Colonoscopy Research Articles

Cost-effectiveness of waiving coinsurance for follow-up colonoscopy after a positive stool-based colorectal screening test in a Medicare population.

e13624 Background: Commercial insurance plans are required to cover, with no patient cost sharing, a follow-up colonoscopy (COL) after a positive stool-based colorectal cancer (CRC) screening test. Medicare beneficiaries may still be responsible for 20% coinsurance for a follow-up COL, posing a financial barrier to screening completion. Removing the coinsurance may increase screening adherence and improve outcomes. The estimated cost-effectiveness of stool-based CRC screening was compared among adherence scenarios that assumed the status quo (20% coinsurance for follow-up COL) or waived follow-up COL coinsurance. Methods: The CRC-AIM microsimulation model simulated US Medicare beneficiaries undergoing stool-based CRC screening between ages 65-75 years. Outcomes of total costs, total quality adjusted life years (QALYs), life-years gained (LYG), CRC incidence reductions (IR), and CRC mortality reductions (MR) were calculated per 1000 individuals versus no screening using the weighted average of the outcome with multitarget stool DNA, fecal immunochemical test, and fecal occult blood test, scaled by their estimated use. Costs of follow-up COL were assumed to have 20% coinsurance in the status quo scenario. Four comparative scenarios assumed that waiving coinsurance increased published, real-world stool-based screening or follow-up COL adherence rates by 5% or 10%. Results: In scenarios where waiving coinsurance was assumed to increase screening and/or follow-up COL adherence, up to 21 more LYG and greater IR and MR were observed vs the status quo (Table). Total costs in waived coinsurance scenarios (≥$6,398) were comparable to the status quo ($6,449) as the cost savings in CRC care offset the increased COL costs. Total QALYs in waived coinsurance scenarios (≥9.3671) were greater than the status quo (9.3643) because of improved clinical outcomes. Stool-based testing in waived coinsurance scenarios was either dominant (more effective and less costly) or cost-effective at $50,000/QALY with minimal incremental costs vs the status quo. Conclusions: In a simulated Medicare population, clinical CRC outcomes improved and stool-based screening was cost-effective or cost-saving when waiving the 20% coinsurance was assumed to modestly (5%) increase adherence rates for total CRC screening and/or a COL following a positive test. [Table: see text]

Cost-effectiveness of mt-sDNA versus mailed FIT outreach for Medicare Advantage enrollees using the CRC-AIM microsimulation model.

e18827 Background: Despite proven effectiveness in reducing colorectal cancer (CRC) cases, screening for CRC remains underutilized, including those enrolled in Medicare Advantage. A mailed fecal immunochemical test (FIT) outreach program may increase CRC screening adherence. This study examined the cost-effectiveness of stool-based tests (FIT and multi-target stool DNA [mt-sDNA]), with FIT offered via a mailed outreach program, in a Medicare Advantage population. Methods: The validated CRC-AIM microsimulation model was used to simulate the costs and clinical outcomes of 2 million average-risk individuals, free of diagnosed CRC at age 40, who initiated CRC screening at age 65. Annual mailed FIT outreach and triennial mt-sDNA were assessed. Test sensitivity and specificity inputs were based on the 2021 United States Preventative Services Task Force modeling study. FIT outreach program cost ($25.92) and direct costs for screening tests, colonoscopies (COLs), complications, and CRC care were included. The model employed a lifetime horizon, 3% discount rates, and a Medicare Advantage perspective. The primary analysis used published real-world adherence rates for stool-based tests and follow-up COLs (FIT/COL: 29%/53%; mt-sDNA/COL: 69.8%/71.5%). Secondary analyses assumed 100% adherence for stool-based tests and/or follow-up COLs and 20% higher than primary analysis for FIT and the corresponding follow-up COLs. Results: In the primary analysis, mt-sDNA had the greatest life-years gained (LYG), incidence reduction (IR), and mortality reduction (MR) and was cost-effective at a willingness-to-pay threshold of $50,000/QALY compared to mailed FIT outreach (Table). This was true when 100% adherence was assumed for follow-up COL and when FIT had 20% higher adherence than the primary analysis. mt-sDNA had 64-129% greater LYG, 79-150% greater IR, and 68-146% greater MR than mailed FIT outreach. When assuming 100% adherence for both screening test and follow-up COL, mt-sDNA was dominated by mailed FIT outreach. Conclusions: Adherence to CRC screening modality and follow-up COL greatly impacts clinical and cost-effectiveness outcomes. Future analysis should consider evidence-based, health plan-specific data to accurately reflect outcomes that aid in payer decision making.[Table: see text]

The Colon Wall Thickness Measured Using Transabdominal Ultrasonography Is Useful for Detecting Mucosal Inflammation in Ulcerative Colitis.

Objective Transabdominal ultrasonography (TUS) is a non-invasive procedure that is reportedly useful for managing ulcerative colitis (UC) and assessing bowel wall thickness (BWT), the most common measure of mucosal inflammation. However, the exact range of BWT that reflects disease activity remains undetermined. The present study clarified the BWT due to disease activity by comparing the use of TUS in each segment of the colon versus using colonoscopy (CS) and determined the usefulness of TUS in patients with UC. Methods We divided the colon into five segments and measured the BWT using TUS. The results were then compared to the Mayo endoscopic subscore (MES) classification to determine the accuracy of BWT measurement. Patients Eighty patients with UC who underwent TUS within 14 days of CS were retrospectively registered. Results We evaluated a total of 268 images depicting each segment among 80 patients with UC. The BWT was positively correlated with endoscopic activity (0.69, p＜0.0001). In each segment, the relationship between a BWT＞2 mm and an MES＞0 had the highest sensitivity, specificity, and accuracy (0.85-1.00, 0.67-0.92, and 0.81-0.97, respectively). Conclusion This study concluded that TUS was a useful method of detecting an MES＞0, which indicates the presence of inflammation and its location among UC patients. MES＞0 was found to be highly accurate when a BWT＞2 mm was considered positive. This non-invasive method may help control disease activity in patients with UC.

Cross-Sectional Imaging Instead of Colonoscopy in Inflammatory Bowel Diseases: Lights and Shadows.

International guidelines recommend a treat-to-target strategy with a close monitoring of disease activity and therapeutic response in inflammatory bowel diseases (IBD). Colonoscopy (CS) represents the current first-line procedure for evaluating disease activity in IBD. However, as it is expensive, invasive and poorly accepted by patients, CS is not appropriate for frequent and repetitive reassessments of disease activity. Recently, cross-sectional imaging techniques have been increasingly shown as reliable tools for assessing IBD activity. While computed tomography (CT) is hampered by radiation risks, routine implementation of magnetic resonance enterography (MRE) for close monitoring is limited by its costs, low availability and long examination time. Novel magnetic resonance imaging (MRI)-based techniques, such as diffusion-weighted imaging (DWI), can overcome some of these weaknesses and have been shown as valuable options for IBD monitoring. Bowel ultrasound (BUS) is a noninvasive, highly available, cheap, and well accepted procedure that has been demonstrated to be as accurate as CS and MRE for assessing and monitoring disease activity in IBD. Furthermore, as BUS can be quickly performed at the point-of-care, it allows for real-time clinical decision making. This review summarizes the current evidence on the use of cross-sectional imaging techniques as cost-effective, noninvasive and reliable alternatives to CS for monitoring patients with IBD.

Abstract PO-225: Patterns of colorectal cancer screening in the US: Analysis of the 2019 National Health Interview Survey

Abstract Introduction: Colorectal cancer (CRC) is the third most common cancer in the United States and, while there is growing conscience towards it, screening is still not widely adopted. Methodology: We used data from the 2019 National Health Interview Survey, which is a cross-sectional study that included 31,997 participants. We focused on the colorectal cancer screening module, and particularly on questions related to participants having ever had a colonoscopy (COL) or sigmoidoscopy (SIG). We then performed bivariate and multivariable analyses to assess the association between participants' variables and having had a COL or SIG. Results: In total, 22,025 participants answered the CRC screening module, and 13,383 participants (60.8%) had done a previous COL/SIG. Participants' sex was not associated with differences in the use of COL/SIG for CRC screening (OR=1.0, P=0.89). When assessing race, Hispanics (OR=0.9, P=0.03) and Asians (OR=0.7, P<0.001) had less odds for undergoing COL or SIG compared to Whites. In the education scope, participants with a college degree (63.2%), some college (62.8%), and high school graduates (58.6%) had undergone more COL or SIG than those with no school or incomplete high school (52.2%). Participants born in the U.S. had more COL or SIG performed than those who were not born in the U.S. (63.6% vs. 45.5%, respectively, P<0.05). Moreover, participants who do not have a usual place for healthcare underwent less COL/SIG for CRC screening (OR=0.3, P<0.001). When assessing insurance, participants with a private or military health insurance were at higher odds for having a COL or SIG, as opposed to any public insurance or no insurance at all (OR=0.8, 0.4, respectively; P<0.001 for both). On multivariable analysis, race, education, nativity in the U.S., insurance, and age were all independently associated with differences in the use of COL/SIG. Conclusions: Colonoscopy and sigmoidoscopy are widely used for CRC screening, however, differences in patterns of use still exist among various U.S. populations. Citation Format: Humberto R. Nieves-Jimenez, Isabela M. Bumanlag, Joseph Abi Jaoude, Ethan B. Ludmir, Cullen M. Taniguchi. Patterns of colorectal cancer screening in the US: Analysis of the 2019 National Health Interview Survey [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-225.

Follow-up outcomes in patients with negative initial colon capsule endoscopy findings.

BACKGROUNDColon capsule endoscopy (CCE), which became clinically applicable in 2006, is a simple and noninvasive procedure to evaluate colonic diseases; the accuracy of second-generation CCE, introduced in 2009, has dramatically improved. Currently, CCE is used as an alternative method for colorectal cancer screening, as well as for evaluating the mucosal lesions of inflammatory bowel disease, in cases where performing colonoscopy (CS) is difficult. However, the outcomes of CCE are uncertain. AIMTo investigate the outcomes of Japanese patients with negative findings (no polyps or colorectal cancer) on initial CCE. METHODSThis retrospective, single-center study was conducted at the Endoscopic Center at Aishinkai Nakae Hospital. This study included patients who underwent continuous CCE between November 2013 and August 2019, that exhibited no evidence of polyps or colorectal cancer at the initial CCE, and could be followed up using either the fecal immunochemical test (FIT), CS, or CCE. The observational period, follow-up method, presence or absence of polyps and colorectal cancer, pathological diagnosis, and number of colorectal cancer deaths were evaluated.RESULTSThirty-one patients (mean age, 60.4 ± 15.6 years; range, 28–84 years; 14 men and 17 women) were enrolled in this study. The reasons for performing the first CCE were screening in 12, a positive FIT in six, lower abdominal pain in nine, diarrhea in two, and anemia in two patients. The mean total water volume at the time of examination was 3460 ± 602 mL (2250–4800 mL), and a total CS was performed in 28 patients (90%). The degree of cleanliness was excellent in 15 patients and good in 16, and no poor cases were observed. No adverse events, such as retention or capsule aspiration, were observed in any of the patients. The mean follow-up period was 3.1 ± 1.5 years (range, 0.3–5.5 years). Follow-up included FIT in nine, CS in 20, and CCE in four patients (including duplicate patients). The FIT was positive in two patients, while CS revealed five polyp lesions (three in the ascending colon, one in the transverse colon, and one in the descending colon), with sizes ranging between 2 mm and 8 mm. Histopathological findings revealed a hyperplastic polyp in one patient, and adenoma with low grade dysplasia in four patients; colorectal cancers were not recognized. In the follow-up example by CCE, polyps and colorectal cancer could not be recognized. During the follow-up period, there were no deaths due to colorectal cancer in any of the patients.CONCLUSIONWe determined the outcomes in patients with negative initial CCE findings.

Bidirectional endoscopy in the assessment of iron deficiency in the elderly.

Iron deficiency is a common pathology in elderly patients. It is most often due to lesions in the digestive tract, which raises the issue of benefit/risk balance and yield from investigation. Current UK guidelines recommend that bidirectional endoscopy (oesophago-gastro-duodenoscopy and colonoscopy) is performed synchronously, with no upper age limit. In studies conducted in people over 75 years of age, the diagnostic yield varies between 63 and 68%, which is similar to that in younger people, with approximately 40% revealing upper lesions and 40% lower lesions. Approximately 10% of elderly patients show upper and lower digestive lesions at the same time. Complications as a result of oesophago-gastro-duodenoscopy are rare and mainly related to anaesthesia. The main complication of colonoscopy is perforation and there is a slightly higher risk of perforation in older patients. This risk is less significant for computed tomographic colonography. Contraindications of endoscopies are very rare. When endoscopy is negative, this raises the question of whether further investigations should be pursued.

DOP36 Non-invasive assessment of postoperative disease recurrence in Crohn’s Disease: A multicenter, prospective cohort study

Abstract Background Prevention of postoperative recurrence is a critical goal in Crohn’s disease (CD) management. Currently, postsurgical CD management and treatment are based on endoscopic monitoring performed within the first year after surgery. However, colonoscopy (CS) is an invasive and expensive procedure, unpleasant to patients. A non-invasive and patient friendly approach is required. Methods Consecutive CD patients who underwent ileo-cecal resection from July 2017 to January 2020 were prospectively enrolled in three Italian Centers and performed CS and bowel ultrasound (US) after six months from the surgery, in a blinded fashion. The patients also underwent complete clinical assessment and blood and stool samples were obtained for C-reactive protein (CRP), and fecal calprotectin (FC) measurements. The disease was considered clinically active if the Harvey–Bradshaw Index (HBI) was higher than 4. Uni- and multivariable analyses were used to assess the correlation between non-invasive parameters, including bowel US findings and FC values and endoscopic recurrence, defined by a Rutgeerts’s score (RS) > 2. Sensitivity, specificity, accuracy, PPV and NPV of bowel US parameters alone and in combination with FC in assessing endoscopic recurrence were calculated. Results Seventy patients were enrolled, 45 patients (64%) had an endoscopic recurrence (RS > 2) at 6 months. Thirteen out of 45 (29%) were symptomatic (HBI > 4). Bowel wall thickness (BWT), bowel wall flow (BWF, presence of vascular signals at color Doppler), the presence of mesenteric hypertrophy, the presence of limph-nodes and FC values significantly correlated with the endoscopic recurrence (p < 0.005). Independent predictors for endoscopic recurrence were BWT (for 1-mm increase: OR 2.63; 95% CI 1.136.12; p= 0.024), presence of lymph-nodes (OR 23.24; 95% CI 1.85291.15; p= 0.014) and FC > 50 µg/g (OR 11.86; 95% CI 2.60–54.09; p= 0.001). Sensitivity, specificity, accuracy, PPV and NPV of bowel US and/or FC are showed in Table 1. Table 1: Diagnostic accuracy of Bowel US and/or FC compared to CS in assessing endoscopic activity (CI 95%): per-patient analysis Conclusion Combined use of bowel US and FC is accurate in assessing endoscopic recurrence at 6 months in CD patients and represent a valid alternative to endoscopic assessment after surgery

OP21 Predictive value of Milan Ultrasound Criteria in Ulcerative Colitis: A prospective observational cohort study

Abstract Background Endoscopic remission is associated with better outcomes in ulcerative colitis (UC). However, colonoscopy (CS) is invasive and poorly tolerated by patients. Recently, we developed and externally validated non-invasive ultrasonography based criteria [Milan ultrasound criteria (MUC)] to assess and grade endoscopic activity in UC. We also confirmed that a MUC score > 6.2 is a valid cut-off to discriminate endoscopic activity, defined by a Mayo endoscopic subscore > 2. Aim of this study was to assess the predictive role of MUC on disease course in a prospective cohort of UC patients. Methods UC consecutive patients were followed for at least 12 months after performing baseline bowel US. UC-related outcomes, including need of treatment escalation (defined as the need of corticosteroids or change/optimization of immunosuppressants), hospitalization and surgery, were assessed at 1 year by logistic regression analysis, and were analyzed after long term follow-up (5 years) using Kaplan-Meier survival analysis. Fig. 1A and 1B. Kaplan–Meier curves for the cumulative probability of hospitalization and surgery in patients with Milan ultrasound criteria (MUC) < 6.2 (solid line) or MUC > 6.2 (dotted line). (p= 0.046; p= 0.023; respectively). Fig. 1C and 1D. Kaplan–Meier curves for the cumulative probability of hospitalization and surgery in patients with Mayo endoscopic subscore 0–1 (solid line) or 2–3 (dotted line). (p= 0.035; p= 0.071; respectively). Results 87 UC consecutive patients were included in the study, 31 (36%) were in endoscopic remission (Mayo endoscopic subscore 0–1) and 56 (64%) in endoscopic activity (Mayo endoscopic subscore 2–3). MUC and Mayo endoscopic subscore significantly correlated at baseline (Spearman’s rank correlations [rho]= 0.642; 95% confidence interval (CI) 0.499 to 0.751; p < 0.001). The multivariable analysis identified as independent predictors of need of treatment escalation throughout the 12-month period as being: MUC > 6.2 (OR: 5.95, 95% CI: 1.32–26.76, p < 0.020) and a partial Mayo score (PMS) > 2 (OR: 26.88, 95% CI: 5.01–144.07, p < 0.001). Kaplan-Meier survival analysis of long-term follow up demonstrated a lower cumulative probability of need for surgery and hospitalization in patients with MUC < 6.2 compared to MUC > 6.2 (Fig. 1A and 1B), as well as in patients with a Mayo endoscopic subscore of < 1 compared to Mayo endoscopic subscore of 2–3 (Fig. 1C and 1D). Conclusion MUC is a novel non invasive tool that predicts the course of UC in the short and long term follow-up.

Evaluation of Performance in Colon Capsule Endoscopy Reading by Endoscopy Nurses.

Background Although there are papers reporting on the accuracy of colon capsule endoscopy (CCE) compared with colonoscopy (CS), there are few reports on the detection rates of significant lesions by endoscopy nurses. We previously reported no significant difference in the detection rates for small bowel capsule endoscopy (SBCE) images among two well-trained physicians and one expert nurse. Objective To evaluate the reading time and detection rate of the significant lesions of CCE images among novice and trained expert endoscopy nurses and novice physicians. Methods CCE videos of 20 consecutive patients who performed both CCE and CS with clinically significant localized lesions were selected. Two trained expert endoscopy nurses, untrained two novice physicians, and novice three endoscopy nurses reviewed CCE videos. The detection rate of the lesions and reading time were compared among the three groups and were evaluated by comparison between the first and the second 10 videos. Results The median reading time was the shortest (19 min) in the trained expert endoscopy nurses and the longest (45 min) in the novice nurses. The number of thumbnails tended to be more in the trained expert endoscopy nurses in the first 10-video reading. Although the detection rates of small polyps (<5 mm) were significantly lower (46.5%, p=0.025) in the novice nurses compared to the others, they were improved (35.2% to 63.5%, p=0.015) in the second 10 videos. The detection rates of tumor lesions by either one of two trained expert endoscopy nurses were higher compared to those by each novice physician. Conclusions The trained expert endoscopy nurses for CCE reading can reduce physician's time and improve the diagnostic yield.

Gastroenterological clinical case

Gastrointestinal polyps are frequent in children and represent the most common cause of colorectal bleeding in this age group. Among those, juvenile polyps are the most frequently found. Intermittent mild hematochezia is the main symptom of colon polyps. Most polyps are pedunculated and, when located in the rectum, may prolapse. In most cases, juvenile polyps are solitary and located in rectosigmoid. Although malignancy risk of a solitary juvenile polyp is very small, excision is recommended to confirm benign nature. Total colonoscopy should be considered to exclude multiple or proximal polyps.

Is the choice of anesthesia during gastrointestinal endoscopic procedures a result of anxiety?

Background and study aimsEsophagogastroduodenoscopy (EGD) and colonoscopy (CS) are vital endoscopic procedures in the diagnosis and follow-up of gastrointestinal tract diseases. Endoscopic procedures can be performed with or without anesthesia as per patient preferences. These procedures can cause some anxiety in almost all patients, and the degree of anxiety differs for each individual. Thus, we aimed to evaluate the trait and state anxiety levels of the patients and assess the relationship between the preference of anesthesia and anxiety levels. Patients and methodsTo investigate this issue, 723 patients who underwent elective endoscopy (EGD and/or CS) were enrolled. The researchers collected sociodemographic data and medical history records as reported by the patients. State and trait anxiety levels of the patients were evaluated using the State and Trait Anxiety Inventory (STAI). ResultsThe patients were divided into two groups as with anesthesia and without anesthesia. Of the respondents, 43.4% requested anesthesia during endoscopic procedure. Sociodemographic data, except sex, showed similar characteristics. The STAI trait scores of the two groups were similar; however, there was a significant difference in the STAI state scores of the groups (p = 0.018). A significant difference was observed in the anesthesia preference and the type of endoscopic procedure (EGD, CS, or both) (p < 0.001). Type of endoscopic procedure, STAI state scores, and sex were determined as the predictors of the anesthesia choice. ConclusionEndoscopic procedures are known to cause anxiety among many patients. Our findings suggest that the anesthesia preferences of patients are an important factor in preventing these situational concerns. However, this study found that being a woman and undergoing a CS procedure are important factors related to anesthesia preferences. Thus, more detailed assessments on this subject are required.

Colonoscopic screening in early detection of colorectal cancer in high-risk groups: a prospective study

Introduction Colorectal cancer (CRC) is the world’s third most common malignant neoplasm. In Egypt, a small incidence of CRC and a high proportion of young-onset disease is observed. Colonoscopy is commonly used for neoplastic colorectal screening. The aim of this work was to assess colonoscopy in high-risk groups as a screening and diagnostic method for early detection of CRC. Patients and methods The study included 200 patients, with age varying from 20 to 83 (mean: 53.42±15.50) years. They were presented to GIT Surgery Unit, Alexandria University Hospital, complaining of lower gastrointestinal tract symptoms and/or high risk of CRC over 9 months. Two professional endoscopists have performed 200 colonoscopies over 9 months. Results Total colonoscopy was done in 94% of cases, and the biopsies were tested. Colorectal polyps were observed in 54 (27%) patients. Of these polyps, the most common were adenomatous polyps (81.5%). Colonic masses were typically seen in males in 22 (11%) cases. Adenocarcinomas were the most common of these masses, accounting for 9% of all cases. A total of 14 (7%) patients reported inflammatory conditions. 6.7% of all cases were diagnosed as colitis. Eight cases were diverticulosis, and 10 cases were hemorrhoid. Conclusion There is an increased rate of detection of adenoma by using screening colonoscopy among endoscopists. Colonoscopy is a valuable screening and diagnostic tool for early detection of CRC.

A 61-year-old man from Iran with intermittent obstruction of colon.

(Please cite as: Zanganeh E, Hosseini SA, Alimadadi M, Seyyedmajidi MR. A 61-year-old man from Iran with intermittent obstruction of colon. Gastroenterol Hepatol Bed Bench 2021;14(2):190-192).

Clearing a colonoscopy waiting list: how we did it.

Clearing a colonoscopy waiting list: how we did it.

A case of mucosal prolapse syndrome complicated by well-differentiated tubular adenocarcinoma and high-grade adenoma after long-term follow-up by colonoscopy

This study included a 45-year-old woman. In 20XX, we performed colonoscopy (CS) on fresh bloody stools, and a diagnosis of rectal mucosal prolapse syndrome (MPS) was made. In 20XX+14 years, CS was reexamined because of fresh bloody stools, and a biopsy of the same site revealed well-differentiated tubular adenocarcinoma. The lesion was resected via endoscopic submucosal dissection (ESD) and histopathologically diagnosed as MPS with high-grade adenoma and well-differentiated tubular adenocarcinoma. The symptoms improved after ESD, and no recurrence was observed during the 18-month follow-up. We experienced a case of a well-differentiated tubular adenocarcinoma in MPS during the long-term follow-up of MPS. In this case, performing ESD was useful not only for cancer treatment but also in terms of therapeutic effects on symptoms. Although MPS is a chronic benign inflammatory disorder, characterized by rectal mucosal prolapse with fibromuscular obliteration, it is necessary to consider the possibility of the appearance of cancer during the follow-up of MPS.

One-Third of Open Access Colon Cancer Screening Requests Require a Clinic Appointment

Background Open access colonoscopy (OAC) allows for patients at low-risk for endoscopic complications to receive a colonoscopy (CSP) without a preprocedural appointment. This can reduce wait times for screening and increase appointment availability for symptomatic patients. Methods At Walter Reed National Military Medical Center, we enacted an OAC program in 2014 for our TRICARE beneficiaries. Patients due for colon cancer screening or polyp surveillance can submit an online questionnaire through a secure website. Our scheduling department reviews all questionnaires, and patients with prespecified criteria are seen in clinic prior to their procedure. The remainder of patients have their surveys reviewed by a gastroenterologist for suitability and are scheduled for CSP or computed tomographic colonography. In 2018, the OAC program was expanded to all military hospitals in the national capital region (NCR). Results Prior to expanding Walter Reed's OAC program, 6713 total screening requests were made. The requested procedure was CSP in 69.9% of patients. Of patients who fell outside the 45-75 age range, 14.1% were under the age of 45, and 2% were over the age of 75. 31.6% of OAC patients required a clinic appointment. Following incorporation of the NCR, 2290 screening questionnaires have been completed without significant change to the absolute percentages of those requiring appointments. Conclusion By avoiding unnecessary clinic visits for asymptomatic individuals, OAC programs increase availability in gastroenterology practices to see symptomatic patients.

The impact of COVID-19 on elective and urgent digestive endoscopic procedures: a report on a year of pandemic in a gastroenterology centre in Italy.

The COVID-19 pandemic (COVID-19) affected digestive endoscopic activity worldwide. Resumption and maintenance of elective endoscopic activity are crucial to containing the impact of COVID-19 on mortality and prognosis of gastrointestinal disorders, primarily cancers. To assess the impact of COVID-19 during and after the lockdown period on endoscopic activity. The endoscopic activity undertaken during the COVID-19-related lockdown (March 2020-May 2020) and in the post-lockdown period (June 2020-March 2021) was compared with that in the corresponding periods of the year before COVID-19 in a gastroenterology centre in Italy. During the lockdown period, there was a reduction in esophagogastroduodenoscopy (EGD), colonoscopy (CSPY), endoscopic ultrasound (EUS), and endoscopic-retrograde cholangiopancreatography (ERCP) of 75.8%, 74.8%, 60%, and 42%, respectively, compared with the corresponding period of the year before COVID-19. During the post-lockdown period to date, EGD, CSPY, EUS, and ERCP increased as compared to the lockdown period (30.6%, 50.6%, 33.6%, and 65.4%, respectively), but only ERCP showed a full recovery when compared with the corresponding period of the year before COVID-19. Endoscopic activity decreased significantly during the COVID-19 lockdown, and only ERCP had a full recovery in the post-lockdown period. The pandemic-related limitations and the backlog of endoscopic procedures represent important reasons for the increased risk or delayed diagnosis of GI cancers.

Validity and Reliability of the Instruments to Measure Colorectal Cancer Screening Benefits and Barriers-Turkish Version.

Perceptions of benefits and barriers are important determinants in understanding colorectal cancer screening (CRCS) behaviors. There is a need for standardized Turkish tools that measure the benefits and barriers of fecal occult blood test (FOBT) and colonoscopy (COL). The aim of this study was to assess the validity and reliability of the Turkish version of the "Instruments to Measure CRCS Benefits and Barriers." This methodological study was carried out in 2 stages in primary care and in 394 adults between the ages of 50 and 70 years. In the first stage, some items of the scales demonstrated low/unacceptable corrected item-total and factor loadings, and in the second stage, it was decided to add emoji-based facial scales, which include emoji expressions. Results with the emoji-based facial scales included internal consistency coefficients of 0.85 for FOBT benefits, 0.79 for FOBT barriers, 0.84 for COL benefits, and 0.86 for COL barriers; the item-total correlations of FOBT varied between 0.39 and 0.73, whereas those of COL varied between 0.38 and 0.76. The factor loadings of all items were higher than 0.40. The emoji-based facial scale for CRC Screening Benefits and Barriers is a valid and reliable tool for measuring the benefits and barriers perceptions of 50- to 70-year-old Turkish adults. The Instruments to Measure CRCS Benefits and Barriers-Turkish version can provide insights for nurses and healthcare professionals to understand individuals' perceived FOBT and COL benefits and barriers and to develop effective interventions to increase CRCS rates.

Colon capsule endoscopy in patients with chronic respiratory disease during the COVID‐19 pandemic

Dear Editor, We read with interest the article by MacLeod et al. [1]. The authors suggest that colon capsule endoscopy (CCE) could be a useful tool for triaging emergency colonoscopy during the COVID-19 pandemic. The literature for CCE in patients with chronic respiratory disease, who comprise one of the COVID-19 high-risk groups [2], is limited. We carried out a retrospective study of CCE in patients with chronic respiratory disease up to May 2020, the first wave of the COVID-19 pandemic in Japan. Thirty-one patients (18 men and 13 women with a mean age of 65.2 ± 15.1 years) with chronic respiratory disease who underwent CCE at our hospital were included. The diagnoses of these patients were pulmonary emphysema in seven patients, bronchial asthma in seven patients, chronic bronchitis in six patients, sleep apnoea syndrome in two patients, pulmonary tuberculosis (old and latent) in eight patients and nontuberculous mycobacteriosis in one patient. The reasons for the procedure were as follows: screening in seven patients, positive for a faecal occult blood test in four patients, lower abdominal pain in five patients, diarrhoea in two patients, abnormal bowel movement in five patients, narrowing of the stool column in one patient, follow-up for Crohn's disease in one patient, suspicion of irritable bowel syndrome in three patients and accumulation of positron emission tomography in the transverse colon in one patient. The overall total colorectal detection rate using CCE was 90.3% (28/31). Polyps were detected in 54.8% of patients by CCE (17/31 cases), and a significant finding (polyp lesion of 6 mm or more) was observed in 64.7% (11/17 cases). Colonoscopy (CS) was performed in 45.1% (14/31). The positive predictive value was 100% (17/17 patients) and the negative predictive value (13/14 patients) was 92.9%. Histopathological examination by therapeutic endoscopy using CS with personal protective equipment revealed six cases of adenoma, six cases of hyperplasia, one case of carcinoma in situ and no advanced cancer. There were no adverse events, such as retention, in any patient and no evidence of SARS-Cov-2 infection in healthcare professionals. There is a report suggesting the possibility of colon CT examination [3] and positron emission tomography [4] as an alternative method during the COVID-19 pandemic. However, CCE is free from radiation exposure and the only examination that can be performed at home without coming to hospital during the pandemic. CCE is expensive, it costs the national health insurance adaptation of Japan approximately ￥30 000 at a 30% burden. However, it can be easily inferred that in patients with chronic respiratory disease it is more cost-effective than the medical cost of ventilators and extracorporeal membrane oxygenation in intensive care units if they become seriously ill with SARS-Cov-2 infection. Also, in Japan, CCE was adopted by the national health insurance plan for chronic obstructive pulmonary disease from March 2020. Our study results suggest that CCE in patients with chronic respiratory disease avoids unnecessary CS and may reduce the risk of SARS-Cov-2 infection by CS in approximately 60% of the patients. All patients consented to data collection, analysis and dissemination. The author participated in the interpretation of study results, and in the drafting, critical revision, and approval of the final version of the manuscript. I declare no conflict of interests. This study was approved by the ethics committee. The data that support the findings of this study are openly available in [repository name e.g. “figshare”] at 10.6084/m9.figshare.13278059.