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Simplify Postoperative Self-removal of Bandages for Isolated Patients With Limited Range of Motion Using Pull Tabs

Article Type
Article
Changed
Wed, 12/28/2022 - 13:58
Display Headline
Simplify Postoperative Self-removal of Bandages for Isolated Patients With Limited Range of Motion Using Pull Tabs
Author(s)
Lily Parker, BS
Jake Myhre, BS
Andy Asher, BS
Taylor Mulkey, MD

Practice Gap

A male patient presented with 2 concerning lesions, which histopathology revealed were invasive squamous cell carcinoma (SCC) on the right medial chest and SCC in situ on the right upper scapular region. Both were treated with wide local excision; margins were clear in our office the same day.

This case highlighted a practice gap in postoperative care. Two factors posed a challenge to proper postoperative wound care for our patient:

• Because of the high risk of transmission of SARS-CoV-2, the patient hoped to limit exposure by avoiding an office visit to remove the bandage.

• The patient did not have someone at home to serve as an immediate support system, which made it impossible for him to rely on others for postoperative wound care.

Previously, the patient had to ask a friend to remove a bandage for melanoma in situ on the inner aspect of the left upper arm. Therefore, after this procedure, the patient asked if the bandage could be fashioned in a manner that would allow him to remove it without assistance (Figure 1).

Case patient wearing prototype #1, an easy-removal pulltab bandage.
FIGURE 1. Case patient wearing prototype #1, an easy-removal pulltab bandage.

Technique

In constructing a bandage that is easier to remove, some necessary pressure that is provided by the bandage often is sacrificed by making it looser. Considering that our patient had moderate bleeding during the procedure—in part because he took low-dose aspirin (81 mg/d)—it was important to maintain firm pressure under the bandage postoperatively to help prevent untoward bleeding. Furthermore, because of the location of the treated site and the patient’s limited range of motion, it was not feasible for him to reach the area on the scapula and remove the bandage.1

For easy self-removal, we designed a bandage with a pull tab that was within the patient’s reach. Suitable materials for the pull tab bandage included surgical tape, bandaging tape with adequate stretch, sterile nonadhesive gauze, fenestrated surgical gauze, and a topical emollient such as petroleum jelly or antibacterial ointment.

To clean the site and decrease the amount of oil that would reduce the effectiveness of the adhesive, the wound was prepared with 70% alcohol. The site was then treated with petroleum jelly.

Next, we designed 2 pull tab bandage prototypes that allowed easy self-removal. For both prototypes, sterile nonadhesive gauze was applied to the wound along with folded and fenestrated gauze, which provided pressure. We used prototype #1 in our patient, and prototype #2 was demonstrated as an option.

 

 

Prototype #1—We created 2 tabs—each 2-feet long—using bandaging tape that was folded on itself once horizontally (Figure 2). The tabs were aligned on either side of the wound, the tops of which sat approximately 2 inches above the top of the first layer of adhesive bandage. An initial layer of adhesive surgical dressing was applied to cover the wound; 1 inch of the dressing was left exposed on the top of each tab. In addition, there were 2 “feet” running on the bottom.

A, Step 1 in preparing prototype #1 bandage: create 2 pull tabs, each 2-feet long, using bandaging tape folded on itself once horizontally. Place these tabs on either side of the lesion, then secure to the patient with adhesive gauze.
FIGURE 2. A, Step 1 in preparing prototype #1 bandage: create 2 pull tabs, each 2-feet long, using bandaging tape folded on itself once horizontally. Place these tabs on either side of the lesion, then secure to the patient with adhesive gauze. Include any necessary wound packing underneath. B, Step 2: fold the tops of the pull tabs over the top side of the adhesive tape and tape down with more adhesive bandage.

The tops of the tabs were folded back over the adhesive tape, creating a type of “hook.” An additional final layer of adhesive tape was applied to ensure adequate pressure on the surgical site.

The patient was instructed to remove the bandage 2 days after the procedure. The outcome was qualified through a 3-day postoperative telephone call. The patient was asked about postoperative pain and his level of satisfaction with treatment. He was asked if he had any changes such as bleeding, swelling, signs of infection, or increased pain in the days after surgery or perceived postoperative complications, such as irritation. We asked the patient about the relative ease of removing the bandage and if removal was painful. He reported that the bandage was easy to remove, and that doing so was not painful; furthermore, he did not have problems with the bandage or healing and did not experience any medical changes. He found the bandage to be comfortable. The patient stated that the hanging feet of the prototype #1 bandage were not bothersome and were sturdy for the time that the bandage was on.

Prototype #2—We prepared a bandage using surgical packing as the tab (Figure 3). The packing was slowly placed around the site, which was already covered with nonadhesive gauze and fenestrated surgical gauze, with adequate spacing between each loop (for a total of 3 loops), 1 of which crossed over the third loop so that the adhesive bandaging tape could be removed easily. This allowed for a single tab that could be removed by a single pull. A final layer of adhesive tape was applied to ensure adequate pressure, similar to prototype #1. The same postoperative protocol was employed to provide a consistent standard of care. We recommend use of this prototype when surgical tape is not available, and surgical packing can be used as a substitute.

In assembling the prototype #2 bandage, pull tabs are left exposed and hanging at the bottom.
FIGURE 3. In assembling the prototype #2 bandage, pull tabs are left exposed and hanging at the bottom.

Practice Implications

Patients have a better appreciation for avoiding excess visits to medical offices due to the COVID-19 pandemic. The risk for exposure to SARS-CoV-2 infection is greater when patients who lack a support system must return to the office for aftercare or to have a bandage removed. Although protection offered by the COVID-19 vaccine alleviates concern, many patients have realized the benefits of only visiting medical offices in person when necessary.

The concept of pull tab bandages that can be removed by the patient at home has other applications. For example, patients who travel a long distance to see their physician will benefit from easier aftercare and avoid additional follow-up visits when provided with a self-removable bandage.

References
  1. Stathokostas, L, McDonald MW, Little RMD, et al. Flexibility of older adults aged 55-86 years and the influence of physical activity. J Aging Res. 2013;2013:1-8. doi:10.1155/2013/743843
Article PDF
CT110005275.pdf
Author and Disclosure Information

From Dermatology Associates of Tallahassee and the Department of Dermatology, Florida State College of Medicine, Tallahassee.

The authors report no conflict of interest.

Correspondence: Lily Parker, BS ([email protected]). 

Issue
Cutis - 110(5)
Publications
MDedge Dermatology
Cutis
Topics
Nonmelanoma Skin Cancer
Wounds
Page Number
275-276
Sections
Practical Pearls
Author(s)
Lily Parker, BS
Jake Myhre, BS
Andy Asher, BS
Taylor Mulkey, MD
Author(s)
Lily Parker, BS
Jake Myhre, BS
Andy Asher, BS
Taylor Mulkey, MD
Author and Disclosure Information

From Dermatology Associates of Tallahassee and the Department of Dermatology, Florida State College of Medicine, Tallahassee.

The authors report no conflict of interest.

Correspondence: Lily Parker, BS ([email protected]). 

Author and Disclosure Information

From Dermatology Associates of Tallahassee and the Department of Dermatology, Florida State College of Medicine, Tallahassee.

The authors report no conflict of interest.

Correspondence: Lily Parker, BS ([email protected]). 

Article PDF
CT110005275.pdf
Article PDF
CT110005275.pdf

Practice Gap

A male patient presented with 2 concerning lesions, which histopathology revealed were invasive squamous cell carcinoma (SCC) on the right medial chest and SCC in situ on the right upper scapular region. Both were treated with wide local excision; margins were clear in our office the same day.

This case highlighted a practice gap in postoperative care. Two factors posed a challenge to proper postoperative wound care for our patient:

• Because of the high risk of transmission of SARS-CoV-2, the patient hoped to limit exposure by avoiding an office visit to remove the bandage.

• The patient did not have someone at home to serve as an immediate support system, which made it impossible for him to rely on others for postoperative wound care.

Previously, the patient had to ask a friend to remove a bandage for melanoma in situ on the inner aspect of the left upper arm. Therefore, after this procedure, the patient asked if the bandage could be fashioned in a manner that would allow him to remove it without assistance (Figure 1).

Case patient wearing prototype #1, an easy-removal pulltab bandage.
FIGURE 1. Case patient wearing prototype #1, an easy-removal pulltab bandage.

Technique

In constructing a bandage that is easier to remove, some necessary pressure that is provided by the bandage often is sacrificed by making it looser. Considering that our patient had moderate bleeding during the procedure—in part because he took low-dose aspirin (81 mg/d)—it was important to maintain firm pressure under the bandage postoperatively to help prevent untoward bleeding. Furthermore, because of the location of the treated site and the patient’s limited range of motion, it was not feasible for him to reach the area on the scapula and remove the bandage.1

For easy self-removal, we designed a bandage with a pull tab that was within the patient’s reach. Suitable materials for the pull tab bandage included surgical tape, bandaging tape with adequate stretch, sterile nonadhesive gauze, fenestrated surgical gauze, and a topical emollient such as petroleum jelly or antibacterial ointment.

To clean the site and decrease the amount of oil that would reduce the effectiveness of the adhesive, the wound was prepared with 70% alcohol. The site was then treated with petroleum jelly.

Next, we designed 2 pull tab bandage prototypes that allowed easy self-removal. For both prototypes, sterile nonadhesive gauze was applied to the wound along with folded and fenestrated gauze, which provided pressure. We used prototype #1 in our patient, and prototype #2 was demonstrated as an option.

 

 

Prototype #1—We created 2 tabs—each 2-feet long—using bandaging tape that was folded on itself once horizontally (Figure 2). The tabs were aligned on either side of the wound, the tops of which sat approximately 2 inches above the top of the first layer of adhesive bandage. An initial layer of adhesive surgical dressing was applied to cover the wound; 1 inch of the dressing was left exposed on the top of each tab. In addition, there were 2 “feet” running on the bottom.

A, Step 1 in preparing prototype #1 bandage: create 2 pull tabs, each 2-feet long, using bandaging tape folded on itself once horizontally. Place these tabs on either side of the lesion, then secure to the patient with adhesive gauze.
FIGURE 2. A, Step 1 in preparing prototype #1 bandage: create 2 pull tabs, each 2-feet long, using bandaging tape folded on itself once horizontally. Place these tabs on either side of the lesion, then secure to the patient with adhesive gauze. Include any necessary wound packing underneath. B, Step 2: fold the tops of the pull tabs over the top side of the adhesive tape and tape down with more adhesive bandage.

The tops of the tabs were folded back over the adhesive tape, creating a type of “hook.” An additional final layer of adhesive tape was applied to ensure adequate pressure on the surgical site.

The patient was instructed to remove the bandage 2 days after the procedure. The outcome was qualified through a 3-day postoperative telephone call. The patient was asked about postoperative pain and his level of satisfaction with treatment. He was asked if he had any changes such as bleeding, swelling, signs of infection, or increased pain in the days after surgery or perceived postoperative complications, such as irritation. We asked the patient about the relative ease of removing the bandage and if removal was painful. He reported that the bandage was easy to remove, and that doing so was not painful; furthermore, he did not have problems with the bandage or healing and did not experience any medical changes. He found the bandage to be comfortable. The patient stated that the hanging feet of the prototype #1 bandage were not bothersome and were sturdy for the time that the bandage was on.

Prototype #2—We prepared a bandage using surgical packing as the tab (Figure 3). The packing was slowly placed around the site, which was already covered with nonadhesive gauze and fenestrated surgical gauze, with adequate spacing between each loop (for a total of 3 loops), 1 of which crossed over the third loop so that the adhesive bandaging tape could be removed easily. This allowed for a single tab that could be removed by a single pull. A final layer of adhesive tape was applied to ensure adequate pressure, similar to prototype #1. The same postoperative protocol was employed to provide a consistent standard of care. We recommend use of this prototype when surgical tape is not available, and surgical packing can be used as a substitute.

In assembling the prototype #2 bandage, pull tabs are left exposed and hanging at the bottom.
FIGURE 3. In assembling the prototype #2 bandage, pull tabs are left exposed and hanging at the bottom.

Practice Implications

Patients have a better appreciation for avoiding excess visits to medical offices due to the COVID-19 pandemic. The risk for exposure to SARS-CoV-2 infection is greater when patients who lack a support system must return to the office for aftercare or to have a bandage removed. Although protection offered by the COVID-19 vaccine alleviates concern, many patients have realized the benefits of only visiting medical offices in person when necessary.

The concept of pull tab bandages that can be removed by the patient at home has other applications. For example, patients who travel a long distance to see their physician will benefit from easier aftercare and avoid additional follow-up visits when provided with a self-removable bandage.

Practice Gap

A male patient presented with 2 concerning lesions, which histopathology revealed were invasive squamous cell carcinoma (SCC) on the right medial chest and SCC in situ on the right upper scapular region. Both were treated with wide local excision; margins were clear in our office the same day.

This case highlighted a practice gap in postoperative care. Two factors posed a challenge to proper postoperative wound care for our patient:

• Because of the high risk of transmission of SARS-CoV-2, the patient hoped to limit exposure by avoiding an office visit to remove the bandage.

• The patient did not have someone at home to serve as an immediate support system, which made it impossible for him to rely on others for postoperative wound care.

Previously, the patient had to ask a friend to remove a bandage for melanoma in situ on the inner aspect of the left upper arm. Therefore, after this procedure, the patient asked if the bandage could be fashioned in a manner that would allow him to remove it without assistance (Figure 1).

Case patient wearing prototype #1, an easy-removal pulltab bandage.
FIGURE 1. Case patient wearing prototype #1, an easy-removal pulltab bandage.

Technique

In constructing a bandage that is easier to remove, some necessary pressure that is provided by the bandage often is sacrificed by making it looser. Considering that our patient had moderate bleeding during the procedure—in part because he took low-dose aspirin (81 mg/d)—it was important to maintain firm pressure under the bandage postoperatively to help prevent untoward bleeding. Furthermore, because of the location of the treated site and the patient’s limited range of motion, it was not feasible for him to reach the area on the scapula and remove the bandage.1

For easy self-removal, we designed a bandage with a pull tab that was within the patient’s reach. Suitable materials for the pull tab bandage included surgical tape, bandaging tape with adequate stretch, sterile nonadhesive gauze, fenestrated surgical gauze, and a topical emollient such as petroleum jelly or antibacterial ointment.

To clean the site and decrease the amount of oil that would reduce the effectiveness of the adhesive, the wound was prepared with 70% alcohol. The site was then treated with petroleum jelly.

Next, we designed 2 pull tab bandage prototypes that allowed easy self-removal. For both prototypes, sterile nonadhesive gauze was applied to the wound along with folded and fenestrated gauze, which provided pressure. We used prototype #1 in our patient, and prototype #2 was demonstrated as an option.

 

 

Prototype #1—We created 2 tabs—each 2-feet long—using bandaging tape that was folded on itself once horizontally (Figure 2). The tabs were aligned on either side of the wound, the tops of which sat approximately 2 inches above the top of the first layer of adhesive bandage. An initial layer of adhesive surgical dressing was applied to cover the wound; 1 inch of the dressing was left exposed on the top of each tab. In addition, there were 2 “feet” running on the bottom.

A, Step 1 in preparing prototype #1 bandage: create 2 pull tabs, each 2-feet long, using bandaging tape folded on itself once horizontally. Place these tabs on either side of the lesion, then secure to the patient with adhesive gauze.
FIGURE 2. A, Step 1 in preparing prototype #1 bandage: create 2 pull tabs, each 2-feet long, using bandaging tape folded on itself once horizontally. Place these tabs on either side of the lesion, then secure to the patient with adhesive gauze. Include any necessary wound packing underneath. B, Step 2: fold the tops of the pull tabs over the top side of the adhesive tape and tape down with more adhesive bandage.

The tops of the tabs were folded back over the adhesive tape, creating a type of “hook.” An additional final layer of adhesive tape was applied to ensure adequate pressure on the surgical site.

The patient was instructed to remove the bandage 2 days after the procedure. The outcome was qualified through a 3-day postoperative telephone call. The patient was asked about postoperative pain and his level of satisfaction with treatment. He was asked if he had any changes such as bleeding, swelling, signs of infection, or increased pain in the days after surgery or perceived postoperative complications, such as irritation. We asked the patient about the relative ease of removing the bandage and if removal was painful. He reported that the bandage was easy to remove, and that doing so was not painful; furthermore, he did not have problems with the bandage or healing and did not experience any medical changes. He found the bandage to be comfortable. The patient stated that the hanging feet of the prototype #1 bandage were not bothersome and were sturdy for the time that the bandage was on.

Prototype #2—We prepared a bandage using surgical packing as the tab (Figure 3). The packing was slowly placed around the site, which was already covered with nonadhesive gauze and fenestrated surgical gauze, with adequate spacing between each loop (for a total of 3 loops), 1 of which crossed over the third loop so that the adhesive bandaging tape could be removed easily. This allowed for a single tab that could be removed by a single pull. A final layer of adhesive tape was applied to ensure adequate pressure, similar to prototype #1. The same postoperative protocol was employed to provide a consistent standard of care. We recommend use of this prototype when surgical tape is not available, and surgical packing can be used as a substitute.

In assembling the prototype #2 bandage, pull tabs are left exposed and hanging at the bottom.
FIGURE 3. In assembling the prototype #2 bandage, pull tabs are left exposed and hanging at the bottom.

Practice Implications

Patients have a better appreciation for avoiding excess visits to medical offices due to the COVID-19 pandemic. The risk for exposure to SARS-CoV-2 infection is greater when patients who lack a support system must return to the office for aftercare or to have a bandage removed. Although protection offered by the COVID-19 vaccine alleviates concern, many patients have realized the benefits of only visiting medical offices in person when necessary.

The concept of pull tab bandages that can be removed by the patient at home has other applications. For example, patients who travel a long distance to see their physician will benefit from easier aftercare and avoid additional follow-up visits when provided with a self-removable bandage.

References
  1. Stathokostas, L, McDonald MW, Little RMD, et al. Flexibility of older adults aged 55-86 years and the influence of physical activity. J Aging Res. 2013;2013:1-8. doi:10.1155/2013/743843
References
  1. Stathokostas, L, McDonald MW, Little RMD, et al. Flexibility of older adults aged 55-86 years and the influence of physical activity. J Aging Res. 2013;2013:1-8. doi:10.1155/2013/743843
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Case patient wearing prototype #1, an easy-removal pulltab bandage.
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Trends in Surveillance and Management of Dysplasia in IBD

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Changed
Wed, 11/09/2022 - 15:29
Display Headline
Trends in Surveillance and Management of Dysplasia in IBD
Author(s)
Joseph Feuerstein, MD, AGAF

Click to view more from Gastroenterology Data Trends 2022. 

References
  1. Yeshi K, Ruscher R, Hunter L, et al. Revisiting inflammatory bowel disease: pathology, treatments, challenges and emerging therapeutics including drug leads from natural products. J Clin Med. 2020;9(5):1273. doi:10.3390/jcm9051273
  2. Xu F, Carlson SA, Liu Y, Greenlund KJ. Prevalence of inflammatory bowel disease among Medicare fee-for-service beneficiaries – United States, 2001-2018. MMWR Morb Mortal Wkly Rep. 2021;70(19):698-701.  doi:10.15585/mmwr.mm7019a2
  3. Rizzello F, Spisni E, Giovanardi E, et al. Implications of the westernized diet in the onset and progression of IBD. Nutrients. 2019;11(5):1033. doi:10.3390/nu11051033
  4. Stidham RW, Higgins PDR. Colorectal cancer in inflammatory bowel disease. Clin Colon Rectal Surg. 2018;31(3):168-178. doi:10.1055/s-0037-1602237
  5. Tariq H, Kamal MU, Sapkota B, et al. Evaluation of the combined effect of factors influencing bowel preparation and adenoma detection rates in patients undergoing colonoscopy. BMJ Open Gastroenterol. 2019;6(1):e000254. doi:10.1136/bmjgast-2018-000254
  6. May FP, Shaukat A. Time to add the "Q" (quality) factor to postpolypectomy surveillance? Gastroenterology. 2021;160(4):1007-1009. doi:10.1053/j.gastro.2020.12.067
  7. Murthy SK, Feuerstein JD, Nguyen GC, Velayos FS. AGA clinical practice update on endoscopic surveillance and management of colorectal dysplasia in inflammatory bowel diseases: expert review. Gastroenterology. 2021;161(3):1043-1051.e4. doi:10.1053/j.gastro.2021.05.063
  8. van der Laan JJH, van der Waaij AM, Gabriëls RY, Festen EAM, Dijkstra G, Nagengast WB. Endoscopic imaging in inflammatory bowel disease: current developments and emerging strategies. Expert Rev Gastroenterol Hepatol. 2021;15(2):115-126. doi:10.1080/17474124.2021.1840352
  9. Colombel JF, D'haens G, Lee WJ, Petersson J, Panaccione R. Outcomes and strategies to support a treat-to-target approach in inflammatory bowel disease: a systematic review. J Crohns Colitis. 2020;14(2):254-266. doi:10.1093/ecco-jcc/jjz131
  10. Atia O, Harel S, Ledderman N, et al. Risk of cancer in paediatric onset inflammatory bowel diseases: a nation-wide study from the epi-IIRN. J Crohns Colitis. 2022;16(5):786-795. doi:10.1093/ecco-jcc/jjab205
  11. Jess T, Simonsen J, Jørgensen KT, Pedersen BV, Nielsen NM, Frisch M. Decreasing risk of colorectal cancer in patients with inflammatory bowel disease over 30 years. Gastroenterology. 2012;143(2):375-381.e1. doi:10.1053/j.gastro.2012.04.016
  12. Di Palma JA, Bhandari R, Cleveland MV, et al. A safety and efficacy comparison of a new sulfate-based tablet bowel preparation versus a PEG and ascorbate comparator in adult subjects undergoing colonoscopy. Am J Gastroenterol. 2021;116(2):319-328. doi:10.14309/ajg.0000000000001020
  13. May FP, Shaukat A. State of the science on quality indicators for colonoscopy and how to achieve them. Am J Gastroenterol. 2020;115(8):1183-1190. doi:10.14309/ajg.0000000000000622
  14. Al-Bawardy B, Shivashankar R, Proctor DD. Novel and emerging therapies for inflammatory bowel disease. Front Pharmacol. 2021;12:651415. doi:10.3389/fphar.2021.651415
  15. Taxonera C, Olivares D, Alba C. Real-world effectiveness and safety of tofacitinib in patients with ulcerative colitis: systematic review with meta-analysis. Inflamm Bowel Dis. 2022;28(1):32-40. doi:10.1093/ibd/izab011
Publications
GI and Hepatology News
Topics
IBD & Intestinal Disorders
Author(s)
Joseph Feuerstein, MD, AGAF
Author(s)
Joseph Feuerstein, MD, AGAF

Click to view more from Gastroenterology Data Trends 2022. 

Click to view more from Gastroenterology Data Trends 2022. 

References
  1. Yeshi K, Ruscher R, Hunter L, et al. Revisiting inflammatory bowel disease: pathology, treatments, challenges and emerging therapeutics including drug leads from natural products. J Clin Med. 2020;9(5):1273. doi:10.3390/jcm9051273
  2. Xu F, Carlson SA, Liu Y, Greenlund KJ. Prevalence of inflammatory bowel disease among Medicare fee-for-service beneficiaries – United States, 2001-2018. MMWR Morb Mortal Wkly Rep. 2021;70(19):698-701.  doi:10.15585/mmwr.mm7019a2
  3. Rizzello F, Spisni E, Giovanardi E, et al. Implications of the westernized diet in the onset and progression of IBD. Nutrients. 2019;11(5):1033. doi:10.3390/nu11051033
  4. Stidham RW, Higgins PDR. Colorectal cancer in inflammatory bowel disease. Clin Colon Rectal Surg. 2018;31(3):168-178. doi:10.1055/s-0037-1602237
  5. Tariq H, Kamal MU, Sapkota B, et al. Evaluation of the combined effect of factors influencing bowel preparation and adenoma detection rates in patients undergoing colonoscopy. BMJ Open Gastroenterol. 2019;6(1):e000254. doi:10.1136/bmjgast-2018-000254
  6. May FP, Shaukat A. Time to add the "Q" (quality) factor to postpolypectomy surveillance? Gastroenterology. 2021;160(4):1007-1009. doi:10.1053/j.gastro.2020.12.067
  7. Murthy SK, Feuerstein JD, Nguyen GC, Velayos FS. AGA clinical practice update on endoscopic surveillance and management of colorectal dysplasia in inflammatory bowel diseases: expert review. Gastroenterology. 2021;161(3):1043-1051.e4. doi:10.1053/j.gastro.2021.05.063
  8. van der Laan JJH, van der Waaij AM, Gabriëls RY, Festen EAM, Dijkstra G, Nagengast WB. Endoscopic imaging in inflammatory bowel disease: current developments and emerging strategies. Expert Rev Gastroenterol Hepatol. 2021;15(2):115-126. doi:10.1080/17474124.2021.1840352
  9. Colombel JF, D'haens G, Lee WJ, Petersson J, Panaccione R. Outcomes and strategies to support a treat-to-target approach in inflammatory bowel disease: a systematic review. J Crohns Colitis. 2020;14(2):254-266. doi:10.1093/ecco-jcc/jjz131
  10. Atia O, Harel S, Ledderman N, et al. Risk of cancer in paediatric onset inflammatory bowel diseases: a nation-wide study from the epi-IIRN. J Crohns Colitis. 2022;16(5):786-795. doi:10.1093/ecco-jcc/jjab205
  11. Jess T, Simonsen J, Jørgensen KT, Pedersen BV, Nielsen NM, Frisch M. Decreasing risk of colorectal cancer in patients with inflammatory bowel disease over 30 years. Gastroenterology. 2012;143(2):375-381.e1. doi:10.1053/j.gastro.2012.04.016
  12. Di Palma JA, Bhandari R, Cleveland MV, et al. A safety and efficacy comparison of a new sulfate-based tablet bowel preparation versus a PEG and ascorbate comparator in adult subjects undergoing colonoscopy. Am J Gastroenterol. 2021;116(2):319-328. doi:10.14309/ajg.0000000000001020
  13. May FP, Shaukat A. State of the science on quality indicators for colonoscopy and how to achieve them. Am J Gastroenterol. 2020;115(8):1183-1190. doi:10.14309/ajg.0000000000000622
  14. Al-Bawardy B, Shivashankar R, Proctor DD. Novel and emerging therapies for inflammatory bowel disease. Front Pharmacol. 2021;12:651415. doi:10.3389/fphar.2021.651415
  15. Taxonera C, Olivares D, Alba C. Real-world effectiveness and safety of tofacitinib in patients with ulcerative colitis: systematic review with meta-analysis. Inflamm Bowel Dis. 2022;28(1):32-40. doi:10.1093/ibd/izab011
References
  1. Yeshi K, Ruscher R, Hunter L, et al. Revisiting inflammatory bowel disease: pathology, treatments, challenges and emerging therapeutics including drug leads from natural products. J Clin Med. 2020;9(5):1273. doi:10.3390/jcm9051273
  2. Xu F, Carlson SA, Liu Y, Greenlund KJ. Prevalence of inflammatory bowel disease among Medicare fee-for-service beneficiaries – United States, 2001-2018. MMWR Morb Mortal Wkly Rep. 2021;70(19):698-701.  doi:10.15585/mmwr.mm7019a2
  3. Rizzello F, Spisni E, Giovanardi E, et al. Implications of the westernized diet in the onset and progression of IBD. Nutrients. 2019;11(5):1033. doi:10.3390/nu11051033
  4. Stidham RW, Higgins PDR. Colorectal cancer in inflammatory bowel disease. Clin Colon Rectal Surg. 2018;31(3):168-178. doi:10.1055/s-0037-1602237
  5. Tariq H, Kamal MU, Sapkota B, et al. Evaluation of the combined effect of factors influencing bowel preparation and adenoma detection rates in patients undergoing colonoscopy. BMJ Open Gastroenterol. 2019;6(1):e000254. doi:10.1136/bmjgast-2018-000254
  6. May FP, Shaukat A. Time to add the "Q" (quality) factor to postpolypectomy surveillance? Gastroenterology. 2021;160(4):1007-1009. doi:10.1053/j.gastro.2020.12.067
  7. Murthy SK, Feuerstein JD, Nguyen GC, Velayos FS. AGA clinical practice update on endoscopic surveillance and management of colorectal dysplasia in inflammatory bowel diseases: expert review. Gastroenterology. 2021;161(3):1043-1051.e4. doi:10.1053/j.gastro.2021.05.063
  8. van der Laan JJH, van der Waaij AM, Gabriëls RY, Festen EAM, Dijkstra G, Nagengast WB. Endoscopic imaging in inflammatory bowel disease: current developments and emerging strategies. Expert Rev Gastroenterol Hepatol. 2021;15(2):115-126. doi:10.1080/17474124.2021.1840352
  9. Colombel JF, D'haens G, Lee WJ, Petersson J, Panaccione R. Outcomes and strategies to support a treat-to-target approach in inflammatory bowel disease: a systematic review. J Crohns Colitis. 2020;14(2):254-266. doi:10.1093/ecco-jcc/jjz131
  10. Atia O, Harel S, Ledderman N, et al. Risk of cancer in paediatric onset inflammatory bowel diseases: a nation-wide study from the epi-IIRN. J Crohns Colitis. 2022;16(5):786-795. doi:10.1093/ecco-jcc/jjab205
  11. Jess T, Simonsen J, Jørgensen KT, Pedersen BV, Nielsen NM, Frisch M. Decreasing risk of colorectal cancer in patients with inflammatory bowel disease over 30 years. Gastroenterology. 2012;143(2):375-381.e1. doi:10.1053/j.gastro.2012.04.016
  12. Di Palma JA, Bhandari R, Cleveland MV, et al. A safety and efficacy comparison of a new sulfate-based tablet bowel preparation versus a PEG and ascorbate comparator in adult subjects undergoing colonoscopy. Am J Gastroenterol. 2021;116(2):319-328. doi:10.14309/ajg.0000000000001020
  13. May FP, Shaukat A. State of the science on quality indicators for colonoscopy and how to achieve them. Am J Gastroenterol. 2020;115(8):1183-1190. doi:10.14309/ajg.0000000000000622
  14. Al-Bawardy B, Shivashankar R, Proctor DD. Novel and emerging therapies for inflammatory bowel disease. Front Pharmacol. 2021;12:651415. doi:10.3389/fphar.2021.651415
  15. Taxonera C, Olivares D, Alba C. Real-world effectiveness and safety of tofacitinib in patients with ulcerative colitis: systematic review with meta-analysis. Inflamm Bowel Dis. 2022;28(1):32-40. doi:10.1093/ibd/izab011
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The prevalence of IBD has nearly doubled worldwide since the early 1990s, with popularity of the Western diet and increased alcohol consumption both being implicated in this rise within the United States and other countries.1-3 IBD serves as an important risk factor for developing colorectal cancer (CRC); risk of CRC rises from 2% 10 years after developing ulcerative colitis to 18% after 30 years.4

Successful bowel prep and highly skilled endoscopists are just some of the factors that affect screening results for CRC in IBD.5,6 New technologies and drugs are changing
the treatment paradigm. Endoscopic technologies and biologics for mucosal healing have elicited this shift to a treat-to-target approach.7-9 

Because IBD is occurring in younger populations, earlier targeted treatment of the inflamed state caused by IBD also has been emphasized.10 The earlier IBD is treated and put into remission, the less risk of CRC – with studies suggesting CRC rates for such patients may be comparable to that of the general population.11 As IBD prevalence increases across age groups, races and ethnicities, and geographical locations, gastroenterologists need to consider IBD as a feasible diagnosis and take action early on to mitigate their patients' risk of developing colon cancer.4,7

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Evolving Therapeutic Goals in Crohn’s Disease Management

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Evolving Therapeutic Goals in Crohn’s Disease Management
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Ryan Ungaro, MD, MS

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References
  1. Dorrington AM, Selinger CP, Parkes GC, Smith M, Pollok RC, Raine T. The historical role and contemporary use of corticosteroids in inflammatory bowel disease. J Crohns Colitis. 2020;14(9):1316-1329. doi:10.1093/ecco-jcc/jjaa053 
  2. Melsheimer R, Geldhof A, Apaolaza I, Schaible T. Remicade® (infliximab): 20 years of contributions to science and medicine. Biologics. 2019;13:139-178. doi:10.2147/BTT.S207246 
  3. Kumar A, Cole A, Segal J, Smith P, Limdi JK. A review of the therapeutic management of Crohn’s disease. Therap Adv Gastroenterol. 2022;15:17562848221078456. doi:10.1177/17562848221078456 
  4. Colombel JF, Panaccione R, Bossuyt P, et al. Effect of tight control management on Crohn’s disease (CALM): a multicentre, randomised, controlled phase 3 trial. Lancet. 2017;390(10114):2779-2789. doi:10.1016/S0140-6736(17)32641-7 
  5. Ungaro RC, Yzet C, Bossuyt P, et al. Deep remission at 1 year prevents progression of early Crohn’s disease. Gastroenterology. 2020;159(1):139-147. doi:10.1053/j.gastro.2020.03.039 
  6. Tsai L, Ma C, Dulai PS, et al. Contemporary risk of surgery in patients with ulcerative colitis and Crohn’s disease: a meta-analysis of population-based cohorts. Clin Gastroenterol Hepatol. 2021;19(10):2031-2045.e11. doi:10.1016/j.cgh.2020.10.039 
  7. Chapman S, Sibelli A, St-Clair Jones A, Forbes A, Chater A, Horne R. Personalised adherence support for maintenance treatment of inflammatory bowel disease: a tailored digital intervention to change adherence-related beliefs and barriers. J Crohns Colitis. 2020;14(10):1394-1404. doi:10.1093/ecco-jcc/jjz034 
  8. Turner D, Ricciuto A, Lewis A, et al; for the International Organization for the Study of IBD. STRIDE-II: an update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) initiative of the International Organization for the Study of IBD (IOIBD): determining therapeutic goals for treat-to-target strategies in IBD. Gastroenterology. 2021;160(5):1570-1583. doi:10.1053/j.gastro.2020.12.031 
  9. Rozich JJ, Dulai PS, Fumery M, Sandborn WJ, Singh S. Progression of elderly onset inflammatory bowel diseases: a systematic review and meta-analysis of population-based cohort studies. Clin Gastroenterol Hepatol. 2020;18(11):2437-2447.e6. doi:10.1016/j.cgh.2020.02.048 
  10. Dahlhamer JM, Zammitti EP, Ward BW, Wheaton AG, Croft JB. Prevalence of inflammatory bowel disease among adults aged ≥18 years — United States, 2015. MMWR Morb Mortal Wkly Rep. 2016;65(42):1166-1169.doi:10.15585/mmwr.mm6542a3 
  11. M’Koma AE. Inflammatory bowel disease: clinical diagnosis and surgical treatment-overview. Medicina (Kaunas). 2022;58(5):567. doi:10.3390/medicina58050567 
  12. Weissman S, Patel K, Kolli S, et al. Obesity in inflammatory bowel disease is associated with early readmissions characterised by an increased systems and patient-level burden. J Crohns Colitis. 2021;15(11):1807-1815. doi:10.1093/ecco-jcc/jjab088 
  13. Agrawal M, Spencer EA, Colombel JF, Ungaro RC. Approach to the management of recently diagnosed inflammatory bowel disease patients: a user’s guide for adult and pediatric gastroenterologists. Gastroenterology. 2021;161(1):47-65. doi:10.1053/j.gastro.2021.04.063 
  14. Tibble J, Teahon K, Thjodleifsson B, et al. A simple method for assessing intestinal inflammation in Crohn’s disease. Gut. 2000;47(4):506-513. doi:10.1136/gut.47.4.506. 
  15. Singh S, Proctor D, Scott FI, Falck-Ytter Y, Feuerstein JD. AGA technical review on the medical management of moderate to severe luminal and perianal fistulizing Crohn’s disease. Gastroenterology. 2021;160(7):2512-2556.e9. doi:10.1053/j.gastro.2021.04.023 
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Ryan Ungaro, MD, MS

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References
  1. Dorrington AM, Selinger CP, Parkes GC, Smith M, Pollok RC, Raine T. The historical role and contemporary use of corticosteroids in inflammatory bowel disease. J Crohns Colitis. 2020;14(9):1316-1329. doi:10.1093/ecco-jcc/jjaa053 
  2. Melsheimer R, Geldhof A, Apaolaza I, Schaible T. Remicade® (infliximab): 20 years of contributions to science and medicine. Biologics. 2019;13:139-178. doi:10.2147/BTT.S207246 
  3. Kumar A, Cole A, Segal J, Smith P, Limdi JK. A review of the therapeutic management of Crohn’s disease. Therap Adv Gastroenterol. 2022;15:17562848221078456. doi:10.1177/17562848221078456 
  4. Colombel JF, Panaccione R, Bossuyt P, et al. Effect of tight control management on Crohn’s disease (CALM): a multicentre, randomised, controlled phase 3 trial. Lancet. 2017;390(10114):2779-2789. doi:10.1016/S0140-6736(17)32641-7 
  5. Ungaro RC, Yzet C, Bossuyt P, et al. Deep remission at 1 year prevents progression of early Crohn’s disease. Gastroenterology. 2020;159(1):139-147. doi:10.1053/j.gastro.2020.03.039 
  6. Tsai L, Ma C, Dulai PS, et al. Contemporary risk of surgery in patients with ulcerative colitis and Crohn’s disease: a meta-analysis of population-based cohorts. Clin Gastroenterol Hepatol. 2021;19(10):2031-2045.e11. doi:10.1016/j.cgh.2020.10.039 
  7. Chapman S, Sibelli A, St-Clair Jones A, Forbes A, Chater A, Horne R. Personalised adherence support for maintenance treatment of inflammatory bowel disease: a tailored digital intervention to change adherence-related beliefs and barriers. J Crohns Colitis. 2020;14(10):1394-1404. doi:10.1093/ecco-jcc/jjz034 
  8. Turner D, Ricciuto A, Lewis A, et al; for the International Organization for the Study of IBD. STRIDE-II: an update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) initiative of the International Organization for the Study of IBD (IOIBD): determining therapeutic goals for treat-to-target strategies in IBD. Gastroenterology. 2021;160(5):1570-1583. doi:10.1053/j.gastro.2020.12.031 
  9. Rozich JJ, Dulai PS, Fumery M, Sandborn WJ, Singh S. Progression of elderly onset inflammatory bowel diseases: a systematic review and meta-analysis of population-based cohort studies. Clin Gastroenterol Hepatol. 2020;18(11):2437-2447.e6. doi:10.1016/j.cgh.2020.02.048 
  10. Dahlhamer JM, Zammitti EP, Ward BW, Wheaton AG, Croft JB. Prevalence of inflammatory bowel disease among adults aged ≥18 years — United States, 2015. MMWR Morb Mortal Wkly Rep. 2016;65(42):1166-1169.doi:10.15585/mmwr.mm6542a3 
  11. M’Koma AE. Inflammatory bowel disease: clinical diagnosis and surgical treatment-overview. Medicina (Kaunas). 2022;58(5):567. doi:10.3390/medicina58050567 
  12. Weissman S, Patel K, Kolli S, et al. Obesity in inflammatory bowel disease is associated with early readmissions characterised by an increased systems and patient-level burden. J Crohns Colitis. 2021;15(11):1807-1815. doi:10.1093/ecco-jcc/jjab088 
  13. Agrawal M, Spencer EA, Colombel JF, Ungaro RC. Approach to the management of recently diagnosed inflammatory bowel disease patients: a user’s guide for adult and pediatric gastroenterologists. Gastroenterology. 2021;161(1):47-65. doi:10.1053/j.gastro.2021.04.063 
  14. Tibble J, Teahon K, Thjodleifsson B, et al. A simple method for assessing intestinal inflammation in Crohn’s disease. Gut. 2000;47(4):506-513. doi:10.1136/gut.47.4.506. 
  15. Singh S, Proctor D, Scott FI, Falck-Ytter Y, Feuerstein JD. AGA technical review on the medical management of moderate to severe luminal and perianal fistulizing Crohn’s disease. Gastroenterology. 2021;160(7):2512-2556.e9. doi:10.1053/j.gastro.2021.04.023 
References
  1. Dorrington AM, Selinger CP, Parkes GC, Smith M, Pollok RC, Raine T. The historical role and contemporary use of corticosteroids in inflammatory bowel disease. J Crohns Colitis. 2020;14(9):1316-1329. doi:10.1093/ecco-jcc/jjaa053 
  2. Melsheimer R, Geldhof A, Apaolaza I, Schaible T. Remicade® (infliximab): 20 years of contributions to science and medicine. Biologics. 2019;13:139-178. doi:10.2147/BTT.S207246 
  3. Kumar A, Cole A, Segal J, Smith P, Limdi JK. A review of the therapeutic management of Crohn’s disease. Therap Adv Gastroenterol. 2022;15:17562848221078456. doi:10.1177/17562848221078456 
  4. Colombel JF, Panaccione R, Bossuyt P, et al. Effect of tight control management on Crohn’s disease (CALM): a multicentre, randomised, controlled phase 3 trial. Lancet. 2017;390(10114):2779-2789. doi:10.1016/S0140-6736(17)32641-7 
  5. Ungaro RC, Yzet C, Bossuyt P, et al. Deep remission at 1 year prevents progression of early Crohn’s disease. Gastroenterology. 2020;159(1):139-147. doi:10.1053/j.gastro.2020.03.039 
  6. Tsai L, Ma C, Dulai PS, et al. Contemporary risk of surgery in patients with ulcerative colitis and Crohn’s disease: a meta-analysis of population-based cohorts. Clin Gastroenterol Hepatol. 2021;19(10):2031-2045.e11. doi:10.1016/j.cgh.2020.10.039 
  7. Chapman S, Sibelli A, St-Clair Jones A, Forbes A, Chater A, Horne R. Personalised adherence support for maintenance treatment of inflammatory bowel disease: a tailored digital intervention to change adherence-related beliefs and barriers. J Crohns Colitis. 2020;14(10):1394-1404. doi:10.1093/ecco-jcc/jjz034 
  8. Turner D, Ricciuto A, Lewis A, et al; for the International Organization for the Study of IBD. STRIDE-II: an update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) initiative of the International Organization for the Study of IBD (IOIBD): determining therapeutic goals for treat-to-target strategies in IBD. Gastroenterology. 2021;160(5):1570-1583. doi:10.1053/j.gastro.2020.12.031 
  9. Rozich JJ, Dulai PS, Fumery M, Sandborn WJ, Singh S. Progression of elderly onset inflammatory bowel diseases: a systematic review and meta-analysis of population-based cohort studies. Clin Gastroenterol Hepatol. 2020;18(11):2437-2447.e6. doi:10.1016/j.cgh.2020.02.048 
  10. Dahlhamer JM, Zammitti EP, Ward BW, Wheaton AG, Croft JB. Prevalence of inflammatory bowel disease among adults aged ≥18 years — United States, 2015. MMWR Morb Mortal Wkly Rep. 2016;65(42):1166-1169.doi:10.15585/mmwr.mm6542a3 
  11. M’Koma AE. Inflammatory bowel disease: clinical diagnosis and surgical treatment-overview. Medicina (Kaunas). 2022;58(5):567. doi:10.3390/medicina58050567 
  12. Weissman S, Patel K, Kolli S, et al. Obesity in inflammatory bowel disease is associated with early readmissions characterised by an increased systems and patient-level burden. J Crohns Colitis. 2021;15(11):1807-1815. doi:10.1093/ecco-jcc/jjab088 
  13. Agrawal M, Spencer EA, Colombel JF, Ungaro RC. Approach to the management of recently diagnosed inflammatory bowel disease patients: a user’s guide for adult and pediatric gastroenterologists. Gastroenterology. 2021;161(1):47-65. doi:10.1053/j.gastro.2021.04.063 
  14. Tibble J, Teahon K, Thjodleifsson B, et al. A simple method for assessing intestinal inflammation in Crohn’s disease. Gut. 2000;47(4):506-513. doi:10.1136/gut.47.4.506. 
  15. Singh S, Proctor D, Scott FI, Falck-Ytter Y, Feuerstein JD. AGA technical review on the medical management of moderate to severe luminal and perianal fistulizing Crohn’s disease. Gastroenterology. 2021;160(7):2512-2556.e9. doi:10.1053/j.gastro.2021.04.023 
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Over the last 2 decades, the armamentarium for Crohn’s disease has expanded with the introduction of targeted biologic therapies. Beginning with the approval of infliximab by the FDA in 1998, the treatment options for Crohn’s disease have greatly improved.1 Although steroids are still prescribed too frequently, novel therapies now can limit the use of steroids in these patients.2 In addition to anti-tumor necrosis factor alpha (anti-TNF-alpha) biologics, new therapies that target  integrins, interleukin (IL)-12/23, and IL-23 have also demonstrated efficacy in inducing and maintaining clinical and endoscopic remission of Crohn’s disease.3

Other studies have shown what consistent therapeutic control can do for patients with Crohn’s disease.  Effective therapies can maintain remission and even halt progression to complications if the disease is  identified and treated in its early stages.4,5 Since the early 2000s, a significant drop in risk for surgery among patients with Crohn’s has also been observed because of improved management.6 Of course, patient acceptance and adherence to their regimens is critical. Patients who understand they need on-time treatment, have access to appropriate treatment, and get their questions answered in a timely fashion will be more adherent than those who do not.7 A key advance in management is the adoption of a treat-to-target strategy in which the therapeutic goal has evolved beyond symptom improvement to include the achievement of objective metrics of remission, in particular endoscopic healing.8

These successes are juxtaposed against Crohn’s disease incidence and prevalence figures, which are rising mostly everywhere.9 In 1999, 1.8 million adults in the United States had the disease; in 2015, that figure was 3.1 million.10 Crohn’s disease, usually considered a younger adult disease, is also growing in incidence in adults older than 60 years.9 While the underlying causes of this disease are not well understood, its development involves environmental factors, dysregulated innate and adaptive immune systems, and genetic predisposition.11 With increasing investigation focused on understanding the disease’s initial triggering events and how environmental factors, like diet, affect Crohn’s disease, there is hope these research findings will lead to better management and treatment options.12

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Achalasia Remains a Challenging Disorder for the Community Gastroenterologist

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Achalasia Remains a Challenging Disorder for the Community Gastroenterologist
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Benson T. Massey, MD

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References

  1. Achalasia articles using keywords esophageal achalasia or cardiospasm or achalasia in PubMed: https://pubmed.ncbi.nlm.nih.gov/?term=esophageal+achalasia+or+cardiospasm+or+achalasia&filter=years.2002-2022&timeline=expanded

  2. Patel DA, Yadlapati R, Vaezi MF. esophageal motility disorders: current approach to diagnostics and therapeutics. Gastroenterology. 2022;162(6):1617-1634. doi:10.1053/j.gastro.2021.12.289

  3. Delshad SD, Almario CV, Chey WD, Spiegel BMR. Prevalence of gastroesophageal reflux disease and proton pump inhibitor-refractory symptoms. Gastroenterology. 2020;158(5):1250-1261.e2. doi:10.1053/j.gastro.2019.12.014

  4. van Hoeij FB, Ponds FA, Smout AJ, Bredenoord AJ. Incidence and costs of achalasia in The Netherlands. Neurogastroenterol Motil. 2018;30(2):e13195. doi:10.1111/nmo.13195

  5. Khan A, Yadlapati R, Gonlachanvit S, et al. Chicago Classification update (version 4.0): technical review on diagnostic criteria for achalasia. Neurogastroenterol Motil. 2021;33(7):e14182. doi:10.1111/nmo.14182

  6. Gaddam S, Reddy CA, Munigala, et al. The learning curve for interpretation of oesophageal high-resolution manometry: a prospective interventional cohort study. Aliment Pharmacol Ther. 2017;45(2):291-299. doi:10.1111/apt.13855

  7. Yadlapati R, Keswani RN, Ciolino JD, et al. A system to assess the competency for interpretation of esophageal manometry identifies variation in learning curves. Clin Gastroenterol Hepatol. 2017;15(11):1708-1714.e3. doi:10.1016/j.cgh.2016.07.024

  8. Saboori S, Jarvis M, Baker J, et al. Hard to swallow results. Dysphagia. 2022;37(4):863-867. doi:10.1007/s00455-021-10344-x

  9. Babaei A, Szabo A, Shad S, Massey BT. Chronic daily opioid exposure is associated with dysphagia, esophageal outflow obstruction, and disordered peristalsis. Neurogastroenterol Motil. 2019;31(7):e13601. doi:10.1111/nmo.13601

  10. Babaei A, Shad S, Massey BT. Motility patterns following esophageal pharmacologic provocation with amyl nitrite or cholecystokinin during high-resolution manometry distinguish idiopathic vs opioid-induced type 3 achalasia. Clin Gastroenterol Hepatol. 2020;18(4):813-821.e1. doi:10.1016/j.cgh.2019.08.014

  11. Babaei A, Shad S, Massey BT. Diagnostic differences in the pharmacologic response to cholecystokinin and amyl nitrite in patients with absent contractility vs type I achalasia. Neurogastroenterol Motil. 2020;32(8):e13857. doi:10.1111/nmo.13857

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Benson T. Massey, MD
Author(s)
Benson T. Massey, MD

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References

  1. Achalasia articles using keywords esophageal achalasia or cardiospasm or achalasia in PubMed: https://pubmed.ncbi.nlm.nih.gov/?term=esophageal+achalasia+or+cardiospasm+or+achalasia&filter=years.2002-2022&timeline=expanded

  2. Patel DA, Yadlapati R, Vaezi MF. esophageal motility disorders: current approach to diagnostics and therapeutics. Gastroenterology. 2022;162(6):1617-1634. doi:10.1053/j.gastro.2021.12.289

  3. Delshad SD, Almario CV, Chey WD, Spiegel BMR. Prevalence of gastroesophageal reflux disease and proton pump inhibitor-refractory symptoms. Gastroenterology. 2020;158(5):1250-1261.e2. doi:10.1053/j.gastro.2019.12.014

  4. van Hoeij FB, Ponds FA, Smout AJ, Bredenoord AJ. Incidence and costs of achalasia in The Netherlands. Neurogastroenterol Motil. 2018;30(2):e13195. doi:10.1111/nmo.13195

  5. Khan A, Yadlapati R, Gonlachanvit S, et al. Chicago Classification update (version 4.0): technical review on diagnostic criteria for achalasia. Neurogastroenterol Motil. 2021;33(7):e14182. doi:10.1111/nmo.14182

  6. Gaddam S, Reddy CA, Munigala, et al. The learning curve for interpretation of oesophageal high-resolution manometry: a prospective interventional cohort study. Aliment Pharmacol Ther. 2017;45(2):291-299. doi:10.1111/apt.13855

  7. Yadlapati R, Keswani RN, Ciolino JD, et al. A system to assess the competency for interpretation of esophageal manometry identifies variation in learning curves. Clin Gastroenterol Hepatol. 2017;15(11):1708-1714.e3. doi:10.1016/j.cgh.2016.07.024

  8. Saboori S, Jarvis M, Baker J, et al. Hard to swallow results. Dysphagia. 2022;37(4):863-867. doi:10.1007/s00455-021-10344-x

  9. Babaei A, Szabo A, Shad S, Massey BT. Chronic daily opioid exposure is associated with dysphagia, esophageal outflow obstruction, and disordered peristalsis. Neurogastroenterol Motil. 2019;31(7):e13601. doi:10.1111/nmo.13601

  10. Babaei A, Shad S, Massey BT. Motility patterns following esophageal pharmacologic provocation with amyl nitrite or cholecystokinin during high-resolution manometry distinguish idiopathic vs opioid-induced type 3 achalasia. Clin Gastroenterol Hepatol. 2020;18(4):813-821.e1. doi:10.1016/j.cgh.2019.08.014

  11. Babaei A, Shad S, Massey BT. Diagnostic differences in the pharmacologic response to cholecystokinin and amyl nitrite in patients with absent contractility vs type I achalasia. Neurogastroenterol Motil. 2020;32(8):e13857. doi:10.1111/nmo.13857

References

  1. Achalasia articles using keywords esophageal achalasia or cardiospasm or achalasia in PubMed: https://pubmed.ncbi.nlm.nih.gov/?term=esophageal+achalasia+or+cardiospasm+or+achalasia&filter=years.2002-2022&timeline=expanded

  2. Patel DA, Yadlapati R, Vaezi MF. esophageal motility disorders: current approach to diagnostics and therapeutics. Gastroenterology. 2022;162(6):1617-1634. doi:10.1053/j.gastro.2021.12.289

  3. Delshad SD, Almario CV, Chey WD, Spiegel BMR. Prevalence of gastroesophageal reflux disease and proton pump inhibitor-refractory symptoms. Gastroenterology. 2020;158(5):1250-1261.e2. doi:10.1053/j.gastro.2019.12.014

  4. van Hoeij FB, Ponds FA, Smout AJ, Bredenoord AJ. Incidence and costs of achalasia in The Netherlands. Neurogastroenterol Motil. 2018;30(2):e13195. doi:10.1111/nmo.13195

  5. Khan A, Yadlapati R, Gonlachanvit S, et al. Chicago Classification update (version 4.0): technical review on diagnostic criteria for achalasia. Neurogastroenterol Motil. 2021;33(7):e14182. doi:10.1111/nmo.14182

  6. Gaddam S, Reddy CA, Munigala, et al. The learning curve for interpretation of oesophageal high-resolution manometry: a prospective interventional cohort study. Aliment Pharmacol Ther. 2017;45(2):291-299. doi:10.1111/apt.13855

  7. Yadlapati R, Keswani RN, Ciolino JD, et al. A system to assess the competency for interpretation of esophageal manometry identifies variation in learning curves. Clin Gastroenterol Hepatol. 2017;15(11):1708-1714.e3. doi:10.1016/j.cgh.2016.07.024

  8. Saboori S, Jarvis M, Baker J, et al. Hard to swallow results. Dysphagia. 2022;37(4):863-867. doi:10.1007/s00455-021-10344-x

  9. Babaei A, Szabo A, Shad S, Massey BT. Chronic daily opioid exposure is associated with dysphagia, esophageal outflow obstruction, and disordered peristalsis. Neurogastroenterol Motil. 2019;31(7):e13601. doi:10.1111/nmo.13601

  10. Babaei A, Shad S, Massey BT. Motility patterns following esophageal pharmacologic provocation with amyl nitrite or cholecystokinin during high-resolution manometry distinguish idiopathic vs opioid-induced type 3 achalasia. Clin Gastroenterol Hepatol. 2020;18(4):813-821.e1. doi:10.1016/j.cgh.2019.08.014

  11. Babaei A, Shad S, Massey BT. Diagnostic differences in the pharmacologic response to cholecystokinin and amyl nitrite in patients with absent contractility vs type I achalasia. Neurogastroenterol Motil. 2020;32(8):e13857. doi:10.1111/nmo.13857

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Achalasia Remains a Challenging Disorder for the Community Gastroenterologist
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Considerable advances in our understanding of esophageal achalasia have been made in the 21st century, accompanied by new diagnostic and treatment modalities. Indeed, about half of the available citations for the term achalasia in PubMed have been published in the past 20 years.1 These developments have increased awareness of this condition among practicing gastroenterologists. But because achalasia is a rare disorder in which the available treatments are palliative, it continues to present a challenge for the community gastroenterologist to diagnose and manage.2

The first problem for diagnosis concerns the rarity of the condition combined with lack of specificity of the presenting symptoms, particularly early in the disease course. Because the prevalence of troublesome GERD (18,000/100,000) is easily 1,000-fold greater than that of achalasia (just 15/100,000), a patient presenting anew with any constellation of esophageal symptoms is far more likely to have them result from GERD than achalasia.3,4 Further, the classic features of achalasia—massive esophageal dilation with retained contents—are often absent on endoscopic or radiographic evaluation early in the disease.

When initial testing shows no findings confirming a GERD diagnosis and symptoms fail to respond to GERD therapy, or testing identifies late-stage morphologic features suggesting an achalasia diagnosis, the next step in evaluation is esophageal high-resolution manometry (HRM). This test is currently the standard of care for an achalasia diagnosis.5 Community gastroenterologists are increasingly incorporating HRM into their practice, and likely discovering that the learning curve for generating high-quality studies and accurate interpretations of HRM findings is steep, particularly if they have had no training with this technology during their fellowship.6-8 

The findings on HRM are characterized into 3 different motor phenotypes, per the Chicago Classification, which have implications for treatment approach and prognosis. Manometric findings always must be considered within the context of the patient’s entire clinical picture, to avoid misdiagnosis of achalasia and subsequent inappropriate treatment decisions. Other diagnoses, such as opiate-induced dysmotility, “pseudoachalasia” due to cancers, and end-stage esophageal dysfunction in systemic sclerosis, can have findings on HRM that mimic those of idiopathic achalasia.9-11

All definitive treatments for idiopathic achalasia (pneumatic dilation, laparoscopic myotomy, peroral endoscopic myotomy [POEM]) have the goal of irreversibly disrupting abnormal smooth muscle function causing outflow obstruction at the esophageal outlet or spastic contractions in the esophageal body. When applied to the appropriate achalasia motor phenotype, all offer reasonable palliation of symptoms in most, but not all, patients, with a small but immediate risk of serious complications.2 The best choice often depends on the degree of locally available expertise for the different treatment options, which in the case of pneumatic dilation is unfortunately declining in the United States. While increasing percentages of patients are being treated with POEM, the high rate of postprocedure reflux has uncertain implications for these patients in the future.2 

Because no treatment can return esophagus function to normal, patients require ongoing follow-up to monito for signs and symptoms of disease progression or new complications. Patients need to be counseled regarding the risks of esophageal pill injury, imprudent eating habits (eg, excessive consumption), excessive weight gain, and neglecting new-onset GERD symptoms.

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Environmental Factors in IBD: Diet and Stress

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References
  1. Ananthakrishnan AN, Kaplan GG, Bernstein CN, et al. Lifestyle, behaviour, and environmental modification for the management of patients with inflammatory bowel diseases: an International Organization for Study of Inflammatory Bowel Diseases consensus. Lancet Gastroenterol Hepatol. 2022;7(7):666-678. doi:10.1016/S2468-1253(22)00021-8 
  2. Byrne G, Rosenfeld G, Leung Y, et al. Prevalence of anxiety and depression in patients with inflammatory bowel disease. Can J Gastroenterol Hepatol. 2017;2017:6496727. doi:10.1155/2017/6496727 
  3. Sun Y, Li L, Xie R, Wang B, Jiang K, Cao H. Stress triggers flare of inflammatory bowel disease in children and adults. Front Pediatr. 2019;7:432. doi:10.3389/fped.2019.00432 
  4. Bernabeu P, van-der Hofstadt C, Rodríguez-Marín J, et al. Effectiveness of a multicomponent group psychological intervention program in patients with inflammatory bowel disease: a randomized trial. Int J Environ Res Public Health. 2021;18(10):5439. doi:10.3390/ijerph18105439 
  5. Chicco F, Magrì S, Cingolani A, et al. Multidimensional impact of Mediterranean diet on IBD patients. Inflamm Bowel Dis. 2021;27(1):1-9. doi:10.1093/ibd/izaa097 
  6. Lo CH, Khandpur N, Rossato SL, et al. Ultra-processed foods and risk of Crohn’s disease and ulcerative colitis: a prospective cohort study. Clin Gastroenterol Hepatol. 2022;20(6):e1323-e1337. doi:10.1016/j.cgh.2021.08.031 
  7. Crooks B, McLaughlin J, Matsuoka K, Kobayashi T, Yamazaki H, Limdi JK. The dietary practices and beliefs of people living with inactive ulcerative colitis. Eur J Gastroenterol Hepatol. 2021;33(3):372-379. doi:10.1097/MEG.0000000000001911 
  8. Zhen J, Marshall JK, Nguyen GC, Atreja A, Narula N. Impact of digital health monitoring in the management of inflammatory bowel disease. J Med Syst. 2021;45(2):23. doi:10.1007/s10916-021-01706-x 
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References
  1. Ananthakrishnan AN, Kaplan GG, Bernstein CN, et al. Lifestyle, behaviour, and environmental modification for the management of patients with inflammatory bowel diseases: an International Organization for Study of Inflammatory Bowel Diseases consensus. Lancet Gastroenterol Hepatol. 2022;7(7):666-678. doi:10.1016/S2468-1253(22)00021-8 
  2. Byrne G, Rosenfeld G, Leung Y, et al. Prevalence of anxiety and depression in patients with inflammatory bowel disease. Can J Gastroenterol Hepatol. 2017;2017:6496727. doi:10.1155/2017/6496727 
  3. Sun Y, Li L, Xie R, Wang B, Jiang K, Cao H. Stress triggers flare of inflammatory bowel disease in children and adults. Front Pediatr. 2019;7:432. doi:10.3389/fped.2019.00432 
  4. Bernabeu P, van-der Hofstadt C, Rodríguez-Marín J, et al. Effectiveness of a multicomponent group psychological intervention program in patients with inflammatory bowel disease: a randomized trial. Int J Environ Res Public Health. 2021;18(10):5439. doi:10.3390/ijerph18105439 
  5. Chicco F, Magrì S, Cingolani A, et al. Multidimensional impact of Mediterranean diet on IBD patients. Inflamm Bowel Dis. 2021;27(1):1-9. doi:10.1093/ibd/izaa097 
  6. Lo CH, Khandpur N, Rossato SL, et al. Ultra-processed foods and risk of Crohn’s disease and ulcerative colitis: a prospective cohort study. Clin Gastroenterol Hepatol. 2022;20(6):e1323-e1337. doi:10.1016/j.cgh.2021.08.031 
  7. Crooks B, McLaughlin J, Matsuoka K, Kobayashi T, Yamazaki H, Limdi JK. The dietary practices and beliefs of people living with inactive ulcerative colitis. Eur J Gastroenterol Hepatol. 2021;33(3):372-379. doi:10.1097/MEG.0000000000001911 
  8. Zhen J, Marshall JK, Nguyen GC, Atreja A, Narula N. Impact of digital health monitoring in the management of inflammatory bowel disease. J Med Syst. 2021;45(2):23. doi:10.1007/s10916-021-01706-x 
References
  1. Ananthakrishnan AN, Kaplan GG, Bernstein CN, et al. Lifestyle, behaviour, and environmental modification for the management of patients with inflammatory bowel diseases: an International Organization for Study of Inflammatory Bowel Diseases consensus. Lancet Gastroenterol Hepatol. 2022;7(7):666-678. doi:10.1016/S2468-1253(22)00021-8 
  2. Byrne G, Rosenfeld G, Leung Y, et al. Prevalence of anxiety and depression in patients with inflammatory bowel disease. Can J Gastroenterol Hepatol. 2017;2017:6496727. doi:10.1155/2017/6496727 
  3. Sun Y, Li L, Xie R, Wang B, Jiang K, Cao H. Stress triggers flare of inflammatory bowel disease in children and adults. Front Pediatr. 2019;7:432. doi:10.3389/fped.2019.00432 
  4. Bernabeu P, van-der Hofstadt C, Rodríguez-Marín J, et al. Effectiveness of a multicomponent group psychological intervention program in patients with inflammatory bowel disease: a randomized trial. Int J Environ Res Public Health. 2021;18(10):5439. doi:10.3390/ijerph18105439 
  5. Chicco F, Magrì S, Cingolani A, et al. Multidimensional impact of Mediterranean diet on IBD patients. Inflamm Bowel Dis. 2021;27(1):1-9. doi:10.1093/ibd/izaa097 
  6. Lo CH, Khandpur N, Rossato SL, et al. Ultra-processed foods and risk of Crohn’s disease and ulcerative colitis: a prospective cohort study. Clin Gastroenterol Hepatol. 2022;20(6):e1323-e1337. doi:10.1016/j.cgh.2021.08.031 
  7. Crooks B, McLaughlin J, Matsuoka K, Kobayashi T, Yamazaki H, Limdi JK. The dietary practices and beliefs of people living with inactive ulcerative colitis. Eur J Gastroenterol Hepatol. 2021;33(3):372-379. doi:10.1097/MEG.0000000000001911 
  8. Zhen J, Marshall JK, Nguyen GC, Atreja A, Narula N. Impact of digital health monitoring in the management of inflammatory bowel disease. J Med Syst. 2021;45(2):23. doi:10.1007/s10916-021-01706-x 
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A multitude of environmental factors affect the presentation, outcome, and treatment of IBD.1 An expert consensus statement, published in April, discussed these environmental factors and provided guidelines in their management.1 Of the many environmental factors examined, 2 commonly reported triggers were stress and diet. Stress-related mental health conditions are common in IBD, with 21.1% of patients with IBD reporting anxiety and 25.5% reporting depression.2 Biologically, stress has been linked to changes in the gut microbiome, which may contribute to intestinal inflammation.3 Modifying stress has also been shown to improve quality of life in patients with IBD and potentially decrease relapses.4

Among the various dietary factors examined, both individual macronutrients or micronutrients and broad dietary patterns such as a Mediterranean diet can positively influence both IBD symptoms and inflammation. In addition to nutritive content, the consumption of processed foods may also play a role in the development of IBD. In prospective cohorts, a diet high in ultraprocessed foods was associated with an increased risk of IBD.5,6 Along with assessing dietary changes, studies examined how a patient feels his diet affects his symptoms.7 As for technology, apps have been developed that help patients track their dietary and lifestyle behaviors and aim to improve IBD symptoms.8 Overall, environmental factors such as these play an important role in IBD etiology, presentation, and treatment, highlighting the importance of more comprehensive approaches that incorporate dietary and psychological interventions in the management of IBD.

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The Impact of COVID-19 on Colorectal Cancer Screening Programs

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The Impact of COVID-19 on Colorectal Cancer Screening Programs
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Rachel B. Issaka, MD, MAS

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References
  1. ​​​​​​Siegel RL, Miller KD, Goding Sauer A, et al. Colorectal cancer statistics, 2020. CA Cancer J Clin. 2020;70(3):145-164. doi:10.3322/caac.21601
  2. Issaka RB, Somsouk M. Colorectal cancer screening and prevention in the COVID-19 era. JAMA Health Forum. 2020;1(5):e200588. doi:10.1001/jamahealthforum.2020.0588
  3. Balzora S, Issaka RB, Anyane-Yeboa A, Gray DM 2nd, May FP. Impact of COVID-19 on colorectal cancer disparities and the way forward. Gastrointest Endosc. 2020;92(4):946-950. doi:10.1016/j.gie.2020.06.042
  4. Truman BI, Chang MH, Moonesinghe R. Provisional COVID-19 age-adjusted death rates, by race and ethnicity – United States, 2020–2021. MMWR Morb Mortal Wkly Rep. 2022;71(17):601-605. doi:10.15585/mmwr.mm7117e2
  5. Czeisler MÉ, Marynak K, Clarke KEN, et al. Delay or avoidance of medical care because of COVID-19-related concerns – United States, June 2020. MMWR Morb Mortal Wkly Rep. 2020;69(36):1250-1257. doi:10.15585/mmwr.mm6936a4
  6. Inadomi JM, Vijan S, Janz NK, et al. Adherence to colorectal cancer screening: a randomized clinical trial of competing strategies. Arch Intern Med. 2012;172(7):575-582. doi:10.1001/archinternmed.2012.332
  7. Fedewa SA, Star J, Bandi P, et al. Changes in cancer screening in the US during the COVID-19 pandemic. JAMA Netw Open. 2022;5(6):e2215490. doi:10.1001/jamanetworkopen.2022.15490
  8. Levin TR, Corley DA, Jensen CD, et al. Effects of organized colorectal cancer screening on cancer incidence and mortality in a large community-based population. Gastroenterology. 2018;155(5):1383-1391.e5. doi:10.1053/j.gastro.2018.07.017
  9. Doubeni CA, Corley DA, Zhao W, Lau Y, Jensen CD, Levin TR. Association between improved colorectal screening and racial disparities. N Engl J Med. 2022;386(8):796-798. doi:10.1056/NEJMc2112409
  10. Lee JK, Lam AY, Jensen CD, et al. Impact of the COVID-19 pandemic on fecal immunochemical testing, colonoscopy services, and colorectal neoplasia detection in a large United States community-based population. Gastroenterology. 2022;S0016-5085(22)00503-0. doi:10.1053/j.gastro.2022.05.014
  11. Issaka RB, Taylor P, Baxi A, Inadomi JM, Ramsey SD, Roth J. Model-based estimation of colorectal cancer screening and outcomes during the COVID-19 pandemic. JAMA Netw Open. 2021;4(4):e216454. doi:10.1001/jamanetworkopen.2021.6454
  12. Gupta S, Coronado GD, Argenbright K, et al. Mailed fecal immunochemical test outreach for colorectal cancer screening: summary of a Centers for Disease Control and Prevention–sponsored summit. CA Cancer J Clin. 2020;70(4):283-298. doi:10.3322/caac.21615
  13. Zorzi M, Battagello J, Selby K, et al. Non-compliance with colonoscopy after a positive faecal immunochemical test doubles the risk of dying from colorectal cancer. Gut. 2022;71(3):561-567. doi:10.1136/gutjnl-2020-322192
  14. Lieberman D, Ladabaum U, Brill JV, et al. Reducing the burden of colorectal cancer: AGA position statements. Gastroenterology. 2022;163(2):520-526. doi:10.1053/j.gastro.2022.05.011
  15. Bell-Brown A, Chew L, Weiner BJ, et al. Operationalizing a rideshare intervention for colonoscopy completion: barriers, facilitators, and process recommendations. Front Health Serv. 2022;1:799816. doi:10.3389/frhs.2021.799816
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Rachel B. Issaka, MD, MAS
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Rachel B. Issaka, MD, MAS

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References
  1. ​​​​​​Siegel RL, Miller KD, Goding Sauer A, et al. Colorectal cancer statistics, 2020. CA Cancer J Clin. 2020;70(3):145-164. doi:10.3322/caac.21601
  2. Issaka RB, Somsouk M. Colorectal cancer screening and prevention in the COVID-19 era. JAMA Health Forum. 2020;1(5):e200588. doi:10.1001/jamahealthforum.2020.0588
  3. Balzora S, Issaka RB, Anyane-Yeboa A, Gray DM 2nd, May FP. Impact of COVID-19 on colorectal cancer disparities and the way forward. Gastrointest Endosc. 2020;92(4):946-950. doi:10.1016/j.gie.2020.06.042
  4. Truman BI, Chang MH, Moonesinghe R. Provisional COVID-19 age-adjusted death rates, by race and ethnicity – United States, 2020–2021. MMWR Morb Mortal Wkly Rep. 2022;71(17):601-605. doi:10.15585/mmwr.mm7117e2
  5. Czeisler MÉ, Marynak K, Clarke KEN, et al. Delay or avoidance of medical care because of COVID-19-related concerns – United States, June 2020. MMWR Morb Mortal Wkly Rep. 2020;69(36):1250-1257. doi:10.15585/mmwr.mm6936a4
  6. Inadomi JM, Vijan S, Janz NK, et al. Adherence to colorectal cancer screening: a randomized clinical trial of competing strategies. Arch Intern Med. 2012;172(7):575-582. doi:10.1001/archinternmed.2012.332
  7. Fedewa SA, Star J, Bandi P, et al. Changes in cancer screening in the US during the COVID-19 pandemic. JAMA Netw Open. 2022;5(6):e2215490. doi:10.1001/jamanetworkopen.2022.15490
  8. Levin TR, Corley DA, Jensen CD, et al. Effects of organized colorectal cancer screening on cancer incidence and mortality in a large community-based population. Gastroenterology. 2018;155(5):1383-1391.e5. doi:10.1053/j.gastro.2018.07.017
  9. Doubeni CA, Corley DA, Zhao W, Lau Y, Jensen CD, Levin TR. Association between improved colorectal screening and racial disparities. N Engl J Med. 2022;386(8):796-798. doi:10.1056/NEJMc2112409
  10. Lee JK, Lam AY, Jensen CD, et al. Impact of the COVID-19 pandemic on fecal immunochemical testing, colonoscopy services, and colorectal neoplasia detection in a large United States community-based population. Gastroenterology. 2022;S0016-5085(22)00503-0. doi:10.1053/j.gastro.2022.05.014
  11. Issaka RB, Taylor P, Baxi A, Inadomi JM, Ramsey SD, Roth J. Model-based estimation of colorectal cancer screening and outcomes during the COVID-19 pandemic. JAMA Netw Open. 2021;4(4):e216454. doi:10.1001/jamanetworkopen.2021.6454
  12. Gupta S, Coronado GD, Argenbright K, et al. Mailed fecal immunochemical test outreach for colorectal cancer screening: summary of a Centers for Disease Control and Prevention–sponsored summit. CA Cancer J Clin. 2020;70(4):283-298. doi:10.3322/caac.21615
  13. Zorzi M, Battagello J, Selby K, et al. Non-compliance with colonoscopy after a positive faecal immunochemical test doubles the risk of dying from colorectal cancer. Gut. 2022;71(3):561-567. doi:10.1136/gutjnl-2020-322192
  14. Lieberman D, Ladabaum U, Brill JV, et al. Reducing the burden of colorectal cancer: AGA position statements. Gastroenterology. 2022;163(2):520-526. doi:10.1053/j.gastro.2022.05.011
  15. Bell-Brown A, Chew L, Weiner BJ, et al. Operationalizing a rideshare intervention for colonoscopy completion: barriers, facilitators, and process recommendations. Front Health Serv. 2022;1:799816. doi:10.3389/frhs.2021.799816
References
  1. ​​​​​​Siegel RL, Miller KD, Goding Sauer A, et al. Colorectal cancer statistics, 2020. CA Cancer J Clin. 2020;70(3):145-164. doi:10.3322/caac.21601
  2. Issaka RB, Somsouk M. Colorectal cancer screening and prevention in the COVID-19 era. JAMA Health Forum. 2020;1(5):e200588. doi:10.1001/jamahealthforum.2020.0588
  3. Balzora S, Issaka RB, Anyane-Yeboa A, Gray DM 2nd, May FP. Impact of COVID-19 on colorectal cancer disparities and the way forward. Gastrointest Endosc. 2020;92(4):946-950. doi:10.1016/j.gie.2020.06.042
  4. Truman BI, Chang MH, Moonesinghe R. Provisional COVID-19 age-adjusted death rates, by race and ethnicity – United States, 2020–2021. MMWR Morb Mortal Wkly Rep. 2022;71(17):601-605. doi:10.15585/mmwr.mm7117e2
  5. Czeisler MÉ, Marynak K, Clarke KEN, et al. Delay or avoidance of medical care because of COVID-19-related concerns – United States, June 2020. MMWR Morb Mortal Wkly Rep. 2020;69(36):1250-1257. doi:10.15585/mmwr.mm6936a4
  6. Inadomi JM, Vijan S, Janz NK, et al. Adherence to colorectal cancer screening: a randomized clinical trial of competing strategies. Arch Intern Med. 2012;172(7):575-582. doi:10.1001/archinternmed.2012.332
  7. Fedewa SA, Star J, Bandi P, et al. Changes in cancer screening in the US during the COVID-19 pandemic. JAMA Netw Open. 2022;5(6):e2215490. doi:10.1001/jamanetworkopen.2022.15490
  8. Levin TR, Corley DA, Jensen CD, et al. Effects of organized colorectal cancer screening on cancer incidence and mortality in a large community-based population. Gastroenterology. 2018;155(5):1383-1391.e5. doi:10.1053/j.gastro.2018.07.017
  9. Doubeni CA, Corley DA, Zhao W, Lau Y, Jensen CD, Levin TR. Association between improved colorectal screening and racial disparities. N Engl J Med. 2022;386(8):796-798. doi:10.1056/NEJMc2112409
  10. Lee JK, Lam AY, Jensen CD, et al. Impact of the COVID-19 pandemic on fecal immunochemical testing, colonoscopy services, and colorectal neoplasia detection in a large United States community-based population. Gastroenterology. 2022;S0016-5085(22)00503-0. doi:10.1053/j.gastro.2022.05.014
  11. Issaka RB, Taylor P, Baxi A, Inadomi JM, Ramsey SD, Roth J. Model-based estimation of colorectal cancer screening and outcomes during the COVID-19 pandemic. JAMA Netw Open. 2021;4(4):e216454. doi:10.1001/jamanetworkopen.2021.6454
  12. Gupta S, Coronado GD, Argenbright K, et al. Mailed fecal immunochemical test outreach for colorectal cancer screening: summary of a Centers for Disease Control and Prevention–sponsored summit. CA Cancer J Clin. 2020;70(4):283-298. doi:10.3322/caac.21615
  13. Zorzi M, Battagello J, Selby K, et al. Non-compliance with colonoscopy after a positive faecal immunochemical test doubles the risk of dying from colorectal cancer. Gut. 2022;71(3):561-567. doi:10.1136/gutjnl-2020-322192
  14. Lieberman D, Ladabaum U, Brill JV, et al. Reducing the burden of colorectal cancer: AGA position statements. Gastroenterology. 2022;163(2):520-526. doi:10.1053/j.gastro.2022.05.011
  15. Bell-Brown A, Chew L, Weiner BJ, et al. Operationalizing a rideshare intervention for colonoscopy completion: barriers, facilitators, and process recommendations. Front Health Serv. 2022;1:799816. doi:10.3389/frhs.2021.799816
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Even before the pandemic, CRC screening was underutilized, despite clear evidence that CRC screening by colonoscopy and stool-based tests was cost-effective and saved lives.1 On March 18, 2020, national agencies and health organizations made necessary initial recommendations to delay nonurgent surgeries and medical procedures, thus causing unprecedented disruptions in CRC screening.2 These delays also risked exacerbating persistent racial and ethnic disparities in CRC screening and outcomes, which had been narrowing.3

COVID-19’s impact on CRC screening was not a singular event. Members of racial and ethnic minority groups, those with limited income, and other historically medically underserved populations were inordinately affected by the disease itself. These populations had the greatest morbidity and mortality from COVID-19,4 and they were understandably more reluctant to return to care,5 including CRC screening.

Since the onset of the pandemic, at home stool-based tests, including FIT, have emerged as promising alternatives for CRC screening due to low cost, ease of completion, and preference in low-resourced settings where CRC mortality is high.6,7 In an integrated health system, a FIT-based CRC screening program increased screening participation8 and nearly eliminated Black-White mortality differences over a 10-year period.9 Yet, COVID-19 demonstrated that even small disruptions in such organized programs could have substantial consequences in detecting and preventing CRC.10

Mailed-to-the-home, stool-based CRC screening tests, including FIT, offer promise for increasing screening rates,11 but must be implemented as part of a broader CRC screening program to realize maximal benefit.12 For example, to ensure that mailed FIT programs do not exacerbate racial and ethnic disparities in CRC outcomes, abnormal results must be followed by a colonoscopy.13 Thankfully, gastroenterology societies including the American Gastroenterological Association, in partnership with federal agencies and advocacy organizations, are leading the way by providing models that can improve screening and follow-up of abnormal results.14

The COVID-19 pandemic has provided our specialty with a clear mandate: To develop long-term solutions that lead to consistent, effective, and trustworthy care for groups who have been historically medically underserved. CRC screening is a valuable way to accomplish this goal.3,15 Doing so is critical for 2 reasons: (1) to maintain momentum in addressing persistent health care disparities, and (2) to guide efforts toward achieving health equity where gaps in care remain.

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Switching to Disposable Duodenoscopes: Risks and Rewards

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References
  1. US Food and Drug Administration. Infections associated with reprocessed duodenoscopes. Updated June 30, 2022. Accessed July 28, 2022. https://www.fda.gov/medical-devices/reprocessing-reusable-medical-devices/infections-associated-reprocessed-duodenoscopes 
  2. Heuvelmans M, Wunderink HF, van der Mei HC, Monkelbaan JF. A narrative review on current duodenoscope reprocessing techniques and novel developments. Antimicrob Resist Infect Control. 2021;10(1):171. doi:10.1186/s13756-021-01037-z 
  3. US Food and Drug Administration. Use duodenoscopes with innovative designs to enhance safety: FDA safety communication. Updated June 30, 2022. Accessed July 28, 2022. https://www.fda.gov/medical-devices/safety-communications/use-duodenoscopes-innovative-designs-enhance-safety-fda-safety-communication 
  4. Pass W. Weighing the pros and cons of disposable duodenoscopes. MDedge News. Published May 19, 2021. Accessed July 28, 2022. https://www.mdedge.com/gihepnews/article/240339/endoscopy 
  5. Le NNT, Hernandez L, Vakil N, Guda N, Patnode C, Jolliet O. Environmental and health outcomes of single-use versus reusable duodenoscopes. Gastrointest Endosc. 2022;S0016-5107(22)01765-5. doi:10.1016/j.gie.2022.06.014 
  6. Ridtitid W, Thummongkol T, Chatsuwan T, et al. Bacterial contamination and organic residue after reprocessing in duodenoscopes with disposable distal caps compared to duodenoscopes with fixed distal caps: a randomized trial. Gastrointest Endosc. 2022;S0016-5107(22)01766-7. doi:10.1016/j.gie.2022.06.015  
  7. Naryzhny I, Silas D, Chi K. Impact of ethylene oxide gas sterilization of duodenoscopes after a carbapenem-resistant Enterobacteriaceae outbreak. Gastrointest Endosc. 2016;84(2):259-262. doi:10.1016/j.gie.2016.01.055 
  8. Muthusamy VR, Bruno MJ, Kozarek RA, et al. Clinical evaluation of a single-use duodenoscope for endoscopic retrograde cholangiopancreatography. Clin Gastroenterol Hepatol. 2020;18(9):2108-2117.e3. doi:10.1016/j.cgh.2019.10.052 
  9. Bang JY, Hawes R, Varadarajulu S. Equivalent performance of single-use and reusable duodenoscopes in a randomised trial. Gut. 2021;70(5):838-844. doi:10.1136/gutjnl-2020-321836 
  10. Bhatt A, Thosani N, Patil P. ID: 3527241. Ergonomic study analyzing differences in endoscopy styles between female and male gastroenterologists [abstract]. Gastrointest Endosc. 2021;93(6 Suppl):AB42-AB43. doi:10.1016/j.gie.2021.03.148 
  11. Trindade AJ, Copland A, Bhatt A, et al. Single-use duodenoscopes and duodenoscopes with disposable end caps. Gastrointest Endosc. 2021;93(5):997-1005. doi:10.1016/j.gie.2020.12.033 
  12. Namburar S, von Renteln D, Damianos J, et al. Estimating the environmental impact of disposable endoscopic equipment and endoscopes. Gut. 2022;71(7):1326-1331. doi:10.1136/gutjnl-2021-324729 
  13. Kröner PT, Bilal M, Samuel R, et al. Use of ERCP in the United States over the past decade. Endosc Int Open. 2020;8(6):E761-E769. doi:10.1055/a-1134-4873 
  14. Patel K, Lad M, Siddiqui E, Ahlawat S. National trends in reimbursement and utilization of advanced endoscopic procedures in the Medicare population [abstract S0904]. Am J Gastroenterol. 2020;115:S465-S466. doi:10.14309/01.ajg.0000705664.35696.6e 
  15. Bang JY, Sutton B, Hawes R, Varadarajulu S. Concept of disposable duodenoscope: at what cost? Gut. 2019;68(11):1915-1917. doi:10.1136/gutjnl-2019-318227 
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References
  1. US Food and Drug Administration. Infections associated with reprocessed duodenoscopes. Updated June 30, 2022. Accessed July 28, 2022. https://www.fda.gov/medical-devices/reprocessing-reusable-medical-devices/infections-associated-reprocessed-duodenoscopes 
  2. Heuvelmans M, Wunderink HF, van der Mei HC, Monkelbaan JF. A narrative review on current duodenoscope reprocessing techniques and novel developments. Antimicrob Resist Infect Control. 2021;10(1):171. doi:10.1186/s13756-021-01037-z 
  3. US Food and Drug Administration. Use duodenoscopes with innovative designs to enhance safety: FDA safety communication. Updated June 30, 2022. Accessed July 28, 2022. https://www.fda.gov/medical-devices/safety-communications/use-duodenoscopes-innovative-designs-enhance-safety-fda-safety-communication 
  4. Pass W. Weighing the pros and cons of disposable duodenoscopes. MDedge News. Published May 19, 2021. Accessed July 28, 2022. https://www.mdedge.com/gihepnews/article/240339/endoscopy 
  5. Le NNT, Hernandez L, Vakil N, Guda N, Patnode C, Jolliet O. Environmental and health outcomes of single-use versus reusable duodenoscopes. Gastrointest Endosc. 2022;S0016-5107(22)01765-5. doi:10.1016/j.gie.2022.06.014 
  6. Ridtitid W, Thummongkol T, Chatsuwan T, et al. Bacterial contamination and organic residue after reprocessing in duodenoscopes with disposable distal caps compared to duodenoscopes with fixed distal caps: a randomized trial. Gastrointest Endosc. 2022;S0016-5107(22)01766-7. doi:10.1016/j.gie.2022.06.015  
  7. Naryzhny I, Silas D, Chi K. Impact of ethylene oxide gas sterilization of duodenoscopes after a carbapenem-resistant Enterobacteriaceae outbreak. Gastrointest Endosc. 2016;84(2):259-262. doi:10.1016/j.gie.2016.01.055 
  8. Muthusamy VR, Bruno MJ, Kozarek RA, et al. Clinical evaluation of a single-use duodenoscope for endoscopic retrograde cholangiopancreatography. Clin Gastroenterol Hepatol. 2020;18(9):2108-2117.e3. doi:10.1016/j.cgh.2019.10.052 
  9. Bang JY, Hawes R, Varadarajulu S. Equivalent performance of single-use and reusable duodenoscopes in a randomised trial. Gut. 2021;70(5):838-844. doi:10.1136/gutjnl-2020-321836 
  10. Bhatt A, Thosani N, Patil P. ID: 3527241. Ergonomic study analyzing differences in endoscopy styles between female and male gastroenterologists [abstract]. Gastrointest Endosc. 2021;93(6 Suppl):AB42-AB43. doi:10.1016/j.gie.2021.03.148 
  11. Trindade AJ, Copland A, Bhatt A, et al. Single-use duodenoscopes and duodenoscopes with disposable end caps. Gastrointest Endosc. 2021;93(5):997-1005. doi:10.1016/j.gie.2020.12.033 
  12. Namburar S, von Renteln D, Damianos J, et al. Estimating the environmental impact of disposable endoscopic equipment and endoscopes. Gut. 2022;71(7):1326-1331. doi:10.1136/gutjnl-2021-324729 
  13. Kröner PT, Bilal M, Samuel R, et al. Use of ERCP in the United States over the past decade. Endosc Int Open. 2020;8(6):E761-E769. doi:10.1055/a-1134-4873 
  14. Patel K, Lad M, Siddiqui E, Ahlawat S. National trends in reimbursement and utilization of advanced endoscopic procedures in the Medicare population [abstract S0904]. Am J Gastroenterol. 2020;115:S465-S466. doi:10.14309/01.ajg.0000705664.35696.6e 
  15. Bang JY, Sutton B, Hawes R, Varadarajulu S. Concept of disposable duodenoscope: at what cost? Gut. 2019;68(11):1915-1917. doi:10.1136/gutjnl-2019-318227 
References
  1. US Food and Drug Administration. Infections associated with reprocessed duodenoscopes. Updated June 30, 2022. Accessed July 28, 2022. https://www.fda.gov/medical-devices/reprocessing-reusable-medical-devices/infections-associated-reprocessed-duodenoscopes 
  2. Heuvelmans M, Wunderink HF, van der Mei HC, Monkelbaan JF. A narrative review on current duodenoscope reprocessing techniques and novel developments. Antimicrob Resist Infect Control. 2021;10(1):171. doi:10.1186/s13756-021-01037-z 
  3. US Food and Drug Administration. Use duodenoscopes with innovative designs to enhance safety: FDA safety communication. Updated June 30, 2022. Accessed July 28, 2022. https://www.fda.gov/medical-devices/safety-communications/use-duodenoscopes-innovative-designs-enhance-safety-fda-safety-communication 
  4. Pass W. Weighing the pros and cons of disposable duodenoscopes. MDedge News. Published May 19, 2021. Accessed July 28, 2022. https://www.mdedge.com/gihepnews/article/240339/endoscopy 
  5. Le NNT, Hernandez L, Vakil N, Guda N, Patnode C, Jolliet O. Environmental and health outcomes of single-use versus reusable duodenoscopes. Gastrointest Endosc. 2022;S0016-5107(22)01765-5. doi:10.1016/j.gie.2022.06.014 
  6. Ridtitid W, Thummongkol T, Chatsuwan T, et al. Bacterial contamination and organic residue after reprocessing in duodenoscopes with disposable distal caps compared to duodenoscopes with fixed distal caps: a randomized trial. Gastrointest Endosc. 2022;S0016-5107(22)01766-7. doi:10.1016/j.gie.2022.06.015  
  7. Naryzhny I, Silas D, Chi K. Impact of ethylene oxide gas sterilization of duodenoscopes after a carbapenem-resistant Enterobacteriaceae outbreak. Gastrointest Endosc. 2016;84(2):259-262. doi:10.1016/j.gie.2016.01.055 
  8. Muthusamy VR, Bruno MJ, Kozarek RA, et al. Clinical evaluation of a single-use duodenoscope for endoscopic retrograde cholangiopancreatography. Clin Gastroenterol Hepatol. 2020;18(9):2108-2117.e3. doi:10.1016/j.cgh.2019.10.052 
  9. Bang JY, Hawes R, Varadarajulu S. Equivalent performance of single-use and reusable duodenoscopes in a randomised trial. Gut. 2021;70(5):838-844. doi:10.1136/gutjnl-2020-321836 
  10. Bhatt A, Thosani N, Patil P. ID: 3527241. Ergonomic study analyzing differences in endoscopy styles between female and male gastroenterologists [abstract]. Gastrointest Endosc. 2021;93(6 Suppl):AB42-AB43. doi:10.1016/j.gie.2021.03.148 
  11. Trindade AJ, Copland A, Bhatt A, et al. Single-use duodenoscopes and duodenoscopes with disposable end caps. Gastrointest Endosc. 2021;93(5):997-1005. doi:10.1016/j.gie.2020.12.033 
  12. Namburar S, von Renteln D, Damianos J, et al. Estimating the environmental impact of disposable endoscopic equipment and endoscopes. Gut. 2022;71(7):1326-1331. doi:10.1136/gutjnl-2021-324729 
  13. Kröner PT, Bilal M, Samuel R, et al. Use of ERCP in the United States over the past decade. Endosc Int Open. 2020;8(6):E761-E769. doi:10.1055/a-1134-4873 
  14. Patel K, Lad M, Siddiqui E, Ahlawat S. National trends in reimbursement and utilization of advanced endoscopic procedures in the Medicare population [abstract S0904]. Am J Gastroenterol. 2020;115:S465-S466. doi:10.14309/01.ajg.0000705664.35696.6e 
  15. Bang JY, Sutton B, Hawes R, Varadarajulu S. Concept of disposable duodenoscope: at what cost? Gut. 2019;68(11):1915-1917. doi:10.1136/gutjnl-2019-318227 
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In 2013, the CDC warned the FDA that patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) were being infected with multidrug-resistant bacteria, and that the bacteria were likely coming from the duodenoscopes.1 Subsequent changes to the instrument’s cleaning protocols did not significantly improve infection rates.2 Thus in 2019, the FDA urged endoscopists to abandon use of reusable, hard-to-clean duodenoscopes when performing ERCP.3 The FDA wanted surgeons to adopt either single-use models or reusable tools redesigned with disposable tips.

The FDA’s request has created a lively debate among endoscopists.4 While single-use instruments would, by definition, eliminate risk of infection and save time related to endoscope cleanings, the constant replacement costs and the environmental impact of their disposal have prompted much discussion.2,4 The estimated amount of greenhouse gas emissions, for example, from manufacturing the single-use instruments is remarkably higher than for other instruments.5

Alternatively, a “hybrid” duodenoscope, a reusable instrument equipped with a one-time-use tip, has been available for a few years; its use has been shown to significantly reduce bacterial contamination.6 However, that use has not entirely eliminated risk of microbial contamination despite adherence to high-level disinfection  and reprocessing.7

Although the primary driver for disposable duodenoscopes has been reduction of infection risk from ERCP, other improvements are anticipated changes in ergonomic design for instrument operators with smaller hands, for example. A small case study has shown that expert endoscopists can finish ERCPs of different levels of complexity using disposable duodenoscopes.8

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Post-COVID-19 Effects

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Post-COVID-19 Effects
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Viren Kaul, MD, FCCP, FACP

Click to view more from Pulmonology Data Trends 2022.

References
  1. Centers for Disease Control and Prevention. COVID data tracker. Updated August 19, 2022. Accessed August 22, 2022. https://covid.cdc.gov/covid-data-tracker
  2. Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome. Nat Med. 2021;27(4):601-615. doi:10.1038/s41591-021-01283-z
  3. Centers for Disease Control and Prevention. Long COVID or post-COVID conditions. Updated May 5, 2022. Accessed June 6, 2022. https://www.cdc.gov/coronavirus/2019-ncov/long-termeffects/index.html
  4. Ghazanfar H, Kandhi S, Shin D, et al. Impact of COVID-19 on the gastrointestinal tract: a clinical review. Cureus. 2022;14(3):e23333. doi:10.7759/cureus.23333
  5. Khan SM, Shilen A, Heslin KM, et al. SARS-CoV-2 infection and subsequent changes in the menstrual cycle among participants in the Arizona CoVHORT study. Am J Obstet Gynecol. 2022;226(2):270-273. doi:10.1016/j.ajog.2021.09.016
  6. Chopra V, Flanders SA, O’Malley M, Malani AN, Prescott HC. Sixty-day outcomes among patients hospitalized with COVID-19. Ann Intern Med. 2021;174(4):576-578. doi:10.7326/M20-5661
  7. Jiang DH, McCoy RG. Planning for the post-COVID syndrome: how payers can mitigate long-term complications of the pandemic. J Gen Intern Med. 2020;35(10):3036-3039. doi:10.1007/s11606-020-06042-3
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References
  1. Centers for Disease Control and Prevention. COVID data tracker. Updated August 19, 2022. Accessed August 22, 2022. https://covid.cdc.gov/covid-data-tracker
  2. Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome. Nat Med. 2021;27(4):601-615. doi:10.1038/s41591-021-01283-z
  3. Centers for Disease Control and Prevention. Long COVID or post-COVID conditions. Updated May 5, 2022. Accessed June 6, 2022. https://www.cdc.gov/coronavirus/2019-ncov/long-termeffects/index.html
  4. Ghazanfar H, Kandhi S, Shin D, et al. Impact of COVID-19 on the gastrointestinal tract: a clinical review. Cureus. 2022;14(3):e23333. doi:10.7759/cureus.23333
  5. Khan SM, Shilen A, Heslin KM, et al. SARS-CoV-2 infection and subsequent changes in the menstrual cycle among participants in the Arizona CoVHORT study. Am J Obstet Gynecol. 2022;226(2):270-273. doi:10.1016/j.ajog.2021.09.016
  6. Chopra V, Flanders SA, O’Malley M, Malani AN, Prescott HC. Sixty-day outcomes among patients hospitalized with COVID-19. Ann Intern Med. 2021;174(4):576-578. doi:10.7326/M20-5661
  7. Jiang DH, McCoy RG. Planning for the post-COVID syndrome: how payers can mitigate long-term complications of the pandemic. J Gen Intern Med. 2020;35(10):3036-3039. doi:10.1007/s11606-020-06042-3
References
  1. Centers for Disease Control and Prevention. COVID data tracker. Updated August 19, 2022. Accessed August 22, 2022. https://covid.cdc.gov/covid-data-tracker
  2. Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome. Nat Med. 2021;27(4):601-615. doi:10.1038/s41591-021-01283-z
  3. Centers for Disease Control and Prevention. Long COVID or post-COVID conditions. Updated May 5, 2022. Accessed June 6, 2022. https://www.cdc.gov/coronavirus/2019-ncov/long-termeffects/index.html
  4. Ghazanfar H, Kandhi S, Shin D, et al. Impact of COVID-19 on the gastrointestinal tract: a clinical review. Cureus. 2022;14(3):e23333. doi:10.7759/cureus.23333
  5. Khan SM, Shilen A, Heslin KM, et al. SARS-CoV-2 infection and subsequent changes in the menstrual cycle among participants in the Arizona CoVHORT study. Am J Obstet Gynecol. 2022;226(2):270-273. doi:10.1016/j.ajog.2021.09.016
  6. Chopra V, Flanders SA, O’Malley M, Malani AN, Prescott HC. Sixty-day outcomes among patients hospitalized with COVID-19. Ann Intern Med. 2021;174(4):576-578. doi:10.7326/M20-5661
  7. Jiang DH, McCoy RG. Planning for the post-COVID syndrome: how payers can mitigate long-term complications of the pandemic. J Gen Intern Med. 2020;35(10):3036-3039. doi:10.1007/s11606-020-06042-3
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Millions of Americans have been affected by the COVID-19 pandemic, with 93.2 million cases as of August 19, 2022.1 Many of these individuals are experiencing long-term effects after infection with the COVID-19 virus, and various disparities are affecting access to care. Post-acute COVID-19 syndrome is defined as symptoms that persist 4 weeks after the onset of symptoms from COVID-19 infection. Although COVID-19 is primarily a respiratory infection, the long-term effects have been seen in various organ systems. The effects of this condition reach beyond physical health, taking a toll on a patient’s economic and psychological well-being. Different racial/ethnic and economic factors also influence likelihood of illness and disease outcomes. Physicians must remain aware of the long-term role these factors will continue to play in patient outcomes.

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Painful and Pruritic Eruptions on the Entire Body

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Liliana Espinoza, BS
Terri J. Nutt, MD

The Diagnosis: IgA Pemphigus

Histopathology revealed a neutrophilic pustule and vesicle formation underlying the corneal layer (Figure). Direct immunofluorescence (DIF) showed weak positive staining for IgA within the intercellular keratinocyte in the epithelial compartment and a negative pattern with IgG, IgM, C3, and fibrinogen. The patient received a 40-mg intralesional triamcinolone injection and was placed on an oral prednisone 50-mg taper within 5 days. The plaques, bullae, and pustules began to resolve, but the lesions returned 1 day later. Oral prednisone 10 mg daily was initiated for 1 month, which resulted in full resolution of the lesions.

Neutrophilic pustule and vesicle formation underlying the corneal layer compartment (H&E, original magnification ×10).
Neutrophilic pustule and vesicle formation underlying the corneal layer compartment (H&E, original magnification ×10).

IgA pemphigus is a rare autoimmune disorder characterized by the occurrence of painful pruritic blisters caused by circulating IgA antibodies, which react against keratinocyte cellular components responsible for mediating cell-to-cell adherence.1 The etiology of IgA pemphigus presently remains elusive, though it has been reported to occur concomitantly with several chronic malignancies and inflammatory conditions. Although its etiology is unknown, IgA pemphigus most commonly is treated with oral dapsone and corticosteroids.2

IgA pemphigus can be divided into 2 primary subtypes: subcorneal pustular dermatosis and intraepidermal neutrophilic dermatosis.1,3 The former is characterized by intercellular deposition of IgA that reacts to the glycoprotein desmocollin-1 in the upper layer of the epidermis. Intraepidermal neutrophilic dermatosis is distinguished by the presence of autoantibodies against the desmoglein members of the cadherin superfamily of proteins. Additionally, unlike subcorneal pustular dermatosis, intraepidermal neutrophilic dermatosis autoantibody reactivity occurs in the lower epidermis.4

The differential includes dermatitis herpetiformis, which is commonly seen on the elbows, knees, and buttocks, with DIF showing IgA deposition at the dermal papillae. Pemphigus foliaceus is distributed on the scalp, face, and trunk, with DIF showing IgG intercellular deposition. Pustular psoriasis presents as erythematous sterile pustules in a more localized annular pattern. Subcorneal pustular dermatosis (Sneddon-Wilkinson disease) has similar clinical and histological findings to IgA pemphigus; however, DIF is negative.

References
  1. Kridin K, Patel PM, Jones VA, et al. IgA pemphigus: a systematic review. J Am Acad Dermatol. 2020;82:1386-1392.
  2. Moreno ACL, Santi CG, Gabbi TVB, et al. IgA pemphigus: case series with emphasis on therapeutic response. J Am Acad Dermatol. 2014;70:200-201.
  3. Niimi Y, Kawana S, Kusunoki T. IgA pemphigus: a case report and its characteristic clinical features compared with subcorneal pustular dermatosis. J Am Acad Dermatol. 2000;43:546-549.
  4. Aslanova M, Yarrarapu SNS, Zito PM. IgA pemphigus. StatPearls. StatPearls Publishing; 2021.
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Dr. Yousefian is from the University of the Incarnate Word School of Osteopathic Medicine, San Antonio, Texas, and the Texas Institute for Graduate Medical Education and Research, San Antonio. Ms. Espinoza is from the Long School of Medicine, University of Texas Health San Antonio. Dr. Nutt is from San Antonio Skin Care and Dermatology Clinic.

The authors report no conflict of interest.

Correspondence: Faraz Yousefian, DO, University of the Incarnate Word School of Osteopathic Medicine, Texas Institute for Graduate Medical Education and Research, 7615 Kennedy Hill Dr, San Antonio, TX 78235 ([email protected]).

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Terri J. Nutt, MD
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Dr. Yousefian is from the University of the Incarnate Word School of Osteopathic Medicine, San Antonio, Texas, and the Texas Institute for Graduate Medical Education and Research, San Antonio. Ms. Espinoza is from the Long School of Medicine, University of Texas Health San Antonio. Dr. Nutt is from San Antonio Skin Care and Dermatology Clinic.

The authors report no conflict of interest.

Correspondence: Faraz Yousefian, DO, University of the Incarnate Word School of Osteopathic Medicine, Texas Institute for Graduate Medical Education and Research, 7615 Kennedy Hill Dr, San Antonio, TX 78235 ([email protected]).

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Dr. Yousefian is from the University of the Incarnate Word School of Osteopathic Medicine, San Antonio, Texas, and the Texas Institute for Graduate Medical Education and Research, San Antonio. Ms. Espinoza is from the Long School of Medicine, University of Texas Health San Antonio. Dr. Nutt is from San Antonio Skin Care and Dermatology Clinic.

The authors report no conflict of interest.

Correspondence: Faraz Yousefian, DO, University of the Incarnate Word School of Osteopathic Medicine, Texas Institute for Graduate Medical Education and Research, 7615 Kennedy Hill Dr, San Antonio, TX 78235 ([email protected]).

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The Diagnosis: IgA Pemphigus

Histopathology revealed a neutrophilic pustule and vesicle formation underlying the corneal layer (Figure). Direct immunofluorescence (DIF) showed weak positive staining for IgA within the intercellular keratinocyte in the epithelial compartment and a negative pattern with IgG, IgM, C3, and fibrinogen. The patient received a 40-mg intralesional triamcinolone injection and was placed on an oral prednisone 50-mg taper within 5 days. The plaques, bullae, and pustules began to resolve, but the lesions returned 1 day later. Oral prednisone 10 mg daily was initiated for 1 month, which resulted in full resolution of the lesions.

Neutrophilic pustule and vesicle formation underlying the corneal layer compartment (H&E, original magnification ×10).
Neutrophilic pustule and vesicle formation underlying the corneal layer compartment (H&E, original magnification ×10).

IgA pemphigus is a rare autoimmune disorder characterized by the occurrence of painful pruritic blisters caused by circulating IgA antibodies, which react against keratinocyte cellular components responsible for mediating cell-to-cell adherence.1 The etiology of IgA pemphigus presently remains elusive, though it has been reported to occur concomitantly with several chronic malignancies and inflammatory conditions. Although its etiology is unknown, IgA pemphigus most commonly is treated with oral dapsone and corticosteroids.2

IgA pemphigus can be divided into 2 primary subtypes: subcorneal pustular dermatosis and intraepidermal neutrophilic dermatosis.1,3 The former is characterized by intercellular deposition of IgA that reacts to the glycoprotein desmocollin-1 in the upper layer of the epidermis. Intraepidermal neutrophilic dermatosis is distinguished by the presence of autoantibodies against the desmoglein members of the cadherin superfamily of proteins. Additionally, unlike subcorneal pustular dermatosis, intraepidermal neutrophilic dermatosis autoantibody reactivity occurs in the lower epidermis.4

The differential includes dermatitis herpetiformis, which is commonly seen on the elbows, knees, and buttocks, with DIF showing IgA deposition at the dermal papillae. Pemphigus foliaceus is distributed on the scalp, face, and trunk, with DIF showing IgG intercellular deposition. Pustular psoriasis presents as erythematous sterile pustules in a more localized annular pattern. Subcorneal pustular dermatosis (Sneddon-Wilkinson disease) has similar clinical and histological findings to IgA pemphigus; however, DIF is negative.

The Diagnosis: IgA Pemphigus

Histopathology revealed a neutrophilic pustule and vesicle formation underlying the corneal layer (Figure). Direct immunofluorescence (DIF) showed weak positive staining for IgA within the intercellular keratinocyte in the epithelial compartment and a negative pattern with IgG, IgM, C3, and fibrinogen. The patient received a 40-mg intralesional triamcinolone injection and was placed on an oral prednisone 50-mg taper within 5 days. The plaques, bullae, and pustules began to resolve, but the lesions returned 1 day later. Oral prednisone 10 mg daily was initiated for 1 month, which resulted in full resolution of the lesions.

Neutrophilic pustule and vesicle formation underlying the corneal layer compartment (H&E, original magnification ×10).
Neutrophilic pustule and vesicle formation underlying the corneal layer compartment (H&E, original magnification ×10).

IgA pemphigus is a rare autoimmune disorder characterized by the occurrence of painful pruritic blisters caused by circulating IgA antibodies, which react against keratinocyte cellular components responsible for mediating cell-to-cell adherence.1 The etiology of IgA pemphigus presently remains elusive, though it has been reported to occur concomitantly with several chronic malignancies and inflammatory conditions. Although its etiology is unknown, IgA pemphigus most commonly is treated with oral dapsone and corticosteroids.2

IgA pemphigus can be divided into 2 primary subtypes: subcorneal pustular dermatosis and intraepidermal neutrophilic dermatosis.1,3 The former is characterized by intercellular deposition of IgA that reacts to the glycoprotein desmocollin-1 in the upper layer of the epidermis. Intraepidermal neutrophilic dermatosis is distinguished by the presence of autoantibodies against the desmoglein members of the cadherin superfamily of proteins. Additionally, unlike subcorneal pustular dermatosis, intraepidermal neutrophilic dermatosis autoantibody reactivity occurs in the lower epidermis.4

The differential includes dermatitis herpetiformis, which is commonly seen on the elbows, knees, and buttocks, with DIF showing IgA deposition at the dermal papillae. Pemphigus foliaceus is distributed on the scalp, face, and trunk, with DIF showing IgG intercellular deposition. Pustular psoriasis presents as erythematous sterile pustules in a more localized annular pattern. Subcorneal pustular dermatosis (Sneddon-Wilkinson disease) has similar clinical and histological findings to IgA pemphigus; however, DIF is negative.

References
  1. Kridin K, Patel PM, Jones VA, et al. IgA pemphigus: a systematic review. J Am Acad Dermatol. 2020;82:1386-1392.
  2. Moreno ACL, Santi CG, Gabbi TVB, et al. IgA pemphigus: case series with emphasis on therapeutic response. J Am Acad Dermatol. 2014;70:200-201.
  3. Niimi Y, Kawana S, Kusunoki T. IgA pemphigus: a case report and its characteristic clinical features compared with subcorneal pustular dermatosis. J Am Acad Dermatol. 2000;43:546-549.
  4. Aslanova M, Yarrarapu SNS, Zito PM. IgA pemphigus. StatPearls. StatPearls Publishing; 2021.
References
  1. Kridin K, Patel PM, Jones VA, et al. IgA pemphigus: a systematic review. J Am Acad Dermatol. 2020;82:1386-1392.
  2. Moreno ACL, Santi CG, Gabbi TVB, et al. IgA pemphigus: case series with emphasis on therapeutic response. J Am Acad Dermatol. 2014;70:200-201.
  3. Niimi Y, Kawana S, Kusunoki T. IgA pemphigus: a case report and its characteristic clinical features compared with subcorneal pustular dermatosis. J Am Acad Dermatol. 2000;43:546-549.
  4. Aslanova M, Yarrarapu SNS, Zito PM. IgA pemphigus. StatPearls. StatPearls Publishing; 2021.
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Painful and Pruritic Eruptions on the Entire Body
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A 36-year-old man presented with painful tender blisters and rashes on the entire body, including the ears and tongue. The rash began as a few pinpointed red dots on the abdomen, which subsequently increased in size and spread over the last week. He initially felt red and flushed and noticed new lesions appearing throughout the day. He did not attempt any specific treatment for these lesions. The patient tested positive for COVID-19 four months prior to the skin eruption. He denied systemic symptoms, smoking, or recent travel. He had no history of skin cancer, skin disorders, HIV, or hepatitis. He had no known medication allergies. Physical examination revealed multiple disseminated pustules on the ears, superficial ulcerations on the tongue, and blisters on the right lip. Few lesions were tender to the touch and drained clear fluid. Bacterial, viral, HIV, herpes, and rapid plasma reagin culture and laboratory screenings were negative. He was started on valaciclovir and cephalexin; however, no improvement was noticed. Punch biopsies were taken from the blisters on the chest and perilesional area.

Painful and pruritic eruptions on the entire body

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COPD Characteristics and Health Disparities

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References

1. Chronic obstructive pulmonary disease (COPD). Centers for Disease Control and Prevention. Updated February 22, 2021. Accessed May 30, 2022. https://www.cdc.gov/copd/index.html

2. Stellefson M, Wang MQ, Kinder C. Racial disparities in health risk indicators reported by Alabamians diagnosed with COPD. Int J Environ Res Public Health. 2021;18(18):9662. doi:10.3390/ ijerph18189662

3. Eisner MD, Blanc PD, Omachi TA, et al. Socioeconomic status, race and COPD health outcomes. J Epidemiol Community Health. 2011;65(1):26-34. doi:10.1136/jech.2009.089722

4. Croft JB, Wheaton AG, Liu Y, et al. Urban-rural county and state differences in chronic obstructive pulmonary disease – United States, 2015. MMWR Morb Mortal Wkly Rep. 2018;67(7):205- 211. doi:10.15585/mmwr.mm6707a1

5. Assari S, Chalian H, Bazargan M. Race, ethnicity, socioeconomic status, and chronic lung disease in the U.S. Res Health Sci. 2020;5(1):48-63. doi:10.22158/rhs.v5n1p48

6. Mamary AJ, Stewart JI, Kinney GL, et al. Race and gender disparities are evident in COPD underdiagnoses across all severities of measured airflow obstruction. Chronic Obstr Pulm Dis. 2018;5(3):177-184. doi:10.15326/jcopdf.5.3.2017.0145

7. Woo H, Brigham EP, Allbright K, et al. Racial segregation and respiratory outcomes among urban black residents with and at risk of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2021;204(5):536-545. doi:10.1164/rccm.202009- 3721OC

8. Hosseini M, Almasi-Hashiani A, Sepidarkish M, Maroufizadeh S. Global prevalence of asthma-COPD overlap (ACO) in the general population: a systematic review and meta-analysis. Respir Res. 2019;20(1):229. doi:10.1186/s12931-019-1198-4

9. Han MK, Agusti A, Celli BR, et al. From GOLD 0 to pre-COPD. Am J Respir Crit Care Med. 2021;203(4):414-423. doi:10.1164/ rccm.202008-3328PP

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References

1. Chronic obstructive pulmonary disease (COPD). Centers for Disease Control and Prevention. Updated February 22, 2021. Accessed May 30, 2022. https://www.cdc.gov/copd/index.html

2. Stellefson M, Wang MQ, Kinder C. Racial disparities in health risk indicators reported by Alabamians diagnosed with COPD. Int J Environ Res Public Health. 2021;18(18):9662. doi:10.3390/ ijerph18189662

3. Eisner MD, Blanc PD, Omachi TA, et al. Socioeconomic status, race and COPD health outcomes. J Epidemiol Community Health. 2011;65(1):26-34. doi:10.1136/jech.2009.089722

4. Croft JB, Wheaton AG, Liu Y, et al. Urban-rural county and state differences in chronic obstructive pulmonary disease – United States, 2015. MMWR Morb Mortal Wkly Rep. 2018;67(7):205- 211. doi:10.15585/mmwr.mm6707a1

5. Assari S, Chalian H, Bazargan M. Race, ethnicity, socioeconomic status, and chronic lung disease in the U.S. Res Health Sci. 2020;5(1):48-63. doi:10.22158/rhs.v5n1p48

6. Mamary AJ, Stewart JI, Kinney GL, et al. Race and gender disparities are evident in COPD underdiagnoses across all severities of measured airflow obstruction. Chronic Obstr Pulm Dis. 2018;5(3):177-184. doi:10.15326/jcopdf.5.3.2017.0145

7. Woo H, Brigham EP, Allbright K, et al. Racial segregation and respiratory outcomes among urban black residents with and at risk of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2021;204(5):536-545. doi:10.1164/rccm.202009- 3721OC

8. Hosseini M, Almasi-Hashiani A, Sepidarkish M, Maroufizadeh S. Global prevalence of asthma-COPD overlap (ACO) in the general population: a systematic review and meta-analysis. Respir Res. 2019;20(1):229. doi:10.1186/s12931-019-1198-4

9. Han MK, Agusti A, Celli BR, et al. From GOLD 0 to pre-COPD. Am J Respir Crit Care Med. 2021;203(4):414-423. doi:10.1164/ rccm.202008-3328PP

References

1. Chronic obstructive pulmonary disease (COPD). Centers for Disease Control and Prevention. Updated February 22, 2021. Accessed May 30, 2022. https://www.cdc.gov/copd/index.html

2. Stellefson M, Wang MQ, Kinder C. Racial disparities in health risk indicators reported by Alabamians diagnosed with COPD. Int J Environ Res Public Health. 2021;18(18):9662. doi:10.3390/ ijerph18189662

3. Eisner MD, Blanc PD, Omachi TA, et al. Socioeconomic status, race and COPD health outcomes. J Epidemiol Community Health. 2011;65(1):26-34. doi:10.1136/jech.2009.089722

4. Croft JB, Wheaton AG, Liu Y, et al. Urban-rural county and state differences in chronic obstructive pulmonary disease – United States, 2015. MMWR Morb Mortal Wkly Rep. 2018;67(7):205- 211. doi:10.15585/mmwr.mm6707a1

5. Assari S, Chalian H, Bazargan M. Race, ethnicity, socioeconomic status, and chronic lung disease in the U.S. Res Health Sci. 2020;5(1):48-63. doi:10.22158/rhs.v5n1p48

6. Mamary AJ, Stewart JI, Kinney GL, et al. Race and gender disparities are evident in COPD underdiagnoses across all severities of measured airflow obstruction. Chronic Obstr Pulm Dis. 2018;5(3):177-184. doi:10.15326/jcopdf.5.3.2017.0145

7. Woo H, Brigham EP, Allbright K, et al. Racial segregation and respiratory outcomes among urban black residents with and at risk of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2021;204(5):536-545. doi:10.1164/rccm.202009- 3721OC

8. Hosseini M, Almasi-Hashiani A, Sepidarkish M, Maroufizadeh S. Global prevalence of asthma-COPD overlap (ACO) in the general population: a systematic review and meta-analysis. Respir Res. 2019;20(1):229. doi:10.1186/s12931-019-1198-4

9. Han MK, Agusti A, Celli BR, et al. From GOLD 0 to pre-COPD. Am J Respir Crit Care Med. 2021;203(4):414-423. doi:10.1164/ rccm.202008-3328PP

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An estimated 16 million Americans have been diagnosed with chronic obstructive pulmonary disease (COPD), which is the fourth leading cause of death in the United States.1 Many of the health disparities in COPD diagnosis and care stem from the usual suspects: racial and ethnic barriers, lack of access, and socioeconomic burdens. Overall, COPD affects about 6.1% of Black Americans and 6.3% of non-Hispanic White Americans.2

However, while lower education and income are generally associated with poorer outcomes, Black and Hispanic patients with COPD who are highly educated and who have high incomes still show worse health status than their White counterparts.3 Incidence of COPD also varies by region, with rural states such as Alabama, Arkansas, and Kentucky having some of the highest rates.2,4  These inequalities support the need for continued research to address the varying health behaviors, comorbidities, and systemic barriers causing disparities for Black and Hispanic patients with COPD.

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