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BACKGROUND: Adherence to gluten free diet (GFD) has been the object of many studies but few have investigated its essential requisite: a thorough knowledge of gluten sources. OBJECTIVE: Our aim was to measure celiac patients’ knowledge of GFD and assess its determinants. METHODS: A 20-item questionnaire was submitted to our celiac outpatients who were asked to indicate which foods or situations might be at risk of gluten intake. A 20-point rating scale was built giving one point for each correct answer. RESULTS: 154 patients were enrolled. The mean score of the knowledge test was 14.3 ± 2.9. Focusing on the incorrect responses, only 20.8% of them would have placed patients at risk of consuming gluten while the other 79.2% concerned foods or situations that were unnecessarily avoided by the patients. A statistically significant lower score was obtained by patients aged over 60 years (p = 0.0002), without a degree or diploma (p = 0.0016), non-members of the Italian Celiac Association (p = 0.043), who never visited the Association website (p = 0.0002) and never ate outside (p = 0.0009). CONCLUSIONS: We identified some categories of celiac patients at risk of less knowledge of GFD who deserve special training and attention.

Many studies, almost all in an Endoscopic Retrograde Cholangiopancreatography (ERCP) setting, have been conducted to establish if a link exists between periampullary diverticula (PADs) and biliopancreatic diseases but the issue is still debated.The objective was to clarify the link between PADs and biliopancreatic disease, for the first time using Endoscopic Ultrasound (EUS).We retrospectively reviewed our database seeking patients scheduled for EUS with an indication that entailed the exploration of the second duodenum. For each patient with a PAD enrolled in the study, 6 controls were randomly selected.2475 patients met the inclusion criteria. Among them, 185 subjects with a PAD were found (prevalence 7.5%), 1110 subjects served as controls. Patients with a PAD had more frequently a history of cholangitis (8.1 vs 2.2%; OR 3.99, p 0.001), a higher prevalence of common bile duct (CBD) dilation (44.3 vs 28.2%; OR 2, p 0.0001) and a higher prevalence of CBD stones (34.1 vs 19.6%; OR 2.1, p 0.0001). No differences were found about history of jaundice, acute/recurrent pancreatitis or EUS signs of chronic pancreatitis.Whereas PADs were linked with history of cholangitis, CBD stones and dilation, no association was found with pancreatic diseases.

Background: Recent data imply young patients (age ≤50 years) undergoing small-bowel (SB) capsule endoscopy (CE) for iron deficiency anaemia (IDA) show higher diagnostic yield (DY) for sinister pathology. We aimed to investigate DY of CE in a large cohort of young IDA patients, and evaluate factors predicting significant SB pathology. Materials and methods: This was a retrospective, multicentre study (2010–2015) in consecutive, young patients (≤50 years) from 18 centres/12 countries, with negative bidirectional gastrointestinal (GI) endoscopy undergoing SBCE for IDA. Exclusion criteria: previous/ongoing obscure-overt GI bleeding; age 50 years; comorbidities associated with IDA. Data retrieved: SBCE indications; prior investigations; medications; SBCE findings; final diagnosis. Clinical and laboratory data were analysed by multivariate logistic regression. Results: Data on 389 young IDA patients were retrieved. In total, 169 (43.4%) were excluded due to incomplete clinical data; data from 220 (122F/98M; mean age 40.5 ± 8.6 years) patients were analysed. Some 71 patients had at least one clinically significant SBCE finding (DY: 32.3%). They were divided into two groups: neoplastic pathology (10/220; 4.5%), and non-neoplastic but clinically significant pathology (61/220; 27.7%). The most common significant but non-neoplastic pathologies were angioectasias (22/61) and Crohn’s disease (15/61). On multivariate analysis, weight loss and lower mean corpuscular volume(MCV) were associated with significant SB pathology (OR: 3.87; 95%CI: 1.3–11.3; p = 0.01; and OR: 0.96; 95%CI: 0.92–0.99; p = 0.03; respectively). Our model also demonstrates association between use of antiplatelets and significant SB pathology, although due to the small number of patients, definitive conclusions cannot be drawn. Conclusion: In IDA patients ≤50 years with negative bidirectional GI endoscopy, overall DY of SBCE for clinically significant findings was 32.3%. Some 5% of our cohort was diagnosed with SB neoplasia; lower MCV or weight loss were associated with higher DY for SB pathology.

Background and objectives Endoscopic variceal ligation (EVL) is recommended to treat esophageal varices (EV) in cirrhosis and portal hypertension. A program of endoscopic surveillance is not clearly established. The aim of this prospective randomized trial was to assess the most effective timing of endoscopic monitoring after variceal eradication and its impact on the patient's outcome and on the costs. Methods A hundred and two cirrhotic patients with esophageal varices treated by EVL were evaluated. After variceal eradication patients were randomized to receive first endoscopic control at 3 (Group 1) and 6 (Group 2) months respectively. Results Variceal obliteration was achieved in all patients. Variceal recurrence was observed in 28 cases at the first control (29.1%) without difference between the two groups (32% vs 29% in group 1 and 2 respectively, p = 0.75). The incidence of large varices is similar in the two groups (33% vs 38% respectively). Using a multivariate analysis, medical therapy with B blockers was the only independent predictor of lowest risk of variceal recurrence [OR 2.30, 95% CI (1.68–3.26)]. Bleeding related to recurrent varices occurred in 3.1% of cases and was associated with portal thrombosis. Child Pugh score ≥ 8 was the only predictor of mortality (p = 0.0002). Conclusions Recurrence of varices after banding ligation is not rare but it is associated with a low risk of variceal progression and bleeding. Accordingly, a first endoscopic control at 6 months after variceal eradication associated with a good risk stratification might be a cost-effective strategy of monitoring.

Background There is scant literature about common bile duct (CBD) dilatation with normal liver function tests (LFTs). Aims The aims of this study were to assess the diagnostic yield of endoscopic ultrasound (EUS) in patients with CBD dilatation, normal LFTs, and prior inconclusive imaging tests, and to assess the natural history of these subjects. Methods We retrospectively reviewed our EUS database for patients referred for evaluation of CBD dilatation, normal LFTs, and prior inconclusive imaging. We excluded patients with a prior endoscopic retrograde cholangiopancreatography or a history of biliary obstruction, pancreatitis, or jaundice. Follow-up data were retrieved from medical records or by calling the general practitioners, referring specialists, patients, or their closest relatives. Results A total of 57 patients were enrolled. The mean CBD diameter was 12.5±3.6 mm. The majority of patients (50.8%) were asymptomatic. Abnormal EUS findings were recorded in 12 (21%) subjects: 6 patients had a periampullary diverticulum, 2 had ampullary adenoma, 2 had signs of chronic pancreatitis, 1 had a cancer of the pancreatic head, and 1 had a 7 mm CBD stone. Neither age, sex, prior cholecystectomy, clinical presentation, CBD diameter, nor a dilated main pancreatic duct were predictors of abnormal EUS findings. None of the patients complained of biliary symptoms or showed abnormal LFTs on long-term follow-up. Conclusions CBD dilatation with normal liver chemistry is not always a benign condition. Even when prior imaging tests are negative, EUS may allow to diagnose conditions overlooked by standard diagnostic imaging.

During 2011 General Population and Housing Census methodological innovations towards the planning of a register-based census were introduced. Such innovations allowed to reach a satisfactory cost-benefit balance but increased the survey complexity and the risk of errors.Istat focus on web technologies was aimed at performing an innovative census, both in terms of methodology and costs and of data dissemination timeliness. This paper shows how a highly integrated web information system was used to manage a census workflow involving several actors and multiple phases and integrating different data sources. The success of 2011 Census led Istat to adopt such technological infrastructure as the core of the ‘Continuous General Population and Housing Census’.

Capsule endoscopy (CE) is currently considered as a first line diagnostic tool for small bowel examination. Some patients find swallowing the capsule difficult. However, capsule aspiration is relatively uncommon and is only reported in isolated cases. The majority of these cases are male (39/41; 95.1%) with an age ranging from 56-93 years and only 4 (9.8%) patients had a recorded history of dysphagia. Twenty-four out of 41 (58.5%) patients experienced symptoms of capsule aspiration. The aspiration self-resolved in 11/41 patients and the CE was retrieved during bronchoscopy in the other cases. We present the case of a 75 year old man with a history of chronic anemia who was referred for CE.

Background and aims: Safety of propofol sedation in patients with liver cirrhosis undergoing colonoscopy or endoscopic retrograde cholangiopancreatography (ERCP) remains to be studied. The aim of this study was to investigate whether the use of propofol is safe for endoscopic procedures more complex than gastroscopy in patients with liver cirrhosis in a prospective controlled study. Methods: Two hundred and fourteen consecutive patients, with or without cirrhosis, who underwent colonoscopy or ERCP with propofol sedation were recruited between January and June 2009. Administration of sedation was performed by anesthesiologists and outcome measures were recorded. Main outcomes were complication rates and recovery times. Results: Sixty-one (28.5%) cirrhotic patients and 153 (71.5%) noncirrhotic patients were included. The incidence of sedation-related complications did not significantly differ between the two populations (11.5 vs. 17.0%, respectively, P=0.31). The mean (±SD) dose of propofol administered (213±86 vs. 239±100 mg, P=0.07), the mean time to achieve adequate sedation (3.3±1.1 vs. 3.0±1.2 min, P=0.21), the mean total duration of the endoscopic procedure (24.5±10.6 vs. 27.4±11.8 min, P=0.08), the mean time to reach Observer's Assessment of Alertness and Sedation Scale 5 (17.2±4.4 vs. 18.4±5.6 min, P=0.15), the mean time from completion of the procedure to release (9.0±2.5 vs. 9.1±3.2 min, P=0.86), and the mean time to full recovery (42.2±7.3 vs. 42.3±7.8 min, P=0.88) were very similar between the two groups. The limitation of this study was lack of randomization, and a control group of cirrhotic patients using standard sedation with benzodiazepines and opioids. Conclusion: Propofol deep sedation administered by an anesthesiologist with appropriate monitorings seems to be a safe procedure during colonoscopy or ERCP in cirrhotic patients.

A. Stacchini, P. Carucci, D. Pacchioni, G. Accinelli, A. Demurtas, S. Aliberti, M. Bosco, M. Bruno, A. Balbo Mussetto, M. Rizzetto, G. Bussolati and C. De Angelis Diagnosis of deep-seated lymphomas by endoscopic ultrasound-guided fine needle aspiration combined with flow cytometry Objective: Although endoscopic ultrasound combined with fine needle aspiration (EUS-FNA) is rapidly becoming the preferred diagnostic approach for the sampling and diagnosis of gastrointestinal and mediastinal malignancies, there are limited data as to its use in the diagnosis of lymphoproliferative disorders. Therefore, we carried out a retrospective evaluation of the performance of EUS-guided FNA combined with flow cytometry (FC) as a tool to improve overall sensitivity and specificity in the diagnosis of lymphoma. Methods: Of 1560 patients having EUS-guided FNA during the period of the study, a total of 56 patients were evaluated by cytology with FC after EUS-FNA. There was adequate material to perform FC analysis for all but one case. Results: EUS-FNA-FC gave a diagnosis of lymphoma in 11 cases and of reactive lymphadenopathy in 20. A specific histological type was defined by FC alone in eight cases. The remaining cases were diagnosed later by cytology and cell block sections: 13 carcinomas, nine granulomatous lymphadenopathies and one mediastinal extramedullary haematopoiesis. One case was considered only suspicious for lymphoma on cytology and FC but was not confirmed on molecular analysis and one had insufficient material for FC. Conclusions: Our results show that a combination of EUS-FNA-FC is a feasible and highly accurate method, which may be used for the diagnosis and subtyping of deep-seated lymphoma, providing a significant improvement to cytomorphology alone both for diagnosis and treatment planning, as long as immunocytochemistry is available for non-lymphoma cases.

The majority of lesions originating from muscularis propria of stomach, duodenum, and colon are gastrointestinal stromal tumors (GISTs). Surgery is indicated when endosonographic criteria of malignancy are met, but little is known about the natural history of lesions with benign endosonographic features. Aim of this study was to evaluate the natural course of benign-appearing lesions originating from muscularis propria in organs where GISTs significantly overcome leiomyomas.A total of 49 asymptomatic patients with hypoechoic lesions originating from the fourth layer of the gastrointestinal tract entered a follow-up program by means of endoscopic ultrasonography. All lesions were nonulcerated,3 cm in maximal diameter, with regular margins, and cystic spaces of3 mm.After a mean follow-up of 31+/-20.8 months and a median of 2 (range, 1 to 5) endosonographies/patient, no change in echostructure or dimensions was seen in 44 subjects whereas in 5, an increase of at least 25% in 1 diameter occurred. Surgical removal was proposed to all: 1 patient refused (she is still alive and symptom-free after 4 y), 3 of the 4 lesions removed proved to be GISTs with very low or low risk of malignancy and 1 lesion was classified as a glomus tumor with no malignant appearance.Even small and benign-appearing lesions from muscularis propria may increase in size over time but this increase cannot be considered as an index of malignancy. As most of these lesions are GISTs, a policy of surveillance is advisable.

NEGREIROS, Fauston; SILVA, Algeless Milka Pereira Meireles da; LIMA, Mauro Bruno Paraguai. Experiências educativas não exitosas: um estudo com discentes avaliando seu próprio processo de reprovação escolar. Revista Educação em Debate, Fortaleza, anos 35-38, v. 38, n.os 66-71, p. 157-171, jul./dez. 2013; jan./jun., jul./dez. 2014; jan./jun., jul./dez. 2015; jan./jun. 2016. The present study was conducted at 20 public schools in Parnaíba and Floriano (Piauí). The subjects were students, a population poorly documented in academic productions about the theme, and, as a result, they are absent in intervention plans regarding the issue of school failure. Therefore, the study aimed to make clear senses and meanings given by students at primary schools. According to Minayo (1992, 1996), a qualitative research was accomplished. The subjects were composed by 94 students – 55 girls and 39 boys – from public schools in Parnaíba and Floriano – PI that were disapproved at least once. They were found trough archives of school offices in both cities. The collected data were analyzed according to the hermeneutical technique (VERONESE; GUARESCHI, 2006), that allows a procedure in three stages: socio-historical analysis; content analysis; (re) interpretation. In conclusion, this study is very important for the educational field, since disapproval is one of the indicators that school is not fulfilling its role as a social segment. O presente estudo foi realizado em 20 escolas da rede de ensino público em Parnaíba e Floriano, no Piauí. Teve como protagonistas os alunos, atores pouco investigados nas produções acadêmicas acerca da temática e negligenciados de escuta nos planejamentos de intervenção diante do fenômeno do fracasso escolar. Dessa maneira, buscou-se evidenciar sentidos e significados atribuídos por alunos vinculados às escolas de ensino fundamental. Trata-se de um estudo de abordagem qualitativa (MINAYO, 1996, 2001). Participaram da pesquisa 94 alunos da rede pública de ensino de Parnaíba (PI) e Floriano (PI). Dentre os alunos, participaram apenas os que já foram reprovados pelo menos uma vez, os participantes eram 55 do sexo feminino e 39 do sexo masculino. Estes foram contatados mediante levantamento dos registros nas secretarias das escolas municipais de ambas as cidades. Os dados foram analisados seguindo a técnica de Hermenêutica de Profundidade (VERONESE; GUARESCHI, 2006), um instrumento teórico-metodológico que possibilita ao pesquisador analisar os dados por meio de três etapas: análise sócio-histórica, análise de conteúdo, (re)interpretação. Pode-se constatar, portanto, que este estudo é relevante para o campo educacional, visto que a reprovação é um dos indicadores de que a escola não está cumprindo seu papel como segmento social.

A mixed factorial design of 2x2x2 was applied (sequence x law x affirmation) to evaluate the effects of prior affirmative representation on the subsequent processing of compound negation. The sequence factor was defined to perform between-subjects comparisons. The other two factors, that is, logic law and prior affirmation were defined as within-subjects factors. The sequence factor was included to evaluate potential artifacts generated by the experimental design. Statistical analyses showed the absence of such artifacts. Three dependent variables were included: response type, an indirect measure of introspection quality, and a direct measure of subjective difficulty. A random sample of 130 participants were recruited for this experiment. All the participants were undergraduate students at the National University of Entre Rios, Argentina. 112 were female (86.2%). The mean age was 23.79 years old (SD = 6.452). 2 sets of 6 exercises each were given to all the participants. The classical selection paradigm was applied, that is, four response options were given in each item. Only one of them was the normative response according to logic (DeMorgan?s equivalences for negated conjunctions and negated disjunctions). One set included prior relevant affirmation before requiring negation, the other set started straightforward with the negation task. The task was to find the logical meaning of such compound negation that operated on a conjunction or a disjunction. By the other side, the set of exercises without prior affirmation asked straightforward to find the equivalence for a given compound negation of a conjunction or a disjunction. After completing each set of 6 responses participants were asked to give an opinion about their own performance (introspection quality) and about the task difficulty (subjective difficulty). In consistence with the mental models theory and the relevance theory, prior affirmation increased the frequency of normative responses and the quality of introspection. However, a direct registry of task difficulty showed no difference between a prior affirmation condition and a straightforward condition in consistence with the Gricean view of negation. An unexpected result showed an incremental effect of normative responses for the negation of conjunctions in comparison with the negation of disjunctions when prior affirmation provided a pragmatically enriched context. These results are discussed in terms of working memory dynamics. In sum, our findings suggest that the processing of compound negation of conjunctions and disjunctions can be explained as a combination of explicit and implicit processes that are strongly influenced by pragmatic factors. Fil: Macbeth, Guillermo Eduardo. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad Nacional de Entre Ríos. Facultad de Ciencias de la Educación; Argentina Fil: Razumiejczyk, Eugenia. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad Nacional de Entre Ríos; Argentina Fil: Crivello, María del Carmen. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad Nacional de Entre Ríos; Argentina Fil: Fioramonti, Mauro Bruno. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad Nacional de Entre Ríos. Facultad de Ciencias de la Educación; Argentina Fil: Pereyra Girardi, Carolina Iris. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Investigaciones Cardiológicas. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Investigaciones Cardiológicas; Argentina

Eye-Tracking technologies have strongly increased in deductive reasoning research during the last years. The aim of this paper is to introduce a brief history of its use, to elaborate on some mathematical problems of Eye-Tracking algorithms, to suggest further engineering developments both for hardware and software, to illustrate our proposal with an example of current research on deductive reasoning focused on compound negation, and to discuss the scope and limitations of our contribution. We conclude that Eye-Tracking is a useful tool for Cognitive Science, in general, and for deductive reasoning research, in particular. We also conclude that the future improvement of hardware and software engineering is critical for the potential contribution of this tool to the understanding of human reasoning. Fil: Macbeth, Guillermo Eduardo. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad Nacional de Entre Ríos. Facultad de Ciencias de la Educación; Argentina Fil: Razumiejczyk, Eugenia. Universidad Nacional de Entre Ríos. Facultad de Ciencias de la Educación; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Crivello, María del Carmen. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad Nacional de Entre Ríos. Facultad de Ciencias de la Educación; Argentina Fil: Fioramonti, Mauro Bruno. Universidad Nacional de Entre Ríos. Facultad de Ciencias de la Educación; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina

Managing antiplatelet and anticoagulant drugs before endoscopy may be challenging.To assess whether the pre-endoscopic management of antiplatelet/anticoagulant drugs is adherent to current guidelines and the influence of patients' characteristics, referring physician's specialty, type of endoscopic procedure and therapeutic regimen on adherence.Two hundred and twenty patients taking aspirin, thienopyridines or warfarin and scheduled for upper endoscopy (± biopsies), variceal band ligation, colonoscopy (± biopsies or polypectomy), were prospectively analyzed.In 109 patients (49.5%) the management of antiplatelet/anticoagulant drugs was thoroughly compliant with guidelines. Neither demographic characteristics, nor in/outpatient status, nor type of endoscopic procedure, nor physician's specialty influenced the adherence but the therapeutic regimen had a significant impact (p0.0001) as compliance was less likely in patients on warfarin. Unwarranted drugs withholding was more frequent before colonoscopy than upper endoscopy (p = 0.0001). Warfarin was stopped longer than recommended more frequently than aspirin (p = 0.009). The International Normalized Ratio was properly checked before endoscopy in 47.7% of patients. Among the 55 patients who withheld warfarin, the decision about bridging to low molecular weight heparin was appropriate in 21 (38.2%).Compliance with guidelines is low especially in the management of warfarin, both among gastroenterologists and other physicians.

Highlights • Diagnostic algorithm for pancreatic head mass. • Differential diagnosis between pancreatic cancer and mass forming autoimmune pancreatitis. • Diagnosis and treatment of IgG4-related systemic disease., INTRODUCTION Autoimmune pancreatitis (AIP) is a rare pancreatic disorder among chronic pancreatitis that can mimick pancreatic cancer (PC). Patients with type 1 AIP usually present obstructive jaundice associated with high level of IgG4 in serum and a pancreatic mass at radiological imaging; these disorders may be associated with other organs lesions presenting the same histopathological features, and in these cases AIP should be considered a pancreatic localization of an IgG4-related systemic disease. PRESENTATION OF CASE We report the case of a young man with initial suspect of PC to be treated with surgery, and final diagnosis of AIP in the context of an IgG4-related systemic disease. DISCUSSION Because of its similar features, several algorithms have been proposed for AIP diagnosis, based on combination of clinical/serological and radiological criteria. However, histology represents the only way to obtain definitive diagnosis, even if sometimes it is difficult to obtain biological samples. CONCLUSION IgG4-related systemic disease must be taken into account among differential diagnosis during the workup for PC, in order to avoid unnecessary surgery.

The purpose of this study is to evaluate the cross-modal Stroop effect between visually presented anagrams and gustatory stimuli. The working hypothesis states that cross-modal Stroop interference is increased by the level of inconsistency and reduced by the level of congruence between gustatory stimuli and linguistic visual stimuli whose order of syllables has been changed. 29 argentine subjects whose average age was 22 years old (SD = 3.024 years) participated in the experiment. A within-subjects repeated measures design was used. The independent variable was determined as the congruence of the stimulus and in it three levels were identified: congruent, incongruent and control stimuli. Two dependent variables were determined: reaction time and number of correct responses. The chosen paradigm was the cross-modal Stroop task. Gustatory stimuli were administered together with anagrams. The task required identifying a gustatory stimulus in the shortest possible time. It was concluded that in conditions of incongruent and control stimuli, subjects were not able to inhibit linguistic distractors to elaborate quick and effective responses concerning the identification of gustatory stimuli. In contrast, in the congruent anagrams condition the stimuli functioned as a key facilitator. Fil: Razumiejczyk, Eugenia. Universidad Nacional de Entre Rios; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Fioramonti, Mauro Bruno. Universidad Nacional de Entre Rios; Argentina Fil: Crivello, María del Carmen. Universidad Nacional de Entre Rios; Argentina Fil: Pereyra Girardi, Carolina Iris. Universidad Nacional de Entre Rios; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Investigaciones Cardiológicas (i); Argentina Fil: Macbeth, Guillermo Eduardo. Universidad Nacional de Entre Rios; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina

In recent years, the description of isolated bile duct dilatation has been increasingly observed in subjects with normal liver function tests and nonspecific abdominal symptoms, probably due to the widespread use of high-resolution imaging techniques. However, there is scant literature about the evolution of this condition and the impact of endoscopic ultrasound (EUS) in the diagnostic work up. When noninvasive imaging tests (transabdominal ultrasound, computed tomography or magnetic resonance cholangiopancreatography) fail to identify the cause of dilatation and clinical or biochemical alarm signs are absent, the probability of having biliary disease is considered low. In this setting, using EUS, the presence of pathologic findings (choledocholithiasis, strictures, chronic pancreatitis, ampullary or pancreatic tumors, cholangiocarcinoma), not always with a benign course, has been observed. The aim of this review has been to evaluate the prevalence of disease among non-jaundiced patients without signs of cytolysis and/or cholestasis and the assessment of EUS yield. Data point out to a promising role of EUS in the identification of a potential biliary pathology. EUS is a low invasive technique, with high accuracy, that could play a double cost-effective role: identifying pathologic conditions with dismal prognosis, in asymptomatic patients with negative prior imaging tests, and excluding pathologic conditions and further follow-up in healthy subjects.

Background Coeliac disease may be associated with a wide variety of diseases of known or suspected immunological aetiology. Objective To screen for both (a) the prevalence of coeliac disease in adults with autoimmune thyroid diseases, and (b) thyroid impairment among adults with coeliac disease, as compared to sex- and age-matched controls. Design Prospective cohort study. Setting University teaching hospital. Patients A total of 152 consecutive adults with autoimmune thyroid diseases, 185 consecutive coeliac disease patients (53 newly diagnosed and 132 already on a gluten-free diet) and 170 sex- and age-matched controls. Methods Screening for coeliac disease was done by means of IgA anti-endomysium antibodies, detected by indirect immunofluorescence on monkey oesophagus. Patients with positive sera underwent duodenal biopsy for diagnostic confirmation. Thyroid function was assessed by measuring the levels of serum thyroid-stimulating hormone, free T3, free T4, thyroperoxidase and thyroid microsome antibodies. Autoimmune thyroid diseases were classified according to the American Thyroid Association guidelines. Results Anti-endomysium antibodies were positive in five of 152 autoimmune thyroid disease patients (3.3%) and coeliac disease was histologically confirmed in all: this prevalence is 10-fold higher than expected. Only one patient presented with gastrointestinal complaints, but iron deficiency was found in three and alterations at bone mineralometry in all. The overall prevalence of autoimmune thyroid diseases was significantly higher (38/185, 20.5%) in coeliac patients than in controls (19/170, 11.2%). The prevalence of both hypo- and hyperthyroidism was not different from that of controls, while the prevalence of autoimmune thyroid disease with euthyroidism was 13% in patients and 4.7% in controls. Conclusions The association of coeliac disease with autoimmune thyroid disease is not surprising as they share common immunopathogenetic mechanisms. It is advisable to screen autoimmune thyroid disease patients for coeliac disease as there is an increased risk for gluten intolerance. In contrast, thyroid function assessment in coeliac disease patients is probably less justified, although the need for a strict clinical follow-up of those patients with euthyroidism and autoimmune thyroid disease, who could develop overt thyroid impairment, remains an open question.

Background The impact of narrow band imaging in improving the adenoma detection rate in a screening scenario is still unclear. Aim To evaluate whether narrow band imaging compared with high definition white light colonoscopy can enhance the adenoma detection rate during screening colonoscopy. Methods Consecutive patients presenting for screening colonoscopy were included into this study and were randomly assigned to the narrow band imaging group (Group 1) or standard colonoscopy group (Group 2). Primary end point was the adenoma detection rate and secondary aim was the detection rate of advanced adenomas. Results Overall, 117 patients were allocated to Group 1 and 120 to Group 2. Both the adenoma detection rate and the detection rate of advanced adenomas were not significantly different between the two groups (respectively, 52.1% vs. 55%, RR = 0.95, 95% CI 0.75–1.20; 32.5% vs. 44.2%, RR = 0.74, 95% CI 0.53–1.02). No significant difference between the proportions of polypoid and flat adenomas was found. Male gender, no prior history of screening, and endoscopist's adenoma detection rate were independent predictive factors of higher advanced adenoma detection rate. Conclusions In a screening scenario, narrow band imaging did not improve the adenoma nor advanced adenoma detection rates compared to high definition white light colonoscopy.

Background: Immunoglobulin A (IgA) anti-endomysium antibodies, the most reliable immunological marker for both the screening and follow-up of coeliac disease, need monkey oesophagus as antigenic substrate; this limits their use because of high costs and the exploitation of endangered species. Objectives: (1) To compare the diagnostic accuracy of anti-endomysium antibodies detected by indirect immunofluorescence on monkey oesophagus and on human umbilical cord; (2) to evaluate their reliability during follow-up in detecting non-compliant patients. Patients: One hundred and four untreated adults with biopsy-proven coeliac disease and 94 controls were investigated. Results: Endomysium antibodies were found in 99 patients (95%) on both substrates, with a specificity, respectively, of 100% and 99% on monkey oesophagus and umbilical cord. One year after gluten withdrawal, out of 47 patients who were investigated, only six presented with complete mucosal recovery: none of these subjects was positive on either substrates, while, among patients with persistent histological alterations, endomysium positivity persisted in only 10 on monkey oesophagus, but in 32 on umbilical cord. Histology (recovery or persistent involvement) was in agreement with endomysium (negative or positive) in 34% on monkey oesophagus, but in 81% on umbilical cord (P

We studied 47 adults (21 men, 26 women), with biopsy-proven celiac sprue and anti-endomysin antibody (EmA) positivity while untreated, to evaluate the usefulness of both serologic markers of celiac sprue [i.e., immunoglobulin A (IgA)-EmA and total Ig-anti-gliadin (AGA) antibodies] and of a detailed dietary inquiry in predicting the mucosal pattern after gluten withdrawal. A second biopsy was repeated 8-30 months after beginning a gluten-free diet, along with EmA and AGA determinations and the dietary inquiry. Both EmA and AGA were appraised by indirect immunofluorescence on monkey esophagus and rat kidney, respectively. Intestinal biopsy was graded according to Cooke's criteria. After gluten withdrawal, intestinal mucosa reverted to normal in only nine patients. Both EmA and AGA showed high positive but low negative predictive values on intestinal histologic outcome. The positive predictive value of admission of dietary lapses was 100%, whereas the negative predictive value was 39.1%. Neither serologic markers nor dietary inquiries are to be regarded as reliable predictors of intestinal outcome after a gluten-free diet. Biopsy remains the best means of ascertaining mucosal recovery.

Background Despite the high diagnostic yield of EUS-guided FNA, room for technical improvements remains. Recently, the EchoBrush (Cook Endoscopy, Winston-Salem, NC), a disposable cytologic brush, was introduced to the market. To date, only 1 study, limited to 10 pancreatic cyst cases, using this device has been published. Objective To assess the diagnostic yield of the EchoBrush in a cohort of consecutive patients, irrespective of the target lesion. Design Case series. Setting Tertiary care university hospital (Molinette Hospital, Turin, Italy). Patients Thirty-nine consecutive patients (12 with solid pancreatic masses, 12 with pancreatic cysts, 7 with enlarged lymph nodes, and 8 with submucosal masses) were enrolled. Interventions The material collected with the EchoBrush and with a standard FNA needle was double-blind evaluated by 2 cytopathologists. Main Outcome Measurements Adequacy of the sample and sensitivity and specificity of the EchoBrush method. Results Adequate material for cytologic analysis was collected in 17 of 39 patients (43.6%) with a single pass of the EchoBrush. Results were better for pancreatic lesions (for solid and cystic lesions, the adequacy was 58.3% and 50%, respectively); adequacy was low (28.6% and 25%, respectively) for lymph nodes and submucosal masses. The overall sensitivity and specificity were 57.9% and 31.2%, respectively. There were no adverse events with the procedure. Limitation Preliminary study. Conclusions This report suggests that the EchoBrush may provide adequate cellularity to diagnose solid and cystic pancreatic lesions. More extensive studies are needed to compare the EchoBrush and standard needles.

El presente trabajo se encuentra inserto en el proyecto de investigación denominado “Modelo físico matemático del ciclo previsto para motores de combustión interna” (CIPREV), realizado en conjunto entre el Departamento de Ingeniería Mecánica de la Universidad Tecnológica Nacional FRBA y la Facultad de Ingeniería de la Universidad de la Marina Mercante. Como ya es sabido el motor alternativo basa su principio de funcionamiento en el aprovechamiento mecánico de la expansión de los gases de combustión dentro del cilindro para transmitir movimiento a los órganos del sistema biela manivela. El presente estudio se propone indagar en la naturaleza y características del fluido de trabajo de la máquina para que sus resultados puedan ser utilizados como datos para el cálculo del ciclo indicado de los motores. El procedimiento experimental se ha basado en la determinación del coeficiente politrópico del proceso de compresión y la determinación de la composición de los gases de combustión durante un ensayo de potencia al freno con obtención del consumo específico.

Background Diagnosis of pancreatic masses is often difficult. Endoscopic ultrasound–fine needle aspiration has been proposed as the best single-step strategy. Aims To prospectively evaluate feasibility, effectiveness and safety of endoscopic ultrasound–fine needle aspiration of pancreatic masses in a consecutive study of unselected patients. Methods Two hundred ninety-three patients were enrolled in two referral Hospitals in Northern Italy. All patients were referred either due to the presence of imaging test abnormalities (suspected or evident masses, or features indirectly suggesting the presence of a mass) or due to clinical or biochemical findings suggesting pancreatic cancer in the absence of positive imaging. All patients underwent linear array endoscopic ultrasound and, when indicated, fine needle aspiration. All procedures were recorded prospectively. The final diagnosis was established at the end of follow-up or when the patients underwent surgery or died. Results Fine needle aspiration was indicated in 246 of 293 cases (84%), considered technically feasible in 232 of 246 cases (94%) and gave adequate samples for histopathological diagnosis in 204 of 232 cases (88%). Endoscopic ultrasound sensitivity, specificity and accuracy were 79, 60 and 72%, respectively; the corresponding figures for endoscopic ultrasound–fine needle aspiration were 80, 86 and 82%. There was good agreement with final diagnosis for endoscopic ultrasound–fine needle aspiration (kappa 0.673, 95%CI 0.592–0.753), greater than that for endoscopic ultrasound alone (kappa 0.515, 95%CI 0.425–0.605). There was one case of intracystic haemorrhage and one case of transient hyperthermia (0.3%). Conclusions Endoscopic ultrasound–fine needle aspiration of pancreatic masses seems to be feasible, effective and safe in this consecutive study of patients.

What Factors Affect the Quality of Bowel Preparation for Colonoscopy? A Multicenter Prospective Cohort Study Mauro Bruno, Emanuele Rondonotti, Cesare Hassan, Lorenzo Fuccio, Nico Pagano, Gabriele Curcio, Pietro Dulbecco, Carlo Fabbri, Chiara Giordanino, Silvia Carrara, Domenico Della Casa, Stefania Maiero, Adriana Simone, Federico Iacopini, Cristiano Spada, Giuseppe Feliciangeli, Gianpiero Manes, Francesca Rogai, Alessandro Repici Servizio di Endoscopia Digestiva, IRCCS Istituto Clinico Humanitas, Rozzano (MI), Italy; Dipartimento di Gastro-Epatologia, A.O. S. Giovanni Battista di Torino Ospedale Molinette, Torino, Italy; Divisione di Medicina U.O. di Gastroenterologia, Ospedale Valduce, Como, Italy; U.O.C. di Gastroenterologia ed Endoscopia Digestiva, Nuova Regina Margherita Azienda Ospedaliera Roma, Roma, Italy; U.O.C di Gastroenterologia ed Endoscopia Digestiva, Policlinico Sant’Orsola Malpighi, Bologna, Italy; Dipartimento di Endoscopia, ISMETT, Palermo, Italy; U.O.C. di Gastroenterologia Universita di Genova, Ospedale S. Martino Cliniche Universitarie Convenzionate, Genova, Italy; U.O.C. di Gastroenterologia ed Endoscopia Digestiva, Presidio Ospedaliero Bellaria Maggiore, Bologna, Italy; S. C. Gastroenterologia Epatologia, Azienda Ospedaliero-Universitaria San Luigi Gonzaga, Orbassano (Torino), Italy; U.O. di Gastroenterologia ed Endoscopia Digestiva, Universita Vita-Salute IRCCS Ospedale San Raffaele, Milano, Italy; Centro di Endoscopia Digestiva, A.O. Spedali Civili Universita degli Studi di Brescia, Brescia, Italy; S.O.C. Gastroenterologia Oncologica, Centro di Riferimento Oncologico Istituto Nazionale Tumori IRCCS, Aviano (Pordenone), Italy; U.O. di Gastroenterologia ed Endoscopia Digestiva, Ospedale G.B. Morgagni L. Pierantoni, Forli, Italy; Struttura Complessa di Endoscopia Digestiva, Ospedale San Giuseppe, Marino (Roma), Italy; U.O. di Endoscopia Digestiva Chirurgica, Policlinico Universitario A. Gemelli Universita Cattolica del Sacro Cuore, Roma, Italy; Servizio di Endoscopia Digestiva, Ospedale di Macerata, Macerata, Italy; U.O. di Gastroenterologia ed Endoscopia Digestiva, Ospedale Polo Universitario L. Sacco, Milano, Italy; Servizio di Endoscopia Digestiva, Ospedale Valdelsa Campostaggia, Poggibonsi (Siena), Italy Background: Good bowel preparation is of paramount importance for colonoscopy since inadequate cleansing results in decreased rates of cecal intubation, increased risk of missing polyps, prolonged duration of colonoscopy and increased rate of repeated colonoscopies. The aim of this study was to identify factors that impact on the quality of bowel preparation and those that are associated with low patient acceptance. Methods: Adult outpatients referred for colonoscopy at 18 Italian centers were enrolled between May and September 2010. The following data were recorded for each patient: age and gender, body mass index (BMI), level of education, source of referral and indication for colonoscopy, medical history and current medications. The patients chose freely one of the scheduled types of bowel preparation available in each center, and the type and timing of bowel preparation, the type of instructions provided (written, verbal) and patient compliance with the cleansing protocol were recorded. The quality of bowel cleansing was assessed using a previously validated (Rex D, et al GIE 2006) 4-point scale (excellent, good, fair and poor) based on the amount and nature of residual material. For statistical analysis, bowel scores were grouped as adequate (excellent or good) or inadequate (fair or poor). Data were evaluated by univariate and multivariate logistic regression analysis. Results: Of 2811 outpatients who were enrolled (52% men, mean age 61 years), inadequate colonic preparation was observed in 925 (32.9%) colonoscopies. At multivariate analysis, inadequate cleansing was associated with male gender (p 0.0014), previous colonoscopy (p 0.0152), and a history of cirrhosis, diabetes or chronic invalidating co-morbidities (p 0.001). Conversely, good predictors of adequate preparation were: adherence to bowel preparation ( 75% of the recommended dose; p 0.0001), use of sennosides or bisacodyl (p 0.05), an interval of less than 12 hours between the completion of bowel preparation and colonoscopy (p 0.0001), a BMI of 25 (p 0.0042), a higher level of education (p 0.005) the level of received instructions (oral plus written vs written alone; p 0.0003) and the tolerability of preparation (patient’s willingness to repeat the same protocol in future; p 0.0002). Difficulty in drinking the entire volume and bad taste of the solution were reported by 26.4 and 21.4% of patients, respectively. Both items were associated with inadequate bowel cleansing at univariate analysis (p 0.001). Conclusions: This study identified multiple factors affecting the quality of colonic preparation, some of which can be modified to achieve a higher degree of bowel cleansing. Important non-modifiable factors may be valuable in identifying subjects for whom more aggressive cleansing protocols should be considered. Tu1508 Enteral Stents Placement With 0.025” Guidewires Is Comparable to Placement With 0.035” Guidewires Douglas G. Adler, Kristen Hilden, John C. Fang Gastroenterology, University of Utah, Salt Lake City, UT Introduction: Duodenal and colonic stents are placed for gastric outlet obstruction (GOO), malignant or benign large bowel obstruction and for temporary preoperative decompression. The guidewire used for stent placement and deployment is generally recommended to be 0.035” for stiffness. 0.025” guidewires offer increased flexibility. At our institution, enteral stent placement is performed with either 0.025” or 0.035” size guidewires. The aim of this study was to compare outcomes in patients undergoing duodenal and colonic stenting by guidewire size. Methods: Retrospective review of all duodenal and colon stents placed between 2005-2010. Immediate and long-term complications were followed. Results: Sixty-two stent procedures (32 duodenal, 30 colonic) were performed on 57 patients (25 F, 32 M). All procedures were technically successful. Mean age was 61.6 (27-92) years. Indications for duodenal stent placement included: pancreatic mass causing obstruction (28), other malignancy causing GOO (4). Colonic stent indications included: mass causing obstruction (24), abnormal CT (2), abnormal barium enema (1), stricture/obstruction (3). Stents were placed with 0.025” guidewires in 32 procedures(20 duodenal, 11 colon) and a 0.035” guidewire in 30 procedures (12 duodenal, 19 colon). There were 3 major complications among all procedures (5%), 2 in the 0.025” guidewire group and one 0.035” guidewire group (p NS). In the 0.025” guidewire group, there were two episodes of delayed perforation. MInor 30-day complications included aspiration pneumonia (1), and infections (3) all of which were not felt to be due to the endoscopy. One of these delayed perforations occurred in a patient with a colon stent who was taking Avastin, a known risk factor for colonic perforation. The other perforation occurred at a separate colonic site 10 months post-procedure. Both perforations required surgery. In the 0.035 guidewire group, the only complication was an acute perforation that required surgery. There were no minor complications. Conclusions: Both 0.025” and 0.035” guidewire size for cannulation during duodenal or colonic stenting appear to be safe and effective. Perforations in the 0.025” guidewire group were both delayed and one occurred in a patient on a medication associated with perforations. Other complications were not directly attributed to the guidewire or stent.

(CB) from endoscopic ultrasound fine needle aspiration (EUS-FNA) offer a nonoperative means to assess tumor grade. Methods: 171 patients who had surgical resection for PNETs at CUMC from 1999 to 2012 were identified. IRB approval was obtained. Clinical and pathological data were collected. Patients who had both EUS-FNA CB and SRS available for review were included. Two pathologists reviewed all CB and SRS in blinded fashion. Immunohistochemical staining for Ki-67 was performed on whole mount slides of CB and SRS, which were assessed for Ki67 labeling index (percentage), intensity (weak, intermediate, or strong), and pattern (homogenous or heterogeneous). CB were also assessed for cellularity (scant or adequate). Statistical analyses using t-, Fisher’s exact, and kappa tests were performed using SAS 9.3. Results: 21 PNET patients with available CB and SRS were included. Mean age was 63.9+/10.2 years. Mean tumor size was 23.0+/13.5mm. 57.1% (12/21) had lymph node involvement and 50.0% (7/14) had invasive features. 40.0% (8/20) had mitotic rateR2 and 10% (2/20) had mitotic rateO10, per 50 high power field (HPF). For CB, WHO tumor grade was low (Ki67 index!3%) in 71.4% (15/21), intermediate (Ki67 index 3-20%) in 19.0% (4/21), and high (Ki67 index O20%) in 9.5% (2/21). For SRS, WHO tumor grade was low in 81.0% (17/21), intermediate in 9.5% (2/21), and high in 9.5% (2/21). 71.4% of observations were concordant, with weighted kappaZ0.47. Homogeneous Ki67 staining on SRS was significantly associated with CB-SRS concordance (pZ0.03). Where SRS had homogenous staining, concordance was 86.7%, with weighted kappaZ0.76. Classifying as low grade a tumor with Ki67 index up to 5%, which has been proposed, improved concordance to 91.3%, with weighted kappaZ0.83. As shown in Table 2, there was no significant relationship between CB Ki67 grade of intermediate or high (versus low) and clinical features, although analysis was limited by sample size. Conclusions: Prior small series compared EUS-FNA CB and SRS Ki67 indices in PNETs, but had discordant findings. Here we report the largest American series. We found a moderate correlation between CB and SRS Ki67 indices. The correlation was strongest with homogeneous Ki67 staining pattern. Staining was reliable even with scant CB cellularity. Our findings support the use of EUS-FNA Ki67 as a prognostic tool in helping to determine PNET management, including resection. Further studies are needed to determine whether increased EUS-FNA passes or different sampling techniques could feasibly improve the accuracy of tumor grading via endoscopy, especially in heterogeneously staining tumors.

Background and aim: The patient, C.A., is a 75 years old male, referred to our centre for abdominal pain and a CT finding of a pancreatic cystic lesion. No cardiac or pulmonary symptoms. The previous medical history was mute except for arterial hypertension. Material and methods: The procedure was performed in deep sedation (Propofol e.v.), with a linear echoendoscope (Olympus GF-UCT 140 AL5). Results: The endosonographic finding was consistent with a small (2 cm) Intraductal Papillary Mucinous Neoplasia in the pancreatic head. On withdrawing the echoendoscope in the mediastinum, a homogeneous hyperechoic, 17 x 14 mm lesion was observed adherent to the left atrium wall. To distinguish between atrial thrombus and myxoma, the patient underwent Magnetic Resonance Imaging that diagnosed the presence of an atrial myxoma. Conclusions: Endoscopic Ultra Sound can sometimes incidentally discover diseases outside the gastro-intestinal tract that can significantly impact on patient management. In this subject the exploration of the mediastinum allowed to diagnose an otherwise undetected pathologic cardiac condition.