Gemini-Assisted Deep Learning Classification Model for Automated Diagnosis of High-Resolution Esophageal Manometry Images.

Background/Objectives: To develop a deep learning model for esophageal motility disorder diagnosis using high-resolution manometry images with the aid of Gemini. Methods: Gemini assisted in developing this model by aiding in code writing, preprocessing, model optimization, and troubleshooting. Results: The model demonstrated an overall precision of 0.89 on the testing set, with an accuracy of 0.88, a recall of 0.88, and an F1-score of 0.885. It presented better results for multiple categories, particularly in the panesophageal pressurization category, with precision = 0.99 and recall = 0.99, yielding a balanced F1-score of 0.99. Conclusions: This study demonstrates the potential of artificial intelligence, particularly Gemini, in aiding the creation of robust deep learning models for medical image analysis, solving not just simple binary classification problems but more complex, multi-class image classification tasks.

Hepatic changes following a high-fat diet: effects of Cornus mas and gold nanoparticles phytoreduced with Cornus mas on oxidative stress, inflammation, and histological damage.

Background and aims: High fat diet (HFD) can lead to liver injury, through oxidative stress and inflammation. The use of natural compounds with antioxidant and anti-inflammatory properties can have a protective potential. We aimed to investigate the effects of Cornus mas (CM) and gold nanoparticles phytoreduced with CM (GNPsCM) on hepatic alterations induced by HFD in rats. Methods: Female Sprague Dawley rats were randomly divided into four groups: control, HFD, HFD +CM and HFD + GNPsCM. The high fat diet was administered for 32 weeks and CM and GNPsCM were administered for 4 weeks after the HFD period. The high fat diet induced oxidative stress in liver, with lipid peroxidation and decreased antioxidant capacity, inflammation and minimal histological alterations. Results: The administration of CM and GNPsCM reduced lipid peroxidation produced by HFD and increased antioxidant potential in liver homogenates, while increasing inflammatory markers. Histological alterations were slightly improved by the intervention of compounds, and hyaluronic acid content of the liver without statistical significance as compared to HFD group. Conclusion: These findings support the potential of these treatments in addressing liver oxidative stress, mitigating liver damage induced by a high-fat diet. This investigation sheds light on the oxidative stress dynamics and histological alterations associated with high-fat diet-induced liver injury, contributing to our understanding of potential therapeutic interventions.

Extra-digestive manifestations of celiac disease.

Introduction: Celiac disease (CD) is a chronic autoimmune disorder triggered by gluten ingestion in genetically predisposed individuals, presenting with a diverse range of symptoms that extend beyond the gastrointestinal tract. The condition's systemic nature is evidenced by its extra-digestive manifestations, which can affect various organs including the skin, joints, liver, and nervous system. Methods: This descriptive, retrospective study was conducted at a tertiary care center, focusing on adult patients diagnosed with CD who exhibited extra-digestive symptoms. Data were extracted from medical records of patients admitted between January 1, 2010 and June 30, 2024. Variables included demographic information, primary diagnosis, and associated extra-digestive manifestations. Descriptive statistical methods were employed for data analysis. Results: The sample included 108 patients with CD, the mean age was 43.21 years, with a predominance of females (76.85%). Iron deficiency anemia was the most common extra-digestive manifestation, affecting 20.37% of patients, followed by hypoproteinemia (18.52%) and Hashimoto's thyroiditis (14.81%). Co-occurrence analysis revealed frequent combinations of conditions, such as anemia with cardiovascular diseases and depressive disorders. Notable associations with neurological conditions like gluten ataxia and peripheral neuropathy were also observed. Conclusion: This study highlights the extensive extra-digestive manifestations of celiac disease, underscoring its systemic impact. The high prevalence of autoimmune conditions such as Hashimoto's thyroiditis and rheumatoid polyarthritis among CD patients reflects the need for holistic management strategies. Discrepancies between our findings and existing literature, particularly regarding skin and neurological conditions, emphasize the need for further research to better understand these associations and the long-term effects of a gluten-free diet.

Prevalence of Celiac Disease in Romania.

BACKGROUND AND AIMS: Celiac disease (CD) is an autoimmune disorder that targets the small intestine, triggered by the ingestion of gluten in genetically predisposed individuals, causing damage to the villi and impairing nutrient absorption. Despite increased awareness and improved diagnostic techniques, CD remains significantly underdiagnosed, with many individuals suffering from unexplained symptoms or misdiagnosed conditions. This study aims to investigate the prevalence and demographic characteristics of CD in a Romanian population using rapid diagnostic tests followed by histological confirmation. METHODS: This cross-sectional study aimed to determine the prevalence of CD in Romania using the BIOHIT Celiac Quick Test among adult participants recruited from tertiary healthcare centers and medical institutions. The prevalence of CD was calculated by dividing the number of confirmed positive cases by the total number of participants, with further evaluation including endoscopy and histological examination for those with positive quick test results. To our knowledge, this is the first prospective study in Romania to assess the prevalence of CD using a serological test. RESULTS: Out of 713 participants from Romania, 9 tested positive for CD using a rapid diagnostic test, confirmed by histological examination, resulting in a prevalence rate of 1.26%. The mean age of the CD-positive group was significantly younger (30.3 years) compared to the general population (49.2 years), and they had a lower mean BMI (22.2 vs. 28.1). Most CD-positive patients were female (66.7%) and resided in urban areas (55.6%). CONCLUSIONS: Our study found the prevalence of CD in a Romanian population to be slightly higher than the global average, highlighting the effectiveness of rapid diagnostic tests followed by histological confirmation. The significant regional variability in CD prevalence suggests the need for further research into environmental, dietary, and genetic factors, along with enhanced awareness and improved diagnostic protocols to better manage and prevent long-term complications of CD.

Self-Perceived Lactose Intolerance Versus Confirmed Lactose Intolerance in Irritable Bowel Syndrome: A Systematic Review.

BACKGROUND AND AIMS: Disorders of gut-brain interaction (DGBI) are prevalent, affecting 20-40% of the population, with irritable bowel syndrome (IBS) being the most common and impactful. While congenital lactose intolerance is rare, lactase deficiency in adults is widespread, causing gastrointestinal symptoms like bloating and diarrhea. Self-perceived lactose intolerance often overestimates symptoms, impacting dietary choices and quality of life, necessitating better understanding and management for improved patient outcomes. This article evaluates the diagnostic accuracy of self-reported lactose intolerance in patients with lactose intolerance and IBS through a systematic review. METHODS: A systematic literature search was conducted using PubMed, EMBASE, and SCOPUS, including terms related to IBS, lactose intolerance, and self-reported symptoms, without applying filters to ensure comprehensive coverage. Inclusion criteria focused on observational studies with adult participants diagnosed with lactose intolerance, addressing symptoms and lactose malabsorption, while excluding non-English articles, reviews, editorials, and studies involving pediatric subjects. RESULTS: The systematic review analyzed six studies with 845 participants, revealing significant variability and moderate accuracy in self-reported lactose intolerance for diagnosing actual lactose intolerance in IBS patients. Hydrogen breath tests (HBTs) showed that self-reported symptoms often led to false positives, underscoring the need for objective diagnostic tools and standardized criteria. The findings highlight the complexity of diagnosing lactose intolerance in IBS patients and suggest that lactose-free diets and routine HBT should not be recommended without clear indications. CONCLUSIONS: The rigorous selection process ensured the inclusion of high-quality, relevant studies, thereby enhancing the reliability and validity of the review's findings. These studies revealed that a lactose-free diet should not be routinely recommended for IBS patients, nor should the routine use of HBT to identify lactose malabsorption in this group. Future research should focus on better understanding the factors influencing lactose perception and tolerance, which is crucial for more effective management of lactose intolerance in IBS patients.

Lifetime Management for Aortic Stenosis: Strategy and Decision-Making in the Current Era.

Aortic stenosis, the most common valvular disease in the Western world, has traditionally been treated with surgical aortic valve replacement (SAVR) but is increasingly treated by transcatheter aortic valve replacement (TAVR). Whereas patients older than 65 years are preferably treated with bioprosthetic tissue valves, there is considerable uncertainty in the choice between TAVR and SAVR. We present various considerations for optimizing the lifelong management of patients receiving bioprosthetic valves (SAVR or TAVR). To maximize life expectancy and to minimize cumulative lifetime risk, we suggest decision-making individualized for patient anatomy and overall (current and future) risk.

Enteroscopy versus Video Capsule Endoscopy for Automatic Diagnosis of Small Bowel Disorders-A Comparative Analysis of Artificial Intelligence Applications.

BACKGROUND: Small bowel disorders present a diagnostic challenge due to the limited accessibility of the small intestine. Accurate diagnosis is made with the aid of specific procedures, like capsule endoscopy or double-ballon enteroscopy, but they are not usually solicited and not widely accessible. This study aims to assess and compare the diagnostic effectiveness of enteroscopy and video capsule endoscopy (VCE) when combined with artificial intelligence (AI) algorithms for the automatic detection of small bowel diseases. MATERIALS AND METHODS: We performed an extensive literature search for relevant studies about AI applications capable of identifying small bowel disorders using enteroscopy and VCE, published between 2012 and 2023, employing PubMed, Cochrane Library, Google Scholar, Embase, Scopus, and ClinicalTrials.gov databases. RESULTS: Our investigation discovered a total of 27 publications, out of which 21 studies assessed the application of VCE, while the remaining 6 articles analyzed the enteroscopy procedure. The included studies portrayed that both investigations, enhanced by AI, exhibited a high level of diagnostic accuracy. Enteroscopy demonstrated superior diagnostic capability, providing precise identification of small bowel pathologies with the added advantage of enabling immediate therapeutic intervention. The choice between these modalities should be guided by clinical context, patient preference, and resource availability. Studies with larger sample sizes and prospective designs are warranted to validate these results and optimize the integration of AI in small bowel diagnostics. CONCLUSIONS: The current analysis demonstrates that both enteroscopy and VCE with AI augmentation exhibit comparable diagnostic performance for the automatic detection of small bowel disorders.

Transcaval Versus Transaxillary TAVR in Contemporary Practice: A Propensity-Weighted Analysis.

OBJECTIVES: The aim of this study was to compare transcaval and transaxillary artery access for transcatheter aortic valve replacement (TAVR) at experienced medical centers in contemporary practice. BACKGROUND: There are no systematic comparisons of transcaval and transaxillary TAVR access routes. METHODS: Eight experienced centers contributed local data collected for the STS/ACC TVT Registry (Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry) between 2017 and 2020. Outcomes after transcaval and axillary/subclavian (transaxillary) access were adjusted for baseline imbalances using doubly robust (inverse propensity weighting plus regression) estimation and compared. RESULTS: Transcaval access was used in 238 procedures and transaxillary access in 106; for comparison, transfemoral access was used in 7,132 procedures. Risk profiles were higher among patients selected for nonfemoral access but similar among patients requiring transcaval and transaxillary access. Stroke and transient ischemic attack were 5-fold less common after transcaval than transaxillary access (2.5% vs 13.2%; OR: 0.20; 95% CI: 0.06-0.72; P = 0.014) compared with transfemoral access (1.7%). Major and life-threatening bleeding (Valve Academic Research Consortium 3 ≥ type 2) were comparable (10.0% vs 13.2%; OR: 0.66; 95% CI: 0.26-1.66; P = 0.38) compared with transfemoral access (3.5%), as was blood transfusion (19.3% vs 21.7%; OR: 1.07; 95% CI: 0.49-2.33; P = 0.87) compared with transfemoral access (7.1%). Vascular complications, intensive care unit and hospital length of stay, and survival were similar between transcaval and transaxillary access. More patients were discharged directly home and without stroke or transient ischemic attack after transcaval than transaxillary access (87.8% vs 62.3%; OR: 5.19; 95% CI: 2.45-11.0; P < 0.001) compared with transfemoral access (90.3%). CONCLUSIONS: Patients undergoing transcaval TAVR had lower rates of stroke and similar bleeding compared with transaxillary access in a contemporary experience from 8 US centers. Both approaches had more complications than transfemoral access. Transcaval TAVR access may offer an attractive option.

Same-Day Discharge Post-Transcatheter Aortic Valve Replacement During the COVID-19 Pandemic: The Multicenter PROTECT TAVR Study.

OBJECTIVES: The aim of this study was to determine the safety and efficacy of same-day discharge (SDD) after transcatheter aortic valve replacement (TAVR) during the COVID-19 pandemic. BACKGROUND: The COVID-19 pandemic has placed significant stress on health care systems worldwide. SDD in highly selected TAVR patients can facilitate the provision of essential cardiovascular care while managing competing COVID-19 resource demands. METHODS: Patient selection for SDD was at the discretion of the local multidisciplinary heart team, across 7 international sites. The primary outcome was a composite of cardiovascular death, stroke, myocardial infarction, all-cause readmission, major vascular complications, and new permanent pacemaker (PPM) implantation. RESULTS: From March 2020 to August 2021, 124 of 2,100 patients who underwent elective transfemoral TAVR were selected for SDD. The average age was 78.9 ± 7.8 years, the median Society of Thoracic Surgeons score was 2.4 (IQR: 1.4-4.2), and 32.3% (n = 40) had preexisting PPMs. There were no major vascular complications, strokes, or deaths during the index admission. One patient (0.8%) required PPM implantation for complete heart block and was discharged the same day. No patient required a PPM between discharge home and 30-day follow-up. The composite of cardiovascular death, stroke, myocardial infarction, all-cause readmission, major vascular complications, and new PPM at 30 days occurred in 5.7% patients (n = 6 of 106). CONCLUSIONS: SDD post-TAVR is safe and feasible in selected patients at low risk for adverse clinical events postdischarge. This strategy may have a potential role in highly selected patients even when the COVID-19 pandemic abates.

Value of GastroPanel in the diagnosis of atrophic gastritis.

Analysis of serum biomarkers for the assessment of atrophic gastritis (AG), considered as precursor of the intestinal type of gastric cancer, is of growing interest. The combination of pepsinogen (PG), gastrin-17 (G17) and anti-Helicobacter pylori (H. pylori) antibody serological assays (panel test) is a non-invasive tool for the diagnosis of atrophic gastritis. However, the diagnostic reliability of this test remains uncertain. The aim of our study was to assess the diagnostic performance of the serum panel test (GastroPanel) for the diagnosis of atrophic gastritis. From dyspeptic patients, endoscopic biopsy samples (two from the gastric corpus and two from the antrum) and blood samples were collected. The determination of sPGI, sPGII, sG17 and IgG antibodies to H. pylori (H.p IgG) was performed using an enzyme-linked immunosorbent assay (GastroPanel; Biohit Oyj). Histopathology results were compared with GastroPanel values. Sixty patients were included: 35 (58.3%) females and 25 (41.66%) males; mean age 67.63±9.36 years; 45% H. pylori-positive. A total of 65% of patients had atrophic gastritis. There were no significant differences between the levels of biomarkers and localization of atrophy. The ratio PG1/PG2 was lower in patients with multifocal atrophy; the difference being close to the threshold of statistical significance. In cases of intestinal metaplasia the values of G17, PG1, PG2, H.p IgG were not statistically altered compared to those without intestinal metaplasia; only the ratio PG1/PG2 was lower in intestinal metaplasia; the difference being almost of statistical significance. Our results revealed that, GastroPanel values did not differ depending on the severity of the atrophy. Biomarkers used by GastroPanel do not have enough accuracy for use in the diagnosis of atrophy in the population studied. A low accuracy only for the ratio PG1/PG2 in patients with multifocal atrophy was found. However, our data revealed a correlation in detecting intestinal metaplasia.

Preventing Coronary Obstruction During Transcatheter Aortic Valve Replacement: Results From the Multicenter International BASILICA Registry.

OBJECTIVES: This study sought to determine the safety of the BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) procedure. BACKGROUND: Transcatheter aortic valve replacement causes coronary artery obstruction in 0.7% of cases, with 40% to 50% mortality. BASILICA is a procedure to prevent coronary obstruction. Safety and feasibility in a large patient cohort is lacking. METHODS: The international BASILICA registry was a retrospective, multicenter, real-world registry of patients at risk of coronary artery obstruction undergoing BASILICA and transcatheter aortic valve replacement. Valve Academic Research Consortium-2 definitions were used to adjudicate events. RESULTS: Between June 2017 and December 2020, 214 patients were included from 25 centers in North America and Europe; 72.8% had bioprosthetic aortic valves and 78.5% underwent solo BASILICA. Leaflet traversal was successful in 94.9% and leaflet laceration in 94.4%. Partial or complete coronary artery obstruction was seen in 4.7%. Procedure success, defined as successful BASILICA traversal and laceration without mortality, coronary obstruction, or emergency intervention, was achieved in 86.9%. Thirty-day mortality was 2.8% and stroke was 2.8%, with 0.5% disabling stroke. Thirty-day death and disabling stroke were seen in 3.4%. Valve Academic Research Consortium-2 composite safety was achieved in 82.8%. One-year survival was 83.9%. Outcomes were similar between solo and doppio BASILICA, between native and bioprosthetic valves, and with the use of cerebral embolic protection. CONCLUSIONS: BASILICA is safe, with low reported rates of stroke and death. BASILICA is feasible in the real-world setting, with a high procedure success rate and low rates of coronary artery obstruction.

Romanian Guidelines for Nonpharmacological Therapy of IBS.

BACKGROUND AND AIMS: The nonpharmacological therapy in irritable bowel syndrome (IBS) is expanding rapidly. Practitioners and medical educators need to be aware of progress and changes in knowledge of this topic. The Romanian Society of Neurogastroenterology aimed to create guidelines based on best evidence on the use of nonpharmacological therapy in IBS. METHODS: A group of experts was constituted. This was divided in eleven subgroups dedicated to eleven categories of nonpharmacological therapy. The subgroups searched the literature and formulated statements and recommendations. These were submitted to vote in order to obtain consensus. RESULTS: The outcome of this activity is represented by the guidelines of the Romanian Society of Neurogastroenterology, presented in this paper. The recommendations are seen as complementary to the pharmacological therapy and are not intended to recommend avoiding pharmacological drugs. CONCLUSIONS: These guidelines were elaborated by a Delphi process and represent a useful tool for physicians managing patients with IBS.

Same Day Discharge during the COVID-19 Pandemic in Highly Selected Transcatheter Aortic Valve Replacement Patients.

Background: Transcatheter aortic valve replacement (TAVR) with a standardized clinical pathway allows most patients to achieve safe next-day discharge. This approach has been successfully implemented across global centers as part of the Benchmark Program. Considering restricted hospital resources resulting from the COVID-19 pandemic, a modified same day discharge (SDD) clinical pathway was implemented for selected TAVR patients at a single Benchmark site. Methods: All patients accepted for TAVR were assessed for the SDD clinical pathway. Eligibility criteria included adequate social support and accessibility to the TAVR program post-discharge. Patients with preexisting conduction disease were excluded. The clinical pathway comprised of mobilization, bloodwork and electrocardiogram 4 hours post-TAVR and discharge ≥8 hours following groin hemostasis. Results: From June to December 2020, 142 patients underwent TAVR at a single community Benchmark site. Of those, 29 highly selected patients were successfully discharged the same day using the SDD clinical pathway. There were no vascular access complications, permanent pacemaker (PPM) implantation, or mortality in the SDD group during index admission or at 30-day follow-up. When compared to a standard therapy group, there was no statistically significant difference in 30-day cardiovascular readmission. Conclusions: This study demonstrates the safety and feasibility of same day discharge post-TAVR in a highly selected cohort of patients, with no observable difference in safety outcomes when compared to patients who were discharged according to standard institutional practice.Abbreviations: AS: aortic stenosis; ACT: Activated clotting time; AV: atrioventricular; AVB: atrioventricular block; BBB: bundle branch block; CAIC: Canadian Society for Cardiovascular Angiography; CCL: cardiac catheterization laboratory; CT: Computed topography; CV: cardiovascular; IQR: Interquartile Range; IVCD: intraventricular conduction delay; LBBB: left bundle branch block; LOS: length of stay; NDD: next day discharge; PPM: permanent pacemaker; RBBB: right bundle branch block; SCAI: Society for Cardiovascular Angiography and Intervention; SD: standard deviation; SDD: same day discharge; ST: standard therapy; STS PROM: society of thoracic surgeons predicted risk of mortality; TAVR: transcatheter aortic valve replacement; TF: transfemoral; THV: transcatheter heart valve; TTE: transthoracic echocardiogram; VARC: Valve Academic Research Consortium.

Clinical and Manometric Characteristics of Patients with Achalasia: One Disease with Three Presentations or Three Diseases with One Presentation?

BACKGROUND AND AIMS: The three manometric patterns of achalasia are considered by some authors as different stages in the evolution of the same disorder. The aims of our study were to characterize patients with achalasia, in order to find key differences supporting the idea of progression from one type to the other, and to assess the clinical evolution in time. METHODS: From 280 high resolution esophageal manometry recordings we selected unique patients with achalasia. A standardized questionnaire used prior to each manometry recorded their symptoms. Manometric parameters (resting lower esophageal sphincter (LES) pressure, 4s-integrated relaxation pressure (IRP), length of the esophagus, etc.) were recorded. Patients were contacted to establish the clinical evolution. RESULTS: We identified 108 new achalasia cases (mean age 48.2±16.2 years, 52.8% type I, 42.6% type II), 52 (48.1%) women. Dysphagia (98.1%), cough (64.8%), belching (60.2%) and reflux symptoms (53.7%) were frequently reported. Patients with type I achalasia reported more often that dysphagia worsened, compared to type II patients (χ2=7.3, p =0.007). Age, duration of dysphagia, body mass index (p=0.067) and esophageal length were similar in type I and type II achalasia. Resting LES pressure (64.7±22.6 mmHg vs. 54.3±21.6 mmHg, p=0.019) and 4s-IRP (45.3±17.6 mmHg vs. 38.4±15.5 mmHg, p=0.036) were higher in type II compared to type I achalasia. Overweight patients had a lower LES resting pressure and 4s-IRP compared to lean subjects. After a mean follow-up of 36.8±13.4 months, 49 (45.3%) patients responded to our follow-up, and 77.5% had an Eckardt score ≤ 3. CONCLUSIONS: Type I achalasia was the most common in our group. Type I patients had lower BMI but similar duration of dysphagia and mean age compared to type II. Type III is seldom and present in older patients. These findings suggest low probability of progression from type III and II to type I achalasia. Patients with type II achalasia had higher resting LES pressure and 4s-IRP than type I achalasia patients.

Antibiotics administration during last trimester of pregnancy is associated with atopic dermatitis - a cross-sectional study.

INTRODUCTION: Studies regarding antibiotics administration during pregnancy and atopic dermatitis (AD) in children are only few. In this context, the objective of our study was to investigate the potential association between the timing of intrauterine exposure to antibiotics or prenatal antibiotic administration in general and AD occurrence in children. METHODS: This was a cross-sectional study in 1046 subjects. The exposure to antibiotics during pregnancy was initially evaluated using simple logistic regressions. Then, each period of antibiotics administration was adjusted with the other periods of antibiotics exposure (model 1) and with the other variables associated with AD in our database (model 2). RESULTS: In simple logistic regression analysis, the administration of antibiotics during pregnancy, as a whole period, presented a trend of association with AD (OR = 1.28, %CI: 0.99 - 1.65). When we analyzed antibiotic administration during each trimester of pregnancy, only antibiotherapy during the 3rd trimester was associated with AD (OR = 2.94, %CI: 1.21 - 7.12). After adjusting with all the other important risk factors associated with AD in the database, antibiotics administration during the 3rd trimester of pregnancy was still independently associated with AD (OR=2.64, %CI: 1.01 - 6.91). CONCLUSION: Antibiotic administration during the 3rd trimester of pregnancy was independently associated with AD in children.

Intravascular Lithotripsy for Treatment of Calcified, Stenotic Iliac Arteries: A Cohort Analysis From the Disrupt PAD III Study.

PURPOSE: The presence of calcification in the iliac arteries is associated with decreased procedural success and increased complication risk during endovascular intervention. The objective of this study was to evaluate the safety and efficacy of peripheral intravascular lithotripsy (IVL) during endovascular treatment of iliac arterial peripheral artery disease (PAD). METHODS: The Disrupt PAD III Observational Study is a prospective, non-randomized, multi-center single-arm study to assess the 'real-world' safety and effectiveness of the Shockwave Peripheral IVL System for the treatment of de novo calcified lesions in the peripheral arteries, with a goal of treating 1500 patients. This is an analysis of consecutive patients enrolled for treatment of an iliac artery, a specified sub-group, with at least moderate calcification and a minimum length of 20 mm. RESULTS: Between December 2017 and July 2019, 118 patients with a total of 200 lesions were enrolled across 20 sites. 101 patients were treated primarily for claudication or critical limb ischemia, while 17 patients were treated to optimize the iliac vasculature for large-bore access. All 118 patients had successful IVL catheter delivery. The average reference vessel diameter was 7.3 mm ± 1.9 mm, with an average diameter stenosis of 83.1% ± 13.4% and an average lesion length of 58.3 mm ± 57.6 mm. Severe calcification was present in 82.0% of overall cases. Stent placement was performed in 72.9% of the overall cases. As expected, the access group received less adjunctive therapies including stents (41.2%, p < 0.001). Angiographic complications were minimal with no flow-limiting dissections and a final mean residual stenosis of 12.0% ± 12.1% with no differences between the groups. CONCLUSIONS: Acute results with IVL in calcified iliac lesions suggest that it is a safe and effective option for calcified, stenotic iliac disease. IVL can be used successfully both for treatment of PAD symptoms and to optimize access for large-bore procedures.

The Value of Staging Laparoscopy for Optimal Multidisciplinary Treatment in Patients with Gastric Cancer.

Introduction: Despite improvements in the conventional preoperative tools used for staging of gastric cancer, their accuracy still needs to be improved. Laparoscopy has the potential to visualize and characterize the tumor, the peritoneal cavity and the lymph nodes and thus to better select patients for the optimal treatment strategy. Material and Method: Patients with gastric cancer staged initially with contrast enhanced computer tomography and endoscopic ultrasound were also evaluated by laparoscopy and laparoscopic ultrasound in a distinct preoperative staging procedure. The perioperative data was recorded in a prospective database and was used to decide within the multidisciplinary team the optimal treatment protocol for each patient. The database was retrospectively reviewed for this study. Results: Among the 20 CT-scan M0 patients analyzed, peritoneal carcinomatosis was detected in 15% of the cases. In other 15% of patients laparoscopy upstaged the tumor and directed the patient towards neoadjuvant chemotherapy. Laparoscopic guided percutaneous core biopsies settled the definitive diagnosis in 3 further cases. In total, laparoscopic staging brought important information in 65% of cases and changed the treatment plan in 30% of patients. Conclusions: In the era of neoadjuvant chemotherapy, laparoscopy has the potential to overcome some of the limitations of the conventional staging methods and offers additional informations which finally change the treatment plan in as much as a third of patients with gastric cancer.

Insulin resistance is associated with all chronic complications in type 1 diabetes.

BACKGROUND: Insulin resistance (IR) is present in type 1 diabetes mellitus (T1DM) and is suggested to be related to chronic diabetic complications. The primary aim of our study was to assess IR in T1DM patients with and without chronic complications. A secondary aim was to evaluate the possible association between IR and chronic diabetic complications. METHODS: This cross-sectional study enrolled 272 patients with T1DM. Insulin resistance was quantified using the estimated glucose disposal rate (eGDR). Associations between eGDR and each diabetes complication were first evaluated using binary logistic regression, then multiparametric logistic regression with stepwise selection of covariates. The discriminative value of eGDR was assessed by receiver operating characteristic (ROC) curve analysis. RESULTS: Estimated GDR was lower in patients with chronic diabetic complications (6.1 vs. 6.9 mg/kg per min [P = 0.02] for retinopathy; 6.3 vs. 7.3 mg/kg per min [P < 0.01] for nephropathy; 6.5 vs. 7.6 mg/kg per min [P < 0.01] for neuropathy; and 5.2 vs. 7.5 mg/kg per min [P < 0.01] for cardiovascular complications). In univariate analysis eGDR was associated all diabetic complications. These associations remained significant after adjustment for different variables in the final regression models. In addition, eGDR was a good discriminator for each diabetic complication, with an area under the curve between 0.609 and 0.759. CONCLUSIONS: Patients with chronic diabetic complications are more insulin resistant than those without complications. Moreover, IR was independently associated with the presence of each chronic diabetic complication, and seems to be a good discriminator for them all.