Keyword-augmented and semi-automatic generation of FESS reports: a proof-of-concept study.

INTRODUCTION: Surgical reports are usually written after a procedure and must often be reproduced from memory. Thus, this is an error-prone, and time-consuming task which increases the workload of physicians. In this proof-of-concept study, we developed and evaluated a software tool using Artificial Intelligence (AI) for semi-automatic intraoperative generation of surgical reports for functional endoscopic sinus surgery (FESS). MATERIALS AND METHODS: A vocabulary of keywords for developing a neural language model was created. With an encoder-decoder-architecture, artificially coherent sentence structures, as they would be expected in general operation reports, were generated. A first set of 48 conventional operation reports were used for model training. After training, the reports were generated again and compared to those before training. Established metrics were used to measure optimization of the model objectively. A cohort of 16 physicians corrected and evaluated three randomly selected, generated reports in four categories: "quality of the generated operation reports," "time-saving," "clinical benefits" and "comparison with the conventional reports." The corrections of the generated reports were counted and categorized. RESULTS: Objective parameters showed improvement in performance after training the language model (p < 0.001). 27.78% estimated a timesaving of 1-15 and 61.11% of 16-30 min per day. 66.66% claimed to see a clinical benefit and 61.11% a relevant workload reduction. Similarity in content between generated and conventional reports was seen by 33.33%, similarity in form by 27.78%. 66.67% would use this tool in the future. An average of 23.25 ± 12.5 corrections was needed for a subjectively appropriate surgery report. CONCLUSION: The results indicate existing limitations of applying deep learning to text generation of operation reports and show a high acceptance by the physicians. By taking over this time-consuming task, the tool could reduce workload, optimize clinical workflows and improve the quality of patient care. Further training of the language model is needed.

The Apparent Asymmetrical Relationship Between Small Bowel Bacterial Overgrowth, Endotoxemia, and Liver Steatosis and Fibrosis in Cirrhotic and Non-Cirrhotic Patients: A Single-Center Pilot Study.

Introduction: Gut microbiota are a complex ecosystem harboring our intestine. They maintain human body equilibrium, while their derangement, namely, "dysbiosis", has been associated with several gastrointestinal diseases, such as liver steatosis (NAFLD) and liver cirrhosis. Small intestinal bacterial overgrowth (SIBO) is an example of dysbiosis of the upper gastrointestinal (GI) tract. Aim: The aim of this study is to evaluate the relationship between SIBO and levels of endotoxemia and grade of liver steatosis (LS) and liver fibrosis (LF) in hepatologic patients. Materials and Methods: Consecutive outpatients referred to our hepatology clinic were tested for SIBO by the lactulose breath test (LBT) and peripheral blood levels of endotoxemia; LS grading and LF were assessed by abdominal ultrasound and transient elastography, respectively. Results: Fifty-two consecutive patients (17 with alcohol abuse (4.5 ± 0.8 alcohol units per day), 4 with HCV and 2 with HBV infection, 24 of metabolic origin, 2 of autoimmune origin, and 3 with cholangiopathies; mean age 54.7 ± 8.3 years, 31 F, BMI 24.1 ± 1.1 Kg/m2) and 14 healthy volunteers (HV) (mean age 50.1 ± 4.3 years, 9 F, BMI 23.3 ± 1.1 Kg/m2) were enrolled. SIBO prevalence was significantly higher in cirrhotic (LC) vs. non-cirrhotic (LNC) patients and vs. HV (all, p < 0.05), with a significant positive trend according to Child-Pugh status (all, p < 0.05). SIBO prevalence was not correlated with LS stages (all, p = NS). Consensually, endotoxin levels were significantly higher in LC vs. LNC and vs. HV (all, p < 0.05) and significantly correlated with LF in patients with LC, according to Child-Pugh status (all, p < 0.05). Conclusion: This study shows that SIBO prevalence and relative endotoxin blood levels seem to be significantly associated with the grade of LF vs. LS in LC. SIBO is also present under pre-cirrhotic conditions, but its prevalence seems to correlate with liver disease irreversible derangement.

Self-poisoning in the acute care medicine 2005-2012.

OBJECTIVE: To describe the trend of acute self-poisoning in the emergency and intensive care. METHODS: Electronic charts of adults who presented to the emergency department of the University Hospital Leipzig with self-poisoning following a suicide attempt (suicide group), intoxication (intoxication group), drug overdose for relief of pain or discomfort (drug overdose group) between 2005 and 2012 were analyzed. RESULTS: 3533 adults (62.6% males) were identified, with the yearly admissions increasing from 305 in 2005 to 624 in 2012. The admission rate in relation to the total emergency department admissions also increased, from 1.2% in 2005 to 1.9% in 2012. 31.7% of the patients were younger than 25 years. The reasons for self-poisoning were suicide attempt (18.1%), intoxication (76.8%) and drug overdose (2.9%). The reason could not be clearly classified in 80 patients. Psychotropic drugs were used in 71.6% of suicide attempts, while alcohol was the sole cause of intoxication in 80.1% of cases in the intoxication group. Self-poisoning using at least two substances was observed in 52.0% of the suicide attempts, 10.3% of those with intoxication and 29.7% of those with drug overdose. While alcohol remains the most common cause of intoxication, there was a drastic increase in the consumption of cannabinoids, Crystal Meth and gamma-hydroxybutyrate in the years 2011 and 2012. ICU admission was necessary in 16.6% of the cases. There were 22 deaths (0.6% of the study population), of whom 15 were in the suicide group (2.3%), four (0.15%) in the intoxication group, and three in the not clearly classified group (3.8%). CONCLUSION: Acute self-poisoning is an increasing medical issue. Psychotropic drugs remain the most common means of suicide attempt. Although alcohol intoxication is very frequent, intake of illicit drugs as the cause of emergency admission is increasing.

Methodology and indications of H2-breath testing in gastrointestinal diseases: the Rome Consensus Conference.

BACKGROUND: Breath tests represent a valid and non-invasive diagnostic tool in many gastroenterological conditions. The rationale of hydrogen-breath tests is based on the concept that part of the gas produced by colonic bacterial fermentation diffuses into the blood and is excreted by breath, where it can be quantified easily. There are many differences in the methodology, and the tests are increasingly popular. AIM: The Rome Consensus Conference was convened to offer recommendations for clinical practice about the indications and methods of H2-breath testing in gastrointestinal diseases. METHODS: Experts were selected on the basis of a proven knowledge/expertise in H2-breath testing and divided into Working Groups (methodology; sugar malabsorption; small intestine bacterial overgrowth; oro-coecal transit time and other gas-related syndromes). They performed a systematic review of the literature, and then formulated statements on the basis of the scientific evidence, which were debated and voted by a multidisciplinary Jury. Recommendations were then modified on the basis of the decisions of the Jury by the members of the Expert Group. RESULTS AND CONCLUSIONS: The final statements, graded according to the level of evidence and strength of recommendation, are presented in this document; they identify the indications for the use of H2-breath testing in the clinical practice and methods to be used for performing the tests.

Computerized O.R. scheduling: is it an accurate predictor of surgical time?

The goal of this project was to determine whether a standardized surgical time, generated by the Operating Room Information System (ORIS), could be used as an accurate predictor of actual surgical time. Utilizing retrospective, quantitative data from the ORIS database, frequency distributions by surgical speciality, were completed. Chi-square analysis was applied to determine the significance of the frequency distributions. The study outcome indicates that ORIS computer generated procedure times were not an accurate predictor of actual surgical time. Further follow-up will be required to determine if alternate scheduling methodologies would lead to higher accuracy rates.

[Possible errors in diagnosis of left atrial thrombosis in transesophageal echocardiography]. / Fehlermöglichkeiten bei der Diagnose linksatrialer Thromben im transösophagealen Echokardiogramm.

The detection of thrombi in the left atrium and left atrial appendage by transesophageal echocardiography has significant diagnostic and therapeutic value. However, it requires high method accuracy in routine evaluation. In order to record the percentage of false positive findings, a reevaluation was performed by two experienced examiners using the video recordings of 51 patients, in whom a thrombus has been diagnosed during the routine evaluation. From 1988 to 1994, these thrombi were diagnosed in 726 patients in whom we looked for a source of possible cardiac embolism. In the reevaluation of the 43 cases with sufficient video recordings, in 26 (60%) the diagnosis was classified as false-positive and in 5 patients (12%) as questionable. Thrombus diagnosis was confirmed in only 12 (28%) cases. The incidence of false-positive findings decreased over the course of years with 8.3% (1988-1990), 2.9% (1991-1992) and 0.4% (1993-1994), p = 0.0001. The agreement in the reevaluation between the two examiners was high (interobserver variability 7%), whereby completely divergent evaluations did not occur. Typical diagnostic pitfalls included a prominent trabecular structure in the left atrial appendage (n = 10), the membranous structure between the left atrial appendage and the upper left pulmonary vein (n = 7), transition of the lower left atrium/left atrial appendage (n = 3) and branches within the apex of the left atrial appendage (n = 2). When searching for thrombi in the left atrium and left atrial appendage, there is a high risk of false-positive findings, especially for the unexperienced investigator. Attention must be paid to the typical causes of diagnostic pitfalls in the case of complex and variable anatomy.

The effects of levosulpiride on gastric and gall-bladder emptying in functional dyspepsia.

BACKGROUND: 50% of patients with functional dyspepsia have delayed gastric emptying. Levosulpiride is an orthopramide drug that stimulates gastrointestinal motility. Aim of our study was to evaluate the effect of levosulpiride on symptoms and gastric and gall-bladder emptying, in dyspeptic patients. METHODS: Thirty adult patients, treated for 20 days with levosulpiride (75 mg/day) or placebo, were evaluated in a randomized double-blind study. Symptoms were assessed by a cumulative index and overall intensity (visual analogue line). Gastric and gall-bladder emptying were evaluated by epigastric impedance (liquid meal) and real-time ultrasonography (mixed meal). RESULTS: Levosulpiride, with respect to placebo, accelerated the mean gastric half-emptying time of liquids (P < 0.05), gastric emptying (P < 0.001 at 180 min; P < 0.05 at 240 min), and gall-bladder emptying (P < 0.05 at 60 and 120 min) emptying after a solid-liquid mixed meal. Both the mean cumulative index (P < 0.05) and the overall intensity (P < 0.025) of dyspeptic symptoms were reduced significantly by levosulpiride. CONCLUSIONS: Our results showed that levosulpiride can be usefully employed in patients affected by functional dyspepsia.

Prevalence and consistency of low breath H2 excretion following lactulose ingestion. Possible implications for the clinical use of the H2 breath test.

The clinical use of the H2 breath test is limited by the finding that a variable fraction of the population fails to excrete appreciable H2 during colonic carbohydrate fermentation. Therefore, we assessed the ability to increase breath H2 excretion in 371 patients (224 female, 147 male) by administering the nonabsorbable sugar lactulose. Following 12g of lactulose, 27% of 94 patients did not increase their breath H2 concentration over 20 ppm and were considered low H2 excretors. Ingestion of 20 g of lactulose in 277 patients yielded a frequency of low H2 excretors of 14%. Six of 10 patients that were low H2 excretors after 12g of lactulose increased their breath H2 levels over 20 ppm when tested with 20g. In 35 patients tested with the same amount of lactulose on two separate occasions, the subject frequently altered his or her H2 producing status over a period of a few weeks. Low H2 excretors had a significantly higher breath CH4 concentration, both fasting (22 +/- 34 ppm) and after lactulose (51 +/- 58 ppm) compared to the remaining patients (5 +/- 13 ppm and 16 +/- 40 ppm, respectively). While the mean age of low excretors (54 +/- 17 years) was significantly higher than the others (44 +/- 17 years), no difference was found for sex prevalence and stool pH. This study demonstrates that respiratory H2 excretion following lactulose ingestion is not consistent and suggests that the application of too restrictive criteria could lead to improper interpretation of the H2 breath test.

Non-absorbable antibiotics and small bowel bacterial overgrowth.

The normal gastrointestinal flora includes no more than 10(3) organisms/ml of gastric aspirate and no more than 10(5) organisms/ml of duodenal or jejunal juice. The organisms are primarily gram-positive and aerobic bacteria. In particular anatomical or functional predisposing conditions, an abnormal colonization takes place in the small bowel with microbial concentrations > or = 10(7)/ml of aspirate and with a predominance of anaerobes and coliforms. At times this small bowel bacterial overgrowth remains asymptomatic, but more often leads to a true malabsorption syndrome with symptoms, such as diarrhoea, weight loss and megaloblastic anemia. The most accurate procedure for confirming the presence of this condition is represented by the bacterological analysis of the jejunal aspirate. The routine use of this method is, however, notably hindered by the need for intubation of the patient and by the lack of laboratories suitably equipped for anaerobe culture. As an alternative to this complex procedure, numerous non-invasive tests have been perfected over the last few years, including the glucose- or lactulose- H2 breath test. The main aim of the treatment of the small bowel bacterial overgrowth is the suppression of the bacterial colonization using antimicrobial therapy. Among the local-action non-absorbable antibiotics, rifaximin, was shown to have bactericidal activity against aerobes and anaerobes bacteria, such as bacteroides, lactobacilli and clostrides. In controlled clinical trials the antibiotic has demonstrated therapeutic efficacy in bacterial origin diarrhoea, in porto-systemic encephalopathy, in diverticulosis and, finally, in small bowel bacterial overgrowth.

beta-Galactosidase from Aspergillus niger in adult lactose malabsorption: a double-blind crossover study.

An assessment was made of the efficacy of a beta-galactosidase, obtained from Aspergillus niger and added to intact milk, in decreasing lactose malabsorption and intolerance. Sixteen adult patients with malabsorption and intolerance to this sugar were studied in a double-blind crossover study vs. placebo. A 5-hour hydrogen breath test was used to assess malabsorption of lactose contained in 400 ml milk. When compared with placebo, the addition of exogenous lactase to intact milk caused a statistically significant reduction in the maximum breath H2 concentration (P less than 0.01) and in the cumulative H2 excretion (P less than 0.005). In the same way, the cumulative index for gastrointestinal intolerance was significantly lower (P less than 0.005) after the ingestion of lactase-added milk. This study demonstrates that enzyme replacement therapy, with beta-galactosidases obtained from Aspergillus niger, is effective in decreasing lactose malabsorption and its consequent intolerance in adult subjects with lactase deficiency.

Methodology of the H2 breath test. II. Importance of the test duration in the diagnosis of carbohydrate malabsorption.

We analyzed the results of 352 consecutive four-hour lactose hydrogen breath tests with the aim of verifying whether the results after two hours have the same accuracy as those after four hours in the diagnosis of malabsorption of 20g of lactose. Our results show that in 208 subjects who proved to be lactose malabsorbers the mean changes in breath H2 concentration were higher at three and a half hours than at any other time. Moreover, although the majority of the subjects (63%) reached the cut-off value (more than 20 parts per million with respect to the baseline value) in the first two hours of the test, in 76 of our 208 lactose malabsorbers (37%) a hydrogen increase higher than the cut-off value is only detectable after the second hour of the test. Therefore, unlike those who believe that two samples of expired air at 0 time and after two hours are sufficient, we think that for greater diagnostic accuracy the lactose H2 breath test must be prolonged for at least 4 hours.

Methodology of the H2 breath test. I. Collection and storage for gas measurement.

The measurement of hydrogen and methane in expired air is widely used in the field of gastrointestinal diagnosis. Techniques as simple and as reliable as possible are therefore requested for the collection and storage of breath samples. As far as collection is concerned, we compared three systems of end-expiratory sampling: a modified Haldane-Priestley tube, a Y-piece device fitted to a plastic syringe and a commercially available two-bag system. There was a significant correlation between the results obtained with all three systems, suggesting that all are sufficiently reliable. However, the two-bag system does not require particular training on behalf of the operator or particular cooperation from the patients and also makes it possible to take samples from more than one patient at the same time. For the storage of breath samples plastic syringes are the most commonly used device. Nonetheless, at room temperature there is a leakage of hydrogen equal to 9% after 24 hours, increasing to 29% after 5 days of storage. Refrigeration of the syringes at -20 degrees C prevents any loss in the first 48 hours and limits it to 5% after 5 days. The stability of the methane was higher than that of the hydrogen: after 5 days the loss is 4% at room temperature and 2% at -20 degrees C. For both gases the losses increase significantly at a temperature of 37 degrees C and are not affected by the initial concentration of the stored gas.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of small intestine bacterial overgrowth with rifaximin, a non-absorbable rifamycin.

In twelve patients affected by small bowel bacterial overgrowth, diagnosed by means of the lactulose hydrogen breath test, the therapeutic efficacy of a non-absorbable derivative of rifamycin, rifaximin, was evaluated. This study showed that this drug has a satisfactory therapeutic efficacy in contaminated small bowel syndrome and, at the doses tested, is free of side-effects.