THE PROFESSIONAL BACKGROUND OF REFERRING PHYSICIAN PREDICTS THE DIAGNOSTIC YIELD OF SMALL BOWEL CAPSULE ENDOSCOPY IN SUSPECTED SMALL BOWEL BLEEDING

Background and aim of the study: The diagnostic yield of small-bowel capsule endoscopy (SBCE) in suspected small bowel bleeding (SSBB) is highly variable. Different reimbursement systems and equipment costs also limit SBCE use in clinical practice. Thus, minimising non-diagnostic procedures is advisable. This study aims to assess the SBCE diagnostic yield and identify factors predicting diagnostic findings in a cohort of SSBB patients. Materials and methods: In this retrospective cohort study, we analysed the medical records of patients who consecutively underwent SBCE for SSBB over nine years. By logistic regression, we identified covariates predicting diagnostic findings at SBCE. Finally, we performed a post-hoc cost analysis based on previous gastroenterologist or endoscopist (G/E) consultations versus direct SBCE ordering by other specialists (OS). Results: The final analysis included 584 patients. Most SBCEs were ordered by G/E (74%). The number of SBCEs without any finding was significantly lower in the G/E group (p<0.001). The SBCE diagnostic yield ordered by G/E was significantly higher than that by OS (63% vs 52%, OR 1.57; 95%CI: 1.07-2.26, p=0.019). At multivariate analysis, older age (OR 1.7, 95%CI 1.2-2.4, p=0.005), anaemia (OR 4.9, 95%CI 1.9-12, p=0.001), small bowel transit time (OR 1, 95%CI 1-1.02, p=0.039), and referring physician (OR 1.8, 95%CI 1.1-2.7, p=0.003), independently predicted diagnostic findings. Implementing prior G/E referral vs direct SBCE ordering would reduce medical expenditures by 16%. Conclusions: The professional background of referring physicians significantly improves the diagnostic yield of SBCE and contributes to controlling public health costs

Non solo “ri-restauri” per la durabilità dell’arte

Facendo tesoro delle indicazioni di Giovanni Urbani (direttore dell’ICR dal 1973 al 1983) gli autori hanno cercato di proporre azioni coerenti che consentano di attivare le condizioni della duratura conservazione dell’arte, anche per ridurne sempre più i bisogni di sempre più frequenti nuovi restauri: “ri-restauri”, appunto. L’ebook è stato redatto dall’Istituto Mnemosyne di Brescia

Lactobacillus casei DG and its postbiotic reduce the inflammatory mucosal response: an ex-vivo organ culture model of post-infectious irritable bowel syndrome

Abstract Background The evidence on the role of gut microbiota in post-infectious irritable bowel syndrome (PI-IBS) is convincing. Lactobacillus spp. positively affect IBS symptoms, although the mechanisms through which probiotics exert their beneficial effects are largely unknown. The aim of the study is to evaluate the role of Lactobacillus casei DG (LC-DG) and its postbiotic (PB) in modulating the inflammatory/immune-response in PI-IBS in an ex-vivo organ culture model. Methods Ex vivo cultures of ileal and colonic mucosa from 10 PI-IBS, diarrhea predominant subtype (D) patients, and 10 healthy controls (HC) were treated with LPS, LC-DG and PB. Interleukin (IL)-1α, IL-6, IL-8 and IL-10 mRNA levels were assessed by real-time PCR and Toll like receptor 4 (TLR-4) protein expression by Western blotting. Results At baseline, IL-1α, IL-6 and IL-8 mRNA levels as well as TLR-4 protein expression were significantly higher while IL-10 mRNA levels were lower in PI-IBS D than in HC in both ileum and colon. LC-DG and PB significantly reduced the mRNA levels of pro-inflammatory cytokines and TLR-4 while increased that of IL-10 after LPS stimulation. The protective effect was more pronounced for PB than LC-DG treatment. Conclusion LC-DG and its PB attenuate the inflammatory mucosal response in an ex-vivo organ culture model of PI-IBS D

Gut--liver axis: the impact of gut microbiota on non alcoholic fatty liver disease

AIM: To examine the impact of gut microbiota on non alcoholic fatty liver disease (NAFLD) pathogenesis. DATA SYNTHESIS: Emerging evidence suggests a strong interaction between gut microbiota and liver. Receiving approximately 70% of its blood supply from the intestine, the liver represents the first line of defence against gut-derived antigens. Intestinal bacteria play a key role in the maintenance of gut-liver axis health. Disturbances in the homeostasis between bacteria- and host-derived signals at the epithelial level lead to a break in intestinal barrier function and may foster "bacterial translocation", defined as the migration of bacteria or bacterial products from the intestinal lumen to mesenteric lymph nodes or other extraintestinal organs and sites. While the full repertoire of gut-derived microbial products that reach the liver in health and disease has yet to be explored, the levels of bacterial lipopolysaccharide, a component of the outer membrane of Gram-negative bacteria, are increased in the portal and/or systemic circulation in several types of chronic liver diseases. Derangement of the gut flora, particularly small intestinal bacterial overgrowth, occurs in a large percentage (20-75%) of patients with chronic liver disease. In addition, evidence implicating the gut-liver axis in the pathogenesis of metabolic liver disorders has accumulated over the past ten years. CONCLUSIONS: Complex metabolic diseases are the product of multiple perturbations under the influence of triggering factors such as gut microbiota and diet, thus, modulation of the gut microbiota may represent a new way to treat or prevent NAFLD

Vitamin B12 supplementation improves rates ofsustained viral response in patients chronicallyinfected with hepatitis C virus

Background In vitro, vitamin B12 acts as a natural inhibitor of hepatitis C virus (HCV) replication. Objective To assess the effect of vitamin B12 on virological response in patients with chronic HCV hepatitis naı ¨ve to antiviral therapy. Methods Ninety-four patients with chronic HCV hepatitis were randomly assigned to receive pegylated interferon a plus ribavirin (standard-of-care; SOC) or SOC plus vitamin B12 (SOC+B12). Viral responsednamely, undetectable serum HCV-RNA, was evaluated 4 weeks after starting treatment (rapid viral response), 12 weeks after starting treatment (complete early viral response) and 24 or 48 weeks after starting treatment (end-oftreatment viral response) and 24 weeks after completing treatment (sustained viral response (SVR)). Genotyping for the interleukin (IL)-28B polymorphism was performed a posteriori in a subset (42/64) of HCV genotype 1 carriers. Results Overall, rapid viral response did not differ between the two groups, whereas the rates of complete early viral response (p¼0.03), end-of-treatment viral response (p¼0.03) and SVR (p¼0.001) were significantly higher in SOC+B12 patients than in SOC patients. In SOC+B12 patients, the SVR rate was also significantly higher in carriers of a difficult-to-treat genotype (p¼0.002) and in patients with a high baseline viral load (p¼0.002). Distribution of genotype IL-28B did not differ between the two groups. At multivariate analysis, only easy-to-treat HCV genotypes (OR¼9.00; 95% CI 2.5 to 37.5; p¼0.001) and vitamin B12 supplementation (OR¼6.9; 95% CI 2.0 to 23.6; p¼0.002) were independently associated with SVR. Conclusion Vitamin B12 supplementation significantly improves SVR rates in HCV-infected patients naı ¨ve to antiviral therapy

Sweetened carbonated drinks do not alter upper digestive tract physiology in healthy subjects

Sweetened carbonated beverages are widely consumed, which has fuelled several conflicting opinions about their effects on upper digestive tract functions. We aimed to evaluate the effect of sweetened carbonated drinks, consumed with a standard meal, on gastro-oesophageal reflux, gastric emptying and gallbladder contraction and postmeal sensations in healthy subjects. Thirteen healthy volunteers (seven women, six males; median age 22 years) were tested following the intake of 300 mL sweetened water containing increasing concentrations of carbon dioxide (seven subjects), and of 300 mL sweetened commercial flavoured drink with and without carbon dioxide (six subjects). Gastro-oesophageal reflux, gastric emptying and gallbladder contraction were studied by pH-impedance, octanoic acid breath test and ultrasound respectively. Gastro-oesophageal refluxes were significantly increased 1 h after meal with both water and commercial beverages; only sweetened water without carbon dioxide determined a persistently increasing number of refluxes 2 h postmeal. No differences were found for gastric emptying, gallbladder contraction or postmeal symptoms with any of the beverages tested. This study shows that 300 mL of sweetened carbonated beverage with different levels of carbonation or a commercial soft drink do not modify the physiology of the upper digestive tract.status: publishe

Lactobacillus paracasei F19 versus placebo for the prevention of proton pump inhibitor-induced bowel symptoms: A randomized clinical trial

BACKGROUND: Proton pump inhibitors may foster intestinal dysbiosis and related bowel symptoms. AIM: To evaluate the effect of Lactobacillus paracasei F19 on bowel symptom onset in patients on long-term proton pump inhibitors. METHODS: In this randomized, double-blind, placebo-controlled study, patients with typical gastroesophageal reflux disease symptoms receiving pantoprazole 40 mg/d for six months were randomly assigned to receive: (A) Lactobacillus paracasei F19 bid for three days/week for six months; (B) placebo bid for three days/week for six months; (C) Lactobacillus paracasei F19 bid for three days/week for three months and placebo bid for three days/week for the following three months; (D) placebo bid for three days/week for three months and Lactobacillus paracasei F19 bid for three days/week for the following three months. Bloating, flatulence, abdominal pain and bowel habit were assessed monthly. RESULTS: 100/312 patients were enrolled. In the parallel groups, the treatment-by-time interaction affected bloating (p = 0.015), while Lactobacillus paracasei F19 treatment alone affected flatulence (p = 0.011). Moreover, the treatment-by-time interaction significantly affected the mean score of bloating (p = 0.01) and flatulence (p < 0.0001), the mean stool form (p = 0.03) and mean stool frequency/week (p = 0.016). Analysis of the cross-over groups, limited to the first three months because of carry-over effect, confirmed these results. CONCLUSION: Lactobacillus paracasei F19 supplementation prevents bowel symptom onset in patients on long-term proton pump inhibitors