Introduction

Climate change is responsible for increasing global health consequences and healthcare-related expenses. Despite efforts to address these issues, the healthcare sector remains a significant contributor to the world's carbon footprint due to increasing greenhouse gas emissions, compromising its own sustainability. Particularly, endoscopy stands out as the second highest waste generator per clinical procedure, largely attributed to its resource-intensive processes and extensive use of single-use devices. This study aimed to assess the waste carbon footprint generated at a high-volume tertiary endoscopy center both before and after implementing a targeted sustainability intervention. Additionally, we assessed the intervention's impact on the daily workflow of the endoscopy staff.

Aims & Methods

A 3-stage prospective interventional study was conducted from December 2023 until March 2024. Pre-intervention: four-week observational audit, during which daily endoscopic waste (landfill, regulated medical waste (RMW), and recycled paper and plastic) was weighed in both endoscopy rooms and recovery areas. Intervention: following data collection, a dedicated training session was conducted for the endoscopy staff. The session included a presentation of the collected data and outlined key sustainability strategies aimed at enhancing waste segregation. Additionally, recycling streams were established with placement of dedicated bins in assessment areas. Post-intervention: four-week period during which daily endoscopic waste was weighed in both endoscopy rooms and recovery areas.
Weighing was conducted using an engineer-calibrated scale. For the purpose of this study, waste carbon footprint calculations were based on the equivalence of 1kg of landfill waste to 1kgCO_2e and 1kg of RMW to 3kgCO_2e.
Upon conclusion of the study, an anonymous survey was distributed to all staff members to assess the impact of the study on the daily work routine.

Results

Total waste carbon footprint was reduced by 28.2%. In endoscopy rooms, waste carbon footprint decreased 20.4% (pre- vs. post-intervention: 1472.8kgCO_2e vs. 1173.7kgCO_2e, p=0.552). RMW was reduced by 24.4% (pre- vs. post-intervention: 462.8kgvs. 336.3kg, p=0.020), whereas landfill waste (pre- vs. post-intervention: 72.2 vs. 151.1, p<0.001) and recycling waste increased (paper – pre- vs. post-intervention: 0 vs. 21, p<0.001; plastic – pre- vs. post-intervention: 0 vs. 33.6, p<0.001). Mean endoscopy load was similar (pre- vs. post-intervention: 517 vs. 541, p=0.48).
In recovery areas, waste carbon footprint decreased 58.3% (pre- vs. post-intervention: 386.7kgCO_2e vs. 161.1kgCO_2e, p=0.002). RMW was reduced by 42.1% (pre- vs. post-intervention: 109.4kgvs. 28kg, p<0.001), whereas landfill waste (pre- vs. post-intervention: 58.4 vs. 77.2, p=0.040) and recycling waste increased (paper – pre- vs. post-intervention: 0 vs. 6, p<0.001; plastic – pre- vs. post-intervention: 0 vs. 9.9, p<0.001).
All staff members agreed the project did not disrupt their daily work routine, emerging as a valuable asset for promoting further sustainable practices.

Conclusion

Our study demonstrated that reducing RMW and implementing daily recycling in endoscopy rooms and recovery areas are attainable objectives that do not hinder endoscopy productivity. As a result, a yearly reduction of 2104kgCO_2e could be achieved in our endoscopy unit. Additionally, this study highlighted the effectiveness of educational initiatives in raising awareness towards more sustainable endoscopy practices.

Introduction

Adequacy of bowel preparation (ABP) directly affects colonoscopy performance and adenoma detection rate. Studies attributed a role to the dosing regimen of the bowel cleansing agent, social and economic factors and comorbidities. However, data on the impact of kidney failure and renal replacement therapy (RRT) are lacking.

Aims & Methods

This study investigated how ABP compares between patients on RRT and age-matched subjects with normal kidney function.
All patients on RRT undergoing an elective colonoscopy between January 2016 and December 2021 were identified from the medical records of a university hospital, and matched to 2 closest age controls undergoing colonoscopy at the same date ± 7 days. Study subjects and controls were compared for demographics, comorbidities including history of abdominal surgery, use of bowel transit-influencing drugs, residential care stay and colonoscopy-related data (bowel preparation regimen, sedation type, colonoscopy findings, ABP defined as a cumulative Bristol Bowel Preparation Score >= 6 and a score of >= 2 for each colon segment). Statistical significant contributors to ABP were assessed by logistic regression.

Results

Ninety-one patients on RRT (76 on haemodialysis and 15 on peritoneal dialysis) and 182 controls were identified. Patients on RRT were older (69±12 vs. 64±14y, p=.008) and less frequently women (34% vs. 50%, p=.013). They had more diabetes (40% vs. 24%, p=.008), more history of abdominal surgery (32% vs. 21%, p=.047) and took more bowel transit-influencing drugs (50% vs. 28%, p<.0001). Bowel preparation regimens were equally distributed between both groups. There was no difference in the rate of ABP between groups (87% vs. 81%, p=NS). Logistic regression analysis did not reveal an association between RRT and ABP. ABP was negatively influenced by residency in residential care, overnight stay in the hospital before colonoscopy, history of central nervous system disease, and positively by split-dose regimen (Nagelkerke R square 0.329, p=<.001).

Conclusion

Despite less favourable associated conditions, ABP in RRT patients remains comparable to controls. Split-dose regimen, neurological conditions and in-hospital stay are significant predictors of adequate bowel preparation.

References

Clark BT, Rustagi T, Laine L. What level of bowel prep quality requires early repeat colonoscopy: systematic review and meta-analysis of the impact of preparation quality on adenoma detection rate. Am J Gastroenterol. 2014;109(11):1714-23; quiz 24.
Hassan C, East J, Radaelli F, Spada C, Benamouzig R, Bisschops R, et al. Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2019. Endoscopy. 2019;51(8):775-94.
Saumoy M, Jesudian AB, Aden B, Serur D, Sundararajan S, Sivananthan G, et al. High prevalence of colon adenomas in end-stage kidney disease patients on hemodialysis undergoing renal transplant evaluation. Clin Transplant. 2016;30(3):256-62.
24. Calderwood AH, Schroy PC, 3rd, Lieberman DA, Logan JR, Zurfluh M, Jacobson BC. Boston Bowel Preparation Scale scores provide a standardized definition of adequate for describing bowel cleanliness. Gastrointest Endosc. 2014;80(2):269-76.
25. Clark BT, Protiva P, Nagar A, Imaeda A, Ciarleglio MM, Deng Y, et al. Quantification of Adequate Bowel Preparation for Screening or Surveillance Colonoscopy in Men. Gastroenterology. 2016;150(2):396-405; quiz e14-5.
artel M, Barkun AN, Menard C, Restellini S, Kherad O, Vanasse A. Split-Dose Preparations Are Superior to Day-Before Bowel Cleansing Regimens: A Meta-analysis. Gastroenterology. 2015;149(1):79-88

Introduction

FOLFIRINOX and Gemcitabine/Nab-paclitaxel are widely used 1st-line regimens in metastatic pancreatic cancer. We would like to present real-world data of 12 years of experience with both regimens including genomics insights

Aims & Methods

Patients with metastatic pancreatic cancer who received FOLFIRINOX or Gemcitabine/Nab-paclitaxel were retrospectively included from January 2010 to December 2022. Outcomes were overall survival (OS) and progression free survival (PFS). Median survival time was calculated using Kaplan-Meier estimates adjusted with 1:1 Propensity Score Matching (PSM). Additional tissue Next Generation Sequencing (NGS) panel data was analyzed.

Results

A total of 521 patients, 251 patients received FOLFIRINOX and 270 patients received Gemcitabine/Nab-paclitaxel as a first-line regimen. FOLFIRINOX group were younger (61.8 vs. 65.9, p <0.001). Before PSM, FOLFIRINOX group showed prolonged median OS (11.1 vs 7.8 months) and PFS (8.8 vs. 5.8 months) ( p = 0.002, both) compared to Gemcitabine/Nab-paclitaxel group. After PSM, FOLFIRINOX group still showed prolonged median OS (11.1 vs 9.0 months, p = 0.010) and PFS (9.2 vs 6.4 months, p = 0.001) than Gemcitabine/Nab-paclitaxel group. NGS was available from 31 and 22 patients in the FOFLIRINOX and Gemcitabine/Abraxane group, respectively. The most frequently mutated genes were KRAS (94.3%), TP53 (84.9%), CDKN2A (24.5%), SMAD4 (24.5%), ARID1A(13.2%) and RNF43(9.4%). On Cox Regression Analysis, RNF43 mutation was correlated with poor PFS with Gemcitabine/Nab-paclitaxel (HR, 4.849; 95% CI, 1.150-20.450, P= 0.032).

Conclusion

FOLFIRINOX showed prolonged OS and PFS compared to Gemcitabine/Nab-paclitaxel. FOLFIRINOX can be considered 1st-line regimen in metastatic disease. The NGS data suggest RNF43 could be a potential predictive marker for the response to Gemcitabine/Nab-Paclitaxel, however, larger size confirmation study is needed to validate this finding.

Introduction

Ulcerative colitis (UC) is characterized by chronic immune mediated inflammation of the colon and rectum. Corticosteroid (CS) is a common treatment for patients with moderate to severe active UC, but its effect varies among patients, including resistance, response, and dependence. In addition, the longer CS therapy continues, the greater the concern regarding drug-related adverse effects. New immunomodulatory therapies are being developed for the treatment of UC drug showing promise in the treatment of patients with moderate UC refractory to aminosalicylic acid (5-ASA). Thus, the clinical benefit of being able to predict whether certain patients would benefit from CS therapy prior to administration cannot be overestimated.

Aims & Methods

We compared the clinical characteristics of patients with steroid-responder (SR) and steroid-non-responder (SNR) UC and retrospectively evaluated for biomarkers that could predict the efficacy of CS prior to administration in patients with moderate to severe active UC who failed to respond to 5-ASA.
We enrolled 100 UC patients presenting at Nippon Medical School Hospital with a history of CS administration prior to December 2023. The patients were divided into two groups, SR patients and SNR patients, and their clinical characteristics were determined according to medical records. Eosinophil counts were measured in the high-power field using Direct Fast Scarlet staining.

Results

Clinical characteristics of UC patients were as follows: the median age, 48±17 years; height 167±9.2 cm, and weight, 58±14 kg; including 61 males to 39 females. The most common disease extent type was the total colitis (63%), followed by left-sided colitis (32%), and proctitis (5%). Complete SNR was observed in 15 patients (15%), with remaining 85 patients (85%) classified as SR. There was no significant difference found in Mayo Endoscopic Score, first dose of CS, number of hospitalizations, number of relapses, propotion of patients with total-colitis type, or duration of CS treatment between the SR group and the SNR group. The non-remission rate, defined as failure to achieve mucosal healing, was significantly higher in the SNR group (66%) than in the SR group (36%) (P=0.03). The proportion of patients treated with azathioprine was significantly higher in the SR group (40%) than in the SNR group (39%). The proportion of patients treated with biologics or small molecular compounds was significantly higher in the SNR group (40%) than in the SR group (22%) (P=0.03).
We then compared hematological biomarkers in blood samples obtained prior to CS administration between the two groups. There was no significant difference in WBC counts, hemoglobin values, serum albumin concentrations, CRP values, and ESR between the two groups. However, eosinophil profiles (both total count numbers and ratio to white blood cell counts) were significantly higher in the SR group than in the SNR group (P=0.02). Neutrophil-lymphocyte ratio tended to be higher in the SR group than in the SNR group (P=0.06). The number of infiltrated eosinophils in the inflamed rectal mucosal tissue was not significantly different between the two groups. The number of infiltrated eosinophils in the rectal mucosa tended to decrease in the steroid-response groups (p = 0.07). However, there was no difference in the number of infiltrated eosinophils in the steroid-non-response groups.

Conclusion

Both eosinophil in the blood and in the rectal mucosa, and neutrophil-lymphocyte ratio in the blood could be potential biomarkers for steroid responsiveness prior to administration.

References

・British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut. 2019; 68: s1–s106
・Severe ulcerative colitis: at what point should we define resistance to steroids? WJG 2008 Sep 28;14(36):5504-7.
・A reproducible grading scale for histological assessment of inflammation in ulcerative colitis: Gut 47：404－409，2000
・Mucosal Eosinophil Abundance in Non-Inflamed Colonic Tissue Is Associated with Response to Vedolizumab Induction Therapy in Inflammatory Bowel Disease：J Clin Med Res,2022