SPLIT-DOSE BOWEL PREPARATION IS SUPERIOR TO STRAIGHT-DOSE IN HOSPITALIZED PATIENTS UNDERGOING INPATIENT COLONOSCOPY.

BACKGROUND: There is a two-fold higher rate of failed colonoscopy secondary to inadequate bowel preparation among hospitalized versus ambulatory patients. Split-dose bowel preparation is widely used in the outpatient setting but has not been generally adapted for use among the inpatient population. OBJECTIVE: The aim of this study is to evaluate the effectiveness of split versus single dose polyethylene glycol bowel (PEG) preparation for inpatient colonoscopies and determine additional procedural and patient characteristics that drive inpatient colonoscopy quality. METHODS: A retrospective cohort study was performed on 189 patients who underwent inpatient colonoscopy and received 4 liters PEG as either split- or straight-dose during a 6-month period in 2017 at an academic medical center. Bowel preparation quality was assessed using Boston Bowel Preparation Score (BBPS), Aronchick Score, and reported adequacy of preparation. RESULTS: Bowel preparation was reported as adequate in 89% of the split-dose group versus 66% in the straight-dose group (P=0.0003). Inadequate bowel preparations were documented in 34.2% of the single-dose group and 10.7% of the split-dose group (P<0.001). Only 40% of patients received split-dose PEG. Mean BBPS was significantly lower in the straight-dose group (Total: 6.32 vs 7.73, P<0.001). CONCLUSION: Split-dose bowel preparation is superior to straight-dose preparation across reportable quality metrics for non-screening colonoscopies and was readily performed in the inpatient setting. Interventions should be targeted at shifting the culture of gastroenterologist prescribing practices towards use of split-dose bowel preparation for inpatient colonoscopy.

O preparo intestinal em dose dividida é superior à dose direta em pacientes hospitalizados submetidos à colonoscopia hospitalar / Split-dose bowel preparation is superior to straight-dose in hospitalized patients undergoing inpatient colonoscopy

ABSTRACT Background: There is a two-fold higher rate of failed colonoscopy secondary to inadequate bowel preparation among hospitalized versus ambulatory patients. Split-dose bowel preparation is widely used in the outpatient setting but has not been generally adapted for use among the inpatient population. Objective The aim of this study is to evaluate the effectiveness of split versus single dose polyethylene glycol bowel (PEG) preparation for inpatient colonoscopies and determine additional procedural and patient characteristics that drive inpatient colonoscopy quality. Methods: A retrospective cohort study was performed on 189 patients who underwent inpatient colonoscopy and received 4 liters PEG as either split- or straight-dose during a 6-month period in 2017 at an academic medical center. Bowel preparation quality was assessed using Boston Bowel Preparation Score (BBPS), Aronchick Score, and reported adequacy of preparation. Results: Bowel preparation was reported as adequate in 89% of the split-dose group versus 66% in the straight-dose group (P=0.0003). Inadequate bowel preparations were documented in 34.2% of the single-dose group and 10.7% of the split-dose group (P<0.001). Only 40% of patients received split-dose PEG. Mean BBPS was significantly lower in the straight-dose group (Total: 6.32 vs 7.73, P<0.001). Conclusion: Split-dose bowel preparation is superior to straight-dose preparation across reportable quality metrics for non-screening colonoscopies and was readily performed in the inpatient setting. Interventions should be targeted at shifting the culture of gastroenterologist prescribing practices towards use of split-dose bowel preparation for inpatient colonoscopy.

RESUMO Contexto: Há uma taxa duas vezes maior de colonoscopia com falha secundária ao preparo intestinal inadequado entre pacientes hospitalizados versus ambulatoriais. O preparo intestinal em dose dividida é amplamente utilizado em ambulatório, mas geralmente não foi adaptado para uso entre a população hospitalar. Objetivo: O objetivo deste estudo é avaliar a eficácia da preparação do intestino de polietilenoglicol (PEG) em dose única versus doses separadas para colonoscopias hospitalares e determinar características adicionais do procedimento e do paciente que promovam a qualidade da colonoscopia do paciente internado. Métodos Um estudo de coorte retrospectivo foi realizado em 189 pacientes que foram submetidos a colonoscopia hospitalar e receberam 4 litros de PEG como dose dividida ou direta durante um período de 6 meses em 2017 em um centro médico acadêmico. A qualidade do preparo intestinal foi avaliada usando-se o Boston Bowel Preparation Score (BBPS), o Aronchick Score, e relatório sobre a adequação do preparo. Resultados O preparo intestinal foi relatado como adequado em 89% do grupo de dose dividida versus 66% no grupo de dose direta (P=0,0003). Preparações intestinais inadequadas foram documentadas em 34,2% do grupo de dose única e 10,7% do grupo de dose dividida (P<0,001). Apenas 40% dos pacientes receberam PEG em dose fracionada. O BBPS médio foi significativamente menor no grupo de dose direta (total: 6,32 vs 7,73, P<0,001). Conclusão O preparo intestinal em dose dividida é superior ao preparo de dose única em todas as métricas de qualidade relacionadas para colonoscopias sem triagem e foi adequadamente realizado no ambiente de internação. As intervenções devem ser direcionadas para mudar a cultura das práticas de prescrição de gastroenterologistas para o uso de preparação intestinal em dose dividida para colonoscopia hospitalar.

Characterization of cyclic Cushing's disease using late night salivary cortisol testing.

OBJECTIVE: To characterize a cohort of patients with cyclic Cushing's disease (CD) in comparison with noncyclic CD using late night salivary cortisol (LNSC) and examine the diagnostic sensitivity of LNSC in comparison with that of 24-hour urine-free cortisol (UFC) in this population. DESIGN: Retrospective study of patients with CD seen in our institution between 2008 and 2017. PATIENTS: A total of 205 patients, including 17 (8%) with cyclic CD (based on a minimum of 3 peaks and 2 troughs in cortisol levels). In a secondary analysis, 38 patients (19%) with cyclic CD were identified (based on a criterion of at least 2 peaks and 1 trough). MEASUREMENTS: Data on presentation, laboratory tests and outcomes were extracted. The diagnostic sensitivity of LNSC vs UFC in establishing cyclic CD was calculated. Kaplan-Meier analyses of recurrence after transsphenoidal pituitary surgery (TSS) were performed. RESULTS: The interval between presentation and TSS was significantly longer in patients with cyclic CD (P < .0001) in comparison with those with noncyclic CD. The sensitivity of LNSC in establishing cyclic CD was 88% and was higher than that of UFC (12%, P = .007). There were no differences in remission and recurrence rates between patients with cyclic CD and those with noncyclic CD. CONCLUSIONS: Patients with cyclic CD account only for a minority of those with CD, but may require a lengthier diagnostic evaluation. The use of LNSC on multiple occasions provides a more sensitive method of detecting cyclic CD than UFC. Outcomes of TSS in cyclic CD are comparable to those with noncyclic disease.

Studying the Relation Between Medial Tibial Stress Syndrome and Anatomic and Anthropometric Characteristics of Military Male Personnel.

BACKGROUND: Medial Tibial Stress Syndrome (MTSS) is common among military recruits and to our knowledge; the factors that might put the military recruits at higher risk of incidence of MTSS are not well known. OBJECTIVES: This study was done to investigate the association between some anthropometric and anatomical factors and the prevalence of MTSS among military recruits. PATIENTS AND METHODS: One hundred and eighty one randomly selected military recruits were included in this cross sectional study. Using history taking and physical examinations they were tested for MTSS. Accordingly the subjects were assigned to the case (those with MTSS) and control groups (normal healthy subjects). Using standard guidelines, the anthropometric and anatomical criteria of the subjects were measured. The correlation between the measurements and the prevalence of MTSS was tested using statistical analysis. RESULTS: Data of all the 181 subjects with the mean age of 30.7 ± 4.68 years were Included in the final analysis. The prevalence of MTSS was found to be 16.6% (30 people). Internal and external rotation range of motion, iliospinale height, the score of navicular drop test, and the trochanteric tibial lateral length were significantly different between healthy subjects and patients with MTSS (P < 0.05). DISCUSSION: The prevalence of MTSS was relatively lower in this study comparing to other studies on military personnel. It was not probably due to type of military shoes or exercise area surface (none of them were standardized); it could be due to low intensity trainings and the long intervals between training sessions.