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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.

Background: There is a lack of multicenter prospective studies on complications of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP)., Methods: We studied 2769 consecutive patients undergoing ERCP at nine centers in the Triveneto region of Italy over a 2-year period. Six centers performed ERCP on less than 200 patients per year (small centers). General and ERCP-specific major complications were predefined. Data were collected at the time of ERCP, before discharge, and in cases of readmission within 30 days. ERCP was defined as therapeutic when endoscopic sphincterotomy (n = 1583), precut (n = 419), or drainage (n = 701) had been carried out, singularly or in combination., Results: One hundred eleven major complications (4.0%) were recorded: moderate-severe pancreatitis 36 (1.3%), cholangitis 24 (0.87%), hemorrhage 21 (0.76%), duodenal perforation 16 (0.58%), others 14 (0.51%). Among 942 diagnostic ERCPs there were 13 major complications (1.38%) and 2 deaths (0.21%), whereas among 1827 therapeutic ERCPs there were 98 major complications (5.4%) and 9 deaths (0.49%). The difference in the incidence of complications between diagnostic and therapeutic ERCPs was statistically significant (p < 0.0001). Small center and precut were recognized as independent risk factors for overall major complications of therapeutic ERCP, whereas the following risk factors were identified in relation to specific complications: (1) pancreatitis: age less than 70 years, pancreatic duct opacification, and nondilated common bile duct; (2) cholangitis: small center, jaundice; (3) hemorrhage: small center; and (4) retroperitoneal duodenal perforation: precut, intramural injection of contrast medium, and Billroth II gastrectomy., Conclusions: Major complications are mostly associated with therapeutic procedures and low case volume. Present data support a policy of centralization of ERCP in referral centers. A more selected and safer use of precut may be expected to further limit the adverse events of ERCP.

Histamine H2-receptor antagonists at conventional doses have proved only partly efficacious in the treatment of reflux oesophagitis. The aim of this study, therefore, was to compare the efficacy of high doses of nizatidine (300 mg b.i.d.) versus placebo in 117 patients with grade I and II oesophagitis. After 6 weeks' treatment, 70.6% of nizatidine-treated patients showed complete endoscopic healing against 25.4% of placebo-treated subjects (p less than 0.001). After 12 weeks, the respective healing rates were 77.5% and 47.4% (p less than 0.01). Nizatidine also proved significantly more effective than placebo in improving overall symptoms (p less than 0.05). Antacid intake was significantly greater in the placebo group (p less than 0.001). Both treatments were well tolerated. In conclusion, this study demonstrates that nizatidine at the dose of 300 mg b.i.d. for 6-12 weeks constitutes an effective treatment for patients with reflux oesophagitis.

The aim of the present study was to investigate the effectiveness of ranitidine in the treatment of duodenal ulcer. Fourty patients with endoscopically proven pyloric or duodenal ulcer were treated with ranitidine 40 mg t.d. with meals and 80 mg nocte, or identical placebo tablets under double-blind conditions. Endoscopy after four weeks of treatment revealed complete healing in 15 out of 18 (83.3%) ranitidine-treated patients and in 5 out of 17 (29.4%) of the placebo patients (P less than 0.01). Ulcer symptoms were significantly less in ranitidine-treated patients, while the difference in antacid consumption between the two groups was found to be only arithmetical. No side effects or significant hematological or biochemical abnormalities were found. Four-week treatment with 200 mg of ranitidine daily seems to correspond to that of 6-8 weeks with 1-1, 6 g of cimetidine.

93 publications concerning drug-induced pancreatitis are reviewed. A confirmed causal relationship between drug and acute pancreatitis so far exists only for 8 compounds: azathioprine, chlorothiazide, furosemide, sulfonamides, tetracycline, estrogens, valproic acid and L-asparaginase. There is less convincing, but still suggestive, evidence for a causal relationship with 5 other drugs, namely: corticosteroids, chlorthalidone, ethacrynic acid, phenformin and iatrogenic hypercalcemia. Due to inadequate or contradictory evidence, the link between a number of additional drugs and acute pancreatitis is considered possible, conditional or doubtful. Finally, the scant literature concerning the pathogenesis and histological lesions of drug-induced pancreatitis is briefly reviewed.

The aim of this study was to compare the ethanol serum concentration curve, the area under the curve and subjective response after acute ingestion of ethanol (red wine, 13 degrees proof, at a dose of 0.8 g/kg of ideal weight in 6 healthy volunteers with a mean habitual alcohol intake of 20 g/day. All the subjects underwent the test a total of three times, after pre-treatment with cimetidine (400 mg X 2/day/7 days) and ranitidine (150 mg X 2/day/7 days), respectively, and after receiving no pre-treatment. The wine was taken orally within the space of 15 min, four hours after taking a standard-weight ham sandwich. Blood samples were drawn at the following times: 0, 30, 60, 90, 120, 180, 240 and 360 minutes. The plasma ethanol curve of the subjects pre-treated with cimetidine lies above that of the subjects pre-treated with ranitidine, and largely coincides with the curve obtained in those who received no pre-treatment, with the exception of the initial hour-and-a-half, when the later show a slightly higher mean plasma concentration. The differences between the three treatment groups are merely arithmetical, but not statistical, with respect to peak plasma ethanol concentrations, time elapsing before peaking, and areas under the curves. These results are at variance with some published data suggesting a significant interaction of cimetidine with the metabolism of alcohol by way of interference either with the hepatic oxidative metabolizing enzymes, or with the activity of alcohol dehydrogenase.