Quality Indicators for Capsule Endoscopy and Deep Enteroscopy.

INTRODUCTION: Capsule endoscopy (CE) and deep enteroscopy (DE) can be useful for diagnosing and treating suspected small-bowel disease. Guidelines and detailed recommendations exist for the use of CE/DE, but comprehensive quality indicators are lacking. The goal of this task force was to develop quality indicators for appropriate use of CE/DE by using a modified RAND/UCLA Appropriateness Method. METHODS: An expert panel of 7 gastroenterologists with diverse practice experience was assembled to identify quality indicators. A literature review was conducted to develop a list of proposed quality indicators applicable to preprocedure, intraprocedure, and postprocedure periods. The panelists reviewed the literature; identified and modified proposed quality indicators; rated them on the basis of scientific evidence, validity, and necessity; and determined proposed performance targets. Agreement and consensus with the proposed indicators were verified using the RAND/UCLA Appropriateness Method. RESULTS: The voting procedure to prioritize metrics emphasized selecting measures to improve quality and overall patient care. Panelists rated indicators on the perceived appropriateness and necessity for clinical practice. After voting and discussion, 2 quality indicators ranked as inappropriate or uncertain were excluded. Each quality indicator was categorized by measure type, performance target, and summary of evidence. The task force identified 13 quality indicators for CE and DE. DISCUSSION: Comprehensive quality indicators have not existed for CE or DE. The task force identified quality indicators that can be incorporated into clinical practice. The panel also addressed existing knowledge gaps and posed research questions to better inform future research and quality guidelines for these procedures.

Quality indicators for capsule endoscopy and deep enteroscopy.

BACKGROUND AND AIMS: Capsule endoscopy (CE) and deep enteroscopy (DE) can be useful for diagnosing and treating suspected small-bowel disease. Guidelines and detailed recommendations exist for the use of CE/DE, but comprehensive quality indicators are lacking. The goal of this task force was to develop quality indicators for appropriate use of CE/DE by using a modified RAND/UCLA Appropriateness Method. METHODS: An expert panel of 7 gastroenterologists with diverse practice experience was assembled to identify quality indicators. A literature review was conducted to develop a list of proposed quality indicators applicable to preprocedure, intraprocedure, and postprocedure periods. The panelists reviewed the literature; identified and modified proposed quality indicators; rated them on the basis of scientific evidence, validity, and necessity; and determined proposed performance targets. Agreement and consensus with the proposed indicators were verified using the RAND/UCLA Appropriateness Method. RESULTS: The voting procedure to prioritize metrics emphasized selecting measures to improve quality and overall patient care. Panelists rated indicators on the perceived appropriateness and necessity for clinical practice. After voting and discussion, 2 quality indicators ranked as inappropriate or uncertain were excluded. Each quality indicator was categorized by measure type, performance target, and summary of evidence. The task force identified 13 quality indicators for CE and DE. CONCLUSIONS: Comprehensive quality indicators have not existed for CE or DE. The task force identified quality indicators that can be incorporated into clinical practice. The panel also addressed existing knowledge gaps and posed research questions to better inform future research and quality guidelines for these procedures.

National Implementation of an Electronic Patient-Reported Outcome Measures Program for Joint Replacement Surgery: Pilot Study.

BACKGROUND: There is a global emphasis on expanding data collection for joint replacement procedures beyond implant attributes and progression to revision surgery. Patient-reported outcome measures (PROMs) are increasingly considered as an important measure of surgical outcomes from a patient's perspective. However, a major limitation preventing wider use of PROMs data in national data collection has been the inability to systematically collect and share electronic information with relevant stakeholders in a comprehensive and financially sustainable manner. OBJECTIVE: This study reports on the development of an electronic data capture and reporting system by a national registry for the collection of PROMs and the processes used to identify and overcome barriers to implementation and uptake. The study also aims to provide a cost breakdown of establishing and maintaining a nationwide electronic PROMs program. METHODS: Between 2018 and 2020, 3 governance and advisory committees were established to develop and implement a PROMs pilot program nested within a nationwide joint replacement registry. The program involved electronic collection of preoperative and 6-month postoperative data for hip, knee, or shoulder replacement surgery from 44 Australian hospitals. Resource requirements for the program included a project manager, software developers, data manager, and statistician. An online platform was tested, refined, and implemented for electronic PROMs collection with scalability considered for future expansion to all Australian hospitals and additional data fields. Technical capabilities included different access for multiple user types, patient registration, automatic reminders via SMS text messages and email, online consent, and patient outcome real-time dashboards accessible for different user groups (surgeons, patients, hospitals, and project stakeholders). RESULTS: During the PROMs pilot period there were 19,699 primary procedures undertaken with 10,204 registered procedures in the electronic system. This equated to 51.80% of people who had a joint replacement at participating hospitals during this period. Patient registration and data collection were efficient (20-30 seconds and 10-12 minutes, respectively). Engagement with the reporting dashboards (as a proportion of those who viewed their dashboard) varied by user group: 197/277 (71.1%) hospital administrators, 68/129 (52.7%) project stakeholders, 177/391 (45.3%) surgeons, and 1138/8840 patients (12.9%). Cost analysis determined an overall cost per patient of Aus $7-15 (approximately US $5-12) for 2 PROMs collections per joint replacement procedure once the program was established. CONCLUSIONS: Successful implementation of an orthopedic PROMs program with planned scalability for a broader national rollout requires significant funding and staffing resources. However, this expenditure can be considered worthwhile, given that collection and reporting of PROMs can drive health care improvement processes. Further consideration of strategies to improve stakeholder engagement with electronic reporting dashboards (particularly for patients and surgeons) will be critical to the ongoing success of a national PROMs program.

Skilful precipitation nowcasting using deep generative models of radar.

Precipitation nowcasting, the high-resolution forecasting of precipitation up to two hours ahead, supports the real-world socioeconomic needs of many sectors reliant on weather-dependent decision-making1,2. State-of-the-art operational nowcasting methods typically advect precipitation fields with radar-based wind estimates, and struggle to capture important non-linear events such as convective initiations3,4. Recently introduced deep learning methods use radar to directly predict future rain rates, free of physical constraints5,6. While they accurately predict low-intensity rainfall, their operational utility is limited because their lack of constraints produces blurry nowcasts at longer lead times, yielding poor performance on rarer medium-to-heavy rain events. Here we present a deep generative model for the probabilistic nowcasting of precipitation from radar that addresses these challenges. Using statistical, economic and cognitive measures, we show that our method provides improved forecast quality, forecast consistency and forecast value. Our model produces realistic and spatiotemporally consistent predictions over regions up to 1,536 km × 1,280 km and with lead times from 5-90 min ahead. Using a systematic evaluation by more than 50 expert meteorologists, we show that our generative model ranked first for its accuracy and usefulness in 89% of cases against two competitive methods. When verified quantitatively, these nowcasts are skillful without resorting to blurring. We show that generative nowcasting can provide probabilistic predictions that improve forecast value and support operational utility, and at resolutions and lead times where alternative methods struggle.

Role of non-coding RNAs in tumor progression and metastasis in pancreatic cancer.

Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal types of cancer with an overall 5-year survival rate of less than 10%. The 1-year survival rate of patients with locally advanced or metastatic disease is abysmal. The aggressive nature of cancer cells, hypovascularization, extensive desmoplastic stroma, and immunosuppressive tumor microenvironment (TME) endows PDAC tumors with multiple mechanisms of drug resistance. With no obvious genetic mutation(s) driving tumor progression or metastatic transition, the challenges for understanding the biological mechanism(s) of these processes are paramount. A better understanding of the molecular and cellular mechanisms of these processes could lead to new diagnostic tools for patient management and new targets for therapeutic intervention. microRNAs (miRNAs) are an evolutionarily conserved gene class of short non-coding regulatory RNAs. miRNAs are an extensive regulatory layer that controls gene expression at the posttranscriptional level. This review focuses on preclinical models that functionally dissect miRNA activity in tumor progression or metastatic processes in PDAC. Collectively, these studies suggest an influence of miRNAs and RNA-RNA networks in the processes of epithelial to mesenchymal cell transition and cancer cell stemness. At a cell-type level, some miRNAs mainly influence cancer cell-intrinsic processes and pathways, whereas other miRNAs predominantly act in distinct cellular compartments of the TME to regulate fibroblast and immune cell functions and/or influence other cell types' function via cell-to-cell communications by transfer of extracellular vesicles. At a molecular level, the influence of miRNA-mediated regulation often converges in core signaling pathways, including TGF-ß, JAK/STAT, PI3K/AKT, and NF-κB.

Review of Duodenoscope Infection Prevention Practices at the Medical University of South Carolina.

A rise in duodenoscope-associated infections, especially in regard to multidrug-resistant organisms, has led to an increase in scrutiny regarding duodenoscope reprocessing. Endoscopic retrograde cholangiopancreatography scopes have a specialized elevator wire channel, allowing more flexible duct cannulation; however, this channel can be difficult to reprocess with standard techniques. Although strict adherence to manufacturer reprocessing protocols remains the primary means of infection prevention, periodic microbiological surveillance is a Food and Drug Administration-recommended practice that the Medical University of South Carolina has implemented to further prevent duodenoscope-associated infections. The Medical University of South Carolina obtains 2 separate cultures from 2 duodenoscopes every 2 months, which undergo standard speciation and sensitivity and are returned to use once negative at 48 hours. The initial results of the Medical University of South Carolina's surveillance cultures are negative for any multidrug-resistant organisms; however, other centers should consider implementing surveillance cultures into their reprocessing practices and closely monitoring for future endoscope infection prevention modalities.

Multimodal intervention for avoiding inappropriate cessation of aspirin prior to outpatient endoscopy.

Background and study aims Existing guidelines recommend continuation of aspirin therapy prior to outpatient endoscopic procedures, as it reduces peri-procedural cardiovascular events and is not associated with an increased risk of bleeding. Despite this, many patients at our institution inappropriately alter their aspirin prior to endoscopy. We sought to identify why this occurs and implement an intervention that could reduce improper aspirin alteration. Patients and methods All adult patients undergoing outpatient endoscopy at the Medical University of South Carolina were administered a survey querying demographics, aspirin use, endoscopic procedure, thromboembolic risk factors, and pre-procedural aspirin alteration, if any. An intervention involving revised written and verbal instructions as well as an automated voicemail aimed at ensuring patients adhere to guidelines was then undertaken. The same survey was administered after the intervention to assess for improved adherence. Results A total of 240 patients from the initial survey reported daily aspirin use, of which 114 (47.5 %) inappropriately altered aspirin therapy. A total of 182 patients from the post-intervention survey reported daily aspirin use, of which 66 (36.3 %) inappropriately altered aspirin therapy. This was a statistically significant reduction ( P  = 0.04), which included adjustments for age, sex, procedure type, and thromboembolic risk. Conclusions A high proportion of patients at our institution inappropriately alter aspirin therapy prior to outpatient endoscopy. The reasons for this behavior include patient self-direction, misguidance from staff, and instruction from other physicians. This alteration can be reduced significantly through an intervention that educates both patients and staff on continuation of aspirin therapy prior to outpatient endoscopy.

The cellular antioxidant and anti-glycation capacities of phenolics from Georgia peaches.

Plant-based polyphenolics have been reported to bestow health benefits when consumed, which are partially ascribed to their antioxidant activity. Yet, many current in vitro chemical assays to characterize antioxidant potential do not truly reflect the physiological properties of food antioxidants in vivo. The present study employed biological approaches, including a cellular antioxidant activity (CAA) and protein glycation assays, to offer an improved picture of antioxidant potential of phenolic extracts from Georgia peach cultivars. The phenolic extracts from two peach varieties, showing contrasting antioxidant capacities according to hydrophilic-oxygen radical absorbance capacity (H-ORACFL) and ferric reducing antioxidant power (FRAP) assays, exhibited significant differences in two biological tests when the assays were performed on a fresh weight basis. The procyanidins fraction displayed notable antioxidant capacity, when compared to other phenolic classes in the peach extract, in these two biologically relevant assays.

Sporadic Fundic Gland Polyps and Gastric Acid Suppression Level.

BACKGROUND: Fundic gland polyps (FGPs) are a common endoscopic finding and are known to be associated with proton pump inhibitors (PPIs) use. It is not known if their prevalence is affected by gastric acidity levels. This study aimed to assess whether there is a correlation between FGPs and gastric acidity levels as identified on 24-hour ambulatory impedance-pH studies in patients on PPI therapy. METHODS: We performed a review of 402 consecutive patients who take at least once daily PPI and underwent esophagogastroduodenoscopy with combined impedance-pH studies in the same setting (time and place) between January 2010 and December 2014. Patients were classified into 2 groups based on the presence or absence of biopsy-confirmed FGPs during endoscopy. RESULTS: Of the 402 patients, 30 (7%) had FGPs. One of these polyps was found with low-grade dysplasia. There was no significant difference of the distributions of the [H+] in the FGPs versus the nonpolyp groups (P = 0.741). There was no significant difference between the 2 groups regarding PPI dose frequency regimens (once and twice) (P = 0.074). However, we found weak ordinal association with PPI duration (P = 0.01) (Spearman = 0.1). CONCLUSIONS: FGPs are common endoscopic lesions. Incidence of dysplasia in FGPs is not only rare, but also of unknown clinical significance. Although they seem to be associated with PPIs, the mechanism remains unclear, as we found no correlation between the presence of FGPs and gastric acid control or PPI dose. Future studies would be useful to elucidate an alternate mechanism.

Success of Percutaneous Endoscopic Gastrostomy by Single Balloon Enteroscopy in Patients Who Have Undergone Roux-en-Y Gastric Bypass.

Data is limited regarding the success and safety of percutaneous endoscopic gastrostomy (PEG) placements by single balloon enteroscopy (SBE) in patients with Roux-en-Y gastric bypass (RNY-GB) anatomy. We report on 23 cases of PEG placements by SBE with overall technical success of reaching the excluded stomach 70% and with PEG placement success rate of 69%. No intra-procedural adverse events occurred. This technique seems safe when feasible for PEG placement in patients with RNY-GB anatomy.

Over-the-scope clip for endoscopic closure of gastrogastric fistulae.

BACKGROUND: Gastrogastric fistulae (GGF) are a well-known complication of Roux-en-Y gastric bypass (RYGB). Endoscopic approaches for closure of GGF have gained popularity, but with limited data and efficacy. OBJECTIVES: The primary arm of the study was to evaluate the safety and efficacy of the endoscopic closure of GGF using the over-the-scope clip (OTSC) device. SETTING: University hospital, United States METHODS: This is a retrospective review of consecutive patients at a single academic center from September 2013 to December 2014 who underwent upper endoscopy with attempted OTSC placement for closure of GGF related to RYGB. Preprocedural, procedural, and postprocedural data were collected. Outcome measures included technical success, primary success, and long-term success. RESULTS: A total of 14 patients underwent attempted GGF closure using OTSC. Twelve of the 14 patients (85.7%) had technical success. Four patients were lost to follow-up. Primary success was achieved in 5 of the 10 patients (50%) in which it was assessed, either by upper gastrointestinal series or endoscopy. One of the 5 patients who had primary success was then lost to follow-up. Of the 4 patients in whom primary success was achieved and had long-term follow up, 75% (n = 3) achieved long-term success at a mean follow-up of 6.6 months from initial OTSC placement (range, 3-9), making for a long-term success rate of 33% (3/9). There were no reported complications. CONCLUSION: OTSC closure of small GGF is feasible, safe, and offers a reasonable alternative to surgical revision. Large GGF may undergo attempted endoscopic closure, acknowledging a high failure rate.

Cap-assisted retrograde single-balloon enteroscopy results in high terminal ileal intubation rate.

BACKGROUND AND STUDY AIMS: Retrograde single-balloon enteroscopy (RSBE) facilitates evaluation of the distal small bowel and provision of appropriate therapy when necessary. Intubation of the terminal ileum (TI) is a major rate-limiting step, with failure rates as high as 30 %. Cap-assisted endoscopy has proven beneficial in other aspects of endoscopy. We have noticed that it similarly aids in TI intubation during RSBE by facilitating opening of the ileocecal valve (ICV). The primary aim of this study was to measure the TI intubation rate using cap-assisted RSBE. Other procedural details and outcomes were also measured. PATIENTS AND METHODS: A total of 36 consecutive RSBEs performed between July 2011 and May 2014 at the Medical University of South Carolina were retrospectively reviewed. All procedures were performed or supervised by our center's small bowel endoscopist (ASB). Outcomes measured included TI intubation rate, procedure time, depth of maximal insertion (DMI), diagnostic yield (DY), therapeutic yield (TY), and complications. RESULTS: The TI intubation rate was 97 % (35 /36). The one failure was due to stool completely obscuring the cecum. Median procedure time was 54 minutes, with a mean DMI of 68 cm beyond the ICV. The technical success rate was 86 %, whereas DY and TY were 61 % and 25 %, respectively. There were no complications. The study was limited in that it involved a single endoscopist at a single center. CONCLUSIONS: Cap-assisted RSBE results in a high TI intubation rate, without compromise to safety or procedural yield.

Open-Access Single Balloon Enteroscopy: A Tertiary Care Experience.

OBJECTIVES: To compare single balloon enteroscopy (SBE) between patients seen in consultation by a member of our gastroenterology team with those performed as open-access cases. METHODS: Retrospective study of all patients who underwent SBE at a single tertiary care center from April 2008 to January 2012. Open- and closed-access procedures were compared in terms of diagnostic and therapeutic yield, adverse events, and procedural success. RESULTS: A total of 125 SBEs were performed on 125 patients. The mean age was 63.1 (53% men) years. In all, 43 procedures were performed open access and 82 after face-to-face consultation. Indications included anemia/gastrointestinal bleeding (110), abdominal pain (8), and other (7). Diagnostic yield for open- and closed-access procedures was 53% and 60%, respectively (P = 0.501) and therapeutic yield was 37% and 52%, respectively (P = 0.11). Overall technical success was 91% with no difference between the groups (P = 0.27). There were no major adverse events in either group. CONCLUSIONS: SBE can be performed as an open-access procedure without compromise to safety or diagnostic yield.

Mechanical Hemostasis Techniques in Nonvariceal Upper Gastrointestinal Bleeding.

One of the most important advances in gastroenterology has been the use of endoscopic hemostasis techniques to control nonvariceal upper gastrointestinal bleeding, particularly when high-risk stigmata are present. Several options are available, including injection therapy, sprays/topical agents, electrocautery, and mechanical methods. The method chosen depends on the nature of the lesion and experience of the endoscopist. This article reviews the available mechanical hemostatic modalities.

Success of single-balloon enteroscopy in patients with surgically altered anatomy.

BACKGROUND: Single-balloon enteroscopy (SBE) was introduced in 2007 to diagnose and treat small-bowel disorders. No study to date has evaluated SBE in patients with surgically altered anatomy outside of ERCP. OBJECTIVE: To evaluate the efficacy, yield, and safety of SBE in patients with surgically altered anatomy. DESIGN: Retrospective study. SETTING: Tertiary-care academic medical center. PATIENTS: All patients with altered surgical anatomy who underwent SBE at the Medical University of South Carolina from July 2007 to September 2013. INTERVENTIONS: SBE. MAIN OUTCOME MEASUREMENTS: Diagnostic yield, therapeutic yield, technical success, and adverse events. RESULTS: A total of 48 patients met inclusion criteria. Mean age was 56 years (77% female). Eleven patients underwent single-balloon PEG placement, 8 single-balloon ERCP, 22 non-PEG/non-ERCP anterograde SBE, and 7 retrograde SBE. Previous surgeries included Roux-en-Y gastric bypass (n=26), small-intestine resection (n=6), colon resection (n=5), Whipple procedure (n=4), choledochojejunostomy (n=3), hepaticojejunostomy (n=1), Billroth I (n=1), Billroth II (n=1), and Puestow procedure (n=1). Procedural indications were PEG tube placement (n=11), choledocholithiasis (n=2), biliary stricture (n=2), obstructive jaundice (n=1), cholangitis (n=1), ampullary mass (n=1), sphincter of Oddi dysfunction (n=1), anemia and/or bleeding (n=15), abdominal pain (n=9), radiologic evidence of obstruction (n=3), and Peutz-Jeghers syndrome (n=2). The technical success rate was 73% in single-balloon PEG placement, 88% in single-balloon ERCP, 82% in other anterograde SBEs, and 86% in retrograde SBEs. No intraprocedural or postprocedural adverse events were observed. LIMITATIONS: Single center, retrospective study. CONCLUSION: SBE is safe and effective in patients with surgically altered anatomy.