Simpler, easier method for performing biopsy can improve patient care
A simpler biopsy procedure than the one traditionally used can give equally good results while reducing stress for patients and workers, and allowing for faster diagnosis, according to a study.
During various procedures performed by gastrointestinal endoscopists, small tissue samples are taken from the patient for examination, which is known as biopsy. The traditional endoscopic forceps biopsy method can be labour intensive as well as stressful for the workplace environment.
With this method, each specimen is removed and placed in fixative vial for identification. This is labour intensive, adding to the length of the procedure and the time under sedation. Biopsy samples from each site are filtered to remove fixative, inspected to record specimen number and size, and transferred to a container to undergo several more processing steps before being mounted on slides to be examined for abnormalities or disease.
According to the study authors, diagnosis is delayed by this complex and costly protocol. In addition, staff may be affected by ergonomic stress and workplace risk from exposure to sharps, toxic fixative, infectious material, and soil.
The researchers aimed to test a faster way of collecting, handling and processing the samples to slides through a method called endoscopic multiple biopsy (MB).
MB uses a single endoscope pass within the patient to obtain up to 25 biopsy specimens during withdrawal of the endoscope. These are collected and stored in a plastic chamber inside the removable metal tip of the endoscope. After completing the biopsy series, the metal tip is cut off, immersed in fixative, and sent to pathology. There, the plastic storage chamber’s design supports rapid logging of specimens, diagnosis by frozen section and microwave (one hour) or routine paraffin processing (four to six hours) of the specimen tissue.
For the study, biopsies were performed during colonoscopy, upper GI endoscopy, and endoscopic retrograde cholangiopancreatography (ERCP). The blinded retrospective study compared 125 colon surveillance biopsies in 15 patients who underwent MB with 15 patients who underwent forceps biopsies performed on the same day.
The researchers found that the processed MB specimens were not significantly different from batched processed forceps biopsy specimens for depth, orientation (done manually), fixation, artifacts, and diagnostic information. Multiple biopsy colonic specimens were significantly (26%) smaller but had better epithelial (cellular covering) preservation than forceps specimens. Each biopsy saves 61 seconds during withdrawal.
The authors concluded that single-pass MB reduces biopsy time with less specimen damage, work, workplace risk, and soiling. Diagnostic quality is equal to forceps biopsy with better cellular preservation, although 26% smaller. In pathology, the plastic chamber reduces work and workplace risk. MB speeds diagnosis and improves productivity in endoscopic biopsy and histopathologic processing (microscopic examination of biopsy samples for signs of or disease). They encourage larger studies at multiple centers to determine the value of MB for diagnosing a larger set of GI diseases.

American Society for Gastrointestinal Endoscopy
www.asge.org/home/about-asge/newsroom/news-list/2017/08/04/august-gie-studies-show-promising-results-for-patients-with-endoscopic-treatments

A study conducted at the Department of Global Public Health and Primary Care (IGS), University of Bergen (UiB), concluded that Norwegian family doctors show little cultural competency when dealing with patients from an immigrant background.
“We need a new strategy on immigrant health, which should include an obligatory component in medical training in cultural competency,” says Associate Professor Esperanza Diaz, at IGS. She is co-author on the study.
The researchers studied a group of general practitioners that were either training to become specialists or were already specialists. The study participants were asked questions about what kind of strategies they used in meetings with patients from immigrant backgrounds.
The doctors responded that they treated these patients similarly to patients without immigrant backgrounds. In follow-up discussions, the participating doctors recognised that they had experienced cultural differences between the different patient groups.
“We discovered that the Norwegian doctors engage in relatively little reflection about cultural differences and the potential impact of such differences. It is as though they think they, themselves, represent the normal zero point, and this concerns us,” Diaz says.
Diaz underlines that cultural competency should be a  part of the medical education curriculum.
“Today, cultural competency depends on medical students taking personal initiatives, such as by joining special courses or engaging in voluntary activities. Cultural competency should be part of the ordinary medical education curriculum,” says Esperanza Diaz.
University of Bergen
www.uib.no/en/med/111669/doctors-need-cultural-training

Researchers at MIT and Brigham and Women’s Hospital have built a flexible sensor that can be rolled up and swallowed. Upon ingestion, the sensor adheres to the stomach wall or intestinal lining, where it can measure the rhythmic contractions of the digestive tract.
Such sensors could help doctors to diagnose gastrointestinal disorders that slow down the passage of food through the digestive tract. They could also be used to detect food pressing on the stomach, helping doctors to monitor food intake by patients being treated for obesity.
The flexible devices are based on piezoelectric materials, which generate a current and voltage when they are mechanically deformed. They also incorporate polymers with elasticity similar to that of human skin, so that they can conform to the skin and stretch when the skin stretches.
In a study the researchers demonstrated that the sensor remains active in the stomachs of pigs for up to two days. The flexibility of the device could offer improved safety over more rigid ingestible devices, the researchers say.
“Having flexibility has the potential to impart significantly improved safety, simply because it makes it easier to transit through the GI tract,” says Giovanni Traverso, a research affiliate at MIT’s Koch Institute for Integrative Cancer Research, a gastroenterologist and biomedical engineer at Brigham and Women’s Hospital, and one of the senior authors of the paper.
Canan Dagdeviren, an assistant professor in MIT’s Media Lab and the director of the Conformable Decoders research group, is the paper’s lead author and one of the corresponding authors. Robert Langer, the David H. Koch Institute Professor and a member of the Koch Institute, is also an author of the paper.
Traverso and colleagues have previously developed ingestible devices that can be used to monitor vital signs or deliver drugs to the digestive tract. With the goal of developing a more flexible sensor that might offer improved safety, Traverso teamed up with Dagdeviren, who previously developed flexible electronic devices such as a wearable blood pressure sensor and flexible mechanical energy harvesters.
To make the new sensor, Dagdeviren first fabricates electronic circuits on a silicon wafer. The circuits contain two electrodes: a gold electrode placed atop a piezoelectric material called PZT, and a platinum electrode on the underside of the PZT. Once the circuit is fabricated, it can be removed from the silicon wafer and printed onto a flexible polymer called polyimide.
The ingestible sensor that the researchers designed for this study is 2 by 2.5 centimeters and can be rolled up and placed in a capsule that dissolves after being swallowed.
In tests in pigs, the sensors successfully adhered to the stomach lining after being delivered endoscopically. Through external cables, the sensors transmitted information about how much voltage the piezoelectrical sensor generated, from which the researchers could calculate how much the stomach wall was moving, as well as distinguish when food or liquid were ingested.
“For the first time, we showed that a flexible, piezoelectric device can stay in the stomach up to two days without any electrical or mechanical degradation,” Dagdeviren says.
This type of sensor could make it easier to diagnose digestive disorders that impair motility of the digestive tract, which can result in difficulty swallowing, nausea, gas, or constipation.
Doctors could also use it to help measure the food intake of patients being treated for obesity. “Having a window into what an individual is actually ingesting at home is helpful, because sometimes it’s difficult for patients to really benchmark themselves and know how much is being consumed,” Traverso says.
In future versions of the device, the researchers plan to harvest some of the energy generated by the piezoelectric material to power other features, including additional sensors and wireless transmitters. Such devices would not require a battery, further improving their potential safety.

MIT
news.mit.edu/2017/flexible-sensors-can-detect-movement-gi-tract-1010

Patients who survive acute respiratory distress syndrome (ARDS) often leave a hospital intensive care unit with debilitating mental, physical, or cognitive problems that may limit their quality of life.
Now, a new study of 645 ARDS survivors by researchers at Intermountain Medical Center, Johns Hopkins University, and the University of Utah, has identified subgroups of ARDS survivors who suffer what’s been called post-intensive care syndrome, a collection of symptoms that can linger for years.
“A lot of work has been done around post-intensive care syndrome. We’re realizing the people who are surviving are often terribly wounded, and they have emotional and psychological distress as severe as combat veterans returning from war,” said Samuel M. Brown, MD, lead author of the study and director of the Center for Humanizing Critical Care at Intermountain Medical Center. “They may have profound weakness or shortness of breath or other important limitations to their quality of life after they survive.”
ARDS is a potentially life-threatening injury to the lungs that occurs most often in an intensive care unit among critically-ill patients with pneumonia or other infections, although it can have other causes.
For many ARDS patients, the primary symptom is shortness of breath so severe they require lung life-support therapies in order to breathe. ARDS can kill, and older patients are especially vulnerable.
Many ARDS survivors leave the hospital with an array of challenges that form post-intensive care syndrome. The survivors may live with long-term effects, including permanent lung damage and different degrees of physical, cognitive, and mental health problems.
During the last quarter-century, the symptoms of post-intensive care syndrome have been increasingly recognized and understood. Critical care specialists say between half and two-thirds of ARDS survivors struggle with it after they’re released from the hospital, Dr. Brown said.
“Patients are struggling and we’re trying to understand how to guide them through the process of the recovery and develop tailored rehabilitation programs to help them,” he said.
To that end, researchers at Intermountain Medical Center and Johns Hopkins University have been seeking common threads among survivors, focusing on combinations of impairments, including physical health, mental health, and brain function. The study builds on previous research by the team.
In the study of ARDS survivors six months out of intensive care, the researchers found four different patient subgroups:
 

• those with mildly impaired physical and mental health (22% of patients)
• those with moderately impaired physical and mental health (39%)
• those with severely impaired physical health and moderately impaired mental health (15%)
• those with severe physical and mental health impairments (24%).

 
According to the research, physical and psychological injuries tend to go hand in hand. Cognitive impairment is independent of those two, however.
The study found people who have worse physical problems have worse symptoms of anxiety, depression, or post-traumatic stress disorder. The one exception was a small but distinct group (15% of all survivors) who had severe physical limitations, but only moderately severe mental health problems.
Researchers speculate that could mean those individuals already had some chronic physical challenges before developing ARDS and were more accustomed to living with physical limitations.
“It’s also possible that group might have more resilience, so they’re better able to respond to the new physical disability, which is consistent with other recent studies suggesting that improving resilience may help ARDS survivors,” Dr. Brown said.
The study noted that six months after leaving intensive care, about half of the subjects in the study still weren’t living independently, even though 91 percent of them had done so prior to contracting ARDS. Instead, they lived in nursing homes or with relatives.

Intermountain Healthcare
intermountainhealthcare.org/news/2017/08/icu-patients-who-survive-respiratory-condition-may-have-post-intensive-care-syndrome/