When to puncture, when not to puncture: Submucosal tumors.

Subepithelial masses of the gastrointestinal (GI) tract are a frequent source of referral for endosonographic evaluation. Subepithelial tumors most often appear as protuberances in the GI tract with normal overlying mucosa. When there is a need to obtain a sample of the mass for diagnosis, endoscopic ultrasound (EUS) - guided fine-needle aspiration (FNA) is superior to other studies and should be the first choice to investigate any subepithelial lesion. When the decision is made to perform EUS-guided FNA several technical factors must be considered. The type and size of the needle chosen can affect diagnostic accuracy, adequacy of sample size and number of passes needed. The use of a stylet or suction and a fanning or standard technique during EUS-guided FNA are other factors that must be considered. Another method proposed to improve the efficacy of EUS-guided FNA is having an on-site cytopathologist or cytotechnician. Large or well-differentiated tumors may be more difficult to diagnose by standard EUS-FNA and the use of a biopsy needle can be used to acquire a histopathology sample. This can allow preservation of tissue architecture and cellularity of the lesion and may lead to a more definitive diagnosis. Alternatives to FNA such as taking bite-on-bite samples and endoscopic submucosal resection (ESMR) have been studied. Comparison of these two techniques found that ESMR has a significantly higher diagnostic yield. Most complications associated with EUS-FNA such as perforation, infection and pancreatitis are rare and the severity and incidence of these adverse events is not known. Controversy exists as to the optimal method in which to perform EUS-FNA and larger prospective trials are needed.

Barrett's esophagus and the risk of obstructive sleep apnea: a case-control study.

BACKGROUND: Prior studies suggest that obstructive sleep apnea may be associated with gastroesophageal reflux disease, a strong risk factor for Barrett's esophagus. The goals of this pilot case-control study were to determine whether Barrett's esophagus patients have an increased likelihood of obstructive sleep apnea and to determine whether nocturnal gastroesophageal reflux symptoms affect the relationship between Barrett's esophagus and obstructive sleep apnea risk. METHODS: Patients with Barrett's esophagus completed the Berlin Questionnaire, a validated survey instrument identifying subjects at high risk for obstructive sleep apnea. Two outpatient control groups were recruited: 1) EGD Group, subjects matched to Barrett's esophagus cases by age, race, and gender with esophagogastroduodenoscopy negative for Barrett's esophagus; and 2) Colonoscopy Group, patients getting colonoscopy. Rates of scoring at high risk for obstructive sleep apnea were compared. Respondents were also questioned regarding severity of their typical gastroesophageal reflux symptoms and presence of nocturnal gastroesophageal reflux symptoms. RESULTS: The study included 287 patients (54 Barrett's esophagus, 62 EGD, and 171 colonoscopy subjects). Barrett's esophagus patients were slightly older than colonoscopy patients and more obese. 56% (n = 30) of Barrett's esophagus subjects scored at high risk for obstructive sleep apnea, compared with 42% (n = 26) of EGD subjects (OR 1.73, 95% CI [0.83, 3.62]) and 37% (n = 64) of colonoscopy patients (OR 2.08, 95% CI [1.12, 3.88]). The association between Barrett's esophagus and scoring at high risk for obstructive sleep apnea compared with colonoscopy patients disappeared after adjusting for age. Barrett's esophagus patients reported more severe typical heartburn and regurgitation symptoms than either control group. Among all subjects, patients with nocturnal reflux symptoms were more likely to score at high risk for obstructive sleep apnea than patients without nocturnal reflux. CONCLUSIONS: In this pilot study, a high proportion of Barrett's esophagus subjects scored at high risk for obstructive sleep apnea. Having Barrett's esophagus was associated with more severe gastroesophageal reflux symptoms, and nocturnal reflux symptoms were associated with scoring at high risk for obstructive sleep apnea. The need for obstructive sleep apnea screening in Barrett's esophagus patients with nocturnal gastroesophageal reflux symptoms should be further evaluated.

Cap-assisted ERCP with a forward-viewing gastroscope as a rescue endoscopic intervention in patients with Billroth II anatomy.

BACKGROUND: ERCP, especially therapeutic, is difficult in patients with Billroth II surgical reconstruction and is associated with a higher rate of complications. This has led to controversy on the choice between a forward-viewing and side-viewing endoscope for performing the procedure. A previous case series from Asia reported a high rate of success with a cap-fitted ERCP technique. To our knowledge, the utility of cap-assisted ERCP with a forward-viewing gastroscope when other techniques fail has not been reported. We describe and demonstrate a novel rescue approach using a cap-fitted, forward-viewing gastroscope in patients with Billroth II anatomy, when attempts with duodenoscopes, pediatric colonoscopes, and gastroscopes previously failed. METHODS: Retrospective case series. Inclusion criteria were: (a) documented Billroth II anatomy; and (b) use of cap-assisted ERCP as a rescue intervention on the first endoscopic encounter after failed attempts to perform ERCP with a duodenoscope. Patients were excluded if they successfully underwent ERCP with a duodenoscope. One advanced endoscopist and one advanced endoscopy fellow performed all but one of the procedures. RESULTS: Five cap-assisted ERCP procedures were performed in three patients with Billroth II anatomy. A wide variety of diagnostic and therapeutic endoscopic maneuvers were technically feasible and successful, including the endoscopic treatment of an afferent limb perforation caused by a duodenoscope. CONCLUSIONS: Cap-assisted ERCP is a novel and underutilized technique that adds to the armamentarium of experienced therapeutic endoscopists. This approach may help ensure a successful endoscopic outcome and spare patients with Billroth II anatomy a percutaneous or surgical approach when ERCP with a duodenoscope, pediatric colonoscope or non-cap-fitted gastroscope fails.

Sedation during endoscopy for patients at risk of obstructive sleep apnea.

BACKGROUND: Obstructive sleep apnea (OSA) has become increasingly prevalent in the United States and often goes undiagnosed. OBJECTIVE: To assess the proportion of patients undergoing routine endoscopic procedures who are at risk of OSA and to determine whether these patients are at risk of sedation-related hypoxia. DESIGN AND SETTING: Prospective case-control study at an academic medical center. PATIENTS AND INTERVENTIONS: Patients undergoing routine EGD and colonoscopy were administered the Berlin Questionnaire, a brief validated survey that stratifies patients into high or low risk of OSA. Data on pulse oximetry and oxygen use were collected. MAIN OUTCOME MEASUREMENTS: Rates of transient hypoxia, defined as a pulse oximetry measurement less than 92% requiring an increase in supplemental oxygen were compared between the high- and low-risk OSA groups. RESULTS: Of the 261 prospectively recruited patients, 28 were excluded for violating study protocol. Ninety (39%) of the remaining 233 patients were scored as being at high risk of OSA. There was no significant difference in the rate of transient hypoxia between the high- and low-risk groups (odds ratio 1.48; 95% CI, 0.58-3.80). LIMITATIONS: Single-center study. OSA was not confirmed with a sleep study. CONCLUSION: Approximately one third of patients undergoing routine outpatient endoscopic procedures at a university hospital scored as being at high risk of OSA. There was no significant difference in the rates of transient hypoxia between high- and low-risk groups, suggesting that the majority of patients with no diagnosis of OSA can undergo conscious sedation for routine endoscopic procedures with standard monitoring practices.

'Streptococcus milleri' aortic valve endocarditis and hepatic abscess.

Although well-recognized animal pathogens, group C streptococci are relatively rare causes of human infection. The phenotypically small-colony group C 'Streptococcus milleri' are typically associated with suppurative disease of soft tissue and organs, including liver abscesses, while bacteraemia and endocarditis are distinctly less common. Herein, a case of 'S. milleri' causing both endocarditis and liver abscess in the same patient is reported.

Identification of Li(+) binding sites and the effect of Li(+) treatment on phospholipid composition in human neuroblastoma cells: a (7)Li and (31)P NMR study.

Li(+) binding in subcellular fractions of human neuroblastoma SH-SY 5 Y cells was investigated using (7)Li NMR spin-lattice (T(1)) and spin-spin (T(2)) relaxation measurements, as the T(1)/T(2) ratio is a sensitive parameter of Li(+) binding. The majority of Li(+) binding occurred in the plasma membrane, microsomes, and nuclear membrane fractions as demonstrated by the Li(+) binding constants and the values of the T(1)/T(2) ratios, which were drastically larger than those observed in the cytosol, nuclei, and mitochondria. We also investigated by (31)P NMR spectroscopy the effects of chronic Li(+) treatment for 4--6 weeks on the phospholipid composition of the plasma membrane and the cell homogenate and found that the levels of phosphatidylinositol and phosphatidylserine were significantly increased and decreased, respectively, in both fractions. From these observations, we propose that Li(+) binding occurs predominantly to membrane domains, and that chronic Li(+) treatment alters the phospholipid composition at these membrane sites. These findings support those from clinical studies that have indicated that Li(+) treatment of bipolar patients results in irregularities in Li(+) binding and phospholipid metabolism. Implications of our observations on putative mechanisms of Li(+) action, including the cell membrane abnormality, the inositol depletion and the G-protein hypotheses, are discussed.

Evaluation of [Co(gly)3]- as a 35Cl- NMR shift reagent for cellular studies.

We studied the efficacy of the tris-glycinatocobaltate(II) complex ([Co(gly)(3)](-)) as a shift reagent (SR) for chloride by (35)Cl NMR spectroscopy and compared to that of Co(2+)((aq)). Due to the relatively low thermodynamic stability of [Co(gly)(3)](-), a 1:3 Co(II)/gly stoichiometric solution at physiological pH is approximately a 2:1 mixture of [Co(gly)(2)(H(2)O)(2)] and [Co(gly)(H(2)O)(4)](+). This SR was found to be stable up to higher pH values than Co(2+)((aq)), better preventing Co(OH)(2) formation at alkaline pH. No significant differences in the (35)Cl(-) NMR chemical shift induced by Co(II)/gly or Co(2+)((aq)) were observed in the presence of physiological concentrations of either Ca(2+) or Mg(2+), or of either Na(+) or K(+). Although Co(2+)((aq)) was almost twice as effective as Co(II)/gly in shifting the (35)Cl(-) NMR resonance at the same high rho ([SR]/[Cl(-)]) value and low ionic strength, Co(2+)((aq)) showed a significant decrease (p < 0.05) in the (35)Cl(-) chemical shift at higher ionic strength. Line widths at half-height were significantly (p < 0.05) less for Co(II)/gly than for Co(2+)((aq)) at rho values in the range 0.066-0.40. Intracellular chloride was clearly detectable by (35)Cl NMR spectroscopy in human skin fibroblast cells suspended in medium containing 40 mM Co(II)/gly SR. We determined that, although Co(2+)((aq)) provides a larger shift than Co(II)/gly at the same rho value, there are significant advantages for using Co(II)/gly, such as pH stability, ionic strength independent chemical shifts, narrow (35)Cl(-) NMR resonances, and reduced cellular toxicity, as a SR in biological systems.