Visceral Adipose Tissue Reduction Measured by Deep Neural Network Architecture Improved Reflux Esophagitis Endoscopic Grade.

INTRODUCTION: Visceral obesity is a risk factor for reflux esophagitis (RE). We investigated the risk of RE according to visceral adipose tissue (VAT) measured by deep neural network architecture using computed tomography (CT) and evaluated the longitudinal association between abdominal adipose tissue changes and the disease course of RE. METHODS: Individuals receiving health checkups who underwent esophagogastroduodenoscopy (EGD) and abdominal CT at Seoul National University Healthcare System Gangnam Center between 2015 and 2016 were included. Visceral and subcutaneous adipose tissue areas and volumes were measured using a deep neural network architecture and CT. The association between the abdominal adipose tissue area and volume and the risk of RE was evaluated. Participants who underwent follow-up EGD and abdominal CT were selected; the effects of changes in abdominal adipose tissue area and volume on RE endoscopic grade were investigated using Cox proportional hazards regression. RESULTS: We enrolled 6,570 patients who underwent EGD and abdominal CT on the same day. RE was associated with male sex, hypertension, diabetes, excessive alcohol intake, current smoking status, and levels of physical activity. The VAT area and volume increased the risk of RE dose-dependently. A decreasing VAT volume was significantly associated with improvement in RE endoscopic grade (hazard ratio: 3.22, 95% confidence interval: 1.82-5.71). Changes in subcutaneous adipose tissue volume and the disease course of RE were not significantly correlated. DISCUSSION: Visceral obesity is strongly associated with RE. VAT volume reduction was prospectively associated with improvement in RE endoscopic grade dose-dependently. Visceral obesity is a potential target for RE treatment.

Automatic assessment of bowel preparation by an artificial intelligence model and its clinical applicability.

BACKGROUND AND AIM: Reliable bowel preparation assessment is important in colonoscopy. However, current scoring systems are limited by laborious and time-consuming tasks and interobserver variability. We aimed to develop an artificial intelligence (AI) model to assess bowel cleanliness and evaluate its clinical applicability. METHODS: A still image-driven AI model to assess the Boston Bowel Preparation Scale (BBPS) was developed and validated using 2361 colonoscopy images. For evaluating real-world applicability, the model was validated using 113 10-s colonoscopy video clips and 30 full colonoscopy videos to identify "adequate (BBPS 2-3)" or "inadequate (BBPS 0-1)" preparation. The model was tested with an external dataset of 29 colonoscopy videos. The clinical applicability of the model was evaluated using 225 consecutive colonoscopies. Inter-rater variability was analyzed between the AI model and endoscopists. RESULTS: The AI model achieved an accuracy of 94.0% and an area under the receiver operating characteristic curve of 0.939 with the still images. Model testing with an external dataset showed an accuracy of 95.3%, an area under the receiver operating characteristic curve of 0.976, and a sensitivity of 100% for the detection of inadequate preparations. The clinical applicability study showed an overall agreement rate of 85.3% between endoscopists and the AI model, with Fleiss' kappa of 0.686. The agreement rate was lower for the right colon compared with the transverse and left colon, with Fleiss' kappa of 0.563, 0.575, and 0.789, respectively. CONCLUSIONS: The AI model demonstrated accurate bowel preparation assessment and substantial agreement with endoscopists. Further refinement of the AI model is warranted for effective monitoring of qualified colonoscopy in large-scale screening programs.

Association Between Metabolic Syndrome and the Risk of Colorectal Cancer Diagnosed Before Age 50 Years According to Tumor Location.

BACKGROUND & AIMS: The increasing prevalence of obesity at younger ages is concurrent with an increased earlier-onset colorectal cancer (CRC) (before age 50 years) incidence, particularly left-sided colon cancer. We investigated whether obesity and metabolic syndrome (MetS) are associated with increased earlier-onset CRC risk according to tumor location. METHODS: Our nationwide population-based cohort study enrolled 9,774,081 individuals who underwent health checkups under the Korean National Health Insurance Service from 2009 to 2010, with follow-up until 2019. We collected data on age, sex, lifestyle factors, body mass index (BMI), waist circumference (WC), blood pressure, and laboratory findings. A multivariate Cox proportional hazards regression analysis was performed. RESULTS: A total of 8320 earlier-onset and 57,257 later-onset CRC cases developed during follow-up. MetS was associated with increased earlier-onset CRC (adjusted hazard ratio, 1.20; 95% CI, 1.14-1.27), similar to later-onset CRC (adjusted hazard ratio, 1.19; 95% CI, 1.17-1.21). The adjusted hazard ratios for earlier-onset CRC with 1, 2, 3, 4, and 5 MetS components were 1.07 (95% CI, 1.01-1.13), 1.13 (95% CI, 1.06-1.21), 1.25 (95% CI, 1.16-1.35), 1.27 (95% CI, 1.15-1.41), and 1.50 (95% CI, 1.26-1.79), respectively (P for trend < .0001). We found that higher body mass index and larger waist circumference were significantly associated with increased earlier-onset CRC (P for trend < .0001). These dose-response associations were significant in distal colon and rectal cancers, although not in proximal colon cancers. CONCLUSIONS: MetS and obesity are positively associated with CRC before age 50 years with a similar magnitude of association as people diagnosed after age 50 years. Thus, people younger than 50 years with MetS require effective preventive interventions to help reduce CRC risk.

Impact of 3-second rule for high confidence assignment on the performance of endoscopists for the real-time optical diagnosis of colorectal polyps.

BACKGROUND: Confusion between high and low confidence decisions in optical diagnosis hinders the implementation of real-time optical diagnosis in clinical practice. We evaluated the effect of a 3-second rule (decision time limited to 3 seconds for a high confidence assignment) in expert and nonexpert endoscopists. METHODS: This single-center prospective study included eight board-certified gastroenterologists. A 2-month baseline phase used standard real-time optical diagnosis for colorectal polyps < 10 mm and was followed by a 6-month intervention phase using optical diagnosis with the 3-second rule. Performance, including high confidence accuracy, and Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) and Simple Optical Diagnosis Accuracy (SODA) thresholds, was measured. RESULTS: Real-time optical diagnosis was performed on 1793 patients with 3694 polyps. There was significant improvement in high confidence accuracy between baseline and intervention phases in the nonexpert group (79.2 % vs. 86.3 %; P = 0.01) but not in the expert group (85.3 % vs. 87.5 %; P = 0.53). Using the 3-second rule improved the overall performance of PIVI and SODA in both groups. CONCLUSIONS: The 3-second rule was effective in improving real-time optical diagnosis performance, especially in nonexperts.

Small sessile serrated polyps might not be at a higher risk for future advanced neoplasia than low-risk adenomas or polyp-free groups.

BACKGROUND: Polypectomy surveillance colonoscopy is recommended according to the risk stratification of initially removed polyps. This study aimed to evaluate the risk of advanced neoplasia following low-risk SSPs compared with that following LRAs and polyp-free groups. MATERIALS AND METHODS: From September 2013 to August 2017, asymptomatic Koreans aged 50-75 years who underwent surveillance colonoscopy post-baseline colonoscopy were enrolled. The 1314 participants who met the study design criteria were stratified into three groups according to the presence of LRAs or low-risk SSPs. The rate of advanced neoplasia was then compared between groups by surveillance colonoscopy. RESULTS: A total of 1314 participants were classified according to baseline colonoscopy findings: no polyp (n = 551), LRA (n = 707), and low-risk SSP (n = 56). All participants underwent surveillance colonoscopy after an average of 28.1 ± 8.7 months. The rate of advanced neoplasia at surveillance was not different between groups: no polyp group (13/551, 2.4%), LRA group (27/707, 3.8%), and low-risk SSP group (0/56, 0%). The LRA group exhibited a significantly higher rate of low- and high-risk polyps (47.5, 13.4%) than did the no polyp (35.6, 7.4%, p < .001, p = .001), but no significant differences to the low-risk SSP group (35.7, 7.1%, p = .117, p = .253), respectively. CONCLUSIONS: Patients with low-risk SSPs were not at a higher risk of advanced neoplasia than LRA patients, even in the polyp-free group. We suggest that surveillance colonoscopy after the removal of low-risk SSPs is not required more often than for LRAs.

Nationwide cohort study: cholesterol level is inversely related with the risk of gastric cancer among postmenopausal women.

BACKGROUND: Recent studies showed inverse relationship between hypercholesterolemia and the risk of gastric cancer, especially among male. However evidence among female is inconsistent. We aimed to investigate the relationship between cholesterol level and the risk of gastric cancer among female according to menopausal status. METHODS: We analyzed the data from a population-based prospective cohort of female ≥ 30 years old who underwent cancer screening and general health screening provided by the Korean National Health Insurance Corporation in 2009. Under quartile stratification of the level of cholesterol components, we calculated the hazard ratio (HR) for gastric cancer incidence until 2018 for each level group according to the menopausal status at 2009. RESULTS: Among total 2,722,614 individuals, 17,649 gastric cancer cases developed after mean 8.26 years of follow-up (premenopausal 3746/1180666; postmenopausal 13,903/1541948). Total cholesterol, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) showed inverse relationship with the risk of gastric cancer among postmenopausal women (adjusted HR (95% confidence interval) for the highest quartile vs. lowest quartile and p-for-trend: 0.88 (0.84-0.92) and < 0.001 for total cholesterol; 0.89 (0.85-0.92) and < 0.001 for HDL-C; 0.92 (0.89-0.97) and 0.001 for LDL-C), whereas none showed statistically significant risk relationship among premenopausal women. Triglyceride was not independently related with gastric cancer risk among both pre- and postmenopausal women. CONCLUSIONS: Cholesterol levels, including total cholesterol, HDL-C, and LDL-C, are inversely related with the risk of gastric cancer among postmenopausal women, but not among premenopausal women.

Impact of comprehensive optical diagnosis training using Workgroup serrAted polypS and Polyposis classification on detection of adenoma and sessile serrated lesion.

OBJECTIVES: Many interventions have been attempted to improve adenoma detection rate (ADR) and sessile serrated lesion detection rate (SDR), and one of these interventions is educational training to recognize polyp characteristics. This study aimed to investigate the change in polyp detection rates of endoscopists before and after comprehensive training through the Gangnam-Real Time Optical Diagnosis (Gangnam-READI) program. METHODS: Fifteen gastroenterologists participated in a 1-year comprehensive training program that consisted of ex vivo and in vivo training that encompasses knowledge and skills in endoscopic characterization of colonic polyps using the Workgroup serrAted polypS and Polyposis (WASP) classification. We evaluated the impact of the training program by comparing the overall and individual ADR and SDR 6 months before and after the training. RESULTS: Overall, 18,280 polyps (9337 adenomas and 855 sessile serrated lesion) were collected. The optical diagnosis training had no significant impact on the difference in ADR after training compared to before training (47.7% vs. 46.5%, P = 0.608). A tendency for a decrease in ADR variance was noted among the endoscopists after training (74.9 vs. 32.7, P = 0.121). The overall pre-training period SDR was 4.5% and showed a statistically significant increase to 5.6%, 8.0%, and 7.1% in the first and second half of the training period, and post-training period, respectively (P = 0.003). The optical diagnosis training did not decrease variance in SDR (8.9 vs. 8.8, P = 0.985). CONCLUSION: Comprehensive optical diagnosis training with WASP classification has a significant impact on increasing the overall SDR of expert endoscopists.

Improved Accuracy in Optical Diagnosis of Colorectal Polyps Using Convolutional Neural Networks with Visual Explanations.

BACKGROUND & AIMS: Narrow-band imaging (NBI) can be used to determine whether colorectal polyps are adenomatous or hyperplastic. We investigated whether an artificial intelligence (AI) system can increase the accuracy of characterizations of polyps by endoscopists of different skill levels. METHODS: We developed convolutional neural networks (CNNs) for evaluation of diminutive colorectal polyps, based on efficient neural architecture searches via parameter sharing with augmentation using NBIs of diminutive (≤5 mm) polyps, collected from October 2015 through October 2017 at the Seoul National University Hospital, Healthcare System Gangnam Center (training set). We trained the CNN using images from 1100 adenomatous polyps and 1050 hyperplastic polyps from 1379 patients. We then tested the system using 300 images of 180 adenomatous polyps and 120 hyperplastic polyps, obtained from January 2018 to May 2019. We compared the accuracy of 22 endoscopists of different skill levels (7 novices, 4 experts, and 11 NBI-trained experts) vs the CNN in evaluation of images (adenomatous vs hyperplastic) from 180 adenomatous and 120 hyperplastic polyps. The endoscopists then evaluated the polyp images with knowledge of the CNN-processed results. We conducted mixed-effect logistic and linear regression analyses to determine the effects of AI assistance on the accuracy of analysis of diminutive colorectal polyps by endoscopists (primary outcome). RESULTS: The CNN distinguished adenomatous vs hyperplastic diminutive polyps with 86.7% accuracy, based on histologic analysis as the reference standard. Endoscopists distinguished adenomatous vs hyperplastic diminutive polyps with 82.5% overall accuracy (novices, 73.8% accuracy; experts, 83.8% accuracy; and NBI-trained experts, 87.6% accuracy). With knowledge of the CNN-processed results, the overall accuracy of the endoscopists increased to 88.5% (P < .05). With knowledge of the CNN-processed results, the accuracy of novice endoscopists increased to 85.6% (P < .05). The CNN-processed results significantly reduced endoscopist time of diagnosis (from 3.92 to 3.37 seconds per polyp, P = .042). CONCLUSIONS: We developed a CNN that significantly increases the accuracy of evaluation of diminutive colorectal polyps (as adenomatous vs hyperplastic) and reduces the time of diagnosis by endoscopists. This AI assistance system significantly increased the accuracy of analysis by novice endoscopists, who achieved near-expert levels of accuracy without extra training. The CNN assistance system can reduce the skill-level dependence of endoscopists and costs.

Longer Withdrawal Time Is More Important than Excellent Bowel Preparation in Colonoscopy of Adequate Bowel Preparation.

BACKGROUND: Adequate bowel preparation is crucial for effective screening colonoscopy. However, it is unclear whether higher bowel preparation scores correspond to beneficial effects on the adenoma and polyp detection rate (ADR and PDR) in the adequate bowel preparation group. AIMS: This study aimed to evaluate the effects of bowel preparation, according to the Boston Bowel Preparation Scale (BBPS), and colonoscopy withdrawal time (CWT) on ADR and PDR in the adequate bowel preparation group. METHODS: Healthy examinees between 50 and 75 years old who underwent colonoscopy between September 2015 and August 2016 were included. BBPS scores, CWT, ADR, and PDR were reviewed retrospectively. Predictors of ADR and PDR were analyzed with a generalized linear mixed model. RESULTS: A total of 5073 cases with adequate bowel preparation (BBPS ≥ 6) were analyzed. Examinees with good (BBPS = 6, 7) and excellent (BBPS = 8, 9) bowel preparation were 1898 (37.4%) and 3175 (62.6%), respectively. Both ADR and PDR were higher in the good bowel preparation group than in the excellent bowel preparation group (ADR 47.3% vs. 45.0%, P = 0.035; PDR 73.7% vs. 69.5%, P = 0.004, respectively). In the multivariate analysis, CWT, rather than BBPS, was significantly associated with both ADR (OR 1.04; 95% CI 1.02-1.06; P < 0.001) and PDR (OR 1.05; 95% CI 1.02-1.07; P = 0.002). CONCLUSIONS: Both ADR and PDR were lower when bowel preparation was excellent rather than good. However, CWT, not BBPS, was significantly associated with ADR and PDR in the adequate bowel preparation group. Therefore, meticulous inspection is important for high-quality colonoscopy regardless of the BBPS score in examinees with adequate bowel preparation.

Multidirectional Colonoscopy Quality Improvement Increases Adenoma Detection Rate: Results of the Seoul National University Hospital Healthcare System Gangnam Center Colonoscopy Quality Upgrade Project (Gangnam-CUP).

BACKGROUND: To prevent colorectal cancer, high-quality colonoscopy is advocated, undertaken by endoscopists with high adenoma detection rates (ADRs). Despite reports that various factors may impact ADRs, the significance of such factors is still unclear. AIMS: The analysis was aimed at quality-oriented interventions for boosting ADRs. METHODS: Study enrollees were adults subjected to screening colonoscopy between September 2013 and August 2016 at the Gangnam Center of Seoul National University Hospital Healthcare System. The investigation entailed six periods (P1-6) of 6 months each, during which serial multidirectional quality improvement efforts were instituted. In particular, we sought to further educate endoscopists, provide feedback on individual ADRs, and introduce a split-dose regimen, gauging results via the Boston Bowel Preparation Score. Changes in polyp detection rates (PDRs) and ADRs were then analyzed. RESULTS: A total of 13,430 colonoscopies were undertaken by 15 experienced endoscopists. Overall, the ADR increased from 45.6% (P1) to 48.2% (P6, p < 0.001). The PDR, ADR, and advanced adenoma detection rate (AdvADR) showed the greatest increases between P3 and P4 [PDR 67.8% → 71.2% (p < 0.001); ADR 44.1% → 47.7% (p = 0.001); AdvADR 2.3% → 3.3% (p = 0.028)] in keeping with the introduction of a split-dose regimen. The sessile serrated adenoma detection rate (SSADR) increased substantially from 2.1% (P1) to 7.9% (P6, p < 0.001), with the largest gain between P1 and P2, just after education (p = 0.023). CONCLUSIONS: Successful quality improvement in colonoscopy was achieved through comprehensive multidirectional efforts in education, feedback, and enhanced bowel preparation. Achieving high-level bowel preparation was paramount in ADR improvement. The SSADR was improved through education.

Improved Real-Time Optical Diagnosis of Colorectal Polyps Following a Comprehensive Training Program.

BACKGROUND & AIMS: The optimal training method for endoscopic characterization of colorectal polyps using narrow-band imaging is uncertain, and sessile serrated lesions (SSLs) optical diagnosis data are lacking. We aimed to evaluate a comprehensive training program for real-time optical diagnosis of colorectal polyps, including SSLs. METHODS: We performed a single-institution prospective study of 15 endoscopists trained with the Workgroup Serrated Polyps and Polyposis classification system. After the first phase of in vivo optical diagnosis, their performances were evaluated. After re-education for insufficient competency, they began the second phase. The learning curves and performance on 2 preservation and incorporation of valuable endoscopic innovations benchmarks were assessed. RESULTS: A total of 7294 polyps, including 486 SSLs, were diagnosed in real-time. The overall accuracy improved from 73.5% in the first phase to 77.1% in the second. The accuracy with high confidence was 79.4% and 85.1% in the first and second phases, respectively. In the first and second phases, the negative predictive values for diminutive neoplastic polyps were 82.1% and 92.5%, respectively, and concordances of the surveillance intervals were 80.7% and 89.7%, respectively. Eight endoscopists achieved the preservation and incorporation of valuable endoscopic innovations benchmarks after the second phase compared with none after the first. In contrast, the high confidence rate decreased from 74.6% to 70.2% as training progressed. CONCLUSION: A comprehensive training program for real-time optical diagnosis significantly improved performance and reduced individual variability in less-experienced endoscopists. ClinicalTrials.gov no: NCT02516748.

Visceral obesity as a risk factor for colorectal adenoma occurrence in surveillance colonoscopy.

BACKGROUND AND AIMS: The aim of this study was to examine the prospective association between visceral obesity and the incidence and recurrence of colorectal adenoma. METHODS: We conducted a cohort study involving 2244 participants between 2006 and 2007. The study participants were prospectively followed until 2014 according to the initial colonoscopy and histopathology findings. Incident and recurrent colorectal adenoma groups were defined as individuals with a positive follow-up colonoscopy result from the normal results and adenoma groups, respectively, at the baseline colonoscopy. RESULTS: Among the 1163 patients (51.8%) who received a follow-up colonoscopy, 509 (43.8%) and 654 (56.2%) were grouped into the normal and adenoma cohorts. Colorectal adenomas occurred in 592 patients (50.9%) during the median period of 43 months, with an incident adenoma prevalence of 39.1% and a recurrent adenoma prevalence of 60.1%. An increase in the visceral adipose tissue (VAT) area was associated with a higher incidence of adenoma (highest quintile vs lowest quintile of the VAT hazard ratios [HRs], 2.16; 95% confidence interval [CI], 1.26-3.71; HR 1.32 [per 1-standard deviation]; 95% CI, 1.10-1.60) in the multivariable analysis. Increases in body mass index and waist circumference were associated with recurrent adenomas (HR 1.33 [per 1 kg/m2], 95% CI, 1.18-1.46; HR 1.04 [per 1 cm], 95% CI, 1.01-1.07, respectively) in the multivariate analysis. CONCLUSION: A higher VAT area was dose-dependently associated with a higher risk of incident adenoma. Furthermore, increases in body mass index and waist circumference as surrogate markers of abdominal obesity were associated with a higher risk of recurrent adenoma.

Training Effect on the Inter-observer Agreement in Endoscopic Diagnosis and Grading of Atrophic Gastritis according to Level of Endoscopic Experience.

BACKGROUND: Endoscopic diagnosis of atrophic gastritis can contribute to risk stratification and thereby tailored screening for gastric cancer. We aimed to evaluate the effect of training on inter-observer agreement in diagnosis and grading of endoscopic atrophic gastritis (EAG) according to the level of endoscopists' experience. METHODS: Twelve endoscopists (six less-experienced and six experienced) participated in this prospective study. The training session consisted of 1) four interventions with two-week intervals, and 2) a follow-up period (two follow-up assessments without feedback). EAG was categorized as C1 to O3 according to the Kimura-Takemoto classification. Kappa statistics were used to calculate inter-observer agreement. RESULTS: At baseline, kappa indexes were 0.18 in the less-experienced group and 0.32 in the experienced group, respectively. After four interventions with feedback, the kappa index improved in both groups and was sustained during the follow-up period. Overall diagnostic yields of EAG were 43.1% ± 10.7% in pre-intervention and 46.8% ± 5.9% in post-intervention. Variability in the rate of diagnosis of EAG significantly decreased in the less-experienced group (r = 0.04, P = 0.003). CONCLUSION: Irrespective of experience level, inter-observer agreement for diagnosis and grading of EAG improved after training and remained stable after intervention.

Ablation of residual gastric tumor by argon plasma coagulation after endoscopic resection.

BACKGROUND: For residual gastric tumors (RT) found at the treated sites after endoscopic resections (ER), additional treatment options are additional ER, surgery or argon plasma coagulation (APC). Long-term efficacy of APC as the curative modality for RT has not been fully elucidated. This study aimed to investigate the efficacy and long-term outcome of APC for RT with relevant tumor factors. METHODS: Eighty-two patients who received ER for gastric adenocarcinoma or adenoma and were subsequently treated with APC for RT were reviewed retrospectively. Characteristics of the tumors curatively ablated with single-session of APC and the non-curatively ablated were compared by multiple logistic regression analysis. Overall rate of curative ablation and follow-up duration was calculated. RESULTS: Initial tumor size <20 mm [odds ratio for second residual recurrence (OR) 0.16; 95 % confidence interval (CI) 0.039-0.63], en-bloc resection (OR 0.16; 95 % CI 0.039-0.72), histologic complete resection (OR 0.14; 95 % CI 0.028-0.66) and RT with flat or depressed type (OR 0.20; 95 % CI 0.051-0.77) were significantly associated with curative ablation of RT by single-session of APC. Anterior wall or lesser curvature location showed a tendency toward curative APC, but not reached statistical significance (OR 0.36; 95 % CI 0.11-1.16). A total of 60 patients (73.2 %) achieved curative ablation after single-session of APC. Eleven among the patients (n = 22) with second or more residual recurrence achieved curative ablation with one or two more additional sessions of APC. Overall rate of curative ablation was 86.6 % (71/82). From the last APC, the final curative ablation group (n = 71) has been followed up for 49.7 ± 37.4 months. CONCLUSIONS: En-bloc resection, histologic complete resection, RT with flat or depressed type and initial tumor size less than 2 cm can be predictors of favorable clinical outcome of APC as an additional treatment for RT. For selected patients with RT, APC and close monitoring could be a reasonable alternative to immediate resection.

Clinical outcomes of re-stenting in patients with stent malfunction in malignant gastric outlet obstruction.

BACKGROUND AND AIMS: Self-expanding metal stents (SEMS) have been used for the palliative treatment of malignant gastric outlet obstruction (GOO). The aim of this study was to evaluate the clinical outcomes of salvage SEMS for stent malfunction and to identify the prognostic factors for a longer patency. METHODS: A total of 108 patients who underwent a secondary salvage SEMS placement for a primary stent malfunction were retrospectively reviewed at the Seoul National University Hospital between August 2004 and May 2013. The duration of patency for salvage SEMS was defined as the time between salvage SEMS placement and the recurrence of obstructive symptoms that were confirmed either endoscopically or radiologically. RESULTS: The technical and clinical success rates for salvage SEMS were 100 and 82.4% (95% confidence interval [CI] 74.0-89.0), respectively. A salvage SEMS malfunction occurred in 29 (26.9%) of the 108 patients. The median duration of patency for salvage SEMS was 59.5 days (range 3-928, 95% CI 73.7-118.3). Longer SEMS patencies of more than 60 days were significantly associated with palliative chemotherapy (odds ratio = 2.539, 95% CI 1.031-6.252, p = .043). For salvage SEMS, covered-uncovered stents had a longer patency duration, as compared with other combinations of primary and salvage stent types. CONCLUSIONS: Longer patency durations for salvage SEMS were associated with palliative chemotherapy after salvage SEMS insertion. Salvage SEMS could be a feasible and effective treatment for primary stent malfunction in malignant GOO.

Enhancing artificial intelligence-doctor collaboration for computer-aided diagnosis in colonoscopy through improved digital literacy.

Establishing appropriate trust and maintaining a balanced reliance on digital resources are vital for accurate optical diagnoses and effective integration of computer-aided diagnosis (CADx) in colonoscopy. Active learning using diverse polyp image datasets can help in developing precise CADx systems. Enhancing doctors' digital literacy and interpreting their results is crucial. Explainable artificial intelligence (AI) addresses opacity, and textual descriptions, along with AI-generated content, deepen the interpretability of AI-based findings by doctors. AI conveying uncertainties and decision confidence aids doctors' acceptance of results. Optimal AI-doctor collaboration requires improving algorithm performance, transparency, addressing uncertainties, and enhancing doctors' optical diagnostic skills.

Association between depression and young-onset dementia in middle-aged women.

BACKGROUND: Dementia is associated with older adults; however, it can also affect younger individuals, known as young-onset dementia (YOD), when diagnosed before the age of 65 years. We aimed to conduct a retrospective cohort study involving middle-aged women to investigate the association between premorbid depression and YOD development. METHODS: We included 1.6 million women aged 40-60 years who underwent health checkups under the Korean National Health Insurance Service and investigated the association between depression and YOD. RESULTS: Women with depression had a significantly higher risk of developing YOD than women without depression. Among premenopausal women, those with depression had a 2.67-fold increased risk, whereas postmenopausal women with depression had a 2.50-fold increased risk. Late age at menarche (> 16 years) and young age at menopause (< 40 years) was associated with an increased risk of YOD. CONCLUSIONS: Depression in middle-aged women is a significant risk factor for the development of YOD. Understanding the role of reproductive factors can aid in the development of targeted therapeutic interventions to prevent or delay YOD.

Boston bowel preparation scale score 6 has more missed lesions compared with 7-9.

Adequate bowel preparation is an important factor in high-quality colonoscopy. It is generally accepted that a Boston Bowel Preparation Scale (BBPS) score ≥ 6 is adequate, but some reports suggest ≥ 7. Subjects who underwent colonoscopy at least twice within 3 years from August 2015 to December 2019 were included. Polyp detection rates (PDRs), adenoma detection rates (ADRs), and number of polyps including adenomas were compared stratified by baseline colonoscopy (C1) BBPS score. Among 2352 subjects, 529 had BBPS 6 (group 1) and 1823 had BBPS 7-9 (group 2) at C1. There was no significant difference in PDR or ADR at C1 and follow-up colonoscopy (C2) between the two groups. However, the numbers of polyps (1.84 vs. 1.56, P = 0.001) and adenomas (1.02 vs. 0.88, P = 0.034) at C2 were significantly higher in group 1 than group 2, respectively. Segmental BBPS score 2 in group 1 compared to group 2, especially, showed higher PDR (P = 0.001) and ADR (P = 0.007) at C2. BBPS 6 is associated with a higher number of polyps and adenomas in short-term follow-up colonoscopy than BBPS 7-9. To reduce the risk of missed polyps, a thorough examination is necessary for BBPS 6.

The Persistence of Hypertriglyceridemia and the Risk of Early Onset Colorectal Cancer According to Tumor Subsites: A Nationwide Population-Based Study.

PURPOSE: The incidence of early-onset colorectal cancer (EoCRC) is increasing worldwide. The association between hypertriglyceridemia (HTG) and EoCRC risk remains unclear. MATERIALS AND METHODS: We conducted a nationwide cohort study of 3,340,635 individuals aged 20-49 years who underwent health checkups between 2009 and 2011 under the Korean National Health Insurance Service. HTG was defined as serum triglyceride (TG) level ≥ 150 mg/dL. According to the change in TG status, participants were categorized into persistent normotriglyceridemia (NTG; group 1), NTG to HTG (group 2), HTG to NTG (group 3), and persistent HTG (group 4) groups. The EoCRC incidence was followed up until 2019. RESULTS: In total, 7,492 EoCRC cases developed after a mean of 6.05 years of follow-up. Group 4 had the highest risk of EoCRC (adjusted hazard ratio [aHR], 1.097; 95% confidence interval [CI], 1.025 to 1.174). While the risk of rectal cancer was significantly increased in groups 3 and 4 (aHR [95% CI], 1.236 [1.076 to 1.419] and 1.175 [1.042-1.325], respectively), no significant risk differences were observed in right colon cancer. In group 4, male sex and diabetes were associated with a further increased risk of EoCRC (aHR [95% CI], 1.149 [1.082 to 1.221] and 1.409 [1.169 to 1.699], respectively). In addition, there was a dose-response relationship between serum TG levels and the risk of EoCRC (p for trends < 0.0001). CONCLUSION: Persistent HTG increased the risk of EoCRC, which was significantly higher only for rectal cancer and marginally higher for other colonic subsites.