Endoscopy

Endoscopy is a fast moving field, and new techniques are continuously emerging. In recent decades, endoscopy has evolved and branched out from a diagnostic modality to enhanced video and computer assisting imaging with impressive interventional capabilities. The modern endoscopy has seen advances not only in types of endoscopes available, but also in types of interventions amenable to the endoscopic approach. To date, there are a lot more developments that are being trialed. Modern endoscopic equipment provides physicians with the benefit of many technical advances. Endoscopy is an effective and safe procedure even in special populations including pediatric patients and renal transplant patients. It serves as the tool for diagnosis and therapeutic interventions of many organs including gastrointestinal tract, head and neck, urinary tract and others

Guideline for disinfection and sterilization in healthcare facilities, 2008. Update: May 2019

The Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, presents evidencebased recommendations on the preferred methods for cleaning, disinfection and sterilization of patientcare medical devices and for cleaning and disinfecting the healthcare environment. This document supercedes the relevant sections contained in the 1985 Centers for Disease Control (CDC) Guideline for Handwashing and Environmental Control. Because maximum effectiveness from disinfection and sterilization results from first cleaning and removing organic and inorganic materials, this document also reviews cleaning methods. The chemical disinfectants discussed for patient-care equipment include alcohols, glutaraldehyde, formaldehyde, hydrogen peroxide, iodophors, ortho-phthalaldehyde, peracetic acid, phenolics, quaternary ammonium compounds, and chlorine. The choice of disinfectant, concentration, and exposure time is based on the risk for infection associated with use of the equipment and other factors discussed in this guideline. The sterilization methods discussed include steam sterilization, ethylene oxide (ETO), hydrogen peroxide gas plasma, and liquid peracetic acid. When properly used, these cleaning, disinfection, and sterilization processes can reduce the risk for infection associated with use of invasive and noninvasive medical and surgical devices. However, for these processes to be effective, health-care workers should adhere strictly to the cleaning, disinfection, and sterilization recommendations in this document and to instructions on product labels.In addition to updated recommendations, new topics addressed in this guideline include1. inactivation of antibiotic-resistant bacteria, bioterrorist agents, emerging pathogens, and bloodborne pathogens;2. toxicologic, environmental, and occupational concerns associated with disinfection andsterilization practices;3. disinfection of patient-care equipment used in ambulatory settings and home care;4. new sterilization processes, such as hydrogen peroxide gas plasma and liquid peracetic acid; and5. disinfection of complex medical instruments (e.g., endoscopes).This guideline discusses use of products by healthcare personnel in healthcare settings such as hospitals, ambulatory care and home care; the recommendations are not intended for consumer use of the products discussed.disinfection-guidelines-H.pd

Guideline for disinfection and sterilization in healthcare facilities, 2008

2008, last update: Feburary 15, 2017"The Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, presents evidence-based recommendations on the preferred methods for cleaning, disinfection and sterilization of patient-care medical devices and for cleaning and disinfecting the healthcare environment. This document supercedes the relevant sections contained in the 1985 Centers for Disease Control (CDC) Guideline for Handwashing and Environmental Control. Because maximum effectiveness from disinfection and sterilization results from first cleaning and removing organic and inorganic materials, this document also reviews cleaning methods. The chemical disinfectants discussed for patient-care equipment include alcohols, glutaraldehyde, formaldehyde, hydrogen peroxide, iodophors, ortho-phthalaldehyde, peracetic acid, phenolics, quaternary ammonium compounds, and chlorine. The choice of disinfectant, concentration, and exposure time is based on the risk for infection associated with use of the equipment and other factors discussed in this guideline. The sterilization methods discussed include steam sterilization, ethylene oxide (ETO), hydrogen peroxide gas plasma, and liquid peracetic acid. When properly used, these cleaning, disinfection, and sterilization processes can reduce the risk for infection associated with use of invasive and noninvasive medical and surgical devices. However, for these processes to be effective, health-care workers should adhere strictly to the cleaning, disinfection, and sterilization recommendations in this document and to instructions on product labels. In addition to updated recommendations, new topics addressed in this guideline include 1) inactivation of antibiotic-resistant bacteria, bioterrorist agents, emerging pathogens, and bloodborne pathogens; 2) toxicologic, environmental, and occupational concerns associated with disinfection and sterilization practices; 3) disinfection of patient-care equipment used in ambulatory settings and home care; 4) new sterilization processes, such as hydrogen peroxide gas plasma and liquid peracetic acid; and 5) disinfection of complex medical instruments (e.g., endoscopes)." - p. 7Environmental Fogging [December 2009]Clarification Statement: CDC and HICPAC have recommendations in both 2003 Guidelines for Environmental Infection Control in Health-Care Facilities and the 2008 Guideline for Disinfection and Sterilization in Healthcare Facilities that state that the CDC does not support disinfectant fogging. Specifically, the 2003 and 2008 Guidelines state:\ue2\u20ac\ua2 2003: \ue2\u20ac\u153Do not perform disinfectant fogging for routine purposes in patient-care areas. Category IB\ue2\u20ac?\ue2\u20ac\ua2 2008: \ue2\u20ac\u153Do not perform disinfectant fogging in patient-care areas. Category II\ue2\u20ac?These recommendations refer to the spraying or fogging of chemicals (e.g., formaldehyde, phenol-based agents, or quaternary ammonium compounds) as a way to decontaminate environmental surfaces or disinfect the air in patient rooms. The recommendation against fogging was based on studies in the 1970\ue2\u20ac\u2122s that reported a lack of microbicidal efficacy (e.g., use of quaternary ammonium compounds in mist applications) but also adverse effects on healthcare workers and others in facilities where these methods were utilized. Furthermore, some of these chemicals are not EPA-registered for use in fogging-type applications.These recommendations do not apply to newer technologies involving fogging for room decontamination (e.g., ozone mists, vaporized hydrogen peroxide) that have become available since the 2003 and 2008 recommendations were made. These newer technologies were assessed by CDC and HICPAC in the 2011 Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, which makes the recommendation:\ue2\u20ac\u153More research is required to clarify the effectiveness and reliability of fogging, UV irradiation, and ozone mists to reduce norovirus environmental contamination. (No recommendation/unresolved issue)\ue2\u20ac?The 2003 and 2008 recommendations still apply; however, CDC does not yet make a recommendation regarding these newer technologies. This issue will be revisited as additional evidence becomes available.CurrentHICPACPrevention and ControlInfectious Diseas

Therapeutic Gastrointestinal Endoscopy

Endoscopy has had a big role in the development of modern gastroenterology. Modern endoscopy will certainly be more therapeutic. It started with endoscopic hemostasis and polipectomy, than beginning of the 1970's with the advent of endoscopic sphincterotomy extended to biliopancreatic pathology and has a huge impact in this difficult pathology. Plastic stents made the first steps in endoscopic palliation of neoplastic jaundice, metallic stents, covered or uncovered are better for biliary palliation and can be used also for palliation neoplastic obstruction at different levels of the digestive tube. Resection of digestive tumors has evolved now to sub-mucosal resection, looking to have one-piece complete resection. Interventional endoscopy is now very complex and takes a lot of time for endoscopists to learn properly these techniques. This book is a very good up-to-date overview of new techniques of interventional endoscopy for those who want to learn or develop their knowledges in this field

Pushing the physical limits of infrared chemical imaging: intravascular photoacoustic & mid-infrared photothermal

Providing molecular fingerprint information, vibrational spectroscopy is a powerful tool for chemical analysis. In the mid-infrared window, FT-IR spectroscopy and microscopy have been routinely used for sample characterization. In the near-IR window, near-infrared spectroscopy has been widely used for tissue analysis and for the detection of lipids in the arterial walls. Yet, these traditional linear spectroscopies have intrinsic limitations. FT-IR spectroscopy suffers from a poor spatial resolution and strong water absorption for the study of living systems. Near-infrared spectroscopy avoids water absorption, yet it suffers from a poor, millimeter-scale spatial resolution in tissue analysis. My thesis focuses on breaking these limitations through photoacoustic and photothermal detection approaches. The first part of my thesis is on improving the spatial resolution in catheter-based intravascular photoacoustic (IVPA) imaging. By near-infrared excitation of lipids and acoustic detection, IVPA allows depth-resolved identification of lipid-laden atherosclerotic plaque. Thus far, most IVPA endoscopes use multimode fibers, which do not allow tight focusing of photons. Recent experiments on pulse propagation in multimode graded-index fibers have shown a nonlinear improvement in beam quality. Here, we harness this nonlinear phenomenon for the fiber-delivery of nanosecond laser pulses. We built a photoacoustic catheter 1.4 mm outer diameter, offering a lateral resolution as fine as 30 μm within a depth range of 2.5 mm. Such resolution is one order of magnitude better than current multi-mode fiber-based intravascular photoacoustic catheters. At the same time, the delivered pulse energy can reach as high as 20 μJ, which is two orders of magnitude higher than that of an optical resolution photoacoustic endoscope built with single-mode fiber. These improvements are expected to promote the biomedical application of photoacoustic endoscopes which require both high resolution and high pulse energy. Based on the technical advances, my thesis work further demonstrated longitudinal imaging of the same plaque in the same living animal. Recently developed mid-infrared photothermal (MIP) microscopy overcomes the limitations in FT-IR microscopy by probing the IR absorption-induced photothermal effect using visible light. MIP microscopy yields sub-micrometer spatial resolution with high spectral fidelity and much-reduced water background. The second part of my thesis work pushes the physical limits of MIP microscopy in aspects of detection sensitivity and imaging speed using two approaches. First, taking advantage of the interference scattering effect, the scattering signal from the sample can be greatly enhanced. Together with the relatively large infrared absorption coefficient, the sensitivity of the infrared spectrum is greatly improved, and single virus detection is achieved. Second, by using fluorescence as a thermo-sensitive probe, the temperature raise by infrared absorption can be retrieved in a more efficient way and much higher imaging speed and sensitivity are thus accomplished

EQUINE PITUITARY PARS INTERMEDIA DYSFUNCTION (PPID): PATHOPHYSIOLOGY AND A SURGICAL APPROACH TO TREATMENT

Equine pituitary pars intermedia dysfunction (PPID) is a common endocrine disease of the older horse. First described in 1932, and likened to human Cushing’s disease, it is associated with an enlargement of the pituitary gland that was classically termed an adenoma. The underlying mechanism is attributable to a lack of dopaminergic inhibition of the pars intermedia. Treatment methods have remained essentially unchanged for 30 years and the prevalence data have mainly stemmed from Eastern Australia and the USA. The general objective of this thesis was to explore the feasibility of developing a targeted cell-specific approach for the treatment of equine PPID. The specific aims were to confirm the need for this advanced therapy by determining the prevalence of PPID in horses globally; to continue the investigation of the underlying cellular mechanism of PPID by confirming the role of pro-hormone convertases, and sequence the equine pro-opiomelanocortin, prohormone convertase 1 and 2 genes; and to investigate the methodology for site-specific applications of future therapy for equine PPID. These aims were met by reporting the prevalence data from a worldwide audience of veterinarians using an internet-based survey tool; by describing partial gene sequences of the equine proopiomelanocortin and prohormone convertase enzymes and their expression in normal and PPID horses; and by showing how low-volume contrast enhancement of the brain using computed tomography can delineate the margins of the pituitary gland, showing how general anesthesia effects the pulsitility and concentration of adrenocorticotrophic hormone, and finally, modifying a previously reported technique, by developing a novel surgical approach to the treatment of this classical condition

Endoscopic Assessment and Treatment of Barrett’s Oesophagus

Oesophageal cancer worldwide is the eighth commonest cancer and carries a poor prognosis. Barrett’s oesophagus is the only known risk factor for oesophageal adenocarcinoma. Cancer progresses along a metaplasia-dysplasia pathway. Dysplastic changes may be seen on endoscopic assessment. This thesis presents evidence that i-Scan virtual chromoendoscopy together with acetic acid chromoendoscopy can improve dysplasia detection using a simple classification system. Superficial lesions, without deeper invasion (low and high grade dysplasia, early cancers) have a low risk of distant metastasis. Endoscopic resection and ablation techniques have been demonstrated to have an excellent efficacy and safety profile. The current standard of care for early Barrett’s neoplasia is endoscopic management rather than surgical intervention. Surgery for oesophageal cancer is centred in specialist units due to improved outcomes in high volume centres. The UK radiofrequency ablation registry collects outcomes for patients undergoing endoscopic therapy for Barrett’s neoplasia. This thesis demonstrates that there is no difference in dysplasia or intestinal metaplasia resolution rates or dysplasia recurrence between low and high volume centres. Learning curve analysis suggests that there is a change point at 18 cases, when the observed successful treatment rate of the centre becomes better than the expected rate. Centres should complete 20 cases before competency can be achieved. Treatment of Barrett’s neoplasia involves endoscopic resection of visible lesions. Due to the high risk of metachronous lesions, the remaining Barrett’s epithelium undergoes field ablation, commonly with radiofrequency ablation. Following successful treatment the risk of dysplasia recurrence is 6%. The risk increases with increasing length of the initial Barrett segment and with increasing age. The risk of untreated islands of Barrett’s IM is unknown but this thesis demonstrates that it does not seem to confer an increased risk of recurrence and may not require further ablation if unresponsive to treatment

Emergency and critical care of the avian patient

Dissertação de Mestrado Integrado em Medicina VeterináriaIncreasing numbers of exotic animals are being kept as pets and owners want to receive the same high quality veterinary medical care as given to other animals. The field of emergency and critical care is rapidly developing so this dissertation focus on clinically relevant information, some new advances and their application to therapy. In the first part of this work, the data gathered regarding all medical and surgical procedures performed during a four-month externship at Great Western Referrals Hospital, United Kingdom, under the scientific supervision of Dr. Neil Forbes is presented. The second part is a description of the most common emergency presentations, effective diagnostic and therapeutic protocols, including the pathophysiology of shock and fluid therapy. In the third part of this work, 12 clinical cases observed during the externship are presented. These cases were chosed due to their being representative of what the clinician may have to deal with in terms of avian emergency and critical care. For each case, clinical signs, diagnostic testing and treatment are described and discussed. The clinical presentation for each case is extremely diverse with inter- and intra- specific variations which is further complicated by the fact that most avian species mask signs of disease so owners are rarely aware of health problems that may occur. One of the limitations of emergency avian procedures is the challenge to reach an adequate diagnosis and establish adequate treatment protocols for critical patients, for which time is crucial. Stabilization on initial presentation is more urgent than making a definitive diagnosis and supportive care can save more exotic animals than any other treatment.RESUMO - EMERGÊNCIA E CUIDADOS INTENSIVOS EM AVES - Cada vez mais animais exóticos são mantidos como animais de estimação e os seus donos desejam receber o mesmo nível de qualidade em termos de cuidados médico-veterinários que o prestado a outros animais. O ramo das emergências e cuidados intensivos está a desenvolver-se rapidamente sendo esta dissertação baseada em informação clinicamente relevante, avanços recentes na área e suas aplicações terapêuticas. Na primeira parte deste trabalho é apresentada informação relativa a todos os procedimentos médicos e cirúrgicos realizados durante um estágio de quatro meses no hospital Great Western Referrals, Reino Unido, sob a supervisão científica do Dr. Neil Forbes. A segunda parte contém uma descrição das apresentações clínicas de emergência mais comuns, protocolos de diagnóstico e terapia, incluindo patofisiologia do choque e fluidoterapia. Na terceira parte deste trabalho são apresentados 12 casos clínicos observados durante o estágio. Estes casos foram escolhidos como sendo representativos do que o clínico poderá encontrar em termos de emergência e cuidados intensivos de aves. Para cada caso, sinais clínicos, exames complementares e tratamento são descritos e discutidos. A apresentação clínica de cada caso é extremamente variada, com variações inter- e intra- específicas, sendo isto complicado pelo facto de que a maioria das espécies de aves escondem sinais de doença estando os seus donos raramente conscientes de problemas de saúde que possam ocorrer. Uma das limitações dos procedimentos de emergência em aves é a dificuldade em estabelecer um diagnóstico adequado com o devido protocolo terapêutico em pacientes críticos para os quais o tempo é crucial. A estabilização inicial é mais urgente do que a elaboração de um diagnóstico definitivo e um tratamento de suporte adequado pode salvar mais animais exóticos do que qualquer outro tratamento

New Techniques in Gastrointestinal Endoscopy

As result of progress, endoscopy has became more complex, using more sophisticated devices and has claimed a special form. In this moment, the gastroenterologist performing endoscopy has to be an expert in macroscopic view of the lesions in the gut, with good skills for using standard endoscopes, with good experience in ultrasound (for performing endoscopic ultrasound), with pathology experience for confocal examination. It is compulsory to get experience and to have patience and attention for the follow-up of thousands of images transmitted during capsule endoscopy or to have knowledge in physics necessary for autofluorescence imaging endoscopy. Therefore, the idea of an endoscopist has changed. Examinations mentioned need a special formation, a superior level of instruction, accessible to those who have already gained enough experience in basic diagnostic endoscopy. This is the reason for what these new issues of endoscopy are presented in this book of New techniques in Gastrointestinal Endoscopy