Overutilization of post-polypectomy surveillance colonoscopy in clinical practice: a prospective, multicentre study

BackgroundAlthough the adherence to post-polipectomy recommendations is advocated as a quality indicator of colonoscopy programmes, prospective data on actual use of surveillance are lacking.AimTo evaluate the appropriateness of post-polypectomy surveillance colonoscopy on a community-wide basis and to identify factors associated with it.MethodsData on consecutive post-polypectomy surveillance examinations performed over a 4-week period in 29 Italian endoscopy units were collected. The time interval between index and surveillance colonoscopy was calculated and compared to guidelines recommendations. Determinants of surveillance timing appropriateness were assessed by logistic step-wise regression.ResultsOf 7081 consecutive outpatients, 1218 (17.2%) were referred for post-polypectomy surveillance and 902 were included into the analysis. Surveillance colonoscopy was prescribed correctly in 330 subjects (36.6%) and earlier than recommended by guidelines in 490 (54.3%). Low-risk subjects had an anticipated surveillance colonoscopy more frequently than global cohort (67.4% vs. 54.3%, p < 0.001). At multivariate analysis, determinants of correct surveillance timing were high-volume workload centres (OR 1.92; 1.41–2.63 95%CI), centres providing written recommendation on surveillance interval (OR 1.70; 1.18–2.58 95%CI) and surveillance examinations performed within the national screening programme (OR 2.62; 1.92–3.59 95%CI).ConclusionsIn community practice, post-polipectomy surveillance colonoscopy is often performed earlier than recommended, especially in low-risk subjects. Interventions to improve adherence to guidelines and to reduce unnecessary examinations are needed.     

Errors and near misses in digestive endoscopy units

Background

Not much is known about errors and near misses in digestive endoscopy.

Aims

To verify whether an incident report, with certain facilitating features, gives useful information about unintended events, only excluding errors in medical diagnosis.

Method

Nine endoscopy units took part in this cross sectional, prospective, multicentre study which lasted for two weeks. Members of the staff were required to report any unintended, potentially dangerous event observed during the daily work. A form was provided with a list of “reminders” and facilitators were appointed to help.The main outcome measurements were type of event, causes, corrective interventions, stage of occurrence in the workflow and qualification of the reporters.

Results

A total of 232 errors were reported (two were not related to endoscopy). The remaining 230 amount to 10.3% of 2239 procedures; 66 (29%) were considered errors with consequences, 164 (71%) “near misses”. There were 150 pre-operative errors (65%), 22 operative (10%) and 58 post-operative (25%). Corrective interventions were provided for 60 cases of errors and 119 near misses. Most of the events were reported by the nurses (106 out of 232, 46%).

Conclusions

Short-term incident reporting focusing on near misses, using forms with lists of “reminders”, and the help of a facilitator, can give useful information on errors and near misses in digestive endoscopy.     

Novel mutations in the fukutin gene in a boy with asymptomatic hyperCKemia

Mutations in the fukutin gene were first identified in Japanese patients with classic Fukuyama congenital muscular dystrophy, a severe form of congenital muscular dystrophy associated with cobblestone lissencephaly and ocular defects. Patients of different ethnicities and with milder phenotypes, including limb girdle muscular dystrophy and cardiomyopathy without brain impairment, have also been reported. The hallmark of this disorder, regardless of the clinical outcome, is moderate-to-severe hypoglycosylation of alpha-dystroglycan in muscle sections. We describe the case of a boy harboring two novel mutations in fukutin gene and presenting a five-year history of asymptomatic hyperCKemia, without overt muscle, brain or ocular involvement. Genetic investigations, guided by the presence of moderate myopathic changes on muscle biopsy with loss of immunodetectable alpha-dystroglycan, led to a definitive diagnosis. Cardiac and echocardiographic examinations at follow-up disclosed low normal left ventricular function but no active cardiovascular symptoms. We suggest that fukutin mutations should be sought in asymptomatic hyperCKemia and subclinical heart dysfunction.     

Prediction of successful dose reduction or discontinuation of adalimumab,etanercept, or infliximab in rheumatoid arthritis patients using serum drug levels and antidrug antibody measurement

Background: To evaluate if TNF inhibitor serum drug levels (DL) or anti-drug antibodies (ADAb) can predict successful dose reduction (in patients with high DL) or discontinuation (in patients with no/low DL or ADAb) in rheumatoid arthritis (RA) patients.

Research design and methods: RA patients that were using adalimumab (n = 42), etanercept (n = 76) or infliximab (n = 51) and were doing well, were tapered until discontinuation or flare (1–1.5 year follow up). Random timed DL for adalimumab and etanercept and trough DL for infliximab were measured before dose reduction: Receiver-Operator-Curves (ROC) analyses with optimal cut-off DL were determined.

Results: No predictive value of adalimumab and infliximab DL for all outcomes were found, except for an inverse association of lower etanercept DL and higher chance for successful dose reduction (Area Under the Curve (AUC) 0.36, 95% CI 0.23–0.49; cut-off <2.6 mg/l). In sub analyses, higher adalimumab trough DL predicted successful dose reduction (AUC 0.86, 0.58–1.00; cut-off >7.8). ADAb were infrequent and not predictive of successful discontinuation.

Conclusions: No predictive value of baseline adalimumab, etanercept and infliximab DL or ADAb for successful dose reduction or discontinuation in RA was found in this context, with the possible exception of high adalimumab trough levels for successful dose reduction.     

Increased Efficacy and Safety of Enteral Nutrition Support with a Protocol (ASNET) in Noncritical Patients: A Randomized Controlled Trial

Background

Unintentional underfeeding is common in patients receiving enteral nutrition (EN), and is associated with increased risk of malnutrition complications. Protocols for EN in critically ill patients have been shown to enhance adequacy, resulting in better clinical outcomes; however, outside of intensive care unit (ICU) settings, the influence of a protocol for EN is unknown.