A model for the pandemic and beyond: Telemedicine for all outpatient gastroenterology referrals reduces unnecessary clinic visits.

The ongoing coronavirus disease 2019 pandemic has forced providers to dramatically scale down in-person clinic visits to enforce social distancing and triage care to the neediest patients. We describe our five-month experience with a hybrid gastroenterology electronic consultation programme starting in 2019 in which we perform electronic consultations for every referral regardless of indication as well as directly initiate telephone-based telehealth visits with patients without the need for in-person clinic. Over five consecutive months, 1243 hybrid electronic consultations were performed with 356 (29%) resulting in a clinic appointment. The remaining 887 (71%) electronic consultations were resolved without need for a clinic visit. Five hundred and fourteen (41%) electronic consultations resulted in a directly scheduled procedure without clinic appointment. Eighty-five per cent of electronic consultations were performed on the same day of referral and 98% of electronic consultations were completed in under 20 min. A hybrid electronic consultation model which pre-emptively reviews all outpatient referrals streamlines access to specialty care. Such a model may be implemented rapidly during the current coronavirus disease 2019 pandemic as well as serve as a platform for long-term improvement in efficiency of care.

Erratum: Open Peroral Endoscopic Myotomy (O-POEM) Without Submucosal Tunneling.

This corrects the article DOI: 10.1038/ajg.2017.214.

Impact of cap-assisted colonoscopy on the learning curve and quality in colonoscopy: a randomized controlled trial.

BACKGROUND AND AIMS: Colonoscopy competency assessment in trainees traditionally has been informal. Comprehensive metrics such as the Assessment of Competency in Endoscopy (ACE) tool suggest that competency thresholds are higher than assumed. Cap-assisted colonoscopy (CAC) may improve competency, but data regarding novice trainees are lacking. We compared CAC versus standard colonoscopy (SC) performed by novice trainees in a randomized controlled trial. METHODS: All colonoscopies performed by 3 gastroenterology fellows without prior experience were eligible for the study. Exclusion criteria included patient age <18 or >90 years, pregnancy, prior colon resection, diverticulitis, colon obstruction, severe hematochezia, referral for EMR, or a procedure done without patient sedation. Patients were randomized to either CAC or SC in a 1:1 fashion. The primary outcome was the independent cecal intubation rate (ICIR). Secondary outcomes were cecal intubation time, polyp detection rate, polyp miss rate, adenoma detection rate, ACE tool scores, and cumulative summation learning curves. RESULTS: A total of 203 colonoscopies were analyzed, 101 in CAC and 102 in SC. CAC resulted in a significantly higher cecal intubation rate, at 79.2% in CAC compared with 66.7% in SC (P = .04). Overall cecal intubation time was significantly shorter at 13.7 minutes for CAC versus 16.5 minutes for SC (P =.02). Cecal intubation time in the case of successful independent fellow intubation was not significantly different between CAC and SC (11.6 minutes vs 12.7 minutes; P = .29). Overall ACE tool motor and cognitive scores were higher with CAC. Learning curves for ICIR approached the competency threshold earlier with cap use but reached competency for only 1 fellow. The polyp detection rate, polyp miss rate, and adenoma detection rate were not significantly different between groups. CONCLUSIONS: CAC resulted in significant improvement in ICIR, overall ACE tool scores, and trend toward competency on learning curves when compared with SC in colonoscopy trainees without prior colonoscopy experience. (Clinical trial registration number: NCT02472730.).

Diarrhea as a Presenting Symptom of Disseminated Toxoplasmosis.

Disseminated toxoplasmosis is uncommon in both immunocompetent and immunocompromised hosts with gastrointestinal involvement being rarely described. We report a case of disseminated gastrointestinal toxoplasmosis in an immunocompromised man who presented with one month of diarrhea and abdominal pain. Imaging showed thickening of the ascending colon and cecum. Esophagogastroduodenoscopy and colonoscopy biopsies revealed Toxoplasma gondii, confirmed by immunostain. Symptoms completely resolved following treatment with pyrimethamine, sulfadiazine, and leucovorin. This case highlights the importance of including toxoplasmosis in the differential diagnosis of any immunocompromised individual presenting with gastrointestinal symptoms.

Endoscopic Ultrasound Guided Rendezvous Drainage of Biliary Obstruction Using a New Flexible 19-Gauge Fine Needle Aspiration Needle.

Background and Aim. A successful endoscopic ultrasound guided rendezvous (EUS-RV) biliary drainage is dependent on accurate puncture of the bile duct and precise guide wire manipulation across the ampulla of Vater. We aim to study the feasibility of using a flexible 19-gauge fine aspiration needle in the performance of EUS-RV biliary drainage. Method. This is a retrospective case series of EUS-RV biliary drainage procedures at a single center. Patients who failed ERCP during the same session for benign or malignant biliary obstruction underwent EUS-RV using a flexible, nitinol covered, 19-gauge needle for biliary access and guide wire manipulation. Result. 24 patients underwent EUS-RV biliary drainage via extrahepatic access while 1 attempt was via intrahepatic access. The technical success rate was 80%, including 83.3% of cases via extrahepatic access. There was no significant difference in success rate of inpatient and outpatient procedures, benign or malignant indications, or type of guide wire used. Adverse events included mild pancreatitis (3 patients) and cholangitis (1 patient). Conclusion. A flexible 19-gauge needle for biliary access can be safe and effective when used to perform EUS-RV biliary drainage. Direct comparison between the nitinol needle and conventional metal needles in the performance of EUS guided biliary drainage is needed.

Esophageal COX-2 expression is increased in Barrett's esophagus, obesity, and smoking.

BACKGROUND: Increased esophageal cyclooxygenase-2 (COX-2) expression has been associated with Barrett's esophagus (BE); however, it is unknown whether COX-2 expression varies among patient groups with different clinical or socio-demographic factors. METHODS: We conducted a case-control study among eligible patients scheduled for elective esophagogastroduodenoscopy and patients eligible for screening colonoscopy recruited from primary clinics. We compared 39 BE tissue samples and 47 squamous tissue samples from BE cases and 240 squamous tissue samples from controls. Clinical and socio-demographic data were prospectively collected. Immunohistochemical staining for esophageal COX-2 was performed and scored. RESULTS: The median COX-2 score was significantly higher in BE tissue than squamous tissue from cases or controls (p < 0.001). Median COX-2 expression levels were higher in tissue samples from participants with a waist-to-hip ratio (WHR) in the 2nd tertile [unadjusted odds ratio (OR) 2.04; 95 % confidence interval (95 % CI) 1.17-3.57] and 3rd tertile (unadjusted OR 2.24; 95 % CI 1.20-4.16) compared with the 1st tertile and from current smokers compared with former or non-smokers (unadjusted OR 1.68; 95 % CI 1.03-2.75). In the multivariate analysis, WHRs in the 2nd tertile (OR 1.92; 95 % CI 1.07-3.45) and the 3rd tertile (OR 2.14; 95 % CI 1.10-4.16) were associated with high COX-2 compared with the 1st tertile, as was current smoking (OR 1.78; 95 % CI 1.06-2.97) compared with former and non-smoking. CONCLUSION: We found a significant association between elevated esophageal mucosa COX-2 levels and the presence of BE tissue, as well as between elevated COX-2 levels and high WHR and current tobacco smoking. This information may assist in identifying patients likely to benefit from chemoprevention with COX-2 inhibitors.

Detection of the JAK2(V617F) mutation in myeloproliferative disorders by melting curve analysis using the LightCycler system.

CONTEXT: A specific mutation, JAK2(V617F), was recently recognized as having diagnostic value for myeloproliferative disorders. No practical assay is currently available for routine use in a clinical laboratory. OBJECTIVE: We report the development of a real-time polymerase chain reaction melting curve analysis assay that is appropriate for molecular diagnostics testing. DESIGN: Specific primers and fluorescence resonance energy transfer probes were designed, and patients with a previously diagnosed myeloproliferative disorder, de novo acute myeloid leukemia, or reactive condition were selected. The DNA was extracted from fresh and archived peripheral blood and bone marrow specimens, and real-time polymerase chain reaction melting curve analysis was performed on the LightCycler platform (Roche Applied Science, Indianapolis, Ind). RESULTS: The JAK2 region was successfully amplified, and wild-type amplicons were reproducibly discriminated from JAK2(V617F) amplicons. Titration studies using homozygous wild-type and mutant cell lines showed the relative areas under a melting curve were proportional to allele proportion, and the assay reliably detected one mutant in 20 total cells. JAK2(V617F) was identified in patients previously diagnosed with a myeloproliferative disorder or acute myeloid leukemia transformed from myeloproliferative disorder, whereas a wild-type genotype was identified in patients with reactive conditions or de novo acute myeloid leukemia. CONCLUSIONS: These findings demonstrate the suitability of this assay for identifying JAK2(V617F) in a clinical laboratory setting. Furthermore, the semiquantitative detection of JAK2(V617F) in archived specimens provides a new tool for studying the prognostic significance of this mutation.