Post-ERCP cholecystitis: Incidence, characteristics, and outcomes from a prospective multicenter biliary endoscopy registry

BACKGROUND AND AIMS

The incidence, risk factors, and outcomes of post-ERCP cholecystitis are poorly described. We aimed to describe cases of post-ERCP cholecystitis from a prospective multicenter registry with protocolized 30-day follow-up.

METHODS

Patient- and procedure-related data from 7 centers were obtained. The primary outcome was post-ERCP cholecystitis, defined according to a Delphi-based criteria and causal attribution system. Risk factors and outcomes were described for all cases.

RESULTS

Seventeen cases of post-ERCP cholecystitis were identified among 4428 patients with gallbladders undergoing ERCP between 2018 and 2023 (incidence, 0.38%; 95% confidence interval, 0.20-0.57). In ERCPs with covered metal stenting, 7 of 467 resulted in cholecystitis (incidence, 1.50%; 95% confidence interval, 0.40-2.60). Patients had symptoms at a median of 5 days (interquartile range, 5) after ERCP. Management strategies included cholecystectomy, percutaneous cholecystostomy, and endoscopic stent removal/exchange.

CONCLUSIONS

Estimates of post-ERCP cholecystitis incidence can inform discussions around procedural risk.

Development and validation of a practical clinical risk prediction model for post-endoscopic retrograde cholangiopancreatography pancreatitis

Background

Pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) can lead to significant morbidity and mortality. We aimed to develop an accurate post-ERCP pancreatitis risk prediction model using easily obtainable variables.

Methods

Using prospective multi-center ERCP data, we performed logistic regression using stepwise selection on several patient-, procedure-, and endoscopist-related factors that were determined a priori. The final model was based on a combination of the Bayesian information criterion and Akaike's information criterion performance, balancing the inclusion of clinically relevant variables and model parsimony. All available data were used for model development, with subsequent internal validation performed on bootstrapped data using 10-fold cross-validation.

Results

Data from 3021 ERCPs were used to inform models. There were 151 cases of post-ERCP pancreatitis (5.0% incidence). Variables included in the final model included female sex, pancreatic duct cannulation, native papilla status, pre-cut sphincterotomy, increasing cannulation time, presence of biliary stricture, patient age, and placement of a pancreatic duct stent. The final model was discriminating, with a receiver operating characteristic curve statistic of 0.79, and well-calibrated, with a predicted risk-to-observed risk ratio of 1.003.

Conclusions

We successfully developed and internally validated a promising post-ERCP pancreatitis clinical prediction model using easily obtainable variables that are known at baseline or observed during the ERCP procedure. The model achieved an area under the curve of 0.79. External validation is planned as additional data becomes available.

Effect of Disposable Elevator Cap Duodenoscopes on Persistent Microbial Contamination and Technical Performance of Endoscopic Retrograde Cholangiopancreatography: The ICECAP Randomized Clinical Trial

Importance

Infection transmission following endoscopic retrograde cholangiopancreatography (ERCP) can occur due to persistent contamination of duodenoscopes despite high-level disinfection to completely eliminate microorganisms on the instrument.

Objective

To determine (1) contamination rates after high-level disinfection and (2) technical performance of duodenoscopes with disposable elevator caps compared with those with standard designs.

Design, Setting, and Participants

In this parallel-arm multicenter randomized clinical trial at 2 tertiary ERCP centers in Canada, all patients 18 years and older and undergoing ERCP for any indication were eligible.

Intervention

The intervention was use of duodenoscopes with disposable elevator caps compared with duodenoscopes with a standard design.

Main Outcomes and Measures

Coprimary outcomes were persistent microbial contamination of the duodenoscope elevator or channel, defined as growth of at least 10 colony-forming units of any organism or any growth of gram-negative bacteria following high-level disinfection (superiority outcome), and technical success of ERCP according to a priori criteria (noninferiority outcome with an a priori noninferiority margin of 7%), assessed by blinded reviewers.

Results

From December 2019 to February 2022, 518 patients were enrolled (259 disposable elevator cap duodenoscopes, 259 standard duodenoscopes). Patients had a mean (SD) age of 60.7 (17.0) years and 258 (49.8%) were female. No significant differences were observed between study groups, including in ERCP difficulty. Persistent microbial contamination was detected in 11.2% (24 of 214) of standard duodenoscopes and 3.8% (8 of 208) of disposable elevator cap duodenoscopes (P = .004), corresponding to a relative risk of 0.34 (95% CI, 0.16-0.75) and number needed to treat of 13.6 (95% CI, 8.1-42.7) to avoid persistent contamination. Technical success using the disposable cap scope was noninferior to that of the standard scope (94.6% vs 90.7%, P = .13). There were no differences between study groups in adverse events and other secondary outcomes.

Conclusions and Relevance

In this randomized clinical trial, disposable elevator cap duodenoscopes exhibited reduced contamination following high-level disinfection compared with standard scope designs, without affecting the technical performance and safety of ERCP.

Trial Registration

ClinicalTrials.gov Identifier: NCT04040504.

Cohort profile: The Forzani & MacPhail Colon Cancer Screening Centre biorepository, Calgary, Alberta

PURPOSE

The Colon Cancer Screening Centre (CCSC) biorepository (Calgary, Canada) supports a wide range of research topics related to colorectal cancer (CRC) by collecting, and storing biospecimens (blood, urine, normal colon tissue) from consenting patient participants. Housing unique biospecimens along with detailed participant lifestyle and health history questionnaire data, the CCSC biorepository can support a variety of research related to CRC risk factors, biomarkers, genetic causes and more.

PARTICIPANTS

Currently, 2292 average risk CRC patients have consented to participate in the CCSC cohort and have provided stored biospecimens. The collected samples and data provide important high-quality materials for research, discovery and evaluation related to CRC screening and carcinogenesis and is available for access by outside researchers. In addition to biological samples, the CCSC collects detailed patient information on their lifestyle, physical activity and dietary patterns through questionnaires at the time of their enrolment.

FINDINGS TO DATE

The majority of participants (75%) are between 50 and 64 years of age. Women make up 46% (1055) of the cohort. Additional characteristics of the cohort included 44% reporting a body mass index of 25-30 kg/m² (overweight), 53% having never smoked tobacco and 13% having a family member with CRC.

FUTURE PLANS

The CCSC cohort plans to include the recruitment of high risk CRC cohorts. High-risk participants would comprise patients with a positive faecal immunochemical test and family history of CRC.

Evaluation of a novel Surgicric® cricothyroidotomy device for emergency tracheal access in a porcine model

A can't intubate, can't ventilate scenario can result in morbidity and death. Although a rare occurrence (1:50 000 general anaesthetics), it is crucial that anaesthetists maintain the skills necessary to perform cricothyroidotomy, and are well-equipped with appropriate tools. We undertook a bench study comparing a new device, Surgicric(®) , with two established techniques; the Melker Emergency Cricothyroidotomy, and a surgical technique. Twenty-five anaesthetists performed simulated emergency cricothyroidotomy on a porcine model, with the primary outcome measure being insertion time. Secondary outcomes included success rate, tracheal trauma and ease of use. The surgical technique was fastest. The median (IQR [range]) was 81 (62-126 [37-300]) s, followed by the Melker 124 (100-217 [71-300]) s, and the Surgicric 127 (68-171 [43-300]), p = 0.003. The Surgicric device was the most traumatic, as evaluated by a blinded Ear, Nose and Throat surgeon. Subsequently, the authors contacted the device manufacturer, who has now modified the kit in the hope that its clinical application might be improved. Further studies are required to evaluate the revised model.

Effectiveness of a battery-powered toothbrush on plaque removal: comparison with four manual toothbrushes

The objective of these four clinical studies was to evaluate the efficacy of the Colgate Actibrush battery-powered toothbrush in comparison with four top-selling manual European toothbrushes (Dr. Best Flex Toothbrush [Germany]; Reach Triple Action Ultra Clean Toothbrush [Germany]; Jordan Multi-Action Toothbrush [Norway]; and Sanogyl Systeme In'Side Double Action Toothbrush [France]) for plaque removal. Each clinical study used a single-use, examiner-blind design in which the Colgate Actibrush battery-powered toothbrush was compared with one of the 4 manual toothbrushes for removal of plaque in adult subjects after 24 hours of no oral hygiene. Supragingival plaque formation was assessed prebrushing and after a 1-minute supervised brushing with either the battery-powered toothbrush or 1 of the manual toothbrushes. After 24 hours of no oral hygiene, Colgate Actibrush removed statistically significantly more plaque than did all 4 of the manual toothbrushes. The results of these clinical studies support the conclusion that Colgate Actibrush is clinically superior for the control of supragingival plaque, compared with the leading selling European manual toothbrushes.

Atopic asthma: differential activation phenotypes among memory T helper cells

BACKGROUND

T cells have been implicated in the pathogenesis of atopic asthma. We have previously shown that memory T helper cells (CD4+CD45RO+) are preferentially activated relative to naïve T helper cells (CD4+CD45RA+) after bronchial allergen challenge. However, specific T helper subpopulations that are activated in atopy and/or asthma remain undefined.

OBJECTIVE

To determine the T helper subpopulations and activation phenotypes relevant to acute and stable asthma that may be common with or distinct from atopy.

METHODS

Two groups of atopic asthmatics (ten acute and nine stable asthmatics) and two non-asthmatic groups (14 non-asthmatic atopics and eight normal non-atopic controls) were analysed. Ten acute asthmatics were assessed in the emergency room during an acute episode (FEV1 43.6% +/- 18.4). Nine stable asthmatics were assessed during a symptom-free period (FEV1 85% +/- 6). Using multiple colour flow cytometry we analysed T cell subpopulations and the expression of IL-2-receptor (IL-2R) and MHC-class II antigens (MHC II) on naïve and memory T helper cells in the peripheral blood of asthmatic and non-asthmatic groups.

RESULTS

Atopic asthmatics (acute and stable) had an increased percentage of memory T helper cells expressing IL-2R compared with normal non-atopics (mean SD 16.1 +/- 6%, 12.4 +/- 2% and 7.7 +/- 1.8%, P < 0.05) but not compared with non-asthmatic atopics (10 +/- 3.5%). Naïve T helper cells had low expression of IL-2R and MHC II in all four groups. MHC II antigen expression was increased in memory T helper cells of asthmatics (acute and stable) compared with normal non-atopics (13.9 +/- 7.5, 10.6 +/- 5 and 4.9 +/- 2.5, P < 0.05) but not compared with non-asthmatic atopics (7.92 4). A novel finding was that IL-2R and the MHC II molecules were mainly expressed in non-overlapping populations and coexpression was found predominantly on memory T helper cells. Asthmatics (acute and stable) had higher proportion of double positive memory T helper cells (IL-2R+MHC II+) compared with both non-asthmatic groups (P < 0.05).

CONCLUSIONS

We demonstrate a differential expression of IL-2R+ and MCH II+ on CD45RO+ T helper cells that would suggest that there are three subsets of activated memory T helper cells in asthmatics. Two non-overlapping IL-2R+ or MHC II+ CD45RO+ T helper cells and a third subpopulation of activated cells that coexpress IL-2R and MHC II (double positives). This latter subpopulation is significantly higher in asthmatics (acute or stable) compared with both non-asthmatic groups, suggesting a specific T helper activation phenotype distinct to atopic asthmatics as compared with atopic non-asthmatics.

An intervention strategy for workplace stress

This article explores a range of sources of workplace stress and a three-prong intervention strategy for managing pressures at work. The three approaches highlighted are primary, secondary, and tertiary prevention interventions. Primary is concerned with stressor reduction, secondary with stress management and tertiary with remedial support. In addition, a number of wider policy issues are suggested, such as risk assessment, economic incentives, and specific measures to help small- and medium-sized workplaces in managing workplace stress.

A critical pathway to evaluate suspected deep vein thrombosis

Uncertainty regarding the optimal evaluation of suspected deep vein thrombosis (DVT) results in wide variations in practice, even within the same institution. To address variation in practice while maximizing the efficiency and quality of care, our institution developed a critical pathway guideline for the emergency department evaluation of patients suspected of having DVT. We present the critical pathway and the clinical rationale underlying its recommendations. The critical pathway was developed by a multidisciplinary team using chart review of practice at our institution, benchmarking at other institutions, and review and discussion of the medical literature. Consensus was achieved for the selection of ultrasound as the primary imaging test for all patients and for recommending initial doses of heparin sodium that are higher than the current norm at our institution to reduce the length of time required to achieve therapeutic anticoagulation. A total time for patient evaluation of 5 hours or less was established as the target. Controversy arose in two key areas: (1) the treatment of patients with normal ultrasound scans when high clinical suspicion for DVT exists and (2) the evaluation and treatment of suspected isolated calf-vein DVT. In its final form, the critical pathway recommendations seek to balance the benefits of standardization with the prerogatives of physicians to make decisions tailored to individual patients.

Maturation antigens present in epididymis of cynomolgus monkeys (Macaca fascicularis)

PROBLEM

The present study was carried out to evaluate the changes in morphology and motility of spermatozoa retrieved from different regions of the epididymis of the cynomolgus monkey. The role of the epididymis in sperm maturation is assessed by assaying protein synthesis within different regions of the epididymis and by correlating these with changes in spermatozoal membrane surface components.

METHOD

Spermatozoa retrieved from proximal caput (CP), midcorpus (CO), and distal cauda (CD) were assessed by morphological evaluation and computerized motion analysis. Membrane surface proteins of spermatozoa of different epididymal regions were extracted and separated on SDS-PAGE. Protein synthesis of different regions of the epididymis were assayed in vitro by [35S]-methionine incorporation.

RESULTS

Spermatozoa obtained from different regions of the epididymis differed morphologically only in the location of the cytoplasmic droplet. Specifically, from caput to corpus to cauda, sperm steadily exhibited a more distal cytoplasmic droplet. When the motion parameters of velocity and amplitude of the lateral head were examined, CP spermatozoa were not progressively motile, and poor duration of movement was most noticeable for CO spermatozoa compared with CD spermatozoa. Membrane extracts from CP, CO, and CD epididymal monkey spermatozoa differed in only several protein bands. Three major polypeptide bands (19, 30, and 60 kD) that were absent from CP sperm were present in CO and CD sperm, with the latter showing increased intensity. Several polypeptides were lost from the sperm during epididymal transit: a 25-kD band was lost in CD sperm; and bands at 27 kD, 50-52 kD, and 90 kD were only present for CP sperm. Additionally, regional differences exist for proteins secreted by the cynomolgus monkey epididymis. Proteins (15, 25 kD) were only secreted in the CP region; a 38-kD protein increased in intensity from the CP to CD regions, whereas a 21-kD protein was absent from CD-secreted medium.

CONCLUSION

These preliminary findings permitted the identification of several "maturational antigens" for cynomolgus monkey spermatozoa. Further characterization of these antigens that are modified during epididymal transit is warranted to determine their significance in the acquisition of progressive motility and fertilizing ability by epididymal spermatozoa.

Selective involvement of the spinal trigeminal nucleus in the conditioned nictitating membrane reflex of the rabbit

These experiments were performed to test the hypothesis that a region associated with the trigeminal nuclear complex is selectively involved in mediating the classically conditioned nictitating membrane reflex in the rabbit. Microinjections of Lidocaine were used to produce a temporary, localized block of neural activity following the conditioning of the reflex using a standard tone/air puff-paired stimulus paradigm. Data indicate that the injection of Lidocaine at the medial pars oralis/reticular formation junction results in a selective suppression of the conditioned reflex.

A new clinical-anatomic staging system for evaluating prognosis and treatment of prostatic cancer

Because the existing systems of staging for prostatic cancer depend exclusively on the extent of anatomic spread, the stages do not demarcate distinctive patterns of survival, particularly in patients with extremely good or poor prognoses. In this research, we demonstrate that the evaluation of prognosis and therapy can be improved if anatomic staging is augmented by various features of the patients' clinical severity. In 280 patients with prostatic cancer, we first created rating scales for severity of three distinct clinical variables: symptoms referable to cancer; host factors unrelated to cancer; and overall level of function. In univariate analysis each of these clinical variables substantially affected 5-year survival for patients with similar anatomic stages, but in multivariate analysis, only the first two (symptoms and host factors) remained impressive. Retaining the anatomic stages and adding the two most important clinical variables, we then created a composite new staging system, containing four clinical-anatomic (C-A) categories. The new C-A categories were statistically more distinctive than conventional anatomic stages, and demarcated patients with more extreme high (91%) and low (8%) 5-year survival rates. In addition to the increased prognostic precision, the new C-A staging system demonstrated an important distinction in treatment. Although radical radiotherapy seemed superior to palliative therapy within conventional anatomic stages, the survival differences disappeared within the C-A stages.

Equivocal test results and prognostic staging uncertainties in the evaluation of patients with cancer of the prostate

In the staging of cancer, equivocal test results may occur in subjectively evaluated imaging procedures whose interpretations raise the possibility of metastases but are too uncertain to rule in or rule out metastatic spread, and in tests whose repetitions in the same patient yield conflicting results about dissemination. We assessed the frequency and prognostic correlates of test results giving equivocal evidence of disseminated (Stage IV) disease in an inception cohort of 280 patients receiving initial treatment for prostatic cancer between 1973-76. Among tests used for clinical staging, lymphangiograms (equivocal in 28 percent of tested patients), bone scans (equivocal in 25 percent of tested patients), and bone radiographs (equivocal in 20 percent of tested patients) most frequently yielded interpretations that equivocally suggested metastatic spread. Eighty-three (45 percent) of the 185 patients without clear-cut dissemination (Stages I-III) had at least one equivocal test result that suggested dissemination and that remained unresolved at the time of selection of therapy. Five-year survival (30 percent) for the 20 patients with local extracapsular spread (Stage III) and multiple equivocal results suggesting dissemination was identical to that for patients with clear-cut dissemination. In contrast, other patients with equivocal dissemination in Stages I-III had survival rates similar to those patients in the same stage and lacking equivocal dissemination. Unresolved equivocal staging results frequently complicate management decisions for patients with prostatic cancer. Survival analyses aid these decisions by demonstrating that equivocal findings of dissemination are prognostically unimportant unless they are multiple and occur in the context of unequivocal extracapsular spread.

Comparison and evaluation of four serological tests for detection of antibodies to Aujeszky's disease virus

Four methods used for the detection of antibodies to Aujeszky's disease virus in porcine sera were compared. The serum neutralisation test, countercurrent immunoelectrophoresis test, micro-immunodiffusion test and the enzyme-linked immunosorbent assay (Elisa) were assessed with particular regard to their use in large scale screening of porcine serum samples. The Elisa test was found to be the most suitable on the grounds of sensitivity, speed and cost.

The [14C]-aminopyrine breath test. A comparison of different forms of analysis

1 Following ingestion of [14C]-aminopyrine, breath 14CO2 data were analysed from normal individuals, patients with hepatic disease, epileptics receiving anticonvulsant therapy and volunteers before and after treatment with glutethimide. 2 The 'standard' 2 h [14C]-aminopyrine breath test discriminated successfully between the main groups but failed to detect the change in microsomal enzyme function produced by glutethimide. 3 A 'modified' form of the 2 h breath test calculated from the area under the breath specific activity curve detected the increase in demethylation following glutethimide. 4 The breath elimination constant (Kb) derived from the breath 14CO2 disappearance curve was as sensitive as the 'modified' 2 h breath test and was simpler to compute. 5 Glutethimide 500 mg/day for 14 days resulted in a 42% increase in the metabolic clearance of antipyrine and a 26% increase in demethylation of [14C]-aminopyrine.