Brian Yan

EUS-guided gold fiducial insertion for image-guided radiation therapy of pancreatic cancer: 50 successful cases without fluoroscopy.

BACKGROUND Image-guided radiation therapy (IGRT) accurately delivers a high dose of potentially tumoricidal radiation to its target while sparing adjacent healthy tissue. Application of IGRT to unresectable pancreatic cancer requires the use of fiducials to track the precise location of the tumor. Fiducial markers have been successfully placed endoscopically. OBJECTIVE To determine the feasibility of EUS-guided gold fiducial placement for IGRT. DESIGN Prospective case series. SETTING Tertiary medical center. PATIENTS Consecutively referred patients with locally advanced unresectable pancreatic adenocarcinoma for EUS-guided insertion of gold fiducials from December 2006 to February 2009. INTERVENTIONS Under only EUS guidance, fiducial markers were deployed into or near the tumor by using a 19-gauge needle. In most cases, a sterile water injection technique was used to insert the fiducials. Fluoroscopy was not used in any case. MAIN OUTCOME MEASUREMENTS Successful placement of an adequate number of fiducials to proceed with IGRT as determined by CT. RESULTS Fifty-seven consecutive patients were included. Fifty cases (88%) were successful. Of the cases in which fiducial placement was attempted and follow-up was adequate, 94% (50 of 53) of cases were successful. LIMITATIONS Single-center, nonrandomized study. CONCLUSIONS EUS-guided fine-needle insertion was safe and effective in delivering gold fiducial markers for image-guided radiation therapy. Fluoroscopy was not required for successful fiducial placement.

Defining quality indicators for best-practice management of inflammatory bowel disease in Canada.

BACKGROUND There is a paucity of published data regarding the quality of care of inflammatory bowel disease (IBD) in Canada. Clinical quality indicators are quantitative end points used to guide, monitor and improve the quality of patient care. In Canada, where universal health care can vary significantly among provinces, quality indicators can be used to identify potential gaps in the delivery of IBD care and standardize the approach to interprovincial management. METHODS The Emerging Practice in IBD Collaborative (EPIC) group generated a shortlist of IBD quality indicators based on a comprehensive literature review. An iterative voting process was used to select quality indicators to take forward. In a face-to-face meeting with the EPIC group, available evidence to support each quality indicator was presented by the EPIC member aligned to it, followed by group discussion to agree on the wording of the statements. The selected quality indicators were then ratified in a final vote by all EPIC members. RESULTS Eleven quality indicators for the management of IBD within the single-payer health care system of Canada were developed. These focus on accurate diagnosis, appropriate and timely management, disease monitoring, and prevention or treatment of complications of IBD or its therapy. CONCLUSIONS These quality indicators are measurable, reflective of the evidence base and expert opinion, and define a standard of care that is at least a minimum that should be expected for IBD management in Canada. The next steps for the EPIC group involve conducting research to assess current practice across Canada as it pertains to these quality indicators and to measure the impact of each of these indicators on patient outcomes.

Self-Screening for Malnutrition Risk in Outpatient Inflammatory Bowel Disease Patients Using the Malnutrition Universal Screening Tool (MUST)

BACKGROUND AND AIMS Malnutrition is common in patients with inflammatory bowel disease (IBD) and is associated with poor outcomes. Our aim is to determine if patient self-administered malnutrition screening using the malnutrition universal screening tool (MUST) is reliable by comparing patient scores with those derived from the healthcare practitioner (HCP), the gold standard. METHODS We conducted a prospective validation study at a tertiary Canadian academic center that included 154 adult outpatients with IBD. All patients with IBD completed a self-administered nutrition screening assessment using the MUST score followed by an independent MUST assessment performed by HCPs. The main outcome measure was chance-corrected agreement (κ) of malnutrition risk categorization. RESULTS For patient-administered MUST, the chance-corrected agreement κ (95% confidence interval [CI]) was 0.83 (0.74-0.92) when comparing low-risk and combined medium- and high-risk patients with HCP screening. Weighted κ analysis comparing all 3 risks groups yielded a κ (95% CI) of 0.85 (0.77-0.93) between patient and HCP screening. All patients were able to screen themselves. Overall, 96% of patients reported the MUST questionnaire as either very easy or easy to understand and to complete. CONCLUSION Self-administered nutrition screening in outpatients with IBD is valid using the MUST screening tool and is easy to use. If adopted, this tool will increase utilization of malnutrition screening in hectic outpatient clinic settings and will help HCPs determine which patients require additional nutrition support.

Transcutaneous Bowel Sonography for Inflammatory Bowel Disease Is Sensitive and Specific When Performed in a Nonexpert Low-Volume North American Center

Transcutaneous bowel sonography is a nonionizing imaging modality used in inflammatory bowel disease. Although available in Europe, its uptake in North America has been limited. Since the accuracy of bowel sonography is highly operator dependent, low‐volume centers in North America may not achieve the same diagnostic accuracy reported in the European literature. Our objective was to determine the diagnostic accuracy of bowel sonography in a nonexpert low‐volume center.

The Utility of Endoscopic Biopsies in Patients with Normal Upper Endoscopy

Background and Aims. Upper endoscopy is a valuable tool in the workup of gastrointestinal (GI) complaints. The purpose of this study is to determine cost and yield of taking biopsies in a normal upper GI tract. Methods. This is a retrospective study where all upper GI biopsies were identified between May 2012 and April 2013, at a tertiary care center. Clinical, procedural, and pathology reports were reviewed to identify patient demographics, procedure information, and pathology diagnosis. Results. Biopsies of the upper GI tract were taken in 1297 patients with normal upper endoscopies. In patients with normal upper endoscopy, 22% of esophageal, 44% of gastric, and 12% of duodenal biopsies were abnormal. The most frequent abnormality was reflux esophagitis in 16% of esophageal biopsies, chronic gastritis in 23% of gastric biopsies, and increased intraepithelial lymphocytes in 6% of duodenal biopsies. The additional cost for taking biopsies in a normal upper GI tract for a diagnosis of eosinophilic esophagitis was

The safety and efficacy of adalimumab in patients with Crohn's disease: the experience of a single Canadian tertiary care centre

2963 Canadian (CAD), H. pylori associated gastritis was

Contrast enhanced endoscopic ultrasound: More than just a fancy Doppler

1404 CAD, and celiac disease was

HLA-DQA1-HLA-DRB1 polymorphism is a major predictor of azathioprine-induced pancreatitis in patients with inflammatory bowel disease

3024 CAD. Conclusions. The yield of biopsy in normal upper endoscopy varied with location, but the additional expense can be costly and should be tailored to appropriate clinical situations.

Performance report cards increase adenoma detection rate

Abstract Background. Adalimumab (ADA), an antitumor necrosis factor (anti-TNF) monoclonal antibody, is effective in treating moderate-to-severely active Crohns disease (CD). ADA has been associated with a variety of adverse events (AE). The purpose of this study is to determine the safety and efficacy of ADA in CD patients in clinical practice. Methods. A retrospective analysis was performed on CD patients treated with ADA. Data extracted and analyzed included patient and CD demographics, remission and response rates with ADA, and safety and tolerability of ADA. Results. A total of 149 ADA-treated CD patients were included. The mean duration of therapy with ADA was 20 months with 32% of patients discontinuing treatment. Anti-TNF-naïve and anti-TNF-exposed patients on ADA achieved clinical remission in 45% and 32%, had a clinical response in 23% and 23%, and had no clinical response in 32% and 45%, respectively. Anti-TNF-naïve and anti-TNF-exposed patients maintained remission in 82% and 67%, respectively. Fistulas healed in 19% and improved in 19%. AE occurred in 38% of patients with infection being the most common (20%). Serious infections lead to death in one (<1%). Logistic regression of AE did not identify statistically significant predictors except for colonic disease location (odds ratio [OR] = 0.31, 95% CI = 0.12–0.82, p = 0.018) and the rate of ADA discontinuation (OR = 3.24, 95% CI = 1.58–6.64, p = 0.0013). Conclusion. ADA is an effective treatment for CD. AE can occur commonly leading to discontinuation of medication and may be influenced by disease location. Although serious complications are rare, close monitoring of all patients on ADA is needed.

Rapid fecal calprotectin testing to assess for endoscopic disease activity in inflammatory bowel disease: A diagnostic cohort study.

Contrast enhanced endoscopic ultrasound (CEUS) is a new modality that takes advantage of vascular structure and blood flow to distinguish different clinical entities. Contrast agents are microbubbles that oscillate when exposed to ultrasonographic waves resulting in characteristic acoustic signals that are then converted to colour images. This permits exquisite imaging of macro- and microvasculature, providing information to help delineate malignant from non-malignant processes. The use of CEUS may significantly increase the sensitivity and specificity over conventional endoscopic ultrasound. Currently available contrast agents are safe, with infrequent adverse effects. This review summarizes the theory and technique behind CEUS and the current and future clinical applications.