Artificial intelligence in detection of small bowel lesions and their bleeding risk:A new step forward

The present letter to the editor is related to the study with the title“Automatic detection of small bowel(SB)lesions with different bleeding risk based on deep learning models”.Capsule endoscopy(CE)is the main tool to assess SB diseases but it is a time-consuming procedure with a significant error rate.The development of artificial intelligence(AI)in CE could simplify physicians’tasks.The novel deep learning model by Zhang et al seems to be able to identify various SB lesions and their bleeding risk,and it could pave the way to next perspective studies to better enhance the diagnostic support of AI in the detection of different types of SB lesions in clinical practice.

Acute left-sided malignant colonic obstruction:Is there a role for endoscopic stenting?

The therapy of left-sided malignant colonic obstruction continues to be one of the largest problems in clinical practice.Numerous studies on colonic stenting for neoplastic colonic obstruction have been reported in the last decades.Thereby the role of self-expandable metal stents(SEMS)in the treatment of malignant colonic obstruction has become better defined.However,numerous prospective and retrospective investigations have highlighted serious concerns about a possible worse outcome after endoscopic colorectal stenting as a bridge to surgery,particularly in case of perforation.This review analyzes the most recent evidence in order to highlight pros and cons of SEMS placement in left-sided malignant colonic obstruction.

Post-trans-arterial chemoembolization hepatic necrosis and biliary stenosis: Clinical charateristics and endoscopic approach

Liver cancer is the fifth most common tumor and the second highest death-related cancer in the world.Hepatocarcinoma(HCC)represents 90%of liver cancers.According to the Barcelona Clinic Liver Cancer group,different treatment options could be offered to patients in consideration of tumor burden,liver function,pa-tient performance status and biochemical marker serum concentration such as alpha-fetoprotein.Trans-arterial chemoembolization(TACE)is the treatment of choice in patients with diagnosis of unresectable HCC not eligible for liver trans-plantation,and preserved arterial supply.TACE is known to be safe and its com-plications are generally mild such as post-TACE syndrome,a self-resolving adverse event that occurs in about 90%of patients after the procedure.However,albeit rarely,more severe adverse events such as biloma,sepsis,hepatic failure,chemoagents induced toxicities,and post-TACE liver necrosis can occur.A prompt diagnosis of these clinical conditions is fundamental to prevent further complications.As a result,biliary stenosis could be a rare post-TACE necrosis complication and can be difficult to manage.Complications from untreated biliary strictures include recurring infections,jaundice,chronic cholestasis,and secon-dary biliary cirrhosis.

Severe immune thrombocytopenia after peg-interferonalpha2a, ribavirin and telaprevir treatment completion: a case report and systematic review of literature

Mild to moderate autoimmune thrombocytopenia(AITP) is a common finding in patients receiving interferonbased antiviral treatment, due to bone marrow suppression. Here we report the case of a patient with chronic genotype 1b hepatitis C virus(HCV) infection treated with pegylated-interferon alpha-2a, ribavirin and telaprevir for 24 wk; the patient developed severe AITP three weeks after treatment withdrawal. We performed a systematic literature search in order to review all published cases of AITP related to HCV antiviral treatment. To our knowledge, this is the second case of AITP observed after antiviral treatment withdrawal. In most published cases AITP occurred during treatment; in fact, among 24 cases of AITP related to interferonbased antiviral treatment, only one occurred after discontinuation. Early diagnosis of AITP is a key factor in order to achieve an early interferon discontinuation; in the era of new direct antiviral agents those patients have to be considered for interferon-free treatment regimens. Prompt prescription of immuno-suppressant treatment(i.e., corticosteroids, immunoglobulin infusion and even rituximab for unresponsive cases) leads to favourable prognosis in most of cases. Physicians using interferonbased treatments should be aware that AITP can occur both during and after treatment, specially in the new era of interferon-free antiviral treatment. Finally, in the case of suspected AITP, presence of anti-platelet antibodies should be checked not only during treatment but alsoafter discontinuation.

Common bile duct lesions-how cholangioscopy helps rule out intraductal papillary neoplasms of the bile duct:A case report

BACKGROUND Intraductal papillary neoplasm of the bile duct(IPNB)is a rare variant of bile duct tumors,characterized by an exophytic growth exhibiting a papillary mass within the bile duct lumen and it can be localized anywhere along the biliary tree,with morphological variations and occasional invasion.CASE SUMMARY We present a patient with obstructive jaundice who was diagnosed with IPNB using cholangioscopy during endoscopic retrograde cholangio-pancreatography.Using the SpyGlass DS Ⅱ technology,we were able to define tumor extension and obtain targeted Spy-byte biopsies.After multidisciplinary evaluation,the patient was scheduled for surgical resection of the tumor,which was radically removed.CONCLUSION Cholangioscopy appears to be crucial for the rapid and clear diagnosis of lesions in the bile duct to achieve radical surgical resection.

Dilation assisted stone extraction for complex biliary lithiasis:Technical aspects and practical principles

Common bile duct stones are frequently diagnosed worldwide and are one of the main indications for endoscopic retrograde cholangio-pancreatography.Endoscopic sphincterotomy(EST)has been used for the removal of bile duct stones for the past 40 years,providing a wide opening to allow extraction.Up to 15%of patients present with complicated choledocholithiasis.In this context,additional therapeutic approaches have been proposed such as endoscopic mechanical lithotripsy,intraductal or extracorporeal lithotripsy,or endoscopic papillary large balloon dilation(EPLBD).EPLBD combined with EST was introduced in 2003 to facilitate the passage of large or multiple bile duct stones using a balloon greater than 12 mm in diameter.EPLBD without EST was introduced as a simplified technique in 2009.Dilation-assisted stone extraction(DASE)is the combination of two techniques:EPLBD and sub-maximal EST.Several studies have reported this technique as safe and effective in patients with large bile duct stones,without any increased risk of adverse events such as pancreatitis,bleeding,or perforation.Nevertheless,it is difficult to analyze the outcomes of DASE because there are no standard techniques and definitions between studies.The purpose of this paper is to provide technical guidance and specific information about the main issues regarding DASE,based on current literature and daily clinical experience in biliary referral centers.

Battery with Integrated Power Supply(BALIN)

The BALIN is a modern device,consisting of a battery with integrated battery charger,dedicated to powering the 24 V services of the carriages.In various Trenitalia rolling stock,used for the regional transport of travelers,there are old and obsolete battery charger devices and there are lead acid batteries that need frequent maintenance operations to be kept efficient.These components,due to their low reliability,are the source of serious disruptions to passenger transport,and the management of their maintenance involves high costs for Trenitalia.In order to solve these problems,Trenitalia has therefore decided to invest resources to develop a new system of integrated power supplies and batteries,therefore the BALIN has been developed.The main advantages of BALIN compared to the original components are the presence of a high energy efficiency battery charger designed to operate in a wide range of temperatures and the presence of sealed lead-acid batteries without maintenance with a life exceeding 6 years.The BALIN is able to disconnect its own batteries from the carriage electrical circuits.The BALIN battery charger also implements an intelligent battery management logic and thanks to the interface with the command and control signals present on the rolling stock,the batteries are isolated from the carriage electric load automatically when the train is off and the service it's over.Another important automatic feature of the BALIN is to protect its batteries from deep discharge,in fact the power supply from the batteries to the electric carriage loads is interrupted when the voltage reaches 21 V.The characteristics mentioned go towards the reduction of the charge/discharge cycles of batteries and contribute to increasing the reliability and durability of batteries throughout the entire life of the rolling stock.

An in vitro prototype of a porcine biomimetic testis-like cell culture system： a novel tool for the study of reassembled Sertoli and Leydig cells

At present, there is no reliable in vitro assembled prepubertal testis-like biomimetic organ culture system designed to assess the functional effects of human gonadotropins on Sertoli and Leydig cells. Spermatogenesis is regulated by endocrine, paracrine, and juxtacrine factors （testicular cross-talk）, mainly orchestrated by gonadotropins such as luteinizing hormone （LH） and follicle-stimulating hormone （FSH） that play a pivotal role by stimulating Leydig and Sertoli cells, respectively. The aim of our study was to set up an in vitro prepubertal porcine bioengineered construct as a new model for experimental studies on reassembled Sertoli and Leydig cells. We have evaluated Sertoli and Leydig cells obtained from 15- to 20-day-old neonatal pig testes in terms of purity and function. Subsequently, purified Sertoli and enriched Leydig cells were subjected to coincubation to obtain an in vitro prepubertal porcine testis-like culture system. We performed enzyme-linked immunosorbent assay （ELISA） for anti-Mullerian hormone （AMH）, inhibin B, and testosterone secretion in the medium, and Real-lime PCR analysis of AMH, inhibin B, FSH-r, aromatase, LHr, and 3βHSD mRNA expression levels. This in vitro testis-like system was highly responsive to the effects of human gonadotropins and testosterone. AMH mRNA expression and secretion declined, and inhibin-B increased, while FSH-receptor expression was downregulated upon FSH/LH exposure/treatment. Finally, the production of testosterone was increased selectively upon LH treatment. In summary, our proposed model could help to better determine the action of human gonadotropins on Sertoli and Leydig cells. The potential usefulness of the system for shedding light into male infertility-related issues is evident.