Advancements in Immunotherapy for Breast Cancer: Mechanisms, Efficacy, and Future Directions.

Breast cancer is a major global health challenge characterized by its diverse biological behavior and varying treatment responses. Traditional therapies, including surgery, radiation, chemotherapy, hormonal therapy, and targeted therapy, have significantly advanced breast cancer treatment but are often limited by issues such as resistance, side effects, and variable efficacy. Immunotherapy has emerged as a transformative approach, leveraging the body's immune system to target and eliminate cancer cells. This review provides a comprehensive overview of recent advancements in immunotherapy for breast cancer, detailing the mechanisms of various therapeutic strategies, including checkpoint inhibitors, monoclonal antibodies, cancer vaccines, adoptive cell therapy, and oncolytic virus therapy. We evaluate the efficacy of these approaches in different stages of breast cancer, highlighting successes and challenges encountered in clinical settings. The review also addresses the current limitations of immunotherapy, such as treatment-related adverse effects, resistance mechanisms, and issues of cost and accessibility. We discuss promising future directions, including emerging targets, combination therapies, and personalized medicine approaches. By integrating recent research and clinical trial data, this review aims to elucidate the potential of immunotherapy to revolutionize breast cancer treatment, offering insights into its future role in improving patient outcomes and shaping the landscape of oncological care.

Advances in the Diagnosis and Treatment of Follicular Thyroid Carcinoma: A Comprehensive Review.

Follicular thyroid carcinoma (FTC) is the second most common type of thyroid cancer, presenting unique diagnostic and therapeutic challenges. This review provides a comprehensive analysis of the recent advancements in the diagnosis and treatment of FTC, emphasizing the significance of these developments in improving patient outcomes. We discuss the evolution of diagnostic techniques, including advancements in imaging modalities, fine needle aspiration biopsy, and molecular diagnostics, which have enhanced the accuracy of FTC detection and differentiation from benign conditions. The review also evaluates current treatment strategies, including surgical interventions, radioactive iodine therapy, and targeted therapies, examining their effectiveness and impact on patient prognosis. Additionally, we address ongoing challenges in FTC management, such as variability in treatment guidelines and disparities in care. Finally, the review explores emerging therapies and future research directions, highlighting innovations that may further optimize FTC management. By synthesizing current knowledge and identifying future research opportunities, this review aims to contribute to refining diagnostic and therapeutic approaches for FTC.

Metastatic Follicular Carcinoma of the Thyroid: A Case Report.

Neck lumps may indicate metabolic disorders of the parathyroid and thyroid glands commonly present in the anterior aspect of the neck. Some neck lumps are detected as follicular thyroid cancer. Follicular thyroid cancer is a malignant epithelial tumor that shows evidence of follicular cell differentiation but lacks the characteristic nuclear features of papillary thyroid carcinoma (PTC). Iodine-deficient regions have higher rates of follicular carcinoma. There has been a decline in the incidence of this kind of tumor in recent years. As with PTC, prior radiation therapy increases the risk of follicular cancer, but to a lesser extent. In some cases, patients have distant metastases that involve the bones. Follicular cancer is divided into minimally invasive and widely invasive types. Early detection is important. Treatment usually consists of thyroidectomy and radioactive iodine therapy, and hormone replacement therapy may be necessary. Fine needle aspiration cytology is an efficient and cost-effective tool for the diagnosis of neck swelling and has the potential to diagnose the mass. We report the case of a 60-year-old Indian woman who had been experiencing neck swelling for the last 12 years. The neglected neck mass was confirmed as a hyperechoic mass with microcalcifications on ultrasound, representative of metastatic follicular thyroid carcinoma, which further spread to the ribs and the vertebrae. The patient was followed without complications.

Optimizing the Clinical Direction of Artificial Intelligence With Health Policy: A Narrative Review of the Literature.

Artificial intelligence (AI) has the ability to completely transform the healthcare industry by enhancing diagnosis, treatment, and resource allocation. To ensure patient safety and equitable access to healthcare, it also presents ethical and practical issues that need to be carefully addressed. Its integration into healthcare is a crucial topic. To realize its full potential, however, the ethical issues around data privacy, prejudice, and transparency, as well as the practical difficulties posed by workforce adaptability and statutory frameworks, must be addressed. While there is growing knowledge about the advantages of AI in healthcare, there is a significant lack of knowledge about the moral and practical issues that come with its application, particularly in the setting of emergency and critical care. The majority of current research tends to concentrate on the benefits of AI, but thorough studies that investigate the potential disadvantages and ethical issues are scarce. The purpose of our article is to identify and examine the ethical and practical difficulties that arise when implementing AI in emergency medicine and critical care, to provide solutions to these issues, and to give suggestions to healthcare professionals and policymakers. In order to responsibly and successfully integrate AI in these important healthcare domains, policymakers and healthcare professionals must collaborate to create strong regulatory frameworks, safeguard data privacy, remove prejudice, and give healthcare workers the necessary training.

Screening for Colorectal Cancer.

Colorectal cancer (CRC) is the second leading cause of cancer death. Screening has been proven to reduce both cancer incidence and cancer-related mortality. Various screening tests are available, each with their own advantages and disadvantages and varying levels of evidence to support their use. Clinicians should offer CRC screening to average-risk persons aged 50 to 75 years; starting screening at age 45 years remains controversial. Screening may be beneficial in select persons aged 76 to 85 years, based on their overall health and screening history. Offering a choice of screening tests or sequentially offering an alternate test for those who do not complete screening can significantly increase participation.

Effect of an online educational module incorporating real-time feedback on accuracy of polyp sizing in trainees: a randomized controlled trial.

BACKGROUND: Although polyp size dictates surveillance intervals, endoscopists often estimate polyp size inaccurately. We hypothesized that an intervention providing didactic instruction and real-time feedback could significantly improve polyp size classification. METHODS: We conducted a multicenter randomized controlled trial to evaluate the impact of different components of an online educational module on polyp sizing. Participants were randomized to control (no video, no feedback), video only, feedback only, or video + feedback. The primary outcome was accuracy of polyp size classification into clinically relevant categories (diminutive [1-5mm], small [6-9mm], large [≥10mm]). Secondary outcomes included accuracy of exact polyp size (inmm), learning curves, and directionality of inaccuracy (over- vs. underestimation). RESULTS: 36 trainees from five training programs provided 1360 polyp size assessments. The feedback only (80.1%, P=0.01) and video + feedback (78.9%, P=0.02) groups had higher accuracy of polyp size classification compared with controls (71.6%). There was no significant difference in accuracy between the video only group (74.4%) and controls (P=0.42). Groups receiving feedback had higher accuracy of exact polyp size (inmm) and higher peak learning curves. Polyps were more likely to be overestimated than underestimated, and 29.3% of size inaccuracies impacted recommended surveillance intervals. CONCLUSIONS: Our online educational module significantly improved polyp size classification. Real-time feedback appeared to be a critical component in improving accuracy. This scalable and no-cost educational module could significantly decrease under- and overutilization of colonoscopy, improving patient outcomes while increasing colonoscopy access.

Testicular Torsion and Irreversible Loss in an Adolescent Male: A Harrowing Case Report With Emphasis on Timely Intervention and Literature Review.

Testicular torsion is a condition characterized by the twisting of the testis and spermatic cord within the scrotum, resulting in the obstruction of venous return and subsequent swelling. If left untreated, the torsion can progress to block the arterial blood supply, leading to ischemia. Prolonged ischemia can result in testicular necrosis and decreased fertility. Recognizing the urgency of this condition, timely diagnosis and management are crucial. In this clinical case, a 16-year-old male presented with left-sided scrotal pain following a minor trauma. Despite prompt medical attention, the delay in seeking treatment resulted in irreversible testicular necrosis. The case emphasizes the urgency of diagnosing and managing testicular torsion to prevent serious consequences such as testicular loss and reduced fertility. It serves as a poignant reminder for healthcare professionals to remain vigilant in recognizing this urological emergency and advocating for timely intervention to optimize patient outcomes.

In Contemporary Reproductive Medicine Human Beings are Not Yet Dispensable.

In the past few years almost every aspect of an IVF cycle has been investigated, including research on sperm, color doppler in follicular studies, prediction of embryo cleavage, prediction of blastocyst formation, scoring blastocyst quality, prediction of euploid blastocysts and live birth from blastocysts, improving the embryo selection process, and for developing deep machine learning (ML) algorithms for optimal IVF stimulation protocols. Also, artificial intelligence (AI)-based methods have been implemented for some clinical aspects of IVF, such as assessing patient reproductive potential and individualizing gonadotropin stimulation protocols. As AI has the inherent capacity to analyze "Big" data, the goal will be to apply AI tools to the analysis of all embryological, clinical, and genetic data to provide patient-tailored individualized treatments. Human skillsets including hand eye coordination to perform an embryo transfer is probably the only step of IVF that is outside the realm of AI & ML today. Embryo transfer success is presently human skill dependent and deep machine learning may one day intrude into this sacred space with the advent of programed humanoid robots. Embryo transfer is arguably the rate limiting step in the sequential events that complete an IVF cycle. Many variables play a role in the success of embryo transfer, including catheter type, atraumatic technique, and the use of sonography guidance before and during the procedure of embryo transfer. In contemporary Reproductive Medicine human beings are not yet dispensable.

Photothermal therapy using graphene quantum dots.

The rapid development of powerful anti-oncology medicines have been possible because of advances in nanomedicine. Photothermal therapy (PTT) is a type of treatment wherein nanomaterials absorb the laser energy and convert it into localized heat, thereby causing apoptosis and tumor eradication. PTT is more precise, less hazardous, and easy-to-control in comparison to other interventions such as chemotherapy, photodynamic therapy, and radiation therapy. Over the past decade, various nanomaterials for PTT applications have been reviewed; however, a comprehensive study of graphene quantum dots (GQDs) has been scantly reported. GQDs have received huge attention in healthcare technologies owing to their various excellent properties, such as high water solubility, chemical stability, good biocompatibility, and low toxicity. Motivated by the fascinating scientific discoveries and promising contributions of GQDs to the field of biomedicine, we present a comprehensive overview of recent progress in GQDs for PTT. This review summarizes the properties and synthesis strategies of GQDs including top-down and bottom-up approaches followed by their applications in PTT (alone and in combination with other treatment modalities such as chemotherapy, photodynamic therapy, immunotherapy, and radiotherapy). Furthermore, we also focus on the systematic study of in vitro and in vivo toxicities of GQDs triggered by PTT. Moreover, an overview of PTT along with the synergetic application used with GQDs for tumor eradication are discussed in detail. Finally, directions, possibilities, and limitations are described to encourage more research, which will lead to new treatments and better health care and bring people closer to the peak of human well-being.

Immunosurveillance shapes the emergence of neo-epitope landscapes of sarcomas, revealing prime targets for immunotherapy.

T cells recognize tumor-derived mutated peptides presented on MHC by tumors. The recognition of these neo-epitopes leads to rejection of tumors, an event that is critical for successful cancer immunosurveillance. Determination of tumor-rejecting neo-epitopes in human tumors has proved difficult, though recently developed systems approaches are becoming increasingly useful at evaluating their immunogenicity. We have used the differential aggretope index to determine the neo-epitope burden of sarcomas and observed a conspicuously titrated antigenic landscape, ranging from the highly antigenic osteosarcomas to the low antigenic leiomyosarcomas and liposarcomas. We showed that the antigenic landscape of the tumors inversely reflected the historical T cell responses in the tumor-bearing patients. We predicted that highly antigenic tumors with poor antitumor T cell responses, such as osteosarcomas, would be responsive to T cell-based immunotherapy regimens and demonstrated this in a murine osteosarcoma model. Our study presents a potentially novel pipeline for determining antigenicity of human tumors, provides an accurate predictor of potential neo-epitopes, and will be an important indicator of which cancers to target with T cell-enhancing immunotherapy.

Baseline Features and Reasons for Nonparticipation in the Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) Study, a Colorectal Cancer Screening Trial.

Importance: The Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) randomized clinical trial sought to recruit 50 000 adults into a study comparing colorectal cancer (CRC) mortality outcomes after randomization to either an annual fecal immunochemical test (FIT) or colonoscopy. Objective: To (1) describe study participant characteristics and (2) examine who declined participation because of a preference for colonoscopy or stool testing (ie, fecal occult blood test [FOBT]/FIT) and assess that preference's association with geographic and temporal factors. Design, Setting, and Participants: This cross-sectional study within CONFIRM, which completed enrollment through 46 Department of Veterans Affairs medical centers between May 22, 2012, and December 1, 2017, with follow-up planned through 2028, comprised veterans aged 50 to 75 years with an average CRC risk and due for screening. Data were analyzed between March 7 and December 5, 2022. Exposure: Case report forms were used to capture enrolled participant data and reasons for declining participation among otherwise eligible individuals. Main Outcomes and Measures: Descriptive statistics were used to characterize the cohort overall and by intervention. Among individuals declining participation, logistic regression was used to compare preference for FOBT/FIT or colonoscopy by recruitment region and year. Results: A total of 50 126 participants were recruited (mean [SD] age, 59.1 [6.9] years; 46 618 [93.0%] male and 3508 [7.0%] female). The cohort was racially and ethnically diverse, with 748 (1.5%) identifying as Asian, 12 021 (24.0%) as Black, 415 (0.8%) as Native American or Alaska Native, 34 629 (69.1%) as White, and 1877 (3.7%) as other race, including multiracial; and 5734 (11.4%) as having Hispanic ethnicity. Of the 11 109 eligible individuals who declined participation (18.0%), 4824 (43.4%) declined due to a stated preference for a specific screening test, with FOBT/FIT being the most preferred method (2820 [58.5%]) vs colonoscopy (1958 [40.6%]; P < .001) or other screening tests (46 [1.0%] P < .001). Preference for FOBT/FIT was strongest in the West (963 of 1472 [65.4%]) and modest elsewhere, ranging from 199 of 371 (53.6%) in the Northeast to 884 of 1543 (57.3%) in the Midwest (P = .001). Adjusting for region, the preference for FOBT/FIT increased by 19% per recruitment year (odds ratio, 1.19; 95% CI, 1.14-1.25). Conclusions and Relevance: In this cross-sectional analysis of veterans choosing nonenrollment in the CONFIRM study, those who declined participation more often preferred FOBT or FIT over colonoscopy. This preference increased over time and was strongest in the western US and may provide insight into trends in CRC screening preferences.

Varied Trainee Competence in Cold Snare Polypectomy: Results of the COMPLETE Randomized Controlled Trial.

INTRODUCTION: Cold snare polypectomy (CSP) is strongly recommended as the optimal technique for the complete removal of small polyps. Though significant variability in polypectomy technique and quality has been established, the learning curve and impact of targeted training on CSP are unknown. Video feedback has shown promise as an effective pedagogy to improve performance among surgical trainees. We aimed to compare CSP performance between trainees who received video-based feedback and those who received conventional apprentice-based concurrent feedback. We hypothesized that video-based feedback would accelerate competence. METHODS: We conducted a single-blinded, randomized controlled trial on competence for CSP of polyps <1 cm, comparing video-based feedback with conventional feedback. We randomly assigned deidentified consecutively recorded CSP videos to blinded raters to assess using the CSP Assessment Tool. We shared cumulative sum learning curves every 25 CSP with each trainee. The video feedback trainees also received biweekly individualized terminal feedback. Control trainees received conventional feedback during colonoscopy. The primary outcome was CSP competence. We also assessed competence across domains and change over polypectomy volume. RESULTS: We enrolled and randomized 22 trainees, 12 to video-based feedback and 10 to conventional feedback, and evaluated 2,339 CSP. The learning curve was long; 2 trainees (16.7%) in the video feedback achieved competence, after a mean of 135 polyps, and no one in the control ( P = 0.481) achieved competence. Overall and in all steps of CSP, a higher percentage of the video feedback group met competence, increasing 3% every 20 CSP ( P = 0.0004). DISCUSSION: Video feedback aided trainees to competence in CSP. However, the learning curve was long. Our findings strongly suggest that current training methods are not sufficient to support trainees to competency by the completion of their fellowship programs. The impact of new training methods, such as simulation-based mastery learning, should be assessed to determine whether such methods can result in achievement of competence at a faster rate; ClinicalTrials.gov : NCT03115008.

Efficacy in Predicting Negative Appendectomy Rates in Operated Acute Appendicitis Patients Using the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) Score Versus Modified Alvarado Score.

Introduction Acute appendicitis is the commonest abdominal surgical emergency globally. The most accepted management of acute appendicitis is surgical, either open or laparoscopic appendectomy. Overlapping clinical presentations with many genitourinary and gynecological conditions lead to difficulty in accurate diagnosis, making negative appendectomies an unwanted reality. With the advancement in technology, there have been constant efforts to minimize negative appendectomy rates (NAR) using imaging modalities like USG of the abdomen and the gold-standard imaging test, the contrast-enhanced computed tomography of the abdomen. Due to the cost incurred and the lesser availability of such imaging modalities and needed expertise in resource-poor settings, various clinical scoring systems were devised to accurately diagnose acute appendicitis and thereby decrease NAR. We conducted our study to determine the NAR between the Raja Isteri Pengiran Anak Saleha Appendicitis score (RIPASA) and the modified Alvarado (MA) scoring methods. Methods A prospective observational analytical study was conducted, including 50 patients presenting to our hospital with acute appendicitis and who underwent emergency open appendectomy. The need to operate was decided by the treating surgeon. Patients were stratified by both scores; the pre-operative scores were noted and were later compared with the histopathological diagnosis. Results A total of 50 clinically diagnosed patients with acute appendicitis were evaluated utilizing the RIPASA and the MA scores. The NAR was 2% using the RIPASA score vs 10% with the MA score. The sensitivity was 94.11% vs 70.58% (p<0.0001), the specificity was 93.75% vs 68.75% (p<0.0001), the positive predictive value (PPV) of 96.96% vs 82.75% (p<0.001), the negative predictive value (NPV) of 88.23% vs 52.38% (p<0.001), and NAR of 2% vs 10% (p<0.0001) in the RIPASA vs MA scoring method, respectively. Conclusions RIPASA score is highly efficacious and statistically significant in diagnosing acute appendicitis with higher PPV at higher scores and higher NPV with lower scores leading to decreased NAR compared with MA score.

The Role of the Mannheim Peritonitis Index for Predicting Outcomes in Patients With Perforation Peritonitis in a Rural Hospital in India.

Introduction Acute secondary peritonitis due to hollow viscus perforation is a life-threatening surgical condition with significant morbidity and mortality, depending on the severity with outcomes that differ in the Western and developing world. Various scoring systems have been developed to assess the severity and its relation to morbidity and mortality. We conducted this study to evaluate the role of the Mannheim peritonitis index (MPI) in predicting outcomes in perforation peritonitis patients in a rural hospital in India. Materials and methods A prospective study of 50 patients with hollow viscus perforation with secondary peritonitis presented to the emergency department, Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe), Wardha, from 2016 to 2020. Each operated patient was scored according to the MPI to predict mortality. Results The majority of the patients were discharged uneventfully and about 16% (8/50) of the patients expired. The patients with an MPI score of more than 29 had maximum mortality of 62.5%. Mortality was seen in 37.5% of the patients with MPI scores between 21 and 29, whereas no mortality was recorded in patients with an MPI score of 21. Higher mortality was associated with age greater than 50 years (p=0.007), the presence of malignancy (p=0.013), colonic perforation (p=0.014), and fecal contamination (p=0.004). There was no significant correlation with gender (p=0.81), the presence of organ failure (p=1.6), delayed presentation, i.e., preoperative duration >24 hours (p=0.17), and the presence of diffuse peritonitis (p=0.25). Conclusion MPI is a specific, easily reproducible, and less cumbersome scoring method for predicting mortality in patients with hollow viscus perforation (secondary) peritonitis with minimal laboratory investigations. Higher scores correlate with a poorer prognosis and need intensive management, making use of MPI in clinical practice relevant and beneficial, especially in resource-poor settings.

Techniques for Diagnosing Anastomotic Leaks Intraoperatively in Colorectal Surgeries: A Review.

Colorectal cancer is one of the most common surgically curable malignancies worldwide, having a good prognosis even with liver metastasis. This improved patient outcome is marred by anastomotic leaks (AL) in operated patients of colorectal cancer despite a microscopically margin-negative resection (R0). Various risk factors have been attributed to causing this. Preoperative non-modifiable factors are age, male sex, cancer cachexia, and neoadjuvant chemo-radiotherapy, and modifiable factors are comorbidities, peripheral vascular disease, anemia, and malnutrition. Intraoperative risk factors include intraoperative surgical duration, blood loss and transfusions, fluid management, oxygen saturation, surgical technique (stapled, handsewn, or compression devices), and approach (open, laparoscopic, or robotic). Postoperative factors like anemia, infection, fluid management, and blood transfusions also have an effect. With the advent of enhanced recovery after surgery (ERAS) protocols, many modifiable factors can be optimized to reduce the risk. Prevention is better than cure as the morbidity and mortality of AL are very high. There is still a need for an intraoperative technique to detect the viability of anastomotic ends to predict and prevent AL. Prompt diagnosis of an AL is the key. Many surgeons have proposed using methods like air leak tests, intraoperative endoscopy, Doppler ultrasound, and near-infrared fluorescence imaging to decrease the incidence of AL. All these methods can minimize AL, resulting in significant intraoperative alterations to surgical tactics. This narrative review covers the methods of assessing of integrity of anastomosis during the surgery, which can help prevent anastomotic leakage.

Optimizing Endoscopy Procedure Documentation Improves Guideline-Adherent Care in Upper Gastrointestinal Bleeding.

BACKGROUND AND AIMS: Upper GI bleeding (UGIB) is a common indication for inpatient esophagogastroduodenoscopy (EGD). Guideline adherence improves post-EGD care, including appropriate medication dosing/duration and follow-up procedures that reduce UGIB-related morbidity. We aimed to optimize and standardize post-EGD documentation to improve process and clinical outcomes in UGIB-related care. METHODS: We performed a prospective quality improvement study of inpatient UGIB endoscopies at an academic tertiary referral center during 6/2019-7/2021. Guidelines were used to develop etiology/severity-specific electronic health record note templates. Participants (39 faculty/15 trainees) completed 10-min training in template content/use. We collected pre/post-intervention process data on "Minimal Standard Report" (MSR) documentation including patient disposition, diet, and medications. We also recorded documentation of re-bleed precautions and follow-up procedures. Study outcomes included guideline-based medication prescriptions, ordering of follow-up EGD, and post-discharge re-bleeding. Pre/post-intervention analysis was performed using chi-square tests. RESULTS: From a pre-intervention baseline of 199 patients to 459 patients post-intervention, compliance improved with inpatient PPI (53.4-77.9%, p < 0.001) and discharge PPI (31.3-61.0%, p < 0.001) prescriptions. There was improvement in MSR completion (28.6-42.5%, p < 0.001). Compliance improved with octreotide prescriptions (75.0-93.6%, p = 0.002) and follow-up EGD order (61.3-87.1%, p < 0.001). There was no change in post-discharge re-bleeding. 82.6% of cases used templates. CONCLUSIONS: Our project leveraged endoscopy software to standardize documentation, resulting in improved clinical care behavior and efficiency. Our intervention required low burden of maintenance, and sustainability with high utilization over 9 months. Similar endoscopy templates can be applied to other health systems and procedures to improve care.

Adoption of Optimal Small (6-9 mm) Colorectal Polyp Resection Technique Over Time.

BACKGROUND: Cold snare polypectomy (CSP) is the preferred resection technique for small (6-9 mm) polyps due to lower rate of incomplete resection compared to cold forceps polypectomy (CFP) and improved safety profile over hot snare polypectomy (HSP). AIMS: To describe resection techniques for small (6-9 mm) polyps and determine factors associated with sub-optimal technique. METHODS: This was retrospective cohort study of colonoscopies performed by gastroenterological and surgical endoscopists from 2012 to 2019 where at least one 6-9 mm polyp was removed. Patient, provider, and procedure characteristics were collected. Univariate and multivariate regression analyses were performed to determine factors associated with sub-optimal technique. RESULTS: In total, 773 colonoscopies where 1,360 6-9 mm polyps removed by 21 endoscopists were included. CSP was used for 1,122 (82.5%), CFP for 61 (4.5%), and HSP for 177 (13.0%). Surgeon specialty was associated with CFP use (aOR 7.81; 95% CI 3.02-20.16). Polyp location in left colon (aOR 1.65; 95% CI 1.17-2.33) and pedunculated morphology (aOR 12.76; 95% CI 7.24-22.50) were associated with HSP. There was a significant increase in overall CSP use from 30.4% in 2012 to 96.8% in 2019. CONCLUSIONS: 82.5% of all 6-9 mm polyps removed from 2012 to 2019 were removed using a cold snare with significant increase in CSP from 2012 to 2019. Differences in how optimal technique was adopted over time based on specialty highlight the need for standardized practice guidelines and quality monitoring.