Ambulatory Colonoscopy Research Articles

Right-side diverticulitis.

Colonic diverticula develop at specific weak spots, where the vasa recta enter the colonic circular smooth muscle layer.1 They are usually seen in the left colon. Their most common complication is diverticulitis, with mild cases resolving even without antibiotic therapy.2 Right-side diverticulitis develops in only 1.5% of cases, primarily on the anterior aspect of the cecum, proximal to the ileocecal valve (80%).4 Given its low incidence, location, and the fact that it involves younger patients, a differential diagnosis is needed to rule out abdominal inflammatory conditions such as appendicitis or ileitis, as well as gynecological disorders. Diverticulitis is diagnosed using imaging modalities. Computed tomography (CT) is the modality of choice,5 and confirmation is required after clinical remission, primarily using colonoscopy. We studied a series of 3 cases of patients initially diagnosed with acute, uncomplicated right-side diverticulitis who were admitted to the Gastroenterology Department, Hospital de León, from January to December 2023. Our goal was to confirm a presumptive diagnosis of right-side diverticulitis using delayed endoscopy or barium enema to ascertain the presence of right-side diverticulosis and rule out other conditions manifesting with abdominal pain in the right iliac fossa. Cases 1 and 3 were admitted with an accurate diagnosis of right-side diverticulitis. Case 1 was confirmed by ambulatory colonoscopy, and case 3 was confirmed by barium enema because of a history of previous colonoscopy without findings. All three patients required surgical assessment to rule out appendicular involvement. The imaging technique of choice was CT, using the WSES scale for severity grading. Case 2 was diagnosed with right-side diverticulitis by means of ultrasonography, and its origin was later confirmed to be in the sigmoid colon. The remaining clinical, laboratory, and diagnostic characteristics are listed in Table 1.

How to manage lower gastrointestinal bleeding in 2022?

Lower gastrointestinal bleeding (LGIB), originating mainly in the colon, rectum and anus, occurs most often in older patients (7th decade) with co-morbidity, half of whom have coagulation abnormalities due to anti-coagulant or anti-aggregant therapy. In three cases out of four, bleeding regresses spontaneously but can recur in up to one third of patients. The main causes are diverticular disease, vascular disorders (hemorrhoids, angiodysplasia) and colitis. Ten to 15% of patients present in hypovolemic shock. The main problem is to determine the precise location and etiology of bleeding. First-line steps include correction of hemodynamics, correction of coagulation disorders and transfusion, as necessary. Rectal digital examination allows differentiation between melena and hematochezia. In patients with severe LGIB, upper endoscopy can eliminate upper gastro-intestinal bleeding (UGIB). Computerized tomography (CT) angiography can pinpoint the source. If contrast material extravasates, the therapeutic strategy depends on the cause of bleeding and the general status of the patient: therapeutic colonoscopy, arterial embolization and/or surgery. In the absence of severity criteria (Oakland score≤10), ambulatory colonoscopy should be performed within 14 days. Discontinuation of anticoagulant and/or antiplatet therapy should be discussed case by case according to the original indications.

Remimazolam: Is the quest for the holy grail of sedation during diagnostic or endoscopic interventions over?

Remimazolam: Is the quest for the holy grail of sedation during diagnostic or endoscopic interventions over?

Risk of ambulatory colonoscopy in patients with cirrhosis: a propensity-score matched cohort study.

Background and study aims Patients with cirrhosis demonstrate alterations in physiology, hemodynamics, and immunity which may increase procedural risk. There exist sparse data regarding the safety of performing ambulatory colonoscopy in patients with cirrhosis. Patients and methods From a population-based sample of three North American states (California, Florida, and New York), we collected data on 3,590 patients with cirrhosis who underwent ambulatory colonoscopy from 2009 to 2014. We created a control cohort propensity score-matched for cirrhotic severity who did not undergo colonoscopy (N = 3,590) in order to calculate the attributable risk for adverse events. The primary endpoint was the rate of unplanned hospital encounters (UHEs) within 14 days of colonoscopy (or from a synthetic index date for the control cohort). Predictors for UHE were assessed in multivariable regression. Results The attributable risk for any UHE following colonoscopy was 3.1 % (confidence interval [CI] 2.1–4.1 %, P < 0.001). There was increased risk for infection (0.9 %, CI 0.7–1.1 %), spontaneous bacterial peritonitis (0.1 %, CI 0.0–0.3 %), decompensation of ascites (0.3 %, CI 0.2–0.4 %), and cardiovascular event (0.4 %, CI 0.3–0.5 %). There was no increased attributable risk for gastrointestinal bleeding, perforation, or development of the hepatorenal syndrome. The presence of ascites at time of procedure was the only predictor for UHE in the fully-adjusted model (OR 2.6, CI 1.9–3.5, P < 0.001). Conclusions There is a moderate though detectable increase in risk for adverse event following ambulatory colonoscopy in patients with cirrhosis. The presence of ascites in particular portends higher risk. These data may guide clinicians when counseling patients with cirrhosis on the choice of colorectal cancer screening modality.

Symptoms and demographic factors associated with early-onset colorectal neoplasia among individuals undergoing diagnostic colonoscopy.

The incidence and mortality of colorectal cancer (CRC) are increasing in adults under 50 years. Risk factors associated with early-onset colorectal neoplasia (CRN) are uncertain. We aimed to identify clinical predictors associated with the presence of CRN detected by diagnostic colonoscopy in symptomatic individuals under 50 years of age. We used a single-center endoscopy database to identify symptomatic patients 18-49 years of age who underwent ambulatory colonoscopy between 2007 and 2017. Pathology reports identified CRN as adenomas, advanced adenomas (based on size or histology), or adenocarcinomas. Multivariable analysis was used to determine factors associated with CRN. We identified 4333 eligible patients of whom 363 (8.4%) had any CRN and 48 (1.1%) had advanced neoplasia (advanced adenoma or adenocarcinoma). Factors associated with any CRN on multivariable analysis included male sex [odds ratio (OR) 1.50 (1.19-1.88)], older age group [compared to 18-29 years, OR for 30-39: 3.12 (1.93-5.04); OR for 40-49: 4.68 (2.97-7.36)], obesity [OR for BMI 30-34.9 compared to 18-24.9: 1.44 (1.04-2.01)], and any tobacco use [OR 1.63 (1.18-2.23)]. Anemia was associated with advanced neoplasia [OR 3.11 (1.32-7.34)]. Of the advanced neoplastic lesions, 38 of 48 (79.2%) were located in the distal colon. In the largest study to date of symptomatic individuals under 50 years of age undergoing colonoscopy in the USA, advanced CRN was most often detected in the distal colon and was associated with anemia, but not with abnormal bowel habits or abdominal pain. We also found that patients with CRN under 50 years of age were more likely to be male, smokers, and obese. These findings should prompt further investigation of these risk factors alone and in combination.

Discharge Readiness after Propofol with or without Dexmedetomidine for Colonoscopy

Enhanced recovery protocols employ various approaches to minimize detrimental side effects of anesthetizing agents. The authors tested the hypothesis that adding low-dose dexmedetomidine to propofol for anesthesia in ambulatory colonoscopies, compared with propofol alone, would lower the propofol requirement, improve the intra-procedure hemodynamic state, and not increase time-to-discharge. In this noninferiority, double-blind, randomized controlled trial, patients having colonoscopies received total IV anesthesia either with propofol and placebo (n = 50), or propofol and a bolus dose of dexmedetomidine, 0.3 μg/kg (n = 51). Additional propofol was administered to maintain a Bispectral Index score of 60. Following the procedure, readiness for discharge was assessed regularly using the Modified Post Anesthetic Discharge Scoring System until discharge criteria were met. The primary outcome was the percentage of patients meeting discharge criteria within 30 min from procedure end-time. Twenty-six of 51 (51%) patients receiving propofol-dexmedetomidine were ready for discharge by 30 min from procedure end time, compared with 44 of 50 (88%) receiving propofol (P < 0.001). Propofol consumption was lower in subjects receiving propofol-dexmedetomidine (140 μg · kg(-1) · min(-1)) compared to those receiving propofol (180 μg · kg(-1) · min(-1)) with P = 0.011. The lowest mean arterial pressure decreased further from baseline in those receiving propofol-dexmedetomidine (-30%; mean decrease -30 ±10.5 mmHg) compared to propofol (-21%; mean decrease, -22 ± 14.2 mmHg) with P = 0.003. There was no difference in incidence of bradycardia, with sustained bradycardia occurring in 3 of 51 (6%) patients receiving propofol-dexmedetomidine compared to 1 of 50 (2%) patients receiving propofol (P = 0.62). No apnea episodes requiring positive-pressure ventilation occurred in either group. For anesthesia in ambulatory colonoscopy, combining low-dose dexmedetomidine with propofol delayed discharge readiness and provoked hypotension compared to propofol alone.

Ambulatory colonoscopy under sedoanalgesia in adult patients with and without irritable bowel syndrome: A prospective, cross-sectional, and double-blind comparison.

It is unclear whether patients with irritable bowel syndrome (IBS) require a high dose of sedatives during colonoscopy. In this study, we investigated the pre-procedural anxiety levels, sedative consumption, procedure times, complications, and patient's satisfaction between patients with IBS and controls for ambulatory colonoscopy under sedation. Rome III criteria were used in the diagnosis of IBS. Anxiety levels were measured using Spielberger's State-Trait Anxiety Inventory (STAI) and Beck Anxiety Inventory (BAI). Patients received a fixed dose of midazolam (0.02 mg/kg), fentanyl (1 μg/kg), ketamine (0.3 mg/kg), and incremental doses of propofol under sedation protocol. Demographic data, heart rate, blood pressure, and oxygen saturation were measured. Procedure times, recovery and discharge times, drug doses used, complications associated with the sedation, and patient's satisfaction scores were also recorded. The mean Trait (p=0.015), State (p=0.029), Beck anxiety scores (p=0.018), the incidence of disruptive movements (p=0.044), and the amount of propofol (p=0. 024) used were significantly higher in patients with IBS. There was a decline in mean systolic blood pressure at the 6th minute in patients with IBS (p=0.026). No association was found between the sedative requirement and the anxiety scores. Patients with IBS who underwent elective colonoscopy procedures expressed higher pre-procedural anxiety scores, required more propofol consumption, and experienced more disruptive movements compared with controls. On the contrary, the increased propofol consumption was not associated with the increased pre-procedural anxiety scores.

Prospective study of the factors associated with poor tolerance to ambulatory colonoscopy under conscious sedation.

conscious sedation with benzodiazepines and opiates for colonoscopy is a widespread clinical practice. to determine the patient's tolerance to colonoscopy and identify the factors associated with lower tolerance. a prospective, single-center, descriptive study of patients undergoing ambulatory colonoscopy under conscious sedation. The pain was assessed using a visual analogue scale with a score of 0 to 100 and also qualitatively. three hundred patients with a median age of 54 years completed the study (p25-75: 45-64); 138 were men (46%). Tolerance was good in 273 cases (91%). The median value of tolerance was 13 (p25-p75: 4-33). Pain was considered as mild in 215 (71.7%), moderate in 57 (19%) and intense in 28 (9.3%). In the univariate study, greater pain was associated with females, anxiety, the indication for the procedure, the length of time and difficulty of the examination, and the doses of sedatives. In the multivariate study, both the indication (OR 2.92, 95% CI = 1.03-8.2, p < 0.05) and the difficulty of the examination (OR 4.68, 95% CI = 1.6-13.6, p < 0.01) were significant. Complications were found in 16 patients (5.3%), although all of them were insignificant. tolerance of patients undergoing ambulatory colonoscopy under conscious sedation is good in most cases and complications are infrequent and minor. A worse tolerance to the test is associated with women patients, individuals with anxiety prior to colonoscopy, indication, difficult and longer exploration and lower doses of sedatives.

Obstructive Sleep Apnea Increases the Risk of Cardiopulmonary Adverse Events Associated with Ambulatory Colonoscopy Independent of Body Mass Index.

The relationship between body mass index (BMI) and cardiopulmonary adverse events (CAEs) for ambulatory colonoscopy is unclear. To assess the association of BMI and CAEs associated with ambulatory colonoscopy. This is a retrospective cohort analysis of 418 patients who underwent outpatient colonoscopy at the Durham Veterans Affairs Medical Center categorized as normal/overweight (BMI<30), obese (BMI 30-34), or morbidly obese (BMI≥35). Adjusted logistic regression analyses were performed. At least one CAE occurred in 46.4% of patients (220 events, 72.7% were hypoxia). The rate of CAEs (BMI<30: 43.8%, BMI 30-34: 48.0%, BMI≥35: 50.6%, p=0.53) and rate of hypoxia (BMI<30: 34.8%, BMI 30-34: 40.9%, BMI≥35: 43.2%, p=0.32) were numerically higher for obese and morbidly obese patients, but not statistically significant. Obese (OR 1.10, 95% CI 0.70-1.73) and morbidly obese (OR 1.07, 95% CI 0.61-1.85) patients did not have an increased risk of CAEs after adjusting for age, ASA class, obstructive sleep apnea (OSA), and type of sedation. OSA was independently associated with an increased risk of CAEs (OR 1.71, 95% CI 1.09-2.74, p=0.02) after adjusting for BMI, age, ASA class, and type of sedation. OSA confers a higher risk of CAEs independent of BMI and sedation type. Consideration of undiagnosed OSA is recommended for appropriate pre-procedure risk stratification. While not statistically significant in this study, there may be clinically significant increased risks of CAEs and hypoxia for patient with BMI>30 that require further evaluation with larger studies.

Caudal Anaesthesia in Ambulatory Colonoscopy: Lidocaine Only vs. Lidocaine/fentanyl Combination

Background: This study aimed to compare the analgesic effects of caudal anaesthesia in patients undergoing ambulatory colonoscopy using lidocaine only or lidocaine/fentanyl combination. Methods: Fifty-one consecutive adult patients scheduled for colonoscopy participated in the study. Participants were randomly allocated into two equal groups (A and B). Caudal anaesthesia was instituted in both groups with 1.5% preservative free lidocaine (19.4 ml); 0.6 ml of normal saline was added in Group A and 30 mcg of fentanyl made to 0.6 ml in Group B. The time of onset and height of caudal block, Numeric Pain Rating Scale (NPRS) score at different stages during colonoscopy were evaluated and compared. The number of patients requiring rescue analgesia (fentanyl/midazolam) were also evaluated and compared. Results: Twenty-six patients in the saline-lidocaine group (A) and twenty-five patients in the fentanyl-lidocaine group (B) completed the study. The mean and standard deviation of the caudal block onset time (minute) in group A was 11.71 ± 4.26 comparable to group B which was 13.50 ± 4.85, p=0.15. The median NPRS while navigating the splenic flexure was 2 in group A and 3 in group B; and while navigating the hepatic flexure it was 5 in group A and 3 in group B. But p values are 0.285 and 0.031 respectively. Rescue analgesia was employed in fewer number of patients in group B (16%) compared to group A (34.6%). Conclusion: Caudal epidural block with lidocaine/fentanyl combination provided superior, safe and satisfactory anaesthesia for ambulatory colonoscopy.

Obstructive Sleep Apnea Is Not Associated with Higher Health Care Use after Colonoscopy under Conscious Sedation.

The use of sedation allows medical procedures to be performed outside the operating room while ensuring patient comfort and a controlled environment to increase the yield of the procedure. There is concern about a higher risk of adverse events with use of sedation in patients with obstructive sleep apnea. We aimed to determine if the presence of obstructive sleep apnea increased the risk of hospitalization and/or health care use after patients received moderate conscious sedation for an elective, ambulatory colonoscopy. We conducted a retrospective case-control database and chart review study. We compared hospital admissions, intensive care unit (ICU) admissions, and emergency room visits at 24 hours, 7 days, and 30 days in patients with obstructive sleep apnea (n = 3,860) and without obstructive sleep apnea (n = 2,374) who had undergone an elective, ambulatory colonoscopy with sedation. We found no significant differences in hospital admissions, ICU admissions, or emergency room visits between the two groups at any time point within the 30 days following the procedures. In a sensitivity analysis in which we compared 827 individuals with polysomnographically confirmed sleep apnea with control subjects, there was still no difference in hospital admissions, ICU admissions, or emergency room visits in the 30 days after receiving sedation for the procedure. Outcomes were not different in individuals with various severities of obstructive sleep apnea. The presence of obstructive sleep apnea was not associated with increased early hospital admissions, ICU admissions, or emergency room visits after colonoscopy with sedation.

Prevalence of obstructive sleep apnea in an ambulatory colonoscopy clinic

Prevalence of obstructive sleep apnea in an ambulatory colonoscopy clinic

Sedentary Behavior and Colorectal Adenoma – Is it a Risk Factor Independent of Physical Activity?

Colorectal cancer is associated with a sedentary lifestyle. Emerging evidence indicate that sedentary behavior is distinct from physical inactivity (ie. too much sitting vs too little exercise) and may have physiologically distinct effects. Prolonged sedentary time is associated with increased all-cause mortality and colorectal carcinoma independent of physical activity levels. The relationship with colorectal adenoma, however, is less well defined. The objective is to determine whether colorectal adenoma are associated with sedentary behavior (defined by sitting hours) independent of physical activity levels. A cross-sectional study was performed as per STROBE guidelines. Eligible subjects (Table 1, Eligibility criteria), aged 45-70 years, scheduled for ambulatory colonoscopy, were prospectively recruited from December 2013 to January 2015. Interviews and anthropometric assessment was conducted by research coordinators. Physical activity data was collected using the validated IPAQ Long questionnaire. Physical activity was characterized both as continuous and categorical variables. Sedentary time was separately measured using the total time reported sitting per week. Baseline assessment was performed prior to colonoscopy to avoid bias. All colonoscopies were performed by gastroenterologists from a tertiary hospital. All polyps were removed or biopsied if removal was not feasible. Histology was reported by a pathologist blinded to the anthropometric and physical activity data. Continuous and categorical data were summarized by median (interquartile range) and frequency (proportion) respectively. Logistic regression was used to identify risk factors of adenoma. 124 patients undergoing colonoscopies were analyzed. 26 patients (21%; 95% CI: 14.7% to 29.0%) had adenoma. Baseline characteristics are reported in Table 2. There was no difference in sitting hours between patients with and without adenoma (2520 vs 2250 minutes, P = .711) after correction for potential confounders (ie, age, gender, obesity, physical activity, smoking).

The Burden of Bowel Preparation on Patients’ Quality of Life: The Elephant in the Colonoscopy Room!

Introduction: An adequate bowel preparation is essential for optimal colonoscopy, yet colon preparations are generally poorly tolerated. Although traditionally described in terms of solution administered, many additional elements are involved in the preparation. These include various dietary modifications and specific time allocation leading to important adjustments in social or work schedule and impacting the immediate pre-procedural quality of life (QoL), which often goes unregistered in clinical trials. We aimed to study the effect of bowel preparations on pre-procedural QoL by examining 7 specific variables (hunger, taste, volume, sleep, social, work, and adverse events). Methods: Patients scheduled for elective ambulatory colonoscopy were asked to complete a questionnaire regarding their experience with the prescribed bowel preparation. Diet liberation was allowed with split-dose PEG (4L PEG or 2L Moviprep®) while full-dose PEG consumers had to adhere to a clear fluid diet after breakfast. Sodium picosulfate recipients had to follow 2 days of low-fiber diet and 1 day of clear fluids prior to examination. The questionnaire was administered by 2 research assistants. The 7 aforementioned variables were graded using a visual scale of 0-10 (best to worst). A score ≥7 was considered to indicate a significant negative impact and was used as primary outcome. Patients were also asked to grade in descending order what they perceived as the worst aspect of the preparation. Results: Two hundred sixteen patients completed the survey. Preparations consisted of split-dose sodium picosulfate (SPS; n=49), 4L split-dose PEG±menthol (n=49), full-dose PEG (n=68), and 2L split-dose Moviprep® (M; n=50). With the exception of work and adverse effects, all other variables were considered to have a negative impact by >20% of patients (range: 20.4-34.2). SPS was superior to the PEG regimens in taste (4.1% vs. 35.9%) and volume (0% vs. 44.9%; p<0.05 for both) but was inferior for hunger (30.6% vs. 19.2%; p=0.09). The addition of menthol to PEG resulted in a significant improvement of taste perception (22.4% vs. 41.5%; p=0.02). Sleep disturbances were most common with SPS and least with split-dose PEG (30.6% vs. 17.4%; p<0.05). Overall, patients ranked volume, taste, and hunger as most burdensome. Conclusion: The burden of bowel preparation is substantial with greater than 20% of patients reporting considerable disturbance in pre-procedural QoL. Taste and volume aversions are conspicuously absent with low-volume sodium picosulfate but are important limitations of PEG preparations. Compared to split-dose PEG regimens, low-volume sodium picosulfate is significantly limited by hunger levied by dietary restriction and by disturbed sleep.

Sa1535 Gastroenterologist-Administered Balanced Propofol Sedation (Bps) Is Safe and Effective for Ambulatory Colonoscopy Procedures

Given its rapid onset and short duration of action, Propofol is an appealing and effective drug for endoscopic procedures. Current product labeling dictates its administration only in the presence of personnel trained in administering general anesthesia. However, studies have shown that Propofol can be safely administered by a Propofol-trained endoscopy team. We aimed to evaluate the safety of gastroenterologist-administered BPS consisting of fentanyl, midazolam and propofol without an anesthesiologist or nurse anesthetist present, during ambulatory colonoscopy procedures.

Double-blind prospective randomized study comparing polyethylene glycol to lactulose for bowel preparation in colonoscopy

BackgroundColonoscopy is the most frequent exam used to evaluate colonic mucosa, allowing the diagnosis and treatment of many diseases. The appropriate bowel preparation is indispensable for the realization of colonoscopy. Therefore, it is necessary the use of laxative medications, preferentially by oral administration.AimTo compare two medications used in bowel preparation in adult patients going to ambulatory colonoscopy and to analyze the patients' profile.MethodsA double-blind prospective study with 200 patients, randomized in two groups: one that received polyethilene glycol and another that received lactulose. The patients answered to questionnaires to data compilation, as tolerance, symptoms and complications related to preparation. Besides, it was also evaluated the prepare efficacy related to the presence of fecal residue.ResultsIntestinal habit alterations and abdominal pain were the main reasons to realize the exams and hypertension was the most prevalent comorbidity. Ten percent of the ones who received lactulose didn't get to finish the preparation and 50% considered the taste "bad, but tolerable". The most common subjective symptom after the medication was nausea, especially after lactulose. During the exam, most of the patients who used lactulose had a "light discomfort" and the ones who used polyethilene glycol considered the discomfort as "tolerable". The quality of the preparation was good in 75%, undependable of the medication that was used.ConclusionPolyethilene glycol was more tolerable when compared to lactulose, without difference on the quality of the preparation.

Comparison between insufflation with air or carbon dioxide during the colonoscopy in sedated patients with propofol

compare the intensity of pain experienced after colonoscopy with air or with CO₂ and evaluate the safety of CO₂ in colonoscopies performed with moderate/deep sedation. individuals undergoing ambulatory colonoscopy without exclusion criteria (severe respiratory disease, morbid obesity) were randomized in air or CO₂ group. We recorded different variables prior to, during and upon completion of the colonoscopy, performing monitoring using pulse oximetry and capnography. Each patient rated, using a visual numeric scale, the intensity of post-colonoscopy pain at different moments. 141 individuals in the air group (sex M/F 63/78, age 24-83) and the CO₂ group (sex M/F 59/70, age 24-82). No significant differences existed in the recorded variables in both groups except for the greater number of explorations performed by an endoscopist in training (TE) in the air group compared to those by a more experienced endoscopist (SE). CO2 in expired air, episodes of oxygen desaturation and of apnoea and dose of propofol, of midazolam were similar in both groups. No episodes of hypercapnea or any complication requiring cardiopulmonary resuscitation measures were recorded. The pain in the air group was significantly higher at 15 minutes and at 1, 3 and 6 hours after the endoscopy, equalising at 24 hours. After multivariant adjustment for type of doctor (TE vs. SE) the differences observed in pain intensity for each group were maintained. a) the use of CO₂ in colonoscopy causes significantly less pain in the first 6 hours after the procedure; b) its use in patients with moderate/deep sedation is safe; and c) performance of the endoscopic technique is not modified, nor are times reduced.

A Randomized Controlled Trial Comparing Participation and Diagnostic Yield in Colonoscopy and CT-Colonography for Population Based Colorectal Cancer Screening

Background: Semi-quantitative immunochemical fecal occult blood tests (I-FOBT) are increasingly used for colorectal cancer (CRC) screening. Their true performance characteristics have been determined clinically or sometimes by colonoscopy as “gold standard”. However, occasionally colonoscopy has false-negative results for CRC & Cancer Registry follow-up can provide information relevant to both tests. Aims: Evaluate true performance characteristics of both I-FOBT & colonoscopy examinations for detecting CRC & advanced adenomatous polyps (AAP). Methods: We reanalyzed a published file of ambulatory colonoscopy patients who also prepared 3 I-FOBTs processed by OC-MICRO automated instrument (Eiken, Tokyo, Japan) with ≥50ngHb/mL buffer in any test determining positivity (Rozen P, et al Cancer 2010). These patients were followed through the Israel National Cancer Registry (INCR) to identify newly diagnosed CRC. Analyses of sensitivities for CRC & AAP refer to results of I-FOBTs & initial colonoscopy. Results: 1630 persons performed both IFOBT & total colonoscopy, mean age 62.7 years, SD 11.9 & 50.1% males. They were followed through the INCR for mean 44.3 months SD13.4 & during this period 25 CRC patients were identified, 41% in the proximal colon & 86% were Stages 1 or 2. Follow-up Data Within 12 months both colonoscopy & I-FOBTs identified 21/22 CRCs, 2 initially classified as AAPs; neither test identified a Stage 1 rectal CRC. Between 12-24 months 2 more CRCs were diagnosed, both had elevated I-FOBTs & initially been identified as AAPs. Between 25-48 months a CRC was diagnosed after 47 months, it did not have elevated IFOBT & initially been identified as AAP. Analyses: At 1 year, sensitivity for CRC by both I-FOBT & initial colonoscopy was 95.5% (95%CI 86.8, 104) & at 24 months & 36 months it was 95.8% (95%CI 87.8, 104). Within 48 months sensitivity for CRC by I-FOBT was 92% (95%CI 81.4, 103) & 96% by colonoscopy. At 1 year 121 patients were identified as having AAPs, I-FOBT was positive in 70, & so had a sensitivity of 63.6% (95%CI 55.8, 71.5) for all significant neoplasms, CRC or AAP. At 24 months I-FOBT had a sensitivity of 63.2% (95%CI 55.8, 71.5) for all significant neoplasms. Conclusions: In this population, neither initial colonoscopy nor I-FOBTs identified all CRC patients. I-FOBTs examined at 50ngHb/mL buffer threshold identified almost all CRC diagnosed within 36 months. Colonoscopy identified most significant neoplasms, but only by clinical follow-up & repeated colonoscopy were AAPs reclassified correctly as CRCs. From this small but carefully documented study, it would be appropriate to repeat I-FOBTs after 1 year so as to identify any CRC missed initially by either test.

Intra- and inter-species spread of carbapenemase genes in a non-hospitalized patient

The purpose of this study was to report intra- and inter-species spread of carbapenemase genes between gram negative rods isolated from a non-hospitalized patient with bacteremia. The approach included chart review, antibiotic susceptibility testing and phenotypic screening for metallo-β-lactamase (MBL) detection, PCR and sequencing of bla, aac(6')-Ib and qnr genes, and plasmid analysis by PCR-based replicon typing. The clonal relationships between the isolates were analysed by comparing PFGE profiles. A non-hospitalized patient presented bacteraemia due to wild type Enterobacter cloacae (4.08), a VIM-1-producing E. cloacae (5.08), a VIM-1- and CTX-M-9-producing E. cloacae (7.08), a VIM-2-producing Pseudomonas aeruginosa, and catheter colonization by VIM-1-producing Klebsiella oxytoca. The patient had no previous hospitalization but had recently undergone an ambulatory colonoscopy. In E. cloacae 7.08 and K. oxytoca isolates, the bla(VIM-1) gene was located on a transferable plasmid of 48.5 kb, while in E. cloacae 5.08 the bla(VIM-1) gene was encoded on a 194 kb non-transferable plasmid. The bla(CTX-M-9) gene detected in E. cloacae was encoded on an HI2 plasmid of 290 kb. To date the prevalence of VIM-1 enzymes in the community is low. This molecular finding suggests an intra-species and/or inter-species horizontal spread of the MBL gene in the same non-hospitalized patient.

Opportunity Costs of Gastrointestinal Endoscopic Training in Canada

No data exist to define the opportunity costs related to instruction in endoscopic procedures in Royal College of Physicians and Surgeons of Canada-accredited teaching centres. Academic and institutional administrators expect staff to achieve acceptable performance standards. There is a need to measure some of the effects of training activity in the establishment of such standards. To measure the effect of resident training in colonoscopy on real procedure times and, as a secondary goal, to estimate procedural losses related to the process of training. Real procedure times for ambulatory colonoscopy in a single academic, hospital-based endoscopy unit were documented. Times for certified endoscopy instructors functioning solo were compared with times for procedures involving trainees at several levels of colonoscopic experience. Procedural reductions associated with resident training were estimated based on the parameters derived from the results. The analysis was executed retrospectively using prospectively collected data. Resident training prolonged procedure times for ambulatory colonoscopy by 50%. The trainee effect was consistent, although variable in degree, among a variety of endoscopy instructors. Such increased procedure times have the potential to reduce case throughput and endoscopist remuneration. Resident training in colonoscopy in a Canadian certified training program has significant negative effects on case throughput and endoscopist billings. These factors should be considered in any assessment of performance in similar training environments.