Ananya Das

Does prophylactic pancreatic stent placement reduce the risk of post-ERCP acute pancreatitis? A meta-analysis of controlled trials

BACKGROUNDnImpaired drainage of the pancreatic duct is one of the possible triggers for post-ERCP acute pancreatitis. The aim of this meta-analysis was to determine whether temporary stent placement across the main pancreatic-duct orifice lowers the frequency of post-ERCP acute pancreatitis in patients at high risk for this complication.nnnMETHODSnTwo reviewers systematically identified prospective studies that (1) compared the risk of post-ERCP acute pancreatitis in patients with pancreatic stent placement vs. no stent placement and (2) included patients at high risk of developing this complication. Studies were assessed for methodologic quality and variations in execution and design. Frequency and severity of post-ERCP acute pancreatitis were the primary outcomes evaluated.nnnRESULTSnFive trials involving 481 patients were selected. Of the 481, 55 (11.4%) patients developed pancreatitis after ERCP. Patients in the no stent group had 3-fold higher odds of developing pancreatitis compared with the stent group (15.5% vs. 5.8%; OR 3.2: 95% CI[1.6, 6.4]). Number needed to treat analysis showed that one in every 10 patients (95% CI[6,18]) could be expected to benefit from pancreatic-duct stent placement.nnnCONCLUSIONSnProphylactic temporary stent placement across the main pancreatic-duct orifice reduces the risk of post-ERCP acute pancreatitis in patients at risk for developing this complication.

The changing landscape of practice patterns regarding unsedated endoscopy and propofol use: A national Web survey

BACKGROUNDnLower reimbursements for endoscopic procedures and increasing demand for screening endoscopy over the past decade have spurred efforts to increase efficiency in the performance of endoscopic procedures. Two dichotomous approaches have emerged: (1) unsedated endoscopy and (2) propofol sedation. The aim was to determine national practice patterns of unsedated endoscopy and propofol sedation, and to assess endoscopists attitudes toward unsedated screening with an electronic survey.nnnMETHODSnA short survey was developed and then was converted to a Web-based format. All national members of the American Society for Gastrointestinal Endoscopy (ASGE) were invited via electronic mail (e-mail) to participate. Survey data were collected electronically.nnnRESULTSnTwo e-mails elicited responses to the Web survey from 18% (724) of national ASGE members contacted, within 2 weeks. Of the respondents, 45% do not routinely offer unsedated EGD and colonoscopy, and only 15% of those respondents plan to incorporate unsedated endoscopy into their practice in the next year. Of the 55% who currently perform unsedated endoscopy, 85% do no more than 25 unsedated procedures per year. Lack of patient acceptance was the most common reason cited for not offering unsedated endoscopy. Most endoscopists felt that the availability of unsedated esophagoscopy or colonoscopy would not significantly increase screening for Barretts esophagus or colonic polyps/colorectal cancer, respectively. Routine use of propofol sedation for EGD, colonoscopy, and ERCP/EUS was reported by 19%, 22%, and 19%, respectively. Community practitioners were more likely to use propofol than those at academic centers (p < 0.0002 for all). Of those not currently using propofol, 43% plan to incorporate it into their practice within the next year. Over 70% of respondents would themselves choose to be sedated for routine endoscopic procedures.nnnCONCLUSIONSnElectronic surveys allow for rapid distribution and data collection but suffer from a limited response rate. The survey suggests that unsedated endoscopy has limited acceptance in the United States, and, without a major intervention that affects endoscopists attitudes, its use is not likely to increase significantly. Unsedated endoscopy will not have a great impact on endoscopic screening. In contrast, propofol sedation has already gained acceptance in the community, and the routine use of propofol in endoscopy units will likely increase in the future.

Prediction of outcome in acute lower-gastrointestinal haemorrhage based on an artificial neural network: internal and external validation of a predictive model

BACKGROUNDnModels based on artificial neural networks (ANN) are useful in predicting outcome of various disorders. There is currently no useful predictive model for risk assessment in acute lower-gastrointestinal haemorrhage. We investigated whether ANN models using information available during triage could predict clinical outcome in patients with this disorder.nnnMETHODSnANN and multiple-logistic-regression (MLR) models were constructed from non-endoscopic data of patients admitted with acute lower-gastrointestinal haemorrhage. The performance of ANN in classifying patients into high-risk and low-risk groups was compared with that of another validated scoring system (BLEED), with the outcome variables recurrent bleeding, death, and therapeutic interventions for control of haemorrhage. The ANN models were trained with data from patients admitted to the primary institution during the first 12 months (n=120) and then internally validated with data from patients admitted to the same institution during the next 6 months (n=70). The ANN models were then externally validated and direct comparison made with MLR in patients admitted to an independent institution in another US state (n=142).nnnFINDINGSnClinical features were similar for training and validation groups. The predictive accuracy of ANN was significantly better than that of BLEED (predictive accuracy in internal validation group for death 87% vs 21%; for recurrent bleeding 89% vs 41%; and for intervention 96% vs 46%) and similar to MLR. During external validation, ANN performed well in predicting death (97%), recurrent bleeding (93%), and need for intervention (94%), and it was superior to MLR (70%, 73%, and 70%, respectively).nnnINTERPRETATIONnANN can accurately predict the outcome for patients presenting with acute lower-gastrointestinal haemorrhage and may be generally useful for the risk stratification of these patients.

Prediction of outcome of acute GI hemorrhage: a review of risk scores and predictive models.

Patients with acute GI hemorrhage are encountered on an almost daily basis by gastroenterologists, endoscopists, emergency room physicians, and other health care personnel. Acute GI hemorrhage encompasses a spectrum of bleeding lesions from the upper GI tract and the small bowel to the colon and the rectum. It is associated with substantial patient morbidity and mortality, as well as economic cost. 1-6 Over the last few decades, the diagnosis and the management of acute GI hemorrhage has undergone remarkable changes, particularly with the rapid dissemination and advancement of diagnostic and therapeutic endoscopy and pharmacotherapeutics. Moreover, by extensive early application of endoscopic evaluation, the natural history and the diverse etiology of acute GI hemorrhage is much better understood today than in the past. Physicians have long been aware that the clinical outcome of an episode of acute GI hemorrhage can be predicted with reasonable accuracy and that such a prediction may be useful in patient management. Although it is difficult to prove a beneficial impact on overall patient mortality, a strong argument can be made that improved medical decision making, particularly at the initial patient triage level, may lead to improvements in patient management, outcome, and resource utilization. 2,7-15 Thus, with the current focus on the economic aspects of health care delivery, it is not surprising that there is increased interest in the early risk stratification of patients with acute GI hemorrhage so that they can be triaged to appropriate, cost-effective levels of care. This review summarizes and critically appraises the major clinical scoring systems promulgated in

Cytomegalovirus Infection in Solid Organ Transplantation: Economic Implications

Cytomegalovirus (CMV) is a pathogen, commonly encountered in the recipients of solid organ transplantation and is an important cause of morbidity and mortality in these patients. CMV infection and disease have been shown to increase the cost of care in transplant recipients and several different strategies of prevention have been shown to be effective in clinical trials. A systematic review of published information on the economic impact of CMV in solid organ transplantation was performed; both clinical- and decision-analysis-based studies were reviewed.Clinical studies have shown that CMV infection and disease is associated with increased length of hospital stay and overall costs. Decision-analysis-based studies suggest that in general, antiviral chemoprophylaxis against CMV in transplant recipients is a cost-effective intervention compared with other established healthcare interventions such as strategies for colorectal cancer screening. Prophylaxis with oral or parenteral ganciclovir is probably the most cost-effective strategy; however, restricting prophylaxis to high-risk groups (such as donor seropositive/recipient seronegative status and the use of an antilymphocyte antibody) or chemoprophylaxis for an extended period does not improve cost effectiveness. Pre-emptive therapy is an evolving strategy for prevention of CMV disease in transplant recipients and is rapidly gaining in popularity. Well-designed trials incorporating prospective cost data and comparing pre-emptive therapy versus conventional antiviral prophylaxis are needed to establish the superiority of one strategy over the other.

A cost analysis of long term antibiotic prophylaxis for spontaneous bacterial peritonitis in cirrhosis

Objective:The aim of this study was to perform a cost analysis of different strategies of long term antibiotic prophylaxis for spontaneous bacterial peritonitis (SBP) in patients with cirrhosis and ascites. The study involved a cost analysis using a decision analysis model and patients with cirrhosis and ascites who are at risk for developing SBP.Methods:Two different strategies of antibiotic prophylaxis were compared with a “no prophylaxis” strategy in patients with cirrhosis and ascites using a decision analysis model. In strategy I, antibiotic prophylaxis was administered in all patients with cirrhosis and ascites and in strategy II, patients were stratified into a low risk and a high risk group on the basis of serum bilirubin and ascitic fluid protein levels; only patients in the high risk group received antibiotic prophylaxis. The cost per patient treated for 1 yr was the outcome measure compared in the different strategies. Clinical input probabilities and ranges used were obtained by searching the MEDLINE database for English language articles. Cost estimates were obtained from a university hospital setting. Cost analysis was done with a societal perspective, and only direct costs were taken into account. Sensitivity analyses were performed to evaluate the effect of variations in the key clinical probabilities and cost estimates ranging from a best case to a worst case scenario on the outcome measure.Results:The estimated cost per patient treated in strategy I, strategy II, and strategy III (the strategy of “no prophylaxis”) were

An international survey of the clinical practice of EUS

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Efficacy of manometry based endoscopic sphincterotomy in sphincter of Oddi dysfunction: a meta-analysis of controlled trials

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4505 Fecal occult blood testing - are we training medical students and residents well enough?

3509, respectively. Over a broad range of clinical and cost variables, the strategy of risk stratification and restriction of antibiotic prophylaxis to the subgroup of patients with cirrhosis and ascites who were at high risk for SBP (as identified by serum bilirubin >2.5 mg/dl and ascitic fluid protein <1 g/dl) was the most favored strategy. However, when the cost of prophylaxis was low or the probability of a primary episode of SBP was at the lower end of the range reported in the literature, administering antibiotic prophylaxis to all patients with cirrhosis and ascites was the least costly strategy.Conclusion:This cost analysis indicates that antibiotic prophylaxis particularly when restricted to a subgroup of patients who, by simple laboratory parameters, are identified to be at high risk for SBP, is very cost-effective in the prevention of SBP in patients with cirrhosis and ascites.

6949 Familial association of barrett's esophagus and esophageal adenocarcinoma.

BACKGROUNDnNo comparative information exists regarding clinical variations in EUS practice patterns among American and international endosonographers.nnnMETHODSnEligible attendees of the XIIIth International Symposium on EUS, October 4-6 2002, New York, New York, were asked to complete a 2-page survey questionnaire on clinical practice of EUS.nnnRESULTSnA total of 191 of 391 eligible attendees (48.9%) participated in the survey (110 from the United States, 81 from 30 different countries). The mean age of participants was 40.5 (10.6) years, and 171 (89.5%) were men. A total of 102 endosonographers (53.4%) were in academic practice. The majority (150, 78.5%) also performed ERCP. Seventy-eight (40.8%) had performed EUS for more than 5 years and 21 (11%) for less than 1 year. Only 36 (18.8%) had more than 6 months of dedicated hands-on EUS training, and more than a third of the respondents learned to perform EUS by observing others or they were self-taught. Compared with respondents from the United States, relatively fewer international respondents were performing open-access EUS, pancreatobiliary EUS procedures, and interventions such as EUS-guided FNA and celiac plexus neuralysis.nnnCONCLUSIONSnThis survey provides insight into the status of EUS as practiced in the United States and internationally. Although it appears that over the last decade EUS has become disseminated fairly uniformly on a global basis, a lack of consistent training standards and also inadequate opportunities for EUS training remain important areas of concern.