Tino Casetti

Oral beclometasone dipropionate in the treatment of active ulcerative colitis: a double-blind placebo-controlled study

Aim : To evaluate efficacy and safety of oral beclometasone dipropionate (BDP) when added to 5‐ASA in the treatment of patients with active ulcerative colitis.

Oral beclometasone dipropionate in the treatment of extensive and left-sided active ulcerative colitis: a multicentre randomised study.

Aim:  To explore the efficacy and safety of the topically acting steroid beclometasone dipropionate (BDP) in an oral controlled release formulation in the treatment of extensive or left‐sided ulcerative colitis.

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 χ2 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.

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.

Distal hyperplastic polyps do not predict proximal adenomas: results from a multicentric study of colorectal adenomas☆☆☆★★★♢

BACKGROUND The association between distal hyperplastic polyps and proximal adenomas is still a matter of debate. We investigated this association while taking into account patient characteristics. METHODS After exclusion of patients with inflammatory bowel diseases, familial adenomatous polyposis, or any cancer, 3088 eligible consecutive subjects aged 18 to 69 years underwent total colonoscopy in four gastroenterology units. The odds ratios (OR) of having proximal adenomas according to patient characteristics (age, sex, medical center, year of endoscopy, reasons for referral, and distal findings) were estimated in univariate and multivariate analyses. RESULTS Patients with distal polyps of any type showed an adjusted OR of 2.5 (95% CI [1.9, 3.1] p < .001) of having proximal adenomas as compared with those without distal polyps. When distal adenomas and distal hyperplastic polyps were included in the multivariate model as independent factors, the presence of adenomas significantly increased the risk of proximal adenomas (OR = 2.8: 95% CI [2.2, 3.6] p < .001), whereas the presence of hyperplastic polyps did not (OR = 1.1: 95% CI [0.8, 1.5] p = .64). No association with number, size, or location of distal hyperplastic polyps was seen. CONCLUSIONS Our data show that the presence of hyperplastic polyps should not be the sole indication for total colonoscopy because they are not associated with proximal adenomas when adjusting for patient characteristics and presence of distal adenomas.

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 Cohens 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.

Colon capsule endoscopy may represent an effective tool for colorectal cancer screening: a single-centre series.

In this case, the presence of pre-existing AIH before natalizumab reatment could be suspected because of previous aminotranserase flare on IFNtreatment and ANA positivity, although as uch as 22.5% of patients with MS show circulating ANA. On the ther hand, immunomodulatory drugs previously administered o the patient might have masked the presence of an underlying IH. Based on clinical presentation and biochemical parameters, he possibility of an idiosyncratic drug-induced liver injury could ot be excluded. A liver biopsy would have been essential to chieve a clear diagnosis, but the procedure was refused by the atient. Conclusive data clarifying the mechanisms of DILI and drugnduced autoimmune hepatitis are still lacking [4,5]. Drugs that odulate T-cell activity and functions (i.e. interferons, antiNF, and natalizumab) could induce liver injury and possible etiopathogenetic theories involve a heightened sensibility against elf-antigens, induced by an immunomodulatory dysregulation Th1 vs. Th2 and Th17), a spontaneous formation of autoantibodes (ANA, anti-dsDNA) and a direct imbalance of liver cytokine ilieu. Natalizumab directly inhibits human leucocyte integrin; he drug did not undergo hepatic or renal metabolism and was ound unmodified in urine. Therefore, reactive metabolite or parnt drug formation is not enough to explain liver injury in this atient. Based on this case report we would emphasize the followng practical messages: (a) autoantibody screening before starting iological therapies; (b) on-treatment monitoring to detect early igns of immune-mediated diseases; (c) positive autoantibodies epresent a controversial issue for biological therapy and treatment hould be considered on a case-by-case basis; finally, (d) AIH or preious DILI should be considered a contraindication to natalizumab reatment.

Double-Balloon Enteroscopy

In the last decade, significant advances have been made in small-bowel endoscopy. In particular, the introduction of capsule endoscopy (2000), double-balloon enteroscopy (2001), single-balloon enteroscopy (2006), and spiral-overtube-assisted enteroscopy (2006) has enabled a practical endoscopic approach to the entire small bowel. Unlike capsule endoscopy, enteroscopy with an endoscope allows the operator to control the function of the device in real time. Moreover, this approach allows various treatments to be performed, such as hemostasis, polypectomy, and dilation. Among the new procedures, double-balloon endoscopy was the first to be introduced and is thus the most well studied. This chapter describes the technology underlying double-balloon enteroscopy, the indications for the procedure, and information that can be expected from it.