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1.
Alexander R. Ende Piet De Groen Bryan L. Balmadrid Joo Ha Hwang John Inadomi Tomasz Wojtera Vladimir Egorov Noune Sarvazyan Louis Korman 《Digestive diseases and sciences》2018,63(1):46-52
Background
Learning to perform colonoscopy safely and effectively is central to gastroenterology fellowship programs. The application of force to the colonoscope is an important part of colonoscopy technique.Aims
We compared force application during colonoscopy between novice and expert endoscopists using a novel device to determine differences in colonoscopy technique.Methods
This is an observational cohort study designed to compare force application during colonoscopy between novice and experienced trainees, made up of gastroenterology fellows from two training programs, and expert endoscopists from both academic and private practice settings.Results
Force recordings were obtained for 257 colonoscopies by 37 endoscopists, 21 of whom were trainees. Experts used higher average forward forces during insertion compared to all trainees and significantly less clockwise torque compared to novice trainees.Conclusions
We present significant, objective differences in colonoscopy technique between novice trainees, experienced trainees, and expert endoscopists. These findings suggest that the colonoscopy force monitor is an objective tool for measuring proficiency in colonoscopy. Furthermore, the device may be used as a teaching tool in training and continued medical education programs.2.
Background
The prevalence of diverticulosis is between 28–45% in the general population and by more than 60% for those over 70 years old. A further increase in the hospitalization rate due to complications can be observed. Furthermore, younger patients are now also increasingly suffering from diverticulosis. It is time to question the non-critical use of antibiotic treatment as well as the necessity of surgery. New treatment approaches must be found.Objective
What significance does conservative treatment, especially antibiotic treatment, have in the treatment of diverticular disease?Methods
The current literature and the first S2k guidelines on “diverticular disease/diverticulitis” were evaluated.Results
There are several options in the primary prophylaxis of diverticular disease. A high-fiber, low-meat diet, physical activity and weight management as well as avoiding cigarettes can reduce complications. Avoiding non-steroidal anti-inflammatory drugs (NSAID), corticoids and opioids also reduces the risk of complications. As long as there are no risk factors, the use of antibiotics is not normally necessary in the treatment of acute uncomplicated diverticular disease. Aminosalicylates and non-resorbable antibiotics have not been proven to be effective. The treatment of acute complicated diverticulitis consists of antibiotics, infusion of electrolytes and, if necessary abscess drainage or surgery.Conclusion
The indications and correct selection of conservative treatment has to be determined by evaluation of the stage of diverticular disease, the physical condition and the patient’s risk factors. Antibiotic treatment is ultimately only one part of the conservative management.3.
N. Horesh Y. Saeed H. Horesh Y. Berger C. Speter R. Pery D. Rosin M. Gutman O. Zmora 《Techniques in coloproctology》2016,20(6):383-387
Background
Colonoscopy is commonly recommended after the first episode of acute diverticulitis to exclude colorectal neoplasia. Recent data have challenged this paradigm due to insufficient diagnostic yield. The aim of this study was to assess whether colonoscopy after the first episode of acute diverticulitis is needed to exclude colorectal neoplasia.Methods
We performed a retrospective cohort analysis of medical records of patients admitted for the first episode of acute diverticulitis between January 2008 and December 2012. Ambulatory colonoscopy was routinely recommended at discharge. Clinical follow-up and telephone surveys were used for data collection.Results
Four hundred and twenty-five patients with a mean age of 62.6 years (range 21–98 years) were admitted during the 5-year period. Three hundred and ten (72.9 %) patients underwent colonoscopy at median time of 3.2 months after discharge. Five patients (1.6 %) of the 310 available for evaluation had malignant findings in colonoscopy. Of those, one patient had rectal carcinoma away from the inflamed site and one had colonic lymphoma. None of the 95 patients <50 years of age was found to have adenocarcinoma of the colon.Conclusions
Cancer is rarely detected in colonoscopy following the first episode of acute diverticulitis. These results question this indication for colonoscopy, especially in patients under 50.4.
E. Lahat A. Nevler M. Batumsky R. Shapiro O. Zmora M. Gutman 《Techniques in coloproctology》2016,20(3):163-169
Background
Splenic injury following colonoscopy is a rare yet life-threatening complication. These injuries are often associated with delayed diagnosis and may require invasive intervention. We sought to study the emergent presentation associated with splenic injury post-colonoscopy and to suggest a new treatment algorithm.Methods
Six cases of splenic injury following colonoscopy were collected from three medical centers. Data regarding patient medical history, clinical presentation, laboratory and imaging findings and clinical management were recorded. A systematic PubMed/MEDLINE search was performed. Non-English-language publications and publications dating earlier than 2010 were excluded. An emergency department trauma-based management algorithm was designed according to the identified publications and review of the available trauma literature.Results
The mean age was 65.3 years and the male-to-female ratio was 1:5. Five of the cases presented within 24 h of the colonoscopy complaining of severe abdominal pain. Hemodynamic instability was noted in four patients who presented with tachycardia (105–130), hypotension and/or a rapid drop in hemoglobin levels. All of the patients underwent initial resuscitation and a computerized abdominal tomography scan. Four of them required emergent splenectomy. No mortality or major morbidity was reported following the hospitalization.Conclusions
Although very rare, splenic injury during colonoscopy is an acute, severe and possible fatal complication. Patients may present with a rapid clinical deterioration and hemodynamic instability. Physicians should be familiar with the practical management of this surgical emergency and the treatment options available.5.
Wilson?Oliveira?Ezequiel?Neto Giovana?Rodrigues?Pereira Márcia?Silva?Barbosa Natan?José?Dutra?Dias Denise?Rossato?Silva
Purpose
Tuberculosis (TB) treatment is often carried out empirically, based on clinical and radiological findings. Chest X-ray (CXR) has good sensitivity but poor specificity in TB diagnosis. Xpert MTB/RIF (Mycobacterium tuberculosis/Rifampicin) is increasingly used in many countries as the initial diagnostic test for TB. The aim of the present study was to evaluate the association of radiological findings with the Xpert MTB/RIF test in patients with suspected pulmonary TB.Methods
Cross-sectional study in an outpatient TB clinic. Sputum AFB smear, culture, Xpert MTB/RIF, and CXR were collected in patients with suspected pulmonary TB.Results
During the study period, 312 patients met the inclusion criteria and were included in the analysis. Among Xpert MTB/RIF-positive cases, the radiographic patterns were classified as typical of TB, compatible of TB, and normal in 78 (70.3%), 31 (27.9%), and 2 (1.8%) patients, respectively. CXRs were classified as typical of TB, compatible of TB, and normal in 20 (10.0%), 25 (12.4%), and 152 (75.6%) patients, respectively, in Xpert MTB/RIF-negative cases.Conclusions
We found an association between radiographic patterns and Xpert MTB/RIF results in patients with suspected pulmonary TB. These results confirm the current recommended diagnosis algorithm.6.
Sasha Taleban Nima Toosizadeh Shilpa Junna Todd Golden Sehem Ghazala Rita Wadeea Coco Tirambulo Jane Mohler 《Digestive diseases and sciences》2018,63(12):3272-3280
Background
Colonoscopy is associated with multiple adverse outcomes. With an aging population undergoing colorectal cancer screening, few modalities exist to assess the patient risk prior to colonoscopy. Frailty, the age-related decline in reserve and function across multiple organ systems, predicts poor surgical outcomes, but its role in endoscopy is unclear.Aims
This prospective cohort study assesses the efficacy of frailty in predicting acute colonoscopy outcomes.Methods
Participants aged ≥?50 years undergoing screening colonoscopy at a tertiary care center were recruited over 2 months ending in July 2017. Frailty was assessed using a validated 20-s upper-extremity frailty test, which measures the capacity of muscle performance. Demographic data, American Society of Anesthesiologists (ASA) status, and Charlson comorbidity index (CCI) were evaluated. Procedure-related adverse events and cardiopulmonary changes during and in the immediate post-procedure period were recorded. Adverse events were stratified into minor and major events. Chi-square and ANCOVA models were used in the analysis.Results
Ninety-nine adults (mean age 62.8 years) were enrolled, among which 49 were non-frail and 50 were pre-frail/frail; 50 were female. Overall, 55 participants experienced a total of 87 adverse events. Frailty and ASA status were significantly associated with colonoscopy adverse events (p?=?0.01 and p?=?0.02, respectively). Age and CCI did not predict colonoscopy outcomes.Conclusions
Compared to age and CCI, frailty status better predicts colonoscopy outcomes in older adults. Among adults undergoing colonoscopy, routine frailty screening should be considered for risk stratification. Additional prospective studies evaluating frailty measurements in endoscopy will further clarify its role in forecasting adverse events.7.
Background
Renal function plays a crucial role in the choice and administration of chemotherapy. The chemotherapy of malignant diseases is associated with potential renal and non-renal adverse side effects and should, therefore, be correctly selected and implemented.Objective
Chemotherapy can induce acute kidney injury or lead to the development or aggravation of chronic kidney disease. In addition, impaired renal function can exacerbate adverse events, necessitate reduction in dosing or even lead to termination of therapy.Material and methods
We present commonly used potentially nephrotoxic chemotherapeutic substances and the corresponding preventive measures. Furthermore, we present thrombotic microangiopathy (TMA) as an undesired side effect triggered by various chemotherapeutic agents.Results
Potential nephrotoxicity should be recognized before induction of therapy as acute kidney failure as well as chronic kidney disease are associated with increased morbidity and mortality during the acute phase as well as during long-term follow-up.Conclusion
Cooperation between nephrologists and hematologist-oncologists is very important in order to provide the best therapy with the lowest rate of side effects for patients.8.
L. A. Shafer J. R. Walker C. Waldman C. Yang V. Michaud C. N. Bernstein L. Hathout J. Park J. Sisler G. Restall K. Wittmeier H. Singh 《Digestive diseases and sciences》2018,63(3):610-618
Background
Previous research has assessed anxiety around colonoscopy procedures, but has not considered anxiety related to different aspects related to the colonoscopy process.Aims
Before colonoscopy, we assessed anxiety about: bowel preparation, the procedure, and the anticipated results. We evaluated associations between patient characteristics and anxiety in each area.Methods
An anonymous survey was distributed to patients immediately prior to their outpatient colonoscopy in six hospitals and two ambulatory care centers in Winnipeg, Canada. Anxiety was assessed using a visual analog scale. For each aspect, logistic regression models were used to explore associations between patient characteristics and high anxiety.Results
A total of 1316 respondents completed the questions about anxiety (52% female, median age 56 years). Anxiety scores > 70 (high anxiety) were reported by 18% about bowel preparation, 29% about the procedure, and 28% about the procedure results. High anxiety about bowel preparation was associated with female sex, perceived unclear instructions, unfinished laxative, and no previous colonoscopies. High anxiety about the procedure was associated with female sex, no previous colonoscopies, and confusing instructions. High anxiety about the results was associated with symptoms as an indication for colonoscopy and instructions perceived as confusing.Conclusions
Fewer people had high anxiety about preparation than about the procedure and findings of the procedure. There are unique predictors of anxiety about each colonoscopy aspect. Understanding the nuanced differences in aspects of anxiety may help to design strategies to reduce anxiety, leading to improved acceptance of the procedure, compliance with preparation instructions, and less discomfort with the procedure.9.
Sarah K. Argyropoulos S. Kashif Mahmood Emily J. Campbell James M. Richter 《Digestive diseases and sciences》2018,63(2):338-344
Background
Hospitalized patients completing bowel preparation for colonoscopy typically have preparations of poorer quality when compared to outpatient populations.Aims
Our study aimed to evaluate the effectiveness of a performance improvement program in improving colonoscopy preparation for an inpatient population.Methods
We identified a cohort of adult patients (n = 641) undergoing an inpatient colonoscopy during a 12-month period at an academic medical center and compared a multifactor intervention group to a historical baseline group. During this 12-month period, a performance improvement program including use of a dedicated gastrointestinal nurse facilitator, implementation of standardized order sets, and introduction of split bowel preparations in the inpatient setting was made available to the cohort group.Results
The primary outcome was quality of bowel preparation for colonoscopy as rated by endoscopists using the modified Aronchick scale. When comparing the baseline group to the intervention group, the rate of acceptable preparations, characterized as excellent, good, or adequate, increased from 69.9 to 78.9%, which was statistically significant (p < 0.001).Conclusions
A comprehensive performance improvement program improved the quality of colonoscopy preparation among inpatients. The use of a dedicated gastrointestinal nurse facilitator, implementation of standardized order sets, and introduction of split bowel preparations are recommended in the inpatient setting for an effective bowel preparation.10.
Mayank Jain Rajiv Baijal Melpakkam Srinivas Jayanthi Venkataraman 《Indian journal of gastroenterology》2018,37(3):255-260
Background
There is insufficient data from India regarding clinical predictors of dyssynergic defecation.Aim
To identify demography, symptom, and colonoscopic parameters that can predict dyssynergic defecation (DD) among patients with chronic constipation (CC) and to compare the profile among male and female patients with DD.Methods
Data collected from three centers during June 2014 to May 2017 included age, gender, symptom duration, form and consistency of stools, digital examination, colonoscopy, and anorectal manometry (ARM). Patients were grouped based on ARM diagnosis: group I (normal study) and group II (DD). The two groups were compared for demography, symptom profile, and colonoscopy findings. Gender-wise subset analysis was done for those with the normal and abnormal ARM using chi-square and unpaired t tests.Results
Of 236 patients with CC evaluated, 130 (55%) had normal ARM and 106 (45%) had DD. Male sex, straining during defecation, bleeding per rectum, and abnormal colonoscopic diagnosis were significantly more common in group II. While bleeding per rectum and absence of urge to defecate were more common in males (p?<?0.02), straining, digital evacuation, and hard stools were commoner in females with DD.Conclusion
Straining during defecation, bleeding per rectum, and abnormal colonoscopy findings were more common in patients with DD. Symptoms of bleeding per rectum and absence of urge to defecate in men and straining during defecation in female patients were significantly associated with DD. Symptoms differ in males and females with DD.11.
Purpose of Review
There has been an explosion in the number of published systematic reviews on chronic rhinosinusitis in the last decade.Recent Findings
While the aim of these reviews in facilitating evidence-based practice is laudable, poor quality reviews may contain significant bias that can mislead a non-discerning reader.Summary
Attention therefore must be given to review methodology before implanting findings. Organisations such as the Cochrane Collaboration promote high-quality reviews, but are limited in chronic sinus disease by heterogeneous outcomes and a paucity of randomised trials.12.
Felippe O. Marcondes Rebecca A. Gourevitch Robert E. Schoen Seth D. Crockett Michele Morris Ateev Mehrotra 《Digestive diseases and sciences》2018,63(4):856-859
Background
There is concern that mental and physical fatigue among endoscopists over the course of the day will lead to lower adenoma detection rate (ADR). There are mixed findings in the prior literature on whether such an association exists.Aims
The aim of this study was to measure the association between the number of colonoscopies performed in a day and ADR and withdrawal time.Methods
We analyzed 86,624 colonoscopy and associated pathology reports between October 2013 and September 2015 from 131 physicians at two medical centers. A previously validated natural language processing program was used to abstract relevant data. We identified the order of colonoscopies performed in the physicians’ schedule and calculated the ADR and withdrawal time for each colonoscopy position.Results
The ADR for our overall sample was 29.9 (CI 29.6–30.2). The ADR for colonoscopies performed at the 9th + position was significantly lower than those at the 1st–4th or 5th–8th position, 27.2 (CI 25.8–28.6) versus 29.9 (CI 29.5–30.3), 30.2 (CI 29.6–30.9), respectively. Withdrawal time steadily decreased by colonoscopy position going from 11.6 (CI 11.4–11.9) min for the 1st colonoscopy to 9.6 (8.9–10.3) min for the 9th colonoscopy.Conclusion
In our study population, ADR and withdrawal time decrease by roughly 7 and 20%, respectively, by the end of the day. Our results imply that rather than mental or physical fatigue, lower ADR at the end of the day might be driven by endoscopists rushing.13.
M. Parolin F. Dassie L. Russo S. Mazzocut M. Ferrata E. De Carlo R. Mioni F. Fallo R. Vettor C. Martini P. Maffei 《Pituitary》2018,21(1):16-24
Purpose
The aim of this study is to investigate guideline application and colonoscopy findings in real-life practice in acromegaly.Methods
We conducted a retrospective observational non-interventional and cross-sectional analysis on 146 patients with acromegaly (ACRO) referred to our clinic. We evaluated colonoscopy data, focusing on the correlation between colonoscopy findings and hormonal/metabolic values.Results
The total number of colonoscopies performed in ACRO patients increased from 6 in the period 1990–1994 to 57 in the period 2010–2014. Colonoscopy procedures were performed according to guidelines in 25% of ACRO patients at diagnosis, 51% at follow-up and 11% globally (both at diagnosis and follow-up). Among the 146 ACRO patients, 68% were subjected to at least one colonoscopy and in 32% of the cases a polyp was detected during the procedure. The presence of polyps was significantly associated with mean levels of growth hormone (GH), insulin-like growth factor 1 (IGF-1), fasting glucose and insulin levels (p?<?0.05). Polyps were detected in 48% of untreated patients and in 26% of patients under treatment for acromegaly (p?=?0.04). The general risk of polyps and adenomatous polyps in ACRO patients was higher compared to the control population of Veneto Region, Italy (odds ratio 1.33 and 1.16, respectively). No cancerous polyps were detected in our analysis.Conclusion
In real-life practice, adherence to ACRO colonoscopy clinical guidelines was lower than expected. Among patients who underwent colonoscopy, the prevalence of colon polyps was higher for ACRO patients, suggesting the need for new strategies to ensure adherence to colonoscopy guidelines.14.
Gregory S. Cooper Sanford D. Markowitz Zhengyi Chen Missy Tuck Joseph E. Willis Barry M. Berger Dean E. Brenner Li Li 《Digestive diseases and sciences》2018,63(6):1449-1453
Background
There is uncertainty as to the appropriate follow-up of patients who test positive on multimarker stool DNA (sDNA) testing and have a colonoscopy without neoplasia.Aims
To determine the prevalence of missed colonic or occult upper gastrointestinal neoplasia in patients with an apparent false positive sDNA.Methods
We prospectively identified 30 patients who tested positive with a commercially available sDNA followed by colonoscopy without neoplastic lesions. Patients were invited to undergo repeat sDNA at 11–29 months after the initial test followed by repeat colonoscopy and upper endoscopy. We determined the presence of neoplastic lesions on repeat evaluation stratified by results of repeat sDNA.Results
Twelve patients were restudied. Seven patients had a negative second sDNA test and a normal second colonoscopy and upper endoscopy. In contrast, 5 of 12 subjects had a persistently positive second sDNA test, and 3 had positive findings, including a 3-cm sessile transverse colon adenoma with high-grade dysplasia, a 2-cm right colon sessile serrated adenoma with dysplasia, and a nonadvanced colon adenoma (p?=?0.045). These corresponded to a positive predictive value of 0.60 (95% CI 0.17–1.00) and a negative predictive value of 1.00 (95% CI 1.00–1.00) for the second sDNA test. In addition, the medical records of all 30 subjects with apparent false positive testing were reviewed and no documented cases of malignant tumors were recorded.Conclusions
Repeat positive sDNA testing may identify a subset of patients with missed or occult colorectal neoplasia after negative colonoscopy for an initially positive sDNA. High-quality colonoscopy with careful attention to the right colon in patients with positive sDNA is critically important and may avoid false negative colonoscopy.15.
Giovanni B. Gaeta Massimo Puoti Nicola Coppola Teresa Santantonio Raffaele Bruno Antonio Chirianni Massimo Galli 《Infection》2018,46(2):183-188
Aim
This paper is aimed at providing practical recommendations for the management of acute hepatitis C (AHC).Methods
This is an expert position paper based on the literature revision. Final recommendations were graded by level of evidence and strength of the recommendations.Results
Treatment of AHC with direct-acting antivirals (DAA) is safe and effective; it overcomes the limitations of INF-based treatments.Conclusions
Early treatment with DAA should be offered when available.16.
Background
Diverticular disease is a common, chronic inflammatory disease of the bowel. This study investigates the differences in body composition between patients with diverticular disease and those without.Methods
Appropriate patients were identified using a search of the radiology database. Demographic and disease information was gathered using scanned medical records. Body composition analysis was performed at level L3 using single-slice computed tomography techniques.Results
Two hundred seventy-one patients were included in this study: 83 controls, 93 with diverticulosis and 95 with diverticulitis. Diverticulitis and diverticulosis were associated with a significantly higher visceral fat area (VFA), than the control group (p?<?0.001, p?<?0.001). Diverticulitis and diverticulosis were associated with a significantly higher visceral fat area to subcutaneous fat area ratio (VFA:SCFA), than the control group (p?=?0.005, p?=?0.019). Only diverticulosis was associated with increased levels of extramyocellular fat, when compared to the control group (p?=?0.001).Conclusion
Diverticular disease is associated with a higher amount and a higher proportion of visceral fat than seen in controls without diverticular disease.17.
Purpose
To determine the predictive value of qSOFA (quick Sequential Organ Failure Assessment) in Malawian patients with suspected infection.Methods
Prospective observational study in a tertiary referral hospital in Malawi.Results
Predictive ability of qSOFA was reasonable [AUROC 0.73 (95% CI 0.68–0.78)], increasing to 0.77 (95% CI 0.72–0.82) when classifying all patients with altered mental status as high risk. Adding HIV status as a variable to the qSOFA score did not improve predictive value.Conclusion
qSOFA is a simple tool that can aid risk stratification in resource-limited settings.18.
Ethan A. Halm Elisabeth F. Beaber Dale McLerran Jessica Chubak Douglas A. Corley Carolyn M. Rutter Chyke A. Doubeni Jennifer S. Haas Bijal A. Balasubramanian 《Journal of general internal medicine》2016,31(10):1190-1197
Background
Population outreach strategies are increasingly used to improve colorectal cancer (CRC) screening. The influence of primary care on cancer screening in this context is unknown.Objective
To assess associations between primary care provider (PCP) visits and receipt of CRC screening and colonoscopy after a positive fecal immunochemical (FIT) or fecal occult blood test (FOBT).Design
Population-based cohort study.Participants
A total of 968,072 patients ages 50–74 years who were not up to date with CRC screening in 2011 in four integrated healthcare systems (three with screening outreach programs using FIT kits) in the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.Measures
Demographic, clinical, PCP visit, and CRC screening data were obtained from electronic health records and administrative databases. We examined associations between PCP visits in 2011 and receipt of FIT/FOBT, screening colonoscopy, or flexible sigmoidoscopy (CRC screening) in 2012 and follow-up colonoscopy within 3 months of a positive FIT/FOBT in 2012. We used multivariable logistic regression and propensity score models to adjust for confounding.Results
Fifty-eight percent of eligible patients completed a CRC screening test in 2012, most by FIT. Those with a greater number of PCP visits had higher rates of CRC screening at all sites. Patients with ≥1 PCP visit had nearly twice the adjusted-odds of CRC screening (OR?=?1.88, 95 % CI: 1.86–1.89). Overall, 79.6 % of patients with a positive FIT/FOBT completed colonoscopy within 3 months. Patients with ≥1 PCP visit had 30 % higher adjusted odds of completing colonoscopy after positive FIT/FOBT (OR?=?1.30; 95 % CI: 1.22–1.40).Conclusions
Patients with a greater number of PCP visits had higher rates of both incident CRC screening and colonoscopy after positive FIT/FOBT, even in health systems with active population health outreach programs. In this era of virtual care and population outreach, primary care visits remain an important mechanism for engaging patients in cancer screening.19.
Purpose of Review
Without a specific biomarker, the diagnosis of drug-induced liver injury (DILI) relies on exclusion of other causes of liver injury. This review examines the importance of testing for hepatitis C (HCV) and hepatitis E (HEV) in patients with suspected DILI.Recent Findings
Several national DILI registries have reported HCV and HEV infection in patients initially diagnosed with DILI. Particularly in patients with suspected DILI who have acute hepatocellular liver injury, acute HCV and acute HEV infection should be considered even in the absence of traditional risk factors. For HCV infection, testing for HCV RNA and HCV antibody are recommended. For HEV, the high prevalence of HEV IgG antibody means that HEV IgM antibody testing is suggested to exclude this infection.Summary
There should be a high clinical suspicion for acute HCV and HEV infection in patients with acute hepatocellular liver injury suspected of being due to DILI.20.
Alai Tan Jie Zhou Yong-Fang Kuo James S. Goodwin 《Journal of general internal medicine》2016,31(2):156-163