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Shinn B, Burdick J, Berk K, Hwang JH, El-Dika S, Juakiem W, Han S, Krishna S, Khashab MA, Mony S, Kadkhodayan K, Khara HS, Ahmed AM, Boortalary T, Agnohortri A, Kumar A, Chiang A, Kamal F, Schlachterman A, Loren D, Kowalski T. Safety, Efficacy and Clinical Utility of the 5.1mm EndoRotor Powered Debridement Catheter for Treatment of Walled-Off Pancreatic Necrosis. Gastrointest Endosc 2024:S0016-5107(24)00131-7. [PMID: 38431104 DOI: 10.1016/j.gie.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 07/18/2023] [Revised: 12/28/2023] [Accepted: 02/18/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND AND AIMS Direct endoscopic necrosectomy (DEN) is a recommended strategy for treatment of walled-off-necrosis (WON). DEN uses a variety of devices including the EndoRotor (Interscope, Inc.) debridement catheter. Recently, a 5.1 mm EndoRotor with increased chamber size and rate of tissue removal was introduced. The aim of this study was to assess the efficacy and safety of this device. METHODS A multi-center cohort study was conducted at eight institutions including patients who underwent DEN with the 5.1 mm EndoRotor. The primary outcome was the number of DEN sessions needed for WON resolution. Secondary outcomes included the average percent reduction in solid WON debris and decrease in WON area per session, total time spent performing EndoRotor therapy for WON resolution, and adverse events. RESULTS 64 procedures in 41 patients were included. For patients in which the 5.1 mm EndoRotor catheter was the sole therapeutic modality, an average of 1.6 DEN sessions resulted in WON resolution with an average cumulative time of 85.5 minutes. Of the 21 procedures with data regarding percent of solid debris, the average reduction was 85% +/- 23% per session. Of the 19 procedures with data regarding WON area, the mean area significantly decreased from 97.6 +/- 72.0 cm2 to 27.1 +/- 35.5 cm2 (p<0.001) per session. Adverse events included two intra-procedural LAMS dislodgements managed endoscopically and three perforations none of which were related to EndoRotor. Bleeding was reported in seven cases, none required embolic or surgical therapy and two required blood transfusions. CONCLUSIONS This is the first multi-center retrospective study to investigate the efficacy and safety of the 5.1 mm EndoRotor catheter for WON. Results from this study showed an average of 1.6 DEN sessions were needed to achieve WON resolution with an 85% single session reduction in solid debris and a 70% single session decrease in WON area with minimal adverse events.
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Affiliation(s)
- Brianna Shinn
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
| | | | | | - Joo Ha Hwang
- Stanford University Medical Center, Palo Alto, California
| | - Samer El-Dika
- Stanford University Medical Center, Palo Alto, California
| | - Wassem Juakiem
- Stanford University Medical Center, Palo Alto, California
| | - Samuel Han
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | | | - Shruti Mony
- Johns Hopkins University Hospital, Baltimore, Maryland
| | | | | | - Ali M Ahmed
- University of Alabama Medical Center, Birmingham, Alabama
| | - Tina Boortalary
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | - Anand Kumar
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Austin Chiang
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Faisal Kamal
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | - David Loren
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Thomas Kowalski
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Jiang J, Chao WL, Cao T, Culp S, Napoléon B, El-Dika S, Machicado JD, Pannala R, Mok S, Luthra AK, Akshintala VS, Muniraj T, Krishna SG. Improving Pancreatic Cyst Management: Artificial Intelligence-Powered Prediction of Advanced Neoplasms through Endoscopic Ultrasound-Guided Confocal Endomicroscopy. Biomimetics (Basel) 2023; 8:496. [PMID: 37887627 PMCID: PMC10604893 DOI: 10.3390/biomimetics8060496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/03/2023] [Accepted: 10/17/2023] [Indexed: 10/28/2023] Open
Abstract
Despite the increasing rate of detection of incidental pancreatic cystic lesions (PCLs), current standard-of-care methods for their diagnosis and risk stratification remain inadequate. Intraductal papillary mucinous neoplasms (IPMNs) are the most prevalent PCLs. The existing modalities, including endoscopic ultrasound and cyst fluid analysis, only achieve accuracy rates of 65-75% in identifying carcinoma or high-grade dysplasia in IPMNs. Furthermore, surgical resection of PCLs reveals that up to half exhibit only low-grade dysplastic changes or benign neoplasms. To reduce unnecessary and high-risk pancreatic surgeries, more precise diagnostic techniques are necessary. A promising approach involves integrating existing data, such as clinical features, cyst morphology, and data from cyst fluid analysis, with confocal endomicroscopy and radiomics to enhance the prediction of advanced neoplasms in PCLs. Artificial intelligence and machine learning modalities can play a crucial role in achieving this goal. In this review, we explore current and future techniques to leverage these advanced technologies to improve diagnostic accuracy in the context of PCLs.
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Affiliation(s)
- Joanna Jiang
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Wei-Lun Chao
- Department of Computer Science and Engineering, College of Engineering, The Ohio State University, Columbus, OH 43210, USA
| | - Troy Cao
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Stacey Culp
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Bertrand Napoléon
- Department of Gastroenterology, Jean Mermoz Private Hospital, 69008 Lyon, France
| | - Samer El-Dika
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA 94305, USA
| | - Jorge D. Machicado
- Division of Gastroenterology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Rahul Pannala
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA
| | - Shaffer Mok
- Division of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Anjuli K. Luthra
- Division of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA
| | - Venkata S. Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
| | - Thiruvengadam Muniraj
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Somashekar G. Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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Narayan RR, Juakiem WY, Poultsides GA, El-Dika S. Peribiliary cysts masquerading as choledocholithiasis. VideoGIE 2023; 8:351-353. [PMID: 37719944 PMCID: PMC10500157 DOI: 10.1016/j.vgie.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Video 1The major papilla was cannulated with a sphincterotome over a straight wire. The polypoid saccular structures were identified by cholangioscopy.
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Affiliation(s)
- Raja R Narayan
- Section of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Wassem Y Juakiem
- Division of Gastroenterology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - George A Poultsides
- Section of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Samer El-Dika
- Division of Gastroenterology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
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Paniccia A, Polanco PM, Boone BA, Wald AI, McGrath K, Brand RE, Khalid A, Kubiliun N, O'Broin-Lennon AM, Park WG, Klapman J, Tharian B, Inamdar S, Fasanella K, Nasr J, Chennat J, Das R, DeWitt J, Easler JJ, Bick B, Singh H, Fairley KJ, Sarkaria S, Sawas T, Skef W, Slivka A, Tavakkoli A, Thakkar S, Kim V, Vanderveldt HD, Richardson A, Wallace MB, Brahmbhatt B, Engels M, Gabbert C, Dugum M, El-Dika S, Bhat Y, Ramrakhiani S, Bakis G, Rolshud D, Millspaugh G, Tielleman T, Schmidt C, Mansour J, Marsh W, Ongchin M, Centeno B, Monaco SE, Ohori NP, Lajara S, Thompson ED, Hruban RH, Bell PD, Smith K, Permuth JB, Vandenbussche C, Ernst W, Grupillo M, Kaya C, Hogg M, He J, Wolfgang CL, Lee KK, Zeh H, Zureikat A, Nikiforova MN, Singhi AD. Prospective, Multi-Institutional, Real-Time Next-Generation Sequencing of Pancreatic Cyst Fluid Reveals Diverse Genomic Alterations That Improve the Clinical Management of Pancreatic Cysts. Gastroenterology 2023; 164:117-133.e7. [PMID: 36209796 PMCID: PMC9844531 DOI: 10.1053/j.gastro.2022.09.028] [Citation(s) in RCA: 40] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 08/22/2022] [Accepted: 09/16/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Next-generation sequencing (NGS) of pancreatic cyst fluid is a useful adjunct in the assessment of patients with pancreatic cyst. However, previous studies have been retrospective or single institutional experiences. The aim of this study was to prospectively evaluate NGS on a multi-institutional cohort of patients with pancreatic cyst in real time. METHODS The performance of a 22-gene NGS panel (PancreaSeq) was first retrospectively confirmed and then within a 2-year timeframe, PancreaSeq testing was prospectively used to evaluate endoscopic ultrasound-guided fine-needle aspiration pancreatic cyst fluid from 31 institutions. PancreaSeq results were correlated with endoscopic ultrasound findings, ancillary studies, current pancreatic cyst guidelines, follow-up, and expanded testing (Oncomine) of postoperative specimens. RESULTS Among 1933 PCs prospectively tested, 1887 (98%) specimens from 1832 patients were satisfactory for PancreaSeq testing. Follow-up was available for 1216 (66%) patients (median, 23 months). Based on 251 (21%) patients with surgical pathology, mitogen-activated protein kinase/GNAS mutations had 90% sensitivity and 100% specificity for a mucinous cyst (positive predictive value [PPV], 100%; negative predictive value [NPV], 77%). On exclusion of low-level variants, the combination of mitogen-activated protein kinase/GNAS and TP53/SMAD4/CTNNB1/mammalian target of rapamycin alterations had 88% sensitivity and 98% specificity for advanced neoplasia (PPV, 97%; NPV, 93%). Inclusion of cytopathologic evaluation to PancreaSeq testing improved the sensitivity to 93% and maintained a high specificity of 95% (PPV, 92%; NPV, 95%). In comparison, other modalities and current pancreatic cyst guidelines, such as the American Gastroenterology Association and International Association of Pancreatology/Fukuoka guidelines, show inferior diagnostic performance. The sensitivities and specificities of VHL and MEN1/loss of heterozygosity alterations were 71% and 100% for serous cystadenomas (PPV, 100%; NPV, 98%), and 68% and 98% for pancreatic neuroendocrine tumors (PPV, 85%; NPV, 95%), respectively. On follow-up, serous cystadenomas with TP53/TERT mutations exhibited interval growth, whereas pancreatic neuroendocrine tumors with loss of heterozygosity of ≥3 genes tended to have distant metastasis. None of the 965 patients who did not undergo surgery developed malignancy. Postoperative Oncomine testing identified mucinous cysts with BRAF fusions and ERBB2 amplification, and advanced neoplasia with CDKN2A alterations. CONCLUSIONS PancreaSeq was not only sensitive and specific for various pancreatic cyst types and advanced neoplasia arising from mucinous cysts, but also reveals the diversity of genomic alterations seen in pancreatic cysts and their clinical significance.
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Affiliation(s)
- Alessandro Paniccia
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Patricio M Polanco
- Department of Clinical Sciences, Surgery, University of Texas Southwestern, Dallas, Texas
| | - Brian A Boone
- Department of Surgery, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Abigail I Wald
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kevin McGrath
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Randall E Brand
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Asif Khalid
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Nisa Kubiliun
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Anne Marie O'Broin-Lennon
- The Sol Goldman Pancreatic Cancer Research Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Walter G Park
- Department of Medicine, Stanford University, Stanford, California
| | - Jason Klapman
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Benjamin Tharian
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Sumant Inamdar
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Kenneth Fasanella
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John Nasr
- Department of Medicine, Wheeling Hospital, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Jennifer Chennat
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Rohit Das
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana
| | - Jeffrey J Easler
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana
| | - Benjamin Bick
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana
| | - Harkirat Singh
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kimberly J Fairley
- Department of Medicine, Section of Gastroenterology & Hepatology, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Savreet Sarkaria
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Tarek Sawas
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Wasseem Skef
- Department of Medicine, Division of Gastroenterology and Hepatology, Loma Linda University Medical Center, Loma Linda, California
| | - Adam Slivka
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Anna Tavakkoli
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shyam Thakkar
- Department of Medicine, Section of Gastroenterology & Hepatology, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Victoria Kim
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | - Michael B Wallace
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida; Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Bhaumik Brahmbhatt
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Megan Engels
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Charles Gabbert
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mohannad Dugum
- Digestive Health Center, Essentia Health-Duluth Clinic, Duluth, Minnesota
| | - Samer El-Dika
- Department of Medicine, Stanford University, Stanford, California
| | - Yasser Bhat
- Department of Gastroenterology, Palo Alto Medical Foundation (PAMF), Mountain View, California
| | - Sanjay Ramrakhiani
- Department of Gastroenterology, Palo Alto Medical Foundation (PAMF), Mountain View, California
| | | | | | | | - Thomas Tielleman
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Carl Schmidt
- Department of Surgery, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - John Mansour
- Department of Clinical Sciences, Surgery, University of Texas Southwestern, Dallas, Texas
| | - Wallis Marsh
- Department of Surgery, West Virginia University Health Sciences Center, Morgantown, West Virginia
| | - Melanie Ongchin
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Barbara Centeno
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida
| | - Sara E Monaco
- Department of Pathology, Geisinger Medical Center, Danville, Pennsylvania
| | - N Paul Ohori
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sigfred Lajara
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Elizabeth D Thompson
- The Sol Goldman Pancreatic Cancer Research Center, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Ralph H Hruban
- The Sol Goldman Pancreatic Cancer Research Center, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Phoenix D Bell
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Katelyn Smith
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jennifer B Permuth
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Christopher Vandenbussche
- The Sol Goldman Pancreatic Cancer Research Center, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Wayne Ernst
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Maria Grupillo
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Cihan Kaya
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melissa Hogg
- Department of Surgery, NorthShore University Health System, Chicago, Illinois
| | - Jin He
- The Sol Goldman Pancreatic Cancer Research Center, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Christopher L Wolfgang
- The Sol Goldman Pancreatic Cancer Research Center, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Surgery, NYU Langone Health, New York, New York
| | - Kenneth K Lee
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Herbert Zeh
- Department of Clinical Sciences, Surgery, University of Texas Southwestern, Dallas, Texas
| | - Amer Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Marina N Nikiforova
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Machicado JD, Napoleon B, Lennon AM, El-Dika S, Pereira SP, Tan D, Pannala R, Girotra M, Kongkam P, Bertani H, Feng Y, Sijie H, Zhong N, Valantin V, Leblanc S, Hinton A, Krishna SG. Accuracy and agreement of a large panel of endosonographers for endomicroscopy-guided virtual biopsy of pancreatic cystic lesions. Pancreatology 2022; 22:994-1002. [PMID: 36089484 PMCID: PMC10548449 DOI: 10.1016/j.pan.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/11/2022] [Accepted: 08/21/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although emerging data evidences that EUS-guided needle-based confocal laser endomicroscopy (nCLE) accurately diagnoses pancreatic cystic lesions (PCLs), there are a lack of interobserver agreement (IOA) studies utilizing reference histopathological diagnosis and for specific PCL subtypes. Hence, we sought to assess the IOA, intra-observer reliability (IOR), and diagnostic performance of EUS-nCLE using a large cohort of patients with histopathological diagnosis amongst a broad panel of international observers. METHODS EUS-nCLE videos (n = 76) of subjects with PCLs [intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), serous cystadenoma (SCA), pseudocyst, and cystic-neuroendocrine tumors/solid pseudopapillary neoplasm (cystic-NET/SPN)], simulating clinical prevalence rates were obtained from 3 prospective studies. An international panel of 13 endosonographers with nCLE experience, blinded to all PCL data, evaluated the video library twice with a two-week washout for PCL differentiation (mucinous vs. non-mucinous) and subtype diagnosis. RESULTS The IOA (κ = 0.82, 95% CI 0.77-0.87) and IOR (κ = 0.82, 95% CI 0.78-0.85) were "almost perfect" to differentiate mucinous vs. non-mucinous PCLs. For PCL subtype, IOA was highest for SCA (almost perfect; κ = 0.85), followed by IPMN (substantial, κ = 0.72), and cystic-NET/SPN (substantial, κ = 0.73). The IOA was moderate for MCN (κ = 0.47), and pseudocyst (κ = 0.57). Compared to histopathology, observers differentiated mucinous vs. non-mucinous PCLs with high accuracy (94.8%, 95% CI 93.3-96.1). For detecting specific PCLs subtypes, EUS-nCLE was highly accurate in diagnosing non-mucinous cysts (SCA: 98%; cystic-NET/SPN: 96%; pseudocyst: 96%) and slightly less accurate for mucinous lesions (IPMN: 86%; MCN: 84%). CONCLUSION Diagnosis of PCLs by EUS-nCLE guided virtual biopsy is very accurate and reliable for the most prevalent pancreatic cysts in clinical practice.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Pradermchai Kongkam
- Division of Hospital and Ambulatory Medicine, Department of Medicine, Chulalongkorn University, Thailand
| | - Helga Bertani
- Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Yunlu Feng
- Peking Union Medical College Hospital, Dongcheng-qu, Beijing, China
| | - Hao Sijie
- Huashan Hospital Fudan University, Shanghai, China
| | - Ning Zhong
- Qilu Hospital of Shandong University Qingdao, Qingdao, Shandong, China
| | | | - Sarah Leblanc
- Hopital Privé Jean Mermoz, Ramsay Generale de Sante, Lyon, France
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, United States
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Krishna SG, Hart PA, Malli A, Kruger AJ, McCarthy ST, El-Dika S, Walker JP, Dillhoff ME, Manilchuk A, Schmidt CR, Pawlik TM, Porter K, Arnold CA, Cruz-Monserrate Z, Conwell DL. Endoscopic Ultrasound-Guided Confocal Laser Endomicroscopy Increases Accuracy of Differentiation of Pancreatic Cystic Lesions. Clin Gastroenterol Hepatol 2020; 18:432-440.e6. [PMID: 31220640 DOI: 10.1016/j.cgh.2019.06.010] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 05/18/2019] [Accepted: 06/07/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Imaging patterns from endoscopic ultrasound (EUS)-guided needle-based confocal laser endomicroscopy (nCLE) have been associated with specific pancreatic cystic lesions (PCLs). We compared the accuracy of EUS with nCLE in differentiating mucinous from nonmucinous PCLs with that of measurement of carcinoembryonic antigen (CEA) and cytology analysis. METHODS We performed a prospective study of 144 consecutive patients with a suspected PCL (≥20 mm) who underwent EUS with fine-needle aspiration of pancreatic cysts from June 2015 through December 2018 at a single center; 65 patients underwent surgical resection. Surgical samples were analyzed by histology (reference standard). During EUS, the needle with the miniprobe was placed in the cyst, which was analyzed by nCLE. Fluid was aspirated and analyzed for level of CEA and by cytology. We compared the accuracy of nCLE in differentiating mucinous from nonmucinous lesions with that of measurement of CEA and cytology analysis. RESULTS The mean size of dominant cysts was 36.4 ± 15.7 mm and the mean duration of nCLE imaging was 7.3 ± 2.8 min. Among the 65 subjects with surgically resected cysts analyzed histologically, 86.1% had at least 1 worrisome feature based on the 2012 Fukuoka criteria. Measurement of CEA and cytology analysis identified mucinous PCLs with 74% sensitivity, 61% specificity, and 71% accuracy. EUS with nCLE identified mucinous PCLs with 98% sensitivity, 94% specificity, and 97% accuracy. nCLE was more accurate in classifying mucinous vs nonmucinous cysts than the standard method (P < .001). The overall incidence of postprocedure acute pancreatitis was 3.5% (5 of 144); all episodes were mild, based on the revised Atlanta criteria. CONCLUSIONS In a prospective study, we found that analysis of cysts by nCLE identified mucinous cysts with greater accuracy than measurement of CEA and cytology analysis. EUS with nCLE can be used to differentiate mucinous from nonmucinous PCLs. ClincialTrials.gov no: NCT02516488.
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Affiliation(s)
- Somashekar G Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio.
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
| | - Ahmad Malli
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
| | - Andrew J Kruger
- Department of Internal Medicine, The Ohio State University, Columbus, Ohio
| | - Sean T McCarthy
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
| | - Samer El-Dika
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
| | - Jon P Walker
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
| | - Mary E Dillhoff
- Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - Andrei Manilchuk
- Department of General Surgery, The Ohio State University, Columbus, Ohio
| | - Carl R Schmidt
- Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University, Columbus, Ohio
| | - Kyle Porter
- Center for Biostatistics, Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Christina A Arnold
- Department of Pathology, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Zobeida Cruz-Monserrate
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University, Columbus, Ohio
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7
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Abu-El-Haija M, El-Dika S, Hinton A, Conwell DL. Acute Pancreatitis Admission Trends: A National Estimate through the Kids' Inpatient Database. J Pediatr 2018; 194:147-151.e1. [PMID: 29174078 PMCID: PMC6136833 DOI: 10.1016/j.jpeds.2017.09.061] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 09/13/2017] [Accepted: 09/21/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To evaluate national health care use and costs for pediatric acute pancreatitis. STUDY DESIGN The Kids' Inpatient Database for 2006, 2009, and 2012 was queried for patients with a principal diagnosis of acute pancreatitis. Cases were grouped by age: preschool (<5 years of age), school age (5-14 years of age), and adolescents (>14 years of age). RESULTS A total of 27 983 discharges for acute pancreatitis were found. The number of admissions increased with age: young n = 1279, middle n = 8012, and older n = 18 692. Duration of stay was highest in preschool children (median, 3.47 days; IQR, 2.01-7.35), compared with school age (median, 3.22 days; IQR, 1.81-5.63) and adolescents (median, 2.87 days; IQR, 1.61-4.81; P < .001). The median cost of hospitalization varied with age: $6726 for preschoolers, $5400 for school-aged children, and $5889 for adolescents (P < .001). Acute pancreatitis-associated diagnoses varied by age. The presence of gallstone pancreatitis, alcohol, and hypertriglyceridemia was more common among older children compared with younger children (P < .001). There was an increasing trend in acute pancreatitis, chronic pancreatitis, and obesity for the 2 older age groups (P < .001). CONCLUSION Admission of children for acute pancreatitis constitutes a significant healthcare burden, with a rising number of admissions with age. However, the cost and duration of stay per admission are highest in young children.
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Affiliation(s)
- Maisam Abu-El-Haija
- Cincinnati Children's Hospital Medical Center, Division of Gastroenterology, Hepatology and Nutrition, Cincinnati, OH.
| | - Samer El-Dika
- Ohio State University Wexner Medical Center, Division of Gastroenterology, Hepatology and Nutrition
| | - Alice Hinton
- Ohio State University, College of Public Health, Division of Biostatistics, Columbus, OH
| | - Darwin L. Conwell
- Ohio State University Wexner Medical Center, Division of Gastroenterology, Hepatology and Nutrition
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Obi K, Ramsey M, Hinton A, Stanich P, Gray DM, Krishna SG, El-Dika S, Hussan H. Insights into insulin resistance, lifestyle, and anthropometric measures of patients with prior colorectal cancer compared to controls: A National Health and Nutrition Examination Survey (NHANES) Study. Curr Probl Cancer 2018; 42:276-285. [PMID: 29395416 DOI: 10.1016/j.currproblcancer.2017.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 11/18/2017] [Accepted: 12/10/2017] [Indexed: 01/05/2023]
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9
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Li F, El-Dika S, Modi RM, Chen W, Krishna SG. Poorly differentiated pancreatic carcinoma with sarcomatoid differentiation: confocal endomicroscopy of an uncommon pancreatic cystic lesion. Endoscopy 2017; 48:E363-E364. [PMID: 27852093 DOI: 10.1055/s-0042-118457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 02/06/2023]
Affiliation(s)
- Feng Li
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Samer El-Dika
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Rohan M Modi
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Wei Chen
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Mansfield SA, El-Dika S, Krishna SG, Perry KA, Walker JP. Routine staging with endoscopic ultrasound in patients with obstructing esophageal cancer and dysphagia rarely impacts treatment decisions. Surg Endosc 2016; 31:3227-3233. [PMID: 27864719 DOI: 10.1007/s00464-016-5351-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 11/09/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic ultrasound (EUS) has been routinely utilized for the locoregional staging of esophageal cancer. One important aspect of clinical staging has been to stratify patients to treatment with neoadjuvant chemoradiation or primary surgical therapy. We hypothesized that EUS may have a limited impact on clinical decision making in patients with dysphagia and obstructing esophageal masses. METHODS This retrospective cohort study included all patients with esophageal adenocarcinoma undergoing esophageal EUS between July 2008 and September 2013. Dysplastic Barrett's esophagus without invasive adenocarcinoma or incomplete staging was excluded. Patient demographics, endoscopic tumor characteristics, the presence of dysphagia, sonographic staging, and post-EUS therapy were recorded. Pathologic staging for patients who underwent primary surgical therapy was also recorded. Locally advanced disease was defined as at least T3 or N1, as these patients are typically treated with neoadjuvant therapy. RESULTS Two hundred sixteen patients underwent EUS for esophageal adenocarcinoma, with 147 (68.1%) patients having symptoms of dysphagia on initial presentation. Patients with dysphagia were significantly more likely to have locally advanced disease on EUS than patients without dysphagia (p < 0.0001). Additionally, 145 (67.1%) patients had a partially or completely obstructing mass on initial endoscopy, of which 136 (93.8%) were locally advanced (p < 0.0001 vs. non-obstructing lesions). CONCLUSIONS An overwhelming majority of patients presenting with dysphagia and/or the presence of at least partially obstructing esophageal mass at the time of esophageal cancer diagnosis had an EUS that demonstrated at least locally advanced disease. The present study supports the hypothesis that EUS may be of limited benefit for management of esophageal cancer in patients with an obstructing mass and dysphagia.
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Affiliation(s)
- Sara A Mansfield
- General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Samer El-Dika
- Section of Advanced Endoscopy, Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Somashekar G Krishna
- Section of Advanced Endoscopy, Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Kyle A Perry
- General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jon P Walker
- Section of Advanced Endoscopy, Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH, 43210, USA.
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Krishna SG, Swanson B, Hart PA, El-Dika S, Walker JP, McCarthy ST, Malli A, Shah ZK, Conwell DL. Validation of diagnostic characteristics of needle based confocal laser endomicroscopy in differentiation of pancreatic cystic lesions. Endosc Int Open 2016; 4:E1124-E1135. [PMID: 27853737 PMCID: PMC5110338 DOI: 10.1055/s-0042-116491] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 08/19/2016] [Indexed: 02/07/2023] Open
Abstract
UNLABELLED Background and aims: Endoscopic ultrasound (EUS)-guided needle-based Confocal Laser Endomicroscopy (nCLE) characteristics of pancreatic cystic lesions (PCLs) have been identified in studies where the gold standard surgical histopathology was available in a minority of patients. There are diverging reports of interobserver agreement (IOA) and paucity of intraobserver reliability (IOR). Thus, we sought to validate current EUS-nCLE criteria of PCLs in a larger consecutive series of surgical patients. Methods: A retrospective analysis of patients who underwent EUS-nCLE at a single center was performed. For calculation of IOA (Fleiss' kappa) and IOR (Cohen's kappa), blinded nCLE-naïve observers (n = 6) reviewed nCLE videos of PCLs in two phases separated by a 2-week washout period. Results: EUS-nCLE was performed in 49 subjects, and a definitive diagnosis was available in 26 patients. The overall sensitivity, specificity, and accuracy for diagnosing a mucinous PCL were 94 %, 82 %, and 89 %, respectively. The IOA for differentiating mucinous vs. non-mucinous PCL was "substantial" (κ = 0.67, 95 %CI 0.57, 0.77). The mean (± standard deviation) IOR was "substantial" (κ = 0.78 ± 0.13) for diagnosing mucinous PCLs. Both the IOAs and mean IORs were "substantial" for detection of known nCLE image patterns of papillae/epithelial bands of mucinous PCLs (IOA κ = 0.63; IOR κ = 0.76 ± 0.11), bright particles on a dark background of pseudocysts (IOA κ = 0.71; IOR κ = 0.78 ± 0.12), and fern-pattern or superficial vascular network of serous cystadenomas (IOA κ = 0.62; IOR κ = 0.68 ± 0.20). Three (6.1 % of 49) patients developed post-fine needle aspiration (FNA) pancreatitis. Conclusion: Characteristic EUS-nCLE patterns can be consistently identified and improve the diagnostic accuracy of PCLs. These results support further investigations to optimize EUS-nCLE while minimizing adverse events. STUDY REGISTRATION NCT02516488.
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Affiliation(s)
- Somashekar G. Krishna
- Section of Advanced Endoscopy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA,Section of Pancreatic Disorders, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA,Corresponding author Somashekar G. Krishna, MD MPH 395 W. 12th AvenueSuite 262Division of Gastroenterology, Hepatology and NutritionColumbusOhioUSA+1-614-293-8518
| | - Benjamin Swanson
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Phil A. Hart
- Section of Pancreatic Disorders, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Samer El-Dika
- Section of Advanced Endoscopy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA,Section of Pancreatic Disorders, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jon P. Walker
- Section of Advanced Endoscopy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sean T. McCarthy
- Section of Advanced Endoscopy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA,Section of Pancreatic Disorders, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ahmad Malli
- Section of Advanced Endoscopy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Zarine K. Shah
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Darwin L. Conwell
- Section of Pancreatic Disorders, Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Shirley LA, Walker J, Krishna S, El-Dika S, Muscarella P, Ellison EC, Schmidt CR, Bloomston M. Routine Cyst Fluid Cytology Is Not Indicated in the Evaluation of Pancreatic Cystic Lesions. J Gastrointest Surg 2016; 20:1581-5. [PMID: 27230996 DOI: 10.1007/s11605-016-3175-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 05/18/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND The work-up of cystic lesions of the pancreas often involves endoscopic ultrasound (EUS) with fine needle aspiration (FNA). In addition to CEA and amylase measurement, fluid is routinely sent for cytologic examination. We evaluated the utility of cytologic findings in clinical decision-making. MATERIALS AND METHODS Records of patients who underwent EUS-guided pancreatic cyst aspiration were reviewed. Findings from axial imaging and EUS were compared to cyst fluid cytology as well as fluid amylase and CEA. All results were then compared to final diagnosis, determined by clinical analysis for those patients not resected, and surgical pathology report for those who underwent resection. RESULTS A total of 167 patients were reviewed. Of 48 patients with suspicious findings on imaging, cytology yielded diagnostic information in 89.6 % of cases (43 patients). However, in the 119 patients where no suspicious components were revealed on imaging, fluid cytology yielded no significant diagnostic results in any case. In all cases where mucin was noted on cytologic review, thick fluid was also seen at the time of aspiration. DISCUSSION In our cohort of patients with cystic pancreatic lesions, cytologic analysis of pancreatic cyst fluid yielded no diagnostic benefit over radiologic findings alone. In such cases where fluid is to be aspirated, specimens that would otherwise be sent for cytologic evaluation would be better served for other purposes, such as molecular analysis or banking for future research.
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Affiliation(s)
- Lawrence A Shirley
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 410 W. 10th Ave, N924 Doan Hall, Columbus, OH, 43210, USA.
| | - Jon Walker
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Somashekar Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Samer El-Dika
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Peter Muscarella
- Department of Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - E Christopher Ellison
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Carl R Schmidt
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 410 W. 10th Ave, N924 Doan Hall, Columbus, OH, 43210, USA
| | - Mark Bloomston
- Division of Surgical Oncology, 21st Century Oncology, Ft. Myers, FL, USA
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13
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Affiliation(s)
- Veeral M Oza
- Division of Gastroenterology and Liver Diseases, Yale New Haven Medical Center, New Haven, Connecticut
| | - Samer El-Dika
- Division of Gastroenterology, Hepatology and Nutrition, Ohio State University-Wexner Medical Center, Columbus, Ohio
| | - Megan A Adams
- Division of Gastroenterology, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
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14
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Krishna SG, Hinton A, Oza V, Hart PA, Swei E, El-Dika S, Stanich PP, Hussan H, Zhang C, Conwell DL. Morbid Obesity Is Associated With Adverse Clinical Outcomes in Acute Pancreatitis: A Propensity-Matched Study. Am J Gastroenterol 2015; 110:1608-19. [PMID: 26482857 DOI: 10.1038/ajg.2015.343] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [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: 02/19/2015] [Accepted: 09/01/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Morbid obesity may adversely affect the clinical course of acute pancreatitis (AP); however, there are no inpatient, population-based studies assessing the impact of morbid obesity on AP-related outcomes. We sought to evaluate the impact of morbid obesity on AP-related clinical outcomes and health-care utilization. METHODS The Nationwide Inpatient Sample (2007-2011) was reviewed to identify all adult inpatients (≥18 years) with a principal diagnosis of AP. The primary clinical outcomes (mortality, renal failure, and respiratory failure) and secondary resource outcomes (length of stay and hospital charges) were analyzed using univariate and multivariate comparisons. Propensity score-matched analysis was performed to compare the outcomes in patients with and without morbid obesity. RESULTS Morbid obesity was associated with 3.9% (52,297/1,330,302) of all AP admissions. Whereas the mortality rate decreased overall (0.97%→0.83%, P<0.001), it remained unchanged in those with morbid obesity (1.02%→1.07%, P=1.0). Multivariate analysis revealed that morbid obesity was associated with increased mortality (odds ratio (OR) 1.6; 95% confidence interval (CI) 1.3, 1.9), prolonged hospitalization (0.4 days; P<0.001), and higher hospitalization charges ($5,067; P<0.001). A propensity score-matched cohort analysis demonstrated that the primary outcomes, acute kidney failure (10.8 vs. 8.2%; P<0.001), respiratory failure (7.9 vs. 6.4%; P<0.001), and mortality (OR 1.6, 95% CI 1.2, 2.1) were more frequent in morbid obesity. CONCLUSIONS Morbid obesity negatively influences inpatient hospitalization and is associated with adverse clinical outcomes, including mortality, organ failure, and health-care resource utilization. These observations and the increasing global prevalence of obesity justify ongoing efforts to understand the role of obesity-induced inflammation in the pathogenesis and management of AP.
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Affiliation(s)
- Somashekar G Krishna
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Veeral Oza
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Phil A Hart
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Eric Swei
- The Ohio State University College of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Samer El-Dika
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Peter P Stanich
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Hisham Hussan
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Cheng Zhang
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Cronley K, Wenzke J, Hussan H, Vasquez AM, Hinton A, El-Dika S, Conwell DL, Krishna SG, Stanich PP. Diverticulitis in HIV-infected patients within the United States. HIV Med 2015; 17:216-21. [PMID: 26283564 DOI: 10.1111/hiv.12304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Diverticulitis in patients on immunosuppressant therapy has been associated with increased mortality, but there are no data for HIV-infected patients. Our aim was to compare the outcomes of hospitalizations for diverticulitis in patients with and without HIV infection. METHODS Cross-sectional study of hospitalizations in the United States accessed through the Nationwide Inpatient Sample, Healthcare Cost and Utilization Project. Patients hospitalized for diverticulitis in 2007-2011 were included in the analysis. The primary outcomes of interest were mortality and surgical therapy rates. Patients from 2003 to 2011 were utilized to analyse trends in prevalence. RESULTS There were 2375 patients with HIV infection hospitalized for diverticulitis and 1 160 391 patients without HIV infection hospitalized for diverticulitis from 2007 to 2011. The patients with HIV infection were younger and more likely to be male and nonwhite (P < 0.001 for all). There were also differences in insurance types (P < 0.001) and hospitals [size (P = 0.008), type (P < 0.001) and location (P < 0.001)]. After multivariate analysis, patients with diverticulitis and HIV infection had a significantly increased in-hospital mortality rate [odds ratio (OR) 3.94 (95% confidence interval, CI, 1.52-10.20)] and a lower rate of surgical intervention [OR 0.74 (95% CI 0.57-0.95)]. From 2003 to 2011, there was a linear increasing trend in the prevalence of HIV infection among patients hospitalized for diverticulitis (P < 0.001). CONCLUSIONS HIV-infected patients with diverticulitis had increased mortality and received less surgical treatment in comparison to the general population. Diverticulitis in HIV-infected patients increased in prevalence over the study period.
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Affiliation(s)
- K Cronley
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University, Columbus, OH, USA
| | - J Wenzke
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University, Columbus, OH, USA
| | - H Hussan
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University, Columbus, OH, USA
| | - A M Vasquez
- Division of Infectious Diseases, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - A Hinton
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University, Columbus, OH, USA.,Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - S El-Dika
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University, Columbus, OH, USA
| | - D L Conwell
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University, Columbus, OH, USA
| | - S G Krishna
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University, Columbus, OH, USA
| | - P P Stanich
- Division of Gastroenterology, Hepatology & Nutrition, The Ohio State University, Columbus, OH, USA
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Wu C, Mikhail S, Wei L, Timmers C, Tahiri S, Neal A, Walker J, El-Dika S, Blazer M, Rock J, Clark DJ, Yang X, Chen JL, Liu J, Knopp MV, Bekaii-Saab T. A phase II and pharmacodynamic study of sunitinib in relapsed/refractory oesophageal and gastro-oesophageal cancers. Br J Cancer 2015; 113:220-5. [PMID: 26151457 PMCID: PMC4506385 DOI: 10.1038/bjc.2015.197] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 04/18/2015] [Accepted: 05/07/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Blockade of the vascular endothelial growth factor (VEGF) pathway shows evidence of activity in gastro-oesophageal (GE) and oesophageal cancer. We investigated the efficacy of sunitinib, a multikinase VEGF inhibitor, in patients with relapsed/refractory GE/oesophageal cancer. METHODS This was a single-stage Fleming phase II study. The primary end point was progression-free survival (PFS) at 24 weeks. If five or more patients out of a total of 25 were free of progressive disease at 24 weeks, sunitinib would be recommended for further study. Patients received sunitinib 37.5 mg orally daily and imaged every 6 weeks. Exploratory correlative analysis included serum growth factors, tumour gene expression and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). RESULTS Twenty-five evaluable patients participated in the study. Progression-free survival at 24 weeks was 8% (n=2 patients; confidence interval (CI): 95% 1.4-22.5%), and the duration of best response for the patients was 23 and 72 weeks. Ten patients (42%) had stable disease (SD) for >10 weeks. Overall response rate is 13%. Median PFS is 7 weeks (95% CI: 5.6-11.4 weeks) and the median overall survival is 17 weeks (95% CI: 8.9-25.3 weeks). Most common grade 3/4 toxicities included fatigue (24%), anaemia (20%) thrombocytopenia (16%), and leucopenia (16%). No patients discontinued therapy due to toxicity. Serum VEGF-A and -C levels, tumour complement factor B (CFB) gene expression, and DCE-MRI correlated with clinical benefit, defined as SD or better as best response. CONCLUSION Sunitinib is well tolerated but only a select subgroup of patients benefited. Serum VEGF-A and -C may be early predictors of benefit. On this study, patients with clinical benefit from sunitinib had higher tumour CFB expression, and thus has identified CFB as a potential predictor for efficacy of anti-angiogenic therapy. These findings need validation from future prospective trials.
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Affiliation(s)
- C Wu
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Arthur G James Cancer Hospital and Richard J Solove Research Institute, Columbus, OH 43210, USA
| | - S Mikhail
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Arthur G James Cancer Hospital and Richard J Solove Research Institute, Columbus, OH 43210, USA
| | - L Wei
- Center for Biostatistics, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA
| | - C Timmers
- The Ohio State University Comprehensive Cancer Center, Arthur G James Cancer Hospital and Richard J Solove Research Institute, Columbus, OH 43210, USA
| | - S Tahiri
- The Ohio State University Comprehensive Cancer Center, Arthur G James Cancer Hospital and Richard J Solove Research Institute, Columbus, OH 43210, USA
| | - A Neal
- The Ohio State University Comprehensive Cancer Center, Arthur G James Cancer Hospital and Richard J Solove Research Institute, Columbus, OH 43210, USA
| | - J Walker
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - S El-Dika
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - M Blazer
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - J Rock
- Anatomic Pathology Laboratory, Mercy Anderson Hospital, Cincinnati, OH 43210, USA
| | - D J Clark
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - X Yang
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - J L Chen
- Division of Medical Oncology, Departments of Biomedical Informatics and Internal Medicine, The Ohio State University Comprehensive Cancer Center, Arthur G James Cancer Hospital and Richard J Solove Research Institute, Columbus, OH 43210, USA
| | - J Liu
- Department of Pathology, Beaumont Medical Center, Grosse Pointe, MI, USA
| | - M V Knopp
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - T Bekaii-Saab
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Arthur G James Cancer Hospital and Richard J Solove Research Institute, Columbus, OH 43210, USA
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Naem M, Stanich PP, El-Dika S. Incidental subepithelial sigmoid colon lesion. Clin Gastroenterol Hepatol 2015; 13:A32. [PMID: 25051513 DOI: 10.1016/j.cgh.2014.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 05/14/2014] [Revised: 07/12/2014] [Accepted: 07/15/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Mohamed Naem
- Department of Internal Medicine and Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Peter P Stanich
- Department of Internal Medicine and Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Samer El-Dika
- Department of Internal Medicine and Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Nichols SD, Albert S, Shirley L, Schmidt C, Abdel-Misih S, El-Dika S, Groce JR, Wu C, Goldberg RM, Bekaii-Saab T, Bloomston M. Outcomes in patients with obstructive jaundice from metastatic colorectal cancer and implications for management. J Gastrointest Surg 2014; 18:2186-91. [PMID: 25300799 PMCID: PMC4809042 DOI: 10.1007/s11605-014-2670-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 09/25/2014] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Patients with metastatic colorectal cancer can develop jaundice from intrahepatic or extrahepatic causes. Currently, there is little data on the underlying causes and overall survival after onset of jaundice. The purpose of this study was to characterize the causes of jaundice and determine outcomes. METHODS Six hundred twenty-nine patients treated for metastatic colorectal cancer between 2004 and 2010 were retrospectively reviewed. Those developing jaundice were grouped as having intrahepatic or extrahepatic obstruction. Demographics, clinicopathologic, and outcome data were analyzed. RESULTS Sixty-two patients with metastatic colorectal cancer developed jaundice. Intrahepatic biliary obstruction was most common, occurring in younger patients. Time from metastatic diagnosis to presentation of jaundice was similar between groups, as was the mean number of prior lines of chemotherapy. Biliary decompression was successful 41.7 % of the time and was attempted more commonly for extrahepatic causes. Median overall survival after onset of jaundice was 1.5 months and it was similar between groups, but improved to 9.6 months in patients who were able to receive further chemotherapy. CONCLUSIONS Jaundice due to metastatic colorectal cancer is an ominous finding, representing aggressive tumor biology or exhaustion of therapies. Biliary decompression is often difficult and should only be pursued when additional treatment options are available.
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Affiliation(s)
- Shawnn D Nichols
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 410 West 10th Ave, N924 Doan Hall, Columbus, OH, 43210, USA
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Stanich PP, Pilarski R, Rock J, Frankel WL, El-Dika S, Meyer MM. Colonic manifestations of PTEN hamartoma tumor syndrome: Case series and systematic review. World J Gastroenterol 2014; 20:1833-1838. [PMID: 24587660 PMCID: PMC3930981 DOI: 10.3748/wjg.v20.i7.1833] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Revised: 09/12/2013] [Accepted: 09/29/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate our clinical experience with the colonic manifestations of phosphatase and tensin homolog on chromosome ten (PTEN) hamartoma tumor syndrome (PHTS) and to perform a systematic literature review regarding the same.
METHODS: This study was approved by the appropriate institutional review board prior to initiation. A clinical genetics database was searched for patients with PHTS or a component syndrome that received gastrointestinal endoscopy or pathology interpretation at our center. These patient’s records were retrospectively reviewed for clinical characteristics (including family history and genetic testing), endoscopy results and pathology findings. We also performed a systematic review of the literature for case series of PHTS or component syndromes that reported gastrointestinal manifestations and investigations published after consensus diagnostic criteria were established in 1996. These results were compiled and reported.
RESULTS: Eight patients from our institution met initial inclusion criteria. Of these, 5 patients underwent 4.2 colonoscopies at mean age 45.8 ± 10.8 years. All were found to have colon polyps during their clinical course and polyp histology included adenoma, hyperplastic, ganglioneuroma and juvenile. No malignant lesions were identified. Two had multiple histologic types. One patient underwent colectomy due to innumerable polyps and concern for future malignant potential. Systematic literature review of PHTS patients undergoing endoscopy revealed 107 patients receiving colonoscopy at mean age 37.4 years. Colon polyps were noted in 92.5% and multiple colon polyp histologies were reported in 53.6%. Common polyp histologies included hyperplastic (43.6%), adenoma (40.4%), hamartoma (38.3%), ganglioneuroma (33%) and inflammatory (24.5%) polyps. Twelve (11.2%) patients had colorectal cancer at mean age 46.7 years (range 35-62). Clinical outcomes secondary to colon polyposis and malignancy were not commonly reported.
CONCLUSION: PHTS has a high prevalence of colon polyposis with multiple histologic types. It should be considered a mixed polyposis syndrome. Systematic review found an increased prevalence of colorectal cancer and we recommend initiating colonoscopy for colorectal cancer surveillance at age 35 years.
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Abhishek K, Kaushik S, Kazemi MM, El-Dika S. An unusual case of hematochezia: acute ischemic proctosigmoiditis. J Gen Intern Med 2008; 23:1525-7. [PMID: 18521689 PMCID: PMC2518031 DOI: 10.1007/s11606-008-0673-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2007] [Revised: 12/04/2007] [Accepted: 05/01/2008] [Indexed: 12/01/2022]
Abstract
Acute ischemia of the rectum is uncommon and usually occurs after aorto-iliac surgery. In this report, we present a case of acute ischemic proctosigmoiditis that developed from a brief episode of hypotension. An 85-year-old male presented to the emergency room with hypotension, mental confusion, and passage of maroon-colored stool. He was resuscitated and treated for presumed sepsis. Computerized tomography of the abdomen and pelvis displayed signs of acute inflammation of the distal colon and rectum. Endoscopic findings and microscopic examination of the rectal biopsy revealed changes consistent with acute ischemic proctosigmoiditis. An evaluation for infectious etiologies was negative. The patient's clinical condition improved over the next 24 h with supportive care. Involvement of the rectum is rare in ischemic colitis because of its abundant collateral blood supply. Acute ischemic proctosigmoiditis should be considered in the differential diagnosis of elderly patients with multiple co-morbidities presenting with hematochezia.
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Affiliation(s)
- Kumar Abhishek
- Department of Internal Medicine, Carilion Clinic, Roanoke, VA, USA
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El-Dika S, Vahabzadeh A, Karageorge L, Kinsey A. A large pedunculated lipoma endoscopically resected with the assistance of a detachable nylon endoloop. Gastroenterol Hepatol (N Y) 2007; 3:880-881. [PMID: 21960802 PMCID: PMC3104152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
| | | | - Lampros Karageorge
- Department of Pathology, Veterans Affairs Medical Center, Salem, Va, and University of Virginia, Charlottesville, Va
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Wahlqvist P, Guyatt GH, Armstrong D, Degl'innocenti A, Heels-Ansdell D, El-Dika S, Wiklund I, Fallone CA, Tanser L, Veldhuyzen van Zanten S, Austin P, Barkun AN, Chiba N, Schünemann HJ. The Work Productivity and Activity Impairment Questionnaire for Patients with Gastroesophageal Reflux Disease (WPAI-GERD): responsiveness to change and English language validation. Pharmacoeconomics 2007; 25:385-96. [PMID: 17488137 DOI: 10.2165/00019053-200725050-00003] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
BACKGROUND A validated productivity questionnaire, the Work Productivity and Activity Impairment questionnaire for Gastroesophageal Reflux Disease (WPAI-GERD), exists for Swedish patients with GERD. OBJECTIVE To assess responsiveness to change of the WPAI-GERD and construct validity of the English language version. METHODS We used the WPAI-GERD in a before-after treatment clinical study of Canadian GERD patients with moderate or severe symptoms treated with esomeprazole 40 mg once daily for 4 weeks. We measured productivity variables including GERD-specific absence from work, reduced productivity while at work and reduced productivity while carrying out regular daily activities other than work during the preceding week. RESULTS The analysis included 217 patients, of whom 71% (n = 153) were employed. Before treatment, employed patients reported an average 0.9 hours of absence from work due to GERD and 14.0% reduced work productivity (5.8 hours equivalent) in the previous week, as well as 21.0% reduced productivity in daily activities (all patients). After treatment, the corresponding figures decreased to 0.3 hours, 3.0% (1.1 hours equivalent) and 4.9%, respectively. Thus, the improvement (difference from start of treatment) in productivity was 0.6 hours (p = 0.011) for absence from work and 11.0% units (p < 0.001) for reduced work productivity (4.7 hours equivalent, p < 0.001). This translated into an avoided loss of work productivity of 5.3 hours in total on a weekly basis per employed patient. In addition, a 16.1% unit (p < 0.001) improvement for reduced productivity in activities was observed. Cross-sectional correlation coefficients of WPAI variables with symptoms (range 0.04-0.63) and health-related quality of life (HR-QOL; range 0.02-0.65) supported cross-sectional construct validity. Corresponding change score correlations between WPAI variables and HR-QOL (range 0.05-0.56) supported longitudinal construct validity of the WPAI-GERD while low change score correlations between productivity variables and relevant symptoms (range 0.06-0.34) did not. CONCLUSION The English version of the WPAI-GERD showed good cross-sectional construct validity, and results indicated that the WPAI-GERD is responsive to change. Although the results also indicated that longitudinal construct validity may be poor, the overall findings suggest that further study of the instrument remains warranted.
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Puhan MA, Guyatt GH, Armstrong D, Wiklund I, Fallone CA, Heels-Ansdell D, Degl'Innocenti A, Veldhuyzen van Zanten SJO, Tanser L, Barkun AN, Chiba N, Austin P, El-Dika S, Schünemann HJ. Validation of a symptom diary for patients with gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2006; 23:531-41. [PMID: 16441474 DOI: 10.1111/j.1365-2036.2006.02775.x] [Citation(s) in RCA: 11] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Symptom diaries are potentially attractive but, because of concerns about patient compliance, they have had limited use in clinical trials. We assessed the validity and responsiveness of a symptom diary for patients with gastro-oesophageal reflux disease. METHODS We included 215 patients with gastro-oesophageal reflux disease after starting treatment for 4 weeks with 40 mg esomeprazole once daily. Patients recorded whether they experienced night-time heartburn (yes/no), the severity of daytime heartburn on a scale from 1 (no heartburn) to 4 (severe heartburn) and their antacid use. Patients also completed a number of disease-specific and preference-based Health-related Quality of Life questionnaires at baseline and follow-up. RESULTS Consistent with a priori predictions, daytime heartburn showed moderate to strong correlations with the Quality of Life in Reflux and Dyspepsia questionnaire (0.36-0.67) and four scales of symptom severity (0.36-0.70) for baseline, follow-up and change scores, but low correlations with the Standard Gamble. Responsiveness of the daytime heartburn item was excellent with a mean change from baseline to follow-up of -1.3 (95% CI -1.4 to -1.1) and a standardized response mean of 1.33 while responsiveness of the daily antacid use item was moderate (mean change scores -1.8 tablets taken, 95% CI -2.3 to -1.3 and standardized response mean of 0.64). CONCLUSIONS The excellent psychometric properties of this simple gastro-oesophageal reflux disease diary make it an attractive measure for future trials.
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Affiliation(s)
- M A Puhan
- Horten Centre, University of Zurich, Switzerland
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El-Dika S, Mahl T, Mehboob S, Miqdadi J, Heels-Ansdell D, Handley B, Sitrin M, Schünemann H. Is blinding the endoscopists to bowel preparations in randomized-controlled trials a reality? ACTA ACUST UNITED AC 2006; 30:552-9. [PMID: 17113722 DOI: 10.1016/j.cdp.2006.10.004] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND A number of studies compared the quality, efficacy and tolerability of oral sodium phosphate (NaP) and polyethylene glycol (PEG)-based solutions in preparation for colonoscopy. The primary aim of this study was to explore whether endoscopists can be effectively blinded to the type of bowel preparation. METHODS We recruited 3 experienced endoscopists and 57 outpatients (18-65 years old) undergoing colonoscopy. We randomized eligible patients to receive one of the two bowel preparations. Endoscopists who performed the tests were blinded to the type of preparation, and made their best judgment on the type and quality of the bowel preparation. RESULTS Forty-five patients completed the study. The overall correct estimation of the type of bowel preparation was 60.0% (95% CI; 45.5%, 73.0%). The cleansing quality did not differ between the two preparations. Patients found oral NaP solution much easier to take (81.8% versus 36.4%; P = 0.005) and the PEG-based group tended to have more nausea or vomiting. 47.6% of patients in the PEG group indicated they would prefer to try another bowel preparation in the future compared to 4.5% in the oral NaP group (P = 0.002). We stopped the study after an interim analysis indicating that more than 600 patients would be required to detect statistically significant differences in the primary aim. CONCLUSION Our findings suggest that blinding of endoscopists in clinical trials comparing oral NaP to PEG had a relatively low likelihood of bias. The study also suggests that oral NaP is easier to take and more tolerable than PEG without impairing cleansing quality.
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Affiliation(s)
- Samer El-Dika
- Department of Medicine, Veterans Affairs Medical Center, Salem, VA 24153, USA.
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25
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El-Dika S, Guyatt GH, Armstrong D, Degl'innocenti A, Wiklund I, Fallone CA, Tanser L, van Zanten SV, Heels-Ansdell D, Wahlqvist P, Chiba N, Barkun AN, Austin P, Schünemann HJ. The impact of illness in patients with moderate to severe gastro-esophageal reflux disease. BMC Gastroenterol 2005; 5:23. [PMID: 16004616 PMCID: PMC1183201 DOI: 10.1186/1471-230x-5-23] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2005] [Accepted: 07/10/2005] [Indexed: 12/26/2022] Open
Abstract
Background Gastro-esophageal reflux disease (GERD) is a common disease. It impairs health related quality of life (HRQL). However, the impact on utility scores and work productivity in patients with moderate to severe GERD is not well known. Methods We analyzed data from 217 patients with moderate to severe GERD (mean age 50, SD 13.7) across 17 Canadian centers. Patients completed three utility instruments – the standard gamble (SG), the feeling thermometer (FT), and the Health Utilities Index 3 (HUI 3) – and several HRQL instruments, including Quality of Life in Reflux and Dyspepsia (QOLRAD) and the Medical Outcomes Short Form-36 (SF-36). All patients received a proton pump inhibitor, esomeprazole 40 mg daily, for four to six weeks. Results The mean scores on a scale from 0 (dead) to 1 (full health) obtained for the FT, SG, and HUI 3 were 0.67 (95% CI, 0.64 to 0.70), 0.76 (95% CI, 0.75 to 0.80), and 0.80 (95% CI, 0.77 to 0.82) respectively. The mean scores on the SF-36 were lower than the previously reported Canadian and US general population mean scores and work productivity was impaired. Conclusion GERD has significant impact on utility scores, HRQL, and work productivity in patients with moderate to severe disease. Furthermore, the FT and HUI 3 provide more valid measurements of HRQL in GERD than the SG. After treatment with esomeprazole, patients showed improved HRQL.
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Affiliation(s)
- Samer El-Dika
- Division of Gastroenterology, Veterans affairs medical center, Salem, Virginia, USA
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics' McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - David Armstrong
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Carlo A Fallone
- Division of Gastroenterology, McGill University Health Center, Montreal, Quebec, Canada
| | - Lisa Tanser
- AstraZeneca R&D, Canada, Mississauga, Ontario, Canada
| | | | - Diane Heels-Ansdell
- Department of Clinical Epidemiology and Biostatistics' McMaster University, Hamilton, Ontario, Canada
| | | | - Naoki Chiba
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Surrey GI Clinic/Research, Guelph, Ontario, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, Montreal, Quebec, Canada
| | - Peggy Austin
- Department of Clinical Epidemiology and Biostatistics' McMaster University, Hamilton, Ontario, Canada
| | - Holger J Schünemann
- Department of Clinical Epidemiology and Biostatistics' McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
- Division of Clinical Research Development and Information Translation/INFORMA, Italian National Cancer Institute, Rome/Istituto Regina Elena, Rome, Italy
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Devereaux PJ, Choi PTL, El-Dika S, Bhandari M, Montori VM, Schünemann HJ, Garg AX, Busse JW, Heels-Ansdell D, Ghali WA, Manns BJ, Guyatt GH. An observational study found that authors of randomized controlled trials frequently use concealment of randomization and blinding, despite the failure to report these methods. J Clin Epidemiol 2005; 57:1232-6. [PMID: 15617948 DOI: 10.1016/j.jclinepi.2004.03.017] [Citation(s) in RCA: 166] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2004] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Readers of randomized controlled trials (RCTs) commonly assume that what was not reported did not occur. We undertook an observational study to determine whether concealment of randomization or blinding was used in RCTs that failed to report these bias-reducing strategies. METHODS We recorded the reporting of concealment of randomization and blinding in 105 RCTs. We subsequently contacted the authors and determined if they had used these methodological safeguards. RESULTS We successfully obtained data from 98 authors. The authors in the full-text publications of these 98 RCTs failed to report the presence or absence of concealment of randomization in 55%, and the blinding status of participants in 26%, health care providers in 64%, data collectors in 84%, outcome assessors in 83%, and data analysts in 96%. In direct contact, authors frequently reported concealing randomization (96%; 95% confidence interval CI=87-100%), blinding participants (20%; 95% CI=7-41%), blinding health care providers (65%; 95% CI=52-77%), blinding data collectors (65%; 95% CI=53-75%), blinding outcome assessors (79%; 95% CI=69-87%), and blinding data analysts (50%; 95% CI=40-60%), despite not reporting the use of these methodological safeguards in their publications. CONCLUSIONS Readers should not assume that bias-reducing procedures not reported in an RCT did not occur.
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Affiliation(s)
- P J Devereaux
- Department of Medicine, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Room 2C8, 1200 Main Street West, Hamilton, ON, L8N 3Z5, Canada.
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Degl' Innocenti A, Guyatt GH, Wiklund I, Heels-Ansdell D, Armstrong D, Fallone CA, Tanser L, van Zanten SV, El-Dika S, Chiba N, Barkun AN, Austin P, Schünemann HJ. The influence of demographic factors and health-related quality of life on treatment satisfaction in patients with gastroesophageal reflux disease treated with esomeprazole. Health Qual Life Outcomes 2005; 3:4. [PMID: 15649314 PMCID: PMC545938 DOI: 10.1186/1477-7525-3-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [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: 11/14/2004] [Accepted: 01/13/2005] [Indexed: 11/24/2022] Open
Abstract
Background The correlation between treatment satisfaction and demographic characteristics, symptoms, or health-related quality of life (HRQL) in patients with gastroesophageal reflux disease (GERD) is unknown. The objective of this study was to assess correlates of treatment satisfaction in patients with GERD receiving a proton pump inhibitor, esomeprazole. Methods Adult GERD patients (n = 217) completed demography, symptom, HRQL, and treatment satisfaction questionnaires at baseline and/or after treatment with esomeprazole 40 mg once daily for 4 weeks. We used multiple linear regressions with treatment satisfaction as the dependent variable and demographic characteristics, baseline symptoms, baseline HRQL, and change scores in HRQL as independent variables. Results Among the demographic variables only Caucasian ethnicity was positively associated with treatment satisfaction. Greater vitality assessed by the Quality of Life in Reflux and Dyspepsia (QOLRAD) and worse heartburn assessed by a four-symptom scale at baseline, were associated with greater treatment satisfaction. The greater the improvement on the QOLRAD vitality (change score), the more likely the patient is to be satisfied with the treatment. Conclusions Ethnicity, baseline vitality, baseline heartburn severity, and change in QOLRAD vitality correlate with treatment satisfaction in patients with GERD.
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Affiliation(s)
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Diane Heels-Ansdell
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - David Armstrong
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Carlo A Fallone
- Division of Gastroenterology, McGill University Health Center, Montreal, Quebec, Canada
| | | | | | - Samer El-Dika
- Department of Medicine, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Naoki Chiba
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Surrey GI Research/Clinic, Guelph, Ontario, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, Montreal, Quebec, Canada
| | - Peggy Austin
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Holger J Schünemann
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
- Department of Social & Preventive Medicine, School of Public Health and Health Professions, University at Buffalo, State University of New York, Buffalo, New York, USA
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Fallone CA, Guyatt GH, Armstrong D, Wiklund I, Degl'Innocenti A, Heels-Ansdell D, Barkun AN, Chiba N, Zanten SJOV, El-Dika S, Austin P, Tanser L, Schünemann HJ. Do physicians correctly assess patient symptom severity in gastro-oesophageal reflux disease? Aliment Pharmacol Ther 2004; 20:1161-9. [PMID: 15569119 DOI: 10.1111/j.1365-2036.2004.02257.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [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: 12/13/2022]
Abstract
BACKGROUND The accuracy of physicians' assessment of the severity of gastro-oesophageal reflux disease is unclear. AIM To correlate physician and patient assessment of gastro-oesophageal reflux disease severity and its response to treatment. METHODS Adult uninvestigated gastro-oesophageal reflux disease patients (n = 217) completed symptom and health-related quality of life questionnaires at baseline and after treatment with esomeprazole 40 mg p.o. daily. Pearson coefficients quantified correlations between physician assessments and patient responses. RESULTS At baseline, the strongest correlations were heartburn severity (0.31), overall symptom severity (0.44) and a domain of the quality of life in reflux and dyspepsia questionnaire (0.31) (P < 0.001). Correlations of change with treatment were greater than baseline correlations: heartburn (0.39), overall symptoms (0.50) and global rate of change -- stomach problems (0.72, all P < 0.001). The mean difference between the physicians' assessment of change and the patients' global rating of change was 0.20 (95% confidence intervals: 0.10-0.29) with physicians overestimating benefit. CONCLUSIONS Correlations were often significant, although weak to moderate and better with symptom severity than with health-related quality of life instruments as well as with change after therapy than at baseline. Increasing attention to health-related quality of life may help physicians better understand patients' experience. In clinical trials, treatment success should be assessed by the patient as well as the physician.
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Affiliation(s)
- C A Fallone
- Division of Gastroenterology, McGill University Health Center, Montreal, QC, Canada.
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29
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Schünemann HJ, Armstrong D, Degl'innocenti A, Wiklund I, Fallone CA, Tanser L, Van Zanten SV, Heels-Ansdell D, El-Dika S, Chiba N, Barkun AN, Austin P, Guyatt GH. A Randomized Multicenter Trial to Evaluate Simple Utility Elicitation Techniques in Patients With Gastroesophageal Reflux Disease. Med Care 2004; 42:1132-42. [PMID: 15586841 DOI: 10.1097/00005650-200411000-00013] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Despite recommendations that patients rating their own health using utility and preference measures such as the feeling thermometer (FT) and standard gamble (SG) should also rate hypothetical marker states, little evidence supports marker state use. We evaluated whether the administration of marker states improves measurement properties of the FT and SG. METHODS We randomized 217 patients with gastroesophageal reflux disease to complete the FT (self-administered) and SG with marker states (FT+ / SG+, n = 112) or without marker states (FT- / SG-, n = 105) before and after 4 weeks of treatment with a proton pump inhibitor, esomeprazole. Patients also completed other health-related quality of life instruments. RESULTS The use of marker states did not influence baseline utility scores (FT+ 0.66, FT- 0.68; SG+ 0.77, SG- 0.78, on a scale from 0 [dead] to 1.0 [full health]). Improvement after therapy was 0.21 in FT+ and 0.15 in FT- (both P < 0.001; difference between FT+ and FT- = 0.06, P = 0.02). Improvement in SG+ was 0.07 (P < 0.001) and 0.06 in SG- (P = 0.003) (difference between SG+ and SG- = 0.01, P = 0.63). Correlations with other health-related quality of life scores were generally stronger, with some statistically significant differences in correlations, for FT+ compared with FT-, but tended to be weaker for SG+ compared with SG-. CONCLUSION The administration of marker states improved the responsiveness and validity of the FT but not of the SG. Decisions about administering marker states should depend on whether the FT and SG is of primary interest and the importance of optimal validity and responsiveness relative to competing objectives such as efficiency.
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Affiliation(s)
- Holger J Schünemann
- Department of Medicine, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA.
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Akl EA, Izuchukwu IS, El-Dika S, Fritsche L, Kunz R, Schünemann HJ. Integrating an evidence-based medicine rotation into an internal medicine residency program. Acad Med 2004; 79:897-904. [PMID: 15326018 DOI: 10.1097/00001888-200409000-00018] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
PURPOSE To measure the impact of a resident focused evidence-based medicine (EBM) educational intervention on EBM knowledge of residents and students, to assess its feasibility, and to evaluate residents' attitudes regarding this rotation. METHOD In 2002, based on the EBM user and EBM practitioner model, the authors designed the EBM elective rotation and conducted a controlled trial of its implementation in the internal medicine residency program in three teaching hospitals affiliated with the University at Buffalo, New York. The intervention group (one hospital, 17 medical students and residents) received a multifaceted intervention. In the control group (two hospitals, 23 medical students and residents), there was no curriculum change. The effectiveness in a pre- and post-test was assessed using the English version of the Berlin Questionnaire. A survey of all internal medicine residents (n = 119) was conducted to evaluate their attitudes toward the EBM elective rotation. RESULTS In the intervention group, knowledge improved slightly, but not significantly (.71 on a scale ranging from 0-15 on the Berlin questionnaire, p =.3). The mean score in the control group decreased significantly (1.65, p =.005). The difference in change scores between the two groups was significant even after adjustment for covariates (2.52, p =.006). Residents (response rate 83%) had positive attitudes regarding the rotation. CONCLUSION An EBM elective rotation was successfully integrated into a residency program. This multifaceted educational approach with an "on-the-ward" EBM resident, may improve the EBM knowledge and skills of targeted students and residents.
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Affiliation(s)
- Elie A Akl
- Department of Medicine, University at Buffalo, ECMC-CC 142, 462 Grider St., Buffalo, NY 14215, USA
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