Faculty Bibliography

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported adverse events of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2024 for articles related to endoscopic submucosal dissection. Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Virtual urgent care (VUC) has become an increasingly utilized resource for acute care delivery. Frequent utilization of VUC may reflect unmet longitudinal care needs and contribute to fragmented care. While high-utilizer patterns are well described in emergency departments, they have not been systematically characterized in telemedicine. We evaluated a clinical decision support (CDS) nudge designed to identify and address high utilizers of VUC at a large academic health system. An electronic health record alert triggered when patients met predefined high-utilizer criteria (>3 visits in 30 days, >12 in six months, or >20 in 12 months) and prompted providers to document a structured follow-up plan using a SmartPhrase. Among 473 eligible patients, 162 (34%) received the SmartPhrase. After adjustment for baseline utilization using negative binomial regression, SmartPhrase use was associated with a 22% relative reduction in VUC visits over the subsequent 30 days (incidence rate ratio 0.78, p = .03). Bootstrapped analyses confirmed a significant reduction in the SmartPhrase group (-1.47 visits; 95% CI [-2.19 to -0.62]), while no significant change occurred in the comparison group. These findings suggest that a low-cost, workflow-integrated CDS nudge may reduce short-term telehealth overutilization by prompting structured follow-up discussions and encouraging longitudinal care planning.

BACKGROUND:Chronic kidney disease (CKD) is associated with cardiovascular disease (CVD). Exceptional parental longevity protects against CVD. We examined whether exceptional parental longevity modified the associations of kidney function and kidney aging with CVD in older adults. METHODS:We used data from LonGenity (2008-2023), a cohort of Ashkenazi Jewish adults aged 65-95, comparing the offspring of parents with exceptional longevity to the offspring of parents with usual survival. Exceptional longevity was defined as living beyond 95 years. Kidney function was estimated using glomerular filtration rate (eGFR); CKD was defined as eGFR < 60 mL/min/1.73m2. Kidney aging was assessed using kidney age gap-the difference between proteomic kidney age and chronological age. Logistic and Cox regression tested associations between eGFR and kidney aging with prevalent and incident CVD, respectively. Effect modification was tested using interaction terms and stratified analyses. RESULTS:Among 1180 participants (mean age 76 ± 7 years), 23% had CKD; median kidney age gap was -0.04 years (IQR: -0.67, 0.66); 15% had baseline CVD. eGFR and kidney aging were associated with prevalent CVD, but not incident CVD. Exceptional parental longevity did not modify the association of eGFR with prevalent or incident CVD. However, it did modify the association of kidney age gap with incident, but not prevalent, CVD. In the offspring of parents with exceptional longevity, higher kidney age gap was associated with increased incident CVD hazard (HR: 1.90; 95% CI: 1.23, 2.94), but not in the offspring of parents with usual survival (HR: 0.79 95% CI: 0.59, 1.05). CONCLUSIONS:Kidney age gap may reflect early CVD risk in biologically resilient populations, thus warranting prospective studies.

BACKGROUND:Redo/revisional ileal pouch-anal anastomosis (IPAA) surgery is technically challenging and more likely to require mesenteric lengthening maneuvers, largely due to mesenteric reach issues, which may affect the perfusion of the critical sites in the pouch. Indocyanine green fluorescence angiography (ICG-FA) offers real-time assessment of tissue perfusion and may reduce the risk of complications, such as anastomotic leak. We aimed to evaluate the impact of intraoperative ICG-FA on surgical outcomes in patients undergoing redo/revisional IPAA surgery. METHODS:This is a retrospective case-control study with 1:1 propensity score matching based on data from a high-volume quaternary inflammatory bowel disease center. Patients who underwent redo/revisional IPAA surgery between September 2016 and December 2023 were included. The primary objective was to evaluate the direct impact of ICG-FA on intraoperative decision-making, measured by the rate of change in surgical plan. Secondary objectives included an exploratory comparison of short- and long-term outcomes, such as anastomotic leak and major complications. RESULTS:A total of 46 patients were included, with 23 patients in each of the ICG and non-ICG groups. ICG-FA led to intraoperative changes in surgical management in 2 patients (8.7%), including one pouch augmentation with resection of the tip of the J pouch and one pouch excision. The 30-day major complication rate was lower in the ICG group (11.1%) compared to non-ICG (18.2%), though not statistically significant (p = 1.00). No significant difference was found in long-term complication rates after adjusting for a marked disparity in follow-up duration between the groups. No adverse reactions related to ICG-FA were observed. CONCLUSIONS:ICG-FA is a safe and feasible adjunct during redo/revisional IPAA surgery. Its use may guide intraoperative decision-making, leading to timely revisions.

BACKGROUND/UNASSIGNED:Recent observational studies have suggested that early treatment (<12 hours from diagnosis) of intermediate risk pulmonary embolism (PE) with catheter-based therapies may reduce morbidity and mortality. However, the effect of early versus late mechanical thrombectomy on acute pulmonary hemodynamics and right ventricular mechanics is less well defined. METHODS/UNASSIGNED:Patients enrolled in SYMPHONY-PE were divided into one of 2 groups based on the time from baseline CT pulmonary angiography to mechanical thrombectomy: Early <12 hours versus late ≥12 hours. The primary safety end point was the rate of major adverse events within 48 hours, as adjudicated by an academic independent safety board. The primary efficacy end point was the core-lab assessed mean change in right ventricle-to-left ventricle ratio from baseline to 48 hours. RESULTS/UNASSIGNED:=0.431) between groups, and there were no mortalities. The differences in efficacy outcomes were greatest in higher-risk patients per the Composite Pulmonary Embolism Shock score. CONCLUSIONS/UNASSIGNED:Early mechanical thrombectomy was associated with larger reductions in right ventricle-to-left ventricle ratio and mean pulmonary artery pressure, with no significant differences in safety event rates compared with patients who underwent late thrombectomy. Randomized trials are needed to test these associations. REGISTRATION/UNASSIGNED:URL: https://www.clinicaltrials.gov; Unique identifier: NCT06062329.

BACKGROUND:Oral diseases are prevalent and linked to systemic health outcomes. People with HIV may face elevated oral disease risk, yet data on dental disease in this population remain limited. METHODS:In this cross-sectional study, we analyzed oral health data collected from 2927 participants in the MACS/WIHS Combined Cohort Study (968 women with HIV [WWH], 450 women without HIV [WWoH], 941 men with HIV [MWH], 568 men without HIV [MWoH]) who had intraoral photographs collected and evaluated by dentist-researchers. We used log-binomial regression to examine associations between demographic and clinical characteristics and two outcomes: missing teeth and untreated caries or residual roots, stratified by sex. RESULTS:Among 2927 participants (median [interquartile range, IQR] age: WWH, 55.3 years [48.3-61.6]; WWoH, 53.3 [44.8-60.3]; MWH, 55.1 [42.6-62.9]; MWoH, 62.9 [50.1-69.5]), women experienced a higher prevalence of tooth loss and untreated decay than men. Among participants aged 65 years or older, 15% to 21% of women were edentulous (compared with 2% to 3% of men), and 30% to 31% were missing at least a full arch of teeth (compared with 4% to 6% of men). In multivariable analyses, age was a dominant predictor of missing teeth among men (age ≥ 65 vs. <45 years: adjusted prevalence ratio [aPR], 1.49; 95% confidence interval [CI], 1.29-1.73). Income was the strongest predictor of untreated decay among women, more strongly predictive than age (highest vs. lowest income: aPR, 0.11; 95% CI, 0.03-0.43). Disparities by race/ethnicity persisted among men but were absent among women, who experienced extreme poverty and poor outcomes regardless of race/ethnicity. HIV serostatus was not independently associated with either outcome. CONCLUSION/CONCLUSIONS:Dental disease burden in this population reflected socioeconomic disparities rather than HIV infection. Racial disparities were absent among women, who had uniformly low incomes and poor oral health outcomes across all groups, highlighting substantial barriers to dental care access that warrant policy attention.

BACKGROUND:Transcatheter aortic valve replacement (TAVR) has become a cornerstone in the management of aortic valve disease. However, delayed complications after hospital discharge and readmission remain in an issue following TAVR. We aimed to evaluate the impact of remote monitoring systems on clinical outcomes after TAVR. METHODS:All patients who underwent TAVR from September 2014 through January 2019 were included retrospectively. Additionally, all patients, clinically indicated for TAVR from 9/1/2018 through 8/30/2021, were screened, and patients who agreed were prospectively enrolled. Medtronic Care Management Service (MCMS) was used to monitor patients following TAVR after discharge (Medtronic, Minneapolis, MN). RESULTS:A total of 1078 patients were included. Among them, 843 (78.2 %) patients were discharged with MCMS (MCMS group) and 235 (21.8 %) patients were discharged without (non-MCMS group). Overall, the mean age was 81.5 years, and mean STS-PROM was 5.53 %. Baseline conduction defect was observed in 427 (39.6 %). Peripheral artery disease was more common in the MCMS group while a history of myocardial infarction was more likely seen in the non-MCMS group. After propensity-score matching, length of hospital stays was significantly shorter in the MCMS group (1.42 days vs. 1.82 days in the non-MCMS group, p < 0.001). Readmission rates and new permanent pacemaker insertion rates were similar between the two groups. All-cause mortality, 30-day and 90-day mortality were comparable between the groups. CONCLUSIONS:MCMS was easily applicable to a clinical practice and may reduce length of hospital stays in patients undergoing TAVR without increasing readmission or mortality.

BACKGROUND:Cardiac dysfunction is more common in people with HIV (PWH) than those without HIV (PWoH), with mitochondrial dysfunction implicated in pathogenesis. We investigated whether variations in mitochondrial DNA (mtDNA) and certain dideoxynucleoside analogs (D-drugs) relate to left ventricular diastolic dysfunction (LVDD) in PWH. METHODS:We included individuals with echocardiograms from the Multicenter AIDS Cohort Study and Women's Interagency HIV Study. LVDD was defined using characterizing heart function on antiretroviral therapy criteria. mtDNA haplogroups were inferred using HaploGrep. Separate exploratory multivariable logistic regressions examined associations between LVDD and African (L0L1, L2, L3, or "other") or European haplogroups (UK, H, JT, or "other"), D-drugs, and their interactions. No adjustments were made for multiple comparisons. RESULTS:Among 842 men (455 PWH and 387 PWoH) and 898 women (620 PWH and 278 PWoH), LVDD prevalence was 29% in women and 24% in men. Among non-Hispanic White men with HIV, European haplogroup H was associated with lower odds of LVDD (odds ratio [OR], 0.50; 95% CI, 0.26-0.93), while haplogroup clade JT was associated with increased odds (OR, 2.09; 95% CI, 1.00-4.36). In men with HIV, D-drug exposure was associated with increased odds of LVDD (OR, 1.94; 95% CI, 1.21-3.13). No significant associations were observed between haplogroups and LVDD in women. HIV serostatus modified the association of haplogroup L2 (pinteraction = 0.036) and L3 (pinteraction = 0.045) with LVDD in women. CONCLUSIONS:Mitochondrial genetic variation and D-drug use were associated with altered LVDD risk in men with HIV, highlighting potential biological mechanisms that may be targeted for surveillance or therapeutic strategies.

This multinational cone-beam computed tomography (CBCT) study evaluated the root canal morphology of mandibular first premolars (M1Ps) from 21 countries and compared how well the Ahmed and Vertucci classification systems represented these patterns. A total of bilateral mandibular first premolars from eligible CBCT scans were assessed using both systems, and the data were analyzed with a hierarchical probabilistic approach to account for population and imaging-related variation. Across the overall dataset, a simple single-canal configuration was the dominant pattern, and this remained the most common finding in all populations despite limited but structured variation in less frequent subclasses. The Ahmed system classified all observed configurations, whereas the Vertucci system left approximately 10.2% of cases without an equivalent category. In addition, Ahmed preserved more anatomical detail, while Vertucci compressed several distinct configurations into broader groups. Demographic and imaging-related factors had modest effects, with voxel size showing the clearest technical influence on the detection of more complex patterns. Overall, M1P morphology showed a stable global pattern with secondary heterogeneity, and the Ahmed system provided a more complete and informative representation for CBCT-based morphology assessment across diverse populations.