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Shergill AK, Rempel D, Barr A, Lee D, Pereira A, Hsieh CM, McQuaid K, Harris-Adamson C. Biomechanical risk factors associated with distal upper extremity musculoskeletal disorders in endoscopists performing colonoscopy. Gastrointest Endosc 2021; 93:704-711.e3. [PMID: 33160978 DOI: 10.1016/j.gie.2020.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 11/02/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopists experience upper extremity musculoskeletal injuries. The primary aim of this study was to compare distal upper extremity biomechanical risk factors during colonoscopy with established risk thresholds. Secondary aims were to determine which subtasks during colonoscopy are associated with the greatest risk and to evaluate an intervention to reduce risks. METHODS Twelve endoscopists performed 2 to 4 colonoscopies while thumb pinch force and forearm muscle loads of extensor carpi radialis (ECR) and flexor digitorum superficialis (FDS) muscles were collected. Peak exertion values were analyzed using amplitude probability distribution functions. An endoscope support device was evaluated during simulated colonoscopy (n = 8). RESULTS Mean endoscopist age was 42.3 years; 67% were men. Peak thumb pinch force exceeded risk thresholds for pinch force (10 N) and percent of time spent in forceful pinch for all colonoscopy subtasks. Peak ECR and FDS muscle activity exceeded the action limit (10% maximum voluntary contraction [MVC]) in both forearms. Peak left FDS, left ECR, and right ECR activity exceeded the threshold limit value (>30% MVC). Peak left FDS and ECR activity were significantly greater during insertion than during withdrawal (P < .05). Peak right FDS and ECR activity were significantly greater during right colon insertion compared with withdrawal (P < .05). The endoscope support device reduced left ECR muscle activity (P = .02). CONCLUSIONS Thumb pinch forces and time spent in forceful pinch indicate high-risk exposures during colonoscopy. Left wrist extensor muscle activity exceeded established thresholds with the greatest risk occurring during insertion. An endoscope support device reduced loads to the left wrist extensors.
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Affiliation(s)
- Amandeep K Shergill
- Department of Gastroenterology, San Francisco VA Health Care Center, San Francisco, California, USA; Department of Medicine, University of California, San Francisco, California, USA
| | - David Rempel
- Department of Medicine, University of California, San Francisco, California, USA; Department of Bioengineering, University of California, Berkeley, California, USA
| | - Alan Barr
- Department of Bioengineering, University of California, Berkeley, California, USA
| | - David Lee
- Department of Medicine, University of California, San Francisco, California, USA; Department of Bioengineering, University of California, Berkeley, California, USA
| | - Anna Pereira
- Human Factors, Microsoft, Redmond, Washington, USA
| | - Chih Ming Hsieh
- Biomedical Engineering, University of California, Davis, Davis, California, USA
| | - Kenneth McQuaid
- Department of Gastroenterology, San Francisco VA Health Care Center, San Francisco, California, USA; Department of Medicine, University of California, San Francisco, California, USA
| | - Carisa Harris-Adamson
- Department of Medicine, University of California, San Francisco, California, USA; School of Public Health, University of California, Berkeley, California, USA
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Lai AR, Gensler LS, McQuaid K. A Terminal Event. Reply. N Engl J Med 2019; 381:2183-2184. [PMID: 31774977 DOI: 10.1056/nejmc1913325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Andrew R Lai
- University of California, San Francisco, San Francisco, CA
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Affiliation(s)
- Andrew R Lai
- From the Department of Medicine, University of California, San Francisco (A.R.L., L.S., L.S.G., K.M., G.D.), and the Medical Service, San Francisco Veterans Affairs Medical Center (L.S.G., K.M., G.D.) - both in San Francisco
| | - Leslie Sheu
- From the Department of Medicine, University of California, San Francisco (A.R.L., L.S., L.S.G., K.M., G.D.), and the Medical Service, San Francisco Veterans Affairs Medical Center (L.S.G., K.M., G.D.) - both in San Francisco
| | - Lianne S Gensler
- From the Department of Medicine, University of California, San Francisco (A.R.L., L.S., L.S.G., K.M., G.D.), and the Medical Service, San Francisco Veterans Affairs Medical Center (L.S.G., K.M., G.D.) - both in San Francisco
| | - Kenneth McQuaid
- From the Department of Medicine, University of California, San Francisco (A.R.L., L.S., L.S.G., K.M., G.D.), and the Medical Service, San Francisco Veterans Affairs Medical Center (L.S.G., K.M., G.D.) - both in San Francisco
| | - Gurpreet Dhaliwal
- From the Department of Medicine, University of California, San Francisco (A.R.L., L.S., L.S.G., K.M., G.D.), and the Medical Service, San Francisco Veterans Affairs Medical Center (L.S.G., K.M., G.D.) - both in San Francisco
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4
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Parekh NK, McQuaid K. The injured endoscopist: A roadmap for recovery. Techniques in Gastrointestinal Endoscopy 2019. [DOI: 10.1016/j.tgie.2019.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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5
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Iacucci M, McQuaid K, Gui XS, Iwao Y, Lethebe BC, Lowerison M, Matsumoto T, Shivaji UN, Smith SCL, Subramanian V, Uraoka T, Sanduleanu S, Ghosh S, Kiesslich R. A multimodal (FACILE) classification for optical diagnosis of inflammatory bowel disease associated neoplasia. Endoscopy 2019; 51:133-141. [PMID: 30541154 DOI: 10.1055/a-0757-7759] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Characterization of colonic lesions in inflammatory bowel disease (IBD) remains challenging. We developed an endoscopic classification of visual characteristics to identify colitis-associated neoplasia using multimodal advanced endoscopic imaging (Frankfurt Advanced Chromoendoscopic IBD LEsions [FACILE] classification). METHODS The study was conducted in three phases: 1) development - an expert panel defined endoscopic signs and predictors of dysplasia in IBD and, using multivariable logistic regression created the FACILE classification; 2) validation - using 60 IBD lesions from an image library, two assessments of diagnostic accuracy for neoplasia were performed and interobserver agreement between experts using FACILE was determined; 3) reproducibility - the reproducibility of the FACILE classification was tested in gastroenterologists, trainees, and junior doctors after completion of a training module. RESULTS The experts initially selected criteria such as morphology, color, surface, vessel architecture, signs of inflammation, and lesion border. Multivariable logistic regression confirmed that nonpolypoid lesion, irregular vessel architecture, irregular surface pattern, and signs of inflammation within the lesion were predictors of dysplasia. Area under the curve of this logistic model using a bootstrapped estimate was 0.76 (0.73 - 0.78). The training module resulted in improved accuracy and kappa agreement in all nonexperts, though in trainees and junior doctors the kappa agreement was still moderate and poor, respectively. CONCLUSION We developed, validated, and demonstrated reproducibility of a new endoscopic classification (FACILE) for the diagnosis of dysplasia in IBD using all imaging modalities. Flat shape, irregular surface and vascular patterns, and signs of inflammation predicted dysplasia. The diagnostic performance of all nonexpert participants improved after a training module.
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Affiliation(s)
- Marietta Iacucci
- Division of Gastroenterology, University of Calgary, Calgary, Canada.,Institute Translational of Medicine, Institute of immunology and immunotherapy and NIHR Biomedical Research Centre, University of Birmingham, Birmingham, United Kingdom
| | - Kenneth McQuaid
- Division of Gastroenterology, University of California, San Francisco, United States
| | - X Sean Gui
- Division of Gastroenterology, University of Calgary, Calgary, Canada
| | - Yasushi Iwao
- Center for Preventive Medicine, Keio University l, Tokyo, Japan
| | | | | | | | - Uday N Shivaji
- Institute Translational of Medicine, Institute of immunology and immunotherapy and NIHR Biomedical Research Centre, University of Birmingham, Birmingham, United Kingdom
| | - Samuel C L Smith
- Institute Translational of Medicine, Institute of immunology and immunotherapy and NIHR Biomedical Research Centre, University of Birmingham, Birmingham, United Kingdom
| | | | - Toshio Uraoka
- Division of Gastroenterology, Tokyo Medical Center, Tokyo, Japan
| | - Silvia Sanduleanu
- Division of Gastroenterology and Hepatology, Maastricht University Medical Center, The Netherlands
| | - Subrata Ghosh
- Division of Gastroenterology, University of Calgary, Calgary, Canada.,Institute Translational of Medicine, Institute of immunology and immunotherapy and NIHR Biomedical Research Centre, University of Birmingham, Birmingham, United Kingdom
| | - Ralf Kiesslich
- Division of Gastroenterology, HSK Hospital, Wiesbaden, Germany
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Fennerty MB, McQuaid K, Gorelick F. Presentation of the Julius M. Friedenwald Medal to Loren A. Laine. Gastroenterology 2018; 154:2266-2269. [PMID: 29733829 DOI: 10.1053/j.gastro.2018.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
| | - Kenneth McQuaid
- University of California, San Francisco, San Francisco, California
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Lin D, Soetikno RM, McQuaid K, Pham C, Doan G, Mou S, Shergill AK, Somsouk M, Rouse RV, Kaltenbach T. Risk factors for postpolypectomy bleeding in patients receiving anticoagulation or antiplatelet medications. Gastrointest Endosc 2018; 87:1106-1113. [PMID: 29208464 DOI: 10.1016/j.gie.2017.11.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 11/18/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Balancing the risks for thromboembolism and postpolypectomy bleeding in patients requiring anticoagulation and antiplatelet agents is challenging. We investigated the incidence and risk factors for postpolypectomy bleeding on anticoagulation, including heparin bridge and other antithrombotic therapy. METHODS We performed a retrospective cohort and case control study at 2 tertiary-care medical centers from 2004 to 2012. Cases included male patients on antithrombotics with hematochezia after polypectomy. Nonbleeding controls were matched to cases 3 to 1 by antithrombotic type, study site, polypectomy technique, and year of procedure. Our outcomes were the incidence and risk factors for postpolypectomy bleeding. RESULTS There were 59 cases and 174 matched controls. Postpolypectomy bleeding occurred in 14.9% on bridge anticoagulation. This was significantly higher than the overall incidence of bleeding on antithrombotics at 1.19% (95% confidence interval, 0.91%-1.54%) (59/4923). We identified similarly low rates of bleeding in patients taking warfarin (0.66%), clopidogrel (0.84%), and aspirin (0.92%). Patients who bled tended to have larger polyps (13.9 vs 7.3 mm; P < .001) and more polyps ≥2 cm (41% vs 10%; P < .001). Bleeding risk was increased with restarting antithrombotics within 1 week postpolypectomy (odds ratio [OR] 4.50; P < .001), having polyps ≥2 cm (OR 5.94; P < .001), performing right-sided cautery (OR 2.61; P = .004), and having multiple large polyps (OR 2.92; P = .001). Among patients on warfarin, the presence of bridge anticoagulation was an independent risk factor for postpolypectomy bleeding (OR 12.27; P = .0001). CONCLUSION We conclude that bridge anticoagulation is associated with a high incidence of postpolypectomy bleeding and is an independent risk factor for hemorrhage compared with patients taking warfarin alone. A higher threshold to use bridge anticoagulation should be considered in patients with an elevated bleeding risk.
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Affiliation(s)
- David Lin
- Division of Gastroenterology, University of California Los Angeles Medical Center, Los Angeles, California, USA; Gastrointestinal Endoscopy Unit, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA
| | - Roy M Soetikno
- Gastrointestinal Endoscopy Unit, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA
| | - Kenneth McQuaid
- Section of Gastroenterology, Department of Medicine, Veterans Affairs San Francisco and the University of California San Francisco, San Francisco, California, USA
| | - Chi Pham
- Office of Research Analytics, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Gilbert Doan
- Office of Research Analytics, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Shanshan Mou
- Gastrointestinal Endoscopy Unit, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA
| | - Amandeep K Shergill
- Section of Gastroenterology, Department of Medicine, Veterans Affairs San Francisco and the University of California San Francisco, San Francisco, California, USA
| | - Ma Somsouk
- Division of Gastroenterology, University of California San Francisco, San Francisco, California, USA
| | - Robert V Rouse
- Department of Pathology, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA
| | - Tonya Kaltenbach
- Gastrointestinal Endoscopy Unit, Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California, USA; Section of Gastroenterology, Department of Medicine, Veterans Affairs San Francisco and the University of California San Francisco, San Francisco, California, USA
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8
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Wani S, Sedlack R, Dewitt J, McQuaid K, Woods KL. Response. Gastrointest Endosc 2017; 86:754-756. [PMID: 28917357 DOI: 10.1016/j.gie.2017.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/17/2017] [Indexed: 02/08/2023]
Affiliation(s)
- Sachin Wani
- Chair, Standards of Practice Committee, ASGE
| | | | - John Dewitt
- Past-Chair, Standards of Practice Committee, ASGE
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9
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Lu Y, Jones DJ, Sharara N, Kaltenbach T, Laine L, McQuaid K, Soetikno R, Subramanian V, Barkun A. Transparency ethics in practice: Revisiting financial conflicts of interest disclosure forms in clinical practice guidelines. PLoS One 2017; 12:e0182856. [PMID: 28841650 PMCID: PMC5571907 DOI: 10.1371/journal.pone.0182856] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 07/25/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Authors of clinical practice guidelines (CPGs) disclose financial conflicts of interest (FCOIs) to promote transparency ethics. Typically, they do so on standard declaration forms containing generic open-ended questions on FCOIs. Yet, the literature is scant on the format and effect of alternative disclosure forms. Does supplementing a standard form with subsequent detailed disclosure forms tailored to the context of the CPG improve the yield or accuracy of FCOIs declarations? METHODS For an international CPG in gastroenterology on the endoscopic surveillance for colorectal neoplasia in inflammatory bowel disease, we compared the use of a standard FCOIs disclosure form with a contextual FCOIs disclosure form that detailed commercial relations related to the CPG topic. This included manufacturers of endoscopes, endoscopy equipment and accessories. Participants completed the generic form early, and the supplementary contextual form six months later. We then compared the FCOI disclosures obtained. FINDINGS 26 participants provided FCOIs disclosures using both disclosure forms. We found discrepancies regarding (1) the disclosure of FCOIs (presence/absence), and (2) the listing of financial entities. While the number of participants who disclosed a FCOI remained the same (30.8%) using the two forms, disclosures were not from the same individuals: two additional participants disclosed a FCOI, whereas two participants withdrew previous disclosures. Among those who reported a FCOI in either form, we noted inconsistencies in disclosures for 70% of the participants. This included changes in FCOIs disclosure status or modifications of "their commercial relations". DISCUSSION Accurate reporting of FCOIs advances the transparency and ethical integrity of CPGs. Our experience suggests that a contextual FCOIs disclosure form tailored to content of the CPG with narrow, detailed questions provides supplementary, more complete FCOIs declarations than generic forms alone. The finding raises challenges on how forms are best written and formatted, optimally timed, and more effectively processed with sensitivity to professional behaviour, so as to heighten transparency.
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Affiliation(s)
- Yidan Lu
- Division of Gastroenterology, McGill University Health Center, Montreal, Quebec, Canada
| | - Derek J. Jones
- Faculty of Law, McGill University, Montreal, Quebec, Canada
- Hospinnomics, Paris School of Economics & Public Hospitals of Paris, Paris, France
| | - Nour Sharara
- Division of Gastroenterology, McGill University Health Center, Montreal, Quebec, Canada
| | - Tonya Kaltenbach
- Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, Unites States of America
- Division of Gastroenterology, University of California, San Francisco, California, Unites States of America
| | - Loren Laine
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, Unites States of America
- Division of Gastroenterology, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, Unites States of America
| | - Kenneth McQuaid
- Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, Unites States of America
- Division of Gastroenterology, University of California, San Francisco, California, Unites States of America
| | - Roy Soetikno
- Division of Gastroenterology, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, Unites States of America
- Division of Gastroenterology, Stanford University School of Medicine, Palo Alto, California, Unites States of America
| | | | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- * E-mail:
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McGill SK, Soetikno R, Rastogi A, Rouse RV, Sato T, Bansal A, McQuaid K, Kaltenbach T. Endoscopists can sustain high performance for the optical diagnosis of colorectal polyps following standardized and continued training. Endoscopy 2015; 47:200-6. [PMID: 25264764 DOI: 10.1055/s-0034-1378096] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND STUDY AIMS The learning curve for optical diagnosis of colorectal polyps with the narrow-band imaging (NBI) is unknown. To forego histological analysis of diminutive polyps diagnosed optically with high confidence, guidelines recommend ≥ 90 % negative predictive value (NPV) and concordance of ≥ 90 % for surveillance intervals predicted optically and histologically. We aimed to study the learning of optical diagnosis for colorectal polyps. PATIENTS AND METHODS We studied five endoscopists as part of a randomized multisite trial comparing near-focus and standard-focus views for optical diagnosis. They trained using a computer-based module, followed by 10 real-time colonoscopies with pathology correlation. Endoscopists then optically diagnosed and resected all the polyps found during 558 consecutive colonoscopies, and diagnoses were compared with pathology. Endoscopists repeated the training module at the study midpoint. NPV and concordance of surveillance intervals for diminutive polyps diagnosed optically with high confidence were measured over time. RESULTS Endoscopists showed high diagnostic performance, with a nonsignificant trend toward higher NPV in the second half of the study. For the 445 polyps in the standard-view arm, the NPV was 88.0 % (95 %CI 75.7 % - 95.5 %) in the first half and 95.8 % (88.3 % - 99.1 %) in the second; P = 0.7. Three endoscopists in the first half and four in the second achieved > 90 % NPV. Concordance of surveillance intervals was identical in the first and second halves at 98.1 % (95 %CI 93.3 % - 99.8 %). CONCLUSIONS High NPV for the prediction of non-neoplasms with NBI was achieved and maintained in this group of endoscopists who participated in standardized and continued training. Both NPV and surveillance interval agreement indicated high performance in the optical diagnosis of colorectal polyps and exceeded thresholds.
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Affiliation(s)
- Sarah K McGill
- GI Endoscopy Unit, Veterans Affairs Palo Alto, Palo Alto, and Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Roy Soetikno
- GI Endoscopy Unit, Veterans Affairs Palo Alto, Palo Alto, and Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Amit Rastogi
- Gastroenterology Section, Veterans Affairs Kansas City, and Department of Medicine, Division of Gastroenterology, University of Kansas, Kansas City, Missouri, USA
| | - Robert V Rouse
- Pathology and Laboratory Medicine Service, Veterans Affairs Palo Alto, USA, and Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
| | - Tohru Sato
- GI Endoscopy Unit, Veterans Affairs Palo Alto, Palo Alto, and Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Ajay Bansal
- Gastroenterology Section, Veterans Affairs Kansas City, and Department of Medicine, Division of Gastroenterology, University of Kansas, Kansas City, Missouri, USA
| | - Kenneth McQuaid
- Gastrointestinal Diagnostic Unit, Veterans Affairs San Francisco, and Division of Gastroenterology, University California San Francisco, San Francisco, California, USA
| | - Tonya Kaltenbach
- GI Endoscopy Unit, Veterans Affairs Palo Alto, Palo Alto, and Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
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Nett A, Velayos F, McQuaid K. Quality bowel preparation for surveillance colonoscopy in patients with inflammatory bowel disease is a must. Gastrointest Endosc Clin N Am 2014; 24:379-92. [PMID: 24975529 DOI: 10.1016/j.giec.2014.03.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Colonoscopy is routinely performed in patients with inflammatory bowel disease (IBD) for surveillance of dysplasia. Thorough bowel preparation is necessary to facilitate lesion detection. Patients with IBD do not have poorer bowel preparation outcomes but may have decreased preparation tolerance affecting adherence to surveillance protocols. A low-fiber prepreparation diet may improve preparation tolerance without affecting preparation quality. The standard preparation regimen should consist of split-dose administration of a polyethylene glycol-based purgative. Low-volume, hyperosmolar purgatives may be considered in patients with previous preparation intolerance, heightened anxiety, stenotic disease, or dysmotility. Appropriate patient education is critical to enhance preparation quality.
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Affiliation(s)
- Andrew Nett
- Department of Medicine, University of California, San Francisco, 513 Parnassus Avenue, Room S-357, San Francisco, CA 94143, USA
| | - Fernando Velayos
- Department of Medicine, University of California, San Francisco, 513 Parnassus Avenue, Room S-357, San Francisco, CA 94143, USA
| | - Kenneth McQuaid
- Department of Medicine, San Francisco VA Medical Center, University of California, San Francisco, 4150 Clement Street, Room 111-B, San Francisco, CA 94121, USA.
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Yukl SA, Shergill AK, Ho T, Killian M, Girling V, Epling L, Li P, Wong LK, Crouch P, Deeks SG, Havlir DV, McQuaid K, Sinclair E, Wong JK. The distribution of HIV DNA and RNA in cell subsets differs in gut and blood of HIV-positive patients on ART: implications for viral persistence. J Infect Dis 2013; 208:1212-20. [PMID: 23852128 DOI: 10.1093/infdis/jit308] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Even with optimal antiretroviral therapy, human immunodeficiency virus (HIV) persists in plasma, blood cells, and tissues. To develop new therapies, it is essential to know what cell types harbor residual HIV. We measured levels of HIV DNA, RNA, and RNA/DNA ratios in sorted subsets of CD4+ T cells (CCR7+, transitional memory, and effector memory) and non-CD4+ T leukocytes from blood, ileum, and rectum of 8 ART-suppressed HIV-positive subjects. Levels of HIV DNA/million cells in CCR7+ and effector memory cells were higher in the ileum than blood. When normalized by cell frequencies, most HIV DNA and RNA in the blood were found in CCR7+ cells, whereas in both gut sites, most HIV DNA and RNA were found in effector memory cells. HIV DNA and RNA were observed in non-CD4+ T leukocytes at low levels, particularly in gut tissues. Compared to the blood, the ileum had higher levels of HIV DNA and RNA in both CD4+ T cells and non-CD4+ T leukocytes, whereas the rectum had higher HIV DNA levels in both cell types but lower RNA levels in CD4+ T cells. Future studies should determine whether different mechanisms allow HIV to persist in these distinct reservoirs, and the degree to which different therapies can affect each reservoir.
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Affiliation(s)
- Steven A Yukl
- Department of Medicine, San Francisco VA Medical Center and University of California, San Francisco
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13
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Soetikno R, Subramanian V, Kaltenbach T, Rouse RV, Sanduleanu S, Suzuki N, Tanaka S, McQuaid K. The detection of nonpolypoid (flat and depressed) colorectal neoplasms in patients with inflammatory bowel disease. Gastroenterology 2013; 144:1349-52, 1352.e1-6. [PMID: 23583483 DOI: 10.1053/j.gastro.2013.04.008] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 04/09/2013] [Indexed: 02/06/2023]
Affiliation(s)
- Roy Soetikno
- VA Palo Alto and Stanford University, Palo Alto, California 94304, USA.
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15
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Abstract
OBJECTIVES Patients with inflammatory bowel disease (IBD) often experience barriers to subspecialty access. We applied telemedicine, using a new computerized system called Collaborative Imaging, to resolve these barriers. We studied patients' experience and satisfaction, and clinic throughput. METHODS We performed a prospective randomized controlled pilot study at a Veterans Affairs hospital, assigning patients into two groups: telemedicine encounter, with the IBD specialist remotely located, and standard encounter. We assessed patient experience and measured differences in satisfaction as well as clinic metrics such as appointment duration, wait time, and throughput. RESULTS We enrolled 34 patients with Crohn's disease and ulcerative colitis who underwent 57 encounters in 9 months. Patients were mostly Caucasian men, with a mean age of 61 years. The two groups similarly rated as excellent their clinic experience and the major clinical satisfaction indices of attention to patient concerns, bedside manner, and perceived skill level of the doctor. The total clinic duration, wait time, and median number of patients per clinic were also similar. The fellow and subspecialist highly rated the technical and informational quality of the telemedicine sessions. CONCLUSIONS IBD outpatient service may be delivered via a novel telemedicine system. In this pilot study, we observed a high level of patient satisfaction similar to that achieved with a direct clinical encounter.
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Affiliation(s)
- Michael Krier
- Veterans Affairs Palo Alto, Stanford University School of Medicine, Palo Alto, California, USA
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Yukl SA, Shergill AK, McQuaid K, Gianella S, Lampiris H, Hare CB, Pandori M, Sinclair E, Günthard HF, Fischer M, Wong JK, Havlir DV. Effect of raltegravir-containing intensification on HIV burden and T-cell activation in multiple gut sites of HIV-positive adults on suppressive antiretroviral therapy. AIDS 2010; 24:2451-60. [PMID: 20827162 PMCID: PMC2997807 DOI: 10.1097/qad.0b013e32833ef7bb] [Citation(s) in RCA: 199] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether raltegravir-containing antiretroviral therapy (ART) intensification reduces HIV levels in the gut. DESIGN Open-label study in HIV-positive adults on ART with plasma HIV RNA below 40 copies/ml. METHODS Seven HIV-positive adults received 12 weeks of ART intensification with raltegravir alone or in combination with efavirenz or darunavir. Gut cells were obtained by upper and lower endoscopy with biopsies from duodenum, ileum, colon, and rectum at baseline and 12 weeks. Study outcomes included plasma HIV RNA, HIV DNA and RNA from peripheral blood mononuclear cells (PBMC) and four gut sites, T-cell subsets, and activation markers. RESULTS Intensification produced no consistent decrease in HIV RNA in the plasma, PBMC, duodenum, colon, or rectum. However, five of seven participants had a decrease in unspliced HIV RNA per 10 CD4(+) T cells in the ileum. There was a trend towards decreased T-cell activation in all sites, which was greatest for CD8(+) T cells in the ileum and PBMC, and a trend towards increased CD4(+) T cells in the ileum. CONCLUSION Most HIV RNA and DNA in the blood and gut is not the result of ongoing replication that can be impacted by short-term intensification with raltegravir. However, the ileum may support ongoing productive infection in some patients on ART, even if the contribution to plasma RNA is not discernible.
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Affiliation(s)
- Steven A Yukl
- San Francisco VA Medical Center (SFVAMC) and University of California, San Francisco (UCSF), San Francisco, California, USA.
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Yukl SA, Gianella S, Sinclair E, Epling L, Li Q, Duan L, Choi ALM, Girling V, Ho T, Li P, Fujimoto K, Lampiris H, Hare CB, Pandori M, Haase AT, Günthard HF, Fischer M, Shergill AK, McQuaid K, Havlir DV, Wong JK. Differences in HIV burden and immune activation within the gut of HIV-positive patients receiving suppressive antiretroviral therapy. J Infect Dis 2010; 202:1553-61. [PMID: 20939732 DOI: 10.1086/656722] [Citation(s) in RCA: 238] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The gut is a major reservoir for human immunodeficiency virus (HIV) in patients receiving antiretroviral therapy (ART). We hypothesized that distinct immune environments within the gut may support varying levels of HIV. METHODS In 8 HIV-1-positive adults who were receiving ART and had CD4(+) T cell counts of >200 cells/μL and plasma viral loads of <40 copies/mL, levels of HIV and T cell activation were measured in blood samples and endoscopic biopsy specimens from the duodenum, ileum, ascending colon, and rectum. RESULTS HIV DNA and RNA levels per CD4(+) T cell were higher in all 4 gut sites compared with those in the blood. HIV DNA levels increased from the duodenum to the rectum, whereas the median HIV RNA level peaked in the ileum. HIV DNA levels correlated positively with T cell activation markers in peripheral blood mononuclear cells (PBMCs) but negatively with T cell activation markers in the gut. Multiply spliced RNA was infrequently detected in gut, and ratios of unspliced RNA to DNA were lower in the colon and rectum than in PBMCs, which reflects paradoxically low HIV transcription, given the higher level of T cell activation in the gut. CONCLUSIONS HIV DNA and RNA are both concentrated in the gut, but the inverse relationship between HIV DNA levels and T cell activation in the gut and the paradoxically low levels of HIV expression in the large bowel suggest that different processes drive HIV persistence in the blood and gut. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00884793 (PLUS1).
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Affiliation(s)
- Steven A Yukl
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA.
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Yukl S, Sinclair E, Epling L, Li Q, Shergill A, McQuaid K, Duan L, Hare B, Lampiris H, Haase A, Havlir D, Wong J. CD4+ T cell reconstitution, T cell activation, and memory T cell subset composition in blood and gut of HIV-negative and ART-suppressed HIV-positive patients: implications for HIV persistence in the gut. J Int AIDS Soc 2010. [PMCID: PMC2999379 DOI: 10.1186/1758-2652-13-s3-o1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Abstract
BACKGROUND & AIMS Although many individuals with pancreatic cancer have diabetes, the association between new-onset diabetes mellitus and the subsequent incidence of pancreatic cancer is unclear. METHODS We conducted a retrospective cohort study to estimate the incidence of pancreatic cancer subsequent to a new diabetes diagnosis and to evaluate factors associated with a subsequent pancreatic cancer diagnosis. We used the Veterans Health Administration National Patient Care Database to assemble a cohort of 1,421,794 US veterans without prior diabetes or pancreatic cancer diagnoses. We recorded coding for new diabetes diagnoses (> or =2 International Classification of Diseases-9 codes for diabetes within a 12-month period), pancreatic cancer, age, sex, race, and common gastrointestinal symptoms. RESULTS A total of 36,631 (2.6%) of the 1,421,794 veterans were diagnosed with new-onset diabetes in 1999; 149 subsequently received a diagnosis of pancreatic cancer. Pancreatic cancer incidence in patients with new-onset diabetes (83.8/100,000 person-years) was 2.2-fold higher (95% confidence interval, 1.84-2.56) than in nondiabetics, and was highest during the first 2 years after diabetes diagnosis. One additional pancreatic cancer was diagnosed for every 332 new diabetics over 6 years. A subsequent pancreatic cancer diagnosis (among new-onset diabetics) was associated independently with younger age groups, changes in bowel habits, constipation, epigastric pain, and malnutrition. CONCLUSIONS New-onset diabetes was associated with a significantly increased rate of pancreatic cancer diagnosis, particularly in the first 2 years after diabetes diagnosis. Factors associated with pancreatic cancer diagnosis included younger age groups and the presence of gastrointestinal symptoms. The absolute incidence of pancreatic cancer was low.
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Affiliation(s)
- Samir Gupta
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
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Bosworth HB, Rockey DC, Paulson EK, Niedzwiecki D, Davis W, Sanders LL, Yee J, Henderson J, Hatten P, Burdick S, Sanyal A, Rubin DT, Sterling M, Akerkar G, Bhutani MS, Binmoeller K, Garvie J, Bini EJ, McQuaid K, Foster WL, Thompson WM, Dachman A, Halvorsen R. Prospective comparison of patient experience with colon imaging tests. Am J Med 2006; 119:791-9. [PMID: 16945615 DOI: 10.1016/j.amjmed.2006.02.013] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2005] [Revised: 02/06/2006] [Accepted: 02/06/2006] [Indexed: 11/15/2022]
Abstract
PURPOSE Patient experience varies with the currently available colon imaging tests, including air contrast barium enema, computed tomographic colonography, and colonoscopy. We examined differences in patient experience with colon imaging tests and whether they varied with gender, age, and race. SUBJECTS AND METHODS Patients with fecal occult blood, hematochezia, iron-deficiency anemia, or a family history of colon cancer underwent air contrast barium enema followed 7 to 14 days later by computed tomographic colonography and colonoscopy. Validated patient experience questionnaires that measured the experience for each test and a separate questionnaire that obtained an overall summary measure were administered after testing. Eleven patient experiences including pain, embarrassment, difficulty with bowel preparation, and satisfaction with tests were examined. RESULTS A total of 614 subjects completed all 3 imaging tests. The test most patients were willing to repeat was colonoscopy; it also was reported to be the least painful procedure. Patients were least satisfied with air contrast barium enema, and fewer would undergo air contrast barium enema compared with computed tomographic colonography or colonoscopy. There were limited racial and gender differences in perceptions of the tests. Younger adults perceived air contrast barium enema to be more painful than older adults. CONCLUSION Taking into account a wide variety of patient experience measures, patients preferred colonoscopy to air contrast barium enema and computed tomographic colonography. This finding has important implications for physicians considering different colon imaging tests.
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Affiliation(s)
- Hayden B Bosworth
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
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Cotton PB, Barkun A, Ginsberg G, Hawes RH, Atkin W, Bjorkman DJ, Dykes C, Elta G, Farrell J, Fleischer D, Ganz R, Glenn T, Janowski D, Johnson D, Kochman M, Kowalski T, Megibow AJ, McQuaid K, Sasa H, Thompson CC, Vargo J, Woods K. Diagnostic endoscopy: 2020 vision. Gastrointest Endosc 2006; 64:395-8. [PMID: 16923489 DOI: 10.1016/j.gie.2006.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Accepted: 05/09/2006] [Indexed: 02/08/2023]
Affiliation(s)
- Peter B Cotton
- Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina, USA
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Affiliation(s)
- Samir Gupta
- Veterans Affairs Medical Center and Department of Medicine, University of California San Francisco, San Francisco, California 94121, USA
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Rockey DC, Paulson E, Niedzwiecki D, Davis W, Bosworth HB, Sanders L, Yee J, Henderson J, Hatten P, Burdick S, Sanyal A, Rubin DT, Sterling M, Akerkar G, Bhutani MS, Binmoeller K, Garvie J, Bini EJ, McQuaid K, Foster WL, Thompson WM, Dachman A, Halvorsen R. Analysis of air contrast barium enema, computed tomographic colonography, and colonoscopy: prospective comparison. Lancet 2005; 365:305-11. [PMID: 15664225 DOI: 10.1016/s0140-6736(05)17784-8] [Citation(s) in RCA: 217] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The usefulness of currently available colon imaging tests, including air contrast barium enema (ACBE), computed tomographic colonography (CTC), and colonoscopy, to detect colon polyps and cancers is uncertain. We aimed to assess the sensitivity of these three imaging tests. METHODS Patients with faecal occult blood, haematochezia, iron-deficiency anaemia, or a family history of colon cancer underwent three separate colon-imaging studies--ACBE, followed 7-14 days later by CTC and colonoscopy on the same day. The primary outcome was detection of colonic polyps and cancers. Outcomes were assessed by building an aggregate view of the colon, taking into account results of all three tests. FINDINGS 614 patients completed all three imaging tests. When analysed on a per-patient basis, for lesions 10 mm or larger in size (n=63), the sensitivity of ACBE was 48% (95% CI 35-61), CTC 59% (46-71, p=0.1083 for CTC vs ACBE), and colonoscopy 98% (91-100, p<0.0001 for colonoscopy vs CTC). For lesions 6-9 mm in size (n=116), sensitivity was 35% for ACBE (27-45), 51% for CTC (41-60, p=0.0080 for CTC vs ACBE), and 99% for colonoscopy (95-100, p<0.0001 for colonoscopy vs CTC). For lesions of 10 mm or larger in size, the specificity was greater for colonoscopy (0.996) than for either ACBE (0.90) or CTC (0.96) and declined for ACBE and CTC when smaller lesions were considered. INTERPRETATION Colonoscopy was more sensitive than other tests, as currently undertaken, for detection of colonic polyps and cancers. These data have important implications for diagnostic use of colon imaging tests.
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Affiliation(s)
- D C Rockey
- Duke University Medical Center, Durham, NC 27710, USA.
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Sharma P, McQuaid K, Dent J, Fennerty MB, Sampliner R, Spechler S, Cameron A, Corley D, Falk G, Goldblum J, Hunter J, Jankowski J, Lundell L, Reid B, Shaheen NJ, Sonnenberg A, Wang K, Weinstein W. A critical review of the diagnosis and management of Barrett's esophagus: the AGA Chicago Workshop. Gastroenterology 2004; 127:310-30. [PMID: 15236196 DOI: 10.1053/j.gastro.2004.04.010] [Citation(s) in RCA: 411] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS The diagnosis and management of Barrett's esophagus (BE) are controversial. We conducted a critical review of the literature in BE to provide guidance on clinically relevant issues. METHODS A multidisciplinary group of 18 participants evaluated the strength and the grade of evidence for 42 statements pertaining to the diagnosis, screening, surveillance, and treatment of BE. Each member anonymously voted to accept or reject statements based on the strength of evidence and his own expert opinion. RESULTS There was strong consensus on most statements for acceptance or rejection. Members rejected statements that screening for BE has been shown to improve mortality from adenocarcinoma or to be cost-effective. Contrary to published clinical guidelines, they did not feel that screening should be recommended for adults over age 50, regardless of age or duration of heartburn. Members were divided on whether surveillance prolongs survival, although the majority agreed that it detects curable neoplasia and can be cost-effective in selected patients. The majority did not feel that acid-reduction therapy reduces the risk of esophageal adenocarcinoma but did agree that nonsteroidal antiinflammatory drugs are associated with a cancer risk reduction and are of promising (but unproven) value. Participants rejected the notion that mucosal ablation with acid suppression prevents adenocarcinoma in BE but agreed that this may be an appropriate strategy in a subgroup of patients with high-grade dysplasia. CONCLUSIONS Based on this review of BE, the opinions of workshop members on issues pertaining to screening and surveillance are at variance with published clinical guidelines.
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Affiliation(s)
- Prateek Sharma
- University of Kansas School of Medicine and VA Medical Center, Kansas City, Missouri 64128-2295, USA.
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Akerkar GA, Yee J, Hung R, McQuaid K. Patient experience and preferences toward colon cancer screening: a comparison of virtual colonoscopy and conventional colonoscopy. Gastrointest Endosc 2001; 54:310-5. [PMID: 11522970 DOI: 10.1067/mge.2001.117595] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Virtual colonoscopy has excellent sensitivity for the detection of cancer and polyps greater than 1 cm in diameter. For virtual colonoscopy to succeed as a screening test for colorectal neoplasia, it must be well tolerated and accepted by patients. Patients' experiences with virtual colonoscopy and conventional colonoscopy were assessed and compared. METHODS Patients referred to the GI clinic for colonoscopy for any indication were recruited to undergo virtual colonoscopy before conventional colonoscopy. Patients were asked to complete a questionnaire twice: after virtual colonoscopy and after completing both tests. Three variables, overall pain, discomfort, and lack of respect, were assessed by using a 7-point Liken scale with higher scores denoting a worse experience. Patients' preferences for virtual colonoscopy versus conventional colonoscopy were determined with a time tradeoff technique. To verify response stability, patients were asked to return an additional questionnaire by mail at 24 hours. RESULTS Two hundred ninety-five patients completed the questionnaire immediately after the procedures, and 83 patients completed the questionnaire at 24 hours. At both 0 and 24 hours, patients reported more pain, discomfort, and less respect after virtual colonoscopy than conventional colonoscopy (p < 0.01). The overall agreement (Kappa statistic) between times 0 and 24 hours was fair. Patients reported that they preferred conventional colonoscopy and would wait longer for conventional colonoscopy (mean = 4.9 weeks) than undergo a virtual colonoscopy (p < 0.01). CONCLUSIONS Patients tolerate both virtual colonoscopy and conventional colonoscopy, although they report more pain, discomfort, and less respect undergoing virtual colonoscopy. Efforts to improve patient experience during virtual colonoscopy need to be investigated.
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Affiliation(s)
- G A Akerkar
- Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, USA
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Frank L, Kleinman L, Ganoczy D, McQuaid K, Sloan S, Eggleston A, Tougas G, Farup C. Upper gastrointestinal symptoms in North America: prevalence and relationship to healthcare utilization and quality of life. Dig Dis Sci 2000; 45:809-18. [PMID: 10759254 DOI: 10.1023/a:1005468332122] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The aim of this study was to determine the prevalence of upper gastrointestinal symptoms (UGIS) in a general population and quantify the relationship of those symptoms to healthcare utilization and quality of life. In-person interviews were conducted with 2056 United States and Canadian residents selected at random. Subjects reported frequency and severity for 11 symptoms, prescription and over-the-counter medication use, primary care and specialty physician visits in prior three months, and completed the Psychological General Well-Being Scale. For analyses, subjects were classified into four mutually exclusive symptom groups: gastroesophageal reflux disease (GERD) -like, GERD plus motility-like (GERD+), ulcerlike, and motility-like. Of the total sample, 51.4% reported the occurrence of at least one UGIS in the prior three months. Subjects in the GERD+ and ulcer groups used more prescription medications and were more likely to see a physician about the symptoms (P<0.001). Subjects with symptoms demonstrated poorer quality of life compared to subjects with no symptoms. The prevalence of UGIS in the general population is high and symptoms are associated with significant health-care utilization and poorer quality of life.
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Affiliation(s)
- L Frank
- Center for Health Outcomes Research, MEDTAP International, Inc., Bethesda, Maryland 20814, USA
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Rockey DC, Koch J, Cello JP, Sanders LL, McQuaid K. Relative frequency of upper gastrointestinal and colonic lesions in patients with positive fecal occult-blood tests. N Engl J Med 1998; 339:153-9. [PMID: 9664091 DOI: 10.1056/nejm199807163390303] [Citation(s) in RCA: 112] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although bleeding lesions anywhere in the gastrointestinal tract can cause a positive reaction on guaiac-based fecal occult-blood tests, the relative frequency of upper gastrointestinal and colonic lesions is unknown. METHODS During a period of 30 months, we prospectively studied all patients with at least one stool specimen containing fecal occult blood who were referred for further evaluation. Fecal occult blood was detected by standard guaiac-based tests of stool specimens obtained as part of routine screening or of stool obtained by digital rectal examination. Patients with documented iron-deficiency anemia or active gastrointestinal bleeding were excluded from the study. All participants had a detailed history taken and underwent colonoscopy, followed by esophagogastroduodenoscopy. RESULTS Of the 409 patients with fecal occult blood who were referred, 310 were potentially eligible to participate, and 248 (mean age, 61 years; range, 40 to 89) were studied; 40 percent were women. We identified lesions consistent with occult bleeding in 119 patients (48 percent); in 71 bleeding lesions were found in the upper gastrointestinal tract, and in 54 they were identified in the colon. Six patients had abnormalities in both areas. The most common upper gastrointestinal lesions were esophagitis (23 patients), gastric ulcer (14), gastritis (12), and duodenal ulcer (10). Thirty patients with lesions in the upper gastrointestinal tract were long-term users of aspirin, ethanol, nonsteroidal antiinflammatory drugs, or a combination of these substances. The most common colonic lesions were adenomas more than 1.0 cm in diameter (29 patients), carcinoma (13), colitis (5), and vascular ectasia (5). Although the overall sensitivity of symptoms for the detection of gastrointestinal lesions was low, logistic-regression analysis demonstrated that the presence of symptoms in the upper gastrointestinal tract was associated with the detection of lesions in the upper gastrointestinal tract (odds ratio, 2.6; 95 percent confidence interval, 1.4 to 4.7). In both patients with symptoms and those without symptoms, the prevalence of lesions in the upper gastrointestinal tract was greater than or equal to that of colonic lesions. CONCLUSIONS In a group of patients with positive fecal occult-blood tests who were referred for further evaluation, from which those with iron-deficiency anemia and active bleeding had been excluded, upper gastrointestinal lesions were identified more frequently than colonic lesions.
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Affiliation(s)
- D C Rockey
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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McQuaid K, Young TL. Rigid gas permeable contact lens changes in the aphakic infant. CLAO J 1998; 24:36-40. [PMID: 9474452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE The purpose of this study was to describe and evaluate the frequent parameter changes required in aphakic infants fit with rigid gas permeable (RGP) contact lenses. METHODS Twenty-five eyes from 18 patients with congenital cataracts were fit postoperatively with RGP lenses and followed for an average of 19 months. The original lens specifications were determined by keratometer readings, corneal diameter, and axial length or retinoscopy obtained under sedation just prior to or after cataract extraction surgery. The frequency of changes in contact lens power, base curve, and diameter was recorded and analyzed. RESULTS Due to rapid growth and/or difficulty in achieving accurate measurements, repeated contact lens adjustments were needed to ensure proper power and fit. CONCLUSIONS The data contained in this study indicates a relatively stable period--from 6 to 12 months postoperatively--where the likelihood that contact lenses will need to be modified falls below 50%.
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Affiliation(s)
- K McQuaid
- Department of Ophthalmology, University of Minnesota, Minneapolis, USA
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Lum DF, McQuaid K, Lee JG. Endoscopic hemostasis of nonvariceal, non-peptic ulcer hemorrhage. Gastrointest Endosc Clin N Am 1997; 7:657-70. [PMID: 9376956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The majority of patients who present with acute upper gastrointestinal hemorrhage are found to be bleeding from acid peptic disease including ulcer, esophagitis and gastritis, and variceal disease. Mallory-Weiss tear, Dieulafoy's lesion, cancer, and other rare lesions account for the bleeding source in the remaining patients. Endoscopic hemostasis may be effective in many of the conditions, but only Mallory-Weiss tear and Dieulafoy's lesion are encountered frequently enough to be clinically significant.
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Affiliation(s)
- D F Lum
- Division of Gastroenterology, University of California, Davis Medical Center, Sacramento, CA, USA
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Cello JP, Ring EJ, Olcott EW, Koch J, Gordon R, Sandhu J, Morgan DR, Ostroff JW, Rockey DC, Bacchetti P, LaBerge J, Lake JR, Somberg K, Doherty C, Davila M, McQuaid K, Wall SD. Endoscopic sclerotherapy compared with percutaneous transjugular intrahepatic portosystemic shunt after initial sclerotherapy in patients with acute variceal hemorrhage. A randomized, controlled trial. Ann Intern Med 1997; 126:858-65. [PMID: 9163286 DOI: 10.7326/0003-4819-126-11-199706010-00002] [Citation(s) in RCA: 160] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Hemorrhage from esophageal varices remains a substantial management problem. Endoscopic sclerotherapy was preferred for more than a decade, but fluoroscopically placed intrahepatic portosystemic stents have recently been used with increasing frequency. OBJECTIVE To compare sclerotherapy with transjugular intrahepatic portosystemic shunt (TIPS) in patients with bleeding from esophageal varices. DESIGN Randomized, controlled clinical trial. SETTING Three teaching hospitals. PATIENTS 49 adults hospitalized with acute variceal hemorrhage from November 1991 to December 1995: 25 assigned to sclerotherapy and 24 assigned to TIPS. INTERVENTION Patients assigned to repeated sclerotherapy had the procedure weekly. In those assigned to TIPS, an expandable mesh stent was fluoroscopically placed between an intrahepatic portal vein and an adjacent hepatic vein. MEASUREMENTS Pretreatment measures included demographic and laboratory data. Postrandomization data included index hospitalization survival, duration of follow-up, successful obliteration of varices, rebleeding from varices, number of variceal rebleeding events, total days of hospitalization for variceal bleeding, blood transfusion requirements after randomization, prevalence of encephalopathy, and total health care costs. RESULTS Mean follow-up (+/-SE) was 567 +/- 104 days in the sclerotherapy group and 575 +/- 109 days in the TIPS group. Varices were obliterated more reliably by TIPS than by sclerotherapy (P < 0.001). Patients having TIPS were significantly less likely to rebleed from esophageal varices than patients receiving sclerotherapy (3 of 24 compared with 12 of 25; P = 0.012). No other follow-up measures differed significantly between groups. A trend toward improved survival, which was not statistically significant, was noted in the TIPS group (hazard ratio, 0.53 [95% CI, 0.18 to 1.5]). CONCLUSIONS In obliterating varices and reducing rebleeding events from esophageal varies, TIPS was more effective than sclerotherapy. However, TIPS did not decrease morbidity after randomization or improve health care costs. It seemed to produce better survival, but the increase in survival was not statistically significant.
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Affiliation(s)
- J P Cello
- University of California at San Francisco 94143-0628, USA
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Abstract
We report a case of metastatic lobular breast carcinoma with extrahepatic gastrointestinal disease. On the basis of clinical findings, radiologic investigations, computerized axial tomography, gastrointestinal endoscopy, and gastric biopsy, the diagnosis of gastric and ileal Crohn's disease was made. The correct diagnosis of peritoneal carcinomatosis was made at laparoscopy. This case exemplifies the utility of laparoscopy in establishing the diagnosis and staging for abdominal disease of uncertain etiology.
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Affiliation(s)
- D W Easter
- Department of Surgery, University of California in San Diego, La Jolla 92037, USA
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Carson KD, Grimes SB, McGinley JM, Thornton MT, Mulhall J, Bourke AM, McCrory C, Marsh B, Hone R, Phelan D, White M, Fabry J, Hughes D, Carson K, Donnelly M, Shanahan E, Fitzpatrick GJ, Bourke M, Warde D, Buggy D, Hughes N, Taylor A, Dowd N, Markham T, Blunnie W, Nicholson G, O’Leary E, Cunningham AJ, Dwyer R, McMechan S, Cullen C, Dempsey G, Wright G, MacKenzie G, Anderson J, Adgey J, Walsh M, O’Callaghan P, Graham I, O’Hare JA, Geoghegan M, Iman N, Shah P, Chander R, Lavin F, Daly K, Johnston PW, Imam Z, Adgey AAJ, Rusk RA, Richardson SG, Hale A, Kinsella BM, FitzGerald GA, King G, Crean P, Gearty G, Cawley T, Docherty JR, Geraghty J, Osborne H, Upton J, D’Arcy G, Stinson J, Cooke T, Colgan MP, Hall M, Tyrrell J, Gaffney K, Grouden M, Moore DJ, Shanik G, Feely J, Delanty N, Reilly M, Lawson JA, Fitzgerald DJ, Reilly MP, McAdam BF, Bergin C, Walshe MJ, Herity NA, Allen JD, Silke B, Singh HP, O’Neill S, Hargrove M, Coleman E, Shorten E, Aherne T, Kelly BE, Hill DH, McIlrath E, Morrow BC, Lavery GG, Blackwood B, Fee JPH, Kevin L, Doran M, Tansey D, Boylan I, McShane AJ, O’Reilly G, Tuohy B, Grainger P, Larkin T, Mahady J, Malone J, Condon C, Donoghue T, O’Leary J, Lyons JF, Tay YK, Tham SN, Khoo Tan HS, Gibson G, O’Grady A, Leader M, Walshe J, Carmody M, Donohoe J, Murphy GM, O’Connor W, Barnes L, Watson R, Darby C, O’Moore R, Mulcahy F, O’Toole E, O’Briain DS, Young MM, Buckley D, Healy E, Rogers S, Ni Scannlain N, McKenna MJ, McBrinn Y, Murray B, Freaney R, Barrett E, Razza Q, Abuaisha F, Powell D, Murray TM, Powell AM, O’Mongain E, O’Neill J, Kernan RP, O’Connor P, Clarke D, Fearon U, Cunningham SK, McKenna TJ, Hayes F, Heffernan A, Sheahan K, Harper R, Johnston GD, Atkinson AB, Sheridan B, Bell PM, Heaney AP, Loughrey G, McCance DR, Hadden DR, Kennedy AL, McNamara P, O’Shaughnessy C, Loughrey HC, Reid I, Teahan S, Caldwell M, Walsh TN, McSweeney J, Hennessy TP, Caldwell MTP, Byrne PJ, Hennessy TPJ, El-Magbri AA, Stevens FM, O’Sullivan R, McCarthy CF, Laundon J, Heneghan MA, Kearns M, Goulding J, Egan EL, McMahon BP, Hegarty F, Malone JF, Merriman R, MacMathuna P, Crowe J, Lennon J, White P, Clarke E, Prabhakar MC, Ryan E, Graham D, Yeoh PL, Kelly P, McKeogh D, O’Keane C, Kitching A, Mulligan E, Gorey TF, Mahmud N, O’Connell M, Goggins M, Keeling PWN, Weir DG, Kelleher D, McDonald GSA, Maguire D, O’Sullivan G, Harvey B, Cherukuri A, McGrath JP, Timon C, Lawlor P, O’Shea J, Buckley M, English L, Walsh T, O’Morain C, Lavelle SM, Kanagaratnam B, Harding B, Murphy B, Kavanagh J, Kerr D, Lavelle E, O’Gorman T, Liston S, Fitzpatrick C, Fitzpatrick P, Turner M, Murphy AW, Cafferty D, Dowling J, Bury G, Kaf Al-Ghazal S, Zimmermann E, O’Donoghue J, McCann J, Sheehan C, Boissel L, Lynch M, Cryan B, Fanning S, O’Meara D, Fennell J, Byrne PM, Lyons D, Mulcahy R, Pooransingh A, Walsh JB, Coakley D, O’Neill D, Ryall N, Connolly P, Namushi R, Lawler M, Locasciulli A, Bacigalupo A, Humphries P, McCann SR, Pamphilon D, Reidy M, Madden M, Finch T, Borton M, Barnes CA, Lawlor SE, Gardiner N, Egan LJ, Orren A, Doherty J, Curran C, O’Hanlon D, Kent P, Kerin M, Maher D, Given HF, Lynch S, McManus R, O’Farrelly C, Madrigal L, Feighery C, O’Donoghue D, Whelan CA, Rea IM, Stewart M, Campbell P, Alexander HD, Crockard AD, Morris TCM, Maguire H, Davidson F, Kaminski GZ, Butler K, Hillary IB, Parfrey NA, Crowley B, McCreary C, Keane C, O’Reilly M, Goh J, Kennedy M, Fitzgerald M, Scott T, Murphy S, Hildebrand J, Holliman R, Smith C, Kengasu K, Riain UN, Cormican M, Flynn J, Glennon M, Smith T, Whyte D, Keane CT, Barry T, Noone D, Maher M, Dawson M, Gilmartin JJ, Gannon F, Eljamel MS, Allcut D, Pidgeon CN, Phillips J, Rawluk D, Young S, Toland J, Deveney AM, Waddington JL, O’Brien DP, Hickey A, Maguire E, Phillips JP, Al-Ansari N, Cunney R, Smyth E, Sharif S, Eljamel M, Pidgeon C, Maguire EA, Burke ET, Staunton H, O’Riordan JI, Hutchinson M, Norton M, McGeeney B, O’Connor M, Redmond JMT, Feely S, Boyle G, McAuliffe F, Foley M, Kelehan P, Murphy J, Greene RA, Higgins J, Darling M, Byrne P, Kondaveeti U, Gordon AC, Hennelly B, Woods T, Harrison RF, Geary M, Sutherst JR, Turner MJ, DeLancey JOL, Donnelly VS, O’Connell PR, O’Herlihy C, Barry-Kinsella C, Sharma SC, Drury L, Lewis S, Stratton J, Ni Scanaill S, Stuart B, Hickey K, Coulter-Smith S, Moloney A, Robson MS, Murphy M, Keane D, Stronge J, Boylan P, Gonsalves R, Blankson S, McGuinness E, Sheppard B, Bonnar J, MacDonagh-White CM, Kelleher CC, Newell J, White O, Young Y, Hallahan C, Carroll K, Tipton K, McDermott EW, Reynolds JV, Nolan N, McCann A, Rafferty R, Sweeney P, Carney D, O’Higgins NJ, Duffy MJ, Grimes H, Gallagher S, O’Hanlon DM, Strattan J, Lenehan P, Robson M, Cusack YA, O’Riordain D, Mercer PM, Smyth PPA, Gallagher HJ, Moule B, Cooke TG, McArdle CS, Burke C, Vance A, Saidtéar C, Early A, Eustace P, Maguire L, Cullinane ABP, Prosser ES, Coca-Prados M, Harvey BJ, Saidléar C, Orwa S, Fitzsimons RB, Bradley O, Hogan M, Zimmerman L, Wang J, Kuliszewski M, Liu J, Post M, Premkumar, Conran MJ, Nolan G, Duff D, Oslizlok P, Denham B, O’Connell PA, Birthistle K, Hitchcock R, Carrington D, Calvert S, Holmes K, Smith DF, Hetherton AM, Mott MG, Oakhill A, Foreman N, Foot A, Dixon J, Walsh S, Mortimer G, O’Sullivan C, Kilgallen CM, Sweeney EC, Brayden DJ, Kelly JG, McCormack PME, Hayes C, Johnson Z, Dack P, Hosseini J, O’Connell T, Hemeryck L, Condren L, McCormack P, McAdam B, Lawson J, Keimowitz R, O’Leary A, Pilkington R, Adebayo GI, Gaffney P, McGettigan P, McManus J, O’Shea B, Wen Y, Killalea S, Golden J, Swanwick G, Clare AW, Mulvany F, Byrne M, O’Callaghan E, Byrne H, Cannon N, Kinsella T, Cassidy B, Shepard N, Horgan R, Larkin C, Cotter D, Coffey VP, Sham PC, Murray LH, Lane A, Kinsella A, Murphy P, Colgan K, Sloan D, Gilligan P, McEnri J, Ennis JT, Stack J, Corcoran E, Walsh D, Thornton L, Temperley I, Lawlor E, Tobin A, Hillary I, Nelson HG, Martin M, Ryan FM, Christie MA, Murray D, Keane E, Holmes E, Hollyer J, Strangeways J, Foster P, Stanwell-Smith R, Griffin E, Conlon T, Hayes E, Clarke T, Fogarty J, Moloney AC, Killeen P, Farrell S, Clancy L, Hynes M, Conlon C, Foley-Nolan C, Shelley E, Collins C, McNamara E, Hayes B, Creamer E, LaFoy M, Costigan P, Al fnAnsari N, Cunney RJ, Smyth EG, Johnson H, McQuoid G, Gilmer B, Browne G, Keogh JAB, Jefferson A, Smith M, Hennessy S, Burke CM, Sreenan S, Power CK, Pathmakanthan S, Poulter LW, Chan A, Sheehan M, Maguire M, O’Connor CM, FitzGerald MX, Southey A, Costello CM, McQuaid K, Urbach V, Thomas S, Horwitz ER, Mulherin D, FitzGerald O, Bresnihan B, Kirk G, Veale DJ, Belch JJF, Mofidi A, Mofidi R, Quigley C, McLaren M, Veale D, D’Arrigo C, Couto JC, Woof J, Greer M, Cree I, Belch J, Hone S, Fenton J, Hamilton S, McShane D. National Scientific Medical Meeting 1994 Abstracts. Ir J Med Sci 1994. [DOI: 10.1007/bf02943102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Doolan CM, Keenan AK, Costello CM, McQuaid K, O’Connor CM, Fitzgerald MX, Southey A, Ryan P, Kelly J, Leonard BE, Grace D, Fee JPH, Milligan KR, Brazil D, Clyne C, Camps M, McHale NG, Keenan AK, Gierschik P, Caldwell M, O’Neill M, Earley B, Thornton F, Martin F, O’Connnell A, Benicourt C, O’Donnell JM, Banyasz T, Kovacs T, Campion DP, Leek BF, Smith KM, Docherty JR, McNamara M, Kelly JP, McGarvey C, O’Donnell J, Nsimba SED, Kelly BE, MacSweeney C, Redrobe JP, Browne I, Gavin K, Thomas G, Docherty JR, Ryan M, Burke W, McDonnell T, Clyne CD, Healy E, Hunt A, Ryan MP, Tashani OA, Curran AK, O’Halloran KD, Bradford A, O’Halloran KD, Ryan JP, Rousseau JP, Kearns PO, Quinn TM, Kevin LG, Doran M, Tansey D, Boylan J, McShane AJ, Wen Y, Feely J, Lowe AS, Baxter GD, Walsh DM, McDowell B, Allen JM, McDowell BC, Allen IM, Niveditha Y, O’Donovan DJ, O’Neill J, Powell D, Kernan RP, Foster NEL, Orr A. Royal academy of medicine in Ireland section of biomedical sciences. Ir J Med Sci 1994. [DOI: 10.1007/bf02943263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Costello CM, McQuaid K, O'Connor CM, Fitzgerald MX. Effect of the addition of protease inhibitors to sputa from cystic fibrosis patients. Biochem Soc Trans 1994; 22:53S. [PMID: 8206281 DOI: 10.1042/bst022053s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- C M Costello
- Department of Medicine, University College Dublin
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Rothman S, Underwood J, McQuaid K, Grendell J. The relationship between the light scattering properties of zymogen granules and the release of their contained proteins. Biochim Biophys Acta 1991; 1074:85-94. [PMID: 2043685 DOI: 10.1016/0304-4165(91)90044-h] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The optical density of suspensions of the digestive enzyme-containing zymogen granule, a roughly spherical 1 micron diameter membrane-enclosed subcellular structure isolated from the exocrine pancreas of mammals, is reduced greatly when they are suspended in physiological media. This reduction in optical density is accompanied by the release of the granule's protein contents. It has traditionally been assumed that this property is due to granule lysis; that is, dissolution of the particle and its consequent disappearance as a strongly scattering object. Thus, lysis would decrease optical density by decreasing the number density of suspended spheres (N) according to Beer's law. However, as a general matter, changes in the optical density of suspensions of spheres may be a function of changes in the refractive index (m) or radius (r) of the objects as well. In this study, we apply Mie theory of scattering by small particles, which, in conjunction with Beer's law, allows us to evaluate whether changes in the scattering properties of granule suspensions are due to changes in N, m or r. Scattering by granule suspensions was reduced in three ways-pH, calcium ion concentration, and detergent concentration. A simple reduction in particle number did not account for decreased scattering and protein release in any of these circumstances. Instead, the changes appear attributable to decreases in particle size and refractive index.
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Affiliation(s)
- S Rothman
- University of California, San Francisco
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Rothman SS, Iskander N, Attwood D, Vladimirsky Y, McQuaid K, Grendell J, Kirz J, Ade H, McNulty I, Kern D. The interior of a whole and unmodified biological object--the zymogen granule--viewed with a high-resolution X-ray microscope. Biochim Biophys Acta 1989; 991:484-6. [PMID: 2730924 DOI: 10.1016/0304-4165(89)90077-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
We report the ability of focused soft X-rays to visualize at spatial resolution well beyond that of the optical microscope (less than 100 nm) the interior of a small, whole biological object without fixation, staining, dehydration or sectioning. Quantitative estimation of its protein content with unique femtogram sensitivity is also reported. The present results represent a significant step towards the goals of natural imaging and chemical mapping of biological structures with soft X-rays.
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Jacobsen C, Kirz J, Howells M, McQuaid K, Rothman S, Feder R, Sayre D. Progress in High-Resolution X-Ray Holographic Microscopy. ACTA ACUST UNITED AC 1988. [DOI: 10.1007/978-3-540-39246-0_44] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Abstract
X-ray holography offers the possibility of three-dimensional microscopy with resolution higher than that of the light microscope and with contrast based on x-ray edges. In principle, the method is especially advantageous for biological samples if x-rays in the wavelength region between the carbon and oxygen K edges are used. However, until now the achieved resolution has not exceeded that of the light microscope because of the poor coherence properties of the x-ray sources and the low resolution of the detectors that were available. With a recently developed x-ray source based on an undulator on an electron storage ring, and high resolution x-ray resist, a hologram has been recorded at about 400-angstrom resolution. The experiment utilized x-rays with wavelengths of 24.7 angstroms and required a 1-hour exposure of the pancreatic zymogen granules under study.
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Affiliation(s)
- M Howells
- Center for X-ray Optics, Lawrence Berkeley Laboratory, University of California, Berkeley 94720
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Berkowitz E, McQuaid K. Welfare reform in the 1950s. Soc Serv Rev 1980; 54:45-58. [PMID: 10297797 DOI: 10.1086/643803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Contrary to the impression left by historians, neither welfare expansion nor welfare reform died in the 1950s. Even conservatives believed in the necessity of federal spending for welfare. Disagreements came over the proper ways to spend federal money. The Eisenhower administration propagated a rehabilitation approach in an attempt to use federal money to end individual, state, and local dependence on the federal government. The administration's 1954 social security and vocational rehabilitation laws reflected this approach. Bureaucrats in the Department of Health, Education, and Welfare, working with a Democratic Congress, managed to extend the 1954 laws into a major expansion of federal power, as the passage of disability insurance in 1956 demonstrated. Institutional continuity, not heroic individual effort, provided the dynamic for welfare reform in the 1950s.
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