Endoscopic findings and esophageal cancer incidence among Fanconi Anemia patients participating in an endoscopic surveillance program

BACKGROUND AND AIMS

The primary clinical characteristics of Fanconi Anemia (FA) include typical physical features, progressive bone marrow failure, and an increased incidence of neoplasms, including esophageal carcinoma. Currently, there are no data regarding endoscopic findings or the interval time to malignancy in these patients. Data about the contribution of Human Papilloma Virus (HPV) to esophageal carcinoma is conflicting. Our objective is to document the upper gastrointestinal (GI) findings at baseline, document cancer incidence, and evaluate the role of HPV among these cancers.

METHODS

We reviewed endoscopic and clinical data of FA subjects who participated in active surveillance before cancer diagnosis. Incident esophageal cancers were stained for HPV ^p16 protein.

RESULTS

Eight FA patients were included (men 62.5%; median age at first endoscopy 20 years, median endoscopies number: 5.5). At baseline, 8/8 had endoscopic evidence for reflux esophagitis. In 3/8 the reflux esophagitis was mild and in 5/8 it was moderate or severe. During the follow up time (median time 4.5 years 2/8 developed Barrett's esophagus and 2/8 patients had incident esophageal squamous cell carcinoma during follow up, at intervals of eight and eighteen months from the previous upper endoscopy. Both cancers stained negative for HPV ^P16.

CONCLUSIONS

FA subjects have both an extremely high risk for esophageal cancer within short intervals and a very high prevalence of reflux esophagitis with various severities. Active surveillance programs in specialized centers including annual upper endoscopies should be considered in these patients.

Temporal Trends in Helicobacter pylori Eradication Success in a Test-and-Treat Population

BACKGROUND/AIMS

Although the efficacy of first-line treatment for Helicobacter pylori infection should aim to be > 90%, it is unclear whether this target has been achieved in Israel. We aimed to determine the success rate of treatment for H. pylori and to describe temporal changes in our region. Methods: Adult patients who underwent a first-time -C13-urea breath test (C13-UBT) at Clalit Health Services between January 1, 2010 and December 31, 2015 were included. In order to isolate a naïve "test-and-treat" population who were unlikely to have undergone an initial endoscopy-based H. pylori test, we excluded patients ≥45 years and those with any previous C13-UBT.

RESULTS

A total of 94,590 subjects (36.1% male, age 28.5 ± 6.0) who underwent at least one C13-UBT during the study period were included. C13-UBT was positive in 48,509 (51.3%) subjects. A confirmatory post-treatment C13-UBT was performed in 37.8, 44.1, 46.6, and 45.9% following 1st, 2nd, 3rd, and 4th-line treatment respectively. Eradication was successful in 65.4% following first-line treatment, and eradication success improved during the study period (59.2, 63.3, 65.7, 66.0, 69.0, and 73.1% in 2010, 2011, 2012, 2013, 2014, and 2015 respectively; OR 1.11; 95% CI 1.09-1.13; p < 0.0001). Eradication was successful in 44.7% following second-line treatment, although eradication success did not significantly improve during the study period (OR 1.05; 95% CI 0.99-1.10; p = 0.09).

CONCLUSIONS

Despite the increasing success of first-line treatment for H. pylori infection over the study period, eradication rates remain suboptimal. Initiatives to implement the Toronto and Maastricht Consensus Reports should be advanced.

Practice styles, knowledge and attitudes of general practitioners and gastroenterology specialists who treat gastroesophageal reflux disease

As little is known on the subject, our aim was to compare practice styles, knowledge and attitudes of general practitioners (GPs), and gastroenterology specialists (GIs) regarding the treatment of gastroesophageal reflux disease (GERD).An internet survey designed by the authors was sent nationwide and randomly to 290 GIs and 1312 GPs. We assessed for the burden of GERD, indications for referral for a GI consultation, criteria for proton pump inhibitors (PPIs) selection, and main unmet treatment needs.Forty (14%) GIs and 132 (10%) GPs returned the questionnaire. Both groups treat 13 to 14 GERD patients weekly (mean age 41-50 years). The most common first and second line drug of choice in both groups was omeprazole and esomeprazole, respectively. GIs stated that the most important consideration for the selection of treatment was high safety profile, whereas GPs considered it to be a rapid symptomatic relief. In the case of first and second line PPI failures, GIs tended to prescribe a non PPI treatment, whereas GPs restarted esomeprazole. GIs stated that the most prevalent conceived limitations of PPI treatment were nighttime heartburn and undesirable side effects, whereas GPs considered treatment inflexibility and drug interactions.GIs and GPs hold different practice styles, knowledge, and attitudes on the treatment of GERD. Our findings ascertain the need for the development of updated National Clinical Guidelines focusing on GERD.

The Role of Botox in Colorectal Disorders

PURPOSE OF REVIEW

To overview the current medical literature on the efficacy of botulism toxin treatment (BTX-A) for lower gastrointestinal disorders (GIT).

RECENT FINDINGS

BTX-A was found to have a short-term efficacy for the treatment of dyssynergic defecation. Surgical treatment was found to be more effective than BTX-A for the healing of chronic anal fissures, and BTX-A can be considered when surgery is undesirable. Data regarding the effects of BTX-A injection for the treatment of chronic anal pain is limited. Beneficial effects were observed only in a minority of patients. BTX-A treatment was found to be effective for the treatment of obstructive symptoms after surgery for Hirsprung's disease as well as for the treatment of internal anal sphincter achalasia. BTX-A treatment has a short-term efficacy and is safe. Further research is still needed in order to establish the exact place of BTX-A treatment of lower GIT disorders.

Optimization of 13 C-urea breath test threshold levels for the detection of Helicobacter pylori infection in a national referral laboratory

BACKGROUND

Threshold values for ¹³ C-urea breath test (13C-UBT) positivity may be affected by various sociodemographic, host, bacterial, and laboratory factors. Manufacturer recommended cutoffs for 13C-UBT assays may not be applicable in all settings. Optimizing 13C-UBT cutoffs may have profound public health ramifications. We aimed to determine the optimal threshold for 13C-UBT positivity in our population.

METHODS

Consecutive test samples collected at our central laboratory from patients undergoing a first-time 13C-UBT between 1 January 2010 and 31 December 2015 were included. The difference between values at 30 minutes and at baseline (T30-T0) was expressed as delta over baseline (DOB). Cluster analysis was performed on the 13C-UBT test results to determine the optimal cutoff point with minimal interclass variance.

RESULTS

Two lakhs thirty four thousand eight hundred thirty one patients (87 291 (37.2%) male, age 39.9 ± 19.9) underwent a first-time 13C-UBT, including 124 701 (53.1%) negative and 110 130 (46.9%) positive tests, using the manufacturer-recommended cutoff of 3.5 DOB. Cluster analysis determined an optimized cutoff of 2.74 DOB, representing an additional 2180 (0.93%) positive subjects who had been previously categorized as negative according to the manufacturer-specified cutoff of 3.5 DOB. Mean positive and negative DOB values were 19.54 ± 14.95 and 0.66 ± 0.51, respectively. The cutoffs for male and female subjects were 2.23 and 3.05 DOB, respectively. Threshold values for <45-year-olds, 45-60-year-olds and >60-year-olds were 2.67, 2.55, and 2.93 DOB, respectively. Of the 2180 (0.93%) patients with DOB 2.73-3.49, 289 (13.3%) performed a subsequent 13C-UBT and 140 (48.4%) remained positive when tested at 20.3 ± 14.4 months.

CONCLUSIONS

Major referral laboratories should optimize threshold values for 13C-UBT positivity for their geographical location. Different cutoff values should be applied for male and female subjects.

Curriculum for neurogastroenterology and motility training: A report from the joint ANMS-ESNM task force

Although neurogastroenterology and motility (NGM) disorders are some of the most frequent disorders encountered by practicing gastroenterologists, a structured competency-based training curriculum developed by NGM experts is lacking. The American Neurogastroenterology and Motility Society (ANMS) and the European Society of Neurogastroenterology and Motility (ESNM) jointly evaluated the components of NGM training in North America and Europe. Eleven training domains were identified within NGM, consisting of functional gastrointestinal disorders, visceral hypersensitivity and pain pathways, motor disorders within anatomic areas (esophagus, stomach, small bowel and colon, anorectum), mucosal disorders (gastro-esophageal reflux disease, other mucosal disorders), consequences of systemic disease, consequences of therapy (surgery, endoscopic intervention, medications, other therapy), and transition of pediatric patients into adult practice. A 3-tiered training curriculum covering these domains is proposed here and endorsed by all NGM societies. Tier 1 NGM knowledge and training is expected of all gastroenterology trainees and practicing gastroenterologists. Tier 2 knowledge and training is appropriate for trainees who anticipate NGM disorder management and NGM function test interpretation being an important part of their careers, which may require competency assessment and credentialing of test interpretation skills. Tier 3 knowledge and training is undertaken by trainees interested in a dedicated NGM career and may be restricted to specific domains within the broad NGM field. The joint ANMS and ESNM task force anticipates that the NGM curriculum will streamline NGM training in North America and Europe and will lead to better identification of centers of excellence where Tier 2 and Tier 3 training can be accomplished.

Effect of Postprandial Administration of Esomeprazole on Reflux Symptoms in Gastroesophageal Reflux Disease: A Randomized, Controlled Trial

BACKGROUND

Esomeprazole is commonly administered with food; however, clinical data to support this practice are lacking. We aimed to determine the effect of postprandial ingestion of esomeprazole on reflux symptoms among patients with gastroesophageal reflux disease (GERD).

METHODS

Consecutive patients with GERD adequately controlled with esomeprazole 40 mg daily, entered a 2-week lead-in period during which esomeprazole was administered 30 min before breakfast. Patients were then randomized to continue preprandial ingestion or to ingest esomeprazole following a standardized meal. Outcomes included GERD frequency and severity indices, GERD-health-related quality of life (GERD-HRQL) questionnaire and Short Form 36 (SF-36).

RESULTS

Thirty-two patients (17 [53.1%] men, aged 53.5 ± 17.2 years) were included, and 16 (50%) switched to postprandial ingestion of esomeprazole. GERD frequency and severity decreased in both groups (Δ9.0 ± 7.2 vs. Δ10.0 ± 8.1, p = 0.29; Δ6.6 ± 6.8 vs. Δ10.2 ± 7.4, p = 0.57 in postprandial group vs. controls, for frequency and severity, respectively). GERD-HRQL improved in both study groups to a similar degree (Δ10.7 ± 10.5 vs. Δ10.0 ± 13.8, p = 0.97). All SF-36 subscores increased in both groups to a similar degree. In a mixed linear model, there were no differences between the study groups in the changes observed in GERD frequency (p = 0.49), severity (p = 0.32), and GERD-HRQL (p = 0.98) during the study period.

CONCLUSION

Switching to postprandial administration of esomeprazole is not associated with deterioration in reflux symptoms among patients with GERD. Esomeprazole seems to remain efficacious when administered after meals.

Comparison of strategies and goals for treatment of chronic constipation among gastroenterologists and general practitioners

BACKGROUND

Although guidelines have been published for the treatment of chronic constipation, little is known about the actual treatment strategies, the definitions of drug efficacy, the parameters for drug selection, and the conceived limitations of the available treatments. The purpose of this study was to address these issues by comparing treatment strategies among gastroenterology specialists (GIs) and general practitioners (GPs).

METHODS

An internet survey was sent nationwide and at random to GIs and GPs in order to define treatment strategies, drug efficacy, main parameters for drug selections and the main limitations of the available drug therapy.

RESULTS

Forty GIs and 132 GPs answered the survey. The maximal sample error was ±13.4% and ±8.8%. Treatment strategies varied considerably between GPs and GIs. The major parameters for drug selection were related to drug safety among GIs and to clinical outcome among GPs. The conceived limitations of drug therapy included lack of experience and unwanted side effects.

CONCLUSIONS

Awareness of the possible treatment options and the recommended order of prescription differs between GIs and GPs. There are still unmet needs for optimizing the treatment for chronic constipation.

[THE ISRAELI NEUROGASTROENTEROLOGY ASSOCIATION RECOMMENDATIONS FOR THE EVALUATION AND TREATMENT OF CHRONIC CONSTIPATION]

This article summarizes the recommendations of the Israeli Neurogastroenterology and Motility Branch of the Israeli Gastroenterology Association for diagnosis and treatment of chronic constipation. It encompasses an overview of the definitions, the diagnostic approach and the possible treatment options in chronic constipation. This document is suitable for primary care physicians who are interested in understanding the major physiologic mechanisms for chronic constipation and the possible treatment options, as well as for the gastroenterology consultant who faces patients with tenacious chronic constipation.

Small Intestinal Bacterial Overgrowth May Increase the Likelihood of Lactose and Sorbitol but not Fructose Intolerance False Positive Diagnosis

BACKGROUND

Small intestinal bacterial overgrowth (SIBO) is defined as a bacterial count of more than 10⁵ colony-forming units per milliliter in duodenal aspirate. It shares many symptoms with carbohydrate intolerance, which makes the clinical distinction of the disorders difficult. The aim of the study was to examine the relationship between a positive carbohydrate breath test and the presence of SIBO suggested by a positive lactulose hydrogen breath test.

METHODS

The electronic database of the gastroenterology laboratory of a tertiary medical center was searched for all patients clinically tested for SIBO in 2012-2013 for whom previous results for lactose, fructose, and/or sorbitol breath test were available. The correlation between positive findings for carbohydrate intolerance and for SIBO was statistically analyzed.

RESULTS

The study group included 349 patients, 231 female and 118 male, of mean age 53±19 years. All had symptoms of abdominal bloating and gas. There was a statistically significant difference in rates of a positive breath test for lactose and sorbitol at ≤90 minutes between patients who were positive and negative for SIBO [χ²(1)=12.8, p<0.01 and χ²(1)=9.5, p<0.01 respectively]. Findings for fructose were not significant. There was no effect of age or gender.

CONCLUSIONS

SIBO may represent an important reversible cause of carbohydrate intolerance. It may be especially prudent to exclude SIBO patients with an early peak (≤90 minutes) in H₂ excretion.

A double-blind, placebo-controlled study to assess the effect of a probiotic mixture on symptoms and inflammatory markers in women with diarrhea-predominant IBS

BACKGROUND

Micro-inflammation is considered an element in the pathogenesis of irritable bowel syndrome (IBS). High-sensitivity C reactive protein (hs-CRP) was previously shown to be higher in IBS compared to healthy controls, albeit within the normal range. Since probiotics may suppress micro-inflammation in the gut, we tested if they reduce symptoms and inflammatory markers (hs-CRP and fecal calprotectin (FC) in diarrhea-predominant IBS (IBS-D). The aim of this study was to assess the clinical and laboratory effects of BIO-25, a multispecies probiotic, in women with IBS-D.

METHODS

A double-blind, placebo-controlled study. Following a 2-week run-in, eligible women were assigned at random to a probiotic capsule or an indistinguishable placebo, twice daily for 8 weeks. IBS symptoms and stool consistency were rated daily by Visual Analogue Scales (VAS) and the Bristol Stool Scale (BSS). High-sensitivity C reactive protein was tested at baseline, 4 and 8 weeks. FC was tested at baseline and 8 weeks.

KEY RESULTS

One hundred and seventy-two IBS-D patients were recruited and 107 eligible patients were allocated to the intervention (n=54) or placebo (n=53) group. All symptoms improved in both groups with no significant difference between them in symptom improvement, hs-CRP or FC levels.

CONCLUSIONS & INFERENCES

An 8-week treatment with BIO-25 improved symptoms in women with IBS-D, but was not superior to placebo. This rigorously designed and executed study supports the findings of other studies that did not demonstrate superiority of probiotics over placebo in IBS. High quality clinical studies are necessary to examine the efficacy of other specific probiotics in IBS-D patients since data are still conflicting.

[THE FAILURE MODES AND EFFECTS ANALYSIS FACILITATES A SAFE, TIME AND MONEY SAVING OPEN ACCESS COLONOSCOPY SERVICE]

BACKGROUND

Failure modes and effects analysis (FMEA) is used for the identification of potential risks in health care processes. We used a specific FMEA - based form for direct referral for colonoscopy and assessed it for procedurerelated perforations.

METHODS

Ten experts in endoscopy evaluated and computed the entire referral process, modes of preparation for the endoscopic procedure, the endoscopic procedure itself and the discharge process. We used FMEA assessing for likelihood of occurrence, detection and severity and calculated the risk profile number (RPN) for each of the above points. According to the highest RPN results we designed a specific open access referral form and then compared the occurrence of colonic perforations (between 2010 and 2013) in patients who were referred through the open access arm (Group 1) to those who had a prior clinical consultation (non-open access, Group 2).

RESULTS

Our experts in endoscopy (5 physicians and 5 nurses) identified 3 categories of failure modes that, on average, reached the highest RPNs. We identified 9,558 colonoscopies in group 1, and 12,567 in group 2. Perforations were identified in three patients from the open access group (1:3186, 0.03%) and in 10 from group 2 (1:1256, 0.07%) (p = 0.024). Direct referral for colonoscopy saved 9,558 pre-procedure consultations and the sum of $850,000.

CONCLUSIONS

The FMEA tool-based specific referral form facilitates a safe, time and money saving open access colonoscopy service.

DISCUSSION

Our form may be adopted by other gastroenterological clinics in Israel.

Appropriateness of Repeating Helicobacter pylori Culture and Susceptibility Testing Following Failure of Individualized Antibiotic Therapy

BACKGROUND

Current guidelines recommend direct Helicobacter pylori culture and antibiotic susceptibility testing following 2 failed eradication attempts. If this process is followed and yet subsequent treatment is unsuccessful, it is unclear whether susceptibility testing should be repeated. This is the first study to examine the appropriateness of repeated H. pylori culture and susceptibility testing following failure of individualized treatment.

METHODS

Between 2007 and 2014, consecutive patients who underwent at least 2 upper gastrointestinal endoscopies with H. pylori culture and susceptibility testing at our institution following several treatment failures were retrospectively identified. Antibiotic susceptibility was recorded and linked to demographic data.

RESULTS

A total of 68 cultures from 34 patients were included (12 (35.3%) men, 41.4 ± 16.6 years), and 20 (58.8%) cultures had a different antibiotic susceptibility profile on repeat testing (8 (23.5%) with new susceptibility and 13 (38.2%) with new resistance). Acquired resistance to clarithromycin, levofloxacin and metronidazole was observed in 9 (26.5%), 2 (5.9%) and 10 (29.4%) cultures, respectively. Subjects with resistance to ≤1 antibiotic at baseline were more likely to develop resistance to at least 1 antibiotic on subsequent culture, compared to subjects with resistance to ≥2 antibiotics at baseline (13 (100%) vs. 5 (23.8%), p < 0.01).

CONCLUSION

Repeating H. pylori culture and susceptibility testing usually yields new antimicrobial susceptibility data. However, the clinical usefulness of this approach remains unclear.

Possible Involvement of Avoidant Attachment Style in the Relations Between Adult IBS and Reported Separation Anxiety in Childhood

Irritable bowel syndrome (IBS) in adults as well as separation anxiety disorder (SAD) and recurrent abdominal pain (RAP) in childhood are associated with anxiety and somatization. Our aim was to examine possible associations between IBS in adulthood and SAD in childhood. Patients with IBS and healthy subjects completed a demographic questionnaire, the Separation Anxiety Symptom Inventory (SASI), the Somatization Subscale of Symptom Checklist-90-R (SCL-90-R), the Attachment Style Questionnaire, and a retrospective self-report questionnaire regarding RAP. Compared with controls, patients with IBS were characterized by an avoidant attachment style and scored higher on the SCL-90-R scale regarding the tendency to somatization (25.35 ± 7.47 versus16.50 ± 4.40, p < 0.001). More patients with IBS (25% versus 7.5%) reported RAP in childhood, but contrary to prediction, also had significantly lower SASI scores. Adults with IBS were characterized by somatization, insecure attachment style and recalled higher rates of RAP and surprisingly less symptoms of SAD in childhood. Based on these results, an etiological model for IBS is suggested, in which an avoidant attachment style and a tendency to somatization play an important role in the development of IBS. Copyright © 2015 John Wiley & Sons, Ltd.

Pharmacological and other treatment modalities for esophageal pain

Treatment of esophageal pain remains a major challenge for the clinician. Although many patients have heartburn and may respond to proton pump inhibitors, there in an unmet need for other treatment modalities in patients where there are no obvious pathological findings. Although analgesics are the mainstay in esophageal pain treatment, many patients are nonresponders to these drugs. The current concise review focuses on other systems affecting pain processing, where better understanding may serve as a framework for therapy. These are the parasympathetic nervous system, exercise, and personality profiles. Finally, treatment with analgesics for functional chest pain remains a challenge, and an overview of treatment with antidepressive drugs is provided.

A novel method for screening colorectal cancer by infrared spectroscopy of peripheral blood mononuclear cells and plasma

BACKGROUND

Early detection of colorectal cancer (CRC) can reduce mortality and morbidity. Current screening methods include colonoscopy and stool tests, but a simple low-cost blood test would increase compliance. This preliminary study assessed the utility of analyzing the entire bio-molecular profile of peripheral blood mononuclear cells (PBMCs) and plasma using Fourier transform infrared (FTIR) spectroscopy for early detection of CRC.

METHODS

Blood samples were prospectively collected from 62 candidates for CRC screening/diagnostic colonoscopy or surgery for colonic neoplasia. PBMCs and plasma were separated by Ficoll gradient, dried on zinc selenide slides, and placed under a FTIR microscope. FTIR spectra were analyzed for biomarkers and classified by principal component and discriminant analyses. Findings were compared among diagnostic groups.

RESULTS

Significant changes in multiple bands that can serve as CRC biomarkers were observed in PBMCs (p = ~0.01) and plasma (p = ~0.0001) spectra. There were minor but statistically significant differences in both blood components between healthy individuals and patients with benign polyps. Following multivariate analysis, the healthy individuals could be well distinguished from patients with CRC, and the patients with benign polyps were mostly distributed as a distinct subgroup within the overlap region. Leave-one-out cross-validation for evaluating method performance yielded an area under the receiver operating characteristics curve of 0.77, with sensitivity 81.5% and specificity 71.4%.

CONCLUSIONS

Joint analysis of the biochemical profile of two blood components rather than a single biomarker is a promising strategy for early detection of CRC. Additional studies are required to validate our preliminary clinical results.

Unmet Needs in the Treatment of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a highly prevalent gastrointestinal disorder. Proton pump inhibitors have profoundly revolutionized the treatment of GERD. However, several areas of unmet need persist despite marked improvements in the ther-apeutic management of GERD. These include the advanced grades of erosive esophagitis, nonerosive reflux disease, main-tenance treatment of erosive esophagitis, refractory GERD, postprandial heartburn, atypical and extraesophageal manifestations of GERD, Barrett's esophagus, chronic protein pump inhibitor treatment, and post-bariatric surgery GERD. Consequently, any fu-ture development of novel therapeutic modalities for GERD (medical, endoscopic, or surgical), would likely focus on the afore-mentioned areas of unmet need.

Gut-directed guided affective imagery as an adjunct to dietary modification in irritable bowel syndrome

This work aimed to study the effect of guided affective imagery on the irritable bowel syndrome. A total of 15 irritable bowel syndrome patients received guided affective imagery and 19 patients served as controls. Symptom severity and irritable bowel syndrome quality of life were measured at baseline and 8 weeks. Symptom severity decreased following guided affective imagery compared to controls (−1.5 ± 1.9 vs 0.1 ± 1.6, p = 0.04). Irritable bowel syndrome quality of life increased following guided affective imagery compared to controls (12.1 ± 12.5 vs −0.7 ± 16.2, p < 0.01). Guided affective imagery predicted reduced symptom severity (odds ratio = 5.71, p = 0.02) and increased irritable bowel syndrome quality of life (odds ratio = 17.88, p = 0.01). Guided affective imagery combined with dietary modification may be beneficial in the management of irritable bowel syndrome, however larger studies are required.

Home electrical stimulation for women with fecal incontinence: a preliminary randomized controlled trial

PURPOSE

The purpose of this study is to compare the effectiveness and cost of home electrical stimulation and standardized biofeedback training in females with fecal incontinence

METHODS

Thirty-six females suffering from fecal incontinence were randomized into two groups, matched for mean age (67.45 ± 7.2 years), mean body mass index (kg/m2) (26.2 ± 3.9), mean disease duration (4.1 ± 0.8 years), mean number of births (2.7 ± 1.3), and reports of obstetric trauma (25%). Questionnaires were used to evaluate their demographics, medical, and childbearing history. Subjects were randomized to home electrical stimulation or standardized biofeedback training for a period of 6 weeks. Subjective outcome measures included the frequency of fecal, urine, and gas incontinence by visual analog scale, Vaizey incontinence score, and subjects' levels of fecal incontinence related anxiety. Objective outcome measures included pelvic floor muscle strength assessed by surface electromyography. We also compared the cost of each treatment modality.

RESULTS

Only females who received home electrical stimulation (HES) reported a significant improvement in Vaizey incontinence score (p = 0.001), anxiety (p = 0.046), and in frequency of leaked solid stool (p = 0.013). A significant improvement in pelvic floor muscle strength was achieved by both groups. HES was much cheaper compared to the cost of standardized biofeedback training (SBT) (US $100 vs. US $220, respectively). Our study comprised a small female population, and the study endpoints did not include objective measures of anorectal function test, such as anorectal manometry, before and after treatment.

CONCLUSIONS

Home electrical stimulation may offer an alternative to standardized biofeedback training as it is effective and generally well-tolerated therapy for females with fecal incontinence.

Establishing an integrated gastroenterology service between a medical center and the community

AIM

To combine community and hospital services in order to enable improvements in patient management, an integrated gastroenterology service (IGS) was established.

METHODS

Referral patterns to specialist clinics were optimized; open access route for endoscopic procedures (including esophago-gastro-duodenoscopy, sigmoidoscopy and colonoscopy) was established; family physicians' knowledge and confidence were enhanced; direct communication lines between experts and primary care physicians were opened. Continuing education, guidelines and agreed instructions for referral were promoted by the IGS. Six quality indicators were developed by the Delphi method, rigorously designed and regularly monitored. Improvement was assessed by comparing 2010, 2011 and 2012 indicators.

RESULTS

An integrated delivery system in a specific medical field may provide a solution to a fragmented healthcare system impaired by a lack of coordination. In this paper we describe a new integrated gastroenterology service established in April 2010. Waiting time for procedures decreased: 3 mo in April 30th 2010 to 3 wk in April 30th 2011 and stayed between 1-3 wk till December 30th 2012. Average cost for patient's visit decreased from 691 to 638 NIS (a decrease of 7.6%). Six health indicators were improved significantly comparing 2010 to 2012, 2.5% to 67.5%: Bone densitometry for patients with inflammatory bowel disease, preventive medications for high risk patients on aspirin/NSAIDs, colonoscopy following positive fecal occult blood test, gastroscopy in Barrett's esophagus, documentation of family history of colorectal cancer, and colonoscopy in patients with a family history of colorectal cancer.

CONCLUSION

Establishment of an IGS was found to effectively improve quality of care, while being cost-effective.

Stability of (13) C-Urea Breath Test Samples Over Time in the Diagnosis of Helicobacter pylori

BACKGROUND

The accuracy and repeatability of breath test in the diagnosis of Helicobacter pylori infection have not been adequately investigated. Although it has been shown that storage for long periods does not affect the analysis results, no data are available on the effect of repetitive testing. In this study, our aim was to evaluate the repeatability of the analyses of breath samples at room temperature.

METHODS

A total of 202 positive breath samples were collected in duplicates, before and after administration of 75 mg (13) C- urea dissolved in 100 ml of orange juice. Breath test results were expressed as delta (13) CO2 . The cut-off value was 3.5 parts per thousand. Each sample was analyzed in a mass spectrometer 7, 14, 21, and 28 days after collection. The accuracy calculation was based on the comparison of the delta (13) CO2 obtained in the three consecutive weeks following the first test run to the delta (13) CO2 obtained in the first test run.

RESULTS

Two hundred (99%), 197 (97.52%), and 196 (97%) of the 202 samples tested positive in the second, third, and fourth test runs, respectively. The accuracy of the delta (13) CO2 was 98.6%, 99.2%, and 96.7% in the three consecutive runs, respectively.

CONCLUSION

Short-term storage of 1 month does not affect sample stability or the results of (13) C-urea breath tests in up to three consecutive repeats.

Safety and efficacy of the vibrating capsule, an innovative non-pharmacological treatment modality for chronic constipation

BACKGROUND

Constipation is a common disorder. Because the prevalence is high and the satisfaction level with currently available treatment is low, there is an unmet need for innovative treatment. We assessed the safety and efficacy of the Vibrant Capsule, a non-pharmacological device that is assumed to induce a normal peristaltic wave in the large intestine to alleviate constipation.

METHODS

Two animal safety studies and a safety study on healthy volunteers were conducted, followed by a prospective, non-randomized, open-label, single group assignment, safety and efficacy study. The latter was conducted among 26 patients who ingested the capsule twice weekly for a study period of 7.5 weeks, after a run-in period of 2 weeks without usual treatment for constipation.

KEY RESULTS

In the studies on animals and healthy volunteers, there were no adverse events. Twenty-eight patients began the clinical trial and 26 completed it (25 women). The mean age was 47.0 ± 12.6 years (range: 19-65). The two dropouts, who completed the safety phase, and the 26 who completed the entire study expelled the capsule without difficulty. Twelve participants reported 27 adverse events, none serious, and all transient. There was a significant increase of 1.60 ± 1.09 in the mean number of bowel movements/week from 2.19 ± 0.67 to 3.79 ± 1.31 (p < 0.001). This increase was seen in 23 of the 26 patients (88.5%). The mean number of spontaneous bowel movements for the study group increased in each treatment week compared to baseline.

CONCLUSIONS & INFERENCES

The Vibrant Capsule is safe and potentially effective in the treatment of constipation, justifying randomized controlled studies.