Comparative Study of Predictive Models for the Detection of Patients at High Risk of Inadequate Colonic Cleansing.

Background: Various predictive models have been published to identify outpatients with inadequate colonic cleansing who may benefit from intensified preparations to improve colonoscopy quality. The main objective of this study was to compare the accuracy of three predictive models for identifying poor bowel preparation in outpatients undergoing colonoscopy. Methods: This cross-sectional study included patients scheduled for outpatient colonoscopy over a 3-month period. We evaluated and compared three predictive models (Models 1-3). The quality of colonic cleansing was assessed using the Boston Bowel Preparation Scale. We calculated the area under the curve (AUC) and the corresponding 95% confidence interval for each model. Additionally, we performed simple and multiple logistic regression analyses to identify variables associated with inadequate colonic cleansing and developed a new model. Results: A total of 649 consecutive patients were included in the study, of whom 84.3% had adequate colonic cleansing quality. The AUCs of Model 1 (AUC = 0.67, 95% CI [0.63-0.70]) and Model 2 (AUC = 0.62, 95% CI [0.58-0.66]) were significantly higher than that of Model 3 (AUC = 0.54, 95% CI [0.50-0.58]; p < 0.001). Moreover, Model 1 outperformed Model 2 (p = 0.013). However, the new model did not demonstrate improved accuracy compared to the older models (AUC = 0.671). Conclusions: Among the three compared models, Model 1 showed the highest accuracy for predicting poor bowel preparation in outpatients undergoing colonoscopy and could be useful in clinical practice to decrease the percentage of inadequately prepared patients.

Agreement between the perception of colon cleansing reported by patients and colon cleansing assessed by a validated colon cleansing scale.

AIMS: Patients' perception of their cleansing quality can guide strategies to improve cleansing during colonoscopy. There are no studies assessing the agreement between the quality of cleansing perceived by patients and cleansing quality assessed during colonoscopy using validated bowel preparation scales. The main aim of this study was to compare the cleansing quality reported by patients with the quality during colonoscopy using the Boston Bowel Preparation Scale (BBPS). PATIENTS AND METHODS: Consecutive patients referred to an outpatient colonoscopy were included. Four drawings representing different degrees of cleansing were designed. Patients chose the drawing that most resembled the last stool. The predictive ability of the patient's perception and agreement between the patient's perception and the BBPS were calculated. A BBPS score of <2 points in any segment was considered inadequate. RESULTS: Six hundred and thirty-three patients were included (age: 62.8±13.7 years, male: 53.4%). Overall, 107 patients (16.9%) had inadequate cleansing during colonoscopy, and in 12.2% of cases, the patient's perception was poor. The patient's perception compared to the quality of cleanliness during colonoscopy presented a positive and negative predictive value of 54.6% and 88.3%, respectively. The agreement between patient perception and the BBPS was significant (P<0.001), although fair (k=0.37). The results were similar in a validation cohort of 378 patients (k=0.41). CONCLUSIONS: The cleanliness perceived by the patient and the quality of cleanliness using a validated scale were correlated, although fair. However, this measure satisfactorily identified patients with adequate preparation. Cleansing rescue strategies may target patients who self-report improper cleaning. Registration number of the trial: NCT03830489.

Design and validation of an artificial intelligence system to detect the quality of colon cleansing before colonoscopy.

BACKGROUND AND AIMS: Patients' perception of their bowel cleansing quality may guide rescue cleansing strategies before colonoscopy. The main aim of this study was to train and validate a convolutional neural network (CNN) for classifying rectal effluent during bowel preparation intake as "adequate" or "inadequate" cleansing before colonoscopy. PATIENTS AND METHODS: Patients referred for outpatient colonoscopy were asked to provide images of their rectal effluent during the bowel preparation process. The images were categorized as adequate or inadequate cleansing based on a predefined 4-picture quality scale. A total of 1203 images were collected from 660 patients. The initial dataset (799 images), was split into a training set (80%) and a validation set (20%). The second dataset (404 images) was used to develop a second test of the CNN accuracy. Afterward, CNN prediction was prospectively compared with the Boston Bowel Preparation Scale (BBPS) in 200 additional patients who provided a picture of their last rectal effluent. RESULTS: On the initial dataset, a global accuracy of 97.49%, a sensitivity of 98.17% and a specificity of 96.66% were obtained using the CNN model. On the second dataset, an accuracy of 95%, a sensitivity of 99.60% and a specificity of 87.41% were obtained. The results from the CNN model were significantly associated with those from the BBPS (P<0.001), and 77.78% of the patients with poor bowel preparation were correctly classified. CONCLUSION: The designed CNN is capable of classifying "adequate cleansing" and "inadequate cleansing" images with high accuracy.

Usefulness of a novel computer-aided detection system for colorectal neoplasia: a randomized controlled trial.

BACKGROUND AND AIMS: Artificial intelligence-based computer-aid detection (CADe) devices have been recently tested in colonoscopies, increasing the adenoma detection rate (ADR), mainly in Asian populations. However, evidence for the benefit of these devices in the occidental population is still low. We tested a new CADe device, namely, ENDO-AID (OIP-1) (Olympus, Tokyo, Japan), in clinical practice. METHODS: This randomized controlled trial included 370 consecutive patients who were randomized 1:1 to CADe (n = 185) versus standard exploration (n = 185) from November 2021 to January 2022. The primary endpoint was the ADR. Advanced adenoma was defined as ≥10 mm, harboring high-grade dysplasia, or with a villous pattern. Otherwise, the adenoma was nonadvanced. ADR was assessed in both groups stratified by endoscopist ADR and colon cleansing. RESULTS: In the intention-to-treat analysis, the ADR was 55.1% (102/185) in the CADe group and 43.8% (81/185) in the control group (P = .029). Nonadvanced ADRs (54.8% vs 40.8%, P = .01) and flat ADRs (39.4 vs 24.8, P = .006), polyp detection rate (67.1% vs 51%; P = .004), and number of adenomas per colonoscopy were significantly higher in the CADe group than in the control group (median [25th-75th percentile], 1 [0-2] vs 0 [0-1.5], respectively; P = .014). No significant differences were found in serrated ADR. After stratification by endoscopist and bowel cleansing, no statistically significant differences in ADR were found. CONCLUSIONS: Colonoscopy assisted by ENDO-AID (OIP-1) increases ADR and number of adenomas per colonoscopy, suggesting it may aid in the detection of colorectal neoplastic lesions, especially because of its detection of diminutive and flat adenomas. (Clinical trial registration number: NCT04945044.).

Prevalence of missed lesions in patients with inadequate bowel preparation through a very early repeat colonoscopy.

OBJECTIVES: When bowel preparation (BP) is inadequate, international guidelines recommend repeating the colonoscopy within 1 year to avoid missing clinically relevant lesions. We aimed to determine the rate of missed lesions in patients with inadequate BP through a very early repeat colonoscopy with adequate BP. METHODS: Post hoc analysis was conducted using data collected from a prospective multicenter randomized clinical trial including patients with inadequate BP and then repeat colonoscopy. Inadequate BP was defined as the Boston Bowel Preparation Scale (BBPS) score <2 points in any segment. We included patients with any indication for colonoscopy. The adenoma detection rate (ADR), advanced ADR (AADR), and serrated polyp detection rate (SPDR) were calculated for index and repeat colonoscopies. RESULTS: Of the 651 patients with inadequate BP from the original trial, 413 (63.4%) achieved adequate BP on repeat colonoscopy. The median interval between index and repeat colonoscopies was 28 days. On repeat colonoscopy, the ADR was 45.3% (95% confidence interval [CI] 40.5-50.1%), the AADR was 10.9% (95% CI 8.1-14.3%), and the SPDR was 14.3% (95% CI 10.9-17.7%). Cancer was discovered in four patients (1%; 95% CI 0.2-2.5%). A total of 60.2% of all advanced adenoma (AA) were discovered on repeat colonoscopy. A colon segment scored BBPS = 0 had most AA (66.1%) and all four cancers. CONCLUSION: Patients with inadequate BP present a high rate of AAs on repeat colonoscopy. When a colonoscopy has a colon segment score BBPS = 0, we recommend repeating the colonoscopy as soon as possible.

Educational nurse-led telephone intervention shortly before colonoscopy as a salvage strategy after previous bowel preparation failure: a multicenter randomized trial.

BACKGROUND: The most important predictor of unsuccessful bowel preparation is previous failure. For those patients with previous failure, we hypothesized that a nurse-led educational intervention by telephone shortly before the colonoscopy appointment could improve cleansing efficacy. METHODS: We performed a multicenter, endoscopist-blinded, randomized controlled trial. Consecutive outpatients with previous inadequate bowel preparation were enrolled. Both groups received the same standard bowel preparation protocol. The intervention group also received reinforced education by telephone within 48 hours before the colonoscopy. The primary outcome was effective bowel preparation according to the Boston Bowel Preparation Scale. Intention-to-treat (ITT) analysis included all randomized patients. Per-protocol analysis included patients who could be contacted by telephone and the control cases. RESULTS: 657 participants were recruited by 11 Spanish hospitals. In the ITT analysis, there was no significant difference between the intervention and control groups in the rate of successful bowel preparation (77.3 % vs. 72 %; P = 0.12). In the intervention group, 267 patients (82.9 %) were contacted by telephone. Per-protocol analysis revealed significantly improved bowel preparation in the intervention group (83.5 % vs. 72.0 %; P = 0.001). CONCLUSION: Among all patients with previous inadequate bowel preparation, nurse-led telephone education did not result in a significant improvement in bowel cleansing. However, in the 83 % of patients who could be contacted, bowel preparation was substantially improved. Phone education may therefore be a useful tool for improving the quality of bowel preparation in those cases.

Gangrena pulmonar con fistula broncopleural persistente / Lung gangrene with a persistent broncho-pleural fistulae

La gangrena pulmonar es una entidad poco frecuente que se ha encontrado asociada a desnutrición y a la ingesta de alcohol. En nuestro centro se trató el caso de un paciente con el diagnóstico de gangrena pulmonar más fístula broncopleural quien a pesar del tratamiento convencional no evolucionó satisfactoriamente siendo necesario la resolución quirúrgica a través de la neumonectomía en el manejo de esta patología

Cocaine long-term administration induces myocardial depressant effects and adrenoceptors desensitization.

Cocaine as a drug of abuse can cause many cardiovascular toxic effects. The objective of this work was to study the mechanism of the negative inotropic effect of cocaine on isolated right ventricle strips and its relationship with myocardial catecholamines desensitization after long- term cocaine administration. Right ventricle strips were incubated in oxygenated Krebs solution at 37 degrees C, and driven with 2 ms, 15 mA, 1.8 Hz electric square pulses. Beat tension force was recorded with a force-displacement transducer. In control long-term saline (0.9% NaCl) treated rats (0.1 mL/Kg x 15 days, s.c.), in vitro 0.1-30 microM cocaine progressively increased the ventricle strip force up to 53% over baseline value. On the contrary, a negative inotropic effect of cocaine was observed in strips obtained from long-term cocaine treated rats (3 mg/Kg x 15 days, s.c.). The contractile force change ("Bowditch" phenomenon) induced by short (30s) rising of myocardial stimulating frequency to 2.7, 3.5 and 4.3 Hz respectively, was completely reversed in ventricular strips obtained from long-term cocaine treated rats. Myocardial desensitization to isoproterenol (saline 4.67 nM Vs cocaine 13.17 nM DE50) and to phenylephrine (saline 5.44 nM Vs cocaine 8.6 nM DE50) was observed in long term cocaine treated rats when compared to the control group. Aorta desensitization to phenylephrine-induced constriction in long-term cocaine treated rats was also observed; phenylephrine DE50 increased from 1.9 nmol/l in control rats to 15.5 nmol/l in long-term cocaine treated ones. Cocaine metabolites, benzoylecgonine and ecgonine methyl ester were excreted (121.6 micrograms/ml) in urine samples from all cocaine treated rats and not in the saline treated group. Long-term cocaine treatment seems to interfere with the cytosolic calcium increase that normally occurs during systole; this could explain its negative inotropic effect observed during in vitro cocaine reexposure. The adrenergic receptor desensitization induced by chronic cocaine administration could lead to a full expression of the negative inotropic effect of this drug. Extrapolated to clinical grounds, this mechanism could explain some clinical cases of heart failure reported in cocaine overdosed addicts.

Cocaine long-term administration induces myocardial depressant effects and adrenoceptors desensitization

Cocaine as a drug of abuse can cause many cardiovascular toxic effects. The objective of this work was to study the mechanism of the negative inotropic effect of cocaine on isolated right ventricle strips and its relationship with myocardial catecholamines desensitization after long- term cocaine administration. Right ventricle strips were incubated in oxygenated Krebs solution at 37 degrees C, and driven with 2 ms, 15 mA, 1.8 Hz electric square pulses. Beat tension force was recorded with a force-displacement transducer. In control long-term saline (0.9% NaCl) treated rats (0.1 mL/Kg x 15 days, s.c.), in vitro 0.1-30 microM cocaine progressively increased the ventricle strip force up to 53% over baseline value. On the contrary, a negative inotropic effect of cocaine was observed in strips obtained from long-term cocaine treated rats (3 mg/Kg x 15 days, s.c.). The contractile force change ("Bowditch" phenomenon) induced by short (30s) rising of myocardial stimulating frequency to 2.7, 3.5 and 4.3 Hz respectively, was completely reversed in ventricular strips obtained from long-term cocaine treated rats. Myocardial desensitization to isoproterenol (saline 4.67 nM Vs cocaine 13.17 nM DE50) and to phenylephrine (saline 5.44 nM Vs cocaine 8.6 nM DE50) was observed in long term cocaine treated rats when compared to the control group. Aorta desensitization to phenylephrine-induced constriction in long-term cocaine treated rats was also observed; phenylephrine DE50 increased from 1.9 nmol/l in control rats to 15.5 nmol/l in long-term cocaine treated ones. Cocaine metabolites, benzoylecgonine and ecgonine methyl ester were excreted (121.6 micrograms/ml) in urine samples from all cocaine treated rats and not in the saline treated group. Long-term cocaine treatment seems to interfere with the cytosolic calcium increase that normally occurs during systole; this could explain its negative inotropic effect observed during in vitro cocaine reexposure. The adrenergic receptor desensitization induced by chronic cocaine administration could lead to a full expression of the negative inotropic effect of this drug. Extrapolated to clinical grounds, this mechanism could explain some clinical cases of heart failure reported in cocaine overdosed addicts