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In 2011 the three major Italian gastroenterological scientific societies (AIGO, the Italian Society of Hospital Gastroenterologists and Endoscopists; SIED, the Italian Society of Endoscopy; SIGE, the Italian Society of Gastroenterology) prepared their official document aimed at analysing medical care for digestive diseases in Italy, on the basis of national and regional data (Health Ministry and Lombardia, Veneto, Emilia-Romagna databases) and to make proposals for planning of care. Digestive diseases were the first or second cause of hospitalizations in Italy in 1999–2009, with more than 1,500,000 admissions/year; however only 5–9% of these admissions was in specialized Gastroenterology units. Reported data show a better outcome in Gastroenterology Units than in non-specialized units: shorter average length of stay, in particular for admissions with ICD-9-CM codes proxying for emergency conditions (6.7 days versus 8.4 days); better case mix (higher average diagnosis-related groups weight in Gastroenterology Units: 1 vs 0.97 in Internal Medicine units and 0.76 in Surgery units); lower inappropriateness of admissions (16–25% versus 29–87%); lower in-hospital mortality in urgent admissions (2.2% versus 5.1%); for patients with urgent admissions due to gastrointestinnal haemorrhage, in-hospital mortality was 2.3% in Gastroenterology units versus 4.0% in others. The present document summarizes the scientific societies’ official report, which constitutes the “White paper of Italian Gastroenterology”

OBJECTIVES To evaluate the performance of contrast-enhanced sonography with a second-generation contrast agent in assessing the severity of chronic diffuse liver disease and differentiating cirrhotic from noncirrhotic liver disease. METHODS Contrast-enhanced sonography was performed after intravenous bolus injection of a second-generation contrast agent in 14 healthy control participants and 160 consecutive patients with cirrhotic and noncirrhotic liver disease (n = 78 and 82, respectively) enrolled between March 2004 and April 2014. The intensity of enhancement in a main hepatic vein was used to determine hepatic vein arrival time, time to peak intensity, and peak contrast enhancement. RESULTS The hepatic vein arrival time was lower in cirrhotic patients compared with both noncirrhotic patients and controls (mean ± SD, 15.0 ± 2.8, 21.5 ± 3.4, and 25.6 ± 4.7 seconds, respectively; P < .05). The hepatic vein arrival time in noncirrhotic patients was also significantly lower than that in controls (P < .05). The time to peak intensity was significantly lower in cirrhotic patients compared with noncirrhotic patients and controls (40.7 ± 13.7, 49.4 ± 12.8, and 51.2 ± 13.7 seconds; P < .05). A receiver operating characteristic curve analysis revealed that the hepatic vein arrival time more accurately excluded a diagnosis of liver cirrhosis than the time to peak intensity (area under the receiver operating characteristic curve, 0.953 versus 0.694). Specifically, a hepatic vein arrival time cutoff value of 17 seconds excluded liver cirrhosis with 91.1% sensitivity and 93.6% specificity. CONCLUSIONS Contrast-enhanced sonography is a valid alternative method for noninvasive staging of liver diseases. The hepatic vein arrival time could be used to exclude liver cirrhosis in a clinical setting.

Coastal areas receive significant amounts of nutrients (nitrogen, phosphorus, silicon) mostly from land-based sources, which contribute to increased biological productivity often exceeding that naturally found in coastal and marine environments. Most coastal zones of southern Europe are naturally oligotrophic with relatively small freshwater discharges. Studies of circulation and mixing processes over the continental shelf off the Ebro River delta are motivated by the need to understand transport pathways of natural and anthropogenic discharges affecting the adjacent marine environment. This paper investigates the characteristics of the last 45 km of the Ebro River in NE Spain, in terms of physiographic conditions, river discharges and hydrochemical and biological environment at three different periods in the annual cycle. In spite of the high variability in water flow and ecological conditions, the study provides a reasonably good estimate of the overall amounts of nutrients discharged to the coastal environment. The largest nutrient load corresponds to nitrogen of which more than 104 tm yr−1 are discharged. Nitrogen regeneration took place in the lower river waters during fall and spring and nitrogen uptake prevailed at all stations in summer. Phosphorus annual load of just 87 tm yr−1 does not contribute in a significant way to the fertilization of the coastal zone unlike other rivers draining highly developed watersheds. This is due to the trapping effect of the dams existing in the middle course of the river. The sudden phosphorus contribution due to the wash out of the salt-water wedge whenever the river flow increases to pre-flood conditions (>400 m3 s−1) may be significant (∼1.5 tm or 2% of the overall P load). The area coverage to which the Ebro River would add a surplus primary production of about 50 gC m−2 d−1 (over a background of about 100 gC m−2 d−1), may be estimated in terms of nitrogen, at about 1200 km2 (40 km×30 km). If, however, the figures were based on phosphorus, the limiting nutrient in the freshwater system, then this increase in fertility would only affect an area of about 68 km2.

To assess if software assisted-contrast-enhanced ultrasonography (CEUS) provides reproducible perfusion parameters of hepatic parenchyma in patients affected by chronic liver disease.Forty patients with chronic viral liver disease, with (n = 20) or without (n = 20) cirrhosis, and 10 healthy subjects underwent CEUS and video recordings of each examination were then analysed with Esaote's Qontrast software. CEUS dedicated software Qontrast was used to determine peak (the maximum signal intensity), time to peak (TTP), region of blood value (RBV) proportional to the area under the time-intensity curve, mean transit time (MTT) measured in seconds and region of blood flow (RBF).Qontrast-assisted CEUS parameters displayed high inter-observer reproducibility (κ coefficients of 0.87 for MTT and 0.90 TTP). When the region of interest included a main hepatic vein, Qontrast-calculated TTP was significantly shorter in cirrhotic patients (vs non-cirrhotics and healthy subjects) (71.0 ± 11.3 s vs. 82.4 ± 15.6 s, 86.3 ± 20.3 s, P0.05). MTTs in the patients with liver cirrhosis were significantly shorter than those of controls (111.9 ± 22.0 s vs. 139.4 ± 39.8 s, P0.05), but there was no significant difference between the cirrhotic and non-cirrhotic groups (111.9 ± 22.0 s vs. 110.3 ± 14.6 s). Peak enhancement in the patients with liver cirrhosis was also higher than that observed in controls (23.9 ± 5.9 vs. 18.9 ± 7.1, P = 0.05). There were no significant intergroup differences in the RBVs and RBFs.Qontrast-assisted CEUS revealed reproducible differences in liver perfusion parameters during the development of hepatic fibrogenesis.

Objectives: Ultrasounds are by now the most widely used tool to assess gallbladder diseases and no other imaging technique can reproduce its accuracy. Abdominal ultrasound is indeed considered the systematic first-line investigation for the management of patients with gallbladder disease. Aim of this study was to evaluate the inter-observer agreement among different observers attending an Italian School of Ultrasound Methods: From march 2013 to november 2013 94 routine ultrasonographic examinations of the gallbladder were consecutively performed. A digital video movie of the gallbladder was recorded for each patient. Three different examiners were involved in this study: a teacher of the school of ultrasound, an experienced trainee and a low experienced student. All observers independently and blindly reviewed the video recording of each examination. For each examination was evaluated the presence or absence of cholelithiasis or gallbladder wall diseases (polyps, cholesterolosis, cancer); absence of lesions and/or presence of septa and or dysmorphia were considered as the same group. Kappa statistics were used to assess interobserver agreement by employing MedCalc Statistical Software (Mariakerke, Belgium) Results: Inter-observer agreement for cholelithiasis was ‘‘almost perfect’’ (k50.86) only between the two trained operators while agreement between a low trained examiner and both the others was ‘‘moderate’’ (k50.60 and k50.56). Inter-rater agreement was form ‘‘fair’’ to ‘‘moderate’’ in evaluating gallbladder wall diseases (just reaching a k50,52 between the two trained ultrasonographer). All observers reached a ‘‘substantial’’ agreement (ranging from k50.69 to k50.75) in confirming any of a gallbladder disease. Conclusions: This study suggests that both ‘‘novice’’ and ‘‘expert’’ ultrasonographers substantially agree in the presence/absence of gallbladder diseases while agreement on what a kind of disease is reached only cholelitiasis and after an adequate training.