Optimizing cecal views during colonoscopy using patient position change.

BACKGROUND: Patient positioning has been found to be a simple technique to improve luminal distention and visualization during colonoscopy. This study examined which position provided the cleanest image of the cecum using the Boston Bowel Prep Scale (BBPS) and the best view of the cecum overall as ranked by blinded assessors. METHODS: A sample of 90 sets of cecal images were obtained from patients undergoing a non-urgent colonoscopy. Each set included cecal images of patients while lying in three positions-right lateral decubitus, left lateral decubitus, and supine. Two authors reviewed these sets of images and excluded those that were unclear. A third author, blinded to the position, selected the final 33 sets of images. Two experienced endoscopists completed a blinded survey of each image set. They used the BBPS to assess and score each image as the primary outcome measure. The endoscopists also ranked each image set in terms of the best overall view of the cecum. Data were collected using Qualtrics software. Nonparametric tests were used to analyze the data using SPSS software (v.25). A p-value of ≤ 0.05 was considered significant. RESULTS: The BBPS showed a significant difference between patient positions when tested by Kruskal-Wallis. Subsequent Mann Whitney U tests indicated that the right lateral decubitus position was ranked higher than left lateral decubitus or supine positions. There was no significant difference in the left and supine positions. Cohen's Kappa suggested moderate agreement between raters. The raters also favored the right lateral position over the other positions when assessing overall image preference displaying the cecum. CONCLUSION: These results indicate that positioning patients in the right lateral decubitus position provides the best view of the cecum during colonoscopy.

A randomized controlled trial comparing right and left lateral decubitus starting position on outcomes in colonoscopy.

BACKGROUND: Patient positioning in colonoscopy has been proposed as a simple and inexpensive technique to increase luminal distention and improve navigation through the large bowel. We sought to determine if the right lateral (RL) starting position compared to the standard left lateral (LL) starting position could improve outcomes in colonoscopy. METHODS: We conducted a randomized controlled trial of 185 patients who were undergoing an elective colonoscopy. Patients were randomized to either a right lateral decubitus starting position or a left lateral decubitus starting position and the primary outcome measure was cecal intubation time. Secondary outcome measures included cecal intubation rate, patient discomfort, and sedation dosage. All colonoscopists who had successfully completed a colonoscopy skills improvement course were included in the trial. A sample size was calculated prior to the start of the study and outcomes were analyzed using univariate and multiple regression analyses. RESULTS: A total of 94 patients were randomized to RL starting position and 91 patients were randomized to LL starting position. No difference was found in time to cecal intubation comparing the RL starting position (542.6 s, SD 360.7 s) to LL starting position (497.85 s, SD 288.3 s) (p = 0.354). Variables associated with prolonged cecal intubation time included female gender, General Surgery specialty, less than 5 years of endoscopist experience, a high patient discomfort score, amount of water used, and number of position changes required to reach the cecum. There was no difference in any of the secondary outcome measures aside from the amount of midazolam used, with more midazolam used for patients starting in the right lateral decubitus position. CONCLUSION: This study failed to show an association between cecal intubation time and patient position comparing right and left lateral starting position.

The Application of Low-fidelity Chest Tube Insertion Using Remote Telesimulation in Training Healthcare Professionals.

Healthcare professionals practicing in rural, remote, or resource-restricted areas have little opportunity to practice "high stakes low-frequency" clinical procedures, despite having higher rates of injury-related death than city inhabitants. Availability of clinical skills instructors, the expense of practicing skills, lack of educational sessions, and distance to simulation centres can be a barrier to teaching and skill maintenance, particularly in rural settings. Telesimulation has the potential to overcome these challenges using audio-visual technology to connect rural learners with instructors in simulation centres. Using low-fidelity simulation models allows learners to acquire clinical skills through hands-on practice without risk or fear of harming real patients. Although not as realistic as high-fidelity models, the low-fidelity three-dimensional (3D) printed model for chest tube insertion is cost-effective and easy to set up and use and is a valid tool for teaching the clinical procedure. The purpose of this technical report was to describe the application of low-cost telesimulation to facilitate teaching chest tube insertion to medical students, emergency medicine residents, and doctors working in remote and rural environments.

A Novel 3-Dimensional Co-culture Method Reveals a Partial Mesenchymal to Epithelial Transition in Breast Cancer Cells Induced by Adipocytes.

Cancer metastases are accountable for almost 90% of all human cancer related deaths including from breast cancer (BC). Adipocytes can alter the tumor microenvironment, which can promote metastasis by inducing an epithelial-to-mesenchymal transition (EMT) in BC cells. However, the role of adipocytes during the mesenchymal-to-epithelial transition (MET), that can be important in metastasis, is not clear. To understand the effect of adipocytes on the BC progression, there is a requirement for a better in vitro 3-dimensional (3D) co-culture system that mimics the breast tissue and allows for more accurate analysis of EMT and MET. We developed a co-culture system to analyze the relationship of BC cells grown in a 3D culture with adipocytes. We found that adipocytes and adipocyte-derived conditioned media, but not pre-adipocytes, caused the mesenchymal MDA-MB-231 and Hs578t cells to form significantly more epithelial-like structures when compared to the typical stellate colonies formed in control 3D cultures. SUM159 cells and MCF7 cells had a less dramatic shift as they normally have more epithelial-like structure in 3D culture. Biomarker expression analysis revealed that adipocytes only induced a partial MET with proliferation unaffected. In addition, adipocytes had reduced lipid droplet size when co-cultured with BC cells. Thus, we found that physical interaction with adipocytes and ECM changes the mesenchymal phenotype of BC cells in a manner that could promote secondary tumor formation.