Comparative performance and external validation of three different scores in predicting inadequate bowel preparation among Greek inpatients undergoing colonoscopy

Background Predictive scores aim to predict bowel preparation adequacy among hospitalized patients undergoing colonoscopy. We evaluated the comparative efficacy of these scores in predicting inadequate bowel cleansing in a cohort of Greek inpatients. Methods We performed a post hoc analysis of data generated from a cohort of inpatients undergoing colonoscopy in 4 tertiary Greek centers to validate the 3 models currently available (models A, B and C). We used the Akaike information criterion to quantify the performance of each model, while Harrell's C-index, as the area under the receiver operating characteristics curve (AUC), verified the discriminative ability to predict inadequate bowel prep. Primary endpoint was the comparison of performance among models for predicting inadequate bowel cleansing. 70.7 +/- 15.4 years-were included in the analysis. Model B showed the highest performance (Harrell's C-index: AUC 77.2% vs. 72.6% and 57.5%, compared to models A and C, respectively). It also achieved higher performance for the subgroup of mobilized inpatients (Harrell's C-index: AUC 72.21% vs. 64.97% and 59.66%, compared to models A and C, respectively). Model B also performed better in predicting patients with incomplete colonoscopy due to inadequate bowel preparation (Harrell's C-index: AUC 74.23% vs. 69.07% and 52.76%, compared to models A and C, respectively).Conclusions Predictive model B outperforms its comparators in the prediction of inpatients with inadequate bowel preparation. This model is particularly advantageous when used to evaluate mobilized inpatients

Remotely Sensed Agroclimatic Classification and Zoning in Water-Limited Mediterranean Areas towards Sustainable Agriculture

Agroclimatic classification identifies zones for efficient use of natural resources leading to optimal and non-optimal crop production. The aim of this paper is the development of a methodology to determine sustainable agricultural zones in three Mediterranean study areas, namely, “La Mancha Oriental” in Spain, “Sidi Bouzid” in Tunisia, and “Bekaa” valley in Lebanon. To achieve this, time series analysis with advanced geoinformatic techniques is applied. The agroclimatic classification methodology is based on three-stages: first, the microclimate features of the region are considered using aridity and vegetation health indices leading to water-limited growth environment (WLGE) zones based on water availability; second, landform features and soil types are associated with WLGE zones to identify non-crop-specific agroclimatic zones (NCSAZ); finally, specific restricted crop parameters are combined with NCSAZ to create the suitability zones. The results are promising as compared with the current crop production systems of the three areas under investigation. Due to climate change, the results indicate that these arid or semi-arid regions are also faced with insufficient amounts of precipitation for supporting rainfed annual crops. Finally, the proposed methodology reveals that the employment and use of remote sensing data and methods could be a significant tool for quickly creating detailed, and up to date agroclimatic zones

Σύνδρομο βακτηριακής υπερανάπτυξης των μικροβίων του λεπτού εντέρου και λειτουργική δυσπεψία

Εισαγωγή - Σκοπός: Το σύνδρομο βακτηριακής υπερανάπτυξης του λεπτού εντέρου που χαρακτηρίζεται από αυξημένο αριθμό ή παρουσία βακτηρίων τύπου παχέος εντέρου στο λεπτό έντερο (ΣΒΥΛΕ) έχει περιγραφεί στην παθογένεια της λειτουργικής δυσπεψίας (ΛΔ), με τη χρήση δοκιμασιών αναπνοής. Σκοπός της παρούσας διατριβής ήταν η εκτίμηση του επιπολασμού του συνδρόμου βακττηριακής υπερανάπτυξης του λεπτού εντέρου μεταξύ ασθενών με λειτουργική δυσπεψία χρησιμοποιώντας καλλιέργεια του υγρού αναρρόφησης από το λεπτό έντερο. Μέθοδοι: Αξιολογήσαμε προοπτικά εξωτερικούς ασθενείς που πληρούσαν τα κριτήρια της ROME IV για ΛΔ. Η σοβαρότητα των συμπτωμάτων αξιολογήθηκε χρησιμοποιώντας το ερωτηματολόγιο PAGI-SYM. Οι ασθενείς υπεβλήθησαν σε ενδοσκόπηση ανώτερου πεπτικού και το δωδεκαδακτυλικό υγρό αναρροφήθηκε σε αποστειρωμένες παγίδες. Το ΣΒΥΛΕ ορίστηκε ως ≥103 CFU / ml αναρρόφησης δωδεκαδακτύλου και / ή παρουσία βακτηρίων παχέος εντέρου. Συμπεριλάβαμε επίσης ως μάρτυρες (ΟΜ) ασθενείς που υπεβλήθησαν σε γαστροσκόπηση λόγω συμπτωμάτων γαστροοισοφαγικής παλινδρόμησης και υλικό από ασθενείς με σύνδρομο ευερέθιστου εντέρου (ΣΕΕ) που πληρούσαν τα κριτήρια της ROME IV. Αποτελέσματα: Εντάξαμε συνολικά 227 ασθενείς με ΛΔ, 30 ΟΜ και 90 με ΣΕΕ. Μεταξύ των ασθενών με ΛΔ, 144 (63,4%), 64 (28,2%) και 19 (8,4%) είχαν σύνδρομο μεταγευματικής δυσφορίας (ΜΓΔ), σύνδρομο επιγαστρικού άλγους (ΣΕΑ) και σύνδρομο αλληλοπεπικάλυψης ΜΓΔ - ΣΕΑ. Ο επιπολασμός του ΣΒΥΛΕ ήταν 20,8%, 12,5% και 31,6% μεταξύ των υποτύπων του συνδρόμων, αντίστοιχα. Συνολικά, ο επιπολασμός του ΣΒΥΛΕ ήταν σημαντικά υψηλότερος στη ΛΔ [44/227 (19,4%)], σε σύγκριση με την ΟΜ [1/30 (3,3%)], (p = 0,037) και παρόμοιος με το ΣΕΕ [44/227 (19,4%, 15/90 (16,7%), p = 0,63]. Η παρουσία του ΣΒΥΛΕ δεν συσχετίστηκε ούτε με το σύνολο ούτε με καμία βαθμολογία υποκλίμακας του ερωτηματολογίου PAGI-SYM. Συμπεράσματα: Σε μια κοόρτη ασθενών με ΛΔ στην Ελλάδα, ο επιπολασμός του ΣΒΥΛΕ ήταν παρόμοιος με εκείνον των ασθενών με ΣΕΕ και υψηλότερος σε σύγκριση με αυτούς των μαρτύρων.Background/Aims: Small intestinal bacterial overgrowth (SIBO), characterized by either increased numbers or presence of colonic type bacteria in the small bowel has been previously described in Functional Dyspepsia (FD), based on breath testing. In this study, we aim to examine the prevalence of SIBO among FD patients using small bowel aspirate culture. Methods: We prospectively enrolled outpatients fulfilling Rome IV criteria for FD. Severity of symptoms was graded using the patient assessment of upper gastrointestinal symptom severity index (PAGI-SYM) questionnaire. Patients underwent upper gastrointestinal endoscopy and duodenal fluid was aspirated in sterile traps. SIBO was defined as ≥103 CFU/ml of duodenal aspirate and/or presence of colonic type bacteria. Patients undergoing gastroscopy due gastroesophageal reflux symptoms - control group (CG) - and patients with irritable bowel syndrome (IBS) fulfilling Rome IV criteria were also recruited. Results: We enrolled 227 FD subjects, 30 CG and 90 IBS patients. Among FD patients, 144(63.4%), 64(28.2%) and 19(8.4%) had Postprandial Distress (PDS), Epigastric pain (EPS) and overlap PDS-EPS syndrome, respectively. SIBO prevalence was 20.8%, 12.5% and 31.6% among PDS, EPS and overlap PDS-EPS FD subtypes, respectively. Overall, SIBO prevalence was significantly higher in FD [44/227(19.4%)], compared to CG [1/30(3.3%)], (p=0.037) and similar to IBS [44/227(19.4%) vs. 15/90(16.7%), p=0.63] subjects. SIBO presence was associated neither with total nor with any subscale score of the PAGI-SYM questionnaire. Conclusions: In a cohort of Greek FD patients, SIBO prevalence was similar to that of IBS subjects and higher compared to that of controls

Small intestinal bacterial overgrowth and functional dyspepsia

Background/Aims: Small intestinal bacterial overgrowth (SIBO), characterized by either increased numbers or presence of colonic type bacteria in the small bowel has been previously described in Functional Dyspepsia (FD), based on breath testing. In this study, we aim to examine the prevalence of SIBO among FD patients using small bowel aspirate culture. Methods: We prospectively enrolled outpatients fulfilling Rome IV criteria for FD. Severity of symptoms was graded using the patient assessment of upper gastrointestinal symptom severity index (PAGI-SYM) questionnaire. Patients underwent upper gastrointestinal endoscopy and duodenal fluid was aspirated in sterile traps. SIBO was defined as ≥103 CFU/ml of duodenal aspirate and/or presence of colonic type bacteria. Patients undergoing gastroscopy due gastroesophageal reflux symptoms - control group (CG) - and patients with irritable bowel syndrome (IBS) fulfilling Rome IV criteria were also recruited. Results: We enrolled 227 FD subjects, 30 CG and 90 IBS patients. Among FD patients, 144(63.4%), 64(28.2%) and 19(8.4%) had Postprandial Distress (PDS), Epigastric pain (EPS) and overlap PDS-EPS syndrome, respectively. SIBO prevalence was 20.8%, 12.5% and 31.6% among PDS, EPS and overlap PDS-EPS FD subtypes, respectively. Overall, SIBO prevalence was significantly higher in FD [44/227(19.4%)], compared to CG [1/30(3.3%)], (p=0.037) and similar to IBS [44/227(19.4%) vs. 15/90(16.7%), p=0.63] subjects. SIBO presence was associated neither with total nor with any subscale score of the PAGI-SYM questionnaire. Conclusions: In a cohort of Greek FD patients, SIBO prevalence was similar to that of IBS subjects and higher compared to that of controls.Εισαγωγή - Σκοπός: Το σύνδρομο βακτηριακής υπερανάπτυξης του λεπτού εντέρου (ΣΒΥΛΕ) που χαρακτηρίζεται από αυξημένο αριθμό ή παρουσία βακτηρίων τύπου παχέος εντέρου στο λεπτό έντερο έχει περιγραφεί στην παθογένεια της λειτουργικής δυσπεψίας (ΛΔ), με τη χρήση δοκιμασιών αναπνοής. Σκοπός της παρούσας διατριβής ήταν η εκτίμηση του επιπολασμού του ΣΒΥΛΕ μεταξύ ασθενών με ΛΔ χρησιμοποιώντας καλλιέργεια του υγρού αναρρόφησης από το λεπτό έντερο. Μέθοδοι: Αξιολογήσαμε προοπτικά εξωτερικούς ασθενείς που πληρούσαν τα κριτήρια της ROME IV για ΛΔ. Η σοβαρότητα των συμπτωμάτων αξιολογήθηκε χρησιμοποιώντας το ερωτηματολόγιο PAGI-SYM. Οι ασθενείς υπεβλήθησαν σε ενδοσκόπηση ανώτερου πεπτικού και το δωδεκαδακτυλικό υγρό αναρροφήθηκε σε αποστειρωμένες παγίδες. Το ΣΒΥΛΕ ορίστηκε ως ≥103 CFU / ml αναρρόφησης δωδεκαδακτύλου και / ή παρουσία βακτηρίων παχέος εντέρου. Συμπεριλάβαμε επίσης ως μάρτυρες (ΟΜ) ασθενείς που υπεβλήθησαν σε γαστροσκόπηση λόγω συμπτωμάτων γαστροοισοφαγικής παλινδρόμησης και υλικό από ασθενείς με σύνδρομο ευερέθιστου εντέρου (ΣΕΕ) που πληρούσαν τα κριτήρια της ROME IV. Αποτελέσματα: Εντάξαμε συνολικά 227 ασθενείς με ΛΔ, 30 ΟΜ και 90 με ΣΕΕ. Μεταξύ των ασθενών με ΛΔ, 144 (63,4%), 64 (28,2%) και 19 (8,4%) είχαν σύνδρομο μεταγευματικής δυσφορίας (ΜΓΔ), σύνδρομο επιγαστρικού άλγους (ΣΕΑ) και σύνδρομο αλληλοπεπικάλυψης ΜΓΔ - ΣΕΑ. Ο επιπολασμός του ΣΒΥΛΕ ήταν 20,8%, 12,5% και 31,6% μεταξύ των υποτύπων του συνδρόμων, αντίστοιχα. Συνολικά, ο επιπολασμός του ΣΒΥΛΕ ήταν σημαντικά υψηλότερος στη ΛΔ [44/227 (19,4%)], σε σύγκριση με την ΟΜ [1/30 (3,3%)], (p = 0,037) και παρόμοιος με το ΣΕΕ [44/227 (19,4%, 15/90 (16,7%), p = 0,63]. Η παρουσία του ΣΒΥΛΕ δεν συσχετίστηκε ούτε με το σύνολο ούτε με καμία βαθμολογία υποκλίμακας του ερωτηματολογίου PAGI-SYM. Συμπεράσματα: Σε μια κοόρτη ασθενών με ΛΔ στην Ελλάδα, ο επιπολασμός του ΣΒΥΛΕ ήταν παρόμοιος με εκείνον των ασθενών με ΣΕΕ και υψηλότερος σε σύγκριση με αυτούς των μαρτύρων

Double-endoscope assisted endoscopic submucosal dissection for treating tumors in rectum and distal colon by expert endoscopists: a feasibility study

Background!#!Colorectal endoscopic submucosal dissection (ESD) is an effective but challenging procedure. To facilitate ESD, several methods that apply traction are available; however, the optimal one remains to be established. The aim of this study was to evaluate the feasibility and safety of the double-endoscope assisted ESD (DEA-ESD) by improving traction to treat complex colorectal lesions.!##!Methods!#!Naïve or previously treated lesions in the rectum and sigmoid colon were included. A grasping forceps advanced through a small-caliber endoscope (GIF-XP190N, Olympus Medical Systems, Tokyo, Japan, 5.4 mm outer diameter) was used to apply traction to the mucosal flap. Lesions were deemed complex when they exceeded a total of nine points on the SMSA scoring system (size, morphology, site, and access) and recurrent when they were previously treated with endoscopic mucosal resection (EMR). Outcome measures included procedural success, total procedure time, complications, and recurrence rate at 3-month follow-up.!##!Results!#!Nine patients (mean age 62.3 ± 14.5 years) were included; five had rectal and four had tumors in the sigmoid colon. The median SMSA score was 14 (SMSA Level IV-complex polyp), while three patients were pre-treated with EMR. DEA-ESD was technically feasible in all cases. En bloc resection and R0 resection rates were 100%, respectively, with a mean procedure time of 128.4 ± 54.1 min. No immediate or delayed complications occurred.!##!Conclusions!#!DEA-ESD is a feasible and safe method for treating complex or recurrent tumors in the rectum and distal colon

Full spectrum endoscopy for an easy and adequate visualization of Vater's papilla

Patients with classical familial adenomatous polyposis (FAP) are at high risk for developing colorectal cancer (CRC) and duodenal adenomas. Current guidelines recommend to start duodenal screening at the age of 25-30 years and standard upper gastrointestinal (GI) endoscopy is considered inadequate for an optimal visualization of the duodenum. We used the Full-Spectrum Endoscopy (R) (FUSE (R) ; EndoChoice Inc., Atlanta, GA, USA) esophagogastroduodenoscope (FUSE-EGD) for an upper GI screening procedure of a 20-year-old Caucasian male with classical FAP. The pioneer design of the FUSE-EGD allowed an easy and accurate examination of the ampulla with standard scope manipulation maneuvers

Adhering to quality medical care: a case report of upper gastrointestinal bleeding due to self-expandable metal stent placed for benign duodenal obstruction

Endoscopic placement of self-expandable metal stent (SEMS) is an efficient method for the palliative decompression of malignant gastro duodenal obstruction. However, its role in treating benign obstructive conditions is controversial. We herein present an unusual case of recurrent upper gastrointestinal (GI) bleeding episodes due to ischemic lesions induced by an uncovered SEMS placed several years before to treat post peptic ulcer pyloric obstruction. Patient's advanced age precluded any attempt for endoscopic or surgical removal of the stent and the patient was successfully treated only with proton pump inhibitors, remaining uneventful on the long term. 71 his case speaks to the need for rational use of innovative treatment modalities for quality of care provision

Strategies to Improve Inpatients’ Quality of Bowel Preparation for Colonoscopy: A Systematic Review and Meta-Analysis

Background and Aims. Inpatients’ bowel preparation before colonoscopy is frequently inadequate, and various interventions have been investigated to improve it, so far. We aimed to evaluate the efficacy of various interventions to improve inpatients’ colon preparation quality. Methods. We systematically reviewed the literature for publications on interventions aiming to improve the quality of inpatients’ colon preparation until June, 2018. Significant heterogeneity—measured with I2—was detected at the level of P<0.1. Adequacy rates were measured using inverse variance, and the size effect of different interventions was calculated using random effects model and expressed as odds ratio (OR). Results. Seventeen studies enrolling 2733 inpatients were included. Overall, 67% (60-75%) of the participants achieved adequate colon cleansing (I2=97%; P<0.001). In six studies assessing the impact of educational interventions to patient/physician/nurse vs. no intervention, adequate bowel preparation was achieved in 77% (62-91%) vs. 50% (32-68%) of the patients (OR 95%CI=3.49 (1.67-7.28), P=0.0009; I2=74%; P=0.002). Ten studies examined variations (qualitative and/or quantitative) in bowel preparation regimens with adequate preparation detected in 71% (60-81%) of the participants, and a single study examined the administration of preparation through an esophagogastroduodenoscope, resulting in adequate prep in 71% of the patients. Conclusions. Despite several interventions, only two-thirds of inpatients achieve adequate colon preparation before colonoscopy. Educational interventions significantly improve inpatients’ bowel preparation quality