IFSO Worldwide Survey 2020-2021: Current Trends for Bariatric and Metabolic Procedures

PURPOSE

This IFSO survey aims to describe the current trends of metabolic and bariatric surgery (MBS) reporting on the number and types of surgical and endoluminal procedures performed in 2020 and 2021, in the world and within each IFSO chapter.

METHODS

All national societies belonging to IFSO were asked to complete the survey form. The number and types of procedures performed (surgical and endoluminal interventions) from 2020 to 2021 were documented. A special section focused on the impact of COVID-19, the existence of national protocols for MBS, the use of telemedicine, and any mortality related to MBS. A trend analysis of the data, both worldwide and within each IFSO chapter, was also performed for the period between 2018 and 2021.

RESULTS

Fifty-seven of the 74 (77%) IFSO national societies submitted the survey. Twenty-four of the 57 (42.1%) reported data from their national registries. The total number of surgical and endoluminal procedures performed in 2020 was 507,806 and in 2021 was 598,834. Sleeve gastrectomy (SG) remained the most performed bariatric procedure. Thirty national societies (52%) had regional protocols for MBS during COVID-19, 61.4% supported the use of telemedicine, and only 47.3% collected data on mortality after MBS in 2020. These percentages did not significantly change in 2021 (p > 0.05).

CONCLUSIONS

The number of MBS markedly decreased worldwide during 2020. Although there was a positive trend in 2021, it did not reach the values obtained before the COVID-19 pandemic. SG continued to be the most performed operation. Adjustable gastric banding (AGB) continues to decrease worldwide.

The 1st EoETALY Consensus on the Diagnosis and Management of Eosinophilic Esophagitis-Current Treatment and Monitoring

The present document constitutes Part 2 of the EoETALY Consensus Statements guideline on the diagnosis and management of eosinophilic esophagitis (EoE) developed by experts in the field of EoE across Italy (i.e., EoETALY Consensus Group). Part 1 was published as a different document, and included three chapters discussing 1) definition, epidemiology, and pathogenesis; 2) clinical presentation and natural history and 3) diagnosis of EoE. The present work provides guidelines on the management of EoE in two final chapters: 4) treatment and 5) monitoring and follow-up, and also includes considerations on knowledge gaps and a proposed research agenda for the coming years. The guideline was developed through a Delphi process, with grading of the strength and quality of the evidence of the recommendations performed according to accepted GRADE criteria.This document has received the endorsement of three Italian national societies including the Italian Society of Gastroenterology (SIGE), the Italian Society of Neurogastroenterology and Motility (SINGEM), and the Italian Society of Allergology, Asthma, and Clinical Immunology (SIAAIC). The guidelines also involved the contribution of members of ESEO Italia, the Italian Association of Families Against EoE.

The 1st EoETALY Consensus on the Diagnosis and Management of Eosinophilic Esophagitis - Definition, Clinical Presentation and Diagnosis

Eosinophilic esophagitis (EoE) is a chronic type 2-mediated inflammatory disease of the esophagus that represents the most common eosinophilic gastrointestinal disease. Experts in the field of EoE across Italy (i.e., EoETALY Consensus Group) including gastroenterologists, endoscopists, allergologists/immunologists, and paediatricians conducted a Delphi process to develop updated consensus statements for the management of patients with EoE and update the previous position paper of the Italian Society of Gastroenterology (SIGE) in light of recent evidence. Grading of the strength and quality of the evidence of the recommendations was performed using accepted GRADE criteria. The guideline is divided in two documents: Part 1 includes three chapters, namely 1) definition, epidemiology, and pathogenesis; 2) clinical presentation and natural history, and 3) diagnosis, while Part 2 includes two chapters: 4) treatment and 5) monitoring and follow-up. This document has received the endorsement of three Italian national societies including the SIGE, the Italian Society of Neurogastroenterology and Motility (SINGEM), and the Italian Society of Allergology, Asthma, and Clinical Immunology (SIAAIC). With regards to patients' involvement, these guidelines involved the contribution of members of ESEO Italia, the Italian Association of Families Against EoE.

The Effect of Esophagogastroduodenoscopy on Intraocular Pressure

BACKGROUND

Esophagogastroduodenoscopy (EGD) is an endoscopic examination of the upper gastrointestinal tract that requires insufflation with gas, leading to intra-abdominal hypertension (IAH). There is evidence suggesting that IAH positively correlates with intracranial pressure (ICP) and possibly with intraocular pressure (IOP). The aim of this study was to examine the effect of a routine screening EGD on the IOP.

METHODS

In this observational study, 25 patients were recruited; 15 males with a mean age of 50 ± 18 years and 10 females with a mean age of 45 ± 14 years. EGD was conducted under sedation in 21 subjects. Both eyes' IOP measurements were performed using Tonopen Avia in the sitting and left lateral decubitus positions before sedation and the start of EGD, and subsequently in the left lateral decubitus position when the endoscope reached the duodenum (D2) and at the end of the procedure. The final measurement was performed in the sitting position 10 min after the end of the procedure.

RESULTS

The mean IOP in the sitting position was 15.16 ± 2.27 mmHg, and in the left lateral decubitus position, 15.68 ± 2.82 mmHg. When the gastroscope entered the D2, it was 21.84 ± 6.55 mmHg, at the end of the procedure, 15.80 ± 3.25 mmHg, and 10 min later, 13.12 ± 3.63 mmHg. There was a statistically significant IOP increase when the gastroscope entered the duodenum (p < 0.01). At the end of the gastroscopy, the IOP significantly decreased compared to the one registered when the gastroscope entered the D2 (p < 0.001) and it became similar to the values measured before the EGD, in the same left lateral decubitus position (p > 0.05).

CONCLUSION

Significant changes in IOP were observed during the EGD. IOP fluctuations during EGD should be taken into account, especially in patients that need repeated EGDs during their life or in patients with glaucoma. Further studies are needed to better understand the short-effect and long-effect influence of an IOP increase in these patients.

An integrated approach for the assessment of the electrochemical oxidation of diclofenac: By-product identification, microbiological and eco-genotoxicological evaluation

Diclofenac (DCF), a contaminant of emerging concern, is a non-steroidal anti-inflammatory drug widely detected in water bodies, which demonstrated harmful acute and chronic toxicity toward algae, zooplankton and aquatic invertebrates, therefore its removal from impacted water is necessary. DCF is recalcitrant toward traditional treatment technologies, thus, innovative approaches are required. Among them, electrochemical oxidation (EO) has shown promising results. In this research, an innovative multidisciplinary approach is proposed to assess the electrochemical oxidation (EO) of diclofenac from wastewater by integrating the investigations on the removal efficiency and by-product identification with the disinfection capacity and the assessment of the effect on environmental geno-toxicity of by-products generated through the oxidation. The electrochemical treatment successfully degraded DCF by achieving >98 % removal efficiency, operating with NaCl 0.02 M at 50 A m-2. By-product identification analyses showed the formation of five DCF parental compounds generated by decarboxylic and CN cleavage reactions. The disinfection capacity of the EO technique was evaluated by carrying out microbiological tests on pathogens generally found in aquatic environments, including two rod-shaped Gram-negative bacteria (Pseudomonas aeruginosa and Escherichia coli), one rod-shaped Gram-positive bacterium (Bacillus atrophaeus), and one Gram-positive coccus (Enterococcus hirae). Eco-toxicity was evaluated in freshwater organisms (algae, rotifers and crustaceans) belonging to two trophic levels through acute and chronic tests. Genotoxicity tests were carried out by Comet assay, and relative expression levels of catalase, manganese and copper superoxide dismutase genes in crustaceans. Results highlight the effectiveness of EO for the degradation of diclofenac and the inactivation of pathogens; however, the downstream mixture results in being harmful to the aquatic ecosystem.

SIED-GISCOR recommendations for colonoscopy in screening programs: Part I - Diagnostic

The implementation of FIT programs reduces incidence and mortality from CRC in the screened subjects. The ultimate efficacy for CRC morbidity and mortality prevention in a FIT program depends on the colonoscopy in FIT+ subjects that has the task of detecting and removing these advanced lesions. Recently, there has been growing evidence on factors that influence the quality of colonoscopy specifically withing organized FIT programs, prompting to dedicated interventions in order to maximize the benefit/harm ratio of post-FIT colonoscopy. This document focuses on the diagnostic phase of colonoscopy, providing indications on how to standardise colonoscopy in FIT+ subjects, regarding timing of examination, management of antithrombotic therapy, bowel preparation, competence and sedation.

Changes in mucosal IgG4+- and IL-10+-cell frequencies in adults with eosinophilic esophagitis on a two-food elimination diet

Eosinophilic esophagitis (EoE) is increasingly diagnosed in patients with dysphagia. Type-2 immunity can induce EoE histopathology via non-IgE-dependent mechanisms, possibly involving IgG4 and IL-10. To elucidate the contribution of this response to EoE pathogenesis, we examined its association with clinical and histologic endpoints in adult EoE patients given a two-food elimination diet. IgG4- and IL-10-expressing cells were counted in esophageal biopsies and serum food-specific IgG4 measured at baseline and follow-up. Variables were correlated with histologic measures of disease activity. Patients exhibited significant reduction in esophageal eosinophilia and overall histology. A significant decrease in IL-10+-cell frequencies correlated with histologic changes. In contrast, a decline in serum and esophageal IgG4, while substantial, did not correlate with IL-10+-cell frequencies or histologic parameters. These results suggest a critical role of IL-10 in EoE pathogenesis. Conversely, IgG4 expression, while reflecting exposure to food antigens, is not obviously related to EoE histopathology or IL-10 expression.

Poliprotect vs Omeprazole in the Relief of Heartburn, Epigastric Pain, and Burning in Patients Without Erosive Esophagitis and Gastroduodenal Lesions: A Randomized, Controlled Trial

INTRODUCTION

In the treatment of upper GI endoscopy-negative patients with heartburn and epigastric pain or burning, antacids, antireflux agents, and mucosal protective agents are widely used, alone or as add-on treatment, to increase response to proton-pump inhibitors, which are not indicated in infancy and pregnancy and account for significant cost expenditure.

METHODS

In this randomized, controlled, double-blind, double-dummy, multicenter trial assessing the efficacy and safety of mucosal protective agent Poliprotect (neoBianacid, Sansepolcro, Italy) vs omeprazole in the relief of heartburn and epigastric pain/burning, 275 endoscopy-negative outpatients were given a 4-week treatment with omeprazole (20 mg q.d.) or Poliprotect (5 times a day for the initial 2 weeks and on demand thereafter), followed by an open-label 4-week treatment period with Poliprotect on-demand. Gut microbiota change was assessed.

RESULTS

A 2-week treatment with Poliprotect proved noninferior to omeprazole for symptom relief (between-group difference in the change in visual analog scale symptom score: [mean, 95% confidence interval] -5.4, -9.9 to -0.1; -6.2, -10.8 to -1.6; intention-to-treat and per-protocol populations, respectively). Poliprotect's benefit remained unaltered after shifting to on-demand intake, with no gut microbiota variation. The initial benefit of omeprazole was maintained against significantly higher use of rescue medicine sachets (mean, 95% confidence interval: Poliprotect 3.9, 2.8-5.0; omeprazole 8.2, 4.8-11.6) and associated with an increased abundance of oral cavity genera in the intestinal microbiota. No relevant adverse events were reported in either treatment arm.

DISCUSSION

Poliprotect proved noninferior to standard-dose omeprazole in symptomatic patients with heartburn/epigastric burning without erosive esophagitis and gastroduodenal lesions. Gut microbiota was not affected by Poliprotect treatment. The study is registered in Clinicaltrial.gov (NCT03238534) and the EudraCT database (2015-005216-15).

Can esophageal symptoms be associated with sleep disorders in esophageal rare diseases? A prospective case-control study across achalasia, eosinophilic esophagitis and gastroesophageal reflux disease

BACKGROUND

The association between sleep disorders and gastroesophageal reflux disease (GERD) has been the subject of several studies; however, quality of sleep has been under investigated in adult patients with eosinophilic esophagitis (EoE) and achalasia (Ach). This study aims to evaluate the prevalence of sleep disturbances in patients with EoE and Ach compared to GERD patients and their associations with esophageal symptoms.

METHODS

Thirty Ach patients and 20 EoE patients were consecutively enrolled and compared to a control group of 46 GERD patients. All patients underwent a standardized questionnaire investigating the intensity-frequency scores (from 0 to 6) of esophageal symptoms, Pittsburgh Sleep Quality Index (PSQI) questionnaire to assess sleep quality, a SF-36 survey to investigate health-related quality of life (both physical (PCS) and mental (MCS) component scales), Beck Depression Inventory-II (BDI-II) and State Trait Anxiety Inventory (STAI) to assess the presence of depression and anxiety.

RESULTS

The prevalence of sleep disturbances was 66.7% in Ach, 50% in EoE, and 60% in GERD patients (P=0.5). PCS and MCS significantly correlated with depression and anxiety levels. Ach patients showed significantly higher intensity-frequency scores of dysphagia for solids (Scheffè P<0.001) and liquids (Scheffè P<0.001) than EoE and GERD patients. No differences were found in the intensity-frequency scores of the esophageal symptoms among the three groups. There was a significant association between worst quality of sleep and higher intensity-frequency scores of regurgitation.

CONCLUSIONS

Sleep disturbances are common with Ach and EoE, similar to GERD patients. Moreover, there is a significant association between regurgitation, a typical GERD symptom, and poor quality of sleep, independent from diagnosis.

Upper Esophageal Sphincter Metrics across Eosinophilic Esophagitis, Gastroesophageal Reflux Disease and Functional Dysphagia: A Pilot Study

BACKGROUND

Recent studies have evaluated the upper esophageal sphincter (UES) with high-resolution manometry (HRM) in some esophageal diseases, but not eosinophilic esophagitis (EoE). The aim of our study was to evaluate the function of the UES across EoE, gastroesophageal reflux disease (GERD), functional dysphagia (FD), and the relationship with esophageal symptoms, esophageal body contraction, and esophagogastric junction (EGJ) metrics.

METHODS

HRM was performed on 30 EoE, 18 GERD, and 29 FD patients according to the Chicago Classification 3.0. The study data were exported to the online analysis platform Swallow Gateway. The UES was assessed in terms of UES Resting Pressure (UES-RP), UES Basal Pressure (UES-BP), UES Integrated Relaxation Pressure (UES-IRP), UES Relaxation Time (UES-RT), Basal UES Contractile Integral (Basal UES-CI), Post-Deglutitive UES Contractile Integral (Post-Deglutitive UES-CI), and Proximal Contractile Integral (PCI).

RESULTS

ANOVA analysis showed significantly higher values of Post-Deglutitive UES-CI in EoE patients compared with FD patients (p = 0.001). Basal UES-CI and UES-RP showed significantly higher values in EoE (p = 0.002, p = 0.038) and GERD (p < 0.001, p = 0.001) patients compared with FD patients. Correlations between LES-CI and Post-Deglutitive UES-CI, Basal UES-CI, and UES-RP (p ≤ 0.001, p = 0.027, p = 0.017, respectively), and between LES-BP and Post-Deglutitive UES-CI (p = 0.019), independent of diagnosis, were shown. No correlations have been demonstrated between the UES, EGJ metrics, and esophageal symptoms.

CONCLUSIONS

Some differences in UES metrics in the three different diseases were found. Further studies are needed to confirm the results of our pilot study and possible applications in clinical practice.

Case report: Laparoscopic nissen-sleeve gastrectomy in a young adult with incidental finding of Morgagni-Larrey hernia

Laparoscopic sleeve Gastrectomy (LSG) is the most performed bariatric procedure worldwide but it is associated with an increased incidence of de-novo or recurrent GERD. Recently a new technique consisting in LSG with associated fundoplication has been described. Morgagni-Larrey hernia is very rare and there is a lack of evidences on its correct surgical treatment. There are only rare cases of a MLH incidental diagnosis in patients submitted to bariatric surgery. We present our experience of Morgagni-Larrey Hernia (MLH) incidentally found intraoperatively in a patient with Gastroesophageal Reflux Disease (GERD) with Hiatal Hernia (HH) undergoing a bariatric surgical procedure.

Gut-Brain Interaction Disorders and Anorexia Nervosa: Psychopathological Asset, Disgust, and Gastrointestinal Symptoms

BACKGROUND

Gastrointestinal (GI) symptoms are very common in subjects with eating disorders (EDs). This study aimed to (a) investigate the prevalence of gut-brain interaction disorders (DGBIs) in anorexia nervosa (AN) patients, according to ROME IV criteria; and (b) explore AN psychopathological assets and disgust that might impact GI symptoms.

METHODS

Thirty-eight female patients consecutively diagnosed with untreated AN (age 19.32 ± 5.59) in an outpatient clinic devoted to EDs underwent Eating Disorder Inventory-3 (EDI-3), Hospital Anxiety and Depression Scale (HADS), Social Phobia Anxiety Scale (SPAS), Body Uneasiness Test (BUT), and Disgust Scale (DS) questionnaires. The presence of DGBIs was evaluated and GI symptoms were assessed using a standardized intensity-frequency questionnaire.

RESULTS

A total of 94.7% of our sample met the diagnostic criteria for functional dyspepsia (FD), of which 88.8% presented the postprandial distress syndrome (PDS) subtype and 41.6% presented the epigastric pain syndrome (EPS) subtype. In addition, 52.6% of the sample met the diagnostic criteria for irritable bowel syndrome (IBS), while for functional constipation (FC), prevalence reached 7.9%. All participants presented a pathological score on the disgust scale. Significant correlations were found between several GI symptoms and psychopathological asset and disgust.

CONCLUSIONS

AN is a multifactorial disorder. It is necessary to implement studies with an integrated approach, taking into account DGBIs, as well as to monitor the emotional-cognitive structure that acts as a factor in maintaining the disorder.

The Role of Globularia alypum Explored Ex Vivo In Vitro on Human Colon Biopsies from Ulcerative Colitis Patients

The existing literature indicates that Globularia alypum L. (GA) influences inflammation and oxidative stress modulation in rats and in vitro. The present study aims to investigate the effects of this plant in patients with ulcerative colitis (UC) and normal controls. In our experiments, we pretreated colon biopsies from 46 UC patients and normal controls with GA leaves aqueous extract (GAAE) used at two concentrations (50 and 100 µg/mL) for 3 h, followed by Lipopolysaccharides (from Escherichia coli) stimulation. We analyzed the effects on inflammation by studying the cyclo-oxygenase-2, the intercellular adhesion molecule-1, the nuclear factor kappa B, and p38 mitogen-activated protein kinase expression. Moreover, we assessed the levels of interleukin 6, the superoxide dismutase activity, and nitric oxide release in the supernatant of cultures. Our data showed that GAAE influences UC patients and normal controls for most studied markers and enzymes. These results acknowledge, with some scientific evidence, the traditional belief in the anti-inflammatory properties of GA and represent the first demonstration of its effect in a human in vitro model of inflammatory conditions.

Italian guidelines for the management of irritable bowel syndrome: Joint Consensus from the Italian Societies of: Gastroenterology and Endoscopy (SIGE), Neurogastroenterology and Motility (SINGEM), Hospital Gastroenterologists and Endoscopists (AIGO), Digestive Endoscopy (SIED), General Medicine (SIMG), Gastroenterology, Hepatology and Pediatric Nutrition (SIGENP) and Pediatrics (SIP)

The irritable bowel syndrome (IBS) is a chronic disorder of gut-brain interaction. IBS is still associated with areas of uncertainties, especially regarding the optimal diagnostic work-up and the more appropriate management. Experts from 7 Italian Societies conducted a Delphi consensus with literature summary and voting process on 27 statements. Recommendations and quality of evidence were evaluated using the grading of recommendations, assessment, development, and evaluation (GRADE) criteria. Consensus was defined as >80% agreement and reached for all statements. In terms of diagnosis, the consensus supports a positive diagnostic strategy with a symptom-based approach, including the psychological comorbidities assessment and the exclusion of alarm symptoms, together with the digital rectal examination, full blood count, C-reactive protein, serology for coeliac disease, and fecal calprotectin assessment. Colonoscopy should be recommended in patients with alarm features. Regarding treatment, the consensus strongly supports a dietary approach for patients with IBS, the use of soluble fiber, secretagogues, tricyclic antidepressants, psychologically directed therapies and, only in specific IBS subtypes, rifaximin. A conditional recommendation was achieved for probiotics, polyethylene glycol, antispasmodics, selective serotonin reuptake inhibitors and, only in specific IBS subtypes, 5-HT3 antagonists, 5-HT4 agonists, bile acid sequestrants.

One-Day versus Three-Day Low-Residue Diet and Bowel Preparation Quality before Colonoscopy: A Multicenter, Randomized, Controlled Trial

BACKGROUND

One-day low-residue diet (LRD) is recommended before colonoscopy, but only three single-center trials compared the 1-day versus 3-day LRD. The aim of this multicenter study was to compare the impact of a 3-day versus 1-day LRD on its ability to adequately and successfully prepare the bowel of outpatients that require a colonoscopy. The outpatients' tolerance and adherence to the LRD were also considered.

METHODS

Consecutive outpatients were randomized to 1-day versus 3-day LRD at three open-access endoscopy units. The primary endpoint consisted of the proportion of patients with a satisfactory degree of bowel cleanliness (Score 2-3 on the Boston Bowel Preparation Scale [BBPS] in each segment). Secondary endpoints were patients' tolerance and adherence to the prescribed diet evaluated by a standardized questionnaire.

RESULTS

289 patients were included in the study (1-day LRD arm = 143, 3-day LRD arm = 146). BBPS ≥2 was not significantly different in the two dietary regimens in any of the three colonic segments (71% vs. 72%, p = 0.9). The percentage of patients with incomplete preparation was similar in the two arms (9% vs. 9%; p = 1.0). No significant differences were found among colonoscopy findings in terms of abnormalities (81% vs. 84%, p = 0.8). Both groups scored similarly in overall tolerance to LRD (48% vs. 49%, p = 1.0) and also in whether they would have adopted a different dietary regimen (p = 0.3).

CONCLUSION

Our multicenter randomized study confirmed that optimal bowel cleansing is reached through a 1-day LRD.

Prevalence, Pathogenesis and Management of Anemia in Inflammatory Bowel Disease: An IG-IBD Multicenter, Prospective, and Observational Study

BACKGROUND

Anemia is a common extraintestinal manifestation of inflammatory bowel disease (IBD), with a 6% to 74% prevalence and a negative impact on patient survival and quality of life, although the prevalence is apparently declining due to improved disease treatment. We aimed to investigate the prevalence, pathogenesis, and clinical correlates of anemia in Italian patients with IBD.

METHODS

A multicenter, prospective, observational study, involving 28 Italian gastroenterology centers, was conducted to investigate the epidemiology and consequences of IBD-associated anemia. Clinical and laboratory data of anemic patients were obtained at study enrolment.

RESULTS

Anemia was diagnosed in 737 of 5416 adult IBD outpatients (prevalence 13.6%); females were more commonly affected than males (odds ratio, 1.5; 95% confidence interval [CI], 1.2-1.7) and had more severe anemia. In the majority of cases, anemia was due to iron deficiency (62.5% of cases; 95% CI, 58.3%-66.6%), either isolated or in association with inflammation and/or vitamin deficiencies; anemia of inflammation accounted for only 8.3% of cases. More severe anemia was associated with increasing fatigue and worse quality of life. Only 68.9% of anemic patients with iron deficiency (95% CI, 63.4%-73.8%) and 34.6% of those with vitamin deficiencies (95% CI, 26.2%-44.2%) were properly treated with supplementation therapy.

CONCLUSIONS

In Italy, the prevalence of IBD-associated anemia is lower than previously reported. Anemia of IBD is most commonly due to iron deficiency and contributes to fatigue and poor quality of life, but remains untreated in a large proportion of patients with iron and/or vitamin deficiencies. This study is registered at clinicaltrials.gov as NCT02872376.

The cost-effectiveness of nurse-led self-care interventions in patients with heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

Nurse-led self-care interventions (NLSCI) in heart failure (HF), defined as the nurse education delivered to improve the daily patient self-management, are not widely adopted by the health-care systems, even though they are effective to improve outcomes (e.g., mortality, readmission). Moreover, few studies have evaluated whether NLSCI are also cost-effective.

Purpose

To determine the cost-effectiveness of NLSCI in the context of HF care compared with standard care (care delivered by general practitioner and/or cardiologist).

Methods

We performed a cost-effectiveness analysis, with a 20-year time horizon, from the perspective of the Italian National Health Service. We developed a Markov model to simulate the progression of a cohort of 1,000 HF patients aged 70 years, who were assumed to alternatively receive a NLSCI after hospital discharge, or usual care. Effectiveness on mortality and on hospitalizations of NLSCI and usual care were extrapolated from a review of randomized control trials. Health-care costs were derived from literature and national formularies. The differences in costs and the differences in Quality Adjusted Life Years (QALY) between the NLSCI and usual care were estimated to present an incremental cost-effectiveness ratio (ICER). A willingness to pay (WTP) threshold of €40,000 per QALY was considered. Probabilistic sensitivity analyses were conducted to test the robustness of results and to estimate a cost-effectiveness acceptability curve.

Results

Over the 20-year time horizon, NLSCI implied an extra cost of € 1.3 million and a gain of 247 QALYs compared to usual care. This resulted in an ICER of € 5,490/QALY, which is far below the €40,000/QALY WTP threshold. Sensitivity analysis showed that the ICER remains below the WTP threshold in 100% of simulations. Moreover, the cost-effectiveness acceptability curve showed a probability of 80% of being under € 7,500/QALY.

Conclusions

This study demonstrated that NLSCI represent an affordable solution to support patients with HF as the related extra costs of € 1.3 million is justified by the reduction in mortality and improvement in quality of life. This finding supports the promotion of NLSCI as part of routine care, in order to pursue an optimal allocation of public health expenditures.

A cluster analysis of psychological and physical symptoms in patients with heart failure

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): CECRI (Center of Excellence for Nursing Scholarship) Rome

Background

The experience of psychological and physical symptoms of heart failure can be burdensome for patients. Identification of profiles of symptom burden may lead to greater understanding of the mechanism underlying this experience and improve symptom-centered care.

Purpose

The aim of this analysis was to identify profiles of psychological and physical symptoms in heart failure patients and compare the sociodemographic and clinical characteristics of patients in each cluster.

Methods

This was a secondary analysis of baseline data from the MOTIVATE-HF trial, that enrolled 510 patients across Italy. Cluster analysis was used to identify profiles of patients based on the two scores of the Hospital Anxiety and Depression scale and the total score of the Heart Failure Somatic Perception Scale. Each profile was described in terms of sociodemographic characteristics (e.g., age, gender, severity of disease), self-care maintenance and management behaviors, and self-efficacy (Self-care of Heart Failure Index), generic quality of life (12-item Short Form Survey), health-related quality of life (Kansas City Cardiomyopathy Questionnaire), and cognitive status (Montreal Cognitive Assessment Scale). Comparisons between the characteristics of each profile were performed by analysis of variance (ANOVA) and chi square test.

Results

Patients (n = 510) were 72.37 years old on average (SD = 12.28), with a slightly higher prevalence of men (58%). Sixty per cent of the sample were symptomatic: New York Heart Association (NYHA) class 2, 31.4% in NYHA class III, and 6.5% in NYHA class IV. Three profiles were identified: (1) low distress, characterized by the youngest patients (69.76, SD = 12.17), mostly in NYHA class II, and with the highest score on self-care self-efficacy and self-care maintenance behaviors; (2) average distress, characterized by the oldest patients (74.45, SD = 11.99), who were mostly retired, with the highest level of education, and poorest (physical) health-related quality of life and low self-care behaviors; (3) high distress, characterized by an average age of 73.08 (SD = 12.29), with the lowest hemoglobin level, the worst cognitive status, and the worst generic and health-related quality of life.

Conclusions

The profiles identified in this study and their characteristics provide new insights into the burden of psychological and physical symptoms experienced by heart failure patients. This represents the first step in promoting symptom-centered care in the future.

Gerd symptoms after laparoscopic Roux-en-Y gastric bypass: an emerging scenario

Laparoscopic Roux-en-Y gastric bypass (RYGB) is the second most performed bariatric procedure and it is considered the procedure of choice to treat patients with severe obesity and gastroesophageal reflux disease (GERD). However, some authors described the new onset or the recurrence of GERD symptoms after RYGB, and data at follow-up were scanty. In our center, we evaluated trend in weight, GERD symptoms and obesity-related comorbidities in 45 patients undergone RYGB at least 60 months before (mean follow-up 99.9 ± 22.9 months). At RYGB 51.1% patients referred preoperative GERD symptoms; among them, 47.8% showed an intraoperative hiatal hernia (HH). At medium-term follow-up mean BMI was significantly lower compared to baseline (p < 0.001). Among patients with preoperative GERD, 69.6% had GERD resolution and 30.4% reported postoperative GERD symptoms. Furthermore, 18.2% without preoperative GERD referred postoperative GERD new onset. We confirmed that RYGB as primary intervention provides satisfactory weight loss and a high percentage of GERD symptoms resolution. However, about 24.4% of patients complained of GERD symptoms at medium-term follow-up. The pathophysiology of GERD after RYGB, de novo or persistence, is not completely understood and several hypotheses could be drawn; however, further studies focusing the pathophysiology of these symptoms are needed.

Pelvic floor biofeedback is an effective treatment for severe bloating in disorders of gut-brain interaction with outlet dysfunction

BACKGROUND

The pathophysiology of bloating is partially understood. We investigated in patients with disorders of gut-brain interaction (DGBI) the relationship between severity of bloating, abdominal girth changes and defecation pattern, and the efficacy of pelvic floor biofeedback treatment on bloating.

METHODS

Disorders of gut-brain interaction patients with severe bloating as the main complaint were prescribed 2 weeks dietary advice and underwent abdominal girth measurements. At the first visit, all patients underwent a questionnaire on the subjective improvement of bloating, a (0-100) VAS abdominal bloating, and abdominal girth measurement. Patients reporting inadequate bloating relief underwent a standardized balloon expulsion test. Furthermore, they were invited to undergo pelvic floor electromyography and biofeedback treatment previously used for constipation due to dyssynergic defecation. The primary outcome was bloating improvement on a 5-point Likert scale. The secondary outcomes were the effect of diet intervention and pelvic floor biofeedback treatment on bloating severity and quality of life changes as well as the effect of pelvic floor biofeedback treatment on BET and EMG on straining.

KEY RESULTS

One hundred and fifty six patients (129 F, 39.3 ± 11.7 mean age) completed the 2-week run-in period. 105 patients were diet non-responder and underwent balloon expulsion test, with the vast majority (64%) failing the test. Patients who scored higher bloating on VAS had a significant association with failed balloon expulsion test (adjusted B 0.4 [95% CI 10.8-25.7], p < 0.0001). 63% agreed to perform pelvic floor biofeedback treatment at Verona center, 54% became responders reporting fair or major improvement/cure (ITT analysis, McNemar test, p < 0.0001), and all of them showed a 50% decrease in bloating severity.

CONCLUSIONS AND INFERENCES

Disordered defecation is a prevalent etiology in DGBI patients with bloating unresponsive to conservative measures; pelvic floor biofeedback treatment to improve the defecation effort significantly relieved bloating (http://www.isrctn.com, ISRCTN17004079).

Association among Disorders of Gut-Brain Interaction (DGBI) and Fibromyalgia: A Prospective Study

The disorders of gut-brain interaction (DGBI) have been associated with Fibromyalgia (FM). However, there are no data about the relationship between FM and DGBI using Rome IV criteria. This study aimed to evaluate the prevalence of FM in patients with Irritable Bowel Syndrome (IBS) and/or Functional Dyspepsia (FD) and the prevalence of IBS and FD in FM patients using Rome IV criteria. DGBI patients and FM patients were recruited from two outpatient clinics devoted to DGBI and FM. All patients underwent a standardized gastrointestinal (GI) symptoms questionnaire. FM symptoms in DGBI patients were assessed through Fibromyalgia Rapid Screening Tool (FiRST) and Fibromyalgia Impact Questionnaire. Thereafter, the rheumatologists evaluated them. 49.0% of FM patients fulfilled the diagnostic criteria for IBS, 81.6% for FD with an overlap for both IBS/FD in 44.9%. IBS-C was the most prevalent IBS-subtype in DGBI patients, whereas IBS-M was the most prevalent in FM patients (p = 0.01). 45.3% of DGBI patients reported pathological FiRST scores. DGBI patients with FM showed the highest score at the standardized GI questionnaire followed by FM patients with DGBI and DGBI without FM. In conclusion DGBI are common in FM patients and vice versa. The presence of FD is extremely frequent in FM patients. A multidisciplinary approach should be routinely used for the management of these patients.

Nonadherence to Micronutrient Supplementation After Bariatric Surgery: Results from an Italian Internet-Based Survey

BACKGROUND AND AIM

Bariatric surgery (BS) is a pillar for the treatment of morbid obesity and its related comorbidities. However, it might be associated with long-term deficiencies and absorption issues. Adherence to micronutrient supplementation is a crucial aspect in the management of these patients.

AIM

The aim of the present survey was to evaluate the adherence to micronutrient supplementation in a cohort of Italian patients submitted to BS (BS patients) and to identify predictors of adherence using a self-administered, anonymous, internet-based instrument.

METHODS

Patients who underwent BS over the last decade in a single center were invited to participate to a self-administered, anonymous, internet-based survey consisting of a 23 items structured questionnaire evaluating: a. demographic information b. Bariatric procedures performed; c. Indication to BS; d. Lapse of time since last BS, e. Frequency of follow up visits post-surgery, f. Perception of well-being post BS; g. Adherence to micronutrient supplementation; h. Changes in their quality of life and self-esteem.

RESULTS

We received an automatic notification of delivery from 1100 out of 1600 BS patients and 290 (81.4% female, mean age 39.5 ± 10.1 years) completed the questionnaire. The main reported bariatric procedures were: Sleeve Gastrectomy (59%), Roux-en-Y Gastric Bypass (31%) and Adjustable Gastric Banding (7.2%). Only 33.1% of the sample acknowledged to have taken all recommended medication regularly. BS patients who underwent malabsorptive procedures and had their last follow up visit more than 5 years earlier, had a higher risk of being nonadherent to micronutrient supplementation. Conversely, BS patients in their forties seemed more likely to adhere to treatment recommendations. Losing more weight was the only independent risk factors for nonadherence to micronutrient supplementation, independently from patient's perception of wellbeing.

CONCLUSION

After BS, several clinical and psychosocial factors might predict nonadherence to micronutrient supplementation.

Perception of the COVID-19 pandemic in patients with Achalasia and its impact on gastrointestinal symptoms: a proof-of-concept study

Background

Currently, no data are available on COVID-19 pandemic perception in patients with achalasia. We evaluated how the COVID-19 lockdown was perceived by these patients and its impact on their upper gastrointestinal symptoms.

Methods

COVID-19 perception was assessed in 64 patients with achalasia using a previously published survey. Upper gastrointestinal symptoms were assessed using a standardized questionnaire and the results were compared to those obtained before the COVID-19 pandemic. All questionnaires were administered by telephone/video calls during the second Italian lockdown.

Results

Fifty-one patients (79.7%) responded to the survey. For the question “On a 0-100 scale, how worried are you about the COVID-19 pandemic?” the mean score was 72.8±27.1, and 64.7% of patients with achalasia gave a score >60 on a visual analog scale of 0-100. In addition, those who considered themselves more vulnerable or anxious about contracting the infection than the general population, showed a significantly higher score for COVID-19 fear compared to those who felt less vulnerable or anxious (79.7±27.6 vs. 62.5±23.6, P=0.027; 80.9±19.6 vs. 57.1±33.1, P=0.002, respectively). The selected patients (n=29), who had not undergone any change in medical/surgical treatment for at least one year before the COVID-19 pandemic, had a significant worsening of the intensity-frequency score of regurgitation, heartburn, odynophagia, water brash, and epigastric burning during the lockdown (P<0.05). Finally, 75% of the patients were very interested in using Telemedicine.

Conclusions

The COVID-19 lockdown had a significant impact on the psychological aspects and upper gastrointestinal symptoms of patients with achalasia. Telemedicine might represent a follow-up strategy.

Globularia alypum L. Modulates Inflammatory Markers in Human Colon and Shows a Potential Antioxidant Role in Myeloid Leukemic Cells

Globularia alypum (GA), a plant of the Globulariacea family, has long been used as a traditional cure for inflammatory and metabolic illnesses. In addition to various in vitro model studies, the current work focuses on the antioxidant and anti-inflammatory properties of GA in human colon biopsies. The phenol components in GA aqueous extract (GAAE) were identified by Liquid Chromatography-Electrospray Ionization Mass Spectrometry. The antioxidant ability of GAAE was tested in vitro utilizing chemiluminescence and flow cytometry using fluorescent yeasts n conjunction with PLB-985-human myeloid leukemia cells. Experiments on human colon biopsies after a biopsy challenge with Escherichia coli-lipopolysaccharides aimed to see if GAAE had an anti-inflammatory impact on human colon inflammation. Western blotting was used to assess the expression of several inflammatory markers. According to the findings, GAAE had a significant influence on hydrogen peroxide and cellular reactive oxygen species. GAAE inhibited the activities of cyclooxygenase 2 and nuclear factor B in inflamed biopsies, indicating anti-inflammatory action. The present study is the first to show that GA has a beneficial effect on human colon inflammation, thanks to its significant antioxidant activity in vitro. According to these preliminary data, GA may be utilized to treat a range of human inflammatory illnesses.

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries

BACKGROUND

There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.

METHODS

We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.

RESULTS

Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.

CONCLUSIONS

BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries

BACKGROUND

There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.

METHODS

We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.

RESULTS

Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.

CONCLUSIONS

BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

A motivational interviewing intervention improves the burden of physical symptoms in patients with heart failure: A secondary outcome analysis of a randomized clinical trial

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Center of Excellence for Nursing Scholarship, Rome, Italy

Background. Patients with heart failure (HF) experience a variety of physical symptoms. Symptoms are perceived by patients as burdensome and, as such, negatively affect  quality of life. Besides, physical symptoms are among the first reasons for seeking emergency care and hospitalization. Findings from the MOTIVATE-HF trial show that motivational interviewing (MI) leads to better self-care. However, whether MI also reduces the burden of physical symptoms is not yet known.

Purpose. To evaluate the effectiveness of MI on the burden of physical symptoms in patients with HF.

Methods. Secondary outcome analysis of the MOTIVATE-HF trial. The study was a three-arm, multicenter randomized controlled trial with a 12-month follow-up. Patients with HF and their informal caregivers were enrolled and randomly divided into three arms: MI performed only with patients (Arm 1); MI performed both with patients and caregivers (Arm 2); usual care (Arm 3). Patients with a diagnosis of HF in NYHA functional class II-IV were recruited in three Italian centers. Participants underwent one face-to-face MI session, followed by three phone calls within two months from enrollment. Physical symptoms were measured with the Heart Failure Somatic Perception Scale (HFSPS) with the dimensions of dyspnea, chest discomfort, early and subtle, and edema. Higher scores at the HFSPS and its dimensions indicate worse physical symptom. Data were collected at baseline, and 3 (T1), 6 (T2), 9 (T3) and 12 (T4) months after enrollment. T-test was used to compare differences in HFSPS scores in Arms 1 and 2 versus Arm 3 at each follow-up. Changes over time were analyzed with mixed linear longitudinal models.

Results. A sample of 510 patients (median 74 years, 58% male) and their caregivers (median 55 years, 75.5% female) were randomized to Arm 1 (n = 155), Arm 2 (n = 177) and Arm 3 (n = 178). Chest discomfort improved in Arms 1 and 2 versus Arm 3 at T4 (mean difference(Δ): -8.13, P = .014). Dyspnea also improved in Arms 1 and 2 than Arm 3 both at T3 and T4 (Δ: -7, P = .027 and Δ: -6.78, P = .038, respectively). HFSPS total score improved in Arms 1 and 2 versus Arm 3 at T3 (Δ: -4.55, P = .048). Over the year of observation, the mixed linear longitudinal models showed a significant improvement in Chest discomfort and total HFSPS score in Arm 2 versus Arm 3 (β = -2.61, P = .002 and, β = -1.35, P = .02).

Conclusions. The results of this secondary analysis indicate that MI may be effective in decreasing the burden of physical symptoms in HF patients, especially if also caregivers are involved in the intervention. Since symptom burden is among the first reasons for seeking emergency care and hospitalization in HF, MI might be a viable option to improve symptom burden via self-care.

Influence of low FODMAP-gluten free diet on gut microbiota alterations and symptom severity in Iranian patients with irritable bowel syndrome

BACKGROUND AND OBJECTIVE

Recently, dietary restriction of fermentable carbohydrates (a low-FODMAP diet) in combination with a gluten-free diet (GFD) has been proposed to reduce the symptoms in irritable bowel syndrome (IBS) patients. Different studies reported that IBS has been associated with dysbiosis in the gut microbiota. Additionally, a few studies have reported inflammation in the gastrointestinal (GI) system of adults with IBS. In this study, we aimed to investigate the effects of low FODMAP-gluten free diet (LF-GFD) on clinical symptoms, intestinal microbiota diversity, and fecal calprotectin (FC) level in Iranian patients with IBS.

DESIGN

In this clinical trial study, 42 patients with IBS (Rome IV criteria) underwent LF-GFD intervention for 6 weeks. Symptoms were assessed using the IBS symptom severity scoring (IBS-SSS), and fecal samples were collected at baseline and after intervention and analyzed by quantitative 16 S rRNA PCR assay. The diversity of gut microbiota compared before and after 6 weeks of dietary intervention. FC was also analyzed by the ELISA method.

RESULTS

Thirty patients (mean age 37.8 ± 10.7 years) completed the 6-week diet. The IBS-SSS was significantly (P = 0.001) reduced after LF-GFD intervention compared to the baseline. Significant microbial differences before and after intervention were noticed in fecal samples. A significant increase was found in Bacteroidetes, and the Firmicutes to Bacteroidetes (F/B) ratio was significantly (P = 0.001) decreased after the dietary intervention. The value of FC was significantly decreased after 6 weeks of dietary intervention (P = 0.001).

CONCLUSIONS

Our study suggests that patients with IBS under an LF-GFD had a significant improvement in IBS symptoms severity, with reduced FC level following normalization of their gut microbiota composition. Further rigorous trials are needed to establish a long-term efficacy and safety of this dietary intervention for personalized nutrition in IBS. Clinical Trial Registry Number: IRCT20100524004010N26.

Influence of low FODMAP-gluten free diet on gut microbiota alterations and symptom severity in Iranian patients with irritable bowel syndrome

BACKGROUND AND OBJECTIVE

Recently, dietary restriction of fermentable carbohydrates (a low-FODMAP diet) in combination with a gluten-free diet (GFD) has been proposed to reduce the symptoms in irritable bowel syndrome (IBS) patients. Different studies reported that IBS has been associated with dysbiosis in the gut microbiota. Additionally, a few studies have reported inflammation in the gastrointestinal (GI) system of adults with IBS. In this study, we aimed to investigate the effects of low FODMAP-gluten free diet (LF-GFD) on clinical symptoms, intestinal microbiota diversity, and fecal calprotectin (FC) level in Iranian patients with IBS.

DESIGN

In this clinical trial study, 42 patients with IBS (Rome IV criteria) underwent LF-GFD intervention for 6 weeks. Symptoms were assessed using the IBS symptom severity scoring (IBS-SSS), and fecal samples were collected at baseline and after intervention and analyzed by quantitative 16 S rRNA PCR assay. The diversity of gut microbiota compared before and after 6 weeks of dietary intervention. FC was also analyzed by the ELISA method.

RESULTS

Thirty patients (mean age 37.8 ± 10.7 years) completed the 6-week diet. The IBS-SSS was significantly (P = 0.001) reduced after LF-GFD intervention compared to the baseline. Significant microbial differences before and after intervention were noticed in fecal samples. A significant increase was found in Bacteroidetes, and the Firmicutes to Bacteroidetes (F/B) ratio was significantly (P = 0.001) decreased after the dietary intervention. The value of FC was significantly decreased after 6 weeks of dietary intervention (P = 0.001).

CONCLUSIONS

Our study suggests that patients with IBS under an LF-GFD had a significant improvement in IBS symptoms severity, with reduced FC level following normalization of their gut microbiota composition. Further rigorous trials are needed to establish a long-term efficacy and safety of this dietary intervention for personalized nutrition in IBS. Clinical Trial Registry Number: IRCT20100524004010N26.

Diagnostic issues faced by a rare disease healthcare network during Covid-19 outbreak: data from the Campania Rare Disease Registry

Background

The aims of this study were: to investigate the capacity of the rare disease healthcare network in Campania to diagnose patients with rare diseases during the outbreak of Covid-19; and to shed light on problematic diagnoses during this period.

Methods

To describe the impact of the Covid-19 pandemic on the diagnosis of patients with rare diseases, a retrospective analysis of the Campania Region Rare Disease Registry was performed. A tailored questionnaire was sent to rare disease experts to investigate major issues during the emergency period.

Results

Prevalence of new diagnoses of rare disease in March and April 2020 was significantly lower than in 2019 (117 versus 317, P < 0.001 and 37 versus 349, P < 0.001, respectively) and 2018 (117 versus 389, P < 0.001 and 37 versus 282, P < 0.001, respectively). Eighty-two among 98 rare disease experts completed the questionnaire. Diagnostic success (95%), access to diagnosis (80%) and follow-up (72%), lack of Personal Protective Equipment (60%), lack of Covid-19 guidelines (50%) and the need for home therapy (78%) were the most important issues raised during Covid-19 outbreak.

Conclusions

This study describes the effects of the Covid-19 outbreak on the diagnosis of rare disease in a single Italian region and investigates potential issues of diagnosis and management during this period.

Food Allergy and Intolerance: A Narrative Review on Nutritional Concerns

Adverse food reactions include immune-mediated food allergies and non-immune-mediated intolerances. However, this distinction and the involvement of different pathogenetic mechanisms are often confused. Furthermore, there is a discrepancy between the perceived vs. actual prevalence of immune-mediated food allergies and non-immune reactions to food that are extremely common. The risk of an inappropriate approach to their correct identification can lead to inappropriate diets with severe nutritional deficiencies. This narrative review provides an outline of the pathophysiologic and clinical features of immune and non-immune adverse reactions to food-along with general diagnostic and therapeutic strategies. Special emphasis is placed on specific nutritional concerns for each of these conditions from the combined point of view of gastroenterology and immunology, in an attempt to offer a useful tool to practicing physicians in discriminating these diverging disease entities and planning their correct management. We conclude that a correct diagnostic approach and dietary control of both immune- and non-immune-mediated food-induced diseases might minimize the nutritional gaps in these patients, thus helping to improve their quality of life and reduce the economic costs of their management.

Impact of COVID-19 lockdown on symptoms in patients with functional gastrointestinal disorders: Relationship with anxiety and perceived stress

BACKGROUND

Psychological stress and anxiety, such those generated by forced quarantine, affect gastrointestinal symptoms course in patients with functional gastrointestinal disorders. Thus, our aim was to assess, in a cohort of patients regularly followed up in a devoted outpatient clinic of Southern Italy, the association between their gastrointestinal symptoms changes, stress, and anxiety reported during the Italian lockdown.

METHODS

We recruited patients from the outpatient clinic of the University of Salerno, devoted to functional gastrointestinal disorders, selecting only patients for whom an evaluation was available in the last 6 months before the lockdown. Gastrointestinal symptoms were evaluated at each visit through standardized questionnaire and pooled in a database. On 45th days from the beginning of the lockdown, patients were re-assessed by phone with the same questionnaire. Anxiety and stress levels were assessed through a self-administered online questionnaire based on Generalized Anxiety Disorder 7 test and Perceived Stress Scale 10 test.

KEY RESULTS

The intensity-frequency scores of several upper gastrointestinal symptoms improved (Wilcoxon test <0.05). Higher anxiety levels had a higher risk of worsening chest pain (OR 1.3 [1.1-1.7]), waterbrash (OR 1.3 [1.0-1.7]), epigastric burning (OR 1.3 [1.0-1.6]), and abdominal pain (OR 1.6 [1.0-2.3]). When compared to the interval preceding the outbreak, half of the patients declared their symptoms remained unchanged, 13.6% worsened, and 36.4% improved.

CONCLUSIONS AND INFERENCES

During the COVID-19 quarantine, there was an improvement of the majority of upper gastrointestinal symptoms in our patients, and anxiety seems an important risk of worsening few of them.

Bariatric Surgery Survey 2018: Similarities and Disparities Among the 5 IFSO Chapters

BACKGROUND

The 2018 IFSO Survey focused on similarities and disparities in the number and types of surgical and endoluminal interventions among the IFSO chapters occurred in the last decade.

METHODS

All IFSO Societies were asked to fill in the IFSO survey form on how many and which surgical and endoluminal interventions have been performed in the 2018. A special section was added, asking about the existence of national guidelines for bariatric and metabolic surgery, national recommendations for preoperative gastroscopy, type of reimbursement for bariatric/metabolic surgery, including for patients with BMI < 35 kg/m². The trend analyses from 2008 to 2018 were also performed.

RESULTS

Fifty-seven/65 (87.7%) IFSO Societies submitted completed forms. The American Society for Metabolic and Bariatric Surgery did not fill the IFSO survey form but provided an official report on the performed interventions. The total number of surgical and endoluminal procedures performed in 2018 in the world was 696,191. Sleeve gastrectomy (SG) remained the most commonly performed bariatric procedure (N = 386,096; 55.4%). Among the total reported bariatric/metabolic interventions, 604,223 (86.8%) were primary surgical and 29,167 (4.2%) primary endoluminal operations; 62,801 (9%) were revisional procedures.

CONCLUSIONS

There was only a slight increase (10.317 procedures) in the total number of the reported bariatric interventions compared to the last IFSO survey. SG continues to be the most commonly performed operation since 2014. The one anastomosis gastric bypass (OAGB), currently the third most performed procedure after SG and Roux-en-Y gastric bypass (RYGB), continues to rise in popularity worldwide.

The mechanisms associated with reflux episodes in ambulant subjects with gastro-esophageal reflux disease

BACKGROUND

The mechanisms associated with gastro-esophageal reflux (GER) episodes were studied using combined High-resolution Impedance Manometry (HRIM) and pH monitoring in ambulant subjects with different patterns of GERD.

METHODS

Sixteen subjects with mild-moderate esophagitis (Los Angeles (LA) grade A&B) (group A) and 11 subjects with severe esophagitis (LA grade C&D) or Barrett's esophagus (BE) were studied before and after a meal, resting, while walking, and during standardized exercise, using a HRIM and a pH probe.

KEY RESULTS

Post-prandial acid GER episodes were more common in group B (median 10 range (3-18) vs A (6.5 (0-18), p = 0.048). Postprandial acid clearance time was much longer in group B (median 0.71( 0.07-2.66 min) vs A (0.17 (0.04-2.44 min), p = 0.02). Transient lower esophageal sphincter relaxation (TLESR) was the most frequent mechanism associated with GER episodes in both groups. Post-prandial TLESRs with GER were more common in group B (median 17 (9-24) vs A 13.5 (7-34), p = 0.014), particularly during exercise (B 8 (6-9) vs A 6 (5-6.8), p = 0.007). Post-prandially TLESR with acid reflux increased during exercise in both groups (A rest median 2.4 (0-6.4) per hour vs exercise 4.7 (0-17.3), p = 0.005 and B 4 (0.8-9.6) vs 5.3 (2.7-13.3) per hour, p = 0.045).

CONCLUSIONS AND INFERENCES

TLESR was the most common mechanism associated with reflux episodes in all subjects. Acid reflux episodes were more common in subjects with severe esophagitis or BE and esophageal acid clearance was much slower. Post-prandial exercise increased TLESR with acid reflux and GERD patients should be encouraged to avoid exercise immediately after a meal.

Long-term results of laparoscopic Roux-en-Y gastric bypass for morbid obesity: 105 patients with minimum follow-up of 15 years

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the second most frequently performed bariatric procedure worldwide; however, long-term results are not frequently reported.

OBJECTIVES

To evaluate the outcomes of LRYGB on weight loss and co-morbidities in a single center 15 years after the operation.

SETTING

Tertiary-care referral hospital.

METHODS

From February 2000 to December 2003, 105 patients (86 women; mean age 39.9 ± 17.4; mean body mass index [BMI] 47.2 ± 6.4 kg/m²; 78 with BMI < 50 kg/m² and 27 with BMI ≥ 50 kg/m²) underwent LRYGB. Retrospective analyses of a prospectively maintained database were carried out to evaluate weight loss; resolution of co-morbidities, including type 2 diabetes mellitus (T2D), hypertension (HTN), and dyslipidemia; complications; and nutritional status.

RESULTS

The follow-up rate at 15 years was 87.6%. Mean excess weight loss was 58.6 ± 27%, with 74.1% of patients achieving a total weight loss ≥ 20%. According to the Biron et al. criteria, an inadequate outcome was found in 11/21 (52.4%) of patients with an initial BMI ≥ 50 kg/m² versus 21/64 (32.8%) of patients with a preoperative BMI < 50 kg/m² (P = .001). Both groups experienced gradual weight regain (WR); specifically, 34.1% of patients regained more than 15% of their lowest postoperative weight. The rates of reoperations due to early and late surgical complications were 3.8% and 9.5%, respectively. T2D was resolved in 50% of patients, HTN in 61.1%, and dyslipidemia in 58.3%. Iron deficiency anemia (53%) was the most common postoperative nutritional finding.

CONCLUSION

LRYGB provides satisfactory weight loss and resolution of co-morbidities up to 15 years. WR was a common finding. A significant proportion of patients with a preoperative BMI ≥ 50 kg/m² did not achieve a favorable weight loss outcome. Indications to perform LRYGB in this group of patients should be definitively reconsidered.

Impact of COVID-19 lockdown on symptoms in patients with functional gastrointestinal disorders: Relationship with anxiety and perceived stress

BACKGROUND

Psychological stress and anxiety, such those generated by forced quarantine, affect gastrointestinal symptoms course in patients with functional gastrointestinal disorders. Thus, our aim was to assess, in a cohort of patients regularly followed up in a devoted outpatient clinic of Southern Italy, the association between their gastrointestinal symptoms changes, stress, and anxiety reported during the Italian lockdown.

METHODS

We recruited patients from the outpatient clinic of the University of Salerno, devoted to functional gastrointestinal disorders, selecting only patients for whom an evaluation was available in the last 6 months before the lockdown. Gastrointestinal symptoms were evaluated at each visit through standardized questionnaire and pooled in a database. On 45th days from the beginning of the lockdown, patients were re-assessed by phone with the same questionnaire. Anxiety and stress levels were assessed through a self-administered online questionnaire based on Generalized Anxiety Disorder 7 test and Perceived Stress Scale 10 test.

KEY RESULTS

The intensity-frequency scores of several upper gastrointestinal symptoms improved (Wilcoxon test <0.05). Higher anxiety levels had a higher risk of worsening chest pain (OR 1.3 [1.1-1.7]), waterbrash (OR 1.3 [1.0-1.7]), epigastric burning (OR 1.3 [1.0-1.6]), and abdominal pain (OR 1.6 [1.0-2.3]). When compared to the interval preceding the outbreak, half of the patients declared their symptoms remained unchanged, 13.6% worsened, and 36.4% improved.

CONCLUSIONS AND INFERENCES

During the COVID-19 quarantine, there was an improvement of the majority of upper gastrointestinal symptoms in our patients, and anxiety seems an important risk of worsening few of them.

Bariatric Surgery Survey 2018: Similarities and Disparities Among the 5 IFSO Chapters

BACKGROUND

The 2018 IFSO Survey focused on similarities and disparities in the number and types of surgical and endoluminal interventions among the IFSO chapters occurred in the last decade.

METHODS

All IFSO Societies were asked to fill in the IFSO survey form on how many and which surgical and endoluminal interventions have been performed in the 2018. A special section was added, asking about the existence of national guidelines for bariatric and metabolic surgery, national recommendations for preoperative gastroscopy, type of reimbursement for bariatric/metabolic surgery, including for patients with BMI < 35 kg/m². The trend analyses from 2008 to 2018 were also performed.

RESULTS

Fifty-seven/65 (87.7%) IFSO Societies submitted completed forms. The American Society for Metabolic and Bariatric Surgery did not fill the IFSO survey form but provided an official report on the performed interventions. The total number of surgical and endoluminal procedures performed in 2018 in the world was 696,191. Sleeve gastrectomy (SG) remained the most commonly performed bariatric procedure (N = 386,096; 55.4%). Among the total reported bariatric/metabolic interventions, 604,223 (86.8%) were primary surgical and 29,167 (4.2%) primary endoluminal operations; 62,801 (9%) were revisional procedures.

CONCLUSIONS

There was only a slight increase (10.317 procedures) in the total number of the reported bariatric interventions compared to the last IFSO survey. SG continues to be the most commonly performed operation since 2014. The one anastomosis gastric bypass (OAGB), currently the third most performed procedure after SG and Roux-en-Y gastric bypass (RYGB), continues to rise in popularity worldwide.

Self-care interventions in patients with coronary artery disease: room for improvement

 

After a coronary artery event it is vital that patients perform self-care Self-care can be defined broadly as a process of maintaining health through treatment adherence and health-promoting practices (self-care maintenance), behavior and condition monitoring (self-care monitoring), and managing signs and symptoms when they occur (self-care management). For patients with coronary artery disease (CAD) essential self-care activities include adherence to medication, risk-factor management, symptom monitoring and preventive behavior. To advance the field of self-care in CAD patients, it is important to understand which self-care elements are currently addressed in interventions studies. The purpose of this study was to describe which behaviors are emphasized in self-care interventions for patients with CAD.

Methods

We conducted a systematic review of self-care interventions in chronic diseases. Four databases were search for randomized controlled trials with allocation to an intervention or to usual care or another intervention in adults with nine major symptomatic chronic conditions, one of which was coronary artery disease. Between 2008 and 2019 there were 9309 potential articles addressing self-care in chronic disease. After duplicates were removed and titles and abstracts were reviewed, 166 full-text articles on CAD studies evaluating a self-care intervention were assessed for eligibility and 15 studies remained after further assessment.

Results

Almost all studies (80%) in CAD patients included all three components of self-care (self-care maintenance, monitoring and management) in their interventions. Self-care maintenance behaviors addressed in these studies were mainly related to physical activity (73%) diet (60%) and medication management (33%) Another 40% included a psychosocial component, but only 4 studies (26%) were specially targeted at smoking behavior. With regard to self-care monitoring, most (60%) included monitoring of their physical activity level and 26% monitoring of symptoms. Self-care management behaviours were addressed rarely, but when addressed, focused on adapting activity level (60%), adapting diet (27%), medication changes (20%) and stress reduction (20%). Goal setting (60%), problem solving (40%) and feedback (33%) were the behavioural change techniques that were used most often to promote self-care. Only 1 study mentioned the use of social support. One study used reminders.

Conclusions

Most interventions that are tested to improve outcomes in patients with CAD address self-care maintenance, monitoring, management. The behavioural change techniques used are limited. There is a large variation in which behaviours are emphasized in research studies and the focus is primarily on changing traditional lifestyle factors, but not all life-style factors are addressed adequately in the interventions.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Australian Catholic University

The mechanisms associated with reflux episodes in ambulant subjects with gastro-esophageal reflux disease

BACKGROUND

The mechanisms associated with gastro-esophageal reflux (GER) episodes were studied using combined High-resolution Impedance Manometry (HRIM) and pH monitoring in ambulant subjects with different patterns of GERD.

METHODS

Sixteen subjects with mild-moderate esophagitis (Los Angeles (LA) grade A&B) (group A) and 11 subjects with severe esophagitis (LA grade C&D) or Barrett's esophagus (BE) were studied before and after a meal, resting, while walking, and during standardized exercise, using a HRIM and a pH probe.

KEY RESULTS

Post-prandial acid GER episodes were more common in group B (median 10 range (3-18) vs A (6.5 (0-18), p = 0.048). Postprandial acid clearance time was much longer in group B (median 0.71( 0.07-2.66 min) vs A (0.17 (0.04-2.44 min), p = 0.02). Transient lower esophageal sphincter relaxation (TLESR) was the most frequent mechanism associated with GER episodes in both groups. Post-prandial TLESRs with GER were more common in group B (median 17 (9-24) vs A 13.5 (7-34), p = 0.014), particularly during exercise (B 8 (6-9) vs A 6 (5-6.8), p = 0.007). Post-prandially TLESR with acid reflux increased during exercise in both groups (A rest median 2.4 (0-6.4) per hour vs exercise 4.7 (0-17.3), p = 0.005 and B 4 (0.8-9.6) vs 5.3 (2.7-13.3) per hour, p = 0.045).

CONCLUSIONS AND INFERENCES

TLESR was the most common mechanism associated with reflux episodes in all subjects. Acid reflux episodes were more common in subjects with severe esophagitis or BE and esophageal acid clearance was much slower. Post-prandial exercise increased TLESR with acid reflux and GERD patients should be encouraged to avoid exercise immediately after a meal.