Gastric cancer missed at endoscopy

Stomach cancer is the fourth most common malignancy worldwide. Endoscopy (with biopsies) is the gold standard for its diagnosis but missed oesophageal and gastric cancers are not infrequent in patients who have undergone previous endoscopy. Errors by the endoscopist account for the majority of these missed lesions. The following report describes an incident in which there was a diagnostic error that led to a failed diagnosis of gastric cancer at first endoscopy. The implications for clinical and endoscopic practice are discussed.Keywords: Gastric cancer; Misdiagnoses; Diagnostic error; Endoscop

Colorectal cancer in Egypt is commoner in young people: Is this cause for alarm?

Background: Colorectal cancer (CRC) is the third most common cancer worldwide after lung and breast cancers with two-thirds of all CRCs occurring in the more developed regions of the world. CRC affects men and women of all racial and ethnic groups, and is most often found in those aged 50 years or older. Aim: The aim of the study was to determine the prevalence of CRC among patients undergoing colonoscopy in Egypt. Materials and methods: This was a descriptive cross-sectional hospital-based study. A total of 412 consecutive patients who underwent planned pancolonoscopy from January 2000 to January 2012 at our institution were assessed. All endoscopic examinations leading to a diagnosis of CRC were evaluated. The following parameters were analyzed: frequency of CRC, patient characteristics, indication for endoscopic examination, endoscopic findings, localization of CRC and histopathology. Results: CRC was diagnosed in 57 patients (14% of all colonoscopies). Fifty-six percent were female. The mean age was 51± 15 years (age range: 16–80 years). Twenty-five percent of cancers occurred in patients aged less than 40 years. The most frequent indication for colonoscopy was rectal bleeding (39%). The most common colonoscopy finding was mass (96%). Sixty-eight percent of CRC were located in the left colon and rectum. Ninety-one percent of CRC wereAdenocarcinoma. Conclusions: CRC is not uncommon among Egyptian patients subjected to colonoscopy. Thereare relatively higher CRC rates in patients under 40 years of age than reported in the West. This has implications relating to future epidemiological trends in Egypt. Physicians must have a greater awareness of the potential for CRC in young people in the Middle East.Keywords: Colorectal cancer; Birth cohort; Egypt 

Prevalence of reflux esophagitis among patients undergoing endoscopy in a secondary referral hospital in Giza, Egypt

Background: Gastro-esophageal reflux disease (GERD) is one of the most prevalent diseases seen in western countries. The prevalence of GERD is lower in the Asian population and the spectrum of the disease is mild. Data from Africa and the Middle East are sparse.Aim: The aim of the study was to determine the prevalence, severity and risk factors of reflux esophagitis (RE) among patients undergoing endoscopy in a secondary referral hospital in Egypt.Materials and methods: This was a retrospective study. Data on patients presenting with gastroesophageal reflux symptoms (RS) and scheduled for upper gastrointestinal endoscopy between January 2000 and January 2013 were collected.Results: Four hundred and thirty-three patients were assessed. Two hundred and fifty-four (59%) were male. Ages ranged from 18 to 85 years, mean 45± 15 years. One hundred and forty-four patients (33%) had a history of smoking, 120 (28%) were taking aspirin or non-steroidal anti-inflammatory drugs and 8 (2%) were consuming alcohol. The duration of RS ranged from one month to 20 years, mean 21 ± 30 months. One hundred and forty-six patients (34%) had the RS daily, 70 (16%) classified RS as severe intensity and 99 (23%) had acid regurgitation. One hundred and six patients (24%) were found to have RE. Ninety-eight of them (23%) showed grade 1. Barrett’s esophagus (BE) was diagnosed in seven patients (2%) and esophageal stricture in one (0.2%). One hundred and four patients (24%) had hiatus hernia (HH), 16 (4%) gastric ulcers and 45 (10%) duodenal ulcers. In multivariate analysis, male sex and HH were two independent risk factors for the development of RE.Conclusion: The prevalence of RE is low among patients undergoing endoscopy. Most of the patients had a mild degree of esophagitis. BE and stricture were rarely seen. Male sex and HH were risk factors of RE

Improving the quality of endoscopic polypectomy by introducing a colonoscopy quality assurance program

Background: Colonoscopy is a routine procedure in patients who present with bowel symptoms. Polyps can be identified and removed during colonoscopy. A colonoscopy quality-assurance program (CQAP) was instituted in 2003.Aim: The aim of the study was to determine the effect of instituting a CQAP on the quality of endoscopic polypectomy (EP) in our patients.Patients and methods: An Initial assessment of EP practice in 2003 showed that four patients had polyps. Cecal intubation had been achieved in only two patients and a complete polyp description (CPD) had not been documented. Polypectomy was performed in two patients but the completeness of removal and retrieval of the polyps had not been assessed and histology had not been recorded. A quality improvement process was therefore instituted. This required full colonoscopy to the cecum, CPD and polypectomy to be performed for every polyp. There should be a 90% retrieval rate of all excised polyps and follow up of all histology reports. Seventy-six patients were assessed prospectively over the period 2004–2011.Results: Cecal intubation rates increased from 65% in years 2004–2007 to 90% in years 2008–2011 (t-proportion = 2.4 & CI= 4.7, highly significant). CPD rates increased from 35% to 100% (t-proportion = 6.5 & CI= 12.7,  highly significant). EP rates increased from 59% to 100% (t-proportion = 3.5 & CI= 6.9, highly significant). Percentage of procedures in which all polyps were judged completely removed increased from 41% to 86% (t-proportion = 3.6 & CI= 7, highly significant). Polyp retrieval rates, with retrieval of P90% of all excised polyps, increased from 80% to 92% (t-proportion = 0.87 & CI= 1.7, significant). Polyp histology documentation rates increased from 41% to 88% (t-proportion =3.7 & CI= 7.3, highly significant).Conclusion: The implementation of a quality assurance and improvement program improved the quality of EP in patients with polyp(s) detected during colonoscopy.Keywords: Colonoscopy; Polypectomy; Quality assurance; Juvenile polyp

Spectroscopic studies of fluorescent perylene dyes

The lowest electronic transition of the fluorescent perylene dye bis-(3,5-di-tertbutylphenyl)-perylene-3, 4:9,10-biscarboximide has been investigated

Photophysics, Molecular Reorientation in Solution and X-Ray Structure of a New Fluorescent Probe 1,7-Diazaperylene

A new fluorescent molecule 1,7-diazaperylene (DP) has been investigated by means of time-resolved and steady-state polarized fluorescence spectroscopy, as well as X-ray spectroscopy. Absorption and fluorescence spectra of DP in solution are similar to those of perylene. However, absorption and fluorescence spectra of 2,8-dimethoxy DP and 2,8-dipentyloxy DP in solution are red-shifted by ca. 55 nm relative to perylene. The fluorescence decay of DP is exponential with a lifetime of 5.1 ns in ethanol, 4.9 ns in glycerol and 4.3 ns in paraffin oil. The radiative lifetime in ethanol was calculated to be 6.3 ns for DP, 8.0 ns for 2,8-dimethoxy DP and 7.6 ns for 2,8-dipentyloxy DP. The calculated fluorescence quantum yields of 0.8 for DP and its alkoxy derivatives in ethanol, are in good agreement with those obtained from measurements. The calculated Förster radius is 37.2 ± 1 Å for DP and 41.9 ± 1 Å for its alkoxy derivatives in ethanol. Examining the S0 S1 transition, we obtain a limiting fluorescence anisotropy of r0 0.38 for DP and its alkoxy derivatives. The rotational rates of DP in paraffin oil and glycerol were compared to that of perylene. In paraffin oil both molecules show an almost identical biexponential decay of the fluorescence anisotropy, which is compatible with a rotational motion like an oblate ellipsoid. The fluorescence anisotropy is monoexponential for DP in glycerol, and DP appears to rotate like a spherical particle while perylene in glycerol appears to rotate like an oblate ellipsoid. Moreover, the rotational diffusion constant, corresponding to rotation about an axis in the aromatic plane (D), is the same for both DP and perylene in glycerol

Sex- and age-related differences in the management and outcomes of chronic heart failure: an analysis of patients from the ESC HFA EORP Heart Failure Long-Term Registry

Aims: This study aimed to assess age- and sex-related differences in management and 1-year risk for all-cause mortality and hospitalization in chronic heart failure (HF) patients. Methods and results: Of 16 354 patients included in the European Society of Cardiology Heart Failure Long-Term Registry, 9428 chronic HF patients were analysed [median age: 66 years; 28.5% women; mean left ventricular ejection fraction (LVEF) 37%]. Rates of use of guideline-directed medical therapy (GDMT) were high (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists: 85.7%, 88.7% and 58.8%, respectively). Crude GDMT utilization rates were lower in women than in men (all differences: P\ua0 64 0.001), and GDMT use became lower with ageing in both sexes, at baseline and at 1-year follow-up. Sex was not an independent predictor of GDMT prescription; however, age >75 years was a significant predictor of GDMT underutilization. Rates of all-cause mortality were lower in women than in men (7.1% vs. 8.7%; P\ua0=\ua00.015), as were rates of all-cause hospitalization (21.9% vs. 27.3%; P\ua075 years. Conclusions: There was a decline in GDMT use with advanced age in both sexes. Sex was not an independent predictor of GDMT or adverse outcomes. However, age >75 years independently predicted lower GDMT use and higher all-cause mortality in patients with LVEF 6445%

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42\ub74% vs 44\ub72%; absolute difference \u20131\ub769 [\u20139\ub758 to 6\ub711] p=0\ub767; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5\u20138] vs 6 [5\u20138] cm H2O; p=0\ub70011). ICU mortality was higher in MICs than in HICs (30\ub75% vs 19\ub79%; p=0\ub70004; adjusted effect 16\ub741% [95% CI 9\ub752\u201323\ub752]; p<0\ub70001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0\ub780 [95% CI 0\ub775\u20130\ub786]; p<0\ub70001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding: No funding

Identifying associations between diabetes and acute respiratory distress syndrome in patients with acute hypoxemic respiratory failure: an analysis of the LUNG SAFE database

Background: Diabetes mellitus is a common co-existing disease in the critically ill. Diabetes mellitus may reduce the risk of acute respiratory distress syndrome (ARDS), but data from previous studies are conflicting. The objective of this study was to evaluate associations between pre-existing diabetes mellitus and ARDS in critically ill patients with acute hypoxemic respiratory failure (AHRF). Methods: An ancillary analysis of a global, multi-centre prospective observational study (LUNG SAFE) was undertaken. LUNG SAFE evaluated all patients admitted to an intensive care unit (ICU) over a 4-week period, that required mechanical ventilation and met AHRF criteria. Patients who had their AHRF fully explained by cardiac failure were excluded. Important clinical characteristics were included in a stepwise selection approach (forward and backward selection combined with a significance level of 0.05) to identify a set of independent variables associated with having ARDS at any time, developing ARDS (defined as ARDS occurring after day 2 from meeting AHRF criteria) and with hospital mortality. Furthermore, propensity score analysis was undertaken to account for the differences in baseline characteristics between patients with and without diabetes mellitus, and the association between diabetes mellitus and outcomes of interest was assessed on matched samples. Results: Of the 4107 patients with AHRF included in this study, 3022 (73.6%) patients fulfilled ARDS criteria at admission or developed ARDS during their ICU stay. Diabetes mellitus was a pre-existing co-morbidity in 913 patients (22.2% of patients with AHRF). In multivariable analysis, there was no association between diabetes mellitus and having ARDS (OR 0.93 (0.78-1.11); p = 0.39), developing ARDS late (OR 0.79 (0.54-1.15); p = 0.22), or hospital mortality in patients with ARDS (1.15 (0.93-1.42); p = 0.19). In a matched sample of patients, there was no association between diabetes mellitus and outcomes of interest. Conclusions: In a large, global observational study of patients with AHRF, no association was found between diabetes mellitus and having ARDS, developing ARDS, or outcomes from ARDS. Trial registration: NCT02010073. Registered on 12 December 2013

Epidemiology and patterns of tracheostomy practice in patients with acute respiratory distress syndrome in ICUs across 50 countries

Background: To better understand the epidemiology and patterns of tracheostomy practice for patients with acute respiratory distress syndrome (ARDS), we investigated the current usage of tracheostomy in patients with ARDS recruited into the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG-SAFE) study. Methods: This is a secondary analysis of LUNG-SAFE, an international, multicenter, prospective cohort study of patients receiving invasive or noninvasive ventilation in 50 countries spanning 5 continents. The study was carried out over 4 weeks consecutively in the winter of 2014, and 459 ICUs participated. We evaluated the clinical characteristics, management and outcomes of patients that received tracheostomy, in the cohort of patients that developed ARDS on day 1-2 of acute hypoxemic respiratory failure, and in a subsequent propensity-matched cohort. Results: Of the 2377 patients with ARDS that fulfilled the inclusion criteria, 309 (13.0%) underwent tracheostomy during their ICU stay. Patients from high-income European countries (n = 198/1263) more frequently underwent tracheostomy compared to patients from non-European high-income countries (n = 63/649) or patients from middle-income countries (n = 48/465). Only 86/309 (27.8%) underwent tracheostomy on or before day 7, while the median timing of tracheostomy was 14 (Q1-Q3, 7-21) days after onset of ARDS. In the subsample matched by propensity score, ICU and hospital stay were longer in patients with tracheostomy. While patients with tracheostomy had the highest survival probability, there was no difference in 60-day or 90-day mortality in either the patient subgroup that survived for at least 5 days in ICU, or in the propensity-matched subsample. Conclusions: Most patients that receive tracheostomy do so after the first week of critical illness. Tracheostomy may prolong patient survival but does not reduce 60-day or 90-day mortality. Trial registration: ClinicalTrials.gov, NCT02010073. Registered on 12 December 2013