Brendan C. Lethebe

A Randomized Trial Comparing High Definition Colonoscopy Alone With High Definition Dye Spraying and Electronic Virtual Chromoendoscopy for Detection of Colonic Neoplastic Lesions During IBD Surveillance Colonoscopy

Objectives:Dye spraying chromoendoscopy (DCE) is recommended for the detection of colonic neoplastic lesions in inflammatory bowel disease (IBD). The majority of neoplastic lesions are visible endoscopically and therefore targeted biopsies are appropriate for surveillance colonoscopy. To compare three different techniques for surveillance colonoscopy to detect colonic neoplastic lesions in IBD patients: high definition (HD), (DCE), or virtual chromoendoscopy (VCE) using iSCAN image enhanced colonoscopy.Methods:A randomized non-inferiority trial was conducted to determine the detection rates of neoplastic lesions in IBD patients with longstanding colitis. Patients with inactive disease were enrolled into three arms of the study. Endoscopic neoplastic lesions were classified by the Paris classification and Kudo pit pattern, then histologically classified by the Vienna classification.Results:A total of 270 patients (55% men; age range 20–77 years, median age 49 years) were assessed by HD (n=90), VCE (n=90), or DCE (n=90). Neoplastic lesion detection rates in the VCE arm was non-inferior to the DCE arm. HD was non-inferior to either DCE or VCE for detection of all neoplastic lesions. In the lesions detected, location at right colon and the Kudo pit pattern were predictive of neoplastic lesions (OR 6.52 (1.98–22.5 and OR 21.50 (8.65–60.10), respectively).Conclusions:In this randomized trial, VCE or HD-WLE is not inferior to dye spraying colonoscopy for detection of colonic neoplastic lesions during surveillance colonoscopy. In fact, in this study HD-WLE alone was sufficient for detection of dysplasia, adenocarcinoma or all neoplastic lesions.

Identification of validated case definitions for chronic disease using electronic medical records: a systematic review protocol

BackgroundPrimary care electronic medical record (EMR) data are being used for research, surveillance, and clinical monitoring. To broaden the reach and usability of EMR data, case definitions must be specified to identify and characterize important chronic conditions. The purpose of this study is to identify all case definitions for a set of chronic conditions that have been tested and validated in primary care EMR and EMR-linked data. This work will provide a reference list of case definitions, together with their performance metrics, and will identify gaps where new case definitions are needed.MethodsWe will consider a set of 40 chronic conditions, previously identified as potentially important for surveillance in a review of multimorbidity measures. We will perform a systematic search of the published literature to identify studies that describe case definitions for clinical conditions in EMR data and report the performance of these definitions. We will stratify our search by studies that use EMR data alone and those that use EMR-linked data. We will compare the performance of different definitions for the same conditions and explore the influence of data source, jurisdiction, and patient population.DiscussionEMR data from primary care providers can be compiled and used for benefit by the healthcare system. Not only does this work have the potential to further develop disease surveillance and health knowledge, EMR surveillance systems can provide rapid feedback to participating physicians regarding their patients. Existing case definitions will serve as a starting point for the development and validation of new case definitions and will enable better surveillance, research, and practice feedback based on detailed clinical EMR data.Systematic review registrationPROSPERO CRD42016040020

Age-specific global epidemiology of hydrocephalus: Systematic review, metanalysis and global birth surveillance

Background Hydrocephalus is a debilitating disorder, affecting all age groups. Evaluation of its global epidemiology is required for healthcare planning and resource allocation. Objectives To define age-specific global prevalence and incidence of hydrocephalus. Methods Population-based studies reporting prevalence of hydrocephalus were identified (MEDLINE, EMBASE, Cochrane, and Google Scholar (1985–2017)). Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Two authors reviewed abstracts, full text articles and abstracted data. Metanalysis and meta-regressions were used to assess associations between key variables. Heterogeneity and publication bias were assessed. Main outcome of interest was hydrocephalus prevalence among pediatric (≤ 18 years), adults (19–64 years), and elderly (≥ 65) patients. Annual hydrocephalus incidence stratified by country income level and folate fortification requirements were obtained (2003–2014) from the International Clearinghouse for Birth Defects Surveillance and Research (ICBDSR). Results Of 2,460 abstracts, 52 met review eligibility criteria (aggregate population 171,558,651). Mean hydrocephalus prevalence was 85/100,000 [95% CI 62, 116]. The prevalence was 88/100,000 [95% CI 72, 107] in pediatrics; 11/100,000 [95% CI 5, 25] in adults; and 175/100,000 [95% CI 67, 458] in the elderly. The ICBDSR-based incidence of hydrocephalus diagnosed at birth remained stable over 11 years: 81/100,000 [95% CI 69, 96]. A significantly lower incidence was identified in high-income countries. Conclusion This systematic review established age-specific global hydrocephalus prevalence. While high-income countries had a lower hydrocephalus incidence according to the ICBDSR registry, folate fortification status was not associated with incidence. Our findings may inform future healthcare resource allocation and study.

Identification of validated case definitions for medical conditions used in primary care electronic medical record databases: a systematic review

Objectives Data derived from primary care electronic medical records (EMRs) are being used for research and surveillance. Case definitions are required to identify patients with specific conditions in EMR data with a degree of accuracy. The purpose of this study is to identify and provide a summary of case definitions that have been validated in primary care EMR data. Materials and Methods We searched MEDLINE and Embase (from inception to June 2016) to identify studies that describe case definitions for clinical conditions in EMR data and report on the performance metrics of these definitions. Results We identified 40 studies reporting on case definitions for 47 unique clinical conditions. The studies used combinations of International Classification of Disease version 9 (ICD-9) codes, Read codes, laboratory values, and medications in their algorithms. The most common validation metric reported was positive predictive value, with inconsistent reporting of sensitivity and specificity. Discussion This review describes validated case definitions derived in primary care EMR data, which can be used to understand disease patterns and prevalence among primary care populations. Limitations include incomplete reporting of performance metrics and uncertainty regarding performance of case definitions across different EMR databases and countries. Conclusion Our review found a significant number of validated case definitions with good performance for use in primary care EMR data. These could be applied to other EMR databases in similar contexts and may enable better disease surveillance when using clinical EMR data. Consistent reporting across validation studies using EMR data would facilitate comparison across studies. Systematic review registration PROSPERO CRD42016040020 (submitted June 8, 2016, and last revised June 14, 2016).

Location and Kudo Pit Pattern Reflect Neoplastic Histology of Lesions Detected at Surveillance Colonoscopy in Inflammatory Bowel Disease

Introduction Effective colonoscopic surveillance of IBD benefit from having reliable predictors of neoplasia, since targeted biopsies and endoscopic resection are increasingly used as standard of practice. It is not clear whether Kudo pit patterns may be applicable in characterising IBD associated lesions. We aimed to identify the specific clinical and endoscopic features of colonic lesions which predict dysplasia in IBD. Method All lesions identified in a randomised study to determine the detection rates of neoplastic lesion (NL) in patients with long standing colitis in IBD ( NCT02098798) were included. NL were classified by the Paris classification, Kudo pit pattern, and by the Vienna classification. Univariate analysis was performed, and age, duration of disease, extra-intestinal manifestations,family or personal history of polyps/cancer, smoking, size of lesion, Paris classification, Kudo pit pattern, localization/extension were considered .Subsequently a multivariate logistic regression model analyses was created and analysed with candidate variables which had p values≤0.05 on univariate analysis. Results A total of 270 patients (55% men; median age 49y) were assessed by High Definition (n=90), virtual chromoendoscopy (n=90) or dye chromoendoscopy (n=90). Among 270 patients, ninety- one (33.7%) colonic dysplastic lesions and 1 adenocarcinoma were found. Sixty–two (68.8%) were polypoid and twenty-nine (31.8%) were non polypoid. Most of these lesions (92.3%) had Kudo pit pattern III-V. By univariate analysis, age- Odds Ratio (OR) 1.05 (95% CI:1.02–1.08), localization of the lesions in the right colon- OR 6.15 ( 95% CI: 3.12–12.12), Kudo pit pattern IIO, III-IV and V- OR 20.91 (95% CI:9.34–46.7) and Paris Is/Ip classification OR- 3.29 (95% CI 1.69–6.38) were associated with NL. Subsequently proportional multivariate logistic regression model for the prediction of colonic neoplasia confirmed that the endoscopic Kudo pit pattern- OR 21.50 (95% CI:86.5–60.1) and localization of the lesions in the right colon- OR 6.52 (95% CI:1.98–22.5) were predictors of colonic neoplasia at surveillance colonoscopy in IBD (Table). The overall accuracy of independent variables which predict neoplastic histological changes was 78% (95% CI 68%–88%), sensitivity 82% (95% CI 68%–97%), specificity 68% (95% CI 47%–89%), PPV 85% (95% CI 76%–95%) and NPV 64% (95% CI 42%–86%) which were significant in the multivariate analysis. Conclusion We demonstrated that the endoscopic Kudo pit pattern and localization of the lesions in the right colon were predictors of neoplasia in IBD. This may guide management strategy of NL detected at IBD surveillance. Disclosure of Interest M. Iacucci Conflict with: Pentax, O Akinola: None Declared, R Panaccione: None Declared, G Kaplan: None Declared, Y Leung: None Declared, K Novak: None Declared, C Seow: None Declared, X Gui: None Declared, S Urbanski: None Declared, P Minoo: None Declared, B Lethebe: None Declared, M Lowerison: None Declared, S Ghosh: None Declared