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H. Pylori infection in endoscopists
CLINICAL ENDOSCOPIC PRACTICE ?89
91
ENDOSCOPIC ULTRASOUND (EUS) GUIDED FINE NEEDLE ASPIRATION (FNA) OF GASTROINTESTINAL (GI) TRACT LESIONS: MULTICENTER PRACTICE GUIDELINES. MF (~talano. B Hoffman, W Wassef, R Erickson, J Scheiman, M Bhutani, C Ngnyen, J Van Dam, G. Aliperti, N Horada, M. Wiersema. American Endosonography Club, EUS is an established imaging modality for the evaluation of a variety of GI disorders. The emergence of EUS guided FNA has improved the diagnostic and therapeutic capability of EUS with the possibility of improving outcome. There are no current established practice guidelines regarding the indications for or preparation of FNA. METHOD: Ten tertiary centers for EUS guided FNA participated in a survey regarding organs biopsied, presence of cytopathologist (CP) at tissue harvesting, frequency of nondiagnostic biopsy, and complication per organ/lesion biopsied. A multi-item questionnaire was completed for all patients. Cases were classified into 4 primary GI categories: 1) lymph nodes (LN) in primary GI malignancy, 2) extra-intestinal (X-INT) mass (pancreas, liver), 3) cystic mass, 4) intramural mass (IM). Number of FNA passes per lesion for adequacy of tissue sampling in each category was recorded. The importance of CP present during FNA to analyze each needle pass sample was also observed. Each case sampling was classified as benign, malignant, "inadequate", or "suspicious" at final pathology. Number of inadequate or suspicious diagnoses for each category was compared to presence/absence of CP. Complication rate was assessed for each disease category, number of FNA passes/case and presence or absence of CP. RESULTS: Data was analyzed in 712 pts. CP was present in all cases at 7 of 10 centers. Table demonstrates Avg FNA passes/pt, # nondiagnostic FNA cases and complications in the presence (pres) or absence (abs) of CP for each disease
MATERNAL AND FETAL OUTCOMES OF CONSCIOUS SEDATION AND ENDOSCOPY DURING PREGNANCY. VJ Colon, FC Ramirez, MS Cappell. Carl T Hayden VA Medical Center, Good Samaritan Regional Medical Center Phoenix, Arizona and Maimonides Medical Center, Brooklyn, New York.
l : cases are significantly increased in the absem of a CP for all cate ories. Rate of complications is small and not correlated with number of passes but rather to certain disease categories (cystic mass). Presence of CP during tissue harvesting is essential for successful sampling. Assessment of X-INT and LN staging represent greater than 90% of FNA cases.
The effects of conscious sedation dunng EGD upon pregnancy and the fetus are unknown. Objectives: To analyze the effects of conscious sedation to the pregnant patient and the fetus. Methods: Retrospective study of consecutive pregnant patients who received conscious sedation for EGD (sedation group). Pregnant patients undergoing EGD without conscious sedation were considered controls. Setting: Six teaching institutions. Study period: 1980 to 1996. Results: There were 37 patients in the sedation group and 11 in the control group. The mean gestation age at the time of endoscopy was 18.9 +1.3 weeks. There were 11 (23%) patients in the first, 18 (37%) in the second and 19 (40%) in the third trimesters. Medications and their mean doses used for sedation inchded moperidine: 56.7+3.8 nag (26 patients), midazolam: 2.38+0.34 nag (17 patients), and diazopam: 5.11+0.97 mg (9 patients). Naloxone was used in 3 patients. No changes in blood pressure, heart rate or pulse oximetry were noted before or after the procedures in either group. No endoscopic complications occurred. The type of delivery (cesarean section versus normal vaginal delivery) was not affected by the use of conscious sedation. Pregnancy outcomes were not different between both [,roups. Group Weight at APGAR APGAR Excellent Birth (Ibs) 1 rain 5 mni outcome* Sedation 5.9+0.6 8.13+0.3 8.7+0.3 23/28 (82%) Control 6.5+0.7 8.5+0.2 9.1+0.1 8/8 (100%7 *12 patients excluded, 9 in the sedation (5 voluntary abortions and 4 unknown pregnancy outcomes) and 3 in the control group (unknown pregnancy outcome). Poor outcomes included l abortion and 4 stillbirths occurring in high risk pregnancies and unrelated to the EGD and/or sedation. In 4 cases with fetal heart monitoring, EGD did not induce rate abnormalities Ore-sedation: 142.5+3.9 beats/rain: post-sedation=145.5+3.7 beats/rain). Conclusions: I) Conscious sedation did not induce hypotensiou, hypoxemia, or arrhythmias in the mother. 2) It did not have an adverse effect on fetal outcome. 3) This study suggests that conscious sedation with the medications and dosages used is not contraindicated in pregnancy.
?90
?92
H. PYLORI INFECTION IN ENDOSCOPISTS. ~ M. Sternthal, C. Bodian, G.Perez- Perez, MJ. Blaser, P.H.R. Green. The New York Society for Gastrointestinal Endoscopy (NYSGE) and Vanderbilt University School of Medicine, Nashville, TN. Back,,round and Aim: Studies have suggested that endoscopists are at increased risk of H. pylori infection (Hp). This study sought to assess the prevalence of H.p. infection in endoscopists and correlate this with demographic and practice factors. Methods: Attendees at the annual NYSGE course and the fellows summer conference were enrolled. Serum was tested for Hp antibody and CagA antibody using ELISA assays. The cut-off values for positivity were 1.0 and 0.35, respectively. Data were analyzed using univariate analysis with and without stratification with respect to Hp and CagA status. Result*: 144 attendees participated (44 females and 100 males). 54% were attendings, 34% were trainees, and 12% were endoscopy assistants. 52 subjects were Hp positive (36%), and 29 (20%) of these also were CagA positive. In the univariate analysis (all 10tscombined) the only statistically significant risk factor for Hp infection was birthplace; foreign-born subjects being twice as likely to be Hp positive (55% vs 26%, p=0.001). There was a suggestion that age >40 was associated with Hp positivity (40% vs 24%) but this did not reach statistical significance (p=0.09). There was no association between positivity and use of gloves during endoscopy. There were no significant differences found when gender, dyspeptic symptoms, use of universal precautions, and number of yrs performing endoscopy were analyzed. In the stratified analyses controlling for birthplace, there was a substantial difference in Hp positivity in different age-groups for the U.S. born subjects (9% for <40 vs 32% for >40, p=0.036) but not for the foreign-bom group (47% vs 58%, p=0.48). Similarly, no difference was seen in the foreign-born group for years performing endoscopy, whereas in the U.S. born group there was a trend toward increase in likelihood of being Hp positive with increasing endoscopic experience (p=0.12). For the CagA analysis on the Hp positive subset, the foreignborn group were more likely to be CagA positive (67% vs 44%, p=0.1). Younger subjects were less likely to be CagA positive (22% for <40 vs 62% for >40, p=0.03). The use of universal precautions seemed to decrease the likelihood of being CagA positive (45% vs 70%, p=0.07) Conclusions: The major risk factor for Hp positivity in this study was birth outside the U.S. Among U.S. born participants, age and duration of endoscopic experience appeared to be pertinent risk factors. CagA positivity also was associated with foreign-birth.
ANTIMICROBIAL EFFICACY OF ENDOSCOPIC DISINFECTION PROCEDURES: A CONTROLLED, MULTIFACTORIAL INVESTIGATION JR Cronmiller. DK Nelson, O Salman, DK Jackson, RS Dean, H Hsu, CH Kim. The Geneses Hospital and University of Rochester, Rochester, NY Adequate disinfection of endoscopes and accessories is important to prevent environment- and patient-to-patient transmissions of infectious agents, but data from controlled studies are limited. Moreover, there is controversy regarding current guidelines for disinfection. AIM: To compare antimicrobial efficacy of endoscopic disinfection procedures (including automated sterilization and several variations of manual soaking), controlling for multiple factors which impact reprocessing. METHODS: Dedicated enlonoscopes were contaminated with 10s CFU/mL of Emerococcussp as standardized inoculum. Scopes and accompanying Bx forceps were then passed through one of 16 study arms (5 reps/arm=80 total runs) which controlled singly for all possible combinations of the following variables: manual pre-cleaning; 10, 20, 45 min glutaraldehyde soak; air or ETOH drying; or automated reprocessing using peracetic acid (STEP,IS System I). Suction/biopsy channels (site I), air/water channels (II) and forceps (lid were harvested for culture. RESULTS: Control runs (no cleaning or disinfection) recovered >5x107 CFU/mL from each sampling site. When instruments underwent manual cleaning alone (without subsequent disinfection), test organism remained in 80-100% of runs. When each processing variable was isolated independent of other variables (TABLE), the benefits of manual pre-cleaning, longer soak time and ETOH drying across glutaraldehyde arms became apparent. When factors were combined, 20 and 45 rain glutaraldehyde exposures followed by ETOH drying were sufficient to remove all test organism, as was STERIS. % of total samples with test organismremaining Sample Soak Time (rain) D~ing Site ManualPre-clean S~r~ + 10 20 45 Air ETOH
Avg No Passes/Pt % Inadeqnate/Susp Complications Disease Total Category No. CP Pres CP Abs CP Pres CP Abs CP Pres CP Abs LN
280
3.5
4.5
2.5%
8.9%
0
0
X-INT
371
4.2
4.6
7.0%
10.7%
2
1
1
2
CYSTIC
16
3.2
3.8
0%
IM
45
4.6
4.9
9.4%
VOLUME 45, NO. 4, 1997
16.7% 23.1%
0
I
17%
8%
25%
10%
10%
27%
3%
0%
II
0%
0%
0%
0%
0%
0%
0%
0%
III 3% 0% 0% 5% 0% 3% 0% 0% CONCLUSION: Though initial cost is higher, the automated STERIS process provides effective sterilization while minimizing worker exposure. In units where chemical disinfection is used, our results suggest that manual pre-cleaning followed by at least 20 rain glutaraldehyde exposure and ETOH rinse drying are necessary to achieve complete disinfection. (Partially supported by Steris Corp, Mentor, OH)
GASTROINTESTINAL ENDOSCOPY
AB47
91
ENDOSCOPIC ULTRASOUND (EUS) GUIDED FINE NEEDLE ASPIRATION (FNA) OF GASTROINTESTINAL (GI) TRACT LESIONS: MULTICENTER PRACTICE GUIDELINES. MF (~talano. B Hoffman, W Wassef, R Erickson, J Scheiman, M Bhutani, C Ngnyen, J Van Dam, G. Aliperti, N Horada, M. Wiersema. American Endosonography Club, EUS is an established imaging modality for the evaluation of a variety of GI disorders. The emergence of EUS guided FNA has improved the diagnostic and therapeutic capability of EUS with the possibility of improving outcome. There are no current established practice guidelines regarding the indications for or preparation of FNA. METHOD: Ten tertiary centers for EUS guided FNA participated in a survey regarding organs biopsied, presence of cytopathologist (CP) at tissue harvesting, frequency of nondiagnostic biopsy, and complication per organ/lesion biopsied. A multi-item questionnaire was completed for all patients. Cases were classified into 4 primary GI categories: 1) lymph nodes (LN) in primary GI malignancy, 2) extra-intestinal (X-INT) mass (pancreas, liver), 3) cystic mass, 4) intramural mass (IM). Number of FNA passes per lesion for adequacy of tissue sampling in each category was recorded. The importance of CP present during FNA to analyze each needle pass sample was also observed. Each case sampling was classified as benign, malignant, "inadequate", or "suspicious" at final pathology. Number of inadequate or suspicious diagnoses for each category was compared to presence/absence of CP. Complication rate was assessed for each disease category, number of FNA passes/case and presence or absence of CP. RESULTS: Data was analyzed in 712 pts. CP was present in all cases at 7 of 10 centers. Table demonstrates Avg FNA passes/pt, # nondiagnostic FNA cases and complications in the presence (pres) or absence (abs) of CP for each disease
MATERNAL AND FETAL OUTCOMES OF CONSCIOUS SEDATION AND ENDOSCOPY DURING PREGNANCY. VJ Colon, FC Ramirez, MS Cappell. Carl T Hayden VA Medical Center, Good Samaritan Regional Medical Center Phoenix, Arizona and Maimonides Medical Center, Brooklyn, New York.
l : cases are significantly increased in the absem of a CP for all cate ories. Rate of complications is small and not correlated with number of passes but rather to certain disease categories (cystic mass). Presence of CP during tissue harvesting is essential for successful sampling. Assessment of X-INT and LN staging represent greater than 90% of FNA cases.
The effects of conscious sedation dunng EGD upon pregnancy and the fetus are unknown. Objectives: To analyze the effects of conscious sedation to the pregnant patient and the fetus. Methods: Retrospective study of consecutive pregnant patients who received conscious sedation for EGD (sedation group). Pregnant patients undergoing EGD without conscious sedation were considered controls. Setting: Six teaching institutions. Study period: 1980 to 1996. Results: There were 37 patients in the sedation group and 11 in the control group. The mean gestation age at the time of endoscopy was 18.9 +1.3 weeks. There were 11 (23%) patients in the first, 18 (37%) in the second and 19 (40%) in the third trimesters. Medications and their mean doses used for sedation inchded moperidine: 56.7+3.8 nag (26 patients), midazolam: 2.38+0.34 nag (17 patients), and diazopam: 5.11+0.97 mg (9 patients). Naloxone was used in 3 patients. No changes in blood pressure, heart rate or pulse oximetry were noted before or after the procedures in either group. No endoscopic complications occurred. The type of delivery (cesarean section versus normal vaginal delivery) was not affected by the use of conscious sedation. Pregnancy outcomes were not different between both [,roups. Group Weight at APGAR APGAR Excellent Birth (Ibs) 1 rain 5 mni outcome* Sedation 5.9+0.6 8.13+0.3 8.7+0.3 23/28 (82%) Control 6.5+0.7 8.5+0.2 9.1+0.1 8/8 (100%7 *12 patients excluded, 9 in the sedation (5 voluntary abortions and 4 unknown pregnancy outcomes) and 3 in the control group (unknown pregnancy outcome). Poor outcomes included l abortion and 4 stillbirths occurring in high risk pregnancies and unrelated to the EGD and/or sedation. In 4 cases with fetal heart monitoring, EGD did not induce rate abnormalities Ore-sedation: 142.5+3.9 beats/rain: post-sedation=145.5+3.7 beats/rain). Conclusions: I) Conscious sedation did not induce hypotensiou, hypoxemia, or arrhythmias in the mother. 2) It did not have an adverse effect on fetal outcome. 3) This study suggests that conscious sedation with the medications and dosages used is not contraindicated in pregnancy.
?90
?92
H. PYLORI INFECTION IN ENDOSCOPISTS. ~ M. Sternthal, C. Bodian, G.Perez- Perez, MJ. Blaser, P.H.R. Green. The New York Society for Gastrointestinal Endoscopy (NYSGE) and Vanderbilt University School of Medicine, Nashville, TN. Back,,round and Aim: Studies have suggested that endoscopists are at increased risk of H. pylori infection (Hp). This study sought to assess the prevalence of H.p. infection in endoscopists and correlate this with demographic and practice factors. Methods: Attendees at the annual NYSGE course and the fellows summer conference were enrolled. Serum was tested for Hp antibody and CagA antibody using ELISA assays. The cut-off values for positivity were 1.0 and 0.35, respectively. Data were analyzed using univariate analysis with and without stratification with respect to Hp and CagA status. Result*: 144 attendees participated (44 females and 100 males). 54% were attendings, 34% were trainees, and 12% were endoscopy assistants. 52 subjects were Hp positive (36%), and 29 (20%) of these also were CagA positive. In the univariate analysis (all 10tscombined) the only statistically significant risk factor for Hp infection was birthplace; foreign-born subjects being twice as likely to be Hp positive (55% vs 26%, p=0.001). There was a suggestion that age >40 was associated with Hp positivity (40% vs 24%) but this did not reach statistical significance (p=0.09). There was no association between positivity and use of gloves during endoscopy. There were no significant differences found when gender, dyspeptic symptoms, use of universal precautions, and number of yrs performing endoscopy were analyzed. In the stratified analyses controlling for birthplace, there was a substantial difference in Hp positivity in different age-groups for the U.S. born subjects (9% for <40 vs 32% for >40, p=0.036) but not for the foreign-bom group (47% vs 58%, p=0.48). Similarly, no difference was seen in the foreign-born group for years performing endoscopy, whereas in the U.S. born group there was a trend toward increase in likelihood of being Hp positive with increasing endoscopic experience (p=0.12). For the CagA analysis on the Hp positive subset, the foreignborn group were more likely to be CagA positive (67% vs 44%, p=0.1). Younger subjects were less likely to be CagA positive (22% for <40 vs 62% for >40, p=0.03). The use of universal precautions seemed to decrease the likelihood of being CagA positive (45% vs 70%, p=0.07) Conclusions: The major risk factor for Hp positivity in this study was birth outside the U.S. Among U.S. born participants, age and duration of endoscopic experience appeared to be pertinent risk factors. CagA positivity also was associated with foreign-birth.
ANTIMICROBIAL EFFICACY OF ENDOSCOPIC DISINFECTION PROCEDURES: A CONTROLLED, MULTIFACTORIAL INVESTIGATION JR Cronmiller. DK Nelson, O Salman, DK Jackson, RS Dean, H Hsu, CH Kim. The Geneses Hospital and University of Rochester, Rochester, NY Adequate disinfection of endoscopes and accessories is important to prevent environment- and patient-to-patient transmissions of infectious agents, but data from controlled studies are limited. Moreover, there is controversy regarding current guidelines for disinfection. AIM: To compare antimicrobial efficacy of endoscopic disinfection procedures (including automated sterilization and several variations of manual soaking), controlling for multiple factors which impact reprocessing. METHODS: Dedicated enlonoscopes were contaminated with 10s CFU/mL of Emerococcussp as standardized inoculum. Scopes and accompanying Bx forceps were then passed through one of 16 study arms (5 reps/arm=80 total runs) which controlled singly for all possible combinations of the following variables: manual pre-cleaning; 10, 20, 45 min glutaraldehyde soak; air or ETOH drying; or automated reprocessing using peracetic acid (STEP,IS System I). Suction/biopsy channels (site I), air/water channels (II) and forceps (lid were harvested for culture. RESULTS: Control runs (no cleaning or disinfection) recovered >5x107 CFU/mL from each sampling site. When instruments underwent manual cleaning alone (without subsequent disinfection), test organism remained in 80-100% of runs. When each processing variable was isolated independent of other variables (TABLE), the benefits of manual pre-cleaning, longer soak time and ETOH drying across glutaraldehyde arms became apparent. When factors were combined, 20 and 45 rain glutaraldehyde exposures followed by ETOH drying were sufficient to remove all test organism, as was STERIS. % of total samples with test organismremaining Sample Soak Time (rain) D~ing Site ManualPre-clean S~r~ + 10 20 45 Air ETOH
Avg No Passes/Pt % Inadeqnate/Susp Complications Disease Total Category No. CP Pres CP Abs CP Pres CP Abs CP Pres CP Abs LN
280
3.5
4.5
2.5%
8.9%
0
0
X-INT
371
4.2
4.6
7.0%
10.7%
2
1
1
2
CYSTIC
16
3.2
3.8
0%
IM
45
4.6
4.9
9.4%
VOLUME 45, NO. 4, 1997
16.7% 23.1%
0
I
17%
8%
25%
10%
10%
27%
3%
0%
II
0%
0%
0%
0%
0%
0%
0%
0%
III 3% 0% 0% 5% 0% 3% 0% 0% CONCLUSION: Though initial cost is higher, the automated STERIS process provides effective sterilization while minimizing worker exposure. In units where chemical disinfection is used, our results suggest that manual pre-cleaning followed by at least 20 rain glutaraldehyde exposure and ETOH rinse drying are necessary to achieve complete disinfection. (Partially supported by Steris Corp, Mentor, OH)
GASTROINTESTINAL ENDOSCOPY
AB47