The management of endoscopic retrograde cholangio- pancreatography-related infections risk: results of an italian survey at regional level.

Background and aim: Among the Endoscopic retrograde cholangiopancreatography (ERCP) adverse events, an increasingly arising problem is the transmission of Multi Drug Resistant (MDR) Bacteria through duodenoscopes. The aim of this survey was to evaluate the current clinical practice of management of ERCP associated infections in Emilia-Romagna, Italy. Methods: An online survey was developed including 12 questions on management of ERCP associated infections risk. The survey was proposed to all 12 endoscopy centers in Emilia Romagna that perform at least > 200 ERCPs per year. Results: 11 centers completed the survey (92%). Among all risk factors of ERCP infections, hospitalization in intensive care units, immunosuppressant therapies, and previous MDR infections have achieved a 80 % minimum of concurrence by our respondents. The majority of them did not have a formalized document in their hospital describing categories and risk factors helpful in the detection of patients undergoing ERCP with an high-level infective risk (9/11, 82%). Most centers (8/11, 72%) do not perform screening in patients at risk of ERCP infections. Post procedural monitoring is performed by 6 of 11 centers (55%). Conclusion: Our survey showed that, at least at regional level, there is a lack of procedures and protocols related to the management of patients at risk of ERCP infections.

Do we trust scientific evidence? A multicentre retrospective analysis of first IVF/ICSI cycles before and after the OPTIMIST trial.

STUDY QUESTION: Has the practice of individualizing the recombinant-FSH starting dose been superseded after the largest randomized controlled trial (RCT) in assisted reproduction technology (ART), the OPTIMIST trial? SUMMARY ANSWER: The OPTIMIST trial has influenced our ART daily practice to a limited degree, but adherence is still generally poor. WHAT IS KNOWN ALREADY: Although the 'one size fits all' approach has been discouraged for decades by most authors, the OPTIMIST study group demonstrated in a large prospective RCT that, in general, dosage individualization does not improve the prospects for live birth, although it may decrease ovarian hyperstimulation syndrome (OHSS) risk in expected high responders. STUDY DESIGN, SIZE, DURATION: Retrospective analysis of all first in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles from 1st January 2017 to 31st December 2018, before and after the OPTIMIST publication on November 2017. PARTICIPANTS/MATERIALS, SETTING, METHODS: Two thousand six hundred and seventy-seven patients, between 18 and 42 years old, undergoing their first IVF-ICSI cycle in seven Italian fertility centres, were included. Patients were allocated to three groups according to their ovarian reserve markers: predicted poor ovarian responders (POR), predicted normo-responders (NR) and expected hyper-responders (HRs). MAIN RESULTS AND THE ROLE OF CHANCE: Between 2017 and 2018, there was an overall increase in prescription of the standard 150 IU dose proposed by the OPTIMIST trial and a reduction in the use of a starting dose >300 IU. After subgroup analysis, the decrease in doses >300 IU remained significant in the POR and NR sub-groups. LIMITATIONS, REASONS FOR CAUTION: The retrospective nature of the study. Physicians need time to adapt to new scientific evidence and a comparison between 2017 and 2019 may have found a greater impact of the Optimist trial, although other changes over the longer time span might have increased confounding. We cannot be sure that the observed changes can be attributed to knowledge of the OPTIMIST trial. WIDER IMPLICATIONS OF THE FINDINGS: Clinicians may be slow to adopt recommendations based on RCTs; more attention should be given to how these are disseminated and promoted. STUDY FUNDING/COMPETING INTEREST(S): No external funding was used for this study. E.P. reports grants and personal fees from MSD, grants from Ferring, from IBSA, grants and personal fees from Merck, grants from TEVA, grants from Gedeon Richter, outside the submitted work. E.S. reports grants from Ferring, grants and personal fees from Merck-Serono, grants and personal fees from Theramex, outside the submitted work. All other authors do not have conflicts of interest to declare. TRIAL REGISTRATION NUMBER: Not applicable.

Colo-rectal endoscopic full-thickness resection (EFTR) with the over-the-scope device (FTRD®): A multicenter Italian experience.

BACKGROUND AND AIM: Endoscopic full-thickness resection(EFTR) with FTRD® in colo-rectum may be useful for several indications.The aim was to assess its efficacy and safety. MATERIAL AND METHODS: In this retrospective multicenter study 114 patients were screened; 110 (61M/49F, mean age 68 ±â€¯11 years, range 20-90) underwent EFTR using FTRD®. Indications were:residual/recurrent adenoma (39), incomplete resection at histology (R1 resection) (26), non-lifting lesion (12), adenoma involving the appendix (2) or diverticulum (2), subepithelial lesions(10), suspected T1 carcinoma (16), diagnostic resection (3). Technical success (TS: lesion reached and resected), R0 resection (negative lateral and deep margins),EFTR rate(all layers documented in the specimen) and safety have been evaluated. RESULTS: TS was achieved in 94.4% of cases. EFTR was achieved in 91% with lateral and deep R0 resection in 90% and 92%. Mean size of specimens was 20 mm (range 6-42). In residual/recurrent adenomas, final analysis revealed: low-risk T1 (11), adenoma with low-grade dysplasia (LGD) (24) and high-grade dysplasia (HGD) (3), scar tissue (1). Histology reports of R1 resections were: adenoma with LGD (6), with HGD (1), low-risk (6) and high-risk (1) T1, scar tissue (12). Non-lifting lesions were diagnosed as: adenoma with HGD (3), low-risk (7) and high risk (2) T1. Adverse clinical events occurred in 12 patients (11%),while adverse technical events in11%. Three-months follow-up was available in 100 cases and residual disease was evident in only seven patients. CONCLUSIONS: EFTR using FTRD® seems to be a feasible, effective and safe technique for treating selected colo-rectal lesions. Comparative prospective studies are needed to confirm these promising results.

Optimal processing of ESD specimens to avoid pathological artifacts.

BACKGROUND: En bloc endoscopic submucosal dissection (ESD) has been recently introduced as a treatment for precancerous/neoplastic gastrointestinal conditions. The aim of the present study was histological assessment of en bloc ESD specimens. METHODS: Fifty-three ESD specimens were positioned over a cellulose acetate support (40 specimens; 12 from the upper gastrointestinal tract and 28 from the lower gastrointestinal tract) or pinned with nails on polystyrene or cork (13 specimens; 7 from the upper gastrointestinal tract and 6 from the lower gastrointestinal tract). We cut consecutive 2 mm-thick sections stained with hematoxylin and eosin. From the first and the last sections, we obtained a second slide, after a 180° rotation and re-embedding. The quality of ESD samples was scored as inadequate, suboptimal and adequate, based on the amount of crushing, shearing and stretching artifacts that were scored from 0 (absent) to 2 (diffuse or maximum). From the sum of these we obtained a global artifact score (GAS). RESULTS: Removed lesions were: adenocarcinoma (5 cases), neuroendocrine tumor (NET) G1 (1 case), premalignant conditions, including adenomatous polyps (41 cases) and hyperplastic lesions (6 cases). A positive deep surgical margin was found in 8/53 cases (15%): high- and low-grade dysplastic glands were detected in 5 cases, low-grade adenocarcinoma in 2, and NET cells in 1. Dysplastic glands were detected in the lateral surgical margins of 12 ESD specimens (23%). Among the ESD specimens positioned on the cellulose acetate support, apart from the modifications due to electrocoagulation, 2 (5%) showed shearing modifications. In the group of ESD specimens fixed with nails, 5 (38%) showed shearing, 10 (77%) crushing artifacts, 11 (85%) stretching and 11 (85%) multiple holes caused by the nails. On the basis of these data all histological specimens from ESD on cellulose acetate were adequate (GAS 0-1).However, in the group of ESD fixed with nails, 1 was adequate (GAS 0), 11 suboptimal (GAS 2-5) and 1 inadequate (GAS 6). CONCLUSIONS: Specific devices including cellulose support and adequate sampling blocks can be helpful to perform accurate histological assessment of ESD specimens after en bloc ESD for precancerous/neoplastic gastrointestinal lesions, with complete analysis of the status of the margins and the entirely en bloc evaluation of the lesion.

Multimodal Surgical Approach for Adult Patients With Chronic Intestinal Pseudo-Obstruction: Clinical and Psychosocial Long-term Outcomes.

BACKGROUND: Clinical and psychosocial outcomes of a multimodal surgical approach for chronic intestinal pseudo-obstruction were analyzed in 24 patients who were followed over a 2- to 12-year period in a single center after surgery or intestinal/multivisceral transplant (CTx). METHODS: The main reasons for surgery were sub-occlusion in surgery and parenteral nutrition-related irreversible complications with chronic intestinal failure in CTx. RESULTS: At the end of follow-up (February 2015), 45.5% of CTx patients were alive: after transplantation, improvement in intestinal function was observed including a tendency toward recovery of oral diet (81.8%) with reduced parenteral nutrition support (36.4%) in the face of significant mortality rates and financial costs (mean, 202.000 euros), frequent hospitalization (mean, 8.8/re-admissions/patient), as well as limited effects on pain or physical wellness. CONCLUSIONS: Through psychological tests, transplant recipients perceived a significant improvement of mental health and emotional state, showing that emotional factors were more affected than were functional/cognitive impairment and social interaction.

Scuba diving death: Always due to drowning? Two forensic cases and a review of the literature.

Scuba diving is an increasingly common recreational activity. We describe the physiopathology of barotrauma in two cases where death was caused by pulmonary barotrauma while diving. An inspection and autopsy were carried out in both cases. The autopsy data were supported by post-mortem radiological investigation. Histological and toxicological analyses were also carried out, and dive computer and tank manometer analysis performed. In both cases, the cause of death was attributable to arterial gas embolism, resulting from pulmonary barotrauma subsequent to pulmonary over-distension. The dive computer analysis and the tank manometer allowed us to understand what happened underwater. In our opinion, a multidisciplinary approach is crucial in order to clarify the cause of death. Some pathological conditions and risk factors should be considered before diving.

Ectopic Bone as a Nidus for Calcium Oxalate Urocystolithiasis in a Cat.

A 7-year-old female spayed domestic shorthair cat was referred to the urology service for nonsurgical urocystolith removal. A urolith was attached to the urothelium by ectopic bone. Interventional removal without surgery was successful. Follow-up evaluation 3 years after urolith removal revealed recurrent uroliths, bladder wall mineralization, and marked renal mineralization. This case illustrates the metaplastic potential of the urothelium and that ectopic bone should be included among the pathological factors that promote lithogenesis.

Barriers against split-dose bowel preparation for colonoscopy.

OBJECTIVE: Although split regimen is associated with higher adenoma detection and is recommended for elective colonoscopy, its adoption remains suboptimal. The identification of patient-related barriers may improve its implementation. Our aim was to assess patients' attitude towards split regimen and patient-related factors associated with its uptake. DESIGN: In a multicentre, prospective study, outpatients undergoing colonoscopy from 8:00 to 14:00 were given written instructions for 4 L polyethylene glycol bowel preparation, offering the choice between split-dose and day-before regimens and emphasising the superiority of split regimen on colonoscopy outcomes. Uptake of split regimen and association with patient-related factors were explored by a 20-item questionnaire. RESULTS: Of the 1447 patients (mean age 59.2±13.5 years, men 54.3%), 61.7% and 38.3% chose a split-dose and day-before regimens, respectively. A linear correlation was observed between time of colonoscopy appointments and split-dose uptake, from 27.3% in 8:00 patients to 96% in 14:00 patients (p<0.001, χ2 for linear trend). At multivariate analysis, colonoscopy appointment before 10:00 (OR 0.14, 95% CI 0.11 to 0.18), travel time to endoscopy service >1 h (OR 0.55, 95% CI 0.38 to 0.79), low education level (OR 0.72, 95% CI 0.54 to 0.96) and female gender (OR 0.74, 95% CI 0.58 to 0.95) were inversely correlated with the uptake of split-dose. Overall, the risk of travel interruption and faecal incontinence was slightly increased in split regimen patients (3.0% vs 1.4% and 1.5% vs 0.9%, respectively; p=NS). Split regimen was an independent predictor of adequate colon cleansing (OR 3.34, 95% CI 2.40 to 4.63) and polyp detection (OR 1.46, 95% CI 1.11 to 1.92). CONCLUSION: Patient attitude towards split regimen is suboptimal, especially for early morning examinations. Interventions to improve patient compliance (ie, policies to reorganise colonoscopy timetable, educational initiatives for patient and healthcare providers) should be considered. TRIAL REGISTRATION NUMBER: NCT02287051; pre-result.

Metabolic polymorphisms and biomarkers of effect in the biomonitoring of occupational exposure to low-levels of benzene: state of the art.

Current levels of occupational exposure to benzene, a genotoxic human carcinogen, in Western countries are reduced by two-three orders of magnitude (from ppm to ppb) as compared to the past. However, as benzene toxicity is strongly dependent on biotransformation and recent evidence underlines a higher efficiency of bio-activation pathways at lower levels of exposure, toxic effects at low doses could be higher than expected, particularly in susceptible individuals. Currently, biological monitoring can allow accurate exposure assessment, relying on sensitive and specific enough biomarkers of internal dose. The availability of similarly reliable biomarkers of early effect or susceptibility could greatly improve the risk assessment process to such an extent that risk could even be assessed at the individual level. As to susceptibility biomarkers, functional genetic polymorphisms of relevant biotransformation enzymes may modulate the risk of adverse effects (NQO1) and the levels of biomarkers of internal dose, in particular S-phenylmercapturic acid (GSTM1, GSTT1, GSTA1). Among biomarkers of early effect, genotoxicity indicators, although sensitive in some cases, are too aspecific for routine use in occupational health surveillance programmes. Currently only the periodical blood cell count seems suitable enough to be applied in the longitudinal monitoring of effects from benzene exposure. Novel biomarkers of early effect are expected from higher collaboration among toxicologists and clinicians, also using advanced "omics" techniques.

Ethics in biomonitoring for occupational health.

Biological monitoring, i.e., the use of biomarkers for the measurement of systemic human exposure, effects and susceptibility to chemicals has increased considerably in recent years. Biomonitoring techniques, originally limited to a few metals and other chemicals in the workplace, are currently applied to a large number of exposure situations and have become a useful tool for occupational and environmental health risk assessment. Almost any biomonitoring program, however, entails a number of relevant ethical issues, which concern all the phases of the entire process, from the selection of the biomarker to the study design, from the collection, storage and analysis of the biological sample to the interpretation, communication and management of the results, from the (truly?) informed consent of the worker to the independence and autonomy of the occupational health professional. These issues require a balanced assessment of the interests and responsibilities of all the parties, the worker primarily, but also the employer, the occupational health professional, the health authorities and, for research studies on new biomarkers, also the scientists involved. Ideally, decisions of ethical relevance concerning biomarkers should be based on, and respectful of the best scientific, legal and ethical evidence available. When, however, a conflict should arise, before any decision is taken a thorough risk-benefit analysis should be done, at the beginning of the process and after listening to the workers and the management involved, by the occupational physician or scientist, based on his/her professional experience, independent judgement and individual responsibility.

Radiofrequency ablation for chronic radiation proctitis: our initial experience with four cases.

BACKGROUND: Chronic radiation proctitis (CRP) occurs up to 20 % of patients after pelvic radiotherapy, with rectal bleeding as the main presenting complaint. Radiofrequency ablation (RFA) has recently been used in the management of Barrett's esophagus, but its efficacy in CRP has to be studied. The aim of this case series was to describe four cases of patients with CRP treated with RFA that demonstrate the efficacy and safety of the technique. METHODS: All the procedures were performed with HALO 90 or HALO 90 Ultra ablation catheter fitted on the distal end of a standard flexible endoscope. For each patient, the severity of symptoms was assessed at baseline and after the last treatment session. RESULTS: At least two sessions of RFA (maximum 4) were necessary, at three-month intervals, to completely control the symptoms. No major complications were observed. CONCLUSIONS: RFA was effective and safe for control bleeding in this case series. Adequately powered randomized controlled trials are needed to establish the safety and efficacy of RFA for CRP.

[Chemical risk assessment in the construction industry: principles and critical issues]. / Valutazione del rischio chimico in edilizia: principi e criticità.

Risk assessment (RA) represents the first step to ensure the protection of the workers' health in all work sectors, production and services included. For this reason RA has become a legal duty for the occupational physician in his/her professional activity. The basic concepts of RA have been developed as a formal procedure for the management of chemical risks but they are currently applied to protect human health against all types of occupational and environmental risk factors. In the construction industry, in particular, chemical risk assessment is specially difficult due to the complexity of the working condition, and the variability and multiplicity of exposure. The critical aspects of RA in the construction industry will be discussed here, in the attempt to highlight how the occupational physician, making use of traditional and new tools, including biological monitoring, can address and partly overcome them.

Desempenho de frangos caipiras alimentados com rações contendo diferentes níveis de energia metabolizável / Performance of broiler chickens fed diets containing different levels of metabolizable energy

Analisaram-se os efeitos da energia metabolizável (EM) e da idade de abate sobre o desempenho zootécnico, o rendimento de carcaça e de partes de frangos da linhagem Caipira Francês Exótico. Foram utilizadas 192 aves, distribuídas em delineamento inteiramente ao acaso, com três tratamentos e quatro repetições de 16 aves cada. Os tratamentos (T) foram definidos de acordo com os níveis de energia das dietas inicial (1 a 28 dias) e final (29 a 90 dias), respectivamente, em: T1 - 3.000 e 3.100kcal de EM/kg; T2 - 3.100 e 3.200kcal de EM/kg; T3 - 3.200 e 3.300kcal de EM/kg. Os abates foram realizados aos 77, 84 e 90 dias. Na fase inicial, as aves do T2 e do T3 apresentaram maior peso médio (655,75 e 713,50g), maior ganho de peso (24,28 e 26,42g/ave) e melhor conversão alimentar (1,59 e 1,77), e não diferiram entre si (P>0,05). Quando abatidas aos 77 dias de idade, as aves que consumiram a dieta com 3.100/3.200kcal de EM/kg apresentaram maior rendimento de carcaça (82,20%) e de peito (24,26%), e não diferiram dos frangos alimentados com dietas contendo 3.000/3.200kcal de EM/kg, nos quais se verificaram rendimento de carcaça de 80,72% e 23,20% de rendimento de peito. Os frangos da linhagem Caipira Francês Exótico apresentaram melhores desempenho zootécnico e rendimento de carcaça quando alimentados com dietas contendo 3.100 a 3.200kcal de EM/kg na ração e abatidos aos 77 dias de idade.

This is study aimed to analyze the effects of metabolizable energy (ME) and age at slaughter on growth performance, carcass yield and prime cuts, relative weight of the wings, back, head + neck and feet of broiler chickens from the Caipira Francês Exótico strain. A total of 192 birds were distributed in a completely randomized design with three treatments and four replicates of 16 birds per treatment. The treatments were defined according to levels of dietary energy (1 to 28 days) and late (29-90 days), respectively: T1 - 3000 and 3100kcal/kg ME, T2 - 3100 and 3200kcal/kg ME, T3 - 3200 and 3300kcal/kg ME. The slaughter was carried out at 77, 84 and 90 days. In the initial phase the birds from T2 and T3 had a higher mean weight (655.75 and 713.50g), weight gain (24.28 and 26.42g/bird) and better feed gain (1.59 and 1.77) and did not differ (P>0.05). When slaughtered at 77 days of age, birds fed the diet with 3.100/3.200kcal/kg ME had higher carcass yield (82.20%) and breast (24.26%), and did not differ from chickens fed diets containing 3.000/3.200kcal/kg ME, where a carcass yield of 80.72% and 23.20% of breast yield was found. The Caipira Francês Exótico broilers had better growth performance and carcass yield than when fed diets containing 3100-3200kcal/kg in the diet and slaughtered at 77 days old.

Effects of cashew nut shell liquid (CNSL) on the performance of broiler chickens / Efeitos do líquido da casca da castanha de caju (LCC) sobre o desempenho de frangos de corte

The effects of cashew nut shell liquid (CNSL) on growth performance, carcass yield, relative weight of internal organs and microbiology of digestive tract of broiler chickens were investigated. Five hundred and forty male broiler chicks at one day of age were arranged in a completely randomized design with six treatments and six repetitions with 15 broiler chicks each. The treatments were: control (T1 - without growth promoter virginiamycin and CNSL); inclusion levels of 0.10mL (T2), 0.20mL (T3), 0.30mL (T4) and 0.40mL (T5) of CNSL/kg of feed; and commercial promoter virginiamycin (T6). At 21 and 40 days of age, body weight, feed intake, feed conversion and viability of birds were similar in all treatments. Carcass yield was higher in the treatment with the growth promoter when compared to the control treatment. There was a linear increase in carcass yield when the level of CNSL was increased in the diet. The relative weight of the intestine was lower in the treatment containing virginiamycin when compared to the treatment without the inclusion of additives. The relative weight of the intestines decreased when the levels of inclusion of CNSL were increased. There was a gradual reduction of Escherichia coli concentration reaching the lowest number on the CNSL level of 0.30mL/kg. It was concluded that CNSL showed similar performance and slaughter yield as the growth promoter and reduced the concentration of Escherichia coli in the intestinal contents.

Um estudo foi conduzido para investigar os efeitos do líquido da casca da castanha de caju (LCC) sobre o desempenho, o rendimento de carcaça, o peso relativo dos órgãos internos e a microbiologia do trato digestivo de frangos de corte. Foram utilizados 540 pintos machos de um dia de idade, distribuídos num delineamento inteiramente casualizado, com seis tratamentos e seis repetições de 15 aves cada. Os tratamentos consistiram em: controle (T1 - sem promotor comercial e sem LCC), níveis de inclusão de 0,10mL (T2), 0,20mL (T3), 0,30mL (T4) e 0,40mL (T5) de LCC/kg de ração e T6 (promotor comercial - virginiamicina). Aos 21 e 40 dias de idade, o peso corporal, o consumo de ração, a conversão alimentar e a viabilidade das aves foram semelhantes em todos os tratamentos. O rendimento de carcaça foi superior no tratamento com promotor de crescimento em relação ao tratamento-controle. Ocorreu uma resposta linear de incremento no rendimento de carcaça com o aumento do nível de LCC na dieta. O peso relativo dos intestinos foi menor no tratamento com virginiamicina em relação ao tratamento-controle. O peso relativo dos intestinos diminuiu com o aumento do nível de inclusão do LCC. Houve uma redução gradual da concentração de Escherichia coli, cuja menor concentração atingiu o nível de 0,30mL/kg. Conclui-se que o LCC mostrou desempenho e rendimento de abate semelhantes ao promotor de crescimento e reduziu a concentração de Escherichia Coli no conteúdo intestinal.

Endoscopic treatment of gastrointestinal fistulas using an over-the-scope clip (OTSC) device: case series from a tertiary referral center.

Gastrointestinal perforations and post-surgical fistulas are dreaded complications that dramatically increase morbidity and mortality. A new endoscopic over-the-scope clip (OTSC) system may be potentially useful for sealing visceral perforations in several clinical settings. We evaluated the advantages and clinical impact of the placement of OTSCs on the management of non-malignant gut leaks in 12 consecutive patients. OTSCs of 9.5 or 10.5 mm were used, according to the diameter of the defect within the wall. The indications for treatment were mainly related to post-surgical fistulas. Healing of the fistula was assessed by endoscopic or radiological means, and failed only once. No OTSC-related complications occurred. Endoscopic closure of perforations and post-surgical fistulas with the OTSC system is a simple and minimally invasive technique. This approach, when feasible, may be less expensive and more advantageous than a surgical approach.

Anti-Müllerian hormone-based prediction model for a live birth in assisted reproduction.

Prediction of assisted reproduction treatment outcome has been the focus of clinical research for many years, with a variety of prognostic models describing the probability of an ongoing pregnancy or a live birth. This study assessed whether serum anti-Müllerian hormone (AMH) concentrations may be incorporated into a model to enhance the prediction of a live birth in women undergoing their first IVF cycle, by analysing a database containing clinical and laboratory information on IVF cycles carried out between 2005 and 2008 at the Mother-Infant Department of University Hospital, Modena. Logistic regression was used to examine the association of live birth with baseline patient characteristics. Only AMH and age were demonstrated in regression analysis to predict live birth, so a model solely based on these two criteria was generated. The model permitted the identification of live birth with a sensitivity of 79.2% and a specificity of only 44.2%. In the prediction of a live birth following IVF, a distinction, however moderate, can be made between couples with a good and a poor prognosis. The success of IVF was found to mainly depend on maternal age and serum AMH concentrations, one of the most relevant and valuable markers of ovarian reserve.