The Environmental Impact of Gastrointestinal Procedures: A Prospective Study of Waste Generation, Energy Consumption, and Auditing in an Endoscopy Unit.

BACKGROUND & AIMS: Gastrointestinal (GI) endoscopy procedures are critical for screening, diagnosis, and treatment of a variety of GI disorders. However, like the procedures in other medical disciplines, they are a source of environmental waste generation and energy consumption. METHODS: We prospectively collected data on total waste generation, energy consumption, and the role of intraprocedural inventory audit of a single tertiary care academic endoscopy unit over a 2-month period (May-June 2022). Detailed data on items used were collected, including procedure type (esophagogastroduodenoscopy or colonoscopy), accessories, intravenous tubing, biopsy jars, linen, and personal protective equipment use. Data on endoscope reprocessing-related waste generation and energy use in the endoscopy unit (equipment, lights, and computers) were also collected. We used an endoscopy staff-guided auditing and review of the items used during procedures to determine potentially recyclable items going to landfill waste. The waste generated was stratified into biohazardous, nonbiohazardous, or potentially recyclable items. RESULTS: A total of 450 consecutive procedures were analyzed for total waste management (generation and reprocessing) and energy consumption. The total waste generated during the study period was 1398.6 kg (61.6% directly going to landfill, 33.3% biohazard waste, and 5.1% sharps), averaging 3.03 kg/procedure. The average waste directly going to landfill was 219 kg per 100 procedures. The estimated total annual waste generation approximated the size of 2 football fields (1-foot-high layered waste). Endoscope reprocessing generated 194 gallons of liquid waste per day, averaging 13.85 gallons per procedure. Total energy consumption in the endoscopy unit was 277.1 kW·h energy per day; for every 100 procedures, amounting to 1200 miles of distance traveled by an average fuel efficiency car. The estimated carbon footprint for every 100 GI procedures was 1501 kg carbon dioxide (CO2) equivalent (= 1680 lbs of coal burned), which would require 1.8 acres of forests to sequester. The recyclable waste audit and review demonstrated that 20% of total waste consisted of potentially recyclable items (8.6 kg/d) that could be avoided by appropriate waste segregation of these items. CONCLUSIONS: On average, every 100 GI endoscopy procedures (esophagogastroduodenoscopy/colonoscopy) are associated with 303 kg of solid waste and 1385 gallons of liquid waste generation, and 1980 kW·h energy consumption. Potentially recyclable materials account for 20% of the total waste. These data could serve as an actionable model for health systems to reduce total waste generation and decrease landfill waste and water waste toward environmentally sustainable endoscopy units.

Adjunctive Use of Wide-Area Transepithelial Sampling-3D in Patients With Symptomatic Gastroesophageal Reflux Increases Detection of Barrett's Esophagus and Dysplasia.

INTRODUCTION: Patients with gastroesophageal reflux (GERD) symptoms undergoing screening upper endoscopy for Barrett's esophagus (BE) frequently demonstrate columnar-lined epithelium, with forceps biopsies (FBs) failing to yield intestinal metaplasia (IM). Repeat endoscopy is then often necessary to confirm a BE diagnosis. The aim of this study was to assess the yield of IM leading to a diagnosis of BE by the addition of wide-area transepithelial sampling (WATS-3D) to FB in the screening of patients with GERD. METHODS: We performed a prospective registry study of patients with GERD undergoing screening upper endoscopy. Patients had both WATS-3D and FB. Patients were classified by their Z line appearance: regular, irregular (<1 cm columnar-lined epithelium), possible short-segment BE (1 to <3 cm), and possible long-segment BE (≥3 cm). Demographics, IM yield, and dysplasia yield were calculated. Adjunctive yield was defined as cases identified by WATS-3D not detected by FB, divided by cases detected by FB. Clinicians were asked if WATS-3D results affected patient management. RESULTS: Of 23,933 patients, 6,829 (28.5%) met endoscopic criteria for BE. Of these, 2,878 (42.1%) had IM identified by either FB or WATS-3D. Among patients fulfilling endoscopic criteria for BE, the adjunctive yield of WATS-3D was 76.5% and absolute yield was 18.1%. One thousand three hundred seventeen patients (19.3%) who fulfilled endoscopic BE criteria had IM detected solely by WATS-3D. Of 240 patients with dysplasia, 107 (44.6%) were found solely by WATS-3D. Among patients with positive WATS-3D but negative FB, the care plan changed in 90.7%. DISCUSSION: The addition of WATS-3D to FB in patients with GERD being screened for BE resulted in confirmation of BE in an additional one-fifth of patients. Furthermore, dysplasia diagnoses approximately doubled.

Analyzing methods for reducing recurrence rates after EMR of large nonpedunculated colorectal polyps: an indirect pairwise comparison.

BACKGROUND AND AIMS: Despite advances in EMR techniques, a high polyp recurrence rate remains a challenge. Due to the scarcity of direct comparisons, we performed an indirect comparison of conventional EMR (EMR alone), underwater EMR (U-EMR), and EMR + adjuvant thermal ablation of polypectomy margins to assess polyp recurrence rates. METHODS: Electronic databases were searched from inception to January 12, 2023, for studies reporting polyp recurrence rates after EMR for large nonpedunculated polyps (>15 mm) with or without adjuvant techniques (snare tip soft coagulation [STSC]/argon plasma coagulation [APC]). An indirect comparison was performed by using the frequentist method. The p-score was calculated to identify preferred intervention. Publication bias was assessed by using a comparison-adjusted funnel plot. RESULTS: A total of 9 full articles were identified. On direct comparisons, EMR + STSC had 82% reduced odds (odds ratio, .18; 95% confidence interval, .13-.26; P < .001), whereas U-EMR alone had 77% reduced odds (odds ratio, .23; 95% confidence interval, .08-.67; P = .007) of polyp recurrence compared with EMR alone. On indirect comparison, all interventions had significantly lower odds of polyp recurrence compared with EMR alone. The p-score ranking showed that EMR + STSC seems a potential first method in reducing the odds of polyp recurrence, followed by U-EMR, EMR + APC, and EMR alone. CONCLUSIONS: EMR + STSC seems to provide favorable odds for reducing polyp recurrence postresection for large nonpedunculated polyps. Standardization of methods to detect residual polyp and prevent polyp recurrence at the time of EMR are required.

Lack of Effectiveness of Computer Aided Detection for Colorectal Neoplasia: A Systematic Review and Meta-Analysis of Nonrandomized Studies.

BACKGROUND AND AIMS: Benefits of computer-aided detection (CADe) in detecting colorectal neoplasia were shown in many randomized trials in which endoscopists' behavior was strictly controlled. However, the effect of CADe on endoscopists' performance in less-controlled setting is unclear. This systematic review and meta-analyses were aimed at clarifying benefits and harms of using CADe in real-world colonoscopy. METHODS: We searched MEDLINE, EMBASE, Cochrane, and Google Scholar from inception to August 20, 2023. We included nonrandomized studies that compared the effectiveness between CADe-assisted and standard colonoscopy. Two investigators independently extracted study data and quality. Pairwise meta-analysis was performed utilizing risk ratio for dichotomous variables and mean difference (MD) for continuous variables with a 95% confidence interval (CI). RESULTS: Eight studies were included, comprising 9782 patients (4569 with CADe and 5213 without CADe). Regarding benefits, there was a difference in neither adenoma detection rate (44% vs 38%; risk ratio, 1.11; 95% CI, 0.97 to 1.28) nor mean adenomas per colonoscopy (0.93 vs 0.79; MD, 0.14; 95% CI, -0.04 to 0.32) between CADe-assisted and standard colonoscopy, respectively. Regarding harms, there was no difference in the mean non-neoplastic lesions per colonoscopy (8 studies included for analysis; 0.52 vs 0.47; MD, 0.14; 95% CI, -0.07 to 0.34) and withdrawal time (6 studies included for analysis; 14.3 vs 13.4 minutes; MD, 0.8 minutes; 95% CI, -0.18 to 1.90). There was a substantial heterogeneity, and all outcomes were graded with a very low certainty of evidence. CONCLUSION: CADe in colonoscopies neither improves the detection of colorectal neoplasia nor increases burden of colonoscopy in real-world, nonrandomized studies, questioning the generalizability of the results of randomized trials.

Risk of Colorectal Cancer and Cancer Related Mortality After Detection of Low-risk or High-risk Adenomas, Compared With No Adenoma, at Index Colonoscopy: A Systematic Review and Meta-analysis.

BACKGROUND & AIMS: The risk of metachronous colorectal cancer (CRC) among patients with no adenomas, low-risk adenomas (LRAs), or high-risk adenomas (HRAs), detected at index colonoscopy, is unclear. We performed a systematic review and meta-analysis to compare incidence rates of metachronous CRC and CRC-related mortality after a baseline colonoscopy for each group. METHODS: We searched the PubMed, Embase, Google Scholar, and Cochrane databases for studies that reported the incidence of CRC and adenoma characteristics after colonoscopy. The primary outcome was odds of metachronous CRC and CRC-related mortality per 10,000 person-years of follow-up after baseline colonoscopy for all the groups. RESULTS: Our final analysis included 12 studies with 510,019 patients (mean age, 59.2 ± 2.6 years; 55% male; mean duration of follow up, 8.5 ± 3.3 years). The incidence of CRC per 10,000 person-years was marginally higher for patients with LRAs compared to those with no adenomas (4.5 vs 3.4; odds ratio [OR], 1.26; 95% CI, 1.06-1.51; I2=0), but significantly higher for patients with HRAs compared to those with no adenoma ( 13.8 vs 3.4; odds ratio [OR], 2.92; 95% CI, 2.31-3.69; I2=0 ) and patients with HRAs compared to LRAs (13.81 vs 4.5; OR, 2.35; 95% CI, 1.72-3.20; I2=55%). However, the CRC-related mortality per 10,000 person-years did not differ significantly for patients with LRAs compared to no adenomas (OR, 1.15; 95% CI, 0.76-1.74; I2=0) but was significantly higher in persons with HRAs compared with LRAs (OR, 2.48; 95% CI, 1.30-4.75; I2=38%) and no adenomas (OR, 2.69; 95% CI, 1.87-3.87; I2=0). CONCLUSIONS: The results of this systematic review and meta-analysis demonstrate that the risk of metachronous CRC and mortality is significantly higher for patients with HRAs, but this risk is very low in patients with LRAs, comparable to patients with no adenomas. Follow-up of patients with LRAs detected at index colonoscopy should be the same as for persons with no adenomas.

Educational intervention to improve quality of care in Barrett's esophagus: the AQUIRE randomized controlled trial.

BACKGROUND AND AIMS: Despite quality measures in upper endoscopy (EGD) for Barrett's esophagus (BE), considerable variability remains in practice among gastroenterologists. This randomized controlled trial evaluated the role of structured intensive training on the quality of EGD in BE. METHODS: In this multicenter study, 8 sites (from the GI Quality Consortium) were cluster randomized (1:1) to receive AQUIRE (A Quality Improvement program in cancer care during Endoscopy) training (intervention) or continue local standard practices (control). The primary outcome was compliance with the Seattle biopsy protocol. Secondary outcomes were change in knowledge of BE detection and sampling assessed by questionnaire and dysplasia detection rate (DDR) before and after completion of the 6-month study period. RESULTS: The intervention sites (n = 4) had 31 gastroenterologists and the control sites (n = 4) had 34. There was a significant improvement in the compliance rates with the Seattle biopsy protocol from baseline to the end of the study in the intervention sites (64.8%-73.2%, P = .002) but not in the control sites (69.5%-69.4%, P = .953). The accurate response rate on the questionnaire at the intervention sites increased from 73% at baseline to 88% after AQUIRE training (difference, 14.8%; standard deviation, 18.7; P = .008). DDR did not change significantly from baseline to 6 months in either the control or intervention groups (P = .06). CONCLUSIONS: This study confirms the capacity of a structured educational intervention to improve utilization of a standard biopsy protocol and knowledge of standards of care in BE but without significant change in DDR.

Narrow-band imaging for the diagnosis of nonerosive reflux disease: an international, multicenter, randomized controlled trial.

BACKGROUND AND AIMS: We examined the accuracy of narrow-band imaging (NBI) findings in nonerosive reflux disease (NERD) patients compared with control subjects and the impact of proton pump inhibitor (PPI) therapy on these mucosal changes in a multicenter, double-blind, randomized controlled trial. METHODS: NERD patients (typical symptoms using a validated GERD questionnaire, absence of erosive esophagitis, and abnormal 48-hour pH study) and control subjects underwent high-definition white-light endoscopy followed by NBI and biopsy sampling of the distal esophagus. Then, NERD patients were randomized to esomeprazole 40 mg/day or placebo for 8 weeks, followed by repeat endoscopy. The presence of distal esophageal mucosal changes on NBI were recorded at baseline and after treatment: intrapapillary capillary loops (IPCLs; number, dilation, and tortuosity), microerosions, increased vascularity, columnar islands, and ridge/villous pattern (RVP) above the squamocolumnar junction. RESULTS: Of 122 screened, 21 NERD and 21 control subjects were identified (mean age, 49.5 ± 14.6 years; 62% men; and 85% white). The combination of IPCL tortuosity, RVP, and microerosions (62% vs 19%, P < .05) had a high specificity (86%) and moderate sensitivity (60%) for NERD with an area under the curve of .74. In 10 NERD patients treated with PPIs, resolution of microerosions was most significant (P = .047) compared with placebo (n = 11). RVP resolved in all NERD patients after therapy (P = .02) and correlated with acid exposure time (P = .004). Papillary length (P = .02) and basal cell thickness (P = .02) significantly correlated with a combination of IPCL tortuosity, RVP, and microerosions. CONCLUSIONS: In this randomized controlled trial, RVP on NBI demonstrated a high specificity, correlated with acid exposure time, and improved with PPI therapy, suggesting that it could be used as a surrogate marker for diagnosis of NERD. (Clinical trial registration number: NCT02081404.).

Post-endoscopy Barrett's neoplasia after a negative index endoscopy: a systematic review and proposal for definitions and performance measures in endoscopy.

BACKGROUND: A high rate of neoplasia, both high grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) has been reported in Barrett's esophagus at index endoscopy, but precise rates of post-endoscopy Barrett's neoplasia (PEBN) are unknown. METHODS: A systematic review and meta-analysis was performed examining electronic databases (inception to October 2021) for studies reporting PEBN. Consistent with the definitions of post-colonoscopy colorectal cancer proposed by the World Endoscopy Organization, we defined neoplasia (HGD/EAC) detected at index endoscopy and/or within 6 months of a negative index endoscopy as "prevalent" neoplasia, that detected after 6 months of a negative index endoscopy and prior to next surveillance interval (i. e. 3 years) as PEBN or "interval" neoplasia, and that detected after 36 months from a negative index endoscopy as "incident" neoplasia. The pooled incidence rates and proportions relative to total neoplasia were analyzed. RESULTS: 11 studies (n = 59 795; 61 % men; mean [SD] age 62.3 [3.3] years) met the inclusion criteria. The pooled incidence rates were: prevalent neoplasia 4.5 % (95 %CI 2.2 %-8.9 %) at baseline and an additional 0.3 % (0.1 %-0.7 %) within the first 6 months, PEBN 0.52 % (0.46 %-0.58 %), and incident neoplasia 1.4 % (0.9 %-2.1 %). At 3 years from the index endoscopy, PEBN accounted for 3 % of total Barrett's neoplasia, while prevalent neoplasia accounted for 97 %. CONCLUSION: Neoplasia detected at or within 6 months of index endoscopy accounts for most cases of Barrett's neoplasia (> 90 %). PEBN accounts for ~3 % of cases and can be used for validation in future. This highlights the importance of a high quality index endoscopy in Barrett's esophagus and the need to establish quality benchmarks to measure endoscopists' performance.

Impact of age, sex, race, and regionality on major clinical outcomes of COVID-19 in hospitalized patients in the United States.

BACKGROUND: The COVID-19 pandemic has affected all people across the globe. Regional and community differences in timing and severity of surges throughout the pandemic can provide insight into risk factors for worse outcomes in those hospitalized with COVID-19. METHODS: The study cohort was derived from the Cerner Real World Data (CRWD) COVID-19 Database made up of hospitalized patients with proven infection from December 1, 2019 through November 30, 2020. Baseline demographic information, comorbidities, and hospital characteristics were obtained. We performed multivariate analysis to determine if age, race, comorbidity and regionality were predictors for mortality, ARDS, mechanical ventilation or sepsis hospitalized patients with COVID-19. RESULTS: Of 100,902 hospitalized COVID-19 patients included in the analysis (median age 52 years, IQR 36-67; 50.7% female), COVID-19 case fatality rate was 8.5% with majority of deaths in those ≥ 65 years (70.8%). In multivariate analysis, age ≥ 65 years, male gender and higher Charlson Comorbidity Index (CCI) were independent risk factors for mortality and ARDS. Those identifying as non-Black or non-White race have a marginally higher risk for mortality (OR 1.101, CI 1.032-1.174) and greater risk of ARDS (OR 1.44, CI 1.334-1.554) when compared to those who identify as White. The risk of mortality or ARDS was similar for Blacks as Whites. Multivariate analysis found higher mortality risk in the Northeast (OR 1.299, CI 1.22-1.29) and West (OR 1.26, CI 1.18-1.34). Larger hospitals also had an increased risk of mortality, greatest in hospitals with 500-999 beds (OR 1.67, CI 1.43-1.95). CONCLUSION: Advanced age, male sex and a higher CCI predicted worse outcomes in hospitalized COVID-19 patients. In multivariate analysis, worse outcomes were identified in small minority populations, however there was no difference in study outcomes between those who identify as Black or White.

Trends and predictors of 30-day readmissions in subjects with eosinophilic esophagitis: results from a national cohort.

BACKGROUND: Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory condition causing recurrent dysphagia and may predispose patients to repeated hospitalizations. We assessed temporal trends and factors affecting readmissions in patients with EoE. METHODS: Patients with primary diagnosis of EoE and/or a complication (dysphagia, weight loss, and esophageal perforation) from EoE between 2010 and 2017 were identified from the National Readmissions Database using the International Classification of Diseases codes. The primary outcome was incidence of EoE related 30-day readmission. Independent risk factors for readmissions were evaluated using multivariable logistic regression analysis. Secondary outcomes were temporal trends of readmissions and healthcare costs. RESULTS: Of the 2,676 (mean age 45 ± 17.8 years, 1,667 males) index adult admissions, 2,103 (79%) patients underwent an upper endoscopy during the admission. The mean length of stay (LOS) was 3 ± 3.7 days. The 30-day readmission rate was steady at 6.8% from 2010 to 2017 and majority of the readmissions occurred by day 10 of index discharge. Age > 70 years was associated with a higher trend in 30-day readmission (P < 0.001). Longer LOS, history of smoking and the presence of eosinophilic gastroenteritis predicted readmission. Conversely, a history of foreign body impaction and upper endoscopy (including esophageal dilation) at index admission were negatively associated with readmission. Mean hospital charges significantly increased from $24,783 in 2010 to $40,922 in 2017. CONCLUSION: Readmissions due to EoE are more likely to occur in the first 10 days of discharge and at a lesser rate when upper endoscopies are performed at the index admission.

In eosinophilic esophagitis, budesonide orodispersible tablets maintained remission at 48 wk.

SOURCE CITATION: Straumann A, Lucendo AJ, Miehlke S, et al. Budesonide orodispersible tablets maintain remission in a randomized, placebo-controlled trial of patients with eosinophilic esophagitis. Gastroenterology. 2020;159:1672-85. 32721437.

Second-generation distal attachment cuff improves adenoma detection rate: meta-analysis of randomized controlled trials.

BACKGROUND AND AIMS: Multiple randomized controlled trials (RCTs) using the second-generation distal attachment cuff device (Endocuff Vision; Olympus America, Center Valley, Pa, USA) have reported conflicting results in improving adenoma detection rate (ADR) compared with standard high-definition colonoscopy without the distal attachment. We conducted a systematic review and meta-analysis of RCTs to compare outcomes between second-generation cuff colonoscopy (CC) versus colonoscopy without the distal attachment (standard colonoscopy [SC]). METHODS: An electronic literature search was performed using PubMed, Google Scholar, Embase, and Cochrane Library through May 2020. The primary outcome was reporting of ADR, and secondary outcomes were polyp detection rate (PDR), mean withdrawal time, mean adenomas per colonoscopy (APC), sessile serrated lesion detection rate, and adverse events. Pooled rates and risk ratios (RRs) with 95% confidence intervals were reported. RESULTS: Eight RCTs with 5695 patients were included in the final analysis, with 2862 patients (mean age, 62.8 years; 52.9% men) in the CC group and 2833 patients (mean age, 62.6 years; 54.2% men) in the SC group. Compared with SC, use of CC was associated with a significant improvement in ADR (49.8% vs 45.6%, respectively; RR, 1.12; P = .02), PDR (58.1% vs 53%, respectively; RR, 1.12; P = .009), and APC (P < .01). Furthermore, use of CC had a .93-minute lower mean withdrawal time (P < .01) when compared with SC. The difference in ADR was larger in the screening/surveillance population (6.5%, P = .02) and when used by endoscopists with ADRs <30% (9.4%, P = .03). CONCLUSIONS: The results of this meta-analysis of randomized trials show a significant improvement in ADR and APC with shorter withdrawal times using the second-generation cuff device compared with SC.

Narrow band imaging for detection of gastric intestinal metaplasia and dysplasia: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Gastric intestinal metaplasia (GIM), a precursor of gastric adenocarcinoma, is challenging to diagnose with white light endoscopy (WLE) and can be missed by random gastric biopsies. Narrowband imaging (NBI) may potentially improve the detection of GIM. However, pooled estimates from prospective studies are lacking. METHODS: Electronic databases were searched for studies comparing NBI and WLE alone for detection of GIM and synchronous dysplasia. Primary outcome was pooled detection rate of GIM by NBI compared with WLE in prospective studies. The secondary outcome was concurrent dysplasia detection. RESULTS: Ten studies were found eligible from 306 articles screened. Eight prospective studies were found eligible for primary endpoint of GIM detection. Two other retrospective studies were included for dysplasia detection. A total of 1366 subjects (694 males, 54.4 ± 5.08 years) underwent upper endoscopy. GIM was detected in 482 (35.3%) subjects. NBI detected GIM in 32% additional subjects (70% vs 38%, RR 1.79; 95% CI 1.34-2.37; P < 0.01). Subgroup analysis revealed newer NBI scopes (GIF260) detected significantly more GIM than WLE (RR 2.47; 95% CI 1.63-3.76; P < 0.01) but not the older (H180) NBI endoscopes (RR 1.33; 95% CI 0.93-1.88; P = 0.11). There was moderate heterogeneity between the studies (I2  = 63%). In five studies (n = 628) that reported dysplasia, there was no significant difference between NBI and WLE in dysplasia detection (RR 1.09; 95% CI 0.81-1.47; P = 0.58). CONCLUSION: Narrowband imaging can significantly increase the detection of GIM when used in addition to standard white light exam during an upper endoscopy.

Proton pump inhibitors do not increase the risk of dementia: a systematic review and meta-analysis of prospective studies.

Published studies have reported variable results on the association between duration of proton pump inhibitor (PPI) use and the risk of dementia. An extensive literature search was performed in PubMed, Embase, Google Scholar, and Cochrane for studies examining the risk of cognitive decline and dementia among PPI users versus non-PPI users in prospective studies. Retrospective database linkage studies, case reports, case series, editorials, uncontrolled cohort studies, cross-sectional studies, and review articles were excluded. Primary outcome was pooled hazard rate (HR) of any dementia among PPI users compared with non-PPI users. Secondary outcomes were pooled HR of Alzheimer's dementia (AD) and risk with long-term PPI follow-up (more than 5 years) studies. Meta-analysis outcomes, heterogeneity (I2), and meta-regression (for the effect of covariates) were derived by statistical software R and Open meta-analyst. A total of six studies (one RCT and five prospective) with 308249 subjects, average age of 75.8 ± 5.2 years, and follow-up of 5 (range 1.5-11) years were included in the analysis. Pooled HR of any dementia was 1.16 (n = 6, 95% confidence interval (CI) = 0.86-1.47). Results remained unchanged when only studies with long-term PPI use (more than 5 years) were analyzed (n = 4, pooled HR 1.10, 95% CI 0.66-1.53). Finally, the pooled HR for AD was 1.06 (n = 3, 95% CI 0.70-1.41). There was substantial heterogeneity among inclusion studies (I2 = 93%). Meta-regression did not demonstrate a significant role of age at study start (P = 0.1) or duration of PPI use (P = 0.62) to incident dementia. The results of this systematic review and meta-analysis do not show a significant relationship between PPI use and dementia in prospective studies with at least a 5-year follow-up.

Surveillance of neo-squamous epithelium after ablation of Barrett's esophagus: is it better to use jumbo over standard biopsy forceps?

BACKGROUND AND AIMS: As obtaining adequate tissue on biopsy is critical for the detection of residual and recurrent intestinal metaplasia/dysplasia in Barrett's esophagus (BE) patients undergone Barrett's endoscopic eradication therapy (BET), we decided to compare the adequacy of biopsy specimens using jumbo versus standard biopsy forceps. METHODS: This is a two-center study of patients' post-radiofrequency ablation of dysplastic BE. After BET, jumbo (Boston Scientific©, Radial Jaw 4, opening diameter 2.8 mm) or standard (Boston Scientific©, Radial Jaw 4, opening diameter 2.2 mm) biopsy forceps were utilized to obtain surveillance biopsies from the neo-squamous epithelium. Presence of lamina propria and proportion of squamous epithelium with partial or full thickness lamina propria was recorded by two experienced gastrointestinal pathologists who were blinded. Squamous epithelial biopsies that contained at least two-thirds of lamina propria were considered 'adequate'. RESULTS: In a total of 211 biopsies from 55 BE patients, 145 biopsies (29 patients, 18 males, mean age 61 years, interquartile range [IQR] 33-83) were obtained using jumbo forceps and 66 biopsies (26 patients, all males, mean age 65 years, IQR 56-76) using standard forceps biopsies. Comparing jumbo versus standard forceps, the proportion of specimens with any subepithelial lamina propria was 51.7% versus 53%, P = 0.860 and the presence of adequate subepithelial lamina propria was 17.9% versus 9.1%, P = 0.096 respectively. CONCLUSIONS: Use of jumbo forceps does not appear to have added advantage over standard forceps to obtain adequate biopsy specimens from the neo-squamous mucosa post-ablation.

Interleukin-17A is dispensable for myocarditis but essential for the progression to dilated cardiomyopathy.

RATIONALE: One-third of myocarditis cases progresses to dilated cardiomyopathy (DCM), but the mechanisms controlling this process are largely unknown. CD4(+) T helper (Th)17 cells have been implicated in the pathogenesis of autoimmune diseases, but the role of Th17-produced cytokines during inflammation-induced cardiac remodeling has not been previously studied. OBJECTIVE: We examined the importance of interleukin (IL)-17A in the progression of myocarditis to DCM using a mouse model. METHODS AND RESULTS: Immunization of mice with myocarditogenic peptide in complete Freund's adjuvant induced the infiltration of IL-17A-producing Th17 cells into the inflamed heart. Unexpectedly, IL-17A-deficient mice developed myocarditis with similar incidence and severity compared to wild-type mice. Additionally, IL-17A deficiency did not ameliorate the severe myocarditis of interferon (IFN)gamma-deficient mice, suggesting that IL-17A plays a minimal role during acute myocarditis. In contrast, IL-17A-deficient mice were protected from postmyocarditis remodeling and did not develop DCM. Flow cytometric and cytokine analysis revealed an important role for IL-17A in heart-specific upregulation of IL-6, TNFalpha, and IL-1beta and the recruitment of CD11b(+) monocyte and Gr1(+) granulocyte populations into the heart. Furthermore, IL-17A-deficient mice had reduced interstitial myocardial fibrosis, downregulated expression of matrix metalloproteinase-2 and -9 and decreased gelatinase activity. Treatment of BALB/c mice with anti-IL-17A monoclonal antibody administered after the onset of myocarditis abrogated myocarditis-induced cardiac fibrosis and preserved ventricular function. CONCLUSIONS: Our findings reveal a critical role for IL-17A in postmyocarditis cardiac remodeling and the progression to DCM. Targeting IL-17A may be an attractive therapy for patients with inflammatory dilated cardiomyopathy.