A computer-aided polyp detection system in screening and surveillance colonoscopy: an international, multicentre, randomised, tandem trial

BACKGROUND

Studies on the effect of computer-aided detection (CAD) in a daily clinical screening and surveillance colonoscopy population practice are scarce. The aim of this study was to evaluate a novel CAD system in a screening and surveillance colonoscopy population.

METHODS

This multicentre, randomised, controlled trial was done in ten hospitals in Europe, the USA, and Israel by 31 endoscopists. Patients referred for non-immunochemical faecal occult blood test (iFOBT) screening or surveillance colonoscopy were included. Patients were randomomly assigned to CAD-assisted colonoscopy or conventional colonoscopy; a subset was further randomly assigned to undergo tandem colonoscopy: CAD followed by conventional colonoscopy or conventional colonoscopy followed by CAD. Primary objectives included adenoma per colonoscopy (APC) and adenoma per extraction (APE). Secondary objectives included adenoma miss rate (AMR) in the tandem colonoscopies. The study was registered at ClinicalTrials.gov, NCT04640792.

FINDINGS

A total of 916 patients were included in the modified intention-to-treat analysis: 449 in the CAD group and 467 in the conventional colonoscopy group. APC was higher with CAD compared with conventional colonoscopy (0·70 vs 0·51, p=0·015; 314 adenomas per 449 colonoscopies vs 238 adenomas per 467 colonoscopies; poisson effect ratio 1·372 [95% CI 1·068-1·769]), while showing non-inferiority of APE compared with conventional colonoscopy (0·59 vs 0·66; p<0·001 for non-inferiority; 314 of 536 extractions vs 238 of 360 extractions). AMR in the 127 (61 with CAD first, 66 with conventional colonoscopy first) patients completing tandem colonoscopy was 19% (11 of 59 detected during the second pass) in the CAD first group and 36% (16 of 45 detected during the second pass) in the conventional colonoscopy first group (p=0·024).

INTERPRETATION

CAD increased adenoma detection in non-iFOBT screening and surveillance colonoscopies and reduced adenoma miss rates compared with conventional colonoscopy, without an increase in the resection of non-adenomatous lesions.

FUNDING

Magentiq Eye.

Endoscopic Ultrasound-guided Radiofrequency Ablation Versus Surgical Resection for Treatment of Pancreatic Insulinoma

BACKGROUND & AIMS

Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is emerging as a safe and effective treatment for pancreatic neuroendocrine tumors. We aimed to compare EUS-RFA and surgical resection for the treatment of pancreatic insulinoma (PI).

METHODS

Patients with sporadic PI who underwent EUS-RFA at 23 centers or surgical resection at 8 high-volume pancreatic surgery institutions between 2014 and 2022 were retrospectively identified and outcomes compared using a propensity-matching analysis. Primary outcome was safety. Secondary outcomes were clinical efficacy, hospital stay, and recurrence rate after EUS-RFA.

RESULTS

Using propensity score matching, 89 patients were allocated in each group (1:1), and were evenly distributed in terms of age, sex, Charlson comorbidity index, American Society of Anesthesiologists score, body mass index, distance between lesion and main pancreatic duct, lesion site, size, and grade. Adverse event (AE) rate was 18.0% and 61.8% after EUS-RFA and surgery, respectively (P < .001). No severe AEs were observed in the EUS-RFA group compared with 15.7% after surgery (P < .0001). Clinical efficacy was 100% after surgery and 95.5% after EUS-RFA (P = .160). However, the mean duration of follow-up time was shorter in the EUS-RFA group (median, 23 months; interquartile range, 14-31 months vs 37 months; interquartile range, 17.5-67 months in the surgical group; P < .0001). Hospital stay was significantly longer in the surgical group (11.1 ± 9.7 vs 3.0 ± 2.5 days in the EUS-RFA group; P < .0001). Fifteen lesions (16.9%) recurred after EUS-RFA and underwent a successful repeat EUS-RFA (11 patients) or surgical resection (4 patients).

CONCLUSION

EUS-RFA is safer than surgery and highly effective for the treatment of PI. If confirmed in a randomized study, EUS-RFA treatment can become first-line therapy for sporadic PI.

Post-POEM Contrast-Enhanced Swallow Study: Is It Always Necessary?

BACKGROUND

Peroral endoscopic myotomy (POEM) is rapidly becoming the procedure of choice for treating esophageal achalasia. In most centers, contrast-enhanced swallow studies (CESS) are routinely performed postoperatively to confirm mucosal integrity. The aim of this study was to determine the necessity of performing these studies routinely after POEM.

METHODS

A retrospective review of a prospectively maintained database of patients who underwent POEM between December 2012 and November 2020 was performed. All patients underwent a CESS on the first postoperative day. Medical records including vital signs, complete blood count, and POD-1 CESS were evaluated.

RESULTS

One hundred thirty-four consecutive patients were included in the study. Sixty-nine (51.49%) CESS showed abnormal findings; while most findings did not change the postoperative course, five (7.2%) demonstrated tunnel leaks, which did alter the overall management. Screening patients for fever, tachycardia, or leukocytosis on POD-1 had a 100% sensitivity and a 62% specificity for finding a clinically significant complication on CESS.

CONCLUSIONS

The study findings suggest that performing routine contrast-enhanced swallow studies on all patients is not necessary following POEM, as leaks can be screened for by clinical or laboratory abnormalities. Herein, we propose an algorithm based on objective measurable findings for the selection of patients who should undergo CESS.

Staple Line Leaks Following Laparoscopic Sleeve Gastrectomy: Low Efficacy of the Over-the-Scope Clip

PURPOSE

The over-the-scope clip (OTSC) enables non-surgical management of gastrointestinal defects. The aim of this study was to report our experience with OTSC for patients with staple line leaks following laparoscopic sleeve gastrectomy (LSG).

MATERIALS AND METHODS

A prospectively maintained IRB-approved institutional database was queried for all patients treated with OTSC for staple line leaks following LSG from 2010 to 2018. Primary outcome was complete resolution of leak following OTSC. Secondary outcome was the number of additional procedures needed following OTSC.

RESULTS

Twenty-six patients (13 males, 13 females) were treated with OTSC for staple line leaks following LSG. The median age was 35 years (range 18-62), and mean body mass index was 44 kg/m2. The median time from index operation to leak diagnosis and from leak diagnosis to OTSC was 18 days (range 2-118), and 6 days (range 1-120), respectively. The initial endoscopic treatment was OTSC (n = 19), stent (n = 5), clip (n = 1), and clip and biologic glue (n = 1). OTSC alone led to final resolution of leak in 8 patients (31%) within 43 days of clip deployment (range 5-87). Five leaks resolved after a combination of OTSC and stent (19%) and one leak (4%) resolved after endoscopic suturing following a failed OTSC. Eleven patients (42%) failed endoscopic management and underwent total gastrectomy and esophagojejunostomy. One mortality (4%) was noted. The number of additional endoscopic sessions ranged from 1 to 10 (median 2).

CONCLUSIONS

OTSC carries a low success rate for controlling staple line leaks following LSG.

The POEM bottom-up technique for achalasia

BACKGROUND

POEM (Per Oral Endoscopic Myotomy) is rapidly becoming a valid option for surgical myotomy in achalasia patients. Several techniques to perform POEM are described, but all concentrate on the division of the circular muscle fibers in a proximal-to-distal fashion. Our aim is to present the distal-to-proximal, or the bottom-up technique using the Flush/Dual knife, which overcomes the disadvantages of the standard technique.

METHODS

A retrospective study on a prospectively maintained database was performed on all patients treated by POEM in our institution. Clinical presentation, operating time, adverse events, and outcomes were studied.

RESULTS

POEM was performed on 105 achalasia patients. The first 15 cases were performed using the standard technique and were compared to the next 90 cases performed using the bottom-up technique. The average preop Eckardt scores in the standard and bottom-up groups were 9.5 and 8.8, respectively, declining to 1.4 and 0.5, 3 months post myotomy (p < 0.001). The average procedure time was 111.2 min for the standard technique and 74.3 for the bottom-up technique. (p = 0.002). Perioperative adverse events included 14 instances of pneumoperitoneum, 3 tunnel leaks, and 4 patients with fever on postoperative day one. Pneumoperitoneum needing decompression and postoperative fever were more prevalent in the standard technique group.

CONCLUSIONS

As POEM is becoming more common for the treatment of achalasia, refinements of the technique and instruments used are valuable. We compared our experience of the standard technique to our bottom-up technique and found the latter to be equally effective as well as safer, faster, and easier. We, therefore, suggest considering performing POEM in this technique.

Reproductive Outcomes Among Women of Childbearing Age with Achalasia After Peroral Endoscopic Myotomy: A Single-Center Experience

Background: Achalasia may occasionally occur among women of childbearing age. Pregnancy may lead to deterioration of the disease and negatively affect maternal and perinatal outcomes. However, the impact of peroral endoscopic myotomy (POEM) on reproductive outcomes has been understudied. Methods: A retrospective study on prospectively maintained database, including women aged 18-45 who underwent POEM during 2012-2017 at a university hospital. Results: During the study period, POEM was performed in 86 patients. Of them, 23 were women of childbearing age (median age 31.9 [26.0-40.7] years). Follow-up data were available for a median of 24 [16-41] months. Treatment success (Eckardt score <3) was achieved in 22 (95.7%) women. Six (26.1%) women reported attempting to conceive after POEM. Overall, 7 post-POEM pregnancies among 5 women were encountered. All 7 pregnancies were naturally conceived with a median surgery-to-conception interval of 16 [10-21] months. The median gestational weight gain was 10 kg, and was insufficient in all pregnancies. None of the women was hospitalized during the index gestation. All pregnancies resulted in term live-birth vaginal delivery. The median neonatal birthweight was 2940 g, with only one case of a small-for-gestational age infant. Achalasia-related symptoms recurred during 2 pregnancies, with resolution following delivery. Conclusions: Pregnancy after POEM for the treatment of achalasia was associated with favorable maternal and perinatal outcomes. This data should reassure women who wish to conceive following peroral myotomy.

Long-term outcomes in MEN-1 patients with pancreatic neuroendocrine neoplasms: an Israeli specialist center experience

PURPOSE

The decreased life expectancy of MEN-1 patients is mainly related to pancreatic neuroendocrine tumors (pNETs). At best, limited data is available on the natural history of MEN-1-associated pNETs, as these tumors are rare and have a wide range of biologic behavior. Our study aims to explore the clinical course of patients with MEN-1-associated pNETs and the long-term outcomes.

METHODS

This longitudinal study was conducted on the MEN-1 cohort treated at our referral center over a 22-year period (1996-2018). Relevant clinical data were retrospectively analysed.

RESULTS

Among the 33 MEN-1 patients included in our study, pNETs were identified in 21 subjects with a penetrance of 48% by the age of 50. Non-functioning and functioning pNETs were diagnosed in sixteen (76%) and five (24%) patients, respectively. Two-thirds of the patients had multifocal tumors. The median number of pancreatic macroscopic lesions per individual was 4.0 ± 3.9 (range 1-8) with a mean size of 1.3 ± 2.1 cm (range 0.5-10). The metastatic rate according to the dominant pNET lesion reached 100%, 62% and 6% for tumors sized > 4 cm, 2.1-4 cm, and 1-2 cm, respectively. Over the study period, one or more therapeutic interventions for pNETs were required in 20 out of the 21 patients. pNET-related metastatic complication was the main cause of death within this MEN-1 cohort. The overall survival rate for the pNETs patients was 86% during a mean follow-up period of 8.0 ± 4.6 years.

CONCLUSIONS

In our MEN-1 cohort, non-functioning pNETs were the most frequent type of pancreaticoduodenal tumor, and the tumor size correlated with the risks of metastasis and death. Increased awareness, early diagnosis, and a multidisciplinary approach may improve the associated morbidity and mortality in these patients.

Live fast, die young: Behavioural and physiological impacts of light pollution on a marine fish during larval recruitment

Artificial light at night (ALAN) is a recently acknowledged form of anthropogenic pollution of growing concern to the biology and ecology of exposed organisms. Though ALAN can have detrimental effects on physiology and behaviour, we have little understanding of how marine organisms in coastal areas may be impacted. Here, we investigated the effects of ALAN exposure on coral reef fish larvae during the critical recruitment stage, encompassing settlement, metamorphosis, and post-settlement survival. We found that larvae avoided illuminated settlement habitats, however those living under ALAN conditions for 10 days post-settlement experienced changes in swimming behaviour and higher susceptibility to nocturnal predation. Although ALAN-exposed fish grew faster and heavier than control fish, they also experienced significantly higher mortality rates by the end of the experimental period. This is the first study on the ecological impacts of ALAN during the early life history of marine fish.

Hospital management of colonic perforations complicating ambulatory outpatient colonoscopy via over-the-scope clips or surgery: a case series

BACKGROUND

Colonoscopy is the standard of care for the diagnosis and treatment of many colonic disorders. Over the past few years, endoscopic closure of colonoscopy-related perforation has become more common. Endoscopic closure of perforation secondary to colonoscopy has been undertaken in patients in the hospital setting and often during the same colonoscopic procedure in which the perforation itself occurred. The aim of our study was to analyze our experience with emergency endoscopic closure of colonoscopy-related perforation with over-the-scope clip (OTSC) technique.

METHODS

We report five cases of colonic perforation that occurred during colonoscopy in an outpatient facility remotely located from our hospital and then referred as an emergency to our institution for endoscopic closure.

RESULTS

Bowel preparation was reported to be adequate in all cases. Prior to attempting endoscopic closure of colonic perforation, all patients were in stable clinical condition, early broad-spectrum antibiotic coverage was initiated, and a surgical consult was obtained. All patients had sigmoidoscopy and were found to have sigmoid colon perforations. In three cases, the perforations were closed successfully using an OTSC clip device 14 mm type t. Two patients were found to have greater than 4-cm sigmoid perforations with irregular margins, incompatible with OTSC closure, and were referred for emergency surgery. All patients had an uneventful course following either OTSC closure or surgery.

CONCLUSIONS

Based on the characteristics of the five cases and a review of the literature, we suggest a practical approach for undertaking closure of colonic perforations occurring during colonoscopy in the outpatient setting, focusing on clinical criteria to determine eligibility of patients for attempted endoscopic closure and outlining required therapeutic and monitoring steps needed to optimize outcomes.

Endoscopic Ultrasound-Guided Radiofrequency Ablation: A New Therapeutic Approach for Pancreatic Neuroendocrine Tumors

CONTEXT

Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is rapidly emerging as feasible therapy for patients with pancreatic neuroendocrine tumors (pNETs) in selected cases, as a result of its favorable safety profile.

OBJECTIVE

To assess the feasibility, safety, and efficacy of EUS-RFA in a cohort of patients with functional and nonfunctional pNETs (NF-pNETs).

DESIGN

Data on pNET patients treated with EUS-RFA between March 2017 and October 2018 at two tertiary centers was retrospectively analyzed.

RESULTS

The cohort included 18 adults (eight women, 10 men), aged 60.4 ± 14.4 years (mean ± SD), seven insulinoma patients, and 11 patients with NF-pNETs. Twenty-seven lesions with a mean diameter of 14.3 ± 7.3 mm (range 4.5 to 30) were treated. Technical success defined as typical postablative changes on a surveillance imaging was achieved in 26 out of 27 lesions. Clinical response with normalization of glucose levels was observed in all (seven of seven) insulinoma cases within 24 hours of treatment. Overall, there were no major complications 48 hours postprocedure. No clinically significant recurrences were observed during mean follow-up of 8.7 ± 4.6 months (range 2 to 21 months).

CONCLUSIONS

EUS-guided RFA of pNETs is a minimally invasive, safe, and technically feasible procedure for selected patients.

[PER-ORAL ENDOSCOPIC MYOTOMY - SUMMARY OF FIVE YEARS EXPERIENCE]

INTRODUCTION

Esophageal achalasia is a rare condition, characterised by progressive dysphagia due to innervation of the esophageal muscles and non-relaxation of the lower esophageal sphincter. The standard of care of surgical treatment is laparoscopic Heller myotomy. POEM-Peroral endoscopic myotomy is a new approach offering incision-less and selective myotomy.

AIMS

This study aims to describe our experience and outcomes using this new surgical technique.

METHODS

We performed a retrospective study using prospectively maintained data of all achalasia patients treated by POEM in our department. Data collected included patient demographics, gender, age, BMI, data related to the disease course in addition to data related to the surgery itself as well as both short and long term post-operative follow-up.

RESULTS

Over the course of five years we performed 86 POEM operations, demonstrating a decrease in the Eckardt score from a mean of 8.87 to a mean of 0.7 in the immediate postoperative. Mean operative time was 86 minutes, with mean hospitalization time of 4 days. Intraoperative complications included 2 mucosal injuries while post-operative complications included 4 incomplete mucosal closures, 5 recurrent dysphagia and 5 patients with reflux requiring medical therapy.

CONCLUSIONS

In the last decade, POEM procedure is being performed worldwide and has been performed in our department for the past five years. Our results show a success rate of 94.2% with minor complications. In our institution, as in many institutions globally, POEM is the preferred method for treating achalasia.

Endoscopic Ultrasound-Guided Angiotherapy for Gastric Varices: A Single Center Experience

There are limited efficacious therapeutic options for management of gastric variceal bleeding. Treatment modalities include transjugular intrahepatic portosystemic shunt, surgical shunts, and endoscopic interventions, including the recent advancement of endoscopic ultrasound (EUS)-guided coiling. We present a case series of 10 patients with portal hypertension (7 with liver cirrhosis and 3 without cirrhosis), complicated by gastric varices (GV) with bleeding. All cases were treated successfully with EUS-guided coiling leading to variceal eradication. There were 10 occurrences of minimal self-limited bleeding at the puncture site during the procedure, and only one occurrence of major bleeding that necessitated cyanoacrylate glue injection for homeostasis. There were no other adverse events within a mean follow-up time of 9.7 months (range, 1-28 months). Conclusion: In our series, EUS-guided angiotherapy was effective for GV eradication with a high safety profile.

Endoscopic submucosal dissection of cecal lesions in proximity to the appendiceal orifice

BACKGROUND AND STUDY AIMS

Endoscopic submucosal dissection (ESD) is performed for treatment of various gastrointestinal lesions; however, the cecum in proximity to the appendiceal orifice remains a challenging area. We reviewed our experience with cecal ESD near the appendiceal orifice in order to clarify whether this procedure is a safe and effective therapeutic option.

PATIENTS AND METHODS

We retrospectively reviewed ESD for lesions within approximately 12 mm of the appendiceal orifice at Kobe University Hospital and an affiliated hospital between January 2003 and December 2014. Lesions were classified as: Type 0, proximity to the appendiceal orifice but does not reach it; Type 1, reaches border of the appendix, but does not enter orifice; Type 2, enters orifice, and transition to normal appendiceal mucosa is discernible on inspection of the appendiceal lumen; and Type 3, enters orifice deeply and tumor edge cannot be observed. ESD was not performed for Type 3 lesions unless appendectomy was performed prior to ESD.

RESULTS

A total of 76 lesions satisfied the inclusion criteria (47 Type 0 lesions, 20 Type 1, 6 Type 2, and 3 Type 3). En bloc resection was achieved in 72 lesions (94.7 %). Median specimen size was 49 mm (range 15 - 114 mm), and median tumor size was 35.5 mm (10 - 110 mm). One patient experienced postoperative bleeding, which was treated by endoscopic hemostasis. Another patient who experienced intraoperative perforation and was treated by clip closure later developed appendicitis; he underwent emergency ileocecal surgical resection. Another patient experienced postoperative appendicitis and recovered with antibiotic treatment.

CONCLUSIONS

ESD in close proximity to the appendiceal orifice seems safe and effective.

First description of the neuro-anatomy of a larval coral reef fish Amphiprion ocellaris

The present study described the neuro-anatomy of a larval coral reef fish Amphiprion ocellaris and hypothesized that morphological changes during the transition from the oceanic environment to a reef environment (i.e. recruitment) have the potential to be driven by changes to environmental conditions and associated changes to cognitive requirements. Quantitative comparisons were made of the relative development of three specific brain areas (telencephalon, mesencephalon and cerebellum) between 6 days post-hatch (dph) larvae (oceanic phase) and 11 dph (at reef recruitment). The results showed that 6 dph larvae had at least two larger structures (telencephalon and mesencephalon) than 11 dph larvae, while the size of cerebellum remained identical. These results suggest that the structure and organization of the brain may reflect the cognitive demands at every stage of development. This study initiates analysis of the relationship between behavioural ecology and neuroscience in coral reef fishes.

Surface acoustic waves enhance neutrophil killing of bacteria

Biofilms are structured communities of bacteria that play a major role in the pathogenicity of bacteria and are the leading cause of antibiotic resistant bacterial infections on indwelling catheters and medical prosthetic devices. Failure to resolve these biofilm infections may necessitate the surgical removal of the prosthetic device which can be debilitating and costly. Recent studies have shown that application of surface acoustic waves to catheter surfaces can reduce the incidence of infections by a mechanism that has not yet been clarified. We report here the effects of surface acoustic waves (SAW) on the capacity of human neutrophils to eradicate S. epidermidis bacteria in a planktonic state and within biofilms. Utilizing a novel fibrin gel system that mimics a tissue-like environment, we show that SAW, at an intensity of 0.3 mW/cm², significantly enhances human neutrophil killing of S. epidermidis in a planktonic state and within biofilms by enhancing human neutrophil chemotaxis in response to chemoattractants. In addition, we show that the integrin CD18 plays a significant role in the killing enhancement observed in applying SAW. We propose from out data that this integrin may serve as mechanoreceptor for surface acoustic waves enhancing neutrophil chemotaxis and killing of bacteria.

Effects in Silicon Explained by Atomic Hydrogen

The chemomechanical polishing mechanism is described as a corrosive attack of water forming Si-H and Si-OH groups. By adding ammonia or amines to the slurry we observe an irlfease of the resistivity corresponding to a neutralization of up to 1 × 1017 acceptor atoms cm−3 in the case of p-type silicon, whereas n-type silicon can show a slight reduction in resistivity due to the neutralization of the residual acceptor concentration.

SIMS measurements show the presence of hydrogen in the bulk. Using deuterium instead of hydrogen, a correlation could be established between the deuterium content of the wafer, measured by the effusion technique, and the degree of the acceptor compensation.

As can be shown by resistivity and C/V-measurements, under the conditions of polishing the supposed inactivator hydrogen migrates to a distance finally corresponding to the thickness of a wafer. This is contrary to the comm on method of plasma treatment, where a damaged silicon layer is supposed to act as a barrier to the hydrogen diffusion. Differences in the IR spectra can be explained this way.

Crystal imperfections in the bulk and on the surface influences the migration of hydrogen essentially.

An endoscopic repair option for acquired esophagorespiratory fistulas

Benign acquired esophagorespiratory fistulas (BERFs) represent a broad spectrum of anatomic pathology presenting in a wide variety of clinical settings. These fistulas can lead to severe respiratory compromise and rarely close spontaneously. Surgical fistula closure has been the traditional therapeutic approach, but is associated with significant morbidity and mortality. The recent advent of endoscopic technologies suggests that minimally invasive procedures may offer a safe alternative to surgery for the treatment of esophagorespiratory fistulas. In this article, we present our experience in treating complex benign esophagorespiratory fistulas of diverse etiologies utilizing a primarily minimal invasive, endoscopic, or combined surgical and endoscopic approaches. Our experience demonstrates that an endoscopic-based approach is safe and technically feasible and can, potentially, spare a subset of patients from open surgery. A multidisciplinary decision-making process, based on individualized parameters, is a prerequisite for a successful outcome.

Development of a groundwater biobarrier for the removal of polycyclic aromatic hydrocarbons, BTEX, and heterocyclic hydrocarbons

A full scale funnel-and-gate biobarrier has been developed for the removal of tar oil pollutants at an abandoned tar factory site near the city of Offenbach, Germany. Laboratory and on-site column studies were done to determine the operation parameters for microbiological clean-up of the groundwater polluted with 12,000 microg/L mono- aromatic hydrocarbons such as benzene and the xylenes, 4,800 microg/L polycyclic aromatic hydrocarbons such as naphthalene and acenaphthene, and 4,700 microg/L heterocyclic aromatic hydrocarbons such as benzofuran and benzothiophene. In the laboratory study, a residence time of approx. 70 h proved to be sufficient for aerobic pollutant biodegradation. Up to 180 mg/L H(2)O(2) were added and did not lead to any toxic effects to the degrading bacteria. The feasibility of the concept was confirmed in an on-site pilot study performed with a sedimentation tank (removal of ferric iron) and two bioreactors. In the bioreactors, >99.3% of the pollutants were degraded. Biodegradation activity corresponded to a significant increase in numbers of pollutant degrading bacteria. In the bioreactors, a fast dissociation of H(2)O(2) was observed resulting in losses of oxygen and temporary gas clogging. Therefore, a repeated addition of moderate concentrations of H(2)O(2) proved to be more favourable than the addition of high concentrations at a single dosing port. The full scale biobarrier consists of three separated bioreactors thus enabling extended control and access to the reactors. The operation of the funnel-and-gate biobarrier started in April 2007, and represents the first biological permeable reactive barrier with extended control (EC-PRB) in Germany.

Positive coeliac serology in irritable bowel syndrome patients with normal duodenal biopsies: Video capsule endoscopy findings and HLA-DQ typing may affect clinical management

OBJECTIVES

To investigate a group of IBS patients (Rome criteria) with positive coeliac serology (EMA, TTG, IgG or IgA AGA) and normal small bowel biopsies. Video capsule endoscopy (VCE) findings of the small bowell were compared with DQ-typing.

METHODS

Twenty-two patients with chronic abdominal pain (with or without diarrhea) and at least one positive result of any of the coeliac serological markers (AGA, TTG, EMA) and normal duodenal biopsy were enrolled and underwent VCE. Twelve healthy volunteers with VCE served as control group. Coeliac related HLA DQ2 or DQ8 markers were determined.

RESULTS

12/ 22 (55%) patients had small bowel abnormalities with VCE. No mucosal abnormalities were recognized in the control group (p = 0.002). Inflammatory changes were classified as moderate or pronounced. Eight patients (36%) had moderate changes and four patients (18%) demonstrated pronounced changes. Only 6 of the 21 IBS patients were positive for DQ2 and/or DQ8.

CONCLUSIONS

The patients in this study fulfilled the diagnostic Rome criteria for Irritable Bowel Syndrome. We suggest that patients with positive coeliac serology and normal duodenal biopsies should undergo HLA typing. In patients positive for DQ2 and/or DQ8, a VCE should be performed. Patients with mucosal abnormalities compatible with CD should be considered as a group distinct from IBS patients and could be tested with gluten challenge or treated with a gluten free diet.

Effective prevention of microbial biofilm formation on medical devices by low-energy surface acoustic waves

Low-energy surface acoustic waves generated from electrically activated piezo elements are shown to effectively prevent microbial biofilm formation on indwelling medical devices. The development of biofilms by four different bacteria and Candida species is prevented when such elastic waves with amplitudes in the nanometer range are applied. Acoustic-wave-activated Foley catheters have all their surfaces vibrating with longitudinal and transversal dispersion vectors homogeneously surrounding the catheter surfaces. The acoustic waves at the surface are repulsive to bacteria and interfere with the docking and attachment of planktonic microorganisms to solid surfaces that constitute the initial phases of microbial biofilm development. FimH-mediated adhesion of uropathogenic Escherichia coli to guinea pig erythrocytes was prevented at power densities below thresholds that activate bacterial force sensor mechanisms. Elevated power densities dramatically enhanced red blood cell aggregation. We inserted Foley urinary catheters attached with elastic-wave-generating actuators into the urinary tracts of male rabbits. The treatment with the elastic acoustic waves maintained urine sterility for up to 9 days compared to 2 days in control catheterized animals. Scanning electron microscopy and bioburden analyses revealed diminished biofilm development on these catheters. The ability to prevent biofilm formation on indwelling devices and catheters can benefit the implanted medical device industry.

PillCam ESO in esophageal studies: improved diagnostic yield of 14 frames per second (fps) compared with 4 fps

BACKGROUND AND STUDY AIM

Capsule endoscopy, using the PillCam ESO and sending images at a rate of 4 frames per second (fps), has a high sensitivity and specificity in diagnosing gastroesophageal reflux disease (GERD) lesions. We tested a new device which produces images at a rate of 14 fps. The diagnostic performance and esophageal visualization of these two devices were compared.

PATIENTS AND METHODS

42 patients with GERD symptoms and eight patients with a history of Barrett's esophagus had an esophagogastroduodenoscopy (EGD). All patients underwent capsule endoscopy of the esophagus within 1 hour prior to EGD. The first 25 patients had a capsule endoscopy examination with the 4-fps device. The following 25 patients underwent capsule endoscopy under identical conditions but using the 14-fps device. The reader of the capsule endoscopy study was blinded to the EGD findings. A diagnosis of GERD or Barrett's esophagus was established with EGD. The findings at capsule endoscopy were compared with the EGD findings. We also examined how frequently the esophagus in its entirety was visualized by these two devices.

RESULTS

The 4-fps device diagnosed 16/19 cases of esophageal erosions or ulcers (sensitivity 84 %) and 6/8 cases of Barrett's esophagus (sensitivity 75 %). The 14-fps capsule diagnosed 16/16 cases of esophageal ulcers or erosions and 7/7 cases of Barrett's esophagus (sensitivity 100 %). The total diagnostic miss rate in the 4-fps group was 5/27 (18 %) whereas the diagnostic miss rate in the 14-fps group was 0/23 (0 %) P < 0.02). The upper esophageal sphincter (UES) was clearly identified in 6/25 patients (24 %) in the 4-fps group and in 20/25 patients (80 %) in the 14-fps group ( P < 0.01). The entire esophagus was well visualized in 3/25 patients (12 %) by the 4-fps device and in 19/25 (76 %) by the 14-fps device ( P < 0.01). The superiority of the 14-fps PillCam ESO capsule is consistent with the data obtained from fluoroscopic studies of swallowed PillCam capsules, showing that capsule speed may reach 20 cm/s. For the 14-fps PillCam this means one image transmitted per 3-cm segment at maximal capsule speed, therefore still allowing for full visualization of the entire esophagus.

CONCLUSIONS

Capsule endoscopy using the 14-fps PillCam ESO showed a greater sensitivity than that of the 4-fps device for identifying GERD. The 14-fps PillCam ESO was statistically superior to the 4-fps device in visualizing the opening of the UES and the entirety of the esophagus.

A prospective study of the diagnostic accuracy of PillCam ESO esophageal capsule endoscopy versus conventional upper endoscopy in patients with chronic gastroesophageal reflux diseases

INTRODUCTION

Endoscopy is commonly performed to evaluate for suspected or established esophageal diseases including gastroesophageal reflux disease (GERD) and its complications. The newly developed PillCam ESO Esophageal Capsule offers an alternative approach to visualize the esophagus and to evaluate patients with suspected esophageal disease.

AIM

Compare the accuracy (specificity, sensitivity, positive predictive value [PPV], and negative predictive value [NPV]) of esophageal capsule endoscopy (ECE) compared with esophagogastroduodenoscopy (EGD) in evaluating patients with GERD.

METHODS

A multicenter pivotal trial was conducted at seven sites. The PillCam ESO esophageal capsule is similar to the standard capsule endoscope used for the small bowel but acquires video images from both ends of the device at 2 frames/second/end. A total of 106 patients (93 GERD; 13 Barrett) underwent ECE followed by EGD. ECE videos were evaluated by an investigator blinded to EGD findings. A blinded adjudication committee reviewed all discrepant findings between ECE and EGD.

RESULTS

Sixty-six of 106 patients had positive esophageal findings, ECE identified esophageal abnormalities in 61 (sensitivity, 92%; specificity, 95%). The per-protocol sensitivity, specificity, PPV, and NPV of ECE for Barrett esophagus were 97%, 99%, 97%, and 99%, respectively, and for esophagitis 89%, 99%, 97%, and 94%, respectively. ECE was preferred over EGD by all patients. There were no adverse events related to ECE.

CONCLUSIONS

ECE is a convenient and sensitive method for visualization of esophageal mucosal pathology and may provide an effective method to evaluate patients for esophageal disease.

New insights into the pathophysiology of gastrointestinal graft-versus-host disease using capsule endoscopy

We investigated gastrointestinal graft-versus-host-disease using capsule endoscopy in patients with abdominal pain and/or diarrhea. We found severe pathology involving most of the gut including loss of villi, ulcerations, narrowing, bleeding and fistula formation. In 2 patients, capsule endoscopy alone established the diagnosis of graft-versus-host-disease. Some ulcerations were associated with cytomegalovirus infection.

Occult inflammatory small-bowel disease: not so occult anymore

Four cases are described in which reliance on small-bowel follow-through would have led to an incorrect diagnosis. In all cases, capsule endoscopy resulted in a diagnosis of inflammatory bowel disease, leading to successful treatment with mesalamine (PENTASA; Ferring Pharmaceuticals, Copenhagen, Denmark) and corresponding reductions in aphthous lesions on repeated capsule endoscopy. Based on our experience and a review of the literature, it is concluded that relying on a negative small-bowel follow-through examination to rule out small-bowel disease would be unfair to patients with suspected small-bowel disease.

The development and application of wireless capsule endoscopy

The introduction of the Video Capsule Endoscope (VCE) by Given Imaging Ltd. (Yoqneam, Israel) in 2001, and its subsequent approval by the FDA as a first line tool in the detection of abnormalities of the small bowel, is indicative of the rapid acceptance of capsule endoscopy by the practicing gastroenterological community. An extensive clinical trials program consistently revealed a high diagnostic yield of the VCE when compared to other diagnostic modalities of the small intestine. The capsule endoscope contains a miniature color video camera, illumination sources, lens, transmitter/controller, antenna, and a power source. It is small enough to easily swallow (11 x 26 mm), and it is propelled through the gastrointestinal (GI) tract by peristalsis. Its development was enabled by a series of technological breakthroughs that occurred at the close of the 20th century. The VCE is one of the most exciting examples of the recent trend for minimally invasive autonomous medical tools in diagnostic, monitoring, and therapeutic applications. Expanding applications of the VCE to additional parts of the GI tract, adding physiological sensors, and--in the more remote future--addition of therapeutic capabilities will likely occur as this new branch of endoscopy develops.

Présentation d’un cas atypique de rétinopathie hypertensive maligne chez une fillette

Stage IV hypertensive retinopathies in children have been described, but their incidence appears to be rare. Most etiologies are nephropathies. The authors present a clinical case of malignant high blood pressure in a young girl whose ophthalmological tests detected an unusual nephropathy, the Ask-Upmark kidney, illustrating the importance of determining high blood pressure chronicity and using Kirkendall's classification. Systematic fluorescein angiography and NMR on atypical subjects prevents the diagnosis of Leber neuroretinis, the main differential diagnosis. Early treatment of high blood pressure can avoid complications such as macular exudes.

Concurrent sequencing of full-dose CMF chemotherapy and radiation therapy in early breast cancer has no effect on treatment delivery

With the increasing use of breast-conserving therapy plus systemic chemotherapy for the treatment of early breast cancer, the optimal sequencing of radiation therapy and chemotherapy remains controversial. Sequencing of therapy may influence not only treatment delivery, but control rates, complications and cosmesis. The aim of this study was to evaluate whether concurrent sequencing of standard doses of CMF (cyclophosphamide, methotrexate and 5-fluorouracil) and adjuvant radiation therapy for early breast cancer impacted on optimum treatment delivery. As both an intravenous (i.v.) 3-week regimen and classic (standard) CMF were utilised in this study, both types of CMF were compared. The effect of sequencing on complications and treatment delays were also assessed. 116 patients treated with CMF chemotherapy and adjuvant tangent breast radiation were studied. 73 patients were treated prospectively with concurrent therapy and were retrospectively compared with a matched group of 40 patients treated with sequential or sandwich therapy. All patients had stage 1 or 2 cancers. There were no planned dose reductions introduced for either treatment modality. Concurrent sequencing had no impact on the ability to deliver optimum radiation or chemotherapy doses. There was no significant difference in acute Radiation Therapy Oncology Group (RTOG) skin reactions or complications between the two groups. Although small, there was a significant delay (1.32 days (0-15 versus 0.36 (0-7)) in the concurrent group (P=0.03) in the delivery of radiation therapy. Sequencing had no significant effect on haematological parameters. 'Standard' CMF had a more profound effect on treatment delivery than i.v. CMF (Radiation delay 2.2 days versus 0.26, P=0.002, % chemotherapy delivered 93% versus 99% P=0.000004). At a mean follow-up of 2.6 years, there was no difference in the cosmetic scores between the two groups. Both local and distant control rates were excellent. This study has shown that standard radiation therapy can be delivered safely concurrently with CMF chemotherapy. Whether this approach may lead to better control rates in the future needs further study.

Initial experience of wireless-capsule endoscopy for evaluating occult gastrointestinal bleeding and suspected small bowel pathology

OBJECTIVE

Small bowel pathology can be diagnosed using enteroscopy (which has limitations) and by x-ray (which is not sensitive for flat lesions). For the first time ever, we used a new technique, wireless-capsule video endoscopy, to diagnose small bowel pathology. Our aim was to prove the effectiveness and safety of this technology.

METHODS

We used the Given (M2A) system in 35 patients, aged 18-80 yr, who suffered from unexplained GI bleeding or in whom there was a clinical suspicion of small bowel disease. All patients had a small bowel x-ray. Patients with suspected narrowing of the bowel or a clinical suspicion of intestinal obstruction, or with a history of major abdominal surgery, were excluded from the study. No pregnant women or patients with diabetes mellitus were included.

RESULTS

Abnormal findings were found in 29 of 35 (82.9%) patients. Twenty-two of 29 (75.9%) patients had significant pathological findings explaining their clinical situation. Diagnostic yield was therefore 62.9% (22 of 35 patients). Among the various findings, the capsule detected ulcers, erosions, angiodysplasia, and submucosal lesions. The source of bleeding was found in 15 of 20 patients with iron deficiency anemia. There were no immediate significant side effects and none reported up to 1 month after ingestion of the capsule. The capsule was evacuated by all patients.

CONCLUSIONS

The wireless-capsule video endoscope, in our study of feasibility, was proven to be a safe, painless, ambulatory, and effective procedure, with a high diagnostic yield. Its major importance is in diagnosing small bowel pathology where all other imaging techniques have failed.

Effect of precocious collection on semen output and quality in young Holstein bulls

Semen production units compete heavily with each other, so they tend to select and collect bulls at the earliest possible age, even before puberty, in order to reduce the interval between generations. This study is a retrospective analysis of the effect of precocious collection on semen quality in Holstein bulls. The semen parameters of early- and late-maturing bulls collected before and after 410 days of age, respectively, were compared over two periods, 1991-1995 and 1997-1999. These periods were defined in relation to the collection rhythms (three collections of two ejaculates at 15 days interval before 1996 and adaptation of the collection rhythms to individual physiological capacity after 1996) and the collection conditions. The effects of age, precocious collection and the interaction between age and precocious collection on mean semen parameters (volume of the ejaculate, sperm motility, percent of motile spermatozoa per ejaculate, total sperm concentration and mobile sperm concentration) measured on collections 1-6 (n = 358 for 1991-1995 and n = 121 for 1997-1999), 7-12 (n = 255 for 1991-1995 and n = 80 for 1997-1999) and 13-18 (n = 92 for 1991-1995 and n = 36 for 1997-1999) were studied by covariance analysis. The semen quality of bulls collected at the early age differed from that of bulls collected after 410 days of age for the first period when the collection rhythm was intense. No effect of precocious collection was evidenced for the second period, suggesting the importance of individual adaptation of the collection rhythm to sexual maturation in young bulls. Early collections at a semen production unit reduced the time needed to obtain the number of insemination straws required for the progeny-testing program by 40 days. Early sperm collection is, thus, of economic and technical interest in well managed semen production units.

Quantifying learning in medical students during a critical care medicine elective: a comparison of three evaluation instruments

OBJECTIVE

To compare three different evaluative instruments and determine which is able to measure different aspects of medical student learning.

DESIGN

Student learning was evaluated by using written examinations, objective structured clinical examination, and patient simulator that used two clinical scenarios before and after a structured critical care elective, by using a crossover design.

PARTICIPATION

Twenty-four 4th-yr students enrolled in the critical care medicine elective.

INTERVENTIONS

All students took a multiple-choice written examination; evaluated a live simulated critically ill patient, requested data from a nurse, and intervened as appropriate at different stations (objective structured clinical examination); and evaluated the computer-controlled patient simulator and intervened as appropriate.

MEASUREMENTS AND MAIN RESULTS

Students' knowledge was assessed by using a multiple-choice examination containing the same data incorporated into the other examinations. Student performance on the objective structured clinical examination was evaluated at five stations. Both objective structured clinical examination and simulator tests were videotaped for subsequent scores of responses, quality of responses, and response time. The videotapes were reviewed for specific behaviors by faculty masked to time of examination. Students were expected to perform the following: a) assess airway, breathing, and circulation; b) prepare a mannequin for intubation; c) provide appropriate ventilator settings; d) manage hypotension; and e) request, interpret, and provide appropriate intervention for pulmonary artery catheter data. Students were expected to perform identical behaviors during the simulator examination; however, the entire examination was performed on the whole-body computer-controlled mannequin. The primary outcome measure was the difference in examination scores before and after the rotation. The mean preelective scores were 77 +/- 16%, 47 +/- 15%, and 41 +/- 14% for the written examination, objective structured clinical examination, and simulator, respectively, compared with 89 +/- 11%, 76 +/- 12%, and 62 +/- 15% after the elective (p <.0001). Prerotation scores for the written examination were significantly higher than the objective structured clinical examination or the simulator; postrotation scores were highest for the written examination and lowest for the simulator.

CONCLUSION

Written examinations measure acquisition of knowledge but fail to predict if students can apply knowledge to problem solving, whereas both the objective structured clinical examination and the computer-controlled patient simulator can be used as effective performance evaluation tools.

Generation of a high-density rat EST map

We have developed a high-density EST map of the rat, consisting of >11,000 ESTs. These ESTs were placed on a radiation hybrid framework map of genetic markers spanning all 20 rat autosomes, plus the X chromosome. The framework maps have a total size of approximately 12,400 cR, giving an average correspondence of 240 kb/cR. The frameworks are all LOD 3 chromosomal maps consisting of 775 radiation-hybrid-mapped genetic markers and ESTs. To date, we have generated radiation-hybrid-mapping data for >14,000 novel ESTs identified by our Rat Gene Discovery and Mapping Project (http://ratEST.uiowa.edu), from which we have placed >11,000 on our framework maps. To minimize mapping errors, ESTs were mapped in duplicate and consensus RH vectors produced for use in the placement procedure. This EST map was then used to construct high-density comparative maps between rat and human and rat and mouse. These maps will be a useful resource for positional cloning of genes for rat models of human diseases and in the creation and verification of a tiling set of map order for the upcoming rat-genome sequencing.

Generation of a high-density rat EST map

We have developed a high-density EST map of the rat, consisting of >11,000 ESTs. These ESTs were placed on a radiation hybrid framework map of genetic markers spanning all 20 rat autosomes, plus the X chromosome. The framework maps have a total size of approximately 12,400 cR, giving an average correspondence of 240 kb/cR. The frameworks are all LOD 3 chromosomal maps consisting of 775 radiation-hybrid-mapped genetic markers and ESTs. To date, we have generated radiation-hybrid-mapping data for >14,000 novel ESTs identified by our Rat Gene Discovery and Mapping Project (http://ratEST.uiowa.edu), from which we have placed >11,000 on our framework maps. To minimize mapping errors, ESTs were mapped in duplicate and consensus RH vectors produced for use in the placement procedure. This EST map was then used to construct high-density comparative maps between rat and human and rat and mouse. These maps will be a useful resource for positional cloning of genes for rat models of human diseases and in the creation and verification of a tiling set of map order for the upcoming rat-genome sequencing.

Patient-controlled interscalene analgesia with ropivacaine 0.2% versus bupivacaine 0.15% after major open shoulder surgery: the effects on hand motor function

We compared the effects of patient-controlled interscalene analgesia with ropivacaine 0.2% and patient-controlled interscalene analgesia (PCIA) with bupivacaine 0.15% on hand grip strength after major open shoulder surgery. Sixty patients scheduled for elective major shoulder surgery were prospectively randomized to receive in a double-blinded fashion either ropivacaine or bupivacaine through an interscalene catheter. Before surgery, all patients received an interscalene block (ISB) with either 40 mL of 0.6% ropivacaine or 40 mL of 0.5% bupivacaine. Six h after ISB, the patients received a continuous infusion of either 0.2% ropivacaine or 0.15% bupivacaine for 48 h. In both groups, the PCIA infusion rate was 5 mL/h plus a bolus of 4 mL with a lockout time of 20 min. Strength in the hand was assessed preoperatively, 24 h, and 48 h after ISB and 6 h after stopping the infusion of local anesthetic. The presence of paresthesia in the fingers was checked. Pain relief was assessed using a visual analog scale; side effects were noted, and the patients rated their satisfaction 54 h after the block. A significant decrease of strength in the hand was observed in the Bupivacaine group 24, 48, and 54 h after ISB (P < 0.05). Paresthesia was more frequently reported in the Bupivacaine group for the second and third fingers 48 h after ISB (P < 0.05) and in the first three fingers 6 h after discontinuation of the local anesthetic infusion (P: < 0.05). The pain score was similar in the two groups at all times, and patient satisfaction was comparable between the two groups. We conclude that the use of the PCIA technique with ropivacaine 0.2% or bupivacaine 0.15% provides a similar pain relief after major shoulder surgery. However, ropivacaine 0.2% is associated with better preservation of strength in the hand and less paresthesia in the fingers.

IMPLICATIONS

We compared the patient-controlled interscalene analgesia technique with ropivacaine 0.2% and bupivacaine 0.15% after major open shoulder surgery. For similar pain control ropivacaine is associated with better preservation of strength in the hand and less paresthesia in the fingers.