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Background and study aims The demand for screening colonoscopy has continued to rise over the past two decades. As a result, the current workforce of gastroenterologists is unable to meet the needs for colorectal cancer (CRC) screening. Therefore, solutions are needed to improve this disparity, with non-physician endoscopists being a potential option. However, current literature on the performance of non-physicians in endoscopy is limited. The aim of this study was to assess the quality of colonoscopy performed by three gastrointestinal fellowship-trained nurse practitioners (NPs). Methods This was a retrospective study performed at a single tertiary academic medical center. Colonoscopies performed by three gastrointestinal-specialized NPs after having completed training of at least 140 supervised colonoscopies were reviewed for analysis. Inclusion criteria were patients undergoing colonoscopy for colorectal cancer screening purposes. Outcomes included colonoscopy quality indicators as defined by the American Society for Gastrointestinal Endoscopy/American College of Gastroenterology Taskforce (ASGE/ACG) Taskforce. Results The study included 1,012 subjects (mean age 56.2 years, female 51.5 %, African American 73.9 %) who underwent screening colonoscopies by three NPs. Cecal intubation was successful in 997 subjects (98.5 %). Mean adenoma detection rate was 35.6 %. Mean withdrawal time was 18.9 minutes. There were no adverse events including colonic perforations or delayed post-polypectomy bleeding. Conclusions Three fellowship-trained NPs in colonoscopy in the United States satisfied the quality indicators proposed by the ASGE/ACG Task force, demonstrating that adequately trained NPs can perform colonoscopy safely and effectively. With the demand for colonoscopy exceeding the supply, non-physicians could be part of the solution to meet the demands for CRC screening.

The aim of our retrospective evaluation was to compare the outcome of patients with prenatal and postnatal diagnosis of Tetralogy of Fallot (TOF) and to analyze prenatal echocardiographic parameters predicting intervention within 30 days postnatal. We evaluated 142 patients in our pediatric heart center and prenatal diagnosis center and prenatal practice Praenatal plus in Cologne between 01/08-06/16. Within the prenatal diagnosis group, 6/74 fetuses (8.1 %) had TOF with pulmonary atresia (TOF-PA), and 6 (8.1 %) had absent pulmonary valve syndrome (TOF-APVS). 14 (18.9 %) had an abnormal karyotype including 9/14 (64.3 %) with microdeletion 22q11.2. 25 (33.8 %) had extracardiac malformation. 4 (5.4 %) had agenesis of ductus arteriosus (DA), 22 (29.7 %) had right aortic arch (RAA) and 9 (12.2 %) had major aortopulmonary collateral arteries (MAPCAs). Within the postnatal diagnosis group, no patient had TOF-PA, 4/68 (5.9 %) had TOF-APVS. 12 (17.6 %) had extracardiac malformations, 9 (13.2 %) had an abnormal karyotype including 2/9 with microdeletion 22q11.2. 10 (14.7 %) had RAA, 9 (13.2 %) had MAPCAs. There were no cases with agenesis of DA. Increasing z-score values of the left/right pulmonary artery (LPA/RPA) prenatally were associated with a lower probability for early postnatal intervention (RPA: p = 0.017; LPA: p = 0.013). Within the prenatal diagnosis group, 12 of 41 (29.3 %) live-born patients with follow-up and intention to treat needed early intervention versus 7 (10.3 %) in the postnatal diagnosis group (p = 0.02). Within the postnatal diagnosis group, there were no deaths, while 2 (4.9 %) post-intervention deaths occurred in the prenatal diagnosis group. There are no significant differences concerning post-intervention survival in the prenatal diagnosis group versus the postnatal diagnosis group. Complex cases may be underrepresented in the postnatal diagnosis group. Smaller RPA/LPA values prenatally seem to be associated with early postnatal intervention.ZIEL: Ziel unserer retrospektiven Auswertung war der Outcome-Vergleich von Patienten mit pränatal und postnatal diagnostizierter Fallot-Tetralogie (TOF) sowie die Auswertung fetaler Echokardiografie-Parameter im Hinblick auf Prädiktion einer Intervention innerhalb 30 Tage postnatal. Ausgewertet wurden 142 Patienten, die von 01/08–06/16 in unserem Kinderherz-Zentrum, unserer Pränataldiagnostik oder in der Praxis Praenatal plus in Köln vorstellig waren. In der Pränatal-Diagnose-Gruppe waren 6 von 74 (8,1 %) mit TOF und Pulmonalatresie (TOF-PA), 6 (8,1 %) mit absent-pulmonary-valve-syndrome (TOF-APVS). 14 (18,9 %) hatten einen auffälligen Karyotyp, darunter 9/14 mit Mikrodeletion 22q11.2 (64,3 %). 25 (33,8 %) hatten extrakardiale Fehlbildungen. 4 (5,4 %) hatten eine Ductus arteriosus (DA) -Agenesie, 22 (29,7 %) einen rechten Aortenbogen (RAA), 9 (12,2 %) hatten aortopulmonale Kollateralen (MAPCAs). In der Postnatal-Diagnose-Gruppe waren keine Patienten mit TOF-PA, 4 von 68 (5,9 %) hatten TOF-APVS. 12 (17,6 %) hatten extrakardiale Fehlbildungen, 9 (13,2 %) hatten einen auffälligen Karyotyp, darunter 2/9 mit Mikrodeletion 22q11.2. 10 (14,7 %) hatten ein RAA, 9 (13,2 %) hatten MAPCAs. Es gab keine DA-Agenesien. Pränatal höhere z-Werte der linken/rechten Pulmonalarterie (LPA/RPA) waren mit einer niedrigeren Wahrscheinlichkeit für eine frühe postnatale Intervention assoziiert (RPA: p = 0,017; LPA: p = 0,013). Innerhalb der Pränatal-Diagnose-Gruppe benötigten 12 von 41 (29,3 %) Lebendgeburten mit follow-up und Intention-to-treat eine frühe Intervention versus 7 von 68 (10,3 %) innerhalb der Postnatal-Diagnose-Gruppe (p = 0,02). In der Postnatal-Diagnose-Gruppe gab es keine Todesfälle, in der Pränatal-Diagnose-Gruppe gab es 2/41 (4,9 %) Todesfälle postinterventionell. Es zeigten sich keine Unterschiede hinsichtlich post-interventionellem Überleben in der Pränatal-Diagnose-Gruppe versus Postnatal-Diagnose-Gruppe. Komplexe Fälle könnten in der Postnatal-Diagnose-Gruppe unterrepräsentiert sein. Pränatal kleinere RPA/LPA-Werte scheinen mit einer frühen postnatalen Intervention assoziiert zu sein.

We examined the hypothesis that major cardiac surgery triggers a more intense adrenal stress response than less intensive noncardiac surgery, which then alters cortisol inactivation. Urinary excretion rates of glucocorticoid metabolites were determined before and after surgery using gas chromatography-mass spectrometry in 29 children undergoing scheduled major cardiac surgery and 17 control children undergoing conventional noncardiac surgery in a prospective observational study. Excretion rates of glucocorticoid metabolites were summed and corrected for creatinine excretion to calculate cortisol production rates (mg/mmol creatinine/m(2) body surface area). Precursor/product ratios from individual metabolites were calculated to characterize cortisol inactivation (11β-hydroxysteroid dehydrogenase). Postoperatively, median cortisol production rates increased in both groups (from 2.7 to 9.3; controls: from 2.7 to 5.8; p0.001) with no significant difference between groups (p=0.12). Ratios of cortisol to cortisone metabolites, indicating the overall activity of 11β-hydroxysteroid dehydrogenase, increased postoperatively in both groups (p0.001). In conclusion, surgery resulted in a distinct postoperative increase in cortisol production. In contrast to our hypothesis, children undergoing major cardiac surgery did not show an increased adrenal stress response compared to children undergoing conventional surgery. Furthermore, the reduction in cortisol inactivation appears to be an essential part of the stress response to pediatric surgery in general.

Immunoglobulins in a dosage of 0,25 g/kg body weight were administered in a prospective randomised study prophylactically to 90 out of 180 patients with gastric surgery of variable extent on the day of operation and on the first postoperative day. Wound infection rates of the treated group were 4.4%, of the control group 14.4%. In addition, the control group had a pneumonia rate of 21% and the treatment group of 11%. However, there were no differences between both groups as regards other assessments (mortality, further postoperative complications, time of hospitalisation, duration of ventilation, postoperative use of antibiotics). It can be concluded that although immunoglobulins lower the risk of infection prophylactic administration should for reasons of expense be limited to patients with preoperatively increased pulmonary risks. The appropriate therapeutic use is to be evaluated.