Richa Shukla

In vivo diagnostic accuracy of high resolution microendoscopy in differentiating neoplastic from non-neoplastic colorectal polyps: a prospective study

OBJECTIVES:High-resolution microendoscopy (HRME) is a low-cost, “optical biopsy” technology that allows for subcellular imaging. The purpose of this study was to determine the in vivo diagnostic accuracy of the HRME for the differentiation of neoplastic from non-neoplastic colorectal polyps and compare it to that of high-definition white-light endoscopy (WLE) with histopathology as the gold standard.METHODS:Three endoscopists prospectively detected a total of 171 polyps from 94 patients that were then imaged by HRME and classified in real-time as neoplastic (adenomatous, cancer) or non-neoplastic (normal, hyperplastic, inflammatory).RESULTS:HRME had a significantly higher accuracy (94%), specificity (95%), and positive predictive value (PPV, 87%) for the determination of neoplastic colorectal polyps compared with WLE (65%, 39%, and 55%, respectively). When looking at small colorectal polyps (less than 10 mm), HRME continued to significantly outperform WLE in terms of accuracy (95% vs. 64%), specificity (98% vs. 40%) and PPV (92% vs. 55%). These trends continued when evaluating diminutive polyps (less than 5 mm) as HRMEs accuracy (95%), specificity (98%), and PPV (93%) were all significantly greater than their WLE counterparts (62%, 41%, and 53%, respectively).CONCLUSIONS:In conclusion, this in vivo study demonstrates that HRME can be a very effective modality in the differentiation of neoplastic and non-neoplastic colorectal polyps. A combination of standard white-light colonoscopy for polyp detection and HRME for polyp classification has the potential to truly allow the endoscopist to selectively determine which lesions can be left in situ, which lesions can simply be discarded, and which lesions need formal histopathologic analysis.

Risk and Predictors of Variceal Bleeding in Cirrhosis Patients Receiving Primary Prophylaxis With Non-Selective Beta-Blockers.

OBJECTIVES:Prior studies have demonstrated the efficacy of non-selective beta-blockers (NSBB) in preventing first variceal bleeding in patients with cirrhosis. However, little is known about the overall effectiveness of NSBB in routine clinical care.METHODS:We conducted a retrospective cohort study of cirrhotic patients without prior bleeding who initiated a NSBB (propranolol, nadolol) at any Veterans Administration facility between 2008 and 2013. The primary outcome was variceal bleeding within 12 months. We conducted Cox-proportional hazards analyses to identify demographic, clinical, and NSBB-related (type of NSBB, mean dose, dose change, and heart rate response) factors associated with variceal bleeding.RESULTS:Of 5,775 patients, 678 (11.7%) developed variceal bleeding. Mean daily dose of NSBB was <40 mg in 58.8%, 18.1% had either upward or downward titration in NSBB dose, and 9.8% had hemodynamic response. Patients who were younger, with ascites, greater medical comorbidity, and higher MELD (Model for end-stage liver disease) scores had a higher risk of variceal bleeding. Patients on a higher daily dose (>60 vs. <40 mg, adjusted hazard ratio (HR) 0.64; 95% confidence interval (CI): 0.51–0.81), who had either upward or downward dose titration (adjusted HR 0.69; 95% CI: 0.52–0.90 and 0.64; 95% CI 0.45–0.90, respectively), and those who achieved hemodynamic response (adjusted HR 0.75; 95% CI=0.57–1.0) had lower risk.CONCLUSIONS:Approximately 12% of patients bled while being on NSBB for primary prophylaxis. A higher NSBB dose and dose titration were protective; yet most patients did not have the NSBB dose titrated to the recommended levels. Our data highlight the need for careful monitoring of cirrhotic patients on NSBB.

Use of Augmented Reality and Virtual Reality Technologies in Endoscopic Training

© 2018 by the AGA Institute 1542-3565/

Factors That Contribute to Indeterminate Results From the QuantiFERON-TB Gold In-Tube Test in Patients With Inflammatory Bowel Disease

36.00 https://doi.org/10.1016/j.cgh.2018.08.021 Gastrointestinal endoscopy training is based largely on a master–apprentice model, wherein the trainee observes an expert and acquires technical proficiency by practicing directly on a live patient. Although this model provides the benefits of direct supervision and immediate real-time evaluation from the mentor, this approach can lead to certain challenges including greater patient discomfort, increased procedure times, reduced reimbursements, and higher total costs associated with training. Computerized endoscopic simulators address some of the aforementioned concerns. By imitating real-life clinical scenarios and patient responses in a laboratory, simulation allows trainees to practice their skills as often as necessary, in a safe and risk-free environment. More recently, augmented reality (AR), fully immersive virtual reality (VR), and mixed reality (MR), technologies that already are being used extensively for training in the defense and aviation industries, have made their way into medical training. By re-creating multi-user, friendly, realistic 3-dimensional (3D) clinical scenarios, they allow trainees not only to practice on a virtual patient, but also to interact with other members of the team. Furthermore, because these technologies are portable and relatively cheaper than the mannequin-based simulators, they do not require a huge investment in infrastructure. The higher degree of realism, multi-user options, portability, and lower cost of set-up makes a case for a promising training tool. As the name suggests, in AR the user’s real world is augmented by the addition of a computer-generated 3D object that is superimposed on the same field of view as the real world. By contrast, in fully immersive VR, by wearing a VR headset, the user is teleported into an artificial 3D world created by the computer. MR includes a mix of virtual and real components, and, unlike fully immersive VR, the user does not block out the real world in MR. It differs from AR in that the superimposed objects are solid and can be touched and manipulated in MR. In AR, the superimposed objects are hologram-like and cannot be manipulated. Although unheard of in endoscopy, there are examples of use of these innovative training approaches in other procedural specialties.

Su1079 Changes in the Incidence and Prevalence of Cirrhosis in the National Veterans Administration Over a Decade: 2002-2012

Background & Aims The QuantiFERON‐Tuberculosis Gold In‐Tube (QFT‐GIT) (QIAGEN Group, Hilden, Germany) test is widely used to screen for latent Mycobacterium tuberculosis infection in patients with inflammatory bowel diseases (IBD) before treatment with a tumor necrosis factor antagonist. The test frequently produces indeterminate results, prompting additional testing. We evaluated factors associated with indeterminate results from the QFT‐GIT test among patients with IBD. Methods We conducted a case–control study among eligible adults with QFT‐GIT test results and a concomitant diagnosis of IBD receiving care at a tertiary referral center from 2011 through 2013. We compared patients with IBD with indeterminate and determinate (positive or negative) results from the QFT‐GIT test. We collected data on patient demographics, clinical features, laboratory parameters, and medication use from medical charts. We calculated odds ratios (OR) and 95% CIs using multivariate logistic regression models. Results A total of 400 patients with IBD (265 Crohn’s disease and 135 ulcerative colitis) were included in the final analyses. Indeterminate results were noted in 11.5% of patients. At the time of testing, a higher proportion of patients with indeterminate results from the QFT‐GIT test were on systemic corticosteroid therapy (60.9% vs 30.5% of patients with conclusive test results; P < .001), had levels of C‐reactive protein above 0.8 mg (62.2% vs 39.9% of patients with clear test results; P = .005), had an erythrocyte sedimentation rate above 15 mm/h (55.6% vs 35.8% of patients with clear test results; P = .01), had serum levels of albumin below 3.5 g/dL (33.3% vs 6.3% of patients with clear test results; P < .001), and had low levels of hemoglobin (52.2% vs 28.3% of patients with clear test results; P = .001). In multivariable analysis, corticosteroid use (adjusted OR, 2.92; 95% CI, 1.44–5.88; P = .003) and serum levels of albumin below 3.5 g/dL (adjusted OR, 3.62; 95% CI, 1.36–9.60; P = .009) were independently associated with increased risk of indeterminate QFT‐GIT test results. We did not identify a dose‐related effect with corticosteroid therapy and the odds of indeterminate QFT‐GIT test results. Conclusions In a case–control study of patients with IBD, we associated systemic corticosteroid therapy and low levels of albumin with an increased likelihood of having indeterminate QFT‐GIT test result.

Sa1829 Detection of Colonic Adenomas Using a Low-Cost, High Resolution Microendoscope: Assessment of Accuracy and Interobserver Variability

BACKGROUND: Cirrhosis is associated with a high morbidity and mortality, and is a risk factor for hepatocellular carcinoma. Yet there is limited information regarding the burden of cirrhosis from population-based studies in the U.S. We aimed to determine the annual incidence and prevalence of cirrhosis as well as time trends in the underlying etiology in a national veterans cohort. METHODS: Using the Veterans Administration Corporate Data Warehouse, we calculated the time trends in the annual incidence and prevalence of overall cirrhosis and decompensated cirrhosis between 2002 and 2012. In addition to the overall trends, we also examined the time trends by subgroups based on the underlying etiology for liver disease. We defined cirrhosis on the basis of previously validated ICD-9 code based algorithms. We used direct standardization method to adjust the time trends for changing age of the cohort (where 2002 VA population used as standard), and used joinpoint regression models to determine the magnitude of these time trends (by calculating average annual percentage change (AAPC)). RESULTS: The age-adjusted incidence rates of cirrhosis per 100 persons slightly increased from 0.22 (95% CI 0.21-0.22) in 2002 to 0.23 in 2012 (95% CI 0.23-0.24). The average annual percentage change (AAPC) in the age-adjusted incidence was 1.76% (p<0.05). The age-adjusted prevalence of cirrhosis per 100 persons increased steeply (AAPC=6.75%) from 0.62 (95% CI 0.61-0.63) in 2002 to 1.27 (95% CI 1.26-1.28) in 2010 and then the rate of increase slowed (AAPC=1.69%) between 2010-2012 to 1.36 (95% CI 1.35-1.37) in 2012. The prevalence of decompensated cirrhosis increased in parallel (0.46 in 2002 to 0.72 in 2012 per 100 persons). There were 68,760 and 41,780 patients with a diagnosis of cirrhosis and decompensated cirrhosis, respectively, who received care in VA facilities in 2012. Figures 1 and 2 shows the trends in overall incidence and prevalence of cirrhosis by etiology. HCV was the leading underlying etiology. In 2002, 47% of prevalent cirrhosis cases had HCV; this proportion increased to 53% in 2012. The proportion of cirrhosis patients with alcohol as the underlying etiology fell slightly from 29.8% in 2002 to 26.1% in 2012, whereas those with HBV remained stable at 0.9% to 1.2%. CONCLUSION: The prevalence of cirrhosis and decompensated cirrhosis has increased significantly over the last decade, and the trend is still upwards. Most patients with cirrhosis have underlying HCV, and successful diffusion of treatment may change the future trajectory of cirrhosis burden. Yet, given the existing and large burden of cirrhosis (and its complications), clinicians and healthcare system need to develop strategies targeted to provide timely and effective care to this high-risk patient population.

High-resolution microendoscopy in differentiating neoplastic from non-neoplastic colorectal polyps

istry (IHC). IECs were isolated and fractionated into cytosolic and nuclear fractions. p53 levels were assessed using WB and RT-PCR. Cleaved caspase-3 protein levels were assessed by WB. Target genes of p53 including survivin, p21, and Perp were measured using RTPCR. Results: WB of purified IECs 5 days after ICR revealed that nuclear p53 levels in the ICR mice were decreased compared to sham operated mice. Survivin, which is repressed by p53 transcription, was increased by RT-PCR (2-fold) and most dramatically by IHC with (3-5 fold) more survivin positive IEC staining through the lower to mid crypt regions in the ICR mice. We next examined other p53 target genes. Perp and p21 mRNA showed a 1.5 and 2 fold respective decreases in the RT-PCR of WT ICR as compared to sham surgery. Cleaved caspase-3 protein levels demonstrated a 2-fold decrease in the WT ICR as compared to sham surgery.Conclusions : The post-surgical epithelial responses after intestinal resection continue to be poorly understood. We demonstrated the importance of the down-regulation of p53 after ICR. As expected, survivin levels increased in the ICR mouse consistent with the notion that p53 repression and survivin induction contribute to the expanded surface area in ICR mice.