Changes in Adenoma Detection Rate From Full-Spectrum Endoscopy to Standard Forward-Viewing Endoscopy.

GOALS: The aim was to investigate the adenoma detection rate (ADR) of endoscopists who have used full-spectrum endoscopy (Fuse) for 3 years and revert back to traditional forward-viewing endoscopes (R-TFV) at an ambulatory surgical center. BACKGROUND: Traditional forward viewing (TFV) endoscopes have 1 camera and provide an angle of view of 140 to 170 degrees, whereas Fuse provides a 330 degrees view through the addition of 2 side cameras. It has previously been reported that Fuse increased the ADR by 5.4% when compared with previous rates using TFV. Fuse is no longer commercially available. The ADR of endoscopists who revert back to TFV is unknown. STUDY: We conducted a retrospective analysis of data examining the ADR from average risk screening colonoscopies at a 5-room ambulatory surgical center where endoscopists transitioned from TFV to Fuse in April 2014 and then reverted back to TFV in 2016. The primary outcome was ADR. Secondary outcomes were ADR for advanced and right-sided adenomas. RESULTS: A total of 6110 procedures were reviewed. The ADR was 23.70% for TFV, 29.02% for Fuse and 28.88% for R-TFV. The ADR for advanced adenomas was 3.8% for TFV, 6.0% for Fuse and 7.3% for R-TFV. The ADR for right-sided adenomas was 13.0% for TFV, 16.7% for Fuse and 16.0% for R-TFV. The results for all 3 categories showed a statistical difference between TFV and Fuse as well as between TFV and R-TFV. There were no statistical differences between the ADR of Fuse compared with R-TFV. CONCLUSIONS: During R-TFV, endoscopists are able to maintain their increased ability to detect adenomas. This would suggest that there was a change in behavior in endoscopists using Fuse that was durable.

A survey of gastroenterologists in the United States on the use of central neuromodulators for treating irritable bowel syndrome.

BACKGROUND: Central neuromodulators are an effective treatment for irritable bowel syndrome (IBS) but may be used less frequently than other therapies. AIMS: To survey gastroenterologists in the United States (US) about their use of neuromodulators in patients with IBS. METHODS: A 23-question survey was distributed to gastroenterologists in the United States. Comparisons in prescribing practices were conducted between (a) gastroenterologists who were "high prescribers" versus "low prescribers" of neuromodulators in patients with IBS and (b) gastroenterologists and "gastroenterology experts" in the use of neuromodulators using descriptive statistics and multivariable logistic regression analyses. RESULTS: The 525 gastroenterologists who were surveyed used neuromodulators for a median range of 21%-30% of their patients with IBS. Neuromodulators were described as extremely/very important in managing IBS by 55% of clinicians. Significant predictors of high-prescribing behaviour were academic versus clinical practice setting (odds ratio [OR] 2.60 [95% CI 1.61-4.20]), disorders of brain-gut interaction focused practice (OR 4.80 [2.60-8.84]), and greater perceived effectiveness of neuromodulators (OR 2.75 [1.30-5.84]). Compared to gastroenterologists, experts prescribed neuromodulators to a higher percentage of their patients with IBS (41%-50% vs 21%-30%; P = 0.019) and more frequently found neuromodulators effective (70% vs 27%; P = 0.003). However, concern about side effects was the most common barrier to neuromodulator use (59%). CONCLUSIONS: The majority of US gastroenterologists believe central neuromodulators are important in treating IBS, and 27% believe they are effective in most patients. High prescribers are in academic practice, focus in IBS and perceive central neuromodulators as effective. Education is needed to improve gastroenterologists' prescribing behaviour.

Changes in Adenoma Detection Rate With Implementation of Full-spectrum Endoscopy: A Report of 3998 Screening Colonoscopies.

GOALS: To investigate the effect of implementing full-spectrum endoscopy (Fuse) on adenoma detection rate (ADR) at an ambulatory surgical center (ASC). BACKGROUND: Traditional forward viewing (TFV) endoscopes have 1 camera and provide an angle of view of 140 to 170 degrees, whereas Fuse provides a 330 degrees view through the addition of 2 side cameras. Although randomized studies have shown that Fuse decreases adenoma miss rates, its impact on ADR in a screening population is currently unknown. STUDY: We conducted a retrospective analysis of data from average risk screening colonoscopies at a 5-room ASC. This ASC transitioned from TFV to Fuse in April 2014. The primary outcome was ADR defined as the percentage of patients who underwent screening colonoscopy and were found to have at least 1 adenomatous polyp. RESULTS: A total of 1696 screening colonoscopies were performed with TFV and 2302 with Fuse. Overall ADR was 23.7% with TFV and 29.0% with Fuse (P<0.01), an absolute increase of 5.3%. ADR for the proximal colon increased from 13.0% with TFV to 16.7% with Fuse (3.8% increase, P<0.01). ADR for advanced adenomas improved from 3.8% with TFV to 6.0% with Fuse (2.2% increase; P<0.01). The mean number of adenomas detected per colonoscopy increased from 0.32 to 0.41 (P<0.01). In multivariate analysis, the adjusted odds ratio for detecting an adenoma with Fuse versus TFV was 1.30 (P<0.01; 95% confidence interval, 1.11-1.51). CONCLUSIONS: ADR significantly increased after adopting Fuse endoscopes at an ASC. Further studies are warranted to further understand the effects of Fuse on ADR in real-world settings.

Ultrasound-guided wire localization of focal ductal dilatation in the evaluation and treatment of pathologic nipple discharge.

Patients presenting with pathologic nipple discharge (PND) often pose a diagnostic and therapeutic challenge. We used ultrasound to identify focal ductal dilatation-hypothesized to be a radiographic manifestation of the causative lesion-in patients with PND and no relevant clinical or radiographic findings. Twenty-two excisions guided by ultrasound wire localization of focal duct dilation were performed. Surgical pathology revealed papilloma in 20 cases (91%); atypia or carcinoma was detected in 7 cases (32%). The ultrasound finding of focal duct dilatation enables excision of otherwise occult though clinically significant lesions and is worthy of further study.

Practices, attitudes, and knowledge about Crohn's disease and smoking cessation among gastroenterologists.

OBJECTIVE: Cigarette smoking is one of the most important, modifiable environmental factors in Crohn's disease (CD) and screening for tobacco use is an official recommendation and quality measure in the care of CD patients. The objective of this study was to learn more about gastroenterologists' practices, opinions, and knowledge in this area. PATIENTS AND METHODS: A 15 question survey was sent through email to two national gastroenterology distribution lists. Questions were written in multiple choice formats and were designed to collect information about gastroenterologists' practices, attitudes, and knowledge regarding smoking cessation in CD patients. Responses were stratified by practice setting, experience, and inflammatory bowel disease-focus. Responses were anonymous and were collected in a secure, online database. RESULTS: A total of 141 respondents completed the survey. Overall, 89% of participants screened their CD patients for smoking more than 75% of the time. In all, 62% provided smoking cessation counseling more than 75% of the time. Overall, 94% of respondents felt comfortable discussing the benefits of smoking cessation with their patients. In all, 56% felt comfortable discussing smoking cessation strategies with their patients. Overall, 88% of respondents agreed that gastroenterologists should provide smoking cessation counseling; however, 43 and 11% agreed that the gastroenterologist should be the primary counselor and primary prescriber of cessation-related pharmacotherapy, respectively. CONCLUSION: Surveyed gastroenterologists agree that smoking cessation is an important part of the care of CD patients and this is reflected in their screening practices. Counseling occurs irregularly and many gastroenterologists do not feel comfortable discussing cessation strategies. Future guidelines should provide further guidance on the gastroenterologist's role in smoking cessation counseling for CD patients.

Severe Ileocolonic Crohn's Disease Flare Associated with Fecal Microbiota Transplantation Requiring Diverting Ileostomy.

Patients with inflammatory bowel disease (IBD) are at increased risk of developing Clostridium difficile infection (CDI). Fecal microbiota transplantation (FMT) is an effective therapy with a high success rate in preventing recurrent CDI. However, patients with IBD have decreased response to FMT for recurrent CDI, with several reports also suggesting potential IBD flare post-FMT. We present a case of mild ileocolonic Crohn's disease in a patient treated with FMT for recurrent CDI who subsequently developed severe steroid-refractory flare requiring surgical intervention 1 week post-FMT. Greater understanding of risk factors associated with post-FMT IBD flare is indicated.

Effect of aromatase inhibitors on background parenchymal enhancement and amount of fibroglandular tissue at breast MR imaging.

PURPOSE: To evaluate whether treatment with an aromatase inhibitor (AI) influences background parenchymal enhancement (BPE) or amount of fibroglandular tissue (FGT) at breast magnetic resonance (MR) imaging in postmenopausal women with prior history of breast cancer. MATERIALS AND METHODS: A waiver of authorization and patient consent was granted by the institutional review board for this HIPAA-compliant retrospective study. Postmenopausal women with breast cancer and MR imaging findings of the contralateral unaffected breast, before and during 6-12 months of AI treatment (anastrozole, letrozole, or exemestane), between August 1999 and June 2010 were retrospectively identified (n = 149). Two readers performed blinded side-by-side comparison of BPE and MR imaging-depicted FGT before and during treatment. BPE and FGT were classified as the same or greater on one of the two MR studies and by using categorical scales: minimal, mild, moderate, or marked for BPE and fatty, scattered, heterogeneously dense, or dense for FGT. Consensus was reached in cases of disagreement. The sign test was used to conduct a side-by-side comparison of BPE and FGT before and during AI treatment. RESULTS: A decrease in BPE occurred in 33.9% (37 of 109) of women during anastrozole treatment, while an increase occurred in only one (P < .0001); 28 of 37 decreases resulted in a category change of BPE. A decrease in MR imaging-depicted FGT occurred in 5.5% (six of 109) of women, while no increases occurred (P = .031). During letrozole treatment, a decrease in BPE occurred in 46% (15 of 33), while an increase occurred in one woman (P = .0003); a decrease in FGT occurred in only one woman, and no increases occurred. Similar results were seen when women also undergoing chemotherapy were excluded. Only seven women were treated with exemestane. CONCLUSION: Treatment with 6-12 months of anastrozole or letrozole was associated with decreases in BPE, which occurred in a greater proportion of women than decreases in FGT.

A feasibility study of bevacizumab plus dose-dense doxorubicin-cyclophosphamide (AC) followed by nanoparticle albumin-bound paclitaxel in early-stage breast cancer.

PURPOSE: Bevacizumab confers benefits in metastatic breast cancer but may be more effective as adjuvant therapy. We evaluated the cardiac safety of bevacizumab plus dose-dense doxorubicin-cyclophosphamide (ddAC) → nanoparticle albumin-bound (nab)-paclitaxel in human epidermal growth factor receptor 2 normal early-stage breast cancer. EXPERIMENTAL DESIGN: Eighty patients with normal left ventricular ejection fraction (LVEF) were enrolled. Bevacizumab was administered for 1 year, concurrently with ddAC → nab-paclitaxel then as a single agent. LVEF was evaluated at months 0, 2, 6, 9, and 18. This regimen was considered safe if fewer than three cardiac events or fewer than two deaths from left ventricular dysfunction occurred. Correlative studies of cardiac troponin (cTn) and plasma renin activity (PRA) were conducted. RESULTS: The median age was 48 years (range, 27-75 years), and baseline LVEF was 68% (53%-82%). After 39 months' median follow-up (5-45 months): median LVEF was 68% (53%-80%) at 2 months (n = 78), 64% (51%-77%) at 6 months (n = 66), 63% (48%-77%) at 9 months (n = 61), and 66% (42%-76%) at 18 months (n = 54). One patient developed symptomatic LV dysfunction at month 15. Common toxicities necessitating treatment discontinuation were hypertension (HTN, 4%), wound-healing complications (4%), and asymptomatic LVEF declines (4%). Neither cTn nor PRA predicted congestive heart failure (CHF) or HTN, respectively. CONCLUSIONS: Bevacizumab with ddAC → nab-paclitaxel had a low rate of cardiac events; cTn and PRA levels are not predictive of CHF or HTN, respectively. The efficacy of bevacizumab as adjuvant treatment will be established in several ongoing phase III trials.

Dose-dense adjuvant Doxorubicin and cyclophosphamide is not associated with frequent short-term changes in left ventricular ejection fraction.

PURPOSE: Doxorubicin and cyclophosphamide (AC) every 3 weeks has been associated with frequent asymptomatic declines in left ventricular ejection fraction (LVEF). Dose-dense (dd) AC followed by paclitaxel (P) is superior to the same regimen given every third week. Herein, we report the early cardiac safety of three sequential studies of ddAC alone or with bevacizumab (B). PATIENTS AND METHODS: Patients with HER2-positive breast cancer were treated on two trials: ddAC followed by P and trastuzumab (T) and ddAC followed by PT and lapatinib. Patients with HER2-normal breast cancer were treated with B and ddAC followed by B and nanoparticle albumin-bound P. Prospective LVEF measurement by multigated radionuclide angiography scan before and after every 2 week AC for 4 cycles and at month 6 from all three trials were aggregated to determine the early risks of cardiac dysfunction. RESULTS: From January 2005 to May 2008, 245 patients were enrolled. The median age was 47 years (range, 27 to 75 years). Median LVEF pre-ddAC was 68% (range, 52% to 82%). LVEF post-ddAC was available in 241 patients (98%) and the median was unchanged at 68% (range, 47% to 81%). Per protocol no patients were ineligible for subsequent targeted biologic therapy based on LVEF decline post-ddAC. In addition, LVEF was available in 222 patients (92%) at 6 months, at which time the median LVEF was similar at 65% (range, 24% to 80%). Within 6 months of initiating chemotherapy, three patients (1.2%; 95% CI, 0.25% to 3.54%) developed CHF, all of whom received T. CONCLUSION: Dose-dense AC with or without concurrent bevacizumab is not associated with frequent acute or short-term declines in LVEF.