowel transit time (P = 0.0015), and were more frequently examined in low-volume centers (P < 0.001). Age and small-bowel transit time were correlated (P < 0.001), with age as the sole independent predictor on multivariable analysis. Findings of the P2 group were artero-venous malformations (54.5%), inflammatory (23.6%) and protruding (10.4%) lesions, and luminal blood (11.5%).

CONCLUSION

In this selected, prospectively collected cohort of small-bowel capsule endoscopy performed for obscure gastrointestinal bleeding, a longer small-bowel transit time was associated with a higher detection rate of significant lesions, along with age and a low center volume, with age serving as an independent predictor.

Hospital care services for digestive diseases in Italy: the first quantitative assessment

The scarcity of human and structural resources for specialized gastroenterology care is a problem in many Western countries. Data regarding the resources for Italian Gastroenterology, so far lacking, have been thus searched and evaluated. Based on an agreement protocol between the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) and the Ministry of Health, national data regarding all Institutions providing gastroenterological care were analysed. Hospital beds in Gastroenterology units are presented by region, regimen of stay and per million inhabitants as of January 2011. Association of Hospital Gastroenterologists and Endoscopists also performed a survey of gastroenterology units in all Italian regions regarding number of ordinary/day hospital beds and the number of staff gastroenterologists. The Ministry data showed a total of 174 Gastronterology Units in Italy, a total of 2062 hospital beds for the discipline, for a proportion of 34.2 beds per million inhabitants. The Association of Hospital Gastroenterologists and Endoscopists survey showed a total of 1425 gastroenterologists in Italy. These data should represent a key reference for appropriate planning of specialized care for digestive diseases.

Electrical conditioning of adipose-derived stem cells in a multi-chamber culture platform

In tissue engineering, several factors play key roles in providing adequate stimuli for cells differentiation, in particular biochemical and physical stimuli, which try to mimic the physiological microenvironments. Since electrical stimuli are important in the developing heart, we have developed an easy-to-use, cost-effective cell culture platform, able to provide controlled electrical stimulation aimed at investigating the influence of the electric field in the stem cell differentiation process. This bioreactor consists of an electrical stimulator and 12 independent, petri-like culture chambers and a 3-D computational model was used to characterize the distribution and the intensity of the electric field generated in the cell culture volume. We explored the effects of monophasic and biphasic square wave pulse stimulation on a mouse adipose-derived stem cell line (m17.ASC) comparing cell viability, proliferation, protein, and gene expression. Both monophasic (8 V, 2 ms, 1 Hz) and biphasic (+4 V, 1 ms and -4 V, 1 ms; 1 Hz) stimulation were compatible with cell survival and proliferation. Biphasic stimulation induced the expression of Connexin 43, which was found to localize also at the cell membrane, which is its recognized functional mediating intercellular electrical coupling. Electrically stimulated cells showed an induced transcriptional profile more closely related to that of neonatal cadiomyocytes, particularly for biphasic stimulation. The developed platform thus allowed to set-up precise conditions to drive adult stem cells toward a myocardial phenotype solely by physical stimuli, in the absence of exogenously added expensive bioactive molecules, and can thus represent a valuable tool for translational applications for heart tissue engineering and regeneration.

A dynamic distention protocol for whole-organ bladder decellularization: histological and biomechanical characterization of the acellular matrix

A combined physical-chemical protocol for whole full-thickness bladder decellularization is proposed, based on organ cyclic distention through repeated infusion/withdrawal of the decellularization agents through the urethra. The dynamic decellularization was intended to enhance cell removal efficiency, facilitating the delivery of detergents within the inner layers of the tissue and the removal of cell debris. The use of mild chemical detergents (hypotonic solution and non-ionic detergent) was employed to limit adverse effects upon matrix 3D ultrastructure. Inspection of the presence of residual DNA and RNA was carried out on decellularized matrices to verify effective cell removal. Histological investigation was focused on assessing the retention of adequate structural and functional components that regulate the biomechanical behaviour of the acellular tissue. Biomechanical properties were evaluated through uniaxial tensile loading tests of tissue strips and through ex vivo filling cystometry to evaluate the whole-organ mechanical response to a physiological-like loading state. According to our results, a dynamic decellularization protocol of 17 h duration with a 5 ml/min detergent infusion flow rate revealed higher DNA removal efficiency than standard static decellularization, resulting in residual DNA content < 50 ng/mg dry tissue weight. Furthermore, the collagen network and elastic fibres distribution were preserved in the acellular ECM, which exhibited suitable biomechanical properties in the perspective of its future use as an implant for bladder augmentation.

Defensive medicine practices among gastroenterologists in Lombardy: between lawsuits and the economic crisis

BACKGROUND

Defensive medicine is becoming more frequent behaviour and has an impact on the economic 'health' of national healthcare systems.

AIM

The aim of this study was to clarify the impact of defensive medicine on gastroenterological practices in Lombardy.

METHODS

Gastroenterologists attending the Lombardy Annual Gastroenterological Conference received a questionnaire based on multiple choice tests and visual analogue scales. The questionnaire was divided into three parts evaluating the respondent's characteristics, the number of procedures prescribed, and the percentage of those performed with a defensive purpose.

RESULTS

Sixty-four of 107 participants (60%) completed the questionnaire, 94% of whom reported practising defensive medicine. The percentage of defensively requested procedures amounted to 18% of all digestive endoscopies, 8.9% of abdominal ultrasonography scans, 4.9% of abdominal computed tomography or magnetic resonance scans, and 12.2% of all consultations. The total number of defensive procedures prescribed per month by the participants was 878, and 31.7% of the performed procedures (n=4897) were reported to defensively based. On the basis of the 2012 regional reimbursement fees, the yearly cost of defensive procedures prescribed and/or performed by all gastroenterologists in Lombardy was estimated to be € 8,637,835.

CONCLUSIONS

Our findings indicate that defensive medicine profoundly affects current medical practices among gastroenterologists, and has a considerable economic impact.

Can we improve the detection rate and interobserver agreement in capsule endoscopy?

BACKGROUND

Data about strategies for improving the diagnostic ability of capsule endoscopy readers are lacking.

AIM

(1) To evaluate the detection rate and the interobserver agreement among readers with different experience; (2) to verify the impact of a specific training (hands-on training plus expert tutorial) on these parameters.

METHODS

17 readers reviewed 12 videos twice; between the two readings they underwent the training. The identified small bowel findings were described by a simplified version of Structured Terminology and classifies as clinically significant/non-significant. Findings identified by the readers were compared with those identified by three experts (Reference Standard).

RESULTS

The Reference Standard identified 26 clinically significant findings. The mean detection rate of overall readers for significant findings was low (about 50%) and did not change after the training (46.2% and 46.4%, respectively). There was no difference in the detection rate among readers with different experience. The interobserver agreement with the Reference Standard in describing significant findings was moderate (k = 0.44; CI95%: 0.39-0.50) and did not change after the training (k = 0.44; CI95%: 0.38-0.49) or stratifying readers according to their experience.

CONCLUSIONS

Both the interobserver agreement and the detection rate of significant findings are low, regardless of the readers' experience. Our training did not significantly increase the performance of readers with different experience.

Capsule endoscopy of the small bowel in the clinical practice: outpatient management is feasible and cheaper

AIM

Four Italian regions have cost coding for outpatient capsule-endoscopy. Elsewhere it is performed in ordinary hospital admission. To identify, in a cohort of patients of a Gastroenterology Unit, those feasible for outpatient versus inpatient treatment; to analyze costs distribution in both management areas.

METHODS

We retrospectively analysed 100 clinical records of admissions to A.O. San-Carlo-Borromeo, Milan between 2005-2008. Hospitalization criteria (at least 3): 1) occult/obscure gastrointestinal bleeding; 2) hemoglobin ≤ 8 gr/dL; 3) indication for blood transfusions; 4) urgent hospital admission.

RESULTS

A total of 62 patients had urgent admission, 60 blood transfusions, 81 underwent EGD and colonoscopy, 8 enteroscopy and 5 surgery. Mean haemoglobin value was 8.67 g/dL. Capsule-endoscopy was positive in 70, uncertain in 8, negative in 22. Positive cases: 33 angiodyplasia, 18 ulcers/erosions, 13 polyps/masses, 5 overt bleeding, 1 celiac disease. 47/100 were appropriate as outpatient, saving 432 days of hospital stays. Admission coding was grouped into 7 DRGs (overall expense: 98,366 Euros). Considering EGD/colonoscopy outpatient costs and 1.100 euros as estimated value for capsule-endoscopy, the total expense could be 53.919.

CONCLUSION

Outpatient capsule-endoscopy small bowel examination is feasible in half of the cases. It is cost saving, (about 45.000 Euros/100 patients), reducing inappropriate hospital stays.

Cost estimation of small bowel capsule endoscopy based on "real world" data: inpatient or outpatient procedure?

BACKGROUND

Although capsule endoscopy is the cornerstone for the evaluation of the small bowel in patients with obscure GI bleeding data about costs are lacking.

AIM

To evaluate, from a third party payer point of view, whether performing capsule endoscopy as an outpatient instead of an inpatient procedure can reduce costs.

MATERIALS AND METHODS

The data source is a multicentre survey collecting data for 2921 patients; 1486 of them underwent capsule endoscopy for obscure GI bleeding or chronic unexplained iron-deficiency anaemia as inpatients (814 with positive, 211 with inconclusive and 461 with negative result). We estimated costs of inpatient procedures based on the diagnosis related groups (DRG) system, while those of outpatient procedures on reimbursement provided in five Italian regions.

RESULTS

We estimated that the cost for each inpatient undergoing capsule endoscopy is about € 1775.90. Assuming that all these patients had undergone the same procedure as outpatients, € 175.00-741.00 per patient (depending on the reimbursement and/or on diagnosis related group codes applied) would have been saved.

CONCLUSIONS

Our estimate suggests that, from the third party payer's perspective and using the diagnosis related group reimbursement system, shifting capsule endoscopy from inpatient to outpatient procedure, would be potentially cost saving at least for patients referred for obscure GI bleeding or chronic unexplained anaemia.

Mechanisms of polymyxin B endotoxin removal from extracorporeal blood flow: molecular interactions

The outer leaflet of Gram-negative bacteria membrane contains a great amount of lipopolysaccharides, also known as endotoxins, which play a central role in the pathogenesis of septic shock. It has been demonstrated that the polymyxin B (PMB) molecule has both antibacterial and antiendotoxin capabilities; in fact, it is able to compromise the bacterial outer membrane and bind lipopolysaccharides, thereby neutralizing its toxic effects. Extracorporeal hemoperfusion treatments based on cartridges containing PMB-immobilized fibers (Toraymyxin PMX-F; Toray Industries, Tokyo, Japan) are used to remove endotoxins circulating in the blood flow. In this study, we focused on the characterization of the interactions occurring in the formation of the PMB-endotoxin complex at the molecular level. In particular, the molecular mechanics approach was used to evaluate the interaction energy and eventually the interaction force between the two molecules. PMB was faced with five molecular portions of lipopolysaccharides differing in their structure. The interaction energy occurring for each molecular complex was calculated at different intermolecular distances and the binding forces were estimated by fitting interaction energy data. Results show that the short-range interactions between PMB and endotoxins are mediated mainly by hydrophobic forces, while in the long term, the complex formation is driven by ionic forces only. Maximum binding forces calculated via molecular mechanics for the PMB-endotoxin complex are in the range of 1.39-3.79 nN. Understanding the interaction mechanism of the single molecular complex is useful both in order to figure out the molecular features of such interaction and to perform higher scale level analysis, where such nanoscale detail is impractical but could be used to account for molecular behavior at a coarse level of discretization.

Gastroenterology in Italian clinical practice. The RING Study: six years' data from gastroenterology departments

AIM

Computer systems in hospitals provide information on the work of each single operative unit and the complexity of its caselist. However, in Italy, there is no official data-base for Gastroenterology Departments, to summarize their work.

METHODS

The RING (Ricerca-INformatizzata-in-Gastroenterologia) study has collected, through a software made on purpose, 113 237 hospital discharge files (HDF) from 55 Italian hospital Gastroenterology Units, since 2001. This caselist provides a picture of the patients and is useful for clinical/management evaluation.

RESULTS

Between January 2001 and December 2006, 55 Gastroenterology Units gathered 88240 HDF referring to ''ordinary admissions''. The male:female rate was 1:1, mean age was 61.3+/-18.5 years. Mean hospital stay was around eight days. Over the years there was a significant drop in DRG183 (miscellaneous digestive disorders-without complications) from 11.5% to 7.4% (P<0.0001), with no similar increase in DRG182 (with complications) which rose from 3.1% to 4.0%. Principal discharge diagnoses are post-hepatic and alcohol-related cirrhosis, hepatocarcinoma, acute pancreatitis, duodenal/gastric ulcer.

CONCLUSIONS

The RING data show that the gastroenterologist has been working increasingly with patients whose pathologies would have been ''inappropriately'' treated surgically (DRGs 204 and 174). Inappropriate gastroenterological treatment seems to have decreased as well as the DRG183 with no apparent ''opportunistic'' compensatory increase in DRGs with complications, such as 182.

Management of patients with nonvariceal upper gastrointestinal hemorrhage before and after the adoption of the Rockall score, in the Italian Gastroenterology Units

OBJECTIVES

Nonvariceal upper gastrointestinal hemorrhage is a frequent reason for ordinary hospital admission. In Italy the use of prognostic scores to stratify the risk has not been adequately validated: the impact on clinical management of a rating system like the Rockall score remains to be established. RING is a 'register' that has been collecting hospital discharge files from hospital gastroenterology units, giving a broad picture of the patients admitted for this pathology.

METHODS

We analyzed the hospital discharge files collected between 2001 and 2005 from 12 gastroenterology units, which issued more than 26,000 hospital discharge files for ordinary hospital admission and have been using the Rockall score for defining nonvariceal upper gastrointestinal hemorrhage since 2003.

RESULTS

There were 2832 hospital discharge files with a main diagnosis of nonvariceal upper gastrointestinal hemorrhage: 1335 'before' the Rockall score was introduced, 1497 'after' the introduction. Patients' mean age was 67.7+/-16.7 years, with a male/female ratio of 1.7 and no significant changes over the years. There were no differences in the distribution of diagnoses in nonvariceal upper gastrointestinal hemorrhage patients before/after the introduction of the Rockall score, though the mean hospital stay became shorter (7.1+/-5.0 vs. 6.3+/-4.5 days), and mortality declined (2.8 vs. 2.3%), in parallel with the caselist as a whole. For 1102 ordinary hospital admission Rockall score was calculated. Diagnoses were more accurate: significantly fewer undefined causes and an increase in peptic ulcer. The mean Rockall score was 4.6+/-2.2: 17.8% low (0-2), 48.7% intermediate (3-5), and 33.5% high (>or=6). Mean hospital stay, rebleeding, and mortality were correlated with the severity of the score.

CONCLUSION

The Rockall score enables the clinician to formulate a more precise diagnosis and substantially shortens the time in hospital, especially for patients at low-risk of rebleeding and death, so more resources can be dedicated to critically ill patients.

Management and outcomes of hepatic cirrhosis: Findings from the RING study

BACKGROUND/AIM

Hepatic cirrhosis is a frequent reason for ordinary hospital admission (OA). The RING study collected hospital discharge files (HDF) from Italian hospital gastroenterology units (IGU). This caselist provides a broad picture of the patients admitted for this pathology.

MATERIAL/METHODS

More than 50,000 HDF for OA were collected between 2001 and 2004 from 26 IGU.

RESULTS

Eight thousand four hundred and eighty-seven HDF (16%) had a diagnosis of hepatic cirrhosis; Child-Pugh classes were 20.2% A, 34.8% B and 45.0% C. Patients' mean age was 63.7+/-12.1 years and 62.5% were male. A 61.1% of the cirrhosis cases had ascites, 29.9% portal-systemic encephalopathy, 29.2% hepatocellular carcinoma (HCC), 10% bleeding varices, 3.0% hepatorenal syndrome (HRS). Mortality for OA for cirrhosis was 5.7% versus 2.6% for other diagnoses. The proportion varied with the severity of the cirrhosis: 0% for Child A, 1.1% B, 10.5% C. Mortality was significantly associated with: Child-Pugh at admission (odds ratio: OR 9.2), HRS (OR 11.7), bleeding varices (OR 2.2), HCC (OR 1.8).

CONCLUSIONS

Hepatic cirrhosis was found in 16% of the OA to IGU and mortality was double the rate for all the other pathologies in the same wards. Child-Pugh is a useful prognostic tool, higher classes implying a greater risk of death. HRS and bleeding varices were the complications with most influence on in-hospital mortality.

Seasonal patterns of hospital treatment for inflammatory bowel disease in Italy

AIM

It is still debated whether clinical flare-ups of chronic inflammatory bowel disease follow a seasonal pattern, and the various reports are based on general practitioners' records or hospital discharge charts. There are, however, no specific figures for treatment in hospital gastroenterology units, which serve as a reference point for these disorders. This study was therefore designed to investigate whether there is a seasonal pattern in admissions for inflammatory intestinal disease in Italy, differing from what is generally known about gastrointestinal pathologies, since there are no nation-wide figures on the subject.

METHODS

The RING (Ricerca Informatizzata in Gastroenterologia) project is an observational study collecting hospital discharge forms from 22 centers in Italy.

RESULTS

From winter 2000 to autumn 2003, the 22 gastroenterology units participating in the RING project discharged 32,357 patients following ordinary hospital admissions. Of these, 2,856 (8.8%) had a main diagnosis of inflammatory bowel disease: 1,541 Crohn's disease, and 1,315 ulcerative colitis. No seasonal patterns were detected for either category, or when the analysis was done by age, sex and site of disease.

CONCLUSIONS

The most serious flare-ups of inflammatory bowel disease, i.e. those requiring routine hospital treatment, do not appear to follow any seasonal pattern, regardless of the site of the disease or the patient's age or sex.

Multi-scale analysis of the toraymyxin adsorption cartridge. Part I: molecular interaction of polymyxin B with endotoxins

Endotoxins or lipopolysaccharides are the main constituents of the outer leaflet of Gram-negative bacteria membrane and play a central role in the pathogenesis of the septic shock. Polymyxin B has both antibacterial and antiendotoxin capability; indeed it is able to destroy the bacterial outer membrane and bind endotoxin neutralizing its toxic effects. Cartridges containing polymyxin B-immobilized fibers (Toraymyxin PMX-F, Toray Industries, Japan) are used in extracorporeal hemoperfusion to remove circulating endotoxin. The aim of this study is the characterization of the polymyxin B-endotoxin system at the molecular level, thus providing quantitative evaluation of the binding forces exerted in the molecular complex. Polymyxin B was interfaced with five molecular models of lipopolysaccharides differing in their structure and molecular mechanics simulations were performed at different intermolecular distances aimed at calculating the interaction energies of the complex. Binding forces were calculated by fitting interaction energies data. Results show that in the short range the polymyxin B-endotoxin complex is mediated by hydrophobic forces and in the long range the complex is driven by ionic forces only. From a mechanical standpoint, polymyxin B-endotoxin complex is characterized by maximum binding forces ranging between 1.39 nN to 3.79 nN. The knowledge of the binding force behavior at different intermolecular distances allows further investigations at higher scale level (Part II).

A numerical and experimental study of compliance and collapsibility of preterm lamb tracheae

Knowledge of the mechanical behaviour of immature tracheae is crucial in order to understand the effects exerted on central airways by ventilatory treatments, particularly of Total Liquid Ventilation. In this study, a combined experimental and computational approach was adopted to investigate the compliance and particularly collapsibility of preterm lamb tracheae in the range of pressure likely applied during Total Liquid Ventilation (-30 to 30 cmH2O). Tracheal samples of preterm lambs (n = 5; gestational age 120-130 days) were tested by altering transmural pressure from -30 to 30 cmH2O. Inflation (Si) and collapsing (Sc) compliance values were calculated in the ranges 0 to 10 cmH2O and -10 to 0 cmH2O, respectively. During the tests, an asymmetric behaviour of the DeltaV/V0 vs. P curves at positive and negative pressure was observed, with mean Si = 0.013 cmH2O(-1) and Sc = 0.053 cmH2O(-1). A different deformed configuration of the sample regions was observed, depending on the posterior shape of cartilaginous ring. A three-dimensional finite-element structural model of a single tracheal ring, based on histology measurements of the tested samples was developed. The model was parameterised in order to represent rings belonging to three different tracheal regions (craniad, median, caudal) and numerical analyses replicating the collapse test conditions were performed to evaluate the ring collapsibility at pressures between 0 and -30 cmH2O. Simulation results were compared to experimental data to verify the model's reliability. The best model predictions occurred at pressures -30 to -10 cmH2O. In this range, a model composed of median rings best interpreted the experimental data, with a maximum error of 2.7%; a model composed of an equal combination of all rings yielded an error of 12.6%.

Pressure drop vs flow relationship in isolated preterm lamb tracheae

Knowledge of immature tracheae mechanical behavior is fundamental in understanding the effects exerted on the upper airways by tidal liquid ventilation (TLV). Particularly, negative pressure can take place along the airways during expiration, which can cause airway collapse and flow limitation; therefore, representing a critical issue in preterm infant patients, whose airways are less stiff than adult ones. In this study, we investigated the expiratory pressure drop vs flow relationship of isolated preterm lamb tracheal samples to determine their hydraulic resistance, collapse pressure and collapse flow rate; a liquid flow through the samples was obtained by applying negative pressure at the outlet (cephalad) extremity of the tra-cheal sample, while keeping the inlet (caudal) extremity at atmospheric pressure. Histological analyzes were performed on the tracheal samples after each test session, in order to examine the morphological structure of the tracheal wall. Flow resistance tests demonstrated progressive lumen narrowing at increasing pressure drop (&#8710;P=P in -P out ). The flow rate increased with &#8710;P un-til a plateau was reached, and then decreased, describing the onset of a collapse phenomenon; however, complete occlusion was not reached. The tracheal samples demonstrated a similar behavior to that of a Starling resistor during the collapse phase: when a critical &#8710;P was reached, collapse was observed starting at the outlet region, which was subjected to the greatest negative pressure, then propagating towards the caudal direction. (Journal of Applied Biomaterials & Biomechanics 2004; 2: 177-82).

Myosin head mechanical performance under different conformational change mechanisms

The present paper puts forward a mathematical approach to model the conformational changes of the myosin head due to ATP hydrolysis, which determine the head swinging and consequent sliding of the actin filament. Our aim is to provide a simple but effective model simulating myosin head performance to be integrated into the overall model of sarcomere mechanics under development at our Laboratory (J. Biomech. 34 (2001) 1607). We began by exploring myosin head mechanics in recent findings about myosin ultrastructure, morphology and energetics in order to calculate the working stroke distance (WS) and the force transmitted to the actin filament during muscle contraction. Two different working stroke mechanisms were investigated, assuming that the swinging of the myosin head occurs either as a consequence of purely conformational changes (Science 261 (1993a) 58) or by thermally driven motion (ratchet mechanism) followed by conformational changes (Cell 99 (1999) 421). Our results show that force and WS values vary markedly between the two models. The maximum force generated is about 10 pN for the first model and 31 pN for the second model, and the WSs are about 13 and 4 nm, respectively. These results are then discussed and compared with published data. The experimental data used for comparison are scarce and non-homogeneous; hence, the final remarks do not lead to definite conclusions. In any event, relatively speaking, the first model is more coherent with experimental findings.

Finite element analysis of a knee joint replacement during a gait cycle

A three-dimensional (3-D) computer model was developed to predict, simultaneously, the knee joint replacement motions and the stresses occurring within the tibial insert under complex loading conditions. Friction contacts, polyethylene elastic- plastic behavior and soft tissue restraints were considered. Finite element analysis of the entire gait cycle was performed applying the displacement and loading conditions reported in the draft ISO 14243-1. The 3-D model was used to predict contact stresses and areas occurring within the polyethylene insert, when static loads of single instants on the gait cycle were applied. Results at 13% and 46% of the gait cycle were calculated with both entire cycle sim-ulation and single instant simulations. The predicted peak contact stress and contact area values were greater for single in-stant analyzes (respectively, 21% and 9%) if compared with those of the entire cycle simulation. In addition, single instant simulations were unable to predict accurately the contact region location, which was displaced in the anterior direction. Two different configurations of soft tissue restraints were compared; the first adopted from the draft ISO 14243-1 and the second from literature data. There were no significant differences observed between the two configurations. In particular, peak contact stresses followed the same trend, although the restraints of the literature data provided lower values in the last phase of the gait cycle. A preliminary verification of model reliability was performed comparing the tibial insert motions with data reported in the literature, under simplified loading conditions applied to the femoral component. (Journal of Applied Biomaterials & Biomechanics 2004; 2: 45-54).