Impact of a computer-based teaching module on characterization of diminutive colon polyps by using narrow-band imaging by non-experts in academic and community practice: a video-based study.

BACKGROUND: Experts can accurately characterize the histology of diminutive polyps with narrow-band imaging (NBI). There are limited data on the performance of non-experts. OBJECTIVE: To assess the impact of a computer-based teaching module on the accuracy of predicting polyp histology with NBI by non-experts (in academics and community practice) by using video clips. DESIGN: Prospective, observational study. SETTING: Academic and community practice. PARTICIPANTS: A total of 15 gastroenterologists participated-5 experts in NBI, 5 non-experts in academic practice, and 5 non-experts in community practice. INTERVENTION: Participants reviewed a 20-minute, computer-based teaching module outlining the different NBI features for hyperplastic and adenomatous polyps. MAIN OUTCOME MEASUREMENTS: Performance characteristics in characterizing the histology of diminutive polyps with NBI by using short video clips before (pretest) and after (posttest) reviewing the teaching module. RESULTS: Non-experts in academic practice showed a significant improvement in the sensitivity (54% vs 79%; P < .001), accuracy (64% vs 81%; P < .001), and proportion of high-confidence diagnoses (49% vs 69%; P < .001) in the posttest. Non-experts in community practice had significantly higher sensitivity (58% vs 75%; P = .004), specificity (76% vs 90%; P = .04), accuracy (64% vs 81%; P < .001), and proportion of high-confidence diagnoses (49% vs 72%; P < .001) in the posttest. Performance of experts in NBI was significantly better than non-experts in both academic and community practice. LIMITATIONS: Selection bias in selecting good quality videos. Performance not assessed during live colonoscopy. CONCLUSION: Academic and community gastroenterologists without prior experience in NBI can achieve significant improvements in characterizing diminutive polyp histology after a brief computer-based training. The durability of these results and applicability in everyday practice are uncertain.

Defining patients at high risk for gastrointestinal hemorrhage after drug-eluting stent placement: a cost utility analysis.

INTRODUCTION: The study goal was to evaluate the cost-effectiveness of drug-eluting stent (DES) placement with consideration of gastrointestinal (GI) bleeding risk. DES reduce the need for future coronary revascularization, but require prolonged dual anti-platelet (DAT) therapy, which may increase the risk for GI bleeding. While DES have been found to be cost-effective in patients at average risk for GI bleeding, they may not be the most cost-effective strategy in higher risk patients. METHODS: A Markov model was created to compare DES with bare metal stents (BMS). Patients were a hypothetical cohort of 60-year-old individuals with coronary artery stenosis that required nonemergent percutaneous coronary revascularization (PCI). The primary outcomes were the threshold incremental risks of GI bleeding from DAT based on willingness to pay (WTP) of $50,000, $100,000, and $150,000 per quality adjusted life year (QALY) gained. RESULTS: For a WTP of $100,000, the relative risk of GI bleeding from DAT could be as high as 10.8 (when compared to aspirin alone) before DES would no longer be cost-effective. In patients with two risk factors for GI bleeding, the threshold relative risk could be as low as 1.6. CONCLUSION: In average-risk patients, the risk of GI bleeding from DAT can be substantial without affecting the cost-effectiveness of DES. However, DES are unlikely to be cost-effective in patients with two or more risk factors for GI bleeding.

The insensitivity of endoscopic markers in celiac disease.

OBJECTIVES: Celiac disease (CD) is characterized by small intestinal inflammation and mucosal atrophy. Endoscopic markers of villous atrophy are reported to be present in 88-100% of untreated celiac patients. In patients being evaluated for iron deficiency anemia (IDA), we examined whether endoscopic markers could predict histological results consistent with CD. METHODS: One hundred thirteen patients without histories of CD had small bowel biopsies to evaluate IDA using videoendoscopy. Markers suggesting villous atrophy were noted at endoscopy. Biopsy specimens were reviewed for consistency with CD. Endoscopic and histological findings were compared. RESULTS: Seventeen patients were diagnosed with CD, both clinically and histologically. Loss of folds was the most sensitive marker of villous atrophy, present in 47% with CD, with 97% specificity. The mosaic pattern was much less sensitive (12%), with 100% specificity. Nodularity and scalloping had low sensitivities (6%), but specificities of 95% and 100%, respectively. A finding of any endoscopic marker yielded a sensitivity of 59% and specificity of 92% for CD. CONCLUSIONS: Although endoscopic markers have been guides for directing small bowel biopsies in patients suspected of having CD, we found sensitivities of these markers to be low and conclude that they should not be relied upon for detecting CD in patients presenting with IDA.

The usefulness of routine small bowel biopsies in evaluation of iron deficiency anemia.

BACKGROUND: Iron deficiency anemia (IDA) may be the sole manifestation of celiac disease. The role of routine small bowel biopsies obtained during endoscopy in the evaluation of IDA is unclear. This study assessed the usefulness of routine small bowel biopsies in patients presenting with IDA. STUDY: Evaluation of 103 consecutive patients with IDA undergoing panendoscopy with routine small bowel biopsies was performed. All patients had a diagnosis of IDA with either a ferritin less than 15 microg/L or iron saturation less than 8%. Celiac disease was defined as total or partial villous atrophy with intraepithelial lymphocytosis, histologically, and a clinical response to gluten free diet. Gastrointestinal symptoms were recorded. RESULTS: Nine patients (8.7%) were diagnosed with celiac disease. Of these patients, endoscopic lesions potentially responsible for IDA were found in 33%. We found no statistically significant difference when comparing reports of diarrhea, weight loss, abdominal pain, nausea or vomiting, aspirin or NSAID use, or menopausal status with celiac disease status. CONCLUSIONS: Routine small bowel biopsies to evaluate for celiac disease are indicated in the evaluation of patients with IDA. The finding of endoscopic lesions that may otherwise explain IDA should not preclude small bowel biopsy.