Neurodevelopmental outcome in complicated twin pregnancy: prospective observational study

OBJECTIVE

Twin pregnancy is associated with increased perinatal mortality and morbidity, but long-term neurodevelopmental outcome remains underinvestigated. The primary objective of this study was to investigate the incidence of adverse neurodevelopment after 1 year of age in complicated monochorionic diamniotic (MCDA) twin pregnancies compared with uncomplicated twin pregnancies.

METHODS

This was a prospective cohort study conducted at St George's University Hospital NHS Foundation Trust, London, UK. Women with a twin pregnancy culminating in at least one surviving child, aged between 12 and 60 months (corrected for prematurity) at the time of assessment, were invited to complete the relevant Ages and Stages Questionnaire® version 3 (ASQ-3) test. The two study groups were: (1) complicated MCDA twin pregnancies, including those with twin-twin transfusion syndrome, twin anemia-polycythemia sequence, selective fetal growth restriction, twin reversed arterial perfusion sequence and/or single intrauterine demise; and (2) uncomplicated MCDA and dichorionic diamniotic twin pregnancies. The primary outcome measure was an abnormal ASQ-3 score, defined as a score of more than 2 SD below the mean in any one of the five domains. Mixed-effects multivariable logistic regression analysis was performed to determine whether a complicated MCDA twin pregnancy was associated independently with an abnormal ASQ-3 score.

RESULTS

The study included 174 parents who completed the questionnaire for one or both twins; therefore, 327 ASQ-3 questionnaires were available for analysis. Of those, 117 (35.8%) were complicated MCDA twin pregnancies and 210 (64.2%) were controls. The overall rate of an abnormal ASQ-3 score in children born of a complicated MCDA twin pregnancy was nearly double that of those from uncomplicated twin pregnancies (14.5% vs 7.6%; P = 0.056). Children born of a complicated MCDA twin pregnancy had a significantly higher rate of impairment in the gross-motor domain compared with the control group (8.5% vs 2.9%; P = 0.031). Complicated MCDA twin pregnancies that underwent prenatal intervention had a significantly higher rate of abnormal ASQ-3 score compared with those that did not undergo prenatal intervention (28.1% vs 1.7%; P < 0.001). On multilevel logistic regression analysis, complicated MCDA twin pregnancy was an independent predictor of abnormal ASQ-3 score (adjusted odds ratio, 3.28 (95% CI, 3.27-3.29); P < 0.001).

CONCLUSIONS

This study demonstrates that survivors of complicated MCDA twin pregnancies have a higher rate of adverse neurodevelopmental outcome, independently of prematurity. Long-term neurodevelopmental follow-up in these pregnancies can ensure timely and optimal management of those affected. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Rationalising the use of specimen pots following colorectal polypectomy: a small step towards greener endoscopy

Aims

In this study, we aim to determine whether combining multiple small colorectal polyps within a single specimen pot can reduce carbon footprint, without an associated deleterious clinical impact.

Methods

This was a retrospective observational study of colorectal polyps resected during 2019, within the Imperial College Healthcare Trust. The numbers of pots for polypectomy specimens were calculated and corresponding histology results were extracted. We modelled the potential reduction in carbon footprint if all less than 10 mm polyps were sent together and the number of advanced lesions we would not be able to locate if we adopted this strategy. Carbon footprint was estimated based on previous study using a life-cycle assessment, at 0.28 kgCO2e per pot.

Results

A total of 11 781 lower gastrointestinal endoscopies were performed. There were 5125 polyps removed and 4192 pots used, equating to a carbon footprint of 1174 kgCO2e. There were 4563 (89%) polyps measuring 0-10 mm. 6 (0.1%) of these polyps were cancers, while 12 (0.2%) demonstrated high-grade dysplasia. If we combined all small polyps in a single pot, total pot usage could be reduced by one-third (n=2779).

Conclusion

A change in practice by placing small polyps collectively in one pot would have resulted in reduction in carbon footprint equivalent to 396 kgCO2e (emissions from 982 miles driven by an average passenger car). The reduction in carbon footprint from judicious use of specimen pots would be amplified with a change in practice on a national level.

Key research questions for implementation of artificial intelligence in capsule endoscopy

BACKGROUND

Artificial intelligence (AI) is rapidly infiltrating multiple areas in medicine, with gastrointestinal endoscopy paving the way in both research and clinical applications. Multiple challenges associated with the incorporation of AI in endoscopy are being addressed in recent consensus documents.

OBJECTIVES

In the current paper, we aimed to map future challenges and areas of research for the incorporation of AI in capsule endoscopy (CE) practice.

DESIGN

Modified three-round Delphi consensus online survey.

METHODS

The study design was based on a modified three-round Delphi consensus online survey distributed to a group of CE and AI experts. Round one aimed to map out key research statements and challenges for the implementation of AI in CE. All queries addressing the same questions were merged into a single issue. The second round aimed to rank all generated questions during round one and to identify the top-ranked statements with the highest total score. Finally, the third round aimed to redistribute and rescore the top-ranked statements.

RESULTS

Twenty-one (16 gastroenterologists and 5 data scientists) experts participated in the survey. In the first round, 48 statements divided into seven themes were generated. After scoring all statements and rescoring the top 12, the question of AI use for identification and grading of small bowel pathologies was scored the highest (mean score 9.15), correlation of AI and human expert reading-second (9.05), and real-life feasibility-third (9.0).

CONCLUSION

In summary, our current study points out a roadmap for future challenges and research areas on our way to fully incorporating AI in CE reading.

Narrow-band imaging for the diagnosis of nonerosive reflux disease: an international, multicenter, randomized controlled trial

BACKGROUND AND AIMS

We examined the accuracy of narrow-band imaging (NBI) findings in nonerosive reflux disease (NERD) patients compared with control subjects and the impact of proton pump inhibitor (PPI) therapy on these mucosal changes in a multicenter, double-blind, randomized controlled trial.

METHODS

NERD patients (typical symptoms using a validated GERD questionnaire, absence of erosive esophagitis, and abnormal 48-hour pH study) and control subjects underwent high-definition white-light endoscopy followed by NBI and biopsy sampling of the distal esophagus. Then, NERD patients were randomized to esomeprazole 40 mg/day or placebo for 8 weeks, followed by repeat endoscopy. The presence of distal esophageal mucosal changes on NBI were recorded at baseline and after treatment: intrapapillary capillary loops (IPCLs; number, dilation, and tortuosity), microerosions, increased vascularity, columnar islands, and ridge/villous pattern (RVP) above the squamocolumnar junction.

RESULTS

Of 122 screened, 21 NERD and 21 control subjects were identified (mean age, 49.5 ± 14.6 years; 62% men; and 85% white). The combination of IPCL tortuosity, RVP, and microerosions (62% vs 19%, P < .05) had a high specificity (86%) and moderate sensitivity (60%) for NERD with an area under the curve of .74. In 10 NERD patients treated with PPIs, resolution of microerosions was most significant (P = .047) compared with placebo (n = 11). RVP resolved in all NERD patients after therapy (P = .02) and correlated with acid exposure time (P = .004). Papillary length (P = .02) and basal cell thickness (P = .02) significantly correlated with a combination of IPCL tortuosity, RVP, and microerosions.

CONCLUSIONS

In this randomized controlled trial, RVP on NBI demonstrated a high specificity, correlated with acid exposure time, and improved with PPI therapy, suggesting that it could be used as a surrogate marker for diagnosis of NERD. (Clinical trial registration number: NCT02081404.).

Polyps seen but not removed during index colonoscopy: an underestimated inefficiency in endoscopy practice

BACKGROUND AND AIMS

In the United Kingdom endoscopists are certified for independent practice once competent in the removal of polyps up to 20 mm in size. Where polyps are detected but not removed during the index colonoscopy, a repeat procedure is required. The aim of this study was to identify the proportion of polyps <20 mm that were not removed at the time of diagnosis.

METHODS

Polyps identified at colonoscopy during a 12-month period in a single institution were included in this study. All polyps were categorized according to the reported size and complexity per the size, morphology, site, access (SMSA) classification. In cases where polyps ≤20 mm were not removed, patient records and endoscopy reports were interrogated to ascertain the reasons for this.

RESULTS

Across 1444 patients, 2442 polyps <20 mm in size were diagnosed. Removal at the time of the index procedure occurred in 1158 patients (80.2%). Nonremoval for a predefined acceptable reason, such as concomitant anticoagulation therapy, accounted for 174 cases (12.0%). Nonremoval without contraindication was noted in 112 cases (7.8%). The mean polypectomy complexity as determined by the SMSA score of these polyps was lower than level 2, denoting low complexity. The requirement for unnecessary repeat procedures equated to 9.3 days of endoscopy capacity per year.

CONCLUSIONS

This study demonstrates that a small but significant proportion of small colorectal polyps are not removed at the time of diagnosis. This practice has implications for both patients and service provision.

POS1573-PARE Patient-Reported Outcome Measures of Pain Alleviation With Cannabinoid Usage in Rheumatoid and Psoriatic Arthritis: a Cross-Sectional Study

Background

Patient-Reported Outcome Measures (PROMs) give us direct, immediate evidence of patient experience. Pain is a chronic, debilitating, multifactorial, presenting symptom that remains a difficult target to treat in populations with Inflammatory Arthritides.1 Increasingly, cannabis products are being utilized and investigated for their potential analgesic and immune-modulatory effects.2 The legislation and form of cannabis products deployed as therapy varies around the world and across populations. More data on usage and patient reported outcomes is needed to guide better clinical practice and inform sound legislative policy.

Objectives

To describe PROMs of pain, stiffness with cannabis use in a population of patients with Rheumatoid Arthritis (RA) or Psoriatic Arthritis (PsA).

Methods

This investigation was a monocentric, cross-sectional study. Inclusion criteria were adults receiving care at a University Rheumatology practice in Central Florida, USA from December 2019 to March 2020 who provided informed, written consent. Those who consented were provided with a brief, voluntary, and anonymous Qualtrics survey which queried patient-reported prevalence and outcome measures of short and long-term pain relief. 236 RA and 43 PsA patients were enrolled in this study. All subjects met the criteria for Rheumatoid, Psoriatic, or Inflammatory Arthritis (seronegative RA). Subjects’ scores before and after cannabinoid use were compared with a paired T-test after the parametric nature of the data was established. Ethical approval was obtained from the University of Central Florida Institutional Review Board (Study00001041).

Results

Cannabis product usage was reported in 16.95% of RA subjects (40/236) and 11.63% of PsA subjects (5/43). Of this group, 71% (RA) and 40% (PsA) endorsed current usage. Inhalation was the most prevalent form used in RA (27.50%). In PsA, the most commonly reported forms were liquid (30%) and topical/skin (30%). On the 10-point pain scale, RA patients reported a significant reduction in average pain by 1.83±1.91 points in the long-term and 2.28±2.10 points in the short-term. Those with PsA reported a significant reduction in average pain by 1.60±0.89 points in the long-term and 1.80±0.84 points in the short term. Stiffness was also reduced in the RA group (7.3%). 17.5% of patients with RA using cannabinoids reported side effects not leading to cessation.

Conclusion

In an academic rheumatology practice population, a substantial number of RA and PsA patients are choosing to self-treat with cannabis therapy to manage their pain and other symptoms. Subjects reported significant reductions in both short- and long-term pain; some patients reported total pain resolution with ongoing cannabinoid therapy. Stiffness was also reduced in a subset of RA patients. Subjects that reported adverse effects did not find these severe enough to warrant cessation. These study results may allow for a more open discussion to improve safety and optimize outcomes. Additionally, the significant prevalence of usage and pain reduction reported provide a compelling rationale for further interventional studies in populations with Inflammatory Arthritides.

References

[1]Scott DL, Wolfe F, Huizinga TW. Rheumatoid arthritis. Lancet. 2010;376(9746): 1094-1108. doi: 10.1016/s0140-6736(10)60826-4.

[2]Fitzcharles, Mary-Ann et al. “Position Statement: A Pragmatic Approach for Medical Cannabis and Patients with Rheumatic Diseases.” The Journal of Rheumatology vol. 46,5 (2019): 532-538. doi:10.3899/jrheum.181120.

Disclosure of Interests

Tara Jehu: None declared, Neha Bhaskar: None declared, Shazia Beg: None declared, Kathlyn Camargo Macias: None declared, Sweta Chalise: None declared, Neha Bhanusali Consultant of: healthcare consultant (non-pharmaceutical)

The impact of reader fatigue on the accuracy of capsule endoscopy interpretation

BACKGROUND AND AIMS

Capsule endoscopy (CE) interpretation requires the review of many thousands of images, with lesions often limited to just a few frames. In this study we aim to determine whether lesion detection declines according to the number of capsule videos read.

METHODS

32 participants, 16 of which were novices (NR) and 16 experienced (ER) capsule readers took part in this prospective evaluation study. Participants read six capsule cases with a variety of lesions, in a randomly assigned order during a single sitting. Psychomotor Vigilance Tests and Fatigue Scores were recorded prior to commencing and then after every two capsules read. Changes in lesion detection and measures of fatigue were assessed across the duration of the study.

RESULTS

Mean agreement with the predefined lesions was 48.3% (SD:16.1), and 21.3% (SD:15.1) for the experienced and novice readers respectively. Lesion detection declined amongst experienced reader after the first study (p = 0.01), but remained stable after subsequent capsules read, while NR accuracy was unaffected by capsule numbers read. Objective measures of fatigue did not correlate with reading accuracy.

CONCLUSION

This study demonstrates that reader accuracy declines after reading just one capsule study. Subjective and objective measures of fatigue were not sufficient to predict the onset of the effects of fatigue.

The impact of submucosal fatty tissue during colon endoscopic submucosal dissection in a western center

OBJECTIVES

Obesity is associated with submucosal fatty tissue. The main aim of this study was to assess the impact of submucosal fatty tissue on the success of colonic endoscopic submucosal dissection (C-ESD) in a western population.

METHODS

This was a retrospective analysis of 125 consecutive C-ESDs performed between October 2015 and July 2017. Fatty tissue sign was defined as positive when the submucosal layer was covered with fatty tissue. The complexity of performing an ESD was assessed by the performing endoscopist, defined by the occurrence of intraprocedural perforation, inability to complete an en-bloc resection or a procedure time exceeding 180 min.

RESULTS

Fatty tissue sign positive was present in 44.8% of the procedures. There were 28 (22.4%) c-ESD defined as complex. Factors associated with complex ESD included; fatty tissue sign [odds ratio (OR) 12.5; 95% confidence interval (CI), 1.9-81.9; P = 0.008], severe fibrosis (OR 148.6; 95% CI, 6.6-3358.0; P = 0.002), poor maneuverability (OR 267.4; 95% CI, 11.5-6212.5; P < 0.001) and polyp size ≥35 mm (OR 17.2; 95% CI, 2.6-113.8; P = 0.003). In patients demonstrating the fatty tissue sign, BMI and waist-to-height ratio (WHtR) were higher (27.8 vs. 24.7; P < 0.001 and 0.56 vs. 0.49; P < 0.001, respectively) and en-bloc resection was achieved less frequently (76.8 vs. 97.1%, P = 0.001). Multivariate analysis revealed higher risk of fatty tissue sign positive associated with WHtR ≥0.52 (OR 26.10, 95% CI, 7.63-89.35, P < 0.001).

CONCLUSION

This study demonstrates that the fatty tissue sign contributes to procedural complexity during C-ESD. Central obesity correlates with the likelihood of submucosal fatty tissue and as such should be taken into account when planning procedures.

Video capsule endoscopy: pushing the boundaries with software technology

Video capsule endoscopy (VCE) has transformed imaging of the small bowel as it is a non-invasive and well tolerated modality with excellent diagnostic capabilities. The way we read VCE has not changed much since its introduction nearly two decades ago. Reading is still very time intensive and prone to reader error. This review outlines the evidence regarding software enhancements which aim to address these challenges. These include the suspected blood indicator (SBI), automated fast viewing modes including QuickView, lesion characterization tools such Fuji Intelligent Color Enhancement, and three-dimensional (3D) representation tools. We also outline the exciting new evidence of artificial intelligence (AI) and deep learning (DL), which promises to revolutionize capsule reading. DL algorithms have been developed for identifying organs of origin, intestinal motility events, active bleeding, coeliac disease, polyp detection, hookworms and angioectasias, all with impressively high sensitivity and accuracy. More recently, an algorithm has been created to detect multiple abnormalities with a sensitivity of 99.9% and reading time of only 5.9 minutes. These algorithms will need to be validated robustly. However, it will not be long before we see this in clinical practice, aiding the clinician in rapid and accurate diagnosis.

Use of rapid reading software to reduce capsule endoscopy reading times while maintaining accuracy

BACKGROUNDS AND AIMS

A typical capsule endoscopy (CE) case generates tens of thousands of images, with abnormalities often confined to a just few frames. Omni Mode is a novel EndoCapsule software algorithm (Olympus, Tokyo, Japan) that proposes to intelligently remove duplicate images while maintaining accuracy in lesion detection.

METHODS

This prospective multicenter study took place across 9 European centers. Consecutive, unselected CE cases were read conventionally in normal mode, with every captured frame reviewed. Cases were subsequently anonymized and randomly allocated to another center where they were read using Omni Mode. Detected lesions and reading times were recorded, with findings compared between both viewing modes. The clinical significance of lesions was described according to the P classification (P0, P1, and P2). Where a discrepancy in lesion detection in either mode was found, expert blinded review at a consensus meeting was undertaken.

RESULTS

The patient population undergoing CE had a mean age of 49.5 years (range, 18-91), with the investigation of anemia or GI bleeding accounting for 71.8% of cases. The average small-bowel transit time was 4 hours, 26 minutes. The mean reading time in normal mode was 42.5 minutes. The use of Omni Mode was significantly faster (P < .0001), with an average time saving of 24.6 minutes (95% confidence interval, 22.8-26.9). The 2127 lesions were identified and classified according to the P classification as P0 (1234), P1 (656), and P2 (237). Lesions were identified using both reading modes in 40% (n = 936), and 1186 lesions were identified by either normal or Omni Mode alone. Normal mode interpretation was associated with 647 lesions being missed, giving an accuracy of .70. Omni Mode interpretation led to 539 lesions being missed, with an accuracy of .75. There was no significant difference in clinical conclusions made between either reading mode.

CONCLUSIONS

This study shows that CE reading times can be reduced by an average of 40%, without any reduction in clinical accuracy.

Diagnosis of Barrett's esophagus and esophageal varices using a magnetically assisted capsule endoscopy system

BACKGROUND AND AIMS

Magnetically assisted capsule endoscopy (MACE) potentially offers a comfortable, patient friendly, and community-based alternative to gastroscopy (EGD). This pilot study aims to explore whether this approach can be used to accurately diagnose Barrett's esophagus (BE) and esophageal varices.

METHOD

The MiroCam Navi capsule system was used to examine the upper GI tract in patients due to undergo a clinically indicated EGD. A total of 50 participants were enrolled: 34 had known pathology (17 BE, 17 esophageal varices [EV]) and 16 controls. Patients underwent the MACE procedure with the operator blinded to the indication and any previous endoscopic diagnoses. The subsequent EGD was performed by an endoscopist blinded to the MACE findings. Diagnostic yield, comfort, and patient preference between the 2 modalities were compared.

RESULTS

The mean age of the participants was 61 years, the male/female ratio was 2.1:1, the mean body mass index was 29.5 kg/m², and the average chest measurement was 105.3 cm. Forty-seven patients underwent both procedures; 3 patients were unable to swallow the capsule. With the use of the magnet, it was possible to hold the capsule within the esophagus for a mean duration of 190 seconds and up to a maximum of 634 seconds. A correct real-time MACE diagnosis was made in 11 of 15 patients with EV (sensitivity 73.3% [95% confidence interval (CI), 44.9%-92.2%] and specificity 100% [95% CI, 89.1%-100%]) and 15 of 16 patients with BE (sensitivity 93.8% [95% CI, 69.8%-99.8%] and specificity of 100% [95% CI, 88.8%-100%]). MACE was considered more comfortable than conventional endoscopy (P < .0001); the mean score was 9.2 for MACE compared with 6.7 for EGD when assessed on a 10-point scale. No MACE- or EGD-related adverse events occurred.

CONCLUSION

This pilot study demonstrates that MACE is both safe and well tolerated by patients. Accuracy for the diagnosis of BE was high, and therefore MACE may have a role in screening for this condition. (Clinical trial registration number: NCT02852161.).

Magnetically assisted capsule endoscopy in suspected acute upper GI bleeding versus esophagogastroduodenoscopy in detecting focal lesions

BACKGROUND AND AIMS

Acute upper GI bleeding is common and requires investigation with EGD, but endotherapy is not always necessary. Magnetically assisted capsule endoscopy (MACE) uses a capsule steerable by an external magnet and allows examination of the upper GI tract and small bowel, but its role in acute upper GI bleeding has not been assessed.

METHODS

We conducted a prospective cohort study comparing the diagnostic yield of MACE and EGD in patients with suspected acute upper GI bleeding. Patient tolerance, mucosal visibility by MACE, and frequency of small-bowel bleeding were assessed. Whether or not MACE could safely predict discharge of patients was also determined.

RESULTS

Thirty-three patients were included for analysis (median age, 60 years; 75.8% male). MACE detected more focal lesions (peptic, vascular, and fresh/altered blood without a clear source) than EGD (40 versus 25, respectively, P = .02) but statistical significance was not reached for significant lesions (considered to be the bleeding source; 14 vs 13, respectively, P = 1). Capsule endoscopy identified an additional cause for bleeding in the small bowel in 18%. Visualization by MACE was excellent in most areas; views of the esophagus, gastroesophageal junction, fundus, and duodenal bulb were suboptimal. MACE was better tolerated than unsedated EGD and correctly identified patients who were safe for discharge.

CONCLUSIONS

MACE had higher diagnostic yield for focal lesions and was better tolerated than EGD. It also correctly predicted safe discharge for patients with acute upper GI bleeding. (Clinical trials registration number: NCT02690376.).

Narrow band imaging and serology in the assessment of premalignant gastric pathology

BACKGROUND

Patient outcomes in gastric adenocarcinoma are poor due to late diagnosis. Detecting and treating at the premalignant stage has the potential to improve this. Helicobacter pylori is also a strong risk factor for this disease.

AIMS

Primary aims were to assess the diagnostic accuracy of magnified narrow band imaging (NBI-Z) endoscopy and serology in detecting normal mucosa, H. pylori gastritis and gastric atrophy. Secondary aims were to compare the diagnostic accuracies of two classification systems using both NBI-Z and white light endoscopy with magnification (WLE-Z) and evaluate the inter-observer agreement.

METHODS

Patients were prospectively recruited. Images of gastric mucosa were stored with histology and serum for IgG H. pylori and Pepsinogen (PG) I/II ELISAs. Blinded expert endoscopists agreed on mucosal pattern. Mucosal images and serological markers were compared with histology. Kappa statistics determined inter-observer variability for randomly allocated images among four experts and four non-experts.

RESULTS

116 patients were prospectively recruited. Diagnostic accuracy of NBI-Z for determining normal gastric mucosa was 0.87(95%CI 0.82-0.92), H. pylori gastritis 0.65(95%CI 0.55-0.75) and gastric atrophy 0.88(95%CI 0.81-0.94). NBI-Z was superior to serology at detecting gastric atrophy: NBI-Z gastric atrophy 0.88(95%CI 0.81-0.94) vs PGI/II ratio < 3 0.74(95%CI 0.62-0.85) p<.0001. Overall NBI-Z was superior to WLE-Z in detecting disease using two validated classifications. Inter-observer agreement was 0.63(95%CI 0.51-0.73).

CONCLUSIONS

NBI-Z accurately detects changes in the GI mucosa which currently depend on histology. NBI-Z is useful in the detection of precancerous conditions, potentially improving patient outcomes with early intervention to prevent gastric cancer.

Optimising the performance and interpretation of small bowel capsule endoscopy

Small bowel capsule endoscopy has become a commonly used tool in the investigation of gastrointestinal symptoms and is now widely available in clinical practice. In contrast to conventional endoscopy, there is a lack of clear consensus on when competency is achieved or the way in which capsule endoscopy should be performed in order to maintain quality and clinical accuracy. Here we explore the evidence on the key factors that influence the quality of small bowel capsule endoscopy services.

Impact of advanced endoscopic imaging on Barrett's esophagus in daily clinical practice

BACKGROUND AND AIMS

Several advanced imaging techniques have been proposed to improve the visualization of dysplastic regions within Barrett's epithelium, with some evidence for the use of narrow-band imaging (NBI) and acetic acid chromoendoscopy (AAC).

METHODS

We retrospectively analyzed consecutive cases of Barrett's esophagus, diagnosed using white-light endoscopy and confirmed histologically by the presence of intestinal metaplasia, between April 2007 and April 2010 in a large community hospital. A change in practice was then instituted, whereby a Barrett's team consisting of specialist endoscopists was formed in an attempt to standardize and improve the quality of surveillance. Barrett's epithelium was inspected with both white-light imaging and NBI in all patients. Where the length of Barrett's epithelium was 3 cm or more, AAC was also used. One and a half percent acetic acid was sprayed onto the Barrett's segment and loss of aceto-whitening observed after a 2-minute period. Any abnormal areas noted during advanced imaging underwent target biopsy sampling. We subsequently compared the dysplasia detection rate in Barrett's epithelium identified between April 2011 and April 2014 after these changes. Observed differences between the cohorts were analyzed with the Fisher exact test and the Student t test.

RESULTS

From 2007 to 2010 Barrett's esophagus was identified during 560 gastroscopies in 392 individual patients. The mean maximal Barrett's esophagus recorded length was 4.4 cm (range, 1-10), with an average of 4.7 esophageal biopsy specimens taken per endoscopy. In comparison, from 2011 to 2014 Barrett's esophagus was identified during 856 endoscopies in 630 patients. From 2011 to 2014 the Barrett's team performed 85% of all procedures using the aforementioned techniques. The mean maximal Barrett's esophagus length was 3.8 cm (range, 1-16), with an increased average of 5.8 biopsy specimens per endoscopy taken (P < .01). Both cohorts were comparable in age and gender distribution. Our data demonstrated no significant difference in the relative frequencies of occurrence of dysplasia detected between both cohorts of patients. From 2007 to 2010 dysplasia was detected in 11.0% (n = 43) of patients. This consisted of low-grade dysplasia in 7.7% of patients and high-grade dysplasia or cancer 3.3%. From 2011 to 2014 this compared with dysplasia in 11.3% (n = 71) of patients, with low-grade dysplasia in 9.4% and high-grade dysplasia or cancer in 1.9%.

CONCLUSIONS

Our data show that the use of NBI and AAC in the imaging of Barrett's esophagus did not result in an increased detection rate of dysplasia in routine clinical practice. These findings concur with the recommendations of existing Barrett's esophagus surveillance guidelines, which advocate the continued use of quadratic biopsy sampling within general surveillance programs.

Quality standards in upper gastrointestinal endoscopy: a position statement of the British Society of Gastroenterology (BSG) and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS)

This document represents the first position statement produced by the British Society of Gastroenterology and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, setting out the minimum expected standards in diagnostic upper gastrointestinal endoscopy. The need for this statement has arisen from the recognition that while technical competence can be rapidly acquired, in practice the performance of a high-quality examination is variable, with an unacceptably high rate of failure to diagnose cancer at endoscopy. The importance of detecting early neoplasia has taken on greater significance in this era of minimally invasive, organ-preserving endoscopic therapy. In this position statement we describe 38 recommendations to improve diagnostic endoscopy quality. Our goal is to emphasise practices that encourage mucosal inspection and lesion recognition, with the aim of optimising the early diagnosis of upper gastrointestinal disease and improving patient outcomes.

The Conversion of Planned Colonoscopy to Sigmoidoscopy and the Effect of this Practice on the Measurement of Quality Indicators

OBJECTIVES

A cecal intubation rate (CIR) of >90% is a well-accepted quality indicator of colonoscopy and is consequently monitored within endoscopy units. Endoscopists' desire to meet this target may mean that incomplete colonoscopies are recorded as flexible sigmoidoscopies. The aim of this study was to examine whether the conversion of requested colonoscopies is a clinically significant phenomenon and whether this impacts upon the measurement of quality indicators.

METHODS

A retrospective review of all flexible sigmoidoscopies performed between 1 January 2015 and 31 December 2015 at Nottingham University Hospitals, Sheffield Teaching Hospitals, and Cambridge University Hospitals was performed. Where a colonoscopy was requested but a flexible sigmoidoscopy performed, the patient's records and endoscopy reports were reviewed to determine whether this conversion was decided before the start of the procedure and documented.

RESULTS

During the 12-month period, 6,839 flexible sigmoidoscopies were performed by 125 endoscopists. The original requests of 149 sigmoidoscopies could not be retrieved and were therefore excluded from this analysis. Of the 6,690 sigmoidoscopy requests reviewed, 2.8% (n=190) procedures were originally requested as a colonoscopy. On review of patient records, 85 conversions were appropriate according to pre-defined criteria. However, 105 conversions were deemed inappropriate, occurring in patients who had a valid documented indication for colonoscopy and had undergone full bowel preparation. The most common reasons cited included poor bowel preparation (n=37), technically challenging procedure (n=24), at the endoscopist's discretion based on clinical factors (n=21), and obstructing patology (n=8). A clear reason for conversion was not apparent in 11 cases. During the study period, 21,271 colonoscopies were performed and so conversions represent 0.45% of the total requests. When inappropriate conversions were included in individuals' performance data, 15 endoscopists fell to ≤90% target cecal intubation target.

CONCLUSIONS

A small, but significant number of colonoscopies are converted to flexible sigmoidoscopies at the time of the procedure. This study demonstrates the conversion of colonoscopy to sigmoidoscopy as being a potential limitation of relying on CIR alone. Endoscopy units should consider monitoring the rate of inappropriate conversions to ensure quality.

Clinical utility of the SMSA grading tool for the management of colonic neoplastic lesions

BACKGROUND

Whilst polyp size has been traditionally used as a predictor of the complexity of endoscopic resection, the influence of other factors is increasingly recognised. The SMSA grading system takes into account polyp Site, Morphology, Size and Access, with higher scores correlating with increased technical difficulty.

AIMS

To evaluate whether the SMSA grading tool correlates with endoscopic and clinical outcomes.

METHODS

This retrospective study was conducted at two high volume centres in the United Kingdom and Italy. All polyps identified at colonoscopy were included in this study and classified as per the SMSA grading system.

RESULTS

A total of 1668 lesions were resected in 1016 patients. There was a positive correlation between increasing SMSA level and the inability to resect lesions "en bloc" (p<0.001). Histologically complete clearance was higher in the lower SMSA groups (p<0.0001). Additional endoscopic therapies, were more commonly required with the higher SMSA groups to achieve histological clearance (p<0.0001). Moreover, advanced histology in resection specimens and procedural complications were significantly less common in SMSA level 1 lesions compared to level 3 or 4 lesions (p<0.0001).

CONCLUSIONS

The SMSA grading tool is a useful predictor of outcome following the resection of colonic neoplastic lesions.

Review on gastrointestinal angiodysplasia throughout the gastrointestinal tract

Gastrointestinal angiodysplasia are rare but clinically important vascular aberrations found within the gastrointestinal mucosa and submucosa. Their clinical impact varies from being an asymptomatic incidental finding, to causing life threatening bleeding. In this review we critically appraise the key findings from the current literature on the pathology, clinical presentation and management of these lesions.

Awareness on Hypertension and its Self-Management Practices Among Hypertensive Patients Attending Outreach Clinics of a Medical College in South India

Background Recent data suggest that hypertension is a significant public health problem in India. The success strategies for hypertension management depend upon clients' awareness on hypertension and its self-management practices. Objective To determine awareness, self-management practices and compliance with treatment among hypertensive patients. Method This cross-sectional study was done in January 2012 at four health centres in Mangalore. All confirmed cases of hypertension attending the outpatient department were interviewed using a semi-structured interview schedule. Result Majority (58.7%) of the 315 participants were of the age group 41 to 60 years and majority (53.6%) were males. Most patients (69.5%) were educated up to high school level. The awareness level about hypertension was average or good in majority (52.4%) of the participants. Self-management practices were found to be average or good among 60.6% cases. Good compliance with treatment was seen in 78.7% cases and blood pressure was in control in 72.4% cases. Quality of self-management practices was found to influence control of blood pressure (p=0.021). Awareness, self-management practices and compliance were found to be significantly poor among aged (above 50 years), males, less educated, unemployed, unskilled or retired patients. Conclusion Awareness on hypertension and self-management practices were average or above among majority of the studied population. However this study identified groups who need to be better educated and further monitored to achieve universal blood pressure control among hypertensive population during the routine health care services in this settings.

The use of optical imaging techniques in the gastrointestinal tract

With significant advances in the management of gastrointestinal disease there has been a move from diagnosing advanced pathology, to detecting early lesions that are potentially amenable to curative endoscopic treatment. This has required an improvement in diagnostics, with a focus on identifying and characterising subtle mucosal changes. There is great interest in the use of optical technologies to predict histology and enable the formulation of a real-time in vivo diagnosis, a so-called 'optical biopsy'. The aim of this review is to explore the evidence for the use of the current commercially available imaging techniques in the gastrointestinal tract.

Early clinical experience of the safety and efficacy of EndoClot in the management of non-variceal upper gastrointestinal bleeding

BACKGROUND AND STUDY AIMS

EndoClot is a novel topical hemostatic powder approved for use in non-variceal upper gastrointestinal bleeding. This study examines its impact as rescue therapy in the management of gastrointestinal bleeding for which standard endoscopic therapy failed to achieve hemostasis.

METHODS

This observational study covered a 24-month period. Data were collated from patients treated with EndoClot for comparison with a cohort of patients managed with standard endoscopic therapy. End points of this study included immediate hemostasis, 30-day rebleed rate, 30-day mortality rate, and adverse events.

RESULTS

Between April 1, 2012, and March 31, 2014, gastroscopic procedures were performed in 1009 patients, of whom 173 required endoscopic therapy. EndoClot was used in 21 patients, with immediate hemostasis achieved in all cases, a 30-day rebleed rate of 4.8 % (95 % confidence interval [95 %CI] - 4.34 % to 3.94 %), and a 30-day mortality rate of 19.0 % (95 %CI 2.29 % - 35.91 %). Despite higher risk bleeds in this cohort of patients, Fisher's exact test demonstrated no significant difference between their 30-day mortality rate (P = 0.51) and rebleed rate (P = 0.31) and those of the patients treated with standard endoscopic hemostatic techniques.

CONCLUSIONS

This study demonstrates that EndoClot can be used both safely and effectively in the management of non-variceal upper gastrointestinal bleeding.

Image-enhanced endoscopy technology in the gastrointestinal tract: what is available?

Gastrointestinal malignancy accounts for approximately a fifth of all cancer deaths in the United Kingdom. By the time patients are symptomatic, lesions are often advanced, with limited treatment options available. The development of effective endoscopic therapies means that neoplastic lesions can now be treated with improved patient outcomes. This has led to a paradigm shift, whereby the aim of digestive endoscopy is to identify premalignant conditions or early neoplastic change, in order to make an impact on their natural history. This has necessitated an improvement in imaging techniques in order to identify subtle mucosal changes that may harbour precancerous cells. At present there is an array of available imaging modalities, each with implications on cost, training and lesion detection. Here we describe the scientific rationale behind the major commercially available techniques as well as offering a glimpse at possible future directions.

Formulation Design, Optimization and Pharmacodynamic Evaluation of Sustained Release Mucoadhesive Microcapsules of Venlafaxine HCl

The objective of present research work was to design and characterize the venlafaxine HCl-loaded sodium alginate-based mucoadhesive microcapsules by ionic gelation technique using HPMC K100M as mucoadhesive polymer. The Placket-Burman Design was applied for preliminary screening of the formulations and systematic optimization by using Box-Behnken Design. The prepared microcapsules were characterized for drug content, entrapment efficiency, micromeritic properties, particle size, swelling index, mucoadhesive strength, in vitro drug release and in vivo antidepressant activity. FTIR and differential scanning calorimetry studies showed no incompatibility. Surface morphology studies revealed spherical nature of the prepared microcapsules. In vitro drug release studies revealed sustained release by diffusion mechanism. Further, the microcapsules were effective in reducing the depression induced by forced swimming test in Sprague-Dawley rats compared to the pure drug. The microcapsules were found to be stable under accelerated stability conditions, which suggest them as better alternative delivery systems for enhanced therapeutic efficacy of antidepressant drug, venlafaxine HCl.

Improvement in Dissolution Rate of Cefuroxime Axetil by using Poloxamer 188 and Neusilin US2

A combination of fusion and surface adsorption techniques was used to enhance the dissolution rate of cefuroxime axetil. Solid dispersions of cefuroxime axetil were prepared by two methods, namely fusion method using poloxamer 188 alone and combination of poloxamer 188 and Neusilin US2 by fusion and surface adsorption method. Solid dispersions were evaluated for solubility, phase solubility, flowability, compressibility, Kawakita analysis, Fourier transform-infrared spectra, differential scanning calorimetry, powder X-ray diffraction study, in vitro drug release, and stability study. Solubility studies showed 12- and 14-fold increase in solubility for solid dispersions by fusion method, and fusion and surface adsorption method, respectively. Phase solubility studies showed negative ΔG⁰_tr values for poloxamer 188 at various concentrations (0, 0.25, 0.5, 0.75 and 1%) indicating spontaneous nature of solubilisation. Fourier transform-infrared spectra and differential scanning calorimetry spectra showed that drug and excipients are compatible with each other. Powder X-ray diffraction study studies indicated that presence of Neusilin US2 is less likely to promote the reversion of the amorphous cefuroxime axetil to crystalline state. in vitro dissolution studies, T50% and mean dissolution time have shown better dissolution rate for solid dispersions by fusion and surface adsorption method. Cefuroxime axetil release at 15 min (Q15) and DE15 exhibited 23- and 20-fold improvement in dissolution rate. The optimized solid dispersion formulation was stable for 6 months of stability study as per ICH guidelines. The stability was ascertained from drug content, in vitro dissolution, Fourier transform-infrared spectra and differential scanning calorimetry study. Hence, this combined approach of fusion and surface adsorption can be used successfully to improve the dissolution rate of poorly soluble biopharmaceutical classification system class II drug cefuroxime axetil.

Alteration in emergency theatre prioritisation does not alter outcome for acute appendicitis: comparative cohort study

BACKGROUND

Despite dedicated emergency theatre, emergency surgery can be often delayed due to competing urgencies, suggesting a need for innovative theatre time management.

AIM

To investigate if a change in the emergency theatre prioritisation affects outcomes for a common urgent operation such as appendicectomy.

METHODS

We prospectively recorded data from 67 patients undergoing appendicectomy, for two cohorts of patients: before and after change in theatre prioritisation: Group 1 (Jan-Mar) and 2 (Aug-Oct) respectively. Demographic and peri-operative data, time from admission to surgery, postoperative length of stay and total length of stay and complications were compared.

RESULTS

The two groups were comparable with regards to gender, age, time of admission and histological confirmation of appendicitis. No differences between the two groups were found regarding time from admission to surgery (24.4 (95% CI 11.2;27.6) hours versus 16.1 (95% CI 10.4;21.7) hours, Mann-Whitney U test, p = 0.35), postoperative length of stay (90.8 (95% CI 61.4;120.1) hours versus 70 (95% CI 48.3;91.6) hours, Mann-Whitney U test, p = 0.25) and total length of stay (115.2 (95% CI 84.6;145.7) hours versus 86 (95% CI 61.6;110.4) hours, Mann-Whitney U test, p = 0.07) as well as complication or re-admission rates.

CONCLUSION

A change in the emergency theatre prioritisation does not affect outcome for appendicectomy. Provision of a second emergency theatre could be a solution to reduce the delays in acute surgical operations.

Association of resident coverage with cost, length of stay, and profitability at a community hospital

OBJECTIVE

The effect of care by medical residents on hospital length of stay (LOS), indirect costs, and reimbursement was last examined across a range of illnesses in 1981; the issue has never been examined at a community hospital. We studied resource utilization and reimbursement at a community hospital in relation to the involvement of medical residents.

DESIGN

This nonrandomized observational study compared patients discharged from a general medicine teaching unit with those discharged from nonteaching general medical/surgical units.

SETTING

A 620-bed community teaching hospital with a general medicine teaching unit (resident care) and several general medicine nonteaching units (no resident care).

PATIENTS

All medical discharges between July 1998 and February 1999, excluding those from designated subspecialty and critical care units.

MEASUREMENTS AND MAIN RESULTS

Endpoints included mean LOS in excess of expected LOS, mean cost in excess of expected mean payments, and mean profitability (payments minus total costs). Observed values were obtained from the hospital's database and expected values from a proprietary risk-cost adjustment program. No significant difference in LOS between 917 teaching-unit patients and 697 nonteaching patients was demonstrated. Costs averaged $3,178 (95% confidence interval (CI) +/- $489) less than expected among teaching-unit patients and $4,153 (95% CI +/- $422) less than expected among nonteaching-unit patients. Payments were significantly higher per patient on the teaching unit than on the nonteaching units, and as a result mean, profitability was higher: $848 (95% CI +/- $307) per hospitalization for teaching-unit patients and $451 (95% CI +/- $327) for patients on the nonteaching units. Teaching-unit patients of attendings who rarely admitted to the teaching unit (nonteaching attendings) generated an average profit of $1,299 (95% CI +/- $613), while nonteaching patients of nonteaching attendings generated an average profit of $208 (95% CI +/- $437).

CONCLUSIONS

Resident care at our community teaching hospital was associated with significantly higher costs but also with higher payments and greater profitability.