Adjunctive Use of Wide-Area Transepithelial Sampling-3D in Patients With Symptomatic Gastroesophageal Reflux Increases Detection of Barrett's Esophagus and Dysplasia.

INTRODUCTION: Patients with gastroesophageal reflux (GERD) symptoms undergoing screening upper endoscopy for Barrett's esophagus (BE) frequently demonstrate columnar-lined epithelium, with forceps biopsies (FBs) failing to yield intestinal metaplasia (IM). Repeat endoscopy is then often necessary to confirm a BE diagnosis. The aim of this study was to assess the yield of IM leading to a diagnosis of BE by the addition of wide-area transepithelial sampling (WATS-3D) to FB in the screening of patients with GERD. METHODS: We performed a prospective registry study of patients with GERD undergoing screening upper endoscopy. Patients had both WATS-3D and FB. Patients were classified by their Z line appearance: regular, irregular (<1 cm columnar-lined epithelium), possible short-segment BE (1 to <3 cm), and possible long-segment BE (≥3 cm). Demographics, IM yield, and dysplasia yield were calculated. Adjunctive yield was defined as cases identified by WATS-3D not detected by FB, divided by cases detected by FB. Clinicians were asked if WATS-3D results affected patient management. RESULTS: Of 23,933 patients, 6,829 (28.5%) met endoscopic criteria for BE. Of these, 2,878 (42.1%) had IM identified by either FB or WATS-3D. Among patients fulfilling endoscopic criteria for BE, the adjunctive yield of WATS-3D was 76.5% and absolute yield was 18.1%. One thousand three hundred seventeen patients (19.3%) who fulfilled endoscopic BE criteria had IM detected solely by WATS-3D. Of 240 patients with dysplasia, 107 (44.6%) were found solely by WATS-3D. Among patients with positive WATS-3D but negative FB, the care plan changed in 90.7%. DISCUSSION: The addition of WATS-3D to FB in patients with GERD being screened for BE resulted in confirmation of BE in an additional one-fifth of patients. Furthermore, dysplasia diagnoses approximately doubled.

Increased Anesthesia Usage in a Large-Volume Endoscopy Unit: Patient Acuity Is Not the Main Predictor.

OBJECTIVES: The use of monitored anesthesia care (MAC) for colonoscopy sedation continues to increase. This study examined trends during a 9-year period in the use of MAC and explored which patient variables may have influenced these trends. METHODS: This was a retrospective review of all colonoscopies performed in our hospital-based endoscopy unit from 2003 through 2012. We determined whether MAC was used and if not, which quantitative doses of sedative agents were used. Several patient-related variables were evaluated for correlation. Data were analyzed (t test, χ(2), logistic regression) using SAS statistical software. RESULTS: Between January 2003 and October 2012, we identified 37,803 performed colonoscopies. The use of MAC increased significantly, from 0.38% in 2003 to 10.0% in 2012 (P < 0.0001). For cases in which conscious sedation was used, the mean doses of sedatives did not change significantly over time. Although there was an association between certain patient variables (female sex; higher American Society of Anesthesiologists class; diagnostic procedures; and pulmonary, psychiatric, renal or cerebrovascular diseases) and the use of MAC, the greatest predictor of MAC use was the year of the procedure. After adjusting for the patient variables that were examined, the odds of using MAC increased by approximately 1.5 times per year from 2003 through 2012. The adjusted odds of using MAC in 2012 were 35.8 times higher than in 2003. CONCLUSIONS: The use of MAC for colonoscopies performed in our endoscopy unit increased significantly from 2003 to 2012. Although increased MAC use was associated with some patient variables, it was most significantly associated with the year of the procedure. This suggests that there were other nonpatient-related factors influencing its use.

Cerebral fat embolism and the "starfield" pattern: a case report.

Nearly all long-bone fractures are accompanied by some form of fat embolism. The rare complication of clinically significant fat embolism syndrome, however, occurs in only 0.9-2.2% of cases. The clinical triad of fat embolism syndrome consists of respiratory distress, altered mental status, and petechial rash. Cerebral fat embolism causes the neurologic involvement seen in fat embolism syndrome. A 19-year-old African-American male was admitted with gunshot wounds to his right hand and right knee. He had diffuse hyperactive deep tendon reflexes, bilateral ankle clonus and decerebrate posturing with a Glasgow Coma Scale (GCS) score of 4T. Subsequent MRI of the brain showed innumerable punctate areas of restricted diffusion consistent with "starfield" pattern. On a 10-week follow up he has a normal neurological examination and he is discharged home. Despite the severity of the neurologic insult upon initial presentation, the majority of case reports on cerebral fat embolism illustrate that cerebral dysfunction associated with cerebral fat embolism is reversible. When neurologic deterioration occurs in the non-head trauma patient, then a systemic cause such as fat emboli should be considered. We describe a patient with non-head trauma who demonstrated the classic "starfield" pattern on diffusion-weighted MRI imaging.