[Show abstract][Hide abstract] ABSTRACT: The American Society of Gastrointestinal Endoscopy (ASGE) published updated guidelines in 2009 to help endoscopists manage the treatment of their patients who have been prescribed antiplatelet therapy (APT).
To assess the use of APT among endoscopists, and to identify factors guiding their use of APT while treating their patients.
A survey questionnaire was distributed to endoscopists at two national meetings to assess their usage of APT while treating patients during the peri-endoscopic period.
The survey was provided to 400 attendees of whom 239 (60 %) responded. Only 30 % of respondents followed the ASGE guidelines for treating their patients and 26 % percent of respondents withheld all APT before engaging in any patient procedure. Endoscopists' decisions appeared to be influenced by their own particular experiences rather than any specific APT usage guidelines (46 % vs 22 %; P < 0.05). As expected, more endoscopists (P < 0.05) continued APT for patients who underwent low risk procedures (90 %) than for patients who underwent high risk procedures (47 %). Approximately 50 % of the respondents did not perform high risk procedures for patients prescribed aspirin therapy.
About one-fourth of endoscopists surveyed discontinued APT treatment of patients who underwent any endoscopic procedure, and one-half of them discontinued use of non-steroidal anti-inflammatory drug treatment of patients who underwent a high risk endoscopic procedure. Inappropriate withdrawal of APT medications may expose patients to unnecessary risks, and efforts to improve endoscopists' application of ASGE guidelines for the use of APT to treat patients during the peri-endoscopic period are warranted.
[Show abstract][Hide abstract] ABSTRACT: It has been postulated that the endoscopic ablation of Barrett's esophagus can lead to complete eradication of the disease. This study was undertaken to evaluate the efficacy of endoscopic eradication therapy for Barrett's esophagus and the rates of recurrence of intestinal metaplasia.
As part of an initial randomized controlled trial, patients with nondysplastic or low grade dysplastic Barrett's esophagus underwent mucosal ablation. Following ablation, the patients had annual surveillance endoscopies. Recurrence was defined as the presence of intestinal metaplasia after initial complete eradication had been achieved.
A total of 28 patients with Barrett's esophagus were followed for a mean of 6.4 years after ablation therapy. At baseline, the majority of the patients had nondysplastic Barrett's esophagus (79 %). Initial complete eradication of intestinal metaplasia was achieved at a mean of 4.1 months. During long-term follow-up, initial recurrence of intestinal metaplasia was seen in 14 of the 28 of patients (50 %) at a mean of 40 months, and further maintenance ablation therapy was applied. At the final follow-up, 36 % of the patients had complete eradication of intestinal metaplasia, 18 % of the patients had intestinal metaplasia, and 21 % had died of unrelated causes; invasive esophageal adenocarcinoma had developed in 1 patient.
The long-term results of this study demonstrate a recurrence rate of 50 % after complete eradication of Barrett's esophagus with endoscopic eradication therapy. In addition, re-recurrence (in 36 %), even after further maintenance endoscopic eradication therapy, and deaths unrelated to the disease (21 %) occurred. Complete remission of Barrett's esophagus appears to be a difficult goal to achieve. These results call into question the role of ablation in patients with low risk Barrett's esophagus.
[Show abstract][Hide abstract] ABSTRACT: Although removal of adenomatous polyps has been shown to decrease the risk of colon cancer, distal hyperplastic polyps are thought to not have malignant potential. Most polyps detected during colonoscopy are diminutive (≤5 mm) and rarely harbor advanced histology, such as high-grade dysplasia or cancer. Therefore, predicting histology in real-time during colonoscopy can potentially decrease the enormous expenditure that ensues from universal histopathologic evaluation of polyps, and several novel imaging technologies have been developed and tested over the past decade for this purpose. Of these different technologies, electronic chromoendoscopy seems to strike a fair balance between accuracy, feasibility, and cost.
Published by Elsevier Inc.
Gastrointestinal endoscopy clinics of North America 04/2015; 25(2):261-286. DOI:10.1016/j.giec.2014.11.009
[Show abstract][Hide abstract] ABSTRACT: Background
Colonoscopy offers limited protection against right-sided colon cancer, a significant proportion of which arise from the serrated pathway of carcinogenesis. The aim of this study was to compare cap-assisted colonoscopy and standard high-definition white light colonoscopy regarding serrated polyps¿ detection.Methods
Post hoc analysis was performed of a previously conducted randomized controlled trial comparing standard and cap-assisted colonoscopy for adenoma detection. Randomization was stratified based on the indication of colonoscopy and all procedures were performed by three experienced endoscopists. Following cecal intubation, the colonic mucosa was carefully inspected during withdrawal of colonoscope and all polyps detected were documented for their size, location, morphology and then removed and sent for histopathology. Detection rates of significant serrated polyps between both arms were compared using the Fisher¿s exact test and Wilcoxon Rank Sum test.Results427 patients were enrolled (7 exclusions, 210 completed study in each arm, mean age of 61 years, 95% male, 75% Caucasian, 67% screening colonoscopies). There were no significant differences in baseline characteristics between both groups. Cap-assisted colonoscopy detected a significantly higher proportion of subjects with significant serrated polyps as well as a higher total number of significant serrated polyps compared to standard colonoscopy (12.8% vs. 6.6%, p =0.047 and 40 vs. 20,p¿=¿0.03 respectively).Conclusions
In this post-hoc analysis, Cap-assisted colonoscopy is a safe technique that offers a higher detection rate of significant serrated polyps when compared to standard colonoscopy. If confirmed in future trials, this simple technique has the potential to improve protection against interval colon cancers.
[Show abstract][Hide abstract] ABSTRACT: Patient outcomes for esophageal adenocarcinoma (EAC) have not improved despite huge advances in endoscopic therapy because cancers are being diagnosed late. Barrett's esophagus (BE) is the primary precursor lesion for EAC, and thus the non-endoscopic molecular diagnosis of BE can be an important approach to improve EAC outcomes if robust biomarkers for timely diagnosis are identified. MicroRNAs (miRNAs) are tissue-specific novel biomarkers that regulate gene expression and may satisfy this requirement.
Patients with gastroesophageal reflux disease (GERD) and BE were selected from an ongoing tissue and serum repository. BE was defined by the presence of intestinal metaplasia. Previously published miRNA sequencing profiles of GERD and BE patients allowed us to select three miRNAs, miR-192-5p, -215-5p, and -194-5p, for further testing in a discovery cohort and an independent validation cohort. Receiver operating curves were generated to calculate the diagnostic accuracy of these miRNAs for BE diagnosis. To test specificity, the miRNA signature was compared with those of the gastric cardia epithelium and the non-intestinal-type columnar epithelium (another definition of BE). In addition, to gain insights into BE origin (intestinal vs non-intestinal), global BE miRNA profiles were compared with the published miRNA profiles of other columnar epithelia in the gastrointestinal tract, that is, normal stomach and small and large intestine.
The discovery cohort included 67 white male patients (40 with GERD and 27 with BE). The validation cohort included 28 patients (19 with GERD and 11 with BE). In the discovery cohort, the sensitivity, specificity and area under the curve (AUC) of the three mRNAs for BE diagnosis were 92-100%, 94-95%, and 0.96-0.97, respectively. During validation, the sensitivity and specificity of miRNAs for BE diagnosis were as follows: miR-192-5p, 92% and 94%, AUC 0.94 (0.80-0.99, P=0.0004); miR-215-5p, 100% and 94%, AUC 0.98 (0.84-1, P=0.0004); and miR-194-5p, 91% and 94%, AUC 0.96 (0.80-0.99, P=0.0001), respectively. The tested miRNAs identified all BE patients in both the discovery and the validation cohorts. When compared with non intestinal-type columnar and gastric cardia epithelia, the miRNA signature was specific to the intestinal-type columnar epithelium. Comparisons of BE miRNA sequencing data to published data sets for the normal stomach, small intestine and large intestine confirmed that two of the three miRNAs (miR-215-5p and -194-5p) were specific to the intestinal-type epithelium.
MicroRNAs are highly accurate for detecting intestinal-type BE epithelia and should be tested further for the non-endoscopic molecular diagnosis of BE.
[Show abstract][Hide abstract] ABSTRACT: Objectives
The objective was to estimate emergency department (ED) visits for Clostridium difficile infection in the United States for the years 2006 through 2010.Methods
Estimates of ED visits for C. difficile infection were calculated in patients 18 years and older using the Nationwide Emergency Department Sample.ResultsDuring the calendar years 2006 through 2010, there were an estimated total of 491,406,018 ED visits. Of these, 462,160 ED visits were associated with a primary International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of C. difficile. The C. difficile infection ED visit rate (visits/100,000 census population) increased from 34.1 in 2006 to 42.3 in 2010, an increase of 24% (p < 0.01). There was also a significant overall increased trend in the number of ED visits for C. difficile from 2006 through 2010 (p < 0.01). The highest ED visit rate for C. difficile was observed for patients 65 years and older (163.18 per 100,000), while the lowest visit rate was for patients aged 18 to 24 years (5.10 per 100,000). The greatest increase in C. difficile infection visits occurred in the age group 18 to 24 years.Conclusions
These results indicate an increased trend of ED visits for C. difficile in the period 2006 through 2010 with an overall population-adjusted increase of 24%. This represents important complementary data to previous studies reporting an increase in the rate of C. difficile infections in the U.S. hospitalized population.
Academic Emergency Medicine 12/2014; 22(1). DOI:10.1111/acem.12552 · 2.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background Diminutive (≤5 mm) colorectal polyps are common, and overwhelmingly benign. Routinely, after polypectomy, they are examined pathologically to determine the surveillance intervals. Advances in equipment and techniques, such as narrow-band imaging (NBI) colonoscopy, now permit reliable real-time optical diagnosis.
Methods We conducted a randomised single-masked study involving three institutions to determine whether optical diagnosis of diminutive colorectal polyps meets clinical practice standards and reduces the need for histopathology. We randomly assigned eligible patients undergoing routine high-definition colonoscopy to optical diagnosis using near focus versus standard view, using computer-generated block sequence. By validated criteria, we rendered an optical diagnosis and a confidence level (high vs low) for all polyps, using NBI. Our primary endpoint was the number of accurate high-confidence optical diagnoses compared with central blinded pathology in the two groups. We analysed data using intention to treat.
Findings We enrolled 558 subjects, and randomly assigned 281 to near focus and 277 to standard view optical diagnosis. We detected 1309 predominantly diminutive (74.5%) and neoplastic (60.0%) polyps. Endoscopists were significantly more likely, OR 2.2 (95% CI 1.6 to 3.0, p<0.0001), to make a high-confidence optical diagnosis with near focus (85.1%) than standard (72.6%) view. High-confidence diagnoses had 96.4% and 92.0% negative predictive value, respectively. Of all polyps, 75.3% (95% CI71.3% to 78.9%) had a high-confidence accurate prediction using near focus, compared with 63.1% (95% CI 58.5% to 67.6%) using standard view. Optical versus histopathological diagnosis showed excellent agreement between the surveillance intervals, 93.5% in near focus and 92.2% in standard view. The median diagnosis time was 14 s.
Conclusions Real-time optical diagnosis using NBI colonoscopy may replace the pathology diagnosis for the majority of diminutive colorectal polyps. Using colonoscopy with near focus view increases the confidence level of the optical diagnosis. Optical diagnosis would be a paradigm shift in clinical practice of colonoscopy for colorectal cancer screening.
Trial registration number ClinicalTrials.gov Identifier: NCT01288833.
Gut 11/2014; DOI:10.1136/gutjnl-2014-307742 · 13.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective
The aim of the study was to evaluate the impact of computer based teaching module on the performance of community gastroenterologists for characterization of diminutive polyps (≤ 5 mm) using narrow band imaging video clips.Methods80 videos were distributed in pre and posttest DVDs along with a 20-minute audiovisual power point teaching presentation detailing endoscopic features differentiating adenomas from hyperplastic polyps using narrow band imaging. Each participant first reviewed pretest video clips and entered their responses for polyp histology and the confidence in diagnosis: high - ≥90% or low - <90%. Following this, they reviewed the teaching module and assessed the posttest videos. Performance characteristics were calculated for pre and posttest by comparing predicted histology with actual histology. Fisher's exact test was used for analysis and kappa statistic was calculated for interobserver agreement.Results15 gastroenterologists in community practice completed the study. Sensitivity, specificity, accuracy and negative predictive value in characterization of polyp histology improved significantly in posttest compared to pretest. In post test, accuracy was 92% for high confidence diagnoses and proportion of these increased with training from 46% (pretest) to 64% (posttest); p<0.001. Interobserver agreement for diagnosis improved from fair (kappa = 0.23) in pre test to moderate (kappa = 0.56) in posttest.ConclusionsA teaching module using video clips can be used to teach community gastroenterologists polyp histology characterization by narrow band imaging. Whether this translates into real time high accuracy in polyp detection needs to be further evaluated.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES:The Paris classification is an international classification system for describing polyp morphology. Thus far, the validity and reproducibility of this classification have not been assessed. We aimed to determine the interobserver agreement for the Paris classification among seven Western expert endoscopists.METHODS:A total of 85 short endoscopic video clips depicting polyps were created and assessed by seven expert endoscopists according to the Paris classification. After a digital training module, the same 85 polyps were assessed again. We calculated the interobserver agreement with a Fleiss kappa and as the proportion of pairwise agreement.RESULTS:The interobserver agreement of the Paris classification among seven experts was moderate with a Fleiss kappa of 0.42 and a mean pairwise agreement of 67%. The proportion of lesions assessed as "flat" by the experts ranged between 13 and 40% (P<0.001). After the digital training, the interobserver agreement did not change (kappa 0.38, pairwise agreement 60%).CONCLUSIONS:Our study is the first to validate the Paris classification for polyp morphology. We demonstrated only a moderate interobserver agreement among international Western experts for this classification system. Our data suggest that, in its current version, the use of this classification system in daily practice is questionable and it is unsuitable for comparative endoscopic research. We therefore suggest introduction of a simplification of the classification system.Am J Gastroenterol advance online publication, 21 October 2014; doi:10.1038/ajg.2014.326.
The American Journal of Gastroenterology 10/2014; DOI:10.1038/ajg.2014.326 · 9.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background and study aims: The learning curve for optical diagnosis of colorectal polyps with the narrow-band imaging (NBI) is unknown. To forego histological analysis of diminutive polyps diagnosed optically with high confidence, guidelines recommend ≥ 90 % negative predictive value (NPV) and concordance of ≥ 90 % for surveillance intervals predicted optically and histologically. We aimed to study the learning of optical diagnosis for colorectal polyps. Patients and methods: We studied five endoscopists as part of a randomized multisite trial comparing near-focus and standard-focus views for optical diagnosis. They trained using a computer-based module, followed by 10 real-time colonoscopies with pathology correlation. Endoscopists then optically diagnosed and resected all the polyps found during 558 consecutive colonoscopies, and diagnoses were compared with pathology. Endoscopists repeated the training module at the study midpoint. NPV and concordance of surveillance intervals for diminutive polyps diagnosed optically with high confidence were measured over time. Results: Endoscopists showed high diagnostic performance, with a nonsignificant trend toward higher NPV in the second half of the study. For the 445 polyps in the standard-view arm, the NPV was 88.0 % (95 %CI 75.7 % - 95.5 %) in the first half and 95.8 % (88.3 % - 99.1 %) in the second; P = 0.7. Three endoscopists in the first half and four in the second achieved > 90 % NPV. Concordance of surveillance intervals was identical in the first and second halves at 98.1 % (95 %CI 93.3 % - 99.8 %). Conclusions: High NPV for the prediction of non-neoplasms with NBI was achieved and maintained in this group of endoscopists who participated in standardized and continued training. Both NPV and surveillance interval agreement indicated high performance in the optical diagnosis of colorectal polyps and exceeded thresholds.