Use of a Novel Artificial Intelligence System Leads to the Detection of Significantly Higher Number of Adenomas During Screening and Surveillance Colonoscopy: Results From a Large, Prospective, US Multicenter, Randomized Clinical Trial.

INTRODUCTION: Adenoma per colonoscopy (APC) has recently been proposed as a quality measure for colonoscopy. We evaluated the impact of a novel artificial intelligence (AI) system, compared with standard high-definition colonoscopy, for APC measurement. METHODS: This was a US-based, multicenter, prospective randomized trial examining a novel AI detection system (EW10-EC02) that enables a real-time colorectal polyp detection enabled with the colonoscope (CAD-EYE). Eligible average-risk subjects (45 years or older) undergoing screening or surveillance colonoscopy were randomized to undergo either CAD-EYE-assisted colonoscopy (CAC) or conventional colonoscopy (CC). Modified intention-to-treat analysis was performed for all patients who completed colonoscopy with the primary outcome of APC. Secondary outcomes included positive predictive value (total number of adenomas divided by total polyps removed) and adenoma detection rate. RESULTS: In modified intention-to-treat analysis, of 1,031 subjects (age: 59.1 ± 9.8 years; 49.9% male), 510 underwent CAC vs 523 underwent CC with no significant differences in age, gender, ethnicity, or colonoscopy indication between the 2 groups. CAC led to a significantly higher APC compared with CC: 0.99 ± 1.6 vs 0.85 ± 1.5, P = 0.02, incidence rate ratio 1.17 (1.03-1.33, P = 0.02) with no significant difference in the withdrawal time: 11.28 ± 4.59 minutes vs 10.8 ± 4.81 minutes; P = 0.11 between the 2 groups. Difference in positive predictive value of a polyp being an adenoma among CAC and CC was less than 10% threshold established: 48.6% vs 54%, 95% CI -9.56% to -1.48%. There were no significant differences in adenoma detection rate (46.9% vs 42.8%), advanced adenoma (6.5% vs 6.3%), sessile serrated lesion detection rate (12.9% vs 10.1%), and polyp detection rate (63.9% vs 59.3%) between the 2 groups. There was a higher polyp per colonoscopy with CAC compared with CC: 1.68 ± 2.1 vs 1.33 ± 1.8 (incidence rate ratio 1.27; 1.15-1.4; P < 0.01). DISCUSSION: Use of a novel AI detection system showed to a significantly higher number of adenomas per colonoscopy compared with conventional high-definition colonoscopy without any increase in colonoscopy withdrawal time, thus supporting the use of AI-assisted colonoscopy to improve colonoscopy quality ( ClinicalTrials.gov NCT04979962).

A comprehensive phylogenomic study unveils evolutionary patterns and challenges in the mitochondrial genomes of Carcharhiniformes: A focus on Triakidae.

The complex evolutionary patterns in the mitochondrial genome (mitogenome) of the most species-rich shark order, the Carcharhiniformes (ground sharks) has led to challenges in the phylogenomic reconstruction of the families and genera belonging to the order, particularly the family Triakidae (houndsharks). The current state of Triakidae phylogeny remains controversial, with arguments for both monophyly and paraphyly within the family. We hypothesize that this variability is triggered by the selection of different a priori partitioning schemes to account for site and gene heterogeneity within the mitogenome. Here we used an extensive statistical framework to select the a priori partitioning scheme for inference of the mitochondrial phylogenomic relationships within Carcharhiniformes, tested site heterogeneous CAT + GTR + G4 models and incorporated the multi-species coalescent model (MSCM) into our analyses to account for the influence of gene tree discordance on species tree inference. We included five newly assembled houndshark mitogenomes to increase resolution of Triakidae. During the assembly procedure, we uncovered a 714 bp-duplication in the mitogenome of Galeorhinus galeus. Phylogenetic reconstruction confirmed monophyly within Triakidae and the existence of two distinct clades of the expanded Mustelus genus. The latter alludes to potential evolutionary reversal of reproductive mode from placental to aplacental, suggesting that reproductive mode has played a role in the trajectory of adaptive divergence. These new sequences have the potential to contribute to population genomic investigations, species phylogeography delineation, environmental DNA metabarcoding databases and, ultimately, improved conservation strategies for these ecologically and economically important species.

Synchronous Gastrointestinal Carcinoid Tumor and Colon Adenocarcinoma: Case Reports and Literature Review.

BACKGROUND Coexistence of carcinoid tumor and colorectal adenocarcinoma is rare. In this report, we present two cases and review the current literature for synchronous carcinoid tumor and colorectal carcinoma occurrence. CASE REPORT In both cases, the rectal carcinoid tumors and sigmoid colon adenocarcinomas were detected by colonoscopy. The colon adenocarcinomas were effectively treated with a laparoscopic sigmoidectomy and the carcinoids were successfully removed endoscopically. Our 40-year-old patient was the youngest among 17 reported patient cases. CONCLUSIONS These two cases demonstrate that the diagnosis of gastrointestinal carcinoid requires a complete assessment of the remainder of the colon for another primary cancer to achieve a timely treatment management strategy.

Pancreatic Cancer Survival Outcomes at a Tertiary Medical Center Based on Sex and Geographic Location.

OBJECTIVES: To describe the survival outcomes of patients with histologically proven primary pancreatic cancer based on geographic location and sex. METHODS: We conducted a retrospective review of medical records from 2009 through 2013 of patients with pancreatic cancer using International Classification of Diseases, Ninth Revision code 157.9 and International Statistical Classification of Diseases, 10th Revision code C 25.9. The variables extracted included demographics, date of diagnosis, mode of diagnosis, duration, treatment methods, family history, history of chronic pancreatitis, and diabetes mellitus. ZIP codes were used to identify the geographic location of each subject, and rural urban commuting area codes were used to further classify the areas as metropolitan, micropolitan, small town, and rural. Population sizes were classified as metropolitan >50,000, micropolitan 10,000 to 49,999, small town 2500 to 9999, and rural <2500. Descriptive analysis and Kaplan-Meier survival for survival outcomes were performed with statistical significance identified as P < 0.05. RESULTS: A total of 400 medical charts were extracted for review, 301 of which belonged to patients with primary pancreatic cancer. Of the 301 cases, we identified 175 men (58%), 125 women (41%), and 1 missing sex data. There were 280 whites (95%), 8 African Americans (2%), 2 Asian Americans (0.64%), 1 Hispanic American (0.34%) and 1 Native American (0.34%), with a mean age of 63.2 ± 12.6 years. Based on geography, there were 34%, 27%, 20%, and 19% in rural areas, metropolitans, small towns, and micropolitans, respectively. No statistically significant difference was noted in sex on survival outcomes (P = 0.85) or geography (P = 0.62). Additional analysis revealed no statistical significant difference between sexes when stratifying by location (P = 0.96). CONCLUSIONS: There is no difference in survival outcomes of patients with primary pancreatic cancer based on sex or geographic location. Our survival outcomes differ from the national survival outcomes, which reveal that mortality in men is higher than it is in women.

Culprit for recurrent acute gastrointestinal massive bleeding: "Small bowel Dieulafoy's lesions" - a case report and literature review.

A Dieulafoy's lesion is a dilated, aberrant, submucosal vessel that erodes the overlying epithelium without evidence of a primary ulcer or erosion. It can be located anywhere in the gastrointestinal tract. We describe a case of massive gastrointestinal bleeding from Dieulafoy's lesions in the duodenum. Etiology and precipitating events of a Dieulafoy's lesion are not well known. Bleeding can range from being self-limited to massive life- threatening. Endoscopic hemostasis can be achieved with a combination of therapeutic modalities. The endoscopic management includes sclerosant injection, heater probe, laser therapy, electrocautery, cyanoacrylate glue, banding, and clipping. Endoscopic tattooing can be helpful to locate the lesion for further endoscopic re-treatment or intraoperative wedge resection. Therapeutic options for re-bleeding lesions comprise of repeated endoscopic hemostasis, angiographic embolization or surgical wedge resection of the lesions. We present a 63-year-old Caucasian male with active bleeding from the two small bowel Dieulafoy's lesions, which was successfully controlled with epinephrine injection and clip applications.

Effect of precut sphincterotomy on post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and meta-analysis.

AIM: To conduct a systemic review and meta-analysis to investigate the role of early precut technique. Multiple randomized controlled trails (RCTs) have reported conflicting results of the early precut sphincterotomy. METHODS: MEDLINE/PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, and recent abstracts from major conference proceedings were searched (June 2013). Randomized and non-randomized studies comparing early precut technique with prolonged standard methods were included. Pooled estimates of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), cannulation and adverse events were analyzed by using odds ratio (OR). Random and fixed effects models were used as appropriate. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I² measure of inconsistency. RESULTS: Seven randomized and seven non-randomized trials met inclusion criteria. Meta-analysis of RCTs showed a decrease trend for PEP with early precut sphincterotomy but was not statistically significant (OR = 0.58; 95%CI: 0.32-1.05; P = 0.07). No heterogeneity was noted among the studies with I² of 0%. CONCLUSION: Early precut technique for common bile duct cannulation decreases the trend of post-ERCP pancreatitis.

Improving Maintenance Medication Adherence in Adult Inflammatory Bowel Disease Patients: A Pilot Study.

Medication nonadherence in inflammatory bowel disease (IBD) may lead to suboptimal control of the disease, decreased quality of life, and poor outcomes. This pilot study evaluated the feasibility, intervention mechanism, and potential effectiveness of a three-month continuous self-improvement (CSI) intervention to enhance medication adherence (MA) in adult nonadherent IBD patients. Adult IBD patients taking a daily or twice-daily dosed maintenance medication were screened electronically for two months to determine baseline MA levels. Nonadherent IBD participants were randomized to the CSI or the attention control (AC) intervention and monitored for three months. The CSI intervention consisted of a data evaluation and system refinement process in which system changes were identified and implemented. The AC group was given educational information regarding IBD disease process, extra-intestinal manifestations of IBD, and medical therapy. Demographic statistics, change scores for within and between-group differences, and effect size estimates were calculated. Nine nonadherent participants (medication adherence score <0.85) were eligible for randomization. The intervention was found feasible and acceptable. Although no statistically significant improvement in MA was found (P=0.14), adherence improved in 3 of 4 of the CSI group and 1 of 2 in the attention control group. The effect size calculation of 1.9 will determine the sample size for future study. The results of this pilot study showed the intervention was feasible and had a positive effect on MA change score and adherence levels. A larger fully powered study is needed to test of the effectiveness of this innovative intervention.