Reduce Patient Discomfort Research Articles

Effect of Cervical Lidocaine Gel for Pain Relief in Pipelle Endometrial Sampling.

To evaluate the efficacy of cervical lidocaine gel in reducing patient discomfort during Pipelle endometrial sampling. From September 2012 to January 2013, 137 patients were evaluated with Pipelle endometrial biopsy. For group 1 (77 women), 2% lidocaine gel was applied to the cervical canal 3 min before endometrial sampling. For group 2 (60 women), a placebo gel was applied. The pain experienced by the patients during biopsy was evaluated using a 100 mm visual analog scale. The pain score was significantly lower during suction curettage (T3) in the group 1 than in the group 2. There was no significant difference between the groups in terms of pain score in other stages of the procedure (2.6±1.3 and 4.5±1.4; p=0.03). Cervical 2% lidocaine gel is simple and effective for decreasing pain associated with Pipelle endometrial biopsy.

Lactate - Arterial and Venous Agreement in Sepsis: a prospective observational study.

Sepsis is a common condition in the emergency department (ED). Lactate measurement is an important part of management: arterial lactate (A-LACT) measurement is the gold standard. There is increasing use of peripheral venous lactate (PV-LACT); however, there is little research supporting the interchangeability of the two measures.If PV-LACT has good agreement with A-LACT, it would significantly reduce patient discomfort and the risks of arterial sampling for a large group of acutely unwell patients, while allowing faster and wider screening, with potential reduced costs to the healthcare system. The aim of this study is to determine the agreement between PV-LACT and A-LACT in septic patients attending the ED. We carried out a prospective observational cohort study of 304 consented patients presenting with sepsis to a single UK NHS ED (110 000 adult attendances annually) taking paired PV-LACT and A-LACT. Bland-Altman analysis was carried out to determine agreement. Receiver operating characteristic curves and 2×2 tables were constructed to explore the predictive value of PV-LACT for A-LACT. The mean difference (PV-LACT-A-LACT) is 0.4 mmol/l [95% confidence interval (CI): 0.37-0.45], with 95% limits of agreement from -0.4 (95% CI: -0.45 to -0.32) to 1.2 (95% CI: 1.14-1.27). A PV-LACT of at least 2 mmol/l predicts an A-LACT of at least 2 with 100% sensitivity (95% CI: 89-100%) and 83% specificity (95% CI: 77-87%). This study is the largest comparing the two measurements, and shows good clinical agreement. We recommend using PV-LACT in the routine screening of septic patients. A PV-LACT less than 2 mmol/l is predictive of an A-LACT less than 2 mmol/l.

Continuous cooling mask devices reduce patient discomfort and postoperative pain and swelling in patients undergoing orofacial surgery.

Data sourcesThe resources searched included: Medline, PubMed, Embase, CINAHL, CAB Abstracts, the Cochrane Library and Google Scholar. The PRISMA guidelines for reporting systematic reviews were followed. Study selection was limited to the English language. Hand searching for additional references was performed. An intensive search was conducted for published articles describing the use of hilotherapy following oral and maxillofacial surgery.Study selectionInclusion criteria involved patients using hilotherapy after oral and maxillofacial surgery. Non-human studies were excluded. All articles were evaluated for study design, perioperative data, ethical suitability, follow-up data and surgical data reporting.Data extraction and synthesisTwo authors independently judged articles for suitability for the review. A kappa statistic test was used to calculate and to measure concordance in the author's final decisions to include studies. The agreement was 83% and considered moderate. Following data extraction a meta-analysis was conducted. Heterogeneity was calculated due to the variability among the studies (different number of surgical procedures, patient age, duration of the device application, different methods of postoperative pain measurement and analgesics protocol). Standard mean differences (SMD) with 95% confidence interval (CI) were calculated for the continuous measurements. The studies were assessed and rated using the Oxford Centre for Evidence-Based Medicine Levels of Evidence criteria (all studies were rated as 2b). Publication bias was assessed.ResultsThe initial search identified 552 results. Twelve papers were included in the review, and five with a total of 206 patients were used for the meta-analysis. The studies analysed were prospective comparative studies of patients undergoing oral maxillofacial surgery. Hilotherapy reduced pain (ten point visual analogue scale) at 48 hrs (P <0.010) and 72 hrs (P<0.050) as well as postoperative facial oedema (P <0.010) compared to ice-cooling treatment. Trismus and facial neurological scores were also improved (P<0.08). Patients preferred hilotherapy to other cooling methods (P< 0.010).ConclusionsHilotherapy appears to be effective in reducing postoperative facial pain, oedema and trismus and in improving patient-reported outcomes.

Is Postsurgical Imaging Necessary for Heterotopic Ossification Prophylaxis?

Heterotopic ossification (HO) following trauma at joints such as the hip can be prevented through prophylactic external beam radiotherapy (XRT). Treatment typically involves pre-operative imaging, surgery, pre-XRT imaging, and lastly XRT. We analyzed if XRT treatment planning for HO prophylaxis can be achieved through pre-operative imaging alone, without the need for independent XRT CT-simulation. We identified our most recent nine patients who received hip joint HO prophylaxis planned using post-op CT-simulation, who had available pre-op imaging. Using the pre-surgical CT scans, a new treatment plan was independently generated using field boundaries specific to each patient’s anatomy. Originally delivered doses (7-8 Gy) and beam energies (15-23 MV) were maintained. The clinical target volume (CTV) (region at high risk for HO formation) was contoured on the pre- and post-surgical CTs. The newly generated pre-operative plans were fused and transferred to the post-surgical CT, including the prescribed monitoring units (MU). We thus were able to gather data on how well the plans generated on pre-op imaging covered the post-op target and could compare attributes of the theoretical pre-op plan with what was actually delivered using the post-op CT-simulation imaging. Paired-sample Wilcoxon signed rank test was used to compare plans. Median treatment field area was 133.9 cm2 on pre-surgical and 166.32 cm2on pre-XRT scans (P = 0.66). Patient thickness (separation) was 21.7 cm on post- and 21.9 cm on pre-surgical CT (P = 0.86). Median MU from the actual plan were 406.5 MU, compared to 391.5 MU on pre-op plans (P = 0.024). In post-op planning, the median hot spot was 106.3% and the CTV receiving 95% of the prescribed dose (V95) was 99.0%, while pre-op plans produced a hot spot of 105.6% (P = 0.56) and V95 of 98.7% (P = 0.17). After the pre-op plan was transferred to the CT-sim and recalculated, the median patient thickness 21.9 cm (P = 0.89), maximum dose 7.67 Gy (P = 0.77) and V95 99.2% (P = 0.14) did not significantly differ from the actual XRT plans. Furthermore, all patients’ V95exceeded 95% when the theoretical pre-op plan was calculated on post-op CT-simulation imaging. This preliminary study indicates that post-operative imaging solely for XRT planning may be unnecessary and that pre-operative imaging may suffice. Since many of these patients experience severe pain with movement eliminating this additional CT-simulation can reduce patient discomfort, as well as radiation exposure, operating costs and procedural turnaround time.

Fabrication of a complete, removable dental prosthesis from a digital intraoral impression for a patient with an excessively tight reconstructed lip after oral cancer treatment: A clinical report

This clinical report describes the management of a patient who had an excessively tight reconstructed lip because of oral cancer surgery and postoperative radiotherapy. The presented technique used an intraoral scanner for a preliminary impression and computer-aided design and computer-aided manufacturing (CAD-CAM) technology for preliminary laboratory procedures. This digital impression technique may reduce patient discomfort.

Sparse reconstruction of compressive sensing MRI using cross-domain stochastically fully connected conditional random fields.

BackgroundMagnetic Resonance Imaging (MRI) is a crucial medical imaging technology for the screening and diagnosis of frequently occurring cancers. However, image quality may suffer from long acquisition times for MRIs due to patient motion, which also leads to patient discomfort. Reducing MRI acquisition times can reduce patient discomfort leading to reduced motion artifacts from the acquisition process. Compressive sensing strategies applied to MRI have been demonstrated to be effective in decreasing acquisition times significantly by sparsely sampling the k-space during the acquisition process. However, such a strategy requires advanced reconstruction algorithms to produce high quality and reliable images from compressive sensing MRI.MethodsThis paper proposes a new reconstruction approach based on cross-domain stochastically fully connected conditional random fields (CD-SFCRF) for compressive sensing MRI. The CD-SFCRF introduces constraints in both k-space and spatial domains within a stochastically fully connected graphical model to produce improved MRI reconstruction.ResultsExperimental results using T2-weighted (T2w) imaging and diffusion-weighted imaging (DWI) of the prostate show strong performance in preserving fine details and tissue structures in the reconstructed images when compared to other tested methods even at low sampling rates.ConclusionsThe ability to better utilize a limited amount of information to reconstruct T2w and DWI images in a short amount of time while preserving the important details in the images demonstrates the potential of the proposed CD-SFCRF framework as a viable reconstruction algorithm for compressive sensing MRI.

A sequential anesthesia technique for surgical repair of unilateral vocal fold paralysis.

Thyroplasty with arytenoid adduction, a combined procedure for treatment of unilateral vocal fold paralysis, is typically performed under local anesthesia with sedation to allow for intraoperative voice assessment. However, the need for patient immobility and suppression of laryngeal responses to surgical manipulation can make sedation-analgesia challenging. We describe our first 26 consecutive cases undergoing thyroplasty and arytenoid adduction with a standardized technique consisting of a combination of general anesthesia with tracheal intubation followed by sedation-analgesia. Most patients (69%) were women, with age of 53±15years (mean±SD). Neck surgery was the cause of vocal fold paralysis in 50% of patients. Initially, general anesthesia was maintained with desflurane and remifentanil with dexmedetomidine added just before tracheal extubation. During the sedation-analgesia phase, patients received infusions of remifentanil and dexmedetomidine. Duration of general anesthesia and sedation-analgesia phases was 162±68.2 and 79±18.3min, respectively. Mean (SD) wake-up time was 8.0±4.0min after desflurane discontinuation. Extubation occurred without coughing, bucking, or agitation in 96% of patients. All the patients were able to phonate appropriately and remained comfortable after emergence. This technique allowed improved surgical conditions with reduced patient discomfort and may be advantageous for other laryngeal and neck surgeries in which intraoperative patient feedback is required.

Electromagnetic-Guided Bedside Placement of Nasoenteral Feeding Tubes by Nurses Is Non-Inferior to Endoscopic Placement by Gastroenterologists: A Multicenter Randomized Controlled Trial.

Electromagnetic (EM)-guided bedside placement of nasoenteral feeding tubes by nurses may improve efficiency and reduce patient discomfort and costs compared with endoscopic placement by gastroenterologists. However, evidence supporting this task shift from gastroenterologists to nurses is limited. We aimed to compare the effectiveness of EM-guided and endoscopic nasoenteral feeding tube placement. We performed a multicenter randomized controlled non-inferiority trial in 154 adult patients who required nasoenteral feeding and were admitted to gastrointestinal surgical wards in five Dutch hospitals. Patients were randomly assigned (1:1) to undergo EM-guided or endoscopic nasoenteral feeding tube placement. The primary end point was the need for reinsertion of the feeding tube (e.g., after failed initial placement or owing to tube-related complications) with a prespecified non-inferiority margin of 10%. Reinsertion was required in 29 (36%) of the 80 patients in the EM-guided group and 31 (42%) of the 74 patients in the endoscopy group (absolute risk difference -6%, upper limit of one-sided 95% confidence interval 7%; P for non-inferiority=0.022). No differences were noted in success and complication rates. In the EM-guided group, there was a reduced time to start of feeding (424 vs. 535 min, P=0.001). Although the level of discomfort was higher in the EM-guided group (Visual Analog Scale (VAS) 3.9 vs. 2.0, P=0.009), EM-guided placement received higher recommendation scores (VAS 8.2 vs. 5.5, P=0.008). EM-guided bedside placement of nasoenteral feeding tubes by nurses was non-inferior to endoscopic placement by gastroenterologists in surgical patients and may be considered the preferred technique for nasoenteral feeding tube placement.

A Comparative Study between Flapped and Flapless Surgical Techniques in Dental Implant Stability According to Resonance Frequency Analysis

Background: Recent implant surgical approach aims to cause less trauma, invasiveness and pain as much as possible and to reduce patient and surgeon discomfort, time of surgery and time needed for functional implant loading. Flapless surgical techniques considered recently as one of the most popular techniques that may achieve these aims especially enhancing osseointegration and subsequently implant stability within less time than the traditional flapped surgical technique. So this study aimed to make a comparison between flapped and flapless surgical techniques in resulted implant stability according to resonance frequency analysis RFA and in duration of surgical operation. Materials and methods: A total of 26 patients with 41 implants (one implant in the study group failed so it was excluded from the statistical analysis) were randomized into two groups: control group which involved 20 implants inserted by conventional flapped surgical approach and study group which involved 20 implants inserted by flapless surgical approach. Estimation of alveolar bone was done for study group by bone (ridge) mapping procedure. Duration of surgical operation for each implant, Implant stability was measured at three time intervals (at surgery, two months and three months after surgery). Results: After three months interval of surgery the mean implant stability of the study (flapless) group achieved significant higher implant stability than control (flapped) group (P< 0.05) and the difference in measured implant stability was (5.05) implant stability quotient(ISQ). The time of surgical operation for implants in the study group significantly was less than that of control group (P< 0.01). Conclusions:implants placed with flapless surgical technique can produce high implant stability in shorter time and consume prominently shorter time for surgical operation compared to those placed with conventional flapped technique.

Dual isotope subtraction SPECT-CT in the diagnosis of primary hyperparathyroidism

light in treating actinic keratoses (AK) with a marked reduction in patient discomfort which is a limiting factor in c-PDT. The aim of this study was to quantify the radiant exposure received by patients having d-PDT between the months of April and July. A further objective was to compare it with artificial white light (wl-PDT) using a theatre light andwith two c-PDT units, an Omnilux© and an Akitilite©. Quantities measured using calibrated equipment during patient d-PDT included irradiance, illuminance, and light spectra. An IPL Radiometer with a PDT detector, an ATP data logger light meter and a Bentham DMc150-MDE compact double integrated spectroradiometer were used respectively. The effective dose (Jeff) was calculated, which is the spectrum weighted by the absorption spectrum of the photosensitizer. The impact of weather conditions and time of year on effective dose was evaluated. The effective dose from daylight ranged from 3.2 Jeff on an overcast day to 43 Jeff on a sunny day for 2 hour treatments. Effective dose for two hours across the treatment area for wl-PDT was between 4.1 and 9.1 Jeff. Typically c-PDT units deliver approximately 1 Jeff in 10–20 minutes. d-PDT is a viable treatment option in Ireland. A review of patients at one and three months showed treatment was effective in reducing AKs, with low pain scores. Treatment scheduling is limited to between April and September for patient comfort (average temperature at least 10 °C) and to avoid lengthier treatment times.

In Vitro and in Vivo Characterization of MOD-4023, a Long-Acting Carboxy-Terminal Peptide (CTP)-Modified Human Growth Hormone.

MOD-4023 is a novel long-acting version of human growth hormone (hGH), containing the carboxy-terminal peptide (CTP) of human chorionic gonadotropin (hCG). MOD-4023 is being developed as a treatment for adults and children with growth hormone deficiency (GHD), which would require fewer injections than currently available GH formulations and thus reduce patient discomfort and increase compliance. This study characterizes MOD-4023's binding affinities for the growth hormone receptor, as well as the pharmacokinetic and pharmacodynamics, toxicology, and safety profiles of repeated dosing of MOD-4023 in Sprague-Dawley rats and Rhesus monkeys. Although MOD-4023 exhibited reduced in vitro potency and lower affinity to the GH receptor than recombinant hGH (rhGH), administration of MOD-4023 every 5 days in rats and monkeys resulted in exposure comparable to daily rhGH, and the serum half-life of MOD-4023 was significantly longer. Repeated administration of MOD-4023 led to elevated levels of insulin-like growth factor 1 (IGF-1), and twice-weekly injections of MOD-4023 resulted in larger increase in weight gain with fewer injections and a lower accumulative hGH dose. Thus, the increased half-life of MOD-4023 in comparison to hGH may increase the frequency of protein-receptor interactions and compensate for its decreased in vitro potency. MOD-4023 was found to be well-tolerated in rats and monkeys, with minimal adverse events, suggesting an acceptable safety profile. These results provide a basis for the continued clinical development of MOD-4023 as a novel treatment of GHD in children and adults.

0331: Predictors of outcome of repeated percutaneous mitral valvuloplasty

Percutaneous mitral valvuloplasty (PMV) has emerged as the procedure of choice in treatment of mitral stenosis and has proved effectiveness in cases of mitral restenosis after surgical commissurotomy Compared with surgery, PMV is associated with shorter hospital stays, reduced patient discomfort, and significantly lower costs. However, it is unknown whether patients who developed symptomatic mitral restenosis after PMV may benefit from repeat PMV (re-PMV) with safety. This study was designed to evaluate the occurrence rate and the predictive factors for severe complications following re-PMV. Retrospective study from a series of 40 procedures of re-PMV with the Inoue balloon at 8±4 years after prior procedure, performed between 1996 and 2011. A clinical and ultrasound follow-up was achieved in 31 patients with a mean follow-up period of 43±26 months. The mean age of patients was 43±11 years [23, 63]. 87.5% of the population being female (5 men and 35 women). The immediate procedural success was achieved in 31 patients (77.5%). A severe mitral regurgitation (MR) was observed in 3 patients (7.5%). A cerebrovascular stroke occurred in 1 patient (2.5%). No procedure-related death or cardiac tamponade were noted. Only a left atrial area ≤25cm 2 was linked to high risk of severe MR. At long-term, mitral restenosis was observed in 13 patients (42%) at 53±30 months [9; 128] after re-PMV, 2 patients presented thromboembolic events (6%) and no death. Only the male had been identified as a predictor of restenosis. The feasibility of re – PMV with a relatively high procedural success rate and an acceptable complication profile makes it an appealing therapeutic strategy for patients with recurrent valve stenosis.

Enhancement of healing of donor hard palate site using platelet-rich fibrin

Gingival recession is not only an aesthetic concern but also often is associated with problems such as tooth hypersensitivity. Among various root coverage modalities, free soft-tissue gingival graft shows promising results, but is associated with patient discomfort due to the need for second surgical palatal donor site. The purpose of this case report is to evaluate the effectiveness of platelet-rich fibrin (PRF) at donor palatal site with root coverage procedure in the treatment of recession-type defects. This paper reports a case of a 31-year-old male with a root coverage procedure, and employing PRF at donor site has been discussed below. Hence, the employment of PRF at donor site not only enhances healing but also reduces patient discomfort that occurs due to palatal plate.

Comparison of Pain Perception for Nasopalatine Nerve Block using Conventional and Computerized Local Anesthesia Delivery Systems in Adults: A Randomized Split-mouth Clinical Study

ABSTRACTIntroductionProfound local anesthesia (LA) is necessary in order to reduce patient discomfort during oral surgical procedures. However, injection technique itself may be a potentially painful procedure. A comfortable and consistent LA can increase the level of trust between the patient and the operator, since even a thought of intraoral injection causes a considerable amount of anxiety in many patients. To reduce this anxiety, a computer-controlled local anesthesia delivery (CCLAD) system is commercially available as a possible means of minimizing the sensation of pain (especially for palatal injections).AimThe aim of the present study was to compare the pain perception, when injections were administered using the CCLAD system or a conventional technique in patients requiring oral surgical procedures in the maxillary anterior region.Materials and MethodsThis randomized split-mouth study included 15 patients (7 females and 8 males). Conventional syringe or computerized single tooth anesthesia (STA) system with a 30-gauge needle was used to give nasopalatine nerve block by the same operator, over a minimum gap of 7 days. Immediately after injection, patient's pain perception was assessed using numeric rating scale (NRS). Overall difference in pain perception and effect of change in sequence of type of anesthesia were determined using unpaired t-test.ResultsResults of the study showed statistically significant difference between the pain scores of STA system and conventional injection technique; however, the change in sequence of anesthesia technique did not show any effect on the effectiveness of STA system.ConclusionThe STA system significantly reduces the pain perception after administration of nasopalatine nerve block in adults.Clinical significanceUse of STA system for administration of nasopalatine nerve block in adults provides better patient acceptance and pain control over conventional cartridge syringe.How to cite this articleKohale BR, Agrawal AA, Erlewad D. Comparison of Pain Perception for Nasopalatine Nerve Block using Conventional and Computerized Local Anesthesia Delivery Systems in Adults: A Randomized Split-mouth Clinical Study. J Contemp Dent 2016;6(3):177-180.

A Simple and Safe Technique for CT Guided Lung Nodule Marking prior to Video Assisted Thoracoscopic Surgical Resection Revisited.

Aim. We describe our experience of a simple, safe, and reproducible technique for lung nodule marking prethoracoscopic metastasectomy. Thoracoscopic lung nodule resection reduces patient discomfort, complications, higher level of care, hospital stay, and cost; however, small deeply placed lung nodules are difficult to locate and resect thoracoscopically. Materials and Methods. We describe and review the success of our novel technique, where nodules are identified on a low dose CT and marked with methylene blue using CT fluoroscopy guidance immediately prior to surgery. Results. 30 nodules were marked with a mean size of 8 mm (4–18 mm) located at a mean depth of 17 mm, distributed through both lungs. Dye was detected at the pleural surface in 97% of the patients and at the nodule in 93%. There were no major complications. Thoracoscopic resection was possible in 90%. Conclusion. This is a simple and safe method of lung nodule marking to facilitate thoracoscopic resection in cases where this may not be technically possible due to nodule location.

A low-cost alternative for nasolaryngoscopy simulation training equipment: a randomised controlled trial.

Flexible nasolaryngoscopy is a key diagnostic procedure used in many specialities. Simulation-based teaching is beneficial for endoscopy training, but it is expensive. This study assessed whether an inexpensive simulation model is an effective training method for flexible nasolaryngoscopy. A three-armed, randomised, controlled trial was performed. One group received no simulation training, while two others were trained with either a high-cost or a low-cost model. All candidates then performed flexible nasolaryngoscopy on a volunteer. Their ability to perform this task was assessed by the patient discomfort score and time taken by a blinded expert. Simulation-based teaching reduced patient discomfort and improved candidate skill level. Low-cost model training did not have a negative effect when compared with high-cost model training. Simulated flexible nasolaryngoscopy training may be more accessible with the use of an effective low-cost model.

Mild ovarian stimulation with clomiphene citrate launch is a realistic option for in vitro fertilization

To validate the use of clomiphene citrate in IVF when mild stimulation approaches are chosen to reduce patient discomfort, risk, and cost. Prospective cohort study. Private IVF clinic. A total of 163 patients undergoing IVF and with a good prognosis (defined as ≤38 years old with normal ovarian reserve and normovulatory cycles, body mass index <29 kg/m(2), no previous assisted reproductive technology cycles, no severe endometriosis, no history of recurrent miscarriage, no endocrine/autoimmune diseases, and no surgical semen extraction). Mild stimulation using a fixed protocol of clomiphene citrate (100 mg/d from cycle days 3 to 7) in combination with low doses of gonadotropins (150 IU of recombinant FSH on cycle days 5, 7, and 9) and GnRH antagonist. The cumulative delivery rate per patient after three fresh and/or frozen embryo transfers and time to pregnancy. No dropouts were observed. The cumulative delivery rate was 70%, and the mean time to pregnancy was 2.4 months. Mild stimulation using clomiphene citrate in combination with low doses of gonadotropins can be considered a realistic option for good-prognosis patients undergoing IVF.

Continuous noninvasive hemoglobin monitoring: ready for prime time?

Determination of hemoglobin (Hb) concentration is essential for the detection of anemia and hemorrhage and is widely used to evaluate a patient for a possible blood transfusion. Although commonly accepted as intrinsic to the process, traditional laboratory measurements of Hb are invasive, intermittent, and time-consuming. Noninvasive Hb (NIHb)-monitoring devices have recently become available and promise the potential for detecting sudden changes in a patient's Hb level. In addition to reduced delays in clinical intervention, these devices also allow for a reduction in patient discomfort, infection risk, required personnel, and long-term costs. Unfortunately, it has been shown that many clinical factors can influence their accuracy. Many studies have been published on the accuracy and precision of NIHb-monitoring devices in various clinical settings. A recent meta-analysis has shown a small mean difference but wide limits of agreement between NIHb and laboratory measurements, indicating that caution should be used by physicians when making clinical decisions based on this device. NIHb measurements may currently be considered to be a supplemental tool for monitoring trends in Hb concentration, but are not currently developed enough to replace an invasive approach. Moreover, further studies are still required before implementing NIHb in the clinical decision-making process. Specifically, no studies have demonstrated that this technology improves clinical outcomes or patient safety.

120 The Instantaneous Wave-Free Ratio (IFR) Is An Accurate Predictor of Fractional Flow Reserve (FFR) In Adult Coronary Arteries so Long As a Grey Zone or Hybrid-Approach is used and not Individual Cut-Offs: The Blackpool Coronary IFR (Bcis) Study

Background Fractional flow reserve (FFR) can be used in the cath lab to assess coronary arteries for ischaemia. To calculate an FFR adenosine needs to be given. The IFR (instantaneous free-wave ratio) has been mooted as an adenosine-independent cath-lab measure of ischaemia, derived using coronary artery wave-intensity analysis. Once validated it may thus reduce patient discomfort and procedural cost. Two approaches have been mooted when using iFR namely a) a single cut-off (iFR 0.93 normal and iFR 0.86–0.93 borderline). In borderline cases adenosine should be given and FFR calculated instead. No study has prospectively assessed these two approaches to assess the validity of iFR in predicting FFR. Methods Consecutive patients undergoing an FFR study in the cath lab underwent an iFR measurement first. Two iFR measurements were taken in the first 25 cases to assess iFR reproducibility. Adenosine was then given in all cases and an FFR was measured. The patients were managed according to the FFR result. Two iFR approaches were compared: a) a single cut-off of iFR 0.93 normal. Results In a preliminary analysis (more data will be available for the meeting), data was collected in 20 patients (12 men (60%), mean age 63 years (range 47–87)) and 41 coronary arteries. Mean FFR was 0.84 (range 0.55–0.98). 13 arteries (32%) had an abnormal FFR ( 0.93, and 16 (39%) iFR 0.86–0.93 (borderline). Of the 16 borderline cases, 7 (44%) had FFR < = 0.80. iFR was highly reproducible with 95% limits of agreement +0.01 to – 0.015. The correlation between iFR and FFR was excellent with R2 0.76. The sensitivity, specificity, PPV, NPV, overall accuracy and Kappa value of agreement comparing single cut-off vs hybrid approach were 53% vs 92%; 89% vs 100%; 70% vs 100%; 81% vs 97%, 78% vs 98%, and 0.46 vs 0.94 respectively. Thus the hybrid approach was superior at each value. Conclusions iFR measurements are quick to obtain and highly reproducible. iFR showed excellent correlation with FFR. There was only 78% agreement between iFR and FFR when using a single cut-off approach. This improved to 98% when using the hybrid approach. This approach consists of only giving adenosine and measuring FFR for borderline iFR values (iFR 0.86–0.93). Higher iFR values (>0.93) can be taken as normal and lower iFR values (<0.86) can be taken as abnormal. There was a false positive rate of only 3% and a false negative rate of 0% using the hybrid approach. 61% of cases fell outside the grey zone in consecutive patients and thus adenosine use could potentially be reduced by 61% and accuracy maintained if using the iFR and hybrid approach.

PTU-027 Is water assisted colonoscopy superior to carbon dioxide assisted standard colonoscopy: results of an observational study:

Introduction Water assisted colonoscopy [WAC] is known to reduce patient discomfort and improve the adenoma detection rate [ADR]. 1 In this retrospective observational study, we compared water assisted colonoscopy against standard colonoscopy[SC] using CO 2 in a bowel cancer screening positive population. Method This was a retrospective review of prospectively collected data. The population studied was undergoing colonoscopies following a positive faecal occult blood test as part of the bowel cancer screening programme [BCSP]. Endoscopist A preferred to intubate the caecum using the water exchange method and endoscopist B would insufflate the bowel using carbon dioxide. Sedation and analgesic use was at the discretion of the endoscopist. The primary outcome was the adenoma detection rate and the comfort scores in the two groups. Secondary outcomes included caecal intubation rate, mean withdrawal time, sedation use and polyp retrieval rate. Results Data from two hundred and seven colonoscopies performed from April 2014 to December 2014 [9 months] were analysed. 102 colonoscopies were performed using the water exchange method [group A] and 105 colonoscopies were performed using CO 2 [group B]. Primary outcomes: Adenoma detection rate [ADR] in group A was 53% compared to of 36% in group B. This was statistically significant [difference in rate = -0.1868 [95% CI 0.0052–0.3685 p = 0.0438]. The proportion of patients experiencing none [score 1] or minimal [score2] discomfort [based on modified Gloucester comfort score] were more in group A [n = 74] compared to group B [n = 62]. This was found to be statistically significant [Z = 2.046, p = 0.0408] Secondary outcomes: Conclusion Our finding of a significant improvement in ADR and better tolerability in the WAC group supports similar conclusions by Hsieh e t al. This may have potential implications for the bowel cancer screening programme since the perception of colonoscopy can influence public participation and improve uptake in the BCSP. Improved ADR may be due to combination of factors like improved bowel preparation, flattening of mucosal folds and floating effect of polyps with water irrigation. We hope our findings are validated in the future through randomised trials. Disclosure of interest None Declared. Reference Hsieh YH, Koo M, Leung FW. A patient blinded randomized, controlled trial comparing air insufflation, water immersion and water exchange during minimally sedated colonoscopy. Am J Gastroenterol. 2014;109(9):1390–400