Comparison of magnetic resonance enterography and video capsule endoscopy in evaluating small bowel disease.

PURPOSE: The goal of this study was to compare magnetic resonance enterography (MRE) and video capsule endoscopy (VCE) in suspected small bowel disease. MATERIALS AND METHODS: Nineteen patients with suspected small bowel disease participated in a prospective clinical comparison of MRE versus VCE. Both methods were evaluated separately and in conjunction with respect to a combined diagnostic endpoint based on clinical, laboratory, surgical, and histopathological findings. The Fisher's exact and j tests were used in comparing MRE and VCE. RESULTS: Small bowel pathologies were found in 15 out of 19 patients: Crohn's disease (n= 5), lymphoma (n= 4), lymphangioma (n= 1), adenocarcinoma (n= 1), postradiation enteropathy (n= 1), NSAID-induced enteropathy (n =1), angiodysplasia (n= 1), and small bowel adhesions (n= 1). VCE and MRE separately and in conjunction showed sensitivities of 92.9, 71.4, and 100% and specificities of 80, 60, and 80% (kappa= 0.73 vs. kappa = 0.29; P= 0.31/kappa = 0.85), respectively. In four patients, VCE depicted mucosal pathologies missed by MRE. MRE revealed 19 extraenteric findings in 11 patients as well as small bowel adhesions not detected on VCE (n= 1). CONCLUSION: VCE can readily depict and characterize subtle mucosal lesions missed at MRE, whereas MRE yields additional mural, perienteric, and extraenteric information. Thus, VCE and MRE appear to be complementary methods which, when used in conjunction, may better characterize suspected small bowel disease.

Wireless capsule pH monitoring: does it fulfil all expectations?

pH monitoring has been used as a diagnostic tool in gastro-oesophageal reflux disease (GERD) for many years. Recent studies have shown that wireless capsule pH monitoring is better tolerated and interferes less with daily activities as compared to traditional catheter-based pH monitoring. Moreover, prolonged recording time (48 h instead of 24 h) is possible with wireless pH monitoring. The main secondary effect of wireless capsule pH monitoring is induction of thoracic discomfort in 10-65% of the patients, which can vary from mild foreign body sensation to severe chest pain. Sensitivity and specificity of wireless capsule monitoring is comparable to that of traditional pH monitoring. It has not been proven yet that better tolerability and a longer recording time increases the diagnostic yield of wireless capsule monitoring in GERD.

Wireless GPS-based phase-locked synchronization system for outdoor environment.

Synchronization of data coming from different sources is of high importance in biomechanics to ensure reliable analyses. This synchronization can either be performed through hardware to obtain perfect matching of data, or post-processed digitally. Hardware synchronization can be achieved using trigger cables connecting different devices in many situations; however, this is often impractical, and sometimes impossible in outdoors situations. The aim of this paper is to describe a wireless system for outdoor use, allowing synchronization of different types of - potentially embedded and moving - devices. In this system, each synchronization device is composed of: (i) a GPS receiver (used as time reference), (ii) a radio transmitter, and (iii) a microcontroller. These components are used to provide synchronized trigger signals at the desired frequency to the measurement device connected. The synchronization devices communicate wirelessly, are very lightweight, battery-operated and thus very easy to set up. They are adaptable to every measurement device equipped with either trigger input or recording channel. The accuracy of the system was validated using an oscilloscope. The mean synchronization error was found to be 0.39 μs and pulses are generated with an accuracy of <2 μs. The system provides synchronization accuracy about two orders of magnitude better than commonly used post-processing methods, and does not suffer from any drift in trigger generation.

Example of Data Telemetry for Biomedical Applications: An In Vivo Experiment

This letter describes a data telemetry biomedical experiment. An implant, consisting of a biometric data sensor, electronics, an antenna, and a biocompatible capsule, is described. All the elements were co-designed in order to maximize the transmission distance. The device was implanted in a pig for an in vivo experiment of temperature monitoring.

Is the diagnostic yield of upper GI endoscopy improved by the use of explicit panel-based appropriateness criteria?

BACKGROUND: Increasing the appropriateness of use of upper gastrointestinal (GI) endoscopy is important to improve quality of care while at the same time containing costs. This study explored whether detailed explicit appropriateness criteria significantly improve the diagnostic yield of upper GI endoscopy. METHODS: Consecutive patients referred for upper GI endoscopy at 6 centers (1 university hospital, 2 district hospitals, 3 gastroenterology practices) were prospectively included over a 6-month period. After controlling for disease presentation and patient characteristics, the relationship between the appropriateness of upper GI endoscopy, as assessed by explicit Swiss criteria developed by the RAND/UCLA panel method, and the presence of relevant endoscopic lesions was analyzed. RESULTS: A total of 2088 patients (60% outpatients, 57% men) were included. Analysis was restricted to the 1681 patients referred for diagnostic upper GI endoscopy. Forty-six percent of upper GI endoscopies were judged to be appropriate, 15% uncertain, and 39% inappropriate by the explicit criteria. No cancer was found in upper GI endoscopies judged to be inappropriate. Upper GI endoscopies judged appropriate or uncertain yielded significantly more relevant lesions (60%) than did those judged to be inappropriate (37%; odds ratio 2.6: 95% CI [2.2, 3.2]). In multivariate analyses, the diagnostic yield of upper GI endoscopy was significantly influenced by appropriateness, patient gender and age, treatment setting, and symptoms. CONCLUSIONS: Upper GI endoscopies performed for appropriate indications resulted in detecting significantly more clinically relevant lesions than did those performed for inappropriate indications. In addition, no upper GI endoscopy that resulted in a diagnosis of cancer was judged to be inappropriate. The use of such criteria improves patient selection for upper GI endoscopy and can thus contribute to efforts aimed at enhancing the quality and efficiency of care. (Gastrointest Endosc 2000;52:333-41).

Capsule permeability via polymer and protein ingress/egress.

Static incubation tests, where microcapsules and beads are contacted with polymer and protein solutions, have been developed for the characterization of permselective materials applied for bioartificial organs and drug delivery. A combination of polymer ingress, detected by size-exclusion chromatography, and protein ingress/ egress, assessed by gel electrophoresis, provides information regarding the diffusion kinetics, molar mass cutoff(MMCO) and permeability. This represents an improvement over existing permeability measurements that are based on the diffusion of a single type of solute. Specifically, the permeability of capsules based on alginate, cellulose sulfate, polymethylene-co-guanidine were characterized as a function of membrane thickness. Solid alginate beads were also evaluated. The MMCO of these capsules was estimated to be between 80 and 90 kDa using polymers, and between 116-150 kDa with proteins. Apparently, the globular shape of the proteins (radius of gyration (Rg) of 4.2-4.6 nm) facilitates their passage through the membrane, comparatively to the polysaccharide coil conformation (Rg of 6.5-8.3 nm). An increase of the capsule membrane thickness reduced these values. The MMCO of the beads, which do not have a membrane limiting their permselective properties, was higher, between 110 and 200 kDa with dextrans, and between 150 and 220 kDa with proteins. Therefore, although the permeability estimated with biologically relevant molecules is generally higher due to their lower radius of gyration, both the MMCO of synthetic and natural watersoluble polymers correlate well, and can be used as in vitro metrics for the immune protection ability of microcapsules and microbeads. This article shows, to the authors' knowledge, the first reported concordance between permeability measures based on model natural and biological macromolecules.

Underutilization of upper gastrointestinal endoscopy.

BACKGROUND & AIMS: Efforts to reduce costs in health care may raise concerns about underuse of medical procedures. This study prospectively assessed underuse of upper gastrointestinal endoscopy in a cohort of patients in whom we have recently published data on overuse of endoscopy. METHODS: Underuse was identified by formal necessity criteria for endoscopy, obtained by an explicit panel process. Outpatients were consecutively included in two clinical settings. Setting A consisted of 20 primary care physicians and 7215 patient visits that occurred within 1 month. Setting B consisted of 920 visits that occurred during 3 weeks at an outpatient clinic. RESULTS: During these 8135 visits, 611 patients complained of upper digestive symptoms; 63 of them underwent endoscopy. Underuse was identified in 72 patients (11.8%). The two clinical situations mainly responsible for underuse of endoscopy were uninvestigated peptic symptoms resistant to treatment and dysphagia. At first follow-up, 29 of the patients with initial underuse still fulfilled criteria of necessity (underuse rate, 4.7%). One-year follow-up showed underuse of endoscopy in 5 patients. CONCLUSIONS: This prospective evidence shows that underuse of a medical procedure exists. The estimated overuse and underuse of endoscopy in this cohort were approximately equal (5%). Improving quality of care will require reductions of both overuse and underuse of medical procedures.

Hémorragie digestive aiguë [Acute gastrointestinal bleeding]

Gastrointestinal bleeding is among the major clinical challenges for the gastroenterologists and the initial approach is very complex. For a big part of bleeding lesions, it is important to perform an endoscopic hemostatis after the introduction of an intravenous treatment (that has to be started as soon as there is a clinical suspicion of an upper gastrointestinal bleeding). The significant progresses made during the last years have allowed firstly to see the entire small bowel mucosa (video capsule) and secondly new treatments have successfully replaced surgical interventions.

Sédation par propofol administrée par un non-anesthésiste pour l'endoscopie digestive [Administration of propofol by non-anesthesiologists for digestive endoscopy].

Propofol is progressively replacing benzodiazepines for sedation during endoscopy, even when the sedation is administered by non-anesthesiologists. Propofol ensures a more rapid induction of sedation and recovery and, in certain conditions, higher patient satisfaction and improved quality of endoscopic examination. Specific training is required to use this drug. Patients at risk of complications should be identified before the endoscopy to optimize patient management with an anesthesiologist. After sedation, psychomotor recovery is faster with propofol compared to traditional sedation agents but tasks requiring particular attention (eg, driving) should be avoided. It is important to advise patients of these restrictions in advance.