BOOSTING EFFICIENCY IN THE ENDOSCOPY SUITE: INTEGRATING TEAM WORKFLOWS IMPROVES PRODUCTIVITY AND MINIMIZES COST.

BACKGROUND AND AIMS: Inefficiencies in the endoscopy suite cause frustration for physicians, hospital administrators, staff, and patients. Turnover time (TOT), the time between one case ending and another beginning, is subjectively disproportionate between various team members. We aimed to define perceptions of TOT and target steps within the process to improve efficiency. METHODS: This is a prospective cohort study at a tertiary center outpatient endoscopy unit. Phase I aimed to identify the TOT process components based on time stamps in the electronic medical record (n=686). We defined gastroenterologist (GI) perceived TOT (PTOT), anesthesiology PTOT and standard TOT (sTOT). TOT length was calculated for each subgroup. Patient transport was identified as an intervenable target. In Phase II, the task of patient transport moved from the anesthesiology team to endoscopy nurses. Mean TOT and proportion of cases with sTOT <15 minutes pre- (n=2192) and post-intervention (n=292) were compared. RESULTS: We identified 7 key TOT components that explain variations in PTOT. Average anesthesia PTOT is 15 minutes, whereas average GI PTOT is 34 minutes (25.9% versus 57.2% of case length, p=0.0007). In Phase II, mean sTOT improved from 18.51 to 14.25 minutes (p<0.0001) and proportion of sTOT within 15 minutes improved from 41.79% to 58.90% (p<0.0001). This intervention saved 45 mins/room per day, allowing for a revenue potential of more than $300,000 per year per procedure room. CONCLUSIONS: This study defines variations in TOT and demonstrates that finding imbalances and sharing the workload significantly cuts costs and improves the overall efficiency of the different subgroups in the turnover process.

Efficacy of Pistacia lentiscus Plant (Rumi Mastagi) in Comparison to Levosulpiride in Patients with Diabetic Gastroparesis: A Double-Blind Non-Inferior Randomised Control Trial Study.

Introduction: Gastrointestinal neuropathies are frequently found in diabetic patients. The pathogenesis of diabetic gastroparesis (DG) is multifactorial. The usual treatment for DG includes dietary modifications, prokinetic and antiemetic agents. There is increasing demand for more effective medicines to treat DG. The current study was conducted on the Pistacia lentiscus stem extract to add to the armamentarium of DG treatment and to find the efficacy of P. lentiscus plant extract (mastic gum) in comparison to levosulpiride in DG for improvement in gastroparesis symptoms and gastric emptying scintigraphy (GES) in a single centric double-blind non-inferiority randomised control trial. Methods: Thirty-eight individuals were recruited and equally randomised into two study groups based on Gastroparesis Cardinal Symptom Index (GCSI) score and TC99 Radionuclide GES, mastic gum group and levosulpiride group. Both pre and post-intervention (8 weeks) GCSI scores were calculated, GES was performed to quantify the improvement in gastric emptying. Power analysis was performed using G*POWER software version 3.1.9.7 and data analysis using SPSS 23.0, variables measured in mean ± standard deviation (SD). Various statistical tests were used such as independent t-test, Chi-square test or Fisher's exact test, Wilcox Mann-Whitney test, analysis of variance (ANOVA) test, and posthoc pairwise tests. Results: The mastic gum is found effective in the improvement of 4 h gastric emptying percentage from the mean (SD) 76.60 (± 9.96) to mean (SD) 97.20 (2.17)% (P < 0.001). Mastic gum has the property of HbA1c reduction, which is more significant than that of levosulpiride (P = 0.044). Mastic gum also had significant Low density lipoprotein (LDL) (mg/dL) levels reduction, (P < 0.001), compared to levosupiride. An absolute increase was observed in haemoglobin (HB) level in mastic gum at a 2-month mean (SD) of 1.03 (0.77) (g/dL) (P-value <0.001). Conclusions: To our knowledge, this is the first study to compare the effect of levosulpiride with mastic gum concerning improvement in diabetic gastroparesis (DG) using GES. In the study, mastic gum was found to have great properties to improve DG with many important pleiotropic effects.

Real-world safety and effectiveness of Pistacia lentiscus (mastic gum) in patients with diabetic gastroparesis: 24-week interim analysis postintervention.

INTRODUCTION: Gastrointestinal neuropathies are frequently found in diabetic patients. AIM: The aim of this study was to find out the safety, adverse reactions, and long-term effectiveness of Pistacia lentiscus plant extract (mastic gum) in diabetic gastroparesis (DG) with respect to sustainable improvement in gastroparesis symptoms (Gastrointestinal Cardinal Symptom Index [GCSI] score) by observational follow-up study of a single-centric double-blind noninferiority randomized control trial. MATERIALS AND METHODS: Thirty-eight individuals were recruited and equally randomized in two study groups based on GCSI score and TC99 radionuclide gastric emptying scintigraphy (GES), i.e. the mastic gum group and the levosulpiride group. After 24 weeks, the GCSI score was recalculated in both the groups, and patients were evaluated for the safety, adverse reactions, and long-term effectiveness of mastic gum and the standard drug levosulpiride. RESULTS: In the extended study, mean GCSI score changes at 24 weeks were statistically significant (P < 0.001) (t-test) between the two groups. In the mastic gum arm, the change in mean GCSI score at 24 weeks was statistically nonsignificant mean ± (standard deviation [SD]) 16.7± (3.81) compared to the GCSI score at 2-month postintervention mean (SD) 16.35± (2.27) (intragroup P = 0.89) (repeated measures ANOVA). It strongly indicates that mastic gum provided a sustainable improvement in DG symptoms in comparison to levosulpiride, with excellent subjective well-being postintervention, without any obvious significant adverse effects. CONCLUSION: Six-month (24-week) interim analysis of patients suggests that mastic gum gives a sustainable improvement in DG symptoms without any obvious adverse effects as compared to levosulpiride.

The 2022 top 10 list of endoscopy topics in medical publishing: an annual review by the American Society for Gastrointestinal Endoscopy Editorial Board.

Using a systematic literature search of original articles published during 2022 in Gastrointestinal Endoscopy and other high-impact medical and gastroenterology journals, the 10-member Editorial Board of the American Society for Gastrointestinal Endoscopy composed a list of the 10 most significant topic areas in GI endoscopy during the study year. Each Editorial Board member was directed to consider 3 criteria in generating candidate lists-significance, novelty, and global impact on clinical practice-and subject matter consensus was facilitated by the Chair through electronic voting. The 10 identified areas collectively represent advances in the following endoscopic spheres: artificial intelligence, endoscopic submucosal dissection, Barrett's esophagus, interventional EUS, endoscopic resection techniques, pancreaticobiliary endoscopy, management of acute pancreatitis, endoscopic environmental sustainability, the NordICC trial, and spiral enteroscopy. Each board member was assigned a consensus topic area around which to summarize relevant important articles, thereby generating this précis of the "top 10" endoscopic advances of 2022.

Does Prescription Length of Buprenorphine Influence Treatment Outcomes in Opioid Use Disorder? A Retrospective Cohort Study from North India.

OBJECTIVE: Buprenorphine (BUP) effectively suppresses non-prescription opioid use and increases treatment retention in opioid use disorder (OUD). However, short prescription length may interfere with treatment retention and recovery. We wanted to examine whether the outcomes of BUP treatment differ in high (HPL up to 4 wk) and low-prescription (LPL 1-2 wk) length groups. METHODS: We compared time to treatment discontinuation (TD), non-prescription opioid-positive urine screen, buprenorphine-negative urine screen, and self-reported non-prescription opioid use between two different cohorts of LPL (case record: June 2018 to August 2019; n = 105; observation endpoint: 31 October 2019) and HPL groups (case record: June 2020 to Aug 2021; n = 133; observation endpoint: 31 October 2021). We used Kaplan-Meier survival analysis and log-rank tests for between-group comparisons. We used Cox regression analysis to adjust for age, opioid potency, comorbidities, family income, and marital status. RESULTS: Subjects' age and buprenorphine dose were significantly lower, and the percentage of high-potency opioid users was significantly higher in the LPL group. In the unadjusted survival analysis, the median time to BUP discontinuation in the HPL was longer than that of the LPL [LPL= 22.4 ± 4.3 wk; HPL = 33.1 ± 8.5 wk; χ2(1)= 5.7; p=.02]. The survival distributions of other outcomes did not differ between groups. When adjusted for covariates, neither the prescription length nor other covariates independently predicted any treatment outcome. CONCLUSION: Higher prescription length might be associated with longer treatment retention. We provide preliminary evidence to support greater flexibility in BUP treatment, enhancing its scalability and attractiveness.

Sarcoidosis of the Bile Duct.

Sarcoidosis is an inflammatory disease that affects multiple organs. The lungs are the most commonly involved organs. Although a large proportion of patients with sarcoidosis have liver involvement, bile duct involvement is rare. Here, we present a case of a 56-year-old African American patient presented with painless jaundice because of extrahepatic bile duct sarcoidosis. Our diagnostic approach using endoscopic cholangioscopy with targeted biopsies confirmed the diagnosis. Multiple bile duct stent exchanges were performed to manage the bile duct stricture in addition to medical therapy.

Sensory Deprivation and Psychiatric Disorders: Association, Assessment and Management Strategies.

Background: Sensory deprivation (SD) is a widely prevalent condition that leads to various health-related consequences and is also an important cause of disability worldwide. Earlier, SD experiments were used as research modalities to alter human behavior. In recent years, the focus has shifted to understand how SD can affect the mental health of individuals (with congenital or acquired sensory impairments). This narrative review focuses on the current understanding about the association of SD and psychiatric disorders. Methods: A comprehensive literature search was done PubMed, Scopus, PsycINFO, and Google Scholar and in the cross-references of relevant articles. Keywords included "sensory deprivation," "blindness," "deafness," "mental illness," "psychiatric disorders," "prevalence," "assessment," and "management" in various combinations. Only original articles (abstract and full text) published in English till October 2020 were included. Results: The prevalence of anxiety, depression, dementia, suicidality, and psychosis in persons with SD is higher than the general population (highest being in persons with dementia with comorbid SD). Several mechanisms/hypotheses have been proposed to explain these associations. Assessment of SD includes a thorough history taking, with adequate awareness about the difficulties faced during a psychiatric interview in this population. Modifications in the psychometric assessment procedures are warranted. Management depends on a multi-disciplinary approach that includes proper referral to specialties, pharmacological management (depending on diagnosis as well as taking care of ototoxic/ocular side-effect profile of the drugs), and nonpharmacological supportive measures. Conclusions: SD is a complex condition, and evidence suggests that persons with SD have higher psychiatric morbidity. A comprehensive assessment, along with holistic management approach is warranted.

GIE Editorial Board Top 10: advances in GI endoscopy in 2021.

The 9-member Editorial Board of the American Society for Gastrointestinal Endoscopy performed a systematic literature search of original articles published during 2021 in Gastrointestinal Endoscopy and 10 other high-impact medical and gastroenterology journals on endoscopy-related topics. Votes from each editorial board member were tallied to identify a consensus list of the 10 most significant topic areas in GI endoscopy over the calendar year of study, with a focus on 3 criteria: significance, novelty, and global impact on clinical practice. The 10 areas identified collectively represent advances in the following endoscopic topics: colonoscopy optimization, bariatric endoscopy, endoscopic needle sampling and drainage, peroral endoscopic myotomy, endoscopic defect closure, meeting systemic challenges in endoscopic training and practice, endohepatology, FNA versus fine-needle biopsy sampling, endoscopic mucosal and submucosal procedures, and cold snare polypectomy. Each board member contributed a summary of important articles relevant to 1 to 2 of the consensus topic areas, leading to a collective summary that is presented in this document of the "top 10" endoscopic advances of 2021.

Multiplex Patient-Based Drug Response Assay in Pancreatic Ductal Adenocarcinoma.

Pancreatic ductal adenocarcinoma (PDA) is an extremely lethal malignancy arising from the pancreas. The treatment of PDA is complicated by ineffective treatments and a lack of biomarkers predictive of treatment success. We have designed a patient-derived organoid (PDO) based high-throughput drug screening assay to model treatment response to a variety of conventional and investigational treatments for PDA. Consecutive patients undergoing endoscopic ultrasound-guided fine-needle biopsy for tissue diagnosis of PDA at Rush University Medical Center were offered to participate in the study. Biopsies were immediately processed to develop organoids. Fifteen PDOs were screened for sensitivity to 18 compounds, including conventional PDA chemotherapies and FDA-approved investigational targeted therapies in cancer using Cell-titer GLO 3D (Promega) cell viability assay. The area under the curve (AUC) was calculated and normalized to the maximum area under the curve to generate a normalized AUC between 0 and 1. Molecular profiling of PDOs was conducted using RNA-seq. Human PDA transcriptomic was extracted from The Cancer Genome Atlas (TCGA). The drug response curves were reproducible. We observed variation in response to conventional therapies overall as well as among individual patients. There were distinct transcriptome signatures associated with response to the conventional chemotherapeutics in PDA. The transcriptomic profile of overall resistance to conventional therapies in our study was associated with poor survival in PDA patients in TCGA. Our pathway analysis for targeted drugs revealed a number of predictors of response associated with the mechanism of action of the tested drug. The multiplex organoid-based drug assay could be used in preclinical to inform patient stratification and therapeutic selection in PDA. When combined with omics data, ex vivo response to treatment could help identify gene signatures associated with response to novel therapies.

GIE Editorial Board top 10 topics: advances in GI endoscopy in 2020.

The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed a systematic literature search of original endoscopy-related articles published during 2020 in Gastrointestinal Endoscopy and 10 other high-impact medical and gastroenterology journals. Votes from each individual board member were tallied to identify a consensus list of the 10 most significant topic areas in GI endoscopy over the calendar year of study using 4 criteria: significance, novelty, impact on national health, and impact on global health. The 10 areas identified were as follows: artificial intelligence in endoscopy, coronavirus disease 2019 and GI practice, third-space endoscopy, lumen-apposing metal stents, single-use duodenoscopes and other disposable equipment, endosonographic needle technology and techniques, endoscopic closure devices, advances in GI bleeding management, improvements in polypectomy techniques, and bariatric endoscopy. Each board member contributed a summary of important articles relevant to 1 to 2 topic areas, leading to a collective summary that is presented in this document of the "top 10" endoscopic advances of 2020.

Colonic Polypoid Arteriovenous Malformation Causing Symptomatic Anemia.

Vascular ectasias, which can be classified as angiodysplasias and arteriovenous malformations (AVMs), accounts for approximately 3% of lower gastrointestinal bleeding. Typically, colonic AVMs are solitary, large, and flat or elevated red lesions on endoscopy. We present an interesting case of a polypoid ulcerated AVM in the transverse colon causing symptomatic anemia, which was resected endoscopically with a resolution of symptoms. Polypoid colonic AVMs are rather rare with only 15 other cases described in the literature. This case highlights the approach to endoscopic management of these lesions.

Can acceptable quality angel food cakes be made using pasteurized shell eggs? The effects of mixing factors on functional properties of angel food cakes.

Due to recent Salmonella outbreaks, the pasteurized shell egg market is rapidly growing. One objection to using pasteurized eggs is the belief that they will produce unacceptable angel food cakes. Eggs were pasteurized using a hot water immersion process (56.7°C for 60 min) similar to that used by industry. Angel food cakes were made from the pasteurized egg white (PEW) as well as from raw egg white (REW) for comparison. Meringues were made using three mixer speed settings (low, medium, and high) and three durations for each speed. Functional qualities such as egg foaming were evaluated. Angel food cakes were compared in terms of cake volume, texture profile, and color values. When the optimal processing factors used for REW were applied to PEW, an inferior meringue was formed. However, by increasing the mixing time for PEW by 200% at the highest speed, an acceptable meringue was formed. The best angel food cake prepared from PEW had a volume only 6.8% less than that of the best cake prepared from REW. Texture profile analyses showed that the best angel food cake made from PEW was 13% firmer, 7.4% less springy, and 62% chewier than that from REW. Color analyses showed that PEW made a slightly darker colored cake crust than REW, although there were no significant differences in the crumb color. Modifying the mixing conditions for PEW resulted in angel food cakes with quality similar to that of cakes made with REW, thus overcoming an objection to using safer pasteurized shell eggs.

The Prevalence, Clinical Spectrum and the Long Term Outcome of ST-segment Elevation Myocardial Infarction in Young - A Prospective Observational Study.

INTRODUCTION: Incidence of coronary artery disease at the younger age is rising. We studied the prevalence, clinical spectrum and long term outcome of ST-segment elevation myocardial infarction in young. MATERIAL AND METHODS: This is a prospective observational study, performed at a tertiary care center from January 2015 to June 2016. Of the total 977 consecutive patients with ST segment elevation myocardial infarction (STEMI), 130 patients aged ≤45 years were included. All patients were followed-up for at least 1-year from the index admission. RESULTS: The overall prevalence of STEMI among younger patients was 12.8%. There was male dominance (96.8%). Smoking (37.6%) was observed to be the most common risk factor for young STEMI, followed by diabetes mellitus (16.8%) and hypertension (16%). Younger patients with acute MI had preponderance to anterior wall (68.8%), single-vessel disease (50%) and left anterior descending artery being the culprit lesion (67.3%). Near normal/normal coronary arteries were observed in 12.9% of cases. The most commonly used management strategy was mechanical revascularisation (43.2%), followed by thrombolysis (28.8%) and medical management (28%). The overall mortality and combined MACCE rates at 1 year were 3.2% and 18.4% respectively. Outcome was better in patients who received mechanical revascularization/thrombolysis than those who received medical management only, with a lower MACCE rates (hazard ratio: 0.36; 95% CI: 0.16-0.8, p = 0.01. CONCLUSION: The young MI patients are unique in having male dominance, better outcome, more of single-vessel disease with significant number of normal coronaries, better response to mechanical as well as pharmacological revascularization.

Double Trouble: A Rare Case of Concurrent Biliary Adenofibroma and Hepatobiliary Mucinous Cystic Neoplasm.

Biliary adenofibroma and hepatobiliary mucinous cystic neoplasm are exceedingly rare tumors. To our knowledge, no case of co-existent biliary adenofibroma and mucinous cystic neoplasm has been previously reported. We present a patient who was diagnosed with both tumors concurrently. Both can present with abdominal pain, although some are diagnosed incidentally in asymptomatic patients. Imaging and tumor markers can be suggestive, but histologic examination is needed for definitive diagnosis. Both have a propensity for malignant transformation, thus complete surgical resection is the treatment of choice. Although rare, awareness of these tumors leads to earlier diagnosis and treatment.

Early increase in blood supply (EIBS) is associated with tumor risk in the Azoxymethane model of colon cancer.

BACKGROUND: The present study aimed to investigate the role of blood supply in early tumorigenesis in colorectal cancer. We leveraged the renin angiotensin system (RAS) to alter colonic blood supply and determine the effect on tumor initiation and progression. METHODS: To test the effect of blood supply on tumorigenesis, 53 male A/J mice were randomly assigned to one of three RAS modulation groups and one of two AOM treatments. The RAS modulation groups were I) water (RAS-unmodulated) as a control group, II) angiotensin-II and III) the angiotensin receptor blocker, Losartan. The mice in each group were then randomly split into either the saline control condition or the AOM-treated condition in which tumors were induced with a standard protocol of serial azoxymethane (AOM) injections. To monitor microvascular changes in the rectal mucosa during the study, we used confocal laser endomicroscopy (CLE) with FITC-Dextran for in-vivo imaging of vessels and polarization-gated spectroscopy (PGS) to quantify rectal hemoglobin concentration ([Hb]) and blood vessel radius (BVR). RESULTS: At 12 weeks post-AOM injections and before tumor formation, CLE images revealed many traditional hallmarks of angiogenesis including vessel dilation, loss of co-planarity, irregularity, and vessel sprouting in the pericryptal capillaries of the rectal mucosa in AOM-Water tumor bearing mice. PGS measurements at the same time-point showed increased rectal [Hb] and decreased BVR. At later time points, CLE images showed pronounced angiogenic features including irregular networks throughout the colon. Notably, the AOM-Losartan mice had significantly lower tumor multiplicity and did not exhibit the same angiogenic features observed with CLE, or the increase in [Hb] or decrease in BVR measured with PGS. The AOM-AngII mice did not have any significant trends. CONCLUSION: In-vivo PGS measurements of rectal colonic blood supply as well as CLE imaging revealed angiogenic disruptions to the capillary network prior to tumor formation. Losartan demonstrated an effective way to mitigate the changes to blood supply during tumorigenesis and reduce tumor multiplicity. These effects can be used in future studies to understand the early vessel changes observed.

Effects of locust bean gum on the structural and rheological properties of resistant corn starch.

In this study, interactions between resistant corn starch (RS) (5% w/w) and locust bean gum (LBG) (0, 0.125, 0.25, 0.50 and 1.0% w/v) on the viscoelastic, pasting and morphological characteristics of aqueous dispersions were evaluated. Results showed that the storage modulus (G'), loss modulus (G''), and apparent viscosity values of starch/gum (RS/LBG) mixtures were enhanced with the addition of LBG, and the rheograms demonstrated a biphasic behavior. RS/LBG samples were predominantly either solid like (G' > G'') or viscous (G'' > G'), depending on the added concentration level of LBG. Gum addition also caused higher peak viscosity, breakdown and total set back of RS/LBG mixtures. A strong correlation between rheological and structural properties was found. Confocal laser scanning microscopy (CLSM) images confirmed the transition of starch particles from a scattered angular shape to clustered structures cross-linked by dense aggregate junction zones justifying the observed changes in rheological properties.