How good is endoscopic ultrasound in differentiating various T stages of rectal cancer? Meta-analysis and systematic review

Published data on accuracy of endoscopic ultrasound (EUS) in differentiating T stages of rectal cancers is varied. Study selection criteria were to select only EUS studies confirmed with results of surgical pathology. Articles were searched in Medline and Pubmed. Pooling was conducted by both fixed and random effects models. Initial search identified 3,630 reference articles, of which 42 studies (N = 5,039) met the inclusion criteria and were included in this analysis. The pooled sensitivity and specificity of EUS to determine T1 stage was 87.8% [95% confidence interval (CI) 85.3-90.0%] and 98.3% (95% CI 97.8-98.7%), respectively. For T2 stage, EUS had a pooled sensitivity and specificity of 80.5% (95% CI 77.9-82.9%) and 95.6% (95% CI 94.9-96.3%), respectively. To stage T3 stage, EUS had a pooled sensitivity and specificity of 96.4% (95% CI 95.4-97.2%) and 90.6% (95% CI 89.5-91.7%), respectively. In determining the T4 stage, EUS had a pooled sensitivity of 95.4% (95% CI 92.4-97.5%) and specificity of 98.3% (95% CI 97.8-98.7%). The p value for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. We conclude that, as a result of the demonstrated sensitivity and specificity, EUS should be the investigation of choice to T stage rectal cancers. The sensitivity of EUS is higher for advanced disease than for early disease. EUS should be strongly considered for T staging of rectal cancers.

Early versus delayed feeding after placement of a percutaneous endoscopic gastrostomy: a meta-analysis

BACKGROUND

Traditionally, tube feedings have been delayed after percutaneous endoscopic gastrostomy (PEG) placement to the next day and up to 24 h postprocedure. However, results from various randomized controlled trials (RCTs) indicate earlier feeding may be an option. We conducted a meta-analysis to analyze the effect of early feedings (< or = 4 h) after PEG placement.

METHODS

Multiple databases were searched (November 2007). Only RCTs on adult subjects that compared early (< or = 4 h) versus delayed or next-day feedings after PEG placement were included. Meta-analyses for the effect of early and delayed feedings were analyzed by calculating pooled estimates of complications, death < or = 72 h, and significant increases in postprocedural gastric residual volume during day 1.

RESULTS

Six studies (N = 467) met the inclusion criteria. No statistically significant differences were noted between early (< or = 4 h) and delayed or next-day feedings for patient complications (OR 0.86, 95% CI 0.47-1.58, P = 0.63) or death in < or = 72 h (OR 0.56, 95% CI 0.18-1.74, P = 0.31). A statistically significant increase in gastric residual volumes during day 1 was noted (OR 1.80, 95% CI 1.02-3.19, P = 0.04).

CONCLUSIONS

Early feeding < or = 4 h after PEG placement may represent a safe alternative to delayed or next-day feedings. Although an increase in significant gastric residual volumes at day 1 was noted, overall complications were not affected.

How good is endoscopic ultrasound for TNM staging of gastric cancers? A meta-analysis and systematic review

AIM: To evaluate the accuracy of endoscopic ultrasound (EUS) for staging of gastric cancers.

METHODS: Only EUS studies confirmed by surgery were selected. Only studies from which a 2 × 2 table could be constructed for true positive, false negative, false positive and true negative values were included. Articles were searched in Medline, Pubmed, Ovid journals, Cumulative index for nursing & allied health literature, International pharmaceutical abstracts, old Medline, Medline nonindexed citations, and Cochrane control trial registry. Two reviewers independently searched and extracted data. The differences were resolved by mutual agreement. 2 × 2 tables were constructed with the data extracted from each study. Meta-analysis for the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. Pooling was conducted by both the Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity of studies was tested using Cochran’s Q test based upon inverse variance weights.

RESULTS: Initial search identified 1620 reference articles and of these, 376 relevant articles were selected and reviewed. Twenty-two studies (n = 1896) which met the inclusion criteria were included in this analysis. Pooled sensitivity of T1 was 88.1% (95% CI: 84.5-91.1) and T2 was 82.3% (95% CI: 78.2-86.0). For T3, pooled sensitivity was 89.7% (95% CI: 87.1-92.0). T4 had a pooled sensitivity of 99.2% (95% CI: 97.1-99.9). For nodal staging, the pooled sensitivity for N1 was 58.2% (95% CI: 53.5-62.8) and N2 was 64.9% (95% CI: 60.8-68.8). Pooled sensitivity to diagnose distant metastasis was 73.2% (95% CI: 63.2-81.7). The P for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10.

CONCLUSION: EUS results are more accurate with advanced disease than early disease. If EUS diagnoses advanced disease, such as T4 disease, the patient is 500 times more likely to have true anatomic stage of T4 disease.

Endoscopic ultrasound: it's accuracy in evaluating mediastinal lymphadenopathy? A meta-analysis and systematic review

AIM

To evaluate the accuracy of endoscopic ultrasound (EUS), EUS-fine needle aspiration (FNA) in evaluating mediastinal lymphadenopathy.

METHODS

Only EUS and EUS-FNA studies confirmed by surgery or with appropriate follow-up were selected. Articles were searched in Medline, Pubmed, and Cochrane control trial registry. Only studies from which a 2 multiply 2 table could be constructed for true positive, false negative, false positive and true negative values were included. Two reviewers independently searched and extracted data. The differences were resolved by mutual agreement. Meta-analysis for the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratios. Pooling was conducted by both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity of studies was tested using Cochran's Q test based upon inverse variance weights.

RESULTS

Data was extracted from 76 studies (n = 9310) which met the inclusion criteria. Of these, 44 studies used EUS alone and 32 studies used EUS-FNA. FNA improved the sensitivity of EUS from 84.7% (95% CI: 82.9-86.4) to 88.0% (95% CI: 85.8-90.0). With FNA, the specificity of EUS improved from 84.6% (95% CI: 83.2-85.9) to 96.4% (95% CI: 95.3-97.4). The P for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10.

CONCLUSION

EUS is highly sensitive and specific for the evaluation of mediastinal lymphadenopathy and FNA substantially improves this. EUS with FNA should be the diagnostic test of choice for evaluating mediastinal lymphadenopathy.

Staging accuracy of esophageal cancer by endoscopic ultrasound: A meta-analysis and systematic review

AIM: To evaluate the accuracy of endoscopic ultrasound (EUS) in the staging of esophageal cancer.

METHODS: Only EUS studies confirmed by surgery were selected. Articles were searched in Medline and Pubmed. Two reviewers independently searched and extracted data. Meta-analysis of the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. Pooling was conducted by both the Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity of studies was tested using Cochran’s Q test based upon inverse variance weights.

RESULTS: Forty-nine studies (n = 2558) which met the inclusion criteria were included in this analysis. Pooled sensitivity and specificity of EUS to diagnose T1 was 81.6% (95% CI: 77.8-84.9) and 99.4% (95% CI: 99.0-99.7), respectively. To diagnose T4, EUS had a pooled sensitivity of 92.4% (95% CI: 89.2-95.0) and specificity of 97.4% (95% CI: 96.6-98.0). With Fine Needle Aspiration (FNA), sensitivity of EUS to diagnose N stage improved from 84.7% (95% CI: 82.9-86.4) to 96.7% (95% CI: 92.4-98.9). The P value for the χ² test of heterogeneity for all pooled estimates was > 0.10.

CONCLUSION: EUS has excellent sensitivity and specificity in accurately diagnosing the TN stage of esophageal cancer. EUS performs better with advanced (T4) than early (T1) disease. FNA substantially improves the sensitivity and specificity of EUS in evaluating N stage disease. EUS should be strongly considered for staging esophageal cancer.

Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety

PROBLEM

Although morbidity and mortality conferences (MMCs) are meant to promote quality care through careful analysis of adverse events, focus on individual actions or the fear of incrimination may interfere with identification of system issues contributing to the adverse outcomes.

DESIGN

Participant attitudes before and after the intervention towards patient safety and conference redesign were assessed using an attitudinal survey. A list of contributing factors, recommended solutions and targeted system improvements was maintained with ongoing progress recorded.

SETTING

Department of Internal Medicine training programme at University of Missouri-Columbia.

PARTICIPANTS

Residents and fellows from the above residency programme.

EDUCATIONAL OBJECTIVES

(1) Distinguish between culture of blame/shame and patient safety culture, (2) identify gaps in quality contributing to adverse outcomes (3) identify strategies to close gaps and (4) participate in root cause analysis, demonstrating an ability to review an adverse event and recommend an action plan.

STRATEGIES FOR CHANGE

An interdisciplinary team modified the internal medicine MMC to emphasise a better understanding of patient safety principles and system-based practice interventions. For each adverse event analysed, root causes were identified, followed by discussion of system interventions that might prevent future such events.

KEY MEASURES FOR IMPROVEMENT

(1) Attitudes of residents and fellows regarding patient safety, as measured on a 20-item, five-point ordinal scale survey, (2) system improvements generated from the patient safety MMC (PSMMC) and (3) attendance at PSMMC.

EFFECTS OF CHANGE

Clinical outcomes: 121 system improvement recommendations were made and 39 were pursued on the basis of likelihood of achieving high impact changes. 23 improvements were implemented, 11 were partially implemented or in progress, and 5 were abandoned due to impracticality or redundancy. Educational outcomes: 58 residents and fellows completed surveys before and after modification of conference format. 6/20 survey items showed substantial change with four of these changes occurring in the desired direction. Eleven of the remaining 14 responses changed in the desired direction. Average MMC attendance increased from 41+/-8 to 50+/-10 participants (p<0.03).

LESSONS LEARNT

The new PSMMC initiated multiple improvements in the quality of patient care without sacrificing attendance or attitudes of the residents or fellows. The new PSMMC promotes opportunities for participants to improve quality of patient care in a safe and nurturing environment.

Bravo (wireless) ambulatory esophageal pH monitoring: How do day 1 and day 2 results compare?

AIM: To investigate if differences exist for patients’ gastroesophageal reflux as measured by the Bravo ambulatory esophageal pH system between d 1 and d 2.

METHODS: A retrospective study of 27 consecutive adult patients who underwent Bravo esophageal pH monitoring was performed. Patients underwent EGD under IV conscious sedation prior to Bravo placement. Acid reflux variables and symptom scores for d 1 were compared to d 2.

RESULTS: The mean doses of fentanyl and midazolam were 90.4 μg and 7.2 mg, respectively. D 1 results were significantly more elevated than d 2 with respect to total time pH < 4, upright position reflux, and mean number of long refluxes. No statistical difference was noted between the two days for supine position reflux, number of refluxes, duration of longest reflux, episodes of heartburn, and symptom score.

CONCLUSION: Patients undergoing Bravo esophageal pH monitoring in association with EGD and moderate conscious sedation experience significantly more acid reflux on d 1 compared to d 2. The IV sedation may be responsible for the increased reflux on d 1. Performed this way, 48-h Bravo results may not be entirely representative of the patients’ true GE reflux profile.