Benchmarking Adenoma Detection Rates for Colonoscopy: Results From a US-Based Registry
INTRODUCTION/BACKGROUND:Adenoma detection rate (ADR) is highly variable across practices, and national or population-based estimates are not available. Our aim was to study the ADR, variability of rates over time, and factors associated with detection rates of ADR in a national sample of patients undergoing colonoscopy. METHODS:We used colonoscopies submitted to the GI Quality Improvement Consortium, Ltd. registry from 2014 to 2018 on adults aged 50-89 years. We used hierarchical logistic models to study factors associated with ADR. RESULTS:A total of 2,646,833 colonoscopies were performed by 1,169 endoscopists during the study period. The average ADR for screening colonoscopies per endoscopist was 36.80% (SD 10.21), 44.08 (SD 10.98) in men and 31.20 (SD 9.65) in women. Adjusted to the US population, the ADR was 39.08%. There was a significant increase in ADR from screening colonoscopies over the study period from 33.93% in 2014 to 38.12% in 2018. DISCUSSION/CONCLUSIONS:The average ADR from a large national US sample standardized to the US population is 39.05% and has increased over time.
What gastroenterologists should know about SARS-CoV 2 vaccine: World Endoscopy Organization perspective
BACKGROUND:The novel Coronavirus (SARS-CoV-2) has caused almost 2 million deaths worldwide. Both Food and Drug Administration and European Medicines Agency have recently approved the first COVID-19 vaccines, and a few more are going to be approved soon. METHODS:Several different approaches have been used to stimulate the immune system in mounting a humoral response. As more traditional approaches are under investigation (inactivated virus vaccines, protein subunit vaccines, recombinant virus vaccines), more recent and innovative strategies have been tried (non-replicating viral vector vaccines, RNA based vaccines, DNA based vaccines). RESULTS:Since vaccinations campaigns started in December 2020 in both the US and Europe, gastroenterologists will be one of the main sources of information regarding SARS-CoV 2 vaccination for patients in their practice, including vulnerable patients such as those with Inflammatory Bowel Disease (IBD), patients with chronic liver disease, and GI cancer patients. CONCLUSIONS:Thus, we must ourselves be well educated and updated in order to provide unambiguous counseling to these categories of vulnerable patients. In this commentary, we aim to provide a comprehensive review of both approved COVID-19 vaccines and the ones still under development, and explore potential risks, benefits and prioritization of vaccination.
Hyperlipasemia in absence of acute pancreatitis is associated with elevated D-dimer and adverse outcomes in COVID 19 disease
BACKGROUND:Coronavirus SARS-CoV-2 affects multiple organs. Studies have reported mild elevations of lipase levels of unclear significance. Our study aims to determine the outcomes in patients with COVID-19 and hyperlipasemia, and whether correlation with D-dimer levels explains the effect on outcomes. METHODS:Case-control study from two large tertiary care health systems, of patients with COVID-19 disease admitted between March 1 and May 1, 2020 who had lipase levels recorded. Data analyzed to study primary outcomes of mortality, length of stay (LOS) and intensive care utilization in hyperlipasemia patients, and correlation with D-dimer and outcomes. RESULTS:992 out of 5597 COVID-19 patients had lipase levels, of which 429 (43%) had hyperlipasemia. 152 (15%) patients had a lipaseÂ >Â 3x ULN, with clinical pancreatitis in 2 patients. Hyperlipasemia had a higher mortality than normal lipase patients (32% vs. 23%, ORÂ =Â 1.6,95%CIÂ =Â 1.2-2.1, PÂ =Â 0.002). In subgroup analysis, hyperlipasemia patients had significantly worse LOS (11vs.15 days, PÂ =Â 0.01), ICU admission rates (44% vs. 66%,ORÂ =Â 2.5,95%CIÂ =Â 1.3-5.0,PÂ =Â 0.008), ICU LOS (12vs.19 days,PÂ =Â 0.01), mechanical ventilation rates (34% vs. 55%,ORÂ =Â 2.4,95%CIÂ =Â 1.3-4.8,PÂ =Â 0.01), and durations of mechanical ventilation (14 vs. 21 days, PÂ =Â 0.008). Hyperlipasemia patients were more likely to have a D-dimer value in the highest two quartiles, and had increased mortality (59% vs. 15%,ORÂ =Â 7.2,95%CIÂ =Â 4.5-11,PÂ <Â 0.001) and LOS (10vs.7 days,PÂ <Â 0.001) compared to those with normal lipase and lower D-dimer levels. CONCLUSION/CONCLUSIONS:There is high prevalence of hyperlipasemia without clinical pancreatitis in COVID-19 disease. Hyperlipasemia was associated with higher mortality and ICU utilization, possibly explained by elevated D-dimer.
A practical guide to establishing a gastroenterology hospitalist program
The COVID-19 Army: Experiences From the Deployment of Non-Hospitalist Physician Volunteers During the COVID-19 Pandemic
OBJECTIVE:New York City was the epicenter of the outbreak of the 2019 coronavirus disease (COVID-19) pandemic in the United States. As a large, quaternary care medical center, NYU Langone Medical Center was one of many New York medical centers that experienced an unprecedented influx of patients during this time. Clinical leadership effectively identified, oriented, and rapidly deployed a "COVID Army," consisting of non-hospitalist physicians, to meet the needs of the patient influx. We share feedback from our providers on our processes and offer specific recommendations for systems experiencing a similar influx in the current and future pandemics. METHODS:To assess the experiences and perceived readiness of these physicians (n = 183), we distributed a 32-item survey between March and June of 2020. Thematic analyses and response rates were examined to develop results. RESULTS:Responses highlighted varying experiences and attitudes of our frontline physicians during an emerging pandemic. Thematic analyses revealed a series of lessons learned, including the need to (1) provide orientations, (2) clarify roles/workflow, (3) balance team workload, (4) keep teams updated on evolving policies, (5) make team members feel valued, and (6) ensure they have necessary tools available. CONCLUSIONS:Lessons from our deployment and assessment are scalable at other institutions.
ACG Presidential Address 2020
Experiences from the deployment of non-hospitalist physician volunteers during the 2020 covid pandemic [Meeting Abstract]
BACKGROUND: New York City was the epicenter of the COVID pandemic in the US during early 2020. NYU Langone Medical Center was one of many New York medical centers that experienced an unprecedented influx of patients. During the onset of the pandemic, clinic leadership identified, oriented, and rapidly deployed a COVID Army, consisting of non-hospitalist physicians, to meet the needs of this patient influx. Orientation and training included an hour-long session with an emphasis on the inpatient electronic medical record system and a plan for at the elbow assistance from senior hospitalists. Here, we share feedback from our providers on our capacity building process and use information gathered to offer specific lessons learned in planning for workforce mobilization.
METHOD(S): A 32-item survey was distributed from March-June of 2020 in order to assess the experiences of these ancillary physicians, all of which were NYU Langone providers. Items included a mix of Likert and open-ended questions on demographics and attitudes toward experiences on the COVID team.
RESULT(S): All 272 volunteers received a survey. 67% (n=183) responded. 84 (46%) were from the Department of Medicine, the remainder were primarily from surgical, pediatrics or obstetrics/gynecology. Respondents worked in combination ambulatory/inpatient practices (n=94; 52%) or outpatient only (n=85; 47%) (Mean years in practice: 7.18). 76% felt that the number of patients they were in charge of felt Just Right (average: 7). 10% rated the experience as challenging (n=17). On their perception of support and training, 94% and 63% rated the support and training they received as somewhat or very effective, respectively. 89% (n=99) and 96% (n=107) of supplemental attendings felt valued and valuable to their team, respectively. 87% of respondents identified as being willing to volunteer again. In review of open-ended feedback, we identified a series of themes surrounding areas for improvement. These include the need to 1) invest time into orientations, including training on EHR use, (2) clarify roles and workflow within each team up front, (3) balance team workload if possible, (4) keep teams updated on evolving policies and recommendations, (5) make team members feel valued and supported, and (6) ensure they have the right tools available.
CONCLUSION(S): Given what we have learned from our survey, the continued waxing and waning of community infection, and the unknown length and extent of the COVID pandemic, we recommend providing transparent leadership, frequent communication, and an educational series to ensure everyone is learning together. In addition, clarity is essential, and it is important to be specific in defining the exact roles of ancillary physicians. It is our hope that the lessons learned from our needs assessment can be applied to other hospitals currently in the throes of a surge of COVID inpatients. LEARNING OBJECTIVE #1: Identify best practices for preparing an ancillary workforce for patient surge. LEARNING OBJECTIVE #2: Understand tools for quality patient care
Recovery of endoscopy services in the era of COVID-19: recommendations from an international Delphi consensus
The COVID-19 pandemic has had a profound impact on provision of endoscopy services globally as staff and real estate were repurposed. As we begin to recover from the pandemic, a cohesive international approach is needed, and guidance on how to resume endoscopy services safely to avoid unintended harm from diagnostic delays. The aim of these guidelines is to provide consensus recommendations that clinicians can use to facilitate the swift and safe resumption of endoscopy services. An evidence-based literature review was carried out on the various strategies used globally to manage endoscopy during the COVID-19 pandemic and control infection. A modified Delphi process involving international endoscopy experts was used to agree on the consensus statements. A threshold of 80% agreement was used to establish consensus for each statement. 27 of 30 statements achieved consensus after two rounds of voting by 34 experts. The statements were categorised as pre-endoscopy, during endoscopy and postendoscopy addressing relevant areas of practice, such as screening, personal protective equipment, appropriate environments for endoscopy and infection control precautions, particularly in areas of high disease prevalence. Recommendations for testing of patients and for healthcare workers, appropriate locations of donning and doffing areas and social distancing measures before endoscopy are unique and not dealt with by any other guidelines. This international consensus using a modified Delphi method to produce a series of best practice recommendations to aid the safe resumption of endoscopy services globally in the era of COVID-19.
The Napoleon: A Pilot Feasibility Study of a Small Endoscopic Ruler for Accurate Polyp Measurement [Meeting Abstract]
INTRODUCTION: Multi-society recommendations state, "Given the importance of polyp size for informing surveillance intervals, documentation of a polyp > 10 mm within a report should be accompanied by an endoscopic photo of the polyp with comparison to an open snare or open biopsy forceps".1 We evaluate the feasibility of the Napoleon, an endoscopically-deployed small ruler to more accurately measure and document the size of colon polyps.
METHOD(S): The Micro-Tech Endoscopic Gauge (Non-FDA approved) named Napoleon, a catheter with a 15 mm ruler calibrated in 1 mm intervals with demarcations every 5 MM, was advanced through the biopsy channel of a colonoscope and positioned adjacent to a polyp to accurately measure polyp size (Image 1). Polyps sizes were first assessed visually and then measured using the Napoleon. Patients included were 50 to 85 years of age and undergoing screening or surveillance colonoscopy. Napoleon placement, extension/retraction, and photograph acquisition were evaluated on a 1-s10 scale (1 = Easy, 10 = Difficult).
RESULT(S): 23 patients were evaluated by 6 physicians. A total of 36 polyps were found. Each score represents the average of several polyps if more than one polyp was identified per patient (Table 1). The most polyps found in any patient was 3. Each polyp size was placed into 1 of 3 categories (Table 2): 1-5 mm (Diminutive), 6-9 mm (Small) and $ 10 mm (Large). 30 of the 36 total polyps (83%) were diminutive. 3 polyps were downgraded into the next smaller size category after measurement with the Napoleon - specifically, 1 polyp (33%) dropped from small to diminutive size and 2 polyps (67%) dropped from large to small size.
CONCLUSION(S): Prior studies on polyp size have shown that visual assessment is inaccurate.2 This study demonstrates the ease and feasibility of the Napoleon as an endoscopic measuring device. The majority of polyps found were diminutive (1-5 mm) and explains why there is such a minute difference noted in the weighted mean polyp size (0.28 mm). Of the 3 polyps that were visually assessed to be $ 10 mm, 2 of those polyps (67%) were measured to be < 10 mm, changing recommended surveillance from 3 years to 7-10 years.1 Further studies utilizing an endoscopic measuring tool such as the Napoleon are needed to evaluate the effect of accurate polyp measurement on our clinical management, training, and colonoscopy surveillance intervals
Colonic intussusception: It's not malignant [Meeting Abstract]
INTRODUCTION: Lipomas are benign submosal lesions, which can be found throughout the gastrointestinal tract. In most patients, these are incidentals findings and patients are asymptomatic. However, there are instances when lipomas can cause symptoms of obstruction if very large. This case highlights a rare complication of a colonic lipoma. CASE DESCRIPTION/METHODS: The case is of a 31-year-old man, who initially presented for intermittent rectal bleeding. On initial evaluation he had a benign abdominal exam, but a rectal exam was performed suggested hemorrhoids. There was no significant past medical history and no family history of colon cancer. A colonoscopy was performed demonstrating sigmoid diverticulosis, an ascending colon lipoma, and internal hemorrhoids, the likely cause of bleeding. Ten days later the patient calls with intermittent abdominal pain for the last several days. On further questioning, the patient does report occasional episodes of a similar sharp pain for the last few years, but in the last few days the pain has intensified. An outpatient CT scan was performed showing a 6.8 cm lipoma in the transverse colon causing colo-colonic intussusception (image 1). The patient was taken for urgent robotic right hemicolectomy with a side to side ileocolic anastomosis. Final pathology confirmed a large lipoma. The patient fully recovered and symptoms have resolved.
Discussion(s): DISCUSSION: Intussusception is when the bowel telescopes on itself. The most common location is the small bowel, but intussusception can occur in the colon 1. A lipoma is a benign submucosal tumor, which can be found in the colon. In the majority of cases lipomas are incidental finding and cause no symptoms. Based on autopsy reports, the incidence rate of colonic lipomas is 0.2-0.8%. However, clinical symptoms might include abdominal pain, bleeding, and perforation. Clinicians should be aware of this unique presentation, which requires surgical intervention