Use of N-acetylcysteine plus simethicone to improve mucosal visibility in upper digestive endoscopy via systematic alphanumeric-coded endoscopy: a randomized, double-blind controlled trial.

Background: The use of antifoaming and mucolytic agents prior to upper gastrointestinal (GI) endoscopy and a thorough systematic review are essential to optimize lesion detection. This study evaluated the effect of simethicone and N-acetylcysteine on the adequate mucosal visibility (AMV) of the upper GI tract by an innovative systematic method. Methods: This randomized, double-blind controlled trial included consecutive patients who underwent diagnostic upper GI endoscopy for screening for early neoplasms between August 2019 and December 2019. The upper GI tract was systematically assessed by systematic alphanumeric-coded endoscopy. Patients were divided into 4 groups: 1) water; 2) only simethicone; 3) N-acetylcysteine + simethicone; and 4) only N-acetylcysteine. The following parameters were assessed in each group: age, sex, body mass index, level of adequate mucosal visibility, and side-effects. Results: A total of 4564 images from upper GI areas were obtained for evaluation. The mean AMV in the 4 groups was 93.98±7.36%. The N-acetylcysteine + simethicone group had a higher cleaning percentage compared with the other groups (P=0.001). There was no significant difference among the remaining groups, but several areas had better cleaning when a mucolytic or antifoam alone was used. No side-effects were found in any group. Conclusion: The combination of N-acetylcysteine plus simethicone optimizes the visibility of the mucosa of the upper GI tract, which could potentially increase diagnostic yield.

International consensus on the management of large (≥20 mm) colorectal laterally spreading tumors: World Endoscopy Organization Delphi study.

OBJECTIVES: There have been significant advances in the management of large (≥20 mm) laterally spreading tumors (LSTs) or nonpedunculated colorectal polyps; however, there is a lack of clear consensus on the management of these lesions with significant geographic variability especially between Eastern and Western paradigms. We aimed to provide an international consensus to better guide management and attempt to homogenize practices. METHODS: Two experts in interventional endoscopy spearheaded an evidence-based Delphi study on behalf of the World Endoscopy Organization Colorectal Cancer Screening Committee. A steering committee comprising six members devised 51 statements, and 43 experts from 18 countries on six continents participated in a three-round voting process. The Grading of Recommendations, Assessment, Development and Evaluations tool was used to assess evidence quality and recommendation strength. Consensus was defined as ≥80% agreement (strongly agree or agree) on a 5-point Likert scale. RESULTS: Forty-two statements reached consensus after three rounds of voting. Recommendations included: three statements on training and competency; 10 statements on preresection evaluation, including optical diagnosis, classification, and staging of LSTs; 14 statements on endoscopic resection indications and technique, including statements on en bloc and piecemeal resection decision-making; seven statements on postresection evaluation; and eight statements on postresection care. CONCLUSIONS: An international expert consensus based on the current available evidence has been developed to guide the evaluation, resection, and follow-up of LSTs. This may provide guiding principles for the global management of these lesions and standardize current practices.

Endoscopic treatment of scarred polyps with a non-thermal device (Endorotor): A review of the literature .

Endoscopic resection (ER) of colorectal polyps has become a daily practice in most endoscopic units providing a colorectal cancer screening program and requires the availability of local experts and high-end endoscopic devices. ER procedures have evolved over the past few years from endoscopic mucosal resection (EMR) to more advanced techniques, such as endoscopic submucosal dissection and endo-scopic full-thickness resection. Complete resection and disease eradication are the ultimate goals of ER-based techniques, and novel devices have been developed to achieve these goals. The EndoRotor® Endoscopic Powered Resection System (Interscope Medical, Inc., Northbridge, Massachusetts, United States) is one such device. The EndoRotor is a powered resection tool for the removal of alimentary tract mucosa, including post-EMR persistent lesions with scarring, and has both CE Mark and FDA clearance. This review covers available published evidence documenting the usefulness of EndoRotor for the management of recurrent colorectal polyps.

Can an educational video improve the adequacy of bowel preparation for patients undergoing their first colonoscopy? Results of the EBOPS RCT.

Background and study aims The aim of this study was to assess the effect of an educational video on the quality of bowel preparation of patients from a UK population attending for their first colonoscopy. Patients and methods A prospective, endoscopist-blinded trial with 1:1 allocation was performed. Patients referred for their first colonoscopy were recruited between February 2019 and December 2019. All participants were prescribed Moviprep and received the trial site's standard written bowel preparation instructions, with the intervention group also receiving a bespoke educational video. Adequacy of bowel preparation (defined as a Boston Bowel Preparation Scale of ≥2 in each segment of the bowel) and polyp detection rates (PDRs) were compared. Fisher's chi squared test was utilized with P <0.05 as the threshold for significance. Results A total of 509 participants completed the trial from six centers; 251 were randomized to the intervention group. The mean age was 57 years and 52.3% were female. The primary endpoint was met with an adequacy rate of 216 of 251 (86.1%) in the intervention group, compared with 205 of 259 (79.1%) in the control group ( P <0.05, odds ratio [OR] 1.626, 95% CI 1.017-2.614). The PDR was significantly higher in the intervention group (39% vs 30%, OR 1.51, 95% CI 1.04-2.19, P <0.05). Conclusions An educational video leads to improved bowel preparation for patients attending for their first colonoscopy, and is also associated with greater detection of polyps. Widespread adoption of an educational video incurs minimal investment, but would reduce the number of inadequate procedures, missed pathology, and the cost that both these incur.

Identifying the best cutoff value of the fecal occult blood immunochemical test in the detection of advanced and neoplastic colorectal lesions.

Objective: Screening is an effective tool for detecting colorectal lesions in asymptomatic subjects. There is a positive correlation between fecal immunochemical test (FIT) values and the size of tumors. Despite the efficacy of screening, the detection of colorectal cancer (CRC) remains low. The primary objective was to evaluate the best FIT cutoff value for detecting advanced adenomas and CRC among individuals at average risk in a country with a high incidence and morbidity from CRC. Methods: This observational and prospective study analyzed consecutive cases in 1461 asymptomatic subjects with a positive FIT (≥ 100 ng hemoglobin [Hb]/mL) referred for colonoscopy (2012-2015) at a tertiary center in Uruguay. Results: Colorectal lesions were detected in 35.3% (516/1461) of cases, with a mean age of 62.8 ± 8.3 years. About 53.2% were men and 65.1% of the tumors were located in the left side of the colon. The size of the lesion and FIT values (p = 0.001) were positively correlated. Laterally spreading tumors predominated in the right colon (586 ng Hb/mL; 95% Confidence interval [CI] 443.4-760). One hundred and thirty-five (26%) lesions were advanced adenomas (15 ± 6.7 mm); 694.6 ng/mL; 95% CI 632.4-756.9). The highest diagnostic yield (0.5112) for advanced adenomas was at a FIT level of 400 ng Hb/mL (accuracy 88.6%). There were significant differences in FIT values early and advanced CRC (927 ng/mL; [95% CI: 637-1082] vs. 1453 [95% CI: 1352-1594; p = 0.001]). Conclusion: A FIT value of 400 ng Hb/mL was the best diagnostic yield to detect advanced adenomas and CRC. This value is useful during the COVID-19 pandemic as it allows prioritization of colonoscopy to those most at risk of significant disease, thus reducing risks to both patients and healthcare workers.

Objetivo: El cribado es una herramienta eficaz para detectar lesiones colorrectales en sujetos asintomáticos. Existe una correlación positiva entre los valores de la prueba inmunoquímica fecal (FIT) y el tamaño de los tumores. A pesar de la eficacia del cribado, la detección del cáncer colorrectal (CCR) sigue siendo baja. El objetivo principal fue evaluar el mejor valor de corte FIT para detectar adenomas avanzados y CCR entre personas con riesgo promedio en un país con alta incidencia y morbilidad por CCR. Métodos: Este estudio observacional y prospectivo analizó 1461 sujetos asintomáticos con FIT positivo (≥ 100 ng de hemoglobina [Hb]/mL) remitidos para colonoscopia (2012-2015) en un centro terciario en Uruguay. Resultados: Se detectaron lesiones colorrectales en el 35,3% (516/1461) de los casos, con una edad media de 62,8 ± 8,3 años. Alrededor del 53,2% eran hombres y el 65,1% de los tumores estaban ubicados en el lado izquierdo del colon. El tamaño de la lesión y los valores FIT (p = 0,001) se correlacionaron positivamente. Los tumores con extensión lateral predominaron en el colon derecho (586 ng Hb/mL; intervalo de confianza [IC] del 95%: 443,4-760). Ciento treinta y cinco (26%) lesiones fueron adenomas avanzados (15 ± 6,7 mm); 694,6 ng/ml; IC 95% 632,4-756,9). El rendimiento diagnóstico más alto (0,5112) para los adenomas avanzados se obtuvo con un nivel FIT de 400 ng Hb/ml (precisión del 88,6%). Hubo diferencias significativas en los valores de FIT de CCR temprano y avanzado (927 ng/mL; [IC 95%: 637-1082] vs. 1453 [IC 95%: 1352-1594; p = 0,001]). Conclusión: Un valor FIT de 400 ng Hb/mL fue el mejor rendimiento diagnóstico para detectar adenomas avanzados y CCR. Este valor es útil durante la pandemia de COVID-19, ya que permite priorizar la colonoscopia a aquellos con mayor riesgo de padecer una enfermedad importante, reduciendo así los riesgos tanto para los pacientes como para los trabajadores de la salud.

Cytosponge procedures produce fewer respiratory aerosols and droplets than esophagogastroduodenoscopies.

Esophagogastroduodenoscopies (EGD) are aerosol-generating procedures that may spread respiratory pathogens. We aim to investigate the production of airborne aerosols and droplets during Cytosponge procedures, which are being evaluated in large-scale research studies and National Health Service (NHS)implementation pilots to reduce endoscopy backlogs. We measured 18 Cytosponge and 37 EGD procedures using a particle counter (diameters = 0.3-25 µm), taking measurements 10 cm from the mouth. Two particle count analyses were performed: whole procedure and event-based. Direct comparison with duration-standardized EGD procedures shows that Cytosponge procedures produce 2.16× reduction (P < 0.001) for aerosols and no significant change for droplets (P = 0.332). Event-based analysis shows that particle production is driven by throat spray (aerosols: 138.1× reference, droplets: 16.2×), which is optional, and removal of Cytosponge (aerosols: 14.6×, droplets: 62.6×). Cytosponge burping produces less aerosols than EGD (2.82×, P < 0.05). Cytosponge procedures produce significantly less aerosols and droplets than EGD procedures and thus reduce two potential transmission routes for respiratory viruses.

Western outcomes of circumferential endoscopic submucosal dissection for early esophageal squamous cell carcinoma.

BACKGROUND AND AIMS: Circumferential endoscopic submucosal dissection (cESD) in the esophagus has been reported to be feasible in small Eastern case series. We assessed the outcomes of cESD in the treatment of early esophageal squamous cell carcinoma (ESCC) in Western countries. METHODS: We conducted an international study at 25 referral centers in Europe and Australia using prospective databases. We included all patients with ESCC treated with cESD before November 2022. Our main outcomes were curative resection according to European guidelines and adverse events. RESULTS: A total of 171 cESDs were performed on 165 patients. En bloc and R0 resections rates were 98.2% (95% confidence interval [CI], 95.0-99.4) and 69.6% (95% CI, 62.3-76.0), respectively. Curative resection was achieved in 49.1% (95% CI, 41.7-56.6) of the lesions. The most common reason for noncurative resection was deep submucosal invasion (21.6%). The risk of stricture requiring 6 or more dilations or additional techniques (incisional therapy/stent) was high (71%), despite the use of prophylactic measures in 93% of the procedures. The rates of intraprocedural perforation, delayed bleeding, and adverse cardiorespiratory events were 4.1%, 0.6%, and 4.7%, respectively. Two patients died (1.2%) of a cESD-related adverse event. Overall and disease-free survival rates at 2 years were 91% and 79%. CONCLUSIONS: In Western referral centers, cESD for ESCC is curative in approximately half of the lesions. It can be considered a feasible treatment in selected patients. Our results suggest the need to improve patient selection and to develop more effective therapies to prevent esophageal strictures.

Bronchoscopy masks mitigate aerosols during upper gastrointestinal endoscopies.

Background and study aims Upper gastrointestinal endoscopies are considered aerosol-generating procedures (AGP) that risk spread of airborne diseases such as SARS-CoV-2. We aimed to investigate where clinically approved bronchoscopy masks applied to patients during esophagogastroduodenoscopies can mitigate spread of aerosols and droplets. Patients and methods This study included patients undergoing routine upper gastrointestinal endoscopy in a standard endoscopy room and used a particle counter to measure size and number of particles 10 cm from the mouths of 49 patients undergoing upper gastrointestinal endoscopies, of whom 12 wore bronchoscopy masks and 37 did not (controls). Particle counts in the aerosol (≤ 5 µm diameter) and droplet (> 5 µm-diameter) size ranges were measured and averaged over the duration of procedures. Results The use of bronchoscopy masks offers a 47% reduction ( P = 0.01) in particle count for particles < 5 µm in diameter over the procedure duration (aerosols). Conclusions Bronchoscopy masks or similar are a simple, low-cost mitigation technique that can be used during outbreaks of respiratory diseases such as COVID-19 to improve safety and reduce fallow times.

Precision endoscopy in colorectal polyps' characterization and planning of endoscopic therapy.

Precision endoscopy in the management of colorectal polyps and early colorectal cancer has emerged as the standard of care. It includes optical characterization of polyps and estimation of submucosal invasion depth of large nonpedunculated colorectal polyps to select the appropriate endoscopic resection modality. Over time, several imaging modalities have been implemented in endoscopic practice to improve optical performance. Among these, image-enhanced endoscopy systems and magnification endoscopy represent now well-established tools. New advanced technologies, such as endocytoscopy and confocal laser endomicroscopy, have recently shown promising results in predicting the histology of colorectal polyps. In recent years, artificial intelligence has continued to enhance endoscopic performance in the characterization of colorectal polyps, overcoming the limitations of other imaging modes. In this review we retrace the path of precision endoscopy, analyzing the yield of various endoscopic imaging techniques in personalizing management of colorectal polyps and early colorectal cancer.

Validation of a new optical diagnosis training module to improve dysplasia characterization in inflammatory bowel disease: a multicenter international study.

BACKGROUND AND AIMS: Inflammatory bowel disease (IBD) increases risk of dysplasia and colorectal cancer. Advanced endoscopic techniques allow for the detection and characterization of IBD dysplastic lesions, but specialized training is not widely available. We aimed to develop and validate an online training platform to improve the detection and characterization of colonic lesions in IBD: OPtical diagnosis Training to Improve dysplasia Characterization in Inflammatory Bowel Disease (OPTIC-IBD). METHODS: We designed a web-based learning module that includes surveillance principles, optical diagnostic methods, approach to characterization, and classifications of colonic lesions using still images and videos. We invited gastroenterologists from Canada, Italy, and the United Kingdom with a wide range of experience. Participants reviewed 24 educational videos of IBD colonic lesions, predicted histology, and rated their confidence. The primary endpoint was to improve accuracy in detecting dysplastic lesions after training on the platform. Furthermore, participants were randomized 1:1 to get additional training or not, with a final assessment occurring after 60 days. Diagnostic performance for dysplasia and rater confidence were measured. RESULTS: A total of 117 participants completed the study and were assessed for the primary endpoint. Diagnostic accuracy improved from 70.8% to 75.0% (P = .002) after training, with the greatest improvements seen in less experienced endoscopists. Improvements in both accuracy and confidence were sustained after 2 months of assessment, although the group randomized to receive additional training did not improve further. Similarly, participants' confidence in characterizing lesions significantly improved between before and after the course (P < .001), and it was sustained after 2 months of assessment. CONCLUSIONS: The OPTIC-IBD training module demonstrated that an online platform could improve participants' accuracy and confidence in the optical diagnosis of dysplasia in patients with IBD. The training platform can be widely available and improve endoscopic care for people with IBD. (Clinical trial registration number: NCT04924543.).

Esófago de Barrett: Actualización en el diagnóstico y tratamiento / Barrett's Esophagus: Update on the Diagnosis and Treatment. Review

El esófago de Barrett (EB) se define como la condición en la cual una mucosa columnar metaplásica predispuesta a neoplasia reemplaza la mucosa escamosa del esófago distal. La guías actuales recomiendan que el diagnóstico requiere el hallazgo de metaplasia intestinal (MI) con células caliciformes de al menos 1 cm de longitud. El EB afecta aproximadamente al 1% de la población general y hasta en 14% de los pacientes con enfermedad por reflujo gastroesofágico (ERGE). El EB es precursor del adenocarcinoma esofágico (ACE), neoplasia en aumento en países occidentales. Los principales factores de riesgo descritos para ACE asociado a EB son: sexo masculino, edad > 50 años, obesidad central y tabaquismo. El riesgo anual de ACE en EB sin displasia, displasia de bajo (DBG) y alto grado es 0,1-0,3%, 0,5% y 5-8%, respectivamente. El tratamiento del EB no displásico consiste en un cambio de estilo de vida saludable, quimioprevención mediante inhibidores de la bomba de protones y vigilancia endoscópica cada 3 a 5 años. Se recomienda que a partir de la presencia de DBG los pacientes sean referidos a un centro experto para la confirmación del diagnóstico, estadio y así definir su manejo. En pacientes con EB y displasia o cáncer incipiente, el tratamiento endoscópico consiste en la resección y ablación, con un éxito cercano al 90%. El principal evento adverso es la estenosis esofágica que es manejada endoscópicamente.

Barrett's esophagus (BE) is the condition in which a metaplastic columnar mucosa predisposed to neoplasia replaces the squamous mucosa of the distal esophagus. The current guidelines recommends that diagnosis requires the finding of intestinal metaplasia (IM) with goblet cells of at least 1 cm in length. BE affects approximately 1% of the general population and up to 14% of patients with gastroesophageal reflux disease (GERD). BE is a precursor of esophageal adenocarcinoma (EAC), which has increased in western countries. The main risk factors described for EAC associated with BE are male sex, age > 50 years, central obesity and tobacco use. Annual risk of EAC in patients with BE without dysplasia, low grade (LGD) and high-grade dysplasia is 0,1-0,3%, 0,5% y 5-8%, respectively. Treatment of non-dysplastic BE consists mainly of a healthy lifestyle change, chemoprevention with proton pump inhibitors and surveillance endoscopy every 3 to 5 years. It is recommended that from the presence of LGD patients are referred to an expert center for confirmation of the diagnosis, stage and thus define their management. In patients with BE and dysplasia or early-stage cancer, endoscopic therapy with resection and ablation is successful in about 90% of the patients. The main adverse event is esophageal stricture, which is managed endoscopically.

Air filtration mitigates aerosol levels both during and after endoscopy procedures.

Objectives: Upper gastrointestinal endoscopies are aerosol-generating procedures, increasing the risk of spreading airborne pathogens. We aim to quantify the mitigation of airborne particles via improved ventilation, specifically laminar flow theatres and portable high-efficiency particulate air (HEPA) filters, during and after upper gastrointestinal endoscopies. Methods: This observational study included patients undergoing routine upper gastrointestinal endoscopy in a standard endoscopy room with 15-17 air changes per hour, a standard endoscopy room with a portable HEPA filtration unit, and a laminar flow theatre with 300 air changes per hour. A particle counter (diameter range 0.3 µm-25 µm) took measurements 10 cm from the mouth. Three analyses were performed: whole procedure particle counts, event-based counts, and air clearance estimation using post-procedure counts. Results: Compared to a standard endoscopy room, for whole procedures we observe a 28.5x reduction in particle counts in laminar flow (p < 0.001) but no significant effect of HEPA filtration (p = 0.50). For event analysis, we observe for lateral flow theatres reduction in particles >5 µm for oral extubation (12.2x, p < 0.01), reduction in particles <5 µm for coughing/gagging (6.9x, p < 0.05), and reduction for all sizes in anesthetic throat spray (8.4x, p < 0.01) but no significant effect of HEPA filtration. However, we find that in the fallow period between procedures HEPA filtration reduces particle clearance times by 40%. Conclusions: Laminar flow theatres are highly effective at dispersing aerosols immediately after production and should be considered for high-risk cases where patients are actively infectious or the supply of personal protective equipment is limited. Portable HEPA filers can safely reduce the fallow time between procedures by 40%.

Rinitis alérgica en pediatría: recomendaciones para su diagnóstico y tratamiento / Allergic rhinitis in pediatrics: recommendations for diagnosis and treatment

La rinitis alérgica (RA) es una de las enfermedades crónicas más frecuentes de la infancia. Sin embargo, permanece subdiagnosticada y subtratada. Su prevalencia ha aumentado en los últimos años y varía del 2 % al 25 %. Los síntomas de la RA incluyen estornudos, prurito, rinorrea y congestión nasal. Un correcto diagnóstico y tratamiento de la RA y sus comorbilidades, tales como rinosinusitis con o sin poliposis nasal, conjuntivitis, otitis media, asma bronquial e infecciones del tracto respiratorio, son importantes para reducir el impacto negativo en la afectación de la calidad de vida del paciente y sus familiares, y los gastos sanitarios que ocasiona. La inmunoterapia alérgeno específica, en pacientes correctamente seleccionados, previene nuevas sensibilizaciones y reduce la hiperreactividad bronquial asociada a la RA. Considerando todos estos factores, el Comité Nacional de Alergia de la Sociedad Argentina de Pediatría propone recomendaciones basadas en la evidencia actual.

Allergic rhinitis (AR) is one of the most common chronic diseases in children. However, it remains underdiagnosed and undertreated. Its prevalence has increased in recent years and varies from 2 to 25 %. Symptoms include sneezing, itching, runny nose, and nasal congestion. A correct diagnosis and treatment of AR and its comorbidities such as rhinosinusitis with or without nasal polyposis, conjunctivitis, otitis media, bronchial asthma and respiratory tract infections, are important to reduce the negative impact on the quality of life of the patient and their relatives, and in medical costs. Specific allergen immunotherapy, in correctly selected patients, prevents new sensitizations and reduces bronchial hyperreactivity associated with AR. Taking into account all these reasons, the National Allergy Committee of the Sociedad Argentina de Pediatría proposes current evidence based recommendations

Artificial Intelligence Enabled Histological Prediction of Remission or Activity and Clinical Outcomes in Ulcerative Colitis.

BACKGROUND & AIMS: Microscopic inflammation has significant prognostic value in ulcerative colitis (UC); however, its assessment is complex with high interobserver variability. We aimed to develop and validate an artificial intelligence (AI) computer-aided diagnosis system to evaluate UC biopsies and predict prognosis. METHODS: A total of 535 digitalized biopsies (273 patients) were graded according to the PICaSSO Histologic Remission Index (PHRI), Robarts, and Nancy Histological Index. A convolutional neural network classifier was trained to distinguish remission from activity on a subset of 118 biopsies, calibrated on 42 and tested on 375. The model was additionally tested to predict the corresponding endoscopic assessment and occurrence of flares at 12 months. The system output was compared with human assessment. Diagnostic performance was reported as sensitivity, specificity, prognostic prediction through Kaplan-Meier, and hazard ratios of flares between active and remission groups. We externally validated the model in 154 biopsies (58 patients) with similar characteristics but more histologically active patients. RESULTS: The system distinguished histological activity/remission with sensitivity and specificity of 89% and 85% (PHRI), 94% and 76% (Robarts Histological Index), and 89% and 79% (Nancy Histological Index). The model predicted the corresponding endoscopic remission/activity with 79% and 82% accuracy for UC endoscopic index of severity and Paddington International virtual ChromoendoScopy ScOre, respectively. The hazard ratio for disease flare-up between histological activity/remission groups according to pathologist-assessed PHRI was 3.56, and 4.64 for AI-assessed PHRI. Both histology and outcome prediction were confirmed in the external validation cohort. CONCLUSION: We developed and validated an AI model that distinguishes histologic remission/activity in biopsies of UC and predicts flare-ups. This can expedite, standardize, and enhance histologic assessment in practice and trials.

[Allergic rhinitis in pediatrics: recommendations for diagnosis and treatment]. / Rinitis alérgica en pediatría: recomendaciones para su diagnóstico y tratamiento.

Allergic rhinitis (AR) is one of the most common chronic diseases in children. However, it remains underdiagnosed and undertreated. Its prevalence has increased in recent years and varies from 2 to 25 %. Symptoms include sneezing, itching, runny nose, and nasal congestion. A correct diagnosis and treatment of AR and its comorbidities such as rhinosinusitis with or without nasal polyposis, conjunctivitis, otitis media, bronchial asthma and respiratory tract infections, are important to reduce the negative impact on the quality of life of the patient and their relatives, and in medical costs. Specific allergen immunotherapy, in correctly selected patients, prevents new sensitizations and reduces bronchial hyperreactivity associated with AR. Taking into account all these reasons, the National Allergy Committee of the Sociedad Argentina de Pediatría proposes current evidence based recommendations.

La rinitis alérgica (RA) es una de las enfermedades crónicas más frecuentes de la infancia. Sin embargo, permanece subdiagnosticada y subtratada. Su prevalencia ha aumentado en los últimos años y varía del 2 % al 25 %. Los síntomas de la RA incluyen estornudos, prurito, rinorrea y congestión nasal. Un correcto diagnóstico y tratamiento de la RA y sus comorbilidades, tales como rinosinusitis con o sin poliposis nasal, conjuntivitis, otitis media, asma bronquial e infecciones del tracto respiratorio, son importantes para reducir el impacto negativo en la afectación de la calidad de vida del paciente y sus familiares, y los gastos sanitarios que ocasiona. La inmunoterapia alérgeno específica, en pacientes correctamente seleccionados, previene nuevas sensibilizaciones y reduce la hiperreactividad bronquial asociada a la RA. Considerando todos estos factores, el Comité Nacional de Alergia de la Sociedad Argentina de Pediatría propone recomendaciones basadas en la evidencia actual.

Development and validation of artificial neural networks model for detection of Barrett's neoplasia: a multicenter pragmatic nonrandomized trial (with video).

BACKGROUND AND AIMS: The aim of this study was to develop and externally validate a computer-aided detection (CAD) system for the detection and localization of Barrett's neoplasia and assess its performance compared with that of general endoscopists in a statistically powered multicenter study by using real-time video sequences. METHODS: In phase 1, the hybrid visual geometry group 16-SegNet model was trained by the use of 75,198 images and videos (96 patients) of neoplastic and 1,014,973 images and videos (65 patients) of nonneoplastic Barrett's esophagus. In phase 2, image-based validation was performed on a separate dataset of 107 images (20 patients) of neoplastic and 364 images (14 patients) of nonneoplastic Barrett's esophagus. In phase 3 (video-based external validation) we designed a real-time video-based study with 32 videos (32 patients) of neoplastic and 43 videos (43 patients) of nonneoplastic Barrett's esophagus from 4 European centers to compare the performance of the CAD model with that of 6 nonexpert endoscopists. The primary endpoint was the sensitivity of CAD diagnosis of Barrett's neoplasia. RESULTS: In phase 2, CAD detected Barrett's neoplasia with sensitivity, specificity, and accuracy of 95.3%, 94.5%, and 94.7%, respectively. In phase 3, the CAD system detected Barrett's neoplasia with sensitivity, specificity, negative predictive value, and accuracy of 93.8%, 90.7%, 95.1%, and 92.0%, respectively, compared with the endoscopists' performance of 63.5%, 77.9%, 74.2%, and 71.8%, respectively (P < .05 in all parameters). The CAD system localized neoplastic lesions with accuracy, mean precision, and mean intersection over union of 100%, 0.62, and 0.54, respectively, when compared with at least 1 of the expert markings. The processing speed of the CAD detection and localization were 5 ms/image and 33 ms/image, respectively. CONCLUSION: To our knowledge, this is the first study describing external (multicenter) validation of AI algorithms for the detection of Barrett's neoplasia on real-time endoscopic videos. The CAD system in this study significantly outperformed nonexpert endoscopists on real-time video-based assessment, achieving >90% sensitivity for neoplasia detection. This result needs to be validated during real-time endoscopic assessment.