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This prospective study examined the appropriate use of colonoscopy in an open-access system with the American Society for Gastrointestinal Endoscopy guidelines and determined whether the American Society for Gastrointestinal Endoscopy guidelines were associated with relevant endoscopic findings.In a cohort of 2221 consecutive patients referred for colonoscopy, the proportion of patients who underwent colonoscopy for appropriate indications was prospectively assessed. The relationship between appropriateness and the presence of clinically relevant endoscopic diagnoses was assessed by calculating (1) the positive and negative likelihood ratio of the indications; and (2) the change in the probability of relevant endoscopic diagnoses in the presence of the American Society for Gastrointestinal Endoscopy criteria.The rate for 'generally not indicated' colonoscopies was 37%. Relevant endoscopic diagnoses were present in 28.5% of cases with American Society for Gastrointestinal Endoscopy indications versus 20.1% of patients without appropriate indications. However, the risk of finding relevant diagnoses was significantly increased by American Society for Gastrointestinal Endoscopy criteria application (odds ratio (OR) 1.58; 99% CI 1.20-2.07; p0.01). Furthermore, in both endoscopic situations (appropriate and not appropriate), the likelihood ratio, positive and negative, varied very little, suggesting a low predictivity for serious pathologies by the appropriate procedure.The use of an appropriateness evaluation system makes it possible to increase the probability of finding relevant endoscopic diseases. However, the exclusive use of such a system for selecting patients to undergo colonoscopy involves a relatively high risk of colorectal neoplasms going undetected.

Robert Frost first famously penned “Poetry is what gets lost in translation.” In the world of advocacy, persuasion is what gets lost in translation. This article examines the distinctions in the common law and civil law methods of legal reasoning. It analyzes why, in form and substance, the traditional common law oral argument methods are neither effective nor persuasive when presented in a civil law jurisdiction. Although the common law and civil law legal traditions share similar social objectives, arguing based on stare decisis is incompatible with the Code-based method applied by civil law courts. This article explores how to transfer common law advocacy skills to create an effective civil law oral argument. By making this transition, a common law advocate will be able to garner a greater awareness of the civil law system, including an understanding of the rules that govern the court or tribunal that will be hearing the argument, an appreciation for the role of the judge hearing the argument, and an appreciation for the role of scholars in the civil law system. As a result, common law practitioners can hone their ability to effectively craft a persuasive civil law argument.

The BioEnterics intragrastric balloon (BIB) has been successfully used for treatment with BMI > 35 or BMI > 40. Gastroesophageal reflux (GER) symptoms are sometimes reported to occur and/or to worsen in patients with BIB, with a variable onset of erosive esophagitis (EE). The aim of this study was to investigate the prevalence and the severity of esophagitis after BIB placement. 121 patients (93 F, 28 M, mean age 45 (19–65), mean BMI 41.5 (30–63.5) were studied. Patients with severe esophagitis (grade C-D Los Angeles (LA) classification), gastric or duodenal ulcers were excluded from the BIB treatment. After BIB placement, proton-pump inhibitors (PPI) were administered in the first month to each patient. The BIB was removed after 6 months. The presence of EE and related severity by LA classification were recorded. Before BIB insertion, 18 patients (15%) showed mild EE (16 grade A and 2 grade B). After BIB removal, EE was observed in 22 patients (18.2%): 11 grade A, 7 grade B, 4 grade C-D. The difference in the prevalence of EE after BIB was statistically significant (Wilcoxon’s test P = 0.030). EE prevalence was significantly increased after BIB placement. We suggest that EE due to enhanced GER could be considered as an adverse effect of such treatment.We therefore recommend maintaining intragastric acid suppression with PPIs during the 6 months of BIB placement.

This prospective study examined the appropriate use of EGD in an open-access system with the American Society for Gastrointestinal Endoscopy (ASGE) guidelines and determined whether the ASGE guidelines were associated with relevant endoscopic findings.In a cohort of 1777 consecutive patients referred for open-access EGD, the proportion of patients who underwent EGD for appropriate indications was prospectively assessed. The relationship between appropriateness and the presence of clinically relevant endoscopic diagnoses was assessed by calculating (1) the likelihood ratio, positive and negative, of the indications; and (2) the change in the probability of relevant endoscopic diagnoses in the presence of the ASGE criteria.The rate for EGDs "generally not indicated" was 15.6%. Relevant endoscopic diagnoses were present in 47.4% of cases with ASGE indications versus 28.8% of patients without appropriate indications as defined by the ASGE criteria (OR: 2.23; 99% CI [1.55, 3.22]; p0.01). A similar difference was observed for erosive gastritis (OR: 1.86; 99% CI [1.17, 2.95]; p0.01), erosive esophagitis (OR: 1.48; 99% CI [0.87, 2.52]; p0.05), and Barrett's esophagus (OR: 9.76; 99% CI [0.72, 132]; p0.05). The pretest probability of finding a relevant endoscopic diagnosis was modified slightly when an ASGE indication(s) was present and decreased markedly when ASGE criteria were absent.The use of the ASGE guideline for appropriate indications for EGD can improve patient selection for the procedure. However, to avoid missed diagnoses of serious disease, use of the guidelines must be tailored to the specific clinical setting.

Background: High incidence rates of gastric cancer are associated with high incidence of so called pre-neoplastic lesions (chronic atrophic gastritis CAG, Intestinal Metaplasia IM and gastric epithelial dysplasia GED). However a reliable estimation of these values is lacking from many countries even those plagued by gastric cancer. Aim: To estimate, by a cross-sectional study, the incidence of CAG, IM and GED in a rural area of Northern Italy characterized by high incidence of gastric cancer. Subjects and Methods: 2792 subjects (77% of total) attending for Esophago-gastro-duodenoscopy (EGDS) in a 2 and half years period, underwent multiple biopsies from antrum-angulus, body and fundus; the percentage of cases affected by CAG, IM and GED was calculated (with 95% CI) globally and for different age classes and Helicobacter Pylori (HP) infection. Differences between percentages were considered significant at 0.05 if 95%CI did not overlap. Results: 134 cases of GED (4.8% of total EGDS), 472 of CAG (16.9%) and 1065 of IM (39.2%) were identified. These lesions were significantly more frequent in older patients (≥ 60 yrs) compared with younger ones: 8% vs 2.8% for GED; 25.8% vs 10.8% for CAG; 58% vs 25% for IM; p

Long-term bone marrow cultures were established from single-cell suspensions of human bone marrow that had been treated with monoclonal antibodies and complement. Each treated cell suspension was evaluated for production of hematopoietic stem cells over 20 weeks. Treatment with antibody to HLA-DR (Ia), B1, J2, or J5 did not remove adherent cells including those differentiating to adipocytes in 17-hydroxycorticosteroid. In contrast, treatment with monoclonal antibody directed against human beta 2-microglobulin reduced adipocyte numbers by 100-fold and reduced the total adherent cell density over 70%. Cumulative total nonadherent cell and granulocyte-macrophage colony-forming units (GM-CFUc) production over 20 weeks was not significantly altered by one cycle of anti-Ia plus complement or up to three cycles of treatment with complement and anti-J2, -J5, or -B1. However, one cycle of treatment with anti-beta 2-micro-globulin depressed production of both GM-CFUc and nonadherent cells by over 100-fold compared to other treatment groups. While one cycle of treatment of anti-Ia and complement killed all detectable cells forming CFU-erythroid-granulocyte-megakaryocyte-macrophage, blast-forming units (erythroid), and GM-CFUc, GM cluster-forming cells survived. Treatment of marrow with three cycles of anti-Ia and complement removed all detectable GM colony- and GM cluster-forming cells; however, this marrow produced fewer cumulative Ia-positive GM-CFUc. Long-term bone marrow cultures may prove to be an interesting system for in vitro analysis of the effects of new immunotherapeutic agents including other monoclonal antibodies prior to clinical use.