Nurse-Administered Propofol Continuous Infusion Sedation: A New Paradigm for Gastrointestinal Procedural Sedation.

INTRODUCTION: Nurse-Administered Propofol Continuous Infusion Sedation (NAPCIS) is a new nonanesthesia propofol delivery method for gastrointestinal endoscopy. NAPCIS is adopted from the computer-assisted propofol sedation (CAPS) protocol. We evaluated the effectiveness, efficiency, and safety of NAPCIS in low-risk subjects. METHODS: Between December 2016 and July 2017, patients who underwent esophagogastroduodenoscopy or colonoscopy with NAPCIS at our center were compared against 2 historical control groups of similar patients who had undergone procedures with CAPS or midazolam and fentanyl (MF) sedation. RESULTS: The mean age of the NAPCIS cohort (N = 3,331) was 55.2 years (45.8% male) for 945 esophagogastroduodenoscopies and 57.8 years (48.7% male) for 2,386 colonoscopies. The procedural success rates with NAPCIS were high (99.1%-99.2%) and similar to those seen in 3,603 CAPS (98.8%-99.0%) and 3,809 MF (99.0%-99.3%) controls. NAPCIS recovery times were shorter than both CAPS and MF (24.8 vs 31.7 and 52.4 minutes, respectively; P < 0.001). On arrival at the recovery unit, 86.6% of NAPCIS subjects were recorded as "Awake" compared with 82.8% of CAPS and 40.8% of MF controls (P < 0.001). Validated clinician and patient satisfaction scores were generally higher for NAPCIS compared with CAPS and MF subjects. For NAPCIS, there were only 4 cases of oxygen desaturation requiring transient mask ventilation and no serious sedation-related complications. These low complication rates were similar to those seen with CAPS (8 cases of mask ventilation) and MF (3 cases). DISCUSSION: NAPCIS seems to be a safe, effective, and efficient means of providing moderate sedation for upper endoscopy and colonoscopy in low-risk patients.

Nurse-Administered Propofol Continuous Infusion Sedation for Gastrointestinal Endoscopy in Patients Who Are Difficult to Sedate.

BACKGROUND & AIMS: Patients who chronically use alcohol, marijuana, or opioids, or suffer from post-traumatic stress disorder (PTSD), can be difficult to sedate with midazolam and fentanyl, and often are referred for monitored anesthesia care during endoscopy. Nurse-administered propofol continuous infusion sedation (NAPCIS), which confers the benefit of propofol-based sedation without the added expense of anesthesia, is effective and safe for sedation of healthy patients. We investigated whether NAPCIS also is effective for patients who are difficult to sedate. METHODS: We performed a retrospective study of patients who underwent upper endoscopy or colonoscopy with NAPCIS at a single center from January 2018 through April 2018. We reviewed records from patients who were heavy users of alcohol (n = 105), daily users of marijuana (n = 267) or opioids (n = 178), had a diagnosis of PTSD (n = 91), or were none of these (controls, n = 786). We compared mean fentanyl and propofol doses (adjusted for body weight), procedure and recovery times, procedure success rates, and adverse events. RESULTS: Compared with the controls, the marijuana group required higher mean adjusted sedative doses for colonoscopies (0.6 vs 0.4 mcg/kg fentanyl and 5.0 vs 4.7 mg/kg propofol; P ≤ .025 for both) and upper endoscopies (0.8 vs 0.3 mcg/kg fentanyl and 3.7 vs 3.2 mg/kg propofol; P ≤ .021 for both), the PTSD group required a higher dose of fentanyl for colonoscopies (0.6 vs 0.4 mcg/kg; P = .009), and the alcohol group required a higher dose of fentanyl for upper endoscopies (0.7 vs 0.3 mcg/kg; P < .001). Procedure success rates were high (95.1%-100%) and did not differ significantly between the difficult-to-sedate groups and controls; mean procedure times (7.0-9.0 minutes for upper endoscopies, 21.1-22.9 minutes for colonoscopies) and recovery times (22.5-29.6 minutes) also were similar among groups. Upper endoscopies were associated with lower sedative doses and shorter procedure and recovery times than colonoscopies. Sedation-related adverse events were rare in all groups (only 26 cases total), and there were no serious complications or deaths. CONCLUSIONS: NAPCIS seems to be a safe and effective means of providing sedation for endoscopy to patients who may be difficult to sedate owing to alcohol, marijuana, or opioid use, or PTSD.

Changes in Lower Gastrointestinal Bleeding Presentation, Management, and Outcomes Over a 10-Year Span.

BACKGROUND: There are only limited data available on changes in the etiology, management, and clinical outcomes in patients with lower gastrointestinal bleeding over the past decade. STUDY: We compared 2 groups of consecutive patients hospitalized with lower gastrointestinal bleeding during 2 time periods: 2005 to 2007 (301 patients) and 2015 to 2017 (249 patients). RESULTS: Compared with the 2005 to 2007 group, the mean Charlson comorbidity index in the 2015 to 2017 group was higher (5.0±2.6 vs. 6.0±3.0, P=0.028), whereas the use of computerized tomographic angiography and small bowel capsule endoscopy was more common (12.9% vs. 58.1%, P<0.001, and 28.8% vs. 69.0%, P=0.031, respectively). In 2005 to 2007, ischemic colitis (12.0%) was the most common confirmed etiology of bleeding and diverticular bleeding the second most common (8.6%), whereas in 2015 to 2017, diverticular bleeding was the most common etiology (10.4%), followed by angiodysplasia (8.4%). Small bowel bleeding sources were confirmed more often in the 2015 to 2017 group (P=0.017). Endoscopic treatment was attempted in 16.6% of patients in 2005 to 2007 versus 25.3% in 2015 to 2017 (P=0.015). Higher rebleeding rates, longer hospitalization durations (4.6±4.3 vs. 5.5±3.4 d, P=0.019), and a higher proportion of patients needing a transfusion (62.0% vs. 78.4%, P=0.016) were noted in 2015 to 2017. CONCLUSIONS: Over a 10-year span, there were several notable changes: (1) more comorbidities in patients hospitalized for lower gastrointestinal bleeding; (2) marked increase in the use of computerized tomographic angiography and capsule endoscopy for diagnostic evaluation; and (3) longer hospitalization durations and greater need for blood transfusion, possibly reflecting the selection of sicker patients for in-patient management in 2015 to 2017.

Computer-Assisted Propofol Sedation for Esophagogastroduodenoscopy Is Effective, Efficient, and Safe.

BACKGROUND AND AIMS: Computer-assisted propofol sedation (CAPS) allows non-anesthesiologists to administer propofol for gastrointestinal procedures in relatively healthy patients. As the first US medical center to adopt CAPS technology for routine clinical use, we report our 1-year experience with CAPS for esophagogastroduodenoscopy (EGD). METHODS: Between September 2014 and August 2015, 926 outpatients underwent elective EGDs with CAPS at our center. All EGDs were performed by 1 of 17 gastroenterologists certified in the use of CAPS. Procedural success rates, procedure times, and recovery times were compared against corresponding historical controls done with midazolam and fentanyl sedation from September 2013 to August 2014. Adverse events in CAPS patients were recorded. RESULTS: The mean age of the CAPS cohort was 56.7 years (45% male); 16.2% of the EGDs were for variceal screening or Barrett's surveillance and 83.8% for symptoms. The procedural success rates were similar to that of historical controls (99.0% vs. 99.3%; p = 0.532); procedure times were also similar (6.6 vs. 7.4 min; p = 0.280), but recovery time was markedly shorter (31.7 vs. 52.4 min; p < 0.001). There were 11 (1.2%) cases of mild transient oxygen desaturation (< 90%), 15 (1.6%) cases of marked agitation due to undersedation, and 1 case of asymptomatic hypotension. In addition, there were six (0.6%) patients with more pronounced desaturation episodes that required brief (< 1 min) mask ventilation. There were no other serious adverse events. CONCLUSIONS: CAPS appears to be a safe, effective, and efficient means of providing sedation for EGD in healthy patients. Recovery times were much shorter than historical controls.

Reducing Cost and Complexity of Fecal Microbiota Transplantation Using Universal Donors for Recurrent Clostridium difficile Infection.

INTRODUCTION: Fecal microbiota transplantation resolves recurrent Clostridium difficile infections in greater than 82% of patients. Highly screened, processed universal donor fecal material is available. We compared cost and scheduling efficiency of fecal microbiota transplantation by universal donors to patient-directed donors. METHODS: Medical records from a prospectively maintained database of recurrent C. difficile patients who underwent fecal microbiota transplantation between 2012 and 2017 were reviewed retrospectively. Patient-directed donor stool was prepared in our microbiology laboratory using protocol-based screening. We transitioned to purchasing and using universal donor fecal material in 2015. Clinical outcomes, adverse events, time between consult to infusion, consultation fees, and material costs were compared. This was a retrospective comparison of two historical cohorts. RESULTS: A total of 111 fecal microbiota transplantations were performed on 105 patients (56 from patient-directed donors and 55 from universal donors). Median recipient age was 66 years (18-96) with male to female ratio of 1:2.7, equivalent in both cohorts. Total consultation fees were significantly lower in the universal donor group owing to fewer infectious disease consultations. Costs for donor screening and stool preparation were lower in the universal donor cohort ($485.0 vs. $1189.90 ± 541.4, p < 0.001, 95% CI 559.9-849.9). Time from consultations to infusion was shorter in the universal donor cohort (18.9 ± 19.1 vs. 36.4 ± 23.3 days, p < 0.001, 95% CI 9.521-25.591). Recurrences within 8 weeks after fecal microbiota transplantation were equivalent (p = 0.354). Adverse events were equivalent. CONCLUSIONS: Fecal microbiota transplantation using universal donors versus patient-directed donors for recurrent C. difficile showed comparable efficacy and short-term complications. The use of universal donors resulted in significant cost savings and scheduling efficiency.

A Review of the Management of Sporadic Colorectal Adenomas in Young People: Is Surveillance Wasted on the Young?

The national incidence of colorectal cancer is increasing in people younger than 50 years old. Although diagnostic colonoscopy is detecting more sporadic adenomas in young adults, there are no guidelines for post-polypectomy surveillance. The aim of this review was to survey the medical literature on the prevalence of sporadic adenomas in young adults, subsequent risk of metachronous neoplasia, and lastly to provide several concluding recommendations for clinical practice. We found that the prevalence of sporadic adenomas in young adults is greater than initially estimated and dependent upon factors such as colonoscopy indication and age. The incidence of metachronous colorectal neoplasia following polypectomy is unclear but does not appear to be greater than that of older adults. Risk factors for metachronous neoplasia include findings on index colonoscopy, male gender, smoking status, and certain medical comorbidities. Upon finding a colorectal adenoma in a young person, we suggest that a detailed family history be obtained to confirm that it is truly sporadic. Testing adenomas for evidence of Lynch syndrome is low yield. Strategies to inform surveillance intervals may include an assessment of risk factors for metachronous neoplasia, although surveillance intervals shorter than those recommended in current guidelines are not warranted. Future research should focus on obtaining long-term, prospective data on the incidence of metachronous neoplasia in diverse patient populations.

Process improvement for a complex dual medical procedure.

Pancreatic extracorporeal shock wave lithotripsy followed by endoscopic retrograde cholangiopancreatography is accepted worldwide as a treatment for a large, symptomatic, obstructing pancreatic stones. However, timely completion of the combined process requires coordination of equipment and personnel from two different complex procedures. We used Lean management tools in a week-long event to redesign the process around the patient. Using idea-generated Plan Do Study Act cycles to refine the process, from scheduling to postprocedure recovery, equipment and personnel were aligned to allow these two procedures to occur in immediate succession. The redesigned process resulted in all patients receiving both procedures without delay. This eliminated over 8 hours of wait time. Standard work and a newly created complex scheduler improved flow. We reduced the number of anaesthetics for patients without prolonging the procedure length.

Young patients with sporadic colorectal adenomas: current endoscopic surveillance practices and outcomes.

BACKGROUND AND AIMS: For young individuals (age <40 years) without strong family histories that would put them at risk for genetic colorectal cancer syndromes, it is unclear if national Multi-Society Task Force surveillance recommendations apply or if endoscopists follow these guideline recommendations when such patients are incidentally found to have adenoma(s) on colonoscopy. METHODS: We reviewed records on young (age <40 years) patients, with either no family history or only a moderate family history (1 first-degree family member with colorectal cancer at age ≥50), who were found to have neoplastic polyp(s) on their index colonoscopy. We assessed the pattern of endoscopist surveillance recommendations, whether endoscopist recommendations complied with national guidelines, and compliance with surveillance recommendations. RESULTS: One hundred forty-one subjects were included, of whom 19 (13.5%) had a moderate family history of colorectal cancer. For patients with non-high-risk findings, 27.7% were asked to repeat their colonoscopy in ≤3 years and 99.0% within 5 years. Endoscopist surveillance recommendation compliance rates with national guidelines were >65.0% for low-risk neoplasia but lower for high-risk (40.0%), nonpolypoid (44.2%), and serrated neoplasia (54.2%, P < .001 for all). Subjects whose endoscopist recommendations were noncompliant with guidelines were usually recalled too early (96%). Only 24.7% of subjects were actually compliant with endoscopist surveillance recommendations. CONCLUSIONS: For young patients with neoplastic polyp(s) but no strong family history, most endoscopists complied with national guidelines and recommended repeat colonoscopy in 3 to 5 years. However, relatively few patients were compliant with repeat colonoscopy recommendations. For most cases that were noncompliant with guidelines, patients were recalled too early as opposed to too late.

Nonoperating room anesthesia for gastrointestinal endoscopic procedures.

PURPOSE OF REVIEW: To assess the trends in nonoperating room anesthesia (NORA) for gastrointestinal endoscopy over the past few years, and to describe alternative methods of delivering propofol sedation in selected low-risk patients. RECENT FINDINGS: The use of NORA for routine gastrointestinal endoscopic procedures has been rising steadily over the past decade in the United States, considerably increasing healthcare costs. Because of this, there have been attempts to develop nonanesthesiologist-administered propofol sedation methods in low-risk patients. There is controversy as to whether properly trained nonanesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation SUMMARY: The deployment of nonanesthesia-administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall healthcare costs without sacrificing sedation quality. We also address the realm of anesthesia provider care for advanced endoscopic procedures including setup for administration of anesthesia, decision-making regarding placement of an endotracheal tube, and the potential need to move a challenging case to the operating room.

Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction.

Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continue to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals (monitored anesthesia care) or whether properly trained non-anesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation. The deployment of non-anesthesia administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall health care costs without sacrificing sedation quality. This review will discuss efficacy, safety, efficiency, cost and satisfaction issues with various modes of sedation for non-advanced, non-emergent endoscopic procedures, mainly esophagogastroduodenoscopy and colonoscopy.

Comparative analysis of diagnostic colonoscopy in symptomatic young adults from South Korea and the United States.

To date, not much is known about ethnic differences in the prevalence of colorectal neoplasia in symptomatic young patients with lower gastrointestinal symptoms. This study sought to compare diagnostic colonoscopic findings in symptomatic young patients from South Korea and the United States. Results from the first diagnostic colonoscopies in symptomatic 18- to 49-year-old patients were compared between the United States and Korean cohorts. The US cohort data were collected at Virginia Mason Medical Center in Seattle, Washington between January 2007 and January 2010, and the Korean cohort data were collected at 14 university hospitals in Korea between June 2006 and June 2015.The prevalence of advanced neoplasias was similar in both cohorts for bleeding and nonbleeding symptoms (P = .966 and P = .076, respectively). In a subgroup analysis for 40- to 49-year-old patients, the prevalence of advanced neoplasias was similar for bleeding symptoms; however, nonbleeding symptoms were significantly higher in the Korean cohort than in the US cohort (6.2% vs 2.6%, P < .001). In an age subgroup analysis for 18- to 39-year-old patients, the prevalence of advanced neoplasias was similar for bleeding and nonbleeding symptoms in both cohorts. Multivariate analysis showed that lower gastrointestinal symptoms were not associated with the risk of any type of advanced neoplasia in young Korean patients.Ethnic disparities in the prevalence of advanced neoplasia on diagnostic colonoscopy were not noticeable between Korean and US young patients. However, 40- to 49-year-old patients with nonbleeding symptoms require more attention to detect advanced neoplasia in Korea than similarly aged patients in the United States.

One year experience with computer-assisted propofol sedation for colonoscopy.

AIM: To report our one-year experience with computer assisted propofol sedation (CAPS) for colonoscopy as the first United States Medical Center to adopt CAPS technology for routine clinical use. METHODS: Between September 2014 and August 2015, 2677 patients underwent elective outpatient colonoscopy with CAPS at our center. All colonoscopies were performed by 1 of 17 gastroenterologists certified in the use of the CAPS system, with the assistance of a specially trained nurse. Procedural success rates, polyp detection rates, procedure times and recovery times were recorded and compared against corresponding historical measures from 2286 colonoscopies done with midazolam and fentanyl from September 2013 to August 2014. Adverse events in the CAPS group were recorded. RESULTS: The mean age of the CAPS cohort was 59.9 years (48.7% male); 31.3% were ASA I, 67.3% ASA II and 1.4% ASA III. 45.1% of the colonoscopies were for screening, 31.5% for surveillance, and 23.4% for symptoms. The mean propofol dose administered was 250.7 mg (range 16-1470 mg), with a mean fentanyl dose of 34.1 mcg (0-100 mcg). The colonoscopy completion and polyp detection rates were similar to that of historical measures. Recovery times were markedly shorter (31 min vs 45.6 min, P < 0.001). In CAPS patients, there were 20 (0.7%) cases of mild desaturation (< 90%) treated with a chin lift and reduction or temporary discontinuation of the propofol infusion, 21 (0.8%) cases of asymptomatic hypotension (< 90 systolic blood pressure) treated with a reduction in the propofol rate, 4 (0.1%) cases of marked agitation or discomfort due to undersedation, and 2 cases of pronounced transient desaturation requiring brief (< 1 min) mask ventilation. There were no sedation-related serious adverse events such as emergent intubation, unanticipated hospitalization or permanent injury. CONCLUSION: CAPS appears to be a safe, effective and efficient means of providing moderate sedation for colonoscopy in relatively healthy patients. Recovery times were much shorter than historical measures. There were few adverse events, and no serious adverse events, related to CAPS.

The First US Clinical Experience With Computer-Assisted Propofol Sedation: A Retrospective Observational Comparative Study on Efficacy, Safety, Efficiency, and Endoscopist and Patient Satisfaction.

BACKGROUND: Computer-assisted propofol sedation (CAPS) is now approved for moderate sedation of American Society of Anesthesiologists (ASA) class I and II patients undergoing routine endoscopy. As the first US medical center to adopt CAPS for routine clinical use, we compared patient and endoscopist satisfaction with CAPS versus midazolam and fentanyl (MF) sedation. METHODS: Patients who underwent elective outpatient upper endoscopy and colonoscopy with CAPS were compared with concurrent patients sedated with MF. The primary end points were patient satisfaction (measured by the validated Patient Sedation Satisfaction Index [PSSI]), and endoscopist satisfaction (Clinician Sedation Satisfaction Index [CSSI]). Secondary end points included procedural success rates, polyp detection rates, adverse events, and procedure/recovery times. Multivariable regression was used for comparative analysis. RESULTS: CAPS was utilized to sedate 244 patients, of whom 55 underwent upper endoscopy, 173 colonoscopy, and 16 double procedures. During the same period, 75 upper endoscopies, 223 colonoscopies, and 30 doubles were performed with MF on similar patients. For upper endoscopy, the procedural success rate was 98.2% for CAPS versus 98.7% for MF (P = .96), whereas for colonoscopy, the success rate was 98.9% vs 98.8% (P = .59). Colonoscopic polyp detection rate was 54.5% for CAPS and 59.3% for MF (P = .67). Procedure times were similar between CAPS and MF. For CAPS, the mean recovery time was 26.4 vs 39.1 minutes for MF (P < .001). One CAPS patient required mask ventilation, 4 experienced asymptomatic hypotension or desaturation, and 5 experienced marked agitation resulting from undersedation. For MF, 5 patients had hypotension or desaturation, and 8 experienced undersedation. For colonoscopy, the CAPS group had higher PSSI scores for sedation adequacy, the recovery process and global satisfaction, and higher CSSI scores for ease of sedation administration, the recovery process and global satisfaction. For upper endoscopy and doubles, the CAPS CSSI score was higher for the recovery process only. All P values were adjusted for confounding by using regression analysis. CONCLUSIONS: In low-risk patients, CAPS appears to be effective and efficient. CAPS is associated with higher satisfaction than MF for colonoscopies and, to a lesser extent, upper endoscopies.

Risks and Benefits of Colonoscopy in Patients 90 Years or Older, Compared With Younger Patients.

BACKGROUND & AIMS: Although the numbers of medical procedures performed on extremely elderly patients (90 years or older, nonagenarians) are increasing, there are no data on the performance, diagnostic yield, or safety of colonoscopy for these patients. We compared the performance and safety of diagnostic colonoscopy, as well as lesions detected, in nonagenarians with patients who were 75 to 79 years old. METHODS: In a retrospective study, we compared data from 76 extremely elderly patients (90 years or older) with data from 140 very elderly patients (75 to 79 years old, controls), all of whom underwent diagnostic colonoscopy from January 2010 through March 2013 at Virginia Mason Medical Center. All colonoscopies were performed by 15 endoscopists. We compared rates of colonoscopy completion, bowel preparation quality, diagnostic yield, and adverse events. RESULTS: In extremely elderly patients, more colonoscopies were performed under general anesthesia, compared with controls (P < .001). When extremely elderly patients underwent colonoscopies with moderate sedation, lower doses of midazolam and fentanyl were given, compared with controls (P < .001). Colonoscopies were completed in a lower proportion of extremely elderly patients (88.2% vs. 99.3% for controls, P < .001), and these patients had a higher incidence of inadequate bowel preparation (29.7% vs. 15.0% for controls, P = .011). Colonoscopies were also associated with cardiopulmonary events in a higher proportion of extremely elderly patients (P = .006) as well as overall adverse events, compared with controls (P = .002). A higher proportion of extremely elderly patients were found to have advanced neoplasia (28.4% vs. 6.4% of controls, P < .001) as well as any neoplasia (P < .001 vs. controls). A greater percentage of extremely elderly patients also had large lesions (P = .002) and malignancies detected by histology (P < .001 vs. controls). Eleven extremely elderly patients (14.9%) were found to have cancer or high-grade dysplasia by colonoscopy. CONCLUSIONS: In patients 90 years or older, diagnostic colonoscopy is associated with increased risk for incomplete procedure, inadequate bowel preparation, and adverse events. However, a large proportion of patients are found to have advanced neoplasia and cancer, compared with patients 75 to 79 years old.

Validation of colonoscopic findings from a structured endoscopic documentation database against manually collected medical records data.

BACKGROUND: Endoscopic documentation software can generate research data on large numbers of subjects automatically. There are increasing numbers of published studies based on endoscopic databases such as the Clinical Outcomes Research Initiative. However, no study has yet validated such data. We compared colonoscopic findings reported by an endoscopic documentation software (Provation) against manually collected medical records data from two similar patient cohorts in the same endoscopy unit. METHODS: In November 2011, our unit switched from dictation-based text documentation to the Provation system. As a quality control initiative, we collected data on 9614 patients who had undergone colonoscopies from January 2010 to November 2011, using manual electronic chart review. We compared these data against those generated by Provation on 7091 similar patients who underwent colonoscopy from November 2011 to March 2013. RESULTS: Age, sex and procedural indication distribution were similar between the Manual and Provation cohorts, as were the large (≥1 cm) polyp (7.6 vs. 8.1%; p = 0.25) and advanced neoplasia (8.3 vs. 8.2%; p = 0.80) prevalences. However, there were significant differences in the polyp (46.9 vs. 49.8%) and adenoma prevalences (31.3 vs. 26.8%; p < 0.001). Furthermore, the Manual cohort had a higher prevalence of diverticulosis and hemorrhoids, and a lower colonoscopy completion rate. Stratification by indication resulted in additional discrepancies between the two cohorts for screening and surveillance patients. There were also differences in the anatomic (right vs. left colon) distribution of large polyps. CONCLUSIONS: There were significant discrepancies between data from Provation and manually collected medical records data. Although the two cohorts were enrolled during slightly different time periods, they came from the same endoscopy unit, had the same endoscopists and indications, and demonstrated similar demographics, making it unlikely for there to be true differences between the cohorts independent of documentation method. Thus, caution is advised when using endoscopic data for research.

Disparities in prevalence, location, and shape characteristics of colorectal neoplasia between South Korean and U.S. patients.

BACKGROUND: Colon cancer screening is being introduced in many countries, but standard Western screening approaches may not be appropriate for Asian societies if differences in colon cancer epidemiology exist. Comparative analysis of colorectal neoplasia patterns in South Korean and Western subjects has implications for appropriate screening approaches in non-Western societies. METHODS: The results of concurrent screening colonoscopies performed in average-risk patients 50 to 69 years old in 2 teaching hospitals, Kyung Hee University Hospital (Seoul, South Korea) and Virginia Mason Medical Center (Seattle, Wash), were compared with respect to prevalence, histologic features, anatomic distribution, and shape characteristics of colorectal neoplasia. RESULTS: The U.S. (n = 3460) and South Korean (n = 2193) cohorts were similar with regard to the prevalence of adenomas (28.5% vs 29.8%, respectively, P = .312) and advanced neoplasia (6.4% vs 5.4%, respectively, P = .102), but the proportion of proximal adenomas was greater in the U.S. cohort (62.8% vs 45.9%, P < .001). The prevalence of adenomas and advanced neoplasia was similar in male patients, but there was a greater prevalence of neoplasia (23.5% vs 18.8%, P = .006) and advanced neoplasia (5.1% vs 2.7%, P < .001) in U.S. women than South Korean women. When large (≥10 mm) adenomas were considered, proximal location and nonpolypoid (flat) shape were more common in the U.S. cohort (79.4% vs 37.1%, P = .003 and 43.5% vs 12.3%, P < .001, respectively). The overall prevalence of large flat adenomas in the U.S. cohort was 5 times that of the South Korean cohort (2.6% vs 0.5%, P < .001). Adjustment for sex ratio discrepancies (48.3% men in the U.S. cohort vs 60.8% in the South Korean cohort, P < .001) did not result in any significant changes in the conclusions. CONCLUSION: Compared with Westerners, South Koreans have a more distal distribution of adenomas and advanced neoplasia and lower prevalence of large flat adenomas. South Korean women have a lower prevalence of colorectal neoplasia than Western women. Such disparities suggest that Western screening strategies cannot be directly adopted by other countries, but need to be customized by society.

Findings of diagnostic colonoscopy in young adults versus findings of screening colonoscopy in patients aged 50 to 54 years: a comparative study stratified by symptom category.

BACKGROUND: The threshold for diagnostic colonoscopy in symptomatic patients aged <50 years remains controversial. Previous studies on the prevalence of neoplasia or other serious pathology in young patients mostly have been uncontrolled, providing only limited data on the risk associated with specific symptoms. OBJECTIVE: To compare colonoscopy findings in patients aged <50 years who have various symptoms (diagnostic cohort) against those of concurrent patients aged 50 to 54 years who are asymptomatic (screening cohort). DESIGN: Retrospective controlled cohort study. SETTING: Teaching hospital. PATIENTS: Symptomatic patients aged between 18 and 49 years and asymptomatic patients aged between 50 and 54 years. INTERVENTIONS: Colonoscopy. MAIN OUTCOME MEASUREMENTS: Prevalence of advanced neoplasia. RESULTS: During the study period, 1638 patients underwent colonoscopy in the screening cohort (mean [± standard deviation{SD}] age 51.7 ± 1.4 years) and 1266 underwent colonoscopy in the diagnostic cohort (40.4 ± 8.0 years). Despite the age difference, the prevalence of advanced neoplasia in patients with rectal bleeding was comparable with that in the screening controls: 28 of 472 (5.9%) versus 113 of 1638 patients (6.9%) (P = .459). Furthermore, 10 patients (2.1%) with rectal bleeding were newly diagnosed with inflammatory bowel disease. In contrast, other symptoms that commonly lead to colonoscopy, such as abdominal pain, changes in bowel habits, and weight loss, were associated with much lower risks for neoplasia. As a result, the overall prevalences of neoplasia and advanced neoplasia were significantly higher in the screening cohort than in the diagnostic cohort: 467 of 1638 patients (28.5%) versus 179 of 1266 patients (14.1%), and 113 patients (6.9%) versus 48 patients (3.8%), respectively (both P < .001). LIMITATIONS: No data on duration of symptoms; discrepant sex ratios between cohorts. CONCLUSION: The threshold for diagnostic colonoscopy in symptomatic young adults should be individualized for each symptom category. Rectal bleeding warrants colonoscopy to detect advanced neoplasia or inflammatory bowel disease in most young patients, especially those aged 40 to 49 years, whereas non-bleeding symptoms, including some traditionally regarded as "alarm" symptoms, were associated with a much lower risk for neoplasia compared with the risk in screening patients aged 50 to 54 years.

Case of cannabinoid hyperemesis syndrome with long-term follow-up.

Long-term cannabis use may be associated with attacks of severe nausea and vomiting, and a characteristic learned behavior of compulsive hot bathing, termed cannabinoid hyperemesis syndrome (CHS). Long-term follow-up and prognosis of CHS have not been reported previously. A 44-year-old Caucasian man with a long history of addiction to marijuana presented with chronic abdominal pain complicated by attacks of uncontrollable vomiting for 16 years. He had a compulsion to take scalding hot showers, as many as 15 times a day, to relieve his symptoms. All previous therapies had been ineffective. However, abstinence from marijuana led to rapid and complete resolution of all symptoms and his compulsive hot showering behavior. He has been followed for nine years, and is still doing well without recurrence of symptoms. Physicians should have a high index of suspicion for this under-recognized condition, as excellent long-term prognosis of CHS can be achieved when abstinence is maintained.