Design and validation of an artificial intelligence system to detect the quality of colon cleansing before colonoscopy.

BACKGROUND AND AIMS: Patients' perception of their bowel cleansing quality may guide rescue cleansing strategies before colonoscopy. The main aim of this study was to train and validate a convolutional neural network (CNN) for classifying rectal effluent during bowel preparation intake as "adequate" or "inadequate" cleansing before colonoscopy. PATIENTS AND METHODS: Patients referred for outpatient colonoscopy were asked to provide images of their rectal effluent during the bowel preparation process. The images were categorized as adequate or inadequate cleansing based on a predefined 4-picture quality scale. A total of 1203 images were collected from 660 patients. The initial dataset (799 images), was split into a training set (80%) and a validation set (20%). The second dataset (404 images) was used to develop a second test of the CNN accuracy. Afterward, CNN prediction was prospectively compared with the Boston Bowel Preparation Scale (BBPS) in 200 additional patients who provided a picture of their last rectal effluent. RESULTS: On the initial dataset, a global accuracy of 97.49%, a sensitivity of 98.17% and a specificity of 96.66% were obtained using the CNN model. On the second dataset, an accuracy of 95%, a sensitivity of 99.60% and a specificity of 87.41% were obtained. The results from the CNN model were significantly associated with those from the BBPS (P<0.001), and 77.78% of the patients with poor bowel preparation were correctly classified. CONCLUSION: The designed CNN is capable of classifying "adequate cleansing" and "inadequate cleansing" images with high accuracy.

Asynchronous electronic consultation between primary care and specialized care proved effective for continuum of care for viraemic hepatitis C patients / La consulta electrónica asíncrona entre atención primaria y atención especializada resultó eficaz para la continuidad de la atención a los pacientes con hepatitis C virémica

Introduction: It has been proposed that primary care diagnose and treat hepatitis C virus (HCV) infection. However, a care circuit between primary and specialized care based on electronic consultation (EC) can be just as efficient in the micro-elimination of HCV. It is proposed to study characteristics and predictive factors of continuity of care in a circuit between primary and specialized care. Methods: From February/2018 to December/2019, all EC between primary and specialized care were evaluated and those due to HCV were identified. Variables for regression analysis and to identify predictors of completing the care cascade were recorded. Results: From 8098 EC, 138 were performed by 89 (29%) general practitioners over 118 patients (median 50.8 years; 74.6% men) and were related to HCV (1.9%). Ninety-two patients (78%) were diagnosed>6 months ago, and 26.3% met criteria for late presentation. Overall, 105 patients required assessment by the hepatologist, 82% (n=86) presented for the appointment, of which 67.6% (n=71) were viraemic, 98.6% of known. Finally, 61.9% (n=65) started treatment. Late-presenting status was identified as an independent predictor to complete the care cascade (OR 1.93, CI 1.71–1.99, p<0.001). Conclusion: Communication pathway between Primary and Specialized Care based on EC is effective in avoiding significant losses of viraemic patients. However, the referral rate is very low, high in late-stage diagnoses, heterogeneous, and low in new diagnoses. Therefore, early detection strategies for HCV infection in primary care are urgently needed.(AU)

Introducción: Se ha propuesto que atención primaria diagnostique y trate la infección por virus de la hepatitis C (VHC). Sin embargo, un circuito asistencial entre atención primaria y especializada basado en la consulta electrónica (CE) puede ser igual de eficiente en la microeliminación del VHC. Se propone estudiar características y factores predictivos de la continuidad asistencial en un circuito entre atención primaria y especializada. Métodos: Desde febrero/2018 y diciembre/2019 se evaluaron todas las CE entre atención primaria y especializada, y se identificaron aquellas por VHC. Se registraron variables para análisis de regresión e identificar factores predictores de completar cascada de atención. Resultados: De un total de 8.098 CE, 138 realizadas por 89 (29%) médicos generales de 118 pacientes (mediana de 50,8 años; 74,6% varones) fueron por VHC (1,9%). Noventa y dos pacientes (78%) fueron diagnosticados hace más de 6 meses), y el 26,3% cumplía criterios de presentación tardía. En total, 105 pacientes requirieron valoración por el hepatólogo. El 82% (n=86) se presentaron a la cita, de los cuales el 67,6% (n=71) eran virémicos, el 98,6% de los conocidos. Finalmente, el 61,9% (n=65) inició tratamiento. El estado de presentación tardía se identificó como un factor predictivo independiente para completar la cascada de atención (OR: 1,93; IC 95%: 1,71-1,99; p<0,001). Conclusión: La comunicación entre atención primaria y especializada basada en la CE es eficaz para evitar pérdidas significativas de pacientes virémicos. Sin embargo, la tasa de derivación es muy baja, elevada en diagnósticos en fase tardía, heterogénea y escasa en nuevos diagnósticos. Por tanto, se necesitan con urgencia, estrategias de detección precoz de infección por VHC en atención primaria.(AU)

Efficacy, Efficiency, and Acceptability of Telemedicine for Inflammatory Bowel Disease Patients' Follow-Up Care during the COVID-19 Pandemic.

BACKGROUND: During the COVID-19 pandemic, ambulatory clinic visits were replaced by the implementation of telehealth modalities in most inflammatory bowel disease (IBD) units. AIMS: The aim of this study was to assess the efficacy, efficiency, patient satisfaction, and acceptability of using telephone consultation in an IBD unit. METHODS: A prospective cohort study was performed in IBD patients who underwent telephone consultation during COVID-19 lockdown (between 16th March and 13th April 2020). To assess the efficacy of this telephone consultation (lockdown visit), nonscheduled visits, emergency consultation, hospital admission, and surgery from lockdown visit to the next scheduled consultation (post-lockdown) were checked. To evaluate efficiency, the time between lockdown visit and post-lockdown consultation was compared with previous consultation (pre-lockdown), and the total number of visits 12 months before and after lockdown visit was checked. A telephone survey was designed to rate perception for a telephone consultation. RESULTS: Out of a total of 274 patients, 220 patients (52.2% male; mean age 49 ± 16 years; Crohn's disease, n = 126; ulcerative colitis, n = 83; indeterminate colitis, n = 11) were included. Only one patient was consulted at the emergency department, 11 patients needed to rearrange the visit, and none patient underwent surgery before the scheduled post-lockdown visit. The interval to post-lockdown visit compared to pre-lockdown visit increased in 37.7% of patients. The satisfaction survey (n = 185) revealed that 94.6% perceived it was effective. However, 44.4% of patients rather prefer on-site consultation for follow-up. CONCLUSIONS: Telemedicine during the COVID-19 pandemic was shown to be effective and efficient to care for IBD patients. In addition, telephone consultation is well accepted by patients in non-extended follow-up periods.

Asynchronous electronic consultation between primary care and specialized care proved effective for continuum of care for viraemic hepatitis C patients.

INTRODUCTION: It has been proposed that primary care diagnose and treat hepatitis C virus (HCV) infection. However, a care circuit between primary and specialized care based on electronic consultation (EC) can be just as efficient in the micro-elimination of HCV. It is proposed to study characteristics and predictive factors of continuity of care in a circuit between primary and specialized care. METHODS: From February/2018 to December/2019, all EC between primary and specialized care were evaluated and those due to HCV were identified. Variables for regression analysis and to identify predictors of completing the care cascade were recorded. RESULTS: From 8098 EC, 138 were performed by 89 (29%) general practitioners over 118 patients (median 50.8 years; 74.6% men) and were related to HCV (1.9%). Ninety-two patients (78%) were diagnosed>6 months ago, and 26.3% met criteria for late presentation. Overall, 105 patients required assessment by the hepatologist, 82% (n=86) presented for the appointment, of which 67.6% (n=71) were viraemic, 98.6% of known. Finally, 61.9% (n=65) started treatment. Late-presenting status was identified as an independent predictor to complete the care cascade (OR 1.93, CI 1.71-1.99, p<0.001). CONCLUSION: Communication pathway between Primary and Specialized Care based on EC is effective in avoiding significant losses of viraemic patients. However, the referral rate is very low, high in late-stage diagnoses, heterogeneous, and low in new diagnoses. Therefore, early detection strategies for HCV infection in primary care are urgently needed.

Role of gap junctions modulating hepatic vascular tone in cirrhosis.

BACKGROUND & AIMS: Gap junctions are formed by connexins (Cx), a family of proteins that couple endothelial and smooth muscle cells in systemic vessels. In this context, Cx allow the transmission of signals modulating vascular tone. Recently, vascular Cx have been observed in liver cells implicated in liver blood flow regulation. Here, we investigated the role of Cx in the regulation of intrahepatic vascular tone in cirrhosis. METHODS: Livers of Sprague-Dawley control and cirrhotic (common bile duct ligation-CBDL and CCl4 ) rats were perfused, and concentration-effect curves in response to acetylcholine (ACh) precontracted with methoxamine were obtained in the presence of the specific Cx inhibitor 18-alpha-glycyrrhetinic acid or vehicle. Cx expression was assessed by immunofluorescence, western blot and reverse-transcription polymerase chain reaction in liver tissue, hepatic stellate cells, sinusoidal endothelial cells and hepatocytes isolated from control and cirrhotic rat livers. Cx protein expression was also determined in cirrhotic human tissue. RESULTS: Gap junction blockade markedly attenuated relaxation of hepatic vasculature in response to ACh in control (maximal relaxation, -55 ± 10.5% vs. -95.3 ± 10% with vehicle; P < 0.01) and CBDL rats (50.9 ± 18.5% vs. -18.7 ± 5.5% with vehicle; P = 0.01). Livers from CBDL rats and patients with cirrhosis exhibited Cx overexpression. By contrast, CCl4 -cirrhotic rats did not show attenuated relaxation of hepatic vasculature after blockade and Cx expression was significantly lower than in controls. CONCLUSIONS: Gap junctions may contribute to modulating portal pressure and intrahepatic vascular relaxation. Liver gap junctions may represent a new therapeutic target in cirrhotic portal hypertension.

Chronic intermittent hypoxia aggravates intrahepatic endothelial dysfunction in cirrhotic rats.

UNLABELLED: Chronic intermittent hypoxia (CIH) occurs with obstructive sleep apnea syndrome (OSAS) and provokes systemic endothelial dysfunction, which is associated with oxidative stress and low nitric oxide (NO) bioavailability. Cirrhotic livers exhibit intrahepatic endothelial dysfunction, which is characterized by an impaired endothelium-dependent response to vasodilators and hyperresponse to vasoconstrictors. We hypothesized that CIH may also contribute to intrahepatic endothelial dysfunction in cirrhosis. Normal and cirrhotic rats were exposed for 14 days to repetitive cycles of CIH mimicking OSAS in humans, or caged with room air (handled controls [HC]). Hepatic endothelial function was assessed in isolated and perfused rat livers by dose-response curves to acetylcholine (ACh) and methoxamine (Mtx). In a group of cirrhotic rats, in vivo systemic and hepatic hemodynamic parameters were evaluated at baseline and after volume expansion. In addition, liver samples were obtained to assess endothelial nitric oxide synthase (eNOS), phosphorylated eNOS (p-eNOS), NO bioavailability, and nitrotyrosinated proteins as a marker of oxidative stress. Cirrhotic rats exposed to CIH exhibited an attenuated vasodilatory response to ACh and hyperresponse to Mtx compared with HC rats. During volume expansion, similar portal pressure increases were observed in CIH and HC rats, although the mean arterial pressure increase was lower after CIH. These functional responses were associated with the presence of increased hepatic oxidative stress without changes in p-eNOS after CIH exposure. In normal rats, no hemodynamic changes were found. CONCLUSION: CIH exacerbates intrahepatic endothelial dysfunction in cirrhotic rats, which is associated with increased oxidative stress that may reduce NO bioavailability. Clinical studies are needed to assess whether OSAS contributes to endothelial impairment in human patients with cirrhosis.

Modifiable endoscopic factors that influence the adenoma detection rate in colorectal cancer screening colonoscopies.

BACKGROUND: Adenoma detection rate (ADR) has become the most important quality indicator for colonoscopy. OBJECTIVE: The aim of this study was to investigate which modifiable factors, directly related to the endoscopic procedure, influenced the ADR in screening colonoscopies. DESIGN: Observational, nested study. SETTING: Multicenter, randomized, controlled trials. PATIENTS: Asymptomatic people aged 50 to 69 years were eligible for a multicenter, randomized, controlled trial designed to compare colonoscopy and fecal immunochemical testing in colorectal cancer screening. A total of 4539 individuals undergoing a direct screening colonoscopy were included in this study. INTERVENTION: Colonoscopy. MAIN OUTCOME MEASUREMENTS: Bowel cleansing, sedation, withdrawal time in normal colonoscopies, and cecal intubation were analyzed as possible predictors of adenoma detection by using logistic regression analysis, adjusted for age and sex. RESULTS: In multivariate analysis, after adjustment for age and sex, factors independently related to the ADR were a mean withdrawal time longer than 8 minutes (odds ratio [OR] 1.51; 95% CI, 1.17-1.96) in normal colonoscopies and split preparation (OR 1.26; 95% CI, 1.01-1.57). For advanced adenomas, only withdrawal time maintained statistical significance in the multivariate analysis. For proximal adenomas, withdrawal time and cecal intubation maintained independent statistical significance, whereas only withdrawal time longer than 8 minutes and a <10-hour period between the end of preparation and colonoscopy showed independent associations for distal adenomas. LIMITATIONS: Only endoscopic variables have been analyzed. CONCLUSION: Withdrawal time was the only modifiable factor related to the ADR in colorectal cancer screening colonoscopies associated with an increased detection rate of overall, advanced, proximal, and distal adenomas.

Immunogenicity and acceptance of influenza A (H1N1) vaccine in a cohort of chronic hepatitis C patients receiving pegylated-interferon treatment.

UNLABELLED: BACKGROUND #ENTITYSTARTX00026; AIMS: Individuals at risk of (H1N1) influenza A infection are recommended to receive vaccination. Chronic hepatitis C (CHC) patients receiving treatment might be at a higher risk of respiratory bacterial infections after influenza infection. However, there are no observational studies evaluating the immunogenicity, tolerance and acceptance of 2009 influenza A vaccine in CHC patients. METHODS: We evaluated the immunogenicity of influenza A vaccine (Pandemrix®) by using the hemagglutination inhibition (HI) titers method in a well defined cohort of CHC patients receiving or not receiving pegylated-interferon and ribavirin, and compared it with healthy subjects (controls). A group of patients with inflammatory bowel disease (IBD) under immunosuppression, thought to have a lower immune response to seasonal influenza vaccine, were also included as a negative control group. In addition, tolerance to injection site reactions and acceptance was assessed by a validated questionnaire (Vaccinees' perception of injection-VAPI-questionnaire). RESULTS: Of 114 subjects invited to participate, 68% accepted and, after exclusions, 72 were included. Post-vaccination geometric mean titers and seroprotection/seroconversion rates were optimal in CHC patients with ongoing treatment (n = 15; 232, CI95% 46-1166; 93%; 93%), without treatment (n = 10; 226, CI95% 69-743: 100%; 100%) and controls (n = 15;168, CI95% 42-680; 93%; 86%) with no differences between groups (P = 0.8). In contrast, IBD patients had a significantly lower immunogenic response (n = 27; 60, CI95% 42-680;66%;66%; P = 0.006). All the groups showed a satisfactory tolerance although CHC patients with ongoing treatment showed more local discomfort after vaccine injection. CONCLUSION: There appeared to be no differences between CHC patients and healthy controls in serological response and acceptance of (H1N1) influenza vaccination.

Situación actual del manejo de la hemorragia digestiva alta no varicosa en España / Current management of nonvariceal upper gastrointestinal bleeding in Spain

Introducción La mortalidad en la hemorragia digestiva alta no varicosa (HDA-NV) no ha variado. Se necesita conocer más información para mejorar las estrategias de tratamiento. Los objetivos de este estudio fueron: a) describir el perfil de presentación de los episodios de HDA-NV; b) el manejo clínico según práctica clínica habitual, y c) establecer cuáles son los resultados clínicos asociados a los tratamientos endoscópicos y médicos en España. Métodos ENERGIB fue un estudio retrospectivo de cohortes que recogió información del manejo y forma de presentación de HDA-NV en Europa. Presentamos los datos relativos a España. Los pacientes se trataron según la práctica clínica habitual. Para las variables cuantitativas se calculó la media y la desviación estándar y para las categóricas se calcularon frecuencias absolutas y relativas. Resultados Los pacientes (n = 403) fueron hombres (71%), con edad media 65 años, asociaron comorbilidad (62,5%). Los equipos encargados de su manejo fueron gastroenterólogos (57,1%) o médicos internistas (25,1%). Los inhibidores de la bomba de protones se usaron de forma empírica preendoscopia en un 80% de los casos. El 6,4% presentó persistencia y el 6,7% resangrado después de la endoscopia. La tasa de mortalidad en los 30 días posteriores fue del 3,5%.ConclusionesEste estudio permite conocer el perfil de presentación de los episodios de HDA-NV en España y el manejo en práctica clínica habitual. Este se ajusta a los estándares propuestos por las recientes guías de práctica clínica. Entre otros datos destaca que los pacientes con hemorragia son cada vez de edad más avanzada y presentan un mayor número de enfermedades asociadas, lo que podría explicar que la mortalidad se haya mantenido estable a pesar de los evidentes avances en el manejo de esta entidad (AU)

Background Mortality related to nonvariceal upper gastrointestinal bleeding (NVUGIB) has not changed. More information is needed to improve the management of this entity. The aims of this study were: a) to determine the characteristics of bleeding episodes, b) to describe the clinical approaches routinely used in NVUGIB, and c) to identify adverse outcomes related to endoscopic or medical treatments in Spain. Methods The European survey of nonvariceal upper GI bleeding (ENERGiB) was an observational, retrospective cohort study on NVUGIB with endoscopic evaluation carried out across Europe. The present study focused on Spanish patients in the ENERGiB study. The patients were managed according to routine care. The mean and standard deviation were calculated for quantitative variables and absolute and relative frequencies were calculated for categorical variables. Results Patients (n=403) were mostly men (71%), with a mean age of 65 years, and co-morbidities (62.5%). Most of the patients were managed by gastroenterologists (57.1%) or internal medicine teams (25.1%). A proton pump inhibitor was used empirically in 80% before endoscopy. Bleeding persistence occurred in 6.4% and recurrence in 6.7%. The mortality rate at 30 days was 3.5%.ConclusionsThis study contributes to the characterization of Spanish patients and NVUGIB episodes in a real clinical setting and identifies the routine management of this entity, which is in line with the standards proposed by recent clinical practice guidelines. A notable finding was that age and the number of comorbidities in NVUGIB patients were increasing. These factors could explain the persistent mortality rate, despite the evident advances in the management of this entity (AU)

[Current management of nonvariceal upper gastrointestinal bleeding in Spain]. / Situación actual del manejo de la hemorragia digestiva alta no varicosa en España.

BACKGROUND: Mortality related to nonvariceal upper gastrointestinal bleeding (NVUGIB) has not changed. More information is needed to improve the management of this entity. The aims of this study were: a) to determine the characteristics of bleeding episodes, b) to describe the clinical approaches routinely used in NVUGIB, and c) to identify adverse outcomes related to endoscopic or medical treatments in Spain. METHODS: The European survey of nonvariceal upper GI bleeding (ENERGiB) was an observational, retrospective cohort study on NVUGIB with endoscopic evaluation carried out across Europe. The present study focused on Spanish patients in the ENERGiB study. The patients were managed according to routine care. The mean and standard deviation were calculated for quantitative variables and absolute and relative frequencies were calculated for categorical variables. RESULTS: Patients (n=403) were mostly men (71%), with a mean age of 65 years, and co-morbidities (62.5%). Most of the patients were managed by gastroenterologists (57.1%) or internal medicine teams (25.1%). A proton pump inhibitor was used empirically in 80% before endoscopy. Bleeding persistence occurred in 6.4% and recurrence in 6.7%. The mortality rate at 30 days was 3.5%. CONCLUSIONS: This study contributes to the characterization of Spanish patients and NVUGIB episodes in a real clinical setting and identifies the routine management of this entity, which is in line with the standards proposed by recent clinical practice guidelines. A notable finding was that age and the number of comorbidities in NVUGIB patients were increasing. These factors could explain the persistent mortality rate, despite the evident advances in the management of this entity.