Hin Hin Ko

Factors influencing patient satisfaction when undergoing endoscopic procedures

BACKGROUND Limited data are available regarding the best mechanism and timing for assessing patient satisfaction with endoscopy. OBJECTIVE To identify factors related to patient satisfaction with endoscopy and to determine if satisfaction after the procedure correlates with measurements at a later date. DESIGN A prospective cohort study. SETTING Tertiary academic hospital. PATIENTS Patients undergoing EGD, colonoscopy, or both. INTERVENTIONS Patients received preprocedure and postprocedure questionnaires on the procedure day. A third questionnaire (telephone or mail) was administered at least 1 week later. MAIN OUTCOME MEASUREMENTS Satisfaction scores. RESULTS A total of 261 patients were studied (53% men). The mean age was 55 +/- 14 years. A total of 226 patients (86.6%) were very satisfied with their endoscopy. Factors positively associated with satisfaction were as follow: doctors personal manner (odds ratio [OR] 3.00 [95% CI, 1.80-5.03]), doctors technical skills (OR 2.65 [95% CI, 1.55-4.51]), nurses personal manner (OR 2.84 [95% CI, 1.74-4.63]), physical environment (OR 1.75 [95% CI, 1.16-2.64]), and more time with doctor discussing the procedure (OR 1.66 [95% CI, 1.02-2.69]). Higher levels of pain or discomfort were associated with less satisfaction (OR 0.57 [95% CI, 0.36-0.90]). A total of 141 of 261 patients (54%) were reached for follow-up (mean [SD] 39 +/- 26 days). These patients were less satisfied (rating dropped mean 0.35 points, P = .03) than those questioned sooner after the procedure and recalled experiencing more pain (rating increased mean 0.44 points, P = 0.01). LIMITATION Single center. CONCLUSIONS This study identified several factors that impacted patient satisfaction. Most patients initially appeared very satisfied, perhaps because of residual sedation and the distinct setting of the surveys. However, patient satisfaction tended to decrease over time, possibly because of recall bias. Future studies with patient satisfaction may require assessment at a date further removed from their endoscopy.

Review of food bolus management

Foreign object ingestion and esophageal food bolus impactions are common problems faced by gastroenterologists. Fortunately, the majority of ingested foreign objects and food boluses will pass spontaneously. However, 10% to 20% may become lodged in the esophagus or other locations in the gastrointestinal tract and may require nonoperative intervention, and 1% or less will require surgery (1–4). A recent study (5) reported an estimated annual incidence rate of food impactions of 13 episodes per 100,000 in a health maintenance organization population. The overall mortality rate is unknown, but deaths have been rarely reported (6,7). The purpose of the present review is to focus on esophageal food bolus impaction – its pathophysiology, clinical presentations, diagnosis and management. Dr Hin Hin Ko

A randomized controlled trial assessing the effect of prescribed patient position changes during colonoscope withdrawal on adenoma detection

BACKGROUND High-quality colonoscope withdrawal technique is associated with a higher adenoma detection rate. Position change is routinely used in barium enema and CT colonography to facilitate adequate distension of the colon and promote movement of fluid from the segment of the colon being assessed. OBJECTIVE To determine whether prescribed position changes during colonoscope withdrawal affect the adenoma detection rate compared with the usual care per endoscopist. DESIGN Prospective, randomized, controlled trial. SETTING Tertiary-care, university-affiliated hospital. PATIENTS Patients referred for outpatient colonoscopy between July 2011 and July 2012 were evaluated for eligibility. Inclusion criteria were outpatient status and age ≥40 years. Exclusion criteria were (1) complete colonoscopy within 1 year before the procedure, (2) inability to provide informed consent, (3) incomplete colonoscopy to the cecum, (4) previous bowel resection, (5) inflammatory bowel disease, (6) colonic polyposis syndrome, (7) inadequate bowel preparation, and (8) musculoskeletal disorder or other mobility issues limiting effective patient position changes during colonoscopy. INTERVENTIONS Prescribed position changes during colonoscope withdrawal. MAIN OUTCOME MEASUREMENTS Polyp detection rate (PDR) and adenoma detection rate (ADR). RESULTS A total of 776 patients were enrolled, with 388 in the dynamic group. There was no difference in PDR (odds ratio [OR] 0.99; P = .93) or ADR (OR 1.17; P = .28). Colonoscope withdrawal time was longer in the dynamic group (median time 466.5 vs 422.5 seconds; P < .0001). LIMITATIONS Single-center study. Indication for procedure not controlled. Lack of standardized bowel preparation and blinding. CONCLUSION Prescribed position changes during colonoscope withdrawal do not affect polyp/adenoma detection compared with the usual practice when the baseline ADR is above the recommended standard. ( CLINICAL TRIAL REGISTRATION NUMBER NCT01395173.).

A concise review of hepatitis C in heart and lung transplantation

Hepatitis C (HCV) infection is prevalent in recipients of, and candidates for, solid organ transplants. The outcomes of HCV infection in cardiac and lung transplant recipients have yet to be clearly established, and future prospective studies are needed. In the absence of safe and effective antiviral treatment for HCV infection in heart and lung transplant recipients, the management of these patients remains a challenge and must be considered on an individual basis. Interferon therapy for HCV before transplantation appears to improve outcomes; however, post-transplant interferon therapy in the cardiac and pulmonary transplant setting may be associated with an increased risk of graft rejection. Given the paucity of information regarding HCV treatment in these transplant recipients, and with appropriate concerns that graft loss from rejection may not be amenable to a second transplant (given the scarcity of suitable cadaveric organs), multicentre, randomized controlled trials are needed to determine the optimal approach for treatment of HCV infection in this population.

Immunogenicity of Mycobacterium avium subsp. paratuberculosis proteins in Crohn's disease patients

Abstract The association between Mycobacterium avium subsp. paratuberculosis (MAP) and Crohns disease (CD) is supported by several studies reporting the detection or isolation of MAP from human tissues, but a direct association is still debatable. Objective. To evaluate the survival of MAP in human intestinal cells and to measure the presence of antibodies against two mycobacterial proteins necessary for the survival of the bacterium in the sera of CD patients. Material and methods. Human-derived intestinal cells were infected with three isolates of MAP and the survival of the microorganism was determined. The presence of antibodies against protein tyrosine phosphatase A (PtpA) and protein kinase G (two proteins secreted within the host in the early stages of the invasion) in the sera of CD patients was evaluated. Sera of 20 CD patients and 20 controls were collected and the presence of the antibodies was assayed using enzyme-linked immunosorbent assay (ELISA). Secretion of the PtpA in vivo was visualized by immunostaining. Results. MAP survived in intestinal cells, and immunostaining of PtpA showed that the protein was secreted within these cells. Wilcoxon rank sum test revealed that CD patient sera had significantly higher titer of antibodies specific for both of these antigens compared to controls. ELISA results for either protein were not statistically different between men and women. Conclusions. The presence of specific antibodies against mycobacterial proteins essential for establishing an infection in the host suggests that MAP can potentially be active in CD patients, and a serological test can be developed for early detection of MAP in CD patients.

Rate, Delay and Predictors of Hepatitis C Treatment in British Columbia

BACKGROUND The current treatment rate for chronic hepatitis C virus (HCV) infection is suboptimal despite the availability of efficacious antiviral therapy. OBJECTIVE To determine the rate, delay and predictors of treatment in patients with chronic HCV infection. METHODS A retrospective chart review of chronic HCV patients who were being evaluated at a tertiary hepatology centre in Vancouver, British Columbia, was performed. RESULTS One hundred sixty-four patients with chronic HCV infection who were assessed for treatment between February 2008 and January 2013 were reviewed. Treatment was initiated in 25.6% (42 of 164). In multivariate analyses, male sex (OR 7.90 [95% CI 1.35 to 46.15]) and elevated alanine aminotransferase (ALT) level (>1.5 times the upper limit of normal) (OR 3.10 [95% CI 1.32 to 7.27]) were positive predictors of treatment, whereas active smoking (OR 0.09 [95% CI 0.02 to 0.53]) and Charlson comorbidity index (per point increase) (OR 0.47 [95% CI 0.27 to 0.83]) were negative predictors of treatment. The most common reasons for treatment deferral were no or minimal liver fibrosis in 57.7% (n=30), persistently normal ALT levels in 57.7% (n=30) and patient unreadiness in 28.8% (n=15). The most common reasons for treatment noninitiation were patient refusal in 59.1% (n=26), medical comorbidities in 36.4% (n=16), psychiatric comorbidities in 9.1% (n=4) and decompensated cirrhosis in 9.1% (n=4). There was a statistically significant difference in the median time delay from HCV diagnosis to general practitioner referral between the treated and untreated patients (66.3 versus 119.5 months, respectively [P=0.033]). The median wait time from general practitioner referral to hepatologist consult was similar between the treated and untreated patients (1.7 months versus 1.5 months, respectively [P=0.768]). Among the treated patients, the median time delay was 6.8 months from hepatologist consult to treatment initiation. CONCLUSIONS The current treatment rate for chronic HCV infection remains suboptimal. Medical and psychiatric comorbidities represent a major obstacle to HCV treatment. Minimal hepatic fibrosis may no longer be a major reason for treatment deferral as more efficacious and tolerable antiviral therapies become available in the future. Greater educational initiatives for primary care physicians would promote early referral of patients. More nursing support would alleviate the backlog of patients awaiting treatment.

How to manage difficult Crohn’s disease: optimum delivery of anti-TNFs

Crohn’s disease is a chronic inflammatory condition that can involve any portion of the GI tract, leading to disabling symptoms and complications. Standard treatment with 5-aminosalicylic acid, antibiotics, corticosteroids and immunosuppressives has limited efficacy and is associated with serious potential adverse events. The anti-TNF-α agents are effective in the induction and maintenance of remission in luminal and fistulizing Crohn’s disease. Recent evidence suggests that early treatment with anti-TNF agents and immunosuppressives may alter the natural history of the disease and prevent late complications. In those patients who have lost response to, or are intolerant of, a single anti-TNF agent, increasing the dose of the medication or switching to alternate biologic agents, such as another anti-TNF drug or natalizumab, have been shown to be effective treatments.

Natalizumab: pharmacology, clinical efficacy and safety in the treatment of patients with Crohn's disease.

Natalizumab is a humanized monoclonal antibody against α4 integrin. In preclinical and clinical studies, natalizumab, which interferes with leukocyte trafficking in the intestinal tract, demonstrated effectiveness in inducing clinical response and maintaining remission in patients with moderate-to-severely active Crohn’s disease. However, during clinical trials, three natalizumab-treated patients (one Crohn’s disease patient and two multiple sclerosis patients) developed progressive multifocal leukoencephalopathy (PML). As a consequence of this unexpected serious adverse event, a retrospective safety evaluation was conducted; in that safety evaluation, no new cases of PML were identified. Natalizumab returned to the market in June 2006 for the treatment of relapsing multiple sclerosis. As of May 2007, an estimated 12,000 patients worldwide had received natalizumab, with no new confirmed cases of PML or opportunistic infections reported. Natalizumab is currently being investigated for use in treating patients with Crohn’s disease. If it is approved for treatment of Crohn’s patients, the clinical benefit of natalizumab should be weighed carefully against the potential risk of serious adverse events.

Acute pancreatitis and ileus postcolonoscopy

Postpolypectomy bleeding and perforation are the most common complications of colonoscopy. A case of acute pancreatitis and ileus after colonoscopy is described. A 60-year-old woman underwent a gastroscopy and colonoscopy for investigation of iron deficiency anemia. Gastroscopy was normal; however, the colonoscope could not be advanced beyond the splenic flexure due to a tight angulation. Two polypectomies were performed in the descending colon. After the procedure, the patient developed a distended, tender abdomen. Bloodwork was remarkable for an elevated amylase level. An abdominal x-ray and computed tomography scan showed pancreatitis (particularly of the tail), a dilated cecum and a few air-fluid levels. The patient improved within 24 h of a repeat colonoscopy and decompression tube placement. The patient had no risk factors for pancreatitis. The causal mechanism of pancreatitis was uncertain but likely involved trauma to the tail of the pancreas during the procedure. Our patient developed ileus, likely secondary to pancreatitis. The present case is the first report of clinical pancreatitis and ileus associated with colonoscopy.

Rate of Corticosteroid-Induced Mood Changes in Patients with Inflammatory Bowel Disease: A Prospective Study

Abstract Background Corticosteroid is an effective therapeutic option for inflammatory bowel disease flares, but its adverse effects may compromise treatment adherence and reduce patients’ quality of life. There is lack of data on the incidence of corticosteroid-induced mood changes in this patient population, which may be underappreciated by healthcare providers in clinical practice and interfere with optimal care. This study aimed to determine the rate of mood changes in this patient population. Methods In this prospective observational study, adult outpatients treated with prednisone for inflammatory bowel disease flares were considered for inclusion. Participants completed validated questionnaires (Beck Depression Inventory-II and Activation Subscale of Internal State Scale version two) before starting prednisone, after two weeks of prednisone, and at the end of prednisone taper to assess for mood changes. Harvey-Bradshaw Index and Simple Clinical Colitis Activity Index were used to monitor clinical disease activity. Results Fifty-three subjects were included in the analyses. The rate of mood change after two weeks of prednisone was 49.1%, primarily driven by increase in mood towards (hypo)mania. Younger age was an independent risk factor. Mood state returned to pretreatment level at the end of treatment. There was no correlation between clinical disease activity change and mood change. Conclusions Oral prednisone for inflammatory bowel disease flare is associated with high rate of mood change. As prednisone is a critical part of induction therapy, ways to minimize this adverse event must be studied. For now, healthcare providers should inform patients and monitor closely for this adverse event.