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BACKGROUND AND AIMS Polyps seen and not removed during colonoscope insertion are sometimes unable to be found during withdrawal. We aimed to evaluate whether additional inspection and polypectomy during insertion increases adenoma detection rate (ADR) compared with inspection and polypectomy entirely during withdrawal. METHODS A total of 421 patients aged ≥ 45 years and undergoing colonoscopy were prospectively randomized to receive inspection and polypectomy during both insertion and withdrawal (study group) or inspection and polypectomy entirely during withdrawal (control group). The primary outcome was the ADR. Secondary outcomes included other adenoma-related parameters and procedure-related measures. RESULTS Baseline demographics, procedure indications, preparation quality, total procedure time, sedative doses, colonoscopy difficulty, and patient discomfort were similar between the groups. The insertion time was significantly longer in the study group (11.1 ± 4.8 vs 6.2 ± 4.7 min, P

Background and Aim Same-day bidirectional endoscopy (BDE) is a commonly performed procedure, but the optimal sequence for the procedure with moderate conscious sedation is not well-established. We investigated the optimal sequence for same-day BDE under moderate conscious sedation and carbon dioxide insufflation in terms of sedation doses, patient discomfort, and colonoscopy performance. Methods We performed a prospective randomized controlled study of 120 patients who were scheduled for BDE examination. Colonoscopy followed by esophagogastroduodenoscopy (EGD) examination was performed in 60 patients (colonoscopy-EGD group) and EGD followed by colonoscopy examination was performed in another 60 patients (EGD-colonoscopy group). Endoscopists and patients completed a questionnaire to assess objective and subjective discomfort. Results Baseline demographics, procedure indications, bowel preparation quality, cecal intubation rate/time, colonoscopy withdrawal time, endoscopic interventions, BDE procedure time, colon polyp/adenoma detection rates, patient discomfort, and adverse events were similar between the two study groups. The total doses of fentanyl and midazolam were significantly higher for the colonoscopy-EGD group than for the EGD-colonoscopy group (83.4 ± 17.7 vs. 68.7 ± 18.6 μg and 6.3 ± 1.4 vs. 5.2 ± 1.3 mg, P < 0.0001 and P < 0.0001, respectively). The recovery time to discharge was significantly longer for the colonoscopy-EGD group than for the EGD-colonoscopy group (43.5 ± 16.2 vs. 34.5 ± 8.9 min, P = 0.0003). Conclusions EGD followed by colonoscopy is the optimal sequence for same-day BDE under moderate conscious sedation and carbon dioxide insufflation. Following this order allows for a reduction of sedation doses and for shorter recovery times.

Objectives/Hypothesis: The goal of this study was to understand the changes to the head and neck musculoskeleton and the pharyngeal airway after surgery. We tested the correlation between the changes in the skeleton and pharyngeal airway and the apnea-hypopnea index (AHI). Study Design: Prospective, noncontrolled study. Methods: In a pilot study, 12 consecutive subjects (3 women, body mass index: 22.4 Kg/m2 ± 2.7, AHI: 35.9/sec ± 18.0) with Class II dentoskeletal malocclusion and high mandibular plane underwent segmental maxillomandibular rotational advancement (SMMRA). Subjects underwent overnight polysomnography and three-dimensional computed tomography scanning of the head and neck before and 3 months after surgery. Linear, angular, and area measurements were obtained from skeletal images placed in the Frankfort horizontal position and from horizontal cross-sectional tomograms derived from the upright pharyngeal airway. Skeletal movements, dimensional changes of the airway, and correlations between measurements and AHI were calculated. A linear regression model was generated using significant bivariate correlations. Results: The AHI was significantly reduced to 4.6/sec ± 4.1 with improvement in the nadir oxygen saturation from 83.0% ± 7.2 to 90.6% ± 3.6 after SMMRA. Following skeletal advancement, the hyoid bone was advanced and elevated by 7.5 mm ± 2.9 and 6.7 mm ± 5.5, respectively; the cervical spine was rotated forward by 4.6° ± 2.8; and the airway length was shortened by 6.8 mm ± 4.0 (all P < .01). Variable improvement of airway dimensions was noted at each horizontal level. A quadratic regression model was derived using the measurements of the Sella-Nasion-B point angle and AHI (Rsq = 0.557, sig = 0.000). Conclusions: Dimensions of pharyngeal airway were correlated with dimensions of craniofacial skeleton. Sella-Nasion-B point angle could be used as a guidance in achieving normalized AHI after surgery.

Excessively sleepy teenagers and young adults without sleep-disordered breathing are diagnosed with either narcolepsy type 1 or narcolepsy type 2, or hypersomnia, based on the presence/absence of cataplexy and the results of a multiple sleep latency test. However, there is controversy surrounding this nomenclature. We will try to find the differences between different diagnoses of hypersomnia from the results of the long-term follow-up evaluation of a sleep study. We diagnosed teenagers who had developed excessive daytime sleepiness based on the criteria of the International Classification of Sleep Disorders, 3rd edition. Each individual received the same clinical neurophysiologic testing every year for 5 years after the initial diagnosis of narcolepsy type 1 (n = 111) or type 2 (n = 46). The follow-up evaluation demonstrated that narcolepsy type 1 (narcolepsy-cataplexy) is a well-defined clinical entity, with very reproducible clinical neurophysiologic findings over time, whereas patients with narcolepsy type 2 presented clear clinical and test variability. By the fifth year of the follow-up evaluation, 17.6% of subjects did not meet the diagnostic criteria of narcolepsy type 2, and 23.9% didn't show any two sleep-onset rapid eye movement periods in multiple sleep latency during the 5-year follow-up. Therefore narcolepsy type 1 (narcolepsy-cataplexy) is a well-defined syndrome, with the presentation clearly related to the known consequences of destruction of hypocretin/orexin neurons. Narcolepsy type 2 covers patients with clinical and test variability over time, thus bringing into question the usage of the term "narcolepsy" to label these patients.

Background and Aim: Bleeding peptic ulcers can be due to Helicobacter pylori (H. pylori) infection, use of non-steroidal anti-inflammatory drugs (NSAIDs), or idiopathic causes. The aim of this prospective study was to identify the clinical outcomes of bleeding peptic ulcers related to different causes. Methods: A total of 390 patients with bleeding ulcers were evaluated consecutively between June 2005 and August 2006. The diagnosis of H. pylori infection was made at index endoscopy, using histology and the rapid urease test. If both endoscopic diagnostic tests were not performed, a serological test was applied to detect the presence of H. pylori infection in a previously untreated patient. The prevalence and outcome of bleeding ulcers are related to H. pylori infection, NSAID use, and non-H. pylori idiopathic causes. The outcome between patients who were admitted for ulcer bleeding (outpatient bleeder) and those who bled while hospitalized (in-hospital bleeder) was also compared. Results: NSAID ulcers were noted in 223 patients, H. pylori ulcers in 102, and non-H. pylori idiopathic ulcers in 65. In total, 298 patients had outpatient bleeders, and 92 had in-hospital bleeders. The overall 3-day rebleeding rate was 11.8% and the mortality rate was 5.4%. Eighteen of the 21 mortality cases died of their underlying comorbid illness. Patients with non-H. pylori idiopathic ulcers had a significantly higher mortality rate than NSAID and H. pylori ulcers (12.3% vs 4.5% vs 2.9%, P = 0.02). Patients with H. pylori ulcers had significantly favorable outcomes than patients with NSAID ulcers (less blood transfusion and a shorter hospital stay) and non-H. pylori idiopathic ulcers (shorter hospital stay and a lower mortality). Patients with in-hospital bleeders had an adverse outcome as compared to outpatient bleeders, including a 3-day rebleeding rate (25.0% vs 7.7%, P