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Hassan C.,Nuovo Regina Margherita Hospital | Rex D.K.,Indiana University | Cooper G.S.,University Hospitals Case Medical Center | Benamouzig R.,Service de Gastroenterologie
Endoscopy | Year: 2012

Background: Propofol for colonoscopy is largely administered by anesthesiologists or anesthesiology nurses in the United States (US) and Europe. Endoscopist-directed administration of propofol (EDP) by nonanesthesiologists has recently been proposed, with potential savings of anesthetist reimbursement costs. We aimed to assess potential EDP-related benefit in a screening setting. Methods: In a Markov model the total number of screening and follow-up colonoscopies in a cohort of 100 000 US subjects were estimated. Anesthetist-assisted colonoscopy was compared with an EDP strategy. Model outputs were projected onto the 50 - 80-year-old US population, assuming 27 % as the current uptake for colonoscopy screening. Anesthetist costs were estimated using the mean reimbursement for the corresponding Medicare code ( 65-year-olds) and from commercial insurance information (50 - 64-year-olds). The proportion of colonoscopies with anesthesiologist assistance was estimated from the Medicare database. Mean nurse salary was used to estimate the cost of a 2-week EDP training. The absolute number of US endoscopists was estimated by inflating by 33 % the number of board-certified gastroenterologists. No EDP mortality was assumed in the reference scenario, and 0.0008 % mortality in the sensitivity analysis. US census data were adopted. Analogous inputs were used for France to assess EDP-related benefit in a European country. Results: EDP training for 17 166 nurses (one for each US endoscopist) showed a cost of $ 47 million. Cost estimates for anesthesiologist assistance for colonoscopy were $ 95 (Medicare) and $ 450 (non-Medicare commercial insurance), with 34.8 % of colonoscopies requiring anesthesiologist assistance. US implementation of an EDP policy showed a 10-year saving of $ 3.2 billion (Monte Carlo analysis 5 - 95 % percentiles $ 2.7 - $ 11.9 billion). In the sensitivity analysis, assuming 50 % of colonoscopies were anesthetist-assisted showed an EDP benefit of $ 4.6 billion. Assuming a 0.0008 % mortality rate, the incremental cost - effectiveness of anesthetist-assisted colonoscopy versus an EDP policy was $ 1.5 million per life-year gained, supporting EDP as the optimal choice. A 31-fold increase of EDP-related mortality or a 17-fold cost reduction for anesthetist-assisted colonoscopy was required for EDP to become not cost-effective in this scenario. Implementation of an EDP policy in France, within a guaiac-fecal occult blood test (g-FOBT) screening program, was estimated to save 0.8 billion in 10 years. Conclusions: The absolute economic benefit of EDP implementation in a screening setting is probably substantial with 10-year savings of $3.2 billion in the US and 0.8 billion in France. The impact of an eventual EDP-related mortality on EDP cost - effectiveness seems marginal. The huge economic and medical resources entailed by anesthetist-assisted colonoscopy could be more efficiently invested in other clinical fields. © Georg Thieme Verlag KG Stuttgart. New York.


Hassan C.,Nuovo Regina Margherita Hospital | Rex D.K.,Indiana University | Zullo A.,Nuovo Regina Margherita Hospital | Cooper G.S.,University Hospitals Case Medical Center
Cancer | Year: 2012

BACKGROUND: Specialty of the endoscopist has been related to the postcolonoscopy interval risk of colorectal cancer (CRC). However, the impact of such a difference on the long-term CRC prevention rate by screening colonoscopy is largely unknown. METHODS: A Markov model was constructed to simulate the efficacy and cost of colonoscopy screening according to the specialty of the endoscopist in 100,000 individuals aged 50 years until death. The postcolonoscopy interval CRC risk (0.02%) and the relative risk (1.4) of interval CRC between gastroenterologist (GI) endoscopists and non-GI endoscopists were extracted from the literature. Both efficacy and costs were projected over a steady-state US population. Eventual increase in endoscopic capacity when assuming all procedures to be performed by GI endoscopists was simulated. RESULTS: According to the simulation model, screening colonoscopy performed by non-GI endoscopists resulted in a 11% relative reduction in the long-term CRC incidence prevention rate compared with the same procedure performed by GI endoscopists. When projected on the US population, the reduced non-GI efficacy resulted in an additional 3043 CRC cases and the loss of $200 million per year. When increasing the relative risk from 1.4 to 2.0, the difference in the prevention rate between GI endoscopists and non-GI endoscopists increased to 19%. It increased further to 38% when also assuming a 3-fold increase in the risk of interval CRC. An additional 165 screening colonoscopies per endoscopist per year would be required to shift all non-GI procedures to GI endoscopists. CONCLUSIONS: When screening colonoscopy is performed by non-GI endoscopists, a substantial reduction in the long-term CRC prevention rate may be expected. Such difference appeared to be greater when a suboptimal efficacy of colonoscopy in preventing CRC was assumed. A 10-year saving of $2 billion may be expected when shifting all screening colonoscopies from non-GI endoscopists to GI endoscopists. Cancer 2012. © 2012 American Cancer Society.


Pickhardt P.J.,University of Wisconsin - Madison | Pickhardt P.J.,Uniformed Services University of the Health Sciences | Hassan C.,Nuovo Regina Margherita Hospital | Halligan S.,University College London | Marmo R.,L Curto Hospital
Radiology | Year: 2011

Purpose: To perform a systematic review and meta-analysis of published studies assessing the sensitivity of both computed tomographic (CT) colonography and optical colonoscopy (OC) for colorectal cancer detection.Materials and Methods: Analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. The primary data source was the results of a detailed PubMed search from 1994 to 2009. Diagnostic studies evaluating CT colonography detection of colorectal cancer were assessed by using predefi ned inclusion and exclusion criteria, in particular requiring both OC and histologic confi rmation of disease. Studies that also included a mechanism to assess true-positive versus false-negative diagnoses atOC (eg, segmental unblinding) were used to calculate OC sensitivity. Assessment and data extraction were performed independently by two authors. Potential bias was ascertained by using Quality Assessment of Diagnostic Accuracy Studies guidelines. Specifi c CT colonography techniques were cataloged. Forest plots of per-patient sensitivity were produced on the basis of random-effect models. Potential bias across primary studies was assessed by using the I 2 statistic. Original study authors were contacted for data clarifi cation when necessary. Results: Forty-nine studies provided data on 11 151 patients with a cumulative colorectal cancer prevalence of 3.6% (414 cancers). The sensitivity of CT colonography for colorectal cancer was 96.1% (398 of 414; 95% confi dence interval [CI]: 93.8%, 97.7%). No heterogeneity ( I2 = 0%) was detected. No cancers were missed at CT colonography when both cathartic and tagging agents were combined in the bowel preparation. The sensitivity of OC for colorectal cancer, derived from a subset of 25 studies including 9223 patients, was 94.7% (178 of 188; 95% CI: 90.4%, 97.2%). A moderate degree of heterogeneity ( I2 = 50%) was present. Conclusion: CT colonography is highly sensitive for colorectal cancer, especially when both cathartic and tagging agents are combined in the bowel preparation. Given the relatively low prevalence of colorectal cancer, primary CT colonography may be more suitable than OC for initial investigation of suspected colorectal cancer, assuming reasonable specifi city. © RSNA, 2011.


Bruzzese V.,Nuovo Regina Margherita Hospital
International Journal of Immunopathology and Pharmacology | Year: 2011

We report the case of a man suffering from rheumatoid arthritis, resistant to common DMARDs and anti-TNF-alpha, who received an excellent response, in terms of effectiveness and depletion of CD20 positive B-lymphocytes, to minimal doses of anti-CD20 monoclonal antibody (rituximab). The dose used was only 100 mg, repeated after 2 weeks. Already after the first infusion of rituximab, a profound depletion of CD20 B-lymphocytes and an improvement of clinical symptoms were evident. The patient, after 4 months from the first two infusions, maintained an accentuated lymphocyte depletion and obtained a low disease activity, passing from an initial DAS28 of 6.3 to a DAS28 of 2.8. The possible practical implications of this observation are taken into consideration. Copyright © by BIOLIFE, s.a.s.


Hassan C.,Nuovo Regina Margherita Hospital | Pickhardt P.J.,University of Wisconsin - Madison
Nature Reviews Gastroenterology and Hepatology | Year: 2013

The advent of CT colonography (CTC) has generated conservative policies for the management of diminutive (<5 mm) and small (6-9 mm) polyps to prevent inefficient duplication of screening tests. The effect of not referring subcentimetric polyps for polypectomy on the efficacy of colorectal cancer screening is still uncertain but depends on the natural history of diminutive and small polyps, as well as on the distribution of advanced neoplasia within these lesions. Simulation modelling enables the efficacy and cost-effectiveness of conservative strategies for the management of subcentimetric lesions to be tested (such as nonreferral to polypectomy for diminutive polyps and early CTC surveillance for small polyps). These policies might be further refined by the inclusion of patient and polyp-related predictive factors for advanced neoplasia, enabling a patient-tailored approach for the management of these lesions. © 2013 Macmillan Publishers Limited. All rights reserved.


Hassan C.,Nuovo Regina Margherita Hospital | Gralnek I.M.,Technion - Israel Institute of Technology
Digestive and Liver Disease | Year: 2015

Background: Compared to standard forward viewing colonoscopy, we aimed to assess the cost-effectiveness of full spectrum endoscopy colonoscopy in a population-based colorectal cancer screening and surveillance program. Methods: A Markov model was constructed to simulate the occurrence of colorectal neoplasia in a cohort of 100,000 subjects aged 50-100 years. The cost-effectiveness of full spectrum endoscopy was compared with that of standard forwarding viewing colonoscopy. Sensitivity for adenomatous and hyperplastic polyps <5. mm, 6-9. mm, and high-risk polyps were derived from the recent randomized tandem Fuse colonoscopy study. Results: The significantly higher sensitivity of full spectrum endoscopy in detecting additional adenomas resulted in an increase in cancer prevention from 58% to 74%, corresponding to a gain of 9 days per person. This 14% increase led to an absolute reduction in the cost of cancer care from $90 million to $57 million. This cost savings was only minimally impacted by the higher cost of more frequent post-polypectomy colonoscopy surveillance rates, leading to full spectrum endoscopy being associated with a savings of $145 per person. Thus, standard colonoscopy appeared to be "dominated" by the full spectrum endoscopy. Conclusions: Compared to standard colonoscopy, full spectrum endoscopy appears to be more cost-effective for colon cancer screening and surveillance. © 2015 Editrice Gastroenterologica Italiana S.r.l.


Hassan C.,Nuovo Regina Margherita Hospital | Pickhardt P.J.,University of Wisconsin - Madison | Pickhardt P.J.,Uniformed Services University of the Health Sciences | Rex D.K.,Indiana University
Clinical Gastroenterology and Hepatology | Year: 2010

Background & Aims: A "resect and discard" policy has been proposed for diminutive polyps detected by screening colonoscopy, because hyperplastic and adenomatous polyps can be distinguished, in vivo, by using narrow-band imaging (NBI). We modeled the cost-effectiveness of this policy. Methods: Markov modeling was used to compare the cost-effectiveness of universal pathology evaluations with a resect and discard policy for colonoscopy screening. In a resect and discard approach, diminutive lesions (≤mm), classified by endoscopy with high confidence, were not analyzed by a pathologist. Base case assumptions of an 84% rate of high-confidence classification, with a sensitivity and specificity for adenomas of 94% and 89%, respectively, were used. Census data were used to project outputs of the model onto the US population, assuming 23% as the current rate of adherence to a colonoscopy screening. Results: With universal referral of resected polyps to pathology, colonoscopy screening costs an estimated $3222/person, with a gain of 51 days/person. Endoscopic polypectomy accounted for $179/person, of which $46/person was related to pathology examination. Adoption of a resect and discard policy for eligible diminutive polyps resulted in a savings of $25/person, without any meaningful effect on screening efficacy. Projected onto the US population, this approach would result in an undiscounted annual savings of $33 million. In the sensitivity analysis, the rate of high-confidence diagnosis and the accuracy for endoscopic polyp determination were the most meaningful variables. Conclusions: In a simulation model, a resect and discard strategy for diminutive polyps detected by screening colonoscopy resulted in a substantial economic benefit without an impact on efficacy. © 2010 AGA Institut.


Alakkari A.,Trinity College Dublin | Zullo A.,Nuovo Regina Margherita Hospital | O'Connor H.J.,Trinity College Dublin
Helicobacter | Year: 2011

Research published over the past year has documented the continued decline of Helicobacter pylori-related peptic ulcer disease and increased recognition of non-H. pylori, non-steroidal anti-inflammatory drugs ulcer disease - idiopathic ulcers. Despite reduced prevalence of uncomplicated PUD, rates of ulcer complications and associated mortality remain stubbornly high. The role of H. pylori in functional dyspepsia is unclear, with some authors considering H. pylori-associated nonulcer dyspepsia a distinct organic entity. There is increasing acceptance of an inverse relationship between H. pylori and gastroesophageal reflux disease (GERD), but little understanding of how GERD might be more common/severe in H. pylori-negative subjects. Research has focused on factors such as different H. pylori phenotypes, weight gain after H. pylori eradication, and effects on hormones such as ghrelin that control appetite. © 2011 Blackwell Publishing Ltd.


Manes G.,Salvini Hospital | Repici A.,Instituto Cinico Humanitas | Hassan C.,Nuovo Regina Margherita Hospital
Endoscopy | Year: 2014

Background and study aim: Sodium picosulfate plus magnesium citrate (PMC) is a very effective, safe, and tolerated low-volume preparation for colon cleansing. This study evaluates whether split dosing is associated with a further increase in efficacy and acceptability compared with the standard dosing regimen. Patients and methods: This was a multicenter, randomized, single-blind study. Adult outpatients undergoing colonoscopy received PMC either in the standard dosing (two sachets taken the day before endoscopy) or in split dosing (the second sachet taken on the morning of colonoscopy). Bowel cleansing was assessed using the Boston Bowel Preparation Scale (BBPS) and was rated as adequate when BBPS was ≥ 2 in each segment. Patient acceptance, satisfaction, and related symptoms were recorded. Results: A total of 862 patients were included in the study (577 in the standard group and 285 in the split-dose group). Preparation was adequate in only 69.8 % of patients in the standard group compared with 85.8 % of those in the split-dose group (P = 0.0001). Mean BBPS scores for the whole colon and the right colon were also statistically significantly higher in the split-dose group (P = 0.0001). Both regimens were well tolerated, and only 8.0 % of patients reported discomfort. Compliance was better with the split regimen (0.7 % vs. 7.1 % unable to take 75 % of the preparation; P < 0.0001), and willingness to repeat the preparation was similar. Performing colonoscopy within 6 hours after preparation was associated with better colon cleansing. Other predictors of poor cleansing at multivariate analysis were constipation, obesity, and discomfort during preparation. Conclusions: The split-dose regimen of PMC was superior to the standard regimen in terms of effective colon cleansing and compliance. ClinicalTrial.gov (NCT01909219). © Georg Thieme Verlag KG Stuttgart · New York.


We report the case of a 47-year-old man with insidious onset of progressively disabling back pain in the dorsal region. The patient had minimal dermatitic lesions to the elbows and behind the ears, which were attributed to minimal psoriasis. An initial MRI of the spine, one month after the onset of symptoms, showed an alteration in the D7-D8 vertebrae as from bone marrow edema. The successive CT scan of the spine, after about six months, showed a significant osteolytic process of the D7 and D8 vertebrae and extensive swelling of surrounding tissues. A contemporary lung CT scan showed opacity in the right lung. A first hypothesis of lung cancer with vertebral metastases was ruled out by the negative bronchoscopy and the subsequent disappearance of lung opacity after antibiotic therapy. A CT-guided needle biopsy of the spine gave negative results for granulomatous and infectious tumor pathology. The later appearance of peripheral polyarthritis and the presence of initial bone marrow edema justied the diagnosis of psoriatic spondylodiscitis. Therapy with anti-TNF-alpha (Eternacept) was initiated, with which both the painful symptomatology and the radiological damage were quickly resolved. This is the first case in literature about spondylodiscitis as the manifestation of the onset of psoriatic spondyloarthritis.

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