Italian consensus conference for colonic diverticulosis and diverticular disease.

The statements produced by the Consensus Conference on Diverticular Disease promoted by GRIMAD (Gruppo Italiano Malattia Diverticolare, Italian Group on Diverticular Diseases) are reported. Topics such as epidemiology, risk factors, diagnosis, medical and surgical treatment of diverticular disease (DD) in patients with uncomplicated and complicated DD were reviewed by a scientific board of experts who proposed 55 statements graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. Comparison and discussion of expert opinions, pertinent statements and replies to specific questions, were presented and approved based on a systematic literature search of the available evidence. Comments were added explaining the basis for grading the evidence, particularly for controversial areas.

Symptom patterns can distinguish diverticular disease from irritable bowel syndrome.

BACKGROUND: Diverticular disease (DD) and irritable bowel syndrome (IBS) share a similar symptom pattern. However, comparative studies are flawed by different age at onset of symptoms. We aimed to verify whether clinical features distinguish DD from IBS. MATERIALS AND METHODS: Patients with DD or IBS, matched for age and gender (1/1) were consecutively recruited. Data on demographic parameters, voluptuary habits, inheritance of disease and symptoms were collected. Moreover, the association between pain > 24 h, and clinical parameters were evaluated. RESULTS: Ninety patients with DD and 90 patients with IBS (DD: F/M: 46/44; age: 50.9 years; IBS: 46/44; 50.4) were selected from an overall population of 1275 patients. Only nine patients with DD (10%) fulfilled the criteria for IBS diagnosis. Abdominal pain > 24 h was more prevalent in SDD than in patients with IBS (20 vs. 6 patients; P < 0.01). Furthermore, compared with IBS, patients with DD showed more episodes of pain > 24 h requiring medical attention (80% vs. 33%; P < 0.01). CONCLUSIONS: Abdominal pain lasting for more than 24 h discriminates patients with DD compared with those with IBS. Identifying this symptom could be an appropriate strategy to define the diagnosis and management.

MiroCam capsule for obscure gastrointestinal bleeding: a prospective, single centre experience.

BACKGROUND: Capsule endoscopy is an established tool for the evaluation of obscure gastrointestinal bleeding but published literature is mostly limited to PillCam SB (Given Imaging, Israel). AIMS: The aims of this study were to determine the findings, the diagnostic yield and the rebleeding rate in a series of patients with overt or occult obscure gastrointestinal bleeding studied with MiroCam(Intromedic, Seoul, Korea) capsule endoscopy. METHODS: Data of 118 patients who underwent capsule endoscopy for overt or occult obscure gastrointestinal bleeding were prospectively collected between March 2009 and March 2011. RESULTS: Evaluation of the entire small bowel (completion rate) was achieved in 96% of cases. Relevant lesions occurred in 58% of patients. Angiodysplasias was the most common finding. Six patients (9% of the positive findings) had a non-small-bowel lesion detected by capsule. The yield of capsule endoscopy in the overt group was greater than in the occult group but without achieving a significant difference (61% vs. 54%, p>0.05). Rebleeding rate was lower in patients with a negative examination (6%) than in patients with a positive one (17%) (p=0.03). Capsule retention was registered in 3 of 118 patients (2.5%). CONCLUSIONS: MiroCam capsule endoscopy is a safe and effective tool for exploring small bowel with a high completion rate.

Errors and near misses in digestive endoscopy units.

BACKGROUND: Not much is known about errors and near misses in digestive endoscopy. AIMS: To verify whether an incident report, with certain facilitating features, gives useful information about unintended events, only excluding errors in medical diagnosis. METHOD: Nine endoscopy units took part in this cross sectional, prospective, multicentre study which lasted for two weeks. Members of the staff were required to report any unintended, potentially dangerous event observed during the daily work. A form was provided with a list of "reminders" and facilitators were appointed to help. The main outcome measurements were type of event, causes, corrective interventions, stage of occurrence in the workflow and qualification of the reporters. RESULTS: A total of 232 errors were reported (two were not related to endoscopy). The remaining 230 amount to 10.3% of 2239 procedures; 66 (29%) were considered errors with consequences, 164 (71%) "near misses". There were 150 pre-operative errors (65%), 22 operative (10%) and 58 post-operative (25%). Corrective interventions were provided for 60 cases of errors and 119 near misses. Most of the events were reported by the nurses (106 out of 232, 46%). CONCLUSIONS: Short-term incident reporting focusing on near misses, using forms with lists of "reminders", and the help of a facilitator, can give useful information on errors and near misses in digestive endoscopy.

Colorectal stenting as a bridge to surgery reduces morbidity and mortality in left-sided malignant obstruction: a predictive risk score-based comparative study.

BACKGROUND: The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity model, and its Portsmouth and colorectal modifications are used to predict postoperative mortality and morbidity after colorectal surgery. AIMS: To compare stent placement as a bridge to surgery vs. emergency surgical resection in patients with acute left-sided colorectal cancer obstruction using P-POSSUM and CR-POSSUM. METHODS: From January 2008 to December 2009, the physiological and operative scores, morbidity and mortality predicted by the P-POSSUM and CR-POSSUM scores were collected in all consecutive patients with LCCO who underwent surgical resection directly (Group A) or after stent placement (Group B). RESULTS: Eighty-six patients were enrolled (Group A-41 and Group B-45). The observed 30-day mortality rate was 9.8% (4/41) in Group A and 2.4% (1/45) in Group B. The 30-day morbidity rate was 61% (25/41) in Group A and 29% (13/45) in Group B. The mean values of P-POSSUM morbidity (A=70.5% vs. B=34.3%; p=0.001), P-POSSUM mortality (A=13.6% vs. B=2.4%; p=0.001) and CR-POSSUM mortality (A=15.1% vs. B=4.9%; p=0.001) were significantly lower in the Group B patients than in the Group A patients. CONCLUSIONS: Bridge to surgery strategy reduces the surgical risks in LCCO, and P-POSSUM and CR-POSSUM scores represent a good tool for comparing the two strategies.

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.

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.

Better postprandial glucose stability during continuous subcutaneous infusion with insulin aspart compared with insulin lispro in patients with type 1 diabetes.

BACKGROUND: Persistent glucose variability is a frequent condition in type 1 diabetes. Continuous subcutaneous insulin infusion (CSII) is a rational option to overcome this clinical issue; however, no comparative studies have been reported for aspart and lispro insulin when used in CSII. This study compare the effects of aspart and lispro delivered by CSII on glycemic stability as measured using a continuous glucose monitoring system. METHODS: This single-center, randomized, controlled, 3-day crossover trial included 17 patients with type 1 diabetes. Patients were randomized to receive insulin aspart or insulin lispro. The next day, they received a standard meal at breakfast and lunch and a bolus of insulin aspart or lispro based on insulin:carbohydrate ratio. Patients were monitored for 8 h, after which they received a crossover treatment with insulin aspart or insulin lispro followed by the same procedure as previously. RESULTS: Postprandial blood glucose was more stable with insulin aspart than insulin lispro (absolute Deltaglucose 7.04 +/- 3.16 vs. 9.04 +/- 4.2, P < 0.0019). Daily blood glucose variability profiles (coefficient of variation and mean amplitude of glucose excursion) and frequency of hypoglycemic episodes (area under the curve <72 mg/dL) were similar with both treatments. CONCLUSIONS: Postprandial glucose was more stable when insulin aspart was infused as a pre-meal bolus compared with insulin lispro, indicating a more favorable effect of insulin aspart on postprandial glucose. No differences in overall daily glucose stability were observed between insulin aspart and insulin lispro when infused as basal rate insulin.

Training with a computer-based simulator achieves basic manual skills required for upper endoscopy: a randomized controlled trial.

BACKGROUND: Changes in medical practice have constrained the time available for education and the availability of patients for training. Computer-based simulators have been devised that can be used to achieve manual skills without patient contact. This study prospectively compared, in a clinical setting, the efficacy of a computer-based simulator for training in upper endoscopy. METHODS: Twenty-two fellows with no experience in endoscopy were randomly assigned to two groups: one group underwent 10 hours of preclinical training with a computer-based simulator, and the other did not. Each trainee performed upper endoscopy in 19 or 20 patients. Performance parameters evaluated included the following: esophageal intubation, procedure duration and completeness, and request for assistance. The performance of the trainees also was evaluated by the endoscopy instructor. RESULTS: A total of 420 upper endoscopies were performed; the computer pretrained group performed 212 and the non-pretrained group, 208. The pretrained group performed more complete procedures (87.8% vs. 70.0%; p < 0.0001), required less assistance (41.3% vs. 97.9%; p < 0.0001), and the instructor assessed performance as "positive" more often for this group (86.8% vs. 56.7%; p < 0.0001). The length of procedures was comparable for the two groups. CONCLUSIONS: The computer-based simulator is effective in providing novice trainees with the skills needed for identification of anatomical landmarks and basic endoscopic maneuvers, and in reducing the need for assistance by instructors.

Interobserver agreement in the histologic diagnosis of colorectal polyps. the experience of the multicenter adenoma colorectal study (SMAC).

Current clinical practice guidelines for patients with colorectal polyps are mainly based on the histologic characteristics of their lesions. However, interobserver variability in the assessment of specific polyp characteristics was evaluated in very few studies. The purpose of this study was to evaluate the interobserver agreement of four pathologists in the diagnosis of histologic type of colorectal polyps and in the degree of dysplasia and of infiltrating carcinoma in adenomas. A stratified random sample of 100 polyps was obtained from the 4,889 polyps resected within the Multicentre Adenoma Colorectal Study (SMAC), and the slides were blindly reviewed by the four pathologists. Agreement was analyzed using kappa statistics. A median kappa of 0.89 (range 0.79-1.0) was estimated for the interobserver agreement for the diagnosis of hyperplastic polyp vs. adenoma. The agreement in the diagnosis of tubular, tubulovillous, and villous type, was given by median kappa values of 0.50, 0.15, and 0.36, respectively. The median kappa for the diagnosis of infiltrating carcinoma was 0.78 (range 0.73-0.84). Agreement on diagnosis of adenoma histologic subtypes, degrees of dysplasia, or infiltrating carcinoma in adenoma was moderate. A simpler classifications might help to better identify patients at different risk of colorectal cancer.