Adenoma detection in excellent versus good bowel preparation for colonoscopy.

GOAL: To determine whether Excellent bowel cleansing is superior to Good for the detection of adenomas. BACKGROUND: High quality colonoscopy requires Adequate bowel preparation. However, it is unknown whether adenoma detection differs between subcategories of Adequate cleansing. STUDY: We utilized a retrospective, cross-sectional study design to obtain data about patients undergoing colonoscopy at a single university center between August 31, 2011 and September 1, 2012. Primary outcome was adenoma detection rate (ADR), the percentage of patients with ≥1 adenoma. Secondary outcomes included adenomas per colonoscopy, adenoma distribution (proximal vs. distal), and detection of advanced adenomas, sessile serrated polyps (SSP), and cancer. RESULTS: The electronic medical record of 5113 consecutive colonoscopies with Good or Excellent preparation was queried for preparation quality, colonoscopy indication, demographics, medical history, and history of adenoma and colon cancer. Exclusion criteria were age below 18 years, inflammatory bowel disease, or familial polyposis. Adenoma detection was not superior with Excellent cleansing as compared with Good for ADR [respectively, 26% vs. 29%, odds ratio 0.97 (0.85, 1.11), P=0.618] or adenomas per colonoscopy [respectively, 0.437 vs. 0.499, incidence rate ratio (IRR) 0.98 (0.90, 1.07), P=0.705]. Excellent cleansing demonstrated superior detection of SSPs [IRR 1.66 (1.14, 2.40), P=0.008] and advanced adenomas [IRR 1.37 (1.09, 1.72), P=0.007] but not colon cancer [odds ratio 0.286 (0.083, 0.985), P=0.0474]. CONCLUSIONS: ADR is not significantly different between the Adequate subcategories of Excellent and Good. However, Excellent cleansing is associated with superior detection of advanced adenomas and SSPs. If confirmed, achieving an Excellent preparation may improve colonoscopy performance in the proximal colon where SSPs primarily occur.

Utility of the short double-balloon enteroscope to perform pancreaticobiliary interventions in patients with surgically altered anatomy in a US multicenter study.

OBJECTIVE: Double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreaticography (DBE-ERCP) is an effective method for interventions in the pancreaticobiliary system in the post-surgical patient. However, use of currently available endoscopic accessories during this procedure is limited due of the length of the conventional instrument (200 cm). The aim of this study was to explore the utility of the short DBE (152 cm) for the management of pancreaticobiliary disorders in patients with surgically altered anatomies. METHODS: Data were collected retrospectively on patients with various anatomic variations in whom ERCP was performed using the short DBE from April 2008 to November 2011. Basic demographic information, clinical presentation, preoperative imaging, and type of surgery, procedural technical success rate, and adverse events were evaluated. Descriptive analysis was used to document the demographic and clinical data of the patients. RESULTS: We identified 79 patients in whom DBE-ERCP was attempted (38 % male, mean age 58 years). Indications for the procedure were removal of a previously placed stent (n = 5), suspected sphincter of Oddi dysfunction type 1 (n = 3), surgical biliary leak (n = 3), pancreatic anastomotic stricture (n = 2), suspected biliary stones (n = 48), and biliary strictures visualized on imaging (n = 18). Overall, the success rate of DBE-ERCP in all patients was 81 % (64/79). The scope could not reach the papilla or surgical anastomosis in 8 cases and duct cannulation failed in 7 cases. The following interventions were performed: biliary sphincterotomy (n = 39), dilation of CBD stenosis with a balloon (n = 30), biliary stent insertion (n = 25), stone removal (n = 35), brushing cytology of biliary strictures (n = 3), and stent retrieval (n = 4). Three patients developed post-procedure pancreatitis. There was 1 episode of self-limited bleeding. CONCLUSIONS: The current study demonstrates that DBE assisted ERCP for pancreaticobiliary interventions using a short enteroscope are feasible in patients with surgically altered anatomy.

O-desulfated heparin improves outcome after rat cerebral ischemia/reperfusion injury.

OBJECTIVE: Inflammatory cascades play a significant role in progressive neurological injury after transient cerebral ischemia. It has been demonstrated that heparin, a potent anticoagulant, also possesses anti-inflammatory properties that diminish postreperfusion damage after stroke. However, the potential for heparin to induce hemorrhagic transformation of an infarct has deterred its use in cases of focal cerebral ischemia. In this study, we examined whether or not administration of a novel O-desulfated heparin (ODSH), with significantly decreased anticoagulant activity but active anti-inflammatory effects, would ameliorate inflammatory neurological injury without increasing intracerebral hemorrhage in a rat model of transient middle cerebral artery occlusion. METHODS: Rats were injected immediately before ischemia with phosphate-buffered saline or ODSH (5 mg/kg, intravenously) and then every 12 hours (15 mg/kg, subcutaneously) for 72 hours. The animals were assessed for neurological function using a foot fault test and modified Bederson scale on Days 1, 2, and 5; plasma samples were analyzed for activated clotting time at multiple time points after the initial ODSH dose. After sacrifice on Day 5, infarct volume was determined and brain tissue was examined for evidence of hemorrhage both grossly and using a previously validated spectrophotometric hemoglobin assay. RESULTS: ODSH-treated animals demonstrated significantly improved foot fault performance (P = 0.03) on Day 5 and reduced stroke volumes (P = 0.03) relative to controls. Although the brains of ODSH-treated rats exhibited significantly higher hemoglobin levels in a standardized assay (P = 0.01), there were no incidences of gross hemorrhage observed in either group, and activated clotting time measurements for the treated animals were not significantly elevated over baseline at any time point. CONCLUSION: Our findings indicate that ODSH can be administered at a dose that provides postischemic anti-inflammatory neuroprotection without an increased risk of intracerebral hemorrhage.

The role of Staphylococcus aureus adhesins in the pathogenesis of ventricular assist device-related infections.

Ventricular assist devices (VADs) are an important form of therapy for end-stage congestive heart failure. However, infection of the VAD, which is often caused by Staphylococcus aureus, poses a major threat to survival. Using a novel in vitro binding assay with VAD membranes and a heterologous lactococcal system of expression, we identify 3 S. aureus proteins--clumping factor A (ClfA) and fibronectin binding proteins A and B (FnBPA and FnBPB) as the main factors involved in adherence to VAD polyurethane membranes. Adherence is greatly diminished by long implantation times, reflecting a change in topological features of the VAD membrane, and is primarily mediated by the FnBPA domains in the staphylococcal proteins. We also compare the adherence of S. aureus mutant strains and show that other staphylococcal components appear to be involved in adherence to VAD membranes. Finally, we demonstrate that ClfA, FnBPA, and FnBPB mediate bacterial infection of implanted murine intra-aortic polyurethane patches.