Periprocedural management of aspirin during colonoscopy: a survey of practice patterns in the United States.

BACKGROUND: The risk of postpolypectomy bleeding for patients taking aspirin is low, and gastroenterology society guidelines state that aspirin is likely safe to continue; however, many practices recommend aspirin discontinuation. OBJECTIVE: To characterize practice patterns of periprocedural aspirin use with colonoscopy in the United States. DESIGN: Survey study. SETTING: Endoscopy units in the United States. INTERVENTIONS: We reviewed colonoscopy preparation instruction sheets available online to characterize recommendations regarding periprocedural aspirin use. The endoscopy units that recommended discontinuation of aspirin before colonoscopy were contacted to determine their reasons for doing so. We also determined which endoscopy units were recognized by the American Society for Gastrointestinal Endoscopy (ASGE) quality recognition program. MAIN OUTCOME MEASUREMENTS: Endoscopy unit recommendations regarding aspirin use before colonoscopy. RESULTS: We reviewed colonoscopy preparation instructions from 317 endoscopy units, of which 138 (43.5%) recommended continuing aspirin, 103 (32.5%) recommended stopping aspirin, and 76 (24%) requested patients to contact a physician. The most common reasons for recommending aspirin discontinuation were concern about bleeding after polypectomy (62%), perceived minimal downside to stopping aspirin (38%), inertia to changing old policies (20%), and concern about medicolegal implications of postpolypectomy bleeding (15%). There was no significant association between endoscopy unit recommendations about periprocedural aspirin use and ASGE quality certification (P = .17) or type of endoscopy facility (ambulatory surgical center vs hospital affiliated) (P = .55). LIMITATION: Non-response bias. CONCLUSION: Less than half of the endoscopy units surveyed in the United States routinely continue aspirin before screening colonoscopies despite evidence that benefits outweigh the risks. It is important for gastroenterology and cardiology societies to make a firm statement, educate their members, and give them confidence and support to continue aspirin periprocedurally.

Readability, suitability, and health content assessment of web-based patient education materials on colorectal cancer screening.

BACKGROUND: Colorectal cancer (CRC) screening rates in the Unites States are still below target level. Web-based patient education materials are used by patients and providers to provide supplemental information on CRC screening. Low literacy levels and patient perceptions are significant barriers to screening. There are little data on the quality of these online materials from a health literacy standpoint or whether they address patients' perceptions. OBJECTIVE: To evaluate the readability, suitability, and health content of web-based patient education materials on colon cancer screening. DESIGN: Descriptive study. SETTING: Web-based patient materials. INTERVENTIONS: Twelve reputable and popular online patient education materials were evaluated. Readability was measured by using the Flesch-Kincaid Reading Grade Level, and suitability was determined by the Suitability Assessment of Materials, a scale that considers characteristics such as content, graphics, layout/typography, and learning stimulation. Health content was evaluated within the framework of the Health Belief Model, a behavioral model that relates patients' perceptions of susceptibility to disease, severity, and benefits and barriers to their medical decisions. Each material was scored independently by 3 reviewers. MAIN OUTCOME MEASUREMENTS: Flesch-Kincaid Reading Grade Level score, Suitability Assessment of Materials score, health content score. RESULTS: Readability for 10 of 12 materials surpassed the maximum recommended sixth-grade reading level. Five were 10th grade level and above. Only 1 of 12 materials received a superior suitability score; 3 materials received inadequate scores. Health content analysis revealed that only 50% of the resources discussed CRC risk in the general population and <25% specifically addressed patients at high risk, such as African Americans, smokers, patients with diabetes, and obese patients. For perceived barriers to screening, only 8.3% of resources discussed embarrassment, 25% discussed pain with colonoscopy, 25% addressed cost of colonoscopy, and none specifically mentioned the need to get colonoscopy when no symptoms are present. No material discussed the social benefits of screening. LIMITATIONS: Descriptive design. CONCLUSION: Most online patient education materials for CRC screening are written beyond the recommended sixth-grade reading level, with suboptimal suitability. Health content is lacking in addressing key perceived risks, barriers, and benefits to CRC screening. Developing more appropriate and targeted patient education resources on CRC may improve patient understanding and promote screening.

Early identification of patients at risk for iron-deficiency anemia using deep learning techniques.

OBJECTIVES: Iron-deficiency anemia (IDA) is a common health problem worldwide, and up to 10% of adult patients with incidental IDA may have gastrointestinal cancer. A diagnosis of IDA can be established through a combination of laboratory tests, but it is often underrecognized until a patient becomes symptomatic. Based on advances in machine learning, we hypothesized that we could reduce the time to diagnosis by developing an IDA prediction model. Our goal was to develop 3 neural networks by using retrospective longitudinal outpatient laboratory data to predict the risk of IDA 3 to 6 months before traditional diagnosis. METHODS: We analyzed retrospective outpatient electronic health record data between 2009 and 2020 from an academic medical center in northern Texas. We included laboratory features from 30,603 patients to develop 3 types of neural networks: artificial neural networks, long short-term memory cells, and gated recurrent units. The classifiers were trained using the Adam Optimizer across 200 random training-validation splits. We calculated accuracy, area under the receiving operating characteristic curve, sensitivity, and specificity in the testing split. RESULTS: Although all models demonstrated comparable performance, the gated recurrent unit model outperformed the other 2, achieving an accuracy of 0.83, an area under the receiving operating characteristic curve of 0.89, a sensitivity of 0.75, and a specificity of 0.85 across 200 epochs. CONCLUSIONS: Our results showcase the feasibility of employing deep learning techniques for early prediction of IDA in the outpatient setting based on sequences of laboratory data, offering a substantial lead time for clinical intervention.

Contrasting Perspectives of Anesthesiologists and Gastroenterologists on the Optimal Time Interval between Bowel Preparation and Endoscopic Sedation.

Background. The optimal time interval between the last ingestion of bowel prep and sedation for colonoscopy remains controversial, despite guidelines that sedation can be administered 2 hours after consumption of clear liquids. Objective. To determine current practice patterns among anesthesiologists and gastroenterologists regarding the optimal time interval for sedation after last ingestion of bowel prep and to understand the rationale underlying their beliefs. Design. Questionnaire survey of anesthesiologists and gastroenterologists in the USA. The questions were focused on the preferred time interval of endoscopy after a polyethylene glycol based preparation in routine cases and select conditions. Results. Responses were received from 109 anesthesiologists and 112 gastroenterologists. 96% of anesthesiologists recommended waiting longer than 2 hours until sedation, in contrast to only 26% of gastroenterologists. The main reason for waiting >2 hours was that PEG was not considered a clear liquid. Most anesthesiologists, but not gastroenterologists, waited longer in patients with history of diabetes or reflux. Conclusions. Anesthesiologists and gastroenterologists do not agree on the optimal interval for sedation after last drink of bowel prep. Most anesthesiologists prefer to wait longer than the recommended 2 hours for clear liquids. The data suggest a need for clearer guidelines on this issue.

Cannulation time is a more accurate measure of cannulation difficulty in endoscopic retrograde cholangiopancreatography than the number of attempts.

BACKGROUND: Cannulation of the common bile duct (CBD) is the initial and sometime challenging step in endoscopic retrograde cholangiopancreatography (ERCP) procedure. Endoscopists often use cannulation attempts and cannulation time to grade cannulation difficulty, but a standard system has yet to be established. The objective of this study was to compare cannulation times with numbers of cannulation attempts, as measures of cannulation difficulty. METHODS: We conducted a prospective study in a tertiary referral center, enrolling 58 patients who were undergoing ERCP for a variety of indications. Cannulation time and the number of cannulation attempts were recorded for each patient. A subset of 14 ERCPs had two observers assessing attempts at cannulation. Cannulation time, number of attempts and inter-observer variability in assessment of attempts were compared and studied. RESULTS: The degree of agreement between two the methods (cannulation times and number of cannulation attempts) was unacceptable. There were considerable discrepancies between attempt tallies from two observers but the mean difference was statistically insignificant. CONCLUSION: The grade of cannulation difficulty for a given ERCP procedure may differ when different methods are used (total cannulation time vs number of attempts); thus, grading by different methods should not be used interchangeably. Cannulation time is a more objective and more accurate assessment tool for grading cannulation difficulty than the number of attempts to cannulate the papilla.

Identification of small-molecule inhibitors of the colorectal cancer oncogene Krüppel-like factor 5 expression by ultrahigh-throughput screening.

The transcription factor Krüppel-like factor 5 (KLF5) is primarily expressed in the proliferative zone of the mammalian intestinal epithelium, where it regulates cell proliferation. Studies showed that inhibition of KLF5 expression reduces proliferation rates in human colorectal cancer cells and intestinal tumor formation in mice. To identify chemical probes that decrease levels of KLF5, we used cell-based ultrahigh-throughput screening (uHTS) to test compounds in the public domain of NIH, the Molecular Libraries Probe Production Centers Network library. The primary screen involved luciferase assays in the DLD-1/pGL4.18hKLF5p cell line, which stably expressed a luciferase reporter driven by the human KLF5 promoter. A cytotoxicity counterscreen was done in the rat intestinal epithelial cell line, IEC-6. We identified 97 KLF5-selective compounds with EC(50) < 10 µmol/L for KLF5 inhibition and EC(50) > 10 µmol/L for IEC-6 cytotoxicity. The two most potent compounds, CIDs (PubChem Compound IDs) 439501 and 5951923, were further characterized on the basis of computational, Western blot, and cell viability analyses. Both of these compounds, and two newly synthesized structural analogs of CID 5951923, significantly reduced endogenous KLF5 protein levels and decreased viability of several colorectal cancer cell lines without any apparent impact on IEC-6 cells. Finally, when tested in the NCI-60 panel of human cancer cell lines, compound CID 5951923 was selectively active against colon cancer cells. Our results show the feasibility of uHTS in identifying novel compounds that inhibit colorectal cancer cell proliferation by targeting KLF5.

An update on the use of pantoprazole as a treatment for gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is a chronic, recurrent disease that affects nearly 19 million people in the US. The mainstay of therapy for GERD is acid suppression. Proton pump inhibitors (PPIs) are the most effective medication for both initial treatment and maintenance therapy of GERD. Pantoprazole, a first-generation PPI, was approved by the FDA in 2000 for the treatment of erosive esophagitis associated with GERD. It has been used in more than 100 different countries worldwide. It is one of the few PPIs available in multiple forms: a delayed-release oral capsule, oral suspension, and intravenous. Pantoprazole been shown to improve acid reflux-related symptoms, heal esophagitis, and improve health-related quality of life more effectively than histamine-2 receptor antagonists. Evaluated in over 100 clinical trials, pantoprazole has an excellent safety profile, is as efficacious as other PPIs, and has a low incidence of drug interactions. It has also been shown to be safe and effective in special patient populations, such as the elderly and those with renal or moderate liver disease.