Improvement of adenoma detection rate by two computer-aided colonic polyp detection systems in high adenoma detectors: a randomized multicenter trial

BACKGROUND

This study aimed to evaluate the benefits of a self-developed computer-aided polyp detection system (SD-CADe) and a commercial system (CM-CADe) for high adenoma detectors compared with white-light endoscopy (WLE) as a control.

METHODS

Average-risk 50-75-year-old individuals who underwent screening colonoscopy at five referral centers were randomized to SD-CADe, CM-CADe, or WLE groups (1:1:1 ratio). Trainees and staff with an adenoma detection rate (ADR) of ≥35% were recruited. The primary outcome was ADR. Secondary outcomes were the proximal adenoma detection rate (pADR), advanced adenoma detection rate (AADR), and the number of adenomas, proximal adenomas, and advanced adenomas per colonoscopy (APC, pAPC, and AAPC, respectively).

RESULTS

The study enrolled 1200 participants. The ADR in the control, CM-CADe, and SD-CADe groups was 38.3%, 50.0%, and 54.8%, respectively. The pADR was 23.0%, 32.3%, and 38.8%, respectively. AADR was 6.0%, 10.3%, and 9.5%, respectively. After adjustment, the ADR and pADR in both intervention groups were significantly higher than in controls (all P<0.05). The APC in the control, CM-CADe, and SD-CADe groups was 0.66, 1.04, and 1.16, respectively. The pAPC was 0.33, 0.53, and 0.64, respectively, and the AAPC was 0.07, 0.12, and 0.10, respectively. Both CADe systems showed significantly higher APC and pAPC than WLE. AADR and AAPC were improved in both CADe groups versus control, although the differences were not statistically significant.

CONCLUSION

Even in high adenoma detectors, CADe significantly improved ADR and APC. The AADR tended to be higher with both systems, and this may enhance colorectal cancer prevention.

Identification of breath volatile organic compounds to distinguish pancreatic adenocarcinoma, pancreatic cystic neoplasm, and patients without pancreatic lesions

BACKGROUND

Volatile organic compounds (VOCs) are a promising potential biomarker that may be able to identify the presence of cancers.

AIM

To identify exhaled breath VOCs that distinguish pancreatic ductal adenocarcinoma (PDAC) from intraductal papillary mucinous neoplasm (IPMN) and healthy volunteers.

METHODS

We collected exhaled breath from histologically proven PDAC patients, radiological diagnosis IPMN, and healthy volunteers using the ReCIVA® device between 10/2021-11/2022. VOCs were identified by thermal desorption-gas chromatography/field-asymmetric ion mobility spectrometry and compared between groups.

RESULTS

A total of 156 participants (44% male, mean age 62.6 ± 10.6) were enrolled (54 PDAC, 42 IPMN, and 60 controls). Among the nine VOCs identified, two VOCs that showed differences between groups were dimethyl sulfide [0.73 vs 0.74 vs 0.94 arbitrary units (AU), respectively; P = 0.008] and acetone dimers (3.95 vs 4.49 vs 5.19 AU, respectively; P < 0.001). After adjusting for the imbalance parameters, PDAC showed higher dimethyl sulfide levels than the control and IPMN groups, with adjusted odds ratio (aOR) of 6.98 (95%CI: 1.15-42.17) and 4.56 (1.03-20.20), respectively (P < 0.05 both). Acetone dimer levels were also higher in PDAC compared to controls and IPMN (aOR: 5.12 (1.80-14.57) and aOR: 3.35 (1.47-7.63), respectively (P < 0.05 both). Acetone dimer, but not dimethyl sulfide, performed better than CA19-9 in PDAC diagnosis (AUROC 0.910 vs 0.796). The AUROC of acetone dimer increased to 0.936 when combined with CA19-9, which was better than CA19-9 alone (P < 0.05).

CONCLUSION

Dimethyl sulfide and acetone dimer are VOCs that potentially distinguish PDAC from IPMN and healthy participants. Additional prospective studies are required to validate these findings.

Performance comparison between two computer-aided detection colonoscopy models by trainees using different false positive thresholds: a cross-sectional study in Thailand

BACKGROUND/AIMS

This study aims to compare polyp detection performance of "Deep-GI," a newly developed artificial intelligence (AI) model, to a previously validated AI model computer-aided polyp detection (CADe) using various false positive (FP) thresholds and determining the best threshold for each model.

METHODS

Colonoscopy videos were collected prospectively and reviewed by three expert endoscopists (gold standard), trainees, CADe (CAD EYE; Fujifilm Corp.), and Deep-GI. Polyp detection sensitivity (PDS), polyp miss rates (PMR), and false-positive alarm rates (FPR) were compared among the three groups using different FP thresholds for the duration of bounding boxes appearing on the screen.

RESULTS

In total, 170 colonoscopy videos were used in this study. Deep-GI showed the highest PDS (99.4% vs. 85.4% vs. 66.7%, p<0.01) and the lowest PMR (0.6% vs. 14.6% vs. 33.3%, p<0.01) when compared to CADe and trainees, respectively. Compared to CADe, Deep-GI demonstrated lower FPR at FP thresholds of ≥0.5 (12.1 vs. 22.4) and ≥1 second (4.4 vs. 6.8) (both p<0.05). However, when the threshold was raised to ≥1.5 seconds, the FPR became comparable (2 vs. 2.4, p=0.3), while the PMR increased from 2% to 10%.

CONCLUSION

Compared to CADe, Deep-GI demonstrated a higher PDS with significantly lower FPR at ≥0.5- and ≥1-second thresholds. At the ≥1.5-second threshold, both systems showed comparable FPR with increased PMR.

What are the priority quality indicators for colonoscopy in real-world clinical practice?

Colonoscopy is widely used as a colorectal cancer (CRC) screening tool. The effectiveness of a screening colonoscopy is associated with a decreased risk of CRC. However, colonoscopy is an operator-dependent procedure, and endoscopists' quality performance varies widely. This article reviewed the priority metrics and practices that contribute to high-quality screening colonoscopy in real-world clinical practice. With growing evidence, quality indicators have been subject to intense research and associated with reducing postcolonoscopy CRC incidence and mortality. Some quality metrics can reflect an endoscopy unit-based practice (i.e. quality of bowel preparation and withdrawal time). Other quality indicators primarily reflect individuals' skill and knowledge (i.e. cecal intubation rate, adenoma detection rate, and appropriately assigned follow-up colonoscopy interval). Measurement and improvement of priority quality indicators for colonoscopy should be made at both the endoscopist and unit levels. Substantial evidence supports the impact of high-quality colonoscopy in reducing the incidence of postcolonoscopy CRC.

Diagnostic validity and learning curve of non-NBI expert endoscopists in gastric intestinal metaplasia diagnosis

BACKGROUND

Endoscopists' experience influences narrow-band imaging (NBI)-guided gastric intestinal metaplasia (GIM) diagnostic performance. We aimed to evaluate the general gastroenterologists (GE) performance in NBI-guided GIM diagnosis compared to NBI experts (XP) and assess GEs' learning curve.

METHODS

A cross-sectional study was conducted between 10/2019 and 2/2022. Histology-proven GIM who underwent esophagogastroduodenoscopy (EGD) were randomly assessed by 2XPs or 3GEs. Endoscopists' performance on NBI-guided diagnoses were compared to the pathological diagnosis (gold standard) in five areas of the stomach according to the Sydney protocol. The primary outcome were GIM diagnosis validity scores of GEs compared to XPs. The secondary outcome was the minimum number of lesions required for GEs to achieve an accuracy of GIM diagnosis ≥ 80%.

RESULTS

One thousand one hundred and fifty-five lesions from 189 patients (51.3% male, mean age 66 ± 10 years) were examined. GEs performed EGD in 128 patients with 690 lesions. the GIM diagnosis sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of GEs compared to the XPs, were 91% vs.93%, 73% vs.83%, 79% vs.83%, 89% vs.93%, and 83% vs.88%, respectively. GEs demonstrated lower specificity (mean difference - 9.4%; 95%CI - 16.3, 1.4; p = 0.008) and accuracy (mean difference - 5.1%; 95%CI - 3.3, 6.3; p = 0.006) compared to XPs. After 100 lesions (50% GIM), GEs achieved an accuracy of ≥ 80% and all diagnostic validity scores were comparable to the XPs (p < 0.05 all).

CONCLUSIONS

Compared to XPs, GEs had lower specificity and accuracy for GIM diagnosis. The learning curve for a GE to achieve comparable performance to XPs would necessitate at least 50 GIM lesions. Created with BioRender.com.

EUS-guided radiofrequency ablation plus chemotherapy versus chemotherapy alone for pancreatic cancer (ERAP): An observational open-label pilot study

Background

No study has compared EUS-guided radiofrequency ablation (EUS-RFA) plus systemic chemotherapy (CMT) with CMT alone for unresectable pancreatic ductal adenocarcinoma.

Methods

This study compared the results of treatment in patients receiving EUS-RFA plus concomitant CMT (group A; n = 14) with those receiving CMT (group B; n = 14) as a pilot study.

Results

From July 2017 to August 2018, 4 and 2 patients from groups A and B, respectively, withdrew from the study because of progression of the disease. In total, 10 and 12 patients from groups A and B, respectively, completed the study. All 30 EUS-RFA procedures were successful. Mean maximal tumor diameter before treatment of group A (n = 10) versus B (n = 12) was 62.2 ± 21.0 versus 50.5 ± 22.0 mm, respectively (P = not significant). After treatment, no statistically significant difference in mean maximal tumor diameter was found between both groups. However, in group B, mean maximal tumor diameter was significantly increased from 50.5 ± 22.0 to 56.3 ± 18.7 mm, respectively (P = 0.017). Tumor necrosis occurred in group A versus B at 10 of 10 (100%) versus 6 of 12 (50%) patients, respectively (P = 0.014). After treatment, group A patients could reduce the mean narcotic pain drug dosage at 26.5 mg of morphine equivalent per day (from 63.6 to 37.1 mg, P = 0.022), whereas group B patients could not reduce the dosage of pain-controlled medication. No statistically significant difference in 6-month mortality rate was found. In group A, 1 procedure-related nonsevere adverse event (n = 1 of 30 [3.3%]) occurred in 1 patient (n = 1 of 14 [7.1%]).

Conclusions

In this study, the mean tumor diameter of group B was significantly increased after the treatment. Group A had a significantly higher rate of necrosis of tumor and required less narcotic.

Real-time gastric intestinal metaplasia diagnosis tailored for bias and noisy-labeled data with multiple endoscopic imaging

This work presents real-time segmentation viz. gastric intestinal metaplasia (GIM). Recently, GIM segmentation of endoscopic images has been carried out to differentiate GIM from a healthy stomach. However, real-time detection is difficult to achieve. Conditions are challenging, and include multiple color modes (white light endoscopy and narrow-band imaging), other abnormal lesions (erosion and ulcer), noisy labels etc. Herein, our model is based on BiSeNet and can overcome the many issues regarding GIM. Application of auxiliary head and additional loss are seen to improve performance as well as enhance multiple color modes accurately. Further, multiple pre-processing techniques are utilized for leveraging detection performance: namely, location-wise negative sampling, jigsaw augmentation, and label smoothing. Finally, the decision threshold can be adjusted separately for each color mode. Work undertaken at King Chulalongkorn Memorial Hospital examined 940 histologically proven GIM images and 1239 non-GIM images, obtained over 173 frames per second (FPS). In terms of accuracy, our model is seen to outperform all baselines. Our results demonstrate sensitivity, specificity, positive predictive, negative predictive, accuracy, and mean intersection over union (IoU), achieving GIM segmentation values of 91%, 96%, 91%, 91%, 96%, and 55%, respectively.

A New Paradigm Shift in Gastroparesis Management

Gastroparesis, once regarded as a rare disease, is difficult to diagnose and challenging to treat; there were many breakthrough advances in the 2010s, shifting the paradigm of the understanding of this complex entity and its management. Similar to diabetes, its increasing prevalence reflects increased accessibility to diagnostic modalities and suggests that gastroparesis was underacknowledged in the past. Major developments in the three main aspects of the disease include the discovery of smooth muscle cells, interstitial cells of Cajal, PDGFRα+ cells syncytium, rather than interstitial cells of Cajal alone, as the main gastric pacemaker unit; the development of validated point-of-care diagnostic modalities such as a wireless motility capsule, the carbon 13-labeled breath test, and impedance planimetry; and the introduction of novel minimally invasive therapeutic options such as newer pharmacologic agents and gastric peroral endoscopic pyloromyotomy. All aspects of these advances will be discussed further in this review.

Factors affecting late complications of percutaneous endoscopic gastrostomy tube replacement

BACKGROUND

Late complications associated with percutaneous endoscopic gastrostomy (PEG) tube in patients are common occurrences. We aimed to identify risk factors associated with PEG-related late complications.

METHODS

Patients who underwent PEG exchange were retrospectively collected from electronic medical records between January 2015 and November 2020. Medical records were reviewed longitudinally from the PEG replacement date until the first complication event, death, or the end of the study. The late complication was defined as the PEG-related complications six months after the initial PEG placement. Potential risk factors were tested using Cox proportional hazard.

RESULTS

A total of 116 patients (mean age 80.5 ± 17.6 years, 52.6% male) were enrolled with a 12 (4-23) months median follow-up. The indications were mostly neurologic disease (89.7%). Non-balloon PEG was used in 93 (80.2%) patients with balloon-type in 23 (19.8%) patients. PEG-related late complications developed in 35 (30.2%) patients with a median time of 9 (4-23) months. In the multivariate analysis, the PEG-related late complication rate was significantly higher in patients with balloon-type PEG tube (HR 5.54; 95%CI, 2.55-12.05; p < 0.001) and also showed a significantly higher cumulative incidence of developing complications (54.9% vs. 12.8% at one year and 76% vs. 22.8% at two years, p < 0.001). The most common complication was PEG dislodgement (n = 14, 40%).

CONCLUSION

Late-onset of PEG tube-associated complications is a common problem. The significant factor associated with PEG tube complication was balloon-type PEG placement.

Real-time semantic segmentation of gastric intestinal metaplasia using a deep learning approach

Background/Aims

Previous artificial intelligence (AI) models attempting to segment gastric intestinal metaplasia (GIM) areas have failed to be deployed in real-time endoscopy due to their slow inference speeds. Here, we propose a new GIM segmentation AI model with inference speeds faster than 25 frames per second that maintains a high level of accuracy.

Methods

Investigators from Chulalongkorn University obtained 802 histological-proven GIM images for AI model training. Four strategies were proposed to improve the model accuracy. First, transfer learning was employed to the public colon datasets. Second, an image preprocessing technique contrast-limited adaptive histogram equalization was employed to produce clearer GIM areas. Third, data augmentation was applied for a more robust model. Lastly, the bilateral segmentation network model was applied to segment GIM areas in real time. The results were analyzed using different validity values.

Results

From the internal test, our AI model achieved an inference speed of 31.53 frames per second. GIM detection showed sensitivity, specificity, positive predictive, negative predictive, accuracy, and mean intersection over union in GIM segmentation values of 93%, 80%, 82%, 92%, 87%, and 57%, respectively.

Conclusions

The bilateral segmentation network combined with transfer learning, contrast-limited adaptive histogram equalization, and data augmentation can provide high sensitivity and good accuracy for GIM detection and segmentation.

Performance status of targeted biopsy alone versus Sydney protocol by non-NBI expert gastroenterologist in gastric intestinal metaplasia diagnosis

Background and study aims  According to a recent guideline, patients with gastric intestinal metaplasia (GIM) should have at least five biopsies performed under the Sydney protocol to evaluate for risk of extensive GIM. However, only narrow-band imaging (NBI)-targeted biopsy may be adequate to diagnose extensive GIM. Patients and methods  A cross-sectional study was conducted between November 2019 and October 2020. Patients with histology-proven GIM were enrolled. All patients underwent standard esophagogastroduodenoscopy performed by a gastroenterology trainee. The performing endoscopists took biopsies from either a suspected GIM area (NBI-targeted biopsy) or randomly (if negative for GIM read by NBI) to complete five areas of the stomach as per the Sydney protocol. The gold standard for GIM diagnosis was pathology read by two gastrointestinal pathologists with unanimous agreement. Results  A total of 95 patients with GIM were enrolled and 50 (52.6%) were men with a mean age of 64 years. Extensive GIM was diagnosed in 43 patients (45.3%). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of NBI-targeted biopsy vs. the Sydney protocol were 88.4% vs.100 %, 90.3% vs. 90.3%, 88.4% vs. 89.6%, 90.3% vs. 100%, and 89.5% vs. 94.7%, respectively. The number of specimens from NBI-targeted biopsy was significantly lower than that from Sydney protocol (311vs.475, P  < 0.001). Conclusions  Both NBI-targeted biopsy and Sydney protocol by a gastroenterologist who was not an expert in NBI and who has experience with diagnosis of at least 60 cases of GIM provided an NPV higher than 90%. Thus, targeted biopsy alone with NBI, which requires fewer specimens, is an alternative option for extensive GIM diagnosis.

Linked color imaging, mucosal exposure device, their combination, and standard colonoscopy for adenoma detection: a randomized trial

BACKGROUND AND AIMS

By different mechanisms, image-enhancement techniques (linked color imaging [LCI]) and mucosal exposure devices (Endocuff-assisted colonoscopy [EAC]) can improve the adenoma detection rate (ADR) during screening colonoscopy. The impact of the combination of the 2 techniques has never been studied. This study aimed to compare the ADR between the combination of LCI and EAC (LCI+EAC), LCI alone, EAC alone, and standard high-definition (HD) colonoscopy.

METHODS

This prospective randomized controlled trial included participants who underwent screening colonoscopy. Participants were randomized to LCI+EAC, LCI, EAC, and standard HD colonoscopy. All colonoscopies were performed by endoscopists with a recorded ADR ≥35%. The primary outcome was the ADR. Secondary outcomes were proximal ADR (pADR) and the mean number of adenomas per colonoscopy (APC).

RESULTS

One thousand participants were included in the study. The LCI+EAC group provided the highest ADR and pADR. The ADRs in the LCI+EAC, LCI, EAC, and standard HD colonoscopy groups were 57.2%, 52.8%, 51.6%, and 47.6%, respectively, with pADRs of 38.4%, 34.8%, 33.6%, and 28.0%, respectively. The mean numbers of APC were 1.28, 1.20, 1.16, and .89, respectively. After a multiple comparison adjustment, a significant difference in pADR was only observed between the LCI+EAC and standard HD colonoscopy groups (difference, 10.3 percentage points; 95% confidence interval, .02%-17.4%; P = .05). The incidence rate ratios of the adenoma numbers were significantly higher in the LCI+EAC (1.43), LCI (1.34), and EAC (1.30) groups relative to the standard HD colonoscopy group (.89) (P < .009 for all comparisons).

CONCLUSIONS

The combination of LCI and EAC can significantly improve the detection of pADR and APC but not ADR by high-ADR performers. (Clinical trial registration number: TCTR20190319001.).

Burden of Inflammatory Bowel Disease on Patient Mood, Fatigue, Work, and Health-Related Quality of Life in Thailand: A Case-Control Study

Background

Inflammatory bowel disease (IBD) has become an emerging disease in Asia. The burden of disease affects health-related quality of life (HRQoL), economics, and society. We compared HRQoL of IBD patients with/without active disease to that of the general population.

Methods

Consecutive patients with active disease and patients in clinical remission were prospectively recruited. For each IBD patient, an age- and sex-matched healthy control was invited. Active disease was defined as patient-reported clinical symptoms (ClinPRO) with endoscopic inflammation. All participants completed five questionnaires: (1) Short IBD Questionnaire (SIBDQ); (2) Hospital Anxiety and Depression Scale (HADS); (3) Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue); (4) Work Productivity and Activity Impairment questionnaire (WPAI); and (5) EuroQol 5-Dimension 5-Level scale (EQ5D5L). Multiple regression analyses were used to assess differences in HRQoL scores between IBD patients and controls.

Results

A total of 418 participants (209 IBD, 209 controls) were included. There were 101 patients with active disease and 108 patients in clinical remission. Regarding patients with active disease compared with controls, there was a significant mean difference in scores (95% CI) of 12.3 (9.5-15.2) on the SIBDQ; 6.7 (4.7-8.8), FACIT-fatigue; 1.6 (0.6-2.7), HADS-anxiety; 1.6 (0.8-2.4), HADS-depression; 20.3% (13.0%-27.7%), work productivity impairment; and 0.089 (0.045-0.134), EQ5Q5L (P < .05, all comparisons). Regarding patients in clinical remission compared with controls, none of these mean differences achieved a minimal clinically important difference.

Conclusions

Active IBD has a negative impact on HRQoL, whereas patients in clinical remission showed no clinically significant difference from the general population on HRQoL.

Perception of Gastrointestinal Endoscopy Personnel on Society Recommendations on Personal Protective Equipment, Case Selection, and Scope Cleaning During Covid-19 Pandemic: An International Survey Study

Background/Aims

The Thai Association for Gastrointestinal Endoscopy published recommendations on safe endoscopy during the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to assess the practicality and applicability of the recommendations and the perceptions of endoscopy personnel on them.

Methods

A validated questionnaire was sent to 1290 endoscopy personnel globally. Of these, the data of all 330 responders (25.6%) from 15 countries, related to the current recommendations on proper personal protective equipment (PPE), case selection, scope cleaning, and safety perception, were analyzed. Ordinal logistic regression was used to determine the relationships between the variables.

Results

Despite an overwhelming agreement with the recommendations on PPE (94.5%) and case selection (95.5%), their practicality and applicability on PPE recommendations and case selection were significantly lower (p=0.001, p=0.047, p<0.001, and p=0.032, respectively). Factors that were associated with lower sense of safety in endoscopy units were younger age (p=0.004), less working experience (p=0.008), in-training status (p=0.04), and higher national prevalence of COVID-19 (p=0.003). High prevalent countries also had more difficulty implementing the guidelines (p<0.001) and they considered the PPE recommendations less practical and showed lower agreement with them (p<0.001 and p=0.008, respectively). A higher number of in-hospital COVID-19 patients was associated with less agreement with PPE recommendations (p=0.039).

Conclusions

Using appropriate PPE and case selection in endoscopic practice during a pandemic remains a challenge. Resource availability and local prevalence are critical factors influencing the adoption of the current guidelines.

Current Status of Colorectal Cancer and Its Public Health Burden in Thailand

Colorectal cancer (CRC) accounts for approximately 10.3% of new cancer cases in Thailand and is currently the 3rd most prevalent cancer found among the Thai population. Starting in 2017, the Thai government announced the national CRC screening program as a response to this important issue. Among the 70 million people currently residing in Thailand, 14 million require screening, while there are approximately a total of 1,000 endoscopists available to perform colonoscopy. Due to the limited resources and shortage of endoscopists in Thailand, applying a population-based one-step colonoscopy program as a primary screening method is not feasible. To reduce colonoscopy workload, with the help of others, including village health volunteers, institution-based health personnel, reimbursement coders, pathologists, and patients due for CRC screening, a two-step approach of one-time fecal immunochemical test (FIT), which prioritizes and filters out subjects for colonoscopy, is chosen. Moreover, additional adjustments to the optimal FIT cutoff value and the modified Asia-Pacific Colorectal Screening risk score, including body weight, were proposed to stratify the priority of colonoscopy schedule. This article aims to give an overview of the past and current policy developmental strategies and the current status of the Thailand CRC screening program.

Decontamination and reuse of surgical masks and N95 filtering facepiece respirators during the COVID-19 pandemic: A systematic review

OBJECTIVES

Surgical masks and N95 filtering facepiece respirators (FFRs) prevent the spread of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection and protect medical personnel. Increased demands for surgical masks and N95 FFRs during the coronavirus disease 2019 (COVID-19) pandemic has resulted in the shortage crisis. However, there is no standard protocol for safe reuse of the N95 FFRs. In this systematic review, we aimed to evaluate the effectiveness of existing decontamination methods of surgical masks and N95 FFRs and provide evidence-based recommendations for selecting an appropriate decontamination method.

METHODS

We performed systematic searches of Ovid MEDLINE and Ovid EMBASE electronic databases. The last search was performed April 11, 2020. Any trials studying surgical masks and/or N95 FFRs decontamination were included. Outcomes were disinfections of virus and bacteria, restoration of the filtration efficiency, and maintenance of the physical structure of the mask.

RESULTS

Overall, 15 studies and 14 decontamination methods were identified. A low level of evidence supported 4 decontamination methods: ultraviolet (UV) germicidal irradiation (9 studies), moist heat (5 studies), microwave-generated steam (4 studies), and hydrogen peroxide vapor (4 studies). Therefore, we recommended these 4 methods, and we recommended against use were given for the other 10 methods.

CONCLUSIONS

A low level of evidence supported the use of UV germicidal irradiation, moist heat, microwave-generated steam, and hydrogen peroxide vapor for decontamination and reuse of N95 FFRs. These decontamination methods were effective for viral and bacterial disinfection as well as restoration of the filtration efficiency, and the physical structure of the FFRs.

Nurse Administered Propofol Sedation (NAPS) versus On-call Anesthesiologist Administered Propofol Sedation (OAPS) in Elective Colonoscopy

BACKGROUND AND AIMS

As on-call anesthesiologist administered propofol sedation (OAPS) is costly and not readily available in all endoscopy units, endoscopy nurse administered propofol sedation (NAPS) can be an effective alternative. This study aimed to compare the dosage of propofol used by NAPS versus OAPS, cardiopulmonary adverse events and recovery time in low risk patients undergoing outpatient elective colonoscopy.

METHODS

A retrospective propensity score-matched cohort study was conducted. Electronic medical records of elective colonoscopies performed by 3 experienced endoscopists from January 2016 to December 2019 were retrieved. OAPSs were performed by 10 certified anesthesiologists while NAPSs were performed by 8 experienced registered endoscopy nurses. Baseline characteristics, performing endoscopist, cecal intubation time, withdrawal time, propofol dosage per procedure, and adverse events were collected and analyzed using 3:1 (NAPS:OAPS) propensity score matching by age, performing endoscopist and difficulty of colonoscopy as co-variates with standardized mean deviation of <0.1.

RESULTS

278 eligible patients were included. After propensity score matching, there were 189 patients in NAPS and 63 in OAPS group for analysis. Demographic data were not different between the two groups. All procedures were technically successful with no difference in cecal intubation time (6.0±4 min vs 6.8±4 min; p=0.13) or total procedural time (17.2±16 min vs 16.3±6 min; p=0.66). Propofol dosage/kg/hour were significantly lower in the NAPS group, (11.4±4 mg/kg/hour vs. 16.6±8 mg/kg/hour; p<0.001). There were less minor cardiopulmonary adverse events in NAPS when compared to the OAPS group (2.2% vs 4.7%; p=0.014).

CONCLUSIONS

NAPS in elective colonoscopy in low-risk patients is as effective as OAPS but requires a significant lower dosage of propofol. Minor cardiopulmonary adverse events were recorded in the NAPS group compared to OAPS.

A newly designed duodenoscope with detachable distal cap significantly reduces organic residue contamination after reprocessing

BACKGROUND

A newly designed duodenoscope with detachable distal cap may reduce bacterial contamination by allowing better access to the elevator. We compared bacterial contamination and organic residue evaluated by rapid adenosine triphosphate (ATP) test and culture from duodenoscopes with detachable vs. fixed distal caps after high-level disinfection (HLD).

METHODS

During December 2018-April 2019, 108 used newly designed duodenoscopes were enrolled. In group A (n = 54), the distal cap of the duodenoscope was detached before manual cleaning. In group B (n = 54), the distal cap was not detached. After HLD, samples were collected from the elevator, submitted for culture, and evaluated using the ATP test, using the cutoff value of 40 relative light units (RLUs).

RESULTS

After HLD, the proportion of potential bacterial contamination and organic residue in group A was significantly lower than in group B (37.0 % vs. 75.9 %; P  < 0.001; relative risk 0.49, 95 % confidence interval 0.33-0.71), and also confirmed by median ATP values (45.2 vs. 141.0 RLU; P  < 0.001). In group B, one sample culture was positive for nonpathogenic bacteria. Pathogenic bacteria were not found in any culture from either group.

CONCLUSIONS

The detachable distal cap was more effective at eliminating bacterial contamination and reducing organic residue than a fixed cap. Nonpathogenic bacteria were detected in the fixed cap group after reprocessing. The ATP test with 40 RLU cutoff is a practical method to ensure the cleanliness of duodenoscope reprocessing without the need to wait for bacterial culture results.