Salvage nitrous oxide cryotherapy of refractory colon neoplasia embedded within an endoclip.

Background and study aims This is a case report on use of the CryoBalloon as a salvage technique for ablation of residual neoplasia at an endoscopic mucosal resection site. The site contained an embedded clip that could not be removed at two different sessions by three experienced endoscopists. On follow-up endoscopy, the clips and residual polyp no longer remained. The subtle scar that was present was biopsied and confirmed complete eradication of neoplasia and no polyp tissue. This case shows the potential of the CryoBalloon to ablate unwanted tissue outside of the esophagus.

Incremental yield of dysplasia detection in Barrett's esophagus using volumetric laser endomicroscopy with and without laser marking compared with a standardized random biopsy protocol.

BACKGROUND AND AIMS: Volumetric laser endomicroscopy (VLE) is a new wide-field advanced imaging technology for Barrett's esophagus (BE). No data exist on incremental yield of dysplasia detection. Our aim is to report the incremental yield of dysplasia detection in BE using VLE. METHODS: This is a retrospective study from a prospectively maintained database from 2011 to 2017 comparing the dysplasia yield of 4 different surveillance strategies in an academic BE tertiary care referral center. The groups were (1) random biopsies (RB), (2) Seattle protocol random biopsies (SP), (3) VLE without laser marking (VLE), and (4) VLE with laser marking (VLEL). RESULTS: A total of 448 consecutive patients (79 RB, 95 SP, 168 VLE, and 106 VLEL) met the inclusion criteria. After adjusting for visible lesions, the total dysplasia yield was 5.7%, 19.6%, 24.8%, and 33.7%, respectively. When compared with just the SP group, the VLEL group had statistically higher rates of overall dysplasia yield (19.6% vs 33.7%, P = .03; odds ratio, 2.1, P = .03). Both the VLEL and VLE groups had statistically significant differences in neoplasia (high-grade dysplasia and intramucosal cancer) detection compared with the SP group (14% vs 1%, P = .001 and 11% vs 1%, P = .003). CONCLUSION: A surveillance strategy involving VLEL led to a statistically significant higher yield of dysplasia and neoplasia detection compared with a standard random biopsy protocol. These results support the use of VLEL for surveillance in BE in academic centers.

Downhill Esophageal Varices Associated With Central Venous Catheter-Related Thrombosis Managed With Endoscopic and Surgical Therapy.

Downhill esophageal varices are a rare cause of upper gastrointestinal hemorrhage. We present a case of downhill variceal bleeding due to superior vena cava thrombosis resulting from a prior central venous catheter. The patient was managed with endoscopic band ligation and later with surgical axillary vein to right atrium bypass grafting. Successful long-term resolution of varices was achieved at 1 year of follow-up. This is the longest follow-up described for combined endoscopic and surgical management in the existing literature for catheter-associated downhill varices.

Resident knowledge of colorectal cancer screening assessed by web-based survey.

BACKGROUND: To evaluate resident knowledge of colorectal cancer (CRC) screening guidelines and to define areas requiring attention. METHODS: A survey was created using three published guidelines for CRC screening. Program directors for internal medicine residency programs were contacted within the metro New York City area to have their residents participate. RESULTS: Five programs participated, and 115 responses were recorded. For the appropriate testing and interval to screen for CRC, 61/115 residents identified flexible sigmoidoscopy every 5 years, 108/115 identified colonoscopy every 10 years, 16/115 identified double contrast barium enema (DCBE) every 5 years and only 12/115 thought CT-colography every 5 years was appropriate. Only 40/115 respondents appropriately identified fecal occult blood testing (FOBT) administered in the patient's home annually, while fecal immunohistochemical testing (FIT) annually at home was identified by 8/115 residents. CONCLUSION: While most residents seem knowledgeable regarding CRC screening with colonoscopy, many deficiencies remain. FOBT for screening purposes remains undervalued, and confusion about administering the test persists. The distinction between screening and prevention needs further reinforcement.

Higher Prevalence and More Severe Coronary Artery Disease in Hepatitis C Virus-infected Patients: A Case Control Study.

BACKGROUND: An association of Coronary artery disease (CAD) with hepatitis C (HCV) has been suggested, but definitive data are still lacking. AIM: Our study sought to estimate the prevalence and severity of CAD in HCV patients compared to with age-, sex-, and race-matched controls without HCV infection. SUBJECTS AND METHODS: 63 HCV-infected patients were compared with 63 age, race, and sex-matched controls without HCV infection undergoing coronary angiography for evaluation of CAD. CAD was defined as more than a 50% blockage in any of the proximal coronary arteries on angiogram. The severity of the stenosis was defined by the modified Reardon severity scoring system: <50% stenosis of the luminal diameter, 1 point; 50-74%, 2 points; 75-99%, 3 points; 100% or total obstruction, 4 points. The points for each lesion in the proximal coronary circulation were summed to give the score for severity. RESULTS: A significantly higher prevalence of CAD was noted in the HCV population (69.8% vs. 47.6%, = 0.01). The combined Reardon's severity score in the HCV group was significantly higher compared to the controls (6.26 ± 5.39 vs. 2.6 ± 3.03, P < 0.0005). Additionally, significant multivessel CAD (>50% stenosis and ≥2 vessels involved) was also noted significantly more commonly in the HCV group compared to controls (57.1% vs. 15.9%, P < 0.0005). CONCLUSION: In this retrospective study the prevalence and severity of CAD was higher in HCV patients who were evaluated for CAD by angiogram compared with matched non-HCV patients. HCV-positive status is potentially a risk factor for CAD.

Recent trends for colorectal cancer screening in HIV-infected patients.

We planned to investigate the recent trends for colorectal cancer (CRC) screening in human immunodeficiency virus (HIV) as compared to non-HIV by interviewing consecutive patients in outpatient clinics during September 2007. Out of a total of 300 patients interviewed, 205 met the inclusion criteria. One hundred and fourteen were HIV-infected, while 91 were non-HIV. HIV received more office visits per year. Despite the high incidence of adenomas on screening colonoscopy, HIV patients were less likely to undergo any type of CRC screening test. A higher number (>or=10) of annual clinic visits and the presence of co-morbid conditions were associated with being up-to-date for CRC screening in HIV patients. Conclusion CRC screening is underutilized in HIV patients. Multiple office visits per year are associated with being up-to-date for CRC screening. Hence, increasing patients' compliance with office visits and educating them about the importance of CRC screening may indirectly increase compliance with CRC screening.

Multicenter, randomized, controlled trial of virtual-reality simulator training in acquisition of competency in colonoscopy.

BACKGROUND: The GI Mentor is a virtual reality simulator that uses force feedback technology to create a realistic training experience. OBJECTIVE: To define the benefit of training on the GI Mentor on competency acquisition in colonoscopy. DESIGN: Randomized, controlled, blinded, multicenter trial. SETTING: Academic medical centers with accredited gastroenterology training programs. PATIENTS: First-year GI fellows. INTERVENTIONS: Subjects were randomized to receive 10 hours of unsupervised training on the GI Mentor or no simulator experience during the first 8 weeks of fellowship. After this period, both groups began performing real colonoscopies. The first 200 colonoscopies performed by each fellow were graded by proctors to measure technical and cognitive success, and patient comfort level during the procedure. MAIN OUTCOME MEASUREMENTS: A mixed-effects model comparison between the 2 groups of objective and subjective competency scores and patient discomfort in the performance of real colonoscopies over time. RESULTS: Forty-five fellows were randomized from 16 hospitals over 2 years. Fellows in the simulator group had significantly higher objective competency rates during the first 100 cases. A mixed-effects model demonstrated a higher objective competence overall in the simulator group (P < .0001), with the difference between groups being significantly greater during the first 80 cases performed. The median number of cases needed to reach 90% competency was 160 in both groups. The patient comfort level was similar. CONCLUSIONS: Fellows who underwent GI Mentor training performed significantly better during the early phase of real colonoscopy training.

Efficacy and costs of a one-day hands-on EASIE endoscopy simulator train-the-trainer workshop.

BACKGROUND: The efficacy of an intensive hands-on training in endoscopic hemostasis on the compactEASIE simulator has been previously demonstrated in a randomized prospective trial. In the current study, we evaluated how quickly and effectively new tutors, without simulator training experience, are able to acquire teaching skills in endoscopic hemostasis. METHODS: Five tutors with prior Erlangen Active Simulator for Interventional Endoscopy (EASIE) teaching experience instructed 7 endoscopists without prior EASIE experience on how to teach when using the model. These new tutors then independently conducted a workshop for 8 fellows in 4 hemostasis techniques. Results were compared with a historical control trained similarly by experienced tutors. Two one-day workshops in endoscopic hemostasis on the compactEASIE ex vivo endoscopy simulator were conducted in a category A hospital in New York City, New York. Skill scores at the end of training were compared with baseline skills assessments, and qualitative ratings of the new tutors were obtained from both the trainees and the experienced tutors. RESULTS: Significant improvement was achieved by the fellows in all 4 skills areas. Both the expert tutors and the trainees consistently rated the teaching skill of the new tutors highly. Fellows' skill acquisition using new tutors was of similar magnitude to that achieved in the prior EASIE trial using experienced trainers teaching the fellows. CONCLUSIONS: It is feasible to conduct an effective EASIE train-the-trainer course in one day. Tutors trained in this manner are able to provide a similar educational experience with objective improvement in trainee skill to experts who have conducted many hands-on workshops.

A randomized trial of pegylated interferon alpha-2b plus ribavirin in the retreatment of chronic hepatitis C.

OBJECTIVES: The efficacy of combination therapy with pegylated interferon (PEG IFN) alpha plus ribavirin (RBV) in the retreatment of chronic hepatitis C (CHC) in patients who previously failed combination standard IFN plus RBV or IFN monotherapy has not been well established. METHODS: Three hundred and twenty-one CHC patients including virologic nonresponders to combination IFN plus RBV (n = 219) or IFN monotherapy (n = 47), and relapsers to combination therapy (n = 55) were randomized to receive PEG IFN alpha-2b 1.5 microg/kg per wk plus RBV 800 mg per day (Regimen A, n = 160) or PEG IFN alpha-2b 1.0 microg/kg per wk plus RBV 1,000-1,200 mg per day (Regimen B, n = 161) for 48 wks. RESULTS: Sustained virologic response (SVR) occurred in 16% of the overall study population (Regimen A vs B, 18%vs 13%, p= 0.21), in 8% of the combination therapy nonresponders (10%vs 6%, p= 0.35), in 21% of the IFN monotherapy nonresponders (16%vs 27%, p= 0.35), and in 42% of the combination therapy relapsers (50%vs 32%, p= 0.18). In nonresponders to prior combination therapy, HCV ribonucleic acid levels <100,000 copies/mL at the end of the prior treatment course were associated with an increased SVR compared with levels >or=100,000 copies/mL (21%vs 5%, p= 0.002). In the overall study population, genotype 1 patients had lower SVR rates than others (14%vs 33%, p= 0.01), and African Americans had lower SVR than Caucasians (4%vs 18%, p= 0.01). CONCLUSION: Combination therapy with PEG IFN alpha-2b plus RBV is more effective in patients who relapsed after combination standard IFN plus RBV than in nonresponders to either combination therapy or IFN monotherapy. There was no significant effect of dosing regimen.