Stability of increased adenoma detection at colonoscopy. Follow-up of an endoscopic quality improvement program-EQUIP-II.

OBJECTIVES: We recently completed a randomized controlled trial of an endoscopic quality improvement program (EQUIP) that demonstrated an improved adenoma detection rate (ADR) through simple educational interventions. The aim of this study (phase III) is to examine whether the improvement in ADR in the trained endoscopists remained stable with further follow-up. METHODS: We prospectively followed up 15 staff endoscopists who had previously been randomized to a quality improvement intervention. In the current study, we examined an additional 1,200 colonoscopy procedures conducted over a 5-month time period following the original study, referred to as phase III. During this time, all physicians received quarterly ADR and other quality metric feedback, and the previous control group was offered the educational intervention voluntarily. ADRs and adenoma per patient (APP) rates were estimated in the endoscopists who were and were not randomized to EQUIP training and compared with those obtained in phases I and II of the original study. The study was conducted in a tertiary care Academic Medical Center. The study sample comprised 1200 patients undergoing routine colonoscopy. The main outcome measurement was adenoma detection rate. RESULTS: The previously observed increase in ADR in the trained group from 36% in phase I to 47% in phase II was maintained into phase III (46%). The ADR of the untrained group remained unchanged from phase I (36%) to phase II (35%); it was increased only marginally in phase III to 39%, which was still lower than the 46% ADR in the trained group. The trained group had an increase in APP, from 0.72 in Phase I to 0.87 in Phase II and 0.98 in Phase III. For the previously untrained group, there was no change in APP from phase I (0.68) to phase II (0.68), but there was possibly a small increase (to 0.74) in Phase III. CONCLUSIONS: This study provides evidence that improvements in ADR obtained through the endoscopic quality-training program can persist for at least 5 months after completion of the program. It further suggests that a focus on ADR does not lead to a "one and done" phenomenon. The limitations of this study were as follows: single-center setting, and lack of sessile polyp information/standardization.

A rare case of neck pain: acute longus colli calcific tendinitis in a possibly immunocompromised individual.

We present a rare case of severe neck pain in a 45-year-old man with severe hidradenitis suppurativa who was participating in a study involving adalimumab. The neck pain was associated with acute longus colli calcific tendinitis, which is a noninfectious inflammatory response in the longus colli tendons secondary to deposition of calcium hydroxyapatite crystal. The diagnosis was made by computed tomography, which showed calcifications and deposits, and magnetic resonance imaging, which showed a retropharyngeal effusion. Ears, Nose, and Throat Services performed a fiberoptic scope examination, which revealed a patent airway and no drainable abscess. Nonsteroidal anti-inflammatory drugs resulted in a dramatic improvement in the patient's clinical symptoms. In acute longus colli tendinitis, differentiating retropharyngeal aseptic effusion from infection is important. Of note, the confounding factor in this case was that the patient was blinded to whether he was receiving the placebo or adalimumab, so whether the patient was immunosuppressed and at risk for infection was unknown. Clinician familiarity and education concerning acute calcific longus colli tendinitis may lead to decreased costs stemming from incorrect diagnosis and unnecessary treatment.

Predictors of esophageal stricture formation post endoscopic mucosal resection.

BACKGROUND/AIMS: Stricture formation is a common complication after endoscopic mucosal resection. Predictors of stricture formation have not been well studied. METHODS: We conducted a retrospective, observational, descriptive study by using a prospective endoscopic mucosal resection database in a tertiary referral center. For each patient, we extracted the age, sex, lesion size, use of ablative therapy, and detection of esophageal strictures. The primary outcome was the presence of esophageal stricture at follow-up. Multivariate logistic regression was used to analyze the association between the primary outcome and predictors. RESULTS: Of 136 patients, 27% (n=37) had esophageal strictures. Thirty-two percent (n=44) needed endoscopic dilation to relieve dysphagia (median, 2; range, 1 to 8). Multivariate logistic regression analysis showed that the size of the lesion excised is associated with increased odds of having a stricture (odds ratio, 1.6; 95% confidence interval, 1.1 to 2.3; p=0.01), when controlling for age, sex, and ablative modalities. Similarly, the number of lesions removed in the index procedure was associated with increased odds of developing a stricture (odds ratio, 2.3; 95% confidence interval, 1.3 to 4.2; p=0.007). CONCLUSIONS: Stricture formation after esophageal endoscopic mucosal resection is common. Risk factors for stricture formation include large mucosal resections and the resection of multiple lesions on the initial procedure.

Survival in esophageal high-grade dysplasia/adenocarcinoma post endoscopic resection.

BACKGROUND: Endoscopic resection followed by ablative therapy is frequently used to treat esophageal high-grade dysplasia or early esophageal adenocarcinoma. AIMS: To study outcomes in patients with high-grade dysplasia compared to those with esophageal adenocarcinoma after endoscopic resection. METHODS: Retrospective, observational, descriptive, single-centre study from a prospective database. We extracted data from 116 endoscopic resections. Survival was plotted using Kaplan-Meier curves multivariable Cox-proportional hazard assess for possible predictors of survival post-endoscopic resection was performed. RESULTS: 116 patients (64 esophageal adenocarcinoma, 52 high-grade dysplasia) underwent endoscopic resection from May 2003 to June 2010. Mean age was 71 ± 11 years for high-grade dysplasia and 72 ± 10 years for esophageal adenocarcinoma. Median follow-up was 17 months. Eighty-five patients had negative margins on endoscopic resection. Five-year survivals for high-grade dysplasia and esophageal adenocarcinoma were 86% (range 68-100%) and 78% (59-96%), respectively. Survival was not significantly different between groups (p=0.20). Overall mortality rate was 10.6% (9/85). At multivariable Cox regression increased Barrett's oesophagus length was associated with worse survival (HR 1.18 [1.06-1.33], p=0.0039). Survival was not affected by the pathology before resection: HR 2.4 [95%CI, 0.70-8.4], p=0.16. CONCLUSIONS: Survival in patients with high-grade dysplasia of the oesophagus is similar to those with esophageal adenocarcinoma. Longer Barrett's oesophagus segments are associated with decreased survival.