Repeated endoscopic ultrasound-guided fine-needle biopsy of solid pancreatic lesions after previous nondiagnostic or inconclusive sampling.

OBJECTIVES: Repeated endoscopic ultrasound (EUS)-guided tissue acquisition represents the standard practice for solid pancreatic lesions after previous nondiagnostic or inconclusive results. Since data are lacking, we aimed to evaluate the diagnostic performance of repeated EUS fine-needle biopsy (rEUS-FNB) in this setting. The primary outcome was diagnostic accuracy; sample adequacy, sensitivity, specificity, and safety were secondary outcomes. METHODS: Consecutive patients undergoing rEUS-FNB for solid pancreatic lesions at 23 Italian centers from 2019 to 2021 were retrieved. Pathology on the surgical specimen, malignant histology together with ≥6-month follow-up, and benign pathology together with ≥12-month follow-up were adopted as gold standards. RESULTS: Among 462 patients, 56.5% were male, with a median age of 68 (59-75) years, malignancy prevalence 77.0%. Tumor size was 26 (20-35) mm. Second-generation FNB needles were used in 89.6% cases. Diagnostic accuracy, sensitivity, and specificity of rEUS-FNB were 89.2%, 91.4%, and 81.7%, respectively (19 false-negative and 12 false-positive results). On multivariate analysis, rEUS-FNB performed at high-volume centers (odds ratio [OR] 2.12; 95% confidence interval [CI] 1.10-3.17; P = 0.03) and tumor size (OR 1.03; 95% CI 1.00-1.06; P = 0.05) were independently related to diagnostic accuracy. Sample adequacy was 94.2%. Use of second-generation FNB needles (OR 5.42; 95% CI 2.30-12.77; P < 0.001) and tumor size >23 mm (OR 3.04; 95% CI 1.31-7.06; P = 0.009) were independently related to sample adequacy. CONCLUSION: Repeated EUS-FNB allowed optimal diagnostic performance after nondiagnostic or inconclusive results. Patients' referral to high-volume centers improved diagnostic accuracy. The use of second-generation FNB needles significantly improved sample adequacy over standard EUS-FNB needles.

Pluvial flood adaptation using nature-based solutions: An integrated biophysical-economic assessment.

Globally, flood events are considered the costliest natural hazard. Changes in precipitation patterns and large areas of impervious surfaces in urban environments are increasing the sensitivity of these systems to runoff production. At the same time, projected global sea-level rise may further increase the frequency of compound flooding due to simultaneous storm surge, sea-level rise and pluvial runoff that cause vast socio-economic and ecological impacts to coastal cities. In this context, over the last decade, the role of Nature-Based Solutions (NBS) has been recognised to support climate change adaptation by addressing ideas of multi-functionality, non-linearity and heterogeneity in urban design. Thus, increasing awareness about NBS benefits increases the willingness to accept these solutions. However, empirical evidence of NBS effectiveness at the urban catchment scale is still subject to debate. This study develops a spatial biophysical-economic framework that allows for the integrated assessment of NBS flood risk mitigation impacts, costs and benefits in the face of climate change, combining the Integrated Valuation of Ecosystem Services and Tradeoffs (InVEST) model, benefit transfer methods and Geographic Information System (GIS) tools. Specifically, the InVEST Urban Flood Risk Mitigation model was used to assess the biophysical impacts of NBS on urban pluvial flood risk, benefit-transfer methods were used to evaluate the economic implications of such solutions, and GIS was used to integrate and map biophysical impacts and economic implications. For the case of the coastal lagoon city of Aveiro (Portugal), NBS scenarios of green roofs and bioswales under current and future climate conditions were assessed. The main findings of this study show that green roofs scenarios would save 32 % of the flood damages to buildings and infrastructures every year, while bioswales help save only 0.1 %. Moreover, green roofs implementation provides larger benefits in the future climate scenario (representative concentration pathway - RCP - 4.5). The findings confirm the extent to which knowledge on NBS benefits and costs is partial and uncertain, thus requiring constant progress through biophysical-economic assessment to support an evolutive decision making process in climate adaptation planning.

Efficacy and safety of capsule endoscopy in octogenarian patients: a retrospective study.

BACKGROUND: Life expectancy and the number of ultra-octogenarians increased significantly, thus making crucial the appropriateness of several endoscopic procedures in elderly patients. The aim of our study was to provide a retrospective analysis of the efficacy and safety of capsule endoscopy (CE) in patients aged over 80 years. METHODS: In this single-centre study, 900 patients underwent capsule endoscopy between 2002 and 2015 for different indications; of these 106 patients aged ≥80 years (group A) and 99 patients aged 40-60 years (control group B) were retrospectively selected. RESULTS: Occult gastrointestinal bleeding accounted for 62.1% of all indications for capsule endoscopy in group B, compared to 95.2% in group A (P<0.001). Although not statistically significant, the diagnostic yield was higher in group A (71%) vs. group B (62%). The percentages of reaching the cecum and the median gastric transit time were uniform within the two groups. In contrast, small bowel transit time was longer in group A vs. B. Small bowel preparation was similar in the two groups. The exam was generally well tolerated in both groups, with capsule aspiration being one of the main adverse events, which occurred in two elderly patients. CONCLUSIONS: Our data expand previous findings confirming that capsule endoscopy can be performed safely even in very old patients and show that the diagnostic yield is similar to that of younger patients.

Land Cover Classification from Very High-Resolution UAS Data for Flood Risk Mapping.

Monitoring the world's areas that are more vulnerable to natural hazards has become crucial worldwide. In order to reduce disaster risk, effective tools and relevant land cover (LC) data are needed. This work aimed to generate a high-resolution LC map of flood-prone rural villages in southwest Niger using multispectral drone imagery. The LC was focused on highly thematically detailed classes. Two photogrammetric flights of fixed-wing unmanned aerial systems (UAS) using RGB and NIR optical sensors were realized. The LC input dataset was generated using structure from motion (SfM) standard workflow, resulting in two orthomosaics and a digital surface model (DSM). The LC system is composed of nine classes, which are relevant for estimating flood-induced potential damages, such as houses and production areas. The LC was generated through object-oriented supervised classification using a random forest (RF) classifier. Textural and elevation features were computed to overcome the mapping difficulties due to the high spectral homogeneity of cover types. The training-test dataset was manually defined. The segmentation resulted in an F1_score of 0.70 and a median Jaccard index of 0.88. The RF model performed with an overall accuracy of 0.94, with the grasslands and the rocky clustered areas classes the least performant.

New Generation Express View: An Artificial Intelligence Software Effectively Reduces Capsule Endoscopy Reading Times.

BACKGROUND: Reading capsule endoscopy (CE) is time-consuming. The Express View (EV) (IntroMedic, Seoul, Korea) software was designed to shorten CE video reading. Our primary aim was to evaluate the diagnostic accuracy of EV in detecting significant small-bowel (SB) lesions. We also compared the reading times with EV mode and standard reading (SR). METHODS: 126 patients with suspected SB bleeding and/or suspected neoplasia were prospectively enrolled and underwent SB CE (MiroCam®1200, IntroMedic, Seoul, Korea). CE evaluation was performed in standard and EV mode. In case of discrepancies between SR and EV readings, a consensus was reached after reviewing the video segments and the findings were re-classified. RESULTS: The completion rate of SB CE in our cohort was 86.5% and no retention occurred. The per-patient analysis of sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of EV compared to SR were 86%, 86%, 90%, 81%, and 86%, respectively, before consensus. After consensus, they increased to 97%, 100%, 100%, 96%, and 98%, respectively. The median reading time with SR and EV was 71 min (range 26−340) and 13 min (range 3−85), respectively (p < 0.001). CONCLUSIONS: The new-generation EV shows high diagnostic accuracy and significantly reduces CE reading times.

Combined Endoscopic Stent-In-Stent Placement by Lumen-Apposing Metal Stents Through Self-Expanding Metal Stents for Simultaneous Malignant Biliary and Duodenal Obstruction.

The palliation of simultaneous biliary and duodenal obstruction in patients with advanced pancreatic cancer is a clinically and technically challenging scenario. Endoscopic procedures are a valid alternative to surgical or percutaneous transhepatic biliary drainage. The availability of self-expanding metal stents (SEMSs) and lumen-apposing metal stents (LAMS) have expanded therapeutic options. We describe a case in which biliary and duodenal obstructions were treated successfully with the combined use of SEMS and LAMS devices. Endoscopic ultrasound-guided biliary drainage with the use of new LAMS and a duodenal SEMS can be a valid option in expert hands as a palliative and minimally invasive treatment for gastric outlet and biliary obstruction.

Right-sided diverticulosis is an independent risk factor for bleeding in patients admitted for diverticular disease.

BACKGROUND: Diverticular bleeding is the main cause of lower gastrointestinal bleeding in both Eastern and Western countries. Several risk factors have been identified, such as comorbidities and concomitant medications. In Eastern population, the prevalence of right-side diverticulosis is higher than in Western one, and some Authors identified bilateral diverticulosis as a risk factor for bleeding. AIMS: To identify risk factors for diverticular bleeding in patients admitted for diverticular disease (DD). METHODS: All patients admitted for DD from January 2017 to December 2018 were retrieved from the hospital Information System. For each patient, age, gender, clinical presentation and concomitant medication were recorded. All patient underwent imaging assessment (computed tomography, ultrasound or MRI) and colonoscopy during hospitalization or within one month. RESULTS: Among 1248 patients discharged with a diagnosis of DD during the study period, 293 (52.2% male, median age 75 years) were finally analyzed; of them, 105 (35.8%) for diverticular bleeding. On multivariate analysis, male gender (OR 4.27), age (OR 1.12), anti-thrombotic medications (OR 2.60) and right-sided DD (OR 5.70) were independently correlated to diverticular bleeding. CONCLUSION: Our study provides evidence that, together with age, male gender and concomitant anti-thrombotic treatment, right-sided DD represents an independent risk factor for bleeding.

Clinical Validation Results of an Innovative Non-Invasive Device for Colorectal Cancer Preventive Screening through Fecal Exhalation Analysis.

Screening is recommended to reduce both incidence and mortality of colorectal cancer. Currently, many countries employ fecal occult blood test (FOBT). In Emilia-Romagna (Italy), since 2005, FOBT immunochemical version (FIT) is performed every two years on people aged between 50 and 69 years. A colonoscopy is then carried out on those who are FIT positive. However, FIT shows approximately 65% false positives (non-tumoral bleedings), leading to many negative colonoscopies. The use of an economic and easy-to-use method to check FOBT-positives will improve screening effectiveness, reducing costs to the national health service. This work illustrates the results of a three-year clinical validation protocol (started in 2016) of a patented device composed of a core of nanostructured gas sensors. This device was designed to identify CRC presence by fecal volatile compounds, with a non-invasive, in vitro and low-cost analysis. Feces are, in fact, affected by tumor-volatile biomarkers, produced by cellular peroxidation and metabolic alterations. The protocol consisted in the analysis of fecal samples of FIT-positive subjects, using colonoscopy as a gold standard. A total of 398 samples were analyzed with machine learning techniques, leading to a sensitivity and specificity of 84.1% and 82.4%, respectively, and a positive predictive value of 72% (25-35% for FIT).

Gallstone ileus treated with non-surgical conservative methods: a case report.

INTRODUCTION: The preoperative diagnosis of gallstone ileus is challenging due to the variability of its presentation, often resulting in late diagnosis. Controversy remains regarding the management of gallstone ileus; surgery is the standard treatment, but also less invasive approaches have proven to be successful. We present an unusual case of gallstone ileus and its conservative treatment. CASE PRESENTATION: We describe the case of a 49-year-old Caucasian woman with a bowel sub-occlusion, treated conservatively. The imaging technique (plain abdominal X-ray and computed tomography scan) led to a diagnosis of gallstones ileus. A surgical intervention was not performed. Instead, she underwent extracorporeal shock-wave lithotripsy to fragment the stones, mechanical intestinal dilatation for ileocolic stenosis and endoscopic removal of the gallstone. The presence of an apricot shell contributed to the bowel occlusion and was removed. The intervention was successful and without complications. CONCLUSIONS: Given the variability of the gallstone ileus presentation, surgery could not be the only treatment for our patient. In our case report, we show that colonoscopy could be a non-invasive approach that allows for diagnosis and treatment at the same time. The available data do not show a higher rate of recurrent biliary disease in cases where this method has been used, therefore in select patients, a conservative treatment could be an effective solution.

Asymptomatic bronchial aspiration and prolonged retention of a capsule endoscope: a case report.

INTRODUCTION: Capsule endoscopy has, over the last few years, become a first-line test to visualize the mucosa of the small intestine. This technique is generally considered safe and does not cause discomfort for patients. However, although patients may have difficulty in swallowing the capsule, bronchial aspiration of a capsule endoscope is a very rare complication. We report the case of an 82-year-old man who experienced prolonged bronchial aspiration of a capsule endoscope without relevant symptoms, followed by a spontaneous return of the capsule to the gastrointestinal tract. CASE PRESENTATION: An 82-year-old Caucasian man was referred to our unit from another local hospital to undergo capsule endoscopy. He swallowed the capsule without any apparent difficulties and did not show any overt symptoms. The following day, when we reviewed the capsule endoscopy images, we realized that the capsule was in the bronchial system and remained there for the duration of the study. An urgent X-ray of the chest confirmed the presence of the capsule in the left side of the bronchopulmonary tree. Two days later a repeat chest X-ray showed the capsule in the right bronchus. After two days the capsule was retrieved in the feces. Our patient remained asymptomatic during the entire admission period. CONCLUSIONS: Aspiration of a capsule endoscope is a rare complication; to the best of our knowledge this is the first reported case in which a capsule endoscope remained for six days in the bronchial system of a patient without causing airway compromise or pneumonitis and spontaneously returned to the gastrointestinal tract.

Portal hypertensive enteropathy diagnosed by capsule endoscopy and demonstration of the ileal changes after transjugular intrahepatic portosystemic shunt placement: a case report.

INTRODUCTION: Recent data suggest that mucosal abnormalities can occur even in the duodenum, jejunum, and distal ileum of cirrhosis patients. We present a case of portal hypertensive enteropathy in a cirrhosis patient shown by capsule endoscopy and the effect of transjugular intrahepatic portosystemic shunt on the ileal pictures. CASE PRESENTATION: An 83-year-old Caucasian woman was admitted to our hospital for anemia and a positive fecal occult blood test. An upper gastrointestinal endoscopy revealed small varices without bleeding signs and hypertensive gastropathy. Colonoscopy was negative. To rule out any other cause of bleeding, capsule endoscopy was performed; capsule endoscopy revealed severe hyperemia of the jejunum-ileal mucosa with active bleeding. Because of the persistence of anemia and the frequent blood transfusions, not responding to ß-blocker drugs or octreotide infusion, a transjugular intrahepatic portosystemic shunt was performed. Anemia improved quickly after the transjugular intrahepatic portosystemic shunt, and no further blood transfusion was necessary in the follow-up. The patient developed portal encephalopathy two months later and was readmitted to our department. We repeated the capsule endoscopy that showed a significant improvement of the gastric and ileal mucosa without any signs of bleeding. CONCLUSION: Hypertensive enteropathy is a rare condition, but it seems more common with the introduction of capsule endoscopy in clinical practice. This case shows that the jejunum can be a source of bleeding in cirrhosis patients, and this is the first demonstration of its resolution after transjugular intrahepatic portosystemic shunt placement.

Screenee perception and health-related quality of life in colorectal cancer screening: a review.

Screening for colorectal cancer (CRC) has become established to varying degrees in several Western countries for the past 30 years. Because of its effectiveness, screening has been adopted or is planned in a number of other countries. In most countries, the screening method (e.g., fecal occult blood test [FOBT], sigmoidoscopy) is followed by colonoscopy, for verification. In other countries (e.g., United States, Germany), colonoscopy is the preferred first-line investigation method. However, because colonoscopy is considered to be invasive, might be poorly tolerated, and can be associated with complications, the idea of adopting colonoscopy as the primary screening method suffers. Negative effects of screening methods can reduce participation in programs and thereby negate the desired effect on individual and societal health. At present, there is no generally accepted method either to assess the perception and satisfaction of patients screened or the outcome of the screening procedures in CRC. In this review, we discuss the past development and present availability of instruments to measure health-related quality of life (HRQoL), the scarce studies in which such instruments have been used in screening campaigns, and the findings. We suggest the creation of a specific instrument for the assessment of HRQoL in CRC screening.

Interobserver agreement in describing video capsule endoscopy findings: a multicentre prospective study.

BACKGROUND AND AIM: Few studies have specifically addressed interobserver agreement in describing lesions identified during capsule endoscopy. The aim of our study is to evaluate interobserver agreement in the description of capsule endoscopy findings. MATERIALS AND METHODS: Consecutive short segments of capsule endoscopy were prospectively observed by 8 investigators. Seventy-five videos were prepared by an external investigator (gold standard). The description of the findings was reported by the investigators using the same validated and standardized capsule endoscopy structured terminology. The agreement was assessed using Cohen's kappa statistic. RESULTS: As concerns the ability to detect a lesion, the agreement with the gold standard was moderate (kappa 0.48), as well as the agreement relating to the final diagnosis (κ 0.45). The best agreement was observed in identifying the presence of active bleeding (κ 0.72), whereas the poorest agreement concerned the lesion size (κ 0.32). The agreement with the GS was significantly better in endoscopists with higher case/volume of capsule endoscopy per year. Diagnostic concordance was better in the presence of angiectasia than in the presence of polyps or ulcers/erosions. CONCLUSIONS: Correct lesion identification and diagnosis seem more likely to occur in presence of angiectasia, and for readers with more experience in capsule endoscopy reading.

[Screening for colorectal cancer in high-risk and intermediate-risk subject: what's the best tool?]. / Screeening per la prevenzione del cancro del colon nei soggetti ad alto rischio ed in quelli a rischio intermedio. Qual e la migliore opzione?

Although several screening tests are now available, at present none of them has been proven the best one. Colonoscopy is usually used in high-risk subjects (family history of either colorectal cancer [CRC] or adenomas). In intermediate-risk subjects, fecal occult blood test (FOBT) is preferred, and colonoscopy is performed only when FOBT results positive. The aim of this study is to better define the role of colonoscopy in a screening program. Three groups of subjects were retrospectively reviewed. RSP (Regional Screening Program), FDR (First Degree Relatives), and Control-groups included 362, 581, and 300 subjects, respectively. Adenoma or carcinoma were more frequent in RSP-group than in FDR- and Control-group (53%, 23.7%, and 20%, respectively; p < 0.001). CRC rate was 11.6% in RSP-group, 2.2% in FDR-group (p < 0.001), 6% in Control-group (p < 0.05). Adenoma rate was 41.4% in RSP-group, 21.5% in FDR-group (p < 0.05), 14% in Control-group (p < 0.01). Our results showed that colonoscopy probably can not be regarded as a first-line tool for the screening of CRC in FDR of patients with CRC or adenoma. Some stratification or scoring system for the risk of CRC should be adopted. As an alternative, FOBT could be used also in these subjects.

Colonoscopy surveillance in asymptomatic subjects with increased risk for colorectal cancer: clinical evaluation and cost analysis of an Italian experience.

The aim of this study was three-fold: (a) to present a surveillance plan for colorectal cancer prevention with colonoscopy, focused on first-degree relatives of colorectal cancer patients in the province of Ferrara (Italy); (b) to analyse the cost of colonoscopy at the University Hospital of Ferrara; and (c) to analyse the cost of the surveillance plan in our province. In January 2000, in the province of Ferrara, following a campaign of public sensitization, a plan of surveillance with colonoscopy was started, addressing the population at an increased risk for colorectal cancer (i.e. over 45-year-old first-degree relatives of patients with either colorectal cancer or adenomatous polyps revealed before 60 years of age). In addition, we estimated the cost of colonoscopy both at the University Hospital of Ferrara and of the surveillance plan. Between January 2000 and October 2003, 585 individuals at increased risk were interviewed. Five hundred and forty-four (94%) accepted to undergo a colonoscopy. By October 2003, 439 (81%) colonoscopies had been performed. Colonoscopy was normal in 330 individuals (75%). In 109 individuals (25%), 144 lesions were found: 35 patients (32%) had hyperplastic polyps, 66 (61%) had adenomas, and eight (7%) adenocarcinomas (six Dukes A, one Dukes B, and one Dukes C stage). Out of a total of 101 adenomas, 68 were tubular adenomas (67%), 24 tubulo-villous adenomas (24%), and nine adenomas with high-grade dysplasia (9%). The cost of colonoscopy at our hospital and the costs of the surveillance plan amounted to euro 130.84 (euro 169.57 with single biopsy) and euro 43,103.66 (euro 42 310.34/year), respectively. These data show (a) the efficacy of colonoscopy in the early diagnosis of colorectal cancer and premalignant lesions in first-degree relatives of colorectal cancer patients; (b) the low cost of colonoscopy at the centre performing the surveillance; and (c) the feasibility of screening and surveillance programmes for colorectal cancer prevention.