Randall Pellish

Impact of experience with a retrograde-viewing device on adenoma detection rates and withdrawal times during colonoscopy: the Third Eye Retroscope study group

BACKGROUND Colonoscopy has been adopted as the preferred method to screen for colorectal neoplasia in the United States. However, lesions can be missed because of numerous factors, including location on the proximal aspect of folds or flexures, where they may be difficult to detect with the forward-viewing colonoscope. The Third Eye Retroscope (TER) is a disposable device that is passed through the instrument channel of a standard colonoscope to provide a retrograde view that complements the forward view of the colonoscope during withdrawal. OBJECTIVE To evaluate whether experience with the TER affects polyp detection rates and procedure times in experienced endoscopists who had not previously used the equipment. DESIGN, SETTING, PATIENTS This was an open-label, prospective, multicenter study at 9 U.S. sites, involving 298 patients presenting for colonoscopy, evaluating the use of the TER in combination with a standard colonoscope. INTERVENTIONS After cecal intubation, the TER was inserted through the instrument channel of the colonoscope. During withdrawal, the forward and retrograde video images were observed simultaneously on a wide-screen monitor. MAIN OUTCOME MEASUREMENTS Primary outcome measures were the number and size of adenomas and all polyps detected with the standard colonoscope and with the colonoscope combined with the TER. Secondary outcome measures were withdrawal phase time and total procedure time. Each endoscopist examined 20 subjects, divided into quartiles according to the order of their procedures, and results were compared among quartiles. RESULTS Overall, 182 polyps were detected with the colonoscope and 27 additional polyps with the TER, a 14.8% increase (P < .001). A total of 100 adenomas were detected with the colonoscope and 16 more with the TER, a 16.0% increase (P < .001). For procedures performed after each endoscopist had completed 15 procedures while using the TER, the mean additional detection rates with the TER were 17.0% for all polyps (P < .001) and 25.0% for adenomas (P < .001). For lesions 6 mm or larger, the overall additional detection rates with the TER for all polyps and for adenomas were 23.2% and 24.3%, respectively. For lesions 10 mm or larger, the overall additional detection rates with the TER for all polyps and for adenomas were 22.6% and 19.0%, respectively. The mean withdrawal times in the first and fourth quartiles were 10.6 and 9.2 minutes, respectively (P = .044). LIMITATIONS There was no randomization or separate control group. The endoscopists judged whether each lesion could have been detected with the colonscope alone by using their standard technique. CONCLUSIONS Polyp detection rates improved significantly with the TER, especially after 15 procedures, when the mean additional detection rate for adenomas was 25.0%. Additional detection rates with the TER for medium-size and large adenomas were greater than for smaller lesions. These results suggest that, compared with a colonoscope alone, a retrograde-viewing device can increase detection rates for clinically significant adenomas without detriment to procedure time or procedure complications. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00969124.).

Efficacy and safety of natalizumab in Crohn's disease patients treated at 6 Boston academic hospitals.

Background:Despite trials demonstrating its efficacy, many physicians harbor concerns regarding the use of natalizumab in the treatment of patients with refractory Crohn’s disease (CD). The purpose of this study was to perform a descriptive analysis of a series of CD patients not currently enrolled in a clinical trial. Methods:A retrospective case review of patients treated with natalizumab at 6 sites in Massachusetts: Boston Medical Center, Beth Israel Deaconess Medical Center, Brigham & Women’s Hospital, Lahey Clinic, Massachusetts General Hospital, and UMass Medical Center. Results:Data on 69 CD patients on natalizumab were collected. At the start of treatment, patients’ disease duration was 12 years. A high proportion of patients were women (68%), presented with perianal disease (65%) and upper gastrointestinal tract involvement (14%). Prior nonbiologic therapies were steroids (96%), thiopurines (94%), antibiotics (74%), methotrexate (58%), and at least two anti-tumor necrosis factor agent failures (81%). Sixty-nine percent (44 of 64 patients) with available medical evaluation had a partial or complete clinical response. Loss of response was 13% after an average of 1 year of treatment. Adverse events were infusion reactions, headaches, fever, and infections. No case of progressive multifocal leukoencephalopathy was observed. Conclusions:In our clinical experience outside the context of a clinical trial, natalizumab is largely reserved for CD patients with extensive ileocolonic disease who have failed conventional immunosuppressants and of at least 2 anti-tumor necrosis factor agents. This drug is, however, well tolerated and offers significant clinical improvement for more than a year in one-third of these difficult-to-treat CD patients.

Fecal Microbiota Transplant Treatment Options for Clostridium difficile Infection in the Intensive Care Unit

Clostridium difficile infection (CDI) has steadily increased in incidence since the 1990s, with an associated increase in recurrence and severity, which has in turn lead to more intensive care unit (ICU) admissions. The development of recurrent CDI, in particular, has been associated with increasing patient morbidity and mortality as well as an immense financial burden on the health care system. Recently, fecal microbiota transplantation (FMT) has received much publicity as an effective means of treatment for recurrent CDI. The goal of this review is to provide evidence-based recommendations for the diagnosis and management of CDI, with a particular focus on FMT and its utilization in the ICU.

Using Therapeutic Drug Monitoring to Identify Variable Infliximab Metabolism in an Individual Patient With Ulcerative Colitis.

Biological drugs have significantly improved the quality of life of patients with inflammatory bowel disease. However, after 15 years of using these drugs in practice, we just now are beginning to better understand how to use them most effectively. It has become evident that antitumor necrosis factor agents, such as infliximab, have variable drug clearance across individuals, mostly related to the disease burden at the time of an infusion. In this case report, we demonstrate how therapeutic drug monitoring can be used to personalize a dosing regimen to ensure appropriate induction, and to safely deescalate therapy after remission is achieved. By identifying a change in drug clearance in an individual patient over time, we were able to attain significant cost savings despite the high price of serially measured drug and antibody concentrations.

The conundrum of indeterminate QuantiFERON-TB Gold results before anti-tumor necrosis factor initiation

Background Tumor necrosis factor alpha (TNFα) is a key cytokine in both the pathogenesis of inflammatory bowel disease (IBD) and rheumatoid arthritis (RA) and the host defense against tuberculosis (TB). Consequently, anti-TNFα medications result in an increased risk of latent TB infection (LTBI) reactivation. Here, we sought to evaluate the factors affecting the results of QuantiFERON-TB Gold In-Tube (QFT-GIT) assay as a screening tool for LTBI. Methods We conducted an observational, retrospective study in patients with IBD and RA who underwent LTBI screening using QFT-GIT at UMass Memorial Medical Center between 2008 and 2016 prior to initiation of anti-TNF medications. Results We included 107 and 89 patients with IBD and RA, respectively. We found that a higher proportion of IBD patients had indeterminate QFT-GIT result compared to RA patients. Furthermore, we found that the majority of patients with indeterminate results were tested during an acute flare of IBD (88%) and while taking corticosteroids. Of all patients receiving ≥20 mg equivalent prednisone dose (n=32), 63% resulted in indeterminate QFT-GIT, compared to only 6% indeterminate testing in patients receiving <20 mg of equivalent prednisone dose (n=164, P<0.001). There was no correlation between indeterminate results and age, gender, disease duration, or distribution, or smoking status within each population. Conclusion We observed that high-dose corticosteroids may affect QFT-GIT outcomes leading to a high proportion of indeterminate results. We propose that IBD patients should be tested prior to initiation of corticosteroids to avoid equivocal results and prevent potential delays in initiation of anti-TNF medications.

Sa1216 Management Differences Between Early and Late-Onset Inflammatory Bowel Disease

Background: As our population has aged more patients are being diagnosed with inflammatory bowel disease (IBD) at a later age. Despite the limited literature on the subject, clinical observation suggests that patients with late-onset IBD (LOIBD) have a different severity of disease compared to younger patients and, therefore, may have different management requirements. The primary objective of this study was to perform a retrospective analysis of the disease severity and therapy requirements of patients with a LOIBD as compared to those diagnosed at an earlier age. Methods: Patients were selected at random from a list of those billed for diagnosis codes attributed to inflammatory bowel disease. Of our initial list of 350 patients, we excluded 88 patients who were inappropriately coded as having IBD leaving us with a final list of 262 patients. We separated our list into three cohorts: those diagnosed with IBD before the age of 45, but who are currently younger than 45 (Group 1); those diagnosed with IBD before the age of 45, but who are currently older than 45

Tamoxifen-associated portal vein thrombosis causing severe oesophageal variceal bleeding

A 46-year-old woman with medical history of breast cancer on tamoxifen presented with syncope. On arrival to the hospital, the patient developed massive haematemesis and a subsequent esophagogastroduodenoscopy revealed oesophageal varices without any known history of liver disease. Further evaluation identified portal vein thrombosis probably caused by tamoxifen use.

S1133 Effectiveness of Third Eye Retroscope in Detection of Colonic Adenomas in Elderly Patients (> 65 Years)

Background: Colonoscopy is considered to be the standard of care for the diagnosis of colorectal cancer. However, population-based studies have reported a subset of patients with cancer who do not undergo colonoscopy. The purpose of this study was to estimate the prevalence and identify the predictors of not having a colonoscopy in the period preceding colorectal cancer diagnosis. Methods: Using the population-based SEER registries, we identified patients aged >= 69 with colorectal cancer diagnosed from 1994-2005. Linked inpatient and outpatientMedicare claimswere used to identify receipt of colonoscopy prior to diagnosis. We divided this group into patients who had did not have colonoscopy within 3 years of diagnosis (Group I) and those who had 1 or more colonoscopies from 6 months prior to 30 days after diagnosis (Group II). Patient, sociodemographic and tumor factors were used to identify predictors of not having colonoscopy in univariate and multivariable logistic regression analysis. Results: We identified 79,032 patients, including 19.6% in Group I and 80.4% in Group II. Among patients in Group I, 31.6% had barium enema, 21.4% had flexible sigmoidoscopy and 57.3% underwent CT scan within 6 months prior to and 30 days after diagnosis. Independent predictors of Group I included age > 85, African American race, non-married, nursing home residence, rural residence, lower comorbidity score, diagnosis before 2000, AJCC Stage II-IV, left sided or rectal tumor site, and emergency presentation. Patients without colonoscopy were also less likely to undergo surgical resection (OR 0.55, CI 0.52-0.59). In a Cox proportional hazards model that adjusted for demographics, stage and treatment, not undergoing colonoscopy was associated with a higher risk of death (HR 1.31, CI 1.28-1.33). Conclusions: In this large, population based analysis, almost 20% of newly diagnosed colorectal cancer patients did not undergo colonoscopy at the time of diagnosis. Although these patients were more likely to be elderly with advanced disease, lack of colonoscopy appears to be an indicator of emergency presentation, less aggressive treatment and poorer prognosis.