Screening colonoscopy and detection of neoplasia in asymptomatic, average-risk, solid organ transplant recipients: case-control study.

The aim of this study was to evaluate the detection of colonic neoplasia in an average-risk population of SOT recipients. Studies regarding colonic neoplasia in solid organ transplantation (SOT) recipients have demonstrated mixed results due to the inclusion of above average-risk patients. We performed a case-control study of 102 average-risk SOT recipients who underwent screening colonoscopy, compared with an average-risk, age and sex-matched control group (n=287). Cancer rates were compared with an age-matched cohort from the National Cancer Institute's Survival, Epidemiology, and End Results (SEER) database. There was no difference in number of patients with adenomas (P=1.00). There was no difference in polyps per patient (P=0.31). Although the number of advanced lesions (excluding adenocarcinoma) between groups did not differ (P=0.25), there were two adenocarcinomas identified in the SOT group and none in the control group (P=0.068). Detection of colorectal cancer was an unexpected finding in the SOT cohort and was more likely when compared to age-matched cancer incidence generated by the SEER database. These results suggest no increased adenoma detection in SOT recipients, but with more cases of colorectal cancer than anticipated. Given previous, larger, transplant database studies demonstrating increased colorectal cancer rates, more frequent screening may be justified.

Surgical resident's training in colonoscopy: numbers, competency, and perceptions.

BACKGROUND: There is currently great discrepancy in the training requirements between medical societies regarding the recommended threshold number of colonoscopies needed to assess for technical competence. Our goal was to determine the number of colonoscopies performed by surgical residents, rate of cecal intubation, as well as trainee perceptions of colonoscopy training after completion of their training period. METHODS: This study consisted of a 12-item electronic survey completed by 21 surgical residents after their 2-month endoscopy rotation at a tertiary care, urban referral center. This survey assessed numbers of colonoscopies performed, number successful to the cecum, and perceptions of training in colonoscopy. The cecal intubation rate was used as a surrogate marker of technical competence. RESULTS: Twenty-one surgical residents performed a mean of 80 ± 35 total colonoscopies during the 2-month rotation. The average cecal intubation rate was 47% (range 9-78%). Resident comfort level for independently performing a total colonoscopy was scored a mean 3.6 on scale of 1-5 (5 = most comfortable), and 43% of the surgical residents planned on performing colonoscopy after residency training. CONCLUSIONS: Surgical residents can obtain the recommended threshold for colonoscopy (N = 50) during a standard 2-month rotation. However, no resident was able to achieve technical competence in colonoscopy as defined by a 90% cecal intubation rate. These data suggest that the method of training of general surgery residents in colonoscopy may need reappraisal.

The behavior of an opponent alters pacing decisions in 4-km cycling time trials.

INTRODUCTION: The present study aimed to explore how athletes respond to different behaviors of their opponents. METHODS: Twelve moderately to highly physically active participants with at least two years of cycling experience completed four 4-km time trials on a Velotron cycle ergometer. After a familiarization time trial (FAM), participants performed three experimental time trials in randomized order with no opponent (NO), a virtual opponent who started slower and finished faster compared to FAM (OP-SLOWFAST), or a virtual opponent who started faster and finished slower compared to FAM (OP-FASTSLOW). Repeated-measures ANOVAs (P<0.05) were used to examine differences in pacing and performance related to power output, velocity and RPE. RESULTS: OP-SLOWFAST and OP-FASTSLOW were completed faster compared to NO (385.5±27.5, 385.0±28.6, and 390.6±29.3s, respectively). An interaction effect for condition×distance (F=3.944, P<0.001) indicated differences in pacing profiles between conditions. Post-hoc analysis revealed that a less aggressive starting strategy was adopted in NO compared to OP-FASTSLOW and OP-SLOWFAST during the initial 1000m. Finally, a faster starting opponent evokes higher power outputs by the participants in the initial 750m compared to a slower starting opponent. CONCLUSION: The present study is the first to show that the behavior of an opponent affects pacing-related decisions in laboratory-controlled conditions. Our findings support the recently proposed interdependence of perception and action, and emphasize the interaction with the environment as an important determinant for an athlete's pacing decisions, especially during the initial stages of a race.

Additive benefits of pravastatin and aspirin to decrease risks of cardiovascular disease: randomized and observational comparisons of secondary prevention trials and their meta-analyses.

BACKGROUND: In randomized trials of secondary prevention, pravastatin sodium and aspirin reduce risks of cardiovascular disease. Pravastatin has a predominantly delayed antiatherogenic effect, and aspirin has an immediate antiplatelet effect, raising the possibility of additive clinical benefits. METHODS: In 5 randomized trials of secondary prevention with pravastatin (40 mg/d), comprising 73 900 patient-years of observation, aspirin use was also prescribed in varying frequencies, and data were available on a large number of confounding variables. We tested whether pravastatin and aspirin have additive benefits in the 2 large trials (Long-term Intervention With Pravastatin in Ischaemic Disease trial and the Cholesterol and Recurrent Events trial) that were designed to test clinical benefits. We also performed meta-analyses of these 2 trials and 3 smaller angiographic trials that collected clinical end points. In all analyses, multivariate models were used to adjust for a large number of cardiovascular disease risk factors. RESULTS: Individual trials and all meta-analyses demonstrated similar additive benefits of pravastatin and aspirin on cardiovascular disease. In meta-analysis, the relative risk reductions for fatal or nonfatal myocardial infarction were 31% for pravastatin plus aspirin vs aspirin alone and 26% for pravastatin plus aspirin vs pravastatin alone. For ischemic stroke, the corresponding relative risk reductions were 29% and 31%. For the composite end point of coronary heart disease death, nonfatal myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, or ischemic stroke, the relative risk reductions were 24% and 13%. All relative risk reductions were statistically significant. CONCLUSION: More widespread and appropriate combined use of statins and aspirin in secondary prevention of cardiovascular disease will avoid large numbers of premature deaths.

From Capsule Endoscopy to Balloon-Assisted Deep Enteroscopy: Exploring Small-Bowel Endoscopic Imaging.

In the past 15 years, the use of endoscopic evaluations in patients with obscure gastrointestinal bleeding has become more common. Indications for further endoscopic interventions include iron deficiency anemia, suspicion of Crohn's disease or small-bowel tumors, assessment of celiac disease or of ulcers induced by nonsteroidal anti-inflammatory drugs, and screening for familial adenomatous polyposis. Often, capsule endoscopy is performed in concert with other endoscopic studies and can guide decisions regarding whether enteroscopy should be carried out in an anterograde or a retrograde approach. Retrograde endoscopy is beneficial in dealing with disease of the more distal small bowel. Multiple studies have examined the diagnostic yield of balloon-assisted deep enteroscopy and have estimated a diagnostic yield of 40% to 80%. Some of the studies have found that diagnostic yields are higher when capsule endoscopy is performed before balloon-assisted deep enteroscopy in a search for small-bowel bleeds. Each of these procedures has a role when performed alone; however, research suggests that they are especially effective as complementary techniques and together can provide better-directed therapy. Both procedures are relatively safe, with high diagnostic and therapeutic yields that allow evaluation of the small bowel. Because both interventions are relatively new to the world of gastroenterology, much research remains to be done regarding their overall efficacy, cost, and safety, as well as further indications for their use in the detection and treatment of diseases of the small bowel.

Endoscopic ultrasound-guided pancreatic pseudocyst cystogastrostomy using a novel self-expandable metal stent with antimigration system: A case series.

BACKGROUND AND OBJECTIVES: Development of symptomatic pseudocysts after acute pancreatitis is a common occurrence. Endoscopic ultrasound (EUS)-guided transmural drainage has become the treatment of choice for symptomatic pseudocysts. Following this procedure, stent migration can occur. A recently developed fully covered biliary metal stent with antimigration system has shown promise as an alternative endoprosthetic option for cystogastrostomy. The aim of this study is to describe the success and complications of using covered metal stents with antimigration system to drain pseudocysts at a single tertiary care center. MATERIALS AND METHODS: The patients undergoing cystogastrostomy using the biliary metal stent with antimigration system over the course of a 10-month period (January-November, 2014) were retrospectively reviewed and all the pertinent information including length of the follow-up, age and sex of the patient, pseudocyst size, pseudocyst size at follow-up, and symptom improvement were recorded. RESULTS: Five patients underwent endoscopic cystogastrostomy using a biliary metal stent with antimigration system. The average age of the patients was 57 years, with all the patients being males. The average size of the largest dimension of pseudocyst was 9 cm. The average follow-up time to repeat imaging was 30 days. All the patients had a significant improvement in their pseudocyst size, with two patients having complete resolution, one patient with a residual 2 cm cyst, and another with a residual 5 cm pseudocyst at follow-up. The average size at follow-up was 2 cm. No complications occurred during the follow-up period. No episodes of stent migration occurred. All the patients had symptom improvement at follow-up. CONCLUSION: Using a novel biliary covered self-expandable metal stent with antimigration system with EUS guidance to drain pseudocysts appears to be a safe and effective procedure in certain settings. Our experience shows rapid cyst resolution with no complications and no stent migration. This stent gives the providers another option when performing cystogastrostomy.

Comparison of Capsule Endoscopy Findings to Subsequent Double Balloon Enteroscopy: A Dual Center Experience.

Background. There has been a growing use of both capsule endoscopy (CE) and double balloon enteroscopy (DBE) to diagnose and treat patients with obscure gastrointestinal blood loss and suspected small bowel pathology. Aim. To compare and correlate sequential CE and DBE findings in a large series of patients at two tertiary level hospitals in Wisconsin. Methods. An IRB approved retrospective study of patients who underwent sequential CE and DBE, at two separate tertiary care academic centers from May 2007 to December 2011, was performed. Results. 116 patients were included in the study. The mean age ± SD was 66.6 ± 13.2 years. There were 56% males and 43.9% females. Measure of agreement between prior capsule and DBE findings was performed using kappa statistics, which gave kappa value of 0.396 with P < 0.001. Also contingency coefficient was calculated and was found to be 0.732 (P < 0.001). Conclusions. Our study showed good overall agreement between DBE and CE. Findings of angioectasia had maximum agreement of 69%.

Glycemic parameters with multiple daily injections using insulin glargine versus insulin pump.

This study compared external insulin pump treatment using insulin lispro or insulin aspart with multiple daily injections (MDI; four or more injections per day) using insulin glargine and insulin lispro or insulin aspart. An electronic database was used to retrieve various parameters of glycemic control for 515 adult patients with type 1 diabetes. An insulin pump was used by 216 patients, and 299 patients were taking insulin glargine for at least 6 months. The mean age (approximately 33 years), duration of diabetes (approximately 16 years), and duration of treatment (approximately 12 months) were similar for both the pump and insulin glargine groups. The mean (+/-SEM) A1C values were significantly reduced in both groups from the baseline to the end of the study (7.7 +/- 0.1% to 7.5 +/- 0.1% for the pump group and 8.0 +/- 0.1% to 7.7 +/- 0.1% for the insulin glargine group, P< 0.001) with similar weight gain (P> 0.05) in both groups. The insulin glargine group significantly reduced basal insulin intake at follow-up. The premeal boluses were similar throughout the study for both groups. The subjects reporting severe hypoglycemic episodes were similar in the two groups; however, there were 12 cases of diabetic ketoacidosis reported in the pump group and none in the insulin glargine group. Patients with type 1 diabetes can achieve similar glycemic control using insulin glargine with premeal insulin lispro or by using an external infusion pump with insulin lispro or insulin aspart. However, costs and episodes of diabetic ketoacidosis are significantly higher for insulin pump users.

Improved glycemic control without an increase in severe hypoglycemic episodes in intensively treated patients with type 1 diabetes receiving morning, evening, or split dose insulin glargine.

OBJECTIVE: To see if insulin glargine improves glycemic control in a clinical setting. RESEARCH DESIGN AND METHODS: A questionnaire and electronic database were used to assess glycemic parameters for 292 type 1 diabetic subjects taking > or =4 injections per day and receiving glargine as their only long-acting basal insulin for at least 6 months. Sixty-three subjects were taking glargine in the morning, 125 were taking glargine in the evening, and 104 were splitting the glargine dose between the morning and evening. RESULTS: The mean (+/-S.D.) age and duration of diabetes were 32 +/- 10 years and 15.9 +/- 10.3 years, respectively. The mean (+/-S.E.M.) durations of treatment with glargine were 13.1 +/- 0.6 months, 12.2 +.- 0.4 months, and 14.3 +/- 0.5 months for the morning, evening, and split treatment groups, respectively (P < 0.01). The A1C values improved significantly from baseline for the evening and the split dosage groups or when all groups were combined. The mean basal insulin dose was significantly reduced at the end of the study in all the three groups from baseline with no change in the short-acting insulin dose. The number of severe hypoglycemic episodes decreased from 379 in the year prior to glargine treatment to 167 in the post-glargine year. The weight gain was significantly higher in the group that took the split glargine dose (P < 0.01). CONCLUSIONS: Similar or improved glycemic control was achieved by administering glargine in the morning, evening, or using a split dose without any further increase in severe hypoglycemic episodes. Splitting the glargine dose did not offer any advantages in glycemic control parameters.

Integrated PET/CT fusion imaging and endoscopic ultrasound in the pre-operative staging and evaluation of esophageal cancer.

PURPOSE: Accurate staging of esophageal cancer (ECA) is critical in determining appropriate therapy. Endoscopic ultrasound (EUS), computed tomography (CT) and positron emission tomography (PET) scanning can be used, but limited data exists regarding the use of combined PET/CT fusion imaging and EUS in ECA staging. The objective of this study is to evaluate the role of integrated PET/CT imaging and EUS in the staging of ECA. PROCEDURES: Identification of patients diagnosed with ECA from 2004 to 2007 that underwent staging PET/CT and EUS. Data regarding tumor detection, lymph node identification, presence of metastatic disease, and affect on patient management were collected and compared between PET/CT and EUS. RESULTS: Eighty-one patients (65 male, 16 female) were identified with mean age of 63.5 years who underwent EUS and PET/CT to stage known ECA. PET/CT identified the primary tumor in 74/81 (91.4%) of cases, compared to 81/81 (100%) with EUS. Locoregional adenopathy was seen by PET/CT in 29/81 (35.8%) of cases, compared to 49/81 (60.5%) by EUS (p = 0.0001). PET/CT identified celiac axis adenopathy in 8/81 (9.9%) of cases, compared to 11/81 (13.6%) with EUS (p = 0.5050). PET/CT identified 17/81 (21.0%) of patients with distant metastases who subsequently did not undergo attempt at curative surgical resection. CONCLUSIONS: In ECA, EUS is superior to PET/CT for T staging and in identifying locoregional nodes, while PET/CT provides M staging. EUS and integrated PET/CT appear to independently affect treatment decisions, indicating complimentary and necessary roles in the staging of ECA.

Utility of colonoscopy in the evaluation of diarrhea in solid organ transplant recipients.

BACKGROUND: Diarrhea is common in solid organ transplant recipients. Colonoscopy with random biopsies is performed frequently in the diagnostic evaluation of the posttransplant population with diarrhea. The purpose of this study was to determine the sensitivity of colonoscopy with random biopsy in determining a specific diagnosis and changing management in solid organ transplant recipients with diarrhea. METHODS: From October 1996 to June 2008, 88 patients were identified who had undergone solid organ transplantation and subsequently underwent colonoscopy for an indication of "diarrhea." These patient's electronic medical records were reviewed to determine patient demographics, laboratory results, findings on colonoscopy and histopathology, and any subsequent diagnoses made and management changes in relation to the diarrhea. RESULTS: Eighty-eight patients (mean age 54 years, 65% male) underwent colonoscopy a mean of 69 months after transplantation. Abnormal colonoscopic findings were seen in 16 (18.2%) patients. Histopathology was abnormal in 17/80 (21.3%). However, only eight (9.1%) had findings on colonoscopy or pathologic condition that led to specific diagnosis being made. In addition, only nine (10.2%) patients had a change in medical management as a direct result of colonoscopy with biopsy. CONCLUSION: Although colonoscopic or histopathologic abnormalities are common in the solid organ transplant recipient with diarrhea, the findings rarely lead to a specific diagnosis or management change. Colonoscopy with biopsy should be performed only after noninvasive testing for infectious diarrhea and a thorough review and adjustment of medications. In many patients, a trial of antidiarrheal medication is warranted before colonoscopy.