Probiotics and Evidence-based Medicine: To All Involved: We have a Problem.

The methods used to discern the structure (anatomy) and function (physiology) of the indigenous microbiota can be divided according to which aspect of the microbiota they can interrogate and are positioned accordingly. At the most basic level, methods can simply describe the community structure of the microbiota, that is, which taxa are present and in what relative amounts. Methods that investigate functional potential generally catalog the coding potential of individual members of the microbiota or the entire community (the metagenome). To measure function directly a catalog of the expressed microbial genes (the metatranscriptome) or the proteins or metabolites present in the microbiome environment must be generated. So, complexity in understanding the role of microbiota is quite rejecting the interested clinician. Evidence-based medicine can offer an answer suggesting strict definition of populations, measurement techniques, and external validity.

Gut Microbiota and the Liver: A Tale of 2 Cities: A Narrative View in 2 Acts.

Microbes are mostly important for the digestion of food, the absorption of some micronutrients, and the production of vitamins. The microbiota stimulates lymphoid structures in the gastrointestinal mucosa and decrease pathogens by competing for nutrients and space. Bacterial translocation is defined as the escape of gut bacteria and their products through the intestinal mucosa to the outside of the intestine as portovenous or systemic circulation. This is induced by a leaky gut barrier. There is evidence for a role of intestinal permeability in the pathogenesis of nonalcoholic fatty liver disease. In the liver, bacterial products can bind to their specific pathogen recognition receptors on parenchymal and nonparenchymal cells, producing an inflammatory response and enhancing disease progression. When binding, bacterial products bind to their receptors, initiating intracellular signalling and inducing an inflammatory cascade, thus accelerating liver cell damage and fibrosis. However, the liver can also increase gut permeability, producing proinflammatory cytokines, and reversing them into the blood stream. Modification of the gut microbiota could lead to benefit in patients with liver disease. Nonabsorbable antibiotics (rifaximin) prevent and relieve overt encephalopathy. Probiotics alone are not capable of turning back overt encephalopathy, but could prevent its development. There is some evidence that probiotics could relent the progression of nonalcoholic liver disease, and possibly reverse steatosis. Antibiotics, such as fluoroquinolones, reduce the risk of development of the first episode of spontaneous bacterial peritonitis and mortality in cirrhotic patients.

Predicting mortality in patients with in-hospital nonvariceal upper GI bleeding: a prospective, multicenter database study.

BACKGROUND: Nonvariceal upper GI bleeding (NVUGIB) that occurs in patients already hospitalized for another condition is associated with increased mortality, but outcome predictors have not been consistently identified. OBJECTIVE: To assess clinical outcomes of NVUGIB and identify predictors of mortality from NVUGIB in patients with in-hospital bleeding compared with outpatients. DESIGN: Secondary analysis of prospectively collected data from 2 nationwide multicenter databases. Descriptive, inferential, and multivariate logistic regression models were carried out in 338 inpatients (68.6 ± 16.4 years of age, 68% male patients) and 1979 outpatients (67.8 ± 17 years of age, 66% male patients). A predictive model was constructed using the risk factors identified at multivariate analysis, weighted according to the contribution of each factor. SETTINGS: A total of 23 Italian community and tertiary care centers. PATIENTS: Consecutive patients admitted for acute NVUGIB. INTERVENTIONS: Early endoscopy, medical and endoscopic treatment as appropriate. MAIN OUTCOME MEASUREMENTS: Recurrent bleeding, surgery, and 30-day mortality. RESULTS: The mortality rate in patients with in-hospital bleeding was significantly higher than that in outpatients (8.9% vs 3.8%; odds ratio [OR] 2.44; 95% confidence interval [CI], 1.57-3.79; P < .0001). Hemodynamic instability on presentation (OR 7.31; 95% CI, 2.71-19.65) and the presence of severe comorbidity (OR 6.72; 95% CI, 1.87-24.0) were the strongest predictors of death for in-hospital bleeders. Other independent predictors of mortality were a history of peptic ulcer disease and failed endoscopic treatment. Rebleeding was a strong predictor of death only for outpatients (OR 5.22; 95% CI, 2.45-11.10). Risk factors had a different prognostic impact on the 2 populations, resulting in a significantly different prognostic accuracy of the model (area under the receiver-operating characteristic curve = 0.83; 95% CI, 0.77-0-93 vs 0.74; 95% CI, 0.68-0.80; P < .02). LIMITATIONS: Study design not experimental, no data on ward specialty, potential referral bias. CONCLUSIONS: In-hospital bleeders have a significantly higher risk of death because they are sicker and more often hemodynamically unstable than outpatients. Predictors of death have a different impact in the 2 populations.

[Environmental factors and clinical course of inflammatory bowel disease: which evidences?]. / Impatto dei fattori ambientali sul decorso delle malattie infiammatorie croniche dell'intestino: quali evidenze?

Identify environmental factors that can influence the course of inflammatory bowel disease (IBD) is of great interest since managing on these factors might improve the prognosis of patients. No environmental factor has been shown to have a linear cause-and-effect link with the relapse of the disease, but many environmental factors (smoking, diet, medications, stress, etc.) seem to play a plausible role in influencing the clinical course of IBD. The aim of this review is to describe the current evidence of the impact of different environmental factors on the long-term course of IBD and to give practical indications that can help doctors and patients in the management of IBD.

Neoadjuvant chemo-radiotherapy for patients with borderline resectable pancreatic cancer: a meta-analytical evaluation of prospective studies.

CONTEXT: For patients with borderline resectable pancreatic cancer, the benefit of neoadjuvant therapy remains to be defined. OBJECTIVE: We did a systematic search of the literature on this topic. METHODS: Prospective studies where chemotherapy with or without radiotherapy was given before surgery to patients with borderline resectable cancer, were analyzed by a meta-analytical approach. MAIN OUTCOME MEASURES: Primary outcome was surgical exploration and resection rates; tumor response, therapy-induced toxicity, and survival were secondary outcomes. Data were expressed as weighted pooled proportions with 95% confidence intervals (95% CI). RESULTS: Ten studies with 182 participants were included. Following treatment, 69% of patients (95% CI: 56-80%) were brought to surgery and 80% (95% CI: 66-90%) of surgically-explored patients were resected. Eighty-three percent (95% CI: 74-90%) of resected specimens were deemed R0 resections. The weighted fractions of resected patients alive at 1 and 2 years were 61% (95% CI: 48-100%) and 44% (95% CI: 32-59%), respectively. At restaging following neoadjuvant therapy, weighted frequencies for complete/partial response were 16% (95% CI: 9-28%), 69% (95% CI: 60-76%) for stable disease, and 19% (95% CI: 13-25%) for progressive cancer. Treatment-related grade 3-4 toxicity was 32% (95% CI: 21-45%). CONCLUSION: This meta-analysis shows that downstaging of the lesion following neoadjuvant therapies is uncommon for patients with borderline resectable pancreatic cancer. A clear benefit of this regimen could be to spare surgery to patients with progressive disease during the frame-time chemo-radiotherapy is being delivered.

[Prevention of post-operative recurrence in Crohn's disease: a critical review of randomized controlled trials and meta-analyses of different therapeutic strategies]. / La prevenzione della recidiva post-chirurgica nella malattia di Crohn. Revisione degli studi clinici controllati e delle meta-analisi sulle strategie terapeutiche.

Surgery is an almost inevitable event in Crohn's disease but is not curative; post-operative recurrence follows a sequential and predictable course. Prevention of post-operative recurrence in Crohn's disease is therefore a relevant problem in the management of the disease. Several drugs have been evaluated to decrease the risk of recurrence: these include mesalazine, antibiotics, probiotics, budesonide, thiopurines and biologic agents. This review focuses on the randomised controlled trials and meta-analyses addressing different drugs and strategies for preventing post-operative recurrence in Crohn's disease.

Neoadjuvant/preoperative gemcitabine for patients with localized pancreatic cancer: a meta-analysis of prospective studies.

BACKGROUND: Long-term prognosis for localized pancreatic cancer remains poor. We sought to assess the benefit of neoadjuvant/preoperative chemotherapy with or without radiotherapy. METHODS: Prospective studies where gemcitabine with or without radiotherapy was provided before surgery in patients with initially resectable or unresectable disease were reviewed by meta-analysis. Primary outcome was survival, and secondary outcomes were tumor response after therapy, toxicity, surgical exploration, and resection rates. RESULTS: Twenty independent studies with 707 participants were included, 366 with resectable lesions and 341 with unresectable lesions. Seven studies were phase I/II trials, 10 phase II, and 3 prospective cohort studies. Estimated 1- and 2-year survival probabilities after resection were 91.7% (95% confidence interval [CI] 75-100) and 67.2% (95% CI 38-87) for initially resectable patients, and 86.3% (95% CI 78-100) and 54.2% (95% CI 25-100) for initially unresectable patients. The complete/partial response rate was 12% (95% CI 4-23) and 27% (95% CI 18-38) in resectable and unresectable lesions, respectively. The rate of treatment-related grade 3-4 toxicity was 31% (95% CI 21-42). Of resectable patients evaluable after restaging, 91% (95% CI 83-97) underwent surgery, and 82% (95% CI 65-95) of explored patients underwent resection. R0 resections amounted to 89% (95% CI 83-94). Of unresectable patients evaluable after restaging, 39% (95% CI 28-50) underwent surgery, and 68% (95% CI 53-82) of explored patients were resected, with 60% (95% CI 50-71) R0 resections. CONCLUSIONS: Current analysis provides marginal support to the assumed benefits of neoadjuvant therapies for patients with resectable cancer, and indicates a potential advantage only for a minority of those with unresectable lesions.

Mortality from nonulcer bleeding is similar to that of ulcer bleeding in high-risk patients with nonvariceal hemorrhage: a prospective database study in Italy.

BACKGROUND: Nonulcer causes of bleeding are often regarded as minor, ie, associated with a lower risk of mortality. OBJECTIVE: To assess the risk of death from nonulcer causes of upper GI bleeding (UGIB). DESIGN: Secondary analysis of prospectively collected data from 3 national databases. SETTINGS: Community and teaching hospitals. PATIENTS: Consecutive patients admitted for acute nonvariceal UGIB. INTERVENTIONS: Early endoscopy, medical and endoscopic treatment as appropriate. MAIN OUTCOME MEASUREMENTS: Thirty-day mortality, recurrent bleeding, and need for surgery. RESULTS: A total of 3207 patients (65.8% male), mean (standard deviation) age 68.3 (16.4) years, were analyzed. Overall mortality was 4.45% (143 patients). According to the source of bleeding, mortality was 9.8% for neoplasia, 4.8% for Mallory-Weiss tears, 4.8% for vascular lesions, 4.4% for gastroduodenal erosions, 4.4% for duodenal ulcer, and 3.1% for gastric ulcer. Frequency of death was not different among benign endoscopic diagnoses (overall P = .567). Risk of death was significantly higher in patients with neoplasia compared with benign conditions (odds ratio 2.50; 95% CI, 1.32-4.46; P < .0001). Gastric or duodenal ulcer significantly increased the risk of death, but this was not related to the presence of high-risk stigmata (P = .368). The strongest predictor of mortality for all causes of nonvariceal UGIB was the overall physical status of the patient measured with the American Society of Anesthesiologists score (1-2 vs 3-4, P < .001). LIMITATIONS: No data on the American Society of Anesthesiologists class score in the Prometeo study. CONCLUSIONS: Nonulcer causes of nonvariceal UGIB have a risk of death, similar to bleeding peptic ulcers in the clinical context of a high-risk patient.

Diagnosis, treatment and survival of patients with hepatorenal syndrome: a survey on daily medical practice.

BACKGROUND & AIMS: Hepatorenal syndrome (HRS) is a severe complication of cirrhosis with ascites. The International Ascites Club recommended strict diagnostic criteria and treatment with vasoconstrictors and albumin. Aim of this prospective cohort study was to investigate the prevalence of HRS, diagnostic criteria, treatment and 3-month outcome in the daily-clinical-practice. METHODS: Two-hundred-fifty-three patients with cirrhosis and renal failure consecutively admitted to 21 Italian hospitals were recruited. RESULTS: The prevalence of HRS was 45.8% (30% type-1 and 15.8% type-2). In 36% of cases HRS was presumed because not all diagnostic criteria could be fulfilled. In 8% of cases HRS was superimposed on an organic nephropathy. Patients with HRS type-1 were younger and showed higher leukocyte count, higher respiratory rates, and worse liver function scores. Sixty-four patients with HRS type-1 received vasoconstrictors (40 terlipressin and 24 midodrine/octreotide). A complete response was obtained in 19 cases (30%) and a partial response in 13 (20%). Age was the only independent predictor of response (p=0.033). Three-month survival of patients with HRS type-1 was 19.7%. Survival was better in patients who responded to therapy. Age (p=0.017), bilirubin (p=0.012), and creatinine increase after diagnostic volume expansion (p=0.02) independently predicted death. The mortality rate was 97% among patients with at least two negative predictors. CONCLUSIONS: The diagnostic criteria of HRS in our daily-clinical-practice could not be completely fulfilled in one third of cases. The treatment with vasoconstrictors and albumin was widely implemented. Mortality was strongly predicted by simple baseline variables.

Artificial neural networks accurately predict mortality in patients with nonvariceal upper GI bleeding.

BACKGROUND: Risk stratification systems that accurately identify patients with a high risk for bleeding through the use of clinical predictors of mortality before endoscopic examination are needed. Computerized (artificial) neural networks (ANNs) are adaptive tools that may improve prognostication. OBJECTIVE: To assess the capability of an ANN to predict mortality in patients with nonvariceal upper GI bleeding and compare the predictive performance of the ANN with that of the Rockall score. DESIGN: Prospective, multicenter study. SETTING: Academic and community hospitals. PATIENTS: This study involved 2380 patients with nonvariceal upper GI bleeding. INTERVENTION: Upper GI endoscopy. MAIN OUTCOME MEASUREMENTS: The primary outcome variable was 30-day mortality, defined as any death occurring within 30 days of the index bleeding episode. Other outcome variables were recurrent bleeding and need for surgery. RESULTS: We performed analysis of certified outcomes of 2380 patients with nonvariceal upper GI bleeding. The Rockall score was compared with a supervised ANN (TWIST system, Semeion), adopting the same result validation protocol with random allocation of the sample in training and testing subsets and subsequent crossover. Overall, death occurred in 112 cases (4.70%). Of 68 pre-endoscopic input variables, 17 were selected and used by the ANN versus 16 included in the Rockall score. The sensitivity of the ANN-based model was 83.8% (76.7-90.8) versus 71.4% (62.8-80.0) for the Rockall score. Specificity was 97.5 (96.8-98.2) and 52.0 (49.8 4.2), respectively. Accuracy was 96.8% (96.0-97.5) versus 52.9% (50.8-55.0) (P<.001). The predictive performance of the ANN-based model for prediction of mortality was significantly superior to that of the complete Rockall score (area under the curve 0.95 [0.92-0.98] vs 0.67 [0.65-0.69]; P<.001). LIMITATIONS: External validation on a subsequent independent population is needed, patients with variceal bleeding and obscure GI hemorrhage are excluded. CONCLUSION: In patients with nonvariceal upper GI bleeding, ANNs are significantly superior to the Rockall score in predicting the risk of death.

[2020: Evidence-Based Medicine odyssey. The fall and rise of evidence-based medicine in the year of coronavirus.] / Odissea per la evidence-based medicine. Caduta e rinascita nell'anno del coronavirus.

It was a very dark year for EBM. One of the side effects of the Covid-19 pandemic is a severe compression of the evidences. Here are some worrying events. May 2020: the saga of hydroxychloroquine. October 2020: the nitazoxanide case. November 2020: Trump Administration Interferes on Expert Opinion. December 2020: the results of the trials on the first two vaccines were announced in press releases, leaving many scientific uncertainties. Peter Piot, head of the London School of Hygiene & Tropical Medicine noted that none of the CoViD-19 vaccines have offered much data to date. «It is frustrating that all of these announcements are delivered via press release, and not give us a chance to review the actual data. We desperately need total transparency on evidence and data¼, says Piot. Better now to relaunch the spread of EBM. In the issue, we have included the best EBM-based readings from the Club for Evidence-Based in Gastroenterology & Hepatology (ebgh.it).

["Probiotic medicine" and certainty of the evidence.] / "Probiotic medicine" e certezza delle evidenze.

These are excellent times for probiotic medicine. We have discovered more than 150,000 genomes of the microbiome, which can be aggregated into 4,930 species. However, the dream of microbiome-based medicine requires a new approach - an ecological and evolutionary understanding of host-microbe interactions, rather than a qualitative analysis of species. Yet researchers still disagree on what constitutes a healthy microbiome or how to define an altered one. There is still uncertainty as to which properties of the microbiome will represent the most informative biomarkers in clinical and epidemiological studies. And little is known about how the microbiomes of different regions of the body, such as the mouth, intestines or skin, interact. It is time to re-establish the foundations for the certainty of evidence in myocrobiome-based medicine. We believe robust new pillars are needed: starting clinical trials whenever possible; extending the role of N-of-1 trials; ending the "one probiotic for every disease" principle; reduce the number of outcomes of each research; search for the replicability of the results (the best test for the validity of an intervention with probiotics is not statistical significance but the replication of the result). Again, we would like to urge probiotic medicine researchers not to publish in "pirate" journals.

[Side effects of antibiotic: diarrhea and Clostridium difficile infection.] / Effetti collaterali degli antibiotici. Diarrea da antibotici e colite da Clostridium difficile.

Antibiotics are some of the most frequently prescribed medications worldwide, but antibiotic therapy may disturb the colonization resistance of gut microbiota to pathogenic bacteria, resulting in a range of symptoms that include, most notably, diarrhea that occurs between 7% and 33% of adults and 66 and 80% in pediatric patients (median of 22%) who take antibiotics. The diverse class of antibiotics may damage the metabolic homeostasis and can alter the level of intestinal metabolites including amino acids, bile acids, glucose, short chain fatty acids through alteration in abundance of metabolically active bacteria. Clostridium difficile is the main cause of antibiotics associated diarrhea: 3rd generation Cephalosporin, Clyndamicin, 2nd and 4th generation Cephalosporines, Sulfamethoxazole-trimethoprim, Quinolones, Penicillin combination show the strongest association with diarrhea.

[Clostridium difficile infection and chronic inflammatory bowel disease.] / Infezione da Clostridium difficile e malattie infiammatorie croniche intestinali.

Patients with IBD are at increased risk of developing Clostridium difficile (CD) infection and have worse outcomes, including higher rates of colectomy and death, and experience higher rates of recurrence. However, it is still not clear whether CD is a cause of IBD or a consequence of the inflammatory state and of intestinal dysbiosis. The association between IBD and CD may be due to different factors, such as drugs that are used for the treatment of IBD, including repeat courses of antibiotics, that might alter the intestinal flora and promote colonization, altered immune and nutritional status, frequent hospitalizations, and even genetic predisposition. It has been suggested that up to 20% of IBD flares were associated with testing positive for CD and retrospective studies demonstrated doubling of the infection incidence among patients with Crohn Disease, and a 3-fold increase among those with Ulcerative Colitis. They have also shown that the CD infection incidence among IBD patients is estimated as being 3-fold higher than that in the general population. Decreased intestinal microbial diversity along with an inadequate immune response is thought to play a causative role in the development of CD infection.

[Probiotics for the antibiotics associated diarrhea and for Clostridium difficile infection.] / Probiotici per la diarrea da antibiotici e per l'infezione da Clostridium difficile.

The term probiotic refers to live microorganisms that survive passage through the gastrointestinal tract and have beneficial effects on the host. Many strains of probiotic microorganisms have been shown to inhibit growth and metabolic activity as well as the adhesion to intestinal cells of enteropathogenic bacteria, to modulate the gut microbiota and to have immunostimulatory or regulatory properties. The use of probiotic microorganisms for the prevention and the treatment of Antibiotic Associated Diarrhea is an obvious measure and perhaps the most usual application of probiotics. This overview summarizes the most commonly used probiotic microorganisms for DAA and IBD.

Predicting mortality in non-variceal upper gastrointestinal bleeders: validation of the Italian PNED Score and Prospective Comparison with the Rockall Score.

OBJECTIVES: We sought (i) to validate a new prediction rule of mortality (Progetto Nazionale Emorragia Digestiva (PNED) score) on an independent population with non-variceal upper gastrointestinal bleeding (UGIB) and (ii) to compare the accuracy of the Italian PNED score vs. the Rockall score in predicting the risk of death. METHODS: We conducted prospective validation of analysis of consecutive patients with UGIB at 21 hospitals from 2007 to 2008. Outcome measure was 30-day mortality. All the variables used to calculate the Rockall score as well as those identified in the Italian predictive model were considered. Calibration of the model was tested using the chi2 goodness-of-fit and performance characteristics with receiver operating characteristic (ROC) analysis. The area under the ROC curve (AUC) was used to quantify the diagnostic accuracy of the two predictive models. RESULTS: Over a 16-month period, data on 1,360 patients were entered in a national database and analyzed. Peptic ulcer bleeding was recorded in 60.7% of cases. One or more comorbidities were present in 66% of patients. Endoscopic treatment was delivered in all high-risk patients followed by high-dose intravenous proton pump inhibitor in 95% of them. Sixty-six patients died (mortality 4.85%; 3.54-5.75). The PNED score showed a high discriminant capability and was significantly superior to the Rockall score in predicting the risk of death (AUC 0.81 (0.72-0.90) vs. 0.66 (0.60-0.72), P<0.000). Positive likelihood ratio for mortality in patients with a PNED risk score >8 was 16.05. CONCLUSIONS: The Italian 10-point score for the prediction of death was successfully validated in this independent population of patients with non-variceal gastrointestinal bleeding. The PNED score is accurate and superior to the Rockall score. Further external validation at the international level is needed.

Oral beclomethasone dipropionate as an alternative to systemic steroids in mild to moderate ulcerative colitis not responding to aminosalicylates.

BACKGROUND: Aminosalicylates (5-ASA) are first-line treatment for mild-moderate ulcerative colitis (UC). Systemic corticosteroids (CS) are considered for patients in whom 5-ASA has been unsuccessful, but their use is limited by adverse effects. Beclomethasone dipropionate (BDP), a topically acting steroid with low systemic bioavailability, has a more favorable safety profile, but its role in clinical practice is not yet well established. AIM: The aim of the present study is to assess whether oral BDP can be an alternative treatment to systemic CS for patients with mild-moderate UC not responding to first-line therapy with 5-ASA. METHODS: From 2003 to 2006, all consecutive patients with mild-moderate UC unresponsive to oral and topical 5-ASA (+/-topical CS) administered for at least 3 weeks received an 8-week course of oral BDP (10 mg/day for 4 weeks and 5 mg/day for an additional 4 weeks). Co-primary end-points were: (1) clinical remission within 8 weeks, without need of systemic CS; (2) steroid-free remission for 12 months. RESULTS: Sixty-four patients were included. In this study, within 8 weeks, 48/64 patients (75%) entered remission without systemic CS, while 16/64 (25%) failed to enter remission. Within 12 months, 37/64 patients (58%) had prolonged steroid-free remission, while 11/64 (17%) relapsed. During 1 year, 75% of patients receiving oral BDP could avoid systemic CS. CONCLUSIONS: Oral BDP can avoid the use of systemic CS in the vast majority of patients with mild-moderate UC not responding to 5-ASA and could be considered as a second-line treatment for these patients.

Predictive factors of mortality from nonvariceal upper gastrointestinal hemorrhage: a multicenter study.

OBJECTIVES: From an Italian Registry of patients with upper gastrointestinal hemorrhage (UGIH), we assessed the clinical outcomes and explored the roles of clinical, endoscopic, and therapeutic factors on 30-day mortality in a real life setting. METHODS: Prospective analysis of consecutive patients endoscoped for UGIH at 23 community and tertiary care institutions from 2003 to 2004. Covariates and outcomes were defined a priori and 30-day follow-up obtained. Logistic regression analysis identified predictors of mortality. RESULTS: One thousand and twenty patients were included. A total of 46 patients died for an overall 4.5% mortality rate. In all, 85% of deaths were associated with one or more major comorbidity. Sixteen of 46 patients (35%) died within the first 24 h of the onset of bleeding. Of these, eight had been categorized as ASA class 1 or 2 and none of them was operated upon, despite a failure of endoscopic intention to treatment in four. Regression analysis showed advanced age, presence of severe comorbidity, low hemoglobin levels at presentation, and worsening health status as the only independent predictors of 30-day mortality (P < 0.001). The acute use of a PPI exerted a protective effect (OR 0.23, 95% CI 0.09-0.73). Recurrent bleeding was low (3.2%). Rebleeders accounted for only 11% of the total patients deceased (OR 3.27, 95% CI 1.5-11.2). CONCLUSIONS: These results indicate that 30-day mortality for nonvariceal bleeding is low. Deaths occurred predominantly in elderly patients with severe comorbidities or those with failure of endoscopic intention to treatment.

[Promoting evidence-based gastroenterology: back to the future.] / Per una gastroenterologia basata sulle evidenze: ritorno al futuro.

Evidence-based medicine continues to thrive thanks to the publication of a considerable amount of papers focusing on data collection and sharing. Assessment of the accuracy of diagnostic tests still remains highly deficient, often leading to inappropriate clinical decision-making. Like most other doctors, gastroenterologists as well have to face the ever-growing availability of complex and expensive exams, being charged with the task of choosing the best diagnostic option and interpreting test results. It is therefore advisable to provide specialists with the tools they need to evaluate the available literature data. Among these, it deserves mentioning the residential courses organized by the Evidence-based Gastroenterology & Hepatology Club, which have been attended by hundreds of participants over the last years.