Variation in Colonoscopy Performance Measures According to Procedure Indication

BACKGROUND & AIMS

Most fulfillment and benchmarking information for colonoscopy quality indicators has been obtained from studies of primary screening colonoscopies. We analyzed differences in the fulfillment of colonoscopy quality indicators based on the indication for endoscopy.

METHODS

We performed an observational, multicenter, cross-sectional study of 14,867 patients who underwent endoscopy procedures for gastrointestinal symptoms (40.3%), a positive result from a fecal immunochemical test (36.0%), postpolypectomy surveillance (15.3%), or primary screening (8.4%), from February 2016 through December 2017 at 14 centers in Spain. We evaluated rates of adequate colon cleansing, cecal intubation, adenoma detection, and colorectal cancer detection, among others. We used findings from primary screening colonoscopies as the reference standard.

RESULTS

Fewer than 90% of patients had adequate bowel preparation; 83.1% of patients with gastrointestinal symptoms had adequate bowel preparation (odds ratio [OR] compared with patients with primary screening colonoscopies, 0.62; 95% CI, 0.49-0.78) and 85.3% of patients receiving postpolypectomy surveillance had adequate bowel preparation (OR, 0.71; 95% CI, 0.55-0.91). The cecal intubation rate was also lower in patients with gastrointestinal symptoms (93.1%) (OR, 0.34; 95% CI, 0.22-0.52). The adenoma detection rate was higher in patients with a positive result from a fecal immunochemical test (46.4%) (OR, 2.01; 95% CI, 1.71-2.35) and in patients undergoing postpolypectomy surveillance (48.2%) (OR, 1.41; 95% CI, 1.20-1.67). The highest proportion of patients with colorectal cancer was in the gastrointestinal symptom group (5.1%) (OR, 5.24; 95% CI, 2.30-11.93) and the lowest was in patients undergoing surveillance (0.8%) (OR, 0.83; 95% CI, 0.32-2.14).

CONCLUSIONS

Fulfillment of colonoscopy performance measures varies substantially by indication. Policies addressing performance measures beyond colonoscopy screening procedures should be developed. Benchmarking recommendations could be adjusted according to colonoscopy indication.

The Roles of Health Literacy and Physician-Patient Relationship in Self-Reported Health Outcomes Within a Diverse Sample of Persons Living with HIV

Objective

Barriers like poor health literacy and patient-provider communication add to health disparities in diverse populations. Perceived autonomy has been shown to improve patients’ health satisfaction and knowledge of their illness. However, no studies have examined these issues in HIV patients. This study examined the roles of health literacy and physician-patient relationship in health outcomes (e.g., mental health and emotional/physical functioning) in persons living with HIV (PLWH).

Participants and Method

This cross-sectional study included 91 PLWH (74% Latinx and 26% non-Latinx White; 68% Male) who completed the Test of Functional Health Literacy in Adults (TOFHLA), Physician–Patient Relationship Scale (PPRS), and Medical Outcomes Study-HIV Health Survey (MOS). The study variables included: TOFHLA total score, PPRS Part Decision- Making (PDM) and Trust subscales, and MOS Mental Health and Health Transition subscales.

Results

A linear regression showed that our model (ethnicity, TOFHLA, PPRS PDM and Trust) predicted MOS HT (R2 = .14, p < 0.05), such that Latinx ethnicity (β = .30) and better TOFHLA scores (β = -.22) predicted better MOS HT scores (ps < .05). Another regression showed that our model predicted MOS MH (R2 = 0.07, p = <.01), such that greater PPRS PDM scores predicted better MOS MH scores (β = .27, p = <.01).

Conclusions

Ethnicity and better health literacy were related to improved emotional/physical functioning over a 4-week period and greater shared decision-making was related to better overall mental health. These findings highlight the importance of identifying sociocultural factors and interpersonal processes of care to inform culturally-tailored interventions that can result in enhanced and effective treatment for PLWH patients and in improved physical and mental health outcomes.

A34 Molecular characterization of Zika virus in Cuba

Until now, three genotypes of Zika virus (ZIKV) have been detected (two African lineages and one Asian lineage). After the declaration of Public Health Emergency of International Concern issued by The Pan American Health Organization and the World Health Organization authors from some Latin American countries have identified the Asian genotype as the lineage responsible for the Zika epidemic in the western hemisphere. However, data from the Caribbean are sparse, and there is no published data regarding the genotypes that produced isolated outbreaks in Cuba. Aiming to realize the molecular characterization of ZIKV in Cuba, we will sequence by next-generation sequencing the full genome of the ZIKV identified in samples from Cuban patients of different provinces in which ZIKV produced outbreaks. All samples required for this study have been collected during the molecular surveillance of Arboviral diseases conducted at the National Reference Laboratory at Pedro Kourí Tropical Medicine Institute. Viral RNA will be purified from urine and serum samples collected from patients with confirmed ZIKV infection by real time PCR. Using evolutionary dynamics studies, we will map the spread of a virus or of particular variants in time and space in order to understand how frequently ZIKV has been introduced into Cuba. Moreover, we will evaluate the amino acid diversity of each ZIKV proteins. Further, we will evaluate the population dynamics of ZIKV in samples from patients with varying clinical outcomes. The results will allow us to characterize the ZIKV genome and its evolution into the Cuban population that would also have impact for vaccine development, diagnosis, and pathogenesis studies.

The role of frugivorous birds and bats in the colonization of cloud forest plant species in burned areas in western Mexico

The extension of montane cloud forests in western Mexico is threatened by several disturbances that limit their extension. In this study we aim to assess the contribution of birds and bats in the dispersal and colonization of cloud–forest plants in contiguous surface–burned pine forests. We sampled seed rain and sapling establishment over one year in two surface–burned sites, which differed in the size of their closest cloud forest patch. A total of 17 plant species were found, most of which were late–successional trees, shrubs and climbers. Distance influenced the seed rain of only one dispersed taxon (Solanum sp.) and had no effect on the sapling distribution of this or other plants. In turn, marked differences were found between sites, with more seeds dispersed and higher sapling density in the site that was next to the larger cloud forest patch. The role of long–distance dispersers and the existence of seed banks before fire could explain the little importance of distance from seed source on seed dispersal and sapling distribution. Nevertheless, dispersal by birds and bats before or after fire facilitates the regeneration and conservation of cloud forests in disturbed areas formerly occupied by other habitats.

Preparation of plasmid DNA-containing liposomes using a high-pressure homogenization–extrusion technique

High-pressure homogenization-extrusion (HPHE) is a method that can be used for downsizing large lipid vesicles with commercially available instrumentation (e.g., from Avestin Inc., Canada), which covers a full range of processing capacities from laboratory (0.5-3.5 mL) to large-scale continuous (1-1000 L/h) production. Consequently, the feasibility (at the laboratory scale) of using HPHE for producing DNA-loaded liposomes by the conventional dehydration-rehydration method was explored. HPHE-generated small unilamellar vesicles had a mean size in the range of 27-76 nm depending on the number of processing cycles and lipid (PC:DOPE:DOTAP or PC:DOPE:Ethyl-DOPC, 1:0.5:0.5, mol/mol) formulation. The size could be further regulated by the pore size (50 or 100 nm) of the extrusion membrane. Using plasmids for the V3 loop of HIV-1, and the capsid, E1 and E2 of hepatitis C, entrapment yields of 72-98.2% into dehydrated-rehydrated vesicles (DRV) were obtained over a wide range (0.309-2.5 mg) of DNA quantities. Most of the plasmid DNA was retained by liposomes even in the presence of sodium dodecyl sulfate (from 0.05% to 0.3%) and efficiently protected from nuclease-mediated degradation. Although the encapsulation process slightly decreased (in the range of 42.8-65.7%) the relative abundance of plasmid super coiled isoforms, the transfection efficiency of monkey kidney COS-7 cells with the plasmid DNA extracted from liposomes (9+/-0.4%) was similar to that of the non-treated DNA (8.7+/-0.2%), using the commercial SuperFect(R) Transfection Reagent. Also, it was found that an appreciable loss of lipid mass-either associated with the HPHE or the dehydration-rehydration steps-occurs during the liposome manufacturing process. These results at the bench scale are a useful reference for planning pilot or large-scale manufacture of DNA vaccine-containing liposomes.

Toxicity of a GM3 cancer vaccine in Macaca fascicularis monkey: a 12-month study

GM3 is a ganglioside that has been biochemically identified as dominating the cell surface of several human tumours, but is also found on human normal cells at much lower density. Since GM3 is widely distributed in essentially all types of animal cells, there is a conflict with the concepts of tumour-associated antigen, immunogen, and toxicity. We have designed a GM3-based cancer vaccine for the treatment of human breast and melanoma tumours. Prior to the Phase I clinical trial, we carried out a 12-month dose repeated toxicity study in five male Macaca fascicularis monkeys. Four male monkeys were treated with placebo in a similar way. During the study, no differences were observed between control and treated monkeys related to daily clinical observations (other than local damage) including rectal temperature, blood pressure, respiratory and cardiac rates, weight gain, biochemical and hematological parameters (with the exception of transitory pathological changes), and anti-DNA and anti-nuclear antibodies, although treated monkeys consistently developed both IgM- and IgG-specific anti-GM3 antibodies. Sixty per cent of treated monkeys developed moderate local reactions at the injection site, which disappeared without sequels. We concluded that this GM3 cancer vaccine overcame in monkeys the natural tolerance to GM3 ganglioside evidenced by a strong immune response, while the local reactions elicited-were transitory without apparent important systemic toxicity effects.

Comparative seven-day clinical evaluation of two tooth whitening products

A 1-week study was conducted to compare the tooth whitening efficacy of two carbamide peroxide-based products (one containing 5% carbamide peroxide and one containing 10% carbamide peroxide). In addition, the perception of transient tooth hypersensitivity associated with the use of these products was subjectively evaluated. Sixty participants took part in a double-blind, randomized, parallel clinical study. Change in tooth color was measured by chroma meter and Vita shade guide at the initiation of the study and after 7 days of product use. Color change (delta E) was calculated using the color-difference equation established by the Commission Internationale de L'Eclairage. Data concerning dental hypersensitivity was assessed by subjective panelist questionnaires administered after the day 7 recall examination. Results of the whitening data showed that there was no significant difference between the two products. After 1 week, the mean delta E for the product containing 5% carbamide peroxide was 4.43 +/- 1.89 and the mean delta E for the product containing 10% carbamide peroxide was 4.05 +/- 1.84. However, the subjective data collected on tooth hypersensitivity showed that the product containing 5% carbamide peroxide was associated with less discomfort. Of the group using the 5% carbamide peroxide product, 20% reported transient sensitivity of their teeth after product use for 1 week compared with 53% of the group using the product with 10% carbamide peroxide. Statistical analysis using a 2-tailed t test showed significant differences between the two groups (P < .05). The data suggest that these products are clinically equivalent for tooth whitening; however, the product containing 5% carbamide peroxide was associated with less tooth hypersensitivity after 1 week of application.

Radiotoxicity of h-R3 monoclonal antibody labeled with 188Re administered intracerebrally in rats

Brain tumors are often incurable despite current aggressive treatment modalities. Regional intracerebral administration of labeled monoclonal antibodies (Mabs) can maximize the radioisotope and Mab concentration to tumor sites while reducing systemic toxicity. h-R3 is a humanized antiepidermal growth factor receptor Mab that successfully targets the epidermal growth factor receptor, which is overexpressed in glioblastomas. We studied the acute local and systemic toxicity effects of intraventricular 188Re-h-R3 in rats. Forty rats were distributed into four groups with five animals of each sex in each group. A single 5 -microl dose (2.5 microl into the left and 2.5 microl into the right lateral ventricles) of neutral solution containing 50 microg of h- R3 labeled with 49.5 +/- 1.7,284 +/- 13.7 or 579 +/- 23.7 muCi of 188Re were stereotactically administered to each animal. Control animals received vehicle alone. Each animal was observed twice daily for detection of toxicity signs. Body weights were recorded on days 0, 7 and 14. Blood samples for analysis of hematological and clinical chemistry parameters were taken on days 0 and 14. Necropsy and histopathological studies were carried out after completion of the study. All animals, but one, remained clinically stable. Toxicities included local radionecrosis, discrete increase in ALAT and creatinine blood values at higher dose level. We concluded that a single intraventricular administration of relatively large doses of 188Re-h-R3 is tolerable and causes minimal local and systemic toxicity effects in rats. Nevertheless, further studies are necessary to discard learning and behavioral problems.

The effect of arcelin-1 on the structure of the midgut of bruchid larvae and immunolocalization of the arcelin protein

Some wild accessions of the common bean (Phaseolus vulgaris) contain a family of proteins called arcelins, that are toxic to the larvae of certain bruchid species. Among the six allelic variants of arcelin tested so far, arcelin-5 and arcelin-1 confer the highest level of resistance against the Mexican bean weevil, Zabrotes subfasciatus. The same proteins are not toxic to the bean weevil, Acanthoscelides obtectus, which is also a serious pest of cultivated beans. Arcelins belong to the bean lectin family that includes phytohemaggutinins and alpha-amylase inhibitors. Although homologous to lectins, arcelins are themselves only very weak lectins, and their binding properties have not been clearly established. The toxic properties of arcelins may be related to their recognition of and interaction with the glycoproteins and other constituents of the membranes along the digestive tract of insects. Since arcelin-1 was shown to have growth inhibitory effects for the larvae of Z. subfasciatus but not of A. obtectus, we examined the effect of an arcelin-1 containing diet on the structure of the cells that line the intestinal tract of the larvae of these two bruchid species, and used antibodies against arcelin to examine the distribution of arcelin within the cells and tissues. Here we show that dietary arcelin-1 caused an alteration of the gut structure and the penetration of arcelin into the haemolymph in Z. subfasciatus but not in A. obtectus. These results lead us to suggest that arcelins exert their toxic effect by severely damaging the epithelial cells.

Different frequency of gene targeting events by the RNA-DNA oligonucleotide among epithelial cells

A unique hybrid oligonucleotide composed of both RNA and DNA has been shown to correct a point mutation in a site-specific and inheritable manner in extrachromosomal and chromosomal targets. In order to develop new gene therapeutics for skin, we tested two oligonucleotides that were shown to create a point mutation in alkaline phosphatase and beta-globin genes in several epithelial cell types. Highly transformed epithelial cells (HeLa) exhibited a conversion frequency of 5% by both RNA-DNA oligonucleotides. In comparison, other immortalized epithelial cells (HaCaT) or human primary keratinocytes did not show any detectable level of gene conversion by the restriction fragment length polymorphism analysis, indicating less than 1% conversion frequency. The concentration of the oligonucleotide in the nuclei of HeLa cells was similar to that of HaCaT or human primary keratinocytes measured by a radiolabeled or a fluorescein-conjugated oligonucleotide. Moreover, the RNA-DNA oligonucleotide exhibited a prolonged stability in the nucleus. Thus, neither uptake nor nuclear stability of the oligonucleotide appears to be a limiting factor in gene targeting events under our experimental conditions. These results indicate that the frequency of gene targeting varies among different cells, suggesting that cellular recombination and DNA repair activities may be important.

[Follow-up serological study of herpes simplex and cytomegalovirus in Cuban patients infected with human immunodeficiency virus (HIV)]

The evolution serological response against the herpes simplex virus and citomegalovirus in HIV infected patients grouped into different stages of the disease was studied. Fluctuations in the TPG of antibodies were observed in these values in a cyclical way through time. There was a greater significant difference among the TPG of antibodies against HSV in the group of asymptomatic patients compared with AIDS patients and with those who died. There is a marked decrease in the TPG of antibodies against HSV and CMV approximately one year before the death of patients.

[Clinical characterization of patients with multiple sclerosis defined in Cuba]

INTRODUCTION

Since 1975 no studies have been done in Cuba defining the clinical characteristics of patients with multiple sclerosis (MS).

OBJECTIVE

To describe the characteristics of a group of Cuban patients with definite clinical MS.

MATERIAL AND METHODS

Fifty eight patients with definite clinical MS were studied (Poser et al) with normal motor (VCM) and sensory (VCS) conduction velocities. Tests were done on them: clinical scale (Scripps), incapacity (EDSS) and quality of life (Steps), together with various complementary tests. Each patient was classified according to the way in which the disease evolved. Also the two commonest clinical types were compared and we applied the difference test between percentages of non-paired samples with an alfa level of 0.05.

RESULTS

Onset of the illness in most cases was before the age of 40 (86.1%), 75.9% were women and 82.8% were white. In 15.3% there was a family history of MS. In 25.9% there were psychiatric disorders and trigger factors (43.1%. The most frequent initial symptoms were pyramidal (48.3%) sensorial (41.4%) and cerebellar (39.7%). Scripps scale scores were < 80 in 60.2%, in EDSS < 5 (61.9%) and in the Clinical Steps < 3 in 65.4%). Motor potentials (81.9%) somatosensory potential (PESS) (72.3%) and magnetic resonance imaging (MR) (76.4%) were the most abnormal results. Exacerbation-remission (ER) was the most frequent type of evolution (53.4%) generally affecting patients aged under 40 years old (p = 0.02), EDSS < 5 (64.4%), Scripps > 80 (61.2%), Steps < 3 (95.6%), pyramidal system involvement (58.5%), cerebellar (29.2%) and MRI abnormality (80%). The progressive primary form (PP) was the second most frequent (29.3%); 29.4% were under 40 years of age, had more marked changes in all functional system (100%), degree of incapacity and quality of life (100%). PESS (92.5%); the urodynamic tests 58.85%) were less positive on MRI (54.5%) as compared with the ER form.

CONCLUSIONS

The differences found between the clinical forms ER and II indicate that there is greater deterioration in the PP form, probably due to age and more cerebellar and spinal cord involvement.

Electron Microscopic Study of Intrastromal Hydrogel Implants in Primates

Three corneas with intrastromal hydrogel implants (surfilcon A) were removed from Green monkey eyes by penetrating keratoplasty and examined by light microscopy, as well as scanning and transmission electron microscopy, in order to assess the tolerance of the primate cornea for this type of synthetic plastic. Placement of these implants in the posterior cornea appears to increase the amount of protrusion into the anterior chamber, which can also be seen clinically on slit-lamp biomicroscopy. Some physiological stress to the cornea was indicated by abnormalities above and below the implant, including thinned epithelium, irregular cell shapes, and vacuolations. It appears that a basement-membrane-like material is produced by keratocytes adjacent to the implant-stroma interface, and that this material fills the spaces and provides some physical continuity between the plastic and the corneal tissue. No inflammatory reaction was seen around the implants, but further long-term studies are necessary to ensure compatibility between the cornea and the implant.

A primate model of human corneal transplantation

Human donor corneas were used for penetrating keratoplasty in one eye of each of 12 rhesus monkeys. In six animals, a 9.5-mm cornea was sutured into a 9.0-mm recipient bed by means of interrupted 10-0 nylon sutures. Six other animals received a 6.5-mm cornea in a 6.0-mm bed. Biomicroscopy, pachymetry, and specular microscopy revealed two distinct healing patterns. Of the six eyes receiving the smaller grafts, five showed prompt, stable clearing and thinning of the grafts with endothelial cell densities ranging from 850 to 1600 cells/mm2 Two of the six animals receiving larger grafts developed fibrinous reactions in the immediate postoperative period, and the grafts never cleared. Three showed a satisfactory early course, but after 10-16 days, developed endothelial keratic precipitates, anterior chamber reaction, and progressive graft edema. The sixth graft remained technically satisfactory 1 year later. This study indicates that the application of small human donor grafts in monkey eyes can provide a useful, clinical model for the future exploration of the response of human corneal transplants to materials such as epidermal growth factor and for the study of surgical manipulation of postkeratoplasty astigmatism.

Neuro-ophthalmological study of late yaws and pinta. II. The Caracas project

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