Rethink analgo-sedation in digestive endoscopy: the role of scientific societies in tracing training path

OBJECTIVE

The Italian Society of Anesthesia, Analgesia, Reanimation and Intensive Care Medicine (SIAARTI) and the Italian Society of Digestive Endoscopy (SIED) worked together to produce a joint Good Clinical Practice (GCP) on analgo-sedation in digestive endoscopy and launched a survey to support the document. The aim was to identify and describe the actual clinical practice of sedation in Italian digestive endoscopy units and offer material for a wider and more widespread discussion among anesthetists and endoscopists.

SUBJECTS AND METHODS

A national survey was planned, in order to support the statements of the GCP. Twelve thousand and five hundred questionnaires were sent to the members of SIAARTI and SIED in June 2020.

RESULTS

A total of 662 forms (5.3%) returned completed. Highly complex procedures are performed according to 70% of respondents; daily anesthesiologist's assistance is guaranteed in 26%, for scheduled sessions in 14.5% and as needed in 8%. 69% of respondents declared not to have a dedicated team of anesthesiologists, while just 5% reported an anesthesiologist in charge. A complete monitoring system was assured by 70% of respondents. Dedicated pathways for COVID-19-positive patients were confirmed in <40% of the answers. With regard to moderate/deep sedation, 90% of respondents stated that an anesthetist decides timing and doses. Propofol was exclusively administered by anesthetists according to 94% of answers, and for 6% of respondents the endoscopist is allowed to administer propofol in presence of a dedicated nurse, but with a readily available anesthetist. Only 32.8% of respondents reported institutional training courses on procedural analgo-sedation.

CONCLUSIONS

The need to provide patients scheduled for endoscopy procedures with an adequate analgo-sedation is becoming an increasing concern, well-known in almost all countries, but many factors compromise the quality of patient care. Results of a national survey would give strength to the need for a shared GCP in gastrointestinal endoscopy. Training and certification of non-anesthetist professionals should be one of the main ways to center the objective.

Infection prevention in endoscopy practice: comparative evaluation of re-usable vs single-use endoscopic valves

Re-usable air/water and suction valves used in endoscopes often demonstrate risk of infection. To the authors' knowledge, the safety and efficacy of re-usable and single-use valves have not been compared to date. As such, a laboratory investigation was undertaken to compare the safety and efficacy of re-usable and single-use valves at 11 Italian endoscopy sites. Safety was evaluated by analysing the rinse liquid of reprocessed re-usable valves ready for use, and efficacy was assessed based on the completion of endoscopic procedures without valve malfunction. This study found significantly lower contamination of single-use valves compared with re-usable valves (0 vs 29.1%, respectively; P=0.007) and similar efficacy (97.6 vs 98.8%, respectively; P=ns). Microbiological analysis of the rinse liquid of reprocessed re-usable valves identified various surviving micro-organisms and highlighted their potential pathogenicity. Such data suggest that sterile single-use valves may be safer than re-usable valves, and have comparable performance.

Five-year risk of CIN3 after short-term HPV-DNA negativity in cytology-negative women: a population-based cohort study

OBJECTIVE

To assess the 5-year risk of high-grade lesions in women with a transient high-risk HPV infection.

DESIGN

Population-based cohort study.

SETTING

HPV primary testing within population-based organised cervical cancer screening programmes.

POPULATION

Italian women enrolled in seven pilot projects and attending the second round.

METHODS

On the basis of the cytology triage performed on HPV-positive women, immediate colposcopy or HPV repeat at 12 months was recommended. Data were collected at the subsequent round 3-4 years after HPV infection clearance.

MAIN OUTCOME MEASURES

Rates of HPV infection, CIN2+ and CIN3+ detection at subsequent round after HPV clearance, and relative risks (RR) in comparison with HPV-negative women (with 95% confidence interval).

RESULTS

Data on 1230 women (1027 aged 25-64 years and 203 aged 35-64 years) have been analysed. Overall compliance with repeat HPV testing was 84%. In comparison with HPV-negative women, those with a transient HPV infection had higher proportions of HPV positivity (15% versus 3.7%) and of CIN2+ lesions (0.87% versus 0.23%) in round two; most of these (7/10) were CIN2; no cancers were detected, and CIN3 occurred in 3/1230 (0.24%).

CONCLUSIONS

HPV-based protocols for cervical cancer screening allow long intervals for HPV-negative women; it is important to monitor the clinical outcome in the women with transient high-risk HPV infection. CIN3 detection is similar to that observed in routine European cytology-based screening programmes (CIN3+: 2.7‰); 5-year intervals may provide reasonable protection but longer intervals are not recommended.

TWEETABLE ABSTRACT

A screening interval of 5 years (but no longer) appears safe in women with transient HPV detection.

Cervical cancer screening with HPV testing in the Valcamonica (Italy) screening programme

OBJECTIVE

We present the results of the first screening round and the first year of the second round of the Valcamonica Human Papillomavirus (HPV) pilot screening project.

SETTING

From 2010 to 2012, the entire target female population (aged 25-64) was invited to the first HPV screening round in an area where Pap test screening had been active since 2002.

METHODS

For HPV-negative women, the interval was three years. For HPV-positive women, a cytological smear was stained and interpreted. Positive cytologies were referred to colposcopy; negatives were referred to repeat HPV after one year. If HPV was persistently positive, women were referred to colposcopy; if negative, to normal screening.

RESULTS

In 2010-12 18728 women were screened, slightly higher participation than with Pap test (18233 64.7%); 1633 were HPV-positive (8.7%); 843 were positive at cytology triage (referral rate at baseline 4.5%). Of those referred at the one year HPV test, 84% complied (660/780); 356 were persistently positive (1.9%). The total referral rate was 6.4% compared with 3.7% for the Pap test. The detection rate was 9.2/1000 compared with 5.0% for the Pap test. The HPV positivity rate during the second round in women previously negative was 3.9% and the detection rate in HPV-positive cytology-positive women was 0.8/1000.

CONCLUSIONS

HPV-based screening increases colposcopies at the first round, but also strongly increases the detection rate. At the second round, HPV prevalence was much lower and the detection rate also fell, corroborating the need for longer screening intervals in HPV-negative women.

Distribution of COL8A2 and COL8A1 gene variants in Caucasian primary open angle glaucoma patients with thin central corneal thickness

PURPOSE

One approach to identify genes that contribute to common complex ocular disorders such as primary open angle glaucoma (POAG) is to study the genetic determinates of endophenotypes that are defined by underlying pre-disposing heritable quantitative traits such as central corneal thickness (CCT). Collagen VIII is a major component of Descemet's membrane and studies in mice have indicated that targeted inactivation of the genes encoding the collagen type 8 alpha1 (Col8a1) and collagen type 8 alpha2 (Col8a2) subunits (COL8A1 and COL8A2) results in thinning of the corneal stroma and of Descemet's membrane. The purpose of this study is to evaluate COL8A1 and COL8A2 as candidate genes for thin CCT in human POAG patients.

METHODS

100 Caucasian POAG patients were enrolled in this study. The entire COL8A1 and COL8A2 coding sequence was determined in 8 patients with CCT<513 µm (one standard deviation (36 microns) below the mean (550 microns) and 8 patients with CCT>586 µm (one standard deviation above the mean). Selected COL8A2 exons containing variants of interest were sequenced in the full POAG cohort. Association and quantitative trait analyses were performed.

RESULTS

Three patients with CCT less than 513 µm and advanced POAG were found to have missense changes in COL8A2; two patients had a previously identified mutation, R155Q and one had a novel change, P678L (p=0.0035, Fisher's exact test). Missense changes were not found in any of the patients with CCT>513 µm and missense changes in the COL8A1 gene were not found in any patient. One common COL8A2 SNP, rs274754 was also statistically associated with CCT (p=0.018).

CONCLUSIONS

In this study we have identified COL8A2 missense changes in a group of Caucasian patients with very thin CCT and advanced POAG. These results suggest that DNA sequence variants in the COL8A2 gene may be associated with thin corneas in some glaucoma patients. Further study of COL8A2 variants in other patient populations, especially those with thinner CCT such as African-Americans would provide further support for a role of COL8A2 in corneal thickness and in glaucoma.

Endoscopic management of symptomatic choledocholithiasis in pregnancy without the use of radiations

We report a case of 26-year-old woman at 10th week of gestation with cholestatic jaundice due to a common bile duct (CBD) stone managed by endoscopical retrograde cholangiopancreatography (ERCP). The procedure was successfully carried out without the use of ionizing radiations and under trans-abdominal ultrasonographical (US) control. A few cases are reported in literature in which ERCP was performed without fluoroscopy examination. We believe that ERCP with US guidance is an effective and safe procedure to treat symptomatic choledocholithiasis in pregnant women.

Antibody response to Helicobacter pylori CagA and heat-shock proteins in determining the risk of gastric cancer development

OBJECTIVE

To investigate whether the systemic antibody response to Helicobacter pylori heat shock protein B can be considered, in addition to anti cytotoxin-associated protein [CagA) antibody determination, a further serological marker of increased risk of gastric cancer development.

METHODS

A total of 98 Giemsa positive Helicobacter pylori patients (28 with gastric cancer, 30 with duodenal ulcer and 40 with nonulcer dyspepsia) were studied. Serum samples obtained from all patients were tested for IgG antibodies to CagA (116 kDa), VacA [89kDa) and heat skock protein B (54 kDa) antigens of Helicobacter pylori by the Western blot technique.

RESULTS

26/28 patients [(92.9% with gastric carcinoma, 29/30 patients [96.7%) with duodenal ulcer and 30/40 patients (75.0%) with non-ulcer dyspepsia were seropositive for CagA protein. The prevalence of serum IgG antibody to CagA in the cancer patients was not significantly higher than in duodenal ulcer and non-ulcer dyspepsia patients. The prevalence of antibodies to VacA was not significantly different between gastric carcinoma and non-ulcer dyspepsia patients. In contrast the prevalence of systemic antibodies to heat skock protein B was significantly higher in gastric cancer patients (78.6%) than in duodenal ulcer (36.7%, p=0.002) or nonulcer dyspepsia patients (52.5%, p=0.029).

CONCLUSIONS

The detection of antibodies to heat shock protein B is proposed as an additional test which, in association with the determination of serum antibodies to CagA, could help in determining the risk of developing severe gastroduodenal disease, and gastric cancer, in particular.

Complex segregation analysis for obsessive compulsive disorder and related disorders

Complex segregation analysis was applied to a sample of 107 Italian families with probands with obsessive compulsive disorder (OCD), using regressive logistic models to test for possible models of genetic transmission. We used two different phenotypic definitions of affection: 1) OCD; and 2) OCD plus Tourette's syndrome/chronic motor tics (CMT). Because of the potential relationship between OCD, Tourette's syndrome (TS), and other tic disorders, we considered these diagnoses to be determined by the same liability in subsequent steps of the analysis. For the 107 OCD families, the best fit was a dominant model of transmission (with a higher penetrance for females). When the phenotype boundaries were widened (OCD + CMT + TS), an unrestricted model of transmission became the best fit. We concluded that additional data are needed to support the hypothesis that Tourette's syndrome and OCD share a common etiology: on the basis of clinical and epidemiological considerations, the OCD phenotype probably presents a higher level of heterogeneity than the TS phenotype, and it could be regulated through different etiologic pathways.

5HT2C CYS23/SER23 polymorphism is not associated with obsessive-compulsive disorder

A great deal of evidence suggests that a genetic component underlies obsessive-compulsive disorder (OCD). The response to serotonergic medications and the worsening of obsessive symptoms after administration of serotonergic agonists indicate that serotonergic mechanisms are involved in OCD. We investigated the role of the Cys23Ser mutation of the 5HT2C receptor gene in the etiology of this disorder by performing an association study comparing a sample of 109 OCD patients with a sample of 107 healthy control subjects. No allelic or genotypic association of OCD with the 5HT2C receptor gene mutation was revealed in our data. We also extended the association analysis to a subsample of 39 OCD patients that had previously been submitted to a challenge test with clomipramine. In the subsample of OCD patients that received the challenge with clomipramine, no association between the 5HT2C receptor gene mutation and response to the challenge test was found. Our results exclude any specific role of the Cys23Ser mutation of 5HT2C receptor gene in the etiology of OCD: it seems probable that more complex genetic models are needed to explain the involvement of serotonergic elements in the etiology of this disorder.

Gastrectomy, lack of gastric first pass metabolism of ethanol and alcoholic liver disease. Results of a multicentre study

BACKGROUND

Some conditions characterized by a loss (anatomical or functional) of parietal cells of the gastric antrum, containing an alcohol-dehydrogenase, may reduce the first pass metabolism of ethanol at that level and, simultaneously, raise its bioavailability. The observation that the first pass metabolism was drastically suppressed after gastrectomy would appear to suggest that the latter condition represents a risk for the development of liver damage in patients who continue to consume alcohol even in a non relevant amount.

METHODS

Consecutively enrolled in the study were 304 individuals of both sexes aged between 45 and 70 years of whom 114 gastrectomized and 190 pair-matched control subjects all submitted to an Upper Gastrointestinal Endoscopy for whatever disturbance. All the patients were diagnosed as having liver disease with routine clinical and instrumental means. Information was collected concerning the mean daily alcohol intake, both before and after the operation.

RESULTS

The overall prevalence of hepatic lesions was shown to be higher in the gastrectomized than in the control group (42.1% vs 25.8%, p = 0.005). Moreover, referring only to alcohol-related hepatic lesions (steatosis, steato-fibrosis and cirrhosis), the prevalence was higher in the gastrectomized patients than in the controls (29.8% vs 17.9%, p = 0.02). As far as concerns alcohol consumption, the gastrectomized group had consumed 71 g/day and the control group 39 g/day alcohol per person (p < 0.05) in a similar period of time (35 and 33 years, respectively). Also the non alcohol-related liver damage (especially the viral type) was slightly higher in the gastrectomized patients (gastrectomized 12.3% vs control 7.9%, p = ns). Accordingly, the percentage of serum markers of viral infection was higher in this group (HBs Ag: gastrectomized 3.9% vs control 2.2%, p = ns; anti-HCV: gastrectomized 13.5% vs control 5.0%, p = 0.03). Finally, to test the eventual damaging effects of gastrectomy alone (excluding ethanol and/or viral infection), two groups of patients with a medium to low alcoholic negative assumption (30-60 g ethanol/day) and no signs of viral infection (HBsAg and anti-HCV negative) were extrapolated. In these two selected groups, the prevalence of alcoholic-related hepatic lesions were not statistically different (28 gastrectomized 20.3% vs 44 control 18.4%).

CONCLUSIONS

In conclusion, data emerging from investigations on the population under study indicate that the alcohol and viral infection appear to play a more important role in determining hepatic lesions than gastroresection.

Obsessive compulsive disorder and mood disorders: a family study

Obsessive compulsive disorder (OCD) often coexists with major depression (MD), with rates varying from 35 to 75%. The nature of the depressive symptomatology can be investigated by familial aggregation analysis, assuming that the disorder which occurs first is the one showing greater genetic liability and should have higher familial concentration. Therefore, the aim of our study was to assess the familial loading for OCD and mood disorders in the families of OCD patients with different chronology of onset for the mood disorder, to evaluate how the familial pattern of the diseases differs with different temporal sequences in which the two syndromes occur. A total of 172 OCD patients entered the study; 112 were pure OCD probands, 12 were unable to separate the onset of the two syndromes, 11 had prior mood disorder, and 37 of them had experienced their first depressive episodes after the onset of OCD. Information about the family history was collected by means of the Family History-Research Diagnostic Criteria (FH-RDC) and by directly interviewing at least 2 relatives per family. Morbidity risks for OCD indicate a familial concentration of the disorder in all groups, except the MD/OCD group. We found the highest rate of relatives affected by mood disorders in the families of patients with first onset of MD (28.8%), whereas in the other 3 groups MRs were much lower. These results suggest the affective nature of OCD patients who experienced first onset of MD. Thus, the chronology of onset seems to identify 2 different typologies of familial distribution.

Alcohol drinking among adolescents from town and mountainous areas in north Italy

Alcohol consumption was investigated among 9th and 13th grade high school students in the town of Brescia (an urban area) and in the Local Health Unit of Breno, a mountainous area in the province of Brescia. A total of 1364 students from Brescia and 1373 from Breno completed an anonymous questionnaire during school time. In both groups alcohol consumption was greater among 13th graders (modal age: 18 years) and males than 9th graders (modal age: 14 years) and females. Beer was the favourite alcoholic beverage, but wine was the most widely consumed daily beverage: among males, about 8% in grade 9 and 15% in grade 13 drank at least one glass of wine every day. The majority of both 9th and 13th graders had more than one type of alcoholic beverage a week, although many females drank beer only. Total alcohol consumption was higher among the mountainous area students than urban students, especially 9th graders, and greater differences were observed in the consumption of beer with respect to wine. The proportion of male students from Brescia and Breno who consumed more than 6 alcohol units a week were, respectively, 17% and 25% in grade 9 and 36% and 42% in grade 13. A higher prevalence of drunkenness was found among the students from the mountainous area with respect to the urban students, especially males. Among 13th grade males, 42% of students from Brescia and 60% from Breno claimed one or more episodes of drunkenness during the year prior to the interview.

[Factors associated with alcohol consumption in the youth of the province of Brescia]

We investigated factors related to adolescent alcohol consumption by administering an anonymous questionnaire to 2737 9th and 13th grade high-school students in the province of Brescia. A total of 1364 students coming from an urban area (the town of Brescia with about 200,000 inhabitants) and 1373 students from a mountainous area (Breno, Local Health Unit N. 37 in the Lombardy Region with 83,000 inhabitants) were interviewed. The associations between alcohol drinking and some demographic, socio-economic, behavioural and environmental variables were assessed by computing the correspective odds ratios (OR) by fitting logistic regression models for ordinal response variables ("cumulative odds" models). The results showed that the following variables were positively associated with alcohol consumption: 1) residence in a mountainous area, especially as regards spirits consumption; 2) experimental and regular smoking; 3) peer alcohol drinking (best friend and partner). Parents' daily alcohol consumption was associated with wine drinking, but not with either spirits consumption or frequency of drunkenness among students. A slight inverse relationship was also found between students' alcohol intake and their knowledge of the health hazards of alcohol, but it was not significant for all groups of students.

Drinking habits among high school students in Perugia, Italy, in 1981 and 1988: time trends and correlates

The prevalence of alcohol consumption among 9th (14-15 years old) and 13th grade (18-19 years old) high school students in Perugia, Italy, was investigated in 1981 and 1988. Wine was the most popular beverage, although its use declined in the 7-year period. Beer consumption remained stable, but it was at a lower level than wine. Overall, alcohol consumption showed a slight decline among both 9th and 13th graders. However, the proportion of excessive drinkers increased, and a growing phenomenon of drunkenness among students was observed. Alcohol consumption was positively associated with sex and smoking and negatively associated with father's education and knowledge of the health hazards of alcohol abuse by multivariate analysis.

Factors associated with non-participation of women in a breast cancer screening programme in a town in northern Italy

STUDY OBJECTIVE

The aim was to investigate the reasons for the high percentage of women refusing to attend a breast cancer screening programme in the Health District of Brescia, Italy.

DESIGN

This was a survey of a sample of non-attenders to the programme, who were interviewed using a structured questionnaire.

SETTING

Non-attenders all lived in a central area of the town near the screening centre.

PARTICIPANTS

Of the 612 non-attenders eligible for interview, 183 could not be interviewed: one had died, 86 were away from home at two different visits, 32 were no longer resident at the known address, eight had serious health problems, 17 had undergone mastectomy, and 39 refused the interview. Overall, a total of 429 of the 612 eligible women were interviewed (70.1%).

MEASUREMENTS AND MAIN RESULTS

Attenders and non-attenders were compared with respect to demographic and socioeconomic factors, use of preventive medicine, and prevalence of risk factors for breast cancer. The response was higher among less educated women, married and widowed women, and those born in the province than among more educated, single or divorced, and immigrant women. Most of the women interviewed gave practical reasons for non-participation, but lack of interest/distrust and fear/worry/anxiety also seemed important. The number of non-attenders who had had a Papanicolaou test within the previous three years was three times higher than those who had had mammography, suggesting that non-attenders were more interested in types of preventive medicine other than screening for breast cancer by mammography. Attenders and non-attenders appeared similar as regards distribution of conventional breast cancer risk factors.

CONCLUSIONS

Greater effort in the information campaign might increase the participation rate in screening for breast cancer, although to a lesser extent than expected: if non-attenders potentially recruitable in our screening were added to attenders, overall compliance of the programme was about 75%, lower than that observed in some programmes in northern Europe.

An experimental test of new theoretical models for the electrokinetic properties of biological membranes. The effect of UO2++ and tetracaine on the electrophoretic mobility of bilayer membranes and human erythrocytes

For a large smooth particle with charges at the surface, the electrophoretic mobility is proportional to the zeta potential, which is related to the charge density by the Gouy-Chapman theory of the diffuse double layer. This classical model adequately describes the dependence of the electrophoretic mobility of phospholipid vesicles on charge density and salt concentration, but it is not applicable to most biological cells, for which new theoretical models have been developed. We tested these new models experimentally by measuring the effect of UO2++ on the electrophoretic mobility of model membranes and human erythrocytes in 0.15 M NaCl at pH 5. We used UO2++ for these studies because it should adsorb specifically to the bilayer surface of the erythrocyte and should not change the density of fixed charges in the glycocalyx. Our experiments demonstrate that it forms high-affinity complexes with the phosphate groups of several phospholipids in a bilayer but does not bind significantly to sialic acid residues. As observed previously, UO2++ adsorbs strongly to egg phosphatidylcholine (PC) vesicles: 0.1 mM UO2++ changes the zeta potential of PC vesicles from 0 to +40 mV. It also has a large effect on the electrophoretic mobility of vesicles formed from mixtures of PC and the negative phospholipid phosphatidylserine (PS): 0.1 mM UO2++ changes the zeta potential of PC/PS vesicles (10 mol % PS) from -13 to +37 mV. In contrast, UO2++ has only a small effect on the electrophoretic mobility of either vesicles formed from mixtures of PC and the negative ganglioside GM1 or erythrocytes: 0.1 mM UO2++ changes the apparent zeta potential of PC/GM1 vesicles (17 mol % GM1) from -11 to +5 mV and the apparent zeta potential of erythrocytes from -12 to -4 mV. The new theoretical models suggest why UO2++ has a small effect on PC/GM1 vesicles and erythrocytes. First, large groups (e.g., sugar moieties) protruding from the surface of the PC/GM1 vesicles and erythrocytes exert hydrodynamic drag. Second, charges at the surface of a particle (e.g., adsorbed UO2++) exert a smaller effect on the mobility than charges located some distance from the surface (e.g., sialic acid residues).