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Geographic cohorting increased direct care time and interruptions
Background: Geographic cohorting localizes hospitalist teams to a single unit. It has previously been shown to improve outcomes.
Design: Prospective time and motion study.
Setting: 11 geographically cohorted services and 4 noncohorted teams at Indiana University Health, a large academic medical center.
Synopsis: Geotracking was used to monitor time spent inside and outside of patient rooms for 17 hospitalists over at least 6 weeks. Eight hospitalists were also directly observed. Both groups spent roughly three times more time outside patient rooms than inside. Geographic cohorting was associated with longer patient visits (ranging from 69.6 to 101.7 minutes per day depending on team structure) and a higher percentage of time in patient rooms. Interruptions were more common with geographic cohorting. These hospitalists were interrupted every 14 minutes in the morning and every 8 minutes in the afternoon. Of these interruptions, 62% were face-to-face, 25% were electronic, and 13% were both simultaneously.
An important limitation of this study is that the investigators did not evaluate clinical outcomes or provider satisfaction. This may give some pause to the widespread push toward geographic cohorting.
Bottom line: More frequent interruptions may partially offset potential increases in patient-hospitalist interactions achieved through geographic cohorting.
Citation: Kara A et al. A time motion study evaluating the impact of geographic cohorting of hospitalists. J Hosp Med. 2020;15:338-44.
Dr. Sweigart is a hospitalist at the Lexington (Ky.) VA Health Care System.
Background: Geographic cohorting localizes hospitalist teams to a single unit. It has previously been shown to improve outcomes.
Design: Prospective time and motion study.
Setting: 11 geographically cohorted services and 4 noncohorted teams at Indiana University Health, a large academic medical center.
Synopsis: Geotracking was used to monitor time spent inside and outside of patient rooms for 17 hospitalists over at least 6 weeks. Eight hospitalists were also directly observed. Both groups spent roughly three times more time outside patient rooms than inside. Geographic cohorting was associated with longer patient visits (ranging from 69.6 to 101.7 minutes per day depending on team structure) and a higher percentage of time in patient rooms. Interruptions were more common with geographic cohorting. These hospitalists were interrupted every 14 minutes in the morning and every 8 minutes in the afternoon. Of these interruptions, 62% were face-to-face, 25% were electronic, and 13% were both simultaneously.
An important limitation of this study is that the investigators did not evaluate clinical outcomes or provider satisfaction. This may give some pause to the widespread push toward geographic cohorting.
Bottom line: More frequent interruptions may partially offset potential increases in patient-hospitalist interactions achieved through geographic cohorting.
Citation: Kara A et al. A time motion study evaluating the impact of geographic cohorting of hospitalists. J Hosp Med. 2020;15:338-44.
Dr. Sweigart is a hospitalist at the Lexington (Ky.) VA Health Care System.
Background: Geographic cohorting localizes hospitalist teams to a single unit. It has previously been shown to improve outcomes.
Design: Prospective time and motion study.
Setting: 11 geographically cohorted services and 4 noncohorted teams at Indiana University Health, a large academic medical center.
Synopsis: Geotracking was used to monitor time spent inside and outside of patient rooms for 17 hospitalists over at least 6 weeks. Eight hospitalists were also directly observed. Both groups spent roughly three times more time outside patient rooms than inside. Geographic cohorting was associated with longer patient visits (ranging from 69.6 to 101.7 minutes per day depending on team structure) and a higher percentage of time in patient rooms. Interruptions were more common with geographic cohorting. These hospitalists were interrupted every 14 minutes in the morning and every 8 minutes in the afternoon. Of these interruptions, 62% were face-to-face, 25% were electronic, and 13% were both simultaneously.
An important limitation of this study is that the investigators did not evaluate clinical outcomes or provider satisfaction. This may give some pause to the widespread push toward geographic cohorting.
Bottom line: More frequent interruptions may partially offset potential increases in patient-hospitalist interactions achieved through geographic cohorting.
Citation: Kara A et al. A time motion study evaluating the impact of geographic cohorting of hospitalists. J Hosp Med. 2020;15:338-44.
Dr. Sweigart is a hospitalist at the Lexington (Ky.) VA Health Care System.
Patient loses prostate after biopsy slide switched; more
It’s difficult enough when a patient’s prostate is removed because of cancer. But it’s another thing altogether when the prostate is removed because of a medical error, as a report on 3 CBS Philly, among other news outlets, makes clear.
The patient, Eric Spangs, lives in southeastern Pennsylvania. Testing indicated an elevation in prostate-specific antigen (PSA) level. He subsequently underwent biopsy of the prostate, which appeared to indicate cancer. In time, though, Mr. Spangs learned there had been an error: the tissue section used in the microscopic diagnosis had come from the biopsy specimen of a different patient. Mr. Spangs himself didn’t actually have cancer.
Ordinarily, such news would be cause for celebration. But this was far from a normal situ ation: Following his initial cancer diagnosis, Mr. Spangs underwent a radical laparoscopic prostatectomy at a local hospital.
“It’s devastated me emotionally and physically,” Mr. Spangs said. It has also been emotionally devastating for his wife, Melissa. (The couple has five children.)
Their attorney, Aaron Freiwald, has filed a suit against the health system to which the local hospital belongs and the area’s largest urologic practice.
The Spangs wish to caution other patients not to make the same mistake they did: they failed to get a second opinion from an oncology specialist, as recommended by the American Cancer Society. (Eric Spangs did receive a second opinion from someone at the urologic practice, but that practice doesn’t specialize in oncology.)
The Spangs also worry about the patient who received the false-negative biopsy result. They have been assured, however, that that patient will be properly notified of his actual cancer status.
Fertility specialist uses own sperm to impregnate patients
A suit claims that a Rochester, N.Y., gynecologist and fertility specialist used his own sperm to inseminate multiple patients, according to a story reported by the Associated Press and other news outlets.
The suit was filed last month by the daughter — call her “Harriet Jones” — of one of the women who received fertility services from the doctor during the 1980s. Ms. Jones’s suit alleges that at the time, the doctor told her mother that the sperm donor would be a medical student at the University of Rochester. In fact, the donor was the doctor himself. He kept that fact a secret for years, even after Ms. Jones — his own daughter — sought him out for gynecologic services.
The secret gradually began to come to light in 2016, when Ms. Jones’s nonbiological father — the man who had helped to raise her — died. Curious about her biological father, Ms. Jones sought to learn his identity from the Rochester gynecologist who had treated her mother and was now her own gynecologist. The doctor said he couldn’t be of help; he claimed he hadn’t kept the relevant records.
Ms. Jones then submitted a blood sample to a direct-to-consumer genetic testing company. The results surprised her: Not only did she learn of her ethnicity, but she also discovered the existence of two half siblings, who were donor-conceived in 1984 and 1985, respectively, the very period when her own mother was undergoing insemination procedures. Ms. Jones subsequently discovered the existence of additional half siblings, all born in the first half of the 1980s.
Initially elated by the discoveries, Ms. Jones soon grew despondent and anxious. She suffered from migraine headaches, among other symptoms. Her biological father, it seemed, had been “a serial sperm donor.”
Still, she continued to go to her Rochester doctor for treatment, having no reason to suspect anything untoward about him. Her visits, including those for prolonged menstrual bleeding, involved routine breast and pelvic exams, transvaginal ultrasounds, and intrauterine contraceptive placements under sedation.
Over this period, her doctor was friendly, asking her a variety of questions about her personal life. During one especially strange visit, however, he began chuckling and said, “You’re a really good kid, such a good kid.” During this visit, he invited his wife into the exam room, presumably to meet Ms. Jones.
It was at this moment that Ms. Jones had a revelation: Could her gynecologist actually be her biological father?
In May 2021, Ms. Jones and a half brother with whom she had been in touch contacted the gynecologist’s daughter from his first marriage. All three underwent genetic testing. The results showed a 99.99% chance of a genetic link.
Ms. Jones has said in her suit that “no reasonable woman” would have submitted to pelvic examinations and other examinations by a doctor whom she knew to be her father.
Besides fraud, her suit alleges medical malpractice, battery, infliction of mental distress, and lack of informed consent. She is seeking compensation for all harm caused to her, including past and future economic damages, past unreimbursed medical expenses, and future expenses related to her mental health treatment and care.
The story included no further details about the civil litigation. As for criminal charges, it’s unlikely Ms. Jones’s biological father — her gynecologist — will face criminal charges for his alleged crimes because they fall outside of the state’s statute of limitations.
Parents say daughter’s stroke wasn’t identified
The Georgia parents of a young woman who died from a stroke following a series of alleged misdiagnoses are suing multiple practitioners, reports Legal Newswire and other news outlets
In June 2019, Michaela Smith was training for her job as a detention officer when she began experiencing a variety of symptoms, including headache, shortness of breath, throat swelling, and slurred speech. She was taken to the emergency department (ED) at Hamilton Medical Center, in Dalton, Ga.
There, she was examined by an attending ED doctor, who ordered a CT scan. The results were read by radiologist Michael J. Cooney, MD. In his reading, the Smith family’s lawsuit alleges, Dr. Cooney failed to identify the basilar artery sign, which is a key indicator of a vessel occlusion in stroke patients. Dr. Cooney concluded that Ms. Smith’s scan showed no acute intracranial abnormality. He sent her home without further discharge instructions.
At home, Ms. Smith fell asleep but awoke in an altered mental state, one of several classic stroke symptoms that she had been experiencing. She returned to the ED. This time, she was examined by David F. Hawkins, MD, an ED physician. Although his differential diagnosis identified Ms. Smith’s symptoms as most likely stroke related, Dr. Hawkins allegedly failed to immediately corroborate his findings with additional vascular imaging. Later in the day, Ms. Smith did undergo an MRI, which a second radiologist, Kevin F. Johnson, MD, misread as showing no signs of ischemia in her basilar artery, according to the lawsuit.
That same day, Dr. Hawkins conferred with a second neurologist, Jeffrey T. Glass, MD, who recommended that Ms. Smith be admitted to the hospital because of her deteriorating condition. The Smiths’ suit claims that Dr. Glass also failed to diagnosis their daughter’s underlying condition, although he did sign off on her transfer to Baroness Erlanger Hospital, in Chattanooga, Tenn.
There, Ms. Smith’s condition continued to worsen. She soon required mechanical ventilation and tube feeding. On July 3, 2019, she was pronounced dead.
“This is an egregious case of negligence,” said the attorney representing the Smiths, who are suing the physicians involved and their practices, as well as Hamilton Medical Center and several unnamed defendants.
“Although two radiology studies and her clinical presentation indicated that Michaela was having a catastrophic stroke, her doctors repeatedly misread the studies as normal, failed to diagnose the stroke, and failed to treat her deficits as a neurological emergency,” the family’s lawyer stated.
At press time, there had been no response from any of the defendants or their attorneys.
A version of this article first appeared on Medscape.com.
It’s difficult enough when a patient’s prostate is removed because of cancer. But it’s another thing altogether when the prostate is removed because of a medical error, as a report on 3 CBS Philly, among other news outlets, makes clear.
The patient, Eric Spangs, lives in southeastern Pennsylvania. Testing indicated an elevation in prostate-specific antigen (PSA) level. He subsequently underwent biopsy of the prostate, which appeared to indicate cancer. In time, though, Mr. Spangs learned there had been an error: the tissue section used in the microscopic diagnosis had come from the biopsy specimen of a different patient. Mr. Spangs himself didn’t actually have cancer.
Ordinarily, such news would be cause for celebration. But this was far from a normal situ ation: Following his initial cancer diagnosis, Mr. Spangs underwent a radical laparoscopic prostatectomy at a local hospital.
“It’s devastated me emotionally and physically,” Mr. Spangs said. It has also been emotionally devastating for his wife, Melissa. (The couple has five children.)
Their attorney, Aaron Freiwald, has filed a suit against the health system to which the local hospital belongs and the area’s largest urologic practice.
The Spangs wish to caution other patients not to make the same mistake they did: they failed to get a second opinion from an oncology specialist, as recommended by the American Cancer Society. (Eric Spangs did receive a second opinion from someone at the urologic practice, but that practice doesn’t specialize in oncology.)
The Spangs also worry about the patient who received the false-negative biopsy result. They have been assured, however, that that patient will be properly notified of his actual cancer status.
Fertility specialist uses own sperm to impregnate patients
A suit claims that a Rochester, N.Y., gynecologist and fertility specialist used his own sperm to inseminate multiple patients, according to a story reported by the Associated Press and other news outlets.
The suit was filed last month by the daughter — call her “Harriet Jones” — of one of the women who received fertility services from the doctor during the 1980s. Ms. Jones’s suit alleges that at the time, the doctor told her mother that the sperm donor would be a medical student at the University of Rochester. In fact, the donor was the doctor himself. He kept that fact a secret for years, even after Ms. Jones — his own daughter — sought him out for gynecologic services.
The secret gradually began to come to light in 2016, when Ms. Jones’s nonbiological father — the man who had helped to raise her — died. Curious about her biological father, Ms. Jones sought to learn his identity from the Rochester gynecologist who had treated her mother and was now her own gynecologist. The doctor said he couldn’t be of help; he claimed he hadn’t kept the relevant records.
Ms. Jones then submitted a blood sample to a direct-to-consumer genetic testing company. The results surprised her: Not only did she learn of her ethnicity, but she also discovered the existence of two half siblings, who were donor-conceived in 1984 and 1985, respectively, the very period when her own mother was undergoing insemination procedures. Ms. Jones subsequently discovered the existence of additional half siblings, all born in the first half of the 1980s.
Initially elated by the discoveries, Ms. Jones soon grew despondent and anxious. She suffered from migraine headaches, among other symptoms. Her biological father, it seemed, had been “a serial sperm donor.”
Still, she continued to go to her Rochester doctor for treatment, having no reason to suspect anything untoward about him. Her visits, including those for prolonged menstrual bleeding, involved routine breast and pelvic exams, transvaginal ultrasounds, and intrauterine contraceptive placements under sedation.
Over this period, her doctor was friendly, asking her a variety of questions about her personal life. During one especially strange visit, however, he began chuckling and said, “You’re a really good kid, such a good kid.” During this visit, he invited his wife into the exam room, presumably to meet Ms. Jones.
It was at this moment that Ms. Jones had a revelation: Could her gynecologist actually be her biological father?
In May 2021, Ms. Jones and a half brother with whom she had been in touch contacted the gynecologist’s daughter from his first marriage. All three underwent genetic testing. The results showed a 99.99% chance of a genetic link.
Ms. Jones has said in her suit that “no reasonable woman” would have submitted to pelvic examinations and other examinations by a doctor whom she knew to be her father.
Besides fraud, her suit alleges medical malpractice, battery, infliction of mental distress, and lack of informed consent. She is seeking compensation for all harm caused to her, including past and future economic damages, past unreimbursed medical expenses, and future expenses related to her mental health treatment and care.
The story included no further details about the civil litigation. As for criminal charges, it’s unlikely Ms. Jones’s biological father — her gynecologist — will face criminal charges for his alleged crimes because they fall outside of the state’s statute of limitations.
Parents say daughter’s stroke wasn’t identified
The Georgia parents of a young woman who died from a stroke following a series of alleged misdiagnoses are suing multiple practitioners, reports Legal Newswire and other news outlets
In June 2019, Michaela Smith was training for her job as a detention officer when she began experiencing a variety of symptoms, including headache, shortness of breath, throat swelling, and slurred speech. She was taken to the emergency department (ED) at Hamilton Medical Center, in Dalton, Ga.
There, she was examined by an attending ED doctor, who ordered a CT scan. The results were read by radiologist Michael J. Cooney, MD. In his reading, the Smith family’s lawsuit alleges, Dr. Cooney failed to identify the basilar artery sign, which is a key indicator of a vessel occlusion in stroke patients. Dr. Cooney concluded that Ms. Smith’s scan showed no acute intracranial abnormality. He sent her home without further discharge instructions.
At home, Ms. Smith fell asleep but awoke in an altered mental state, one of several classic stroke symptoms that she had been experiencing. She returned to the ED. This time, she was examined by David F. Hawkins, MD, an ED physician. Although his differential diagnosis identified Ms. Smith’s symptoms as most likely stroke related, Dr. Hawkins allegedly failed to immediately corroborate his findings with additional vascular imaging. Later in the day, Ms. Smith did undergo an MRI, which a second radiologist, Kevin F. Johnson, MD, misread as showing no signs of ischemia in her basilar artery, according to the lawsuit.
That same day, Dr. Hawkins conferred with a second neurologist, Jeffrey T. Glass, MD, who recommended that Ms. Smith be admitted to the hospital because of her deteriorating condition. The Smiths’ suit claims that Dr. Glass also failed to diagnosis their daughter’s underlying condition, although he did sign off on her transfer to Baroness Erlanger Hospital, in Chattanooga, Tenn.
There, Ms. Smith’s condition continued to worsen. She soon required mechanical ventilation and tube feeding. On July 3, 2019, she was pronounced dead.
“This is an egregious case of negligence,” said the attorney representing the Smiths, who are suing the physicians involved and their practices, as well as Hamilton Medical Center and several unnamed defendants.
“Although two radiology studies and her clinical presentation indicated that Michaela was having a catastrophic stroke, her doctors repeatedly misread the studies as normal, failed to diagnose the stroke, and failed to treat her deficits as a neurological emergency,” the family’s lawyer stated.
At press time, there had been no response from any of the defendants or their attorneys.
A version of this article first appeared on Medscape.com.
It’s difficult enough when a patient’s prostate is removed because of cancer. But it’s another thing altogether when the prostate is removed because of a medical error, as a report on 3 CBS Philly, among other news outlets, makes clear.
The patient, Eric Spangs, lives in southeastern Pennsylvania. Testing indicated an elevation in prostate-specific antigen (PSA) level. He subsequently underwent biopsy of the prostate, which appeared to indicate cancer. In time, though, Mr. Spangs learned there had been an error: the tissue section used in the microscopic diagnosis had come from the biopsy specimen of a different patient. Mr. Spangs himself didn’t actually have cancer.
Ordinarily, such news would be cause for celebration. But this was far from a normal situ ation: Following his initial cancer diagnosis, Mr. Spangs underwent a radical laparoscopic prostatectomy at a local hospital.
“It’s devastated me emotionally and physically,” Mr. Spangs said. It has also been emotionally devastating for his wife, Melissa. (The couple has five children.)
Their attorney, Aaron Freiwald, has filed a suit against the health system to which the local hospital belongs and the area’s largest urologic practice.
The Spangs wish to caution other patients not to make the same mistake they did: they failed to get a second opinion from an oncology specialist, as recommended by the American Cancer Society. (Eric Spangs did receive a second opinion from someone at the urologic practice, but that practice doesn’t specialize in oncology.)
The Spangs also worry about the patient who received the false-negative biopsy result. They have been assured, however, that that patient will be properly notified of his actual cancer status.
Fertility specialist uses own sperm to impregnate patients
A suit claims that a Rochester, N.Y., gynecologist and fertility specialist used his own sperm to inseminate multiple patients, according to a story reported by the Associated Press and other news outlets.
The suit was filed last month by the daughter — call her “Harriet Jones” — of one of the women who received fertility services from the doctor during the 1980s. Ms. Jones’s suit alleges that at the time, the doctor told her mother that the sperm donor would be a medical student at the University of Rochester. In fact, the donor was the doctor himself. He kept that fact a secret for years, even after Ms. Jones — his own daughter — sought him out for gynecologic services.
The secret gradually began to come to light in 2016, when Ms. Jones’s nonbiological father — the man who had helped to raise her — died. Curious about her biological father, Ms. Jones sought to learn his identity from the Rochester gynecologist who had treated her mother and was now her own gynecologist. The doctor said he couldn’t be of help; he claimed he hadn’t kept the relevant records.
Ms. Jones then submitted a blood sample to a direct-to-consumer genetic testing company. The results surprised her: Not only did she learn of her ethnicity, but she also discovered the existence of two half siblings, who were donor-conceived in 1984 and 1985, respectively, the very period when her own mother was undergoing insemination procedures. Ms. Jones subsequently discovered the existence of additional half siblings, all born in the first half of the 1980s.
Initially elated by the discoveries, Ms. Jones soon grew despondent and anxious. She suffered from migraine headaches, among other symptoms. Her biological father, it seemed, had been “a serial sperm donor.”
Still, she continued to go to her Rochester doctor for treatment, having no reason to suspect anything untoward about him. Her visits, including those for prolonged menstrual bleeding, involved routine breast and pelvic exams, transvaginal ultrasounds, and intrauterine contraceptive placements under sedation.
Over this period, her doctor was friendly, asking her a variety of questions about her personal life. During one especially strange visit, however, he began chuckling and said, “You’re a really good kid, such a good kid.” During this visit, he invited his wife into the exam room, presumably to meet Ms. Jones.
It was at this moment that Ms. Jones had a revelation: Could her gynecologist actually be her biological father?
In May 2021, Ms. Jones and a half brother with whom she had been in touch contacted the gynecologist’s daughter from his first marriage. All three underwent genetic testing. The results showed a 99.99% chance of a genetic link.
Ms. Jones has said in her suit that “no reasonable woman” would have submitted to pelvic examinations and other examinations by a doctor whom she knew to be her father.
Besides fraud, her suit alleges medical malpractice, battery, infliction of mental distress, and lack of informed consent. She is seeking compensation for all harm caused to her, including past and future economic damages, past unreimbursed medical expenses, and future expenses related to her mental health treatment and care.
The story included no further details about the civil litigation. As for criminal charges, it’s unlikely Ms. Jones’s biological father — her gynecologist — will face criminal charges for his alleged crimes because they fall outside of the state’s statute of limitations.
Parents say daughter’s stroke wasn’t identified
The Georgia parents of a young woman who died from a stroke following a series of alleged misdiagnoses are suing multiple practitioners, reports Legal Newswire and other news outlets
In June 2019, Michaela Smith was training for her job as a detention officer when she began experiencing a variety of symptoms, including headache, shortness of breath, throat swelling, and slurred speech. She was taken to the emergency department (ED) at Hamilton Medical Center, in Dalton, Ga.
There, she was examined by an attending ED doctor, who ordered a CT scan. The results were read by radiologist Michael J. Cooney, MD. In his reading, the Smith family’s lawsuit alleges, Dr. Cooney failed to identify the basilar artery sign, which is a key indicator of a vessel occlusion in stroke patients. Dr. Cooney concluded that Ms. Smith’s scan showed no acute intracranial abnormality. He sent her home without further discharge instructions.
At home, Ms. Smith fell asleep but awoke in an altered mental state, one of several classic stroke symptoms that she had been experiencing. She returned to the ED. This time, she was examined by David F. Hawkins, MD, an ED physician. Although his differential diagnosis identified Ms. Smith’s symptoms as most likely stroke related, Dr. Hawkins allegedly failed to immediately corroborate his findings with additional vascular imaging. Later in the day, Ms. Smith did undergo an MRI, which a second radiologist, Kevin F. Johnson, MD, misread as showing no signs of ischemia in her basilar artery, according to the lawsuit.
That same day, Dr. Hawkins conferred with a second neurologist, Jeffrey T. Glass, MD, who recommended that Ms. Smith be admitted to the hospital because of her deteriorating condition. The Smiths’ suit claims that Dr. Glass also failed to diagnosis their daughter’s underlying condition, although he did sign off on her transfer to Baroness Erlanger Hospital, in Chattanooga, Tenn.
There, Ms. Smith’s condition continued to worsen. She soon required mechanical ventilation and tube feeding. On July 3, 2019, she was pronounced dead.
“This is an egregious case of negligence,” said the attorney representing the Smiths, who are suing the physicians involved and their practices, as well as Hamilton Medical Center and several unnamed defendants.
“Although two radiology studies and her clinical presentation indicated that Michaela was having a catastrophic stroke, her doctors repeatedly misread the studies as normal, failed to diagnose the stroke, and failed to treat her deficits as a neurological emergency,” the family’s lawyer stated.
At press time, there had been no response from any of the defendants or their attorneys.
A version of this article first appeared on Medscape.com.
Injectable patch shows promise for heart attack recovery
After a heart attack, the damaged area of the heart often becomes scar tissue that can’t receive electrical messages to contract and pump blood to the body. The result is a weakened heart that could get an irregular beat, known as an arrhythmia, or go into failure.
Right now, doctors have two imperfect options for repairing this damaged tissue. One is to surgically implant a scaffold that conducts electrically and bridges the heart’s signaling system past the dead tissue. But these implants require open-chest surgery, which is risky and can lead to other heart problems.
Clinicians can use an approach that avoids opening the chest, but the patch used for these procedures may not hold its shape when grafted to damaged tissue.
Now,
The patch hasn’t been tested in humans -- any such trials are still a long way off -- but early results in animals show potential.
This experimental patch can be rolled up, threaded into a catheter or a syringe, and injected into damaged heart tissue, where it unfurls and attaches to the muscle. Once in place, the patch supports normal heart function, according to results from studies using rats and pigs. The findings were published in Nature Biomedical Engineering.
When researchers placed the patch on damaged heart muscle in rats, they found this fix resulted in a return to mostly normal heart function within 4 weeks. Results were similar when scientists tested the patch in a small number of pigs, which are considered to resemble humans more closely than rodents.
The patched hearts did a better job in pumping oxygen-rich blood to the body, and the amount of heart tissue that wasn’t getting enough oxygen also declined.
A version of this article first appeared on WebMD.com.
After a heart attack, the damaged area of the heart often becomes scar tissue that can’t receive electrical messages to contract and pump blood to the body. The result is a weakened heart that could get an irregular beat, known as an arrhythmia, or go into failure.
Right now, doctors have two imperfect options for repairing this damaged tissue. One is to surgically implant a scaffold that conducts electrically and bridges the heart’s signaling system past the dead tissue. But these implants require open-chest surgery, which is risky and can lead to other heart problems.
Clinicians can use an approach that avoids opening the chest, but the patch used for these procedures may not hold its shape when grafted to damaged tissue.
Now,
The patch hasn’t been tested in humans -- any such trials are still a long way off -- but early results in animals show potential.
This experimental patch can be rolled up, threaded into a catheter or a syringe, and injected into damaged heart tissue, where it unfurls and attaches to the muscle. Once in place, the patch supports normal heart function, according to results from studies using rats and pigs. The findings were published in Nature Biomedical Engineering.
When researchers placed the patch on damaged heart muscle in rats, they found this fix resulted in a return to mostly normal heart function within 4 weeks. Results were similar when scientists tested the patch in a small number of pigs, which are considered to resemble humans more closely than rodents.
The patched hearts did a better job in pumping oxygen-rich blood to the body, and the amount of heart tissue that wasn’t getting enough oxygen also declined.
A version of this article first appeared on WebMD.com.
After a heart attack, the damaged area of the heart often becomes scar tissue that can’t receive electrical messages to contract and pump blood to the body. The result is a weakened heart that could get an irregular beat, known as an arrhythmia, or go into failure.
Right now, doctors have two imperfect options for repairing this damaged tissue. One is to surgically implant a scaffold that conducts electrically and bridges the heart’s signaling system past the dead tissue. But these implants require open-chest surgery, which is risky and can lead to other heart problems.
Clinicians can use an approach that avoids opening the chest, but the patch used for these procedures may not hold its shape when grafted to damaged tissue.
Now,
The patch hasn’t been tested in humans -- any such trials are still a long way off -- but early results in animals show potential.
This experimental patch can be rolled up, threaded into a catheter or a syringe, and injected into damaged heart tissue, where it unfurls and attaches to the muscle. Once in place, the patch supports normal heart function, according to results from studies using rats and pigs. The findings were published in Nature Biomedical Engineering.
When researchers placed the patch on damaged heart muscle in rats, they found this fix resulted in a return to mostly normal heart function within 4 weeks. Results were similar when scientists tested the patch in a small number of pigs, which are considered to resemble humans more closely than rodents.
The patched hearts did a better job in pumping oxygen-rich blood to the body, and the amount of heart tissue that wasn’t getting enough oxygen also declined.
A version of this article first appeared on WebMD.com.
White House unveils plan to combat endocrine-disrupting PFAS pollution
The federal government is stepping up actions to protect Americans from per- and polyfluoroalkyl substances that continue to threaten health through pollution in the air, water, and foods, according to a statement from the White House on Oct. 18.
The comprehensive plan includes efforts to prevent per- and polyfluoroalkyl substances (PFAS) from being released into the air, drinking and ground water, and the food supply chain, according to the statement. Other efforts will expand cleanup and remediation of the impact of PFAS already present in the environment.
PFAS are a category of endocrine-disrupting chemicals (EDCs) that have been used for decades in a range of consumer products including cookware, stain-resistant clothes, fast food wrappers, treatments for carpets and furniture, and firefighting foams. PFAS can be released into the air, and also into surface water, drinking water, and ground water, because of how they are disposed, according to a 2020 report from the Endocrine Society and the International Pollutants Elimination Network. The report suggested that creation of more plastic products will likely increase exposure to PFAS and other EDCs.
The Environmental Protection Agency will take the lead on the Biden administration’s PFAS reduction efforts. The agency announced a PFAS Roadmap, which outlines actions to control PFAS over the next 3 years. The Roadmap’s goals include keeping PFAS out of the environment, holding polluters accountable for their actions, investing in scientific research to learn more about the impact of PFAS on human health, and prioritizing protection for disadvantaged communities. The EPA described its approach to PFAS as three pronged (Research, Restrict, Remediate). Planned actions noted on the EPA website include publication of a national PFAS testing strategy, establishing an improved review process for new PFAS, reviewing existing PFAS, and enhancing reporting to track sources and quantities of PFAS.
White House statement noted that other agencies committed to controlling PFAS include the Department of Defense, which will conduct cleanups and assessments at DOD and National Guard locations; the Food and Drug Administration, which will to expand its food supply testing to estimate dietary exposure to PFAS; and the Department of Agriculture, which is investigating causes and impacts of PFAS in the food system, and supporting research on environmental contaminants including PFAS.
The Department of Homeland Security has conducted an inventory of PFAS use, notably the use of PFAS in firefighting foams, and established an Emerging Contaminants Working Group to remediate PFAS and other contaminants. In addition, the Department of Health & Human Services monitors the evolving science on human health and PFAS and anticipates a report by the Centers for Disease Control and Prevention on the health effects of PFAS exposure, with data from eight states.
The American Chemistry Council (ACC), a trade association for American chemistry companies, issued a statement in response to the EPA’s PFAS Strategic Roadmap in which they supported the value of science-based regulation, but emphasized that PFAS are distinct from one another, and should not be grouped together for regulation purposes.
“According to EPA, approximately 600 PFAS substances are manufactured or in use today, each with its own unique properties and uses, from cellphones to solar panels, for which alternatives are not always available,” according to the ACC statement. “EPA’s Roadmap reinforces the differences between these chemistries and that they should not all be grouped together.” The newly formed Interagency Policy Committee on PFAS will coordinate PFAS response efforts across agencies and “help develop new policy strategies to support research, remediation, and removal of PFAS in communities across the country,” according to the White House statement.
The federal government is stepping up actions to protect Americans from per- and polyfluoroalkyl substances that continue to threaten health through pollution in the air, water, and foods, according to a statement from the White House on Oct. 18.
The comprehensive plan includes efforts to prevent per- and polyfluoroalkyl substances (PFAS) from being released into the air, drinking and ground water, and the food supply chain, according to the statement. Other efforts will expand cleanup and remediation of the impact of PFAS already present in the environment.
PFAS are a category of endocrine-disrupting chemicals (EDCs) that have been used for decades in a range of consumer products including cookware, stain-resistant clothes, fast food wrappers, treatments for carpets and furniture, and firefighting foams. PFAS can be released into the air, and also into surface water, drinking water, and ground water, because of how they are disposed, according to a 2020 report from the Endocrine Society and the International Pollutants Elimination Network. The report suggested that creation of more plastic products will likely increase exposure to PFAS and other EDCs.
The Environmental Protection Agency will take the lead on the Biden administration’s PFAS reduction efforts. The agency announced a PFAS Roadmap, which outlines actions to control PFAS over the next 3 years. The Roadmap’s goals include keeping PFAS out of the environment, holding polluters accountable for their actions, investing in scientific research to learn more about the impact of PFAS on human health, and prioritizing protection for disadvantaged communities. The EPA described its approach to PFAS as three pronged (Research, Restrict, Remediate). Planned actions noted on the EPA website include publication of a national PFAS testing strategy, establishing an improved review process for new PFAS, reviewing existing PFAS, and enhancing reporting to track sources and quantities of PFAS.
White House statement noted that other agencies committed to controlling PFAS include the Department of Defense, which will conduct cleanups and assessments at DOD and National Guard locations; the Food and Drug Administration, which will to expand its food supply testing to estimate dietary exposure to PFAS; and the Department of Agriculture, which is investigating causes and impacts of PFAS in the food system, and supporting research on environmental contaminants including PFAS.
The Department of Homeland Security has conducted an inventory of PFAS use, notably the use of PFAS in firefighting foams, and established an Emerging Contaminants Working Group to remediate PFAS and other contaminants. In addition, the Department of Health & Human Services monitors the evolving science on human health and PFAS and anticipates a report by the Centers for Disease Control and Prevention on the health effects of PFAS exposure, with data from eight states.
The American Chemistry Council (ACC), a trade association for American chemistry companies, issued a statement in response to the EPA’s PFAS Strategic Roadmap in which they supported the value of science-based regulation, but emphasized that PFAS are distinct from one another, and should not be grouped together for regulation purposes.
“According to EPA, approximately 600 PFAS substances are manufactured or in use today, each with its own unique properties and uses, from cellphones to solar panels, for which alternatives are not always available,” according to the ACC statement. “EPA’s Roadmap reinforces the differences between these chemistries and that they should not all be grouped together.” The newly formed Interagency Policy Committee on PFAS will coordinate PFAS response efforts across agencies and “help develop new policy strategies to support research, remediation, and removal of PFAS in communities across the country,” according to the White House statement.
The federal government is stepping up actions to protect Americans from per- and polyfluoroalkyl substances that continue to threaten health through pollution in the air, water, and foods, according to a statement from the White House on Oct. 18.
The comprehensive plan includes efforts to prevent per- and polyfluoroalkyl substances (PFAS) from being released into the air, drinking and ground water, and the food supply chain, according to the statement. Other efforts will expand cleanup and remediation of the impact of PFAS already present in the environment.
PFAS are a category of endocrine-disrupting chemicals (EDCs) that have been used for decades in a range of consumer products including cookware, stain-resistant clothes, fast food wrappers, treatments for carpets and furniture, and firefighting foams. PFAS can be released into the air, and also into surface water, drinking water, and ground water, because of how they are disposed, according to a 2020 report from the Endocrine Society and the International Pollutants Elimination Network. The report suggested that creation of more plastic products will likely increase exposure to PFAS and other EDCs.
The Environmental Protection Agency will take the lead on the Biden administration’s PFAS reduction efforts. The agency announced a PFAS Roadmap, which outlines actions to control PFAS over the next 3 years. The Roadmap’s goals include keeping PFAS out of the environment, holding polluters accountable for their actions, investing in scientific research to learn more about the impact of PFAS on human health, and prioritizing protection for disadvantaged communities. The EPA described its approach to PFAS as three pronged (Research, Restrict, Remediate). Planned actions noted on the EPA website include publication of a national PFAS testing strategy, establishing an improved review process for new PFAS, reviewing existing PFAS, and enhancing reporting to track sources and quantities of PFAS.
White House statement noted that other agencies committed to controlling PFAS include the Department of Defense, which will conduct cleanups and assessments at DOD and National Guard locations; the Food and Drug Administration, which will to expand its food supply testing to estimate dietary exposure to PFAS; and the Department of Agriculture, which is investigating causes and impacts of PFAS in the food system, and supporting research on environmental contaminants including PFAS.
The Department of Homeland Security has conducted an inventory of PFAS use, notably the use of PFAS in firefighting foams, and established an Emerging Contaminants Working Group to remediate PFAS and other contaminants. In addition, the Department of Health & Human Services monitors the evolving science on human health and PFAS and anticipates a report by the Centers for Disease Control and Prevention on the health effects of PFAS exposure, with data from eight states.
The American Chemistry Council (ACC), a trade association for American chemistry companies, issued a statement in response to the EPA’s PFAS Strategic Roadmap in which they supported the value of science-based regulation, but emphasized that PFAS are distinct from one another, and should not be grouped together for regulation purposes.
“According to EPA, approximately 600 PFAS substances are manufactured or in use today, each with its own unique properties and uses, from cellphones to solar panels, for which alternatives are not always available,” according to the ACC statement. “EPA’s Roadmap reinforces the differences between these chemistries and that they should not all be grouped together.” The newly formed Interagency Policy Committee on PFAS will coordinate PFAS response efforts across agencies and “help develop new policy strategies to support research, remediation, and removal of PFAS in communities across the country,” according to the White House statement.
AGA News
New patient care resource: NASH Clinical Care Pathway
The American Gastroenterological Association – in collaboration with seven professional associations – assembled a multidisciplinary taskforce of 15 experts to develop an action plan to develop a nonalcoholic fatty liver disease (NAFLD)/nonalcoholic steatohepatitis (NASH) Clinical Care Pathway providing practical guidance across multiple disciplines of care. The guidance ranges from screening and diagnosis to management of individuals with NAFLD and NASH, as well as facilitating value-based, efficient, and safe care that is consistent with evidence-based guidelines.
This clinical care pathway is intended to be applicable in any setting in which care for patients with NAFLD is provided, including primary care, endocrine, obesity medicine, and gastroenterology practices.
Read the special report: Clinical Care Pathway for the Risk Stratification and Management of Patients with Nonalcoholic Fatty Liver Disease.
To learn more about the development of this publication, visit NASH.gastro.org.
GI societies push CMS for payment rules favorable for practices
As part of our longstanding collaboration and ongoing efforts on critical policy and payment issues impacting GI clinicians, AGA, the American College of Gastroenterology, and American Society for Gastrointestinal Endoscopy submitted comments on proposed 2022 Medicare payments to physicians, ambulatory surgery centers (ASCs), and hospital outpatient departments to the CMS. We advocated for the following:
Increased and more accurate valuation for peroral endoscopic myotomy (POEM) and capsule endoscopy services.
Continued flexibility and payment parity for telehealth and telephone services.
Elimination of the secondary scalar for ASCs, which contributes to the widening differential in payments to ASCs compared to the hospital outpatient department.
You can access our letter here.
New patient care resource: NASH Clinical Care Pathway
The American Gastroenterological Association – in collaboration with seven professional associations – assembled a multidisciplinary taskforce of 15 experts to develop an action plan to develop a nonalcoholic fatty liver disease (NAFLD)/nonalcoholic steatohepatitis (NASH) Clinical Care Pathway providing practical guidance across multiple disciplines of care. The guidance ranges from screening and diagnosis to management of individuals with NAFLD and NASH, as well as facilitating value-based, efficient, and safe care that is consistent with evidence-based guidelines.
This clinical care pathway is intended to be applicable in any setting in which care for patients with NAFLD is provided, including primary care, endocrine, obesity medicine, and gastroenterology practices.
Read the special report: Clinical Care Pathway for the Risk Stratification and Management of Patients with Nonalcoholic Fatty Liver Disease.
To learn more about the development of this publication, visit NASH.gastro.org.
GI societies push CMS for payment rules favorable for practices
As part of our longstanding collaboration and ongoing efforts on critical policy and payment issues impacting GI clinicians, AGA, the American College of Gastroenterology, and American Society for Gastrointestinal Endoscopy submitted comments on proposed 2022 Medicare payments to physicians, ambulatory surgery centers (ASCs), and hospital outpatient departments to the CMS. We advocated for the following:
Increased and more accurate valuation for peroral endoscopic myotomy (POEM) and capsule endoscopy services.
Continued flexibility and payment parity for telehealth and telephone services.
Elimination of the secondary scalar for ASCs, which contributes to the widening differential in payments to ASCs compared to the hospital outpatient department.
You can access our letter here.
New patient care resource: NASH Clinical Care Pathway
The American Gastroenterological Association – in collaboration with seven professional associations – assembled a multidisciplinary taskforce of 15 experts to develop an action plan to develop a nonalcoholic fatty liver disease (NAFLD)/nonalcoholic steatohepatitis (NASH) Clinical Care Pathway providing practical guidance across multiple disciplines of care. The guidance ranges from screening and diagnosis to management of individuals with NAFLD and NASH, as well as facilitating value-based, efficient, and safe care that is consistent with evidence-based guidelines.
This clinical care pathway is intended to be applicable in any setting in which care for patients with NAFLD is provided, including primary care, endocrine, obesity medicine, and gastroenterology practices.
Read the special report: Clinical Care Pathway for the Risk Stratification and Management of Patients with Nonalcoholic Fatty Liver Disease.
To learn more about the development of this publication, visit NASH.gastro.org.
GI societies push CMS for payment rules favorable for practices
As part of our longstanding collaboration and ongoing efforts on critical policy and payment issues impacting GI clinicians, AGA, the American College of Gastroenterology, and American Society for Gastrointestinal Endoscopy submitted comments on proposed 2022 Medicare payments to physicians, ambulatory surgery centers (ASCs), and hospital outpatient departments to the CMS. We advocated for the following:
Increased and more accurate valuation for peroral endoscopic myotomy (POEM) and capsule endoscopy services.
Continued flexibility and payment parity for telehealth and telephone services.
Elimination of the secondary scalar for ASCs, which contributes to the widening differential in payments to ASCs compared to the hospital outpatient department.
You can access our letter here.
November 2021 – ICYMI
Gastroenterology
August 2021
How to perform a high-quality endoscopic submucosal dissection
Saito Y et al. Gastroenterology. 2021 Aug;161(2):405-10. doi: 10.1053/j.gastro.2021.05.051.
Comparative effectiveness of multiple different first-line treatment regimens for Helicobacter pylori infection: A network meta-analysis
Rokkas T et al. Gastroenterology. 2021 Aug;161(2):495-507.e4. doi: 10.1053/j.gastro.2021.04.012.
The optimal age to stop endoscopic surveillance of patients with Barrett’s esophagus based on sex and comorbidity: A comparative cost-effectiveness analysis
Omidvari AH et al. Gastroenterology. 2021 Aug;161(2):487-94.e4. doi: 10.1053/j.gastro.2021.05.003.
Development and validation of test for “leaky gut” small intestinal and colonic permeability using sugars in healthy adults
Khoshbin K et al. Gastroenterology. 2021 Aug;161(2):463-75.e13. doi: 10.1053/j.gastro.2021.04.020.
September 2021
Pregnancy and the working gastroenterologist: Perceptions, realities, and systemic challenges
David YN et al. Gastroenterology. 2021 Sep;161(3):756-60. doi: 10.1053/j.gastro.2021.05.053.
New drugs on the horizon for functional and motility gastrointestinal disorders
Camilleri M. Gastroenterology. 2021 Sep;161(3):761-4. doi: 10.1053/j.gastro.2021.04.079.
A randomized trial comparing the specific carbohydrate diet to a Mediterranean diet in adults with Crohn’s disease
Lewis JD et al. Gastroenterology. 2021 Sep;161(3):837-52.e9. doi: 10.1053/j.gastro.2021.05.047.
How to promote career advancement and gender equity for women in gastroenterology: a multifaceted approach
Chua SG et al. Gastroenterology. 2021 Sep;161(3):792-7. doi: 10.1053/j.gastro.2021.06.057.
October 2021
How to approach a patient with difficult-to-treat IBS
Chang L. Gastroenterology. 2021 Oct;161(4):1092-8.e3. doi: 10.1053/j.gastro.2021.07.034.
Early-age onset colorectal neoplasia in average-risk individuals undergoing screening colonoscopy: A systematic review and meta-analysis
Kolb JM et al. Gastroenterology. 2021 Oct;161(4):1145-55.e12. doi: 10.1053/j.gastro.2021.06.006.
Adalimumab subcutaneous in participants with ulcerative colitis (VARSITY)
Peyrin-Biroulet L et al. Gastroenterology. 2021 Oct;161(4):1156-67.e3. doi: 10.1053/j.gastro.2021.06.015.
Extraintestinal manifestations of inflammatory bowel disease: Current concepts, treatment, and implications for disease management
Rogler G et al. Gastroenterology. 2021 Oct;161(4):1118-32. doi: 10.1053/j.gastro.2021.07.042.
Clinical Gastroenterology and Hepatology
August 2021
Health equity and telemedicine in gastroenterology and hepatology
Wegermann K et al. Clin Gastroenterol Hepatol. 2021 Aug;19(8):1516-9. doi: 10.1016/j.cgh.2021.04.024.
AGA Clinical Practice Update on evaluation and management of early complications after bariatric/metabolic surgery: Expert review
Kumbhari V et al. Clin Gastroenterol Hepatol. 2021 Aug;19(8):1531-7. doi: 10.1016/j.cgh.2021.03.020.
Clinical, pathology, genetic, and molecular features of colorectal tumors in adolescents and adults 25 years or younger
de Voer RM et al. Clin Gastroenterol Hepatol. 2021 Aug;19(8):1642-51.e8. doi: 10.1016/j.cgh.2020.06.034.
Safety of tofacitinib in a real-world cohort of patients with ulcerative colitis
Deepak P et al. Clin Gastroenterol Hepatol. 2021 Aug;19(8):1592-601.e3. doi: 10.1016/j.cgh.2020.06.050.
September 2021
Association of adenoma detection rate and adenoma characteristics with colorectal cancer mortality after screening colonoscopy
Waldmann E et al. Clin Gastroenterol Hepatol. 2021 Sep;19(9):1890-8. doi: 10.1016/j.cgh.2021.04.023.
Prevalence and characteristics of abdominal pain in the United States
Lakhoo K et al. Clin Gastroenterol Hepatol. 2021 Sep;19(9):1864-72.e5. doi: 10.1016/j.cgh.2020.06.065.
Model using clinical and endoscopic characteristics identifies patients at risk for eosinophilic esophagitis according to updated diagnostic guidelines
Cotton CC et al. Clin Gastroenterol Hepatol. 2021 Sep;19(9):1824-34.e2. doi: 10.1016/j.cgh.2020.06.068.
October 2021
A high-yield approach to effective endoscopy teaching and assessment
Huang HZ et al. Clin Gastroenterol Hepatol. 2021 Oct;19(10):1999-2001. doi: 10.1016/j.cgh.2021.07.013.
2021 E/M code changes: Forecasted impacts to gastroenterology practices
Francis DL et al. Clin Gastroenterol Hepatol. 2021 Oct;19(10):2002-5. doi: 10.1016/j.cgh.2021.07.008.
You can’t have one without the other: Innovation and ethical dilemmas in gastroenterology and hepatology
Couri T et al. Clin Gastroenterol Hepatol. 2021 Oct;19(10):2015-9. doi: 10.1016/j.cgh.2020.05.024.
Psychiatric disorders in patients with a diagnosis of celiac disease during childhood from 1973 to 2016
Lebwohl B et al. Clin Gastroenterol Hepatol. 2021 Oct;19(10):2093-101.e13. doi: 10.1016/j.cgh.2020.08.018.
Mast cell and eosinophil counts in gastric and duodenal biopsy specimens from patients with and without eosinophilic gastroenteritis
Reed CC et al. Clin Gastroenterol Hepatol. 2021 Oct;19(10):2102-2111. doi: 10.1016/j.cgh.2020.08.013.
Cellular and Molecular Gastroenterology and Hepatology
Sex differences in the exocrine pancreas and associated diseases
Wang M et al. Cell Mol Gastroenterol Hepatol. 2021;12(2):427-41. doi: 10.1016/j.jcmgh.2021.04.005.
Mesenteric neural crest cells are the embryological basis of skip segment Hirschsprung’s disease
Yu Q et al. Cell Mol Gastroenterol Hepatol. 2021;12(1):1-24. doi: 10.1016/j.jcmgh.2020.12.010.
Helicobacter pylori–induced rev-erbα fosters gastric bacteria colonization by impairing host innate and adaptive defense
Mao MY et al. Cell Mol Gastroenterol Hepatol. 2021;12(2):395-425. doi: 10.1016/j.jcmgh.2021.02.013.
Techniques and Innovations in Gastrointestinal Endoscopy
Staying (mentally) healthy: The impact of COVID-19 on personal and professional lives
Alkandari A et al. Tech Innov Gastrointest Endosc. 2021;23(2):199-206. doi: 10.1016/j.tige.2021.01.003.
Establishing new endoscopic programs in the unit pitfalls and tips for success
Siddiqui UD. Tech Innov Gastrointest Endosc. 2021;23(3):263-7. doi: 10.1016/j.tige.2021.03.002.
Chief of endoscopy: Specific challenges to leading the team and running the unit
Michelle A. Anderson MA et al. Tech Innov Gastrointest Endosc. 2021;23(3):249-55. doi: 10.1016/j.tige.2021.03.004.
Safety in endoscopy for patients and healthcare workers During the COVID-19 pandemic
Lui RN. Tech Innov Gastrointest Endosc. 2021;23(2):170-178. doi: 10.1016/j.tige.2020.10.004.
Gastroenterology
August 2021
How to perform a high-quality endoscopic submucosal dissection
Saito Y et al. Gastroenterology. 2021 Aug;161(2):405-10. doi: 10.1053/j.gastro.2021.05.051.
Comparative effectiveness of multiple different first-line treatment regimens for Helicobacter pylori infection: A network meta-analysis
Rokkas T et al. Gastroenterology. 2021 Aug;161(2):495-507.e4. doi: 10.1053/j.gastro.2021.04.012.
The optimal age to stop endoscopic surveillance of patients with Barrett’s esophagus based on sex and comorbidity: A comparative cost-effectiveness analysis
Omidvari AH et al. Gastroenterology. 2021 Aug;161(2):487-94.e4. doi: 10.1053/j.gastro.2021.05.003.
Development and validation of test for “leaky gut” small intestinal and colonic permeability using sugars in healthy adults
Khoshbin K et al. Gastroenterology. 2021 Aug;161(2):463-75.e13. doi: 10.1053/j.gastro.2021.04.020.
September 2021
Pregnancy and the working gastroenterologist: Perceptions, realities, and systemic challenges
David YN et al. Gastroenterology. 2021 Sep;161(3):756-60. doi: 10.1053/j.gastro.2021.05.053.
New drugs on the horizon for functional and motility gastrointestinal disorders
Camilleri M. Gastroenterology. 2021 Sep;161(3):761-4. doi: 10.1053/j.gastro.2021.04.079.
A randomized trial comparing the specific carbohydrate diet to a Mediterranean diet in adults with Crohn’s disease
Lewis JD et al. Gastroenterology. 2021 Sep;161(3):837-52.e9. doi: 10.1053/j.gastro.2021.05.047.
How to promote career advancement and gender equity for women in gastroenterology: a multifaceted approach
Chua SG et al. Gastroenterology. 2021 Sep;161(3):792-7. doi: 10.1053/j.gastro.2021.06.057.
October 2021
How to approach a patient with difficult-to-treat IBS
Chang L. Gastroenterology. 2021 Oct;161(4):1092-8.e3. doi: 10.1053/j.gastro.2021.07.034.
Early-age onset colorectal neoplasia in average-risk individuals undergoing screening colonoscopy: A systematic review and meta-analysis
Kolb JM et al. Gastroenterology. 2021 Oct;161(4):1145-55.e12. doi: 10.1053/j.gastro.2021.06.006.
Adalimumab subcutaneous in participants with ulcerative colitis (VARSITY)
Peyrin-Biroulet L et al. Gastroenterology. 2021 Oct;161(4):1156-67.e3. doi: 10.1053/j.gastro.2021.06.015.
Extraintestinal manifestations of inflammatory bowel disease: Current concepts, treatment, and implications for disease management
Rogler G et al. Gastroenterology. 2021 Oct;161(4):1118-32. doi: 10.1053/j.gastro.2021.07.042.
Clinical Gastroenterology and Hepatology
August 2021
Health equity and telemedicine in gastroenterology and hepatology
Wegermann K et al. Clin Gastroenterol Hepatol. 2021 Aug;19(8):1516-9. doi: 10.1016/j.cgh.2021.04.024.
AGA Clinical Practice Update on evaluation and management of early complications after bariatric/metabolic surgery: Expert review
Kumbhari V et al. Clin Gastroenterol Hepatol. 2021 Aug;19(8):1531-7. doi: 10.1016/j.cgh.2021.03.020.
Clinical, pathology, genetic, and molecular features of colorectal tumors in adolescents and adults 25 years or younger
de Voer RM et al. Clin Gastroenterol Hepatol. 2021 Aug;19(8):1642-51.e8. doi: 10.1016/j.cgh.2020.06.034.
Safety of tofacitinib in a real-world cohort of patients with ulcerative colitis
Deepak P et al. Clin Gastroenterol Hepatol. 2021 Aug;19(8):1592-601.e3. doi: 10.1016/j.cgh.2020.06.050.
September 2021
Association of adenoma detection rate and adenoma characteristics with colorectal cancer mortality after screening colonoscopy
Waldmann E et al. Clin Gastroenterol Hepatol. 2021 Sep;19(9):1890-8. doi: 10.1016/j.cgh.2021.04.023.
Prevalence and characteristics of abdominal pain in the United States
Lakhoo K et al. Clin Gastroenterol Hepatol. 2021 Sep;19(9):1864-72.e5. doi: 10.1016/j.cgh.2020.06.065.
Model using clinical and endoscopic characteristics identifies patients at risk for eosinophilic esophagitis according to updated diagnostic guidelines
Cotton CC et al. Clin Gastroenterol Hepatol. 2021 Sep;19(9):1824-34.e2. doi: 10.1016/j.cgh.2020.06.068.
October 2021
A high-yield approach to effective endoscopy teaching and assessment
Huang HZ et al. Clin Gastroenterol Hepatol. 2021 Oct;19(10):1999-2001. doi: 10.1016/j.cgh.2021.07.013.
2021 E/M code changes: Forecasted impacts to gastroenterology practices
Francis DL et al. Clin Gastroenterol Hepatol. 2021 Oct;19(10):2002-5. doi: 10.1016/j.cgh.2021.07.008.
You can’t have one without the other: Innovation and ethical dilemmas in gastroenterology and hepatology
Couri T et al. Clin Gastroenterol Hepatol. 2021 Oct;19(10):2015-9. doi: 10.1016/j.cgh.2020.05.024.
Psychiatric disorders in patients with a diagnosis of celiac disease during childhood from 1973 to 2016
Lebwohl B et al. Clin Gastroenterol Hepatol. 2021 Oct;19(10):2093-101.e13. doi: 10.1016/j.cgh.2020.08.018.
Mast cell and eosinophil counts in gastric and duodenal biopsy specimens from patients with and without eosinophilic gastroenteritis
Reed CC et al. Clin Gastroenterol Hepatol. 2021 Oct;19(10):2102-2111. doi: 10.1016/j.cgh.2020.08.013.
Cellular and Molecular Gastroenterology and Hepatology
Sex differences in the exocrine pancreas and associated diseases
Wang M et al. Cell Mol Gastroenterol Hepatol. 2021;12(2):427-41. doi: 10.1016/j.jcmgh.2021.04.005.
Mesenteric neural crest cells are the embryological basis of skip segment Hirschsprung’s disease
Yu Q et al. Cell Mol Gastroenterol Hepatol. 2021;12(1):1-24. doi: 10.1016/j.jcmgh.2020.12.010.
Helicobacter pylori–induced rev-erbα fosters gastric bacteria colonization by impairing host innate and adaptive defense
Mao MY et al. Cell Mol Gastroenterol Hepatol. 2021;12(2):395-425. doi: 10.1016/j.jcmgh.2021.02.013.
Techniques and Innovations in Gastrointestinal Endoscopy
Staying (mentally) healthy: The impact of COVID-19 on personal and professional lives
Alkandari A et al. Tech Innov Gastrointest Endosc. 2021;23(2):199-206. doi: 10.1016/j.tige.2021.01.003.
Establishing new endoscopic programs in the unit pitfalls and tips for success
Siddiqui UD. Tech Innov Gastrointest Endosc. 2021;23(3):263-7. doi: 10.1016/j.tige.2021.03.002.
Chief of endoscopy: Specific challenges to leading the team and running the unit
Michelle A. Anderson MA et al. Tech Innov Gastrointest Endosc. 2021;23(3):249-55. doi: 10.1016/j.tige.2021.03.004.
Safety in endoscopy for patients and healthcare workers During the COVID-19 pandemic
Lui RN. Tech Innov Gastrointest Endosc. 2021;23(2):170-178. doi: 10.1016/j.tige.2020.10.004.
Gastroenterology
August 2021
How to perform a high-quality endoscopic submucosal dissection
Saito Y et al. Gastroenterology. 2021 Aug;161(2):405-10. doi: 10.1053/j.gastro.2021.05.051.
Comparative effectiveness of multiple different first-line treatment regimens for Helicobacter pylori infection: A network meta-analysis
Rokkas T et al. Gastroenterology. 2021 Aug;161(2):495-507.e4. doi: 10.1053/j.gastro.2021.04.012.
The optimal age to stop endoscopic surveillance of patients with Barrett’s esophagus based on sex and comorbidity: A comparative cost-effectiveness analysis
Omidvari AH et al. Gastroenterology. 2021 Aug;161(2):487-94.e4. doi: 10.1053/j.gastro.2021.05.003.
Development and validation of test for “leaky gut” small intestinal and colonic permeability using sugars in healthy adults
Khoshbin K et al. Gastroenterology. 2021 Aug;161(2):463-75.e13. doi: 10.1053/j.gastro.2021.04.020.
September 2021
Pregnancy and the working gastroenterologist: Perceptions, realities, and systemic challenges
David YN et al. Gastroenterology. 2021 Sep;161(3):756-60. doi: 10.1053/j.gastro.2021.05.053.
New drugs on the horizon for functional and motility gastrointestinal disorders
Camilleri M. Gastroenterology. 2021 Sep;161(3):761-4. doi: 10.1053/j.gastro.2021.04.079.
A randomized trial comparing the specific carbohydrate diet to a Mediterranean diet in adults with Crohn’s disease
Lewis JD et al. Gastroenterology. 2021 Sep;161(3):837-52.e9. doi: 10.1053/j.gastro.2021.05.047.
How to promote career advancement and gender equity for women in gastroenterology: a multifaceted approach
Chua SG et al. Gastroenterology. 2021 Sep;161(3):792-7. doi: 10.1053/j.gastro.2021.06.057.
October 2021
How to approach a patient with difficult-to-treat IBS
Chang L. Gastroenterology. 2021 Oct;161(4):1092-8.e3. doi: 10.1053/j.gastro.2021.07.034.
Early-age onset colorectal neoplasia in average-risk individuals undergoing screening colonoscopy: A systematic review and meta-analysis
Kolb JM et al. Gastroenterology. 2021 Oct;161(4):1145-55.e12. doi: 10.1053/j.gastro.2021.06.006.
Adalimumab subcutaneous in participants with ulcerative colitis (VARSITY)
Peyrin-Biroulet L et al. Gastroenterology. 2021 Oct;161(4):1156-67.e3. doi: 10.1053/j.gastro.2021.06.015.
Extraintestinal manifestations of inflammatory bowel disease: Current concepts, treatment, and implications for disease management
Rogler G et al. Gastroenterology. 2021 Oct;161(4):1118-32. doi: 10.1053/j.gastro.2021.07.042.
Clinical Gastroenterology and Hepatology
August 2021
Health equity and telemedicine in gastroenterology and hepatology
Wegermann K et al. Clin Gastroenterol Hepatol. 2021 Aug;19(8):1516-9. doi: 10.1016/j.cgh.2021.04.024.
AGA Clinical Practice Update on evaluation and management of early complications after bariatric/metabolic surgery: Expert review
Kumbhari V et al. Clin Gastroenterol Hepatol. 2021 Aug;19(8):1531-7. doi: 10.1016/j.cgh.2021.03.020.
Clinical, pathology, genetic, and molecular features of colorectal tumors in adolescents and adults 25 years or younger
de Voer RM et al. Clin Gastroenterol Hepatol. 2021 Aug;19(8):1642-51.e8. doi: 10.1016/j.cgh.2020.06.034.
Safety of tofacitinib in a real-world cohort of patients with ulcerative colitis
Deepak P et al. Clin Gastroenterol Hepatol. 2021 Aug;19(8):1592-601.e3. doi: 10.1016/j.cgh.2020.06.050.
September 2021
Association of adenoma detection rate and adenoma characteristics with colorectal cancer mortality after screening colonoscopy
Waldmann E et al. Clin Gastroenterol Hepatol. 2021 Sep;19(9):1890-8. doi: 10.1016/j.cgh.2021.04.023.
Prevalence and characteristics of abdominal pain in the United States
Lakhoo K et al. Clin Gastroenterol Hepatol. 2021 Sep;19(9):1864-72.e5. doi: 10.1016/j.cgh.2020.06.065.
Model using clinical and endoscopic characteristics identifies patients at risk for eosinophilic esophagitis according to updated diagnostic guidelines
Cotton CC et al. Clin Gastroenterol Hepatol. 2021 Sep;19(9):1824-34.e2. doi: 10.1016/j.cgh.2020.06.068.
October 2021
A high-yield approach to effective endoscopy teaching and assessment
Huang HZ et al. Clin Gastroenterol Hepatol. 2021 Oct;19(10):1999-2001. doi: 10.1016/j.cgh.2021.07.013.
2021 E/M code changes: Forecasted impacts to gastroenterology practices
Francis DL et al. Clin Gastroenterol Hepatol. 2021 Oct;19(10):2002-5. doi: 10.1016/j.cgh.2021.07.008.
You can’t have one without the other: Innovation and ethical dilemmas in gastroenterology and hepatology
Couri T et al. Clin Gastroenterol Hepatol. 2021 Oct;19(10):2015-9. doi: 10.1016/j.cgh.2020.05.024.
Psychiatric disorders in patients with a diagnosis of celiac disease during childhood from 1973 to 2016
Lebwohl B et al. Clin Gastroenterol Hepatol. 2021 Oct;19(10):2093-101.e13. doi: 10.1016/j.cgh.2020.08.018.
Mast cell and eosinophil counts in gastric and duodenal biopsy specimens from patients with and without eosinophilic gastroenteritis
Reed CC et al. Clin Gastroenterol Hepatol. 2021 Oct;19(10):2102-2111. doi: 10.1016/j.cgh.2020.08.013.
Cellular and Molecular Gastroenterology and Hepatology
Sex differences in the exocrine pancreas and associated diseases
Wang M et al. Cell Mol Gastroenterol Hepatol. 2021;12(2):427-41. doi: 10.1016/j.jcmgh.2021.04.005.
Mesenteric neural crest cells are the embryological basis of skip segment Hirschsprung’s disease
Yu Q et al. Cell Mol Gastroenterol Hepatol. 2021;12(1):1-24. doi: 10.1016/j.jcmgh.2020.12.010.
Helicobacter pylori–induced rev-erbα fosters gastric bacteria colonization by impairing host innate and adaptive defense
Mao MY et al. Cell Mol Gastroenterol Hepatol. 2021;12(2):395-425. doi: 10.1016/j.jcmgh.2021.02.013.
Techniques and Innovations in Gastrointestinal Endoscopy
Staying (mentally) healthy: The impact of COVID-19 on personal and professional lives
Alkandari A et al. Tech Innov Gastrointest Endosc. 2021;23(2):199-206. doi: 10.1016/j.tige.2021.01.003.
Establishing new endoscopic programs in the unit pitfalls and tips for success
Siddiqui UD. Tech Innov Gastrointest Endosc. 2021;23(3):263-7. doi: 10.1016/j.tige.2021.03.002.
Chief of endoscopy: Specific challenges to leading the team and running the unit
Michelle A. Anderson MA et al. Tech Innov Gastrointest Endosc. 2021;23(3):249-55. doi: 10.1016/j.tige.2021.03.004.
Safety in endoscopy for patients and healthcare workers During the COVID-19 pandemic
Lui RN. Tech Innov Gastrointest Endosc. 2021;23(2):170-178. doi: 10.1016/j.tige.2020.10.004.
Lupin recalls irbesartan and hydrochlorothiazide/irbesartan tablets
Lupin Pharmaceuticals is recalling all batches of irbesartan tablets USP 75 mg, 150 mg, and 300 mg and irbesartan and hydrochlorothiazide (HCTZ) tablets USP 150 mg/12.5 mg and 300 mg/12.5 mg because of the potential presence of the N-nitrosoirbesartan impurity.
“As part of Lupin’s ongoing assessment, analysis revealed that certain tested active pharmaceutical ingredient (API) batches (but not finished product batches) were above the specification limit for the impurity, N-nitrosoirbesartan,” the company said in a news release posted on the U.S. Food and Drug Administration’s website. It notes that the impurity is a “probable human carcinogen.”
Lupin discontinued the marketing of irbesartan and irbesartan/HCTZ tablets on Jan. 7, 2021. It says it “has received no reports of illness that appear to relate to this issue” and is issuing the recall out of “an abundance of caution.”
The company, however, goes on to note that from Oct. 8, 2018 (the earliest date of shipment from the manufacturing site of any of the affected batches) to September 30 of this year, Lupin received four reports of illness from irbesartan and 0 reports from irbesartan/HCTZ.
Irbesartan is an angiotensin II receptor blocker indicated for treatment of hypertension in patients with type 2 diabetes, elevated serum creatinine, and proteinuria.
Irbesartan/HCTZ tablets include irbesartan and hydrochlorothiazide, a thiazide diuretic, indicated for hypertension in patients not adequately controlled with monotherapy or as an initial therapy in patients likely to need multiple drugs to achieve blood pressure goals.
Lupin is notifying wholesalers, distributors, and retail outlets to immediately discontinue sales of the affected product lots and return them to the company. Specific lot numbers can be found here.
The company is advising patients to continue taking their medication and to contact their pharmacist, physician, or health care professional for advice regarding an alternative treatment.
Patients and physicians are also advised to report any adverse events or side effects related to the affected products to MedWatch, the U.S. Food and Drug Administration’s Safety Information and Adverse Event Reporting program.
A version of this article first appeared on Medscape.com.
Lupin Pharmaceuticals is recalling all batches of irbesartan tablets USP 75 mg, 150 mg, and 300 mg and irbesartan and hydrochlorothiazide (HCTZ) tablets USP 150 mg/12.5 mg and 300 mg/12.5 mg because of the potential presence of the N-nitrosoirbesartan impurity.
“As part of Lupin’s ongoing assessment, analysis revealed that certain tested active pharmaceutical ingredient (API) batches (but not finished product batches) were above the specification limit for the impurity, N-nitrosoirbesartan,” the company said in a news release posted on the U.S. Food and Drug Administration’s website. It notes that the impurity is a “probable human carcinogen.”
Lupin discontinued the marketing of irbesartan and irbesartan/HCTZ tablets on Jan. 7, 2021. It says it “has received no reports of illness that appear to relate to this issue” and is issuing the recall out of “an abundance of caution.”
The company, however, goes on to note that from Oct. 8, 2018 (the earliest date of shipment from the manufacturing site of any of the affected batches) to September 30 of this year, Lupin received four reports of illness from irbesartan and 0 reports from irbesartan/HCTZ.
Irbesartan is an angiotensin II receptor blocker indicated for treatment of hypertension in patients with type 2 diabetes, elevated serum creatinine, and proteinuria.
Irbesartan/HCTZ tablets include irbesartan and hydrochlorothiazide, a thiazide diuretic, indicated for hypertension in patients not adequately controlled with monotherapy or as an initial therapy in patients likely to need multiple drugs to achieve blood pressure goals.
Lupin is notifying wholesalers, distributors, and retail outlets to immediately discontinue sales of the affected product lots and return them to the company. Specific lot numbers can be found here.
The company is advising patients to continue taking their medication and to contact their pharmacist, physician, or health care professional for advice regarding an alternative treatment.
Patients and physicians are also advised to report any adverse events or side effects related to the affected products to MedWatch, the U.S. Food and Drug Administration’s Safety Information and Adverse Event Reporting program.
A version of this article first appeared on Medscape.com.
Lupin Pharmaceuticals is recalling all batches of irbesartan tablets USP 75 mg, 150 mg, and 300 mg and irbesartan and hydrochlorothiazide (HCTZ) tablets USP 150 mg/12.5 mg and 300 mg/12.5 mg because of the potential presence of the N-nitrosoirbesartan impurity.
“As part of Lupin’s ongoing assessment, analysis revealed that certain tested active pharmaceutical ingredient (API) batches (but not finished product batches) were above the specification limit for the impurity, N-nitrosoirbesartan,” the company said in a news release posted on the U.S. Food and Drug Administration’s website. It notes that the impurity is a “probable human carcinogen.”
Lupin discontinued the marketing of irbesartan and irbesartan/HCTZ tablets on Jan. 7, 2021. It says it “has received no reports of illness that appear to relate to this issue” and is issuing the recall out of “an abundance of caution.”
The company, however, goes on to note that from Oct. 8, 2018 (the earliest date of shipment from the manufacturing site of any of the affected batches) to September 30 of this year, Lupin received four reports of illness from irbesartan and 0 reports from irbesartan/HCTZ.
Irbesartan is an angiotensin II receptor blocker indicated for treatment of hypertension in patients with type 2 diabetes, elevated serum creatinine, and proteinuria.
Irbesartan/HCTZ tablets include irbesartan and hydrochlorothiazide, a thiazide diuretic, indicated for hypertension in patients not adequately controlled with monotherapy or as an initial therapy in patients likely to need multiple drugs to achieve blood pressure goals.
Lupin is notifying wholesalers, distributors, and retail outlets to immediately discontinue sales of the affected product lots and return them to the company. Specific lot numbers can be found here.
The company is advising patients to continue taking their medication and to contact their pharmacist, physician, or health care professional for advice regarding an alternative treatment.
Patients and physicians are also advised to report any adverse events or side effects related to the affected products to MedWatch, the U.S. Food and Drug Administration’s Safety Information and Adverse Event Reporting program.
A version of this article first appeared on Medscape.com.
COVID-19, yes, but so much more
Nearly 2 years into the pandemic, all things COVID-19 will of course be a major focus at the annual meeting of the American College of Chest Physicians, held virtually this year.
“During the pandemic, critical care has been at the forefront of what people are interested in,” said CHEST 2021 program cochair Christopher Carroll, MD, FCCP, from Connecticut Children’s Medical Center, Hartford.
“There is so much volume in critical care units that people have interest in anything related to critical care, including infectious diseases and disaster management in critical care,” he said in an interview.
Sessions at this year’s meeting that have a COVID-19 theme will focus on care of both patients and caregivers. Multiple symposiums, oral abstracts, scientific posters, and case reports will focus on clinical aspects of SARS-CoV-2 infections and COVID-19, including complications such as ventilator-associated and hospital-acquired pneumonia, a session called “Viruses, Variants, Vaccines, and Virulence: The Present and Future of COVID-19,” and support of patients and families.
Other presentations will focus on how COVID-19 has affected lung cancer screening, outpatient practices, pulmonary care, and sleep medicine.
Importantly, the meeting will include sessions focusing on the mental, physical, and social health of clinicians, especially those on the front lines in critical care and intensive care units. There will be sessions on how to recognize and avoid burnout, practice mental health awareness, and take time for self-care.
Presidential Honor Lecturer Curtis N. Sessler, MD, Master FCCP, FCCM, of Virginia Commonwealth University, Richmond, with give a talk titled, “Navigating the Road to Well-Being in the ICU.”
Empathy and diversity
Program cochair David Zielinski, MD, FCCP, of Montreal Children’s Hospital, Quebec, told this news organization that the COVID-19 pandemic has brought into even starker contrast inequities in patient care and in the health care system at large.
“This is a subject people are very keen about right now, whether it’s about how providers are treated, opportunities for improvement, or correcting inequities in outcomes for patients,” he said in an interview.
The program doesn’t shy away from the controversy, either, with a session provocatively titled, “Racism in Health Care: The Fuel That Lit the COVID-19 Fire.”
Keynote speaker Demondes Haynes, MD, FCCP, professor of medicine and associate dean of admissions at the University of Mississippi, Jackson, will speak on the importance of empathy in physician-patient communications and on ways to create a more diverse and inclusive workforce in medicine.
Beyond COVID-19
CHEST 2021 will include important information for sleep medicine physicians, including the latest news regarding an equipment recall affecting one of the two major manufacturers of continuous positive airway pressure devices.
“This has caused a lot of angst among sleep physicians and patients, and there are not enough devices to replace them,” Dr. Zielinski said.
“People who are on home ventilators are also affected by this recall,” Dr. Carroll added. “The population of patients who have sleep apnea is much greater than the population who are on home ventilators, but patients who are on home ventilators need it to save their lives.”
The meeting will include informative sessions summarizing U.S. and European asthma guidelines published over the past 2 years, as well as pending guidelines from the American College of Chest Physicians on venous thromboembolism and lung cancer screening.
Additional topics of importance include chronic obstructive pulmonary disease, interstitial lung disease, asthma management, acute respiratory failure in special populations, new therapies and strategies for treating tuberculosis, and many others.
There will be skill-polishing simulation sessions designed to help clinicians connect with experts in the field, update their knowledge, and sharpen their technique.
Fun and games
In addition to the serious subjects, CHEST 2021 attendees will have the chance to network with colleagues and friends and enjoy online games, including the 20th annual CHEST Challenge, which will pit teams of fellows-in-training from the Interfaith Medical Center, in Brooklyn, New York; the State University of New York, in Buffalo; and the Ohio State University Medical Center, in Columbus, in a Jeopardy!-style battle of wits and medical knowledge.
Close to 7,000 registrants from around the world took part in last year’s CHEST annual meeting, and a similar number is expected for this year’s edition, Dr. Carroll and Dr. Zielinski said.
A version of this article first appeared on Medscape.com.
Nearly 2 years into the pandemic, all things COVID-19 will of course be a major focus at the annual meeting of the American College of Chest Physicians, held virtually this year.
“During the pandemic, critical care has been at the forefront of what people are interested in,” said CHEST 2021 program cochair Christopher Carroll, MD, FCCP, from Connecticut Children’s Medical Center, Hartford.
“There is so much volume in critical care units that people have interest in anything related to critical care, including infectious diseases and disaster management in critical care,” he said in an interview.
Sessions at this year’s meeting that have a COVID-19 theme will focus on care of both patients and caregivers. Multiple symposiums, oral abstracts, scientific posters, and case reports will focus on clinical aspects of SARS-CoV-2 infections and COVID-19, including complications such as ventilator-associated and hospital-acquired pneumonia, a session called “Viruses, Variants, Vaccines, and Virulence: The Present and Future of COVID-19,” and support of patients and families.
Other presentations will focus on how COVID-19 has affected lung cancer screening, outpatient practices, pulmonary care, and sleep medicine.
Importantly, the meeting will include sessions focusing on the mental, physical, and social health of clinicians, especially those on the front lines in critical care and intensive care units. There will be sessions on how to recognize and avoid burnout, practice mental health awareness, and take time for self-care.
Presidential Honor Lecturer Curtis N. Sessler, MD, Master FCCP, FCCM, of Virginia Commonwealth University, Richmond, with give a talk titled, “Navigating the Road to Well-Being in the ICU.”
Empathy and diversity
Program cochair David Zielinski, MD, FCCP, of Montreal Children’s Hospital, Quebec, told this news organization that the COVID-19 pandemic has brought into even starker contrast inequities in patient care and in the health care system at large.
“This is a subject people are very keen about right now, whether it’s about how providers are treated, opportunities for improvement, or correcting inequities in outcomes for patients,” he said in an interview.
The program doesn’t shy away from the controversy, either, with a session provocatively titled, “Racism in Health Care: The Fuel That Lit the COVID-19 Fire.”
Keynote speaker Demondes Haynes, MD, FCCP, professor of medicine and associate dean of admissions at the University of Mississippi, Jackson, will speak on the importance of empathy in physician-patient communications and on ways to create a more diverse and inclusive workforce in medicine.
Beyond COVID-19
CHEST 2021 will include important information for sleep medicine physicians, including the latest news regarding an equipment recall affecting one of the two major manufacturers of continuous positive airway pressure devices.
“This has caused a lot of angst among sleep physicians and patients, and there are not enough devices to replace them,” Dr. Zielinski said.
“People who are on home ventilators are also affected by this recall,” Dr. Carroll added. “The population of patients who have sleep apnea is much greater than the population who are on home ventilators, but patients who are on home ventilators need it to save their lives.”
The meeting will include informative sessions summarizing U.S. and European asthma guidelines published over the past 2 years, as well as pending guidelines from the American College of Chest Physicians on venous thromboembolism and lung cancer screening.
Additional topics of importance include chronic obstructive pulmonary disease, interstitial lung disease, asthma management, acute respiratory failure in special populations, new therapies and strategies for treating tuberculosis, and many others.
There will be skill-polishing simulation sessions designed to help clinicians connect with experts in the field, update their knowledge, and sharpen their technique.
Fun and games
In addition to the serious subjects, CHEST 2021 attendees will have the chance to network with colleagues and friends and enjoy online games, including the 20th annual CHEST Challenge, which will pit teams of fellows-in-training from the Interfaith Medical Center, in Brooklyn, New York; the State University of New York, in Buffalo; and the Ohio State University Medical Center, in Columbus, in a Jeopardy!-style battle of wits and medical knowledge.
Close to 7,000 registrants from around the world took part in last year’s CHEST annual meeting, and a similar number is expected for this year’s edition, Dr. Carroll and Dr. Zielinski said.
A version of this article first appeared on Medscape.com.
Nearly 2 years into the pandemic, all things COVID-19 will of course be a major focus at the annual meeting of the American College of Chest Physicians, held virtually this year.
“During the pandemic, critical care has been at the forefront of what people are interested in,” said CHEST 2021 program cochair Christopher Carroll, MD, FCCP, from Connecticut Children’s Medical Center, Hartford.
“There is so much volume in critical care units that people have interest in anything related to critical care, including infectious diseases and disaster management in critical care,” he said in an interview.
Sessions at this year’s meeting that have a COVID-19 theme will focus on care of both patients and caregivers. Multiple symposiums, oral abstracts, scientific posters, and case reports will focus on clinical aspects of SARS-CoV-2 infections and COVID-19, including complications such as ventilator-associated and hospital-acquired pneumonia, a session called “Viruses, Variants, Vaccines, and Virulence: The Present and Future of COVID-19,” and support of patients and families.
Other presentations will focus on how COVID-19 has affected lung cancer screening, outpatient practices, pulmonary care, and sleep medicine.
Importantly, the meeting will include sessions focusing on the mental, physical, and social health of clinicians, especially those on the front lines in critical care and intensive care units. There will be sessions on how to recognize and avoid burnout, practice mental health awareness, and take time for self-care.
Presidential Honor Lecturer Curtis N. Sessler, MD, Master FCCP, FCCM, of Virginia Commonwealth University, Richmond, with give a talk titled, “Navigating the Road to Well-Being in the ICU.”
Empathy and diversity
Program cochair David Zielinski, MD, FCCP, of Montreal Children’s Hospital, Quebec, told this news organization that the COVID-19 pandemic has brought into even starker contrast inequities in patient care and in the health care system at large.
“This is a subject people are very keen about right now, whether it’s about how providers are treated, opportunities for improvement, or correcting inequities in outcomes for patients,” he said in an interview.
The program doesn’t shy away from the controversy, either, with a session provocatively titled, “Racism in Health Care: The Fuel That Lit the COVID-19 Fire.”
Keynote speaker Demondes Haynes, MD, FCCP, professor of medicine and associate dean of admissions at the University of Mississippi, Jackson, will speak on the importance of empathy in physician-patient communications and on ways to create a more diverse and inclusive workforce in medicine.
Beyond COVID-19
CHEST 2021 will include important information for sleep medicine physicians, including the latest news regarding an equipment recall affecting one of the two major manufacturers of continuous positive airway pressure devices.
“This has caused a lot of angst among sleep physicians and patients, and there are not enough devices to replace them,” Dr. Zielinski said.
“People who are on home ventilators are also affected by this recall,” Dr. Carroll added. “The population of patients who have sleep apnea is much greater than the population who are on home ventilators, but patients who are on home ventilators need it to save their lives.”
The meeting will include informative sessions summarizing U.S. and European asthma guidelines published over the past 2 years, as well as pending guidelines from the American College of Chest Physicians on venous thromboembolism and lung cancer screening.
Additional topics of importance include chronic obstructive pulmonary disease, interstitial lung disease, asthma management, acute respiratory failure in special populations, new therapies and strategies for treating tuberculosis, and many others.
There will be skill-polishing simulation sessions designed to help clinicians connect with experts in the field, update their knowledge, and sharpen their technique.
Fun and games
In addition to the serious subjects, CHEST 2021 attendees will have the chance to network with colleagues and friends and enjoy online games, including the 20th annual CHEST Challenge, which will pit teams of fellows-in-training from the Interfaith Medical Center, in Brooklyn, New York; the State University of New York, in Buffalo; and the Ohio State University Medical Center, in Columbus, in a Jeopardy!-style battle of wits and medical knowledge.
Close to 7,000 registrants from around the world took part in last year’s CHEST annual meeting, and a similar number is expected for this year’s edition, Dr. Carroll and Dr. Zielinski said.
A version of this article first appeared on Medscape.com.
FROM CHEST 2021
QI reduces daily labs and promotes sleep-friendly lab timing
Background: Daily labs are often unnecessary on clinically stable inpatients. Additionally, daily labs are frequently drawn very early in the morning, resulting in sleep disruptions. No prior studies have attempted an EHR-based intervention to simultaneously improve both frequency and timing of labs.
Study design: Quality improvement project.
Setting: Resident and hospitalist services at a single academic medical center.
Synopsis: After surveying providers about lab-ordering preferences, an EHR shortcut and visual reminder were built to facilitate labs being ordered every 48 hours at 6 a.m. (rather than daily at 4 a.m.). Results included 26.3% fewer routine lab draws per patient-day per week, and a significant increase in sleep-friendly lab order utilization per encounter per week on both resident services (intercept, 1.03; standard error, 0.29; P < .001) and hospitalist services (intercept, 1.17; SE, .50; P = .02).
Bottom line: An intervention consisting of physician education and an EHR tool reduced daily lab frequency and optimized morning lab timing to improve sleep.
Citation: Tapaskar N et al. Evaluation of the order SMARTT: An initiative to reduce phlebotomy and improve sleep-friendly labs on general medicine services. J Hosp Med. 2020;15:479-82.
Dr. Lockwood is a hospitalist and chief of quality, performance, and patient safety at the Lexington (Ky.) VA Health Care System.
Background: Daily labs are often unnecessary on clinically stable inpatients. Additionally, daily labs are frequently drawn very early in the morning, resulting in sleep disruptions. No prior studies have attempted an EHR-based intervention to simultaneously improve both frequency and timing of labs.
Study design: Quality improvement project.
Setting: Resident and hospitalist services at a single academic medical center.
Synopsis: After surveying providers about lab-ordering preferences, an EHR shortcut and visual reminder were built to facilitate labs being ordered every 48 hours at 6 a.m. (rather than daily at 4 a.m.). Results included 26.3% fewer routine lab draws per patient-day per week, and a significant increase in sleep-friendly lab order utilization per encounter per week on both resident services (intercept, 1.03; standard error, 0.29; P < .001) and hospitalist services (intercept, 1.17; SE, .50; P = .02).
Bottom line: An intervention consisting of physician education and an EHR tool reduced daily lab frequency and optimized morning lab timing to improve sleep.
Citation: Tapaskar N et al. Evaluation of the order SMARTT: An initiative to reduce phlebotomy and improve sleep-friendly labs on general medicine services. J Hosp Med. 2020;15:479-82.
Dr. Lockwood is a hospitalist and chief of quality, performance, and patient safety at the Lexington (Ky.) VA Health Care System.
Background: Daily labs are often unnecessary on clinically stable inpatients. Additionally, daily labs are frequently drawn very early in the morning, resulting in sleep disruptions. No prior studies have attempted an EHR-based intervention to simultaneously improve both frequency and timing of labs.
Study design: Quality improvement project.
Setting: Resident and hospitalist services at a single academic medical center.
Synopsis: After surveying providers about lab-ordering preferences, an EHR shortcut and visual reminder were built to facilitate labs being ordered every 48 hours at 6 a.m. (rather than daily at 4 a.m.). Results included 26.3% fewer routine lab draws per patient-day per week, and a significant increase in sleep-friendly lab order utilization per encounter per week on both resident services (intercept, 1.03; standard error, 0.29; P < .001) and hospitalist services (intercept, 1.17; SE, .50; P = .02).
Bottom line: An intervention consisting of physician education and an EHR tool reduced daily lab frequency and optimized morning lab timing to improve sleep.
Citation: Tapaskar N et al. Evaluation of the order SMARTT: An initiative to reduce phlebotomy and improve sleep-friendly labs on general medicine services. J Hosp Med. 2020;15:479-82.
Dr. Lockwood is a hospitalist and chief of quality, performance, and patient safety at the Lexington (Ky.) VA Health Care System.
AGA Clinical Practice Update: Expert review on GI perforations
A clinical practice update expert review from the American Gastroenterological Association gives advice on management of endoscopic perforations in the gastrointestinal tract, including esophageal, gastric, duodenal and periampullary, and colon perforation.
There are various techniques for dealing with perforations, including through-the-scope clips (TTSCs), over-the-scope clips (OTSCs), self-expanding metal stents (SEMS), and endoscopic suturing. Newer methods include biological glue and esophageal vacuum therapy. These techniques have been the subject of various retrospective analyses, but few prospective studies have examined their safety and efficacy.
In the expert review, published in Clinical Gastroenterology and Hepatology, authors led by Jeffrey H. Lee, MD, MPH, AGAF, of the department of gastroenterology at the University of Texas MD Anderson Cancer Center, Houston, emphasized that gastroenterologists should have a perforation protocol in place and practice procedures that will be used to address perforations. Endoscopists should also recognize their own limits and know when a patient should be sent to experienced, high-volume centers for further care.
In the event of a perforation, the entire team should be notified immediately, and carbon dioxide insufflation should be used at a low flow setting. The endoscopist should clean up luminal material to reduce the chance of peritoneal contamination, and then treat with an antibiotic regimen that counters gram-negative and anaerobic bacteria.
Esophageal perforation
Esophageal perforations most commonly occur during dilation of strictures, endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD). Perforations of the mucosal flap may happen during so-called third-space endoscopy techniques like peroral endoscopic myotomy (POEM). Small perforations can be readily addressed with TTSCs. Larger perforations call for some combination of TTSCs, endoscopic suturing, fibrin glue injection, or esophageal stenting, though the latter is discouraged because of the potential for erosion.
A more concerning complication of POEM is delayed barrier failure, which can cause leaks, mediastinitis, or peritonitis. These complications have been estimated to occur in 0.2%-1.1% of cases.
In the event of an esophageal perforation, the area should be kept clean by suctioning, or by altering patient position if required. Perforations 1-2 cm in size can be closed using OTSCs. Excessive bleeding or larger tears can be addressed using a fully covered SEMS.
Leaks that occur in the ensuing days after the procedure should be closed using TTSCs, OTSCs, or endosuturing, followed by putting in a fully covered stent. Esophageal fistula should be addressed with a fully covered stent with a tight fit.
Endoscopic vacuum therapy is a newer technique to address large or persistent esophageal perforations. A review found it had a 96% success rate for esophageal perforations.
Gastric perforations
Gastric perforations often result from peptic ulcer disease or ingestion of something caustic, and it is a high risk during EMR and ESD procedures (0.4%-0.7% intraprocedural risk). The proximal gastric wall isn’t thick as in the gastric antrum, so proximal endoscopic resections require extra care. Lengthy procedures should be done under anesthesia. Ongoing gaseous insufflation during a perforation may worsen the problem because of heightened intraperitoneal pressure. OTSCs may be a better choice than TTSCs for 1-3 cm perforations, while endoloop/TTSC can be used for larger ones.
Duodenal and periampullary perforations
Duodenal and periampullary perforations occur during duodenal stricture dilation, EMR, endoscopic submucosal dissection, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography (ECRP). The thin duodenal wall makes it more susceptible to perforation than the esophagus, stomach, or colon.
Closing a duodenum perforation can be difficult. Type 1 perforations typically show sudden bleeding and lumen deflation, and often require surgical intervention. Some recent reports have suggested success with TTSCs, OTSCs, band ligation, and endoloops. Type 2 perforations are less obvious, and the endoscopist must examine the gas pattern on fluoroscopic beneath the liver or in the area of the right kidney. Retroperitoneal air following ERCP, if asymptomatic, doesn’t necessarily require intervention.
The challenges presented by the duodenum mean that, for large duodenal polyps, EMR should only be done by experienced endoscopists who are skilled at mucosal closure, and only experts should attempt ESD. Proteolytic enzymes from the pancreas can also pool in the duodenum, which can degrade muscle tissue and lead to delayed perforations. TTSC, OTSC, endosuturing, polymer gels or sheets, and TTSC combined with endoloop cinching have been used to close resection-associated perforations.
Colon perforation
Colon perforation may be caused by diverticulitis, inflammatory bowel disease, or occasionally colonic obstruction. Iatrogenic causes are more common and include endoscopic resection, hot forceps biopsy, dilation of stricture resulting from radiation or Crohn’s disease, colonic stenting, and advancement of colonoscope across angulations or into diverticula without straightening the endoscope
Large perforations are usually immediately noticeable and should be treated surgically, as should hemodynamic instability or delayed perforations with peritoneal signs.
Endoscopic closure should be attempted when the perforation site is clean, and lower rectal perforations can generally be repaired with TTSC, OTSC, or endoscopic suturing. In the cecum, or in a torturous or unclean colon, it may be difficult or dangerous to remove the colonoscope and insert an OTSC, and endoscopic suturing may not be possible, making TTSC the only procedure available for right colon perforations. The X-Tack Endoscopic HeliX Tacking System is a recently introduced, through-the-scope technology that places suture-tethered tacks into tissue surrounding the perforation and cinches it together. The system in principle can close large or irregular colonic and small bowel perforations using gastroscopes and colonoscopes, but no human studies have yet been published.
Conclusion
This update was a collaborative effort by four endoscopists who felt that it was timely to review the issue of perforations since they can be serious and challenging to manage. The evolution of endoscopic techniques over the last few years, however, has made the closure of spontaneous and iatrogenic perforations much less fear provoking, and they wished to summarize the approaches to a variety of such situations in order to guide practitioners who may encounter them.
“Although perforation is a serious event, with novel endoscopic techniques and tools, the endoscopist should no longer be paralyzed when it occurs,” the authors concluded.
Some authors reported relationships, such as consulting for or royalties from, device companies such as Medtronic and Boston Scientific. The remaining authors disclosed no conflicts.
This article was updated Oct. 25, 2021.
A clinical practice update expert review from the American Gastroenterological Association gives advice on management of endoscopic perforations in the gastrointestinal tract, including esophageal, gastric, duodenal and periampullary, and colon perforation.
There are various techniques for dealing with perforations, including through-the-scope clips (TTSCs), over-the-scope clips (OTSCs), self-expanding metal stents (SEMS), and endoscopic suturing. Newer methods include biological glue and esophageal vacuum therapy. These techniques have been the subject of various retrospective analyses, but few prospective studies have examined their safety and efficacy.
In the expert review, published in Clinical Gastroenterology and Hepatology, authors led by Jeffrey H. Lee, MD, MPH, AGAF, of the department of gastroenterology at the University of Texas MD Anderson Cancer Center, Houston, emphasized that gastroenterologists should have a perforation protocol in place and practice procedures that will be used to address perforations. Endoscopists should also recognize their own limits and know when a patient should be sent to experienced, high-volume centers for further care.
In the event of a perforation, the entire team should be notified immediately, and carbon dioxide insufflation should be used at a low flow setting. The endoscopist should clean up luminal material to reduce the chance of peritoneal contamination, and then treat with an antibiotic regimen that counters gram-negative and anaerobic bacteria.
Esophageal perforation
Esophageal perforations most commonly occur during dilation of strictures, endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD). Perforations of the mucosal flap may happen during so-called third-space endoscopy techniques like peroral endoscopic myotomy (POEM). Small perforations can be readily addressed with TTSCs. Larger perforations call for some combination of TTSCs, endoscopic suturing, fibrin glue injection, or esophageal stenting, though the latter is discouraged because of the potential for erosion.
A more concerning complication of POEM is delayed barrier failure, which can cause leaks, mediastinitis, or peritonitis. These complications have been estimated to occur in 0.2%-1.1% of cases.
In the event of an esophageal perforation, the area should be kept clean by suctioning, or by altering patient position if required. Perforations 1-2 cm in size can be closed using OTSCs. Excessive bleeding or larger tears can be addressed using a fully covered SEMS.
Leaks that occur in the ensuing days after the procedure should be closed using TTSCs, OTSCs, or endosuturing, followed by putting in a fully covered stent. Esophageal fistula should be addressed with a fully covered stent with a tight fit.
Endoscopic vacuum therapy is a newer technique to address large or persistent esophageal perforations. A review found it had a 96% success rate for esophageal perforations.
Gastric perforations
Gastric perforations often result from peptic ulcer disease or ingestion of something caustic, and it is a high risk during EMR and ESD procedures (0.4%-0.7% intraprocedural risk). The proximal gastric wall isn’t thick as in the gastric antrum, so proximal endoscopic resections require extra care. Lengthy procedures should be done under anesthesia. Ongoing gaseous insufflation during a perforation may worsen the problem because of heightened intraperitoneal pressure. OTSCs may be a better choice than TTSCs for 1-3 cm perforations, while endoloop/TTSC can be used for larger ones.
Duodenal and periampullary perforations
Duodenal and periampullary perforations occur during duodenal stricture dilation, EMR, endoscopic submucosal dissection, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography (ECRP). The thin duodenal wall makes it more susceptible to perforation than the esophagus, stomach, or colon.
Closing a duodenum perforation can be difficult. Type 1 perforations typically show sudden bleeding and lumen deflation, and often require surgical intervention. Some recent reports have suggested success with TTSCs, OTSCs, band ligation, and endoloops. Type 2 perforations are less obvious, and the endoscopist must examine the gas pattern on fluoroscopic beneath the liver or in the area of the right kidney. Retroperitoneal air following ERCP, if asymptomatic, doesn’t necessarily require intervention.
The challenges presented by the duodenum mean that, for large duodenal polyps, EMR should only be done by experienced endoscopists who are skilled at mucosal closure, and only experts should attempt ESD. Proteolytic enzymes from the pancreas can also pool in the duodenum, which can degrade muscle tissue and lead to delayed perforations. TTSC, OTSC, endosuturing, polymer gels or sheets, and TTSC combined with endoloop cinching have been used to close resection-associated perforations.
Colon perforation
Colon perforation may be caused by diverticulitis, inflammatory bowel disease, or occasionally colonic obstruction. Iatrogenic causes are more common and include endoscopic resection, hot forceps biopsy, dilation of stricture resulting from radiation or Crohn’s disease, colonic stenting, and advancement of colonoscope across angulations or into diverticula without straightening the endoscope
Large perforations are usually immediately noticeable and should be treated surgically, as should hemodynamic instability or delayed perforations with peritoneal signs.
Endoscopic closure should be attempted when the perforation site is clean, and lower rectal perforations can generally be repaired with TTSC, OTSC, or endoscopic suturing. In the cecum, or in a torturous or unclean colon, it may be difficult or dangerous to remove the colonoscope and insert an OTSC, and endoscopic suturing may not be possible, making TTSC the only procedure available for right colon perforations. The X-Tack Endoscopic HeliX Tacking System is a recently introduced, through-the-scope technology that places suture-tethered tacks into tissue surrounding the perforation and cinches it together. The system in principle can close large or irregular colonic and small bowel perforations using gastroscopes and colonoscopes, but no human studies have yet been published.
Conclusion
This update was a collaborative effort by four endoscopists who felt that it was timely to review the issue of perforations since they can be serious and challenging to manage. The evolution of endoscopic techniques over the last few years, however, has made the closure of spontaneous and iatrogenic perforations much less fear provoking, and they wished to summarize the approaches to a variety of such situations in order to guide practitioners who may encounter them.
“Although perforation is a serious event, with novel endoscopic techniques and tools, the endoscopist should no longer be paralyzed when it occurs,” the authors concluded.
Some authors reported relationships, such as consulting for or royalties from, device companies such as Medtronic and Boston Scientific. The remaining authors disclosed no conflicts.
This article was updated Oct. 25, 2021.
A clinical practice update expert review from the American Gastroenterological Association gives advice on management of endoscopic perforations in the gastrointestinal tract, including esophageal, gastric, duodenal and periampullary, and colon perforation.
There are various techniques for dealing with perforations, including through-the-scope clips (TTSCs), over-the-scope clips (OTSCs), self-expanding metal stents (SEMS), and endoscopic suturing. Newer methods include biological glue and esophageal vacuum therapy. These techniques have been the subject of various retrospective analyses, but few prospective studies have examined their safety and efficacy.
In the expert review, published in Clinical Gastroenterology and Hepatology, authors led by Jeffrey H. Lee, MD, MPH, AGAF, of the department of gastroenterology at the University of Texas MD Anderson Cancer Center, Houston, emphasized that gastroenterologists should have a perforation protocol in place and practice procedures that will be used to address perforations. Endoscopists should also recognize their own limits and know when a patient should be sent to experienced, high-volume centers for further care.
In the event of a perforation, the entire team should be notified immediately, and carbon dioxide insufflation should be used at a low flow setting. The endoscopist should clean up luminal material to reduce the chance of peritoneal contamination, and then treat with an antibiotic regimen that counters gram-negative and anaerobic bacteria.
Esophageal perforation
Esophageal perforations most commonly occur during dilation of strictures, endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD). Perforations of the mucosal flap may happen during so-called third-space endoscopy techniques like peroral endoscopic myotomy (POEM). Small perforations can be readily addressed with TTSCs. Larger perforations call for some combination of TTSCs, endoscopic suturing, fibrin glue injection, or esophageal stenting, though the latter is discouraged because of the potential for erosion.
A more concerning complication of POEM is delayed barrier failure, which can cause leaks, mediastinitis, or peritonitis. These complications have been estimated to occur in 0.2%-1.1% of cases.
In the event of an esophageal perforation, the area should be kept clean by suctioning, or by altering patient position if required. Perforations 1-2 cm in size can be closed using OTSCs. Excessive bleeding or larger tears can be addressed using a fully covered SEMS.
Leaks that occur in the ensuing days after the procedure should be closed using TTSCs, OTSCs, or endosuturing, followed by putting in a fully covered stent. Esophageal fistula should be addressed with a fully covered stent with a tight fit.
Endoscopic vacuum therapy is a newer technique to address large or persistent esophageal perforations. A review found it had a 96% success rate for esophageal perforations.
Gastric perforations
Gastric perforations often result from peptic ulcer disease or ingestion of something caustic, and it is a high risk during EMR and ESD procedures (0.4%-0.7% intraprocedural risk). The proximal gastric wall isn’t thick as in the gastric antrum, so proximal endoscopic resections require extra care. Lengthy procedures should be done under anesthesia. Ongoing gaseous insufflation during a perforation may worsen the problem because of heightened intraperitoneal pressure. OTSCs may be a better choice than TTSCs for 1-3 cm perforations, while endoloop/TTSC can be used for larger ones.
Duodenal and periampullary perforations
Duodenal and periampullary perforations occur during duodenal stricture dilation, EMR, endoscopic submucosal dissection, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography (ECRP). The thin duodenal wall makes it more susceptible to perforation than the esophagus, stomach, or colon.
Closing a duodenum perforation can be difficult. Type 1 perforations typically show sudden bleeding and lumen deflation, and often require surgical intervention. Some recent reports have suggested success with TTSCs, OTSCs, band ligation, and endoloops. Type 2 perforations are less obvious, and the endoscopist must examine the gas pattern on fluoroscopic beneath the liver or in the area of the right kidney. Retroperitoneal air following ERCP, if asymptomatic, doesn’t necessarily require intervention.
The challenges presented by the duodenum mean that, for large duodenal polyps, EMR should only be done by experienced endoscopists who are skilled at mucosal closure, and only experts should attempt ESD. Proteolytic enzymes from the pancreas can also pool in the duodenum, which can degrade muscle tissue and lead to delayed perforations. TTSC, OTSC, endosuturing, polymer gels or sheets, and TTSC combined with endoloop cinching have been used to close resection-associated perforations.
Colon perforation
Colon perforation may be caused by diverticulitis, inflammatory bowel disease, or occasionally colonic obstruction. Iatrogenic causes are more common and include endoscopic resection, hot forceps biopsy, dilation of stricture resulting from radiation or Crohn’s disease, colonic stenting, and advancement of colonoscope across angulations or into diverticula without straightening the endoscope
Large perforations are usually immediately noticeable and should be treated surgically, as should hemodynamic instability or delayed perforations with peritoneal signs.
Endoscopic closure should be attempted when the perforation site is clean, and lower rectal perforations can generally be repaired with TTSC, OTSC, or endoscopic suturing. In the cecum, or in a torturous or unclean colon, it may be difficult or dangerous to remove the colonoscope and insert an OTSC, and endoscopic suturing may not be possible, making TTSC the only procedure available for right colon perforations. The X-Tack Endoscopic HeliX Tacking System is a recently introduced, through-the-scope technology that places suture-tethered tacks into tissue surrounding the perforation and cinches it together. The system in principle can close large or irregular colonic and small bowel perforations using gastroscopes and colonoscopes, but no human studies have yet been published.
Conclusion
This update was a collaborative effort by four endoscopists who felt that it was timely to review the issue of perforations since they can be serious and challenging to manage. The evolution of endoscopic techniques over the last few years, however, has made the closure of spontaneous and iatrogenic perforations much less fear provoking, and they wished to summarize the approaches to a variety of such situations in order to guide practitioners who may encounter them.
“Although perforation is a serious event, with novel endoscopic techniques and tools, the endoscopist should no longer be paralyzed when it occurs,” the authors concluded.
Some authors reported relationships, such as consulting for or royalties from, device companies such as Medtronic and Boston Scientific. The remaining authors disclosed no conflicts.
This article was updated Oct. 25, 2021.
FROM THE CLINICAL GASTROENTEROLOGY AND HEPATOLOGY