Michelle L. Matteson-Kome

Miralax With Gatorade for Bowel Preparation: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVES:Polyethylene glycol (PEG) is a very popular bowel preparation for colonoscopy. However, its large volume may reduce patient compliance, resulting in suboptimal preparation. Recently, a combination of Miralax and Gatorade has been studied in various randomized controlled trials (RCTs) as a lower volume and more palatable bowel preparation. However, results have varied. Therefore, we conducted a meta-analysis assessing the use of Miralax–Gatorade (M–G) vs. PEG for bowel preparation before colonoscopy.METHODS:Multiple databases were searched (January 2014). RCTs on adults comparing M–G (238–255 g in 1.9 l that is 64 fl oz) vs. PEG (3.8–4 l) for bowel preparation before colonoscopy were included. The effects were analyzed by calculating pooled estimates of quality of bowel preparation (satisfactory, unsatisfactory, excellent), patient tolerance (nausea, cramping, bloating), and polyp detection by using odds ratio (OR) with fixed- and random-effects models.RESULTS:Five studies met inclusion criteria (N=1,418), with mean age ranging from 53.8 to 61.3 years. M–G demonstrated statistically significantly fewer satisfactory bowel preparations as compared with PEG (OR 0.65; 95% confidence interval (CI): 0.43–0.98, P=0.04) but more willingness to repeat preparation (OR 7.32; 95% CI: 4.88–10.98, P<0.01). Furthermore, no statistically significant differences in polyp detection (P=0.65) or side effects were apparent between the two preparations for nausea (P=0.71), cramping (P=0.84), or bloating (P=0.50). Subgroup analysis revealed similar results for split-dose M–G vs. split-dose PEG.CONCLUSIONS:M–G for bowel preparation before colonoscopy was inferior to PEG in bowel preparation quality while demonstrating no significant improvements in adverse effects or polyp detection. Therefore, PEG appears superior to M–G for bowel preparation before colonoscopy.

The effect of indomethacin in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a meta-analysis.

Objectives Acute pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) is a severe complication with substantial morbidity and mortality. Indomethacin has been identified to prevent this complication; however, the results using indomethacin have varied. Therefore, we performed a meta-analysis on the efficacy of rectally administered indomethacin in the prevention of post-ERCP pancreatitis (PEP). Methods A systematic search was performed in November 2012. Randomized, placebo-controlled trials (randomized controlled trials) in adult patients that compared rectally administered indomethacin versus placebo in prevention of PEP were included. Meta-analysis was performed using a fixed-effects model to assess the primary outcome (PEP) and secondary outcomes (mild or moderate to severe PEP) using Review Manager 5.1. Results Four randomized controlled trials met the inclusion criteria (n = 1422). The use of indomethacin near the time of ERCP demonstrated a statistically significant decrease in PEP (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.34–0.71; P < 0.01), mild PEP (OR, 0.52; 95% CI, 0.32–0.86; P = 0.01), and moderate to severe PEP (OR, 0.45; 95% CI, 0.24–0.83; P = 0.01) as compared with placebo. The number needed to treat with indomethacin to prevent 1 episode of pancreatitis is 17 patients. Conclusions Rectal indomethacin significantly reduced the incidence of PEP. We recommend using indomethacin before or just after the procedure in patients undergoing ERCP.

Prophylactic clipping and post-polypectomy bleeding: a meta-analysis and systematic review

Background Bleeding after polypectomy is a common issue associated with colonoscopy. To help prevent post-polypectomy bleeding, many endoscopists place clips at the site. However, this practice remains controversial. Therefore, we performed a meta-analysis of the efficacy of clip placement in the prevention of post-polypectomy bleeding. Methods Multiple databases, including Embase, Scopus, MEDLINE/PubMed, CINAHL, Cochrane databases, and recent abstracts from major American meetings were searched in April 2016. Using the DerSimonian and Laird (random effects) model with odds ratio (OR), a meta-analysis was performed of post-polypectomy bleeding with prophylactic clip versus no prophylactic clip. Results Five hundred and thirty potential articles and abstracts were discovered. Thirty-five articles were reviewed, with 12 studies satisfying the inclusion criteria. No statistically significant difference in prophylactic clipping versus no prophylactic clipping for post-polypectomy bleeding in all polyps was found when all studies (OR 1.49; 95% CI: 0.56–4.00; P=0.42), only peer-reviewed studies where abstracts were excluded (OR 0.84; 95% CI: 0.42–1.69; P=0.63), and only randomized controlled trials (OR 1.24; 95% CI: 0.69–2.24; P=0.47) were analyzed. Conclusions The use of prophylactic clipping for all polypectomies does not seem to prevent post-polypectomy bleeding and should not be a routine practice. However, for large polyps (>2 cm), prophylactic clipping may or may not be beneficial in preventing post-polypectomy bleeding. Further studies are required to fully evaluate this subgroup.

Asa Classification Pre-endoscopic Procedures: A Retrospective Analysis on the Accuracy of Gastroenterologists.

Objectives Before an endoscopic procedure, an evaluation to assess the risk of sedation is performed by the gastroenterologist. To risk stratify based on medical problems, the American Society of Anesthesiologists (ASA) classification scores are used routinely in the preprocedure evaluation. The objective of our study was to evaluate among physicians the ASA score accuracy pre-endoscopic procedures. Methods At a single tertiary-care center an institutional review board–approved retrospective study was performed. Upper endoscopies performed from May 2012 through August 2013 were reviewed; data were collected and recorded. Statistical analysis was performed using descriptive statistics and linear weighted kappa analysis for agreement (⩽0.20 is poor agreement, 0.21–0.40 is fair, 0.41–0.60 is moderate, 0.61–0.80 is good, and 0.81–1.00 is very good). Results The mean ASA scores by the gastroenterologist compared with the anesthesiologist were 2.28 ± 0.56 and 2.78 ± 0.60, respectively, with only fair agreement (weighted kappa index 0.223, 95% confidence interval [CI] 0.113–0.333; 48% agreement). The mean ASA scores for gastroenterologists compared with other gastroenterologists were 2.26 ± 0.5 and 2.26 ± 0.44, respectively, with poor agreement (weighted kappa index 0.200, 95% CI 0.108–0.389; 68% agreement). Agreement on ASA scores was only moderate between the gastroenterologist and himself or herself (weighted kappa index 0.464, 95% CI 0.183–0.745; 75% agreement). Conclusions Gastroenterologists performing preprocedure assessments of ASA scores have fair agreement with anesthesiologists, poor agreement with other gastroenterologists, and only moderate agreement with themselves. Given this level of inaccuracy, it appears that the ASA score pre-endoscopy is of limited significance.

Cap-assisted colonoscopy versus standard colonoscopy: is the cap beneficial? A meta-analysis of randomized controlled trials

Background: In an effort to improve visualization during colonoscopy, a transparent plastic cap or hood may be placed on the end of the colonoscope. Cap-assisted colonoscopy (CAC) has been studied and is thought to improve polyp detection. Numerous studies have been conducted comparing pertinent clinical outcomes between CAC and standard colonoscopy (SC) with inconsistent results. Methods: Numerous databases were searched in November 2016. Only randomized controlled trials (RCTs) involving adult subjects that compared CAC to SC were included. Outcomes of total colonoscopy time, time to cecum, cecal intubation rate, terminal ileum intubation rate, polyp detection rate (PDR), and adenoma detection rate (ADR) were analyzed in terms of odds ratio (OR) or mean difference (MD) with fixed effect and random effects models. Results: Five hundred eighty-nine articles and abstracts were discovered. Of these, 23 RCTs (n=12,947) were included in the analysis. CAC showed statistically significant superiority in total colonoscopy time (MD -1.51 min; 95% confidence interval [CI] -2.67 to -0.34; P<0.01) and time to cecum (MD -0.82 min; 95%CI -1.20 to -0.44; P<0.01) compared to SC. CAC also showed better PDR (OR 1.17; 95%CI 1.06-1.29; P<0.01) but not ADR (OR 1.11; 95%CI 0.95-1.30; P=0.20). In contrast, on sensitivity analysis, ADR was better with CAC. Terminal ileum intubation and cecal intubation rates demonstrated no significant difference between the two groups (P=0.11 and P=0.73, respectively). Conclusions: The use of a transparent cap during colonoscopy improves PDR while reducing procedure times. ADR may improve in cap-assisted colonoscopy but further studies are required to confirm this.

Airway assessment of patients undergoing endoscopic procedures.

Objectives In advance of endoscopic procedures, an evaluation to assess the risk of sedation is performed by the gastroenterologist. Based on regulations, gastroenterologists are required to perform an airway assessment. At this time, data supporting this regulation are limited; therefore, we evaluated airway assessment accuracy by gastroenterologists before endoscopic procedures. Methods A retrospective, single tertiary care center study was performed from May 2012 through August 2013. Patients who underwent an endoscopy or colonoscopy performed at the University of Missouri–Columbia with documented Mallampati scores were included in the analysis. Three primary cohorts of patients were included in our study: gastroenterologist versus anesthesiologist, gastroenterologist versus other gastroenterologists, and gastroenterologists versus themselves. Data were collected and recorded for patient age, body mass index, and Mallampati score. Statistical analysis was performed using descriptive statistics and linear weighted kappa analysis for agreement. Results For gastroenterologists versus anesthesiologists and versus other gastroenterologists, the agreement on Mallampati scores was poor (weighted kappa index 0.103, 95% confidence interval [CI] −0.0126 to 0.219; percentage of agreement 42% and 0.120, 95% CI −0.0211 to 0.260; percentage of agreement 46%, respectively). For gastroenterologists versus themselves for the same patient, the agreement on Mallampati scores was only moderate (weighted kappa index 0.420, 95% CI 0.119–0.722; percentage of agreement 65%). Conclusions Gastroenterologists performing a preprocedure assessment using Mallampati scores have poor agreement with anesthesiologists and colleagues and only moderate agreement with themselves.

Attainment of the Elusive Attributions for Long-term Success in Kidney Transplantation

Survival of a kidney transplant recipient beyond 2 decades is a relatively rare event. No studies have been conducted to describe individuals’ longevity attributions, who have had their kidney transplant for many years. The purpose of this qualitative analysis was to examine longevity attributions of kidney transplant recipients who have had a kidney transplant for 25 years or longer. The initial sample was obtained from an informal support group that includes only those who have had their kidney transplant >25 years. A semistructured 1-hour interview was conducted over the phone, audio-taped, and transcribed. Data were examined using thematic content analyses. The sample consisted of 19 participants (7 males and 12 females) ranging in age from 43 to 67 years, with a mean age of 52.8 years (standard deviation [SD] = 6.82). Transplants were performed between 26 and 36 years prior to the interviews, with a mean of 30.7 years (SD = 3.2). Emerging attributions included maintaining a healthy lifestyle, social support, positive attitude, faith, normalcy, participation in decision making, and luck. Prior to transplantation, patients were engaging in self-management behaviors, which many attributed to their success posttransplant. The findings of this study may provide insight and understanding for health-care providers and other transplant recipients regarding longevity attributions of those who have had their kidney transplants for over a quarter century. Future research should explore the impact of supporting kidney transplant recipients in self-management prior to and after transplantation.

Improving maintenance medication adherence in adult inflammatory bowel disease patients: a pilot study

Medication nonadherence in inflammatory bowel disease (IBD) may lead to suboptimal control of the disease, decreased quality of life, and poor outcomes. This pilot study evaluated the feasibility, intervention mechanism, and potential effectiveness of a three-month continuous self-improvement (CSI) intervention to enhance medication adherence (MA) in adult nonadherent IBD patients. Adult IBD patients taking a daily or twice-daily dosed maintenance medication were screened electronically for two months to determine baseline MA levels. Nonadherent IBD participants were randomized to the CSI or the attention control (AC) intervention and monitored for three months. The CSI intervention consisted of a data evaluation and system refinement process in which system changes were identified and implemented. The AC group was given educational information regarding IBD disease process, extra-intestinal manifestations of IBD, and medical therapy. Demographic statistics, change scores for within and between-group differences, and effect size estimates were calculated. Nine nonadherent participants (medication adherence score <0.85) were eligible for randomization. The intervention was found feasible and acceptable. Although no statistically significant improvement in MA was found (P=0.14), adherence improved in 3 of 4 of the CSI group and 1 of 2 in the attention control group. The effect size calculation of 1.9 will determine the sample size for future study. The results of this pilot study showed the intervention was feasible and had a positive effect on MA change score and adherence levels. A larger fully powered study is needed to test of the effectiveness of this innovative intervention.

Sa1105 Ursodiol As a Chemoprotective Agent for Colorectal Cancer in Inflammatory Bowel Disease and Primary Sclerosing Cholangitis: A Meta-Analysis

response rate to infliximab. We conducted a meta-analysis to assess the effect of variations of this unique enteral nutrition therapy with infliximab for clinical remission in patients with Crohns disease. METHODS: Multiple databases were search (October 2013). Studies on adult patients with Crohns disease were included that compared enteral nutrition therapy (elemental or polymeric formula, with or without low-fat diet restriction) with infliximab versus infliximab alone with no dietary manipulation. Meta-analysis was performed using the Mantel-Haenszel (fixed effects) model with odds ratio (OR) to assess clinical remission based upon Crohns disease activity index (remission defined as < 150 or a reduction in score by 70), resolution of clinical symptoms, or reduction in C-reactive protein levels. Publication bias and heterogeneity were assessed. RESULTS: Five studies (n=403) met the inclusion criteria. Specialized enteral nutrition therapy with infliximab resulted in 60% (124/ 206) of patients achieving initial clinical remission compared to 45% (88/197) with infliximab alone. Similarly, 75% (79/106) of patients receiving enteral nutrition therapy and infliximab remained in long-term clinical remission after one year, compared to 49% (62/126) of patients receiving infliximab monotherapy alone. The use of combination therapy of infliximab with specialized enteral nutrition therapy resulted in a statistically significant increase in achieving an initial clinical response (OR 2.43; 95% CI: 1.58-3.74, p<0.01) followed by long-term clinical remission after one year (OR 2.93; 95% CI: 1.66-5.17, p<0.01) as compared to infliximab alone with no dietary manipulation. After adjusting for two trials (Sazuka and Matsumoto) that included use of an elemental or polymeric formula and no diet restrictions, the results were similar for initial clinical remission (p<0.01) and long-term clinical remission (p<0.01). No publication bias or heterogeneity was noted for either outcome. CONCLUSION: Use of a specialized enteral nutrition therapy consisting primarily of an elemental formula combined with or without a low-fat diet restriction appears to enhance the response rate to infliximab, better achieving and maintaining clinical remission among patients with Crohns disease than drug therapy alone with no dietary manipulation.