Development of a Low-Cost Gastroscope Prototype (GP) for Potential Cost-Effective Gastric Cancer Screening in Prevalent Regions

Background Screening for gastric cancer is known to be associated with reduced mortality in populations with high prevalence. However, many countries with high prevalence do not screen, with high costs being a significant reason for this.

Aims To describe, develop, and assess the potential for a low-cost gastroscope for early cancer screening and patient risk stratification.

Methods Our interdisciplinary team used both off-the-shelf and fabricated components to create multiple gastroscope prototypes (GP) in iterative fashion based off clinician feedback. Clinician endoscopists were surveyed using Likert scales regarding device potential, video quality, and handling when testing on a GI training device. Video quality comparison to clinically standard high-definition white light endoscopy (HD-WLE) was done using the absolute categorical ratings (ACR) method.

Results A candidate cost-effective GP with clinical potential was developed. Although initial versions were scored as inferior via ACR on all views tested when compared to HD-WLE (p < 0.001), participants agreed the concept may be beneficial (M = 4.52/5, SD = 0.72). In testing improved versions, participants agreed the device had the ability to identify discrete (M = 4.62/5, SD = 0.51) and subtle lesions (M = 4/5, SD = 0.7) but most felt video quality, although improved, was still less than HD-WLE. Sufficiency of maneuverability of device to visualize gastric views was rated as equivocal (M = 2.69/5, SD = 1.25). Conclusion The presented low-cost gastroscopic devices have potential for clinical application. With further device development and refinement including the possible addition of technologies in telemedicine and artificial intelligence, we hope the GP can help expand gastric cancer screening for populations in need.

Therapeutic Impact of Deep Balloon-assisted Small Bowel Enteroscopy on Red Blood Cell Transfusion

Objective Evaluate impact of balloon-assisted deep small bowel enteroscopy on red blood cell transfusion requirement in patients with obscure gastrointestinal (GI) bleeding.

Methods Retrospective study of patients, who underwent balloon-assisted deep enteroscopy with double-balloon enteroscopy (DBE) at two tertiary care academic centers (University of Wisconsin and Aurora St. Luke’s Medical Center) over a 55-month consecutive period. Sixty-nine patients with reliable blood transfusion records were identified during this time period. DBE was preceded by small bowel capsule endoscopy (CE) within 1 year in 38 cases. Transfusion requirements 6 months prior and postintervention were measured to see if DBE had any impact on the need for blood transfusions.

Results Sixty-nine patients (25 females and 44 males) were included. Mean age ± standard deviation (SD) was 63 ± 17 years. Wilcoxon signed rank test statistics were used to find the difference in the rate of blood transfusion. There was a statistically significant decrease in rate of packed red blood cell (pRBC) transfusion post DBE and endoscopic therapy with coagulation (p < 0.001). Argon plasma coagulation was used to ablate all arteriovenous malformations (AVMs) except in one (subepithelial lesion). Those that required > 5 units pRBC transfusions pre-DBE had the most benefit.

Conclusions Our study demonstrates that transfusion requirements are significantly reduced in those undergoing therapy with DBE and coagulation for obscure GI bleed.

A tertiary care hospital's 10 years' experience with rectal ultrasound in early rectal cancer

Background and Objectives:

Rectal endoscopic ultrasound (RUS) has become an essential tool in the management of rectal adenocarcinoma because of the ability to accurately stage lesions. The aim of this study was to identify the staging agreement of early RUS-staged rectal adenocarcinoma with surgical resected pathology and ultimately determine how this impacts the management of early rectal cancer (T1–T2).

Methods:

Retrospective chart review was performed from November 2002 to November 2013 to identify procedure indication, RUS staging data, surgical management, and postoperative surgical pathology data.

Results:

There were a total of 693 RUS examinations available for review and 282 of these were performed for a new diagnosis of rectal adenocarcinoma. There was staging agreement between RUS and surgical pathology in 19 out of 20 (95%) RUS-staged T1 cases. There was staging agreement between RUS and surgical pathology in 3 out of 9 (33%) RUS-staged T2 cases. There was significantly better staging agreement for RUS-staged T1 lesions compared to RUS staged T2 lesions (P = 0.002). Nearly 60% of T1N0 cancers were referred for transanal excisions (TAEs), and 78% of T2N0 cancers underwent low anterior resection.

Conclusions:

This study identified only a small number of T1–T2 adenocarcinomas. There was good staging agreement between RUS and surgical pathology among RUS-staged T1 lesions whereas poor staging agreement among RUS-staged T2 lesions. Although TAE is largely indicated by the staging of a T1 lesion, this approach may be less appropriate for T2 lesions due to high reported local recurrence.

Differentiating primary pancreatic lymphoma from adenocarcinoma using endoscopic ultrasound characteristics and flow cytometry: A case-control study

Background:

Primary pancreatic lymphoma (PPL) is a rare pancreatic neoplasm that is difficult to diagnose. PPL has a vastly different prognosis and treatment regimen than other pancreatic tumors; therefore, accurate diagnosis is vital. In this article, we describe the characteristic presentation, endoscopic ultrasound (EUS) features, and the role of fine-needle aspiration (FNA) in the diagnosis of PPL compared with pancreatic adenocarcinoma.

Materials and Methods:

This was a retrospective case-control study of 11 patients diagnosed with PPL via EUS between 2002 and 2011. The clinical and EUS features of the cases were then compared with age-matched controls with adenocarcinoma in a 1:3 ratio.

Results:

There were 11 patients with PPL and 33 with adenocarcinoma. At last follow-up, 7 of 11 PPL patients were alive, and 3 of 33-adenocarcinoma patients were alive (P < 0.001). The most common presenting symptoms for PPL were pain 73%, weight loss 45%, and jaundice 18%, while patients with adenocarcinoma presented with pain 52% (P = 0.3), weight loss 30% (P = 0.47) and jaundice 76% (P = 0.001). The EUS appearance was similar in the two groups in that ultrasound imaging of the pancreas lesions tended to be hypoechoic and heterogenous, but the PPL group was more likely to have peripancreatic lymphadenopathy (LAD) (64% vs. 18%, P = 0.008) and were larger (4.8 cm × 5.3 cm vs. 3.2 cm × 3.1 cm, P < 0.001). The PPL group was less likely to have vascular invasion (18% vs. 55%, P = 0.045) and less likely to be found in the head of the pancreas (36% vs. 85%, P = 0.004). FNA and cytology (without flow cytometry [FC]) made the diagnosis in 28% of PPL patients compared with 91% of adenocarcinoma patients (P = 0.002). In the PPL group, 7 of 11 FNA samples were sent for FC. If FC was added, then the diagnosis of PPL was increased to 100%.

Conclusions:

Compared with adenocarcinoma, pancreatic lymphoma has a better prognosis, is less likely to present with jaundice and less likely to have vascular invasion. PPL is more likely to be located outside the head of the pancreas and to include peripancreatic LAD, and is less likely to be diagnosed with cytology. The diagnostic accuracy of FNA for PPL is improved greatly with the addition of FC.

Fiscal analysis of establishment of a double-balloon enteroscopy program and reimbursement

BACKGROUND & AIMS

As double-balloon enteroscopy (DBE) programs continue to be established, further research is needed to assess their financial impact. We evaluated actual financial outcomes and compared them with estimated return on investment (ROI) projections for DBE.

METHODS

We retrospectively compared the predicted and actual financial results for outpatients referred for DBE at an academic tertiary referral center.

RESULTS

The ROI analysis was based on a 5-year time frame. The analysis projected a net present value of $64,623 and an internal rate of return of 24.6%. The projected first-year volume was 52 outpatient cases; however, the actual experience was 20 outpatient cases. The predicted percent margin for these outpatient cases was 16.6%; the actual margin was 24.4%. After 37 months, 52 outpatient cases were completed, and the actual percent margin was 4.6%. Payer type had a significant influence on the financial outcomes when projected activity and actual activity were compared.

CONCLUSIONS

Institutions interested in establishing a DBE program should be aware of the financial implications of program establishment, which can be evaluated in a return on investment analysis. Payer mix significantly influences DBE reimbursement and collection rates.

EUS and ERCP complication rates are not increased in elderly patients

BACKGROUND

Further studies evaluating the safety of advanced endoscopic procedures in elderly patients are needed.

AIM

To evaluate the safety of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) in the elderly.

METHODS

The study population, consisting of 1,000 patients who underwent ERCP or EUS, was divided into two cohorts. The elderly cohort consisted of patients ≥ 75 years old. The nonelderly cohort consisted of patients <75 years old. The data collected included demographic information, type of procedure completed, procedure medication used, and endoscopic intervention performed. Complications included any event which occurred during the procedure or up to 1 month post procedure.

RESULTS

A total of 600 ERCPs and 400 EUS were included. The mean age of the elderly cohort was 80 years (range 75-95 years, n = 184) versus 54 years (range 13-74 years, n = 816) for the nonelderly cohort. The ERCP complication rate was 10.0% in the elderly versus 10.6% (P = 1.0) for the nonelderly. The EUS complication rate was 4.8% in the elderly versus 3.1% in the nonelderly (P = 0.49). The overall complication rates were identical at 7.6% (P = 1.0). Sedation doses were lower for the elderly cohort (P < 0.001). There was a higher rate of procedure bleeding in the elderly cohort (P = 0.016).

CONCLUSION

Advanced age is not a contraindication for advanced endoscopic procedures. There is no significant increase in the rate of overall procedure-related complications seen with either ERCP or EUS in elderly patients; however, elderly patients have a higher risk of bleeding. Less procedure-related sedation medication is required for elderly patients.

Variation in colonoscopic technique and adenoma detection rates at an academic gastroenterology unit

The purpose of this research is to evaluate the quality of colonoscopy at an academic institution with a focus on factors influencing withdrawal times and adenoma detection rates. Procedural data and pathologic results of 550 consecutive screening colonoscopies in average risks patients (mean [+/-SD] age, 57 +/- 7.6, 44% male) completed by ten academic gastroenterologists were reviewed. Per individual gastroenterologist, the adenoma detection rates ranged widely from 0.09 to 0.82 adenomas per patient with a mean of 0.46 for the group. The mean withdrawal time was 7.0 min for the group and ranged from 3.4 to 9.6 min. There was a significant positive relationship between the number of adenomas detected and the withdrawal time (P = 0.006). Endoscopists with cecal intubation time to withdrawal time ratios of less than 1 detected significantly more adenomas compared to endoscopists with ratios greater than 1 (P = 0.001). (1) Significant variation in academic gastroenterologists' abilities to detect adenomas during screening colonoscopies exists. (2) Colonoscopic withdrawal time and the cecal intubation to withdrawal time ratio are important factors associated with increased adenoma detection rates.

Lactation curves of commercial ewes rearing lambs

Three-hour milk production measurements determined by machine milking at 3-d intervals throughout a 63-d lactation period were used to describe lactation curves for crossbred ewes lambing at 1 and 2 yr of age and rearing single and twin lambs. Age of ewe, type of rearing, and day of lactation affected (P < 0.05) milk production. Over the 63-d lactation, average daily milk production was 2.56 and 2.63 kg, respectively, for 1- and 2-yr-old ewes rearing single lambs and 2.73 and 3.47 kg, respectively, for 1- and 2-yr-old ewes rearing twins. Milk production of 2-yr-old ewes rearing twin lambs peaked at 21 d of lactation, and that of 1- and 2-yr-old ewes rearing singles peaked between 27 and 30 d of lactation. The largest differences in the lactation curves among age and rearing ewe classes were found in early lactation. These differences were reduced by midlactation, and by late lactation, milk production for all ewes was similar. Diurnal variation in milk production by ewes was evaluated in an 8 x 8 Latin square design. Diurnal variation in milk yield measurements of eight mature ewes, each bearing and rearing twin lambs, was similar between d 21 and 24 of lactation. Time of milk production measurements within a day did not affect yield determinations. Extrapolation from 3-h production estimates to daily milk production is valid in determining a ewe's milk contribution in support of lamb growth.

Grazing methods and stocking rates for direct-seeded alfalfa pastures: I. Plant productivity and animal performance

A 4-yr study was conducted to determine the effects of two grazing methods (GM) at two stocking rates (SR) on alfalfa pasture plant productivity and animal performance and to ascertain the effect of grazing systems on subsequent performance of steers fed a high-concentrate diet. Eight pasture plots (.76 ha) were seeded in 1988 with alfalfa (Medicago sativa L. var. WL225) and divided into two blocks of four pastures each. Grazing methods consisted of a traditional four-paddock or an intensive 13-paddock system. Pastures were managed to allow a 36-d rest period with an average grazing season of 110 d. The low and high SR were 5.9 vs 11.7, 5.3 vs 10.5, 5.3 vs 7.9, and 5.3 vs 7.9 steers/ha for years 1989 to 1992, respectively. Following the grazing season, steers were placed in a feedlot and fed a high-concentrate diet (81% high-moisture corn, 14% corn silage, 5% protein-mineral supplement) for an average of 211 d. There was no effect of GM on herbage mass, pasture phase ADG, or live weight gain/hectare. Increasing the number of paddocks was beneficial when herbage mass was limited and stocking rate was above 7.9 steers/ha. Increasing SR above 7.9 steers/ha decreased herbage mass and pasture-phase ADG. As forage allowance increased, pasture-phase ADG increased quadratically (R2 = .82, P < .001), reached a plateau, and then decreased. Previous grazing system did not influence the performance of steers in the feedlot or their carcass characteristics. Optimum SR is dependent on herbage mass produced.

Grazing methods and stocking rates for direct-seeded alfalfa pastures: II. Pasture quality and diet selection

A 2-yr study was conducted to determine the effects of two grazing methods (GM) and two stocking rates (SR) on alfalfa (Medicago sativa L. var. WL225) pasture quality and diet selection by Holstein steers. Eight pasture plots (.76 ha) were seeded in 1988 and divided into two blocks of four pastures each. Pastures were managed to allow a 36-d rest period with an average grazing season of 105 d. Before steers entered the next paddock, canopy heights (CH) of alfalfa plants were determined and pasture-forage samples were collected. Forage samples were analyzed for DM, OM, CP, and in vitro OM digestibility (IVOMD). At 12-d intervals beginning with the second grazing cycle, extrusa samples were collected from steers with esophageal fistulas. Extrusa samples were frozen, freeze-dried, and analyzed for OM, CP, IVOMD, in situ ruminal DM degradation, and ruminal undegradable protein. There were no effects of GM on alfalfa CH or pasture DM, OM, CP, and IVOMD. Increasing the SR increased pasture CP content in both years and increased DM, OM, and IVOMD in the 2nd yr. There was no effect of GM or SR on the quality of forage selected by esophageally fistulated steers. Esophageally fistulated steers selected forage that had greater OM, CP, and IVOMD than the average nutrient content of the forage. Although forage quality was greater when stocking rates were increased, the quantity of forage available per animal may have limited gains.

Social status regulates growth rate: consequences for life-history strategies

The life-history strategies of organisms are sculpted over evolutionary time by the relative prospects of present and future reproductive success. As a consequence, animals of many species show flexible behavioral responses to environmental and social change. Here we show that disruption of the habitat of a colony of African cichlid fish, Haplochromis burtoni (Günther) caused males to switch social status more frequently than animals kept in a stable environment. H. burtoni males can be either reproductively active, guarding a territory, or reproductively inactive (nonterritorial). Although on average 25-50% of the males are territorial in both the stable and unstable environments, during the 20-week study, nearly two-thirds of the animals became territorial for at least 1 week. Moreover, many fish changed social status several times. Surprisingly, the induced changes in social status caused changes in somatic growth. Nonterritorial males and animals ascending in social rank showed an increased growth rate whereas territorial males and animals descending in social rank slowed their growth rate or even shrank. Similar behavioral and physiological changes are caused by social change in animals kept in stable environmental conditions, although at a lower rate. This suggests that differential growth, in interaction with environmental conditions, is a central mechanism underlying the changes in social status. Such reversible phenotypic plasticity in a crucial life-history trait may have evolved to enable animals to shift resources from reproduction to growth or vice versa, depending on present and future reproductive prospects.

Comparison of weigh-suckle-weigh and machine milking for measuring ewe milk production

Thirteen crossbred ewes were used to compare weigh-suckle-weigh (WSW) and machine milking (MM) methods for determining milk production of ewes that were rearing single or twin lambs. At parturition, ewes were 13 mo of age and produced six single lambs and seven pairs of twin lambs. Milk production estimates were initiated on d 6 of lactation and a 3-d rotation of the two techniques was implemented. On d 6, milk production was measured using WSW; on d 7, MM was used. No measurement was made on d 8. The 3-d rotation was repeated 20 times throughout a 63-d lactation, resulting in 20 point estimates of milk production for each method of measurement for each ewe. The WSW procedure consisted of a 3-h period in which lambs were withheld from suckling their dams. This was followed by a suckling period, a second 3-h withholding period, and a second suckling period. Differences in pre- and postsuckling lamb weights of the second suckling period were defined as milk consumption and, indirectly, 3-h milk production. The MM procedure included an administration of 10 IU of oxytocin (i.v.), followed by evacuation of the udder with a machine using commercially available sheep milking equipment, and the milk was discarded. Lambs were withheld from suckling the ewes for a 3-h period, followed by a repetition of the oxytocin and machine milking procedures. Milk from the second milking was weighed. Milk production estimates determined using the WSW and MM techniques were similar (P = .42). Average 3-h milk production was 340 and 351 g for WSW and MM, respectively. Machine milking provides a reliable tool in evaluating the milk-producing ability of ewes that are rearing single or twin lambs.

Occurrence and range of dicumarol concentrations in sweet clover

The dicumarol concentration in 272 cured sweet clover samples from 4 counties in North Dakota was determined. Dicumarol concentrations ranged from 0 to 164.7 mg/kg of sweet clover, with 64.6% of the 272 samples containing less than 10 mg/kg. Round bales were significantly (P less than 0.05) higher in dicumarol concentration (mean of 22.9 +/- 3.10 mg/kg) than were stacks or silage (means of 1.8 +/- -6.3 mg/kg and 0.6 +/- 2.1 mg/kg, respectively). The outer section of core samples taken from round bales contained significantly (P less than 0.0021) higher concentrations of dicumarol than did the inner section of the core, with means of 30.8 mg/kg and 16.6 mg/kg, respectively. A significant (P less than 0.0001) correlation existed between crude protein and dicumarol values (r = 0.44).