The environmental impact of small-bowel capsule endoscopy.

INTRODUCTION: The environmental impact of endoscopy, including small-bowel capsule endoscopy (SBCE), is a topic of growing attention and concern. This study aimed to evaluate the greenhouse gas (GHG) emissions (kgCO2) generated by an SBCE procedure. METHODS: Life cycle assessment methodology (ISO 14040) was used to evaluate three brands of SBCE device and included emissions generated by patient travel, bowel preparation, capsule examination, and video recording. A survey of 87 physicians and 120 patients was conducted to obtain data on travel, activities undertaken during the procedure, and awareness of environmental impacts. RESULTS: The capsule itself (4 g) accounted for < 6 % of the total product weight. Packaging (43-119 g) accounted for 9 %-97 % of total weight, and included deactivation magnets (5 g [4 %-6 %]) and paper instructions (11-50 g [up to 40 %]). A full SBCE procedure generated approximately 20 kgCO2, with 0.04 kgCO2 (0.2 %) attributable to the capsule itself and 18 kgCO2 (94.7 %) generated by patient travel. Capsule retrieval using a dedicated device would add 0.98 kgCO2 to the carbon footprint. Capsule deconstruction revealed materials (e. g. neodymium) that are prohibited from environmental disposal; 76 % of patients were not aware of the illegal nature of capsule disposal via wastewater, and 63 % would have been willing to retrieve it. The carbon impact of data storage and capsule reading was negligible. CONCLUSION: The carbon footprint of SBCE is mainly determined by patient travel. The capsule device itself has a relatively low carbon footprint. Given that disposal of capsule components via wastewater is illegal, retrieval of the capsule is necessary but would likely be associated with an increase in device-related emissions.

Cardiac sarcoidosis with extensive and heterogeneous left ventricular FDG uptake in absence of guidelines indication for an implantable defibrillator: Ventricular tachycardia precipitated by immunosuppressive therapy, should we have done differently?

A 40-year-old man, newly diagnosed with cardiac sarcoidosis (CS) presented with symptomatic ventricular tachycardia three days after starting steroid-based immunosuppressive therapy (IT). There was no clear guideline indication for implantable cardioverter-defibrillator (ICD) before the initiation of IT. Shortly after ICD implantation and the initiation of anti-arrhythmic drugs, recurring ventricular arrhythmias required titration of the anti-arrhythmic drug therapy. One-year follow-up assessment showed no significant arrhythmias and complete PET scan FDG uptake suppression. This case, along with recent publications, suggests transient pro-arrhythmic effects of steroids in patients with CS, which are not appropriately addressed in the current guidelines. We believe ICD implantation should be considered in clinically manifest CS before initiating IT, particularly in cases with heterogeneous and/or extensive FDG uptake on PET scans.

How often do both core competencies of shared decision making occur in family medicine teaching clinics?

OBJECTIVE: To assess how often risk communication and values clarification occur in routine family medicine practice and to explore factors associated with their occurrence. DESIGN: Qualitative and quantitative cross-sectional study. SETTING: Five university-affiliated family medicine teaching clinics across Quebec. PARTICIPANTS: Seventy-one health professionals (55% physicians, 35% residents, 10% nurses or dietitians) and 238 patients (76% women; age range 16 to 82 years old). MAIN OUTCOME MEASURES: The presence or absence of risk communication and values clarification during visits in which decisions were made was determined. Factors associated with the primary outcome (both competencies together) were identified. The OPTION5 (observing patient involvement in decision making) instrument was used to validate the dichotomous outcome. RESULTS: The presence of risk communication and values clarification during visits was associated with OPTION5 scores (area under the curve of 0.80, 95% CI 0.75 to 0.86, P < .001). Both core competencies of shared decision making occurred in 150 of 238 (63%) visits (95% CI 54% to 70%). Such an occurrence was more likely when the visit included discussion about beginning something new, treatment options, or postponing a decision, as well as when health professionals preferred a collaborative decision-making style and when the visit included more decisions or was longer. Alone, risk communication occurred in 203 of 238 (85%) visits (95% CI 82% to 96%) and values clarification in 162 of 238 (68%) visits (95% CI 61% to 75%). CONCLUSION: Health professionals in family medicine are making an effort to engage patients in shared decision making in routine daily practice, especially when there is time to do so. The greatest potential for improvement might lie in values clarification; that is, discussing what matters to patients and families.

Multicenter prospective evaluation of the express view reading mode for small-bowel capsule endoscopy studies.

BACKGROUND: Reducing the reading time of capsule endoscopy films is of high priority for gastroenterologists. We report a prospective multicenter evaluation of an "express view" reading mode (Intromedic capsule system). METHODS: Eighty-three patients with obscure gastrointestinal bleeding were prospectively included in 10 centers. All patients underwent small-bowel capsule endoscopy (Intromedic, Seoul, Republic of Korea). Films were read in standard mode, then a second reading was performed in express view mode at a second center. For each lesion, the precise location, nature, and relevance were collected. A consensus reading and review were done by three experts, and considered to be the gold standard. RESULTS: The mean reading time of capsule films was 39.7 minutes (11 - 180 minutes) and 19.7 minutes (4 - 40 minutes) by standard and express view mode, respectively ( P  < 1 × 10  - 4 ). The consensus review identified a significant lesion in 44/83 patients (53.0 %). Standard reading and express view reading had a 93.3 % and 82.2 % sensitivity, respectively (NS). Consensus review identified 70 significant images from which standard reading and express view reading detected 58 (82.9 %) and 55 (78.6 %), respectively. The informatics algorithm detected 66/70 images (94.3 %) thus missing four small-bowel angiodysplasia. CONCLUSION: The express view algorithm allows an important shortening of Intromedic capsule film reading time with a high sensitivity.

Prospective randomized comparison between axial- and lateral-viewing capsule endoscopy systems in patients with obscure digestive bleeding.

BACKGROUND AND STUDY AIM: Video capsule endoscopy (VCE) is recommended as the first exploration in obscure digestive bleeding. The efficiency of the PillCam SB2 (Given Imaging) has been widely reported. The CapsoCam capsule (Capsovision) has four cameras allowing the exploration of the small bowel through 360° lateral viewing. This system does not include a recording system so the capsule has to be retrieved by the patient after expulsion in order for the film to be downloaded. The aim of this study was to evaluate diagnostic concordance (kappa value) of the PillCam SB2 and CapsoCam capsules in the same patients. METHODS: This was a prospective comparative study in four French referral endoscopy units. Consecutive patients ingested the two capsules 1 hour apart and in a randomized order. RESULTS: In the 73 included patients there were 13 technical issues (11 CapsoCam, 2 PillCam SB2). Of the 60 patients with analyzable data, and following expert review of all discordant cases, a concordant positive diagnosis was obtained in 23 (38.3 %) and a negative diagnosis was obtained and 26 patients (43.3 %). Concordance was good, with a kappa value of 0.63 in analyzable patients, and 46.7 % diagnosis with CapsoCam vs. 48.3 % with PillCam SB2. CapsoCam and PillCam SB2 procedures identified 81.8 % (27 /33) and 84.8 % (28 /33) of positive patients, respectively (P = 0.791). In a per lesion analysis, the CapsoCam capsule detected significantly more lesions (108 vs. 85 lesions; P = 0.001). Reading time was longer for CapsoCam procedures (32.0 vs. 26.2 minutes; P = 0.002). CONCLUSION: This study shows comparable efficiency of the CapsoCam and PillCam SB2 capsule systems in terms of diagnostic yield and image quality.

Prospective, randomized comparison of two small-bowel capsule endoscopy systems in patients with obscure GI bleeding.

BACKGROUND: Video capsule endoscopy is the first-intention examination in patients with obscure GI bleeding. The new MiroCam capsule, when using electric-field propagation for transmission, has been poorly evaluated in a clinical setting, in contrast with the PillCam SB2 capsule. OBJECTIVE: To evaluate the diagnostic concordance (κ value) between PillCam SB2 and MiroCam capsule examinations performed in the same patients. DESIGN AND SETTING: Prospective, randomized study in 7 endoscopy units. PATIENTS AND INTERVENTION: Eighty-three consecutive patients, ingesting the 2 capsules at a 1-hour interval. RESULTS: Seventy-three patients were analyzed (10 technical issues). There were 31 concordant negative cases (42.4%) and 30 concordant positive cases (41.1%). The study showed satisfactory diagnostic concordance between the 2 systems (κ = 0.66). In 12 patients (16.4%), the final diagnosis was different: 9 patients had positive findings on MiroCam examination but no image detected with PillCam SB2, 2 had positive findings on PillCam examination only, and 1 patient had 2 different diagnoses. A positive diagnosis was obtained in 46.6% and 56.2% of patients with PillCam SB2 and MiroCam capsule, respectively, so that the procedures identified 78.6% and 95.2% of positive cases, respectively (P = .02). Small-bowel transit time and capsule reading time were significantly longer in MiroCam procedures. LIMITATIONS: Technical failures possibly related to capsule interference. CONCLUSION: This study shows at least comparable efficiency of the MiroCam compared with the PillCam SB2 capsule system for the diagnosis of obscure GI bleeding.

Capsule endoscopy and bowel preparation with oral sodium phosphate: a prospective randomized controlled trial.

BACKGROUND: Capsule endoscopy (CE) is the first procedure to explore the small bowel in obscure GI bleeding (OGB). OBJECTIVE: To evaluate the role of bowel preparation with oral sodium phosphate (NaP) in this indication. DESIGN: A prospective multicenter, controlled, randomized, blind study. METHODS: A total of 129 patients with the diagnosis of OGB were included and were randomized into 2 groups (group A [n = 64] and group B [n = 63]). In group A, a CE was performed after an 8-hour fasting period. In group B, patients were asked to drink 2 doses of 45 mL NaP before swallowing the capsule. The quality of the images was assessed at 5 different locations of the small bowel. Bowel cleanliness and visibility were evaluated by using 2 scoring systems, which included assessing the presence of bubbles, liquid, and the rate of visibility. RESULTS: A total of 127 patients (53 men; mean age 56.9 years, range 19-90 years) were analyzed for the preparation and detection of lesions (2 patients were not able to swallow the capsule). No difference was observed for cleanliness and visibility between the 2 groups at any of the small-bowel segments; no difference was found for gastric transit time (39.8 minutes vs 35.7 minutes, P = .63), small-bowel transit time (257.5 minutes vs 248.6 minutes, P = .59), and the detection of lesions (35.9% vs 42.8%, P = .54). LIMITATIONS: The evaluation of bowel cleanliness was based on subjective features. CONCLUSIONS: The results of the present study, despite a significant number of limitations, did not support that small-bowel preparation with oral NaP can be recommended for CE exploration in patients with OGB.