Sepulveda Ambulatory Care Center

Los Angeles, CA, United States

Sepulveda Ambulatory Care Center

Los Angeles, CA, United States
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Yen A.W.,10535 Hospital Way | Yen A.W.,University of California at Davis | Leung J.W.,10535 Hospital Way | Leung J.W.,University of California at Davis | And 2 more authors.
Gastrointestinal Endoscopy | Year: 2013

Background: Water exchange provides salvage cleansing and improves adenoma detection, but drawbacks include prolonged procedure time. Cap-assisted colonoscopy decreases cecal intubation time but is limited by impaired views when feces lodge in the cap. Objective: To investigate the impact of combined water-exchange and cap-assisted colonoscopy (WCC) on detection of adenomas and proximal colon serrated polyps. Design: Retrospective, single-center, single-colonoscopist, consecutive group observational study. Setting: Veterans Affairs outpatient endoscopy suite. Patients: Outpatients undergoing screening or surveillance colonoscopy. Intervention: WCC data collected from 100 consecutive patients were compared to a control group of 101 consecutive patients examined with conventional air insufflation colonoscopy during the prior 4-month period. Main Outcome Measurements: Adenoma detection rate (ADR), adenomas detected per colonoscopy, proximal colon serrated polyp detection rate, and proximal colon serrated polyps per colonoscopy rate. Results: Compared with controls, the WCC group had a higher polyp detection rate (93.0% vs 84.2%; P =.07), ADR (75.0% vs 59.4%; P =.02), proximal colon ADR (61.0% vs 47.5%; P =.07), proximal colon serrated polyp detection rate (24.0% vs 9.9%; P =.009), number of adenomas per colonoscopy (2.70 vs 1.50; P =.002), and mean number of proximal colon serrated polyps per colonoscopy (0.38 vs 0.12; P =.004). Limitations: Retrospective study; single, unblinded endoscopist. Conclusion: ADR and adenomas per colonoscopy are both sensitive indicators of colonoscopy quality. WCC merges two simple methods to improve the performance of screening and surveillance colonoscopy. The data suggest that larger, prospective studies are necessary to determine if there are differences between water-exchange combined with cap-assisted maneuvers and the individual components used alone in lesion detection in screening and surveillance colonoscopy. Copyright © 2013 by the American Society for Gastrointestinal Endoscopy.

Cadoni S.,S Barbara Hospital | Sanna S.,N S Of Bonaria Hospital | Gallittu P.,S Barbara Hospital | Argiolas M.,N S Of Bonaria Hospital | And 5 more authors.
Gastrointestinal Endoscopy | Year: 2015

Background: A recent American Society for Gastrointestinal Endoscopy Technology Status Evaluation Report recommended comparative studies of water-aided colonoscopy methods to refine the optimal insertion technique. Objective: Air insufflation (AI), water immersion (WI), and water exchange (WE) were compared head-to-head to test the hypothesis that WE produces the least insertion pain. Design: Patient-blinded, prospective, randomized, controlled trials. Setting: Two community hospitals in Italy. Patients: First-time diagnostic or screening colonoscopy in unsedated patients with the option of on-demand sedation. Intervention: Colonoscopy with AI, WI, or WE. Main Outcome Measurements: Real-time maximum insertion pain (0 = none, 10 = worst). To avoid interventional bias, the timing of recording was at the discretion of the nurse assistant. Adjunct measures were implemented to ensure patient perception of minimal discomfort. Recalled pain and patients' guess of insertion methods were recorded after colonoscopy. Results: Results were merged for 576 randomized patients. Correct patient guesses lower than 33% confirmed adequate blinding. Significant correlation (Pearson coefficient 0.6, P < .0005) between real-time and recalled pain provided internal validation of the former as the primary outcome. Real-time pain (95% confidence interval [CI]: AI, 4.1 [3.7-4.5]; WI, 3.5 [3.0-3.9]; and WE, 2.5 [2.2-2.9] [P < .0005] was the lowest in the WE group. The proportions of patients completing unsedated colonoscopy based on the assigned methods were significantly different (WE, 74.7% vs WI, 62.4%; P = .009; vs AI, 65.3%; P = .04). WE required the least implementation of adjunct maneuvers. Limitations: Unblinded colonoscopists. Conclusion: The current findings with an internally validated primary outcome in adequately blinded patients support the hypothesis that WE is superior to WI in attenuating real-time insertion pain and enhancing completion of unsedated colonoscopy. Copyright © 2015 by the American Society for Gastrointestinal Endoscopy.

Koek R.J.,University of California | Koek R.J.,Sepulveda Ambulatory Care Center | Yerevanian B.I.,Sepulveda Ambulatory Care Center | Mintz J.,University of Texas Health Science Center at San Antonio
Journal of Affective Disorders | Year: 2012

Objective: Antipsychotics are commonly used in bipolar disorder, with newer (SGA) agents increasingly replacing FGA antipsychotics, particularly in bipolar depression. There are few data on differences between FGA and SGA antipsychotics in terms of their relationship to suicidal behavior in bipolar disorder. Method: This was a retrospective chart review of 161 bipolar veterans treated naturalistically with antipsychotics at a university-affiliated VA hospital and clinics for up to 8 years. Charts were reviewed to determine monthly antipsychotic use and occurrence of suicidal behavior: completed suicide, attempted suicide or hospitalization to prevent suicide. Suicidal behavior events were compared across patients during treatment with individual antipsychotics and FGAs or SGAs as a class. Results: Non-lethal suicide events were more common during FGA than SGA monotherapy (9 events/110 months of exposure vs. 6 events/381 months of exposure; χ2=9.65, p=0.002). Suicide event rates did not differ between FGAs and SGAs when used in conjunction with mood stabilizers. Event rates were lower with lithium than anticonvulsants when used in conjunction with antipsychotics. No differences were found between olanzapine, risperidone and quetiapine. Limitations: The retrospective chart review methodology may have led to confounding by indication and diagnostic inaccuracy. No completed suicides occurred. Study participants were primarily male veterans. Results may not be generalizable to SGAs marketed since 2003. Conclusions: FGA antipsychotic monotherapy may be associated with higher suicidal behavior risk than SGA antipsychotic monotherapy. Antipsychotics used in conjunction with mood stabilizers, particularly lithium, are associated with lower rates, independent of antipsychotic subtype. © 2012 Elsevier B.V.

Cadoni S.,S Barbara Hospital | Gallittu P.,S Barbara Hospital | Sanna S.,N S Of Bonaria Hospital | Fanari V.,N S Of Bonaria Hospital | And 4 more authors.
Endoscopy | Year: 2014

Background and study aim: Water-aided colonoscopy includes water immersion and water exchange. Several small single-center studies have suggested that the use of water rather than air insufflation during colonoscopy reduces pain on insertion. The aim of this study was to investigate whether water-aided colonoscopy is less painful than air insufflation in a large cohort of patients. Patients and methods: This was a two-center, randomized controlled trial. Consecutive patients who agreed to start colonoscopy without premedication were included. Sedation was administered on demand. Water-aided colonoscopy was performed using water immersion in the early phase of the study, and subsequently water exchange was used. The primary endpoint was cecal intubation with pain scores of ≤ 2 and sedation with no or ≤ 2mg midazolam. Secondary outcomes were pain score at discharge, cecal intubation rate and time, and adenoma detection rate (ADR). Results: A total of 672 patients were randomized to water exchange (n= 338) or air insufflation (n= 334). The primary endpoint was achieved in more patients in the water exchange group (83.8% vs. 62%; P< 0.0005). On-demand sedation was also required less (11.5% vs. 26.0%; P< 0.0005) and mean pain score was lower (1.3 vs. 2.3; P< 0.0005) in the water exchange group. The cecal intubation rates were comparable. Water exchange had a significantly higher overall ADR (25.8% vs. 19.1%; P= 0.041), proximal ADR (10.1% vs. 4.8%; P= 0.014), and proximal < 10mm ADR (7.7% vs. 3.9%; P= 0.046); proximal ADR was also higher in screening-only patients in the water exchange group (18.9% vs. 7.4%; P = 0.015). No detailed analysis was possible for the air insufflation vs. water immersion comparison. Conclusion: The current results confirmed that water exchange minimized the requirement for sedation and increased the ADR. © Georg Thieme Verlag KG Stuttgart, New York.

Leung F.W.,Sepulveda Ambulatory Care Center | Leung F.W.,University of California at Los Angeles
Gastroenterology Clinics of North America | Year: 2013

Water-aided methods for colonoscopy include the established water immersion and the recent novel modification of water exchange. Water immersion entails the use of water as an adjunct to air insufflations to facilitate insertion. Water exchange evolved from water immersion to facilitate completion of colonoscopy without discomfort in unsedated patients. Infused water is removed predominantly during insertion rather than withdrawal. A higher adenoma detection rate has been reported with water exchange. Aggregate data of randomized controlled trials suggest that water exchange may be superior to water immersion in attenuating colonoscopy discomfort and optimizing adenoma detection, particularly in the proximal colon. © 2013.

Leung F.W.,Sepulveda Ambulatory Care Center | Leung F.W.,University of California at Los Angeles
American Journal of Gastroenterology | Year: 2013

Interval (missed) cancers and lower-than-expected mortality reduction of proximal colon cancers after screening colonoscopy drew attention to quality indicators. Small proximal polyps (prone to be advanced neoplasms) missed by colonoscopy are possible contributing factors. In this issue of AJG, the subject of polyp detection rates (PDRs) and adenoma detection rates (ADRs) in the proximal and distal colon is discussed by one group of investigators to address the issue of monitoring performance and to achieve improvement. The authors observed that these two parameters correlated well in segments proximal to the splenic flexure, but not in the left colon. They suggested that caution should be exercised when using PDR as a surrogate for ADR if data from the rectum and sigmoid were included. Avoidance of missed lesions at the time of colonoscopy may require new adjunct measures to enhance ADR. The impact of new adjunct measures on ADR is mixed. In contrast to water immersion, water exchange during insertion has consistently increased ADR during withdrawal inspection. Water exchange may be a suitable alternative platform to replace insertion by air insufflation in the evaluation of new adjunct measures of quality improvement to increase ADR. Payment reforms may be necessary to bring about inclusion of ADR reporting for monitoring of quality performance. ©2013 by the American College of Gastroenterology.

Leung F.W.,Sepulveda Ambulatory Care Center | Leung F.W.,University of California at Los Angeles
Progress in Drug Research | Year: 2014

Laboratory studies support a role of capsaicin as an anti-obesity agent. Intestinal mucosal afferent nerves appear to play a role in controlling adipose tissue distribution between visceral and subcutaneous sites. Activation of the transient receptor potential vanilloid-1 channels by capsaicin prevents adipogenesis. A neurogenic mechanism modulates the regulation of fat metabolism by transient receptor potential vanilloid-1-sensitive sensory nerves. A neural pathway enables the selective activation of the central network that regulates brown adipose tissue sympathetic nerve activity in response to a specific stimulation of gastrointestinal transient receptor potential channels. Dietary capsaicin reduces metabolic dysregulation in obese/diabetic mice by enhancing expression of adiponectin and its receptor. The effects of capsaicin in adipose tissue and liver are related to its dual action on peroxisome proliferator-activated receptor alpha and transient receptor potential vanilloid-1 expression/activation. Local desensitization of the abdominal capsaicin-sensitive fibers attenuates the hypometabolic adaptation to food deprivation. Truncal vagotomy leads to significant reductions in both diet-induced weight gain and visceral abdominal fat deposition. Vagal de-afferentation leads to a more modest, but clinically and statistically significant, reduction in visceral abdominal fat. Thermogenesis and lipid metabolism-related proteins are altered upon capsaicin treatment in white adipose tissue. Capsaicin induces apoptosis and inhibits adipogenesis in preadipocytes and adipocytes. Epidemiologic data show that consumption of foods containing capsaicin is associated with a lower prevalence of obesity. Clinical evidence supports a role of capsaicin as an anti-obesity agent. Both oral and gastrointestinal exposure to capsaicin increase satiety and reduce energy and fat intake; the stronger reduction with oral exposure suggests a sensory effect of capsaicin. Bioactive components containing capsaicin may support weight maintenance after a hypocaloric diet. Capsaicin consumption 1 h before low intensity exercise is a valuable supplement for the treatment of individuals with hyperlipidemia and/or obesity because it improves lipolysis. Capsinoid ingestion increases energy expenditure through the activation of brown adipose tissue in humans. Capsinoid ingestion is associated with an increase in fat oxidation that is nearly significant; and two common genetic variants may be predictors of response. Further clinical research to develop convenient approaches for obese individuals to take advantage of this common dietary ingredient to prevent the onset or curtail the progression of obesity will be instructive and clinically relevant. © Springer Basel 2014.

Leung F.W.,Sepulveda Ambulatory Care Center | Leung F.W.,University of California at Los Angeles
Scandinavian Journal of Gastroenterology | Year: 2011

Objective. Several factors such as significant procedure-related discomfort, excessive intubation time or failed cecal intubation have been associated with difficult colonoscopy. An update of these factors and colonoscopy techniques reported to be efficacious in enhancing completion of cecal intubation in difficult colonoscopy patients is provided in this review. Material and methods. A Medline search (January 2006 to July 2010) was conducted using the following search terms: colonoscopy, difficult, abdominal pain, and discomfort. Results. Reviewed data are tabulated for presentation. Several water-related techniques have been described separately as adjuncts to usual air insufflation to minimize discomfort, reduce intubation time and improve success rate of cecal intubation. A combination of these techniques was subjected to trial-and-error modifications followed by randomized controlled comparisons. Progressive improvement in colonoscopy outcomes that paralleled stepwise incorporation of exclusion of air insufflation, removal of residual colonic air by suction and removal of residual feces by water exchange during the insertion phase has been described. Conclusions. The water method is potentially important for improving results of colonoscopy (cecal intubation) especially in unsedated patients. The unsedated option may lower costs. The success of the water method in difficult cases should be evaluated in randomized controlled trials. The call should be considered and explored by endoscopists interested in improving the quality of colonoscopy. A multicenter study to optimize the number of cases will be most desirable. In pragmatic terms, the use of the water method in difficult (unsedated) colonoscopy in the United States did receive recent editorial endorsement. © 2011 Informa Healthcare.

Liu X.,PLA Fourth Military Medical University | Luo H.,PLA Fourth Military Medical University | Zhang L.,PLA Fourth Military Medical University | Leung F.W.,Sepulveda Ambulatory Care Center | And 9 more authors.
Gut | Year: 2014

Background Despite advances in bowel preparation methods, the quality of bowel preparation in some patients undergoing colonoscopy remains unsatisfactory. The effect of telephone re-education (TRE) on the day before colonoscopy on the quality of bowel preparation and other outcome measures had not been studied. Methods A prospective colonoscopist-blinded study was conducted. All patients received regular instructions during a visit to discuss colonoscopy. Those scheduled for colonoscopy were randomly assigned to receive TRE on the day before colonoscopy (TRE group) for bowel preparation or no TRE (control group). The primary outcome was the rate of adequate bowel preparation. The secondary outcomes included polyp detection rate (PDR), non-compliance with instructions, and willingness to repeat bowel preparation. Results A total of 605 patients were randomised, 305 to the TRE group and 300 to the control group. In an intention-to-treat analysis of the primary outcome, adequate preparation was found in 81.6% vs 70.3% of TRE and control patients, respectively ( p=0.001). PDR was 38.0% vs 24.7% in the TRE and control group, respectively (p<0.001). Among patients with successful colonoscopy, the Ottawa scores were 3.0±2.3 in the TRE group and 4.9±3.2 in the control group (p<0.001). Fewer patients who showed non-compliance with instructions were found in the TRE group (9.4% vs 32.6%, p<0.001). No significant differences were observed between the two groups with regard to willingness to have a repeat bowel preparation (p=0.409). Conclusions TRE about the details of bowel preparation on the day before colonoscopy significantly improved the quality of bowel preparation and PDR.

Yerevanian B.I.,Sepulveda Ambulatory Care Center
Bipolar disorders | Year: 2013

To examine the impact of psychotropic drugs on suicide and suicidal behaviors in bipolar disorders. A Medline search of articles published from January 1960 to January 2013 was performed using relevant keywords to identify studies examining the relationship of psychotropic drugs to suicidal behaviors. The publications were further reviewed for relevant references and information. Additionally, the US Food and Drug Administration Center for Drug Evaluation Research website was searched. The available studies used differing methodologies, making interpretation of the findings difficult. Studies suggest that antidepressants may increase suicidal risk in bipolar disorder, this possibly being related to the induction of broadly defined mixed states. There is no evidence that antiepileptic drugs as a class increase suicidal risk in patients with bipolar disorder. Only lithium provides convincing data that it reduces the risk of suicide over the long term. There is little known regarding the effects of antipsychotics, as well as anti-anxiety and hypnotic drugs, on suicidal behavior. The available evidence for the impact of psychotropics on suicidal risk in patients with bipolar disorder is largely methodologically flawed and, except for a few instances, clinically not useful at this point. Adequately powered, prospective randomized controlled studies are needed to assess the impact of each class of psychotropic and each psychotropic as well as common combination therapies. Until such studies have been carried out, clinicians are urged to exercise caution in using these drugs and rely on the traditional means of carefully assessing and monitoring patients with bipolar disorder who are at high risk for suicide. Published 2013. This article is a U.S. Government work and is in the public domain in the USA.

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