Pancreaticoduodenal Artery Pseudoaneurysm Associated with Pancreatic Fibroinflammatory Mass and Duodenal Obstruction.

BACKGROUND When people in their 60s experiences abdominal pain, vomiting, and unexplained weight loss without a history of abdominal surgery, the usual diagnosis is obstruction caused by a neoplastic mass. Nevertheless, in exceptionally rare cases, these symptoms arise from complications linked to a visceral artery aneurysm. CASE REPORT We present a case of a 60-year-old man with immunodeficiency and Sneddon-Wilkinson disease (a rare subcorneal pustular dermatosis), who developed a pancreaticoduodenal aneurysm of uncertain origin, associated with pancreatic mass, retroperitoneal hematoma, and duodenal obstruction. The treatment approach included transcatheter arterial coil embolization with supportive measures such as parenteral nutrition, a nasogastric tube, octreotide administration, and antiemetics. Despite these interventions, persistence gastrointestinal symptoms prompted an endoscopic ultrasound fine-needle aspiration to rule out malignancy. The biopsy confirmed localized fibro-inflammation. Although he was initially considered for a gastro-jejunal bypass, conservative management effectively improved the pancreatic lesion and duodenal obstruction, leading to discontinuation of parenteral nutrition. The patient was able to resume a regular diet 4 weeks after embolization. CONCLUSIONS Pancreaticoduodenal artery aneurysm is a rare visceral aneurysm with multiple etiologies and potentially fatal consequences. We report an unusual case of a pancreaticoduodenal artery aneurysm associated with pancreatic mass and duodenal obstruction. This diagnosis warrants consideration when an immunodeficient patient presents symptoms of abdominal pain and vomiting. Early endovascular embolization, combined with conservative approaches, effectively alleviated the symptoms in our patient.

[The use of ultrasound in IBD: an essential tool?] / Échographie dans les maladies inflammatoires chroniques de l'intestin†: nouvel outil indispensable†?

Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory bowel diseases (IBD) characterized by an inflammation of the digestive tract wall. Current guidelines recommend a «treat to target¼ management and a "tight control" of the inflammation for an optimal follow-up. Intestinal ultrasound, due to its low cost, its feasibility at bed side, its absence of preparation and its non-invasive character, has proved its place in the diagnosis and the follow-up of IBD. It allows the evaluation of various parameters of the lumen, the intestinal wall, the mesentery, the vascularization as well as complications.

La maladie de Crohn (MC) et la rectocolite hémorragique (RCH) sont des maladies inflammatoires chroniques de l'intestin (MICI) caractérisées par une inflammation de la paroi du tube digestif. Les recommandations de prise en charge suggèrent de viser une cible thérapeutique et de procéder à une évaluation régulière de l'inflammation appelée «â€…contrôle serré ¼ (tight control en anglais). Le but est de proposer une adaptation thérapeutique si la cible n'est pas atteinte (concept du treat-to-target). L'échographie, par son faible coût, sa faisabilité au lit du malade, son absence de préparation colique et son caractère non invasif, a démontré sa place dans le diagnostic et le suivi des MICI. Elle permet d'évaluer divers paramètres de la lumière, de la paroi intestinale, du mésentère, la vascularisation et de rechercher des complications.

Specchio-COVID19 cohort study: a longitudinal follow-up of SARS-CoV-2 serosurvey participants in the canton of Geneva, Switzerland.

INTRODUCTION: The COVID-19 pandemic has affected billions of people around the world both directly through the infection itself and indirectly through its economic, social and sanitary impact. Collecting data over time is essential for the understanding of the disease spread, the incidence of COVID-19-like symptoms, the level and dynamics of immunity, as well as the long-term impact of the pandemic. The objective of the study was to set up a longitudinal follow-up of adult participants of serosurveys carried out in the canton of Geneva, Switzerland, during the COVID-19 pandemic. This follow-up aims at monitoring COVID-19 related symptoms and SARS-CoV-2 seroconversion, as well as the overall impact of the pandemic on several dimensions of health and on socioeconomic factors over a period of at least 2 years. METHODS AND ANALYSIS: Serosurvey participants were invited to create an account on the dedicated digital platform Specchio-COVID19 (https://www.specchio-covid19.ch/). On registration, an initial questionnaire assessed sociodemographic and lifestyle characteristics (including housing conditions, physical activity, diet, alcohol and tobacco consumption), anthropometry, general health and experience related to COVID-19 (symptoms, COVID-19 test results, quarantines, hospitalisations). Weekly, participants were invited to fill in a short questionnaire with updates on self-reported COVID-19-compatible symptoms, SARS-CoV-2 infection testing and vaccination. A more detailed questionnaire about mental health, well-being, risk perception and changes in working conditions was proposed monthly. Supplementary questionnaires were proposed at regular intervals to assess more in depth the impact of the pandemic on physical and mental health, vaccination adherence, healthcare consumption and changes in health behaviours. At baseline, serology testing allowed to assess the spread of SARS-CoV-2 infection among the general population and subgroups of workers. Additionally, seropositive participants and a sample of randomly selected participants were invited for serologic testing at regular intervals in order to monitor both the seropersistance of anti-SARS-CoV-2 antibodies and the seroprevalence of anti-SARS-CoV-2 antibodies in the population of the canton of Geneva. ETHICS AND DISSEMINATION: The study was approved by the Cantonal Research Ethics Commission of Geneva, Switzerland (CCER Project ID 2020-00881). Results will be disseminated in a variety of ways, via the Specchio-COVID-19 platform, social media posts, press releases and through regular scientific dissemination methods (open-access articles, conferences).

A new screening tool for SARS-CoV-2 infection based on self-reported patient clinical characteristics: the COV19-ID score.

BACKGROUND: While several studies aimed to identify risk factors for severe COVID-19 cases to better anticipate intensive care unit admissions, very few have been conducted on self-reported patient symptoms and characteristics, predictive of RT-PCR test positivity. We therefore aimed to identify those predictive factors and construct a predictive score for the screening of patients at admission. METHODS: This was a monocentric retrospective analysis of clinical data from 9081 patients tested for SARS-CoV-2 infection from August 1 to November 30 2020. A multivariable logistic regression using least absolute shrinkage and selection operator (LASSO) was performed on a training dataset (60% of the data) to determine associations between self-reported patient characteristics and COVID-19 diagnosis. Regression coefficients were used to construct the Coronavirus 2019 Identification score (COV19-ID) and the optimal threshold calculated on the validation dataset (20%). Its predictive performance was finally evaluated on a test dataset (20%). RESULTS: A total of 2084 (22.9%) patients were tested positive to SARS-CoV-2 infection. Using the LASSO model, COVID-19 was independently associated with loss of smell (Odds Ratio, 6.4), fever (OR, 2.7), history of contact with an infected person (OR, 1.7), loss of taste (OR, 1.5), muscle stiffness (OR, 1.5), cough (OR, 1.5), back pain (OR, 1.4), loss of appetite (OR, 1.3), as well as male sex (OR, 1.05). Conversely, COVID-19 was less likely associated with smoking (OR, 0.5), sore throat (OR, 0.9) and ear pain (OR, 0.9). All aforementioned variables were included in the COV19-ID score, which demonstrated on the test dataset an area under the receiver-operating characteristic curve of 82.9% (95% CI 80.6%-84.9%), and an accuracy of 74.2% (95% CI 74.1%-74.3%) with a high sensitivity (80.4%, 95% CI [80.3%-80.6%]) and specificity (72.2%, 95% CI [72.2%-72.4%]). CONCLUSIONS: The COV19-ID score could be useful in early triage of patients needing RT-PCR testing thus alleviating the burden on laboratories, emergency rooms, and wards.

Physician Assessment and Feedback During Quality Circle to Reduce Low-Value Services in Outpatients: a Pre-Post Quality Improvement Study.

BACKGROUND: The impact of the Choosing Wisely (CW) campaign is debated as recommendations alone may not modify physician behavior. OBJECTIVE: The aim of this study was to assess whether behavioral interventions with physician assessment and feedback during quality circles (QCs) could reduce low-value services. DESIGN AND PARTICIPANTS: Pre-post quality improvement intervention with a parallel comparison group involving outpatients followed in a Swiss-managed care network, including 700 general physicians (GPs) and 150,000 adult patients. INTERVENTIONS: Interventions included performance feedback about low-value activities and comparison with peers during QCs. We assessed individual physician behavior and healthcare use from laboratory and insurance claims files between August 1, 2016, and October 31, 2018. MAIN MEASURES: Main outcomes were the change in prescription of three low-value services 6 months before and 6 months after each intervention: measurement of prostate-specific antigen (PSA) and prescription rates of proton pump inhibitors (PPIs) and statins. KEY RESULTS: Among primary care practices, a QC intervention with physician feedback and peer comparison resulted in lower rates of PPI prescription (pre-post mean prescriptions per GP 25.5 ± 23.7 vs 22.9 ± 21.4, p value<0.01; coefficient of variation (Cov) 93.0% vs 91.0%, p=0.49), PSA measurement (6.5 ± 8.7 vs 5.3 ± 6.9 tests per GP, p<0.01; Cov 133.5% vs 130.7%, p=0.84), as well as statins (6.1 ± 6.8 vs 5.6 ± 5.4 prescriptions per GP, p<0.01; Cov 111.5% vs 96.4%, p=0.21). Changes in prescription of low-value services among GPs who did not attend QCs were not statistically significant over this time period. CONCLUSION: Our results demonstrate a modest but statistically significant effect of QCs with educative feedback in reducing low-value services in outpatients with low impact on coefficient of variation. Limiting overuse in medicine is very challenging and dedicated discussion and real-time review of actionable data may help.

Cancer-associated retinopathy preceding the diagnosis of a pulmonary carcinoid tumour.

Cancer-associated retinopathy (CAR) belongs to the paraneoplastic retinopathy syndromes and manifests itself by rapidly progressive vision loss, scotoma and photopsia. We herein reported the case of a 77-year-old woman without a cancer history who presents typical CAR symptoms. A complete workup followed by lung biopsy enabled the detection of a pulmonary carcinoid tumour. Treatment of oral cortisone was then initiated with dramatic improvements in the symptoms.

Systematic review with meta-analysis: limited benefits from early colonoscopy in acute lower gastrointestinal bleeding.

BACKGROUND: The optimal timing of colonoscopy in acute lower gastrointestinal bleeding (LGIB) remains controversial. AIM: To characterise the utility of early colonoscopy (within 24 hours) in managing acute LGIB. METHODS: A systematic literature search to October 2019 identified fully published articles and abstracts of randomised controlled trials (RCTs) and observational studies with control groups assessing early colonoscopy in acute LGIB. The primary outcome was rebleeding. Secondary outcomes included mortality, surgery, length of stay (LOS), definite cause of bleeding and adverse events. Odds ratios (ORs) and mean differences (MD) were calculated. RESULTS: Of 1116 citations, 4 RCTs (466 patients) and 13 observational studies with elective colonoscopy (>24 hours) as control group (1 061 281 patients) were included. No differences in rebleeding were noted between early and elective colonoscopy groups among RCTs alone (OR = 1.70; 0.79; 3.64), or observational studies alone (OR = 1.20; 0.69; 2.09). No other significant between-group differences in outcomes were found when restricting the analysis to RCTs. Among observational studies only, early colonoscopy was associated with lower rates of all-cause mortality (OR = 0.86; 0.75; 0.98), surgery (OR = 0.52; 0.42; 0.64), blood transfusion (OR = 0.81; 0.75; 0.87), units of blood transfusion (MD = -4.30; -6.24; -2.36) and shorter LOS (MD = -1.70; -1.70; -1.70 days). CONCLUSION: In contradistinction to observational studies, data from RCTs do not support a role for early colonoscopy in the routine management of acute LGIB with regards to the most important clinical outcomes. Further research is needed to better identify patients with high-risk LGIB who may benefit from early colonoscopy.

[Indirect consequences of PSA testing for prostate cancer screening]. / Conséquences indirectes du dosage du PSA dans le dépistage du cancer de la prostate.

Prostate cancer screening remains controversial as the reduction in mortality is outweighed by overdiagnosis and overtreatment. Prostate specific antigen (PSA) testing remains a recurring issue for primary care physicians. Although the last guidelines recommend against the screening, everyone agreed on the importance of the shared decision-making process to inform the patient about the potential benefits and harms of screening. Existing decision support tools can help in this complex discussion. This clinical case report depicts the infectious risks of prostate biopsy that are often underestimated.

Le dépistage du cancer prostatique reste controversé car la baisse de la mortalité est contrebalancée par les inconvénients de la surdétection et du surtraitement. La question du dosage du PSA (prostate specific antigen) revient toutefois de manière récurrente lors des consultations des médecins de premier recours. Bien que les recommandations récentes parlent plutôt en défaveur du dépistage, tous les acteurs concernés s'accordent sur l'importance de la décision partagée pour éclairer le patient sur les implications du dosage du PSA. Des outils d'aide à la décision existent et peuvent être utiles dans cette discussion complexe. La vignette clinique ci-après illustre les risques infectieux, souvent sous-estimés, de la biopsie de prostate consécutive à un dosage du PSA.

Faecal Calprotectin Predicts Endoscopic and Histological Activity in Clinically Quiescent Ulcerative Colitis.

INTRODUCTION: Faecal calprotectin [FC] is a reliable surrogate marker for disease activity in ulcerative colitis [UC]; however, there are no consensus cut-off values for remission. The study aim was to correlate FC with Mayo Endoscopic Score [MES] and histological disease activity of UC patients in clinical remission. METHODS: Our study recruited adult UC patients at the McGill IBD Center between 2013 and 2017. Patients in clinical remission [partial Mayo score ≤2], undergoing endoscopy for disease activity or dysplasia surveillance, were enrolled. Before bowel preparation, FC was collected. MES was documented during colonoscopy. Biopsies were taken; histological activity was assessed using Geboes score and the presence of basal plasmacytosis. RESULTS: A total of 185 patients were recruited. The area under the curve [AUC] in receiver operating characteristic [ROC] analysis to predict MES 1-3 [from 0] was 0.743 [95% CI 0.67-0.82; p <0.001] with an FC cut-off value 170 µg/g [64% sensitivity, 74% specificity], and to predict MES 2-3 [from 0-1] was 0.722 [95% CI 0.61-0.83; p <0.001] with an FC cut-off value 170 µg/g [69% sensitivity, 65% specificity]. To differentiate MES 0 from MES 1, an FC value 130 µg/g yields a 70% sensitivity and 68% specificity. The AUC in ROC analysis to predict Geboes <3.1 was 0.627 [95% CI 0.55-0.71; p = 0.003], with an FC value 135 µg/g [54% sensitivity, 69% specificity]. CONCLUSIONS: In this large study, FC ≥170 µg/g predicts endoscopic activity and FC ≥135 µg/g predicts histological activity. Therefore in clinical practice, lower faecal calprotectin thresholds can be chosen to optimise identification of patients with ongoing endoscopic and histological disease activity.

Low endoscopy bleeding risk in patients with congenital bleeding disorders.

INTRODUCTION: Haemophilia A and haemophilia B, von Willebrand disease (VWD), factor VII deficiency and factor XI deficiency are congenital bleeding disorders predisposing to bleeding during invasive procedures. The ageing population of people with congenital bleeding disorders will likely increasingly require gastrointestinal endoscopy. The bleeding risk postgastrointestinal endoscopy and optimal prophylactic treatment regimens are not well described. METHODS: We performed a retrospective chart review at the McGill University Health Centre. Adult patients with haemophilia A or B, VWD, FVII deficiency and FXI deficiency who underwent gastrointestinal endoscopic procedures were included. Bleeding prophylaxis included combinations of plasma-derived factor (VWD) or recombinant factor (haemophilia A and haemophilia B), desmopressin and/or tranexamic acid. Our primary outcome was the 72-hour postendoscopy bleeding rate. RESULTS: One hundred and four endoscopies were performed in 48 patients. Haemophilia A (45.3% of endoscopies) was the most common bleeding disorder, followed by VWD (38.5%), FXI deficiency (8.7%), haemophilia B (4.8%) and FVII deficiency (2.9%). All patients were reviewed by the Haemophilia Treatment Center with peri-procedure treatment protocols put in place as required. The overall 72-hour bleeding rate was 0.96%, confidence interval (CI) 95% (0.17%-5.25%). The colonoscopic postpolypectomy bleeding rate was 1/21 (4.8%, CI 95% (0.9%-22.7%)) in comparison with the general population rate of 0.3%-10% for high-risk endoscopy (including colonoscopic polypectomy). CONCLUSION: To the best of our knowledge, this is the largest study describing patients with inherited bleeding disorders undergoing gastrointestinal endoscopy. The bleeding risk is not significantly higher to the general population when haemostatically managed by a team experienced in bleeding disorders.

[Effectiveness of sunscreen against melanoma]. / Efficacité des écrans solaires contre le mélanome.

Melanoma represents the fifth most common cancer in Switzerland and its incidence is rising over the past decades. A new debate is going on about the efficacy of sunscreen against the risk of developing melanoma. Few studies have proven its efficacy with a significant risk of overexposure to sunlight due to the feeling of overprotection offered by those sunscreens. The role of the physician is to explain this risk and to integrate sunscreens among a wide range of other strategies existing in primary prevention of melanoma.

Le mélanome représente le cinquième cancer le plus fréquent en Suisse, avec une incidence qui ne fait qu'augmenter depuis des décennies. Parmi les mesures de prévention primaire, un nouveau débat a émergé concernant l'efficacité des écrans solaires contre le mélanome. Peu d'études ont en effet réussi à démontrer un bénéfice des écrans solaires pour prévenir la survenue de mélanome avec un risque non négligeable de surexposition aux rayons solaires inhérent au sentiment de surprotection offert par ces produits. Le rôle du médecin est d'expliquer ces risques et d'intégrer les écrans solaires dans les mesures photoprotectrices à disposition, en insistant sur l'importance des mesures de protection physique.

Overuse of plain abdominal radiography in emergency departments: a retrospective cohort study.

BACKGROUND: Plain abdominal radiography (PAR) is routinely performed in emergency departments (EDs). This study aimed to (1) identify the indications for PAR in EDs and compare them against international guidelines, (2) uncover predictors of non-compliance with guidelines, and (3) describe the use of additional radiological examinations in EDs. METHODS: Retrospective cohort study in the EDs of two hospitals in Geneva, Switzerland, including all adult patients who underwent PAR in the EDs. Indications were considered "appropriate" if complying with guidelines. Predictors of non-compliance were identified by univariate and multivariate analyses. RESULTS: Over 1 year, PAR was performed in 1997 patients (2.2% of all admissions). Their mean age was 59.7 years, with 53.1% of female patients. The most common indications were constipation (30.8%), suspected ileus (28.9%), and abdominal pain (15.3%). According to the French and American guidelines, only 11.8% of the PARs were indicated, while 46.2% of them complied with the Australian and British guidelines. On multivariate analysis, admission to the private hospital ED (odds ratio [OR] 3.88, 95% CI 1.78-8.45), female gender (OR 1.95, 95% CI 1.46-2.59), and an age >  65 years (OR 2.41, 95%CI 1.74-3.32) were associated with a higher risk of inappropriate PAR. Additional radiological examinations were performed in 73.7% of patients. CONCLUSIONS: Most indications for PAR did not comply with guidelines and elderly women appeared particularly at risk of being exposed to inappropriate examination. PAR did not prevent the need for additional examinations. Local guidelines should be developed, and initiatives should be implemented to reduce unnecessary PARs. TRIAL REGISTRATION: ClinicalTrials.gov , identifier NCT02980081 .

Clinical Parameters Correlate With Endoscopic Activity of Ulcerative Colitis: A Systematic Review.

BACKGROUND & AIMS: Optimal management of patients with ulcerative colitis (UC) requires assessment of disease activity-usually by endoscopy, which is invasive, costly, and not risk free. We performed a systematic review to determine whether clinical symptoms correlate with findings from endoscopy assessments of patients with UC. METHODS: We performed a systematic review of publication databases from January 1980 through July 2018 to identify clinical trials and observational studies reporting correlations among symptoms, disease activity index scores and/or patient reported outcomes (rectal bleeding and/or stool frequency), and endoscopic disease activity. Correlations were ascertained in patients with active vs inactive disease and by disease extent and treatment type. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Because of significant heterogeneity, meta-analysis was not possible. Results were synthesized qualitatively and systematically. RESULTS: Our final analysis included 23 studies (1 randomized trial, 22 observational studies) comprising 3320 patients with UC. The studies used a variety of measures to assess clinical activity, endoscopic activity, and measures of correlation (sensitivity, specificity, correlation coefficients, area under the receiver operator curve). Overall, studies were at moderate-high risk of bias. Composite clinical measures, including rectal bleeding and stool frequency, had moderate to strong correlations with endoscopic disease activity; the absence of rectal bleeding identified patients with inactive disease with higher levels of sensitivity than normalization of stool frequency. In general, symptoms correlated more strongly with endoscopic activity in patients with left-sided colitis than extensive colitis. The effect of different medications on the correlation between clinical and endoscopic activity has not been well studied. CONCLUSIONS: In a systematic review, we found a moderate to strong correlation between clinical activity, particularly the combination of rectal bleeding and stool frequency, and endoscopic activity in patients with UC. Although these clinical assessments could help prioritize patients for endoscopic evaluation in resource-limited settings, challenges associated with treating patients based on symptoms alone preclude adaptation of current management algorithms.

Which Patient-Related Factors Determine Optimal Bowel Preparation?

PURPOSE OF REVIEW: Adequate bowel cleansing before colonoscopy is a simple concept but the high rate of inadequate or incomplete bowel cleanliness and its consequences have been the subject of many studies, guidelines, and meta-analysis. The complexity resides in all the factors surrounding preparation intake such as type and regimen of bowel preparation, diets, compliance, and also patient-related factors that all influence quality of the bowel preparation. The purpose of this review is to focus specifically on patient-related factors and their challenges. Patients with lower GI bleeding are excluded from this review. RECENT FINDINGS: Patient factors that may be associated with a poor bowel preparation were searched for in the literature. With regard to patient's characteristics, higher age, male gender, and socio-economic status (lower income, Medicaid, and lower education) were all associated with higher rates of inadequate bowel preparation. Comorbidities such as inflammatory bowel disease (IBD), in-patients, body mass index (BMI), cirrhosis, constipation, and neurological condition as well as some pharmacotherapy were also associated with inadequate bowel preparation. Studies identifying predictive patient factors as well as those studying these patients in particular showed variability in the strength of the patient factor associations. Patients taking tricyclic antidepressant, narcotics, and those with neurological conditions were identified to have a stronger association with worse bowel cleanliness. Those can be implemented with the current recommendations of split-dosing. Identifying individual factors that can impact the quality of bowel cleanliness can be challenging. Some have been well-studied in the literature such as age, in-patient status, or constipation and others such as male gender or higher BMI have required more studies to clearly conclude on any possible association. In many studies, simple recommendations like walking 30 min during the preparation, and additional instructions or support have also been added to instructions to improve motility and compliance.

Therapeutic Drug Monitoring Guides the Management of Crohn's Patients with Secondary Loss of Response to Adalimumab.

Background: Managing loss of response (LOR) in Crohn's disase (CD) patients remains challenging. Compelling evidence supports therapeutic drug monitoring (TDM) to guide management in patients on infliximab, but data for other biologics are less robust. We aimed to asses if empiric dose escalation led to improved clinical outcome in addition to TDM-guided optimization in CD patients with LOR to adalimumab (ADA). Methods: Retrospective chart review of patients followed between 2014 and 2016 at McGill IBD Center with index TDM for LOR to ADA was performed. Primary outcomes were composite remission at 3, 6, and 12 months in those with empiric adjustments versus TDM-guided optimization. Results: There were 104 patients (54.8% men) who were included in the study. Of this group, 81 patients (77.9%) had serum level (SL) ≥5µg/ml at index TDM with a median value of 12µg/ml (IQR 6.1-16.5). There were 10 patients (9.6%) who had undetectable SL with high anti-ADA antibodies and 48 (46.2%) received empiric escalation. TDM led to change in treatment in 58 patients (55.8%). Among them, 28 (48.3%) had discontinued ADA, 12 (21.7%) had addition of immunomodulator or steroid, and 18 (31%) had ADA dose escalation. Empiric dose escalation before TDM-based optimization was not associated with improved outcomes at 3, 6, and 12 months, irrespective of SL levels. Clear SL cutoff associated with composite remission was not identified. Conclusions: Our data do not support empiric dose adjustment beyond that based on the result of the TDM in patients with LOR to ADA. TDM limits unnecessary dose escalation and provides appropriate treatment strategy without compromising clinical outcomes. 10.1093/ibd/izy044_video1izy044.video15768828880001.

[VIPoma : a rare etiology of diarrhea with hypokalemia]. / VIPome : étiologie rare d'une diarrhée hypokaliémiante.

VIPoma or Verner Morrison syndrome is a very rare disease with an incidence rate of 1 case per 10 000 000 person-years. It is a neuroendocrine tumor issue from ß-pancreatic islets leading to profuse diarrhea, hypokalemia and gastric achlorydria due to secretion of vasoactive intestinal polypeptide (VIP) hormone. Diagnosis is based on histology of tumor and the dosage of VIP in a blood sample. Somatostatin analog is a simple and efficient treatment for diarrhea. Curative treatment with surgery could be proposed for a localized disease. For disseminated disease, there are different treatments and a multimodal assessment that should be discussed in a multidisciplinary team might be curative.

Le VIPome ou syndrome de Verner Morrison est une maladie très rare, avec une incidence annuelle estimée à 1/10 000 000 habitants. Il s'agit d'une tumeur neuroendocrine issue des îlots ß pancréatiques qui sécrète une hormone appelée vasoactive intestinal polypeptide (VIP), à l'origine d'une achlorhydrie gastrique et de diarrhées profuses entraînant une hypokaliémie. Le diagnostic est posé à partir d'une analyse anatomopathologique de la tumeur et du dosage du VIP sanguin. Le traitement symptomatique par les analogues de la somatostatine est efficace sur la diarrhée. Un traitement curatif par la chirurgie peut être proposé pour une maladie tumorale localisée. Pour les maladies disséminées, différentes modalités thérapeutiques existent et dans certains cas une approche multimodale discutée dans un colloque spécialisé peut être curative.

Implementation of a checklist before colonoscopy: a quality improvement initiative.

BACKGROUND AND STUDY AIMS: Checklists can prevent errors and have a positive impact on patient morbidity and mortality in different surgical settings, and possibly also in gastrointestinal endoscopy. The aims of this study were to reinforce commitment in safety culture and better communication among team members in endoscopy, and to prove the feasibility of successful checklist adoption before colonoscopy. PATIENTS AND METHODS: The study involved a pre - post quality improvement intervention involving all consecutive patients undergoing a colonoscopy at a single academic endoscopy unit. The first part of the study was a retrospective audit, carried out over a 3-month period (July to September 2016). A checklist developed through a formal validation process was implemented during the intervention period (October to December 2016). Primary outcomes were changes in patient and team satisfaction after the quality improvement intervention, using validated 5-point scale questionnaires. Secondary outcomes included successful procedure completion rates and safety outcomes. RESULTS: During the baseline and comparative intervention period, 1317 and 1141 colonoscopies, respectively, were performed. Overall, checklists were fully completed by nurses and physicians for 791 patients (69.3 %). Mean overall patient satisfaction was high at baseline and did not differ following the quality improvement intervention (4.66 vs. 4.63; P  = 0.5). Perception of team communication and teamwork was improved after checklist implementation. Comparative analyses of per-procedure and safety outcomes did not differ between the pre- and post-checklist implementation. CONCLUSION: Adoption of an endoscopy checklist before colonoscopy is feasible, and significantly increases perception of team communication and teamwork. Additional studies are needed to assess the generalizability of these results to complex endoscopic procedures and to characterize any improvement in patient safety outcomes.

Do adjuvants add to the efficacy and tolerance of bowel preparations? A meta-analysis of randomized trials.

BACKGROUND AND STUDY AIMS : Recommendations on adjuvant use with bowel preparations remain disparate. We performed a meta-analysis determining the clinical impact of adding an adjuvant to polyethylene glycol (PEG), sodium phosphate, picosulfate (PICO), or oral sulfate solutions (OSS)-based regimens. METHODS: Systematic searches were made of MEDLINE, EMBASE, Scopus, CENTRAL and ISI Web of knowledge for randomized trials from January 1980 to April 2016 that assessed preparations with or without adjuvants, given in split and non-split dosing, and PEG high- (> 3 L) or low-dose (≤ 2 L) regimens. Bowel cleansing efficacy was the primary outcome. Secondary outcomes included patient willingness to repeat the procedure, and polyp and adenoma detection rates. RESULTS: Of 3093 citations, 77 trials fulfilled the inclusion criteria. Overall, addition of an adjuvant compared with no adjuvant, irrespective of the type of preparation and mode of administration, yielded improvements in bowel cleanliness (odds ratio [OR] 1.23 [1.01 - 1.51]) without greater willingness to repeat (OR 1.40 [0.91 - 2.15]). Adjuvants combined with high-dose PEG significantly improved colon cleansing (OR 1.96 [1.32 - 2.94]). The odds for achieving adequate preparation with low-dose PEG with an adjuvant were not different to high-dose PEG alone (OR 0.95 [0.73 - 1.22]), but yielded improved tolerance (OR 3.22 [1.85 - 5.55]). However, split high-dose PEG yielded superior cleanliness to low-dose PEG with adjuvants (OR 2.53 [1.25 - 5.13]). No differences were noted for OSS and PICO comparisons, or for any products regarding polyp or adenoma detection rates. CONCLUSIONS: Critical heterogeneity precludes firm conclusion on the impact of adjuvants with existing bowel preparations. Additional research is required to better characterize the methods of administration and resulting roles of adjuvants in an era of split-dosing.