K Drew

BACKGROUND AND STUDY AIMS: Endoscopic mucosal resection provides an alternative to surgery for resection of sessile and flat colorectal lesions. High-magnification chromoscopic colonoscopy may allow early detection and anticipate histological diagnosis by identifying colonic crypt patterns. The aim of the present study was to assess the efficacy and safety of en-bloc endoscopic mucosal resection with high-magnification chromoendoscopy in the management of sessile and flat colorectal lesions </= 20 mm. PATIENTS AND METHODS: A single endoscopist using high-magnification chromoendoscopy prospectively examined 1000 patients attending for routine colonoscopy. Patients were selected for inclusion in the study if they were considered to be at high risk for underlying colorectal neoplasia or polyps. Within the study period, 1000 patients (29 %) qualified for entry from a total of 3480 colonoscopies conducted in our institution. Endoscopic mucosal resection was carried out in appropriate flat and sessile lesions. RESULTS: Endoscopic mucosal resection was carried out in 599 lesions. Complete histological resection was confirmed in 576 (96 %). Perforation occurred in one patient (0.2 %) and bleeding in 12 (2 %). A total of 254 lesions (40 %; excluding hyperplasia/metaplasia) were flat or depressed, and 374 (60 %) were sessile. Fifty-eight flat lesions (23 %) contained high-grade dysplasia or beyond, compared to 33 sessile lesions (9.0 %; P = 0.001). After resection, 21 lesions were upgraded histologically, with 17 being defined as adenoma with high-grade dysplasia or beyond. CONCLUSIONS: This study confirms that flat adenomas and carcinomas occur in the West and demonstrates the malignant potential of such lesions, which can be managed successfully using endoscopic techniques. Endoscopic mucosal resection with high-magnification chromoscopy is a safe and effective form of treatment for sessile or flat colorectal lesions. Complete resection can improve the accuracy of histopathological diagnosis. However, colonoscopists require training in these procedures in order to improve the rate of colorectal cancer detection.

Measurements of mucosal dimension, architecture, and cell counts in both lamina propria and epithelium were made on rectal biopsy specimens from 20 patients with irritable bowel syndrome ("normal" controls); 54 patients with ulcerative colitis, Crohn's disease, and non-specific proctitis; eight patients with small bowel Crohn's disease; and 34 in whom the rectal biopsy specimen was not diagnostic. Discriminant analysis was applied to multiple variables based on the measurements, and three variables were identified as of high predictive value. The most powerful discriminant was increased lamina propria cellularity in all forms of chronic colitis. The ratios of surface length to mucosal length and of surface epithelial height to crypt epithelial height also emerged as discriminants. Chronic inflammatory bowel disease was distinguished from normal in 95% of cases with a definite pathological diagnosis, and 85% of borderline cases were correctly classified as either normal or inflammatory when judged by the final diagnosis after follow up. This study provides a basis for automated diagnosis of rectal biopsy specimens and provides objectively validated criteria which can also be applied in routine histological diagnosis.

BACKGROUND: Primary aldosteronism (PA) causes hypertension and is potentially surgically curable when it is caused by a unilateral aldosterone-producing adrenal adenoma (APA). Adrenal vein sampling (AVS) is required to guide surgery, but it is invasive, is technically difficult, and has limited availability. OBJECTIVE: F]CETO). DESIGN: Prospective within-patient comparison of diagnostic interventions. (ClinicalTrials.gov: NCT02945904). SETTING: Three referral centers. PARTICIPANTS: 174 patients with PA desiring surgery if a unilateral source of PA was diagnosed. INTERVENTION: F]CETO in the final 31. MEASUREMENTS: F]CETO. RESULTS: C]MTO agreed in 29 of 31 patients (κ = 0.85 [CI, 0.68 to 1.00]). LIMITATION: C]MTO could be assessed only in the surgical group. CONCLUSION: Molecular imaging is an accurate, noninvasive alternative to AVS. PRIMARY FUNDING SOURCE: National Institute for Health and Care Research.

Introduction The authors have previously shown that experience improves lesion identification1 in capsule endoscopy (CE) and that a nurse reader overcalled lesions but did not miss significant pathology.2 Diagnostic nurse endoscopy is widely accepted in the UK but there is little data regarding proficiency in diagnostic capsule endoscopy (CE). Methods Consecutive CE videos read and reported by the nurse were examined by the doctor and vice versa in a blinded fashion and differences were arbitrated by a panel of both participants and two additional experts. The nurse is an experienced conventional endoscopist who had preread over 200 CE procedures; the doctor had read over 2000 CE videos. Gut symptoms refer to abdominal discomfort ± altered bowel habit and symptoms ‘plus’ with ‘alarm’ features (clinical or other investigation). Findings were considered ‘insignificant’ if they did not contribute to diagnosis or management. Data was analysed using a paired t test. Results Indications (95 patients, mean age 55 years, 35 male) included obscure bleeding (n=44), symptoms ‘plus’ (24), symptoms (12), coeliac disease (7), Crohn's disease (5) and other (3). The number of thumbnails did not differ (p=0.24) but the doctor read more quickly (17 vs 24 min, p&lt;0.001). Of 262 landmarks recorded by both, 259 (99%) were identical (arbitrarily decided as within 10 frames). Diagnoses were made in 30 (32%) patients: both identified Crohn's disease (n=9); NSAID enteropathy (6); active bleeding (4); coeliac disease (2); tumour (2); angioectasia, anastamotic ulcer, biopsy site, pouchitis and infectious enteropathy (1 each). The nurse, but not the doctor, commented on altered blood in the stomach felt by the panel to be significant. The doctor diagnosed an ulcerated Meckel's diverticulum described by the nurse as an ulcerated stricture. A diverticulum was noted by the doctor but not the nurse in a patient presenting with anaemia who also had Crohn's disease. Of 35 management decisions, 27 (77%) were identical. Of the remaining decisions, both nurse (n=2) and doctor (n=2) failed to suggest what the panel considered appropriate actions. The nurse suggested repeating CE after aspirin cessation when deemed unnecessary by the panel and both nurse (n=3) and doctor (n=1) suggested one form of endoscopy when another was felt more appropriate. Conclusion There was no difference in landmark recognition or diagnostic yield between an experienced nurse endoscopist and a doctor CE reader. Moreover, management advice was not demonstrably different and varied only in the advised use of different endoscopes to target areas of the small bowel, for which there is no evidence on which to base practice.

Purpose: We sought to evaluate outcomes for clinical management after a genetic diagnosis from the Deciphering Developmental Disorders study. Methods: = 5010). Clinical notes from regional clinical genetics services notes were reviewed to assess predefined clinical outcomes relating to interventions, prenatal choices, and information provision. Results: Outcomes were recorded for 4237 diagnosed probands (85% of those eligible) from all 24 recruiting centers across the United Kingdom and Ireland. Clinical management was reported to have changed in 28% of affected individuals. Where individual-level interventions were recorded, additional diagnostic or screening tests were started in 903 (21%) probands through referral to a range of different clinical specialties, and stopped or avoided in a further 26 (0.6%). Disease-specific treatment was started in 85 (2%) probands, including seizure-control medications and dietary supplements, and contra-indicated medications were stopped or avoided in a further 20 (0.5%). The option of prenatal/preimplantation genetic testing was discussed with 1204 (28%) families, despite the relatively advanced age of the parents at the time of diagnosis. Importantly, condition-specific information or literature was given to 3214 (76%) families, and 880 (21%) were involved in family support groups. In the most common condition (KBG syndrome; 79 [2%] probands), clinical interventions only partially reflected the temporal development of phenotypes, highlighting the importance of consensus management guidelines and patient support groups. Conclusion: Our results underscore the importance of achieving a clinico-molecular diagnosis to ensure timely onward referral of patients, enabling appropriate care and anticipatory surveillance, and for accessing relevant patient support groups.