Linked-color imaging versus white-light colonoscopy in an organized colorectal cancer screening program.

BACKGROUND AND AIMS: Linked-color imaging (LCI), a new image-enhancing technology emphasizing contrast in mucosal color, has been demonstrated to substantially reduce polyp miss rate as compared with standard white-light imaging (WLI) in tandem colonoscopy studies. Whether LCI increases adenoma detection rate (ADR) remains unclear. METHODS: Consecutive subjects undergoing screening colonoscopy after fecal immunochemical test (FIT) positivity were 1:1 randomized to undergo colonoscopy with LCI or WLI, both in high-definition systems. Insertion and withdrawal phases of each colonoscopy were carried out using the same assigned light. Experienced endoscopists from 7 Italian centers participated in the study. Randomization was stratified by gender, age, and screening round. The primary outcome measure was represented by ADR. RESULTS: Of 704 eligible subjects, 649 were included (48.9% men, mean age ± standard deviation, 60.8 ± 7.3 years) and randomized to LCI (n = 326) or WLI (n = 323) colonoscopy. The ADR was higher in the LCI group (51.8%) than in the WLI group (43.7%) (relative risk, 1.19; 95% confidence interval, 1.01-1.40). The proportions of patients with advanced adenomas and sessile serrated lesions were, respectively, 21.2% and 8.6% in the LCI arm and 18.9% and 5.9% in the WLI arm (not significant for both comparisons). At multivariate analysis, LCI was independently associated with ADR, along with male gender, increasing age, and adequate (Boston Bowel Preparation Scale score ≥6) bowel preparation. At per-polyp analysis, the mean ± standard deviation number of adenomas per colonoscopy was comparable in the LCI and WLI arms, whereas the corresponding figures for proximal adenomas was significantly higher in the LCI group (.72 ± 1.2 vs .55 ± 1.07, P = .05) CONCLUSIONS: In FIT-positive patients undergoing screening colonoscopy, the routine use of LCI significantly increased the ADR. (Clinical trial registration number: NCT03690297.).

Barrett's esophagus and adenocarcinoma risk: the experience of the North-Eastern Italian Registry (EBRA).

OBJECTIVE: To establish the incidence and risk factors for progression to high-grade intraepithelial neoplasia (HG-IEN) or Barrett's esophageal adenocarcinoma (BAc) in a prospective cohort of patients with esophageal intestinal metaplasia [(BE)]. BACKGROUND: BE is associated with an increased risk of BAc unless cases are detected early by surveillance. No consistent data are available on the prevalence of BE-related cancer, the ideal surveillance schedule, or the risk factors for cancer. METHODS: In 2003, a regional registry of BE patients was created in north-east Italy, establishing the related diagnostic criteria (endoscopic landmarks, biopsy protocol, histological classification) and timing of follow-up (tailored to histology) and recording patient outcomes. Thirteen centers were involved and audited yearly. The probability of progression to HG-IEN/BAc was calculated using the Kaplan-Meier method; the Cox regression model was used to calculate the risk of progression. RESULTS: HG-IEN (10 cases) and EAc (7 cases) detected at the index endoscopy or in the first year of follow-up were considered to be cases of preexisting disease and excluded; 841 patients with at least 2 endoscopies {median, 3 [interquartile range (IQR): 2-4); median follow-up = 44.6 [IQR: 24.7-60.5] months; total 3083 patient-years} formed the study group [male/female = 646/195; median age, 60 (IQR: 51-68) years]. Twenty-two patients progressed to HG-IEN or BAc (incidence: 0.72 per 100 patient-years) after a median of 40.2 (26.9-50.4) months. At multivariate analysis, endoscopic abnormalities, that is, ulceration or nodularity (P = 0.0002; relative risk [RR] = 7.6; 95% confidence interval, 2.63-21.9), LG-IEN (P = 0.02, RR = 3.7; 95% confidence interval, 1.22-11.43), and BE length (P = 0.01; RR = 1.16; 95% confidence interval, 1.03-1.30) were associated with BE progression. Among the LG-IEN patients, the incidence of HG-IEN/EAc was 3.17 patient-years, that is, 6 times higher than in BE patients without LG-IEN. CONCLUSIONS: These results suggest that in the absence of intraepithelial neoplastic changes, BE carries a low risk of progression to HG-IEN/BAc, and strict surveillance (or ablative therapy) is advisable in cases with endoscopic abnormalities, LG-IEN or long BE segments.

Sustainability in gastroenterology and digestive endoscopy: Position Paper from the Italian Association of Hospital Gastroenterologists and Digestive Endoscopists (AIGO).

Climate crisis is dramatically changing life on earth. Environmental sustainability and waste management are rapidly gaining centrality in quality improvement strategies of healthcare, especially in procedure-dominant fields such as gastroenterology and digestive endoscopy. Therefore, healthcare interventions and endoscopic procedures must be evaluated through the 'triple bottom line' of financial, social, and environmental impact. The purpose of the paper is to provide information on the carbon footprint of gastroenterology and digestive endoscopy and outline a set of measures that the sector can take to reduce the emission of greenhouse gases while improving patient outcomes. Scientific societies, hospital executives, single endoscopic units can structure health policies and investment to build a "green endoscopy". The AIGO study group reinforces the role of gastrointestinal endoscopy professionals as advocates of sustainability in digestive endoscopy. The "green endoscopy" can shape a more sustainable health service and lead to an equitable, climate-smart, and healthier future.

Correct use of telemedicine in gastroenterology, hepatology, and endoscopy during and after the COVID-19 pandemic: Recommendations from the Italian association of hospital gastroenterologists and endoscopists (AIGO).

The purpose of the present document is to provide detailed information on the correct and optimal use of digital media to ensure continuity of care for gastroenterological patients in everyday clinical practice, in health emergencies and/or when the patient cannot reach the hospital for other reasons. During the recent COVID-19 pandemic, telemedicine has allowed many patients with chronic diseases to access remote care worldwide, proving to be the ideal solution to overcome restrictions and carry out non-urgent routine follow-ups on chronic patients. The COVID-19 pandemic has therefore made organizational and cultural renewal essential for the reorganization of healthcare in order to ensure greater continuity of care with a minimum risk of spreading the virus to users, practitioners and their families. These AIGO recommendations are intended to provide Italian gastroenterologists with a tool to use this method appropriately, in compliance with current legislation, in particular the proper approach and procedures for conducting a remote examination using a video conferencing tool, the so-called televisit. In the near future, telemedicine may contribute to a possible reorganization of healthcare systems, through innovative care models focusing on the citizen and facilitating access to services throughout the entire Country.

People's attitude toward xenotransplantation: affective reactions and the influence of the evaluation context.

BACKGROUND: One of the major issues in transplantation is to find a strategy to overcome the scarcity of human organs. One of the interventions under investigation is represented by xenotransplantation. The present study aimed to understand the role of psychological factors on people's perception of xenotransplantation. In particular, we tested a condition in which different alternatives (e.g., human vs. pig donors) are presented together allowing people to compare among them (joint evaluation) and two conditions in which people are presented with only one of the two alternatives and cannot compare them (separate evaluation). METHODS: The study was conducted with three different groups of participants: patients waiting for liver transplantation (N = 31 in joint evaluation and N = 30 in each of the two separate evaluation conditions); students (N = 30 in join evaluation and N = 30 in each of the two separate evaluation conditions); and healthy adults (N = 30 in joint evaluation and N = 30 in each of the two separate evaluation conditions). Participants were presented with hypothetical scenarios and asked how good (or bad) were their feelings toward one or two types of donor (e.g., human and pig). RESULTS: Patients showed a skeptical attitude toward xenotransplantation both when it was evaluated together with the human donor (P < 0.01) or when it was evaluated separately (P < 0.01). Differently, when asked to evaluate each donor separately healthy adults and students showed similar affective reactions toward the two alternatives (human organ and xenograft). CONCLUSIONS: The present study demonstrates that the evaluation context may increase the impact of affective reactions and reduce healthy people's ability to use information on the potential benefit of a novel biomedical technology. Regardless of the evaluation context, patients always rely on affective reactions and show an overall preference for the human organ.

Strengthening acceptance for xenotransplantation: the case of attraction effect.

BACKGROUND: Despite being still at the experimental level, xenotransplantation may become an effective strategy to overcome the scarcity of human organs. However, at the present time there is considerable resistance to this kind of biomedical technology. The aim of the present study was to identify novel strategies to reduce patients' negative affective reactions towards xenotransplantation helping them to understand the advantages of xenotransplantation in a more analytical fashion and increase their acceptance for this approach. METHODS: The study was conducted in a group of patients with liver cirrhosis waiting for liver transplantation. They were presented with hypothetical scenarios and asked to choose among either two or three alternative types of donor defined by their species (e.g., livers from humans vs. other species) and availability (low for human donors and high for livers from non-human species). RESULTS: Patients were unwilling to accept xenotransplantation if they were presented with livers from humans (chosen by 97.5% of participants) vs. livers from genetically modified pigs (2.5%). On the other hand, a different group of patients was significantly more willing to accept xenotransplantation if they were presented with three different types of donors: respectively, human beings (74.4%), genetically modified pigs (25.6%) and genetically modified dogs. In addition, human livers were judged significantly more attractive than genetically modified livers from pigs, monkeys, dogs, or sheep and pig livers were rated as significantly more attractive than livers from monkeys, dogs, or sheep (for all comparisons P < 0.01). CONCLUSIONS: These results demonstrate that paradigms from other fields, like decision-making, might help to communicate more effectively the potential of xenotransplantation, modulating patients' affective reactions and allowing them to understand the potential strengths of this biomedical technology.

Different neurological outcome of liver transplantation for Wilson's disease in two homozygotic twins.

Wilson's disease is a genetic disorder characterized by accumulation of copper in many organs and tissues. Phenotypic manifestations are wide-ranging from neuropsychiatric disorders, to severe liver disease requiring liver transplantation. Clinical presentation is not often related to the genetic defect and siblings may have different type of disease. Liver transplantation is indicated for all patients with Wilson's disease and decompensated liver cirrhosis unresponsive to medical therapy, but its efficacy in resolving the neurological symptoms is still controversial, because as far now, very different outcomes have been reported. We describe here on the exceptional case of two homozygotic twins, both with liver cirrhosis due to Wilson's disease, one of them with severe neuropsychiatric involvement, who both underwent liver transplantation and subsequently had very different outcome despite same genetic background. The presence of neurological clinical manifestations in Wilson's disease should recommend caution indicating liver transplantation, because irreversible brain damage may exist.

Occurrence of post-transplant lymphoproliferative disorders among over thousand adult recipients: any role for hepatitis C infection?

BACKGROUND: Post-transplant lymphoproliferative disorders represent an increasingly important complication of organ transplantation. Although the majority of the post-transplant lymphoproliferative disorder are etiologically related to Epstein-Barr virus infection other factors may play a role. Hepatitis C virus may induce clonal expansion of B-lymphocytes and has been associated with extrahepatic lymphoproliferative disorders. OBJECTIVES: In this study, we have evaluated: (i) the prevalence of post-transplant lymphoproliferative disorder; (ii) presence of Epstein-Barr virus in post-transplant lymphoproliferative disorder tissue; and (iii) the potential association between post-transplant lymphoproliferative disorder development and hepatitis C virus infection in a large cohort of adult solid organ transplant recipients. METHODS: The study involved 1011 liver, heart and kidney-transplanted patients. Different immunosuppression therapy was recorded from all patients, all were screened for hepatitis C virus infection. When post-transplant lymphoproliferative disorder developed, Epstein-Barr virus encoded RNA by in-situ hybridization and EBNA-1 and gp220 by polymerase chain reaction was assessed in tissue samples. RESULTS: The overall prevalence of post-transplant lymphoproliferative disorder was 1.4% (2.5% in heart, 0.9% in liver and 0.8% in kidney-transplanted patients) and significantly higher in hepatitis C virus positive than in hepatitis C virus negative patients (3.6 % vs 1.2 %; P=0.04). Epstein-Barr virus was present in 10 (77%) out of 13 tumors tested. Two out of three Epstein-Barr virus-negative post-transplant lymphoproliferative disorder developed in hepatitis C virus-positive patients. Thirteen out of 15 (86%) post-transplant lymphoproliferative disorder patients had undergone antithymocyte globulin/OKT3 induction therapy. CONCLUSIONS: Epstein-Barr virus, induction immunosuppression, rejection therapy and also hepatitis C virus infection may play a role in the multifactorial pathogenesis of post-transplant lymphoproliferative disorder.

Clean Colon Software Program (CCSP), Proposal of a standardized Method to quantify Colon Cleansing During Colonoscopy: Preliminary Results.

BACKGROUND AND STUDY AIMS: Neoplastic lesions can be missed during colonoscopy, especially when cleansing is inadequate. Bowel preparation scales have significant limitations and no objective and standardized method currently exists to establish colon cleanliness during colonoscopy. The aims of our study are to create a software algorithm that is able to analyze bowel cleansing during colonoscopies and to compare it to a validate bowel preparation scale. PATIENTS AND METHODS: A software application (the Clean Colon Software Program, CCSP) was developed. Fifty colonoscopies were carried out and video-recorded. Each video was divided into 3 segments: cecum-hepatic flexure (1st Segment), hepatic flexure-descending colon (2nd Segment) and rectosigmoid segment (3rd Segment). Each segment was recorded twice, both before and after careful cleansing of the intestinal wall. A score from 0 (dirty) to 3 (clean) was then assigned by CCSP. All the videos were also viewed by four endoscopists and colon cleansing was established using the Boston Bowel Preparation Scale. Interclass correlation coefficient was then calculated between the endoscopists and the software. RESULTS: The cleansing score of the prelavage colonoscopies was 1.56 ±â€Š0.52 and the postlavage one was 2,08 ±â€Š0,59 (P < 0.001) showing an approximate 33.3 % improvement in cleansing after lavage. Right colon segment prelavage (0.99 ±â€Š0.69) was dirtier than left colon segment prelavage (2.07 ±â€Š0.71). The overall interobserver agreement between the average cleansing score for the 4 endoscopists and the software pre-cleansing was 0.87 (95 % CI, 0.84 - 0.90) and post-cleansing was 0.86 (95 % CI, 0.83 - 0.89). CONCLUSIONS: The software is able to discriminate clean from non-clean colon tracts with high significance and is comparable to endoscopist evaluation.

Torque Teno Virus: any pathological role in liver transplanted patients?

Few studies have been performed on the prevalence of Torque Teno Virus (TTV) infection in liver transplant (LT) recipients. The aim of this study was to assess the prevalence, viremia and genogroup pattern of TTV among LT patients and to ascertain whether TTV causes liver damage in liver transplanted patients with biochemical and histological changes of unknown origin. Twenty-five patients were evaluated before and after LT; 80 healthy subjects were considered as controls. Serum samples were serially obtained from all the patients before LT and thereafter at 3, 6 and 12 months post-transplant. Serum TTV-DNA and genogroups were assessed by PCR. Patients underwent protocol serial liver biopsies at 6 and 12 months after LT. Results were compared using the Chi-squared tests, McNemar's and Student's t-tests. TTV-DNA was found in 25/25 patients before LT and in 60/80 blood donors (P < 0.01). The TTV-DNA load increased significantly after LT (P < 0.001). TTV-DNA was significantly higher in patients on calcineurin inhibitors (CNI) and azathioprine or mycophenolate mofetil than in patients on CNI alone (P = 0.04) at 3 months after LT. Genogroup analysis showed a significant increase in genogroup 5 positivity after LT. No differences were seen in the viremia of patients compared according to their viral versus other etiologies of their liver disease before transplantation. Viremia and TTV genotype patterns did not correlate with the presence of hypertransaminasemia or histological liver damage of unknown etiology. The prevalence of TTV-DNA was significantly higher in patients with liver cirrhosis than in controls and the viral load was significantly higher after LT than beforehand. On the basis of our data, TTV does not seem to cause liver damage following LT, although larger studies with a long-term follow up are needed to confirm these findings.

Influence of steroids on HCV recurrence after liver transplantation: A prospective study.

BACKGROUND/AIMS: To assess the effect of long-term maintenance of steroids on HCV recurrence after liver transplantation (LT), that is still controversial, a prospective multicentre trial was conducted at the centres of Bologna and Padua, Italy. METHODS: From September 2002, 47 eligible HCV positive LT recipients were randomized to receive 2 different steroid schedules in association with tacrolimus: group A: rapid tapering and withdrawal 91 days after LT group B: slow tapering and withdrawal 25 months after LT. Thirty-nine patients were assessable: 23 in group A and 16 in group B. Donor and recipient characteristics were similar in the two groups. Median follow-up was 841 days (130-1376). One hundred liver biopsies were performed, and every patient had a biopsy at month 12. RESULTS: Twenty-two out of 23 (95, 65%) patients in group A and 15 out of 16 (93, 75%) in group B had histologically-confirmed HCV recurrence. Twelve-month histology showed advanced fibrosis (score 3 or 4) in 42.1% of the patients in group A versus 7.6% in group B (P=0.03). One-and 2-year advanced fibrosis-free survival were 65.2 and 60.8 in group A and 93.7% in group B (P=0.03 and =0.02, respectively). CONCLUSIONS: Slow tapering of steroids reduced the progression of recurrent hepatitis C after LT.

Understanding of and attitudes to organ donation and transplantation: a survey among Italian university students.

BACKGROUND: Students have a positive attitude to organ donation and transplantation, usually associated with their personal willingness to donate their organs after death. The aim of this study was to evaluate the opinions of university students on transplantation and organ donation, at a single Italian university. METHODS: University undergraduates attending the first year on five different courses in 2001 were surveyed at Padua University by using an anonymous 13-item questionnaire. RESULTS: 97.2% of the students completed the questionnaire (77.4% females, mean age 20.4 yr); they were attending Medicine (33.8%), Agriculture (5.9%), Veterinary Medicine (11.4%), Psychology (18.5%) and Educational Sciences (30.4%). The majority was aware of the problem of the paucity of organ donations and deaths on the waiting list in Italy. Most students would accept transplantation in the case of a human donor (97%), an artificial organ (95%) or an animal donor (76%); and 87% of them were prepared to donate their own organs after death. No differences were seen when students attending science courses were compared with those attending art courses. Italian university students have a very positive attitude and willingness to donate their own organs after death, with no differences emerging as regards type of university education.

Understanding of and attitude to xenotransplantation among Italian university students: impact of a 3-yr university course.

BACKGROUND: Young people, and students in particular, generally have a positive attitude to xenotransplantation. We reported previously that university students attending their first year approved of the idea of transplanting animal organs into humans. The aim of this study was to evaluate the impact of a 3-yr course at various faculties on the university students' understanding of and attitude to xenotransplantation. METHODS: University students in their fourth year at five different faculties of Padua University (Italy), who had previously been surveyed in exactly the same way 3 yr earlier, were re-administered an anonymous 19-item questionnaire on their attitude to xenotransplantation. RESULTS: A total of 453 students completed the fourth year questionnaire (84 males, 369 females; mean age 24.6 yr, range 21-36 yr). Students were attending courses in Medicine (22.1%), Veterinary Science (16.5%), Agriculture (10.4%), Educational Sciences (22.1%) and Psychology (28.9%). In their fourth year, 85% of the students knew that animal organs could, at some stage, be transplanted into humans, 81.5% approved of this idea and 84% would accept an animal organ to save their life if necessary (these percentages were 88%, 78% and 76%, respectively 3 yr earlier). A significantly larger proportion of the students who approved of xenotransplantation were attending science courses rather than art courses, while no differences emerged as regards gender. Those who refused xenotransplantation justified their position mainly on ethical-moral (41.7%) and immunological (35.7%) grounds. CONCLUSION: As in their first year, so too in their fourth, University students were well informed about the feasibility of transplanting animal organs into human beings and those attending science courses were more likely to accept this idea than art students. Approval of xenotransplantation was much the same among fourth year males and females, whereas in the first year, male students had approved more than female students.

Understanding of and attitudes to xenotransplantation: a survey among Italian university students.

UNLABELLED: Xenotransplantation is currently at the experimental stages on animal models and many problems still have to be overcome in the biomedical, immunological and ethical fields. Moreover, people's attitudes to xenotransplantation vary: surveys among intensive-care staff have revealed negative opinions, while the general public and students seem to be more positive. Little is known about the influence of schooling and the choice of university faculty on attitudes to xenotransplantation. The aims of this study were: (i) to evaluate university students' attitudes to xenotransplantation; (ii) to investigate any socio-demographic, religious and educational determinants behind students' opinions on xenotransplantation. University undergraduates on five different courses were surveyed at Padua University. A 24-item questionnaire was distributed to students at the end of lectures and completed anonymously immediately after its distribution. No information was given to students beforehand. STATISTICAL ANALYSIS: chi-squared, Pearson's test; P-values <0.05 were considered significant. A total of 585 of 602 (97.2%) students completed the questionnaire (132 males, 453 females, mean age 20.4, range 19 to 43 yr). They were on courses in Medicine (33.85%), Agriculture (5.98%), Veterinary Medicine (11.45%), Psychology (18.46%) and Educational Sciences (30.26%). As for their previous schooling, they came from classical or scientific high school (58.3%), technical college (14.7%), language college (6.3%), teacher training college (11.9%) or others (8.8%). Concerning their religious beliefs, 83% were Catholics, and 56.2% defined themselves as practising Catholics. Eighty-eight percentage of the students knew of the possibility of animal organs being transplanted into humans and 77.9% of them approved of this idea. When grouped according to gender and education, a higher proportion of students approving of xenotransplantation were male (P = 0.017) and had attended classical or scientific high school (P = 0.011). Disapproval for moral, ethical or religious reasons was higher among practising than among non-practising Catholics; the latter rejected xenotransplantation more for immunological and infectious reasons (P = 0.014). As for the type of university course, a higher proportion of students approving of xenotransplantation attended science courses (Veterinary Medicine, Agriculture and Medicine vs. Educational Sciences and Psychology) (P = 0.013). University students generally approved of xenotransplantation. Male gender and a high-school education were associated with a greater acceptance of xenotransplantation. Practising vs. non-practising Catholics reported significantly different reasons for any disapproval of xenotransplantation. The choice of a science rather than an arts faculty at university was more strongly associated with a positive opinion on xenotransplantation.